Osteopathic Evaluation and Treatment of the Hip & Knee · Osteopathic Evaluation and Treatment of the Hip & Knee LOMA August 20, 2016 New Orleans, Louisiana Eva B. Shay, D.O. Assistant

Osteopathic Evaluation and Treatment of the Hip & Knee

LOMA August 20, 2016

New Orleans, Louisiana

Eva B. Shay, D.O.

Assistant Professor, Osteopathic Principles & Practice

William Carey University College of Osteopathic Medicine

Lower Back Pain and the Hip Restrictors

Dysfunctional hip restrictors can markedly influence the low back mechanics. Fred Mitchell, Sr., D.O., estimated that the legs played a major role, as much as 50% of the time, with lower back pain.

Hip restrictor imbalance is frequently a contributing factor for chronic low back pain.

The legs and the lower back are both complex regions.

http://www.anybodytech.com/



The Six Groups of Hip Restrictors and Treatment Positions

Prone Position Flexors (Quads)

Internal rotators

External rotators

Supine Position Extensors (Hamstrings)

Adductors

Abductors




Hip & Leg

MUSCLE ENERGY TREATMENT STEPS

Tell the patient to stop her contraction (gently) and simultaneously match the patient’s decreased force

Allow the patient to relax; sense the tissue relaxation

Take up the slack to the new initial barrier. This will slowly, passively lengthen the muscle(s)

Repeat three to five times, or until the best possible increase in motion is obtained

Retest

Position the body part to be treated at the point of initial restriction of motion (the feather edge of the restrictive barrier)

Direct the patient to contract the appropriate muscle(s), in the appropriate direction(s), with the appropriate intensity and duration

Ensure that your patient’s counterforce equals the amount of force you apply

Maintain the force until the contraction is palpated at the appropriate location (generally, 3-5 seconds)

HIP RESTRICTORS – treat prone

Hip Flexors – Quadriceps Rectus Femoris

Vastus lateralis

Vastus medialis

Vastus intermedius

Innervation: Femoral L2-4

Hip Internal Rotators Gluteus medius

Gluteus minimus

Tensor fascia lata (TFL) Innervation: Superior Gluteal L5-S1

Hip External Rotators

Piriformis

Obturator internus

Obturator externus

Gemellus superior

Gemellus inferior

Gluteus maximus

Quadratus femoris

Innervation: Obturator L5-S1

Gilroy, MacPherson, Ross, editors; Atlas of Anatomy, 2nd Edition

TREATMENT OF TIGHT QUADRICEPS Physician flexes the lower leg to the

barrier

Patient’s lower leg is placed against the physician’s hand or chest/shoulder to provide counterforce

Patient is asked to straighten the leg for 3 – 5 seconds (contracting the quads)

After the patient relaxes for a short time:

Physician repositions the leg to the new feather edge of the restrictive barrier

Cycle is repeated 2-4 times or until the restriction is resolved

Retest

FEMORAL EXTERNAL ROTATION SOMATIC DYSFUNCTION Diagnosis

Patient’s internal rotation of the thigh is restricted by tight external rotators

Both legs can be tested and compared at the same time with the patient in the prone position

Treatment Physician’s hand is placed against the medial malleolus of the

involved extremity Physician internally rotates the extremity to the feather edge of the

barrier Physician’s cephalad hand should be placed on the posterior pelvis to

prevent rotation of the pelvis on the table to assess for proper patient’s force of contraction

Patient is asked to bring their ankle into the physician’s hand for 3-5 seconds

After the patient relaxes for a short time: Physician repositions the leg & hip to the new feather edge of the

restrictive barrier Cycle is repeated 2-4 times or until the restriction is resolved Retest

