Clinical Anatomy Quiz 4 - Lower Extremity, ALL LE, Clinical Anatomy Quiz 5 - LE#2

Patella Alta and Patella Baja

#1

4 Layers of the Foot: AFA 22 FAF Interossei

#1: AFA: Abductor Hallucis, Flexor Digitorum Brevis, Abductor Digiti Minimi #2: 22: 2 tendons (Flexor Hallucis Longus, Flexor Digitorum Longus), 2 muscles (Quadratus Plantae, Lumbricals) #3: FAF: Flexor Digiti Minimi, Adductor Hallucis, Flexor Hallucis Brevis #4: Interossei

Patella Alta and Patella Baja2

#2

Calcaneal Fractures

(A) Hard fall from a ladder on heel can produce comminuted fracture. Usually disabling because it disrupts subtalar (talocalcaneal) joint

Medial Meniscal Attachments

(Firm attachments - torn more frequently) -MCL -Semimembranosus through capsule -Few fibers from anterior horn from ACL

Genu Valgum

(Knock-knee) Frequently observed in children 2-4 years. -Persistence into late childhood could lead to deformity. -Eventually will lead to wear/tear on articular cartilages.

Lateral Meniscal Attachments

(Loose connections for mobility - less tears)-PCL-Variable attachment to ACL-Popliteus muscle-Posterior meniscofemoral ligaments

Fibular Bone Grafts

*-If long piece of fibula is removed, ability to walk, jump and run can be normal* -Fibula good option for bone graft because it's proximity to surface, length, and function as non-weight bearing bone Use it for: -Congenital bone defects -Replace segments of bone removed due to trauma/tumor

What to avoid in Non-Operative Rehab of PCL

*AVOID strengthening at deep flexion angles - PROTECT PATELLA *NO Isolated (OKC) hamstring strengthening - get plenty of it with other activities

Injury Variables: Open Fractures

- Impeding or preventing formation of Hematoma Delaying formation repair tissue Risk of infection

Movement of Meniscus: Flexion/Extension

-Menisci follow point of contact between femoral and tibial condyles -Move posteriorly in flexion (relative to tibia)-Move anteriorly in extension

Diagnosing ITBS

-Noble compression test- positioned with the knee at 90 degrees of flexion- pressure is applied at the proximal prominent part of the lateral femoral condyle as the knee is gradually extended +30-40 degrees with pain -(Rennes)-Creak test- patient stands on involved leg- as they flex to about 30 degrees- a creak will occur over the lateral femoral condye -Ober- tests itb length

Posterior Drawer Test

-PCL-Arcuate-popliteus complex-Posterior oblique ligament-ACL

Ottawa Ankle Guidelines

-Palpation that reveals tenderness over the medial malleolus, lateral malleolus, navicular, and/or base of the fifth metatarsal; -Inability to WB immediately following injury or during the clinical evaluation -Tenderness that extends 6 cm superiorly from the tip of either malleolus, not over the ATFL -Radiographs should be performed immediately if gross abnormalities are visualized

Treatment for Hip Dislocation

-Reduction (open vs closed) - surgically open. -THR revision (constrained liner) -Bracing (hip abd. brace)

femoral patella joint

-Sellar joint (saddle)-Modified plane joint

-Radial/Ulnar Styloid Process -Distal Radioulnar Joint

...

3 C's for Considering Soft Tissue Injuries of the Knee

1. Collateral Ligaments 2. Cruciate Ligaments 3. Cartilages or menisci

bony end feel

1. Feels like: Bone to bone approximation 2. Hard, abrupt stop 3. i.e. elbow extension

Factors Affecting Bone Formation

1. Fracture Type 2. Gap condition - space between bones 3. Fixation rigidity (pin-bone interface stresses) 4. Loading 5. Biological environment

Proximal Humeral Fracture: 4 main spots

1. GREATER TUBEROSITY: supra/infraspinatus insertion 2. SURGICAL NECK/SHAFT: deltoid/pectoralis major largely dictates fx behavior compression: stable shear: unstable 3. HUMERAL HEAD: Affects blood supply Risk of AVN 4. LESSER TUBEROSITY: subscapularis insertion

Superficial Muscle Group

1. Gastrocnemius 2. Soleus 3. Plantaris -Plantar flexors -Large due to upright stance - must support body weight. INNERVATION: Tibial Nerve

*2 Major Superficial Veins of Lower Limb*

1. Great Saphenous Vein 2. Small Saphenous Vein

Common Rehab setbacks

1. Hip flexor contracture -Trigger point release -Thomas stretch 2. Meralgia Paresthetica -Neuropraxia of lateral femoral cutaneous nerve (especially for anterior approach) 3. Gluteus medius tendinitis (Similar clinical presentation to trochanteric bursitis) -Slow down - back to basics 4. Quadratus Lumborum tenderness -Pain at pelvic ridge

4 Parts to Lower Limb

1. Hip: Iliac crest -> thigh 2. Thigh: Femur/patella 3. Leg: Tibia/Fibula 4. Foot: Tarsus, Metatarsus, Phalanges

TMT Joint Ligaments

1. Interosseous 2. Dorsal TMT ligament 3. Plantar TMT Ligament

6 external rotators of the hip

1. Piriformis 2. Obturator Internus 3. Superior Gemell i4. Inferior Gemelli 5. Quadratus Femoris 6. Obturator Externus

6 Lateral Rotators of Thigh

1. Piriformis 2. Obturator Internus 3. Superior Gemelli 4. Inferior Gemelli 5. Quadratus Femoris 6. Obturator Externus

Midfoot Plantar Ligaments

1. Plantar Calcaneonavicular (Spring) Ligament 2. Plantar Calcaneocuboid (Short Plantar) Ligament 3. Long Plantar Ligament

Important Veins of Popliteal Fossa

1. Popliteal Vein: Formed at distal border of popliteus close to popliteal artery. Lies superficial to and in same fibrous sheath as artery. Ends at adductor hiatus (becomes femoral vein) 2. Small Saphenous Vein: {asses from posterior aspect of lateral malleolus. Pierces deep popliteal fascia and enters popliteal vein.

Deep Muscles of Posterior Compartment

1. Popliteus 2. Flexor Digitorum Longus 3. Flexor Hallucis Longus 4. Tibialis Posterior

Types of Fixation

1. Porous-No cement used. NEED good bone quality.-Press fit (shoved in) or fixated with screws. -Biologic fixation - coats with hydroxyapetate to promote bone growth and prevents body from seeing components as foreign bodies .2. Cemented (NOT COMMON) 3. Hybrid-Acetabular cup is press fit/screwed into socket-Femoral stem is cemented into femoral shaft

capsular firm end feel

1. Sub-acute, gentle movement and stretching (joint mob) 2. Feels like: Firm stop with reduced or absent creep 3. Similar to normal but now occurs before normal range is achieved. 4. Tighten capsule 5. Indication: Capsular pattern with abnormal ROM 6. Example: shoulder at end ER

Superior vs. Inferior tibio-fibular joint

1. Superior = diarthrodial, plane synovial ARTICULAR SURFACES: Convex tibiaConcave fibula 2. Inferior = synarthrodial (good for weight-bearing stress off talus)*two articulations above talocrural joint that are important to its integrity fibula- convex tibia- concave

Main Bursae Around Knee

1. Suprapatellar Bursa 2. Popliteus Bursa 3. Subcutaneous Prepatellar Bursa 4. Subcutaneous Infrapatellar Bursa 5. Deep Infrapatellar Bursa

CORE

1. TA 2. Pelvic floor muscles 3. Diaphragm 4. Multifidi AUTOMATIC FIRING

Midfoot (Midtarsal) Joints

1. Talonavicular 2. Cuneonavicular 3. Cuboidonavicular 4. Intercuneiform 5. Calcaneocuboid Synovial

2. Appropriate Resistance OR Agonist contraction (AC)

1. The pt. is cued to move into the low resistance of the therapist moving the limb in the direction that is restricted 2. This helps inhibit the antagonist muscle due to reciprocal inhibition 3. This is followed by slow passive stretch in the same direction

Thumb Techniques

1. Thumbs resting behind greater trochanter 2. Thumbs superior to GT Patient in sidelying - pillow between legsUse Grade I or Grade IIOscillate A/P (soothing and rhythmic) RATIONALE: Endorphins - chemical release (systemic)NOT mechanical - (direction irrelevant) 3. SUPINE - resting position of hip-Pillow under knee-Hand on distal femur/proximal tibia-Oscillation of femur IR/ER

Anterior compartment of leg

1. Tib ant (sway back, TA contracts)2. EHL3. EDL4. Fibularis tertius

Midtarsal joint motion

1. subtalar pronation = midtarsal unlocked for supination or pronation-pronation in the hindfoot, raises lateral border of foot, supination of midtarsal (very subtle) 2. subtalar supination = locked to increase stability*cuboid is somewhat concave, while calcaneus is somewhat convex

% of fibula WB

10 percent

Leg Press (degrees and progression)

100° Progression - 2 legs, 2 up and 1 down, 1 up/down

Hindfoot: Inferior Tibiofibular Joint Resting Position

10° PF, midway between inversion and eversion NO Close packed or capsular pattern = NOT SYNOVIAL JOINT

Posterior Drawer Sign of Ankle

10° PFPush mortise backward Posterior talofibular ligament HYPOMOBILE - tight jointHYPERMOBILE - ligament sprain

Hip Flexion Goniometry, muscles/nerves, angles

130 degrees Iliopsoas - femoral nerve Sartorious - femoral nerve TFL - superior gluteal nerve rectus femoris- femoral nerve MMT Seated Pivot - greater trochanter Static Arm - mid axillary line Moving Arm - lateral femoral condyle

Normal flexion ROM for Tibiofemoral joint

140 degrees (160 for catcher's squat; gravity)

knee extension

140°-0 PIVOT: Lateral femoral condyle SA: Greater trochanter MA: Lateral malleolous POSITION: Supine-Put roll under leg to see for hyperextension Primary Mover: Quads NERVE: Femoral (L2-L4) POSITION: Sitting (allowed to lean back - tights hamstrings) RESISTANCE: Above malleoli (tibia) PALPATION: Interior thigh SUBSTITUTION: Hip flexion gravity eliminated side lying

4 Layers of the Foot:AFA 22 FAF Interossei

1: AFA: Abductor Hallucis, Flexor Digitorum Brevis, Abductor Digiti Minimi #2: 22: 2 tendons (Flexor Hallucis Longus, Flexor Digitorum Longus), 2 muscles (Quadratus Plantae, Lumbricals) #3: FAF: Flexor Digiti Minimi, Adductor Hallucis, Flexor Hallucis Brevis #4: Interossei

Metarsus

1st metatarsal is shorter and stouter than others 2nd is longest -Base of 5th metatarsal has a large tuberosity that projects over the lateral margin of the cuboid -On plantar surface of head of 1st metatarsal: prominent medial and lateral sesamoid bones that are embedded or covered by the plantar ligaments.

Knee Injuries: ACL

2 bands:-Posterolateral (most taut extension) Anteromedial (most taut flexion)

Scar Tissue Timeline

2-4 days: no collagen, stretch will disrupt 5-21 days: Scar tissue increases, collagen remodeling 21-60 days: Scar stops increasing, mainly collagen, vascularity decreases as strength increases 60 days-1 year: Collagen turnover remains high early on (dangerous), slow maturation.

THR Post-OP Recovery (D/C options)

2.04 days D/C options -In home (3-6x/week) -Acute (7-10 days up to 3 hours of therapy) -Subacute (>14 days, PT/OT varies)

Hip adduction

20 degreess Adductor Longus - obturator nerve Adductor Brevis - obturator nerve Adductor Magnus - obturator nerve and tibial branch of sciatic nerve (for hamstrings attachment) Gracilis - obturator nerve pectineus- femoral

Material Properties of Bone

22% organic matrix consisting of proteins (type I collagen, non-collagenous proteins, proteoglycans and phospholipids) 70% inorganic matrix consisting of mineral hydroxyapatite (HA) 8% water by weight

Resting Position

25-40 flexion

Ankle/Foot Complex

26 bones 55 joints (30 synovial) 25 component joints: -Talocrural (ankle jt) -Talocalcaneal (subtalar jt )-Talonavicular & Transverse Tarsal jts-Calcaneocuboid -5 TMT & 5 MTP jts-9 IPT jts

Body of Fibula

3 borders: 1. Anterior 2. Interosseous 3. Posterior 3 Surfaces 1. Medial 2. Posterior 3. Lateral

Thomas test

3-Way Thomas Test BRING Patients both legs to test and then let one go and hold other against their chest . 1. Hip flexor 2. Rectus Femoris 3. IT band (go into adduction) if begins to and- also sartorial tight cause hip flexor, er, and

Acetabular Fractures (complications/treatment)

4-5% of all fractures May be associated with femoral neck fracture, hip pain (pelvic ring fracture) -STRONG FORCE to cause it. Specific complications: -injury to femoral head -urogenital -Lumbosacral plexus injuries Treatment: Allow early ambulatory function Decrease the chance of posttraumatic OA

hip internal rotation

40-50 Glute Min - superior gluteal nerve TFL - superior gluteal nerve Seated - pivot - patella static and moving aligned with tibial crest to begin

Hip abduction

45 degrees gluteus medius/minimus- superior gluteal pivot- ASIS static arm- opposite ASIS Moving Arm Patella

Palpation of Dorsal Artery: 5 Ps

5 P signs of Acute Arterial Occlusion: 1. Pain 2. Pallor 3. Parasthesia 4. Paralysis 5. Pulselessness

hip external rotation

50-60 degrees 6 external rotators: Piriformis - nerve to piriformis Obturator Externus - obturator nerve Gemellus Superior - nerve to obturator internus Obturator Internus - nerve to obturator internus Gemellus Inferior - nerve to quadratus femoris Quadratus Femoris - nerve to quadratus femoris

external rotation mmt

6 external rotators:Piriformis - nerve to piriformis Gemellus Superior - nerve to obturator internus Obterator Externus - obturator Gemellus Inferior - nerve to quadratus femoris Obturator Internus - nerve to obturator internus Quadratus Femoris - nerve to quadratus femoris A.G. seated G.E. supine. begin with maximum internal rotation and then see if they can ext rotate with your hands bracing them. people in bed for a long time get tight lying in ext rotation all the time.substitution - flexion with abduction (sartorious)

When walking, max knee flexion is ____

65 degrees

Skipped

693-694

Posterior talofibular ligament:

: a strong band that extends medially and posteriorly from the distal part of the lateral malleolar fossa of the fibula to the lateral tubercle of the talus. It is also connected to the medial malleolus by a tibial slip of fibres.

Groin Pull

A strain, stretching, and probably some tearing of proximal attachments of anteromedial thigh muscles. -Usually involves flexor and adductor muscles. Proximal attachments of these muscles in inguinal region (groin). -Occur in sports that require quick starts.

Iliac crest -ASIS -PSIS

ASIS: L4/L5 level PSIS: S2 level

Adhesions

Abnormal adherence of collagen fibers to surrounding structures during immobilization, after trauma, or as a complication of surgery, which restricts normal elasticity and gliding of the structures involved.

Signs/Sx of Acute Exertional CS

Aching, burning, cramping pain -Tightness -Numbness/tingling -Weakness -Foot drop (nerve damage)

-Lateral Aspect of Acromion -Acromioclavicular Joint -Subacromial Space

Acromion is lateral aspect of scapular spine. AC joint - glide medially towards clavicle on acromion. Will feel small step onto clavicle - backtrack slightly. Subacromial space is right below AC joint on anterior side

Acute vs. Definitive Stages

Acute -Patient stabilization -Injury assessment - bony, soft tissue, neurovascular and visceral injuries, open wounds -Wound care -Reduction of joint dislocation Definitive -Definitive rigid fixation in optimal alignment -Appropriate rehabilitation

Contractures

Adaptive shortening of skin, fascia, muscle, or a joint capsule that prevents normal mobility or flexibility of that structure. STARTS in muscle before moving to joints.

Adductor tubercle

Adductor tubercle: medial side near VMO

*Subluxation

An incomplete or partial dislocation of the bony partners in a joint that often involves secondary trauma to surrounding soft tissue.

angle of torsion femur

Angle of Torsion line through head/neck of femur and one straight through condyles (flat in transverse plane)-Measure is of the anterior/posterior angle of head of femur into acetabulum. Acetabulum should have 20° of anteversion-Excessive IR is called anteversion (>15°). Someone with a lot of anteversion will use hip IR to offset it (pigeon toed). Excessive ER is called retroversion (<15°)-toe out

Ankle plantarflexion

Ankle plantarflexion 0-45/50°PIVOT: lateral malleolusSA: in line with fibulaMA: Parallel to 5th MTPOSITION: Prone with bent knee (take out gastroc) - doesn't have to be prone Primary Mover: GastrocnemiusNERVE: Tibial (S1-S2) POSITION: Standing (can support arm), single leg. 25x = 5 10-24 = 4 1-9 = 3 Prone w/ resistance full ROM = 2 RESISTANCE: Gravity PALPATION: back of calf SUBSTITUTION: Using arms, pelvic momentum

Superior Tibiofibular Joint Ligaments

Anterior (2-3 flat bands) and Posterior Superior TIbiofibular (stronger) ligaments reinforce capsuleInterosseous membrane

PFPS Sx

Anterior knee pain in and around the patella from :-Prolonged sitting -Squatting -Kneeling -Stair climbing

abnormal pelvic tilt

Anterior pelvic tilt: weak abs, tight hip flexors or back extensors Posterior pelvic tilt: tight hamstrings

Deltoids

Anterior: flex Middle: abduct Posterior: extend

Special Tests: Leg Length Discrepancy

Apparent: Umbilicus to medial malleolus True: ASIS to medial malleolus (attached to tibia) Can also break down to measure length of femur and tibia.

Gluteal Arteries

Arise from internal iliac arteries. MAJOR GLUTEAL BRANCHES: 1. Superior Gluteal Artery 2. Inferior Gluteal Artery 2. Internal Pudendal Artery

Femoral Ring

At base of femoral canal and extends distally to saphenous opening. -Allows femoral vein to expand when blood flow increases. -Contains loose CT, fat, lymphatic vessels and lymph nodes (Cloquet's node) BOUNDARIES: Laterally: Partition between femoral canal and femoral vein Posteriorly: Superior ramus of pubis covered by pectineus and fascia Medially: Lacunar ligament Anteriorly: Medial part of inguinal ligament

Lateral Distraction Mobilization of the hip

BEST FOR: Flexion OR extension (best for entire capsule stretched) POSITION: Supine -Ulnar borders on inside of groin -Lean in with shoulder for counter-force

Talocalcaneonavicular Joint Classification (°freedom, close packed, ligaments)

Ball and socket synovial Degrees of movement: 3 CLOSE PACKED: Supination LIGAMENTS: -Dorsal talonavicular-Bifurcate-Plantar calcaneonavicular (spring)

Coracoid Process

Beak-like projection inferior (<1.5 inches) to lateral aspect of clavicle.

ITBS: Recovery & Strengthening Phase

Begins once range of motion and myofascial restrictions are resolved Goals: Graded strength program- especially hip abductors Treatment:Side-lying clamshells, leg lifts Single leg step downs Pelvic drops3 plane lunges, bridges, standing hip abduction with theraband monster walks

Deep Plantar Arch

Begins opposite base of 5th metatarsal - completed medially by union with deep plantar artery. Crosses foot and gives off: -4 Plantar metatarsal arteries -3 Perforating arteries -Many branches to sole of foot that supply skin, fascia and muscles.

Mastoid Process

Behind ear and mandible.

Sustentaculum Tali

Below medial malleolus - evert/invert (pops out with eversion)

SHM: First 20° of knee flexion

Between 0°extension and 20° of flexion, posterior glide on the medial side produces relative tibial internal rotation, a reversal of the screw-home mechanism.

*Hemarthrosis

Bleeding into a joint, usually due to severe trauma.

Impacted Fracture

Bone ends are driven into each other eg: Buckle # commonly seen in arm # in children

Heterotopic Ossification (& Risk factors)

Bone formation in soft tissue that can limit ROM -Exact etiology unknown s/p THR RISK FACTORS -Males -Prolonged OR time with significant soft tissue trauma -Previous hip surgery -Pagets (Paget's disease of bone interferes with your body's normal recycling process, in which new bone tissue gradually replaces old bone tissue. Over time, the disease can cause affected bones to become fragile and misshapen)/ankylosing spondylitis

Cross friction massage

Break up adhesions

PCL

Broader, bigger and stronger than ACL. With ACL determines gliding/sliding of tibia and femur -Dashboard injury = PCL (no ligamentous synergists in flexed knee -Increased forces with hamstring loading 12-100° MOI: A/P forced on flexed knee -Rotary force with varus or valgus force

*Contusion

Bruising from a direct blow, resulting in capillary rupture, bleeding, edema, and an inflammatory response.

Patellar Fractures

CAUSE: Direct blow to patella. Fracture in 2 or more fragments. Transverse fracture: blow to knee, sudden contraction of quad (slip and prevent falling backwards. Proximal fragment pulled superiorly by quad tendon and distal fragment remains with patellar ligament.

1. Acute CS

CAUSE: Direct trauma/fracture SX: Pain w/ passive stretching, tightness and swelling, decreased pedal pulse and sensory changes DX CONFIRMATION: Intercompartmental pressure measurements SOLUTION: Emergency fasciotomy

3. Acute Exertional CS

CAUSE: Intense, repetitive exercise most frequently distance runners ETIOLOGY: Repetitive muscle contractions cause muscles to swell due to increased blood flow

Metatarsophalangeal Joints (Classification, articular surfaces, degrees of freedom)

CLASSIFICATION: Condyloid synovial ARTICULAR SURFACES: Metatarsals = convex Phlanges = concave DoF: 2 - flexion/extension and Abduction/Adduction

Tarsometatarsal Joints

CLASSIFICATION: Plane synovialTogether called Lisfranc's joint

Posterior Talocalcaneal

CONCAVE on CONVEX Concave facet of talus Convex facet of calcaneus Own joint capsule

THR Approaches - Anterior (cut & precautions)

CONS: -Poor femur exposure (femoral stem malpositioning) --Lateral femoral cutaneous/femoral nerve palsy (ant. thigh numbness) 20% of people PROS:-Muscle sparing-Lower dislocation rates- PRECAUTIONS-No extension-No ER-Surgeon dependent

Meniscal Tests

Clinical Practice Guideline for Meniscus injury 1.Mechanism of injury is twisting 2.Tearing sensation at the time of injury 3.Delayed effusion (6-24 hours) 4.History of catching or locking 5.Pain with forced hyperextension 6.Pain with maximum hyperflexion 7.Positive McMurray 8.Positive Thessaly 9.Meniscal Pathology Composite score A.Combination of catch/lock B.Pain with hyperextension C.Pain with Max flexion D.Joint line tenderness E. Positive Mcmurray alleys compression/distraction

Obturator Foramen

Closed by thin, strong obturator membrane. -Covered on both sides by attached muscles: obturator externus, obturator internus

3-Headed Triceps Surae

Combination of 2-head Gastrocnemius (medial and lateral heads) and Soleus. -Share common tendon: Achilles tendon AKA Calcaneal Tendon ACTION: Plantarflexes ankle, raising heel against body weight. "Stroll with soleus but win long jump with gastrocnemius"

Infections of Foot

Common -Infected areas may be drained. -Plantar fascial spaces usually incised and drained on medial side of foot so painful scar won't be in weight bearing area

2. Congenital Dislocation of Hip Joint

Common (occurs in 1.5/1000 births) -Girls 8x more likely than boys.

Tibial Fracture: Transverse Stress (March) Fracture

Common in people who take long walks when not conditioned. -Strain may fracture anterior cortex of tibia

Hip Fracture Complications

Complications: -Non-union -Mal-union -AVN femoral head -Shortening /LLD -Post traumatic OA

Pelvic Girdle

Composed of 2 hip bones (largest flat bone) joined at: 1. pubic symphysis 2. Sacrum

Medial Longitudinal Arch

Composed of: Calcaneus, Talus, Navicular, 3 Cuneiforms and 3 metatarsals -Talar head is keystone -Tibialis Anterior attaching to 1st metatarsal/medial cuneiform helps strengthen arch -Fibularis Longus tendon passing lateral to medial supports arch

Tx of Proximal Humeral Fractures

Conservative-sling Surgical Management (Open/closed reduction) Hemi or TSA

Fascia of Lower Limb

Consists of 2 layers: 1. Superficial Fascia: -Subcutaneous, deep to the skin, consists of loose CT. -CT fibers blend with those in dermis. -Continuous with inferior part of anterolateral abdominal and buttock. -At knee, subcutaneous tissue loses its fat and blends with deep fascia. 2. Deep Fascia: -Dense layer of CT between subcutaneous tissue and muscles. -Forms fibrous septa that separates muscles from one another. -Especially strong in lower limb and invests limb like an elastic stocking. -Prevents bulging of muscles during contraction. -Deep fascia in thigh=Fascia Lata, Deep fascia in leg=Crural fascia

Strength of Connective Tissue (3 factors)

Constantly remodeling and normally becoming stronger. FACTORS: 1. Alignment of collagen fibers along stress lines 2. Increased size of collagen fibers 3. Increase strength of bonds

3. Lateral Compartment

Contains: -Abductor Digiti Minimi Brevis -Flexor Digiti Minimi Brevis

1. Medial Compartment

Contains: -Abductor Hallucis -Flexor Hallucis Brevis -Medial Plantar Nerve -Medial Plantar Vessels

2. Central Compartment

Contains: -Flexor Digitorum Brevis -Flexor Digitorum Longus -Quadratus Plantae -Lumbricals -Proximal part of Flexor Hallucis Longus tendon -Lateral Plantar Nerve -Lateral Plantar Vessels

Sternocleidomastoid

Contralateral rotation, ipsilateral lateral flexion - sticks out

Superior Tibiofibular Joint Movements

Cranial and caudal glide (or superior/inferior) Ventral and dorsal glide (fibular rotation)

Using Elliptical

Criteria: Forward step-up 6"

Inferior Tibiofibular Joint Ligaments

Crural Tibiofibular Interosseous ligament - consists of oblique fibers from fibula to tibia-Serves as axis of motion for fibula ...Anterior (limits posterior glide) & Posterior (limits anterior glide) tibiofibular ligaments - very strong, fibula will fracture distally before torn Inferior transverse ligamen tInterosseous membrane

Medial Ligaments of talocrural Joint

DELTOID LIGAMENT Runs from medial malleolus to navicular anteriorly and talus and calcaneus distally and posteriorlySuperficial ligs 1. Posterior tibiotalar 2. TIbial calcaneal 3. Anterior tibial navicular Deep ligs 4. Anterior tibiotalar FUNCTION: Check valgus force (eversion)

ROM for descending stairs/walking

DESCEND: Full DF - 20° WALKING:DF of 10° PF 20-25°

Decrease of Fracture Healing

DM Hypervitaminosis D Rickets, OP Nicotine - decreases vascularization

PFPS: Decreased Quad Strength can lead to ____

Decreased quad strength can lead to:-Abnormal patella tracking-Patellofemoral joint loading stress (avoid loaded open chain extension from 50-20° and CC >50°)

PFPS: Alter running mechanics

Decreased stride length correlates with increasing cadence and a reduction in patellofemoral joint forces

Venae Comitantes

Deep veins accompany all major arteries and pulsations help compress and move blood in veins.

Nerve Supply to Ankle Joing

Derived from: -Tibial Nerve -Deep Fibular Nerve -Division of Common Fibular Nerve

Ottawa Knee Rules

Determine necessity of X rays->55 yo-Tenderness over fibular head-Isolated tenderness over patella (often pinpoint) -Unable to flex knee to 90° -Unable to WB immediately and in the ED

Injury to Nerve Supply of Biceps Femoris

Different nerve supplies could allow for paralyzing of one head and not the other.

*Varicose Veins/DVT/Thrombophlebitis*

Dilation of great saphenous vein and it's tributaries can cause valves to no longer close and result in varicose veins. -Veins of lower limb subject to DVT (blood clotting) after bone fractures and causes venous stasis (stagnation). -Venous thrombosis may lead to inflammation that could cause development of thrombophlebitis around vein. -Can lead to *PULMONARY THROMBOEMBOLISM* where thrombus breaks free from lower limb vein and passes to lungs and can obstruct main pulmonary artery and lead to death.

