KNES 230 EXAM 2

Injury Assessment

(HOPS) 1. History 2. Observation 3. Palpation 4. Stress

Evaluation

(HOPS) History - mechanism, previous hx. Observation - deformity, swelling, etc... Palpation - origin to insertion Special Tests - manual muscle testing

MMT Grading

0 - ZERO (no evidence of muscle contraction) 1 - TRACE (slight contractability no joint motion) 2 - POOR (complete ROM with gravity eliminated) 3 - FAIR (complete ROM against gravity) 4 - GOOD (complete ROM against gravity with moderate resistance) 5 - NORMAL (complete ROM against gravity full resistance)

Hip Joint - "Ball and Socket"

1. Acetabular - Femoral Joint 2. Articulation: a) spherical femoral head, b) deep acetabular socket 3. Anatomy: a) increased bony support, b) 1/3 femoral head incased in socket

Medial Thigh Muscles

1. Adductor Brevis 2. Adductor Longus 3. Adductor 4. Pectineus 5. Gracilis

Pelvic Girdle

1. Anatomy - Ilium, Ischium, Pubis 2. Function - a) skeletal support, b) transfer body wt. to lower extremity, c) muscle attachment, d) visceral protection

Thigh Musculature

1. Anterior = Flexion 2. Posterior = Extension 3. Medial = Adduction 4. Lateral = Abduction

Hip Musculature

1. Anterior = Flexion 2. Posterior = extension 3. Medial = Adduction 4. Lateral = Abduction

Ankle Mortise

1. Composed of tibia, fibula, and talus 2. Configuration - wider anteriorly and injury consequences

Foot Anatomy

1. Designed For - strength, flexibility, and coordinated movement 2. Transmits Bodily Stress From Locomotor Activities - Running, Walking, and Jumping 3. 26 Bone (14 Phalanges, 5 Metatarsals, 7 tarsals)

Ankle Musculature

1. Dorsiflexion: a) Tibialis Anterior, b) Ext Digitorum Longus, c) Extensor Hallucis (Longus/Brevis) 2. Plantarflexion: a) Gasrocnemius, b) soleus, c) peroneals (L/B), d) tibialis posterior

Observation (HOPS)

1. General - appearance, normal gait, FWB, PWB, NWB 2. Specific - swelling, discoloration, deformity (boney or soft-tissue). "Bilateral Comparison"

Joint Capsule of the Hip

1. Glenoid Labrum: a) Fibrocartilage, b) Surrounds Femoral Head 2. Synovial Membrane: a) tubular sleeve, b) encloses hip 3. Ligamentum Teres: a) supply nourishment to femoral head, b) acts as tether for stability

"Shin Splint" Grading

1. Grade One: Pain after activity 2. Grade Two: Pain before and after activity 3. Grade Three: Pain before, during, and after activity 4. Grade Four: no participation due to pain and loss of normal ankle function

History Identifications of Hip pain

1. Has it occurred before 2. Pain Description 3. Exact Pain Location (Referred Pain?) 4. Age and Gender

History - Fundamentals

1. Hear/ Feel Anything? (crack, snap, or pop) 2. Injury Disability (FWB-Full weight bearing, PWD - partial weight bearing, NWD - non weight bearing) 3. Was there any swelling. 4. Past Foot Injuries (Diagnosis, Treatment, X-ray, MEDs, REHAB)

Manual Muscle Testing of the ankle (foot dorsiflexion and inversion)

1. Isolate Individual Muscles 2. Strength Limitation (due to pain) 3. MMT Classification

Manual Muscle Testing (MMT) of the Ankle

1. Isolate individual muscles 2. Strength Limitation (due to pain) 3. MMT classification

Dorsal Pedal Artery

1. Location Between the exterior halluces longus and the exterior digitorum longus 2. Midpoint: Medial/ Lateral Malleoli and 1st Interior Metatarsal Space

Plantar Fasciitis (strain)

1. Mechanism - chronic overuse as in running. 2. Symptoms - pain on plantar surface; sticking pain when taking 1st steps in morning 3. Signs - tenderness over Attachment; increased Pain with dorsiflexion

Foot: Sever's Disease "Traction Apophysitis"