FEMORAL INTERNAL ROTATION SOMATIC DYSFUNCTION Diagnosis

Patient’s external rotation of the thigh is restricted by tight internal rotators Each leg is assessed independently then the ROM is compared with the patient

in the prone position

Treatment Patient’s involved extremity is taken to the feather edge of the restrictive

barrier Physician assures patient’s knee is at 90° Physician’s cephalad hand should be placed on the posterior pelvis of the

affected side to prevent rotation of the pelvis on the table and to assess for proper patient’s force of contraction

Physician’s hand is at the lateral malleolus to provide a point of resistance The patient is asked to internally rotate his leg, matching the physician’s

counterforce for 3-5 seconds Patient relaxes After the patient relaxes for a short time: Physician repositions the leg and hip to the new feather edge of the restrictive

barrier Cycle is repeated 2-4 times or until the restriction is resolved Retest

Hip Extensors - Hamstrings Biceps femoris – long

head Biceps Femoris – short

head Semimembranosus Semitendenosus

Innervation: Tibialus L2-4

Hip Abductors Gluteus medius

Gluteus minimus

Tensor fascial lata (TFL)

Innervation: Superior Gluteal L5-S1

Gilroy, MacPherson, Ross, editors; Atlas of Anatomy, 2nd Edition

HIP RESTRICTORS – treat supine Hip Adductors

Adductor brevis

Adductor longus

Adductor magnus

Gracilis

Innervation: Obturator L2-4

TREATMENT OF TIGHT HAMSTRINGS Patient is supine on the table

Physician is on the same side of the table as the involved extremity

Physician places patient’s distal leg on his shoulder

Physician’s hands are placed just proximal to the patient’s knee

Patient is asked to bring his heel or ankle into the physicians shoulder and push his away by extending the hip (contracting the hamstrings)

Effort is held for 3-5 seconds


Physician repositions the patient to the new feather edge of the restrictive barriers (hip flexion & knee extension)


Retest

ADDUCTION SOMATIC DYSFUNCTION Diagnose

First, test each side for relative abduction restriction

Use one hand to abduct the restricted leg to the barrier

Physician provides counterforce and supports the patient’s knee

Physician uses caudad hand for fine tuning.

Treat Physician uses cephalad hand to stabilize the opposite

leg (or pelvis)

Patient makes their muscle effort by attempting to adduct the lower extremity toward midline (matching the physician’s force) for 3-5 seconds


Physician abducts the leg to the new feather edge of the restrictive barrier


Retest

ABDUCTION SOMATIC DYSFUNCTION

Diagnose Test each side for

adduction restriction, lifting the LE enough to clear the opposite side

The physician adducts the patient’s leg to the feather edge of the restrictive barrier

The physician uses his other hand to stabilize the pelvis (ASIS) on the side of the restriction, to prevent the pelvis from rotating

Treat The patient is asked to abduct their leg away from

midline, matching the physician’s counterforce for 3-5 seconds


Physician adducts the leg to the new feather edge of the restrictive barrier


Retest

HIP Posterior Pelvis Counterstrain

Piriformis

Posterior Lateral Trochanter (PLT)

Lateral Trochanter (LT)

Dx: Piriformis (PIR) Tenderpoint

• About half to two thirds of the way from the ILA (inferolateral angle of the sacrum) to the greater trochanter

• Push toward or away from the musculotendinous junction of the piriformis muscle (either direction will stretch the nociceptors and cause them to fire)

Piriformis

Tx: Piriformis (PIR) Counterstrain

Marked flexion of the hip and abduction

Fine tune with external or internal rotation

Leg is off the table (prone) or ankle is resting on your knee (supine) and flexed up to 135º

Hip is abducted

External rotation of the thigh

Prone - “The peeing dog” position

Dx & Tx: Posterior Lateral Trochanter (PLT)

Superolateral aspect of the posterior surface of the greater trochanter

Probably the lateral aspect of the piriformis muscle

(PLT)

Extension

Marked external rotation

Abduction if needed for fine tuning

Dx & Tx: Lateral Trochanter (LT)

