okay guys so today we're going to be talking about the knee so we're entering into the knee section of the class or the lab and we'll always start every a lab section with palpations because if you can't palpate thin you really don't know how to move into the special testing component of for each joint so first what you're going to see is the skeleton because it's easier to see the anatomical structures on a skeleton and then eventually we'll make our way over to a patient so you can see what the differences are when you begin to palpate in your lab sheet i've kind of ordered your palpations into an anterior posterior medial lateral lateral segments and so hopefully that'll this will allow you to go along with the lab sheet as you're watching this this lecture so on the anterior surface of the knee um we have uh six anatomical structures that will become important for us to be able to palpate and that first anatomical structure that everyone should palpate is the patella the patella is here it's located deep um to your proteller tendon um and it's embedded within within that tendon so it kind of lives there and that patella has four different surfaces to it that should be palpated and the first surface of the patella is going to be the inferior pole of the patella you have the superior pull the patella and then if you're looking at the patella in this position here you have the lateral facet and the medial facet so again the inferior pull of the patella you have the superior pull of the patella last but not least you have the lateral and the medial pulls of the patella and it becomes important to palpate each of those poles or structures because those are important attachment sites for different ligaments tendons or other connective tissue structures okay guys and so then next on your sheet is the patellar ligament oh i see a green so next on your sheet is the patellar ligament and so as the name implies a ligament is going to be a structure that will attach a bone to a bone so the patellar ligament itself has a proximal attachment to the inferior pole of the patella hence the reason i said it's important to palpate the poles and it also has a distal attachment to the tibial tuberosity of the knee and so the tibial tuberosity is a bony prominence which is located on the anterior structure of this bone here which you all know as what you got it right it's the the tibia itself next on your sheet we have the what's called the quadriceps tendon and here's where i'd like to spend some time really talking about this structure and most of what we've called or what we know is the patellar ligament which is this structure this small structure here right but then you have the quadriceps tendon which is this long tendon so proximally it's going to have an attachment to the mid shaft of the femur and then it's going to come all the way down across the patella and have a distal attachment to the tibial tuberosity so you guys might be saying uh patellar ligament quadriceps tendon um what is that right so you have this segment of the quadriceps tendon which is the patellar ligament the entire structure is known as the quadriceps tendon oh i just realized i messed up ah i was rocking too sue's phone on silence i okay i gotta start all the way over oh that'll be good because i can see what you can see thank you hello everyone welcome to the knee lab section of the course we've just moved into the the knee unit and so it only makes sense that we start discussing the lab component to the the knee the knee is known as the tibial femoral joint which you probably have already learned in class but if we're really looking at this structure right the it's formed by the distal tibial tibia and then approximately it's formed by the distal portion of the femur so the two together make up what's called the tibial femoral joint itself in terms of palpations for the knee we're going to break that up into four different segments the first segment is going to be the anterior segment we'll talk about the posterior segment and then last but not least we'll talk about the the medial um the lateral and medial sides of of the knee joint okay on the anterior side there are six anatomical structures that really become important to make sure you're palpating at all times the first anatomical structure that's going to be important is the patella you can see that patella here the patella has really four different bony landmarks on it that we should all be palpating when we assess a patient that first anatomical landmark is going to be the superior pull of the patella the second anatomical structure or landmark on the patella is going to be the inferior pull of the patella you're going to be palpating the medial facet and then last but not least the lateral facet of of the patella and so those are those are some of the anatomical structures that you're going to be palpating when you are palpating the anterior structure of the knee next you're going to palpate what we all call the patellar tendon is actually known as a patellar ligament okay and so what do i mean by a ligament in class you've learned that a ligament is a structure right that connects bones to bone so in this instance if we're referring to the patellar ligament essentially what we're saying is it's connecting two bones right so what we know about the knee is that that patellar ligament is going to have a proximal attachment to the inferior pole of the patella and then distally it's going to come down and attach to this very anterior structure known as the tibial tuberosity right and so those two bones again distally are the tibial tuberosity and proximally it would be the inferior pull of the patella which is why it's so important you guys to make sure that you're palpating that inferior pull we're thinking about um patellar tendinitis or patellar tendinopathies a lot of the patellar tendinopathies will present with pain to the inferior pull of of the patella so we've got tibial tuberosity as we're moving down that checklist on your sheet and then the next uh large structure that we need to talk about is the quadriceps tendon the quadriceps tendon as the name implies is an extension off of the the major quadriceps group itself right so we can imagine like if you're in the gross anatomy lab you're looking at the quadriceps the quadriceps right proximally have attachments up here on the