CONDITIONS AFFECTING

THE LOWER EXTREMITY

Dexter M. Sotto, PTRP, MAG, COMT
 ROM (N) Values and Endfeel
Joint Motion Value Endfeel
Hip Flexion 120
Extension 20
Abduction 45
Adduction 30
IR 45
ER 45
Knee Flexion 135
Extension 10
Ankle and Foot Dorsiflexion 20
Plantarflexion 50
Inversion 35
Eversion 15
 Goniometer Alignments (Hip)
Flexion Extension Abduction Adduction IR ER

Testing Pos. Supine Prone Supine Supine Short Sitting Short Sitting

Fulcrum G. Troch G. Troch ASIS ASIS Ant. Aspect Ant. Aspect

of Patella of Patella

Prox. Arm Lat. Midline Lat. Midline Imaginary Imaginary Perpendicula Perpendicula
of Pelvis of Pelvis horizontal horizontal r to the floor r to the floor
line between line between
2 ASIS 2 ASIS

Distal Arm Lat. Lat. Midline of Midline of Tibial Crest / Tibial Crest /
Epicondyle Epicondyle patella patella in between 2 in between 2
malleoli malleoli
 Goniometer Alignments (Knee)

Flexion Extension
Testing Supine Supine
Position
Fulcrum Lat. Lat.
Epicondyle Epicondyle
of Femur of Femur
Prox. Arm Greater Greater
Trochanter Trochanter
 Goniometer Alignments
(Ankle and Foot)
Dorsiflexion Plantarflexio Inversion Eversion
n (Subtalar) (Subtalar)
Testing Short Sitting Short Sitting Prone Prone
Position
Fulcrum Lateral Lateral Post. Aspect Post. Aspect
Malleoli Malleoli of ankles in of ankles in
between the between the
malleoli malleoli
Proximal Arm Head of Head of Post. Midline Post. Midline
Fibula Fibula of lower leg of lower leg
Distal Arm Fifth Fifth calcaneus calcaneus
metatarsal metatarsal
CONDITIONS AFFECTING
THE HIP AND PELVIS
Anterior Hip Dislocation

MOI: Trauma (ABER) /

Infection

Manifestations:
-Limb Shortening
-Maybe associated with
femoral nerve, artery or
vein damage.
Posterior Hip Dislocation

MOI: Posteriorly directed

force applied to the knee

Manifestations:
-Limb Shortening
-Maybe associated with
sciatic nerve injury.
-inability to abduct the
affected LE
Posterior Hip Dislocation
 Legg-Calve-Perthes Disease (Coxa Plana)

- Usually occurs during 4 – 8 years old

- M>F
- Usually thin
- Adult version
 Legg-Calve-Perthes Disease (Coxa Plana)

MOI:
a. Injury / disease of the blood vessels
supplying the femoral head.
b.Increased intra-articular pressure d/t
disease or trauma

Manifestations:
MC Early Sign: Limp
Pain: Inner side of the thigh, knee or groin
LOM: Abduction + IR
Atrophy: Hip Muscles
Gait: Psoatic Limp
 Slipped Capital Femoral Epiphysis
- Common in Adolescent patients
- M>F
- Obese

MOI:
1. Rapid Growth
2. Obliquity of the epiphyseal plates
3. Minor traumas

Manifestations:
- Hip pain → Knee pain
- (+) LLD
- LOM: ABIR
- Tenderness: Anterolateral aspect of hip
 Snapping Hip Syndrome (Coxa Saltans)
MOI: MC Tight ITB / Gmax tendon riding over
the greater trochanter

Manifestations:
- Reproduction of a snap or click at the hip
with repetitive motion
- Snapping is worse when affected LE is held in
IR and hip flexion/extension is done
- Can be felt by palpation when movement is
done

MODALITIES ARE GENERALLY NOT REQUIRED

BECAUSE IT IS USUALLY PAIN FREE
 Hip Pointer Injury
MOI: Blow to the iliac crest or hip
region

Manifestation:
- Hematoma formation
- Trunk position: forward flexed and
ipsilateral flexion towards the
affected side
- Pain: any movement involving
muscles that attach to the iliac
crest (TFL, EO)
 Hamstring Strain
MOI: Rapid uncontrolled stretch with
hip flexed and knee is extended

