KNEE JOINT

KNEE EXTENSION
Muscle Tested:
* Quadriceps femoris:
- Origins:
1. Rectus femoris:
a) Straight head from anterior inferior iliac spine.
b) Reflected head from groove above rim of acetabulum.
2. Vastus lateralis:
a) Proximal part of inter-trochanteric line.
b) Anterior and inferior borders of greater trochanter.
c) Lateral lip of gluteal tuberosity.
d) Proximal of lateral lip of linea aspera.
e) Lateral inter-muscular septum.
3. Vastus intermedius:
a) Anterior and lateral surfaces of proximal !" of body of femur.
b) #istal of linea aspera.
c) Lateral inter-muscular septum.
4. Vastus medialis:
a) #istal of inter-trochanteric line.
b) $edial lip of linea aspera.
c) Proximal part of medial supracondylar line.
d) %endons of adductor longus and adductor magnus.
e) $edial inter-muscular septum.
- Common Insertion: Proximal border of patella and through patellar ligament to
tuberosity of tibia.
- Nerve Sul!: &emoral 'erve( L) L") L*
Range of Motion:
%he range of motion of complete extension of the +nee ,oint is of -.
o
to -".
o
.
%he range of motion may be limited by(
a) %ension of obli/ue popliteal) cruciate and collateral ligaments of the +nee ,oint.
b) %ension of +nee flexor muscles.
Test Procedures:
" #rade 3 $%air Strengt&':
- (atient Starting (osition: Sitting 0ith legs over the edge of the table. %he affected leg
is a0ay from the therapist) small cushion under the +nee. %he patient1s hands grasp the
edges of table to stabili2e pelvis or if possible cross both arms on the chest.
" )&eraist (osition and #rass: %he therapist stands beside the table on the side of the
sound leg. %o stabili2e the pelvis) his proximal hand is placed over the rectus femoris
origin 0ithout applying pressure.
- Command: 3Raise your lo0er leg up through full range of motion 0ithout medial or
lateral rotation of the hip) Relax(.
" #rade 4 $#ood Strengt&':
- (atient Starting (osition: Same as for 34rade "5.
- )&eraist (osition and #rass: Same as for 34rade "5 plus the distal hand is placed on
the anterior part of the leg ,ust over the an+le ,oint to give resistance.
- Resistance: $oderate leading resistance is given in a form of pressing do0n directly
opposing the line of rising.
- Command: Same as 34rade "5.
" #rade * $Normal Strengt&':
- (atient Starting (osition: Same as for 34rade *5.
- )&eraist (osition and #rass: Same as for 34rade *5.
- Resistance: $aximum leading resistance is given in a form of pressing do0n directly
opposing the line of rising plus hold position at the end of the range.
- Command: Same as for 34rade *5 plus 3hold5 at the end of the range.
" #rade 2 $(oor Strengt&':
- (atient Starting (osition: Side lying) affected leg do0n and flexed) the upper leg is
supported.
- )&eraist (osition and #rass: %he therapist stands behind the patient) the distal hand
support the upper leg) 0hile the proximal hand is placed above the +nee ,oint to stabili2e
the thigh. Avoid pressure over /uadriceps femoris.
- Command: 36xtend your +nee by moving your lo0er leg for0ard through full R7$)
Relax5.
" #rade 1 and + $)race and ,ero Strengt&':
- (atient Starting (osition: 8ac+ lying) affected +nee flexed and supported.
- )&eraist (osition and #rass: %herapist stands beside the table) the proximal hand
supporting the affected leg under the +nee) the distal hand palpates contraction of
/uadriceps femoris on its tendon bet0een patella and tuberosity of tibia and also fibers of
muscles.
- Command: 3%ry to extend your +nees by lifting your foot of the table and pushing in
my hand) Relax5.
Effects of Knee Extensor Muscles Weakness:
a) 9nee extensors 0ea+ness interferes 0ith the functions of going up and do0n stairs and
incline as 0ell as getting up and do0n from a sitting position.
b) %he 0ea+ness results in +nee hyperextension) not in the sense that such 0ea+ness
permits.
c) A posterior +nee position) but in the sense that 0al+ing 0ith a 0ea+ /uadriceps
re/uires that the patient loc+ the +nee ,oint by slight hyperextension.
d) :ontinuous push suddenly by force thrust in the direction of hyperextension in
gro0ing children may result in a very mar+ed degree of deformity.
Effects of Sortness or !ontracture:
a) Shortness or contracture of the +nee extensor muscles 0ill produce restriction of the
+nee flexion.
b) ;n addition) a shortness of the rectus femoris part of the /uadriceps results in a
restriction of the +nee flexion 0hen the hip is extended or a restriction of the hip
extension 0hen the +nee is flexed.
$A'<AL $<S:L6 %6S%;'4 7& 9'66 6=%6'S;7'