1. Mechanism: Achilles stress on apophysis 2. Symptoms: Posterior Heel Pain and Tenderness 3. Signs: a) Posterior swelling, b) tight Achilles unit, c) weight bearing pain, d) Pain with ambulation

Hammer Toe

1. Mechanism: Congenital, improperly fitted shoes, and intrinsic/extrinsic contracture 2. Symptoms: pain from callus or corn 3. Signs" "Hammer Head" Appearance, dip flexion, toe callus formation, and toe corn formation

Metatarsal Fracture

1. Mechanism: Direct Force - "Stepped on" and Extreme Inversion - Avulsion 2. Symptoms: Sudden Pain and Inability to weight bear 3. Signs: a) possible deformity, swelling along metatarsal, possible crepitus, and delayed ecchymosis

Foot: Phalangeal Fracture

1. Mechanism: Direct Trauma (Kicking an object or stubbing toe) 2. Symptoms: Sudden pain, loss of foot function, and abnormal gait 3. Signs: Possible deformity, rapid swelling, possible crepitus, and delayed ecchymosis

Foot: Heel Contusion

1. Mechanism: Direct Trauma or fall from height/jumping 2. Symptoms: plantar calcaneal pain or limited function 3. Signs: a) possible ecchymosis, b) hematoma formation, c) inability to weight bear

Hip Injuries: Iliac Crest Contusion

1. Mechanism: Direct Trauma to Iliac Crest 2. Symptoms: a) Hip Pain, b) transitory flexor paralysis 3. Signs: a) hematoma formation, b) ecchymosis, c) iliac crest tenderness, d) muscle spasm

Foot: Subungal Hematoma

1. Mechanism: Direct Trauma to Nail 2. Symptoms: Throbbing Pain 3. Signs: a) Point Tenderness, b) Function Loss, c) Abnormal Gait, d) "Blood Under Nailbed"

Lower Leg Contusion

1. Mechanism: Direct trauma and kicked in leg 2. Symptoms: Pain, Loss of function, and transitory paralysis 3. Signs: point tenderness, hematoma formation, and ecchymosis

Fibular Fracture

1. Mechanism: Direct trauma to fibula and indirect - ankle eversion 2. Symptoms: Pain (with forced eversion) and loss of function 3. Signs: a) possible deformity, b) rapid swelling, c) delayed ecchymosis, d) possible false joint motion, e) weight bearing

Tarsal Tunnel Syndrome

1. Mechanism: Entrapment of the posterior tibial nerve 2. Symptoms: Paraesthesia, mostly at night; hanging foot relieves pain; pain on ML arch and ball of foot 3. Signs: tenderness on palpation of posterior tibial nerve

1st MTP Sprain - "Turf Toe"

1. Mechanism: Extreme toe hyperextension and kick nonyielding object 2. Symptoms: Pain---AROM and Pain --- Passive stretch 3. Signs: a) 1st MTP Joint Tenderness, b) swelling, c) Instability (2nd and 3rd degree)

Posterior Ankle: Luxation

1. Mechanism: Force Applied to Posterior Lower Leg and With foot plantarlexed 2. Symptoms: Sudden pain and loss of ankle function 3. Signs: a) marked deformity, b) swelling, c) lengthened heel, d) shortened forefoot

Anterior Ankle: Luxation

1. Mechanism: Forced dorsiflexion and fall on heel 2. Symptoms: Sudden pain and loss of ankle function 3. Signs: a) marked deformity, b) rapid swelling, c) shortened heel, d) false joint motion, e) prominent malleoli

Eversion Sprain (ANKLE)

1. Mechanism: Forced eversion and stretched medial ligaments 2. Symptoms: Medial ankle tenderness and loss of normal function 3. Signs: a) swelling and hemorrhage, b) possible deformity and instability (2nd and 3rd degree)

Open Bulla - "Blister"

1. Mechanism: Friction Trauma, Improper fitting shoes, or ball of foot, great toe, or heel 2. Symptoms: Pain or Burning "hot spot" 3. Signs: Fluid accumulation (clear or blood) and poor tx: --- Infection

Foot: Callus Durum - Hard Corn

1. Mechanism: Friction and Improperly fitted shoes 2. Symptoms: Pain, inability to participate, point tender in corn area 3. Signs: dorsum thickening and redness

Foot: Hallux Rigidus

1. Mechanism: Fusion of the 1st MTP due to arthritic changes 2. Symptoms: pain, inability to push off, tenderness of MTP 3. Signs: inability to extend great toe, and abnormal gait.

