Functional Movement Analysis in the Differential Diagnosis of a Patient with a Posterolateral Corner Knee Injury
DOI:
https://doi.org/10.17140/SEMOJ-1-108Keywords:
Functional Movement Assessment (FMA), Observational gait analysis, Postero lateral corner, Knee painAbstract
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.
References
La Prade RF, Heikes C, Bakker AJ, Jakobsen RB. The re-producibility and repeatability of varus stress radiographs in the assessment of isolated fibular collateral ligament and grade-III posterolateral knee injuries: an in vitro biomechanical study. J Bone Joint Surg Am. 2008; 90: 2069-2076. doi: 10.2106/ JBJS.G.00979
Devitt BM, Whelan DB. Physical examination and imaging of the lateral collateral ligament and posterolateral corner of the knee. Sports Med Arthrosc. 2015; 23(1): 10-16. doi: 10.1097/ JSA.0000000000000046
Bonadio MB, Helito CP, Gury LA, Demange MK, Pecora JR, Angelini FJ. Correlation between magnetic resonance imaging and physical exam in assessment of injuries to posterolateral corner of the knee. Acta Ortop Bras. 2014; 22(3): 124-126. doi: 10.1590/1413-78522014220300928
Cooperman JM, Riddle DL, Rothstein J. Reliability and va-lidity of judgments of the integrity of the anterior cruciate liga-ment of the knee using the Lachman test. Phys Ther. 1990; 70: 225-233.
Choi JY, Chang CB, Kim TK, Hong SH, Kang HS. Mag-netic resonance imaging findings of the lateral collateral liga-ment and popliteus tendon in symptomatic knees without in-stability. Arthroscopy. 2015; 31(4): 665-672. doi: 10.1016/j. arthro.2014.11.027
Binkley JM, Stratford PW, Lott SA, et al. The lower extrem-ity functional scale (LEFS): scale development, measurement properties and clinical application. Phys Ther. 1999; 79(4): 371- 383.
Alford W, Cole BJ. The indications and technique for menis-cal transplant. Orthop Clin North Am. 2005; 36: 469-484. doi: 10.1016/j.ocl.2005.05.003
Dutton, Mark. Fundamentals of Orthopedics. In: Catherine Johnson and Christie Naglieri, eds. Orthopedic Examination, Evaluation and Intervention. 2nd ed. Chicago: McGraw Hill; 2008: 217.
Newmann, DA. Essential Topics of Kinesiology - Biome-chanical Principles. In Nawoczenski DA, Newmann DA, eds. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. 1st ed. Philadelphia: Mosby, Inc; 2002: 434-476.
Newmann, DA. Lower Extremity - Knee. In: Newmann DA, ed. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. 1st ed. Philadelphia: Mosby, Inc; 2002: 434-476.
Dutton, Mark. The Nervous System. In: Johnson C, Naglieri C, eds. Orthopedic Examination, Evaluation and Intervention. 2nd ed. Chicago: McGraw Hill; 2008: 72-74, 78-88.
Finlayson ML, Peterson EW, Cho CC. Risk factors for fall-ing among people aged 45 to 90 years with multiple sclerosis. Archives of Physical Medicine and Rehabilitation. 2006; 87: 1274-1249. doi: 10.1016/j.apmr.2006.06.002
Cameron MH, Lord S. Postural control in multiples scle-rosis: implications for fall prevention. Current Neurology and Neuroscience Reports. 2010; 10: 407-412. doi: 10.1007/s11910- 010-0128-0
Harilainen A. Evaluation of knee instability in acute liga-mentous injuries. Ann Chir Gynaecol. 1987; 76: 269-273.
Bae JH, Choi IC, Suh SW, et al. Evaluation of the reliability of the dial test for posterolateral rotatory instability: a cadaveric study using an isotonic rotation machine. Arthroscopy. 2008; 24: 593-598.
Jung YB, Lee YS, Jung HJ, Nam CH. Evaluation of pos-terolateral rotatory knee instability using the dial test accord-ing to tibial positioning. Arthroscopy. 2009; 25: 257-261. doi: 10.1016/j.arthro.2008.10.007
Katz, JW, Fongeroth RJ. The diagnostic accuracy of ruptures of the anterior cruciate ligament comparing the Lachman test, the anterior drawer sign, and the pivot shift test in acute and chronic knee injuries. Am J Sports Med. 1986; 14: 88-91.
Kim SJ, Kim HK. Reliability of the anterior drawer test, the pivot shift test and the Lachman test. Clin Orthop. 1995; 317: 237-242.
Cooper JM, McAndrews PT, LaPrade RF. Posterolateral corner injuries of the knee: anatomy, diagnosis, and treatment. Sports Med Arthrosc. 2006; 14: 213-220.
