NPTE : LE Anatomy MASTER (+ pathologies)
Lateral Cuneiform Articulates with
Intermediate Cuneiform Cuboid 3rd Metatarsal
Adductor Tubercle
adductor magnus Medial Femoral Epicondyle (just proximal / medial)
Medial (Tibial) Collateral Ligament (MCL) : attachments what ligaments cross over it?
"Broad" From : Medial epicondyle of femur To : Medial Condyle of Tibia, = Attaches to medial meniscus posteriorly (anterior margin is free) Crossed by tendons of: - sartorius, gracilis + semitendinosus = Pes Anserinus (separated by anserine bursa).
Time to heal : Ligament
6 weeks to NEVER (if you get rid of blood supply when you tear the ligament... ex. ACL , UCL (elbow)
Tarsal Bones name them / put them in order
7 Total Talus Calcaneus Navicular Cuboid Cuneiforms (3) (medial , intermediate + lateral)
Time to heal : Capsule
7 to 10 days = immediate PT required
Scar formation vs. Maturation
7-10 days --> 3 weeks = start working now 3-6 weeks = mature
Interphalangeal + function of toes
: 1 IP, 4 PIP, 4 DIP; Uniaxial, hinge jts - flexion/extension. Function of toes: Smooth weight shift to opposite foot in gait Help maintain stability by pressing against ground both during static posture when necessary and in gait.
1. Explain what Neumann means by "there are no primary internal rotators" know specifically how/why some external rotators (which ones?) can actually switch roles to become internal rotators (pg 507-508).
"ideal" primary internal rotator muscle would be oriented in the horizontal plane during standing, BUT From the anatomic position there are no primary internal rotators because no muscle is oriented even close to the horizontal plane. Active Internal Rotation Torque Increases with hip flexion approaching 90 = reorients the lines of force of these muscles from nearly parallel to nearly perpendicular to the longitudinal axis of rotation of the femur. maximal-effort internal rotation torque in healthy persons is 35-55% greater with the hip flexed to about 90 degrees as compared to when it is extended Some ER ex. posterior fibers of the gluteus medius, piriformis, anterior (superior) fibers of the gluteus maximus, and posterior fibers of the gluteus minimus, = switch actions = IR @ hip flexion of 60+
Lateral (Fibular) Collateral (LCL) name attachments what ligaments cross over it?
"thin / pencil like" From : Lateral Epicondyle of femur (Posterior portion superior to groove for popliteus) To : Head of Fibula Not directly attached to lateral meniscus. Mostly covered by biceps femoris tendon.
High Ankle Sprain which ligaments
"tib-fib sprain" Anterior & Posterior Tibiofibular Ligaments
Determinants to Healing
#1 = Blood Supply to Area Skin + Capsule = heal fast = capsular involvement in an injury will help it heal faster
Tibial N. roots pathway what does it supply
(Anterior Branches of L4-S3) Supplies: - All of Posterior Thigh (-short head of biceps femoris) *In popliteal fossa it gives off:* -articular branches to the knee - medial sural cutaneous - muscular branches to both heads of gastroc, the soleus, plantaris, and popliteus *In the leg* - travels deep (anterior) to the tendinous arch of the soleus + descends just deep (anterior) to the transverse intermuscular septum = branches to: - tibialis posterior - flexor digitorum longus - flexor hallucis longus *At Ankle* Articular branches: travel through the deltoid ligament to ankle joint *At medial malleolus:* - lies posterior (lateral) to the posterior tibial A and Vv + - anterior (medial) to the tendon of flexor hallucis longus. Deep to the origin of the abductor hallucis divides: - Medial + Lateral Plantar Ns = motor + sensory to foot (see next slide) - Medial calcaneal branches: -Pierce flexor retinaculum = skin of heel and posterior sole of foot.
Tibial N. roots describe pathway Cutaneous innervation (from branches)
(L4-S3) H = General + Colors Pale Purple (top nerve) = Medial Sural Cutaneous N. -arises in popliteal fossa -descends under deep fascia groove between the two heads of the gastrocnemius - emerges mid calf = communicates with lateral sural n. = forms Sural N. Pale Purple (bottom nerve) = Sural N. = combination medial + lateral sural nerves Purple (Foot) = Plantar Ns (Medial + Lateral)
External Pelvic Rotation Pelvic Movement LE Movement Spine Movement ' What causes this motion
(Left Picture) Step Backwards (Posterior Rotation) Moving Leg (NWB) = IR Opposite/ Stationary Leg (WB/Axis) = ER Spine = Rotates opposite of moving (NWB) Caused by couple of hip and trunk rotators - whatever side of the pelvis is forward, that side hip is ER and the spine rotates toward whatever side of pelvis is forward more
Internal Pelvic Rotation Pelvic Movement LE Movement Spine Movement What causes this motion
(Right Picture) Step Forward (Anterior Rotation) Moving Leg (NWB) = ER Opposite/ Stationary Leg (WB/Axis) = IR Spine = Rotates to with moving (NWB) Caused by couple of hip and trunk rotators - whatever side of the pelvis is forward, that side hip is ER and the spine rotates toward whatever side of pelvis is forward more
Using Orthoses to correct Forefoot issues
(understand / describe this better or get rid of it)
Plantar Fascitis possible causes ... supination vs. pronation?
- increased incidence with prolonged standing, improper footwear, & increased body weight; excessive pronation or supination can also stress the tissue too much.
Tight FHL causes _________
-The key support for the medical ankle (along with the PTT) -Supports the sustentaculum tali -Tightness leads to less great toe contact and inability to pre-load before push-off
Tightness in Gastroc Soleus causes _____
-The keystone to the posterior foot and ankle -Tightness can lead to: •Increased pronation or supination •Early heel rise in gait •Increased risk of ankle sprains •Sub-talar laxity
If the angle of inclination at the hip is normal than what do you see distally at the knee
0-15 degrees of Genu Valgus
1st MTP Flexion Normal AROM
0-20
1st MTP Extension Normal AROM
0-80
Hybrid Total Hip Replacement (THA)
1 component wi cement (femoral stem) + 1 component w/o cement (acetabular socket) used for 20 yrs but just now being able to see results
Lateral Ankle Structures 6 major structures + importance of each
1. Draw Lateral Malleolus 2. ABDUCT = two peroneal tendons 3. Peroneal Tubercle Just inferior to Medial Malleolus on Calcaneus = Splits PL + PB Tendons 4. Sinus Tarsi Anterior to Medial Malleolus = Soft Spot 5. Calc-Cuboid Joint (Trumpet of Calcalneous) Below Sinus Tarsi = Calcaneous... move anteriorly until your reach a ledge = joint line = Covered by Extensor Digitorum/Hallicus Brevis mms . 6. Dome of Talus Medial + Slightly Inferior to Medial Malleolus (superomedial to sinus tarsi) = Expose Via Plantar Flexion 8. From Dome = Move Inferiorly = Dome - Neck - Head of Talus
Medial Ankle Palpations 6 major structures + importance of each
1. Draw Medial Malleolus 2. Navicular Tuberosity Dorsiflex + ADduct Foot Find Tibialis Posterior Tendon + follow to insertion 3. Sustentaculum Tali (Calcaneous) Find Abductor Hallicus (pic) Move above mm belly + inferior to medial malleolus - Should be posterior + slightly inferior to Nav. Tub. 4. Talor Head Place finger between Medial Malleolus + Navi Tub ABDUCT foot = Talor Head will move your finger 5. Head + Neck of Talus = between Talor head + Medial Malleolus 6. Posterior Medial Talor Tubercle Draw Line: - Inferior to POSTERIOR BORDER of Medial Malleolus = Posterior to line + directly inferior medial malleolus = FHL Tendon runs directly behind this
3 Major Functions of the Pelvis
1. attachment point for many muscles of trunk / LE 2. transmits the weight of the upper body and trunk to : - ischial tuberosities during sitting (sitz bones) or -lower extremities during standing and walking. 3. supports the organs involved with bowel, bladder, and reproductive functions. (with the aid of the muscles and connective tissues of the pelvic floor, the pelvis)
Where should you be able to find the Femoral Artery (pulse) - what can you find to either side of this
1/2 way between the ASIS and public tubercle in femoral triangle (inferior to inguinal ligament) = Sartorious and Adductor Longus move: - medial = pectineus - lateral = iliospoas
Time to heal : Skin
10 to 14 days = scar is mature enough start loosening scar tissue
Total Knee Arthroplasty : Rehab Protocol how much time total describe each phase (4) + criteria between each + discharge
12-16 weeks Total Start wi Closed Chain + Isometrics Phase I: Immediate Post Surgical Phase (Day 0-7) ● Decrease swelling ● Increase ROM immediately ● Enhance muscle control and strength ● Maximize mobility = functional independence ● Education and introduction to home exercise activities Therapeutic Exercise Component ● LE ROM and strengthening as indicated based on evaluation findings: ○ BFR (keystone of total arthroplasty) ○ A / AA / PROM exercises (0-90+) ○ Isometric exercises (quadriceps, hip abductors) [hamstrings and glute exercises] ○ Closed chain exercises (quadriceps, hip abductors) ○ TKE ○ NMES for quads if poor quad contraction is present ● Light hamstring stretching ● Patello-femoral joint mobilization as indicated ● Soft tissue mobilization ● Gait training: Flat surfaces & stairs CRITERIA FOR PROGRESSION TO PHASE II ● Ability to demonstrate Quadriceps contraction ● ROM at -10° ACTIVELY! ● Active knee range of motion (AROM) -10°-80° ● Minimal pain and inflammation Phase II - Motion Phase (Day 7 - Week 6) ● Improve knee ROM to >/= 0-110 degrees ACTIVELY! ● Mm strengthening of the entire operative extremity ● Hamstring stretching ● Proprioceptive training ● Endurance training ● Functional training = independence in ADLs ● Gait training - get rid of assistive devices ASAP ● Decrease inflammation/swelling A / AA / PROM of LE, stretching for flexion (>90 degrees) and extension ● Stationary Bicycle for ROM (full rotation on pedals), begin with partial revolutions then progress as tolerated to full revolutions (no resistance) ● Joint mobilization as indicated: patellofemoral and tibial-femoral ● Continue isometric exercises (quadriceps, hip abductors, adductors, flexors) [hamstring and glutes] ● Continue BFR for all muscle groups (3x/week) ● Gait training to improve function and quality of involved limb performance. ● Long Arc Quad when tolerated (seated) ● Supine heel slides SLR 4 planes (flexion, abduction, adduction, extension) ● 1/2 front lunge (in weeks 4-6) ● Use sit to stand and chair exercises More aggressive scar management (beginning no later than week 3) Criteria for Progression to Phase III ● AROM 0-110° ● Good voluntary quadriceps control ● Independent ambulation community distances (</= one mile), without deviations or antalgic gait. ● Minimal pain and inflammation Phase III - Intermediate Phase (Week 7-12) General Goals ● Maximize postoperative ROM (0-120+ degrees) ● Normalized patello-femoral mobility ● 80% return of LE strength ● Return to most functional activities and begin recreational activities (i.e. walking, climbing) ● Education and home exercise program Therapeutic Exercise and Mobility ● Continue exercises listed in Phase II with progression including resistance and repetitions. ○ Continue BFR until the patient can perform HIT ● Assess hip/knee and trunk stability at this time and provide patient with open/closed chain activities that are appropriate for individual needs ● Continue Joint mobilization as indicated. ● Continue scar management as indicated. ● Initiate endurance program, walking, and climbing (stair or other). ● Initiate and progress age-appropriate balance and proprioception exercises. CRITERIA FOR PROGRESSION TO PHASE IV ● Achieve detectable change in 2 functional tests ○ Timed Up and Go: 2.6 s ○ 6 Minute Walk: 61 m ● Minimal to no pain or swelling Phase IV - Advanced Strengthening & Higher Level Function Stage (Week 12-16) General Goals ● Return to appropriate recreational and functional activities as indicated ● Enhance strength, endurance and proprioception as needed for activities of daily living and recreational activities. ● Education and home exercise program Therapeutic Exercises ● Continue previous exercises with progression of resistance and repetitions as indicated ● Increased duration of endurance activities ● Return and train for specific recreational activity Criteria For Discharge ● *These are general guidelines as patients may progress differently depending on previous level of function and individual goals. ● Non-antalgic, independent activities ● Pain-free AROM. ● Appropriate improvement in functional test scores. ● Normal, age appropriate balance and proprioception.
intercondylar groove about what angle/depth why is this important
120 - 150° more shallow = less stability / control for patella
Amount of Hip Forces during Walking (maybe more than we need to know specifically) How are these changes in force mitigated within the joint?
13% of body weight = midswing phase 300% + of body weight = midstance phase. stance phase = when forces are the greatest = the lunate surface deforms and the acetabular notch widens slightly, increasing contact area that reduces peak pressure This natural damping mechanism represents yet another design that keeps the stress on the subchondral bone within physiologically tolerable levels.
Ankle Sprain Alternate Grading Scale based on Ligaments involved
1st degree--anterior talofibular involved 2nd degree--add calcaneofibular involvement 3rd degree--add posterior talofibular involvement
Standing Calf Raise (1 leg) AI vs. PI
AI too long: Gastrocnemius [starting position] - performing initial range of plantarflexion from a position of full dorsiflexion with knee fully extended PI: Dorsiflexion ROM may be limited with knee extended due to passive tension (stretch) in the gastrocnemius.
Subtalor Joint ... more inversion or eversion??
2:1 ratio Inversion to Eversion
How long does it take for Mm Scar Tissue formation
3 weeks
Time to heal : Muscle
3 weeks to good scar formation = start light WB 6 weeks to solid resistive tissue = return to aggressive weight bearing
Where should you inject into the buttocks to avoid injuring the sciatic nerve?
Superolateral Quadrant of the Buttock
Ankle/Foot Inversion - part of which motion - normal range
Supination 0-35
Time to heal : Graft ACL Example wi time frames
4-6 months = revascularization ex autografted ACL 0-8 = aggressive 8-12 = weakest = back off 12+ = ramp back up ... minimum 6 months back to sport
Seated Leg Curl AI vs. PI
AI too long: Hamstrings [starting position]- performing initial range of knee flexion with hip flexed to 90° or more PI: Prior to the exercise, in trying to get into the starting position, knee extension ROM may be limited with hip in 90° flexion (or more) due to passive tension (stretch) in the hamstrings.
Cuboid articulates with
4th + 5th Metatarsal + Calcaneous Lateral column of the foot
Metatarsophalangeal joints (MTPs) compare the flexion/extension of these joints to your fingers
= 5 biaxial condyloid joints. - flexion/extension + abduction/adduction. More extension than flexion compared to fingers, 14.52 shows the importance of ample extension range of motion at the metatarsophalangeal joints. plantar flexor muscles use joints to increase internal moment arm, + full extension of these joints pulls the plantar fascia taut via the windlass effect = helps the intrinsic muscles support the medial longitudinal arch + maintain a rigid forefoot = allowing the foot to accept the load of body weight.
Tarsometatarsal joints
= 5 nonaxial, plane synovial joints; = function is primarily a continuation of mid-tarsal joint.
What can occur at the Talocrural Joint when the foot is Plantar flexed
= weaker position Inversion Sprain
Popliteal Artery pathway including branches
=continuation of femoral artery after adductor canal / hiatus ends by dividing into anterior and posterior tibial arteries. It has muscular, cutaneous, and genicular branches. Muscular branches: to adductor magnus, hamstring muscles, gastrocnemius, soleus, and plantaris. + These branches are mirrored by Popliteal Vein
Arcuate popliteal ligament from / to function
=reinforces posterior + lateral aspect of the joint capsule From : Head of Fibula (Posterior Aspect) "Arches" over poplitius m (superomedially) To : posterior aspect of the joint capsule
Osteo/Arthrokinematics of Tibiofibular Joints
A subtle superior and inferior sliding movement of fibula occurs during ankle motion.
Describe positions of Active & Passive Insufficiency for the Gastrocnemius. Describe specifically how knee position can affect ankle ROM.
AI too short = Knee Flexed - ex. seated half raise PI too Long = full Dorsiflexion??? Tib Ant , Ext Dig. , Ext Hallicus Longus ???
Seated Calf Raise (2 leg) AI vs. PI
AI too short: Gastrocnemius [starting position] - performing end-range plantarflexion with knee flexed 90° or more PI: Uncommon Dorsiflexion ROM may be limited with knee extended due to passive tension (stretch) in the soleus ms (not a 2 joint muscle). How could this be changed to become a stretching technique?
1 Leg Hip Extension (Machine)
AI too short: Hamstrings [up phase] - performing end-range hip extension with knee flexed 90° or more PI: Hip extension ROM may be limited with the knee flexed 90° of more due to passive tension (stretch) in the rectus femoris. How could this be changed to become a stretching technique?
Single Leg Standing Leg Curl AI vs. PI
AI too short: Hamstrings [up phase] - performing end-range knee flexion with the hip near or in extension (or if extending the hip further). PI: Knee flexion ROM may be limited with hip at 0° due to passive tension (stretch) in the rectus femoris.
Sesamoids of the foot found within which tendon function
FHB tendon limit friction on the tendon + Creates space for FHL tendon can be broken in some people with excessive loading (become gravelly)
Mms that incline the great toe toward the ground = raise the longitudinal arch
FHL + Posterior Tibialis
Weakness in which mm at the hip can negatively impact patellofemoral alignment + how
ABd + ER = coxa varus --> genu valgus weak ABd can also cause a lateral lean towards the side of weakness (trendelenburg) which further increases medial distraction forces at the knee
Intracapsular Ligaments of the Knee What are they Tests for each
ACL + PCL intracapsular but extrasynovial
Treatment of ACL Tears what % get surgery what is prehab type of reconstruction (in terms of tissue used) - pros and cons of each
ACL does not heal ○ 1/3 avoid sx ○ 1/3 aggravate later ○ 1/3 surgery (when it interferes w/life/happiness) Surgical considerations Prehab - hard to operate on "hot" joint ○ Eliminate effusion ○ Restore full ROM ○ Walk without limp Reconstruction ● Autograft: use of own tissue ● Allograft: use of someone else's tissue Autograft ● Patellar tendon (most common) vs hamstring Actually - two interventions (one sx) ○ Harvest tissue ○ Reconstruct ACL Allograft ● Eliminates harvest of tissue ● Auto-immune response? ○ Weaken graft? Ligamentization process ● Graft is avascular, tissue begins to die (strongest when first put in) ● Revascularization occurs at 5-6 weeks - weakens graft ● Appropriate stress result in fibroblastic activity ○ Ligamentization Graft strengthens
Unhappy Triad of Knee
ACL, MCL, medial meniscus
ACL from / to limits
ACL: Limits: OKC= anterior movement of tibia on femur (hyperextension) CKC = posterior movement of femur on tibia M-L orientation = IR of tibia / ER of femur Intracapsular but Extrasynovial Compensated by Hamstring - need to strengthen prior to surgery + need to AVOID extension (quads) just after surgery because this wants to create anterior tibial translation (ie stresses ACL)
Strongest internal rotators of the hip (as per Forbush)
ADductors
Seated Leg Extension AI vs. PI
AI too short: Rectus Femoris [up phase] - performing end-range knee extension with hip flexed near or beyond 90° Is there any AI change in the Vastus ms? PI:Knee extension ROM may be limited with hip in 90° flexion (or more) due to passive tension (stretch) in the hamstrings.