Along the iliotibial band distal to the greater trochanter

Greater Trochanter

(LT) Iliotibial Band

TFL

(LT)

Patient prone Moderate abduction of the thigh

off the table Slight flexion

Posterior Pelvis Counterstrain

Tenderpoint Location Treatment Position

Piriformis

Midpoint between the ILA

and the greater trochanter

Marked flexion of the hip

Abduction

Fine tune with external or internal rotation

PLT

Posterior lateral trochanter

Extension

Marked external rotation

Possibly slight abduction

Lateral

trochanter

Along the iliotibial band distal

to the greater trochanter

Moderate abduction of the thigh

Slight flexion

Combined Myofascial Release / Muscle Energy Unwinding of Hip

Patient supine with physician standing adjacent to the dysfunctional hip, facing the patient’s head

Flex patient’s hip and knee, slide your hand furthest from the patient under their pelvis so as to monitor the sacroiliac (SI) joint with your finger pads

Hold the flexed knee with your hand closest to the patient or stabilize it against your chest/upper abdomen

Use the knee as a long lever to mobilize the femur, slowly in a circular manner, evaluating the full range of motion of the hip and treating with MFR

Pause at any region that feels restricted

Have the patient push against your hand or body, in a perpendicular direction from the circle, to loosen the area of restriction with ME

Continue to mobilize and treat the hip, with the previous three steps, until there is an increased range of motion in the hip

If the patient expresses pain when the femur is flexed and adducted, check the psoas muscle at the inguinal ligament. If it is tender or painful, treat it with either Counterstrain or a Muscle Energy stretch and then return to the hip unwinding.

Oblique view of Psoas attachment on the lesser trochanter

Lymphatic Drainage

Popliteal Fossa – Direct MFR and Lymphatic Drainage (Supine Traction Hamstring Spread)

Posterior view - Hand placement

Palpate the tissues in the popliteal fossae to see if

they feel congested or tight.

Sit or stand by the supine patient on the side to be

treated.

Place your fingers in the popliteal fossa and exert

traction, pulling the hamstring tendons gently

laterally.

Allow the foot to hang freely while you support

the leg, adjusting the traction to keep the patient

comfortable.

Hold for 15 to 60 seconds or until the tissue

relaxes

The patient feels progressive warmth in the

thigh, leg, and foot.

Retest

Lower Extremity Petrissage

UPPER LEG Place your hands around the upper thigh, close to the hip Using light pressure from the hands, twist the superficial tissue gently

in the same direction (counterclockwise or clockwise), starting proximally and proceeding distally toward the foot.

Pause for several seconds as you apply this stretch to the tissues. Move down a hand’s length distance each time. This can be repeated up to three to four times until adequate drainage

is achieved.

LOWER LEG Circle the lower leg with your fingers, with your fingers or thumbs in

the middle of the calf muscles Squeeze the calf muscles gently, progressing distally to the ankle. You may also rock your body forward and backward slightly to create

flexion and extension of the knee and hip.

Face the supine patient’s head, sitting on the side to be treated Place the patient’s leg over your shoulder, leg, or pillows to stabilize and augment the treatment (leg

higher than the heart).

Posteriorly Subluxed Meniscus Technique: Supine direct ligamentous articular release

Symptoms/Diagnosis: Pain in the knee, quite often anterior and inferior to the patella and either lateral or medial. There may be pain deep in the middle of the knee accompanied by a popping or clicking sensation. There may also be a Baker’s cyst present.

The patient is supine with the legs straight and relaxed.

The physician stands or sits at the side of the table inferior to the patient’s knee, facing the head of the table.

Once all strains in the popliteal fossa have been released (direct myofascial pressure works well in this space), palpate the back of the knee for any firm or tender lumps (looking for a posteriorly subluxed meniscus).

If either condition or a combination of both conditions is encountered, use the tip of the pad of the finger of one hand reinforced with the tip of the finger from the other hand to put direct, steady pressure on the posterior aspect of the meniscus until it slips back into its normal position and the lump disappears.