femur come down and essentially they become one tenderness-like structure and that tenderness-like structure has pretty much an attachment to that that middle portion of the femur and then we'll essentially travel distally to connect to that tibial tuberosity anteriorly right so let's go ahead and say that again quadriceps tendon will attach to the medial or most mid shaft portion of the femur and i'm sorry guys we'll have an attachment to the superior pull of the patella so please disregard what i just said quadriceps tendon by way of the quadriceps comes down becomes a tendon and has an attachment to the superior pull of the patella so then let's define what the entire structure would be so from quadriceps muscles all the way down to the distal attachment to the tibia tibial tuberosity that is referred to as the patellar tendon okay so let's redefine everything okay let's take a step back because even i uh messed up so let's say it again patellar ligament attachment site inferior pole of the patella to the tibial tuberosity anteriorly quadriceps tendon comes by way of the large quadriceps muscle group becomes a tendonis structure which will have an attachment site to the superior pull of the patella and this whole structure that we see here on the skeleton is known as the patellar tendon and that patellar tendon is going to have a distal attachment site to the tibial tuberosity so as we're learning about these structures one thing that we can really say is that there are two attachment sites that become instrumentally important in the anterior portion of the knee the first one is going to be the tibial tuberosity and the second one is going to be that inferior pull of of the patella anteriorly we also have the large quadriceps muscles which we'll look at on an actual patient and then proximally on the pelvis what we have is at that asis or that anterior superior iliac spine we have the proximal attachment of the largest muscle in the body known as the sartorius and again when we get into the actual patient setting i'll go ahead and show you what that that actually looks like posteriorly there are a few anatomical structures that become hugely important in in palpation and so we'll talk about them there are three to be specific the first anatomical structure that you should palpate is in the posterior aspect of the knee so if we're looking at this let's go ahead and orient ourselves right this is the posterior aspect of the knee and this part right here so this articulation posteriorly between the distal femur and the proximal tibia this structure right here if i were to put my hand over it is known as the popliteal fossa right and that popliteal fossa is important because it houses guess what the popliteal artery and so a lot of times with knee dust locations for example that popliteal artery will get impinged and it could lead to the loss of of a limb or the knee in particular so we want to make sure that we're palpating that pulse in the popliteal fossa now of course in the popliteal fossa lie other structures that will cross the knee for example the hamstring muscles cross the knee right the popliteus muscle is going to live there and the plantaris muscle is also going to live within that popliteal fossa so it's an important anatomical site to make sure we're palpating posteriorly if we're looking at the femur as a whole right guys then what we know is that the hamstrings come up and they have an attachment right to the pelvis and they travel distally to control knee motions which we'll talk about a little bit later and then distally what we have are the gastroc heads right arising off of the tibia and the fibula having a proximal attachment to the posterior aspect of of the tibia okay guys so we have the anterior palpations we have the posterior palpations let's go ahead and move to the medial side of of the knee we're going to go back to this bony structure so on the medial side of of the knee we got to talk about joint lines so if i were to extend this cadaver's knee or this skeleton's knee a joint line is the segment between or the spacing between the two bones that are coming together so let's let's take a look at what that means if the knee joint is made up of the tibia distally and the femur proximally where those two bones come together there's a space right there's a little bit of a space or a little bit of a gap where the two bones are going to articulate right we call this the joint line now what we know about the joint line is that we have a medial side joint line and then we have a lateral side joint line right in the within those joint lines what we know is that the menisci right so if i were to move away the patellar tendon what we know about the joint line and you can see it here on this image is that those meniscus are going to live on each side within that joint line yeah so that joint line palpation both medially and laterally become instrumentally important you guys it becomes important to figure out whether or not that patient has a meniscal injury right so we have to make sure if we're on the lateral side if we're on the medial side that we're palpating the joint line to rule out a meniscal injury next we have our collateral ligaments on the the medial side of the limb we're going to call that either the medial collateral ligament or the tibial collateral ligament and then on the lateral side we're going to call that either the lateral collateral ligament or the fibular collateral ligament and you all might be saying well dr cosby why are you refer referring to it as two different names what we know is that as anatomy textbooks are changing the new name the true name is known as the tibial collateral ligament and the fibular collateral ligament but i'm old school the way i learned it was mcl and lcl so as you're reading interpret with with caution okay how do we know where those uh collateral ligaments lie what we know about the collateral ligaments is that each of them either laterally attached to the epicondyle if i'm the lateral right if i'm the lateral collateral ligament i'm going to have a proximal attachment to that lateral epicondyle i'm going to have um a distal attachment to the fibular head okay so you've got proximal attachment here to the lateral epicondyle i'm gonna have a distal attachment to that fibular head if i am the medial collateral ligament per se i'm gonna