Straight Single Let Raise (Supine + opposite knee flexed) AI vs. PI
AI too short: Rectus Femoris [up phase]- performing end-range hip flexion with the knee extended (or close to extension). Is there any AI change in the Vastus ms? PI: Hip flexion ROM will be limited with the knee fully extended due to passive tension (stretch) in the hamstrings. All of the hamstring ms?How could this be changed to become a stretching technique?
Where is there a weakness in the Joint Capsule of the Hip what makes up for this weakness
ANTERIORLY between pubofemoral + iliofemoral ligaments = point of iliopectineal bursa = is reinforced by iliopsoas tendon
TFL actions (traditionally vs. forbush)
Abd + Flexion + IR of Hip Tenses IT band which has attachments to Lateral : Quads , Gluts + Hamstrings(?) = Helps to stabilized these Mm
Metal on Metal Total Hips (THR) pros vs. cons
Advantages of Metal to Metal Very Precise = restoration of biomechanics + leg length corrections sturdy long lasting (up to 20 years) Disadvantages = noisy "clanking" or "clicking" noise when on and off weight-bearing or when moving suddenly.
SITZ bones
Also called the ischial tuberosity, these are the bones that make contact with the ground while sitting.
Bipolar Prosthesis
Any femoral head replacement device that is composed of a metallic shaft and a metallic acetabular cup with an interposed polyethylene liner
Q-angle what is it normal range compare male vs. female
Angle from from: The line of pull of the quadriceps (ASIS to midpoint of patella) + line of pull of the patellar tendon (tibial tuberosity -> midpoint patella) 10-15° normal greater than 20° abnormal Greater in females Excessive Q angle = excessive lateral patellar tracking due to increased lateral force on patella due to MANY FACTORS
Lateral Ligaments of the Ankle which is strongest vs. weakest
Anterior TaloFibular = weakest = most common sprain vs. Posterior TaloFibular = strongest
Major Causes of Hip Replacements 2 categories + subcategories
Arthritis (OA, RA or Traumatic A) + Congenital Irregularities / Fx
Jones Fracture
Avulsion fracture due to the fibularis brevis pulling away the bone of the base of the 5th metatarsal
Explain how the axis of motion at the knee migrates during flexion / extension
Axis migrates with femoral condyles. The path of AOR is influenced by the eccentric curvature of the condyles. Biomechanically, the migrating axis alters length of the internal moment arm of the flexor and extensor mm. important when administering orthotics - have to measure at the average otherwise it will rub the skin
Ligaments / Tendons : Anterior Knee (3)
Quadriceps (patellar) tendon - anterior support Iliotibial Band - anterolateral support Pes Anserine tendons - medial support
Types of Fixation used in Total Hip (THR) (3) advantages / disadvantages of each
Bone Cement - can WB immediately after surgery, used in older pts - doesnt last as long as press fit / may loosen over time Press-Fit - immediately unstable = NWB = younger pts - lasts longer than cement - special porous coating = allows bone to grow into implant combo - may also be used
Bone Preservation in Total Hip Replacement (THR) why is this important what happens if this is not accomplished
Bone needs stimulation to stay healthy. = don't let the implant do all the work implant shields the bone from stress ("stress-shielding"), bone = resorbed/broken down by the body = bone loss vs. if the bone is required to take on too much stress, abnormal growth = "adaptive remodeling." Bone Loss (Osteolysis) - eating away of bone = immune response to loose bodies caused by rubbing of implants causing bone degradation overtime Many orthopedic surgeons identify osteolysis as the number one cause of hip implant failure. New Ceramic Components help hope to reduce this
Popliteal Fossa Boundaries Structures Superficial vs. Deep
Borders: Superior: - Lateral: biceps femoris tendon -Medial: tendons of semitendinosus & semimembranosus mm. Inferior: - Lateral: plantaris & lateral head of gastrocnemius mm. - Medial: medial head of gastrocnemius m. Roof (posterior): Popliteal fascia (pierced by lesser saphenous vein) Floor (anterior): Popliteal Surface of Posterior Femur - Oblique popliteal lig - Popliteaus M. (/ Fascia Covering Muscles) - Proximal tibia Superficial Structures: - lesser saphenous vein - lateral sural cutaneous N - medial sural cutaneous N Deep Structures - Popliteal A/V - Sciatic N = bifurcates in Tibial + Common Fibular - Lymphatics -Genicular A/V -Genicular N (from Tibial + Common Fibular)
Popliteal Fossa boundaries + contents
Boundaries Heads of Gastroc Semimem/tendonosis (Superomedial) Biceps Femoris (Superolaterally) Floor (anterior): posterior knee joint capsule & popliteus muscle. Roof (posterior): fascia, superficial veins & nerves, & skin Contents Sciatic Nerve - enters the fossa & splits into the tibial & common peroneal nerve Tibial nerve continues down the posterior low leg Common Peroneal follows tendon of biceps femoris muscle, travels around neck of fibula, under the peroneus longus muscle, and divides into superficial and deep peroneal nerves. Popliteal Vein - ascends through fossa and then through the medial thigh to become the femoral vein Popliteal Artery - continuation of femoral artery
Genu Varus range compresses which compartment of the knee?
Bowlegged less than 0 degrees of genu valgum vs. 0-5 degrees = decreased genu valgus compresses medial compartment (of knee)
Obturator n. Cutaneous Branch (L2-L4)
C
MSK 1 Supination/Pronation at Ankle/Foot when do we use this to describe motion
CKC ONLY To describe 3 plane WB activities
Sustenaculum tali - part of which bone - importance / articulations
Calcaneous tibocalcaneal ligament (deltoid) calcaneal navicular (spring) ligament FHL tendon passes under
Sciatic Nerve Injuries causes muscles affected movements affected compensations
Can be injured by: - fractures of pelvis - posterior dislocations of hip joint - most frequently injured by badly placed intramuscular injections (should inject into superolateral quadrant of buttock). Motor: the hamstring muscles would be paralyzed but weak flexion of knee would be possible via sartorius (femoral nerve) and gracilis (obturator nerve). All muscles inferior to the knee would be paralyzed. - The weight of foot causes a foot drop = plantar flexion Sensory: loss of sensation below knee except for medial band supplied by saphenous nerve (branch of femoral).
Gluteus Min/Medius Injury causes signs + symptoms exam
Cause •Similar to rotator cuff pathology (RC of the Hip) Progression from tendonitis and edema to progressive tendon thickening, partial tearing and ultimately complete rupture at gluteal insertion Signs and Symptoms Dull lateral hip pain Focal tenderness at gluteal insertion (right above Troch) •Trendelenberg gait Exam •Weak hip abduction •Pain with passive and resisted ER with hip @ 90° flexion •Pain with single-leg stance >30 seconds Treatment 1. Decrease inflammation •Rest - avoid aggravating activities •Modalities •Light exercise (IM's/AROM) for pumping effect 2. Correct muscle imbalances which caused initial problem 3. Proceed thru functional progression as able
Loose Bodies in the Hip causes signs + symptoms treatment
Causes •Osteochondritis dessicans, avascular necrosis, degenerative osteoarthritis, synovial chondromatosis, pigmented villonodular synovitis •Traumatic hip dislocations •Chondral injury following lower-energy trauma Signs & Symptoms Similar to labral pathology Catching, locking, clicking, or giving way Anterior groin pain Hip stiffness Occasionally have hx of dislocation or low-energy trauma Exam •Limited ROM •Catching and grinding Imaging •Plain radiographs best for ossified or osteochondral loose bodies (chondral wont show up well on plain radiographs) •MRI or MRA best or cartilaginous loose bodies Treatment •Arthroscopy •Post-op rehab for gait retraining and strengthening if appropriate and when too long incapacitated or limited
Cemented vs. Non-cemented THA
Cemented Hips - FWB + walk w/o support immediately = faster rehab ... critical for older pts but dont last as long and are susceptible to loosening over time, especially with individuals who are very active - may also result in debris causing osteolysis Cementless Fixation - not immediately secure = NWB while bone begins to form through implant - should last longer esp. in active individuals = better for younger pts
14.2 - clinical assessment of subtalar joint
Clinicians often measure subtalar joint motion solely by the amount of inversion and eversion of the calcaneus Neutral subtalar joint is used for evaluating a foot before issuing of an orthodonic device Created by placing calcaneus in position that allows both lateral and medial sides of talus to be equally exposed for palpation in the mortise
Mortons Neuroma
Common Only with Distal Pain Complaints Tender Between ONE set of Distal Metatarsals (2-3 or 3-4) Easy to Reproduce with Pressure (pinch test) Check for Inter-Metatarsal Mobility (Hyper/Hypo) Biomechanics of NWB to FWB in Forefoot Medial Plantar N
Foot Slap due to injury of actions affected
Common fibular Nerve Damage = weakness of dorsiflexors causes "foot drop" = permanent plantar flexion also causes foot slap because foot comes down suddenly
Steppage Gait due to injury of actions affected
Common fibular Nerve Damage = weakness of dorsiflexors causes "foot drop" = permanent plantar flexion also causes foot slap because foot comes down suddenly
Osteoarthritis in the Foot
Commonly - First MTP - First MTT Similar Inflammation as Already Discussed not as "hot" as gout Abnormal Bony End Feels = will become stiff Avoidance of Compressive Load in Foot and Ankle
Describe Types of Joint found in Knee
Compound Joint = 3 articulations within one joint cavity: 2 Condyloid joints : between each condyle of the femur + corresponding condyle of Tibia (Each of the condyloid joints is partially divided by a fibrocartilagenous meniscus between the articular condyles) 1 modified plane synovial joint = between patella + femur
Post Surgical Rehab for Hip Replacements concerns to watch out for - anterior vs. posterior approach - cemented vs. cementless how to successfully rehab
Concerns for Rehabilitation ● Must protect the hip from dislocation Posterior approach ○ Minimize adduction (neutral) ○ Minimize internal rotation (neutral) ○ Minimize excessive flexion (>100 degrees) Cement Rehabilitation Concerns ● Cementless hips: ○ Protected weight-bearing early ○ Use of walker for the first few weeks ○ Limited ROM for the first few weeks ● Cemented hips: ○ Immediate weight-bearing ○ Limitations in the range from incision early Success through Rehabilitation! AVOID (until healed) Fatigue - repetitive heavy lifting (fatigue) - excessive stair climbing (fatigue) Maintaining appropriate weight = Staying healthy and active Avoiding "impact loading" sports jogging, downhill skiing, and high impact aerobics Avoiding quick stop-start, twisting or impact stresses Heavy lifting + bending over Kneeling - leads to adaptive hip rotation low seating surfaces and chairs = excessive flexion
Atrophic Fat Pad causes signs / symptoms treatment
Constant contact on heel = causes bleed , causes fibrosis of fat pad , feels like you are stepping on rock .... Give them a cushion, break up scar tissue + hope fat pad comes back)
Talocrural Joint : Arthrokinematics What motions open vs. closed chain
Dorsi/Plantar Flexion (as part of supination/pronation) Open Chain: Moving Convex - Convex talus moving on - fixed concave tib/fib mortise: Closed Chain: Moving Concave - Tib/fib mortise moving on talus
The ankle if most stable when _____________
Dorsiflexed
Supination motion Affect on the Leg/Foot as a whole
Down + In Plantarflexion Adduction, Inversion Raises the arch creates a firm, rigid foot functionally lengthen the leg.
Saphenous nerve (L3-L4) = terminal branch of Femoral N.
D
decreased angle of inclination
Cox Vara
increased angle of inclination
Coxa Valga
Hip angle of inclination & Knee alignment relationship between the two (potentially)
Coxa Valga = Genu Vara vs. Coxa Varus = Genu Valga
identifies abnormal femoral antetorsion angle
Craig's Test
"C" Sign describe it possible sign of
FAI , Labrum Pathology + other hip / femur issues
Blood supply of head of femur
Cruciate Anatomoses - includes which arteries (for our purposes) - function surround neck and greater trochanter of femur connects branches of internal + external iliac arteries for our purposes Internal = Inferior Gluteal external = Deep Femoral (via circumflex branches)
Intra-articular Structures of Knee
Cruciate ligaments = "X" inside the joint named by their attachment sites to tibia. - intraarticular but extrasynovial ACL Limits: OKC= anterior movement of tibia on femur (hyperextension) CKC = posterior movement of femur on tibia M-L orientation = IR of tibia / ER of femur PCL Limits OKC = posterior movement of tibia on femur CKC = anterior movement of femur on tibia L-M orientation = IR of femur / ER of tibia Medial Meniscus and Lateral Meniscus crescent/wedge shaped fibrocartilage disks = deepen the tibial plateaus .
Total Knee Arthroscopy cruciate maintained vs. cruciate sacrificed
Cruciate maintained ○ More normal motion ○ More wear over time Cruciate sacrificed = Hinged and stable BUT Not as much auxiliary motion ● Rotation design ● Patella or non-patella included Surgical Approaches ● Incision lines are different now (less invasive) Robotic and Computer Guided Procedure = much more precise
What are these symptom of? at the HIP Sharp anterior pain with endrange flexion, IR or ADD (or combinations of these) Lateral or post pain with ER Pain with stair climbing or prolonged sitting Athletes: pain with squats or with lateral & cutting movements
FAI : CAM , Pincer or Mixed
Location & function of the hip bursae
Decrease Friction Iliopectineal found between iliopsoas tendon and hip joint ligaments. Trochanteric found over the greater trochanter
Compare Deltoid Ligaments vs. Lateral Ankle Ligaments
Deltoid = more elastic but also stronger - easier to stretch but harder to tear
Eversion Injuries
Deltoid Ligament Sprains / Tears Forces acting to open medial side of ankle may actually fracture off (avulse) the tibial malleolus before the deltoid ligament tears ... POTTs fracture BECAUSE DELTOID LIGAMENTS ARE SO STRONG
Medial Ligaments of the Ankle name them what do they support what do they prevent most injured?
Deltoid Ligaments Support Medial Side of Talocrural 1 = anterior tibiotalor = head of talus 2 = tibionavicular = navi. tuberosity 3 = tibiocalcaneal = sustenaculum tali 4 = posterior tibiotalor = posterior medial talor tuberosity NOTE : naming = Tibo________ LIMIT EVERSION
Shape of the talus why is this important
Dome is wider anteriorly than posterior = locks in during dorsiflexion
Talocrural Joint Weight-Bearing Surface
Distal Tibia
Supination (CKC) describe position at each segment of foot
Equinus Foot = high arch Rigid Foot Osteoarthritic at Mid-foot - Bc is locked in without any way to spread out into pronation Increased Inclination of the MTP's Hammer Toes = much more common in supinated foot
Potts Fracture occurs due to which type of roll
Eversion
Describe motion of Patella during Knee Flexion / Extension
Extension = superior to groove freely mobile when relaxed 10-20 degrees flexion inferior aspect of medial/ lateral facets touching groove Past 90 degrees flexion = inferior to groove - contact with odd facet & lateral facet
Motor Screening for Leg describe actions / nerve roots at each joint remember trick of 2's reflexes
Extension of knee (L3) Flexion of knee (L5, S1) Dorsiflexion of foot (L4, L5) Plantar flexion of foot (S1, S2) Inversion (L4, L5) Eversion (L5, S1) Great toe extension (L5) Great toe flexion (S1) L4/5 = Patellar S1/S2 = Achilles Each Joint is Moved by 4 Nerve Roots TRICK as per Forbush leg it all starts with L2 Mm that move each joint = 4 nerve roots (see pic) As you move down one joint, you move down one nerve root level Front before back In the ankle it all starts with L4
First MTP Joint why is it important
Extension of this joint is very important for late stance phase of gait
Describe the complex functioning of Mm in the foot Intrinsic vs. Extrinsic Mm describe the Mm pairs at the foot and their stabilizing Mm
Extrinsic Mm gross actions / control of foot intrinsic muscles - fine tune + stabilize quadratus plantae = stabilizes FDL anterior tibialis + posterior tibialis = stabilize the navicular fibularis longus + posterior tibialis = stabilize the transverse arch FHL + posterior tibialis = incline the great toe toward the ground + raise the longitudinal arch
Who tends too have more patellar issues (men or women?) + Why
Females tend to have a slightly greater Genu Valgus = may lead to more patella issues
FAI : Mixed
Femoral Acetabular Impingement malformation of femoral head + neck AND Acetabulum
FAI : Pincer where is the deformity , what does it damage how might you see this via imaging
Femoral Acetabular Impingement malformation of the acetabulum = acetabular over-coverage resulting in impingement of a normal femoral head-neck junction on the acetabular rim seen via crossover sign - acetabulum extends beyond femoral neck line
FAI : CAM where is the deformity , what does it damage how might you see this via imaging
Femoral Acetabular Impingement malformation of the femur @ head + neck causes cartilage + labral wear in acetabulum Increased alpha angle - not pathogenic but suggestive of possible CAM FAI
Femoral Hernias - occur through what "tube" + - what opening - why? more common in men or women?
Femoral Canal occur through femoral canal + pass through saphenous hiatus occurs due to weakening of abdominal wall by the passage of the lymphatics* women
Superior vs Inferior Surface Stress fx of the hip most commonly at
Femoral Neck superior surface = under tension = mechanically unstable inferior surface = under compression = mechanically stable
Fatigue vs. Insufficiency fx of the hip most commonly seen at
Femoral neck Fatigue fractures - normal bone subject to repeated abnormal stresses Insufficiency fractures - normal stresses applied to abnormal bone
Hip Stress Fx most commonly seen at the _________ 4 types
Femoral neck (also found in sacrum, pubic rami, acetabulum, and femoral head) Fatigue fractures - normal bone subject to repeated abnormal stresses Insufficiency fractures - normal stresses applied to abnormal bone superior surface = under tension = mechanically unstable inferior surface = under compression = mechanically stable
Longest Bone of the Body
Femur
Acetabular Labrum is made of _____________ vascularization / innervation
Fibrocartilage = Poorly Vascularized Acetabular Labrum Fibrocartilage = Poorly Vascularized - limited healing potential Well Innervated with afferent nerves = propriocetermtive feedback and sensation of pain is often involved in hip pathologies such as: - degenerative osteoarthritis - acute trauma, - developmental hip dysplasia - repeated femoral-acetabular impingement
Inferior Tibiofibular Joint type of joint supporting structures common injury
Fibrous Joint from distal fibular (convex) to fibular notch of distal tibia Ligaments: - anterior + posterior tibiofibular ligaments -tibiofibular interosseous membrane (deep to posterior tibiofibular) - very strong - important for maintaining ankle integrity and keeping T+F together High Ankle Sprain
Inferior Tibiofibular Joint between relative position in anatomical position type of joint movements
Fibrous Joint from distal fibular (convex) to fibular notch of distal tibia anterior + posterior tibiofibular ligaments tibiofibular interosseous membrane (deep to posterior tibiofibular) - very strong - important for maintaining ankle integrity and keeping T+F together Damaged in High Ankle Sprains
compare & contrast the weightbearing functions of the tibia & fibula.
