Hip & Knee Extremity Notes

By: Glenn Sorgenfrey, D.C.

Modified by: Pamela S. Gindl, D.C., D.C.C.P.

Lower Extremities Evaluation

Research

Greenman, D.O. stated in 1989 that

restriction of a major joint(s) in lower
extremity d energy used for walking

1 joint = by 40%
2 joints in same extremity =

by 300%

Research

Foot over pronation (if untreated)

leads to:

Tibia & Femur rotation knee

complaints & pelvic unleveling
center of gravity shifts lateral lumbar
curve forms myofascial pain
lumbar disc degeneration

Lower extremity subluxations

A leg length inequality is not always a

function of an anatomically short leg
or a pelvic misalignment.

Hip - Evaluation - Overview

Case History
Visualization
ROM
Palpation
Static
Motion
Orthopedic tests
X-ray

Hip - Evaluation

Case History

Trauma
Repetitive Use

Hip Evaluation

Hip
ROM

Hip Range of Motion

Flexion 120
Extension 30
Abduction 45
Adduction 30
Internal Rotation 40
External Rotation 45

Flexion: 120

Extension: 30

Abduction: 45

Abduction: 45

Adduction: 30

Internal Rotation: 40

External Rotation: 45

Inguinal Ligament

Anterior Iliofemoral
Ligament

Pubofemoral Ligament

Bursa
Pectineus m.

Adductor Brevis m.

Gluteus Medius

Gluteus Maximus

Orthopedic Tests

Fabere-Patrick Test
Hibbs Test
Thomas Test
Trendelenburg Test

Fabere-Patrick Test

Acronym for these hip motions

Flexion
Abduction
External Rotation
Extension

3 Parts to the test

Fabere-Patrick Test 3 Parts

1st Flex hip to 90 & press femur into
acetabulum
This motion is also considered to be fluid
motion of the hip joint.

Fabere-Patrick Test 3 Parts

2nd Cross leg into Figure 4 position (abduction &
external rotation)
Allow patients leg a chance to relax the muscles to
stress the joint.

Fabere-Patrick Test 3 Parts

3rd Stabilize opposite hip then press leg
down toward bench (extension)

Fabere-Patrick Test

+ = Pain or inability to perform test

Indication = Hip joint pathology (many
possibilities)

Arthritis
Sprain/strain
Fracture
Tight hip adductors
Legg-Calve-Perthes Dz
Etc

Hibbs Test

Test is usually
done to
determine hip
joint pathology

Internal
Rotation

Hibbs Test

BUT Can take hip

through

Abduction
Extension
External Rotation
As well as Internal
Rotation

Hibbs Test

+ = Pain or inability to perform test

Indication = Hip joint pathology (many
possibilities)

Arthritis
Sprain/strain
Fracture
Tight hip adductors
Etc

Thomas Test

Done Passively

Patient holding their own leg

OR
Doctor using thigh to induce hip flexion

Thomas Test

+ = Opposite hip flexes

This flattens lumbar spine, the tight hip flexor

is revealed by the opposite hip flexing

Indicates = Hip flexor contracture, such as

iliopsoas

Thomas Test
Patient with this problem will visually present:
If chronic

Flat rear-end
lumbar lordosis
Subluxations BP, PI

If acute

lumbar lordosis

Thomas Test
Patients gait will present:
One leg will stride long

This is the side of the tight muscles

Already greater flexion to moving leg forward
is no problem

Other will stride short

As the leg on this side goes into flexion as

striding forward the opposite hip (with tight
flexors) will not allow this leg to move
forward as far.

Trendelenburg Test

Dr hold patients
crests of ilium ready
to support the patient
if they start to fall
from performing
maneuver.
Patient raises leg

Trendelenburg Test

+ = ilium drops forward and down on lifted leg

side
Indicates = hip abductor muscle (gluteus medius)
weakness possibly due to:

Polio (age group ~ mid 40s)

Legg-Calve-Perthes Dz
MD, MS
Hip Dislocation
Gluteal m. paralysis
Subluxation

Differential Diagnoses

Osteoarthritis
Bursitis/Hip Pointer
Snapping Hip Syndrome
Piriformis Syndrome
Retroverted Hip
Introverted Hip

Bursitis

Trochanteric Bursitis inflammation of 1 of

the bursa b: gluteus maximus & minimus &
the greater trochanter.
Tx:

Rest, avoid activity that aggravates

Adjust
Soft tissue work
PT, etc

Internal Hip
Bursa
Obturator Externus

Hip Pointer

Contusion to iliac crest or ASIS

Sometimes including an avulsion or tendonitis

From trauma from sports or MVAs

Tx:

Adjust whats needed (if side posture keep this

side up)
Soft Tissue work, passive ROMs, etc
Protective padding

Snapping Hip Syndrome

Click or snap in the hip upon active hip

motion. Common benign & painless
Lateral/external most common

ITB catches on greater trochanter

Anterior/internal common

Iliopsoas catches on iliopectineal eminence

on femoral head, or from iliofemoral
ligament catching on femoral head

Snapping Hip Syndrome

Posterior - rare

Biceps femoris tendon catching on lateral

ischial tuberosity

Intra-articular labral tear, loose body,

subluxation, dislocation, etc..

Piriformis Syndrome

Definition: Sciatic neuritis due to spasm of

the piriformis m. leading to mechanical
and/or chemical irritation that results in
pain/paresthesia in the distribution of the
sciatic n.

Piriformis Syndrome

Etiology:

Sudden myotactic reflex

Tight external rotators
L5-S1 neurological insult (VS?)
Overuse and/or biomechanical fault (over
pronation)
Fatigue or strain of piriformis m.
Leg length assymmetry

Piriformis Syndrome

Visual Findings:

Foot flare, especially on involved side

Over pronation
Change in gait

Piriformis Syndrome

Palpation:

Tender piriformis in gluteal region

Possible low back pain and tenderness

ROM:

AROM & PROM internal rotation w/pain

Active & passive abduction
Tight hamstrings or atrophy

Piriformis Syndrome

Motion:

internal rotation at the hip

external rotation at the hip

Weak:

Hip rotators
Abductors
Hamstrings & gluteals

Piriformis Syndrome

Treatment

PRICE
Adjust spine & pelvis as needed
Stretch into internal rotation & adduction
US/ice
Correct leg length deficiency/pronation
Home exercises low back

Osteoarthritis

Common in hip
Some chiropractors say if you keep L3 and
the lumbars subluxation free you wont
develop hip arthridities
Watch how patient walks

In Children

Calve`/Perthes` Disease-osteochondritis of
the femoral head
Slipped Capital Epiphysis
Hip Dysplasia
http://www.hawaii.edu/medicine/pediatrics
/pedtext/pedtext.html

In Kids Legg-Calve-Perthes
Disease

Avascular necrosis of the femoral head

In Children - Hip Dysplasia

In Kids - Slipped Capital Epiphysis

Hip Examination

Usually an aching pain patient grasping hip

Fluid motion done with hip telescoping and
Fabere Patrick part I
Fixation is commonly found in internal or
external rotation

Procedure

Hip Traction
Variations can incorporate drops

Knee - Evaluation - Overview

Case History
Visualization
ROM
Palpation
Static
Motion
Orthopedic tests
X-ray

Knee - Evaluation

Case History

Trauma
Repetitive Use
Does the knee:
Lock

up
Buckle
Catch
When?

Knee - Evaluation - Overview

Visualization

Edema
Bruising
Discoloration
Front - Alignment of patella to
anterior tubercle
Back Swelling in popliteal fossa,
does it pulsate?

Knee - Evaluation - Overview

Palpation
Static
Motion

Orthopedic Tests

Appleys
Compression
Appleys Distraction
Valgus Stress Test
Varus Stress Test
Drawer Sign
Lachmans Test

Sag Sign
McMurrays Test
Bounce Home Test
Patella Femoral
Grinding Test
Apprehension for
Patella

Joint Mouse

This is a free floating body in the joint

Synovial Osteochondral Metastasia
Synovial villa swell and as they expand
they develop a bulbous end which fractures
from the villa then ossifying

Knee Traction Supine

PP: Supine
CP: Drs wrist (thumb up into joint space) in
popliteal fossa
Procedure: Flex lower leg over wrist till
either Patient tolerance or joint opens
Best for Tibia Posterior

Knee Traction Prone

PP: Prone
CP: Drs thumb web into joint space (fingers
palpate for the joint to open
Procedure: Flex lower leg over wrist till
either Patient tolerance or joint opens
Preferred knee traction move
Best for Tibia Posterior

Knee Traction Limited Flexion

ROM flexion is limited so DC is unable to

perform traction due to amount of flexion
required.
PP: Prone
DS: Kneeling, side of table near feet.