Foot: Sesamoiditis

1. Mechanism: Great toe hyperextension and articular surface roughening 2. Symptoms: weight bearing pain (loss) 3. Signs: a) abnormal gait, b) sesamoid tenderness, c) inflammation

Ingrown Toe Nail

1. Mechanism: Improper footwear and improper nail care 2. Symptoms: pain and possible activity loss (severe cases) 3. Signs: a) swelling and inflammation, b) improperly cut nail, c) possible infection

Ankle: Jones Fracture

1. Mechanism: Indirect Force (inversion and plantatflexion) 2. Symptoms: Sudden 5th Metatarsal Pain and Inability to weight bear. 3.Signs: a) Possible deformity, b) swelling along metatarsal, c) possible crepitus, d) delayed ecchymosis

Ankle Sprain - 1st degree

1. Mechanism: Inversion Force and Stretched Lateral Ligaments 2. Symptoms: Lateral Ankle Tenderness and Loss of normal function 3. Signs: a) swelling and hemorrhage, b) possible deformity and instability (2nd and 3rd degree), c) Positive anterior drawer test

The Foot: Rectocalcaneal Bursitis

1. Mechanism: Overuse running and posterior heel pressure 2. Symptoms: Achilles attachment pain and ankle function loss 3. Signs: redness and swelling and chronic calcific changes

Stress Fracture (lower leg)

1. Mechanism: Overuse; distance runners 2. Symptoms: more pain after activity 3. Signs: positive bone scan

Hip Exostoses

1. Mechanism: Repetitive hip trauma and overuse syndrome 2. Symptoms: aching pain and loss of hip ROM 3. Signs: Possible swelling and inflammation

Morton's Foot

1. Mechanism: Short 1st Metatarsal, weight bear on 2nd, and stress fracture predisposition 2. Symptoms: Pain 3. Signs: Forefoot pronation, callus formation and possible abnormal gait.

Achilles Tendon Rupture

1. Mechanism: Strenuous games involving rising on toes and repeated microtrauma 2. Symptoms: a) sudden sever posterior leg pain, b) audible "snapping", c) loss of function 3. Signs: a) swelling and ecchymosis, b) Achilles defect - "rent", c) positive Thompson test

Foot: Interdigital Neuroma "Morton's Neuroma"

1. Mechanism: Thickened Plantar Nerve and Thick area pinched between the metatarsal heads 2. Symptoms: Intermittent, sharp pain, and 3rd-4th degree toes 3. Signs: Metatarsal tenderness and palpable mass

Osteochondritis Dessicans - "Joint Mice" (Lower leg)

1. Mechanism: Unknown and impaired circulation causing articular degeneration 2. Symptoms: Pain after activity and also chronic, intermittent, nonspecific locking 3. Signs: muscle atrophy and palpable loose bodies

Hip Injuries: Pelvic Avulsion Fracture

1. Mechanism: a) Acute trauma with associated muscle spasm, b) ischial tuberosity with HAMS, c) ASIS - Quad/Sartotius 2. Symptoms: a) sudden pain, b) direct tenderness 3. Signs: a) swelling, b) delayed ecchymosis

The Foot: Pes Planus "Flat Food"

1. Mechanism: a) Congenital, b) poorly fitted shoes, c) muscle atrophy; support loss 2. Symptoms: Medial Longitudinal Arch Pain 3. Signs: a) Bulging/Lowered Navicular Tubercle, b) Feiss' Line

Hip Injuries: Coccyx Fracture

1. Mechanism: a) Direct force to coccyx, b) landing in sitting position 2. Symptoms: a) unable to tolerate sitting 3. Signs: a) pain - center of buttocks, b) passible swelling, c) pain > 72 hrs = referral

Hip Injuries: Trochanteric Bursitis

1. Mechanism: a) Direct hip trauma, b) chronic irritation 2. Symptoms: a) hip pain, b) balancing difficulty, c) "snapping" hip 3. Signs: a) swelling, b) inflammation, c) possible crepitus

Pelvic Fracture

1. Mechanism: a) Direct trauma, b) crushing force 2. Symptoms: a) sudden pain, b) loss of function 3. Signs: a) Possible deformity, b) rapid swlling, c) delayed ecchymosis, d) special tests??