Fibula = largely NWB bone important for ms and ligament attachment = Not Technically Part of the Knee Joint = could play with a broken fibula if you are able to deal with the pain
Ligaments / Tendons : Lateral Knee (3) name + function
Fibular (Lateral) Collateral Ligament (LCL) - round & thick from lateral femoral epicondyle to head of fibula no attachment to meniscus LIMIT VARUS FORCE
Innervation : Low Leg, Ankle + Foot Anterior general pathway
Fibular nerve (common peroneal nerve) -Split in distal H/S -Around distal fibular head -Split into superficial and deep fibers -One travels lateral and one travel anterior -Anterior behind retinaculum -Lateral to anterior tibialis tendon Into anterior foot
AVG ROM : Femur on Pelvis what motions
Flexion = Extension = ABD = 0-45 ADD = 0-30 IR / ER = both 0-40
Pronation of Foot (CKC) describe at each section of foot
Floppy Foot Forefoot Abduction Hallux Valgus Mid-foot Laxity Posterior Tibialis & Flexor Hallucis Strain, Sprain, or Avulsion talus + navicular slide off each other = loose foot because are different functional segments
Bones of the Foot - which tarsals are related to each metatarsals
Forbush preferred naming of cuneiforms 1st -> 2nd -> 3rd to match metatarsals
Posterior Tibial Artery Pathway including branches
From : Popliteal A. (at inferior border of poplitius m.) Bifurcates at origin of abductor hallucis Lateral Plantar A. : - Superficial branch (lateral side of 5th toe) - Deep branch Plantar arterial arch Medial Plantar A : Metatarsal - Proper Plantar Digital arteries (medial 1 ½ toes) Veins accompany all vessels as listed
Transverse Tarsal Joint : Primary Motion
HAS 2 Axis = Motions in all 3 Planes plantar/dorsi abd/add inv/evert
Describe blood supply around the hip/femur
From Internal Iliac A: - Superior Gluteal A/V/N = gluteus med/min + TFL (only structures to pass above piriformis in GSF) - Inferior Gluteal A/V/N = gluteus maximus - Obutrator A/V/N = Obturator Int/ext , bladder , ilium + adj. muscles Branch to Head of Femur = alternate supply vs. Deep Femoral - Internal Pudendal A/V + Pudendal N = Perineum = leaves GSF + Loops back through LSF From External Iliac - Femoral A - Deep Femoral A - medial + lateral circumflex (+their branches) - perforating branches to adductor magnus - anastomoses (see other slides for more in depth) Creates Cruiciate Anastomoses Around the Proximal Femur
Rehab + Healing times for Hip Fx femoral neck vs. intertrochanteric fx
Full bone healing = 8 to 10 weeks - depending on age and condition Rehabilitation of Fractures ● Femoral Neck Repair ○ Weight-bearing early with partial ○ Limited rotation ○ Limited by pain in activities ● Intertrochanteric Repair ○ Partial to less weight-bearing ○ Neutral position of the limb ○ No pivoting with weight-bearing ○ ROM within limits of incisions Healing Times ● Problem with mortality following hip fractures ● Weight-bearing is the most important element ● Full bone healing within 8 to 10 weeks depending on age and condition ● Strength issues from surgical insult
Closed-Packed Position of Talocrural Joint
Fully Dorsiflexed limited more by muscles KNEE POSITION CAN AFFECT DORSIFLEXION ROM
Closed-Packed Position of Talocrural Joint common end feel
Fully Dorsiflexed = Locks into widest part of Talus generally most limited by Mm (ex Gastroc tightness) ... which can be affected by knee position
Dorsiflexion + Plantarflexion ROM needed - gait - other activities
GAIT - Dorsi = 15 degrees - Plantar = none NEEDED Dorsi = 40 + vball, bball etc Plantar = 50+ ballet , divers ,etc
Preventative Stretching for Ankle Injuries 2 most important 3 others tightness in each causes ____________
Gastroc Soleus -The keystone to the posterior foot and ankle -Tightness can lead to: •Increased pronation or supination •Early heel rise in gait •Increased risk of ankle sprains •Sub-talar laxity Flexor Hallucis Longus -The key support for the medical ankle (along with the PTT) -Supports the sustentaculum tali -Tightness leads to less great toe contact and inability to pre-load before push-off Flexor Digitorum Longus/Brevis, Plantaris -Help to propel -Tightness is same problem in pre-load before push-off -Eccentric pull on heel (could cause tendonitis) Peroneals -Tightness causes an increase in supination -Great ray affected Plantar Fascia -Restricts range of toes in pre-load before push-off
Knee position can affect dorsiflexion ROM, but not plantarflexion. HOW/WHY?
Gastrocs = two joint across knee No two joint mm in anterior compartment
Gluteus Maximus gait
Gluteus Maximus gait you lean back to compensate for the fact that you do not have any gluteus max to keep you in extension due to injury to the Inferior Gluteal N
Trendelenburg gait - which nerve / muscle(s) - which action
Gluteus Medius / Superior Gluteal N = Due to Weak ABDUCTION (gluteus medius , maximus + TFL) Trendelenburg gait: - during the Stance Phase of the gait cycle when one foot is off the ground, the gluteus medius of the the leg that is on the ground contracts to prevent the opposite hip from dropping. When the superior gluteal nerve (or gluteus medius directly) is injuried this does not occur causing the opposite hip to drop = Hip Drop and the close hip to raise up (relative to the dropping hip) Due to weak ABDUCTION When weak side is planted on the ground, opposite side drops and weak side "raises" IF weakness on both sides = = Waddling Gait = drop on both sides
Ankle Sprain Grading System (From Class) include specific tests
Grade 1 ● Slight/no swelling ● Slight point tenderness ● No loss of function ● Ant. Drawer - neg ● Talor tilt - neg Grade 2 ● Moderate swelling ● Possible ecchymosis (discoloration of the skin resulting from bleeding underneath--bruising) ● Moderate point tenderness ● Loss of function ● Ant. Drawer - pos ● Talor tilt - neg Grade 3 ● Severe swelling ● Ecchymosis ● Major loss of function ● Ant. Drawer - pos ● Talor rock - pos
Greater vs. Lesser Trochanter general position + attachments
Greater - more superolateral - tons of ERs Lesser - inferior/posterior/lateral - Iliopsoas
Greater Sciatic Foramen: Boundaries Transmitted Structures
Greater Sciatic Foramen Boundaries: - Greater sciatic notch - Sacrospinous ligament - Sacrum Transmitted structures: -Superior gluteal artery, vein + nerve = only structures above piriformis m -Piriformis muscle -Inferior gluteal artery, vein, nerve -Nerve to quadratus femoris (+ gemmelus inferior) -Nerve to obturator internus (+ gemmelus superior) -Internal pudendal vessels (dive back in via lesser Sciatic Foramen) -Pudendal nerve -Sciatic nerve -Posterior femoral cutaneous N
Someone with limited (<10º) dorsiflexion will demonstrate abnormal gait at which phase?
Heel OFF
Partial Hip : Hemi-Resurfacing Hip Arthroplasty
Hemi-Resurfacing Hip Arthroplasty Avascular necrosis - early stage only affect femoral head -> ball collapses ○ Resulting in a loss of roundness and this causes pain round metal "cap" on the ball + pts own socket Advantages - does not take away much bone (more options available for subsequent re-operations), does not last as long as total hip ○ BUT remember that patients with this stage of avascular necrosis are often quite young ○ Anywhere from their 20's to 40 or so--and so total hip replacement is not considered an ideal approach for them
Define Hindfoot , Midfoot + Forefoot - which bones / joints are in each
Hindfoot: - Talocrural (ankle) - Subtalor = talus + calc (2 articulations in 2 capsules) - transverse tarsal = talonavicular + calcaneocuboid (dividing line) Midfoot - Intertarsal Joints Forefoot - TMT - MTP - IP
Hyperpronation of the foot due to which motions at Hip , Knee , Rearfoot + Midfoot
Hip - IR , Flexion + ADduction Knee - Increased Genu Valgus Rearfoot - Pronation (eversion) with lowering of medial longitudinal arch Midfoot/Forefoot - Supination (inversion) = compensates for Rear foot
Knee AI/PT Based on Hip Position (flexion / extension)
Hip Flexion - AI too short Rectus Femoris (knee ext) + - PI too long Hamstrings (knee flexion) Hip Extension - AI too short Hamstrings (knee flexion) + - PI too long quads (knee extension) May related to flexibility +/- ability to generate force
Most Common type of bone fx that requires hospitalization in the US
Hip Fx Greatly increases mortality rates in older individuals
Partial Hip : Hip Resurfacing
Hip Resurfacing - socket (acetabulum) replaced - femur is spared BUT "resurfaced" with a hemispherical component via cement + short stem into femoral neck used in younger individuals with avascular necrosis
Additional CC 13.4 : Atypical Movement Combos
Hip flexion + Knee extension or Hip extension + knee flexion physiologic consequences opposite of movements are very different hip + knee ext or hip + knee flexion (describe earlier) the biarticular rectus femoris - shorten a great distance - at relatively high velocity = in order to simultaneously flex hip + extend knee. AI too short biarticular PI due to opposing biarticular Based on the length-tension + force-velocity = rectus femoris is not able to develop maximal knee extensor force. function : Consider the action of kicking a ball. Elastic energy = stored in the stretched rectus femoris by the preparatory movement of combined hip extension and knee flexion. The action of kicking the ball involves a rapid and near full contraction of the rectus femoris to simultaneously flex the hip and extend the knee. goal of this action is to dissipate force in the rectus femoris as quickly as possible. vs. activities such as walking, jogging, or cycling use biarticular muscles in a manner that forces are developed more slowly and in a repetitive or cyclic fashion. In this way, muscles avoid repetitive cycles of storing and immediately releasing relatively large amounts of energy. More moderate levels of active and passive forces are cooperatively shared between muscles, thereby optimizing the metabolic efficiency of the movement.
Hip Fractures how do they occur why do they occur reread types of fx in doc (dont need to memorize)
How Do Hip Fractures Occur? Caused by (or result in?) a FALL in Elderly younger adults = high impact stress - car accidents , football , etc pathogenic fx = tumors , infection , etc
Most common direction of ankle sprain / injury (inversion or eversion?)... WHY ? Most Common Tendon to be sprained
Hyperinversion Plantar Flexion = Inversion (coupled due to axis) - least stable / most mobile position Anterior Talofibular (ATF) - lateral ligaments of talocrural joint
Talus Articulates with
I = Calcaneous A= Naviculum S= Tibia + Fibula
What is something you should do immediately after an ankle sprain to improve outcomes
ICE Quicker the ice application after injury, the better the results
ITB Syndrome cause exam (inc tests) treatment
IT Band Syndrome #2 cause of knee pain in runners (patellofemoral syndrome is #1) Repetitive stress = ITB sliding over lateral femoral epicondyle Clinical picture + Obers + Nobles may have minimal pain at rest but have a lot of pain after activity Clinical management modify intensity / frequency of workouts (ex. over doing it while training for marathon) -> increase distance OR speed OR days/week (one at a time) ITB stretch = difficult -> stretch quads + hamstrings -> Strengthen abd/ER
Club Foot
Idiopathic , neurological disorder, or as part of other congenial defects; Incidence - 1/1000 births; 2X more in boys; > 50% are bilateral; Treatment: Mobilization, stretching, serial casting, clubfoot shoes, and Denis-Browne splint
1st Mm Layer of the foot = Mm + Tendons how do you know it is injured (vs. deeper structures)
If you flex the toes = FDB contracts and there is pain then the issue is FDB not plantar fascia
Hanging on my Ys
Iliofemoral -(Y ligament of Bigalow) = anterior surface of the joint capsule. The ligament is shaped like and inverted "Y". It is triangular, strong, and blends with the capsule. The apex is attached to the anterior inferior iliac spine. Distally it divides into 2 bands: 1) to lower part of intertrochanteric line, 2) to upper part of intertrochanteric line; between the 2 bands the capsule is thinner. Limits hip extension and abduction = allows you to lean back on you leg even
Strongest / Stiffest of Hip Joint Ligaments attachments limits ___________ WHY is this important
Iliofemoral Ligament (Y Ligament) = Hanging on my Ys. - someone without function in their legs can lean against these tendons Attachments: 1) AIIS 2) Intertrochanteric line Limits: 1) Hip Extension = "spiral motion" 2) Abduction
Hanging on My Y's explain this concept Which Ligament What motions would fully stretch this ligament
Iliofemoral Ligament (Y Ligament) hip extension = stretches iliofemoral + anterior capsule When a person stands with the hip fully extended, the anterior surface of the femoral head presses firmly against the iliofemoral ligament and superimposed iliopsoas muscle. From a position of standing, passive tension in these structures forms an important stabilizing force that resists further hip extension. (read description under picture) A person with paraplegia may rely on the passive tension in an elongated and taut iliofemoral ligament to assist with standing = Hanging on my Ys
Arthrology of the Hip : - 3 main ligaments - what does each limit - when is each the tightest
Iliofemoral/Y-Ligament: ilium to femur, tightens in hip extension -->Hanging on my Ys Pubofemoral: pubis to femur tightens in hip extension and abduction Ischiofemoral: ischium to femur tightens in hip extension and external rotation the joint position(s) in which the various ligaments of the hip become the tightest? See above, tightening indicates limiting those movements as well 🡪ALL = tight in extension= limits extension
Transverse /Midtarsal Joint = Compensates forefoot in reaction to position of the hind foot explain Read text: Special Focus 14-3 & 14-5; Figures 14-32 & 14-33; pgs 590-599 .
In WB Postion (ie during loading response & midstance) pronation at hindfoot = absorption of forces. - If pronation continued distally through the rest of the foot, the lateral border of the foot would tend to lift from the ground = decreased stability = midtarsal joint =movement of the midfoot/ forefoot in the opposite direction of talus and calcaneus. = compensatory supination hindfoot = absorbs forces of the ground + rotation of the lower limb via pronation, + mid-tarsal joint maintains normal weight-bearing forces on the forefoot via supination,. = maintain appropriate contact of the forefoot ... even beyond compensatory movement, if the demands of uneven terrain require it. Pronation of Hindfoot = "Unlocks" Midfoot/Forefoot = allowing for this compsenatory supination ... once hindfoot starts to supinate = limits supination of midtarsal joint hindfoot supination occurs when foot is required to serve as a rigid lever (last half of stance phase & at initial contact). hindfoot supinates forefoot/midfoot = pronates = maintians stability + visa versa
Benefits of Active Gait
Increased caloric expenditure and may lead to loss of weight Better loading of knee, hip, and back with less jarring from ground reaction in all areas More "shapely" legs??? Faster gait Less eccentric load and less likely to have tendonitis or fasciitis problems Less forces on central ligaments of foot Painful foot population improve 2-4 weeks faster with active gait in program than without active gait in program
Anterior Cruciate Ligament (ACL) From / To Function compensated by which muscles
Inferior : anterior intercondylar area on tibial plateau - blends w/ anterior extremity of lateral meniscus -passes superior, posterior and lateral to posterior Superior : medial surface of lateral condyle of femur . Function: Limits : - hyperextension - anterior movement of tibia with respect to femur - posterior movement of femur with respect to tibia - medial rotation of tibia ?????????? compensated by hamstrings
Gerdys Tubercle
Insertion: IT band
Tibial Torsion Abnormalities relate to femoral torsion
Internal torsion (potentially toed-in) vs. excessive external torsion (potentially toed-out) can be caused by excessive anteversion / retroversion of femur (see pic) .... Tibia turns in opposite direction
Midfoot Joints what are they function
Intertarsal joints : navicular, cuboid, & cuneiforms gliding movements = allow the forefoot to react to position/movement of the hindfoot.
Describe Knee Joint Stability
Intrinsically unstable arrangement. body weight is supported apposed ends of two long bones = No specific joint socket (ex acetabulum) However joint is stabilized by: - 2-3 fold expansion of weight bearing surfaces of the femur and tibia (ie broader than shafts of bones) - strong collateral ligaments - aponeurosis and tendons - strong joint capsule - intra-articular ligaments. = Static Stabilizers vs. Muscles = Dynamic Stabilizers
Most common direction of ankle sprain / injury + WHY? Most Common Tendon Injured
Inversion Plantar Flexion = Inversion (coupled due to axis) = least stable / most mobile position Anterior Talofibular (ATF) - lateral ligaments of talocrural joint
Rearfoot OKC more motion in inversion or eversion?
Inversion (2/3 of total)
ATF stressed via
Inversion = bc is lateral + Plantar flexion = Because is Anterior
Most Common Type of Ankle Sprain (what %) what % seen by GP / ER
Inversion = lateral ligaments 85% of total 50% seen High Reinjury Rate
Calcaneal = Hindfoot varus vs. valgus
Inversion = varus - supination / high arches Eversion = valgus - pronation / flat foot
Foot Position for Calcaneofibular Sprain
Inversion while Dorsiflexed
Foot Position for ATFL Sprain
Inversion while Plantarflexed
Neurological Irritation vs. Lesion/pathology
Irritation = HOT without loss of function Pathology = loss of function , sensation , etc
Lumbar Spine Radicular Issues which levels refer pain to the hip
L2-L3 refer to the hip joint and the upper thigh area PA compression would be irritated if segment is irritated This patient is without irritation upper lumbar No neural signs and symptoms
Ankle Sprain Rx (4 keys)
Isometrics - early and often Progress to isotonics when isometrics are pain free Ankle taping - does not replace rehab Balance training - Vital !
Compare Knee Extensions vs. Squats in terms of Mm Targeted - based on amount of hypertrophy
Knee Extensions = Targets Rectus Femoris (increases size) vs. Squats = Targets VL + VM Probably because RF = 2 joint mm
Obturator Nerve Injury muscles affected actions affected + compensations
L2-4 enters thigh as anterior and posterior divisions through superior part of obturator foramen. Motor: adductor muscles except hamstring part of adductor magnus (sciatic), the gracilis which adducts thigh and helps flex the leg and the obturator externus, a lateral rotator of the thigh. o Sensory: small cutaneous field on medial thigh and branches to the hip and knee joints.
Femoral Nerve Injury muscles affected actions affected + compensations
L2-L4 enters thigh deep to inguinal ligament. This nerve is not very vulnerable to injury. = gunshot wounds Motor: quadriceps femoris (1 joint - vastus lateralis, vastus Intermedius, vastus medialis longus, and vastus medialis obliquus; 2 joint muscles rectus femoris and sartorius) are paralyzed. Also iliacus and a portion of pectineus. The knee cannot be extended = compensated for using adductors. = One can still flex the hip using the psoas supplied by lumbar plexus . Sensory: loss of knee jerk reflex (L2-L3) / Patellar Tendon + loss of sensation over medial thigh (ant cutaneous branches of femoral), leg, and foot (branches from saphenous nerve), and lateral thigh by LFC.
