1. Knee and Ankle
Mazyad Alotaibi

2. Testing The Muscles of Knee

3. Knee Extension ANATOMY:
Prim mover /agonist: Quadriceps muscle group which consists of 4 muscles
rectus femoris
vastus lateralis
vastus intermedius
vastus medialis
Synergist / Accessory Muscles:
Tensor Fascia Latae
Range of motion: 135 to 0
Substitution:
when pt in side-lying (grade 2),pt may use hip internal rotators.

4. Knee Extension Procedures: a- Position of Patient:
Effect of weakness and contracture:
effect of weakness : - difficulty in getting up & down from sitting position as well as on going up & down stairs.
- knee hyperextension.
effect of contracture : - restriction of knee flexion
shortness of the Rectus Femoris, results in a restriction of the knee flexion when the hip is extended or a restriction of the hip extension when the knee is flexed.
Procedures:
a- Position of Patient:
b- Position of Therapist : inner hand, Outer hand, Direction of Resistance
c- Test
d- Instruction to patient
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5. ROM

6. Knee Flexion ANATOMY: Prim mover /agonist:
Hamstring muscles Biceps femoris, Semitendinosus, and Semimembranosus
- Synergist / Accessory Muscles:
Gracilis, TFL, Sartorius, Poplieus, Gastrocnemius, &Plantaris.
Range of motion: O to 135
Substitution:
- hip flexors.
- Sartorius
- Gracilis

7. Knee Flexion Procedures: Effect of weakness and contracture:
effect of weakness : - weakness of both med & lat hamstring causes knee hyperextension.
-weakness of lat. Hamstring causes loss of lateral knee stability.
-weakness of med. Hamstring decrease medial knee stability.
effect of contracture: - knee flexion deformity accompanied by posterior tilting of the pelvis and flattening of the lumbar curve.
- restriction of knee extension when the hip is flexed
or restriction of the hip flexion when the knee is extended.
Procedures:
a- Position of Patient:
b- Position of Therapist : inner hand, Outer hand,
Direction of Resistance
c- Test
d- Instruction to patient
Knee Flexion
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8. Knee flexion should be measured with the subject supine
Knee flexion should be measured with the subject supine. This position allows assessment of the joint range of motion without interference from tightness in the rectus femoris muscle.  If the examiner wishes to assess length of the rectus femoris, have the patient lie prone

9. Ankle Planter Flexion ANATOMY:
Prim mover /agonist: Gastrocnemius and Soleus
Synergist / Accessory Muscles:
Tibialis posterior, plantaris, peroneus longus & brevis,
Flexor digitorum & hallucis longus.
Range of motion: 0 to 45
Substitution:
Flexor hallucis longus and flexor digitorum longus
Peroneus longus and brevis.
Tibialis posterior.

10. Ankle Planter Flexion Effect of weakness and contracture:
effect of weakness : - result in an hyperextension of the knee as well as in a non-weight bearing position as in standing.
- during walking the inability to rise on toes.
effect of contracture: result in an equnus position of the foot and flexion of the knee.
- also a restriction of the ankle dorsiflexion when the knee is extended and a restriction of the knee extension when the ankle is dorsiflexed.
Procedures:
WB test and Non WB test
a- Position of Patient:
b- Position of Therapist : inner hand, Outer hand, Direction of Resistance
c- Test
d- Instruction to patient
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13. Foot Dorsiflexion and Inversion.
ANATOMY:
Prime mover/agonist: Tibialis Anterior
Synergist/ Accessory muscles:
peroneus tertius, extensor digitorum and hallucis longus.
Range of motion: 0 – 20
Substitution:
By the extensor digitorum and extensor hallucis longus muscles results in toes extension

14. Foot Dorsiflexion and Inversion.
Effect of weakness/contracture/shortening:
effect of weakness: decrease the ability to dorsiflex the ankle joint (droop foot).
effect of contracture: in ability to plantarflex the ankle.

