Sports and Exercise Medicine · Vol. 1, No. 2 · 2015 · pp. 47–53 · e-ISSN 2379-6391

Functional Movement Analysis in the Differential Diagnosis of a Patient with a Posterolateral Corner Knee Injury

Santo S. Riva, Jonathan C. Sum, George F. Rick Hatch III

Victory Performance and Physical Therapy, Los Angeles, CA, USAUnited States
Division of Biokinesiology and Physical Therapy, Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USAUnited States
Department of Orthopedics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USAUnited States

DOI: https://doi.org/10.17140/semoj-1-108 · Published 2015-06-04 · Licence: https://creativecommons.org/licenses/by/4.0 · © 2015 The Author(s)

Also available as PDF (figures and tables appear in the PDF).

Abstract

Study Design: Resident’s case study. Background and Purpose: Functional Movement Analysis (FMA) including observational gait analysis are powerful tools that can be used to guide patient examination and differential diagnosis process. Case description: An 18-year-old female was referred to physical therapy with a diagnosis of gait abnormality and a chief complaint of left medial knee and left medial hip pain. Two orthopedic surgeons suspected neurologic pathology due to inconclusive findings on physical examination, an abnormal antalgic gait pattern, and negative findings on Magnetic Resonance Imaging (MRI) and radiographic studies. The physical therapist gathered a comprehensive subjective history, and performed a functional movement analysis including observational gait analysis. The findings were used to guide a full musculoskeletal examination. Correlating the functional movement analysis with subjective history and comprehensive musculoskeletal examination, the therapist found the patient to have subtle but definite lateral knee joint laxity. This was hypothesized to be driving the abnormal gait pattern and causing her hip and knee pain. Outcomes: Stress radiographs, suggested by the physical therapist, were ordered and confirmed the therapist’s finding of lateral knee instability. The patient subsequently had surgery to repair and augment her popliteal fibular ligament and lateral collateral ligament. She underwent post operative physical therapy, and returned to her prior level of function with full resolution of her gait deviations and pain. Discussion: Functional movement analysis is a powerful and unique tool that clinicians can use when evaluating and treating patients. Level of Evidence: Therapy, level 4.

Keywords: Functional Movement Assessment (FMA); Observational gait analysis; Postero lateral corner; Knee pain; Postero- lateral corner

Discussion

The patient’s gait demonstrated an abnormal varus thrust during loading response that was not seen on the contral ateral limb. This was immediately followed by valgus collapse during the mid-stance phase of gait. This gait deviation may indicate that the lateral knee structures, specifically the LCL, could be compromised. Injury to the LCL is the least common of all knee ligament injuries with an incidence of 4%. Injury to the LCL usually occurs as a soft-tissue avulsion off the proximal attachment on the femur or as a bone avulsion associated with an arcuate fracture of the fibular head. 3,27 LCL injuries usually are part of more extensive injuries that involve the PLC.27 The LCL attaches to the femur approximately equidistant from the posterior and distal borders of the lateral femoral condyle and distally to a superior and laterally facing V-shaped plateau on the head of the fibula. 28 It is the main structure responsible for resisting varus stress, particularly in the initial 0° to 30° of knee flexion, and limits external rotation of a flexed knee.29,30 Posterolateral corner injuries account for 16% of all knee ligament injuries and often occur in combination with other ligament injuries.31-33 Most common mechanisms of injury include: a blow to the anteromedial aspect of the knee when the joint is in or near full extension; contact and noncontact hyperextension injuries; a valgus contact force applied to a flexed knee; or extreme tibial external rotation with the knee in flexion or hyperextension.30,31 The three most important stabilizing structures of the posterolateral knee are the PFL, popliteus tendon, and fibular collateral ligament. 34 Their main role is to prevent excessive knee varus, tibial external rotation and posterolater al rotation.35,36 Though it is unclear from the description of the original injury, this patient may have injured her PLC, PFL and popliteus tendon with a similar knee varus and tibial external rotation overload, either from the lateral kick or the lateral lunge. Patients who have suffered an injury to their posterolateral cor ner commonly present with altered gait mechanics, however a recognizable pattern has not yet been reported. In this and other clinicians’ experiences, a varus force at the knee can commonly be seen during the loading response to mid-stance phases of gait.3 The patient may then fully contract the quadriceps to lock out the knee in hyperextension in order to create additional stability through the passive intact posterior knee structures and compression of the tibiofemoral joint.30 As seen with the patient presented in this case study, it is also possible that they will overcorrect a varus thrust using a compensatory valgus thrust during the phases of loading response to mid-stance. This pattern allows for support by medial passive and active structures such as the medial collateral ligament, semimembranosus, semitendinosus, sartorius and gracilis.30 It is important to note that while a standard physical examination with special testing for structural integrity is vital to the evaluation process; functional movement analysis can significantly affect the differential diagnosis. In this case study, the functional movement and gait analysis helped guide the clini cian to request appropriate imaging and ultimately lead to a correct diagnosis, which was confirmed intraoperatively.37-39

Conclusion

In this case study, a very systematic approach to col- Radiograph with varus stress applied in knee flexion, revealing lateral joint line laxity.

Figure 1. Stress radiographs left knee.

lecting subjective information led to functional movement tests and table examination that revealed findings contrary to the or thopedists’ impression and imaging results. These findings were used to help guide clinical reasoning and ultimately confirm the hypothesis of lateral instability.

While there is more discussion about the use of functional movement analysis, the literature is sparse defining how and when it should be implemented. It is a powerful and unique tool physical therapists can use in evaluating and treating patients. The findings should always be correlated with subjective information, objective tests and measures, and be confirmed by imaging when possible. More research should be done to demonstrate the role of functional movement analysis, and how it can best be implemented to determine a patient’s diagnosis and treatment plan.

Acknowledgements

A special thank you to Dr. Kornelia Kulig, PT, PhD, FAPTA, FFAAOMPT for her initial guidance with this manuscript.

Conflicts Of Interest

The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the manuscript.

Consent

For the videos shown in the practise, we have obtained the consent statement from the girl who was involved in this case study.

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