*Dorsal Artery of the Foot*

Direct continuation of Anterior Tibial Artery. -Begins midway between malleoli -Runs anteromedially deep to inferior extensor retinaculum between Extensor Hallucis Longus and Extensor Digitorum Longus. Then passes 1st interosseous space and divides into Deep Plantar Artery to sole of foot (joins Plantar arch and 1st dorsal metatarsal artery)

Scaphoid

Distal to radial SP, ulnar deviate to pop out

1st Dorsal Metatarsal Artery

Divides into branches to SUPPLY: -Both sides of great toe -Medial side of 2nd toe.

Venous Drainage of Dorsal Side of Foot

Dorsal digital veins-> join to form Dorsal venous arch then communicates with -> Plantar Venous Arch -> Converge medially to form Great Saphenous Vein, OR Laterally to form Small Saphenous Vein

Extensor Digitorum Longus Tendon

Dorsiflex and invert

phase 2 TKR balance and functional training

Double limb static stance single leg static stance single leg dynamic stance Vary surfaces to challenge your patient Hard Floor, foam, tilt board, BOSU Eyes open, eyes closed Sit <> stand transfers Various heights, different surfaces (foam?) ADL training Picking objects up off the floor Tub and Car transfers Falling and how to get up step up progressions

SHM: Last 20° of knee extension

During the last 20° of knee extension, anterior tibial glide persists on the tibia's medial condyle because its articular surface is longer in that dimension than the lateral condyle's.

Passive Movement Testing (end feels)

END FEELS Flexion = soft Extension = hard/firm (squishy if large effusion) ER in flexion = firm IR in flexion = firm

Movement of Meniscus: Rotation

ER (motion relative to tibia): lateral meniscus pulled posteriorly and medial meniscus pulled anteriorly(lateral meniscus moves 2x as much from extension to flexion because of femur ER) -Menisci injured when don't follow movement of femoral condyles and becomes wedged between femoral and tibial condyles

Greater Trochanter

ER and IR and feel movement

Arthrokinematics: Rotation

ER of tibia on femur, lateral femoral condyle moves forward over lateral tibial condyle, medial femoral condyle moves backwards

Erector Spinae

EXTEND BACK Central: Spinalis Middle: Longissimus Lateral: Iliocostalis

Cannulation of Femoral Artery

Easily exposed and thus good option for cannulation (tube insertion). Occurs at base of femoral triangle just inferior to midpoint of inguinal ligament. -For left cardial angiography: Long slender catheter is inserted percutaneously into artery. Passed up the external iliac artery -> common iliac artery -> aorta -> Left ventricle of heart

Patella medial/lateral Glide

Especially important for knee flexion. Embedded in quad tendon. Mobilize with medial/lateral glide - use 1 finger proximal and 1 distal. Check mobility with little flexion.

Complications of Fracture Healing: Delayed Union

Exact timing of # healing/union cannot be defined -Union is delayed when healing has not advanced at the average rate for the location and type of fracture (Btn 3-6 months) -Treatment usually is by an efficient cast that allows least movement at # site -May continue for ~4 to 12 additional weeks

FAI - Femoroacetabular Impingement

Excessive bony deposit on acetabulum (pincer) or neck of femur (CAM) Mixed = both

Subcutaneous Infrapatellar Bursitis

Excessive friction between skin and tibial tuberosity -Swelling over proximal end of tibia "Clergyman's Knee" - roofers, tilers, carpet layers

Post-Operative Phase I: Weeks 2-8 Hip Hinging/Lumbopelvic Dissociation

Exercise progression for hip hinging: Wall tap hip hinge Dowel hip hinge Band resisted hip hinge in standing *Can perform a quadruped hip hinging series if cleared from precautions or if an anterior approach was performed: - Quadruped rocking - Band resisted hip hinge in quadruped

Post-Operative Phase II: Weeks 9-16 Exercise Progression THR

Exercise progression: Single limb exercises within age appropriate norms - Balance Narrow BOS tandem stance single leg on flat surface single leg on uneven surface Functional progression of Phase I exercises: - Hip hinge sit to stand squats single leg squats - Step ups/downs lunges (static) lunges (dynamic) - Standing hip abduction monster walks - Glute sets bridges standing hip ext fwd lunges Return to full functional/recreational activity Cardio: stationary bike, elliptical Advance balance and proprioception exercises Continue step progression Progressive resistance exercise of bilateral LEs Core exercises Aquatic therapy (have to be able to get into/out of pool + have access to pool) Activity specific training

Diaphragmatic Breathing

Expand into my hands (to get lateral expansion)

Extensor Carpi Radialis Longus Tendon

Extend - 2nd MC

Extensor Carpi Radialis Brevis Tendon

Extend, 3rd MC

Extensor Carpi Ulnaris Tendon

Extend, 5th MC

ligament movement at the hip

Extension winds ligaments Flexion unwinds them

Gluteus Maximus

Extension with ER

Causes of Fracture (extrinsic/intrinsic)

Extrinsic Causes -Direct/indirect Violence -Bending forces -Tortional forces -Shearing forces Intrinsic Causes -Fracture due to muscular action -Pathological fractures

Load> Deformation =

FRACTURE Result of single or repetitive load Occurs within a fraction of millisecond Results in loss of bone continuity with or without displacement of the fragments. Results in damage to soft tissue, nerves, blood vessels, nerves, periosteum, internal organs and skin

*Iliotibial Tract (IT Band)*

Fascia lata thickens and strengthens laterally and additional longitudinal fibers form iliotibial tract.

Proximal Radioulnar Joint

Find radial head and move down and medial?

First Ray

First Ray: Single foot segment consisting of 1st metatarsal and first cuneiform -Serves important purpose during gait cycle. -Provides: -Shock absorption during load response -Stability during terminal stance and push-off phases ABNORMAL FIRST RAY POSITION: -Plantar flexion -Dorsiflection ABNORMAL MOBILITY: -Hypermobility -Hypomobility These will decrease ability to function normally during gait.

Mechanism of Syndesmosis (HIGH) Ankle Sprain

Fixed Foot with tibial internal rotation or relative fibula external rotation

Flexor Carpi Radialis Tendon

Flex and radially deviate - find tendon going to 2nd MC

Flexor Carpi Ulnaris Tendon

Flex and ulnarly deviate - find tendon going to 5th MC

Slipped Capital Femoral Epiphysis

Fracture through physis (growth plate) of femoral head. Head stays in socket and neck slips inferior, anterior, and ER

Skeletal Disorders: Slipped Capital Femoral Epiphysis

Fracture through physis (growth plate) of femoral head. Head stays in socket and neck slips inferior, anterior, and ER

-Frontalis -Temporalis -Masseter

Frontalis - raise eyebrows Temporalis/Masseter - clench jaw

Immediate Fracture Complications

Functional deficit Deficient skin-soft tissue DVT Compartment syndrome Infection

Hip Flexion

GLUTEUS MAXIMUS -Flex the hip and knee simultaneously. -Stabilize the opposite femur in extension to prevent posterior tilt of the pelvis. -Move the patient's hip and knee into full flexion to lengthen the one-joint hip extensor.

Greater Trochanteric Fx

GREATER TROCH ATTACHMENTS: GLUT MED/MIN, PIRIFORMUS, GEMILLIS, all er

Post-Operative Phase I: Weeks 2-8 Exercise Goals/Progression

Gait training (with walker/cane, progress to no AD) Symmetrical weight-bearing - Remember to look at this in all positions (sitting, standing, walking, stairs) Adequate hip flexion during swing initial contact Adequate hip extension during terminal stance Strengthening Emphasize hip abductors and hip extensors Global strengthening What are other areas might be weak? - Core stability- Balance/proprioception- Cardio (walkingelliptical) Stair Negotiation (Progress from 2" step to 8" step) Forward step ups Forward step downs Lateral steps ups Lateral step downs General exercise progression Bilateral unilateral Static dynamic

Sacrum Attachments

Gluteus Maximus Piriformis

Gluteus Medius

Gluteus Medius:PROXIMAL: External surface of ilium between anterior and posterior gluteal lines DISTAL: Lateral surface of greater trochanter ACTION: Abducts and medially rotates thigh; keeps pelvis level when opposite leg raised post fibers- ER INNERVATION: Superior gluteal nerve (L4-S1) mmt- s/l hip abduction

Achilles Rupture Post-op (Wks 28-DC - goals/precautions)

Goal Lack of apprehension with sport activity 85-90% limb symmetry with vertical jump 85-90% limb symmetry with isokinetic testing Progress to Discharge

Ankle inversion/Eversion (Pronation/Supination)

Grab calcaneus...

Upper Trapezius

Have patient shrug

Fractures of Metatarsals

Heavy object falls on foot. Run over by car. -Common in dancers. -Fatigue fractures (usually transverses): -prolonged walking, repeated stress on metatarsals

Pes Cavus

High arch and supinated foot.WB on heel or MT heads - develop plantar fasciitis

Mobility Testing: Longitudinal Distraction of hip

Hip in resting position (30 hip flexion, 30 abd) Hand around distal thigh (or above malleoli)

Middle Traps

Horizontal adduction

iliopsoas stretch

ILIOPSOAS -Stabilize opp leg against chest to prevent anterior pelvic tilt. *Can add knee flexion for Rectus Femoris.

Mobility Testing: Ventral Glide for the hip

IMPROVE EXTENSION-Prone-Wedge/pillow under anterior pelvis -Hand over proximal posterior femur & press down

Collateral/Cruciate Ligaments in Rotation

IR: Relaxes collateral ligaments and tightens cruciates ER: Tightens collateral ligaments and relaxes cruciates

er/ir ligaments

IR: iliofemoral lig slack, ischiofemoral taut ER: iliofemoral lig taut, ischiofemoral slack

Injury Variables: Intra-articular fractures

If alignment & congruity joint surface is not restored, it can result in - Delayed healing or non-union - Joint stiffness

Major Failure Region

If max load is reached, strain (elongation) increases without increased stress.

Tibial Plateau Fx

Immobilization in Bledsoe brace to provide stability Protected WBing (TTWB) with crutches or RW

Tibial Fracture: Diagonal Fracture

Indirect violence applied to tibial body when bone turns with foot fixed during a fall may produce this fracture. -Severe torsion during skiing may produce diagonal fracture of tibial body at junction of middle/inferior thirds as well as fracture to fibula.

Lymphadenopathy (Enlargement of Lymph Nodes)

Infections of foot may spread proximally causing enlargement of popliteal and inguinal lymph nodes. -Inflammation that doesn't decrease could be inflammation of lymph nodes and could be very serious. Refer to doctor.

Other RC Muscles: -Infraspinatus -Teres Minor

Infraspinatus - below spine. ER Teres minor - on upper 2/3 lateral border and connects to posterior portion of humeral head. Put in prone and do ER

Initial Eval for ACL

Initial eval evaluative techniques -ROM -MMT - dorsiflexors/plantarflexors, hip ab/add, hip ext. -Quad set -Patella mobility -pain-edema-skin inspection -measure girth for swelling -mid patella is starting point -2", 6", 10" above and below mid patella -gait w crutches including stairs-Sensation-Distal pulses

PCL Injury

Injured when: 1. Tibia driven posteriorly on femur. Caused by superior part of tibia struck with knee flexed (knee against dashboard) 2. Femur driven anteriorly on tibia 3. Knee joint severely hyperflexed.

Later Fracture Complications

Injury to growth plate AVN Deformity / LLD Mal-union, delayed or Non-union Post traumatic OA - not loading correctly.

*Puncture Wounds of Sole of Foot*

Involving deep plantar arch - severe bleeding because depth and structures that surround it. Ligature of arch is difficult.

Dissociation of Hip

Isolate motion of femur in acetabulum

Radial Head120

Just distal to lateral epicondyle - bit of a depression before head. Can pronate/supinate to feel it spin.

Obturator Internus Nerve

L5-S2 SUPPLIES: Obturator Internus

Adductor Canal Borders

LATERAL: Vastus Medialis MEDIAL: Sartorius ANTERIOR: Vastus Medialis POSTERIOR: Adductor Longus and Magnus

Lesser Trochanteric Fx

LESS TROCH ATTACHMENTS: ILIOPSOAS

*Sciatic Nerve*

Largest nerve in body -Arises from ventral rami of L4-S3 -Receives own blood supply from Inferior Gluteal Artery.

Nutrient Artery of Fibula

Largest nutrient artery in body. -Arises from posterior tibial artery near its origin. -Pierces Tibialis Posterior (supplies branches) and enters nutrient foramen in proximal 1/3 of posterior surface of tibia.

Lateral Toes PIP Flexion

Lateral Toes PIP Flexion 0-35° 0 ext

Tibiofemoral Joint Rotation

Lateral rotation of tibia occurs during last 10-15 degrees of extension -To begin flexion, must be unlocked by tibia rotating medially -This rotation should not be confused with voluntary rotation movement possible at the joint -Greatest range of voluntary knee rotation occurs at 90 degrees of flexion; at this point about 40-45 degrees of lateral rotation and 15 degrees of medial rotation possible.

Laxity vs. Instability

Laxity (objective measurement) Instability (subjective) - feeling from patient.

Hamstring tendons (Biceps femoris, semitendinosus, semimembranosus)

Lay prone and flex Biceps femoris tendon attaches to fibula Semimembranosus more medial than semitendinosus

Trendelenberg Gait

Lean to side of weakness. Secondary to OA due to pain and thus leading to gluteus medius weakness.

Arthrokinematics: Flexion/Extension

Length of femoral condyles 2x as long as tibial condyles -Starting from full extension: Femoral condyles roll (posterior) then slide (anterior) First 15-20° movement is roll then glide comes in-Axis not fixed - moves through ROM

Altered gluteal muscle activation in PFPS

Less Glut max (abd, ext, ER) and compensate with adductor magnus and TFL BUT these hip extensors adduct and IR adding to valgus force.

Wipe Test

Less Swollen knee SUPINEKnee extended Move fluid from medial to lateral, then move lateral to medial POSITIVE: Bulge of fluid interomedially to patella = joint effusion

Post-Operative PCL Reconstruction

Less aggressive ROM & strengthening than ACL -Patella mobilization (want to avoid tendon shortening) -QUAD STRENGTH -ROM (0-90° after 6 weeks) -TTWB for 4 weeks (keep brace locked at 0°)

MCL Rehab exercises

Limit WB because provides valgus stress Fairly aggressive in sagittal plane

Sacroiliac Joints

Line connecting dimples lies at S2 spinous process and passes through center of SI joints -Indicate termination of iliac crests from which bone marrow and pieces of bone for grafts can be obtained.

Transverse Tarsal Line

Line from posterior aspect of tuberosity of navicular -> point halfway between lateral malleolus and tuberosity of 5th metatarsal

Transverse Ligament of meniscus

Links 2 anterior horns of menisci-Attached to patella by strands of infrapatella pad

Plantaris

Long thin tendon - often absent (similar to palmaris longus) -High density of muscle spindles (receptors for proprioception). Possible proprioceptor for large plantar flexors. -Plantaris tendon can be removed for grafting of hand tendons PROXIMAL: Inferior end of lateral supracondylar line of femur and oblique popliteal ligament DISTAL: Calcaneal tendon ACTION: Weakly assists gastroc in plantaflexing ankle and flexing knee INNERVATION: Tibial Nerve

Result of Injury to Common Fibular Nerve

Loss of eversion of foot and dorsiflexion= foot-drop -While walking, foot drops and toes drag on floor Stepping Gait: -Impossible to make heel strike ground first -Patient has a high stepping gait - raising foot as high as necessary to propel foot forward and keep toes from hitting ground. -Foot comes down suddenly - a distinctive "clop" (no exentric lowering) Loss of Sensation: -Anterolateral aspect of leg -Dorsum of foot

Creep

Low-magnitude loads applied for long periods increase the deformation of connective tissue and allow gradual rearrangement of collagen fiber bonds (remodeling) and redistribution of water to surrounding tissues. Increasing the temperature of the part increases the creep and therefore the distensibility of the tissue.

unhappy triad

MCL, ACL, medial meniscus

Metacarpophalangeal Joints -Phalanges -PIP -DIP

MCP=Knuckles

Meniscus

MEDIAL - C shaped, larger in diameter, more WB LATERAL - Circular, greater mobility Vascularity - Outer 1/3 from capsule and synovial attachments

-Mandibular Condyle -Temporomandibular Joint -Angle of mandible -Body and Ramus of mandible

Mandibular condyle - in front of ear -TMJ - open jaw and feel depression Ramus - vertical part Body - horizontal part

Ankle Special Tests: ER Test

Manual passive ER of foot and ankle in a neutral or slightly dorsiflexed position would widen the ankle mortise. POSITIVE: Pain over distal syndesmosis is positive for a syndesmotic injury.

Medial Collateral Ligament

Medial femoral condyle->tibia posterior to pes anserinus -Anterior fibers are separate from capsule -Posterior fibers blend with border of medial meniscus -Superficial band blends with posteromedial corner of capsule (posterior oblique lig.) RUNS inferio-anteriorly

Stages of Motor Control

Mobility -> Stability -> Controlled mobility -> Skill

THR Approaches - Posterior Lateral (cut & precautions)

Most commonly used. -Technically easiest. CUT: Gluteus Maximus/Capsule PRECAUTIONS (6-8 weeks) -Hip flexion >90° -Adduction past neutral -IR past neutral

Lateral Longitudinal Arch

Much flatter than medial part of arch, -Rests on ground during standing. Composed of: Calcaneus, Cuboid and lateral 2 metatarsals

Lateral Plantar Artery

Much larger -Accompanies nerve of same name -Runs laterally and anteriorly first deep to Abductor Hallucis and then deep to Flexor Digitorum Brevis. -Arches medially, crosses foot and forms deep plantar arch with deep branch of lateral plantar nerve.

Genu valgum / Genu Varum

NORMAL 170-175°VALGUM = knock-kneed (angle<170°) More compression laterally, more laxity medially (Patella in danger of subluxation) VARUM = bow-legged (angle>180°) Femur slopes inward relative to tibia. Normally 170/175 degrees. A little more for women.

Role of Quadratus Plantae

Neutralizes pull of FDL (which would pull toes medially without QP tendon)

Trochanteric Precautions

No active hip abduction No passive hip adduction Restricted weight bearing (20%) Hip abduction brace may be required with associated dislocation

Artery in Lateral Compartment

No artery -Muscles supplied: 1. Superiorly by perforating branches of anterior tibial artery 2. Inferiorly by perforating branches of fibular artery

Patellofemoral Contact Areas

No clue what this is - slide 646

Hip Resurfacing

No femoral Stem -Femoral head resurfaced: Birmingham head Larger circumference -Acetabulum resurfaced Press fit metal acetabulum

Hip Resurfacing

No femoral Stem-Femoral head resurfaced: Birmingham head Larger circumference-Acetabulum resurfaced Press fit metal acetabulum

Post-Operative Phase II: Weeks 9-16 THR

No pain Normalize gait without AD Reciprocal stair negotiation with good control Sufficient ROM for independence in all ADLs Gross LE strength 4+/5 or better Restore flexibilit

Post-Operative Phase III: Return to Sport (4 months - 1 year) THR

ONLY with MD Clearance! Goals: Full hip ROM Symmetrical LE strength No increased pain or edema with activity Core strength to meet demands of activity Able to descend an 8" step without pain or deviation Symmetrical single leg balance Cardio endurance to meet demands of activity

Subtalar Joint (Open/closed)

OPEN: Calcaneus moving on fixed talusCalcaneal DF, ...CLOSED: Talus moving on fixed calcaneusCalcaneus fixed (everted) and then PF and adduction of talus(have this slide elsewhere)

Physical Examination for Lateral Ankle Sprain

Observation -gross abnormalities -edema -ecchymosis Assess Neurovascular systems -Dorsal pedal pulse -Capillary refill -Sensation to light touch. PalpationRange of Motion StrengthSpecial Tests

Fractures of Talar Neck

Occur during severe dorsiflexion of ankle. In some cases the body of talus dislocated posteriorly.

Avulsion Fractures

Occur where muscles attach: -Anterior superior and inferior iliac spines -Ischial tuberosities -Ischiopubic rami

Ruptured Calcaneal (Achilles) Tendon

Often occurs in poorly conditioned 30-45 y.o. people with history of Calcaneal tendinitis. SYMPTOM: Sudden calf pain with audible snap Usually result of sudden dorsiflexion of plantarflexed foot

Supraspinatus

On top of spine. Abduct first 15 degrees.

Calcaneocuboid ° of Freedom and Axes

One - supination/pronation2 axes: 1. Longitudinal - nearly horizontal. Inclined upward, medially and anteriorly 2. Oblique - Inclined anterorly upward (40°) and medially (30°) - primarily for PF with some ADD and DF with some ABD

TMT Joints Degrees of Freedom

One degree of triplanar motionPrimarily DF/PF1/ 2 = DF + Inversion + Adduction, PF + Eversion + Abduction 3 = DF and PF around coronal axis4/5 = DF + eversion + abduction, PF + inversion + adduction

Adductor Hiatus

Opening in aponeurotic distal attachment of adductor magnus (in Gracilis picture). -Transmits femoral artery and vein from adductor canal in thigh to popliteal fossa posterior to knee. -Located just superior to adductor tubercle of femur

Palmaris Longus Tendon

Oppose and flex

iliopsoas attachment

Origin Psoas Major: Vertebral bodies of T12-L4, Intervertebral discs between T12-L4, transverse processes of L1-L5 vertebrae Iliacus: Iliac fossa InsertionLesser trochanter of femurInnervation Psoas major: anterior rami of spinal nerves L1-L3 Iliacus: femoral nerve (L2-L4) Function Flexion of the thigh at the hip; flexion of the trunk at the hip, external rotation of the thigh at the hip; lateral flexion of the trunk (psoas major only) Blood supplyIliolumbar artery mainly with contributions from the obturator, external iliac, femoral arteries

plantar is

Origin Lateral supracondylar line of femur, oblique popliteal ligament of knee InsertionPosterior surface of calcaneus (via calcaneal tendon) Action Talocrural joint: foot plantar flexion Knee joint: knee flexion InnervationTibial nerve (S1, S2)

flexor digitorum longus

Origin Posterior surface of tibia (inferior to soleal line) InsertionBases of distal phalanges of digits 2-5Action Metatarsophalangeal and interphalangeal joints 2-5: toe flexion Talocrural joint: foot plantar flexion Subtalar joint: foot inversion Innervation Tibial nerve (L5, S1, S2)

-Ischial Tuberosity -Sciatic Nerve Region

Origin of hamstrings Sciatic Nerve region - just lateral to IT

extensor hallcuis longus

Origin: anterior surface of fibula and interosseous membrane Insertion: distal phalanx of great toe Innervation: deep fibular Vasculature: anterior tibial Action: dorsiflexion, extend great toe

fibularis tertius

Origin: anterior surface of fibula, interosseus membrane Insertion: dorsal surface of base of 5th metatarsal Innervation: deep fibular Vasculature: anterior tibial Action: dorsiflexion

fibulas brevis

Origin: inferior 2/3 of lateral surface of fibula Insertion: tuberosity of 5th metatarsal Innervation: superficial fibular L5-S1 Vasculature: branches from fibular Action: eversion

flexor hallucis longus

Origin: posterior surface of fibula, interosseus membrane Insertion: base of distal phalanx of great toe Innervation: tibial Vasculature: posterior tibial and fibular Action: plantarflexion, flexion of great toe

fibulas longus

Origin: superior 2/3 of lateral surface of fibula Insertion: medial cuneiform and base of 1st metatarsal Innervation: superficial fibular (L4-S1) Vasculature: branches from fibular Action: eversion and plantarflexion

Skeletal Disorders: Legg-Calve Perthes

Osteonecrosis of femoral head due to disruption in blood flow (usually in children)

*Strain

Overstretching, overexertion, overuse of soft tissue. Tends to be less severe than a sprain.

Obturator Nerve (L2-L4)

PATH: Enters thigh via Obturator Foramen and then divides. Anterior branch between Adductor Longus and Brevis. Posterior between Adductor Brevis and Adductor Magnus INNERVATION: Anterior - Adductor Longus, Adductor Brevis, Gracilis and Pectineus Posterior - Obturator Externus and Adductor Magnus SENSATION: Medial aspect of the thigh INJURY: Difficulty adducting thighs

Iliopsoas

PROXIMAL: Psoas major: Sides of T12/L5 vertebrae and discs, TPs of Lx Psoas minor: Sides of T12/L1 vertebrae and IV disc Ilacus: Iliac crest, iliac fossa, ala of sacrum and anterior sacroiliac ligaments DISTAL: Psoas major: Lesser trochanter of femur Psoas minor: Pectineal line, iliopectineal eminence via iliopectineal arch Ilacus: Tendon of psoas major, lesser trochanter, and femur distal to it. INNERVATION: Psoas major: Ventral rami of lumbar nerves (L1-L3) Psoas minor: Ventral rami of lumbar nerves (L1-L2) Ilacus: Femoral nerve (L2-L3) ACTION: Flex thigh at hip joint and stabilize joint. Psoas major is also postural muscle stopping deviation of trunk during standing.

Brachialis

Palpate in from distal part of biceps

Pathological Fracture

Pathological # - Weak or abnormal bone- eg: osteoporosis, osteopenia, osteogenesis imperfecta, bone cyst

Hip Special Considerations

Pelvis must be stabilized because of attachments to it and lumbar spine. IF not stabilized, stretch force transferred to lumbar spine.

pes anserine

Pes Anserinus:(Means goose foot) Insertion of three tendons:1. semitendonosus2. gracilis3. sartorius Also location of a major bursa that separate the bone from the tendons. If bursa gets inflamed, you get tightness on medial side of the knee.

Knee ROM by Phase for TKA

Phase 1: 1-5 days: 85-90 °Phase 2: 2-8wks: 90-105/110 °Phase 3: 9-16wks: >110

supination is linked to

Plantar flexion, adduction, inversion

What happens to Fibula during Plantar/Dorsiflexion?

Plantarflex - fibula head goes down and IRDorsiflex - fibula head goes up and ER

Mechanism of Medial Ankle Sprain Injury

Plantarflexion Eversion Valgus Stress

Mechanism of Lateral ankle injury

Plantarflexion Inversion External Rotation

Greenstick Fraxture

Plastic deformation of immature bones of young children, Risk of deformity/ shortening bone bends and breaks

Tibial Fracture: Epiphyseal Plates

Primary ossification center on superior end of tibia. Ossifies around 16-18 y/o. -Fracture of tibia in children more serious if involve epiphyseal plate because it can jeopardize normal growth.

Surgical Repair for Achilles Rupture

Primary repair Percutaneous repairReconstructionLow rate of re-rupture

SHM: End of knee extension

Prolonged anterior glide on the medial side produces external tibial rotation, the "screw-home" mechanism.

Wrist Flexion

Push on dorsal aspect of hand.

What movements may be contraindicated with trochanteric fracture?

Quads and hamstrings cross over the subtrochanteric region, so forceable contractions can de-stabilize a fracture!

Talocrural Joint: Resting position, Closed Packed position, Capsular Pattern

RESTING: 10° PF and midway between supination/pronation CLOSED PACKED: Maximum DF CAPSULAR: PF > DF

Superior Tibiofibular Joint Positions (resting, closed pack)

RESTING: 25° knee flexion and 10° plantarflexion

Midtarsal Joints Resting position, close packed position and capsular pattern

RESTING: Between extremes of range CLOSE PACKED: Supination CAPSULAR: 1. DF, 2. PF, 3. ADD, 4. IR

Ankle Special Tests: TIb/Fib Squeeze Test

Result is positive for a syndesmotic sprain if compression of the tibia and fibula in the midcalf region produces pain over the distal syndesmosis.

Fracture of Sesamoid Bones of Great Toes

Results from crushing injury - heavy object falls on great toe.

FAI can lead to...

Results in early OA of hip from chondral and labral injury

Revision after hip resurfacing

Revised to THR

Revision after Anterior THR

Revised to posterior-lateral THR

THR Revision Indications

Revision of cup/liner/femoral stem -Pain -Recurrent Dislocations -Infection -Prosthetic loosening -Gradual debonding between component and bone -Osteolysis - bone reaction to components, inflammatory response, increased osteoclast activity, bone resorption.

Inferior Tibiofibular Joint Superior & Inferior Glide

SIDE LYING (medial surface of foot on plinth) STABILIZE: Foot or distal leg against table MOBILIZE: Inferior surface of lateral malleolus DIRECTION: -SUPERIOR for DF/Eversion-INFERIOR for PF/Inversion (Superior aspect of LM)

Talar Tilt Test

SIDE LYING OR SUPINEKnee flexed to relax gastroc Test normal side first CALCANEOFIBULAR LIG: Tilt talus into VARUS DELTOID LIG: Tilt talus into Valgus

Calcaneocuboid Joint Plantar and Dorsal Glides

SIDE-LYING with tibial side of foot resting on table STABILIZE: Calcaneus MOBILIZE: Cuboid in plantar/dorsal directionFUNCTION: ??

