MMT of Knee.pdf

MMT of Knee

1. Muscle Testofthe
KneeJoint
Dr. Ahmed Assem
LecturerofPhysicalTherapy

2. KneeFlexion
•TheHamstringMusclesofthePosterior
CompartmentoftheThigh
•Thereare3muscles
•MedialHamstringMuscles:
1.Semitendinosus.
2.Semimembranosus.
•LateralHamstringMuscles:
3.Bicepsfemoris

3. Semimembranosus
•Origin:posteriorsurfaceischial
tuberosity
•Insertion:Posterior surface ofthe
medialtibialcondyle
•Action:flexionandmedial
rotationtheknee
•Nerve Supply:Tibialportionof
sciaticnerve (L5, S1)

4. Semitendinosus
ischial
Origin:posteriorsurfaceischial
tuberosity
•Insertion:Superioraspect,medial
tibialshaftin pesanserinbursea
•Action:Extendship,flexesand
mediallyrotatesknee
•NerveSupply:Tibialportionsciatic
nerve(L5,S1)

5. Bicepsfemoris
•Origin:Long Head: theposterior
surfaceofthe ischialtuberosity
•ShortHead:lineaaspera,lateralsupracondylarridge
offemur
•Insertion:Fibularheadandlateraltibialcondyle
•Action:Flexestheknee,rotatestibialaterally,
extendsthehipjoint
•Nerve supply Long head: tibialcomponent of sciatic
nerve,
•Short head: common peroneal component of sciatic
nerve

6. AccessoryMuscles:
1.Poplitealmuscle.
2.Sartoriusmuscle.
3.Gracilismuscle.
4.Gastrocnemiusmuscle.

7. FactorsLimitingMotion:
•Therangeofmotionofthekneeflexionisof120
o
to
130
•Tensionofthekneeextensor musclesparticularly
Rectusfemorisifhipisextends.
•Contactof calfwithposteriorthigh.
Fixation:Weightofthighandpelvis

8. NORMALANDGOOD
•PatientPosition:Prone with limbs straight and
toes hanging over the edge of the table. Test may be
started in about 45°of knee flexion.
•TherapistPositionandGrasps:Standingbesidethe
tableonthe sideofthe affected leg,
•Theproximalhandstabilizepelvisandthedistal
handgraspingabove ankletogiveresistance.
•Instructions to Patient: "Bend your knee. Hold it!
Don't let me straighten it."

9. Totestbicepsfemoris
•Position of Patient: Prone with knee flexed
to less than 90°. Leg is in external rotation
(toes pointing laterally).
•Position of Therapist: Therapist resists
knee flexion at the ankle using a downward
and inward force
•Test: Patient flexes knee, maintaining leg
in external rotation (heel away from
examiner, toes pointing toward examiner)
NORMALANDGOOD

10. •Grade 5 (Normal) : Resistance will be maximal,
and the end knee flexion position (approximately
90°) cannot be broken.
•Grade 4 (Good) : End knee flexion position is
held against strong to moderate resistance.
•Grade 3 (Fair) : Holds end range position but
tolerates no resistance
NORMALANDGOOD

11. NORMALANDGOOD
•Totestsemitendinosusandsemimembranosus
PositionofPatient:Pronewithkneeflexedtoless
than90°.Legininternalrotation(toespointingtoward
midline).
•Position of Therapist: Hand giving resistance
grasps the leg at the ankle. Resistance is applied
in an oblique direction (down and out) toward knee
extension
•Test:Patientflexesknee,maintainingthelegin
internalrotation(heeltowardexaminer,toespointing
•towardmidline).

12. NORMALANDGOOD
•Totestsemitendinosusandsemimembranosus
only,thelowerlegisrotatedmediallytoputthe
muscleinagoodalignment.

13. •Resistance:
•Grade4:Moderateleadingresistanceisgiveninaform
ofpressingdowndirectlyopposinglineofraising.
•Grade5:Maximumresistanceisappliedthroughoutthe
rangeofmotionplusa"hold"positioniskeptattheend
oftherange.
•Command:
•“Raiseyourlowerlegupthroughfullrangeof
motion,Relax”.