Balanced Ligamentous Tension: The ‘Million Dollar Knee’ Technique Compliments of Anne Wales, D.O.

TIBIOFEMORAL MOTION

The larger articular surface of the medial joint surface allows for internal rotation of the tibia on the femur during flexion

Associated with short leg

The larger articular surface of the medial joint surface allows for external rotation of the tibia on the femur during extension

Associated with long leg

Knee Extension Knee Flexion

Diagnosis of Tibial Rotation with Patient Seated The physician should make sure hip, fibular and ankle function is normalized to give greater efficacy and

duration to the technique; otherwise, dysfunctions in these areas may interfere with accurate diagnosis and treatment.

The patient is seated with knees slightly past the edge of the table so that the tibias may move freely.

The physician gently grasps the tibia with both hands from an anterior approach position.

The patient rotates their trunk to one side. The tibia should follow the turning of the shoulders based on the myofascial relationships of the lower leg with the thorax and pelvis. For example, turning the trunk right turns both tibias to the right; this is a subtle motion, but with practice becomes much more obvious.

The patient then returns to neutral.

The patient then turns their trunk in the opposite direction. Whichever direction the tibia doesn’t turn as far is the direction of limited motion.

Internally Rotated Tibia - The Gist: Same Shoulder + Plantarflex + Inhale

While performing the following maneuvers, the physician is gently grasping and following the motion of the tibia.

The patient turns their torso toward the side of the affected tibia, which brings the tibia into external rotation.

As the tibia externally rotates, the physician follows it.

The patient then plantarflexes the foot of the symptomatic knee and inhales deeply; this brings the patient’s tibia into even greater external rotation.

The physician should hold the tibia in this position.

Once these three maneuvers are accomplished and the tibia has gone as far as it can, the physician should firmly hold the tibia to prevent its return towards the center as you ask the patient to turn back to the center, and release their breath and relax their foot. This holds the tibia in external rotation.

It is very important for the physician to remain patient as this release may take a few minutes.

As release of the myofascial, ligamentous and articular components occurs, there will initially be a subtle, but increasingly obvious release of the tibia into external rotation. This often occurs in stages and ultimately will end at the physiologic barrier with the sensation of the knee joint decompressing and the tibia gently dropping towards the floor.

The physician should then gently allow the tibia to return to neutral and reassess the ROM.

Externally Rotated Tibia - The Gist: Opposite Shoulder + Dorsiflex + Exhale

While performing the following maneuvers, the physician is gently grasping and following the motion of the tibia.

The patient turns their torso toward the side opposite of the affected tibia, which brings the tibia into internal rotation.

As the tibia internally rotates, the physician follows it.

The patient then dorsiflexes the foot of the symptomatic knee and exhales deeply; this brings the patient’s tibia into even greater internal rotation.

The physician should hold the tibia in this position.

Once these three maneuvers are accomplished and the tibia has gone as far as it can, the physician should firmly hold the tibia to prevent its return towards the center as you ask the patient to turn back to the center, and release their breath and relax their foot. This holds the tibia in internal rotation.

It is very important for the physician to remain patient as this release may take a few minutes.

As release of the myofascial, ligamentous and articular components occurs, there will initially be a subtle, but increasingly obvious release of the tibia into internal rotation. This often occurs in stages and ultimately will end at the physiologic barrier with the sensation of the knee joint decompressing and the tibia gently dropping towards the floor.

The physician should then gently allow the tibia to return to neutral and reassess the ROM.

HVLA – Fibular Head

Fibular Head Physiologic Motion

The proximal fibular head moves in anterolateral and posteromedial directions, relative to the proximal tibia

Reciprocal Motions

When the proximal fibular head moves posteriorly, the distal fibula moves anteriorly (and vice versa).

Related Motion

External rotation of the tibia causes the proximal fibular head to move anteriorly (and the distal fibula, posteriorly).