have a proximal attachment to the medial epicondyle and then as you can see here a distal attachment to what we know as the tibial flare okay and then last but but not least on the lateral side one of the things that we have to consider palpating uh is is way distal so it's downward right so one of the things that we have to consider palpating is what is known as gertie's tubercle okay so if we look at the tibia gurney's tubercle is right here okay and it is the distal attachment site to the it band or the iliotibial band okay guys so we've just covered all of the palpations for the knee right and i'm making it seem like it's an easy task like it's something that's easy to do but it's really not so let us go ahead and conclude the palpation segment on the skeleton and move to looking at palpations on an actual patient thank you for your time so it was easy right to kind of look at the skeleton and say oh yes i can do that but now let's really truly focus on what the anatomy is going to look like when we have a patient sitting in front of us and so we're going to break this down the same way we did with the skeleton palpations which would be anterior medial lateral and then we'll flip our patient over and look at the posterior structures just to give you a little bit of orientation however what we are doing right now is we are looking at the patient's lateral side of the knee okay so just to orient you guys a little bit more this big bony prominence that we're looking at on the lateral side of this patient's knee is the fibular head okay so now that we have at least the landscape of our patient's knee let's go ahead and take a look at different anatomical structures that exist since we're looking at the lateral side on the lateral side of the knee so this structure right here that's popping out at you is known as the lateral facet of of the patella and this is a really good patient to palpate on because you can actually see her lateral facet of the patella okay our next palpation since we're on the lateral side of the patient is going to be a gerdy's tubercle and i really want you guys to kind of take a look at this this is gertie's tubercle it's this bony anatomical landmark right here and as you guys will recall remember what i said it is the distal attachment site for which anatomical structure great if you said it ban then you are tracking right along with me if not please review the bony palpations on the skeleton but it is the distal attachment site to the iliotibial band track okay now what else might we see on the lateral side of our patient well we can see the patient's vastus lateralis so patient go ahead and contract for me a little bit right so now what you'll see is the patient's vastus lateralis right which is the most lateral structure of the quadriceps muscle group okay now if i were to continue distally onto this patient one of the things that you might see is her tibial tuberosity it's an anterior structure right so this tibial tuberosity which is palpated anteriorly remember it distally receives the patellar tendon and the patellar ligament so two anatomical structures right all right i'm going to lay this patient's knee down on the table and so as the patient it goes into a knee extended position that vastus lateralis becomes even more apparent but what you're also seeing on this patient is the it band so you can see the it band tendon and you can see how it's coursing along its way to attach to that gertie's tubercle on the lateral aspect of the knee now in terms of palpation it becomes extremely important you guys to do a couple of things every palpation that technique that we use we should be using what we know as a flat-handed sweep right so essentially what we want to do is see that flat-handed sweep go across the patient using that flat-handed technique or sweep will also allow us to fill the different crevices the different changes and the shapes in the anatomical structure so let's go ahead and do that so if i want to palpate my patient's fibular head i'm going to flat hand sweep the lateral side of her tibia and so as i flat hand sweep what that allows me to do is really truly feel her fibular head which is located here right now on the lateral side we also talked about the joint line space and so the best way to palpate that is actually to move the patient from an extended position to a flex position so the patient's gonna go into a flex position here and as we get into that flex position that joint line space will be in between the femur proximally and the tibia dissilly right and as you can tell my palpation technique is going to change right so i'm going to be here in the joint line trying to figure out if there's pain on on that particular patient right all right so just for a recap on the lateral side what we've talked about is the vastus lateralis we've talked about the iliotibial band which has that distal attachment to gertie's tubercle right we are now going to talk about um the fibular collateral ligament or what we would call is the lateral collateral ligament so if we palpate the fibular head we know that that's the distal attachment site for the fibular collateral ligament and then we have to sweep up and find the epicondyle of the femur to know that it's its proximal attachment so proximal attachment would be lateral epicondyle distal attachment would be the fibular head so we could imagine that that lcl is going to span from here to here and its major role in the knee as you guys will know in lecture or learned in lecture is to prevent a varus force so if i pick up the patient's knee here and i'm trying my hardest to push it outwardly it's supposed to prevent my leg from moving in a lateral or what we call is a varus direction okay so those are the lateral structures of the knee anteriorly what we have um on the knee are the quadriceps so right we're thinking quad we're thinking that there has to be four muscles in that particular group those four muscles are the rectus femoris the vastus lateralis the vastus medialis and then very deep to those i think you guys covered that in gross anatomy is the vastus intermedius right so most centrally located is the rectus femoris it is a major hip flexor but also knee extender laterally we've already talked about the vastus lateralis and then most immediately what you can see right so think medially this is the opposite leg go