Dermatomes of the Leg describe them
L3: medial side of knee and superior L4: medial malleolus (instep) L5: great toe (metatarsal pads and great toe) S1: small toe and lateral malleolus S2: proximal Achilles' tendon
Medial Plantar N roots + from which larger nerve motor + cutaneous
L4+5 from Tibial N arises deep to origin of abductor hallucis supplies (1LAFF): - 1st lumbrical - Abductor Hallicus - Flexor Digitorum Brevis - Flexor Hallucis Brevis + Cutaneous (Shown/other Set)
Common Fibular (Peroneal) Nerve Describe Pathway , Branches , etc
L4-S2 bifurcates from Sciatic N at apex of popliteal fossa. - Gets into the leg by curving around the neck of fibula. *At this point, the nerve is very vulnerable to injury* *Bifurcates between peroneus longus and neck of fibula = superficial + deep peroneal Nn. Superficial peroneal: more lateral - Descends along anterior intermuscular septum = motor branches to peroneus longus and brevis = cutaneous branches to the inferior part of the ant/lat leg; (Lateral Sural Cutaneous) 2/3 the way down leg = turns cutaneous - pierces deep fascia divides into : medial + intermediate dorsal brs. = Distal 1/3 of leg and dorsum of toes except: - web space between toes 1+2 - nail beds (supplied by plantar ns from tibial) - lateral aspect of 5th toe / foot = Femoral?? Deep peroneal N: = more medial - arises between the fibularis longus and the neck of the fibula + enters the anterior compartment - descends lateral to the anterior tibial A (between tibialis anterior and extensor digitorum longus Mm) -supplies: tibialis ant., ext. dig. Longus, extensor hallucis longus, peroneus tertius, and articular branches to the tibiofibular syndesmosis and ankle joint. *Bifurcates at inferior border of the inferior extensor retinaculum* ,Medial br: travels lateral to dorsalis pedis A, divides into 2 dorsal digital branches that supply cutaneous innervation to adjacent sides of 1st and 2nd digits Lateral Br: supplies the extensor digitorum brevis and joints of foot
Leg Length Discrepancy
LLE •Commonly found at odd times in life and living •Obvious structural change in levels and scoliosis from stand to sit Anomalous L5 segment or other low lumbar •(fusion of transverse processes) L6, hemi-vertebra, spina-bifida occulta, etc. Cause deviations which can lead to unequal weight
FAI or Labrum differential dx
Labrum / CAM Pain with IR, adduction, flexion •Worse with rotational activities •Can improve then worsen •Not uncommon to persist for long periods •Better with distraction •Worse with compression or Scour Test •Better with distraction + worse with WB - can be caused by FAI CAM FAI Pincer? Overgrowth of the acetabulum Causes increased pressure from femoral rotation and end range activities Can lead to strain on labrum and possible tear Hard to diagnose: Cross-over sign with X-ray Sometimes negative with MRI (lots of false -) Sharp anterior pain with endrange flexion, IR or ADD (or combinations of these) Lateral or post pain with ER Pain with stair climbing or prolonged sitting Athletes: pain with squats or with lateral & cutting movements Most common in hockey, but also golfers, dancers, football players, soccer players, and even cross country runners CAM may be caused by slipped capital epiphysis, premature closure of the plates, or physical activity at too young an age Pincer may be caused by acetabular retro-ante-version, other
Possible Causes of Patellofemoral Syndrome
Last 30 degrees = trains VMO + Articularis Genu Pronation - work on excessive pronation forces VMO-adductor relationship - share fibers with adductor = femoral + obturator N Tight posterior muscles - quads have to work harder against tight posterior Mm = will tire out faster causing increasing forces on the patella ... stretch hamstrings Weak gluteus maximus = most proven? Tight IT band - stretch quads + hamstrings
Which is More Mobile : Medial or Lateral Meniscus
Lateral bc no attachement to LCL vs. Medial = attached to MCL
Which is More Mobile : Medial or Lateral Meniscus why might this be?
Lateral bc no attachement to LCL vs. Medial = attached to MCL
Chronic Ankle Instability: Lateral Ankle Sprains and the Potential for Chronic Ankle Instability which muscles help limit this
Lateral ankle or "inversion" sprains = most common injuries in sports Real Time Ankle Sprain Data via EMG - enhanced + prolonged EMG response from tibialis anterior and fibular longus suggests these muscles may naturally help protect the ankle by reflexively decelerating and thus limiting the extremes of damaging movements. activation of the tibialis anterior could limit the extremes of plantar flexion but may contribute to excessive inversion. may cause injury to: - anterior talofibular + calcaneofibular ligaments. (most often) also often involve injury to the deltoid ligament and a compression or shear-based bony bruising between the talus and medial malleolus This concurrent trauma to the medial side of the ankle may explain why some severe "inversion" sprains show swelling on both medial + lateral sides of foot 30% and 70% of ppl who experience an isolated inversion sprain requiring medical intervention will later experience multiple ankle sprains to the same foot, chronic pain, and generalized joint instability greater risk for developing ankle osteoarthritis. Mechanical characteristics : - excessive anterior laxity of the talus relative to the mortise - decreased posterior slid = reduced dorsiflexion Functional characteristics - chronic pain - weakness, - subjective feelings of the ankle "giving away," -reduced balance, - altered sense of ankle joint positon or proprioception. pathogenesis of CAI involves diminished sensation = decreased proprioception = cant generate an effective and timely defensive muscular response to protect the ankle, CAI enter the stance phase with their subtalar joint inverted = delay in activating fibularis mms muscles, or a combination thereof. 76 Both of these It remains uncertain, however, whether the postural unsteadiness or lack of muscular control often associated with CAI is the cause or the effect of repeated ankle sprains. special focus of PT = single-limb support. regarding the effectiveness of proprioception exercises in reducing the recurrence rate of ankle sprains. 144
Tibial Nerve Injury causes muscles affected movements affected compensations
Leaves popliteal fossa deep to gastrocnemius and soleus. The tibial nerve is pretty well protected in popliteal fossa, so it is rarely injured. If cut, all muscles of posterior compartment of leg and sole of foot are paralyzed. In thigh, the tibial N supplies hamstring muscles: semitendinosus, semimembranosus, biceps femoris long head, hamstring portion of adductor magnus. In leg: gastrocnemius, soleus, plantaris, popliteus, tibialis posterior, flexor digitorum longus, flexor hallucis longus, muscles of sole of foot. IF Cut = would lose hamstrings and posterior compartment leg muscles = plantar flexor + some inverters = Foot would remain Dorsiflexed (except weight of foot would allow it to fall when not planted on the ground??? = no ability to push off in step) Sensory: loss of sensation on sole of foot.
Superficial Structures of Popliteal Fossa
Lesser saphenous vein = pierces cural fascia posteriorly to drain into popliteal vein Medial sural cutaneous nerve—A branch of the tibial nerve that runs with the small saphenous vein superficial to gastrocnemius. Lateral sural cutaneous nerve—A branch of the common peroneal nerve. It usually joins with the medial sural nerve to form the sural nerve which supplies skin on posterior midline of the leg.
Ligamentization Process of ACL graft
Ligamentization process ● Graft is avascular, tissue begins to die (strongest when first put in) ● Revascularization occurs at 5-6 weeks - weakens graft ● Appropriate stress result in fibroblastic activity Ligamentization = Graft strengthens
Femoroacetabular Impingement (FAI) Rehab
Limit ABd + Rotation 10-21 days + Full Flexion (4 weeks) depends on surgeons and on procedures performed get it moving to start remodeling bone FWB to PWB (4-8 wks MF) Hip immobilizer (limit ABD/Rot 10-21 days CR) Night boots early on to protect rotation (10-21 days) Limited hip flexion (4 weeks) to minimize hip flex tendonitis •12-16 wks return to full competition
Phases of Bone Fracture Healing compare long bones vs. Squamous
Long Bones (heal outside-in) Early repair phase = 0-4 weeks •Intermediate repair phase fibrocart. callous = 4-8 weeks •Late repair phase = minerals deposit 8-12 weeks •Remodeling (up to 6 months) vs. squamous bones = heal similar to skin (inside-out) strong bone = 3-4 weeks
Individual Attachments to Medial Meniscus
MCL Semimembranosis
Maximizing internal torque of Knee EXTENSION what angles / range
Maximal knee extension (internal) torque = @ 45- 70 degrees of knee flexion (ie limited near extremes) ... shape may change based on speed of motion This high-torque potential of the quadriceps within this arc of motion is used during many functional activities that incorporate femoral-on-tibial kinematics, such as ascending a high step, rising from a chair, or holding a partial squat position while participating in sports, such as basketball or speed skating. Note the rapid decline in internal torque potential as the knee angle approaches full extension...range matches external torque produced during femoral on tibial extension (see graph 2 slides previous) There is a general biomechanical match in the internal torque potential of the quadriceps and the external torques applied against the quadriceps during the last approximately 45 to 70 degrees of complete femoral-on-tibial knee extension. This match accounts, in part, for the popularity of "closed-kinematic chain" exercises that focus on applying resistance to the quadriceps while the upright person moves the body through this arc of femoral-on-tibial knee extension.
ACL tear mechanism of injury how to diagnose (tests , etc)
Mechanism of Injury Change of direction (70% of all injuries are non-contact) - Hyperextension - Blow to the knee females > males Audible pop? Rapid/immediate effusion (hemiarthrosis) + Lachman + Pivot shift / jerk (recommend surgery consult)
Which is Larger : Medial or Lateral Meniscus
Medial
tibial plateau compare medial vs. lateral plateau
Medial = 50% larger articular surface (vs. lateral)
Trick to naming the Ligaments of the Ankle
Medial = Deltoid = Tibio ________ vs. Lateral = Talocrural = _________ Fibular
MCL Injuries
Medial Collateral Ligament Injuries ● Valgus and External rotation ○ Ex: push off right leg; cut left ● Often associated with medial meniscus Clinical picture ● Medial knee pain ● Perceived knee instability ● + Valgus test Clinical management ● MCL - excellent healing potential ○ Even grade III (more likely to do surgery but may not because of healing potential) ● Conservative care (non-operative) ● Note: multi-ligamentous injuries ○ Will repair MCL Clinical management points of emphasis ● Avoid full flexion and extension early ○ Puts tension on MCL ● Quad strength ● Abduct/ER strengthening ○ Similar to PFS in class ○ To avoid medial collapse ● Proprioception/balance ● Caution with frontal plane stress (cutting) for up to 6 weeks
Medial vs. Lateral Condyles of Femur compare their locations + explain
Medial Condyle is longer distally Allows the 2 condyles to be at essentially level distally despite the angle of inclination of the femur (pic) If angle of inclination of the hip is normal = slight Genu Valgus (normal) vs. Lateral projects more anteriorly = to prevent lateral movement of patella
Arches of the foot name them are supported primarily by healthy arch vs. flat footed
Medial Longitudinal Lateral Longitudinal Transverse arches supported by the shape & arrangement of the bones, ligaments & thick fascia in the sole of the foot, and muscles. particular importance = plantar fascia. vs. Muscles play a minimal part in maintenance of the shape of a NORMAL foot... little to no mm activity BUT However, a great deal of muscle activity is found in a person with flattened arch.
Joggers Foot
Medial Plantar Nerve Compression
Deltoid ligaments of the foot are found on the
Medial Side
Which meniscus at the knee is torn most often whay in what position
Medial bc lager and directly connected to MCL forceful rotation on a flexed & WB knee.
Meniscofemoral ligaments what are they function
Meniscofemoral ligaments serve as the only bony attachment of the posterior horn of the lateral meniscus = helps stabilize lateral meniscus during movement = anterior or posterior meniscofemoral ligaments, named relative to position to PCL THUS medial meniscus attaches to MCL lateral meniscus attaches meniscofemoral ligaments (not LCL)
Meniscus Injuries at knee mechanism of injury how do you test for this
Meniscus Pathology ● Medial > lateral--medial is more intimate with the MCL Weight bearing with a twist / Change of direction Clinical picture ● Swelling? ● Popping, clicking, joint locking, giving way ● Very sharp pain at joint line Diagnosis Apley's compression/distraction Steinmans McMurray Thessaly <- Best?
Patellofemoral Joint Type of Joint Articulating parts Function Movements Allowed
Modified plane synovial joint Articulation : - posterior surface of patella - + intercondylar region of the femur (trochlear groove) Function : increase the mechanical advantage of the quadriceps - by increases its internal moment arm Actions : Knee Flexion = patella glides inferiorly Knee Extension = patella glides superiorly How : The line of pull of the quadriceps is in line with the femur while the patellar tendon attachment at the tibial tuberosity exerts tension in line with the tibia. Therefore there is a lateral pull on the patella. ??
Distal (only) foot pain common pathologies
Mortons Neuroma Medial plantar N.
Partial Hip : Bipolar Prosthesis
Most common = Bipolar Prosthesis replaces femoral head/neck = metallic shaft and a metallic acetabular cup with an interposed polyethylene liner - acetabulum left intact
Understand how, in a weightbearing (closed chain) position, the transverse tarsal AND tarsometatarsal joints "compensate" the midfoot & forefoot in reaction to position of the hindfoot". (see previous) Does this "compensation" work equally well for pronation AND supination?
NO bc Supination "locks" foot into more stable position to create a solid base of support to push off from
Posterior Cruciate Ligaments (PCL) From / To Function compensated by which muscles
Name stronger and shorter than anterior Inferior: posterior intercondylar area of tibia + medial corner of lateral meniscus - Passes anterior, superior, and medially to lateral surface Superior : medial femoral condyle. Function: Limits: - posterior movement of tibia with respect to femur - anterior movement of femur with respect to tibia - lateral rotation of the tibia compensated by quads
Cruciate Ligaments of the Knee how are they named describe their function are they found within joint capsule +/or synovial membrane?
Named by their attachment sites to tibia. - anterior = attached to tibia anteriorly - posterior = attached to tibia posteriorly Function: ACL limits: - Anterior movement of tibia to femur (or posterior movement of the femur on the tibia) - medial rotation of the Tibia vs. PCL limits: - posterior movement of tibia to femur (or anterior movement of the femur on the tibia) - lateral rotation of Tibia (look at name = prevents opposite movement + look at orientation = prevents opposite rotation) Both ligaments : intracapsular but extrasynovial.
Heel Spurs
Natural + common Manifestation of Stress Through Soft Tissue on a Bone (50% + ppl have them based on xrays) usually found IN tendon, not pushing down on tendon can present identically in painful + nonpainful foot = dont jump to the conclusion that it is the issue •Not usually pushing on tissue ... found IN tendon Not usually the cause of injury / pain ... might be secondary to pain
Tensor Fascia Latae (TFL)
O : Iliac crest just posterior to ASIS (where your hands would be in your pockets ) IT BAND I: Lateral tibial condyle = Gerdys Tubercle
ASIS : what attaches here
O : Sartorious Inguinal Ligament
Meniscus Injuries Operate or Not? If you operate do you remove or repair?? - how might this relate to an athlete
Non-operative ● Increased success rate for degenerative tears ○ No joint locking ○ No ROM restrictions ○ Education ○ Aerobics: pool, bike, walk ○ Strengthening: quad, hip core ○ Proprioception, balance Partial Meniscectomy VS repair LOCATION IS KEY - Outer ⅓ meniscus is vascular - can heal - can do a meniscus repair Partial meniscectomy treatment ● Rehab is symptom limited ● RTP - 1 week ● Increase risk of ACL injury and osteoarthritis? Meniscal repair - Protective period ● Limited WB: 2-6 weeks ● Limited ROM - Full ROM: 4-8 weeks ● Greatest risk of retear is loaded flexion Meniscus repair - Progression ● Mostly symptom limited ● No running before 3-4 months (Based off function, not time) ● RTP - Not before 6 months ○ Removal - 1 week ○ Repair - 6 months
Alpha Angle of Hip what is it normal range increased alpha is a possible sign of ____________
Normal alpha angle is 55 to 60 degrees or less. Increased alpha angles suggest cam impingement alpha angle is not pathognomonic of symptomatic cam impingement, only suggestive.
Plantar Fasciitis Forbush opinion on dx what is a sign of TRUE PF
Not the same as heel pain , could have lots of other causes hurts with PROM of toes into full dorsiflexion (extension) = very superficial pain should not hurt with AROM/RROM (ie due to Mm)
Explain the screw-home mechanism at the knee (OKC vs. CKC) 3 factors related to biomechanics
OKC Locking knee in full extension = 10 degrees of ER - occurs during last 30 or so degrees of extension maximizes the overall contact area of the adult knee: = increases joint congruence and favors stability ---------------------------------------------------------- CKC When one rises up from a squat position, for example, the knee locks into extension as the femur internally rotates relative to the fixed tibia. Locking is natural motions Unlocking is done via the popliteus mm WHY DOES THIS OCCUR 1. the shape of the medial femoral condyle 2. passive tension in the anterior cruciate ligament, and the slight lateral pull of the quadriceps muscle 3. The most important (or at least obvious) factor is the shape of the medial femoral condyle. - articular surface curves about 30 degrees laterally, as it approaches the trochlear groove. Because the articular surface of the medial condyle extends farther anteriorly than the lateral condyle, the tibia is obliged to "follow" the laterally curved path into full tibial- on-femoral extension. During femoral-on-tibial extension, the femur follows a medially curved path on the tibia. In either case the result is external rotation of the knee at full extension
OKC vs. CKC Hindfoot vs. Midfoot vs. Forefoot generally how do they related to each other
OKC = All go the same direction - supination/pronation = @ TCJ + STJ ... midfoot + forefoot follow CKC = Midfoot / Forefoot (via TTJ) opposite direction as Hindfoot ... foot is loaded via hindfoot pronation = TTJ = supinates back in the other direction to bring medial longitudinal arch back into contact with floor for more even loading (dissipates force)
Some Groups of Individuals who will NOT heal from foot injuries + why
Obese individuals Too much weight and force to control eccentrically Break down is imminent for most of these patients Can't wear orthotics as they break down also Staying off feet complicates the condition Diabetes Slow Healing Times Particularly Problematic in the Foot Necrosis of the Sub-talar Joint Poor Circulation in General Numbness and Poor Feedback to Load and Stresses Smokers poor circulation (similar to diabetes)
Ligaments / Tendons : Posterior Knee name + function
Oblique Popliteal Ligament = expansion of Semimembranosus tendon reinforces posteromedial aspect of capsule Arcuate Popliteal Ligament head of fibula upward and posterior over tendon of popliteus muscle - reinforces posterolateral capsule Hamstring Tendons - posterior on medial & lateral side Heads of the Gastroc posterior on medial & lateral side Diamond of Control
Arthritis in the Hip types (4) + describe each
Osteoarthritis degenerative joint disease (DJD) / "wear-and-tear" localized to the joint itself = NO systemic manifestations causes young adults (below 50) = due to hip malformation in childhood - doesn't show up until later (65+), Weight, Trauma, and/or Overuse Rheumatoid Arthritis autoimmune disease that attacks articular cartilage. may affect any joint in the body = systemic Traumatic Arthritis After a severe fracture of the pelvis or a dislocation of the hip, the joint surface cartilage may suffer damage Causes: ○ Direct trauma ○ Loss of joint congruity ○ Vascular deficiency leading to pain and stiffness = can lead to osteonecrosis conditions Osteonecrosis (not a true arthritis) Avascular necrosis of the femoral head = bone dies + collapses. The process can be quite painful. changes shape of femoral head = creates incongruency + stiffness
#1 Causes of Hip Implant Failure causes how has this changed over time
Osteolysis - eating away of bone = immune response to loose bodies caused by rubbing of implants causing bone degradation overtime Many orthopedic surgeons identify osteolysis as the number one cause of hip implant failure. New Ceramic Components help hope to reduce this
Causes of Weak Bones how to prevent this
Osteoporosis. -> Hip fractures = serious -> treatment for osteoporosis = measured by % of hip fx Vitamin D deficiency = supplement with vit D + calcium = reduce hip fx 43% Homocysteine = toxic 'natural' amino acid = Reduced by B-vitamins Take vitamin B + D = reduce risk of hip fractures!! stress fx , tumors , infections , cancers , etc
Recovering from ACL repair overall considerations for graft healing compare types of grafts when can you return to play
Overall Protect graft early = Avoid resisted quads Full extension ROM early!! lack of full extension ROM = OA ○ Can't manipulate later ○ Mobilize in the first 7-10 days to achieve full extension (anterior glide) Gradually restore strength ○ Knee ○ Hip ○ Core ○ Gastroc ○ Electrical stim ● Proprioception ● Plyometrics (proper landing) ● Functional return Return to play (RTP) ○ Full ROM ○ Strength - 80-85% R-L diff ○ No effusion ● Functional ○ Hop tests (variety exist) ○ Sport/work replication activities = 5-6 months Patellar tendon autograft Mid 1/3 of patellar tendon ○ Patella baja ○ Anterior knee pain ○ Patellar fracture Emphasize patellar mobility slowly strengthen quads Return to play (RTP) - 5-6 months Hamstring graft ● Protect hamstring - 4-6 weeks ● NO hamstring isotonics Allograft = Time frames for progression a bit slower
Which is Stronger ACL or PCL
PCL
PCL from / to limits compensated by which Mm??? + why is this important
PCL: Limits: OKC = posterior movement of tibia on femur CKC = anterior movement of femur on tibia L-M orientation = IR of femur / ER of tibia Intracapsular but Extrasynovial Compensated by Quads
Patellofemoral pain syndrome
PFPS = associated with overuse injuries Exact Cause is Unknown diffuse prepatellar or retropatellar pain wi insidious onse aggravated by squatting or climbing stairs, or sitting with knees flexed for a prolonged period of time Excessive stress typically results from abnormal movement (tracking) and alignment of the patella with the trochlear groove· Complicating these pathomechanics is the strong relationship between the kinematics and kinetics of the patellofemoral joint with those of other joints of the lower extremity, especially in a weight-bearing situation.