Superficial Infection

SKIN -Cellulitis of extremity -Incensional infection Treatment: -Irrigation and debridement -Antibiotics -Incisional VAC

Too Many Toes Test

STANDING View from behind and count toesIf too many :-Forefoot abducted OR-Heel in valgus OR-Tibia too ER>2.5 toes = calcaneus valgus, tibia ER, forefoot abducted

Neutral Position of Talus Test Neutral Position of Talus Test 2

STANDING-Thumb and index on head of talus on dorsal aspect of foot -Patient rotates trunk medially and laterally NEGATIVE: Talus remains in neutral position SUPINE (feet off end of table)One hand over 4/5 MT headsOne hand has index and 1st finger over dorsal talar head Passively DF foot then move foot in arc of supination/pronation NEGATIVE: Talus remains in neutral

subjective for Hip Labrum Tear or DJD

SUBJECTIVE -Pain during sitting -Click or popping during gait, squatting or other activities -Click during PROM

Superficial and Deep Fibular Nerves

SUPERFICIAL FIBULAR: Lies between fibular muscles -Leaves them around junction of middle 2/3 and inferior 1/3 of lateral side of leg. Ends by supplying dorsom of foot DEEP FIBULAR: *Passes deep to Extensor Retinaculum (ski boot syndrome)*. Supplies skin on contiguous sides of 1st and 2nd toes.

Motion of Subtalar Joint WB & NWB

SUPINATION Non-WB: Calcaneal inversion, adduction and PF WB: Calcaneal inversion, Talar abduction, DF and ER of the leg PRONATION Non-WB: Calcaneal eversion, abduction and DF WB: Calcaneal eversion, talar adduction, PF and IR of the leg

Test for Fracture of Hip/Femur

SUPINE Place stethoscope over pubic symphysis -Tap patella on symptomatic side -Repeat on asymptomatic side POSITIVE FINDING: Difference in auscultation between sides

Cuneiform-MT Joint Dorsal and Plantar Glides

SUPINE STABILIZE: Rearfoot up to first cuneiform MOBILIZE: 1st MT

Subtalar Joint: Talar Rock

SUPINE Ankle PF 10° STABILIZE: Talus by holding ankle mortise MOBILIZE: Calcaneus - scoop subtalar joint away from mortise to distract and rock talus (up & down) FUNCTION: DF & PF

Cuneonavicular Dorsal and Plantar Glides

SUPINESTABILIZE: Hindfoot near navicular MOBILIZE: Medial cuneiform FUNCTION: plantar helps plantar flexion and supination

Superior Tibiofibular Joint: Posterior Glide Mobilization

SUPINESit on foot. MOBILIZER: Anterior head of fibula DIRECTION: Posterior and medial INDICATION: Increase PF

Genicular Branches of Popliteal Artery (5) Anastomose along with: -Genicular branch of Femoral Artery (superomedially) -Descending branch of Lateral Femoral Circumflex (superolaterally) -Anterior Recurrent Branch of Anterior Tibial Artery (inferolaterally)

SUPPLY: Articular Capsule of knee joint -Ligaments of knee joint

chronic CS

SX: Activity related Most likely anterior or deep posterior compartments Low success rate with conservative management

Articularis Genu

Small, derivative of vastus intermedius. Attaches superiorly to inferior part of anterior aspect of femur. Inferiorly to synoviual membrane of knee joint. FUNCTION: Pulls synovial capsule superiorly during extension of leg. Preventing folds of capsule from being compressed between femur and patella.

Lateral Plantar Nerve

Smaller of 2 terminal branches of tibial nerve PATH: Begins deep to Flexor Retinaculum and Abductor Hallucis. -Runs anterolaterally medial to Lateral Plantar Artery between 1st and 2nd layers of plantar muscles. -Terminates by dividing into: Superficial branch -> 2 digital nerves that send cutaneous branches to lateral 1.5 digits Deep branch -> Supply motor branches to muscles of sole not supplied by Medial Plantar Nerve

trendelenburg test

Stand on one leg and pelvis should remain levelTESTING: Gluteus medius

Stress / Strain

Stress: Amount of tension or load per unit of cross sectional area placed on a structure Strain: Refers to proportional elongation that occurs

Shoulder Internal Rotation

Stretch external rotators

Shoulder Flexion

Stretching the shoulder extensors -Stabilize the axillary border of the scapula to stretch the teres major, or stabilize the lateral aspect of the thorax and superior aspect of the pelvis to stretch the latissimus dorsi. Move the -ER humerus

Subjective portion of ankle injury eval should include _____

Subjective portion of ankle injury eval should include _____ Date of injury Mechanism of injury Presence of a popping sound at time of injury Ability to bear weight through the injured leg History of ankle injury, including treatment receivedSport-specific goals

Subtalar Joint ligaments

Subtalar Joint ligaments Interosseous talocalcaneal ligament - runs length of tarsal canal FUNCTION: Checks Pronation -Lateral talocalcaneal lig -Posterior talocalcaneal lig- Ligamentum cervicis (neck to neck) FUNCTION: Checks supination

Venous Drainage of Plantar Side of Foot

Superficial veins of sole unite -> Plantar Venous network -> Medial and Lateral Marginal vein -> Join Great and Small Saphenous Veins.

Progression of movement

Supine Quadruped Seated Half kneeling Kneeling Standing

Posterior Cutaneous Nerve of Thigh

Supplies more skin than any other cutaneous nerve. -Arises from sacral plexus -> Leaves pelvis with inferior gluteal nerve and vessels and sciatic nerve -> passes through greater sciatic foramen inferior to piriformis -> descends to deep gluteus maximus. SUPPLIES: Posterior division - skin of inferior part of buttock Anterior division - skin of perineum Other branches - skin of posterior thigh and proximal part of leg.

Findings on Examination for Lateral Ankle Sprain

Swelling observed distal to the lateral malleolus- TTP over the ATFL in more severe cases, the CFL -The anterior drawer and the talar tilt test may reveal joint laxity -Stress radiographs may reveal excessive anterior translation of the talus or inversion of the talus.

Subtalar (Talocalcaneal) Joint Classification

Synovial 3 separate plane articulations 1. Anterior talocalcaneal 2. Middle talocalcaneal 3. Posterior talocalcaneal

Complications: Leg Length Discrepency

TRUE (structural) APPARENT -No boney discrepancies between LEs -Soft tissue changes -Pre-operative affected limb most likely shorter (decreased joint space, decreased cartilage, muscle shortening (flexion, rotators contracted) -Surgery restores joint space -LE feels longer

Talar Surface

Talar Surface Trochlea wider anteriorly than posteriorly (2-4mm) Lateral facet is larger than medial facet Into DF, stabilizes ankle mortise as it splays.

Ankle during DF

Talus is wider anteriorly-Spreading of mortise as talus moves into DF -Fibula glides cranially, abducts and glides posteriorly (ER) in DF -Fibula head glides anteriorly. distal tibia goes posteriorly -Convex talus must glide posteriorly on concave mortise

Ankle Special Tests: Talar Tilt Test

Talus tilted into adduction and abduction. TESTS: CFL when foot in neutral. With PF it also tests ATFL POSITIVE: 5° to 10° of increased inversion compared with noninjured ankle = tear of the CFL.

Triceps Brachii

Tendon attached to olecranon process. Extend arm to contract.

Elastic limit

The point beyond which the tissue does not return to its original shape and size is the elastic limit.

Plastic range

The range beyond the elastic limit extending to the point of rupture. PERMANENT deformation. Want to get here for major results. Collagen doesn't stretch but ruptures resulting in increased length.

Progression of Acute Post-op Femoral Neck/Shaft ORIF POD#1-4:

Therex: Phase 1: ankle pumps, quad sets, heel slides (A/AAROM) to 45 degrees Phase 2: Knee flex/ext in sitting, Hip Flexion <90 degrees, Standing Hip Abd (if no Trochanteric precautions), Standing Hip Ext, Standing Knee Flex Progressive functional mobilization -Dangle at bedside Be aware of precautions!

Anatomy of Menisci

Thick peripheral margins are vascularized by genicular branches of popliteal artery. -Thin unattached edges in interior of joint are avascular.

Capsule of ankle

Thin and weak anteriorly and posteriorly -Ligaments of distal tib-fib and talocrural and subtalar joint support capsule

Charley Horse thigh contusion

Thing contusion CARE: Ice in flexed position (internal and external compression), NSAIDs RETURN TO PLAY (RTP): Full ROM, 90% strength, Protection (donut pad) PROBLEM: Myositis ossificans

1. Static Stretching

Tissue elongated to resistance and held tension created in muscle during static stretching is approximately half that created during ballistic stretching "Static Progressive Stretching" - increase as comfortable.

Elastic range/linear phase

Tissue taken to end of ROM, collagen fibers straighten and some microfailure occurs. There is complete recovery from this deformation, and the tissue returns to its original size and shape when the load is released if the stress is not maintained for any length of time.

Stress/Strain Curve

Toe Region: Add stress and collagen fibers straighten Elastic Range: More stress and recoverable deformation occurs Plastic Range: Elastic limit reached and damage occurs resulting in release of heat (hysteresis) and new length when stress released. Necking: Weakening of tissue and less force needed for deformation. Total failure quickly follows.

Local observation for feet

Toe alignmentArches of feetSkin integrity: ulcers, callouses, corns, venous/arterial insufficiency

How long will I need assistive device?

Until you can walk with normal pattern.

ITBS: Return to Running Phase

When open and closed chain exercises are performed pain free and normal strength bilaterally has returned Goals:Full activity over 3-4 weeks TreatmentGradual return to run program every other day Avoid hill training -ESPECIALLY DOWNHILL Increase frequency and intensity gradually

Fracture Classification (documentation)

Which bone? Where in the bone is the fracture? ... Which type? - -Type A = simple, -Type B = wedge -Type C = complex Which group? -Type A = Spiral/Oblique/Transverse -Type B = Spiral/Bending/Fragmented -Type C = Spiral/Segmental/Irregular Which subgroup?

Hip joint

ball and socket -3 axes, 3° of freedom (flex/ext, ab/add, IR/ER) FLEX/EXT in saggital plane around x axis AB/ADD in frontal plane around z axis IR/ER in transverse plane around y axis

deep infrapatellar bursa

between infrapatellar tendon & bone

Semimembranosus bursa

between semimembranosus tendon & posteriomedial portion of tibia (Baker's cyst)

Superficial Infrapatellar bursa

between skin & infrapatellar tendon

Tibiofemoral joint is (uniaxial/biaxial/triaxial)?

biaxial (flex/ext, rotation diarthrodial

Pump Bump (Haglund's Deformity)

bony enlargement on the back of the heel that most often leads to painful bursitis (high heels)

Pre patellar bursa

bursa between kneecap & skin

Effects of WB on Subtalar Joint (closed chain pronation)

calcanea eversion, TALAR and adduction with IR of the leg supination- calcanea inversion talar abduction, er leg

Bifurcate ligament

calcaneonavicular & calcaneocuboid ligs (group 4 dorsal)

CKC vs. OKC FOR ACL

ckc: Less cruciate stress -More joint stability -Less articular cartilage shear force -P/F joint reaction force OKC knee extension has big load on ACL CKC squat - MUCH LESS

Tibial Condyles

concave Articular surface of medial is 50% larger and cartilage is 3x thicker (but UKA almost always medial)

dermatomes

dermatomes: outer buttock L1, inner upper quadrant L2,3, inner lower quadrant S1,2

motions of the ankle around planes

dorsi/plantarflexion- sagittal plane, coronal axis inversion/eversion-frontal longitudinal axis abduction/adduction- transverse vertical axis

Tibialis Anterior

dorsiflex and invert

pronation is linked to

eversion, abduction, dorsiflexion

Latissimus Dorsi

extend arm in prone position.

What plane does patellar gliding (superior/inferior & medial/lateral) occur in?

frontal plane

glides and slides

hip flexion- anterior roll post glide hip extension- post roll ant glide abd- superior roll inferior glide add- inferior roll superior glide -ER: rolls post & glides ant IR: rolls ant & glides post

External/Internal Fixators

https://www.youtube.com/watch?v=VQup8vFLY2A https://www.youtube.com/watch?v=GukL80YEVjk

capsular end feel

i. Capsular (Firm end feel) 1. Feels like: Capsular stretch 2. Firm stops with slight give 3. Knee extension with hip extended

firm end feel

i. Muscular (Firm end feel) 1. Feels like: Feels of muscle tendon 2. Rubbery elastic 3. i.e. hip abduction (adductors), SLR (hamstring)

dorsal glide of the femur

improves knee extension

acetabulum angled

laterally, anteriorly, and inferiorly

Angle of Inclination of femur

line through femoral shaft and one straight through head and neck of femur. 125-135 coxa vara- less than 120 coxa valga- over 140

Glycosaminoglycans?

maintains water volume

close packed position knee

max ext and max er

Close-Packed Position of the hip

max extension, max abduction, max IR

Menisci are larger on the (lateral/medial) side

medial side

Tailor's Bunion

nflammation of the fifth metatarsal bone at the base of the little toe

Flaccid paralysis

no muscle tone due to immobilization. If no trauma - don't have to worry about contractures.

Internal Rotation/ external Mobilization (flapping technique)

or physiological IR POSITION: Prone-hip extended and knee flexed Pain relief: Grade II Stretching: Grade IV WHY?: IR is first to go in capsular pattern

vastus intermedius

origin: anterior and lateral surface of femur insertion: tibial tuberosity and patella action: extends leg nerve: femoral l2-l4

Pes Anserine bursa

pes anserine and tibia

oblique popliteal ligament

prevents hyperextension semimembranosus tendon which originates posterior to the medial tibial condyle and reflects superiorly and laterally to attach on the lateral condyle of the femur.r

-Orbicularis Oris

pucker lips

muscle strains:General Principles of Rehab

rice, protect, arom, strength, flexibility

What plane does patellar flexion/extension occur in?

sagittal plane- x axis

pes anserine

sartorius, gracilis, semitendinosus

Skeletal Disorders: Hip Dysplasia

socket doesn't fully cover head of femur

Anterior Labral (FADDIR) Test

start at 90 degrees. flex and adduct the hip then IR POSITIVE FINDING:anterior superior impingement, soas tendonitis. FAI syndrome.

princer hip impingement

when excessive bone grows at the edge of the hip's socket

Clavicle Fx

-Can be treated with our without surgery -Mechanism of injury is usually fall on outstretched hand (FOOSH) or direct shoulder impact -Fracture occurs most commonly at the mid shaft -Patient is TTP, has a deformity that is usually proximal superior displacement -Crepitus usually noted -Acutely managed similar to Proximal humeral fracture

Flexors of the Hip

-Iliopsoas (Illacus-Femoral, Major/Minor-Lumbar nerves L1/L2) -Sartorius (Femoral Nerve) -Tensor of Fascia Lata (Superior Gluteal Nerve) -Rectus Femoris (Femoral Nerve) -Pectineus (Femoral Nerve) -Adductor Longus (Obturator Nerve) -Adductor Brevis (Obturator Nerve) -Adductor Magnus (anterior part - Obturator Nerve) -Gracilis (Obturator Nerve)

Femoral Artery Branch - Deep Artery (Profundus Femoris)

*Chief artery of thigh* -Arises from femoral triangle 1-5cm inferior to inguinal ligament. -Passes deeply into thigh as it descends. -Lies posterior to femoral artery and vein on medial side of femur. -Leave femoral triangle between Pectineus and Adductor Longus. -Descends posterior to Adductor Longus. -Gives off arteries that supply Adductor Magnus and hamstrings.

*Location of Femoral Vein*

*Femoral vein has no tributaries at this level, except for the Great Saphenous Vein that joins it approx. 3 cm inferior to inguinal ligament. -In varicose vein operations it's important to identify Great Saphenous Vein correctly and not tie off femoral vein by mistake.

Meniscal Attachments (both)

-Intercondylar tubercles of tibia-Attached around periphery to tibia by CORONARY (meniscotibial) LIGAMENTS -Attached to patella by patellameniscal or patellotibial ligaments -Anterior horns attached by transverse ligament

Medial Rotators of the Hip

-Interior fibers of Gluteus Medius (Superior Gluteal Nerve) -Gluteus Minimus (Superior Gluteal Nerve) -Tensor of Fascia Lata (Superior Gluteal Nerve)

Arcuate Artery (x)

-Runs laterally across bases of lateral 4 metatarsals deep to -Extensor tendons and gives off the 2-4 dorsal metatarsal arteries. -Then runs to clefts of toes - each divides into 2 dorsal digital arteries for sides of adjoining toes.

PFPS: Phase 2 exercises (3-5 wks)

-SL stance with hip abduction -SL cable column directions -Plank/side plank -Minisquats STRETCH: Ham, quad, calf, IT band -Monster walks -SLS with sports specific upper body-Minisquat progression (lunge->SLS-step down)STRETCH

Fibula

-Serves mainly for muscle attachment -No function on weightbearing -Lateral malleolus helps hold talus in socket

Transplanation of Gracilis

-Relatively weak member of adductors. Can be removed without noticeable loss of actions in leg.

Inferior Tibiofibular Joint Movement

Allows for spread of 1-2mm during DF 2° of freedom :1. Cranial/Caudal glide (superior/inferior) 2. Ventral/Dorsal glide 3. Medial/Lateral Splay 4. Lateral rotation around fibula

Next Progression of treatment (up to 3 months) ACL

-Step-ups (more) -Step-downs (less) -Strength - squat with weights, eccentric leg press -Balance - single leg -Backwards treadmill

Proximal Humeral Fractures: conservative treatment

-non-surgical- (1,2 part fractures with minimal displacement) Sling immobilization 1-3 weeks Follow MD protocol re: degrees of ROM, early mobilization optimal

soft end feel

1. Feels like: Contact of muscle bulk on either side of joint 2. Soft spongy 3. i.e. elbow flexion, knee flexion with hip flexed

ligamentous end feel

1. Feels like: Ligamentous stretch 2. Firm stops with no give 3. i.e. ankle eversion, valgus knee stopped by MCL

empty end feel

1. Feels like: No resistance to movement, but stopped by onset of pain 2. Pain 3. Indication: Resistance of pain

Morton's Neuroma

Between 3rd and 4th MTs

Comminuted Fracture

Bone fragments into several pieces.

bony palpation for hip

Bony landmarks related to hip Iliac crest Iliac tubercle ASIS PSIS Greater trochanters Pubic tubercles Sacral base Ischial tuberosities

3rd layer of foot muscles

1. Flexor Hallucis Brevis (flexor of proximal phalanx of hallux) 2. Adductor Hallucis (adductor of hallux) 3. Flexor Digiti Minimi Brevis (flexor of proximal phalanx of small toe)

Hip Internal Rotation

Can also do in supine with leg and knee at 90.

Tibial Fracture: Bumper Fracture

Caused when bumper of car strikes leg. Often open and compound fracture.

Treatment of Patellofemoral Pain

1. Stretch tight lateral structures 2. Patient self stretch 3. Passively position with tape (do AFTER stretching)

Superficial and Deep Calcaneal Bursas

2 Bursas: 1. Superficial Calcaneal Bursa - Between skin and tendon 2. Deep Calcaneal Bursa (Retrocalcaneal) Between tendon and calcaneus Inflammation of Deep Calcaneal Bursa=Calcaneal Bursitis.

Fibularis Longus

Feel below fibular head and evert

Hip Injuries

Hip fractures uncommon in sports, except high-enery trauma such as vehicle, rodeo, horse racing accidents. -Contusions and hematomas more common.

Pes equinus

Horses weight-bear on toesplantar flexed foot; toes flexed

-Hyoid bone -Thyroid cartilage -Cricoid cartilage -Tracheal cartilages

Hyoid at about C4 Thyroid - V notch Cricoid - C6/C7

CT Response to Injury (2-4 days) (Effect/Intervention)

INFLAMMATION last 2-4 days BUT only needed for a few hours. So implement RICE. -INTERVENTION -NO active movements. Only passive below pain threshold. No collagen fibers presents so stretch is BAD - can lead to bigger scar, rupture, exacerbation of inflammation.

Closed Pack Position of Hip

IR and extension (and abduction?) Need this for normal gait and chondral health (load joint?)

Movement of Tarsal Joint during early stages of gait

IR force through tibia, hindfoot moves into eversion. The transverse tarsal joints (which are unlocked in eversion) are then able to move into relative supination to allow forefoot to adjust to maintain contact with the floor pronation-unlocks supination-locks

OA Clinical Presentation

PAIN -Anterior hip to groin -Buttocks to posterior hip -Knee -Low back pain ANTALGIC GAIT -Trendelenberg gait DECREASED ROM DECREASED FUNCTION - inability to perform ADLs -unable to cross legs -LE dressing

Popliteus

PROXIMAL: Lateral surface of lateral condyle of femur and lateral meniscus DISTAL: Posterior surface of tibia, superior to soleal line ACTION: Weakly flexes knee and unlocks it INNERVATION: Tibial Nerve

Instability Test: Lachman Test

Postero-lateral part of ACL (0-20° range) Put your knee under patient's Stabilize femur and ER then lift upward on tibia ' STRUCTURES INVOLVED (2nd restraints)-Posterior oblique ligament-Arcuate-popliteus complexMOST RELIABLE

Diagnosis of MCL Tear

Predictor variables-Hx of external force to leg or trauma -Pain and laxity with valgus stress at 30°Positive reference: MCL tear on MRI

Cuboidometatarsal IV & V Dorsal and Plantar Glides

SUPINE or Side-Lying Tibial side of foot resting on table, midway between pronation/supination in slight PF STABILIZE: CuboidMOBILIZE: 4/5th MT

Reverse Lachman

SUPINE- Knee flexed 30° Rest foot on your leg (or use pillow etc.) STABILIZE: Distal femur MOBILIZE: Anterior surface of proximal tibia TESTING: Posterior fibers

Hip Scour Test

SUPINE-Flex hip and knee -Load through knee-Compress in an arc going from IR to ER POSITIVE FINDING: Pain or apprehension (anterior labral tear)

Anterior Drawer Sign of Ankle (stability test)

SUPINE: Draw mortise forward 20° PFHIP/KNEE/ANKLE flexed: Push leg back PRONE: Push mortise forward TESTING: Anterior talofibular and/or anterior talocalcaneal ligaments

Proximal Humeral Fracture Complications**

Shoulder dislocation Injury to Axillary nerve (most common) Suprascapular, radial and musculocutaneous nerves can also be affected. Axillary/brachial artery (rare) Avascular necrosis of the humeral head Mal-union associated glenohumeral dislocation/ rotator cuff injury.

Knee Extension

Stabilize the hip by placing your hand or forearm across the anterior thigh to prevent hip flexion OR let gravity do work over edge of table.

Knee Flexion

Stabilize the pelvis by applying downward pressure across the buttocks. -Towel to prevent compression of patella. Can lift hip for more stretch.

Hip External Rotation

Stabilize the pelvis by applying pressure with your other hand across the buttocks.

Hip Abduction

Stabilize the pelvis by placing pressure on the opposite anterior iliac crest or by maintaining the opposite lower extremity in slight abduction. Keep leg in neutral (don't allow ER)

subjective examination

Subjective Examination Area - where does it hurt?Use body chartMark area of radiationClear other joint by examine bilaterally, record with check mark on body chart Onset - When did it started?Probably cause, precipitating factorHas it gotten better or worst? Nature - What does it feel likePain analogDescription with stiffness, weakness, throbbing, dull, sharp, burning i. Throbbing - inflammation, vascular ii. Burning - neurological Behavior - When are symptoms present?When do you feel it, how long does it last, what is the pattern? How often, daily? Once daily? Constant vs intermittent? i. Constant pain (chemical process) 1. SAME Intensity (Both quality and quantity are the same) 2. SAME Location 3. SAME sensation ii. Intermittent pain (mechanical issue) 1. Decrease or increase pain with position change? Aggravation i. Irritable vs not irritable 1. Irritable - Low stimulation, long duration of discomfort or pain. 24-hour clock. i. Slept with pain IS NOT wake up with pain. 1. Pain in sleep is same when wake up? ii. How they feel when they wake up iii. Day goes on, does it 1. Worsen - Overuses. 2. Better - with complain of stiffness = classic OA Functional limitation i. Our goal is to get patient back to prior functional level.

Post-Operative Phase I: Weeks 2-8 Assessment thr

Subjective outcome measures (LEFS, HOOS) Functional Gait Stairs 5xSTS TUG 10 MWT (gait speed) Balance Hip ROM + strength Neurovascular screen Incision/post-op dressing check

-Tibialis Anterior Tendon -Extensor Hallucis Longus Tendon

TA tendon more lateral. Can follow EHL from toe up.

Traumatic Fracture

Vehicular accidents or falls, May result in soft tissue damage

Superior Gluteal Nerve

Ventral Rami L4-S1. -Leaves pelvis through greater sciatic foramen (superior to piriformis). -Runs laterally between gluteus medius and minimus -Runs with deep branch of superior gluteal artery. SUPPLIES: Gluteus Medius, Gluteus Minimus and Tensor Fascia Lata

How much ROM do I actually need? gait, stairs, low chair, tying shoe knee

gait: 0 - 65 degrees Ascend stairs: ~ 85 degrees Descend stairs: ~ 95 degrees Sit in a low chair: ~ 95 degrees Tying your shoe: ~ 105 degrees To lift an object from the floor: ~ 115 degrees

plantar fascia

wide, nonelastic ligamentous tissue that extends from the anterior portion of the calcaneus to the heads of the metatarsals

Extensor Digitorum

wiggle fingers

2. Pubofemoral Ligament

pubis to trochanteric line (prevents excessive abduction)

Buccinator

pull cheeks in

Advantages to Hip Resurfacing

-Bone conservation -No restrictions = early/increased ROM -Return to higher level activity than s/p THR

What do I need to walk?