Foot: Callus

1. Mechanism: a) Friction from increased activity, b) changing direction, c) shoes---too short or tight 2. Symptoms: pain along fat pads or cushion loss 3. Signs: Epidermal thickening, "cracked" appearance, or possible blisters

Ankle Avulsion

1. Mechanism: a) Indirect - ankle eversion, b) widened mortise, c) fibular --- tibial fracture 2. Symptoms: a) pain with forced eversion, b) loss of function 3. Signs: a) possible deformity, b) rapid swelling, c) delayed ecchymosis, d) possible false joint motion

Hip Injuries: Hip Luxation

1. Mechanism: a) Indirect - planted foot with IR femoral force, b) "open-packed" mechanism, c) posterior - most common 2. Symptoms: a) sudden pain, b) function loss 3. Signs: a) deformity - appearance??, b) Prominent G. Trochanter

Hip Injuries: Ilium Apophysitis

1. Mechanism: a) Overuse long distance, b) ischial/ ASIS/ AIS, c) may lead to avulsion 2. Symptoms: Apophysis pain and loss of hip function 3. Signs: Loss of strength and avulsion ---Sx:

Plantar Calcanceal Exostoses - "Heel Spur"

1. Mechanism: a) Unknown, b) Repeated heel trauma, c) Associated plantar fasciitis 2. Symptoms: Anteromedial Heel Pain and "Sticking Pain" -- Walking 3. Signs: Point tender (M) calcaneal tubercle and abnormal gait

Foot: Plantar Warts

1. Mechanism: a) Viral Infection, b) abnormal friction, c) excessive weight bearing 2. Symptoms: Localized Pain and "Walking on Glass" 3. Signs: Wart Growing Inward (Singular and Clusters)

Hip Injuries: Legg-Perthes Disease

1. Mechanism: a) avascular necrosis, b) insidious onset, c) ages 3-12 2. Symptoms: a) Groin pain referred to abdomen or knee 3. Signs: a) walk with "painless limp", b) ROM loss

Hip Injuries: Slipped Capital Epiphysis

1. Mechanism: a) direct hip trauma, b) insidious onset 2. Symptoms: a) sudden pain, b) normal hip function loss 3. Signs: a) Pain AROM and PROM, b) Limited abduction/ flexion/ and IR, c) Possible deformity

Thigh Contusion

1. Mechanism: a) direct trauma 2. Symptoms: a) Anterior thigh pain, b) Quad transitory pain 3. Signs: a) Hematoma Formation, b) Ecchymosis, c) 3rd degree --- Mytosis ossificans, d) Acute Tx:

Femoral Fracture

1. Mechanism: a) direct trauma to femur, b) indirect - torsion 2. Symptoms: a) sudden pain, b) loss of function 3. Signs: a) false joint motion, b) rapid swelling, c) deformity - appearance?, d) treat for shock, e) neurovascular

Myositis Ossificans

1. Mechanism: a) direct trauma to muscle, b) aggressive quad MOB in early rehab stages, c) repeated aggravation 2. Symptoms: pain/loss of function 3. Signs: a) palpable mass, b) 3-4 weeks post-injury, c) surgical excision

Hip Injuries: Osteitis Pubis

1. Mechanism: a) overuse and chronic irritation 2. Symptoms: a) groin pain and symphysis, b) loss of hip function 3. Signs: a) Pain with sit-ups and running, b) adductor spasm, c) "waddling gait"

Achilles Tendinitis

1. Mechanism: a) overuse, b) repeated microtrauma, c) degenerative changes 2. Symtoms: AROM pain and PROM stretch pain 3. Signs: swelling, point tenderness, and possible crepitus

Foot: Hallux Valgus "Bunion"

1. Mechanism: congenital and indirect - shot/narrow shoes 2. Symptoms: 1st metatarsal joint pain and abnormal gait. 3. Signs: a) Angulated deformity, b) "Valgus", c) Bunion Formation