ahead and contract for me patient is the vastus medialis most of you probably know this as like the soccer muscle or something like that right soccer soccer athletes tend to use this a lot because they kick the ball and so that allows for them to have a stronger kick um or kicking motion or more forceful kick for lack of of better words okay so anteriorly we're going to have those quadriceps muscles and then if i were to have my patient lay down so patient go ahead and lay down the next thing that we're going to do is kind of move up to the hip a little tiny bit so that you guys can see just how long that sartorius is okay let me orient you guys just a little tiny bit this is now my patient's medial side of the knee okay so we're on the medial side of this patient's knee and currently if i were to do a flat handed sweep this would be the tibial flare okay now what we know about the tibial flare is a few things it has a distal attachment site for the medial collateral ligament or the tibial collateral ligament and so if we were to trace that i'm going to flex this patient's knee just a tad bit if we were to trace that we would say its proximal attachment is the medial epicondyle and so this is where your medial collateral will run it is the length of the medial collateral ligament so from here which would be the medial epicondyle to the tibial flare this is the span of your medial collateral ligament and just as a fun fact the medial collateral ligament is almost four times stronger four times wider than its lateral collateral counterpart and that's because what we know about the knee is that the majority of forces about the knee joint are going to be what are called valgus forces in other words blows are most often happening to the outside of the knee and forcing the knee inward right so it makes sense that this medial ligament is going to be larger longer and stronger because there are more forces that are going to be placed on it as a as a whole okay now if we move upwardly or proximally to the hip i think it's important to really look at the length of this artoria so its distal attachment is to the fibula or the the tibial flare and then its proximal attachment is way up here on the pelvis okay guys so just imagine proximal attachment to the anterior superior iliac spine distal attachment to the uh tibial flare it is the longest muscle in the body just uh fun fun thoughts there so let's do that again anterior superior iliac spine uh proximally and then distally we've got the the tibial flare so it's a long long long muscle okay so let's review medial structures just really quick so on the medial side we have the tibial flare and it's really cool when you do a flat handed sweep you'll feel it flare out which is why it gets its name the flare so we've got the the tibial flare here right we've got if we continue to sweep up we're going to be in that medial joint line so remember that joint line is just dead space right it's the space where the femur right and the tibia are coming together to articulate right and so then that's just dead space so here right here what we have is the medial joint line makes sense guys if i continue proximally the widest portion of the femur is known as the condyle and then if i continue more posteriorly the little knobby guy that you'll feel right here is the epicondyle right and all of these bony anatomical structures are important because they serve as attachment sites for our muscles our tendons and the ligaments of of the knee okay we're going to do now is have our patient turn over so that we can look at the posterior structures of of the knee in a better view so as the patient turns over right you guys might have noticed what i did with my technique one of the things that i like to do is if i can keep a patient in a certain position and palpate every structure i'll do that so palpate anterior structures palpate medial and lateral structures and then have my patient flip over it creates this kind of confidence about our patients that we know what we're doing right the worst thing that you want is a clinician who keeps making their patient turn over i'm sure you've all been injured maybe once or twice in your life and probably have had either an athletic trainer or a physical therapist who did that to you it's the most uncomfortable thing especially when you're injured so one key thing about being a good clinician try to do everything in one position before moving them to another position so on the posterior aspect of the knee we have the anatomical structure that i refer to as the popliteal fossa and the popliteal fossa is right here you guys okay so i'll flatten the knee out so you can see that it's right here right so i'm pointing to both popliteal fossas for perspective this is your patient's right leg and this is your patient's left leg okay so this is the popliteal fossa and as i mentioned in the skeleton part of this the popliteal fossa houses the popliteal artery which gets impinged when a patient has a tibial femoral knee dislocation and can lead to amputation if we don't get that knee relocated quickly in addition what we also have in the popliteal fossa are the heads of the gastroc muscles right and in gross anatomy you guys i know you've dissected both the gastroc heads and the soleus so much so that you have an appreciation for their relationship to not only the foot or the ankle but then also to the knee joint itself so what we know about the gastrocs is that proximally they come up and they have a posterior attachment to the posterior condyles which is why we put them in the knee palpation section because you cannot palpate the knee posteriorly without palpating the heads of the gastrocs in fact if you do not do that then you may miss a what we call a proximal gastrocnemius strain right and that's the worst i've done it clinically patient was out for eight weeks and if i would have just taken time to palpate those heads then they wouldn't have been out for so long because i wouldn't have been treating a hamstring strain that was really a gastrocnemia strain so make sure that proximally you're palpating those posterior condyles now the best way to do that is actually not in an extended position it's actually in a flex position so what i'm going to do is bring the patient's foot up a little bit here and so then what you'll be able to see is that now those condyles