14. FAIR
PatientPosition:Pronelyingwith
legstraight.
TherapistPositionandGrasps:
Standingbesidethetableon
thesideoftheaffectedleg,
proximalhandabovethethigh
proximaltokneetostabilize
thighmediallyandlaterally
withoutpressureoverthe
musclegroupbeingtested.
Command:“Raiseyourlowerleg
throughfullrangeofmotion,
Relax”.

15. POOR
•PatientPosition:Sidelyingwithboth
legsstraight;theupperlegis
supportedandtheaffectedlegis
down.
•TherapistPositionandGrasps:
Standingbesidethetable
•Thedistalhandsupportingthe
upper leg.
•Theproximalhandisplacedabove
the kneetostabilizethethigh.

16. TRACEANDZERO
•PatientPosition:Prone
lying,withtheaffectedleg
slightlyflexedkneeandthe
lowerlegsupported.
•Thedistalhandsupports
theloweraffected leg
•While the proximalhand
Palpatestendonofkneeflexor
musclesonbackofthethigh,
nearthekneejoint.
•Command:“Trytoraiseyour
lowerlegup,Relax”.

17. Notes:
a)Flexionofkneejointisactivelyproducedupto
90°onlyagainstgravitybutafterthatwillbewith
gravityassistanceandproducesmoothlyby
eccentriccontractionofquadricepsmuscle.
b)IntestsforGrades3and2,thekneemaybe
placedina10°flexedpositiontostartthetestwhen
gastrocnemiusweaknessispresent(the
gastrocnemiusassistsinkneeflexion).
c)Ifbicepsfemorisisstronger,lowerlegwill
laterallyrotateduringflexion.
d)Ifsemitendinosusandsemimembranosusarestronger,
lowerlegwillmediallyrotateduringflexion.

18. Substitutions
•Hipflexionsubstitution:Thepronepatient
mayflexthehiptostartkneeflexion.The
buttockonthetestsidewillriseasthehip
flexes,andthepatientmayappeartoroll
slightlytowardsupine

19. •Sartoriussubstitution:Thesartoriusmay
trytoassistwithkneeflexion,butthisalso
causesflexionandexternalrotationofthe
hip.Kneeflexionwhenthehipisexternally
rotatedislessdifficultbecausethelegis
notraisedverticallyagainstgravity.

20. •Gracilissubstitution:Actionofthegracilis
contributesahipadductionmotion.
•Gastrocnemiussubstitution:Donotpermit
thepatienttostronglydorsiflexinan
attempttousethetenodesiseffectofthe
gastrocnemius.

21. EffectsofWeakness
•Weaknessofbothmedialand lateral
hamstringscauseshyperextensionofthe
knee.
•Whenthisweaknessisbilateral,anterior
pelvictiltandthelumbar lordoticposition

22. •Weaknessoflateralhamstringscauses
tendencytowardlossoflateralstabilityof
theknee.
•Weaknessofmedialhamstringsdecreases
themedialstabilityoftheknee

23. EffectsofShortness
•Shortnessofthehamstringsmuscleswillcausea
restrictionofkneeextensionandrestrictionof
thehipflexion

24. EffectsofContracture
•Contractureofbothmedialandlateralhamstrings
resultsinapositionofkneeflexion.Ifthe
contractionisextreme,itwillbeaccompaniedby
posteriortiltingofthepelvisandflatteningofthe
lumbarcurve.

25. Kneeextension
•RECTUSFEMORIS
•VASTUSINTERMEDIALIS
•VASTUSINTERMEDIALIS
•VASTUSLATERALIS

26. RECTUSFEMORIS
•ORIGIN
Straighthead:AIIS.
•Reflectedhead:iliumaboveacetabulum
•INSERTION
Quadricepstendonto patella,via
ligamentum patellaeintotubercleoftibia
•ACTION:Extendslegatknee.Flexes thighat
hip
•NERVE:femoralnerve(L2,3,4)

27. VASTUSINTERMEDIALIS
•ORIGIN:Anteriorandlateralshaft of
proximal2/3of bodyoffemur
•INSERTION:Quadricepstendonto
patella, via ligamentum patellae into
tubercleof tibia
•ACTION:Extendsknee
•NERVE:femoralnerve(L2,3,4)

28. VASTUSLATERALIS
•ORIGIN: Upper intertrochanteric line, base of
greatertrochanter,lineaaspera,lateral
supracondylar ridgeand lateralintermuscular
septum
•INSERTION
Lateralquadricepstendontopatella,via
ligamentum patellaeintotubercleof tibia
•ACTION:Extendsknee
•NERVE:femoralnerve(L2,3,4)