Hip Labral Tears causes sign & symptoms exam treatment
PT cannot fix a labral tear , only guide rehab = do not treat if they don't have surgery... you can teach them how to avoid pain/issues but you cannot fix this Causes •Activities requiring repetitive hip flexion or rotation •Hockey, soccer, football, ballet, running •Structural labral abnormalities with pathology in many disorders: •Femoroacetabular impingement (FAI) •Perthes' disease •Slipped capital epiphysis PT CANNOT FIX LABRAL TEAR ... only guide rehab Signs & Symptoms •Pain with activity + at end range / some specific range •Typically gradual onset but occasionally after trauma •Injury mechanics: excessive hip External Rotation •Combination of dull and sharp groin pain with movement •Worse with activity, walking, prolonged sitting •Catching or painful clicking in ~50% •Anterior hip pain especially with flexion and IR •Catching primarily with hip rotation Exam •May demonstrate Trendelenberg gait •Positive impingement (90°flex, add, IR) = pain in groin •Improve with intra-articular injection •Radiographs: mild DJD, or associated condition such as developmental dysplasia of hip, FAI, or acetabular ante/retroversion •MRA most reliable study •90% sensitivity 100% specificity treatment = do not treat if they don't have surgery... you can teach them how to avoid pain/issues but you cannot fix this Hip arthroscopy with debridement: •Rehab: (2 to 4 weeks) •Limited ROM early •WBAT •Gait retraining •Post-op strengthening •Functional progression Labral repair: •Repair site must be protected during early healing phase •Protected WBing 2-6 weeks •Avoid extremes of hip flex and ER for 4-6 weeks
Adductor Strain
Painful with PROM ABd (or end ROM flex/extension) Pain with RROM ADd Heals within 6 weeks with rest and reduced end range and resisted activity (already done) Mm scar tissue not until 3 weeks so not end range or weighted motion until at least 3 wks Causes •Repetitive kicking, quick starts or changes in direction •Each muscle with a different function •Must find individual muscle of injury to properly rehab •Pectineus: Flexor, extensor and very eccentric at ends of range •Brevis: Both flexor/extensor and adductor •Long: Pure adductor •Magnus, Gracilis: Many functions Signs and Symptoms •Aching groin •medial thigh pain (only if you can find it and its within Mm) - If its not in Mm may be avulsion fraction •May or may not report specific incident of injury (might be over time) •Pain with activity in earlier phases Chronic dull pain in more progressed cases Treatment Start with rest, ice, gentle ROM (no stretching to begin with) •Isolated strengthening open chain ex's - Bc its less load / easier to control •Closed chain "global" neuromuscular control and core stabilization activities •Increase resistance and intensity •Controlled motion to sport-specific drills
most commonly dislocated joint in females
Patella Almost always laterally
Explain how the patella provides a biomechanical benefit to the quads how quad function is impacted when the patella is removed
Patella = increases internal moment arm for Quads Removal of patella can cause decrease in quadriceps strength/torque of up to 25% or more.
What Stabilizes the Patella on the Knee (not Talking about Tendons / Ligaments ... see below)
Patella Stabilization: 1) the deep trochlear groove of the intercondylar area of the femur 2) the large lateral femoral condyle 3) compressive forces = holds patella close to trochlear groove = due to quadriceps contractions 4) vastus medialis obliquus (VMO) = prevents excessive lateral patellar movement. posterior surface of the patella = thick layer of articular cartilage. - necessary bc compressive forces between patella + femur can be 10 times body weight when the knee is flexed during weight bearing.
What is "the low back of the knee" how do you evaluate for this
Patellofemoral Syndrome Incidence ● 25% of the population ● Female:male = 3:2 ● Crepitus and pain will guide you ● Never "work through" patellofemoral crepitus EVALUATION ● Unique to PFS ● Diffuse ache ● Pain with stairs ● Grinding ● Giving way ○ Clicking--Meniscus ● Swelling [Inhibits strength of VMO--need to get rid of the swelling to strengthen the musculature]
Top 2 Causes of Knee Pain in Runners
Patellofemoral syndrome + ITB syndrome
Upper vs. Lower Limb structure = bones , joints ,etc function stability vs. mobility
Pectoral Girdle = Scapula + Clavicle - only connection to axial = SC joint - incomplete anteriorly (ie only supported by muscles) - very mobile but not very stable - function = put arm/hand in functional positions Pelvic Girdle = Hip bones + Sacrum + Coccyx - very strong connection to axial skeleton at Lumbosacral Joints - very well connected : = acetabulum = deep + holds femur well = strong ligamentous connections - very stable but not as mobile as upper extremity - Function = Locomotion + weight bearing
14.4 - pes cavus - abnormally raised medial longitudinal arch
Pes cavus = abnormally raised medial longitudinal arch + excessive rearfoot varus (inversion) Excessive forefoot valgus (eversion) may also be present, often as a compensation mechanism used to keep the medial forefoot firmly in contact with the ground The chronically raised arch: - reduces the area of contact between plantar surface of the foot + floor - shifts the center of plantar pressure laterally - places metatarsal bones at a greater angle with the ground. = why people with pes cavus may have pain and callous formation over the region of the metatarsal heads · A foot with chronically raised arch cannot optimally absorb the repeated impacts of walking and running Conservative management includes PT, stretching the tight mms, and using orthosis children = ponseti method - a series of 5-7 plantar casts applied to the relatively malleable clubfoot in the infant
Femoroacetabular Impingement (FAI) : Rehab name + describe the 5 phases
Phase I - Maximal Protection Phase Limited WB to protect osteotomy PROM Phase II - Controlled Ambulation Phase PROM/AROM Neuromuscular control ex's Stabilization of LE/pelvis Begin strengthening of ABD Phase III - Controlled Progression Phase Improve NM stabilization Begin sport-specific strengthening/endurance Intensify ADB strengthening Begin weight training Phase IV - Intensive Training Phase More intensive flexibility, coordination, agility, strength endurance Initiate sport-specific drills Phase V- Return to sports
Total Knee Rehab when should you try and regain full ROM when should you start a HEP
Phase I: Immediate Post Surgical Phase (Day 0-7)
FAI Crossover Sign describe it which type of FAI
Pincer = due to overgrowth of acetabulum malformation of the acetabulum = acetabular over-coverage resulting in impingement of a normal femoral head-neck junction on the acetabular rim
The ankle is Least Stable When ____________
Plantar Flexed
Loose-Packed Position of Talocrural Joint
Plantar Flexed limited more by anterior capsule good for joint mobilizations vs. bad for spraining ankle
Loose-Packed Position of Talocrural Joint common end feel
Plantar Flexed limited more by anterior capsule good for joint mobilizations vs. bad for spraining ankle
Talocrural Joint Primary Motion
Plantar Flexion + Dorsiflexion but is on a slightly oblique angle why -supination is down and in vs. - pronation is up and away
Which Ligament Supports the head of the Talus
Plantar calcaneonavicular (spring) ligament
Popliteus mm
Popliteus mm: internal rotator and flexor of the knee joint · As extended knee prepares to flex = popliteus = IR torque = mechanically unlock the knee (OKC = IR on Tibia vs. CKC = ER on Femur) · The popliteus mm oblique line of pull = most favorable leverage of all knee flexor mms for producing axial rotation on an extended knee · "key to the knee" dynamically stabilizes lateral + medial sides of the knee. provides significant resistance to varus load applied to the knee bc of its strong intracapsular tendon stabilizes medial side of the knee by decelerating and limiting excessive external rotation of the knee - via eccentric activation = reduces stress placed on the MCL , ACL + Post Cap. ... few other as well
Individual Attachments to Lateral Meniscus
Poplitieus M PCL
Femoroacetabular Impingement (FAI) : Examination What would you expect to see (inc. tests)
Positive "C" sign Significantly limited hip flexion and IR (combined) history of groin strains + impingement test wi groin pain at 90° flex and max IR + FABER Distance of lateral knee to table differs side to side, OR Elicits groin pain
Structures to exit the Greater Sciatic Foramen above Piriformis M
Superior Gluteal (A/V/N)
PCL Injuries
Posterior Cruciate Injury ● Relatively rare ● "dashboard" injury - must drive your tibia posteriorly ● Falls directly on anterior knee/patella ● Concomitant injury common (Due to significant force needed to strain a strong PCL) Clinical picture ● Perceived instability after event ● Increased pain - knee flexion at end range Diagnosis ● + Posterior drawer (make sure tibial tubercles are lined up) ● + Godfrey Clinical management - grade I & II ● Non-operative ● Emphasize quad strengthening ● Proprioception/balance ● Caution early with hamstring strengthening Clinical management - grade III ● If not functionally unstable ○ Conservative management ● If unstable - surgical reconstruction ○ Typically allograft Post surgical points of emphasis ● Progress ROM slowly ○ Limit full flexion ROM for 2-4 weeks ● Some advocate ROM be performed prone ○ Control effect of gravity on tibia Caution early with hamstring strengthening
Ankle Dorsiflexion - part of which motion - normal range
Pronation 0-20
Ankle/Foot Eversion - part of which motion - normal range
Pronation 0-20
Talocrural : Osteokinematics major motions plane of movement + axis of movement limited by __________ closed-packed position __________
Pronation & Supination = Dorsiflexion and Plantarflexion = major components + ABd / ADd = minor Plane of movement = close to sagittal vs. axis of movement = runs obliquely Both limited primarily by muscle and capsule/lig tightness rather than bone Closed packed position is full dorsiflexion
Name Each Joint of the Ankle Foot (3) Dr. Forbush's preferences when discussing motion at these joints
Pronation + Supination = CKC only = When describing three plane WB activities Inversion/eversion = STJ OKC Only - can be combined with dorsi / plantar ABd / ADd = forefoot only not with calcaneus or subtalar Dorsiflexion + Plantar Flexion = Mortise Only
Subtalor Joint : Osteokinematics explain the axis
Pronation / Supination via Eversion & Inversion (most) + Abduction & Adduction (some) + dorsiflexion + plantarflexion (minimal) LOOK AT THE AXIS Pictured VISUALIZE 2:1 ration Inversion to Eversion Arthrokinematics: optional independent study = very hard to define
Mm that stabilizes the FDL in the foot
Quadratus Plantae
Key to allowing Foot / Ankle to Heal
Reducing eccentric loads Transference from heel strike and eccentric stance to concentric push off as soon as possible -Assisted with forward lean -Assisted with great toe force and push -Assisted with G/S effort and PTT combined movements and activity Reduced eccentric moment reduces fascial, muscular, and tendon strain and allows better healing Painful foot population improve 2-4 weeks faster with active gait in program than without active gait in program
Total Knee Rehab considerations when planning for rehab
Rehabilitation ● Considerations: ○ What has been cut or altered? ○ How was the joint fixated? Cement/cementless ○ What other procedures were added? ○ What does the patient want to do? ○ What is the patient's condition at time of surgery? Active/inactive
Plica of the knee how do you treat pain here?
Remnant of formation of the capsule Can become thick, fibrotic, and painful (usually on medial side) Exercise end range knee extension (30-0) = focus on articularis genu
Lateral Plantar N roots + from which larger nerve motor + cutaneous
S1+2 from Tibial N arises deep to origin of abductor hallucis Before division -Quadratus plantae -Abductor digiti minimi Superficial branch - Flexor digiti minimi - 2 interossei mm of the 4th space Deep branch: - Adductor hallucis - Interossei Mm of spaces 1-3 - Lateral 3 lumbrical Mm + Cutaneous (shown/other set)
14.8 - biomechanics of raising up on toes
SECOND CLASS LEVER - axis @ MTP joints = HUGE MECHANICAL ADVANTAGE Performed by the plantar flexor mms · Maximally raising the body requires an interaction of two concurrent internal plantar flexion torques: - one at the talocrural joint + - one at the metatarsophalangeal joints · The plantar flexor mms, represented by the gastric, plantar flex the talocrural joint by rotating the calcaneous and talus within the mortise. · The primary torque used to raise the body, however, occurs through extension across the metatarsophalangeal joints · Acting about a medial-lateral axes of rotation at the toes, the gastric has an internal moment arm that greatly exceeds the external moment arm of BW. Such a large mechanical advantage is rare in the MSK system. Acting as a second-class lever with the pivot point at the metatarsophalangeal joints, the gastric lifts the body using mechanics similar to those of a person lifting a large load with a wheelbarrow
What laymen's term is typically used to describe "low leg pain", esp. in running athletes and can include conditions such as tendonitis, myositis, periostitis, or even mild compartment syndrome.
SHIN SPLINTS??
Innervation : Low Leg, Ankle + Foot Posterior general pathway
Sciatic : -Gluteal notch -Piriformis -Hamstring entry and exit Tibial nerve (sural branch) -Distal H/S -Upper Gastrocnemius -Deep muscle layer -Exit distal medial leg -Tarsal tunnel -Anterior medial heel -Sole of foot
Deep Structures of the Popliteal Fossa
Sciatic Nerve (BIFURCATION) Tibial nerve: deep to fascia at midline of fossa: genicular branches to knee joints medial sural cutaneous nerve, motor branches : to gastrocnemius and plantaris muscles. Common Fibular nerve : follows tendon of biceps femoris laterally genicular branches to knee joint lateral sural cutaneous nerve = distal to fossa travels around neck of femur + bifurcates into superficial and deep branches Popliteal V: formed by junction of anterior and posterior tibial Vv. Ascends through fossa and then through the adductor hiatus to become the femoral vein in adductor canal. Popliteal Artery: (continuation of femoral artery) continuation of the femoral artery after Adductor Hiatus. supplies : Adduct Magnus, Hamstrings , Gastroc , Soleus + Plantaris branches : genicular arteries (photo on on next slide) Ends by dividing into anterior and posterior tibial arteries (see blood supply set) Genicular arteries: wind around femur proximal to condyles Superior Genicular As. Medial: deep to adductor magnus Lateral: deep to tendon of biceps femoris tendon Middle genicular A: (small); arises opposite back of knee, pierces oblique popliteal ligament to supply ligaments and synovial membrane on interior of knee joint. Inferior genicular As. Arise inferior to knee joint deep to heads of gastrocnemius. Lateral: superior to head of fibula, deep to lateral head of gastroc Medial: descends along proximal margin of popliteus
FAI Signs + Symptoms
Signs & Symptoms Sharp anterior pain with endrange flexion, IR or ADD (or combinations of these) Lateral or post pain with ER Pain with stair climbing or prolonged sitting Athletes: pain with squats or with lateral & cutting movements Most common in hockey, but also golfers, dancers, football players, soccer players, and even cross country runners CAM may be caused by slipped capital epiphysis, premature closure of the plates, or physical activity at too young an age Pincer may be caused by acetabular retro-ante-version, other
Iliotibial Band/Troch Bursitis signs + symptoms examination (including tests) treatment
Signs and Symptoms Pain over greater trochanter radiating down lateral thigh Difficulty lying on involved side More common in middle-aged women More common in runners of younger population Usually on leg that is on the low side but occasionally is on the high side Exam Pain with direct compression of trochanteric bursa + Obers test (bc of pain) or Thomas Test Painful MMT of TFL Snapping can be elicited laying on affected side Hip brought from Flex/IR to Ext/ER Treatment •NSAIDs •Stretching of H/S, Quad, and ITB ß ITB attach to quad + hs so need to stretch them all •Rehab •IT band release if 6 mos of failed conservative Rx •Correction of structural abnormality (heel lift)
Affects of Diabetes on the Foot
Slow Healing Times bc of poor circulation ... end of chain Necrosis of the STJ Numbness = Poor Feedback to Load and Stresses
Iliopsoas Tendonitis
Snapping Hip (coxa saltans) - not common 3 Types 1.Intra-articular- loose bodies, labral defect, etc... 2.Internal - iliopsoas tendon moving over a bony prominence 3.External - IT band or glut max tendon snapping over greater trochanter Usual Cause •Iliopsoas tendon snapping over the iliopectineal eminence, femoral head, or lesser trochanter (during extension > flexion ... but seen in both) •May or may not be painful •Pain or discomfort with the snapping may be indicative of ilipsoas tendonitis Signs and Symptoms •Anterior groin pain with extending hip from flexed position •Intermittent catching, snapping, or popping of hip •Occasionally may present with associated LBP Treatment •NSAIDS •Rehab - More next if rehab fails •US guided injection with lidocaine and corticosteroid if s/s relieved with injection but return •Arthroscopic release at musculotendinous jct. or near the insertion on the lesser trochanter Rehab - Find cause of tendonitis (psoas (L) vs. Iliacus (R)
Gluteal injections - where should they be made + why?
Superlateral Quadrant = Avoid Sciatic Nerve + Inferior Gluteal N. these should always be made superior to a line extending from the posterior superior iliac spine to the superior border of the greater trochanter.
Talonavicular Joint : Ligaments
Spring ligament (Calcaneonavicular) = sustentaculum tali - navicular tuberosity supports head of talus
Describe relative forces for squats where knees pass toes
Squats with knees in front of toes = increase in : - peak ankle dorsiflexion - peak knee flexion angles + net joint movement = Increases patellofemoral joint (PFJ) reaction forces and thus Stress ... likely due to increase in net joint movement @ knee = max quads force
Apophysitis pathologies that commonly occur in the lower extremity : KNEE
Strong activation of the quadriceps muscle during running and jumping activities = too much force on patellar/quad tendon --> tension leads to hypertrophy of the tibial tuberosity, creating an obvious lump, just distal to the patella. = Osgood-Schlatter disease. especially during puberty
Main Joint of Inversion / Eversion
Subtalor
Lesser Saphenous Vein location/ pathway
Superficial Vein of Lateral Leg from: dorsal venous arch of the foot (lateral) + dorsal vein of 5th digit - posterior to lateral malleolus - ascends along mid calf to : pierces crural fascia + drains into popliteal vein
Greater Saphenous Vein
Superficial Vein of medial leg / thigh from : dorsal venous arch (medial side) + dorsal vein of great toe - anterior to medial malleolus (tibia) - posterior medial margin of tibia - posterior to medial condyle (@ popliteal) - medial thigh to : saphenous opening in fascia lata has communicating branches with deep veins
Superior Gluteal N Injury - which muscles - causes which action?