-Quad control -Full knee extension -Mobility

Inversion

0-35°PIVOT: Dorsum of ankle joint at level of lateral malleolus SA: Tibial crest MA: in line with 2nd MTPOSITION: Primary Mover: Posterior tibialisNERVE: Tibial (L4-S1) POSITION: sidelying with foot on bottom. Keep toes plantarflexed. RESISTANCE: PALPATION: by navicular tuberosity SUBSTITUTION: Anterior tibialis (in dorsiflexion), using toes (FHL, FDL)GE: Sitting

Lateral Toes MTP Extension/flexion

0-40, 10-40-felxion

Great Toe MTP Flexion

0-40°PIVOT: Medial aspect of 1st MTPSA: in line with 1st MTMA: Medial aspect of proximal phalangePOSITION: prone with knee at 90° (or sitting)

Hindfoot Inversion

0-5/10° (usually more than eversion)PIVOT:SA: MA: POSITION:

Great Toe MTP Extension

0-50/70°PIVOT: Medial aspect of 1st MTPSA: in line with 1st MTMA: Medial aspect of proximal phalangePOSITION: prone with knee at 90° (or sitting)

Hindfoot Eversion

0-5°PIVOT: Achilles tendon on level of lateral malleolusSA: Up center of calfMA: back of calcaneusPOSITION: prone

Great Toe IP Flexion

0-90°PIVOT: medial aspect of 1st IPSA: Medial aspect of proximal phalangeMA: Medial aspect of distal phalangePOSITION: prone with knee at 90° (or sitting)

-True Ribs -False ribs -Free floating ribs

1-7 8.9.10-false 11,12 free floating

phase 2 TKR ROM

1-8 weeks Heel slides Wall slides Stair stretches Physioball curls Use of the Stationary Bike Half Moons Adjustment of seat height

1st Layer of Plantar Muscles:

1. Abductor Hallucis (abductor of great toe) 2. Flexor Digitorum Brevis (flexor of 1-4 toes) 3. Abductor Digiti Minimi (abductor of small toe)

4 Types of Hip Dislocations

1. Acquired Dislocation 2. Congenital Dislocation 3. Posterior Dislocation 4. Anterior Dislocation

Interosseous Membrane and Intermuscular Septa Divide Leg into 3 Compartments

1. Anterior (extensor) compartment 2. Lateral (fibular) compartment 3. Posterior (flexor) compartment Transverse Intermuscular Septum Divides Posterior into 2 Parts -Superficial -Deep (STD-LA)

Lateral ligaments of the talocrural joint

1. Anterior talofibular lig (most often sprained) - check PF 2. Calcaneofibular lig - checks inversion 3. Posterior talofibular lig - checks DF FUNCTION: Checks varus force (inversion)

THR Implants

1. FEMORAL STEM -Metal (titanium, cobalt, stainless steel) 2. FEMORAL HEAD -Ceramic OR Metal (titanium,, cobalt, stainless steel) 3. Liner - Polyethylene 4. Acetabular Cup (metal - titanium, cobalt, stainless steel)

THR Implants

1. FEMORAL STEM -Metal (titanium, cobalt, stainless steel) 2. FEMORAL HEAD -Ceramic OR Metal (titanium,, cobalt, stainless steel) 3. Liner - Polyethylene 4. Acetabular Cup (metal - titanium, cobalt, stainless steel)

boggy end feel

1. Feels like: Soft and mushy feeling 2. Acute soft tissue edema, intra/extra-articular fluid 3. Indication: joint effusion, synovitis 4. i.e. severe sprained angle.

soft end feel (pannus)

1. Feels like: Soft or crunchy or most likely squeaky resistance 2. Indication Overgrowth of synovium(RA), entrapment of fat pad 3. Example: entrapment of posterior fat pad on elbow extension

Factors Which Promote Dense Adhesion Formation (4)

1. Immobilization (eliminate ASAP) 2. Edema (restricts ROM) 3. Trauma (inflammation slows) 4. Poor circulation (cartilage, RC)

Fibular movements

1. In DF - Fibula abducts, ER and glides superiorly 2. In PF - Fibula adducts, IR and glides inferiorly 3. In Subtalar Pronation - Slides proximally and anteriorly (talus is wider anteriorly so in DF it is more stable )4. In Subtalar Supination - Distal and posteriorly

Factors Affecting Patellar Alignment

1. Increased Q-angle 2. Tight lateral structures 3. Tightness of gastrocnemius and hamstrings 4. Excessive pronation 5. Patella Alta 6. VMO insufficiency

springy rebound end feel

1. Joint mobs with exercise, medical/surgical intervention. 2. Feels like: Springy rebound/bounces back 3. Internal derangement, cartilage block. 4. Loose, displaced knee meniscus or hip labrum

CT Response to Immobilization without Trauma (3)

1. Loss of water content 2. Loss of GAG concentration 3. Increase collagen cross linkages (adhesion)

Forefoot ROM

1. MTP ext (GT 50-70 /LT 40) 2. MTP flex (GT 40 /LT 10-40) 3. IP/PIP flex (GT 90/LT 35) 4. IP/PIP ext to neutral 5. DIP flex 45-60 6. DIP ext 0-10

3 Cuneiform Bones

1. Medial (1st) Cuneiform (largest) 2. Intermediate (2nd) Cuneiform (smallest) 3. Lateral (3rd) Cuneiform Each articulates :posteriorly with navicular bone :Anteriorly to appropriate metatarsal :Laterally with cuboid

Ankle Mortise

1. Medial TIbial malleolus 2. Latera Fibular malleolus 3. Trochlea of talus Cartilage of talar trochlea is continuous with malleloli

soft end feel (loose)

1. Needs: Stabilization, stability exercises. Surgical intervention 2. Feels like: Increased movement without firm resistance (which should be there) 3. Indication: Ligament laxity, capsule injury, hyper mobile 4. Example: grade 2 ligament sprain, torn capsule with hyper mobility

Subtalar Joint motions

1. OKC: pronation (ev, abd, df) & supination (inv, add, pf) 2. CKC: pronation (tibial ir, talar add, calc ev) & supination (tibial er, talar abd, calc inv)

Talocrural Joint Motion

1. OKC: talus (convex) moves on crural (concave tibia); R/T movements opposite 2. CKC: crural (concave) moves on talus (convex); R/T movements same direction

Role of Acute Care PT s/p Fracture

1. Pain control Elevation, Positioning, Cryotherapy, RN/MD Communication 2. Restore ROM/strength PROM -> AAROM/AROM -> Resistive exercises (Likely outpatient PT) 3. Restore functional mobility Consider Weight bearing status (UE and LE) Assistive devices and ADL equipment *Early mobility to prevent Pneumonia, Pressure sores, Pulmonary embolism (from DVT) 4. Request detailed orders for initiating PT Is this a staged procedure?

Types of Fixation

1. Porous -No cement used. NEED good bone quality. -Press fit (shoved in) or fixated with screws. -Biologic fixation - coats with hydroxyapetate to promote bone growth and prevents body from seeing components as foreign bodies. 2. Cemented (NOT COMMON) 3. Hybrid -Acetabular cup is press fit/screwed into socket -Femoral stem is cemented into femoral shaft

2nd layer of foot muscles

1. Quadratus Plantae (flexor of 1-4) 2. Lumbricals (flexors of proximal phalanges/extensors of middle and distal phalanges of 1-4) -Flexur Hallucis Longus Tendons (flexor of hallux)-Flexor Digitorum Longus (flexor of 1-4)

Foot Arches Maintained by:

1. Shape of interlocking bones 2. Strength of plantar ligaments (especially plantar calcaneonavicular, long and short plantar ligaments) 3. Plantar Aponeurosis 4. Action of muscles through bracing action of tendons.

Dx of Hip OA

1. Squatting pain 2. Active hip flexion causes lateral hip pain 3. Scour test with adduction causing lateral hip/groin pain 4. Active hip extension causing pain 5. Passive IR <=25°

Stages of Healing

1. Tissue destruction and Hematoma formation 2. Inflammation and cellular proliferation 3. Callus formation 4. Consolidation 5. Remodeling

Toe deformities

1. hammer toe: ext at MTP, flex at IP, ext at DIP 2. Claw toe: ext at MTP, flex at IP, flex at DIP 3. Mallet toe: PIP fixed into flexion. Rupture in long extensor tendons.

Complications of Fracture Healing: Mal-Union

A MALUNITED Fracture is one that has healed with the fragments in a non anatomical position. Causes 1 Inaccurate Reduction 2 Ineffective immobilization - move too early Mal-union can impair function by: -Abnormal Joint surface -Rotation or angulation -Over-riding (crossing over each other) -Blocking movement of neighbouring joint

phase 2 TKR manual therapy

AAROM/PROM Joint Mobilizations (as appropriate) Patella femoral joint glides Tibiofemoral Joint STM For edema controlScar mobility - when healed

ACL Mechanism of Injury

ACL Mechanism of Injury 1. Hyperextension 2. Varus/valgus force 3. Rotation USUALLY Non-contact

Actions/Nerve Supply to Adductor Group

ACTION: Adduct hip. Adductor Longus, Brevis and Magnus used in all movements in which thighs are adducted. NERVE: All supplied by Obturator Nerve EXCEPT Hamstrings part of Adductor Magnus (Sciatic Nerve)

Medial Plantar Nerve Entrapment

AKA "Jogger's Foot" -As nerve passes deep to Flexor Retinaculum or curves deep to abductor hallucis, compressive irritation may cause paraasthesia: Aching, Burning, Numbness, Tingling On: -Medial side of sole (region of navicular tuberosity) May occur during repetitive eversion of foot (gymnasts/runners)

Anterior Tibialis Strain

AKA Shin Splints -Edema and pain in area of distal 2/3 of tibia. -Results from repetetive microtrauma of TIBIALIS ANTERIOR and small tears in periosteum covering body of tibia. -Mild form of anterior compartment syndrome.

Deep Fibular Nerve Entrapment

AKA Ski Boot Syndrome -Tight-fitting boots can compress deep fibular nerve deep to inferior extensor retinaculum and the extensor hallucis brevis. *Results in pain in dorsum of foot and radiates to web space between 1st and 2nd digits.* = DEEP FIBULAR NERVE -Happens with tight shoes (soccer players, runners)

Tibial Nerve Entrapment

AKA Tarsal Tunnel Syndrome -Entrapment/compression of tibial nerve by flexor retinaculum. -Edema, tightness in ankle involving synovial sheaths of tendons of muscles in posterior compartment. Pain from Medial Malleolus to Calcaneus in heel.

Characteristics for Fracture Reduction

ALIGNMENT (most important) -Rotation - Restoration of Normal Length - Actual position of fragments (least important)

Metabolic Bone Disease

ALL OF THESE MAKE HEALING WORSE Osteoporosis Osteomalacia Primary malignant bone tumors Metastatic bone tumors Fibrous dysplasia Benign bone tumors Bone cysts Osteogenesis imperfecta Paget's disease Hyperparathyroidism

*Pubofemoral Ligament*

ATTACHES -Obturator crest of pubic bone -Merges with fibrous capsule of hip joint Blends with medial part of iliofemural ligament ACTION: TIghtens during extension and abduction -Prevents overabduction of hip joint (leg slipping laterally)

Pectoralis Minor96*

Abduct arm and place fingers under pec major. Muscle right on top of ribs.

Ligament movement:: Abduction/Adduction

Abduction: pubofemoral taut, iliotrochanteric band slack, ischiofemoral taut Adduction: Iliotrochanteric (superior of Y) taut, pubofemoral slack, ischiofemoral slack

Arthroscopy of Knee Joint

Allows for removal of torn meniscii, loose bodies in joint (bone chips, debridement)

Levator Scapula

Attached to superior angle of scapula. Laterally flex and rotate head to same side.

Hurdler's Injury

Avulsion of biceps femoris and semitendinosus from ischial tuberosity. Results from forcible flexion of hip with knee extended (hurdle, kicking football)

4. Subcutaneous Infrapatellar Bursa

Between skin and tibial tuberosity -Allows skin to glide over tibial tuberosity -Withstand pressure when kneeling with trunk upright

Bifurcate Ligaments

Bifurcate Ligaments Consists of: -Medial (lateral calcaneonavicular) band -Lateral (calcaneocuboid) band

Cuboideonavicular Joint (classification, movement, close packed position, resting position, capsular pattern)

CLASSIFICATION: Fibrous MOVEMENT: Slight gliding and rotation CLOSE PACKED: Supination RESTING: Midway between supination/pronation and 10° PF CAPSULAR: Limitation of supination > Pronation

Cuneocuboid Joint (classification, movement, close packed position

CLASSIFICATION: Plane synovial MOVEMENT: Slight gliding and rotation CLOSE PACKED: Supination

Cuneonavicular Joint (classification, movement, close packed position)

CLASSIFICATION: Plane synovial MOVEMENT: Slight gliding and rotation CLOSE PACKED: Supination

Intercuneiform Joints (classification, movement, close packed position)

CLASSIFICATION: Plane synovial MOVEMENT: Slight gliding and rotation CLOSE PACKED: Supination

Calcaneocuboid Joint Classification, Movement, Close Packed Position, Ligaments

CLASSIFICATION: Saddle synovial MOVEMENT: Gliding and rotation CLOSE PACKED: Supination LIGAMENTS: -Bifurcate-Calcaneocuboid-Short and Long Plantar Has its own capsule

Intermetatarsal Joints (classification, degrees of freedom)

CLASSIFICATION: Synarthrosis DEGREES OF FREEDOM: 1 - Dorsal and plantar glides

Inferior Tibiofibular Joint

CLASSIFICATION: Syndesmosis - fibrocartilaginous junction (NO CAPSULE) ARTICULAR SURFACES: Concave tibiaConvex fibula NERVE SUPPLY: Deep Fibular Nerve & TIbial Nerve

IP Joints (classification, articular surfaces, degrees of freedom, resting, close packed, capsular)

CLASSIFICATION: Synovial ARTICULAR: Proximal phalanx = convex. Distal phalanx = concave DoF: 1 - flexion/extension RESTING: Slight flexion CLOSE PACKED: Full extension CAPSULAR: Flexion > extension

THR Approaches - Anterior (cut & precautions)

CONS: -Poor femur exposure (femoral stem malpositioning) --Lateral femoral cutaneous/femoral nerve palsy (ant. thigh numbness) 20% of people PROS:-Muscle sparing -Lower dislocation rates -PRECAUTIONS -No extension -No ER -Surgeon dependent

Anterior and Middle Talocalcaneal

CONVEX on CONCAVE 2 convex facets of inferior body and neck of talus 2 concave facets on calcaneus Share joint capsule with talonavicular joint

Calcaneal Tendon Reflex

Calcaneal tendon struck with reflex hammer proximal to calcaneus SHOULD result in plantarflexion. Tests S1/S2 nerve roots

Calcaneocuboid Joint

Calcaneus: Concave dorsal to plantar and convex medial to lateral Cuboid: Convex dorsal to plantar and concave medial to lateral

Cam hip impingement

Cam femoroacetabular impingement (FAI) occurs when the head of the femur alters the movement in the joint. Specifically, a less spherical femoral head alters the contact area within the joint (at the acetabulum).

ACL Injury

Can be torn when: -Tibia driven anteriorly on femur -Femur driven posteriorly on tibia -Knee joint is severely hyperextended

Supination/Pronation Limitations

Can use all the ones for DF/PF-SUPINATION: Varus tilt Dorsal glide of navicular Dorsal glide of cuboid ?PRONATION Valgus tilt Plantar glide of navicular Plantar glide of cuboid ?

Slipped Epiphysis

Children (10-17) Epiphysis of femoral head may slip away from neck because of weak epiphyseal plate. -Caused by acute trauma/repetitive microtraumas with increased shearing stress on epiphysis - ESPECIALLY with abduction and lateral rotation of thigh. -Often slips slowly and results in progressive coxa vara. INITIAL symptom: hip pain, referred to the knee.

Transverse Arch

Composed of: Cuboid, Cuneiforms and bases of metatarsals -Medial and lateral parts of longitudinal arch serve as pillars for it. -Tendon of Fibularis Longus crossing sole of foot obliquely helps maintain curvature of arch.

Waldron Test

Compress patella and unilateraly WB on that side (give them something to hang onto)Deep knee bends slowly POSITIVE = Crepitus, pain or knee locking = Patellofemoral athritis

Definitive DX of Compartment Syndrome

Definitive DX of Compartment Syndrome Compartment pressure testing - pre and post exercise levels NORMAL: 0-10mmHg POSITIVE: >35mmHg

Hip Resurfacing Contraindications

FEMALE (especially during childbearing age) -Metal ions (chromium and cobalt negative impact on fetal development) -Poor outcomes with females (2x as likely to fx as male counterparts) OBESITY OSTEOPOROSIS SIGNIFICANT BONE DEFORMITY -Leg length discrepancy (LLD)>1cm -Neck/shaft angle <120 -Better correction with THR

Orientation of femoral and tibial condyles (retroversion/retroflexion)

Favor knee flexion-Retroversion: tibial condyles inclined posteriorly -Retroflexion: tibia bent to be concave posteriorly (allows for soft tissue mass in flexion)

Femoral Condyles

Feel shaft and where it starts to fan out

Tibiofemoral Joint: Rolling & Sliding

Femoral articulating surfaces larger than tibial articulating surfaces. -When femoral condyles are moving on tibial condyles (weight-bearing situation), femoral condyles must roll and slide to remain on tibia

Thenar / Hypothenar Eminence

Fat pads on palm.

ITBS: Acute Phase

Goal: -Pain reduction -Reduction of inflammation Treatment-Activity modification-Ice-NSAIDS-Corticosteroid injection of severe pain or swelling

*Palpation of Femoral Artery*

Femoral pulse is palpated: -With person lying supine -Femoral artery begins at inguinal ligament. -Runs midway between ASIS and pubic symphysis. -Can be palpated just inferior to midpoint of this ligament. IF DIMINISHED - Might be lumina of common or external iliac arteries are partially occluded.

Potentially Lethal Misnomer

Femoral vein is NOT "Superficial Femoral Vein". "Superficial Femoral Vein" is a DEEP vein. Acute thrombosis of this vein is potentially life threatening. DO NOT USE "Superficial".

Fibularis Brevis Tendon

Fibularis longus on outside and brevis on inside

Sural Nerve

Formed by union of branches from: -Tibial Nerve -Common Fibular Nerve Sometimes they don't join and no Sural Nerve forms. In this case, skin is supplied by TIbial and Fibular branches. PATH: -Accompanies Small Saphenous vein. -Enters foot posterior to lateral malleolus. SUPPLIES: Skin along lateral margin of foot -> lateral side of 5th digit.

Prepatellar Bursitis

Friction between skin and patella leads to bursitis. -If chronic, bursa become distended with fluid and forms swelling anterior of knee.

Cause of IT Band Syndrome?

Friction forces between the ITB and lateral femoral condyle are greatest between 20° - 30° of flexion ITB impinges on the lateral femoral condyle just after foot strike Repetitive irritation can leads to chronic inflammation

Anterior Cruciate Ligament

From anterior intercondylar fossa of tibia to internal lateral condyle of femur DIRECTION: Runs superior, posterior and lateral-Takes 87% of load with anterior translation with extended knee

glute minimus

Gluteus Minimus: PROXIMAL: External surface of ilium between anterior and inferior gluteal lines DISTAL: Anterior surface of greater trochanter ACTION: Abducts and medially rotates thigh; keeps pelvis level when opposite leg raised INNERVATION: superior gluteal (L4-S1)

ITBS: Subacute Phase

Goal: -Correction of biomechanical abnormalities -Release of myofascial restrictions Treatment:-Stretch ITB/TFL complex, iliopsoas, rectus femoris-Foam roller

Achilles Rupture Post-op (Wks 12-20 - goals/precautions)

Goals Restore all active ROM Normalize PF Strength Mormalize Balance Return to functional activities without pain Ability to descend stairs Precautions Avoid Pain with therex and functional activities Avoid high loading of the achilles tendon (jumping)

Achilles Rupture Post-op (Wks 20-28 - goals/precautions)

Goals Run forward on a treadmill syptom free Max strength and flexibility to meet demands of ADLs Return to functional ADLs PrecautionsNo apprehension or pain with dynamic activity Avoid running or sport activity until adequate strength and flexibility is achieved

Phase 2: 1-8 weeks post-op TKR

Goals: Maximize ROM- Goal is 0-105 degreesFocus on increasing LE strength, emphasis on quads Minimize edema Normalize Gait- Progression of Assistive Devices to no device Independent with all ADLs Address balance impairments Continued ROM emphasis Manual therapy Neuromuscular re-education Strength training Gait training Functional mobility training Modalities Aquatic Therapy

Talocrural Anterior Glides

PRONE Foot over edge of table w/ 10° PF STABILIZE: Table MOBILIZE: Talus (between malleoli and calcaneus) FUNCTION: Increase PF

Superior Tibiofibular Joint: Anterior Glide Mobilization

PRONE Knee flexed, foot on pillow, ankle PF'd 10° STABILIZER: Medial tibia MOBILIZER: Posterior head of fibula DIRECTION: Anterior and latera lINDICATION: Increase splaying for DF

Posterior Labral Test

PRONE Move painful hip into just short of full extension Apply ER and extension force POSITIVE FINDING: Pain

Thompson Test

PRONE or Kneeling on stoolSqueeze calf and foot should PF POSITIVE: Torn Achilles

Craig's Test

PRONE-Flex knee to 90°-IR/ER hip -Palpate trochanter then put it parallel to table TESTING: Anteversion (normal ROM 8-15°) greater than 15- anterversion less than 15- femoral retro version

Pros & Cons of Hip Resurfacing

PROS: No precautions Decreased risk of dislocation CONS: Increased risk of femoral neck fracture (due to larger head) -Decrease in ROM?

ITBS most likely resulting from ____

PROXIMAL ORIGINS To control coronal plane movement during stance phase, the glut medius and tfl must exert a continuous hip abduction moment. Fatigued runners or those with weak glut medius muscles are prone to increase adduction and internal rotation at midstance --- increased valgus vector at the knee

Gastrocnemius

PROXIMAL: Lateral head - Lateral aspect of lateral condyle of femur Medial head - Popliteal surface of femur, superior to medial condyle DISTAL: Posterior surface of calcaneus via calcaneal tendon ACTION: Plantarflexes ankle when knee extended (max power when muscle fully extended), raises heel during walking, and flexes leg at knee joint INNERVATION: Tibial Nerve

Biceps Femoris

PROXIMAL: Long head: Ischial tuberosity Short head: Linea aspera and lateral supracondylar line DISTAL: Lateral side of head of fibula; tendon split at this site by fibular collateral ligament ACTION: Flexes knee and also rotates tibia laterally; long head also extends hip joint INNERVATION: Long head: Tibial division of Sciatic Nerve Short head: Common Fibular Division of Sciatic Nerve

piriformis

PROXIMAL: Anterior surface of sacrum and sacrotuberous ligament DISTAL: Superior border of greater trochanter notch ACTION: Laterally rotate extended thigh and abduct fleced thigh; steady femoral head in acetabulum 90 degrees becomes an internal rotator INNERVATION: Piriformis Nerve (S1-S2) mmt- HIP external rotation

Piriformis

PROXIMAL: Anterior surface of sacrum and sacrotuberous ligament DISTAL: Superior border of greater trochanter notch ACTION: Laterally rotate extended thigh and abduct fleced thigh; steady femoral head in acetabulum INNERVATION: Piriformis Nerve

Vastus Intermedius

PROXIMAL: Anterior/lateral surfaces of femur DISTAL: Base of patella/patellar ligament ACTION: Extend leg, help iliopsoas flex thigh INNERVATION: Femoral Nerve (L2-L4)

Talocrural Joint: Articular Surfaces

PROXIMAL: Concave mortise -Distal tibia and medial and lateral malleoli -Fibular malleolus extends further distally and posteriorly Convex talus: Medial (tibial) - smaller Lateral (fibular) - larger Superior (trochlear)

McMurray Test

SUPINE - Knee completely flexed IR/ER knee first Medial rotation with varus (lateral) lateral rotation with valgus (medial) -Rotate tibia externally and apply varus/valgus stress then go into extension POSITIVE: Painful click on rotation = lateral meniscus (left pic), medial meniscus (right pic)- Posterior HornHIGH SPECIFICITY, MODERATE SENSITIVITY

Talonavicular Plantar Glide

SUPINE - knee bent STABILIE: Talus/cuboid MOBILIZE: Plantar aspects of navicularDIRECTION: Plantar FUNCTION: ??

MTP & IP Joint Dorsal and Plantar Glides

SUPINE - knee flexed and foot on wedgeMTP STABILIZE: MT on wedgeMOBILIZE: apply distraction, proximal phalanx with grip close to joint lineIP STABILIZE: close to joint line of proximal or middle phalanx MOBILIZE: close to joint line for middle or distal phalanx

Subtalar Joint Distraction

SUPINE Ankle PF 10° STABILIZE: Talus by holding ankle mortise MOBILIZE: Calcaneus - pull back

Posterior/Anterior Glide of Talus (or tibia)

SUPINE Flex knee on table with 10° PF STABILIZE: midfoot MOBILIZE: Distal tib-fib Moving posteriorly = talus anteriorly = increase PF Moving anteriorly = talus posteriorly = increase DF

Instability Testing: Posterolateral Rotary Instability (Hughston's posterolateral drawer test

SUPINE Hip flexed 45°, knee flexed 90°, leg/foot in 15° ER POSITIVE =■ PCL ■ Arcuate-popliteus ligament ■ LCL ■ Biceps femoris ■ Posterolateral capsule ■ ACL

Instability Testing: Posteromedial Rotary Instability (Hughston's posteromedial drawer test)

SUPINE Hip flexed 45°, knee flexed 90°, leg/foot in 30° IR POSITIVE = ■ Posterior cruciate ligament ■ Posterior oblique ligament ■ MCL ■ Semimembranosus ■ Posteromedial capsule ■ ACL

Subtalar Joint Varus and Valgus Tilt

SUPINE Hip/knee flexed to 90°, slight ER STABILIZE: Cradle distal thigh against your body and stabilize talus MOBILIZE: Tilt Calcaneus into varus or valgus FUNCTION: Varus for inversion Valgus for eversion

Talocrural Joint Distraction

SUPINE PF 10°, foot off edge of table STABILIZE: Lower leg to table (belt or grip) MOBILIZE: Trochlea of Talus (use ulnar border) FUNCTION: Assists DF but PF too

Noble Compression Test

SUPINE Test for IT band friction syndrome -Flex hip with knee flexed to 90° -Apply pressure with thumb to lateral femoral condyle -Maintain pressure while patient extends knee POSITIVE FINDING: Pain over lateral femoral condyle at 30°

Dorsal Glide of the Femur

SUPINE-Knee close to end of extension (towel under knee)-Stabilize proximal anterior tibia-Mobilize distal anterior femur CONVEX on CONCAVE DIRECTION: Posterior PURPOSE: Increase very end of extension

Instability Testing: Lateral Gapping

SUPINE-Knee flexed 30°LATERAL (adduction): Apply varus force to knee by pushing tibia (test for LCL integrity)STRUCTURES (with slight flexion)-LCL, posterolateral capsule, arcuate-popliteal complex, IT band, biceps femoris tendon

Instability Testing: Ventral Glide of Tibia (anterior drawer test)

SUPINE-Knee flexed to 70-90° -Thumbs on medial/lateral joint lines -Pull tibia anteriorly -STABILZE FOOT (sit on it) TESTING: Antero-medial part of ACL

Mobility Testing: Posterior Glide of Tibia

SUPINE-Knee flexed to 90° -Thumbs on medial/lateral joint lines Direction: Push tibia posteriorly USED FOR: Flexion Can do prone (works well to stretch into flexion at end range)

Patellofemoral Grinding Test

SUPINEDegenerative changes to under surface of patella Just short of full extension Pressure on patella and grind in groove POSITIVE: Pain and crepitus (apprehension sign)Follow this with Clarke's test

MTP Joint distraction

SUPINESTABILIZE: Dorsal and plantar aspects of MT MOBILIZE: Distract proximal phalanx gripping joint line and longitudinal pull

Intermetatarsal Glide

SUPINESTABILIZE: MT II MOBILIZE: MT I in dorsal then plantar directions Stabilize II, mobilize IIIStabilize III, mobilize IVStabilize IV, mobilize V

Muscular Branches of Popliteal Artery

SUPPLY: -Hamstring -Gastrocnemius -Soleus -Plantaris

Medial Plantar Artery

Small -Supplies mainly muscles of great toe. -Most plantar digital arteries arise from this vessel -Superficial branch suppplies skin on medial side of sole -Digital branches accompany digital branches of medial plantar nerve and contribute little to circulation of toes

Hip Adduction

TFL and IT Band -Stabilize pelvis -Flex knee and put into extension and pull down. TFL - Extend at hip, flex at knee, ER a bit.

-Tensor Fascia Lata -Iliotibial band

TFL: Right behind ASIS. Flex, IR and abduct IT band: quad set and above depression at lateral knee

Complication: Periprosthetic Fracture (THR/Resurfacing - where? WB status? Fix?)

THR -Can occur intra-operatively -Femoral shaft > acetabulum -Protective WB -Revision (screws to stabilize) RESURFACING -Femoral neck fx -Protective WB -Revision to THR

Surgical Hip Replacement

THR - 1st joint to get replaced. During hip replacement - Metal prosthesis is anchored to femur by bone cement and replaces femoral head and neck. Plastic socket cemented to hip bone to replace acetabulum (prevents heat generation)

-Tibialis Posterior Tendon -Flexor Digitorum Longus* -Posterior Tibial Artery -Tibial Nerve* -Flexor Hallucis Longus*

TP tendon - behid medial malleolus

Vastus Medialis

PROXIMAL: Intertrochanteric Line and medial lip of linea aspera DISTAL: Base of patella/patellar ligament ACTION: Extend leg, help iliopsoas flex thigh INNERVATION: Femoral Nerve (L2-L4)

Superior Gemelli

PROXIMAL: Ischial Spine DISTAL: Medial surface of greater trochanter ACTION: Laterally rotate extended thigh and abduct flexed thigh INNERVATION: Obturator Internus Nerve

Superior Gemelli

PROXIMAL: Ischial Spine DISTAL: Medial surface of greater trochanter ACTION: Laterally rotate extended thigh and abduct flexed thigh INNERVATION: Obturator Internus Nerve l5,s1

Inferior Gemelli

PROXIMAL: Ischial tuberosity DISTAL: Medial surface of greater trochanter ACTION: Laterally rotate extended thigh and abduct flexed thigh INNERVATION: Obturator Internus Nerve and Inferior Gemellus Nerve

Inferior Gemelli

PROXIMAL: Ischial tuberosity DISTAL: Medial surface of greater trochanter ACTION: Laterally rotate extended thigh and abduct flexed thigh INNERVATION: nerve to quadrates femoris (L4-S1)

Semitendinosus

PROXIMAL: Ischial tuberosity DISTAL: Medial surface of superior part of tibia ACTION: Extend thigh; flex leg and rotate it medially when knee is flexed; when thigh and leg are flexed, can extend trunk INNERVATION: Tibial Nerve (L5-S2)

Semitendinosus

PROXIMAL: Ischial tuberosity DISTAL: Medial surface of superior part of tibia ACTION: Extend thigh; flex leg and rotate it medially when knee is flexed; when thigh and leg are flexed, can extend trunk INNERVATION: Tibial division of Sciatic Nerve

Subtalar Joint Resting position, closed packed position and capsular pattern

RESTING: Midway between supination/pronation and 10° PF CLOSED PACKED: Supination CAPSULAR: Inversion > eversion-Limited supination

Complication: Infection (risk factors, prevention, signs/sx)

RISK FACTORS -Dental infections -Smoking -Co-morbidities (Obesity, DM, RA) PREVENTION -Sterile OR, Safe handling post-op (handwashing/gloves) SIGNS/SX -Red, hot, swelling, TTP -Fever -Drainage -Increase in WBCs

Risk Factors/Prevention of Blood clots (DVT/PE)

RISK FACTORS -Prior hx -Female -Delayed mobilization post-surgery PREVENTION -Prophylaxis - Coumadin (PT INR - prothrombin time international normalized ratio), Aspirin -Early mobilization -Bed Ther-ex

Fractures of Femoral Neck

Realignment of neck fragments requires internal skeletal fixation -Most troublesome of all fractures -CAREFUL of Medial Circumflex Femoral Artery - supplies most of blood to head and neck. Sometimes only artery supplying blood to head.

