HISTORY *** MECHANISM OF INJURY.. MOST IMPORTANT *** Age of patient - Certain conditions are more prevalent in particular age groups (Hip pain in children may refer to the knee from Legg-Calve-Perthes Disease. Older adults will be more prone to Degenerative Joint Disease) Sport / Occupation - Useful in determining mechanism of injury / overuse Level of Activity - Training Schedule / Job Ergonomics - Position Played - Terrain - Footwear - Warm-up / Cool-down Pain Characteristics Site Duration - Lateral vs. anterior vs. posterior / referral to knee - Constant vs. with certain movements (i.e. side-lying in bed, walking) Associated Symptoms - Radiation from back / to the knee / changes in gait Treatment to date Past Hx of similar condition Family Hx of related conditions Copyright 2006 Page 1 of 6 mskeducation.com
PHYSICAL EXAMINATION Observation and Surface Anatomy Anterior view: Posture Musculature - Muscle wasting Deformity - Swelling, ecchymosis, abrasions, scars Alignment - Genu varum / valgum / recurvatum / pes planus / cavus Assistive Devices Appliances Gait - Excessive pronation / supination Posterior view: Posture Musculature Deformity Alignment Gait - Gluteal wasting / scapulothoracic atrophy - Scoliosis / kyphosis / scars - Uneven popliteal creases / gluteal / skin folds - Trendelenburg / other Range of Motion (ROM) Active ROM Trunk (pain with) - Forward Flexion (soft tissue, disc) - Extension (S.I. joint / Spondylolesthesis / lysis / facet joint) - Lateral Side Flexion (vertebral dysfunction, stretching of soft tissues) - Twisting + Extension (facet joint) Passive ROM Hips - Abduction (gluteus medius 0-45 ) - Adduction (adductors / gracilis / pectineus 0-30 ) - External / lateral rotation (obturators / Piriformis / gluteus maximus 0-50 ) - Internal / medial rotation (gluteus minimus 0-45 ) Copyright 2006 Page 2 of 6 mskeducation.com
SPECIAL TESTS Pelvic Symmetry Bony Pain Neurological Tests - Level of iliac crests (standing and supine - after neutralizing pelvis) - Level of PSIS (posterior superior iliac spines) - Level of ASIS (anterior superior iliac spines) - Palpation of spinous processes - Palpation of sacroiliac joints - Palpation of greater trochanter - Slump Test (modified SLR) - patient sits on the side of the exam table with their arms crossed on their chest. Patient slumps forward with their head down. Patient then extends one leg at a time. Monitor for radicular pain extending below the knee level. - Straight Leg Raise (SLR) - patient is supine. Examiner passively extends a straight leg monitoring for pain from 45-90. - Deep Tendon Reflexes (DTR s) - Knee L4 / Ankle S1 - Dermatomes Upper Leg - Anterior: proximal - L1 / mid-lateral - L2 / medial L3 Posterior: medial L3 / lateral L2 Lower Leg - Anterior: medial - L4 / lateral - L5 Posterior: medial - L4 / lateral - L5 central - S2 (proximal) / central - S1 (distal) Foot - Dorsal: medial - L5 / lateral S1 Foot - Plantar medial - L5 / lateral S1 - Myotomes - Knee extension (quadriceps) L3 / L4 - Knee flexion (hamstrings) L5 / S1 - Foot dorsiflexion L4 / L5 - Great toe extension L5 / S1 - Hip Flexion L2 / L3 - Hip Extension L5 / S1 / S2 / S3 - Hip Abduction L4 / L5 / S1 - Hip Adduction L3 / L4 - Hip Medial rotation L4 / L5 / S1 - Hip Lateral Rotation L3 / L4 / L5 / S1 / S2 Copyright 2006 Page 3 of 6 mskeducation.com
Sacroiliac Tests - FABER Test - patient is supine. Examiner passively Flexes the knee / hip, then ABducts the hip and Externally Rotates the hip so the patient s foot is across the opposite knee. The examiner then places one hand on the medial aspect of the knee and the other on the anterior aspect of the opposite hip and applies a gentle traction in opposing directions to elicit pain under flexed and abducted hip. Resisted Muscle Testing - SI Compression Test - patient is supine. Examiner passively flexes hip and knee so the foot is off the exam table. The examiner then applies downward pressure over the top of the flexed knee in the direction of the exam table in order to reproduce discomfort in the ipsilateral SI joint. Anterior - Iliopsoas - patient is supine. Examiner has the patient actively abduct and lift their leg off the table with their foot externally rotated. Examiner then applies a downward force over the medial aspect of the leg, below the knee, while the patient attempts to maintain their position. - Quadriceps - patient is supine. Examiner passively flexes the patient s knee and then asks the patient to actively straighten their leg against resistance. The quadriceps may also be tested by asking the patient to actively lift their straight leg off the exam table and maintain this position while the examiner applies a downward force over the anterior lower leg. Often, the iliopsoas may be involved in quadriceps testing as both muscles are hip flexors, but only the rectus femoris is a knee flexor so the Modified Thomas Test is often helpful in isolating the muscle which is most involved. Copyright 2006 Page 4 of 6 mskeducation.com
- Modified Thomas Test - patient sits on the very edge of the exam table and grasps one flexed knee with both hands while rolling backwards onto the exam table. Examiner then assesses the amount of apparent tightness in the anterior hip by measuring the height the leg sits naturally above or below the table edge. If the leg sits above the table edge, the hip flexors are considered tight. Examiner then applies a downward force over the distal upper leg to reproduce discomfort. Examiner then passively flexes the knee by moving the lower leg in towards the table to see if pain is again reproduced. If the discomfort felt is greater with downward force on the distal upper leg, the iliopsoas may be more involved but, if the patient is more uncomfortable with the passive movement of the lower leg, the rectus femoris may be more involved (as it is the only muscle of the 2 which crosses both the hip and knee joints). Posterior - Gluteals - patient is prone. Examiner passively flexes one knee to 90. Patient actively extends the flexed leg off the exam table while examiner applies counterforce on the posterior upper leg. - Hamstrings - patient is prone. Examiner passively flexes one knee to approximately 45-60. The examiner then applies counterforce over the posterior lower leg while the patient actively flexes their knee. - Piriformis - patient is prone. Examiner passively abducts one straight leg to approximately 30-45. Patient actively extends the straight leg while the examiner applies counterforce over the posterior aspect of the lower leg. A positive test produces pain in the posterior lateral gluteal area. Copyright 2006 Page 5 of 6 mskeducation.com
Lateral - Iliotibial band (ITB) - Ober s Test - For assessment of Iliotibial Band function - Patient lying on side, hips flexed to 90 - Examiner stabilizes hip with one hand, grasps upper knee with the other hand to fully flex then fully extend hip - Note is made of the resting position of the leg after this maneuver is complete in order to assess tightness of the band - Examiner then places his / her thumb over lateral femoral condyle while patient slowly flexes / extends knee - A positive test will demonstrate tightness in the band, +/- pain under examiners thumb - Palpation of the insertional sight on Gerdys Tubercle may also elicit pain Palpation - Paraspinal soft tissue for tension - Piriformis insertion pain - Gluteal tone / bulk imbalance - Sciatic notch pain - Lateral hip pain over Tensor Fascia Lata / Iliotibial Band Knee Exam - Remember hip pain may be referred to the knee or, may be of knee origin - especially in children or adolescents Copyright 2006 Page 6 of 6 mskeducation.com