Supplies Gluteus Medius, Minimus + TFL All ABDUCT + Medially Rotate Trendelenburg gait: - during the Stance Phase of the gait cycle when one foot is off the ground, the gluteus medius of the the leg that is on the ground contracts to prevent the opposite hip from dropping. When the superior gluteal nerve (or gluteus medius directly) is injuried this does not occur causing the opposite hip to drop = Hip Drop and the close hip to raise up (relative to the dropping hip) Due to weak ABDUCTION When weak side is planted on the ground, opposite side drops and weak side "raises" IF weakness on both sides = = Waddling Gait = drop on both sides
Long Plantar Ligament
Supports - Calcaneocuboid Joint - Longitudinal Arch of Foot
location & function of knee bursae
Suprapatellar Prepatellar - between skin and bone Superficial & Deep Infrapatellar - anterior and posterior to patellar tendon pockets of swelling = bursa bc if it was tendinous, muscular , bony , etc the whole knee would likely be swollen
Femoroacetabular Impingement (FAI) Treatment
Surgical correction - typically arthroscopic + Correct bony abnormalities + Fix any labral injuries + Restore capsular integrity Reshaping (osteoplasty) of femur (cam FAI) •Femoral neck fracture possible; not likely •FWB allowed, but no twisting movements •Some advocate crutches x 4 weeks •Full bony remodeling takes 3 months, during which time high impact and torsional forces should be avoided •4-6 months before return to sports (= 3 months for healing + 2-3m to regain strength)
High Ankle Sprain
Syndesmosis injuries and Tib-Fib ligament injuries: •Caused by distraction of the fibula away from the tibia •If fibula does not break, the ligament of syndesmosis will tear •Any weight bearing or dorsiflexion of the ankle will cause worsening of the pain •Harder to heal as the tissues have lower blood supply and can develop osseous characteristics with healing •Also referred to as HIGH ANKLE SPRAIN
Coverage of Synovial Membrane in the Knee Joint
Synovial membrane: - lines articular capsule and reflects onto bones at edges of articular cartilage. Superiorly : extends to /lines suprapatellar bursa Inferiorly: separated from patellar ligament by fat pad. Posterior : invaginated forward to between femoral + tibial condyles. cruciate ligaments are inside of joint capsule but outside of the synovial cavity
Anterior Compartment of Low Leg Motions Origins + Insertions
TA , EHL, EDL + EDB 1. Dorsiflexion + Inversion = Tib Anterior (medial cuneiform / base of the 1st MT) 2. Extend great toe = distal phalanx = EHL 3. Extend rest of Toes only = extensor expansions - trace back to common bundle between + up = ED ------------------------------------------------------------- 4. Fibularis tertius - common bundle of ED to dorsal 5th MT 5. EHB = under Fib Tert
Importance of 2nd ray of foot
TMT joint is set back from others locked in = gives rigidity
Major vs. Minor Actions of: - Talocrural Joint vs. - Subtalar Joint - explain why this is the case
Talocrural Medial Malleolus = Anterior / Superior to Lateral thus axis = posterior/inferior - anterior/superior Close to Medial - Lateral = mostly Sagittal motions = Dorsiflexion + Plantarflexion but Some angulation towards vertical axis (@ ankle) = frontal plane motions = ABd/ADd (rotated 90 degrees naturally) --------------------------------------------------------- Subtalar (see pic) axis = basically 45 degrees from A-P vs. S-I = 42 degree upward angle A-P thus split motions A-P (@ ankle) ... rotation = Inversion + Eversion (rotated 90 degrees) + Vert (@ ankle) = ABd / ADd (frontal plane motions rotated 90 degrees)
What component movements make up pronation & supination what are the main contributions made by the ankle joints (x3)
Talocrural = Dorsi /Plantar Subtalar : Eversion & Inversion = major components = ABd + ADd Transverse Tarsal : = motion in all 3 planes 1. Adds to pronation/supination ROM in WB or NWB 2. Compensates the forefoot in reaction to position of the hindfoot. (Next Card)
Lateral Ligaments of the Ankle name them what do they support what do they prevent most injured?
Talocrural Ligaments 1. anterior talofibular ligament = Most Sprained 2. calcenofibular ligament 3. posterior talofibular ligament supports the talocrural joint laterally LIMITS INVERSION NOTE : Naming = ________Fibular
Main Joint of Dorsi/Plantar Flexion
Talorcrural
Calcaneous articulates with?
Talus + Cuboid not the naviculum
Position of Talus - why is this surprising
Talus is way out laterally and is held up by sustanticulum tali (outrigger for support)
Forefoot
Tarsometatarsal joints = 5 nonaxial, plane synovial joints; = function is primarily a continuation of mid-tarsal joint. Metatarsophalangeal joints (MTPs) = 5 biaxial condyloid joints. - flexion/extension + abduction/adduction. More extension than flexion compared to fingers, why?? An excessive amount of weight should not be placed on the first metatarsal head. In static standing, the ratio of weight distribution from heads 1-5 is 2:1:1:1:1. This varies greatly with gait with heads 2-4 generally taking more weight than 1 & 5. Interphalangeal: 1 IP, 4 PIP, 4 DIP; Uniaxial, hinge jts - flexion/extension. Function of toes: Smooth weight shift to opposite foot in gait Help maintain stability by pressing against ground both during static posture when necessary and in gait.
Avulsion Fracture
Tendon or ligament pulls bone away at site of attachment.
Femoral Version normal = too much = - how might you see it in foot too little = - how might you see it in foot
The angle typically created by a twisting (torsion) of the femoral shaft (from proximal to distal) normal : 15° (10-20°) of Anteversion Excessive Anteversion- greater than 20° = could lead to in-toeing (pigeon toed) Retroversion - less than 10° = could lead to out-toeing (duck foot) Pigeon Toe / Duck Foot = due to natural correction to realign the head of the femur / put it back in ideal position in acetabulum Craig's Test
Patellar Tracking name the forces acting on / driving the tracking of the patella (7)
The patella is kept in place by (and tracking is affected by): Intercondylar groove of the femur i large lateral femoral condyle The compressive forces between the patella and trochlear groove due to pull of quad & patellar tendons. Vastus Medialis (esp. VMO) prevents excessive lateral movement. · Vastus Lateralis that prevents excessive medial patellar movement. Iliopatellar Band - fibers connecting IT Band to lateral patella. Medial & Lateral Retinacular/Patellotibial Ligaments: anterior thickenings of capsule that extend from inferior border of patella distally to tibia on each side of patellar tendon.
CKC Pronation Describe motions at Tibia , Talus + Calcaneus
Tibia = IR > opp. of OKC Talus = Plantar Flexion + ADduction Calcaneous = Eversion -> same as OKC
Describe how the piriformis can cause neuropathic pain
The sciatic nerve usually exits the pelvis inferior to the pirifor- mis. As described earlier in this chapter, the sciatic nerve may passthrough the belly of the piriformis. A shortened, thickened, or"tight" piriformis may compress and irritate the sciatic nerve, acondition known as "piriformis syndrome."
1. Describe the general role of the Abs in stabilizing pelvis when the femur is being flexed (Figure 12-29)
The stabilizing role of the abdominal muscles is shown during a unilateral straight-leg raise. (A) With normal activation of the abdominal muscles (such as the rectus abdominis), the pelvis is stabilized and prevented from anterior tilting by the strong inferior pull of the hip flexor muscles. ... similar to how the serratus anterior prevents scapular winging at the shoulder = stabilizes anchor point (B) With reduced activation of the rectus abdominis, contraction of the hip flexor muscles causes a marked anterior tilt of the pelvis. Note the increase in lumbar lordosis that accompanies the anterior tilt of the pelvis. The reduced activation in the abdominal muscle is indicated by the lighter red.
Total Hip Replacement (THR) describe the parts
The stem, which fits into the femur The ball = replaces head of the femur The cup = replaces hip socket Each part comes in various sizes to accommodate various body sizes and types
Ligaments / Tendons : Medial Knee name attachments function
Tibial (Medial) Collateral Ligament (MCL) broad & flat from medial femoral epicondyle to tibia; deep part = attaches to the medial meniscus. - part of terrible triad LIMIT VALGUS FORCE
4th Mm Layer of the foot (deepest) = Mm + Tendons how do you know it is injured (vs. deeper layers)
Tib Posterior + Fibularis Longus tendon
Extra-articular Ligaments of Tibiofemoral joint
Tibial (Medial) Collateral Ligament (MCL) broad & flat from medial femoral epicondyle to tibia = attaches to the medial meniscus. Fibular (Lateral) Collateral Ligament (LCL) - round & thick from lateral femoral epicondyle to head of fibula no attachment to meniscus
CKC Supination Describe motions at Tibia , Talus + Calcaneus
Tibial = ER > opp. of OKC Talus = Dorsiflexion + ABduction Calcaneous = Inversion -> same as OKC
Tarsal Tunnel Syndrome causes signs/symptoms how do you treat it
Tibial N Irritation SWELLING + PAIN with motion of any TDvanH = numbness + irritability of foot after the tarsal tunnel Most often due to friction from NEW ill fitting shoes = RICE + change shoes
Tarsal Tunnel Syndrome structures involved signs/symptoms
Tibial Nerve Entrapment Tarsal tunnel = medial malleolus, calcaneous + flexor retinatuclum contains : T D van H - tib posterior - flexor digitorum longus - flexor hallicus longus heel pain results from compression of the tibial nerve by the flexor retinaculum.
Peripheral nerves innervating (sensory) knee joint (capsule/ligs). If a person has a medically-induced femoral nerve block in the femoral triangle, which region of the knee joint will be anesthetized by the femoral nerve block? Which thigh muscles will not function from the femoral nerve block? [pg 558-559 Neumann]
Tibial n (from sciatic) - post capsule + associated ligaments - most of the internal structures of the knee as far anterior as the infrapatellar fat pad. Obturator nerve = cutaneous over medial aspect of knee Femoral nerve = ant-medial and ant-lateral capsul Will Block : - Anterior Femoral Cutaneous N. = anterior thigh + - Saphenous (inc. infrapatellar braches) - Anterior + Medial Knee (inc capsule , etc) - Medial Low Leg - Quads , Sartorious + Pectineus vs. Would NOT Block : - Iliopsoas Mm - Lateral Knee ( lateral sural cutaneous N. )
Describe how "external rotation of the knee" is different than "external rotation of the femur".
Tibial-on-femoral (knee) rotation =KNEE MUST BE FLEXED the femur is stationary direction of the knee rotation (internal or external) is the same as the motion of the tibia VS. (B) Femoral-on-tibial rotation. tibia is stationary and the femur is rotating (over a partially flexed knee). The direction of the knee ER or IR = is opposite of the motion of femur - external rotation of the knee occurs by internal rotation of the femur + - internal rotation of the knee occurs by external rotation of the femur.
Mm that stabilize the Navicular
Tibialis Anterior + Tibialis Posterior
Transverse Arch of the foot Mm Support
Tibialis Posterior Fibularis longus
Navicular Tubercle attachment for
Tibialis Posterior near Calcaneonavicular (spring) ligament attachment?
Tibiofemoral Joint type of joint movements allowed general structure
Tibiofemoral Joint Modified hinge joint: = movement is primarily flexion/extension, but a small amount of rotation occurs Articular surfaces: Tibial condyles: slightly concave to flat (covered in hyaline cartilage) vs. Femoral condyles: convex (covered in hyaline cartilage) - separated posteriorly by deep intercondylar notch - anteriorly the condyles fuse to form the patellar surface of femur. Largest joint in the body
Inversion Sprain Prognosis Based on Ligaments Damaged
Traditional injuries of lateral ligaments: ● Anterior talo-fibular ligament is a capsular ligament without much definition ○ Torn easily and heals well without much loss of function ○ Occurs with plantar flexed ankle at time of injury ● Calcaneofibular ligament is a more structured ligament ○ Injury usually occurs if ankle is dorsiflexed ○ Ligament becomes vertical and is prime limiter in this position ○ More often leads to proprioceptive loss and some instability after healing ● Posterior talo-fibular ligament is a prime restrictor to talar translation ○ Interruption of this ligament causes severe instability ○ Almost always will require surgical intervention if torn
Arches of the foot what is the major form of support (as per Forbush)
Transverse = BOW wi Mm support Mm support is key to arches (not just ligamentous) - if a foot loses Mm = FLAT feet / no arches
Inferior Gluteal N Injury which muscles which motions compensation
Travels through the greater sciatic foramen inferior to piriformis: supplies gluteus maximus = extends the thigh and rotates thigh laterally. Seldom injured. Injury would result in paralysis of gluteus maximus m. "gluteus maximus gait" = you lean back when weak side is planted because you do not have the ability to keep you leg extended (straight up/down) Hanging on my Ys = Iliofemoral Ligament - limits extension + hip abduction so when hip extensors are weak you are able to lean back without falling over and then swing your leg through
Hip Capsular Laxity 2 types causes signs + symptoms treatment
Two Types Traumatic - acute dislocation causing stretching of the capsule - Fall on flexed hip/knee - Striking dashboard with knees Atraumatic - overuse or repetitive rotation with axial loading •Repetitive overload with axial loading •Factory workers working overhead and turning •Ball players with hitting and throwing •Pregnancy •People with generalized ligamentous laxity, acetabular dysplasia, labral pathology Signs and Symptoms •Painful and limited ROM (maybe not always limited) •Stretch of capsule (prone passive ext and ER) produces anterior hip pain •Stiffness, pain, flexion contracture of iliopsoas (if iliopsoas becomes dominant as stabilizer) Treatment •Traumatic dislocation •TTWB x 6 wks •Early A/PROM as tol with flex ≤ 90° and IR≤10° •Atraumatic instability •NSAIDS (you do not prescribe this , just ask them and find out if they already take at true antinflammatorys then that's it ... do not recommend bc high risk if they aren't used to it •Rehab - think shoulder instability = strengthen in limited ROM •If rehab unsuccessful - arthroscopy for capsular plication or labral repair
Pronation motion mobility? Affect on the Leg/Foot as a whole
Up + Away Dorsiflexion Abduction Eversion Flattens the arch creates a loose, mobile foot will functionally shorten the leg.
Strength of Deltoid Ligament?
VERY Strong Forces acting to open medial side of ankle may actually fracture off (avulse) the tibial malleolus before the deltoid ligament tears
Valgus vs. Varus stresses at knee what ligaments will be strained by each
Valgus = MCL + Medial Meinsicus + ACL? vs. Varus = LCL + Lateral Meniscus + PCL
Pelvic Drop: effect on: WB side LSpine muscles
WB hip ADduction + L-spine lateral flexion away from the drop (L-spine always towards higher leg)
When should you get imaging if you suspect a stress fx of the femur
Wait for 2 weeks wont show up for 2 weeks because wont be enough internal changes within the bone to be visible on the xray
Treatment of Patellofemoral Syndrome
Weak hip muscles = adduction/IR during gait ● Causes an increase in Q angle = Strengthen abductors/ER (Glut Max) Stretch - posterior muscles VMO training VMO Insufficiency ● Femoral nerve ● Obturator nerve ● Only dynamic medial constraint ● Specific strength via biofeedback? Taping - into optimal position ER - lateral structures slack Decrease effusion
Explain why hyper-inversion ankle sprains are far more common than hyper-eversion ankle sprains
When hyper-inversion occurs, the lateral ligaments are stretched/torn. = Anterior Talofibular = Most common The mechanics of the typical "sprained ankle" usually involve a component of excessive inversion. relative high frequency of inversion sprains can be partially explained by the slight inversion of the calcaneus at the instant the heel contacts the ground while walking, coupled with the inability of the medial malleolus to adequately block the medial side of the mortise.
Suprapatellar bursitis
abrasions or penetrating wounds may result in suprapatellar bursitis caused by bacteria entering the bursa from the torn skin. This infected bursa differs from acute bursitis because of the localized redness and enlarged popliteal and inguinal lymph nodes. The infection may spread to the knee joint.
What is true of most post surgical hip rehab
You want alot of motion early just not FWB and avoid ER , ABd + end ranges
Piriformis syndrome
a pain in the buttock that results from compression of the sciatic nerve by the piriformis muscle Persons in sports that require excessive use of the gluteal muscles and women are more likely to develop this syndrome (ice & roller skaters, cyclists, mountain climbers). In 50% of cases, histories indicate trauma to the buttock associated with hypertrophy and spasm of the piriformis muscle.
Groin pull
a strain, stretching, and probably some tearing of the proximal attachments of the anteromedial thigh muscles has occurred. Usually involves the flexor and adductor thigh muscles. -The proximal attachments of these muscles are in the inguinal region (groin), the junction of the thigh and trunk. Groin pulls usually occur in sports that require quick starts such as short-distance racing, base stealing in baseball, and quick starts in basketball, football, and soccer.
pronation of foot ... why is it good? too much?
absorbs / dissipates force during loading but excessive pronation = over stresses mm + fascia = collapses arches
Transverse Tarsal Joint aka two parts
aka Midtarsal Joint Divides hindfoot from midfoot. Combination of 2 joints: Talonavicular & Calcaneocuboid = form an S-shaped joint line across the foot. Talonavicular Joint: reinforced by calcaneonavicular (spring) ligament. (sustentaculum tali - navicular tuberosity) middle portion supports the head of the talus Spring ligament also supports longitudinal arch of the foot (will discuss later) Calcaneocuboid Joint: - support is via long and short plantar ligaments. - Long plantar ligament supports both calcaneocuboid joint as well as longitudinal arch of foot
Flat Footed aka due to ______ drop caused by ________ affects which ligament(s) + which arches
aka Pes Planus Talor Drop = Longitudinal Arches calcaneonavicular (spring) ligament
Flat Footed (aka Pes ________) due to ______ drop caused by ________ affects which ligament(s) + which arches
aka Pes Planus Talor Drop = Longitudinal Arches calcaneonavicular (spring) ligament
Primary Functions of the Transverse (/mid) TARSAL JOINT:
aka Transverse Tarsal Joint 1. Adds to pronation/supination ROM in WB or NWB 2. Compensates the forefoot in reaction to position of the hindfoot. Loading Response - hindfoot = pronates - to absorb shock + - Midfoot/forefoot = supinates - stabilizes foot Pronation of Hindfoot = "Unlocks" Midfoot/Forefoot = allowing for this compsenatory supination ... once hindfoot starts to supinate = limits supination of midtarsal joint hindfoot supination occurs when foot is required to serve as a rigid lever
Two Primary Functions of the Transverse (/mid) TARSAL JOINT:
aka Transverse Tarsal Joint 1. Adds to pronation/supination ROM in WB or NWB 2. Compensates the forefoot in reaction to position of the hindfoot. (Next Card)
Hip Joint aka type of joint main function
aka acetabulofemoral joint Attachement between LE and Pelvic Girdle synovial ball + socket = multiaxial -wider ROM -stability and weightbearing
Plantar calcaneonavicular ligament location function
aka spring ligament - thick band of fibers that connects sustentaculum tali to naviculum (plantar surface) supports head of talus forming part of an articular socket on dorsal surface for talocalcaneonavicular joint. supports the medial longitudinal + transverse arches of the foot
Adductor Canal - aka - borders - contents begins / ends
aka subsartorial canal starts :where femoral triangle ends (sartorius meets adductor longus) runs medial to vastus medialis in medial thigh (according to picture??) ends : Adductor Hiatus Contents: - Femoral A. term-1 - Femoral V. - Saphaneous N - N to Vastus Medialis (both branches of Femoral N.)
calcaneus inversion when does it occur
aka varus will naturally occur as you stand on your tip toes / push off during gait
Hallux Valgus aka
an abnormal enlargement of the joint at the base of the great toe (bunion)
Angle of Inclination define why is it important normal adult range + overall average
angle formed by the neck and shaft of the femur. Allows lower extremities to be parallel during standing. 120 - 140° normal range in adults; 125° avg Can be greater than 150° in infants = need a wider base of support when start walking
ACL function most common mechanism of injury
anterior displacement of tibia (on femur) + Prevents IR of tibia bc of its medial lateral orientation Mechanism of Injury Change of direction (70% of all injuries are non-contact) - Hyperextension - Blow to the knee females > males
ACL rupture most often caused by (be specific about knee position) special test
anterior force on a semi-flexed knee (loose packed) also seen with ER of hip / IR of tibia (landing awkwardly after jumping) results in Anterior drawer sign = Tibia slides anteriorly on the femur The ACL may tear away from the femur or tibia; however, tears commonly occur in the midportion of the ligament.