The Foot: Pes Cavus "High Arch"

1. Mechanism: congenital and muscular imbalance 2. Symptoms: general foot pain and plantar fascia sx: 3. Signs: a) claws or hammer toes, b) shortened Achilles, c) calluses on ball of foot, d) high medial longitudinal arch, e) inversion sprain predisposition

Tibia Fracture

1. Mechanism: direct force to fibula or indirect -- tibial torsion (skiing) 2. Symptoms: sudden pain and loss of function 3. Signs: a) possible deformity and crepitus, b) rapid swelling, c) delayed ecchymosis, d) possible false joint motion, e) painful weight bearing

Calcaneal Exostoses "SPURS"

1. Mechanism: repetitive calcaneal trauma and predisposing factors 2. Symptoms: retrocalcaneal pain and tenderness 3. Signs: Bony overgrowth and seen on x-ray

Achilles Tenosynovitis

1. Mechanism:1

Functional (stress) testing

1. PROM, AROM, and MMT 2. Dorsiflexion, plantarflexion, inversion, and eversion 3. Toe flexion and toes extension "Bilateral Comparison"

History Specifics (HOPS)

1. Pain Location 2. Onset (Gradual or Rapid) 3. Type (Sharp/Dull Aching and Burning/Tingling) 4. Mechanism (direct blow, overstretch, forceful contraction, and overuse)

6 Deep Outward Rotators of the Hip

1. Piriformis 2. Gemellus Inferior 3. Gemellus Superior 4. Obturator Internus 5. Obturator Externus 6. Quadratus Femoris Fuction: a) dynamic stabilization, b) force coupling

Hip - "Open (loose) packed position"

1. Position: a) Hip flexion, b) abduction, c) external rotation 2. Hip "unwinding": a) improved motion, b) injury consequences?

Hip - "Closed Packed Position"

1. Position: a) hip extension, b) abduction, c) internal rotation 2. Stabilizers taut: a) ligaments, b) joint, c) joint capusle

Lateral Ligaments of the Ankle

1. Posterior Talofibular 2. Anterior Tibiofibular 3. Anterior Talofibular 4. Calcaneofibular 5. Deltoid

Posterior Drawer Test

1. Posterior Translation of the Ankle 2. Assessment: Posterior talofibular ligament

Medial Tibial Stress Syndrome (Shin Splints)

1. Predisposing Mechanism: Postural anomalies and falling arches 2. Symptoms: a) anterior leg pain, b) loss of function, c) MTSS gradations 3. Signs: a) possible swelling, b) ankle function loss, c) abnormal gait, d) (PROM) dorsiflexion pain

Posterior Thigh Muscles

1. Semitendinosus 2. Semimembranosus 3. Biceps Femoris (long head)

Deltoid Ligament in the Ankle

1. Strong and Dense 2. Triangular Appearance 3. Size and Strength Compensate for: (shortened medial malleolus)

Manual Muscle Testing of Hamstring

1. Subject is prone 2. Proximal hand will stabilize the leg 3. Distal hand will provide resistance

Palpation (HOPS)

1. Swelling 2. Deformity 3. Crepitus - "Grating" 4. Temperature 5. Pulses 6. Skin Integrity "Bilateral Comparison"

Lateral Thigh Muscles of the Hip

1. Tensor fascia lata 2. Iliotibial Tract

Foot Anatomy

1. Toes: Give Wider Base (Balance and propel body forward) 2. Sesamoid Bones: (reduce pressure, increase mechanical advantage, pulley system) 3. Metatarsals: (5 bones and tarsal-metatarsal articulation)

Anterior Thigh Muscles

1. Vastus Intermdedius 2. Vastus Lateralis 3. Rectus Femoris 4. Vastus Medialis

QUIZ: A positive anterior drawer test would indicate which type of injury?

ACL

Talar Tilt Test

Anterior Talfibular and Calcaneofibular Ligament Sprain. (Evert the foot more)

Anterior Drawer Test

Anterior Talofibula Ligament (slide the ankle joint forward)

QUIZ: The hip joint is a classic...

Ball and Socket Joint

QUIZ: Term refers to a structure on both sides of the body or body part...