become exposed right i'm going to do the other knee just so you can get a better view but i'm going to be here and what you'll see is is that i can now get in there and get a really good palpation of those gastroc heads so note to self clinical tool to put in your toolbox make sure that you flex the knee when you're palpating the head of the heads of the gastrocs the last posterior structures that we're going to talk about are the hamstring muscles unlike the quads on the anterior side of the thigh they only have three muscles to them and those three muscles are the biceps femoris which is a lateral ligament to structure so patient come on up a little bit for me come on up a little bit more you'll see that biceps femoris tendon pop out at you again orient yourself this is the lateral malleolus this is the fibular head right and so then this is the lateral side so the lateral posterior hamstring muscle is going to be the biceps femoris we know that distally it has an attachment to that fibular head right so that is two anatomical structures that attach distally to that fibular head the first one is going to be that lateral collateral ligament right and the second structure that attaches to the fibular head distally is going to be the biceps femoris muscle on the medial side we have two hamstring muscles that have an attachment to either the tibial flare medially okay and and those muscles are the semi muscles so patient go ahead and flex up for me a little bit more you'll see that tendon pop out at me right here right so these are the muscles of the tendons of the semitendinosus and the semimembranosus which is a deeper muscle that semitendinosus tendon is going to come down and have a distal attachment to the tibial flare which is located more medially in in nature okay so this is going to conclude our patient palpation section will now progress into the range of motion section of the lab so now we're going to discuss the ranges of motion and also perform manual muscle testing for our patients but just as a quick like i mean i'm talking quick review right now just remember goniometer has two arms you have the movement arm and then you have the stationary arm which is the one with the big big bulb on it okay so there are two ranges of motion that you we assess at the knee there are others that certainly could be assessed but the two ranges of motion that give us a good grasp on if a patient is injured or not or how much range of motion they actually have about the tibial femoral joint it's going to be knee flexion and and knee extension and you are going to see this done many different ways there are two ways that it most often is done it can be done in a prone position like our patient currently is in or it certainly could be done in a supine position or with the patient lying on their back but in order to really make sure that you can see all of the components that go into assessing knee flexion range of motion the patient is in a prone position for this particular lab video that said in our lab class we will do it both ways and you'll be just allowed to decide which way works best for for you so with with the goniometer the stationary arm of the goniometer or the uh fixed arm is going to go um is going to align with the center of the greater trochanter so we're going to have to find that on our patient right we have to do a massive lateral sweep until we come to the greater trochanter and essentially just like we did with the ankle joint what we want to do with that stationary arm is we want to bisect that greater trochanter the uh most central portion of the goniometer which is here this little knob right here is going to go over the lateral epicondyle so see that there and then the movement arm is going to bisect the the fibular head if that makes sense and a good reference point would be that if it's bisecting that lateral malleolus then you know you are in good shape so let me go ahead and i'm going to start by flexing the patient's leg just a little bit what this does is it allows me to find their lateral epicondyle so once i have their lateral epicondyle remember i said the metal part of this is actually going to go on that epicondyle and then want to make sure that the fixed arm is bisecting that greater trochanter and you can see my kind of hand technique what i use is like a 7 and what i want to do is make sure that my thumb and my index finger are bisecting that greater trochanter here and then distally or when we move down want to make sure two things are happening happening this movement arm is bisecting the fibular head but that it's also bisecting that that lateral fibula okay and as that patient moves into a flexed position what i'm going to do is make sure that this movement arm is moving with that lateral malleolus so what i'm going to have my patient do is i'm going to focus on holding here and i'm going to have my patient go ahead and flex their knee and you'll see like my goniometer is still in the same position that's okay once she gets into her end range of motion suez is that all you got what i'm going to do is then move my movement arm so that it's bisecting okay the lateral malleolus right and so if my patient is at their fullest range actively does that make sense active range of motion what we're saying guys here is what's happening the patient is doing the movement not me the clinician okay so once she's at her full capacity make sure i have everything aligned the way i want to i'm going to take that off of my patient and then the next thing that i'm going to do is look at just how much range of motion my patient actually has so if we're looking at this we can see that this patient has approximately 100 degrees of knee flexion which when we're thinking about normative values right one of the things that we have to ask ourselves is what's a normative value for knee flexion so most often reported in the literature the normative ranges of motion for for the knee are 130 to 150 degrees of knee flexion so i'll ask the question back to you if our patient has 100 degrees of knee flexion does she have full range of motion the answer would be no right so that could be a tell-tale sign that the patient has maybe a meniscal injury maybe a loose body in in this particular patient's case she's actually had a tibial tuberosity transectomy and had some things removed or shifted so this is