Knee Traction Limited Flexion

Patients knee flexed as much as their

limited motion allows with ankle over Drs
shoulder
CP: Behind tibia
3 Steps

Knee Traction Limited Flexion

3 Steps:
1.
2.
3.

Dr tractions joint open

Releases the traction pull
Flexes knee further into ROM gained

Repeat steps 1-3 until no more gain in motion or

motion back
Repeat: Traction Release Flex

Patella Traction

Performed for a dislocated patella

History:

usually a blow to medial side of knee pushing

patella out of groove

Visually

See it superior & lateral (quadriceps pulls it

that way)
Thus keeping the knee in flexion
Swelling around the patella

Patella Traction

X-ray

ROM

should be taken to rule out fracture

Patient unable to extend knee (the quadricep

group will become flexors)

Pain

Present around the patella

Differential Diagnosis

Complete tear of the quadricep tendon

Fractured Patella

Patella Traction

PP: supine (knee is flexed due to

quadriceps contraction)
DS: patients ankle between Drs legs
SCP: 10 & 2 position at superior aspect of
patella
CP: Drs thumbs work well here

Patella Traction
Procedure:
Drs legs will guide patients leg into
extension
Drs thumbs guide the patella back into the
groove

Tibia Posterior

History

Fall/blow/constant pressure on front of tibia

Pain

usually found over the popliteal fossa

also be found under the Patella

Tibia P

Differential Diagnosis

ROM

Bakers cyst
Varicose Veins
Aneurism of the popliteal arteries
(loss) of flexion
On full flexion by feel like it should pop

Fluid Motion

on anterior draw sign indicates Tibia P

Tibia AM

History - varies
Visualization may note

patella tracking laterally

toe out
tibial tuberosity visualized laterally

Pain point

usually over the medial side of knee and

medial meniscus

Tibia AM

Fluid motion

lost on valgus stress

present on full extension when doing a valgus
pressure

Tibia AL

History

Varies

Visualization may show

Patella tracking medially

Toe in
Tibial tuberosity may visualize medial of
normal.

Tibia AL

Pain point

over the lateral joint space

should be differentiated from the fibula

Fluid motion

lost on varus stress test

noted on full extension when doing a varus
press.

Fibula L

History of sprains in the ankle are usually

present.
Differential Diagnosis

Fibular fracture
Lateral collateral ligament damage
Shin splints

Fibula L

Pain

Found over the fibular head

May also have pain lateral malleolus

Fluid motion

on P-A and A-P

also on plantar and dorsi flexion of the
ankle.

Knee
Procedures

Patellar Traction
Knee Traction Prone
Knee Traction Supine
Knee Traction
Limited Flexion
Tibia AM
Tibia AL
Tibia P
Fibula L

Appleys Compression
Appleys Distraction
Valgus Stress Test
Varus Stress Test
Drawer Sign
Lachmans Test
Sag Sign
McMurrays Test
Bounce Home Test
Patella Femoral Grinding
Test
Apprehension for Patella

Review Hip & Knee

Knee Traction Limited

Flexion
Knee Traction Prone
Knee Traction Supine
Patellar Traction
Tibia AM
Tibia AL
Tibia P
Fibula L
Hip Traction
Trendelenburg
Fabere Patrick
Thomas Test

Hibbs
Appleys Compression
Appleys Distraction
Valgus Stress Test
Varus Stress Test
Drawer Sign
Lachmans Test
Sag Sign
McMurrays Test
Bounce Home Test
Patella Femoral Grinding Test
Apprehension for Patella

Seated:
St-Cl Traction Seated
St-Cl S
G-H Traction Seated
A-C PS
St-Co Traction Seated
G-H I
G-H P Seated
Kochers Maneuver
Frozen Shoulder
Wrist Traction (longitudinal)
Wrist Traction (transverse)
Elbow Traction
Ulna P
Radius P
Ulna PM
C-MC 2nd-5th
C-MC 1st

Supine:
St-Cl Traction Supine
G-H Traction Supine
St-Co Traction Supine
St-Co S
St-Co I
Prone:
S-T M Prone
G-H P Prone

Dugas

Drop Arm
Yergasons
Dawburns
Allens Test
Edens Test
Side Lying:
Adsons Test
S-T M Side Lying
Wrights Test
S-T L
Cozen Test
Lift Test
Carpal Single Thumb Mills Test
Carpal Double Thumb Tinel Tap Test
MC-P Traction
Phalens Test
I-P Traction
English Test