Somatic Dysfunction Dx

Anterior fibular head Fibular head prefers anterior movement/position Fibular head has restricted posterior movement

Posterior fibular head Fibular head prefers posterior movement/position Fibular head has restricted anterior movement

Reciprocal motions. External rotation of the tibia (C) moves the distal fibula posteriorly (B) and reciprocally is associated with the fibular head moving anteriorly (B1). The opposite is true (A, A1) with internal rotation (D) of the lower leg. (Illustration by W.A. Kuchera.)

FOM 3rd edition Fig. 42.15

Fibular Head Diagnosis

• Hold the leg in place with one hand around it, and your thumb in front of the tibia (not shown). Grip the fibular head between your thumb and index finger.

• Push posteromedially and pull anterolaterally along the glide path to test motion.

• Anterolateral glide • An anterior fibular head resists posteromedial motion.

• Posteromedial glide • A posterior fibular head resists anterolateral motion.

• You may perform the test with the patient seated or supine. If supine, the knee should be flexed 15°.

Posterior Fibular Head HVLA

1. Flex the hip and knee. 2. Place the proximal phalanx of your index finger (or MTP

joint) behind the fibular head as a wedge. 3. Start externally rotating the tibia through the ankle

(reciprocal motion moves the fibular head anteriorly as cylindrical rotation compresses the fibular head against your wedge).

4. At the same time, increase knee flexion to take out the tissue slack, applying slight lateral traction with the hand behind the fibular head.

5. When you reach the barrier, direct a short lever thrust by flexing the knee further (long lever).

Peroneal Neuropathy

Damage to the peroneal nerve that causes some sensory loss, but primarily muscle weakness of the muscles that dorsi flex the foot. The patients usually have a foot drop and what is termed “steppage gait.”

These neuropathies can be induced by trauma. The peroneal nerve runs around the posterior portion of the fibular head before diving deep into the leg.

Counterstrain - Knee

Anterior Cruciate Ligament ANTERIOR

VIEW POSTERIOR

VIEW

ANTERIOR CRUCIATE LIGAMENT (ACL)

Tenderpoint Locations: In the hamstring muscle tendons at the level of the widest part of

the popliteal space (medially and laterally) (L. Jones preferred)

Fibular Head

ACL

PCL

© Kitokophotography 2016 Eva Shay DO

ACL Patient supine

Stand on the side of the tenderpoint

Place a rolled up towel under the distal femur

Slowly, gently push the tibia posteriorly to shorten the ACL

at times up to forty pounds of force may be needed

Monitors the tenderpoint for tissue texture changes

Re-check tenderness after 30 seconds

Hold for a minimum of 90 seconds

Slowly take the patient out of the treatment position

Retest

Posterior Cruciate Ligament

POSTERIOR VIEW

ANTERIOR VIEW

POSTERIOR CRUCIATE LIGAMENT (PCL)

Tenderpoint Location: Close to the middle of the popliteal space (L. Jones preferred)

PCL Patient lies supine

Physician stands on the side of the tenderpoint

A rolled up towel is placed under the proximal tibia

The femur is pushed posteriorly

Shortens PCL

Requires some force

Force is applied slowly and gently

Physician monitors the tenderpoint for tissue texture changes during treatment

Physician re-checks tenderness every 30 seconds


Slowly take patient out of treatment position

Recheck tenderpoint

MEDIAL MENISCUS / MEDIAL COLLATERAL LIGAMENT


Tenderpoint Location:

Antero-medial aspect of the meniscus on the joint line

Medial Hamstring


Flexion/Adduction/internal rotation

Patient lies supine

Physician sits on the side of the tenderpoint

Patient hangs the leg off of the table Knee is flexed to about 60°

Applied force is mostly internal rotation of the tibia

Slight adduction of the tibia (varus)