Manifestations:
- Pain is reproduced by forceful
hamstring contraction or knee
extension. Located at origin of
muscle.
- Can be assessed by: 90 90 SLR,
Tripod Sign, Hamstring Contracture
Test
90 90 Straight Leg Raise (Hamstring Contracture
Method 1)
- Pt. in Supine
- Flexed both hips to 90 while the
knees are bent
- Patient grasps behind knees with
both hands to stabilize the hips
at 90 deg. flexion
- Patient actively extends each
knee in turn
- (N) flexibility of hamstring = knee
extension should be within 20
deg. of full extension
 Tripod Sign
(Hamstrings Contracture, Method 3)
- Patient in short sitting
- PHYSICAL THERAPIST
extends one knee
- If the hamstring muscle on
that side are tight, the
patient extends the trunk
to relieve the tension.
Method is repeated on the
other side
 Hip Adductor Strain
MOI: Resisted forceful abduction of
the hip and it mainly happens
during eccentric contraction

Manifestations:
- Pain: origin of adductors
- Symptoms reproduced by resisted
adduction and occasionally with
hip flexion
 Quadriceps Strain / Contusion
 MOI: Rapid deceleration from a sprint
- direct blow from another player

Manifestations:
- inability to perform flexion and extension of the
knee
- Inability to perform SLR or quads isometrics
- Presence of hematoma
- Gait: Antalgic
- Tenderness and swelling on the anterior thigh
- Knee flexion is also restricted
- Massage is contraindicated
 Myositis Ossificans

MOI: Complication of Quads contusion

Early treatment of contusion with massage
or heat
Premature return to aggressive stretching
and
strengthening or sports
DIRECT BLOW TO THE THIGH BY HARD
OBJECTS: Football
player whose thigh is struck by an opposing
player’s
helmet

Manifestations:
- LOM: knee flexion
- Palpable bony mass on the muscle involved
 Trochanteric Bursitis
MOI: overuse, LLD, running on banked
surfaces, trauma, tight ITB

Manifestations:
- LE held in abduction and ER to relax
tension on Gmax and bursa
- Pain: trochanter along the lateral thigh,
present during ascending stairs, lying on
the affected side, running and jumping
- (+) snapping at the lateral hip
- May radiate on the ipsilateral lumbar
region
 Ischial Bursitis (Weaver’s Bottom)
 MOI: Sedentary occupations
Direct fall on the ischial
tuberosity

Manifestations:
- Pain: referred to the posterior
thigh, aggravated by sitting
- Gait: Decreased hip extension
(late stance)
- Tenderness: Ischial tuberosity
CONDITIONS AFFECTING
THE KNEE JOINT
COMPLEX
 Recurrent Patellar Subluxation /
Dislocation
 MOI: trauma on the medial side of the patella, sudden
contraction of quads with tibia in ER and valgus thrust
occurs as in pushing off while turning

 Manifestations:
- Tenderness: medial border of the patella
- Knee weakness and feeling that the knee is not secure
- Abnormal patellar tracking (subjective feeling of patella
slipping or moving laterally)
- Slight or moderate amount of effusion

Management: Quadriceps Strengthening

 Patellofemoral Pain Syndrome
 MOI: Repeated microtrauma
 Manifestations:
- Pain on anterior knee

- Present during descending stairs or

repetitive knee flexion
- (+) theatre / moviegoer’s sign
- Effusion and crepitus may be
present
- Ascending / descending stairs aggravates the
condition
- May have tight VL and relative VMO weakness ->
patellar tracking
 Patellofemoral Pain Syndrome
 Clarke’s Sign (Patellar Grind Test)
- PT presses down proximal to the
upper pole / base of the patella
with the web of the hand as the
patient lies relaxed with the knee
extended.
- Patient is then asked to contract
the quads while the examiner
pushes down
- If the pt. can complete and
maintain the contraction without
pain, the test is negative.
 Chondromalacia Patella (Runner’s Knee)
 MOI: Degenerative process after repeated
minor or acute severe trauma. Usually
associated with patella alta.
- softening of the patellar articular cartilage
 Manifestations: difficulty in climbing and
descending stairs
 Tenderness: when patella is pressed against
the femur with the knee slightly flexed
 Pain: resisted knee extension
 X ray: no diagnostic changes except for severe
ones
 Waldron’s Test