"rade #: &air Strength "rade $% &: 4ood and 'ormal Strength

"rade ': Poor Strength "rade ( ) *: %race and >ero Strength
KNEE +,EXION
Muscles Tested:
1. -edial .amstring -uscles:
a/ Semitendinosus.
0/ Semimem0ranosus.
2. 1ateral .amstring -uscles:
c/ 2ices femoris: Refer to the chapter on hip extensors for the description of these
muscles.
-ccessor. Muscles:
-. Popliteal muscle.
. Sartorius muscle.
". 4racilis muscle.
*. 4astrocnemius muscle.
Range of Motion:
%he range of motion of the +nee flexion is of -.
o
to -".
o
. %he range of motion
may be limited by(
a) %ension of +nee extensor muscles) particularly the Rectus &emoris if the hip is
extended.
b) :ontact of calf 0ith the posterior surface of the thigh.
Test Procedures:
" #rade 3 $%air Strengt&':
- (atient Starting (osition: Prone lying 0ith leg straight.
- )&eraist (osition and #rass: Standing beside the table on the side of the affected leg)
proximal hand above the thigh proximal to +nee to stabili2e thigh medially and laterally
0ithout pressure over the muscle group being tested.
- Command: 3Raise your lo0er leg through full range of motion) Relax5.
Notes:
a) &lexion of +nee ,oint is actively produced up to ?.@ only against gravity but after that
0ill be 0ith gravity assistance and produce smoothly by eccentric contraction of
/uadriceps muscle.
b) ;f gastrocnemius is 0ea+) +nee may be flexed to -.@ for starting position.
c) ;f biceps femoris is stronger) lo0er leg 0ill laterally rotate during flexion.
d) ;f semitendinosus and semimembranosus are stronger) lo0er leg 0ill medially rotate
during flexion.