*Vastus Medialis Oblique*

Realigns patella medially Active through whole ROM -Arises from adductor magnus tendon -Innervated from branch of femoral nerve EMG recordings: Looking for 1:1 ratio of VL to VMO

WB Status if femoral stem revised

protective WB

Genu Varum

(Bow-legged) All pressure is taken by inside of knee joint. -Arthrosis-destruction of cartilages -Patella tendon moves laterally (to weight bearing line) when leg is extended. -Movement increased by pull of vastus lateralis -Children commonly appear bowlegged for 1-2 years after starting walking.

Pre-Op ACL

*GET FULL EXTENSION* -Want 0-120° -Walk up stairs -Normal gait pattern

Phalanges

*Middle and distal phalanges of 5th digit are often fused in elderly people. DO NOT DO JOINT MOBILIZATION*

Navicular

*Navicular tuberosity: important landmark for palpation*

Patellar Dislocation

*Nearly always lateral dislocation* -More often in women -Lateral dislocation is counterbalanced by medial, horizontal pull of VMO. -Lateral femoral condyle is mechanical deterrent to lateral dislocation.

*Sole Artery of the Foot*

*Prolific blood supply* -Arteries derive from Posterior Tibial Artery. -Divides deep to Abductor Hallucis to form: 1. Medial Plantar Artery 2. Lateral Plantar Artery (bigger because more area to cover) -Runs parallel to similarly named nerves.

Early Stance

*heel-strike, foot up 1. Subtalar Pronation: tibial IR, talar add, calc eversion 2. Midtarsal joint: unlocked 3. TMT: supination twist

Late Stance

*whole foot on ground 1. Subtalar Supination: tibial ER, talar abd, calc inv 2. Midtarsal joint: locked (in slight supination) 3. TMT: pronation twist-more rigid foot

Trendelenburg Test/Sign: NORMALLY gluteus medius contracts as soon as contralateral foot leaves floor - prevents tipping of pelvis.

+ = Pelvis of unsupported side descends Other causes: Fracture of greater trochanter Results in "Waddling gait" -lean away from unsupported side OR "Steppage gait": Lifts foot higher as it's brought forward.

4th layer of foot muscles

-3 Plantar interossei (adduct/flex metatarsophalangeal joint of 3-5 -4 Dorsal interossei (abduct/flex metatarsophalangeal joints of 2-4)

Proximal Humeral Fracture

-4-5% of all fractures -Commonly seen in women with OP or adolecents -Mechanism of injury: FOOSH/MVA/sports injury

First treatment and HEP for post op ACL

-AAROM in sitting -E-stim with contracting (russian stim) -Cryotherapy -Work distally and proximally -Extension at knee and dorsiflexion stretch

anterior drawer sign

-ACL-MCL-Posterolateral capsule-Posteromedial capsule-IT band-Posterior oblique ligament-Arcuate popliteus complex

Patella

-Able to withstand compression placed on quad tendon during kneeling and friction occurring when knee is flexed/extended during running. -Provides additional leverage for quad in placing tendon more anteriorly

Acetabulum

-Acetabular fossa/notch: articulate with head of femur to form hip joint

Conservative Management of CS

-Activity modification -Deep soft tissue massage -Myofascial release -Correction of biomechanical deficiences -Change of shoes/running surfaces -Orthotics to correct foot mechanics

Adductors of the Hip

-Adductor Longus (Obturator Nerve) -Adductor Brevis (Obturator Nerve) -Adductor Magnus (Obturator Nerve) -Gracilis (Obturator Nerve) -Pectineus (Femoral Nerve) -Obturator Externus (Obturator Nerve)

OA Risk Factors

-Age -Skeletal disorders 1. Legg-Calve perthes 2. Hip Dysplasia 3. Slipped Capital Femoral Epiphysis -Race - caucasian more likely -Previous injury -Overweight/Obesity

Hamstring Injuries

-Almost always proximal and medial -Violent exertion may tear part of proximal tendinous attachments of hamstrings to ischial tuberosity -Hamstring strains are twice as common as quad strains. -Usually accompanied by: Contusion Tearing muscle fibers Rupture of blood vessels Hematoma contained by dense fascia lata -Often turns black and blue days later.

Ankle Sprains

-Ankle is most frequently injured major joint. Sprains: Tearing fibers of ligaments *Nearly always inversion injury involving twisting of weight bearing foot*

Articular Capsule of Ankle Joint

-Anteriorly and posteriorly: fibrous capsule is thin -Each side supported by strong collateral ligaments -Superiorly: Attached to borders of tibia and malleoli -Inferiorly: Attached to talus

Specific Hip Injuries

-Anteroposterior compression= fractures pubic rami -Lateral compression or falls on feet from roof= fracture of acetabula -Avulsion fracture (of ischial tuberosity) occur in kids with sudden acceleration. These fracture occur at apophyses (bony projections that lack secondary ossification centers).

Common Pitfalls of Slings

-Arm/Elbow not correctly seated in sling -Shoulder strap too tight/loose -Sling position (too forward, too adducted)

Functional Progression (later) for ACL post op

-Ascend stairs -Descend stairs -Running - impact (usually 3-4 months )-Return to sport - jumping, agility, plyos

Functional Progression: Stairs for ACL

-Ascend stairs (extensors and flexors -Descend stairs (harder because extensors and flexors on slack & ALL QUADS - so go down with bad leg first)

Lateral Tarsal Artery (x)

-Branch of Dorsal Artery of foot. PATH: Runs laterally in an arched course beneath Extensor Digitorum Brevis. Then anastomoses with other branches such as Arcuate Artery. Creates part of Plantar Arch. SUPPLIES: -Extensor Digitorum Brevis -Underlying Tarsals -Underlying joints

Diagnosis/Treatment of Blood Clots

-Calf red, hot, swollen, sig. TTP (tender to palpation) -Doppler -IVC filter - inferior vena cava filter: wire mesh to catch embolism

Paralysis of Quadriceps Femoris

-Can't extend leg against resistance -Presses on distal end of thigh during walking to prevent inadvertent flexion of knee joint (hands on tibial tuberosity) CAUSE: Weakness of vastus medialis or vastus lateralis resulting from arthritis or trauma to knee

Proximal Humeral Fx PT (Hemiarthroplasty, TSA, Reverse TSA for 4 part fractures)

-Codman/pendulum exercises (in/out of sling) -Distal ROM: elbow flex/ext, forearm sup/pronation, wrist flex/ext, digit ROM/gripping -Shoulder PROM into FF in the scapular plane and ER -PROM: done by PT/family member *IF THERE IS A ROTATOR CUFF REPAIR- INITIATION OF ROM MAY BE DELAYED!*

Femoral Fractures

-Common in 60+ (especially women): 1. Intertrochanteric Fractures: Fracture between greater and lesser trochanter 2. Pertrochanteric fractures: through trochanters (often comminuted)

Fibular Fractures

-Commonly occur 2-6cm proximal to distal end of lateral malleolus. -Often associated with fracture/dislocation of angle. -Fracture of Lateral Malleolus: When slip and foot forced into excessive inverted position, tear ankle ligaments and avulse lateral malleolus.

Tibial Plateau Fracture Complications

-Compartment syndrome -Peroneal/Fibular nerve injury -Popliteal artery injury

Revision after multiple dislocations

-Constrained liner -Bigger head -Bracing

Rehab guidelines: Meniscus

-Control effusion -Activity modification - start slow -Quad re-education -Restore ROM-Functional progression (from earlier)

Hip and Thigh Contusions

-Contusion of iliac crest -> "hip pointer" injury. Bleeding from ruptured capillaries that then go into muscles, tendons and soft tissues. -"Charley Horse" - Cramping of thigh muscle due to ischemia (inadequate circulation) caused by direct trauma. Contusion/tearing of muscle fibers leads to rupture of blood vessels sufficient enough to form hematomas. Sometimes results in quadriceps tendon partial tear.

Fracture Healing divided by bone type

-Cortical bone of the shaft. -Cancellous bone of the metaphyseal region of the long bones and the small bones.

Leg Length Discrepancy

-Could be result of femoral fracture True Leg Length Discrepancy: -Measure ASIS to distal tip of medial malleolus. -Also measure ASIS to lateral femoral condyle (to determine if shortening is in thigh) Differences of 1.25cm are normal

Hip Joint Fatpad

-Covered with synovial membrane -Fills part of acetabular fossa not occupied by femoral head. -Malleable in nature so it can change shape to accomodate varying shape of head and movements.

Fibularis Brevis

-DEEP to Fibularis Longus -Has slip of muscle: Fibularis Tertius PROXIMAL: Inferior 2/3 of lateral surface of fibula DISTAL: Dorsal surface of tuberosity on lateral side of base of 5th metatarsal ACTION: Everts foot and weakly plantarflexes ankle INNERVATION: Superficial Fibular Nerve

Soleus

-Deep to gastrocnemius Named because resembles flat sole fish -Fibers slope inferomedially DOESN'T ACT ON KNEE JOINT -Contracts alternately with extensor muscles to maintain balance PROXIMAL: Posterior aspect of head of fibula, superior 1/4 of posterior surface of fibula soleal line and medial border of tibia DISTAL: Calcaneal tendon ACTION: Powerful (but slow) plantarflexor of ankle; steadies leg on foot INNERVATION: Tibial Nerve

Tributaries/Perforating Veins

-Diameter of tributaries remains same as they ascend leg. -Perforating veins contain valves that only allow blood to flow from superficial to deep veins. They pass through deep fascia at oblique angle so when muscle contracts the pressure increases inside deep fascia and perforating veins are compressed.

Meniscus Function

-Distribute WB -Increase joint congruency -Limit abnormal motions -Improve articular nourishment

ADLs for LE Injuries

-Donning/doffing brace (if applicable) -Dressing Dress the surgical LE first -Showering Instruct patient to shower with brace on (shower chair) Cover brace with cast bag Tub vs. shower, dry floor prior to entering -Toileting Raised toilet seat or bed-side commode

Resisted toe abduction

-Dorsal interossei -Abductor Hallucis -Abductor Digiti Minimi

3 Parts of Hip Bone (474N)

-Each part forms own primary ossification center.

Early ACL Rehab

-Early mobilization - sitting - other leg helps lift and lower it -Early WB - WITH LOCKED BRACE (need quad strength) Lock brace - WB, sleeping and SLR initially

5. Remodeling

-Excess material on the bone shaft exterior and in the medullary canal is removed -Compact bone is laid down to reconstruct shaft walls LONGEST PHASE

Complications of Fracture Healing: Non-union

-FDA defined nonunion as "established when a minimum of 9 months has elapsed since fracture with no visible progressive signs of healing for 3 months" -Every fracture has its own timetable (eg: long bone shaft fracture 6 months, femoral neck fracture 3 months)

Nerves of the Hip

-Femoral Nerve (anteriorly) -Accessory Obturator Nerve (anteriorly) -Obturator Nerve (inferiorly) -Superior Gluteal Nerve (superiorly/posteriorly) -Nerve to Quadratus Femoris (posteriorly)

Total Femur Replacement: Indications

-Femoral bone stock so deficient that standard revision implants can't be securely fixed in remaining bone. -Significant femur resection due to tumor/multi-trauma (Historically only option was trans-femoral amputation)

Femur Landmarks (Cont'd)

-Femoral condyles articulate with tibial condyles to form knee joint. -Anteriorly, femoral condyles merge at patellar surface and articulate with patella. -Medial epicondyle -Adductor tubercle

Reasons for Increased Q-Angle

-Femoral neck anteversion -External tibial torsion -Lateral displacement of tibial tubercle (SLIDES 648/649)

3. Callus formation

-Fibrocartilaginous callus forms -Granulation tissue (soft callus) forms a few days after # -Capillaries grow into the tissue and phagocytic cells begin cleaning debris

Principles of Fracture Treatment

-Fracture Stabilization -Restoration of anatomy -Preservation of blood supply

Return to Sports CRITERIA

-Full ROM -Flexibility based on sport -Lack of apprehension with sport specific movement -Quality movement -85-90% strength - isokinetic testing OR functional testing -MD direction

Plantar Fasciitis: Criteria to Return to Sport

-Full range of motion -Flexibility to meet demands of th sport -Lack of apprehension with sport specific movements -Quality of movement-Muscle strength > 85-90% of uninjured limb-MD direction

Ischium

-Fuses with pubis and ilium to form posteroinferior border of acetabulum, -Ramus of ischium joins inferior ramus of pubis to form ischiopubic ramus= inferomedial boundary of obturator foramen -Ramus of Ischium: Gracilis, Obturator Externus/Internus, -Greater sciatic notch -Ischial spine: separates greater sciatic notch from lesser sciatic notch -Ischial tuberosity: sit on it - Adductor Magnus

Abductors of the Hip

-Gluteus Medius (Superior Gluteal Nerve) -Gluteus Minimus (Superior Gluteal Nerve) -Tensor of Fascia Lata (Superior Gluteal Nerve)

Palpating Femur

-Head of femur: Can be felt deep to a point approx. 2cm inferior to midpoint of inguinal ligament. -Greater Trochanter: Responsible for shape of adult female pelvis. Posterior edge relatively uncovered. Should lie in line with center of femoral heads and pubic tubercles. *-Adductor Tubercle: Palpated by pushing thumb inferiorly along medial side of thigh until felt

4 Muscular Layers of the Foot

-Help maintain arches of foot (resist flattening) -Enable to stand on uneven ground -Little importance individually because fine motor controls of toes unimportant to most people.

Resting Position of the hip

-Hip flexed to 30° -Abducted to 30° -Slight ER (20°)

Hip Resurfacing vs. THR Procedure

-Hip resurfacing longer surgery time so more anasthesia. -Less drugs post-op. -Less LOS (length of stay)

Plantar Aponeurosis

-Holds parts of foot together -Helps protect plantar surface from injury -Helps support longitudinal arches of foot

Proximal Humeral Fx PT (with surgical intervention)

-Immobilization for 3-4 weeks -Codman/pendulum exercises (in/out of sling) -Shoulder PROM into Forward Flexion (FF) as tolerated, ER to 0 degrees, Abd per MD -Shoulder PROM into FF and ER performed in supine/semi-reclined position -AROM begins around week 6

Muscle Tissue Response to Immobilization

-In LENGTHENED POSITION: # of sarcomeres increase to maintain optimal length-tension relationship. -In SHORTENED POSITION: # of sarcomeres decrease.

Maturation of Hip Bone

-In children - large parts of hip bone are incompletely ossified. -At puberty, 3 primary bones still separated by Y-shaped triradiate cartilage centered in acetabulum. -Primary bones begin to fuse 15-17 years old and completed 20-25. -5 Secondary Ossification Sites solidify towards end of range

vastus lateralis

-Origin Greater trochanter, gluteal tuberosity , and lateral Linea aspera of the Femur -Insertion Patella via the Quadriceps tendon and Tibial tuberosity via the Patellar ligament -Nerve femoral nerve -Actions Extends and stabilizes knee -Antagonist Hamstring

tibialis anterior

-Origin Upper 1/2 & Lateral Condyle of Tibia, interosseous membrane -Insertion medial cuneiform and first metatarsal bones of the foot -*Nerve*: Deep Fibular (peroneal) nerve (L5) -*Actions* Dorsiflexion and Inversion of the foot

THR Indications

-Pain -Limited ADLs -Radiographic evidence with good bone quality -LE Deformity -Failed conservative treatment

Proximal Humeral Fractures: Treatment (a lot of education)

-Pain management/ edema control -Positioning for lying and sitting -Donning/doffing sling -Dressing and bathing -Scapular stabilization/strengthening, distal ROM -Postural correction -Address balance needs -Treat the whole chain!

Key Components to treating PFPS

-Pain reduction -Activity modifcation -Quads strength -Proximal/core stability -Running mechanics need to strengthen hips and quads strengthen vmo release lateral structures

Overuse Injuries: Initial Treatment

-Patella tendinitis -ITB Syndrome -PFPS -Plantar Fascitis Initial Treatment -Determine cause -Activity modification -Decrease activity -Avoid painful activities -NSAIDs -Therapeutic modalities

Patellar Ligament and Infrapatellar Fatpads

-Patellar ligament easily observes as thick band running from patella to tibial tuberosity -Infrapatellar Fatpads: can palpate mass of loose fatty tissue on both sides of patellar ligament

Patellofemoral Dysfunction Tests

-Patellofemoral Grinding Test -Clarke's Sign -Patella Stability -Fairbank's Test - Apprehension test for Patella dislocation-Waldron Test

Pre-Op Plans for ACL

-Patient education -KT 1000 Exam- Ambulation training-Brace management-Exercise

Superior Tibio-Fibula Joint

-Plane synovial joint -Movement occurs with ankle movement-10% of population capsule is continuous with femoral-tibial joint.

Ligaments of MTP

-Plantar ligaments -Collateral ligaments

Complications post-op/RED FLAGS

-Post-op delirium (narcotics or dimentia) -ETOH withdrawal (or other substances) - agitation/confusion -DVT/PE (tender, erythema, redness, Homans sign) -Compartment synd. -Depression and anxiety -Stroke or TIA -Fatty Embolism humans sign-Homan's sign-knee extended, foot is dorsiflexed, if there is pain in calf then the result is positive

3-6 Month acl

-Progress to jogging - (alter-G... - careful with tendinitis) -Plyos - small box jumps, lateral and eventual single leg -Open chain for quad strength (40-90°)

Total Femur Replacement (process, precautions, WB, ROM?)

-Proximally THR -Rod to replace/femur (femur is resected) -Distally TKR REHAB -Post/Lat THR precautions -Protective WB -ROM added in later

Palpating Hips (Cont'd)

-Pubic crest/Pubic Symphysis: Hand's width inferior to umbilicus (Difficult to palpate) -Pubic Tubercles: Lies anteriorly (2.5cm) on each side of symphysis. Important landmark in diagnosis and repair of inguinal femoral hernias. -PSIS: Posterior Superior Iliac Spine (difficult to palpate). Lies at bottom of skin dimple approx. 4cm lateral to midline. -Ischial tuberosity: Easily palpated in buttock when thigh is flexed.

Functional Progression (early) For acl

-Quad control - SLR with no pain and no lag -ROM - flexion/extension -Normalize gait - HUGE time frame for this

Quads Re-training

-Quad sets (can do e-stim with it) -SLRs -TKE

Treatment after 3-4 weeks for ACL

-ROM - half-moon bike, lean on stair -Strength - Leg press, wall squats-Balance & proprioception - foam, BOSU etc.

Treatment of Heterotopic Ossificans

-Radiation therapy - preventative measure. Performed POD1 in high risk patient. -Operative resection

1. Contract-relax (CR)

-Rangelimiting muscle is first lengthened to the point of limitation and back to resting state. -then pt performs isometric contraction of tight muscle(for 5 to 10 seconds) followed by voluntary relaxation of the tight muscle. -Limb is then passively moved into the new range as the range-limiting muscle is elongated. The golgi tendon organs lie in the tendon of a muscle that mediate the stimulation of inhibitory interneurons in the spinal cord that cause relaxation of that muscle's motor neuron.

Anatomy of Back Stability

-Rectus abdominus -Spinal extensors -External obliques -Quadratus lomborum -Psoas muscles -Latissimus VOLUNTARY EFFORT

Ankle Sprain: Reparative Phase

-Reducing inflammation -Facilitating the ligament healing process -Restoring active and passive ranges of motion -Minimizing loss of strength -Maintaining cardiovascular fitness -Proprioceptive rehabilitation

quad weakness post TKR

-Reflexive inhibition/Arthrogenic Muscle Inhibition: protective response following injury. Can't contract muscle.-OA can induce 20% quad weakness pre-operatively-Weakness continues to decline post-op-At 6-12 months post-op strength recovers but still lacking compared to non-op leg.

Treating Deep Infection

-Remove prosthesis -Insert antibiotic spacer (rod coated with antibiotics) -Antibiotics x6 weeks (PICC line) -Re-implant prosthesis when cultures are negative.

Mobility Testing: Lateral Distraction

-Resting position-Hands around proximal medial thigh -Shift backwards and lateral- Use ulnar border of hand for contact

Ankle Sprain: Remodeling phase Goals (15-28 days)

-Restoration of tensile strength-Proprioception -Return to sport Modified training may progress and include activities such as jumping rope, higher-intensity training runs, or sprints

*Injury to Superior Gluteal Nerve*

-Results in motor loss of gluteus medius APPEARANCE: Weakened abduction, limp -Gluteal gait - Compensatory limp of body to weakened gluteal side. -Shift center of gravity over supporting lower limb.

Gluteus Medius/Minimus

-Same fiber direction -Same action/innervation/blood supply (superior gluteal artery) -Largely responsible for preventing sagging of unsupported side of pelvis during walking (the leg on the ground) Palpating Gluteus Medius: Can be felt inferior to iliac crest and contract during hip abduction.

Signs/Sx of ITB Syndrome

-Sharp pain and burning in the lateral aspect of the knee 2 cm superior to the joint line -Swelling and thickening of the tissue near the lateral femoral condyle -Early on: only noticeable during a run and will stop after a run is finished -If progresses: can persist with daily walking ADL and stairs

Specific History Questions for feet

-Shoes, orthotics, socks-Occupation - stress on feet vs. weekend rest -Sports: type, duration, warmup/cool down

PFPS: Phase 1 exercises for control (1-2 wks)

-Side-lying clamshells -Sidelying abduction -Dead bugs-Quadruped arm/leg extension -SL stance STRETCH: Hamstrings, quads, calf

CT Response to Injury (5+) (subacute)

-Significant collagen and ground substance. INTERVENTION -MOBILIZE - If scar on slack = disorganized fiber -Some tension = will organize along lines of tension.

Clinical Significance of MCL

-Since attached to medial meniscus, often injure both -Most common type of football injury -Frequently caused by blow to lateral side of knee UNHAPPY TRIAD of KNEE INJURIES 1. Rupture TIbial Collateral Ligament 2. Tear Medial Meniscus 3. Tear Anterior Cruciate Ligament

Fracture Classification...

-Single vs. Multiple -Displaced vs. non-displaced (maintains alignment) -Closed vs. Open (through skin)

Contents of Popliteal Fossa

-Small Saphenous Vein -Popliteal arteries and veins -Tibial and Common Fibular Nerves (from Sciatic?) -Posterior Cutaneous Nerve of Thigh -Popliteal Lymph nodes and vessels

Ankle Fx: Non-Surgical Treatment

-Small fractures may be treated more like a sprain -RICE -Splint, followed by short leg cast or brace when swelling decreases -Limited weight bearing (NWB/TTWB/PWB) with crutches vs. walker

Injury variables: Segmental Fractures

-Soft tissue interposition -Damage to the blood supply

Functional Tests for feet

-Squatting (symmetrical DF) -Standing on toes (symmetrical PF) -Squatting and bouncing at end of squat -Standing on one foot at a time -Standing on toes of one foot at a time -Ascending/descending stai rs-walking on toes -running-Run, twist and cu t-jumping-jumping and going into full squat

Cruciates stabilize knee ____ and their role in movement is _____.

-Stabilize knee A/P-Cruciates pull back femoral condyles and make them slide on tibial plateau in direction opposite of rolling motion(-in flexion PCL is vertical, ACL is horizontal) -During flexion, ACL responsible for sliding movement of femoral condyle anteriorly -In extension, PCL glides femoral condyle posteriorly.

ACL: Non-operative management

-Strength - hamstring-strength ratio 1:1-Proprioception -Conditioning -Brace for sports activities

Borders of Popliteal Fossa

-Superolateral Border: Biceps femoris -Superomedial Border: Semimembranosus, Semitendinosus (lateral to semimembranosus) -Inferolateral Border: Lateral head of Gastrocnemius -Inferomedial Border: Medial head of Gastrocnemius Posterior Border: Skin, fascia Anterior Border: Popliteal surface of femur, oblique popliteal ligament, popliteal fascia over popliteus, floor of fossa

Long Plantar Ligament

-Supports calcaneocuboidmetatarsal joints and lateral longitudinal arch (Calcaneus->cuboid and base of 2-4 MTs) The long plantar ligament lies superficial to the plantar calcaneocuboid ligament and the tendon of fibularis longus muscle on the plantar aspect of the foot. It runs from the anterior calcaneal tubercle to the ridge and tuberosity of cuboid bone, attaching to both of them. It also sends some superficial fibers towards the lateral four metacarpal bases. Therefore, the long plantar ligament spans almost the entire length of the lateral plantar aspect of the foot, reinforcing the plantar aspects of all the respective lateral foot joints, including the calcaneocuboid joint. It also prevents excessive depression of the lateral longitudinal arch of the foot during weight bearing.

Patellar Tendon Reflex

-Tapping patellar ligament with reflex hammer. -Should lead to quad contraction. -Tests L2-L4 nerves -Activates muscle spindles in quad. -Afferent impulses from spindles -> femoral nerve -> spinal cord -> efferent impulses via motor fibers in femoral nerve -> action

Surface Anatomy and Nerves of Gluteal Region

-Tibial nerve bisects popliteal fossa -Common fibular nerve follows biceps femoris which covers it. -Sciatic nerve stretches when hip is flexed, knee is extended. -Sciatic nerve relaxes when hip is extended, knee is flexed

1. Tissue destruction and Hematoma formation

-Torn blood vessels hemorrhage -A mass of clotted blood (hematoma) forms at the fracture site -Site becomes swollen, painful, and inflamed

Fracture Stabilization Techniques

-Traction (pull apart so body wants to form bony bridge) -Cast Immobilization -External Fixation -Internal Fixation -Protecting soft tissue

THR Contraindications

-Unstable medical conditions -Active infection -Pseudoarthrosis/ankylosed joint -Poor bone quality -Neurologic impairments/disease -Morbid obesity

Ankle Fx: Surgical Treatment

-Usually kept NWB for several weeks crutches, walker, knee walker, WC -Encourage elevation to decrease swelling- 80% of time for the first few weeks -"Toes above the nose" Splinted for 2-6 weeks, then placed in CAM walker

Coxa Vara / Coxa Valga

-Varies with age/sex/development. -Coxa Vara: Angle of inclination is decreased - mild shortening of lower limb and limits passive abduction of hip -Coxa Valga: Angle of inclination is increased

Anterior Cruciate Ligament (ACL)

-Weaker -Arises from anterior part of intercondylar area of tibia just posterior to attachment of medial meniscus. -Extends superiorly, posteriorly and laterally to attach to posterior part of medial side of lateral condyle of femur.