a telltale sign that there's something wrong within the knee the question is what is it exactly okay so again just as a recap for knee flexion the central portion of the goniometer right here is going to go on that lateral epicondyle okay the fixed arm this guy right here the one with the bulb on it is going to transect the greater trochanter of of the femur right so it's going to it's going to transect that greater trochanter of the femur and then the movement arm is going to move with the actual fibula of the limb right so it's going to move with the fibula right so right here it's going to move with the fibula and if we wanted a really good way to kind of gauge that i always align it with my lateral malleolus normative ranges of motion are going to be between 130 and 150 depending on which book you consult okay now if we move into extension extension gets a little bit tricky right because normative extension is just zero degrees can our patients get to zero if the answer is yes we're happy about that right if the answer is no they can't get to zero degrees then we're concerned what's preventing the knee from moving into a knee extended position in order to assess just how much knee extension range of motion a patient has patients should actually be in a prone position here but the one thing that we're going to do is we're going to actually have our patient slide off the edge of the table so she's going to continue to slide in such a way that now if we're looking at her knee joint what we will see is that knee joint is hanging off the edge of the table do you guys see that this will allow the knee to move into more extension right we also want to know you guys if the patient has what's called genurique or bottom right you've ever seen those people who stand and their knees pop all the way back we want to assess that too because what we know about those patients is guess what they're at a higher risk for acl injuries they're at a higher risk for straining their hamstring muscles so we also want to know if they have more range of motion not just less at the knee so the same places apply for the goniometer i'm still going to put my fixed point right over that lateral epicondyle i'm still going to put my movement arm right on the lateral fibula and bisect that lateral malleolus and my fixed point is going to be the greater choke cancer of the femur so same position okay so let's go ahead and do that i'm going to find that epicondyle of the femur my movement arm as you can see here is transecting right that lateral malleolus here and then last but not least making sure my proximal arm is transacting that greater chocanter okay so now that i'm here the only thing that i want to do is number one make sure that i'm at zero go ahead and try to extend your knee a little bit more and so then i'm going to align this right to make sure that i'm aligned and if we look at our patient's results right so if we're looking at those what we will see is that this particular patient has about nine degrees of extension so she probably suffers a little bit from what we call is genuine recurve bottom or the the knees poking backwards okay guys so that's going to end our goniometry session for today but just in recap for knee extension remember in terms of of movement spaces okay we want to make sure that the fixed arm right it's on the epicon lateral epicondyle and is transecting the greater trochanter and that that movement arm is bisecting the fibular head and the lateral malleolus normative ranges of motion for knee flexion are between 130 and 150 and the ideal for for knee extension would truly just be that the patient is able to get to zero but if they get past that we want to know that too that'll help us determine do we need to strengthen our hamstring muscles do we need to work on quadriceps what do we need to do to make sure that our patients aren't at a higher risk for for injury okay we're going to be moving into special testing next all right so now we're moving into the manual muscle testing segment of this online lecture one thing that i want to hit home on here is that palpations and range of motion must go first when you are doing anything with the patient manual muscle testing is not the first thing that we want to go to in an evaluation so now that i made that clear let's talk about the role of manual muscle testing what it tells us in a clinical evaluation if i'm going to manually muscle test a specific muscle or muscle group i am trying to figure out if that muscle group is compromised right can it hold or withstand the pressure i'm applying to it and if it can't what's the causative factor is it a strain is it swelling is it a spasm right so doing manual muscle testing will also give us an insight into what the patient's pathology is but in order to do manual muscle testing one of the things that you really have to make sure of is that you know which muscle you're testing and in order to do that you have to understand anatomy right guys so this is why we start the program with gross anatomy because if you don't have an understanding of anatomy then you won't understand what you're testing when you do manual muscle testing so for the knee joint there are four muscles that we're going to test and we're going to test the hamstrings but we're going to divide those into two muscle groups we're going to test the quads overall and then last but not least we are going to test this our the sartorius muscle okay we're going to begin with the biceps femoris muscle which is a muscle in the hamstring group which side of the limb is it on is it on the lateral side or is it on the medial side okay great i'm assuming you all said dr cosby it is on the lateral side of the knee and if you said that you are right okay what we know about the hamstring muscle group okay what we know about the hamstring muscle group is two things number one it is a knee flexor when we actively concentrically contract it is a knee flexor we would all agree there but what's different between the biceps femoris and the semitendinosus and membranosis muscles is that the biceps femoris also causes tibial external rotation so not only is it a knee flexor right it also if we're looking at the tibia will cause tibial external rotation okay so when we manually muscle test the biceps fem we have to do two things we have to make sure that we have a hand on the