Subtalar Joint
articulation: Inferior talus and calcaneus Three articulations & two joint capsules - one capsule = posterior articulation - second capsule = middle + anterior articulations. Ligamentous support: Interosseous talocalcaneal ligaments from inferior talus to superior calcaneus. most lateral = cervical ligament + inferior retinaculum (sinus tarsi) + Deltoids + Lateral ankle ligaments = not a ton of support at this joint
Heel Spur Syndrome
associated with plantar fascitus
Calcaneal Tuberosity
attachment for calcaneal tendon (gastro + soleus)
Lines of Function of the Foot
function independently of each other Pink = Talus Functional Arm -1st , 2nd + 3rd rays -Motion at talus = motion @ pink Green = Cuboid functional arm -4th + 5th rays Motion at cuboid = motions @ greem
Talonavicular Joint (of transverse / mid tarsal joint) type of joint articulation between actions ligamentous support
ball-and-socket type articulation Mobility is expressed as a twisting and bending of the mid-foot and forefoot relative to the rearfoot Convex head of talus on concave navicular bone reinforced inferiorly = calcaneonavicular (spring) lig. l from the sustentaculum tali - medial naviculum = "floor and medial wall" of talonavicular joint Important bc BW depresses head of talus in a plantar and medial direction
Increase ROM of Dorsiflexion (OKC) what kind of glides do you want to do + why ?
bc having a hard time to pick stuff up off the ground Anterior - Posterior GLIDE bc will increase the space for anterior rolling keep knee bent to relax gastrocs (at least 30 degrees) will be opposite + opposite moving bone for CKC
Abnormal Patellar Tracking
best option : providing advice on ways to modify physical activities that create unnecessarily large stress on the patellofemoral joint . Ex: anterior knee pain - limit exercises or functional activities that demand large forces from the quads, especially when performed in higher degrees of flexion. - activities such as bending or squatting should be modified when possible in a way that partially shifts the muscular forces from the quads to the hip extensor mm conservative treatments: alter alignment of the tibiofemoral and patellofemoral joints = reduce the magnitude of the lateral bowstringing force of the patella o Strengthening of challenging the control over the hip abductor and external rotators mms o Trunk mms o Quads (particularly oblique fibers of vastus medialis) o Stretching tight periarticular connective tissues of the hip and knee o Mobilizing the patella o Using patella brace or using a foot orthosis to reduce excessive pronation of the foot o Patellar taping has been used in attempt to guide the patella's tracking, alter the mm activation pattern of the oblique fibers of the vastus medialis, or provide increased biofeedback from the region
Superior Tibofibular Joint between relative position in anatomical position type of joint movements
between: - lateral condyle of tibia - head of fibula lies lateral and slightly posterior in Anatomical Position = plane synovial joint movements = superior / inferior gliding
Superior Tibofibular Joint type of joint supporting structures
between: - lateral condyle of tibia - head of fibula lies lateral and slightly posterior in Anatomical Position = plane synovial joint movements = superior / inferior gliding FX/Dislocation = Common Fibular N issues
Femoral Neck Fractures key to recovery
blood supply - often cut off to fx area = high risk of not healing, especially when the fracture is badly displaced (↓ healing potential) many will be treated by a partial hip replacement
Lateral Ligaments of the Ankle name them what does each prevent
calcaneofibular = dorsiflexion + inversion Anterior Talofibular = plantarflexion + inversion Posterior Talofibular = dislocations + shearing double check this
Spring Ligament aka function
calcaneonavicular (spring) lig. l sustentaculum tali - medial naviculum = "floor and medial wall" of talonavicular joint Important bc BW depresses head of talus in a plantar and medial direction Supports Transverse Arch of Foot
Bony Composition of Femur what are the two types of bones what is the function of each
callcaneous (spongy) = absorbs shock - tends to be found along lines of stress cortical (compact) = resists shear + torsion
Femoral nerve (nerve block):
can be blocked with anesthetic during surgery - results in paresthesia (tingling, burning, tickling) that radiates to the knee and over the medial side of the leg if the saphenous nerve (terminal branch of femoral) is affected.
Increase ROM of Plantarflexion (OKC) what kind of glides do you want to do + why ?
cant stand up on toes Posterior - Anterior GLIDE bc will increase the space for posterior rolling will be opposite + opposite moving bone for CKC
pubic symphysis type of joint is it moveable?
cartilaginous yes it is movable
Iliotibial Band/Troch Bursitis : Causes
cause (External Snapping hip) Thickened IT band or gluteus maximus tendon snapping over the greater trochanter Repetitive friction b/w greater troch and ITB causes inflammation of the greater trochanteric bursa Pts often have spinal or other hip disorders causing gait alterations Common to have leg length discrepancy LLD prior to irritation (lifelong) •PAIN LATERALLY over Greater Trochanter
Pelvic Hike: effect on: WB Hip LSpine muscles
causes : WB hip ABduction + L-spine Lateral flexion towards the hike. (l-spine always towards higher leg)
Ottawa Ankle Rules
class : ■ there is bone tenderness at A, B, C, or D = shaded areas on this picture) ■ Inability to weight bear (4 steps) ■ Ankle or mid foot pain Ankle film if: -Bone tenderness at lateral malleolus -Bone tenderness at medial malleolus -Inability to to walk 4 steps after injury and in ER Foot films if: -Bone tenderness at base of 5th metatarsal -Bone tenderness at navicular bone -Inability to to walk 4 steps after injury and in ER
Ottawa Ankle Rules X-rays are only required if _____ (3)
class: ■ there is bone tenderness at A, B, C, or D ■ Inability to weight bear (4 steps) ■ Ankle or mid foot pain
Meniscal tears in the knee which is more common signs / symptoms - pain with medial vs. lateral rotation commonly paired with what other injurys prognosis of healing treatment
commonly involve medial meniscus. - lateral meniscus does not usually tear due to its mobility. Pain wi - ER = lateral meniscus - IR = medial meniscus Medial meniscus + MCL + ACL = terrible triad of knee Peripheral meniscal tears can often be repaired or will heal on their own because of the generous blood supply to the area. Meniscal tears that do not heal or cannot be repaired are usually removed (arthroscopic surgery). Knee joints from which the menisci have been removed suffer no loss of mobility; however, the tibial plateaus often undergo inflammatory reactions.
Meniscal tears
commonly involve medial meniscus. The lateral meniscus does not usually tear because of its mobility. Pain on lateral rotation of the tibia on the femur indicates injury of the lateral meniscus, whereas pain on medial rotation of the tibia on the femur indicates injury of the medial meniscus. Most meniscal tears occur when the tibial collateral ligament and/or the ACL is torn. Peripheral meniscal tears can often be repaired or will heal on their own because of the generous blood supply to the area. Meniscal tears that do not heal or cannot be repaired are usually removed (arthroscopic surgery). Knee joints from which the menisci have been removed suffer no loss of mobility; however, the tibial plateaus often undergo inflammatory reactions.
Head of Femur covered by ______________ with the exception of the _______
completely covered by articular (hyaline) cartilage with the exception of the fovea capitis femoris
Medial Plantar Nerve Compression where does it occur what is affected name?
compression as the nerve passes deep to the flexor retinaculum or curves deep to the abductor hallucis may cause aching, burning, numbness, and tingling (paresthesia) on the medial side of the sole and in the region of the navicular tuberosity. Medial plantar nerve compression may occur during repetitive eversion of the foot. Because of its frequency in runners, these symptoms have been called "jogger's foot."
Femoral Artery branches + pathways
continuation of External Iliac A from : inguinal ligament to : adductor hiatus = becomes popliteal artery Course: - femoral triangle - adductor (subsartorial canal) - adductor hiatus Supplies Anterior Compartment of thigh Branches: Deep Femoral Artery = supplies posterior + medial compartments of thigh Descending Genicular : knee anastomoses = medial side of knee just before adductor hiatus - 4 branches just inferior to inguinal ligament (lat - circumflex iliac - superficial epigstric - superficial external pudendal - deep external pudendal)
Sinus Tarsi
covered by interosseous talocalcaneal ligaments = of subtalor joint
Medial vs. Lateral Meniscus made of which is larger which is more mobile vascularized / innervated?? Function
crescent/wedge shaped fibrocartilage discs deepen the tibial plateaus Increase joint congruency absorbs shock / distributes compressive forces improve stability medial meniscus is larger Lateral is more mobile. Outer 1/3 to 1/4 is vascular & innervated = horns are vascular & innervated...rest is not. (so called "Red", "Pink", "White" zones)
Strengthening the Quads while limiting external torques on knee what exercises should you do / in what ranges to accomplish this
exercises that significantly challenge the quadriceps also stress the knee joint, patellofemoral joint, and periarticular connective tissues such as the ACL. = potentially damaging or therapeutic, depending upon any underlying pathologies (ex arthritis vs. elite Athlete) external torques are relatively large from - 90 to 45 flexion via femoral-on-tibial ext (squat) vs. - 45 to 0 flexion via tibial-on-femoral ext (seated ext) How to use this to reduce stress = Do motions only in the ranges with the lowest amounts of external torque + combine them to create a full ROM of Knee Extension do resisted tibial-on-femoral knee extension specifically between 90 and 45 degrees of flexion. + rising from a partial squat position, a motion that incorporates femoral-on-tibial extension between 45 and 0 degrees of flexion. = strengthen the quadriceps yet minimize the stress on the underlying patellofemoral joint
Tibial collateral ligament (MCL) Tear due to what type of force paired with what other injuries + why does this occur
damage is frequently caused by a blow to the lateral side of the knee. Injury to the medial meniscus results from the twisting strain on the knee when it is flexed. Because the meniscus is firmly adherent to the MCL, twisting strains of this ligament may tear and/or detach the medial meniscus from the fibrous capsule. This injury is common in athletes who twist their flexed knees while running (football, volleyball). The ACL may tear when the tibial collateral ligament ruptures. First, the tibial collateral ligament ruptures, opening the joint on the medial side and possibly tearing the medial meniscus and ACL. This "unhappy triad of injuries" can result from clipping in football.
How do retinactular tissues of the ankle differ from those at the wrist
differ from flexor retinaculum of wrist bc they are under constant irritation from shoes etc
Patellar dislocation:
dislocation is nearly always lateral and happens more often in women. It is counterbalanced by the medial, more horizontal pull of the vastus medialis
Osgood-Schlatter disease:
disruption of the epiphyseal (growth ) plate at tibial tuberosity which may cause inflammation of the tibial tuberosity and chronic recurring pain during adolescence, especially in young athletes. pulls tibial bone away via the patellar tendon (avulsion fracture)
Anterior tibialis strain (shin splints)
edema and pain in the area of the distal 2/3 of the tibia results from repetitive microtrauma of the tibialis anterior and small tears in the periosteum covering the body of the tibia. These commonly result from traumatic injury or athletic overexertion of muscles in the anterior compartment, especially the tibialis anterior, by untrained persons. Often persons who lead sedentary lives develop shin splints when they participate in walkathons. Shin splints also occur in trained runners who do not warm up and warm down sufficiently. Muscles in the anterior compartment swell from sudden overuse, and the edema and muscle-tendon inflammation reduce the blood-flow to the muscles. Shin splints are a mild form of the anterior compartment syndrome. The swollen muscles are painful and tender to pressure.
Talocrural (Ankle) Joint type of joint WB surface support structures
essentially a uniaxial hinge joint Tib/Fib form a mortise = weightbearing surface is tibia Support : Deltoid ligament (Medially) = Strong triangular bands medial malleolus to: - talus, calcaneus and navicular. = Supports the medial side of the ankle limits eversion Laterally: Anterior talofibular ligament Calcaneofibular ligament Posterior talofibular ligament all limit inversion ATF = weakest vs. PTF = strongest
Talocrural (Ankle) Joint type of joint weightbearing surface support
essentially a uniaxial hinge joint Tib/Fib form a mortise = weightbearing surface is tibia Support : Deltoid ligament (Medially) = Strong triangular bands medial malleolus to: - talus, calcaneus and navicular. = Supports the medial side of the ankle limits eversion Laterally: Anterior talofibular ligament Calcaneofibular ligament Posterior talofibular ligament all limit inversion ATF = weakest vs. PTF = strongest
CC 13.10 Case report: pathomechanics and treatment of severe genu recurvatum
excessive and fixed plantar flexed ankle can, over time predispose a person to genu recurvatum tibia must be tilted posteriorly = so that foot makes full contact with the ground may cause overstretching of the posterior structures of the knee = hyperextension deformity. greater hyperextension = external moment arm for BW makes deformity worse vicious cycles = allowing continuous stretching of the posterior structures of the knee, increased length of the external moment arm, greater extension external torque, and a continuous progression of the deformity Treatment: tennis shoes with "built up" heels provide excellent reduction in the severity of the genu recurvatum. raised heel = tilts tibia and knee anteriorly = reducing the length of the deforming external moment arm at the knee
toe in (pigeon toe) can be caused by _________ at the hip
excessive anteversion commonly seen in people with CP
Deep fibular nerve entrapment
excessive use of muscles supplied by the deep fibular nerve (skiing, running, dancing) may result in muscle injury and edema in the anterior compartment. This entrapment may cause compression of the deep fibular nerve and pain in the anterior compartment. Compression of the nerve by tight-fitting ski boots, for example, may occur where the nerve passes deep to the inferior extensor retinaculum and the extensor hallucis brevis. Pain occurs in the dorsum of the foot and radiates to the web space between the 1st and 2nd digits.
Common peroneal nerve Injury causes muscles affected movements affected compensations
exposed position = winds around the head of the fibula (just before bisecting) commonly injured in fractures of fibular head or from pressure from plaster casts or splints . Motor: Superficial peroneal nerve = peroneus longus and brevis—can't evert ankle. Deep peroneal nerve = tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius and extensor digitorum brevis. Lose dorsiflexion and toe extension. = The opposing muscles, plantar flexor, inverters of subtalar and transverse tarsal joints are unopposed and cause the foot to be plantar flexed (foot drop) and inverted. Sensory: = loss of sensation on anterior and lateral leg, dorsum of foot and toes, except for nail beds = distal phalanges
Deep Femoral Artery branches + pathway of each
femoral just inferior to inguinal ligament supplies posterior + medial compartments of thigh exits femoral triangle between pectineus + adductor longus runs deep to adductor longus = perforating branches branches: - medial circumflex = to head + neck of femur =*between iliopsoas + pectineus* - lateral circumflex = to head + neck of femur = *between sartorius + rectus femoris* +Lateral Descending Branch to knee = anastomoses - perforating branches (4) to adductor longus
distal tibiofibular joint location type of joint support
fibrous joint (syndesmosis) = no actual bony contact between fibula and tibia Crural tibiofibular interosseous lig = maintains proximity of Tib/Fib strongest and most important Anterior & Posterior Tibiofibular Ligaments "tib-fib sprain", aka: high ankle sprain) Interosseous membrane - supports both proximal distal tibiofibular joints.
Styloid process of the 5th metatarsal attachment for
fibularis brevis
Mm that stabilize the Transverse arch of the foot
fibularis longus + Tibialis Posterior
Hip Chondral Damage causes signs + symptoms treatment
flaking of Hyaline Cartilage = loose bodies (next) No direct blood supply , gets nutrition via synovial fluid from compression + from attached bone •Multiple traumatic /a traumatic etiologies: •Labral tears •Loose bodies •Dislocation •FAI •Avascular necrosis •Acetabular dysplasia •Previous slipped capital femoral epiphysis Signs and Symptoms: •Same as with loose bodies •Sometimes more irritation with weight bearing on osseous exposed area Treatment •Arthroscopic microfracture for appropriate lesions •Post-op rehab (surgeon typically will have protocol) •CPM (continuous passive motion) - not used anymore •TTWB x 6-8 wks FWB after 8 weeks You want them to move A LOT just NOT weightbearing •Ex's: regain motion to regain muscular endurance, regain power, strength, and agility •3 months: no twisting or impact activities •Perhaps another 1-3 months before RTSports •Return to sports typically 4-6 months post-op
Pes Planus
flat arched foot = Pronated (typically pronated hindfoot)
Popliteal cysts
fluid-filled herniations of the synovial membrane of the knee joint, or distensions of the gastrocnemius or semimembranosus bursa. A popliteal cyst is almost always a complication of chronic knee joint effusion. Synovial fluid may escape from the knee joint (synovial effusion) or a bursa around the knee and collect in the popliteal fossa. Here it forms a new synovial-lined sac or popliteal cyst (Baker's cyst). The cyst may communicate with the synovial cavity of the knee joint by a narrow stalk, which suggests that some cysts result from herniation of the synovial membrane Popliteal cysts are common in children but seldom cause symptoms. In adults, popliteal cysts can be large and may extend as far as the midcalf. In some cases, the cyst may interfere with knee movements.
Knee plica what are they / function
folds in synovial membrane Plicae may serve to reinforce the synovial membrane of the knee · 3 most common: suprapatellar plicae, inferior plicae, and medial plica (also called alar ligament, synovialis patellaris, and intra-articular medial band pathology occurs most often in the medial plica, = pain in anterior-medial region of the knee. Inflammation can cause patellar tendonitis, torn medial meniscus, or patellofemoral joint pain
14.5 - example of the kinematic versatility of the foot hindfoot vs. midfoot vs. forefoot = loaded vs unloaded
foot loaded of otherwise fixed to the ground = pronating rearfoot --> midfoot and forefoot regions, which are receiving firm upward counterforce from the floor = twist into relative supination foot is not under load of body: - pronation of the unloaded foot = summation of pronation at STJ + TTJ OKC = STJ + TTJ = Pronation + Supination ... about fixed TCJ vs. CKJ = Primarily TCJ + IR/ER of low leg ... about fixed foot
Hammer toes more commonly seen in pronation or supination?
fore commonly see in supination due to increased inclination of MTP
Fibular Artery pathway including branches
from : Posterior Tibial A. supplies the lateral compartment of the leg via perforating branches (does not directly enter compartment)
Ligamentum Teres from/to structure function
from : acetabeular notch (under transverse acetabular ligament) to : fovea capitis (on femoral head) is ensheathed in a synovial membrane -Provides Blood Supply to Head of Femur via foveal artery = branches of obturator artery* - provides some level of support to hip (unclear how much) (see separate slide)
Posterior meniscofemoral ligament to / from
from : posterior surface of lateral meniscus (superior and medial) to : the medial epicondyle of femur (just posterior to attachment of posterior cruciate)
Plantar aponeurosis ("plantar fascia") from / too
from tuberosity of calcaneus and ends in 5 slips that attach to skin over the heads of the 5 metatarsals and into flexor tendon sheaths.
