Knee PP revision:

Active Range of Motion (AROM)

✓ Important things to asses during ROM:
1. If patella is moving smoothly during movement (esp. in flex and
extension)
2. The ROM available (measure)
3. If there is any pain during movement? And location?
4. What limits the movement (over-pressure)

1. Flexion (0 – 135)
Starting position: Supine
Instruction: “try to move your heels towards your buttocks”
Goniometer:
- Axis: lateral epicondyle of femur
- Stationary arm: parallel to lateral shaft of femur, poining to greater trochanter
- Moving arm: parallel to lateral shaft of fibula, pointing towards lateal malleolus
When trying to measure ROM, hold the moving arm by putting your hand around the
calf, its more stable that way, and the stationary arm on the thigh itself

Over-pressure:
ask patient to flex as much as possible then at the end of range, he relaxes and I
perform overpressure to feel the end feel, which is soft end fee
2. Extension (0-15)
Starting position: supine and put towel under distal thigh (help us see
hyperextension)
Instruction: from a bent knee, ask patient to extend as much as possible. The
towel will help us knee if there is hyperextension
Goniometer:
- Axis: lateral femoral condyle of femur
- Stationary arm: parallel to lateral shaft of femur, pointing to greater trochanter
- Moving arm: parallel to lateral shaft of fibula, pointing towards lateral malleolus
Over-pressure: ask patient to extend knee, the at the end of range, relax and I
perform over pressure (firm end feel). How to hold? Hold lower calf and stabilise
the femur (above the patella)

• Note:
- Active knee extension is approximately 0 but may be -15, specially in women
“genu recurvatum – hyper extended knees”. Why? Because quadriceps greatest
force is near 60 while hamstring is 45 = so 15
- As the patient moves the knee through F and E, the examiner should observe the
patella as it “tracks” along the femoral trochlea (whether movement is smooth
from beginning to end? Abrupt jump of patella?)
- When moving knee from flexion to extension. During early flexion, it moves
medially and then goes laterally
- In the presence of patellar instability, when going to a squat (initating flexion) the
laterally located patella shifts medially quickly to enter the trochlea = J sign
(sudden movement medially instead of normal smooth pattern)

3. Internal Rotation (at 90 flexion = 40 – 58) 40 in women / 58 in men

Starting position: sitting, fists between thighs
Instruction: try to move your feet towards the other feet (on the inside)
Goniometer:
Axis: patella
Stationary arm: pointing towards the floor
Moving arm: shaft of tibia
Over-pressure: ask patient to do internal rotation, then end of range, relax and I
perform over-pressure (firm). How to hold? Hold femur then lower end of tibia

To Ask ms mariam, show her tibial internal and external rotation, for that we cant use
goniometer cuz the movement is small, shall we use belt with gonio in it?
 4. External rotation (at 90 flexion = 40 – 58)
Starting position: sitting with 2 fists between thighs
Instruction: try to move your feet outwards
Goniometer:
Axis: patella
Stationary arm: pointing to the floor
Moving arm: shaft of tibia
Over-pressure: ask patient to do external rotation, then end of range, relax and I
perform over-pressure (firm). How to hold? Hold femur then lower end of tibia

Before continuing with passive range of motion, consider this:

If the ROM of the active movements are full, overpressure may be gently
applied to test the end feel of various movements at the tibiofemoral joint
(you wouldn’t need to do PROM then)
HOWEVER= examiner must do movements of patella passively

Passive Range of Motion (PROM) – physiological movement @ tibiofemoral

joint
1. Flexion:
Start position: supine. Knee and hip in anatomical position. A towel is placed in
the distal thigh (esp. for extension)
Stabilization: patient’s weight will stabilize the pelvis. Examiner must stabilize
femur
Instruction: grasp distal tibia and fibula, then bring the knee into flexion till the
end of range, usually till buttocks
End-feel: firm/soft

2. Extension:
Start position: supine. From flexion of hip and knee.
Stabilization: the pelvis is stabilized by the weight of the patient. Examiner
stabilizes femur
Instruction: from a flexed hip/knee. Examiner grasps distal tibia and fibula and
extends knee till the end of range (either normal extension or hyperextension)
or
hip and knee are already extended, stabilize the femur and start slowly extending
knee further
End-feel: firm
 3. IR: (can be in sitting or supine) – in supine, flex hip then perform
rotations
Start position: supine, flex hip slightly and bring knee to 25 degrees flexion
Stabilization: hold lower part of femur or may use a pillow
Instruction: one hand holds lower femur, the other hold distal tibia and move it
to the inside
End-feel: firm