2. Inflammation and cellular proliferation

-Within 8 hours inflammatory reaction starts. -Proliferation and Differentiation of mesenchymal stem cells (in bone marrow) -Secretion of protein growth factors. (TGF-B , PDGF and various BMP factors)

Factors Influencing Contracture Developments

-amt of tissue damage -duration of damage -degree of fixation -advanced age -circulatory status

Classification of Talocrural Joint

-ankle joint-uniaxial-hinge joint -main actions: dorsiflexion/plantar flexion (sagittal plane)* Joint axis through malleoli (certain amount of external torsion in tibia since malleoli aren't even)

Windlass effect

-as you go into extension at MTP, it pulls on aponeurosis which pushes tarsal bones up -high arches = pes cavus

patella

-for leverage (increases angle of insertion = more torque)-quads away from axis-less compression

Tri-malleolar fracture

-fracture medial/lateral malleoli & distal posterior aspect of the tibia

Feiss Line

-line between medial malleolus and medial aspect of 1st MTP -middle point is the navicular tuberosity Too high = Pes Cavus Too low = Pes Planus

Radial (transverse) tear

-meniscus tear that's perpendicular to the "C"-poor blood flow, poor healing

q angle

-represents the line of pull of knee extensors-from ASIS to middle of patella (not just straight down femur)-straight line up through patella-where these lines intersect is the Q-angle* In women, the Q angle should be less than 22 degrees with the knee in extension and less than 9 degrees with the knee in 90 degrees of flexion. In men, the Q angle should be less than 18 degrees with the knee in extension and less than 8 degrees with the knee in 90 degrees of flexion . A typical Q angle is 12 degrees for men and 17 degrees for women

Trochlea's role in movement

-superior convex portion of talus-narrower posteriorly -wider anteriorly allow for more plantarflexion

TCN joint (talocalcaneal navicular)

-this is NOT the mid-tarsal joint -supination/pronation -Shares part of joint capsule with subtalar joint. MAIN FUNCTION:carries motion from subtalar into midfoot

Tibiofemoral Joint - OKC

-tibial plateau is concave while femoral condyle is convex EXTENSION (OKC)-Tibia glides anteriorly on femur -Tibia rotates externally (last 20°) FLEXION (OKC) -Tibia glides posteriorly on femur -Tibia rotates internally (last 20°)

Subtalar Joint axis

-very oblique; a little bit of x, y, & z-supination is a combination of inversion, adduction, & PF -pronation is a combination of eversion, abduction, & DF 1° FreedomMOTIONS-Pronation/Supination-Secondary motions: Inversion/Eversion & Abduction/AdductionAxis is inclined due to triplanar inclinations of hindfoot jts

-Sternocostal Joints

...

1st Carpometarcapal Joint

...

Pg 297 - Stages of Inflammation = what happens and what are the PT interventions

...

mobility testing scale

0 - ankylosed → DO NOT mobilize 1 - very hypomobile → mobilize 2 - hypomobile → mobilize 3 - normal→ check/adjust posture 4 - hypermobile → stabilize 5 - very hypermobile → immobile 6 - unstable → refer for surgery

Lateral Toes DIP Extension

0-10, flexion 45-60

Ankle dorsiflexion

0-10/20° PIVOT: lateral malleolus SA: in line with fibula MA: Parallel to 5th MT POSITION: Prone with bent knee (take out gastroc) - doesn't have to be prone

Eversion

0-20°PIVOT: Dorsum of ankle joint at level of lateral malleolus SA: Tibial crest MA: in line with 2nd MTPOSITION: Primary Mover: FIbularis longus, Fibularis BrevisNERVE: Superficial Fibular (L5-S1)POSITION: Sidelying with foot on top. Foot plantarflexed RESISTANCE: Push 1st MT into inversion...PALPATION: Longus - below head of fibula.Brevis - proximal to tuberosity of 5th MT SUBSTITUTION: Fibularis tertius, EDL if supinated.GE: Sitting

CS#1: 51 y.o. male fell ~25' from a ladder sustaining bilateral Tri-malleolar fractures Underwent ORIF for BLEs Orders from MD for functional activities, NWB BLEs

TRANSFER TRAINING SUP TO SIT, SIT TO WC..... EXERCISE: QUAD SET,GLUT SET, KNEE ROM, UE STRETCHING...HOME SET UP EDUCATION, LIMITED SITTING -Wheelchair legrests for mobility -bedside commode for easy toileting

*Tenosynovitis Tenovaginitis Tendinosus

Tenosynovitis is inflammation of the synovial membrane covering a tendon. Tenovaginitis is inflammation with thickening of a tendon sheath. Tendinosis is degeneration of the tendon due to repetitive microtrauma.

Quadrutus Femoris Nerve

Ventral Rami L4-S1 -Leaves pelvis anterior to sciatic nerve and obturator internus. -Passes over posterior surface of hip joint SUPPLIES: -Articular branch of hip joint -Inferior Gemellus -Quadratus Femoris

Inferior Gluteal Nerve

Ventral Rami L5-S2 -Leaves pelvis through greater sciatic foramen (inferior to piriformis), superficial to sciatic nerve. -Divides into several branches SUPPLIES: Gluteus Maximus

Pudendal Nerve

Ventral Rami S2-S4 SUPPLIES: -Structures in perineum -NO structures in gluteal region

anterior talofibular ligament

a weak, flat band that originates on the lateral malleolus of the fibula and extends anteromedially to the lateral side of the neck of the talus.

gastrocnemius origin and insertion

a. Medial head: medial condyle of femur and area just above condyle .b. Lateral head: lateral condyle of femur and area just above condyle. inserts- calcaneus via calc tendon Tibial nerve (S1, S2) function- flex knee and pf ankle

Ground Substance

an organic gel containing water that reduces friction between fibers, transports nutrients and metabolites, and may help prevent excessive cross-linking between fibers by maintaining space between fibers.

Skeletal Disorders: Hip Dysplasia

any malformation in orientation of acetabulum/femoral head.

What plane does patellar medial/lateral rotation occur in?

frontal plane-y

Subtalar (aka Talocalcaneal) joint

inferior surface of the talus -built for stability, not mobility -absorb forces from above -reciprocal concavity/convexity (doesn't lend itself to a lot of motion)

femoral triangle

inguinal ligament- superior border adductor longus- medial border sartorius- lateral border iliopsoas lateral pectineus medial - floor

Ehler-Danlos Syndrome

inherited CT disorder that creates joint laxity due to inadequate collagen production

Lisfranc Fracture

injury of the foot in which one or more of the metatarsal bones are displaced from the tarsusUSUALLY - step into hole and fall forward

4. PNF Stretching

integrate active muscle contractions into stretching maneuvers purportedly to facilitate or inhibit muscle activation and to increase the likelihood that the muscle to be lengthened remains as relaxed as possible as it is stretched. It is believed that when muscle fibers are reflexively inhibited through autogenic or reciprocal inhibition, there is less resistance to elongation by the contractile elements of the muscle

Plantar aponeurosis

most superficial-extend toes, feel tension here-from calcaneus to proximal phalange

3. Hold-relax

move the limb to the point that tissue resistance is felt in the tight (range-limiting) muscle; then have the patient resist pertuberations in every direction, then relax and stretch.

When can I drive?

non-operative: 2 weeks Operative: 3-4 (surgeon has to clear)

● How accessory movement can be applied

o Sustain stretch - hold the movement for 7 second at the desired position o Oscillatory - rhythmic application at rate of 1~2 per second o Progressive oscillation - start at grade I and progressing to IV o Grades of movement - increase the range of the motion mobilization of movement

telescoping hip

o With congenitally dislocated hip, with longitudinal the femur pops out and looks longer. We don't do this test. o People who can pop their hip in and out is more likely a labral tear.

rectus femoris

origin: anterior inferior iliac spine and superior margin of acetabulum insertion: tibial tuberosity and patella action: extends leg and flexes thigh nerve: femoral l2-l4

vastus medialis

origin: medial lip of the linea aspera and intertrochanteric line insertion: tibial tuberosity via patellar tendon nerve: femoral l2-l4 function- knee extension

IT Band Syndrome: Primary Function of IT Band

passively resists hip adduction and internal rotation as well as anterior translation and internal rotation of the tibia -Lateral hip and knee stabilizer-Resist hip adduction and knee internal rotation

suprapatellar bursa

quad tendon and superior pole of patella

-Tibial crest -Tibial Tuberosity

tibial tuberosity = bump below knee tibial crest = side of tibia (lateral border)

What plane does patellar medial/lateral tilt occur in?

transverse-z

Rectus Femoris

"Kicking muscle" -Crosses 2 joints: hip and knee PROXIMAL: *Anterior Inferior Iliac Spine*, and ilium superior of acetabulum DISTAL: Base of patella by patellar ligament to tibial tuberosity ACTION: Extend leg, steadies hip joint and helps iliopsoas flex thigh INNERVATION: Femoral nerve (L2-L4)

Chondromalacia Patella

"Runner's knee" -Quadriceps imbalance May result from excessive running sports overstressing knee (especially downhill running), blow to patella or extreme flexion of knee.

Popliteal Aneurysm

-Dilation of popliteal artery usually causes: -Edema -Pain in popliteal fossa. -If Femoral Artery has to be ligated blood can bypass the occlusion through the genicular anastomoses and reach popliteal artery distal to ligation

Surface Anatomy of Gluteal Region

-Lumbar Puncture: Line joining highest points of iliac crests crosses L4/L5 IV discs -Superior Edge of Gluteus Maximus: Draw line from PSIS to point slightly superior to greater trochanter -Intergluteal Cleft: Begins inferior to apex of sacrum. Extends as far superiorly as 3rd/4th sacral segment -Palpate greater trochanter as lateral bony point in gluteal region -Nelaton's line: Between ASIS and ischial tuberosity. Normally passes over or near top of greater trochanter. If not, could be dislocated hip or fractured femoral neck.

Resisted toe flexion

-Lumbricals -FDL and FDB -FHL and FHB -FDMB -Dorsal and plantar interossei

Hallux Valgus

-MT migrates medially-phalange migrates laterally-bunion = calcification of medial side

ACL (2 bands and taut/lax)

-Maximally taut at 0-20° and 70-90° flexion-Anteromedial band (AMB) lax in extension, max tension at 70°-90° flexion -Posterolateral band (PLB) taut in extension 0-20°, lax at 70° flexion-Max excursion at 30° when neither band is tense

Medial vs. Lateral Femoral Condyle

-Medial condyle juts out more and is narrower-Lateral more directly in line with shaft than medial secondary to obliquity of shaft of femur-WB stress equally distributed in bilateral stance

Acetabular Fx PT POD 1-4

-Pain control & Positioning -TherEx: ankle pumps, quad sets, heel slides (A/AAROM) to 45 degrees, ab set -Progressive mobilization Dangle at bedside -Initiate standing with appropriate assistive device -Ambulation as tolerated with appropriate weight bearing status (TTWB &PWB) -OOB to Hip chair for meals w/LE support -ADL and family training Discharge planning with case manager/social worker

Resisted toe adduction

-Plantar interossei-Adductor Hallucis

Sciatic Nerve Innervation

-Supplies no muscle in gluteal region -Supplies all muscles in posterior department of thigh and sole of foot. -Supplies muscles to anterior and lateral compartment of leg via common fibular nerve. -Supplies skin of foot (sole provided by tibial nerve), entire lower leg (except medial side) via common fibular nerve TIBIAL NERVE: Flexor muscles COMMON FIBULAR: Extensor and abductor muscles

Plantar Calcaneocuboid (Short Plantar) Ligament

-Supports calcaneocuboid joint and lateral longitudinal arch (combine with above)

Plantar calcaneonavicular (spring) ligament

-Supports talocalcaneonavicular joint -Main support for medial longitudinal arch - supports head of talus and deepens concavity for navicular articulation with talus -Weakness leads to fallen arches

Pain Pattern of Acute Exertional CS

-Takes time to come on after beginning exercise -Worsens as exercise continues -Stops 15-30 min after stopping exercise -Pain begins sooner and last longer as it progresses

Tests for Swelling

-Wipe Test -Patella Tap -Indentation Test

hip extension

0-20

spasm/muscular reactivity end feel

1. Chronic - Resistance before pain, well response to stretching 2. Feels like: Abrupt stop with rebound 3. Reflexive muscle guarding during motion. 4. Indication: Protective guarding following joint injury 5. Example: Acute, subacute OA

Types of PNF Stretching (3)

1. Contract-relax (CR) 2. Appropriate Resistance 3. Hold-relax with agonist contraction (HR-AC).

3. Ballistic Stretching

A rapid, forceful intermittent stretch—that is, a high-speed and high-intensity stretch Use of quick, bouncing movements that create momentum to carry the body segment through the ROM "Dynamic warmup"

2. Cyclic Stretching

A relatively short-duration stretch force that is repeatedly but gradually applied, released, and then reapplied Slow velocity, low intensity

Most common sprained ankle ligaments

ATFL- resists inversion and plantarflexion (WEAKEST) CFL resists inversion and endrange plantarflexion PTFL- rarely sprained unless it is a very large tear or a disloation of the talus Atib fib lig- function of the syndesmotic ligaments is to hold the fibula tight to the tibia, thereby preventing abnormal widening of the ankle mortise

Wrist Special Considerations

Apply force proximal to MCP joints and have fingers be relaxed.

phase 2 TKR gait training

Appropriate progression of AD to no device Goals: Reciprocal gait pattern Symmetric weight bearing Emphasize heel strike, push off and active knee flexion and extension Tap - ups (in picture) and Step-ups promote weight shifting

Tensor Fascia Lata

Approx. 15cm long -Enclosed between 2 layers of fascia lata *Actually a gluteal muscle* -Acts with iliopsoas for flexion -Too far anteriorly to be strong abductor -Tenses fascia lata and IT to support femur/tibia while standing.

Contusion of Extensor Digitorum Brevis

Knowing location of belly of extensor digitorum brevis is important for distinguishing it from an abnormal edema

Circumflex Fibular Artery

Arises from Anterior or Posterior Tibial Artery of knee and passes laterally over neck of fibula and anastomoses around knee.

Blood Supply to Ankle Joint

Arteries derives from malleolar branches : -FIBULAR ARTERY -ANTERIOR and POSTERIOR TIBIAL ARTERIES

Talus

Articulates with leg bone -Has body, neck and head -Articulates with fibula, tibia, calcaneus and navicular bone -Only tarsal bone with no muscular or tendinous attachments -Grooves for tendons

Consequences of Abnormal First Ray

Association between abnormal first ray and: -Hallux Valgus -Forefoot Valgus -Rheumatoid acquired flatfoot -Plantar Ulcerations Highly correlated with: -Excessive knee rotation -Altered ground reaction forces during gait

Fascia Lata

Attaches superiorly to: -Inguinal ligament -Pubic arch -Body of pubis -Pubic Tubercle -Membranous layer of subcutaneous tissue (Scarpa's) of lower abdominal wall. Laterally to: Iliac crest Posteriorly to: -Iliac crest -saccrum -coccyx -sacrotuberous ligament -Ischial tuberosity Distally to: Exposed parts of bones around knee, continuous with crural fascia

Jones Avulsion

Avulsion fracture of the 5th metatarsal styloid (attachment for fibularis longus/brevis) CAUSE: Trauma/repetitive stress

Longitudinal Distraction Mobilization of the hip

BEST FOR: Lack of hip flexion POSITION: supine- Stabilize pelvis-Hip flexed to 90° (close to end of pathological range)- Hands resting on femoral condyles

Dorsal Glide Mobilization of the hip

BEST FOR: Restricted hip flexion at end range POSITION: Supine-Hip near end of flexion range -Pelvis fixated on table -Force in same direction as femur- Lends itself to sustained stretch DON'T COMPRESS PATELLA CONTRAINDICATIONS:-Posterior Labral tear-THR

Connective Tissue (and 3 elements) (Pg. 73)

BROAD TERM - muscles, tendons, ligaments, nerves, blood vessels etc. 1. Cells 2. Fiber -Collagen -Elastin -Reticulum 3. Ground Substance 4? Glycosaminoglycans (GAG's)

1. Toe region

Considerable deformation without much force Collagen fibers can begin to straighten under this stress.

Necking

Considerable weakening of the tissue, and it rapidly fails.

Popliteal Artery

Continuation of femoral artery Deepest structure in fossa. Begins when artery passes through adductor hiatus. End at inferior border of popliteal and divides into: -Anterior Tibial Artery -Posterior Tibial Artery

Plantar Fasciitis: Contributing Factors

Contributing Factors Body weight Leg length discrepancy Gastroc and Soleus tightness Pes Cavus Excessive pronation at the subtalar joint

Tibiofemoral Joint - CCK

Convex moving on concave = opposite direction Flexion = anterior sliding of femoral condyles EXTENSION (CCK) -Femur glides posteriorly on tibia -Femur rotates internally on stable tibia (last 20°) FLEXION (CCK) -Femur glides anteriorly on tibia -Femur rotates externally on stable tibia (last 20°)

ankle during plantar flexion

Convex talus glides anteriorly on concave mortise -Fibula glides inferiorly and rotates medially (IR) -Anterior glide of distal fibula, posterior glide of fibula head

SHM: Knee Extension

DURING KNEE EXTENSION, the tibia glides anteriorly on the femur.

Plantar Reflex

Deep tendon reflex (L4-S2 nerve roots) -Routinely tested during neurological examinations for potential brain injury or cerebral disease -Lateral aspect of sole of foot is stroked with blunt object beginning at heel and crossing to base of great toe -Motion is firm but not painful nor ticklish

Navicular Tuberosity

Distal and anterior to medial malleolus - sticks out (anterior to sustentaculum tali)

Medial Cuneiform

Distal to navicular tuberosity

Pubis

Divided into: 1. Flattened body 2. Two Rami: a. Superior ramus b. Inferior ramus -Pubic crest: united bodies and symphysis form crest -Pubic tubercles: important landmarks of inguinal regions -Pecten pubis (pectineal line): MUSCLES: pectinius, adductor longus, adductor brevis, adductor magnus, gracilis

Scapula Upward/Downward Rotation

Do along with shoulder abduction.

Female Athlete Triad

Eating less and working out more results in: -Eating disorders -Amenorrhea (loss of menstruation) -Osteoporosis

Phase III: Therapeutic & Functional Exercise

Eccentric Quads Eccentric SL leg press Ball Squats Retro Treadmill Walking on Incline Continue Forward Step-up Progressin Increase height of step Add opposite LE hip flexion to simulate reciprocal stairs Initiate Forward Step Down Continue to progress LE strengthening Sidelying Clams with band Clams in supine with band Bridges with Hip ABD Pball Bridges

Palpation of Dorsalis Pedis Pule (Pulse of Dorsal Artery of Foot)

Evaluated during physical examination of peripheral vascular system. -Palpated with feet slightly dorsiflexed. -Usually easy to palpate. Subcutaneous and pass along a line from extensor retinaculum to point just lateral to Extensor Hallucis Longus Tendon. NONPALPABLE: Happens in some healthy adults and children. Usually bilateral and replaced by enlarged and perforating fibular artery. If diminished or absent could be resulting from arterial disease.

Muscles of Dorsum of Foot:

Extensor Hallucis Brevis - Part of Extensor Digitorum Brevis. Small fleshy belly may be felt when toes extended. Ex Superolateral surface of calcaneus bone InsertionProximal phalanx of great toe Extensor Digitorum Brevis - Extends digits 2-4 at metatarsophalangeal joints (both muscles help long extensors of toes) Origin: Superolateral surface of calcaneus bone, interosseous talocalcaneal ligament; stem of inferior extensor retinaculum Insertion: Extensor digitorum longus tendons of toes 2-4

Biceps Brachii

Flex at elbow

Sartorius

Flex, ER, and abduct knee flexion and IR

Ortolani Click

Flex, abduct and IR? Dislocates hip and hear click For congenital dislocated hipPEDIATRIC POPULATION

FABER test

Flexion, abduction, external rotaton and extension -Differentiate between hip and SI problems If pain one way....If pain another way...

Capitate

Follow 3rd MC proximal and flex (feel divot)

Bicipital Groove

Follow biceps tendon up and can strum it.

Tuberosity of 5th Metatarsal

Follow fibularis brevis tendon

Deep Lymphatic Vessels (x)

Follow main blood vessels: -Anterior Tibial -Posterior Tibial -Fibular -Popliteal -Femoral

Pes Planus

Foot flat Loss of longitudinal archNavicular drop test - NWB - mark navicular & Base of 1st MTWB - if navicular drops below line 10mm

Pott's Fracture-Dislocation of Ankle

Foot forcibly everted resulting in tearing off of medial malleolus. Talus then moves laterally and shears off lateral malleolus OR more commonly, breaking fibula superior to inferior tibiofibular joint.

Avulsion Fracture of 5th Metatarsal Tuberosity

Foot suddenly and violently inverted. Tuberosity of 5th metatarsal may be avulsed by tendon of fibularis brevis. Common in basketball and tennis players.

Stress-Relaxation

Force required to stretch decreases with time, resulting in an increase in tissue tension.

Phase 1: Acute Care (Post-Op Days 1-5)

Functional Mobility Training Bed Mobility Sit <> Stand Transfers Gait training - Appropriate Assistive Device - Stair Negotiation Therapeutic Exercise ROM!! Continuous Passive Motion Machine (if applicable) Discharge Planning ROM ROM ROM!!! A/AROM Flexion Stair Stretch Passive extension Strength training Gluteal Sets Quad Sets Short Arc Quad Long Arc Quad Straight Leg Raise (SLR)

Ankle Dorsiflexion

GASTROCNEMIUS Bend knee to stretch SOLEUS Grab heel medially and pull calcaneus distally (and a little pressure on foot from forearm)

Early Post-Op Rehab Goals for ACL

GET EXTENSION-Towel under ankle Effusion control Quad re-education - e-stim, quad sets

internal rotation hip mmt

Glute Min - superior gluteal nerve TFL - superior gluteal nerve palpate - right behind ASIS behind the sartorious substitution - flexion with adduction

Gluteal Fold/Gluteal Sulcus

Gluteal fold: Coincides with inferior border of gluteus maximus Gluteal Sulcus: Skin crease inferior to gluteal fold. Indicates separation of buttock from thigh

Ankle Sprain Grades

Grade 1: Minimal swelling and point tenderness directly over ATFL; BUT no instability, and the athlete can ambulate with little or no pain. Grade 2: Broader region of point tenderness over the lateral aspect of the ankle, a painful limp if able to ambulate, and bruising and localized swelling due to tearing of the anterior joint capsule, ATFL, and surrounding soft tissue structures. Grade 3: Diffuse swelling that obliterates the margins of the Achilles tendon, inability to ambulate, and tenderness on the lateral and medial aspects of the ankle joint.

Operative Management of ACL

Graft choice -Patella tendon - central 1/3 of patella tendon .-Hamstrings (4 strand) - Gracilis/ST tendon -Allograft -

Saphenous Vein Grafts

Great Saphenous vein commonly used for coronary arterial bypass graft because: -Readily accessible -Sufficient distance occurs between tributaries and perforating veins -Wall contains higher percentage of muscular and elastic fibers than other superficial veins. -Rarely causes problems in lower limb because so many other leg veins. REASON: Used to bypass obstructions in blood vessels (intracoronary thrombus) PROCEDURE: Vein is reversed so valves don't obstruct bloodflow*

Importance of Sleep

HGH repairs muscle - secreted by pituitary gland during sleeping. Insufficient sleep decreases function of immune system.

Tibial Torsion Test Tibial Torsion Test 2

HIGH SITTINGVisualize axis of knee (through condyles and palpates axis of ankle through apex of malleoli) ANGLE: 12-18° lateral torsion UNDER = Toe in OVER = Toe out Tibial Torsion Test 2 SUPINE (can do prone)-Draw horiontal line on heel of tibial plane with patella -superior-Draw line from malleolar apicesANGLE: 12-18° tibial torsion

Passive Movement

HINDFOOTPF/DF @ Talocrural Pronation/Supination @subtalar MIDFOOTAdduction/Abduction @ midtarsal FOREFOOTFlexion/Extension & Adduction/Abduction @ phalangeal

Subtalar Motion of Foot Flat to Push-Off

HS (little supination) -> Foot flat needs pronation Foot flat -> neutral then begin to supinate Supination/pronation twist at anterior/mid and posterior articulations

Great Saphenous Vein Info

Has 10-12 valves (more numerous in leg than thigh) -Valves located just inferior to perforating veins. -As it ascends receives numerous tributaries. -Accessory saphenous vein: If present, becomes main communication between great and small saphenous veins. Other major veins that drain into it: -Lateral and anterior cutaneous veins -Superficial circumflex iliac vein -Superficial epigastric vein -External pudendal vein

Veins of the Lower Limb

Have superficial and deep veins. -Superficial: In subcutaneous tissue -Deep: beneath deep fascia and accompany all major arteries. Both have valves (more numerous in deep veins)

Hip Resurfacing Indications

Hip Resurfacing Indications Similar to THR-Male-Age <55-Active-Good bone quality-OA with minimal femoral head deformity

Trimalleolar Fracture

If tibia is carried anteriorly the posterior margin of distal end of tibia is also sheared off by talus producing a "Trmialleolar Fracture". -Medial Malleolus -Lateral Malleolus -Posterior Lip of Tibular articular surface

Capsular Pattern (passive ROM) of the hip

In order of what is lost the most 1. IR 2. Extension 3. Abduction 4. Flexion 5. ER

Injury to Common Fibular Nerve

In superficial position around fibular neck so most likely nerve in lower extremities to be injured. -If knee joint is injured/dislocated it could stretch nerve. Severing nerve results in paralysis of muscles in: -anterior compartment (dorsiflexors of ankle) -lateral compartment (Evertors of foot)

Effects of Systemic Hormones

Increase Healing (if long-term use can decrease) -Corticosteroid -Growth hormone -Thyroid hormone -Calcitonin -Insulin -Anabolic steroids

Myofascial compartment syndromes

Increased interstitial pressure in a closed, nonexpanding, myofascial compartment that compromises the function of the blood vessels, muscles, and nerves. It results in ischemia and irreversible muscle loss if there is no intervention. CAUSES: fractures, repetitive trauma, crush injuries, skeletal traction, and restrictive clothing, wraps, or casts.

Pectoralis Major93

Inferior to medial shaft of clavicle -Sternal head: lift arm above 90 degrees and resist against flexion -Clavicular head: arm below 90 degrees and resist against extension (sternal and clavicular head)

Non-union: Internal vs. External Fixation

Internal fixation by intamedullary, or plates and screws (neck of femur most common) External fixation: ie Ilizarov (pierces through skin and slowly turn pins to increase distance

Management of PCL Injury

Isolated injury = rehab PCL avulsion = Acute repair Combined injury (PCL & MCL, LCL, PLC) = surgery Reconstruction - allograft, patella tendon

arcuate popliteal ligament

It is Y-shaped and is attached to the head of the fibula. From there it goes to its two insertions; one goes over popliteus muscle and attaches to the intercondylar area of the tibia, the other to the lateral epicondyle of the femur and blends there with the lateral head of gastrocnemius muscle. The arcuate popliteal ligament reinforces the posterolateral part of the joint capsule, and together with the oblique popliteal ligament, prevents overextension of the knee joint.

Instability Testing: Anteromedial Rotary Instability (Slocum Test)

Knee flexed to 90°Leg/foot in 30° ER (not pictured) POSITIVE TEST: Anterior movement primarily from medial side = MCLADD STRUCTURES ■ MCL ■ Posterior oblique ligament ■ Posteromedial capsule ■ ACL

Plica Tests: Mediopatella Plica Test

Knee bent 20-30°Push patella medially and attempt to pluck plica on medial aspect of patella POSITIVE: Pain

Fairbank's Test (Apprehension Test)

Knee flexed 30°Push patella laterally POSITIVE: Patient feels patella going to dislocate and contracts quads = prior dislocation Should see 1/3 size of patella move laterally (greater height of trochlea) and 1cm medially (more movement)

Dorsalis Pedis

Lateral to extensor hallucis longus

Inferior Gluteal Artery

Leaves pelvis through greater sciatic foramen inferior to piriformis. -Enters gluteal region deep to gluteus maximus. -Descends medial to sciatic nerve. SUPPLIES: -Gluteus maximus -Obturator Internus -Quadratus Femoris Anastomoses with superior gluteal artery. Anastomoses in thigh too.

Instability Testing: Anterolateral Rotary Instability (Slocum Test)

Leg/foot in 30° IR (pictured )POSITIVE: Anterior movement primarily from lateral side = ■ ACL ■ Posterolateral capsule ■ Arcuate-popliteus capsule ■ LCL ■ IT Band

dorsiflexion and inversion met

MMT Dorsiflexion & Inversion Primary Mover: Anterior TibialisNERVE: Deep Fibular (L4-S1) POSITION: Sitting RESISTANCE: side of foot pushing toward eversion and plantarflexion PALPATION: Lateral to tibial crest SUBSTITUTION: inversion without dorsiflexion, EHL and EDL (using toes for dorsiflexionGE: None

3. Posterior Dislocations

MOST COMMON -Head-on collision causes knee to strike dashboard and dislocate hip when femoral head is forced out of acetabulum. -Sciatic Nerve may be injured. -May cause paralysis of: -Hamstrings -Muscles distal to knee -Muscles supplied by Sciatic Nerve

Shoulder Special Considerations

Many muscles attached to scapula so must stabilize. IF stabilized, only 120° of shoulder flexion.