" #rade 4 $#ood Strengt&':
- (atient Starting (osition: Same as for 34rade "5) the sound leg is a0ay from the
therapist.
- )&eraist (osition and #rass: Same as for 34rade "5) near the affected leg) 0ith the
proximal hand stabili2e pelvis and the distal hand grasping above an+le to give
resistance.
- Resistance: $oderate leading resistance is given in a form of pressing do0n directly
opposing the line of rising.
- Command: 3Raise your lo0er leg up through full range of motion) Relax5.
Note:
a) %o test biceps femoris only) the lo0er leg is laterally rotated to put the muscle in a
good alignment.
b) %o test semitendinosus and semimembranosus only) the lo0er leg is rotated medially
to put the muscle in a good alignment.
" #rade * $Normal Strengt&':
- (atient Starting (osition: Same as for 34rade *5.
- )&eraist (osition and #rass: Same as for 34rade *5.
- Resistance: $aximum leading resistance is given in a form of pressing do0n directly
opposing the line of rising) plus 3hold5 position at the end of the range of motions.
- Command: Same as for 34rade *5) plus 3hold5 at the end of the range of motion.
" #rade 2 $(oor Strengt&':
- (atient Starting (osition: Side lying 0ith both legs straightA the upper leg is supported
and the affected leg is do0n.
- )&eraist (osition and #rass: Standing beside the table) the proximal hand supporting
the upper leg. %he distal hand is placed above the +nee to stabili2e the thigh.
- Command: 3$ove your lo0er leg bac+0ard through full range of motion) Relax5.
Note: <neven muscular pull 0ill cause rotation of lo0er leg.
" #rade 1 and + $)race and ,ero Strengt&':
- (atient Starting (osition: Prone lying) 0ith the affected leg is near the therapist 0ith
slightly flexed +nee and the lo0er leg supported.
- )&eraist (osition and #rass: Same as for 3grade 5A the distal hand supports the
lo0er affected leg) 0hile the proximal hand palpates tendon of +nee flexor muscles on
bac+ of the thigh) near the +nee ,oint.
- Command: 3%ry to raise your lo0er leg up) Relax5.
Effects of Weakness of te Knee +lexor Muscles:
a) Bea+ness of both medial and lateral hamstrings causes hyperextension of the +nee.
Bhen this 0ea+ness is bilateral) the pelvis tilts anteriorly and the lumbar spine assumes a
lordotic position. ;f the 0ea+ness is unilateral) a pelvic rotation 0ill result.
b) Bea+ness of lateral hamstrings causes tendency to0ard loss of lateral stability of the
+nee) allo0ing a thrust in the direction of bo0 leg position in 0eight bearing.
c) Bea+ness of medial hamstrings decreases the medial stability of the +nee and permits
a 3+noc+-+nee5 position 0ith a tendency to0ard lateral rotation of the leg on the femur.
Effects of Sortness or !ontracture:
a) :ontracture of both medial and lateral hamstrings results in a position of +nee flexion.
;f the contraction is extreme) it 0ill be accompanied by posterior tilting of the pelvis and
flattening of the lumbar curve.
b) Shortness of the hamstrings muscles 0ill cause a restriction of +nee extension) 0hen
the hip is flexed or restriction of the hip flexion) 0hen the +nee is extended.
Effects Related to Patient Position:
a) #o not expect the sub,ect to hold full +nee flexion nor to hold against the same amount
of pressure 0ith the hip extended in prone position) that he could resist 0ith the hip
flexed in the sitting position.
b) %he fre/uent occurrence of muscle cramping during the hamstrings test on non-
paralytic individuals is evidence of too much +nee flexion in proportion to the amount of
pressure.
c) &or maximum pressure) hip flexion should be used by testing in the sitting position.
Su/stitution:
-. Substitution of Sartorius action appears in the form of hip flexion) as +nee flexion is
initiated.
. A short rectus femoris limiting +nee flexion range of motion 0ill cause hip flexion) as
the +nee flexion motion is completed.
-3N431 -4SC15 )5S)IN# %OR 6N55 %157ION

"rade #: &air Strength "rade $% &: 4ood and 'ormal Strength

"rade #%$% &: #eviation medially or laterally indicating a medial or lateral 0ea+ness

"rade ': Poor Strength "rade ( ) *: %race and >ero Strength
-NK,E P,-NT-R +,EXION

Muscle Tested:
1. Soleus muscle:
- Origin:
a) Posterior surface of head of fibula and proximal of its body.
b) Soleal line and middle -!" of medial border of tibia.
c) %endinous arch bet0een tibia and fibula.
- Insertion: Bith tendon of gastrocnemius into posterior surface of calcaneum.
- Nerve Sul!: %ibial nerve) LC) S-) S.
- 3ction: Plantar flexes the an+le ,oint.
2. #astrocnemius muscle:
- Origins:
D $edial head(
a) Proximal and posterior part of medial condyle ad,acent part of femur.
b) :apsule of +nee ,oint.
D Lateral head(
a) Lateral condyle and posterior surface of femur.
b) :apsule of +nee ,oint.
- Insertion: $iddle part of posterior surface of calcaneum.
- Nerve Sul!: %ibial nerve) S-) S.
- 3ctions:
a) Plantar flexes the an+le ,oint.
b) Assists in the flexion of the +nee ,oint.
3. (lantaris muscle:
- 7rigins(
a) #istal part of lateral supracondylar line of the femur and ad,acent part of its popliteal
surface.
b) 7bli/ue popliteal ligament of the +nee ,oint.
- Insertion: Posterior part of calcaneum.
- Nerve Sul!: %ibial nerve) L*) LC) S-.
- 3ctions:
a) Plantar flexes the an+le ,oint.
b) Assists in the flexion of the +nee ,oint.
-ccessor. Muscles:
-. %ibialis posterior.
. Peroneus longus. &ore foot and an+le plantar flexors.
". Peroneus brevis.
*. &lexor hallucis longus. %oe) forefoot and an+le plantar flexors.
C. &lexor digitorum longus.