Recheck tenderpoint

** Caution is emphasized against too much adduction secondary to the long lever of the leg

MEDIAL HAMSTRING (SEMIMEMBRANOSIS)

Tenderpoint Location: 1. Either in front of or behind the attachment of the medial hamstring (L. Jones preferred)

2. In the posterior thigh medial to the midline approximately halfway down the shaft of the femur

1

2

Medial Hamstring / Semimembranosus counterstrain tenderpoints

Right leg Left leg Left leg

1

2

MEDIAL HAMSTRING

Flexion/Internal Rotation of lower leg/adduct leg

Patient lies supine or prone

Physician stands on the side of the tenderpoint

Hip and knee flexed to about 90°

Leg/Knee is adducted

Internally rotated lower leg

Almost all force with rotation

Plantar flexion of the ankle





Recheck tenderpoint Physician may ABduct the opposite leg so as to facilitate the Adduction.

LATERAL MENISCUS / LATERAL COLLATERAL LIGAMENT

LATERAL MENISCUS / LATERAL COLLATERAL LIGAMENT

Tenderpoint Location: Lateral aspect of the meniscus on the joint line

Patellar Tendon

Lateral Meniscus

Lateral Collateral Ligament

Lateral Hamstring

Tibial Tuberosity

Lateral Meniscus

Patellar Tendon

Patellar Tenderpoints

Medial Meniscus

Knee Extender Tenderpoints

LATERAL MENISCUS/LATERAL COLLATERAL LIGAMENT Flexion/Slight abduction/+/- Internal or External

rotation This treatment is variable

Patient lies supine

Physician sits on the side of the tenderpoint

Patient hangs the leg off of the table

Knee is flexed to about 35-40°

Slight abduction of tibia

May require mild internal or external rotation) of the tibia





Recheck tenderpoint

Lateral Hamstring (Biceps femoris)

Tenderpoint Location:

1. Lateral aspect of the meniscus on the joint line

(L. Jones preferred) 2. In the posterior

thigh lateral to the midline approximately halfway down the shaft of the femur

1

2

Lateral Hamstring / Long Head Biceps Femoris counterstrain tenderpoints

LATERAL HAMSTRING Flexion/External rotation of lower leg/abduction

of upper & lower leg

Patient lies supine or prone

Physician sits stands on the side of the tenderpoint

Knee flexed to about 90°

Leg/Knee slight abducted

Externally rotated lower leg

Almost all force with rotation

Plantar flexion of the ankle





Recheck tenderpoint

KNEE EXTENDERS

3 Tenderpoints for the Knee Extenders

Over the front (anterior) of the medial meniscus

On the patellar tendon

On the front medial surface of the tibia

Patient complains of pain with hyperflexion (i.e. squat)

1. ANTERIOR ASPECT OF MEDIAL MENISCUS Hyperextension ± Internal Rotation

2. PATELLAR TENDON Hyperextension ± Internal Rotation

3. REGION OF TIBIAL TUBEROSITY Hyperextension ± External Rotation

PATELLA Patient

complains of pain usually felt 1.5” above the patella

Tenderpoints are found along the perimeter of the patella

Treatment is pressure (only a few ounces) over the part of the perimeter of the patella that is opposite of the tenderpoint

Knee Counterstrain

Tenderpoint Location

Treatment

Anterior Cruciate Ligament (ACL)

In the hamstring muscle tendons at the level of the widest part of the popliteal space (medially and laterally)

Place a rolled up towel under the distal femur Slowly, gently push the tibia posteriorly to shorten the ACL

Posterior Cruciate Ligament (PCL)

Close to the middle of the popliteal space A rolled up towel is placed under the proximal tibia The femur is pushed posteriorly & shortens PCL Requires some force Force is applied slowly and gently

Medial meniscus/ Medial collateral ligament

Antero-medial aspect of the meniscus on the joint line

Patient hangs the leg off of the table Knee is flexed to about 60° Applied force is mostly internal rotation of the tibia Slight adduction of the tibia (varus)