• PT palpates the patella

while the patient
performs several slow
deep knee bends (maybe
uni / bilateral)
• PT should note the
amount of crepitus
(significant only if
accompanied by pain)
• (+) if both symptoms are
present
 Osgood – Schlatter Disease
 MOI: Relative overload at the patellar tendon
insertion
 Manifestations:
- Pain with activity: climbing stairs / running / strong
knee extension / worse with squatting, jumping or
kneeling
- ENLARGED AND TENDER TIBIAL TUBEROSITY
RADIOGRAPHIC HALLMARK: irregularity and
fragmentation of tibial tuberosity
 ITB Friction Syndrome
 MOI: Excessive running (specially on uneven surface and
sudden increase in mileage), bicycling or hiking, incorrect
footwear
 Manifestations:
- Pain: Lateral Knee (between 20 – 30 degrees of knee flexion)
- Assessed via Noble Compression Test
1. Pt in supine, PT flexes pt’s knee to 90 accompanied by hip
flexion
2. Presssure is applied to the proximal lateral femoral
epicondyle with the thumb while the pt’s knee is passively
extended
3. Pt. would feel severe pain at 30 deg. Flexion (0 being
straight leg)
Patellar Tendinitis (Jumper’s Knee)

 MOI: Jumping, squatting and

kneeling
 Pain and tenderness: present
on patellar tendon, forceful
knee extension, squats may
aggravate it (specially rapid)
 Can be treated by Chopat
Strap
Pes Anserine Bursitis

 MOI: Friction of pes anserine on the medial

aspect of the proximal tibia. Can also be caused
by OA, increased femoral anteversion, excessive
pronation and genu valgum

 Pain: Anteromedial Knee

Popliteal Bursitis

 MOI: Congenital / secondary to trauma

 Manifestation:
- Feeling of fullness in the popliteal fossa
- Firm and hard swelling when the knee is extended,
disappears when the knee is flexed
Meniscal Injuries
 MOI: rotational movement of the tibia on the
femur with the knee partially flexed
- Direct blow to the knee
- Twisting while rising from a squat position
- MEDIAL: cutting injuries; lateral tibial rotation
while the knee is partially flexed during WB
- LATERAL: squatting full flexion with medial tibial
rotation
 MANIFESTATIONS:
- Tenderness: Joint Line
- Catching / feeling of instability
- LOCKING: Knee could not be fully bent /
straightened due to a displaced meniscal
McMurray Test

- Patient in supine with knee fully

flexed (heel to buttocks
- PT medially rotates the tibia
and extends the knee
- This causes a snap / click
accompanied by pain (LATERAL
MENISCUS)
- Same process but change to
lateral rotation (MEDIAL
MENISCUS)
 Apley’s Test
- Pt. in prone with knee flexed to 90
- Pt’s thigh anchored with PT’s knee
- PT medially and laterally rotates the
tibia combined first with distraction
while noting any restriction, excessive
movement or discomfort
- The process is repeated using
compression
- IF ROTATION PLUS DISTRACTION IS MORE
PAINFUL / SHOWS INCREASED ROTATION
RELATIVE TO THE NORMAL SIDE
(LIGAMENTOUS)
- IF ROTATION PLUS COMPRESSION IS MORE
PAINFUL / SHOWS DECREASED ROTATION
 Thessaly Test

- Pt. stands flat footed on one leg while

the PT provides his / her hands for
balance
- Pt. then flexes the knee to 20 and rotates
the femur on the tibia medially and
laterally THREE TIMES while maintaining
the 20 degree flexion.
- Good leg is tested first
- (+) patient experiences medial / lateral
Medial Collateral Ligament Injury

 MOI: Valgus / Abduction force

- Sudden valgus force with the foot planted
- Side step cut maneuver with valgus force
 Tenderness: Medial Side
 Assessed by Valgus (Abduction Stress Test)
 Abduction (Valgus Stress Test)
PT applies a valgus stress
(knee medially) at the
knee while the ankle is
stabilized in slight ER
Done first in full
extension, then slightly
flexed (20 – 30 deg)
(+) tibia moves away from
Lateral Collateral Ligament Injury

 MOI: Varus or adduction force (blow on the medial side of the knee)
Manifestation: may cause stretch injury to _______________ nerve?

 Varus (Adduction Stress Test)

 Motor and Sensory Testing
Anterior Cruciate Ligament Injury

 MOI: CLIPPING INJURY – MC injury associated with valgus

force while the tibia is ER and the foot is planted on the
ground
 Manifestations:
- Audible pop
- Marked hemarthrosis
- Immediate swelling (2-3 hrs)
- Significant effusion
- Knee instability
 Lachman Test

- Pt is in supine with knee

placed in 30 deg. Flexion
- Femur is stabilized and the
proximal aspect of the tibia is
moved forward with the other
- (+) indicated by a mushy or
soft end feel when the tibia is
moved forward (increased
anterior translation)
Posterior Cruciate Ligament Injury