calcaneus we have a hand on the muscle belly of the hamstrings that our patient is not only going to we're not only going to resist flexion but we're going to turn that foot into external rotation and we're going to be resisting external rotation and knee flexion moment so let's go ahead and try that hand mid belly hamstring muscle group hand kind of posterior lateral right i'm going to externally rotate the tibia and my instruction to my patient is going to be bring your calcaneus to your butt ready go ahead and do that and you can see here that a little bit of pressure is applied on the top hand not much more for stability and pressure is being applied distally to that calcaneus so are you ready let's go ahead and push against me push push keep going keep going now i could certainly do this you guys you ready i could lean into that right but you would cause a muscle strain the goal of manual muscle testing is to allow the limb to engage and to move through the range of motion while slowly providing a force so let's try that again ready hand here and the mid belly just just laying there to provide support hand posterior lateral knee or foot to your butt sue's go keep going keep going keep going keep going keep going keep going keep going i'm gonna let her keep going go go go go go and hold now it's in this hold that we want to apply a counter for so we want to try to push that foot down towards the ground go ahead and hold that suze and we're going to hold for five seconds and five and four and three and two and one so what we can see with this patient is number one the inability to hold the the limb into flexion which tells me either she has some sort of muscular weakness right or she may just have a strain we don't know until we start diving deeper into our palpations right and into our special testing so for biceps femoris as a review hand goes here proximally hand goes uh lateral and external rotation and go ahead and pull up pull push don't let me pull you down right and if for example we were to get a positive are you ready for this ready come on up zeus don't let me push you down but give me a positive break test we would just fall back onto the patient right makes sense guys now of course with manual muscle testing we're going to do everything bilaterally right so we're going to test the good limb first and then we'll move to the bad limb to get a side by side comparison so if i were doing this right i would also test my patient's other limb right foot into external rotation hand here and here come on up right don't let me push you down so we can see that the weakness exists bilaterally right and so in this case what we would say to our patient is let's go and put you on a hamstring strengthening program and this would be huge for our female basketball players for our female soccer players who we know are at a higher risk for the development of acl springs right the ability to identify a weakness that exists and change that weakness into a strength reduces the number of acl injuries that you'll see in a season particularly in those two female sports okay so that was testing for the biceps femoris so the lateral hamstring muscle but what if we want to test the semitendinosus and membranosis right well the biceps femoris was an external tibial rotator and knee flexor and your semitendinosus and membranosis believe it or not are internal rotators of the tibia but also knee flexors right so we're going to do in this case is internally rotate the tibia so bring that foot in and hand goes there so it's going to go posterior medial same hand positioning for the proximal hand the difference is that foot is now pointed inward does that make sense my instructions are going to be the same patient can you please bring your foot to your butt while keeping that foot turned in and hold do not let me push you down now this is a real live video if you are seeing what i am feeling you would know that her semitendinosus and membranosis muscles are extremely stronger when i compare it to her biceps femoris manual muscle test okay guys so let's try that again ready hand here proximally internally rotate that foot hand medial right and posterior come on up shoes pull pull pull pull don't let me push you down right remember with the biceps fib it was uh uh she was struggling to keep that foot up right and so what we can say about this this is a true live patient she has a weakness of her biceps femoris she's extremely strong with her semitendinosus so this is going to tell me that not only do i need to train knee flexion but what direction does it drive the foot into external rotation right so some of the exercises that i'm going to do are going to be external rotation exercises to make sure that we're strengthening the external rotators of the tibia so i hope you got that that was that wasn't planned but extremely exciting when it comes to life now what we're going to do since we've tested the posterior muscles with the patient in a prone position we now have to flip our patient over and the reason we do that is because we have to test the quadriceps and we have to test the sartorius so our patient's going to go ahead and flip over and in an ideal world the patient would be seated with her legs off the edge of the table so come on to the edge of the table a little bit there and so now we're testing the quadriceps okay guys what we know about the quadriceps muscles is that they are knee extensors we know this without a doubt so if we want to test the quadriceps muscles at the knee believe it or not the quads do stuff at the hip but today we're talking knee the patient is going to be seated off the edge of the table now if i'm looking at my patient's torso okay which becomes important we want to do a few things patience when we test quadriceps and my patient is doing it now will grip the table do you see it and that's a cheat we don't want that because then it's an assessment of their upper body strength and not their quadriceps so what i'll have my patients do is cross their hands over their chest to make sure the only thing active during this testing are their quadriceps muscles so that's number one so let's go back down to the knee where we're now going to talk about hand placement okay and so in terms of hand placement let's say i'm testing this patient's quadriceps muscles okay um if i'm testing this patient's quadriceps