15. Foot Dorsiflexion and Inversion.
Procedures:
a- Position of Patient:
b- Position of Therapist : inner hand, Outer hand, Direction of Resistance
c- Test
d- Instruction to patient
Patient Position:
·        Sitting, with the patient’s heel resting on the thigh of the therapist. Patient's foot should be dorsiflexed and inverted.
Therapist and Patient Instructions:
·        Therapist is sitting on stool beside the limb being tested. The heel of the patient can be resting on the therapist’s thigh. The resistance hand should be placed around the dorsum and medial aspect of the foot. Resistance is given down and out toward eversion. The stabilizing hand is around the posterior leg just above the

16. ROM

17. Foot Inversion From Planter Flexion
ANATOMY:
Prime mover/agonist: Tibialis posterior
peroneus tertius (with Dorsiflexion), extensor digitorum
and hallucis longus.
Range of motion: 0 – 35
Substitution:
the flexors digitorum and hallucis longus muscles results in toes flexion

18. Foot Inversion From Planter Flexion
Effect of weakness/contracture/shortening:
effect of weakness: may dropping in medial arch of the foot. ( flat foot).
effect of contracture: in ability to plantarflex & evert the ankle.
Procedures:
a- Position of Patient:
b- Position of Therapist : inner hand, Outer hand, Direction of Resistance
c- Test
d- Instruction to patient

19. ROM

20. Foot Eversion From Plantar Flexion
ANATOMY:
Prime mover/agonist:
Peroneus longus and Peroneus brevis
Synergist/ Accessory muscles:
Extensor digitorum longus and Peroneus Tertius.
- Range of motion: 0- 35
- Substitution:
No substitution.

21. Synergist/ Accessory muscles: Extensor digitorum longus and Peroneus Tertius.

22. Foot Eversion fromPlantar Flexion
Effect of weakness/contracture/shortening:
effect of weakness: may results in:
- Decrease the strength of eversion of the foot & planter flexion of the ankle jt.
- Decrease lateral stability of the foot.
effect of contracture: results in an everted or valgus position of the foot.
Procedures:
a- Position of Patient:
b- Position of Therapist : inner hand, Outer hand, Direction of Resistance
c- Test
d- Instruction to patient

23. ROM

24. Test for Lower limb discrepancy
Definition:
Lower limb discrepancy is a condition of unequal long or round measurements of the lower limbs. Long measurements or Leg length discrepancy (LLD) may comes from difference in length of the femur, or tibia, or both. In some conditions, the whole side is affected, including the upper limbs. Round measurement or Leg circumference discrepancy may comes from difference in lower limbs size due to muscle atrophy or swelling.
Leg length discrepancy : Many people walk around with LLD’s of up to 2 cm. and not even know it. However, discrepancies above 2 cm. becomes more noticeable, and a slight limp is present. But even up to 3 cm. a small lift compensates very well. Beyond 3 cm. however, the limp is quite pronounced, and medical care is often sought at that point. Walking with a short leg gait is not only unsightly, but increases energy expenditure during ambulation. It could also put more stress on the long leg, and causes functional scoliosis.

25. Test for Leg Length Discrepancy
A- True leg length Discrepancy
Measure from A.S.I.S to inferior border of medial malleolus Fix point to fix point
Patient lies supine on a table with trunk, pelvis, and legs in straight alignment and legs close together. The distance from ASIS to the medial malleolus is measured on right and left.
To determine the reason of shorted leg whether in the tibia or in the femur :
Ask the patient lies in crock lying position by support his feet on the surface of table with knees and hips flexed. Make good observation on the knees level. (tibia and femur bone). If one knee project further anteriorly than the other, the femur of that extremity is longer. If one knee appears higher than the other, the tibia of that extremity is longer.

26. Gross Leg Length Discrepancy
Magee 4th Edition – pg. 628

27. B- Apparent leg length discrepancy
In apparent shortening, the limb is not altered in length, but appears shortened. This may be as a result of an adduction contracture of the hip joint, which has to be compensated for by tilting of the pelvis, or SIJ pathology causing pelvic rotation.
Non-Fix point to fix point
-Measure from tip of xiphoid process to inferior border of medial malleolus.
- Measure from the umbilicus to the medial malleolus

28. Leg Length Measurements
Eyeball method
Measurement method

29. Prone Knee Flexion Test for Tibial Shortening

30. Measurement of circumference of the knee
Swelling around the knee joint
- at middle of patella
-below the patella 5cm
-above the patella 5cm
Muscle atrophy:
Above the patella 10cm
Above the patella 15cm
Above the patella 20cm
Above the patella 25cm