Diagnosis of Achilles Rupture (mechanism of injury)

Mechanism of Injury -Sudden Acceleration or deceleration -Tennis; Squash; Basketbal l-Audible "pop" -Feeling like someone kicked them in the back of the ankle -Gait deviation -Pain, or no pain -Swelling around the calf and ankle-No strength + Thompson test Inability to stand on tippy toes

-Gluteus Medius -Gluteus Minimus

Medius: Abduct, IR Minimus: Anterior to PSIS, IR

Ballottement Test/ Patella Tap

More swollen knee Push on patella and if lots of fluid under, fluid will disperse. Push down and fluid exits either side of patella

Knee Injuries

Most common are ligament sprains -Occur when foot is fixes in ground and force applies against knee.

Tibial Fracture: Compound Fracture

Most common place to fracture is middle/inferior thirds. -Tibia most common bone for compound fracture and most common long bone to fracture. -Because it's so close to surface it has poor blood supply and often fracture through nutrient canal and take a long time to heal.

Hip Dislocation (with what surgery? Signs/Sx?)

Most common post-op complication -Post/lat approach -More common with revisions than primary THR -Precautions until soft tissue healing occurs. SIGNS/SX -Pain -LE in ER -LE is shorter than unaffected limb (dislocates outwardly and comes up and ER

THR Approaches - Posterior Lateral (cut & precautions)

Most commonly used.-Technically easiest .CUT: GluteusMaximus/Capsule PRECAUTIONS (6-8 weeks)-Hip flexion >90°-Adduction past neutral-IR past neutral

Cuboid

Most lateral bone in distal row of tarsus -Groove for tendon of fibularis longus muscle -Can feel on lateral side of foot

Purpose/Action of PCL

Most posterior structure in knee -Tightens during flection Prevents: -Anterior displacement of femur on tibia -Posterior displacement of tibia on femur -Hyperflexion

Platysma

Most superficial under jaw

Subcostal Nerve

ORIGIN: T12 anterior ramus COURSE: Descends iliac crest toward ASIS and enters superolateral part of thigh. DISTRIBUTION: Skin of hip region inferior to anterior part of iliac crest and anterior to greater trochanter

THR Approaches - Lateral (cut & precautions) ?? - don't get precautions

NOT COMMON CUT: Gluteus medius/minimus/vastus lateralis -Increased incidence of post-op limp (trendelenberg gait) -Nerve/Vessel damage (superior gluteal nerve, femoral nerve/artery/vein) PRECAUTIONS -No extension -No adduction past neutral -No ER

General Early Rehab Overview of Achilles Rupture

PROTECT THE REPAIR Active range of motion Gradual strengthening avoiding heavy loads

Iliohypogastric Nerve

ORIGIN: L1 (occasionally T12) COURSE: Parallels iliac crest; divides into lateral and anterior cutaneous branches DISTRIBUTION: Superolateral quadrant of buttocks

Ilioinguinal Nerve

ORIGIN: L1 (occasionally T12) COURSE: Passes through inguinal canal; divides into femoral and scrotal or labial branches DISTRIBUTION: Femoral branch supplies skin on anterior and medial aspects of thigh

Fibula Landmarks

PROXIMAL END -Head of fibula BODY -Shaft DISTAL END *-Lateral malleolus - extends approx. 1cm more distal than medial malleolus* -Fibular articular surface

Local Factors that can cause delay

Open Infected Segmental (impaired blood supply) Comminuted Insecurely fixed Immobilized for an insufficient time Treated by ill-advised open reduction Distracted by (traction/plate and screws) Irradiated bone Delayed weight-bearing > 6 weeks

Popliteus

Origin- Lateral condyle of femur, posterior horn of lateral meniscus of knee join Proximal posterior surface of tibia; just above the soleal (popliteal) line. innervation- tibial l4-s1 Function- Unlocks knee joint; Knee joint stabilization

adductor brevis

Origin: Anterior body of pubis, inferior pubic ramus InsertionLinea aspera of femur (medial lip) ActionHip joint: thigh flexion, thigh adduction, thigh internal rotation; pelvis stabilization InnervationObturator nerve (L2-L4)

adductor longus

Origin: Anterior body of pubis, inferior pubic ramus InsertionLinea aspera of femur (medial lip) middle 1/3 ActionHip joint: thigh flexion, thigh adduction, thigh internal rotation; pelvis stabilization Innervation:Obturator nerve (L2-L4):

gracilis

Origin: Anterior body of pubis, inferior pubic ramus, ischial ramus Insertion: Medial surface of proximal tibia (via pes anserinus) ActionsHip joint: Thigh flexion, thigh adduction;Knee joint: leg flexion, leg internal rotation InnervationObturator nerve (L2-L3)

pectinous muscle

Origin: Superior pubic ramus (pectineal line of pubis) Insertion: Pectineal line of femur, linea aspera of femur ActionHip joint: Thigh flexion, thigh adduction, thigh external rotation, thighinternal rotation; pelvis stabilization InnervationFemoral nerve (L2, L3)(Obturator nerve (L2, L3))

adductor Magnus

OriginAdductor part: Inferior pubic ramus, ischial ramus Ihamstring insertion : Ischial tuberosity Insertion Adductor part: Gluteal tuberosity, linea aspera (medial lip), medial supracondylar line Ischiocondylar part: Adductor tubercle of femur ActionAdductor part: Hip joint - Thigh flexion, thigh adduction, thigh external rotation Hamstring part: Hip joint - Thigh extension, thigh internal rotation Innervation Adductor part: Obturator nerve (L2-L4) Ischiocondylar part: Tibial division of sciatic nerve (L4) Mnemonic: African Mouse Sneaks Out (refers to Adductor Magnus Sciatic Obturator)

Patellofemoral Syndrome

Pain deep in patella -Often results from: 1. Excessive running (especially downhill) - "runner's knee" 2. Repetitive microtrauma caused by abnormal tracking of patella with patellar surface of femur 3. Direct blow to patella 4. Osteoarthritis of patellofemoral compartment (degenerative wear and tear of articular cartilages)

*Muscle/tendon rupture or tear:

Partial rupture tear = pain at region of damage when contract or stretch. Complete tear = muscle doesn't pull against injury, so stretching/contraction doesn't cause pain in muscle.

Thomas Test

Patient in supine Bring both legs up and have patient hold one leg up. Lower other leg - if it hangs in air then iliopsoas is tight. To test other - reset and start over.

Phase 1: Goals for progression TKR

Phase 1: Goals for progression Independent transfers Independent ambulation Level surface with appropriate assistive device 100-150 feet ambulation distance Step-to for stair negotiation Independent with HEP A/AROM Goals Flexion: >/= 80 degrees Extension: =/< 10 degrees

phase 2 TKR strengthening

Phase 2: Strengthening & Re-education Combination of OKC and CKC Important to address any compensatory movements SLR all planes - SeatedHipABD/ADD machine if present Leg Press (double leg) Terminal knee extension Bridging Mini Squats

Phase III: Goals: TKR

Phase III: (9-16+ weeks) Goals: ROM > 115 degrees Symmetrical sit <> stand transfer from normal height surface Independent with ADLs ( ie. shoes & socks) Reciprocal stairs - Ascend6-8inch - Descend4-6inch We want to maximize LE strength, flexibility and control for return to high level ADL and/or recreational activity Balance: Single Leg stance activities: With UE taps 3 way reach (Clock) Ball toss (varying surfaces) With opposite hip kicks Squats 100 On BOSU, Tilt board

phase 3 discharge TKR

Phase III: Criteria for Discharge Patient has achieved all functional goals at outcomes Functional tests and measure within age appropriate parameters Ascend 6-8 inch forward step-up Descend 4-6 inch step down

Knee Special Considerations

Position of hip influences flexibility of flexors and extensors. -Hamstrings and rectus femoris must be examined separately from one-joint muscles that affect knee motion.

tibialis posterior

Posterior Muscles of Leg (Deep Group) Origin: interosseous membrane, posterior surface of tibia inferior to soleal line, posterior surface of fibula Insertion: navicular tuberosity, cuneiform, cuboid, and bases of 2-4 metatarsals Innervation: tibial nerve (L4,L5) Vasculature: posterior tibial and fibular Action: plantarflexion and inversion

Ischiofemoral Ligament

Posterior portion of acetabulum - spirals up and over neck of femur (prevents excessive IR and extension as well)

Extend toes MMT

Primary Mover: EDL, EHL, EDB, EHBNERVE: Deep Fibular (L5-S1) POSITION: sitting - Stabilize MTs and look for active curling of toes RESISTANCE: Test each on dorsal side (can tell them to don't allow to push into flexion) PALPATION: EHL (lateral to anterior tib tendon), EDB (lateral malleoli - distal) SUBSTITUTION: PlantarflexionFlexion and then relax

Flex toes MMT

Primary Mover: FHB, Lumbricals, FDB, FDL, FHLNERVE: Med & Lat Plantar, Tibial (L5-S3) POSITION: sitting - Stabilize MTs and look for active curling of toes RESISTANCE: Test each toe on plantar side PALPATION: SUBSTITUTION: Dorsiflexion & inversion (passive)extension and then relax

Movements of Ankle: Plantarflexion

Produced by muscles in posterior compartment of leg. At this position, some rotation, abduction and adduction of ankle joint is possible.

Movements of Ankle: Dorsiflexion

Produced by muscles of anterior compartment of leg. Usually limited by passive resistance of triceps surae to stretching and tension in medial and lateral ligaments.

Reflex muscle guarding

Prolonged contraction of a muscle in response to a painful stimulus. When not referred pain, the contracting muscle functionally splints the injured tissue against movement. Guarding ceases when the painful stimulus is relieved.

Complication: Nerve Injury

Prolonged surgical time -Prolonged retraction -Positioning on OR table Usually transient but may be permanent LATERAL APPROACH = Superior gluteal nerve (gluteus medius weakness) ANTERIOR APPROACH = Lateral Femoral cutaneous nerve (superficial anterior/lateral thigh) POSTERIOR/LATERAL APPROACH - Sciatic/Obturator (rare)

Pronator Teres

Pronate while palpating distal to medial epicondyle

Lower Traps

Prone, arm at 140°, palpate T7-T12, patient lifts arm

Rehab guidelines following repair MENSICUS

Protection phase (4-6 weeks) -Limited ROM to 90° flexion (more strain post 90°) -WBAT w/ brace locked at 0° (avoid load) HOLD OFF on running/sports for about 4 months

Elastin Fiber

Provide extensibility. They show a great deal of elongation with small loads and fail abruptly without deformation at higher loads. Tissues with greater amounts of elastin have greater flexibility.

Reticulum Fiber

Provide tissue with bulk

Clarke's Sign

SUPINE knee extended Patient contracts quads while you push down on superior border of patella POSITIVE: Pain with contraction = PFP dysfunction

Cuboid

Proximal to tuberosity of 5th metatarsal

Pelvic neutral

Pubic symphysis, R and L ASIS in line

Integrity of Calcaneofibular Ligament

SUPINE or SIDE LYINGSTABILIZE: Distal tib-fib MOBILIZE: Turn foot into supination, slight PF

elys test

Rectus Femoris(can do in prone as well)

Neurological Tests

Reflexes:-Posterior tibial (L4-L5)- Achilles (S1-S2) -Babinski - fanning of toes etc.

5 - core rotation

Regress - just rotation (keep pelvis in same spot) "don't pull with arms - keep arms going with shoulders) Progress - arms out range of motion -Change angle of motion - works different muscles Increase band (double it up) -BoS - sitting on butt, knees, standing, foam, single leg

Plantar Fasciitis: Rehab Interventions

Rehab Interventions Activity Modification NSAIDS Stretching Strengthening Taping Heel Cup Orthotic consult

Movement of Ankle Joint: Plantarflexion

Relatively unstable because trochlea is narrower posteriorly (lies relatively loose within mortise) -Most injuries of ankle occur in plantarflexion usually as a result of sudden, unexpected inversion.

Patellectomy

Removal of patella for a comminuted fracture. Results in quad needing more force to extend leg. -Recent developments can repair tendon after patellectomy.

Process of Bone Graft

Remove bone with: -Periosteum -Nutrient artery: So it will remain alive and grow when transplanted Remaining parts of fibula usually don't regenerate. -Transplanted piece: 1. Secured to new site 2. Restores blood supply of bone it's now attached to. 3. Healing proceeds as if merely fracture were at each of its ends.

Stress Fracture

Repeated loading + inadequate rest eg: Long distance runners, military boot camp, Common sites: Tibia Overtraining? Lack of recovery time? Cross training? Diet? ADVICE: "Active" rest = avoid impact, bike/walk/swim. CAM boot?

Brachioradialis

Resist flexion in neutral position

Resisted toe extension

Resisted toe extension -EDL and EDB -EHL -Lumbricals (IP joints)

Collagen Fiber

Responsible for the strength and stiffness of tissue and resist tensile deformation.

Non-Operative Rehab of PCL

Restore ROMQUAD STRENGTHENING Functional progression-Proprioception

Mobility Testing: Anterior Glide of tibia

SUPINE Knee flexed at 90°Stabilize femur Mobilize hand on posterior proximal tibia Direction: Anterior CONCAVE on CONVEX so occurs in SAME direction USED FOR: Extension (because same direction) until -15°

Posterior Cruciate Ligament

Runs posterior part of posterior intercondylar fossa of tibia to lateral surface of medial condyle DIRECTION: Obliquely in medial, anterior and posterior STRONGEST STABILIZER93% of load with posterior translation in extended knee50% larger than ACL (but shorter)-LEAST likely to tear

Talocrural Posterior Glide

SUPINE PF 10° (use fingers to get in this position) STABILIZE: Table MOBILIZE: Talus and calcaneus FUNCTION = Increase DF

Distraction of Tibia

SITTING Stabilize femur on table Knee in resting position (25° flexion) Mobilize hand on distal tibia (DON'T CROSS ANKLE JOINT) Direction: Longitudinal USED FOR: Limitation of knee flexion POSITION: Sitting - but can go to prone if beyond about 100°GRADE: IV for stretching (if subacute )MOVEMENT: Easier to do sustained than oscillation

Mobility Testing: Medial and Lateral Glide of Tibia

SITTING-Secure ankle between legs STABILIZER: Distal medial (or lateral) aspect of femur MOBILIZER: Proximal lateral (or medial) part of tibia USED FOR: Increasing extension into screw home mechanism Medial glide facilitates ER (but gets IR secondarily) - more often than lateral glide Lateral glide facilitates IR

Cannulation of Femoral Vein

SKIPPED SLIDES 281-282

*Sprain

Severe stress, stretch, or tear of soft tissues, such as joint capsule, ligament, tendon, or muscle. Frequently used for ligament injury. Grades: first- (mild), second- (moderate), or third- (severe) degree sprain.

Short-Term and Long-Term Goals FOR acl

Short term (2-3 weeks): -Decrease pain/inflammation -Getting to 0° extension -Flexion 0-110° -Eliminate quad lag -Normalize gait 4-6 weeks) -Ascend 6" step Long term: -Full ROM -Descend 8" step -Functional tests - hop test

Elbow Special Considerations

Should be done both pronated and supinated because several muscles cross elbow joint involved in these.

TFL mmt

Side lying Hip FLEXED to 45 degrees action- hip flexion, abd, IR palpate on asis and after 5 reps push the down into adduction G.E. TFL - long siting reclined to get hips to 45 degree flexion Substitution - hip hiking, ext rotate leg and use flexorsto test Glute med alone - start in NEUTRAL, not flexed hip. bend bottom leg. Substitution - hip hike or ext rotate leg, rotate lumbar spine

Scapula Depression/Elevation

Sidelying Depression - grab shoulder anterior and posterior and pull down Elevation - pull up.

Scapula Protraction/Retraction

Sidelying with straight arm Gripping arm and shoulder blade and pull out an push back.

Fibularis Tertius (x)

Slip of muscle from Fibularis Brevis -Often attaches to tendon of extensor digitorum longus or continues and attaches to dorsum of base of 5th metatarsal (NOT proximal phalanx) PROXIMAL: Inferior third of anterior surface of fibula DISTAL: Dorsum of base of 5th metatarsal ACTION: Dorsiflexes ankle and aids in eversion INNERVATION: Deep Fibular Nerve

Hip Resurfacing Indications

Similar to THR -Male -Age <55 -Active -Good bone quality -OA with minimal femoral head deformity

Phantom Foot

Skiing - Foot goes behind hip and torque ACL

Subtalar Triplane motion?

Slide 688

Sternoclavicular Joint Suprasternal Notch

Slide medially on clavicle until just before suprasternal notch. Can abduct and elevate to feel movement.

Extensor Digitorum Brevis

Slightly distal/anterior to lateral malleolus Most prominent muscle on lateral aspect of foot.

SAID Principle

Specific adaptations to imposed demands OR specificity of training

lumbopelvic rhythm

Spinal flexion = 3/4 Anterior pelvic tilt = 1/4

Comminuted Fracture

Spiral fracture can cause comminuted fracture and take up to 20 weeks for firm union of fragments and up to a year to completely heal.

Ankle Special Tests: Anterior Drawer ANKLE

Stabilizing the tibia and fibula, the foot is held in 20° of PF while talus is drawn forward. TESTS: ATFL/Anterior capsule POSITIVE: >5mm motion of STJ compared to non-injured ankle, audible clunk. (if inverted too -

Conservative Treatment for Achilles tendonitis

Stretching and flexibility exercises.- gastrocs, soleus, standing calf stretch, strap stretch, Strengthening exercises- heel raises, band plantar flexion/ 4 way ankle progress to challenging balance, single leg stability, proprioception Ultrasound heat therapy. It improves blood circulation, which may aid the healing process. Deep massage. It helps you increase flexibility and blood circulation in the lower leg. It can also help prevent further injury.

Shoulder Abduction

Stretch Adductors -With the elbow flexed to 90, grasp the distal humerus. -Stabilize the axillary border of the scapula.

Shoulder Horizontal Abduction

Stretch Pec muscles Grasp the anterior aspect of the distal humerus. Stabilize the anterior aspect of the shoulder. Move the patient's arm below the edge of the table into full horizontal abduction.

Shoulder Extension

Stretch Shoulder Flexors Support the forearm and grasp the distal humerus. Stabilize the posterior aspect of the scapula to prevent substitute movements.

Digits Special Considerations

Stretch individually. Both individual fingers AND individual joints. Stabilize one and stretch the other.

Shoulder External Rotation

Stretch internal rotators -Towel under the distal humerus to maintain shoulder in slight flexion. -Table stabilizes scapula. Be careful of elbow.

Biggest difference between superior and inferior tibiofibular joint is _____

Superior tibiofibular has a synovial membrane (joint capsule).

HS -> Foot flat

Supination -> pronation Talocrural - DF-> PF

Heel Strike

Supination at subtalar talocrural - DF

Systemic Factors that can cause delay

Systemic factors: Metabolic Nutritional status General health Activity level Tobacco and alcohol use

Deep Infrapatellar Bursitis

Swelling between patellar ligament and tibia - superior to tibial tuberosity. -Swelling usually less pronounced than that associated with superficial prepatellar bursitis. -Enlargement here obliterates dimples on each side of patellar ligament when leg is extended.

Synovial Capsule of Knee Joint

Synovial capsule of knee joint more extensive than any other joint; thus synovial cavity of knee joint is largest joint space in body.

Baker's Cyst (Popliteal Cyst)

Synovial fluid escapes from knee joint and accumulates in popliteal fossa. -Becomes enclosed in membranous sac known as popliteal cyst. -In case of rheumatoid or DJD, if there is synovial effusion (escape of synovial fluid), popliteal cyst becomes distended and may extend inferiorly into as far as middle calf.

Synovial Membrane

Synovial membrane is loose and lines fibrous capsule. -Synovial cavity often extends superiorly between tibia and fibula as far as interosseous ligament of dital tibiofibular joint.

Arches of the Foot

Tarsal and Metatarsal ones arranged in longitudinal and transverse arches - add to weight bearing capabilities and resiliency. -Act as shock absorbers for: 1. Supporting weight of body 2. Propelling it during movement -Resilient arches of foot make it adaptable to surface and weight changes.

Articular surfaces of TMT Joints

Tarsals = ConvexMetatarsals = Concave 1st TMT: Base of 1st MT articulates with medial cuneiform 2nd TMT: Base of 2nd MT articulates with mortise of middle cuneiform and sides of medial and lateral cuneiform 3rd TMT: Base of 3rd MT articulates with lateral cuneiform 4/5th TMT: Bases of 4/5th MT articulate with cuboid

1. Iliofemoral Ligament

The iliofemoral ligament is a thick triangular ligament that lies on the anterior and superior aspects of the hip joint, and blends with the joint capsule. I ts proximal attachment is between the anterior inferior iliac spine and the acetabular rim. Distally, it attaches to the intertrochanteric line. The central part of this ligament is thinner compared with its outer bands, giving the ligament an inverted Y-shape. It is the strongest ligament in the body and functions to prevent hyperextension of the hip joint when standing.

Lateral Collateral Ligament

The lateral (fibular) collateral ligament is a strong ligament that originates from the lateral epicondyle of the femur, just posterior to the proximal attachment of the popliteus, and extends distally to attach on the lateral surface of the fibular head. As it attaches to the fibular head, the ligament splits the tendon of biceps femoris muscle in two. The lateral collateral ligament is found deep to the lateral patellar retinaculum, and superficial to the tendon of popliteus muscle, which separates the ligament from the lateral meniscus.

Effect of Rate of Stretch

The slower the rate of stretch, the greater the strain/elongation that occurred. The faster the rate, the less strain and greater chance of rupture.

Fascial Intermuscular Septa

Thigh muscles in 3 compartments: 1. Anterior compartment 2. Medial compartment 3. Posterior compartment (AMPLe thigh) Walls formed by 3 fascial intermuscular septa (only LATERAL INTERMUSCULAR SEPTUM is important) that arise from deep aspect of fascia lata and attach to linea aspera of femur. 1. Lateral intermuscular septum: Strong, extends from iliotibial tract to lateral lip of linea aspera and lateral supracondylar line of femur

Altered Mechanics with PCL tear

Tibia drops back and excessive force on PF joint with knee flexion

Movement of Tarsal Joint during end of stance phase

Tibia is ER and hindfoot is locked in inversion. Transverse tarsal joints also become locked.

-Tibial plateaus -Poles of Patella -Infrapatellar tendon

Tibial plateaus: each side of patella Poles of patella: superior/inferior of patella Infrapatellar tendon: distal end (fibrous band)

*Osgood-Schlatter Disease*

Tibial tuberosity usually forms by inferior bone growth from epiphyseal center at 10 y/o. -Separate center for tibial tuberosity may appear at approx. 12 y/o. -Disruption of epiphyseal plate at tibial tuberosity may cause inflammation of tibial tuberosity and lead to chronic recurring pain. -Especially prevalent in young athletes.

Activating TA

Tighten muscles like trying to zip up pair of pants

treatment of a painful hip

Treatment of the painful hip i. Painful movement limited more than 50% 1. Work on accessory movement/joint play 2. At pain free range perform Grade I a. Manipulation for pain, grade I i. Thumb technique at GT posterior to anterior, side lying ii. Thumb technique at GT superior to inferior, side lying b. Oscillation for pain, grade I. One bout for 20 seconds i. Hip IR/ER oscillation, supine ii. Distal longitudinal oscillation of femur, supine iii. Proximal longitudinal oscillation of femur, supine c. Reassess range of motion ii. Pain decreased 1. Repeat manipulation a. With increase amplitude, I+, II- remain at pain free range 2. Repeat oscillation a. With increase bout, more bouts of 20 seconds 3. Internal rotation mobilization, prone, knee flexed at 90°, therapist hand guard at grade II iii. Pain decreased, range increase 50% or more 1. Work on physiological movement, joint ROM 2. Grade III, short of pain iv. Pain decreased, range increased 1. Go into pain range with larger amplitude - grade III, IV a. Proximal longitudinal oscillation of femur, supine, III, IV (specific for weight bearing OA hip) b. Longitudinal distraction, supine, hip and knee flexed at 90°, with hand or strap. c. Lateral traction distraction, supine, hip flexed at 90°, with hand or strap. d. Dorsal glide mobilization, supine, specialized for hip flexion >100° e. Internal rotation mobilization, prone, knee flexed at 90°, therapist hand guard at grade IV 2. Move out of resting position into position of limitation up to pathological limit. v. Full range without pain 1. Discharge vi. Pain and range remain the same, resistance is the limiting factor 1. Mobilization at limited range 2. Contract-relax techniques

Precautions if greater trochanter involved in revision

Trochanteric precautions (no active abduction, WB on leg, passive adduction) all about gluteus medius**.

1. Acquired Dislocation

Uncommon because hip is strong and stable. May occur during car accident when hip is flexed, adducted and medially rotated (limb when driving)

Anterior Cruciate Ligament (ACL)

Up and back to lateral femoral condyle-prevents anterior slippage -prevents excessive anterior translation of tibia on femur*has connection to medial meniscus

Patella Inferior/Superior Glide

Use webspace to move. More inferior than superior Inferior glide important for knee flexion.

Separation of Sciatic Nerve

Usually occurs halfway or morte down thigh. In 12% of people they separate as they leave the pelvis. -The tibial nerve passes inferior to piriformis -*Common fibular nerve PIERCES piriformis or passes superior to it*

Vastus Medialis Oblique (VMO) Insufficiency

VMO realigns patella medially. Only dynamic stabilizer active through whole ROM. -Arises from adductor magnus tendon. -Innervated from branch of femoral nerve - can be activated as single motor unit.

Valgus/Varus Effects on medial joint angle

Valgus position INCREASES medial joint angle POSTERIOR CALCANEUS -> Posterior midline Varus DECREASES medial joint angle

4. Anterior Dislocation

Violent injury forcing hip into extension, abduction and lateral rotation. -Femoral head is inferior to acetabulum. Often fractures acetabular margin.

WB Status if cup/liner revised

WBAT

Evaluating Subtalar Neutral

WHY: ideal position of calcaneus on talus. For orthotics/taping, evaluate supination/pronation. PRONEPalpate medial and lateral talus. Swing calcaneus from max inversion to max eversion.Find where it is centered over calcaneus

Females more prevalent than males for ACL tear

WOMEN -wider pelvis -Increased flexibility -Less muscle -Narrower femoral notch -Increased genu valgum -Increased external tibial torsion

Pelvic floor activation

WOMEN: Stop flow of urine, squeeze tampon MEN: Stop flow of urine. Lift scrotum out of freezing water

Tibial Fracture: Boot-Top Fracture

When skiing at high-speed, fall with leg going over rigid ski boots. -Usually comminuted (many pieces) fracture at middle/distal third.

Effect of Gravity

When standing, bloodflow is reduced. -During exercise, blood received from superficial by deep veins is propelled by muscular contraction. -If valves are working - blood can't reverse direction. Deep veins are: -More variable -anastomore more frequently than arteries they accompany -Superficial and deep can be ligated with impunity if necessary.

SHM: Beginning of flexion

When the knee begins to flex from a position of full extension, posterior tibial glide begins first on the longer medial condyle.

Compartment Syndromes in the Leg

When there's a trauma, muscles in compartments hemorrhage, edema and inflammation can lead to increased pressure and compression in compartment. -SOLUTION: RICE or... -Fasciotomy (incision of a crural fascia) to relieve pressure.

Important Foot Joints: Subtalar Joint

Where talus rests on and articulates with calcaneus. -Synovial joint surrounded by an articular capsule attached near margins of articular facets. -Fibrous capsule is weak but supported by: -Medial Ligament -Lateral ligament -Posterior Ligament -Interosseous Talocaneal ligament

Calcaneofibular ligament:

a long band that originates from the apex of the lateral malleolus of the fibula, and extends posteroinferiorly to attach on a tubercle on the lateral aspect of the calcaneus.

Movement of Ankle Joint: Dorsiflexion

Wider, anterior part of trochlea moves posteriorly, spreading tibia and fibula slightly apart. This makes grip of malleoli strong. Spreading limited by ligaments that united tibia and fibula: 1. Strong interosseous ligaments 2. Anterior Tibiofibular Ligaments 3. Posterior Tibiofibular Ligaments 4. Tranverse Tibiofibular Ligaments

Helfet Test (Screw Home Mechanism)

With knee flexed - Make mark on tibia tubercle and another on center of patellaExtend knee and make same marks

Proximal stability for distal mobility

Work on core

-Sternum -Xiphoid Process

Xiphoid process = T10

Stress-Strain Curve

Yield point: point at which bone can still return to its original shape and form Slope of the curve (Young's modulus): measure of "intrinsic stiffness of the material" Loads applied beyond the yield point results in bone fracture Area under the curve: Amount of energy that is required for material to fail

How will I know if hip is dislocated?