Evans PJ, Bell GD, Frank C. Prospective evaluation of the McMurray test. Am J Sports Med. 1993; 21: 604-608.
Boeree NR, Ackroyd CE. Assessment of the menisci and cruciate ligaments: an audit of clinical practice. Injury. 1991; 22: 291-294.
Leibold MR, Huijbregts PA, Jensen R. Concurrent criteri-on-related validity of physical examination tests for hip labral lesions: a systematic review. J Man Manip Ther. 2008; 16(2): E24-E41.
Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. 1st ed. New York: Thieme; 2008: 376-377.
Martin RL, Sekiya JK. The interrater reliability of four clini-cal tests used to assess individuals with musculoskeletal hip pain. J Orthop Sports Phys Ther. 2008; 38(2): 71-77. doi: 10.2519/ jospt.2008.2677
LaPrade RF, Gilbert TJ, Bollom TS, Wentorf F, Chaljub G. The magnetic resonance imaging appearance of individual struc-tures of the postero-lateral knee. A prospective study of normal knees and knees with surgically verified grade III injuries. Am J Sports Med. 2000; 28: 191-199.
Gwathmey FW, Tompkins MA, Gaskin CM, et al. Can stress radiography of the knee help characterize posterolateral corner injury? Clin Orthop Relat Res. 2012; 470: 768-773. doi: 10.1007/ s11999-011-2008-6
Souza RB, Selkowitz D, Powers CM. The effect of femoral strapping on pain response, hip rotation and gluteus maximus activation in persons with patellofemoral pain. Physiotherapy. 2007; 93: S198.
LaPrade RF, Terry GC. Injuries to the posterolateral aspect of the knee. Association of anatomic injury patterns with clinical instability. Am J Sports Med. 1997; 25: 433-438.
Meister BR, Michael SP, Moyer RA, Kelly JD, Schneck CD. Anatomy and kinematics of the lateral collateral ligament of the knee. Am J Sports Med. 2000; 28: 869-878.
Grood ES, Noyes FR, Butler DL, Suntay WJ. Ligamentous and capsular restraints preventing straight medial and lateral lax-ity in intact human cadaver knees. J Bone Joint Surg Am. 1981; 63: 1257-1269.
Csintalan RP, Ehsan A, McGarry MH, Fithian DF, Lee TQ. Biomechanical and anatomical effects of an external rotational torque applied to the knee: a cadaveric study. Am J Sports Med. 2006; 34: 1623-1629. doi: 10.1177/0363546506288013
Fanelli GC, Edson CJ. Posterior cruciate ligament injuries in trauma patients: part II. Arthroscopy. 1995; 11: 526-529.
LaPrade RF, Wentorf FA, Fritts H, Gundry C, High- tower CD. A prospective magnetic resonance imaging study of the in-cidence of posterolateral and multiple ligament injuries in acute knee injuries presenting with a hemarthrosis. Arthroscopy. 2007; 23: 1341-1347. doi: 10.1016/j.arthro.2007.07.024
LaPrade RF, Wentorf F. Diagnosis and treatment of postero-lateral knee injuries. Clin Orthop Relat Res. 2002; 110-121.
Nielsen S, Helmig P. Posterior instability of the knee joint. An experimental study. Arch Orthop Trauma Surg. 1986; 105: 121-125.
Lunden, JB, Bzdusek PJ, Monson JK, et al. Current concepts in the recognition and treatment of posterolateral corner injuries of the knee. J Orthop Sports Phys Ther. 2010; 40(8): 502-516. doi: 10.2519/jospt.2010.3269
Morris C, Chaitow L, Janda V. Funtional examination for low back syndromes. In: Morris C, ed. Low Back Syndromes: Integrated Clinical Management. New York: McGraw-Hill; 2006: 333-416.
Goodman CC, Snyder TK: Introduction to the interviewing process. In: Goodman CC, Snyder TK, eds. Differential Diagno-sis in Physical Therapy. Philadelphia, PA: WB Saunders; 1990: 7-42.
Graven-Nielsen T, Lund H, Arendt-Nielsen L, et al. Inhi-bition of maximal voluntary contraction force by experimental muscle pain: a centrally mediated mechanism. Muscle Nerve. 2002; 26: 708-712. doi: 10.1002/mus.10225
Downloads
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
All content published in Sports and Exercise Medicine (SEM) is licensed under the Creative Commons Attribution 4.0 International License (CC BY 4.0). This license allows anyone to copy, distribute, transmit, and adapt the work — including for commercial purposes — provided appropriate credit is given to the original author(s) and source.