4. ER:
Start position: supine, flex hip slightly and bring knee to 25 degrees flexion
Stabilization: hold lower part of femur or may use a pillow
Instruction: one hand holds lower femur, the other hold distal tibia and move it
to the outside
End-feel: firm

Passive range of accessory movement at the patellofemoral joint

Flex the knee slightly by putting a towel underneath it (quadriceps are most relaxed)
Using 2 fingers move the patella
For inferior glide, you may use area between thenar and hypothenar area

Distal glide [end feel = firm]

1. Superior glide
2. Inferior glide
Medial-lateral glide [end feel =firm]
3. Medial glide
4. Lateral glide
Muscle Strength Test (MST) using oxford scale
Grades:
0 – no contractions
1 – light contractions/flicker at palpation
2 – full ROM, with gravity (gravity eliminated)
3 – full ROM, against gravity (no resistance)
4 – full ROM, against gravity, slight resistance
5 – full ROM, against gravity, full resistance = normal strength

Asses muscle strength isometrically and isotonically

1. Extensors (quadriceps)
• Isotonically (oxford scale)
Position: sitting
Instruction: put resistance over middle tibia, ensure full ROM using oxford scale
starting from grade 3
If grade 2: side lying, hug the thigh and put knee in flexion, then ask patient to do
extension
• Isometrically
Position: supine
Instruction: ask patient to try to push legs into plinth (to contract quads muscle), then
relax, then they should lift their leg (mid-range). My one hand should resist the test leg
in the distal tibia then my other hand is under the test leg, touching the other leg “keep
your leg straight, don’t let me bend your knee” + compare with other leg
 2. Flexors (hamstring)
• Isotonically (oxford scale)
Position: prone, pillow under hips
Instruction: from an extended knee, ask patient to flex it, starting with grade 3, then I
add gradual resistance for grade 4 and 5. Ensure full ROM “try to put your help up
towards your butt” + compare with other leg

• Isometrically (at different ranges = asses muscle strength)

Position: prone with pillow under hip
Instruction: in 3 ranges, I need to put resistance. First range (beginning of range) I ask
patient to bend knee and I put resistance in distal tibia then 2 nd range (midrange), I put
resistance and ask her to contract again and then last range (almost end of range), I put
resistance again

Muscle length test

1. Hamstring
- Position: supine
- Instruction: I flex hip then slowly lift knee
- Patient should feel the stretch behind (ask if there is pain)

2. Whole quadriceps
- Position: prone
- Instruction: I flex knee then lift the hip (some patients, only by flexing knee
they feel the stretch)
- Patient should feel stretch anteriorly
 (For rectus femoris specifically)
- Position: prone. To position pelvis into posterior lift, the non-test leg goes down
over the side of plinth and foot is on the ground (this position ensures posterior
pelvic tilt = increase hip extension of the test leg). The test leg is in full extension
0, a towel may be under the patella to reduce pressure on it
- Instruction: bend the knee 90 degrees

“alternatively”
Ely’s test:
- Position: prone. A towel may be placed under the thigh to eliminate pressure
on the patella. Leg is extended (both legs)
- Instruction: bend the knee towards buttocks to the limit of flexion
- Positive test: when bending the knee, the hip starts raising

“alternatively”

Thomas test (mostly for ilopsoas but tests hip flexors as well such as
rectus femoris, gracillis, tensor fascia latta, pectineus, and sartorius)
- Position: supine at the end of plinth
- Instruction: lift one leg (hug it) and the other leg is down the plinth
= if leg is extended past 90 (stays up doesn’t go fully down) = tight quads
 tip: if thigh is not touching plinth, it could be iliopsoas tightness
if knee is lifted (not flexed) its rectus femoris tightness, could be both

3. Iliotibial band (ober’s test)

- Position: side lying
- Instruction: examiner is behind patient + passively abduct the leg and bring it
to extension while the other hand fixates the pelvis and slowly bring it back to
plinth
Positive test = tight iliotibial band. Upper leg stays in the air (doesn’t fall down on plinth)