Medial hamstring (Semi-membranosis)

1. In the posterior thigh medial to the midline approximately halfway down the shaft of the femur 2. Either in front of or behind the attachment of the medial hamstring

Hip and knee flexed to about 90° Leg/Knee is adducted Internally rotated lower leg Plantar flexion of the ankle by compression on the calcaneus

Knee Counterstrain

Tenderpoint Location

Treatment

Lateral meniscus/ Lateral collateral ligament

Lateral aspect of the meniscus on the joint line

This treatment is variable: Patient hangs the leg off of the table, Knee is flexed to about 35-40° Slight abduction of tibia May require mild internal or external rotation) of the tibia

Lateral hamstring (Biceps femoris)

1. In the posterior thigh lateral to the midline approximately halfway down the shaft of the femur 2. Lateral aspect of the meniscus on the joint line

Knee flexed to about 90° Leg/Knee slight abducted Externally rotated lower leg Almost all force with rotation Plantar flexion of the ankle by compression on the calcaneus

Knee extenders 3 Tenderpoints for the Knee Extenders 1. Over the front (anterior) of the medial

meniscus 2. On the patellar tendon 3. On the front medial surface of the tibia

1 & 2 Hyperextension and ± Internal Rotation 3. Hyperextension and ± External Rotation

Patella Found along the perimeter of the patella

Pressure (only a few ounces) over the part of the perimeter of the patella that is opposite of the tenderpoint

Knee Counterstrain Tenderpoint Location Treatment

Anterior Cruciate Ligament (ACL)

In the hamstring muscle tendons at the level of the widest part of the popliteal space (medially and laterally)

Place a rolled up towel under the distal femur Slowly, gently push the tibia posteriorly to shorten the ACL

Posterior Cruciate Ligament (PCL)

Close to the middle of the popliteal space A rolled up towel is placed under the proximal tibia The femur is pushed posteriorly which shortens PCL, Requires some force, Force is applied slowly and gently

Medial meniscus/ Medial collateral ligament

Antero-medial aspect of the meniscus on the joint line Patient hangs the leg off of the table, Knee is flexed to about 60° Applied force is mostly internal rotation of the tibia, Slight adduction of the tibia (varus)

Medial hamstring (Semi-membranosis)

1. In the posterior thigh medial to the midline approximately halfway down the shaft of the femur 2. Either in front of or behind the attachment of the medial hamstring

Hip and knee flexed to about 90° Leg/Knee is adducted, Internally rotated lower leg, Plantar flexion of the ankle by compression on the calcaneus

Lateral meniscus/ Lateral collateral ligament

Lateral aspect of the meniscus on the joint line This treatment is variable: Patient hangs the leg off of the table, Knee is flexed to about 35-40°, Slight abduction of tibia, May require mild internal or external rotation) of the tibia

Lateral hamstring (Long Head-Biceps femoris)

1. In the posterior thigh lateral to the midline approximately halfway down the shaft of the femur 2. Lateral aspect of the meniscus on the joint line

Knee flexed to about 90°, Leg/Knee slight abducted, Externally rotated lower leg, Almost all force with rotation Plantar flexion of the ankle by compression on the calcaneus

Knee extenders 3 Tenderpoints for the Knee Extenders 1. Over the front (anterior) of the medial meniscus 2. On the patellar tendon 3. On the front medial surface of the tibia

1 & 2 Hyperextension and ± Internal Rotation 3. Hyperextension and ± External Rotation

Patella Found along the perimeter of the patella

Pressure (only a few ounces) over the part of the perimeter of the patella that is opposite of the tenderpoint

Documents

Osteopathic Evaluation and Treatment of the Hip & Knee · Osteopathic Evaluation and Treatment of the Hip & Knee LOMA August 20, 2016 New Orleans, Louisiana Eva B. Shay, D.O. Assistant