You'll know... Shorter leg and ER.

obers test

itb tightness

Mechanism of injury for compartment syndrome

↑Pressure = ↓Venous BF = ↑Capillary leakage = ↓Arterial flowNerves compressed and can result in weakness/sensory impairments.

Godfrey sign

○ This is when the PCL is not present -- the tibia will drop posteriorly because of gravity

patella mobility testing

● Glides ○ Superior ○ Inferiorly ○ Medially ○ Laterally

Maitland grades

● Grade 1 - slow, small movement, beginning of range ● Grade 2 - slow, large movement, beginning to the middle of the range ● Grade 3 - slow, large middle to end of the range ● Grade 4 - slow, small movement, end of the range. ● Grade 5 - thrust, Fast, small movement, end of the range

Factors Affecting Patella Alignment

● Lateral aspect ○ Lateral retinaculum, vastus lateralis, ITB ● Medial aspect ○ Medial retinaculum, VMOFactors ● Increased Q Angle ● Tight lateral structures ● Tight gastrocnemius and hamstrings ● Excessive pronation ● Patella Alta ● VMO insufficiency

patella tracking

● Patella Tracking ○ Should center in groove by 30º flexion ○ Lateral overhang is acceptable in extension

Instability Testing: Medial Gapping

● Structures involved with knee in extension (listed in order of contribution to stability) ○ MCL ○ Posterior oblique ligament ○ Posteromedial capsule ○ ACL ○ PCL ○ Medial quadriceps expansion ○ Semimembranosus muscle ● Structures involved with knee in flexion ○ MCL ○ Posterior oblique ligament ○ PCL

Compartment Syndromes

-Increased pressured within a fixed osseofascial compartment causing compression of muscular and neurovascular structure

Types of Stretching (4)

1. static stretching 2. cyclic stretching 3. ballistic stretching 4. PNF stretching

Patellofemoral Pain Syndrome Contributing Factors

-Increased Q angle and dynamic valgus -Larger patellar tilt and sulcus angle -Lower peak torque for knee extension (abnormal patella tracking, altered patellofemoral joint loading) -Altered VMO firing (delayed onset of VMO compared to VL) -Greater hip adduction angles-Contralateral hip drop -Lower hip abduction and ER strength-WB: Relatively FIXED tibia ad patella on MOVING femur-Altered gluteal muscle activation

Disadvantages to Hip Resurfacing

-Increased risk of femoral neck fracture -Metal ion dispersal (need yearly blood tests) -Longevity not yet analyzed (only began about 15 years ago)

Possible Causes of Acute Exertional CS

-Increased volume/intensity -Uphill running (posterior compartment) -Poor biomechanics (overstriding, increased HS, Increased pronation, weak hip/core causing increased ground reaction forces)

Phase 1 (Acute days 1-5): Goals for Progression for tka

-Independent transfers -Independent ambulation (level surface with AD, steps to stairs) -HEP -A/AAROM (Flexion >80°, extension <10°

Scapula Palpations (and vertebrae): -Medial border -Superior angle -Inferior angle -Spine of scapula -C7

-Inferior angle (T7) -Spine of scapula (T3) -Superior angle - site of levator scapula

Calcaneal (Achilles) Tendinitis

-Inflammation of Achilles tendon -Constitutes 9-18% of running injuries -Tears of vcollagen fibers in tendon RESULTS IN: Pain during walking, especially when wearing rigid-soled shoes -Often occurs during repetitive activities (running after prolonged inactivity)

Femur Landmarks

-Intertrochanteric Line: Site where neck joins body -Intertrochanteric Crest: Joins trochanters posteriorly (Quadratus Femoris) -Quadrate tubercle: rounded elevation on crest -Trochanteric fossa: Obturator Externus -Linea aspera: Has medial and lateral lips: Adductor Brevis, Longus, Magnus -Pectineal line: Extends from central part of linea aspera to base of lesser trochanter: Pectineus, Adductor Brevis -Linea aspera divides into medial and lateral supracondylar lines that lead to medial and lateral condyles (separated by intercondylar fossa)

Ankle Sprain: Treatment during reparative phase

-Joint mobilization-Soft tissue techniques of the TCJ and the STJ -Passive stretch of the gastroc and soleus musculature -Isometric exercise -Active and passive range of motion with minimal painDorsiflexionPlantar flexionEversionPain-free range of inversion FOCUS: Fibularis longus/brevis, tib anterior, triceps surae Glutes: prevent lateral sway

Radiographic Findings in Identifying OA

-Joint space width -Osteophytes/bone spurs

Vastus Lateralis

-Largest component of quad PROXIMAL: Greater trochanter and lateral lip of linea aspera DISTAL: Base of patella and by patellar ligament of tibial tuberosity ACTION: Extend leg at knee joint (also helps iliopsoas flex thigh) INNERVATION: Femoral nerve (L2-L4)

Cutaneous Innervation of Lower Limb (Anterior) Lately, Simon and Garfunkel Instinctively Counted Only Apples For Lunch Food Leg: LSS LDD

-Lateral Subcostal, Genitofemoral, Ilioinguinal, Cutaneous Obturator, Anterior Cutaneous Femoral, Lateral Cutaneous Femoral -Lateral Sural, Saphenous, Lateral Dorsal, Deep Femoral

Femoral Neck Fractures

-May have protected WB (check MD orders) -Restore normal hip and knee ROM Avoid PROM on fractures that have been reduced and not fixated -Tolerate functional positions 90 degrees hip flexion for sitting, supine, length of time in positions -Normalize gait -Stair training with/without rails -If patient is having difficulty with mobility in bed, teach repositioning to avoid pressure ulcers

capsular pattern of the knee

-More limitation of flexion (90°) than extension (5°)

Osteoarthritis (and disease process)

-Most common chronic condition in elderly population. DISEASE PROCESS -Cartilage wearing - -Joint surface breakdown -Joint space narrowing -Capsular restrictions/labral tear -Osteophytes/cyst growth (causes locking often) -Inflammation -Muscular weakness

Osteoarthritis (and disease process)

-Most common chronic condition in elderly population.DISEASE PROCESS-Cartilage wearing - -Joint surface breakdown-Joint space narrowing-Capsular restrictions/labral tear-Osteophytes/cyst growth (causes locking often)-Inflammation-Muscular weakness

Lateral Ligament Sprains

-Much weaker than medial ligament. -Occur in sports - running, jumping, basketball -Fibers of Anterior Talofibular Ligament (ATFL) torn during ankle sprains - partially or completely. Results in instability of ankle joint. Calcanofibular Ligament (CFL) may also be torn. -Severe sprains can fracture/avulse lateral malleolus

Injury to Adductor Longus

-Muscle strains of adductor longus may occur in horseback rider's. "Riders' bones": Ossification sometimes occurs in tendons of these muscles because riders actively adduct their thighs.

PFPS Treatment Strategies

-NSAIDs -Activity modification (no pain, stairs non-reciprocally, avoid prolonged sitting, stop running - bike/swim instead)-Alter running mechanics

4. Consolidation

-New bone trabeculae appear in the fibrocartilaginous callus -Fibrocartilaginous callus converts into a bony (hard) callus -*Bony callus begins 3-4 weeks after injury, and continues until firm union is formed 2-3 months later*

Precipitating Factors to THR

-OA -SLE (systemic lupus erythematosus) - creates inflammatory response and effect tissue damage - eventually joints. -RA/JRA - Rheumatoid arthritis. Fuse joints. -AVN - avascular necrosis (trauma after femoral neck fracture) -Dysplasia -Ehler-Danlos Syndrome -Trauma/Fracture -Bone tumor

Lateral Rotators of the Hip

-Obturator Externus (Obturator Nerve) -Obturator Internus (Obturator Internus Nerve) -Superior/Inferior Gemelli (Superior=Obturator Internus, Inferior=Quadratus Femoris -Piriformis (Anterior Rami S1/S2) -Quadratus Femoris (Quadratus Femoris Nerve) -Gluteus Maximus (Inferior Gluteal Nerve)

extensor digitorum longus

-Origin Anterior lateral condyle of tibia, anterior shaft of fibula and superior 3⁄4 of interosseous membrane -Insertion: Dorsal surface; middle and distal phalanges of lateral four digits -Nerve deep fibular nerve l5,S1 -*Actions* =extension of toes =dorsiflexion of ankle -Antagonist Flexor digitorum longus, Flexor digitorum brevis

Post-Operative Phase I: Weeks 2-8 THR

Goals: Education, stretching, and strengthening based on precautions Activity modification as appropriate (precautions typically lifted at 6 weeks post-op) Normalize gait pattern Avoid reciprocal stair negotiation and ambulation without AD until: - appropriate strength and control - NO PAIN Decrease Pain/Swelling Education on pain management Education on indications for infection: swelling/draining at incision, erythema/redness at incision, hot/warm to touch, fever HEP: therapeutic exercise emphasizing hip extensors, hip abductors, general hip/knee/ankle strengthening Total Hip Arthroplasty Outpatient Rehabilitation Guidelines

Post-Operative Phase I: Weeks 2-8 THR

Goals: Increase flexibility and strength + normalize mobility Exercise progression goals: Target the glutes!!! Criteria for advancement to next phase: Cleared from precautions (typically 6 weeks post-op) Good hip hinging/lumbopelvic dissociation Normalized gait Hip Flexion + ABD + ER- Bent knee fall out

Achilles Rupture Post-op (Wks 6-12 - goals/precautions)

GoalsNormalize gait Restore full functional ROM gait (15 degrees of DF) Stairs (25 degrees of DF) Normalize DF, INV, EV ankle strength Precautions Avoid pain with therex Avoid passive achilles stretching

Achilles Rupture Post-op (Wks 1-6 - goals/precautions)

GoalsProtection and Healing Control Edema and pain Minimize scar formation Improve ROM to DF to neutral Progress weightbearing- **Surgeon Directed Precautions Avoid passive achilles/calf stretching Limit active DF ROM to 0 Avoid prolonged dependent position

Teres Major81

Grab Latissimus dorsi and then slide medially until feel lateral border of scapula. Muscle fibers medial to lat.

Instability Testing: Anterolateral Rotary Instability (Lateral Pivot Shift Test) ??

Grab ankle and create IR and flexion Other hand at proximal tibia applies valgus stres sSTART in extension and then go into 30-40° flexion POSITIVE: Patient feels like it's going to buckle (clunk - tibia comes out and goes back in)

*Severity of Tissue Injury (Grades)

Grade 1 (first-degree). Mild pain at the time of injury or within the first 24 hours. Mild swelling, local tenderness, and pain occur when the tissue is stressed. Grade 2 (second-degree). Moderate pain that requires stopping the activity. Stress and palpation of the tissue greatly increase the pain. When the injury is to ligaments, some of the fibers are torn, resulting in some increased joint mobility. Grade 3 (third-degree). Near-complete or complete tear or avulsion of the tissue (tendon or ligament) with severe pain. Stress to the tissue is usually painless; palpation may reveal the defect. A torn ligament results in instability of the joint.

Saphenous Cutdown

Great saphenous vein often used to insert cannula for administration of blood, plasma expanders, electrolytes or drugs. When done, have to be careful not to sever Saphenous Nerve which accompanies vein.

Hip Flexion With Knee Extended

HAMSTRINGS ER hip to isolate medial hamstrings IR hip to isolate lateral hamstrings.

Posterior Capsule Ligaments

HYPEREXTENSION PROTECTORS1. Oblique popliteal lig: tendinous expansion of semimembranosus muscle (also prevent valgus) 2. Popliteal (arcuate) ligament (lateral side) (also prevents varus)

Extensors of the Hip

Hamstrings -Semitendinosus (Tibial Nerve) -Semimembranosus (Tibial Nerve) -Long head of Biceps Femoris (Tibial Nerve) -Adductor Magnus (posterior part - Tibial part of Sciatic Nerve) -Gluteus Maximus (relatively inactive unless forceful extension) (Inferior Gluteal Nerve)

Paralysis of Hamstrings

Hamstrings are active hip extensors when standing. -If paralyzed, person tends to fall forward because gluteus maximus muscles cannot maintain muscle tone to stand straight.

Rhomboids

Handcuff position and lift hand up. Palpating through thin trapezius.

Medial Plantar Nerve

Larger of 2 terminal branches of tibial nerve. PATH: Passes deep to Abductor Hallucis and runs anteriorly between Abductor Hallucis and Flexor Digitorum Brevis. On lateral side of medial plantar artery. Terminates near bases of metatarsals and divides into 3 sensory branches. -SUPPLIES: -Cutaneous branches of medial 3.5 digits. -2 Motor branches to: A. Abductor Hallucis B. Flexor Digitorum Brevis C. Flexor Hallucis Brevis D. The most medial Lumbrical muscle (1st lumbrical muscle)

Posterior Tibial Artery

Larger terminal branch of popliteal. Passes inferomedially on posterior surface of tibialis posterior- accompanied by tibial nerve and tibial veins. Deep to Flexor Retinaculum and origin of Abductor Hallucis, it divides into Medial and Lateral Plantar Artery.

Fibular Artery

Largest and most important branch of tibial artery. -Begins inferior to distal border of popliteus and tendinous arch of soleus. -Descends obliquely toward fibula and passes along its medial side usually within Flexur Hallucis Longus.

Calcaneus

Largest and strongest bone -Transmits most of body weight from talus->ground -Sustentaculum Tali: shelflike, projects from superior border of medial surface -Fibular trochlea (peroneal trochlea) -Calcaneal tuberosity -Medial tubercle: only tubercle rests on ground during standing -Lateral tubercle: Strike on lateral but stand on medial (involved in plantar fascitis) -Anterior tubercle

Superior Gluteal Artery

Largest branch of internal iliac artery. -Leaves pelvis through greater sciatic foramen superior to piriformis. -Divides immediately into Superficial Branch and Deep Branch. Superficial: Gluteus maximus, skin over muscle Deep: Gluteus medius/minimus and tensor fascia lata -Anastomoses with: -inferior gluteal artery -medial circumflex artery

Saphenous Nerve

Largest cutaneous branch of femoral nerve SUPPLIES: *Skin and fascia on anterior and medial sides of leg* IN FOOT: Medial side of foot and head of 1st metatarsal PATH: Passes anterior to medial malleolus to dorsum of foot

Inferior Tibiofibular Joint Anterior Glide Mobilization

PRONE Distal leg on wedge: Ankle PF'd 10° STABILIZE: Medial side of tibia MOBILIZE: Posterior lateral malleolus DIRECTION: Anterior INDICATION: PF

Apley's Test compression and distraction

PRONE Downward force on calcaneus with ankle dorsiflexed (lock talus into mortis) and IR/ERPOSITIVE = Meniscus Upward force on foot and IR/ER (stabilize thigh with knee) POSITIVE - Collateral ligament (not great test)HIGH SPEC, LOW SENS

1. Ilium (515)

MARKERS -ASIS (Anterior Superior Iliac Spine): Sartorius, Tensor Fascia Latae -AIIS (Anterior Inferior Iliac Spine): Rectus Femoris -Iliac crest: Iliacus, Psoas Major joins it -Tubercle of iliac crest (5-6cm posterior to ASIS): Iliotibial tract -PIIS (Posterior Inferior Iliac Spine - marks superior end of greater sciatic notch): -Iliac fossa (bone forming superior part may be thin and translucent) -Auricular Surface (forms SI Joint) Lateral surface: 1. Posterior gluteal lines 2. Anterior gluteal lines 3. Inferior gluteal lines (separate muscle attachments of 3 gluteal muscles on external surface of ala of ilium - Gluteus Maximus, Medius and Minimus)

Lymphatic Drainage

Most numerous in the sole. Follow veins (Small and Great Saphenous). Drain mainly into External Iliac Lymph nodes, some into Deep Inguinal Lymph nodes.

THR Approaches - Lateral (cut & precautions) ?? - don't get precautions

NOT COMMONCUT: Gluteus medius/minimus/vastus lateralis -Increased incidence of post-op limp (trendelenberg gait) -Nerve/Vessel damage (superior gluteal nerve, femoral nerve/artery/vein) PRECAUTIONS-No extension-No adduction past neutral-No IR

Genitofemoral Nerve

ORIGIN: L1/L2 COURSE: Descends anterior surface of psoas major; divides into genital and femoral branches DISTRIBUTION: Femoral branch supplies skin over lateral part of femoral triangle; genital branch supplies anterior scrotum or labia majora

*Femoral Nerve*

ORIGIN: L2-L4 COURSE: *Enters thigh deep to inguinal ligament, lateral to femoral vessels* COURSE OF Anterior Femoral Cutaneous: Arise from femoral nerve in femoral triangle. Pierces fascia lata along path of sartorius muscle. DISTRIBUTION: Branches into 1.Thigh muscles 2. Anterior femoral cutaneous nerve: Supplies skin of anterior/medial region of thigh

Cutaneous Branch of Obturator Nerve

ORIGIN: L2-L4 COURSE: Descends between adductor longus and brevis, anterior division pierces fascia lata to reach skin of thigh DISTRIBUTION: Middle part of medial thigh

Lateral Femoral Cutaneous Nerve

ORIGIN: L2/L3 COURSE: Passes deep to inguinal ligament; 2-3cm medial to ASIS DISTRIBUTION: Supplies skin on anterior and lateral aspects of thigh

Posterior Femoral Cutaneous Nerve

ORIGIN: S2/S3 COURSE: Gluteal region deep to greater sciatic foramen deep to gluteus maximus; then descends deep to fascia lata DISTRIBUTION: Supplies skin on posterior aspect of thigh over popliteal fossa

Sciatic Nerve

ORIGIN: Sacral Plexus COURSE: Passes through greater sciatic foramen to inferior gluteal region into posterior thigh. At apex of popliteal fossa, it divides into: -Common fibular -Tibial nerves -Cutaneous branches DISTRIBUTION:

sartorius

OriginAnterior superior iliac spine (ASIS) InsertionProximal end of tibia below medial condyle (via pes anserinus) InnervationFemoral nerve (L2-L4) Function Hip joint: thigh flexion, thigh abduction, thigh external rotation Knee joint: leg flexion, leg internal rotation

soleus muscles

OriginSoleal line, medial border of tibia, head of fibula, posterior border of fibulaInsertionPosterior surface of calcaneus (via calcaneal tendon)InnervationTibial nerve (S1, S2)VascularizationPosterior tibial artery and veinFunctionTalocrural joint: Foot plantar flexio

Diagnosis of plantar fasciitis

PAIN!-Medial Arch and heel-With toe flexion or forefoot DF Increased tension with WB -Plantar aponeurosis -Increased facial tightness, especially with running (2-8x body weight)

OA Clinical Presentation for hip

PAIN-Anterior hip to groin -Buttocks to posterior hip -Knee-Low back pain ANTALGIC GAIT-Trendelenberg gait DECREASED ROMDECREASED FUNCTION - inability to perform ADLs-unable to cross legs-LE dressing

Common fibular nerve (Component of Sciatic - L4-S2)

PATH: Around neck of fibula into superficial position INNERVATION: SENSATION: Branches to Lateral Sural Cutaneous Nerve which supplies skin on posterior and lateral surfaces of leg INJURY: Lose eversion and dorsiflexion (FOOT DROP) DIVIDES: Superficial Fibular Nerve & Deep Fibular Nerve BRANCHES: Sural Nerve, Lateral Sural Nerve (part of anterolateral leg)

Deep fibular nerve (From Common Fibular)

PATH: From neck of fibula, travels in anterior compartment of leg on anterior surface of interosseous membrane (with anterior tibial artery) INNERVATION: Muscles of anterior compartment, Extensor Digitorum Brevis, First 2 Dorsal Interossei SENSATION: Webspace between hallux and 2nd digit INJURY: Loss of dorsiflexion (footdrop), loss of extension of toes. DIVIDES: Lateral and Medial Terminal Branches

Superficial fibular nerve (From Common Fibular)

PATH: From neck of fibula, travels in lateral compartment of leg and splits Fibularis Longus and Brevis INNERVATION: Fibularis Longus, Fibularis Brevis SENSATION: Distal half of anterolateral aspect of leg and dorsum of foot (EXCEPT webspace between 1st and 2nd digit) INJURY: Loss of eversion of foot DIVIDES: Medial and Lateral Dorsal Cutaneous Branches

Tibial Nerve (Component of Sciatic)

PATH: Posterior leg with posterior tibial artery between superficial and deep muscle groups. Passes posterior to medial malleolus INNERVATION: Posterior compartment of leg SENSATION: Posterior aspect of leg (via Sural Nerve) and sole of foot INJURY: Loss of plantarflexion, loss of flexion of toes, weakened inversion of foot. DIVIDES: Medial (medial sole, medial 3.5 toes) and Lateral Plantar Nerves (lateral sole, 1.5 toes) in sole of foot (most muscles in foot) BRANCHES: Sural Nerve (posterolateral leg/lateral foot), Calcaneal Nerve (skin of heel)

Acetabular Fx

PRE - OP: OOB if ordered, start d/c planning now! Teach Isometric exercises if ordered by MD, educate on post-op expectations

Primary and Secondary Purposes of MCL

PRIMARY: Takes MOST valgus force. SECONDARY: Prevents anterior translation due to direction (runs inferio-anteriorly)

Leg-Heel Alignment Test

PRONE Mark:1. Middle of calcaneus 2. 1cm distal to form line 3. Two midline marks on lower 1/3 of tibia Find talar neutral and check line alignmentNEGATIVE: 2-8° deviation

Talonavicular Dorsal Glide

PRONE - distal leg and talus on wedge, foot over table STABILIZE: Talus and cuboid MOBILIZE: Inferior surface of navicular DIRECTION: Dorsal/plantarFUNCTION: ??

Gluteus Maximus

PROXIMAL: Ilium posterior to posterior gluteal line, dorsal surface of sacrum and coccyx and sacrotuberous ligament DISTAL: Most fibers end in iliotibial tract that inserts into lateral condyle of tibia; some instert on gluteal tuberosity of femur ACTION: Hip joint: Thigh extension, thigh external rotation, thigh abduction (superior part), thigh adduction (inferior part) NNERVATION: Inferior Gluteal Nerve L5-S2 ARTERIES: Inferior AND Superior Gluteal Arteries= BIG MUSCLE MMT- prone knee bent

Gluteus Maximus

PROXIMAL: Ilium posterior to posterior gluteal line, dorsal surface of sacrum and coccyx and sacrotuberous ligament DISTAL: Most fibers end in iliotibial tract that inserts into lateral condyle of tibia; some instert on gluteal tuberosity of femur ACTION: Extends thigh (especially from flexed position) and assists in lateral rotation; steadies thigh and assists in Sit-to-stand INNERVATION: Inferior Gluteal Nerve ARTERIES: Inferior *AND* Superior Gluteal Arteries= BIG MUSCLE

Flexor Hallucis Longus

PROXIMAL: Inferior 2/3 of posterior surface of fibula DISTAL: Base of distal phalanx of great toe (hallux) ACTION: Flexes hallux at all joints and weakly plantarflexes ankle INNERVATION: Tibial nerve

semimembranosus

PROXIMAL: Ischial tuberosity DISTAL: Posterior part of medial condyle of tibia; reflected attachment forms oblique popliteal ligament ACTION: Extend thigh; flex leg and rotate it medially when knee is flexed INNERVATION: Tibial Nerve (L5-S2) *NOT part of Pes Anserinus

quadrates femoris

PROXIMAL: Lateral border of ischial tuberosity DISTAL: Quadrate tubercle and inferior to it ACTION: Strong lateral rotator of thighINNERVATION: Quadratus Femoris Nerve

Extensor Digitorum Longus

PROXIMAL: Lateral condyle of tibia and superior 3/4 of medial surface of fibula and interosseous membrane DISTAL: Middle and distal phalanges of lateral 4 digits ACTION: Extends lateral 4 digits and dorsiflexes ankle INNERVATION: Deep Fibular Nerve

bicep femoris

PROXIMAL: Long head: Ischial tuberosity Short head: Linea aspera and lateral supracondylar line DISTAL: Lateral side of head of fibula; tendon split at this site by fibular collateral ligament ACTION: Flexes knee and also rotates tibia laterally; long head also extends hip joint INNERVATION:Long head: Tibial NerveShort head: Common Fibular Division of Sciatic Nerve

Obturator Externus

PROXIMAL: Margins of obturator foramen and obturator membrane DISTAL: Trochanteric Fossa ACTION: Laterally rotates thigh INNERVATION: Obturator Nerve -Tendon passes deep to quadratus femoris

obturator externus

PROXIMAL: Margins of obturator foramen and obturator membrane DISTAL: Trochanteric Fossa ACTION: Laterally rotates thigh INNERVATION: Obturator Nerve-Tendon passes deep to quadratus femoris

Flexor Digitorum Longus

PROXIMAL: Medial part of posterior surface of tibia inferior to soleal line. DISTAL: Bases of distal phalanges of lateral 4 digits ACTION: Flexes lateral 4 digits and plantarflexes ankle; supports longitudinal arches of foot INNERVATION: Tibial Nerve

obturator internus

PROXIMAL: Pelvic surface of obturator membrane and surrounding bones DISTAL: Medial surface of greater trochanter ACTION: Laterally rotate extended thigh and abduct flexed thigh INNERVATION: Obturator Internus Nerve

Obturator Internus

PROXIMAL: Pelvic surface of obturator membrane and surrounding bones DISTAL: Medial surface of greater trochanter ACTION: Laterally rotate extended thigh and abduct flexed thigh INNERVATION: Obturator Internus Nerve

Conservative Treatment of OA

PT -Address pain: Modalities, Mobilizations, Activity modification, Patient education -Address muscle weakness: strengthen (extensors, abductors, quads, hamstrings, core) -Address Decreased Mobility: Stretch (iliopsosas, TFL, hamstrings, ERs -Activity modification -Injections - cortisone -Pain Medications/NSAIDs -Weight loss

Conservative Treatment of OA

PT-Address pain: Modalities, Mobilizations, Activity modification, Patient education -Address muscle weakness: strengthen (extensors, abductors, quads, hamstrings, core) -Address Decreased Mobility: Stretch (iliopsosas, TFL, hamstrings, ERs -Activity modification-Injections - cortisone-Pain Medications/NSAIDs-Weight loss

Knee Flexion MMT

Primary Mover: Hamstrings NERVE: Sciatic (L5-S2) POSITION: Prone-Towel under distal thigh-Flexion with Tibia IR = more medial hamstrings-Flexion with tibia ER = more lateral hamstrings RESISTANCE: Above malleoli (tibia) in about 90° flexion PALPATION: Medial (SM, ST), Lateral (BF)SUBSTITUTION: Gracilis, Sartorius, Gastrocnemius 0-140°PIVOT: Lateral femoral condyleSA: Greater trochanterMA: Lateral malleolousPOSITION: Supine-90/90 position for flexion

MMT Plantar flexion (Bent Knee)

Primary Mover: SoleusNERVE: Deep Fibular (L4-S1)POSITION: Standing with bent knee (can support arm)20 = 510-19 = 41-9=3

MTP Joints (resting, close packed, capsular)

RESTING: Midway between flexion/extension and abduction/adduction CLOSE PACKED: Full extension CAPSULAR: First toe: Extension > flexion 2-5 toe: Flexion > extension

TMT Joints (resting position, close packed & capsular)

RESTING: Midway between pronation and supination CLOSE PACKED: Full supination CAPSULAR: Not described

Pain/stiffness to ankle following acute sprain.Immobilized 4 weeks7/10 painStiffness in all directions AROM - 5° DF, 10° PF, Supination/pronation 5°PROM - 8° DF PALPATION - swelling 1/2 inch in joint, tenderness at talus/susentaculum tali MOBILITY TESTING - Superior tib-fib joint - hypomobile in both directions-Distal tib-fib joint - hypomobile superiorly, anteriorly and posteriorly Next visit4/10 painStiffness

Re-assess AROM, PROM, maybe do resistedMOBILITY - re-assess and treat next visit2/10 pain " "Continue with treatment that's workingIsometric Next visit Lacking supination Subtalar distraction and then progress to varus/valgus or rock

Inferior Tibiofibular Joint Posterior Glide Mobilization

SUPINE (can do sidelying)Ankle PF'd 10° STABILIZE: Medial tibia MOBILIZE: Anterior lateral malleolus DIRECTION: Posterior INDICATION: DF