muscles one thing that we want to do is one hand goes on the center portion of the muscle does that make sense guys and then the other hand we're gonna take that and we're gonna put it at the ankle joint right so we're gonna put it right on top of the ankle joint right here do you guys see that so we've got one hand on the mid belly of the of the quadriceps we have our other hand right over the table curl joint right and i want to be in a position that's to the side of the quadriceps what i learned very early on as a clinician you guys is that um with strong lineman 300 350 pound lineman standing directly in front of the leg is probably not a good idea i actually suffered from a nasal fracture when i was doing quadriceps manual muscle testing on alignment so note to self don't do that okay you want to be on the side all right so we're here right and we're here and now my instruction to my patient is go ahead and kick your leg all the way out uh and and believe it or not quads are stronger than hamstrings so they're going she's going to be more forceful so you ready go ahead and push against me push push push right and can you guys see that how stronger she was with her hamstrings than she was with her quads how stronger she was with her quads than she was with their hamstrings okay so in this position i'm gonna say hold do not let me push you down hold hold hold hold hold right a positive however would be uh go down to resting position patient go ahead and push against me and let me break you right that would be a positive test right the question then becomes is it a strain is it a spasm what is it exactly but in this position i wanted to take a moment to show you something really interesting and unique go ahead and push against me um you can really see that patient's vlog you can see the it band here it's like this is like one of the best patients that i could have ever have had come and do this video you're getting you're seeing a really good anatomical specimen right look at that vlo you can see the break off in the separation into the the iliotibial band and then believe it or not this is your biceps femoris muscle so really good opportunity to see real live anatomical structures on a patient okay the last muscle in our manual muscle testing segment is going to be uh the sartorius okay and so the sartorius for this particular segment what we're going to have our patients do is our patient is going to lie down on their back in a supine position and here's why what we know about the sartorius you guys is the sartorius is a long two-joint muscle okay remember i said it attaches proximally way up here on the pelvis to the asis and then distally it has an attachment to the fibular flare right so that means it's going to have motion or actions at the hip joint it's going to have actions at the knee joint and there's just a lot of them okay so here's how i remember how to test the sartorius the way i tell my patient to do it is to trace their shin with their foot and if they trace the shin with their foot they will do every single action of the sartorius the sartorius is a tibial internal rotator it is a knee flexor it is a hip a b ductor and flexor and it is a hip external rotator so we get all of those motions you ready internal rotation of the tibia knee flexion abduction hip flexion external rotation in one segment if they trace their shin so it is the easiest way to figure out how to manually muscle test now you all might be saying well how am i going to put my hands where am i going to place them let me show you the trick so hand placement is important when assessing this artorias your first hand placement is going to be i'm going to show you on this leg first is going to be here so it's going to be anterior lateral right there right your second position distally at the ankle is going to be a little bit different so let me show you that placement you're going to have a hand placement anterior lateral then what you're going to do to encourage knee flexion and internal rotation is kind of cut the achilles tendon on the medial side see that medial side of the limb so it looks like i'm here so now if i get ready to tell my patient to trace the shin patient trace the shin a couple things are happening stop patient i'm resisting knee flexion with my hand here i'm resisting internal rotation with my hand here i'm resisting hip flexion because i'm on top and abduction because i'm on the outside and i'll do it on both legs so you can see positioning so let's do it first here ready patient come on up there there it is keep going keep going keep going and now how do we do the resistance or counteractive test do ready patient hold do not let me pull you down i'm gonna push her and pull her in the opposite directions does that make sense and now you're seeing her adductors pop out at you okay now i'll show you on this side of the patient just so that you can see and note this is a sample video so that you can see things so my body position for this one won't be how it should be in the clinical setting but i want you to be able to see what it would look like so i'm going to be resisting hip flexion here abduction there does that make sense i'm going to be resisting knee flexion here and internal rotation here again do as i said on the other side not as i'm doing right now because i want to make sure that you're just seeing hand placement okay so it's patient go ahead and come on up now you can see lateral hand placement so i'm resisting hip abduction here i'm re resisting hip flexion here and knee flexion there can you guys see that better on that side now it doesn't look as great because this isn't how i would be living life in the clinic certainly would be more here and here because what this does is it gives me a good ergonomic position right everything we do as clinicians you guys want to make sure that our back our abs our arms our shoulders our hands are always protected so we always want to put our patients and our bodies in a position of protection right i want to be around long in the field of athletic training so that's going to be manual muscle testing of the five or six different muscles for the knee joint pretty simplistic when we get to the hip it gets a little bit more complex now we're going to enter into the special testing segment which is probably my most favorite part of of knee pathologies you