29. VASTUSMEDIALIS
•ORIGIN
Lowerintertrochantericline,spiralline,
medial lineaasperaandmedial
intermuscularseptum
•INSERTION
Medialquadricepstendontopatellaand
directlyintomedialpatella,vialigamentum
patellaeintotubercleoftibia
•ACTION:Extendsknee.Stabilizespatella
•NERVE:femoralnerve(L2,3,4)

30. Kneeextension
RangeofMotion:I2O°-13O°TO0°'
FactorsLimitingMotion:
cruciate•Tensionofobliquepopliteal, and
collateralligaments ofkneejoint
•Tensionof kneeflexormuscles
Fixation:
•Weightofthighand pelvis

31. NORMALANDGOOD
-PatientPosition:Sittingwithlegsoverthe
edgeofthetable.Theaffectedlegisaway
fromthetherapist,smallcushionunderthe
knee.Thepatient’shandsgrasptheedgesof
tabletostabilizepelvis.
Thepatientshouldbeallowedtoleanbackward
torelievehamstringmuscletension.
Donotallowthepatienttohyperextendthe
kneebecausethismaylockitintoposition.
TherapistPositionandGrasps:Standingatside
oflimbtobetested
Theproximalhandisplaced over
the rectus femorisorigin without
applyingpressure.
Thedistalhandisplacedon the
anteriorpart of the leg just above the
ankle joint to give resistance

32. •Resistance:
•Grade4:Moderateleadingresistanceisgivenina
formofpressingdowndirectlyopposinglineof
raising.
•Grade5:Maximumresistanceisappliedthroughout
therangeofmotionplusa"hold"positioniskeptat
theendoftherange.
•Command:“Raiseyourlowerlegupthrough
fullrangeofmotionwithoutmedialorlateral
rotationofthehip,Relax”.

33. FAIR
•-PatientPosition:Sittingwithlegsover
theedgeofthetable.Theaffectedlegis
awayfromthetherapist,smallcushion
undertheknee.Thepatient’shands
grasptheedgesoftabletostabilize
pelvis
•*TherapistPositionandGrasps:
Standingatsideoflimbtobetested.
•proximalhandisplacedovertherectus
femorisoriginwithoutapplying
pressure.

34. POOR
•PatientPosition:Sidelying,
affectedlegdownandflexed,the
upperlegissupported.
•TherapistPositionandGrasps:
Thetherapiststandsbehindthe
patient,thedistalhandsupport
theupperleg,whiletheproximal
handisplacedabovetheknee
jointtostabilizethethigh.Avoid
pressureoverquadricepsfemoris.

35. POOR
Position of Patient: Side-lying with test limb
uppermost. Lowermost limb may be flexed for
stability. Limb to be tested is held in about 90°of
knee flexion. The hip should be in full extension.
Position of Therapist: Standing behind patient at
knee level. One arm cradles the test limb around
the thigh with the hand supporting the underside
Of the knee .The other hand holds the leg
just above the malleolus.
Test: Patient extends knee through the available
range of motion. The therapist supporting the limb
provides neither assistance nor resistance to the
patient's voluntary movement. This is part of the
art of muscle testing that must be acquired.
Be alert to activity by the internal rotators (see
Substitution, below).
Instructions to Patient: "Straighten your knee."

36. TRACEANDZERO
•Supine:Withkneeflexedandsupported
•Patientattemptstoextendknee.
•ContractionofQuadricepsfemorisis
determinedbypalpationoftendon
betweenpatellaandtuberosityoftibia
andfibersofmuscle.
•InstructionstoPatient:"Pushthebackof
yourkneedownintothetable."OR
"Tightenyourkneecap"
•(quadricepssetting).

37. EffectsofKnee Extensor
MusclesWeakness
•Difficultinupanddownstairsandgettingup
anddownfromsittingchair.
•Leaningoftrunkforwardandextendingthe
kneejointbyhishand

38. Effectsofcontracture
•Shortnessorcontractureoftheknee
extensormuscleswillproducerestriction
ofthekneeflexion.
Substitution
When the patient is side-lying (as in the Grade 2 test), he or she
may use the hip internal rotators to substitute for the quadriceps,
thereby allowing the knee to fall into extension.

39. than