4. Gastrocnemius (nwb & wb)

NWB
- Position: supine
- Instruction: move the ankle into dorsiflexion
WB
- Position: standing and leaning towards a wall. Non-test leg is in front and
bended. Test leg is behind and extended (heels stays on floor). DO NOT FLEX TEST
KNEE
- Instruction: move forwards (front/non-test leg is bending as you move
forward) to feel stretch in gastroc

5. Soleus (nwb & wb)

NWB
- Position: supine with knee flexed (put cylinder under)
- Instruction: move ankle into dorsiflexion
WB
- Position: standing and leaning towards a wall. Non-test leg is in front and
bended. Test leg is behind and flexed (heels stays on floor).
- Instruction: move forwards (front/non-test leg is bending as you move
forward) to feel stretch in soleus
Distinguish between oedema (general) and effusion (localized):

1. Brush and swipe test (to see if there is fluid)

Position: supine with fully extended leg
Instruction: begin by brushing the medial side of the knee (multiple times) then take a
“u-turn” and brush lateral side of knee (multiple times)
Positive test: you will see the fluid moving medially as you do brushing on lateral side
2. Tap test (to asses swelling)
Position: supine with fully extended leg
Instruction: one hand above patella (push downwards towards patella slightly) and
one hand below (push upwards towards patella slightly), then lastly, tap that patella and
see whether its floating

positive: if you can feel the patella is floating when you are tapping, this means fluid has
accumulated under it = indication of swelling
Special tests:
1. Patellar apprehension test
Position: supine/sitting with knee flexed to 30 degrees (may put a towel under – this is
the position where quads are most relaxed which allows movement of patella)
Instruction:
- On the medial side, using two thumbs, slowly move the patella from medial to
lateral
- Positive test: feels uncomfortable and apprehensive when patella moves laterally
+ may show fear as well + might extend knee to put patella back in position

Testing ligaments (to determine ligamentous integrity)

1. Posterior/anterior tibia on femur at 90 degrees flexion (Anterior
Drawer Test)
Purpose: to check ACL
Instruction:
- Knee is flexed
- I sit on toes
- Thumbs on tibia and hands around knee
- Pull tibia
+ compare

2. Posterior/anterior tibia on femur at 90 degrees flexion (Posterior

Drawer Test)
Purpose: to check PCL
Instruction:
- Knee is flexed
- I sit on toes
- Thumbs on tibia and hands around knee
- I push tibia (force form thumbs)
 3. Lachman’s test – posteroanterior movement of tibia on femur – in
slight kn F (almost 30 degrees)
Purpose
Position:
Instruction:

4. Valgus/ medial stress test – abduction of tibia on femur in full

extension and 20-30 knee flexion and lateral flexion
Purpose:
Position: supine with knee slightly flexed (to relax quads) – I rest the leg on my lap
Instruction:

5. Varus/lateral stress test – adduction of tibia on femur in full extension

and 20-30 knee flexion
Purpose
Position:
Instruction:

6. Apley’s
Purpose
Position:
Instruction:

7. Mcmurray
Purpose
Position:
Instruction:
 8. Thessaly
Purpose
Position:
Instruction:

What is “quadriceps lag”?

The quadriceps muscles are not strong enough to fully extend the knee.
They can’t extend the last 25 – 30
How to observe:
- Push knee on bed/lock the knee
- Ask patient to do a leg lift (lift entire thigh+ leg)
- When they lift, the knee flexes slightly
“when you left your leg, make sure to keep the knee straight”

Another way to observe:

- Put cylinder under knee (knee is flexed)

- Ask patient to extend
Another way to observe:

Or we can do it passively, by lifting the knee to extension, then asking

the patient to hold the position, however, it’ll drop
Kendall test similar to Thomas for rectus

Treatment
Exercises to improve strength
1. Knee flexors
2. Knee extensors

Ways to improve muscle length

By physiotherapist
1. Passive static stretch
2. Hold-relax
3. Reciprocal inhibition

By patient (active)
For the following muscles
1. Hamstring
2. Quadriceps
3. Gastrocnemius
4. Adductors
5. Abductors

Ways to increase ROM

Accesory mobilizations (maitland)

Anterior mobilization to improve extension
Posterior mobilization to improve flexion