Range of Motion:
%he an+le plantar flexion has a range of motion of approximately *.
o
to *C
o
. %he
range of motion may be limited by(
a) %ension on anterior talo-fibular ligament.
b) %ension of dorsiflexor muscles of the an+le.
c) :ontact of posterior portion of the talus bone on the tibia.
Test Procedures 0Weigt /earing and non12eigt /earing tests3:
a) Weight bearing test:
" #rade 3 $%air Strengt&':
- (atient Starting (osition: Standing on leg to be tested) +nee straight.
- )&eraist (osition: %herapist stands beside the patient.
- Command: 3Rise on your toes clearing your heel off the floor) Relax5.
" #rade 4 and * $#ood and Normal Strengt&':
- (atient Starting (osition: Same as in 34rade "5.
- )&eraist (osition: Same as in 34rade "5.
- Command: 3Rise on your toes through full range of motion) Relax5. Repeat for * to C
times.
Note:
-. %o do the test in the 0eight bearing position) the tibialis posterior and peroneus
longus brevis muscles must be normal or good to give sufficient stabili2ation to the
forefoot on the ground.
. A 34ood 4rade *5 is given) if the patient has difficulty to complete the R7$ or if he
fatigues easily.
b) Non Weight Bearing Test:
" #rade 3 $%air Strengt&':
- (atient Starting (osition: Prone lying 0ith the foot to be tested over end of the table.
- )&eraist (osition and #rass: Standing beside the patient foot. Proximal hand is
placed on the lo0er leg) proximal to the an+le to stabili2e.
- Command: 3Pull the heel up0ard and push bac+0ard 0ith your toes) Relax5.
" #rade 4 $#ood Strengt&':
- (atient Starting (osition: Same as in 34rade "5.
- )&eraist (osition and #rass: Same as in 34rade "5 but the proximal hand hold the
sides of the heel and the distal hand is placed on the plantar surface of the forefoot. 8oth
hands apply resistance.
Resistance: $oderate leading resistance is given simultaneously at the heel and at the
forefoot directly against the lines of motion) the resistance is given through the full range
of motion.
- Command: Same as for 34rade "5.
" #rade * $Normal Strengt&':
Same procedures as for 34rade *5 are used but 0ith a maximal resistance and
3hold5 position at the end of range of motion.
" #rade 2 $(oor Strengt&':
- (atient Starting (osition: Side lying 0ith the lateral border of the foot to be tested on
the table.
- )&eraist (osition and #rass: Standing beside the table at the level of the patient foot.
Proximal hand grasps the lo0er leg ,ust above the an+le ,oint to stabili2e it.
- Command: 3Push your foot do0n through full range of motion5.
" #rade 1 and + $)race and ,ero Strengt&':
Same procedures as for 3grade 5 but the therapist palpates the contraction over
the muscle fibers and on the tendon above calcaneum.
Effects of 2eakness:
Bea+ness of the plantar flexor muscles results in a hyper-extended position of the
+nee as 0ell in a non-0eigh bearing position as in standing. #uring 0al+ing) the inability
to rise on toes and conse/uently to transfer 0eight normally for0ards results in a
34astrocnemius limp5.
Results of !ontracture and Sortness of Plantar +lexors:
a) :ontracture results in an 36/uinus5 position of the foot and flexion of the +nee.
b) $uscle shortness causes restriction of the an+le dorsiflexion 0hen the +nee is
extended and a restriction of +nee extension 0hen the an+le is dorsi flexed.
-3N431 -4SC15 )5S)IN# %OR 6N55 %157ION %OR 3N615 (13N)5R %17ION

"rade #% $% &: &air) good) 'ormal Strength "rade (% *: %race and >ero Strength
EBeight bearing %est)
"rade #%$% &: 'on 0eight bearing test