Bilateral

QUIZ: The common term for bulla is the...

Blister

Quadriceps/Hamstrings Injuries

Contusions: 1. Grade one (A) - very superficial bruise with mild hemorrhage, no ROMA loss 2. Grade two (B) - deeper than grade one, mild pain, swelling, and loss of ROM 3. Grade Three (C) - moderate pain, swelling, and loss of ROM, notable limp 4. Grade Four (D) - severe pain, deep hematoma, possible muscle herniation

History of Direct Trauma to the Hip

Direct Trauma: a) hip pointer, b) greater trochanteric bursitis, c) fractures (pelvic and femoral), d) dislocation

Homan's Sign (ANKLE)

Dorsiflex the ankle and deep vein thrombophlebitis occurs

QUIZ: Ankle fractures are most commonly associated with forced ankle inversion?

False

QUIZ: Eversion sprains are the most common type of ankle sprains?

False

QUIZ: Restricted toe extension at the first MTP joint due to a ridge of osteophytes palpable along the dorsal aspect of the metatarsal head is a hallmark sign of...

Hallux Rigidus

QUIZ: A contusion by direct compression to an unprotected iliac crest is referred to as...

Hip Pointer

QUIZ: The pelvic girdle is made up of which three sections?

Ilium, Ischium, Pubis

QUIZ: A difference in bilateral height in the ASIS can be indicative of which condition?

Leg Length Discrepancy

Posterior Tibial Artery

Location: Behind medial malleolus and in front of medial Achilles border

QUIZ: The adductor, adductor longus, adductor brevic, pectineus, and gracillus are located on the__________ aspect of the leg and are commonly referred to as the _____ muscles.

Medial, Groin

Posteior Thigh Muscles--> Semimembranosus and Semitendinosus

Origin: 1. Ischial Tuberosity Insertion: 1. (membrane.) - medial condyle of tibia 2. (tendin.) - Pes Anserinus

Posterior Thigh Muscle --> Biceps Femoris

Origin: 1. Long Head - Ischial Tuberosity 2. Short Head - Linea Aspera Insertion: 1. Head of fibula

QUIZ: An excessive Q-angle predisposes an individual to which condition?

Patella Injuries

QUIZ: A highly specialized band of tissue on the plantar surface of the foot that provides support for the longitudinal arch is the...

Plantar Fascia

QUIZ: The gastrocnemius, soleus, peroneals, and tibialis posterior are muscles primarily responsible for which movement of the ankle?

Plantarflexion

QUIZ: An athlete experienced an acute muscular injury to the soft tissue of the anterior hip. Manual muscle testing indicates weakness with hip flexion and extension. What condition?

Rectus Femoris Strain

Thompson Test

Squeeze the calf and the back of the foot lifts up

Hamstring Injuries

Strains: 1. First degree - mild soreness, and point tenderness, minimal loss of ROM 2. Second degree - moderate to severe pain, very point tender, hematoma formation, moderate loss of ROM and strength 3. Third degree - very severe pain and point tenderness, notable deformity, severe loss of ROM and strength

Inversion Sprains

Stretch the Anterior Talofibular Ligament

QUIZ: The square - shaped, weight- bearing bone that permits ankle plantar flexion and dosiflexion is the...

Talus

QUIZ: The ankle mortise is made up of the...

Tibia, fibula, and talus

QUIZ: The anterior talofibular ligament and the calcaneofibular ligament are most commonly associated with inversion ankle sprains?

True

QUIZ: Muscle that's primarily responsible for resisting lateral displacement of the patella?

Vastus medialis oblique

Arches - Anatomy

a. Bony Orientation Form "Springy" Base b. Highly stable and resilient base c. Types: (medial longitudinal, lateral longitudinal, metatarsal, and transverse)

Calcaneus

a. Largest tarsal bone b. supports talus c. shapes the heel Function: conveys body weight and muscle attachment.

Talus

a. Main weight bearing bone b. square shaped c. "Mortise" ?? Composed of 2 movements: Plantarflexion and dorsiflexion

Plantar Aponeurosis "Fascia"

a. Thick Fibrous Tissue b. Function - supports foot and against downward forces c. Palpation d. Injury Concerns