 MOI: Dashboard Injury, hyperflexion, posterior directed force to a bent knee

(being tackled or receiving a blow with the knee in 90 deg flexion)
- Fall on flexed knee with foot in plantarflexion
- Blow to the proximal, anterior leg
 Manifestations:
- minimal swelling, inability to fully extend the knee
- Tenderness: Popliteal area
- May weightbear without pain
 Gravity / Posterior Sag / Godfrey Test

- Pt lies supine and PT holds both

LE in a 90 90 position.
- (+) if a posterior sag of the tibia
is seen (POSTERIOR INSTABILITY)
- Manual posteriorly directed
force may be applied to
increase posterior displacement
Unhappy / Terrible Triad of O’Donoghue

MOI: valgus force applied

to a flexed and rotated
knee
Involves injury to the ACL,
MCL and medial meniscus
Rotatory Instability
 Grading of Sprain and Management
Grade Description Management
I (mildly stretched) No instability Immobilization;
early movement of
the knee as soon as
pain and swelling
subside
II (moderately Mild to moderate Immobilization in a
stretched / partial instability plaster cast for 6 – 8
tear) weeks.
Quads and Hams str.
III (severe / Significant Surgery
complete tear) Instability
CONDITIONS AFFECTING
THE ANKLE AND FOOT
 ANKLE EVERSION SPRAIN
 MOI: Forceful and sudden ankle eversion
 Assessed by KLEIGER’s TEST (External Rotation Stress Test)
- Patient in short sitting
- PT stabilizes the leg with one hand and the other holds the foot and applies external rotation
- (+) pain over the anterior / posterior tibiofobular ligaments (SYNDESMOSIS INJURY)
- (+) pain medially and PT feels the talus displace from the medial malleolus (DELTOID LIGAMENT
TEAR)
 Shin Splints

MOI: Overloading and fatigue

of anterior compartment
muscles
- Running on hard surfaces,
overly rapid increase in
training intensity, weak Dfors,
improper footwear and
Medial Tibial Stress Syndrome

 MOI: Forefoot Runners / Toe

Runners
- Persistent stress, rapid increase
in running or other athletic
events
 MANIFESTATIONS:
- Pain during exercise but relieved
by rest
- Tenderness: posterior medial
 Achilles Tendinitis
 MOI: Repetitive eccentric overload causing inflammation and
microtears of the tendon
- Uphill running
- Recent change in footwear / increase in training (intensity /
mileage) / interval training
 Manifestations: Pain on the distal Achilles tendon (post. Ankle)
 Swelling
 Painful push off phase
 Thompson’s (Simmonds’) Test
- Pt in prone / kneels on a chair with feet over the edge
of the table
- PT squeezes the calf muscles
- (+) absence of plantarflexion (ruptured Achilles
tendon)
Calcaneal Bursitis

 MOI: Prolonged walking or running especially in

footwear with poor shock absorption
 Manifestation:
- Tenderness over the calcaneus without pain on
toe-walking or plantar fascial stretch
Mgnt: heel cups
Plantar Fasciitis

 Disorders causing PF: Pes Cavus , Pes Planus, Obesity

- Tibialis Posterior weakness, excessive pronation
 Painful first step in the morning / after a period of inactivity. Pain increases
with hyperdorsiflexion of great toe
 Pain decreases throughout the day
 1st degree flatfoot –
Feiss Line Test tubercle falls one third
of the distance to the
 PT marks the apex of the medial malleolus and the plantar aspect
of the first metatarsophalangeal joint while the patient is not WB. floor
 PT palpates the navicular tuberosity noting where it lies relative 2nd degree flatfoot – falls
to a line joining the two previous lanrmarks.
two thirds of the
Patient then stands with the feet 3 – 6 inches apart

distance
 Navicular tuberosity normally lies on or close to the line.
3rd degree flatfoot – if
the navicular tuberosity
rests on the floor
 Morton’s Neuroma

• MOI: shearing forces between the

metatarsal heads, tight footwear
• Manifestations:
- Pain: sharp, shooting, radiating to
the affected digits
- Numbness
- Burning sensation which may
radiate into the adjacent toes
Sever’s Disease (Calcaneal Apophysitis)

 Apophysitis is an independent area of ossification separated

from the main bone
 Seen in active adolescents at a time of rapid growth
 Bony prominence to the posterior superior lateral aspect of
the calcaneus
 Aggravated with activity, relieved with rest
 Tenderness: Achilles tendon insertion
 Toe Deformities
Hammer Toe Claw Toe Mallet Toe
MTP Joint Extended Hyperextended NA
PIP Joint Flexed Flexed NA
DIP Joint Usually NA, may be Flexed Flexed
flexed, straight or
hyperextended