Anterior Tibial Artery pathway including branches
from: Popliteal A. (at inferior border of popliteus M) - passes to anterior compartment at superior margin of interosseus membrane near neck of fibula. - Descends on anterior interosseus membrane accompanied by venae commitantes + deep fibular N. At Talocrural Joint = becomes Dorsalis Pedis A. Veins accompany the arteries listed above.
close packed joint position for the knee
fully extended knee
Hallux Valgus
genetics improper footwear excessive pronation valgus deformity at the 1st MTP (mostly due to excessive adduction at the tarsometatarsal joint) = exposes the metatarsal head; + osteophyte formation & arthritis of the 1st MTP results in bunion formation, pain, and loss of motion & function
Rotator Cuff of the Hip explain
gluteus medius / minimus Progression from tendonitis and edema to progressive tendon thickening, partial tearing and ultimately complete rupture at gluteal insertion
Ankle Sprain Rx : Crutches based on grade of injury what are you looking for overall??
grade I = 2-3 days grade II = 3-4 weeks grade III = surgery Use as guideline - When walk without a limp
Excessive Q Angle
greater than 20 degrees (normal 10-15) results in genu valgum (knock knee) Greater in females (bc wider hips) Excessive Q angle can result in excessive lateral patellar tracking due to increased lateral force on patella
Active vs. Passive Gait easy way to tell which is better + why
gripping toes = active active is better bc Passive = more time in eccentric - more strain on Mm tissue vs. Active = less time + "depth" of eccentric loading on Mm Forbush = Foot Stability is based on Mm not just ligaments
proximal tibiofibular joint location type of joint support
head of fibula + posterolateral aspect prox tibia. SYNOVIAL Surrounded by joint capsule (separate from knee joint) supported by: - anterior + posterior tibiofibular ligaments Interosseous membrane
Patella sit high during ________ vs. Low during _________
high = full extension low = flexion (gets pulled down)
Pes Cavus
high arched foot = Supinated (typically supinated hindfoot)
Why might an Inversion Sprain Occur How does the body naturally prevent this
hindfoot supination occurs when foot is required to serve as a rigid lever (last half of stance phase & at initial contact). If hindfoot becomes supinated and the mid & forefoot is unable to compensate, then the entire medial border of the foot may lift. If this happens, an inversion sprain of the lateral ligaments of the ankle will often result, unless the muscles/tendons on the lateral side of the foot are strong and well controlled Body naturally prevents this by allowing the midfoot + forefoot to supinate at the subtalar joint when the foot is loaded
Clinical Connections 13.4 : TYPICAL MOVEMENT COMBINATIONS: HIP-AND-KNEE EXTENSION OR HIP-AND-KNEE FLEXION
hip-and-knee extension or hip-and-knee flexion. = fundamental to walking, running, jumping, climbing. Hip-and-knee extension propels the body forward or upward. vs. hip-and-knee flexion advances lower limb or slowly lowers body towards the ground. controlled through a synergy of monoarticular and polyarticular muscles Fig. 13.43 (see attached) VL , VM + glut max monoarticular muscles = synergistic with biarticular semitendinosus + rectus femoris mm both concentrically contracting but vastus muscles overpower the contraction efforts of the semitendinosus. = tension stored in the forced lengthening of the semitendinosus across the knee is used to assist with active extension at the hip. Biarticular mm has to shorten a shorter distance and thus at a lower velocity due to the monoarticular mm overpowering it and preventing one of its motions slower velocity = relatively high force production per level of neural drive or effort. (force-velocity curve) + length-tension relationship, the internal resistance or force within a muscle increases as it is stretched. = passive force created within the stretched semitendinosus (across the extending knee).. by vastus ... recycled = helps to extend the hip acts as a traducer = transfers force ultimately produced by the contracting vastus muscles to the extending hip. ------------------------------------------------------------- THIS EX IS EASIER TO UNDERSTAND another example monoarticular gluteus maximus extends hip more strongly than RF can flex it = stretches the activated rectus femoris rectus femoris is the biarticular transducer transfers force from the gluteus maximus to knee extension. -------------------------------------------------------------- See Table 13.8 (next slides) for summary of relationships at hip/knee The functional interdependence among the hip-and-knee extensor muscles and among the hip-and-knee flexor muscles should be considered in evaluation of functional activities that require these active movement combinations. Consider, for example, the combined movements of hip-and-knee extension required to stand from a seated position. Weakness of the vastus muscle = indirectly cause difficulty in extending the hip and/or weakness of the gluteus maximus could indirectly cause difficulty in extending the knee. Strengthening programs may benefit by designing resistive challenges that incorporate this natural synergy between these muscles. Consider also someone with patellofemoral joint pain during active contraction of the quadriceps. = Encouraging this person to activate his or her hip extensor muscles to assist with knee extension may reduce the active demands placed on the quadriceps, thereby potentially lowering the compression forces placed on the patellofemoral joint.
Function of FHL in Normal Gait
hold up sustentaculum tali = not allow talus to fall medially with weight bearing between heel contact and mid-stance (pronation)
Function of Posterior Tib in Normal Gait
holds navicular in stable position and resist pronation (talus falling medially and anteriorly)
genu recurvatum
hyperextension of the knee
How low leg rotation & hindfoot motion are related
in WB (CKC) IR of tibia = pronation of hindfoot ...+ visa versa vs. ER of Tibia =supination of the hindfoot ...+ vica versa. = last half of stance & at the end of swing
Trochanteric bursitis
inflammation of the trochanteric bursae which often results from repetitive actions such as climbing stairs when carrying heavy objects or running on a steeply elevated treadmill. These movements involve the gluteus maximus and move the superior tendinous fibers repeatedly back and forth over the bursae of the greater trochanter. It causes deep diffuse pain in the lateral thigh region. This type of friction bursitis is characterized by point tenderness over the greater trochanter. The pain radiates along the iliotibial tract that extends from the iliac tubercle to the tibia. This thickening of the fascia lata receives tendinous reinforcements from the tensor of the fascia lata and the gluteus maximus. The pain from an inflamed trochanteric bursa, usually localized just posterior to the greater trochanter, can be elicited by manually resisting abduction and lateral rotation of the thigh while the person is lying on the unaffected side.
Navicular Tuberosity importance
insertion of tibialis posterior + tibonavicular ligament (deltoid)
PTF stressed via
inversion = bc is lateral + Dorsiflexion = bc is posterior
intertrochanteric fracture key to recovery
just below the femoral neck = No WB early more amenable to repair vs. femoral neck fractures - bc blood supply may not be compromised placement of a plate and screws to stabilize the fractures Because the bone blood flow is usually intact, these fractures can usually be repaired, and do not require the hip replacement procedure described previously
Extensor Lag of Knee describe condition + when/why it might occur treatment?
knee can be fully extended passively BUT AROM = Lacks last 15-20 degrees of extension. = quadricep weakness occurs during post-surgery rehab Mechanisms of injury - knee approaches terminal extension, the max internal torque potential of the quads is greatest ( not observed in people with normal quad strength) Swelling can physically impede full extension. + Increased intraarticular pressure can reflexively inhibit the neural activation of the quads muscle. PI of hamstrings in seated position can also limit extension Treatment - reduce swelling of the knee, therefore, can have an important role in a therapeutic exercise program of the knee
Excessive Genu Valgus range compresses which compartment of the knee?
knock kneed 15 + degrees of genu valgum compresses lateral compartment (of knee)
Peripheral N Sensory Testing in Leg describe which N + where to test
less commonly used than dermatomes bc damage to a nerve usually requires some sort of acute injury (fx , cut, etc) Medial leg - Saphenous nerve (medial cutaneous nerve) off of the femoral nerve complex (L2-L4) Lateral leg - Lateral sural cutaneous (superior), superficial fibular (central lateral leg and dorsal foot except 1st web space) Lateral foot - Sural nerve via lateral dorsal cutaneous branch of tibial nerve 1st web space - Deep fibular n. (L5)
Why are ROM of Hip IR / ER greatest when hip is flexed??
ligaments are relatively loose
Tibialis Posterior
loading : eccentric = slowing / controls pronation/eversion of calcaneous (overuse injuries) push off : concentric = main supinator Mm to lock in foot before you push off
Tibialis Posterior : role in gait
loading : eccentric = slowing / controls pronation/eversion of calcaneous (overuse injuries) push off : concentric = main supinator Mm to lock in foot before you push off
Femoral Acetabular Impingement (FAI) what is it 3 types
malformed hip joint = leads to breakdown of the intraarticular structures (labrum + articular cartilage) -> causing pain and associated dysfunction -> followed by premature osteoarthritis 3 types Cam abnormalities of femoral head (@ head-neck junction) - often seen with increase Alpha angle = cartilage and labral wear in acetabulum Pincer acetabular over-coverage, = impingement of femoral head/neck on acetabular rim Mixed both
Longitudinal Arches of the Foot are supported by what ligament(s)
medial : = calcaneonavicular (SPRING) ligament both : Short and long plantar ligaments
Deltoid Ligament where is it is it strong?
medial ankle VERY Strong Forces acting to open medial side of ankle may actually fracture off (avulse) the tibial malleolus before the deltoid ligament tears
Describe position of the Medial Condyle of the Femur how does this affect stability related to what measurement
medial condyle is located more distally = put WB directly under pelvis Q angle normal = 12-15 degrees
Deltoid Ligaments of the Ankle which side name them
medial side of foot
How do you differentiate between OA/RA in the foot
might have same visual presentation BUT RA = loose joints OA = extremely tight / rigid joints
Longitudinal Arch of the foot Mm support
mm support by 3 FHL = only active structure that controls sustentaculum tali Tibialis anterior Flexor Digitorum Longus
Dorsalis Pedis Artery pathway + branches
name the vessel and its pathway/branches - continuation of the Anterior Tibial A after the artery crosses the talocrural joint. (anterior to medial malleolus) - gives rise to - Arcuate A Dorsal metatarsal As (3) - Dorsal digital As - Deep plantar A: continuation of dorsalis pedis. = descends between 2 heads of origin of 1st dorsal interosseous muscle = to sole of foot = It anastomoses w/ the lateral plantar A to form plantar arch
Subtalar Joint Neutral Position why is this important functionally Question: Which muscle groups may, theoretically, serve to "decelerate" pronation via eccentric contraction b/c the location of their tendons seems to support the medial longitudinal arch?
neutral position subtalar joint neither pronated or supinated. = assumed that weight-bearing foot will be more efficient and less prone to injury if the subtalar joint's range of movement and function stays close to neutral, Some have questioned the actual existence of STJN. However, remains a common reference point that has been described repeatedly in the literature. We need to be able to identify subtalar malalignment so that Tibialis Posterior = Pure supinator - eccentrically limits/slows pronation during loading
Acetabular Fossa contents function?
non articulating surface = no hyaline cartilage allows space for the ligamentum teres, mobile fat pad + synovial membrane, and blood vessels. mobile fat fad = shock absorber "squish , squish"
Tibial Torsion normal vs. toe in / toe our
normal = external (lateral) torsion of 15-20° Internal torsion (potentially toed-in) vs. excessive external torsion (potentially toed-out)
Ischial bursitis
occurs from recurrent microtrauma from repeated stress (cycling) which overwhelms the ischial bursa's ability to dissipate applied stress. The recurrent trauma results in inflammation of the bursa (ischial bursitis); calcification in the bursa may occur with chronic bursitis.
Open vs. Closed Packed Positions of Hip
open = ER + slight flexion + ABd tight = IR + Extension + ADd
Arthrokinematics of Knee (Open vs Closed Chain) describe each including locking/unlocking
open chain = tibia crest on femoral condyles - moving concave - roll and slide = same direction + - "locking" via external rotation OF TIBIA (extension) -"unlocking" via internal rotation of TIBIA (flexion) vs. closed chain = femoral condyles on tibial crest - moving convex - roll + slide in opposite direction + - "locking" via internal rotation OF FEMUR (extension) ... standing up - "unlocking" via external rotation OF FEMUR (flexion) ... squatting / leg press
Forbush : When should an orthoses be used (2)
orthoses = splint used to stabilize something while it heals or when there is a LOSS of a structure
Most common type of arthritis
osteoarthritis (degenerative joint disease) - specifically of the knee
14.6 - the use of a foot orthosis for controlling excessive pronation
overuse injuries associated with excessive pronation - inflammation of the IT tract - patellofemoral pain syndrome - plantar fasciitis, stress fractures - achilles + patellar tendinopathy foot orthosis can reduce peak rearfoot pronation during walking, standing, and running by an average of about 2 degrees - reduces the demand on mms (such as the tibialis posterior) - optimizes the alignment of the bones and joints - produces a subtle change in the kinematic sequencing in the joints proximal to the foot - or simply provides physical support to the plantar medial aspect of the foot Greater "eccentric" control over the mms that decelerate pronation and other associated motions mechanically linked to pronation may reduce the rate of loading of tissues throughout the lower limb
Sciatica
pain along sensory distribution of sciatic nerve - posterior aspect of thigh, posterior and lateral sides of leg, and lateral foot. Can be caused by: - prolapse of an intervertebral disc - pressure of individual roots - pressure on sacral plexus - sciatic nerve by tumor
Patellofemoral syndrome
pain deep to the patella often results from excessive, especially downhill (runner's knee). The pain results from repetitive microtrauma caused by abnormal tracking of the patella with the patellar surface of the femur. The patellofemoral syndrome may also result from a direct blow to the patella and from osteoarthritis of the patellofemoral compartment (degenerative wear and tear of articular cartilages). Prepatellar bursitis: usually a friction bursitis caused by friction between the skin and the patella;
FAI pain is seen with which motions vs. which motions do you limit after surgery
pain with end range Flexion , IR + ADd (or combo) after surgery avoid : Limit ABd + Rotation 10-21 days + Full Flexion (4 weeks)
Jumpers Knee aka caused by intrinsic vs. extrinsic factors biomechanics of landing a jump
patellar tendinopathy chronic pain in the patellar tendon associated with explosive and repetitive jumping, like basketball and volleyball signs: - overuse and wear, = collagen disorganization and vascular proliferation. Typically involved tendons lack classic indicators associated with actual inflammation extrinsic factors - training intensity, playing surface, and footwear intrinsic factors - strength, endurance, flexibility, skill level, tendon elasticity, males gender, anthropometrics (BW and height), patellar hypermobility, and patellar alta. Large tendon forces associated with specific landing or jumping techniques as been also been associated forces up to 7 times BW biomechanics of landing from a jump. = dissipating the kinetic energy of landing form a jump 1. rate and magnitude of ankle dorsiflexion 2. eccentric activation of lower limb muscles particularly the quads and plantar flexors. limited ankle dorsiflexion (and stiff Achilles tendon) = reduce load absorption capability of the plantar flexor muscles = greater percentage of the total load absorption would shift to the quads mechanism. Athletes who developed patellar tendinopathy = on avg 5 degrees less ankle dorsiflexion than the group who did not develop this condition. Treatment - exercises that increase dorsiflexion of the ankle
Paralyzed quadriceps
patient cannot extend the leg against resistance and usually presses on the distal end of the thigh during walking to prevent inadvertent flexion of the knee joint.
which position do you put the ankle in for mobilization (at Talocrural Joint) vs. More Distally?
plantar flexed because is open packed position distal = dorsiflexed bc locks talocural ... prevents extra motion / stable base
Describe the compressive forces acting on the knee how does the patella protect from these?
posterior patella = thick layer of articular cartilage. compressive forces between the patella and femur : - 3-4 times body weight on stairs - 7-8 times body weight with deep squatting. due to: - combined pull of quads and patellar tendon increases compressive forces on patellofemoral joint ... especially if flexion occurs with weight bearing. with knee near extension: - If the pull of vastus lateralis is significantly greater than that of vastus medialis oblique = patella may be forced laterally out of the groove dislocation of the patella
Posterior Medial Talar Tuberosity attachment for
posterior tibotalar ligament
Housemaids Knee
prepatellar bursitis
Functions of the Acetabular Labrum
provides significant mechanical stability to the hip = "gripping" the femoral head + deepening the acetabular socket. maintains a negative intra-articular pressure. The resulting so-called "suction seal" has been shown to be more effective than the capsule at resisting the first 1-2 mm of joint distraction (separation). forms a seal around the joint = prevents leakage of synovial fluid - Maintaining the synovial fluid over weight-bearing surfaces enhances the lubrication of the articular cartilage and thereby reduces frictional resistance to movement - thin coating of synovial fluid over the articular surfaces helps mechanically dissipate contact stress
Function of Tibofibular Joints
proximal articular of ankle joint = allows that surface to be both stable and adjustable. Fibula = several muscles attached therefore must be relatively stable/fixed
2nd Mm Layer of the foot = Mm + Tendons how do you know it is injured (vs. deeper structures)
quadratus plantae controls FDL = they fire together FDL + FHL Tendons
Anterior dislocation of the hip joint
results from a violent injury that forces the hip into extension, abduction, and lateral rotation. In these cases, the femoral head is inferior to the acetabulum. Often, the acetabular margin fractures, producing a fracture-dislocation of the hip joint. When the femoral head dislocates, it usually carries the acetabular bone fragment and acetabular labrum with it.
Vastus medialis or lateralis weakness
results from arthritis or trauma of the knee joint; can result in abnormal patellar movement and loss of joint stability.
Anterior compartment syndrome
results from hemorrhage from the anterior tibial artery Compartmental pressure builds up within the anterior fascial compartment, compressing the deep fibular nerve in this compartment = person could not extend his toes or dorsiflex his foot. Severe compression of the tibialis anterior and deep fibular nerve also results in foot-drop and a stepping gait. Compression and hemorrhage of the anterior tibial also causes loss of the dorsalis pedis pulse because the dorsal artery of the foot is the terminal branch of the anterior tibial artery. The severe pain could be relieved by performing a fasciotomy, an incision through the anterior crural intermuscular septum to relieve the compartmental pressure.
Superior gluteal nerve injury:
results in a characteristic motor loss = weakened abduction of the thigh by the gluteus medius, a disabling gluteus medius limp, a compensatory lean of the body to the weakened gluteal side. The compensation occurs to place the center of gravity over the supporting lower limb and reduce the adduction moment. Medial rotation of the thigh is also severely impaired. When a person with paralysis of the superior gluteal nerve is asked to stand on one leg, the pelvis on the unsupported side descends, indicating that the gluteus medius on the supported side is weak or nonfunctional. This observation is referred to clinically as a positive Trendelenburg test.
toe out (duck foot) can be caused by _____________ at the hip
retroversion
Anterior (whole) pelvic tilt what plane causes pubic symphysis to move results in: hip _____ lumbar _____ +/- lumbar lordosis muscles
sagittal plane. Anterior tilt causes symphysis pubis to move inferiorly. Anterior tilt results: - hip flexion - lumbar extension = increasing normal lumbar lordosis. hip flexors and spine extensors
Posterior (whole) pelvic tilt what plane causes pubic symphysis to move results in: hip _____ lumbar _____ +/- lumbar lordosis muscles
sagittal plane. Posterior tilt causes symphysis pubis to move superiorly. Posterior tilt results in: - hip extension - lumbar flexion = decrease / flattening of normal lumbar lordosis rectus abdominis, internal obliques, glut max, & hamstrings
ACL rupture
severe force directed anteriorly with the knee semi-flexed may also tear the ACL. ACL ruptures, one of the most common knee injuries in skiing accidents, allow the tibia to slide anteriorly on the femur - the anterior drawer sign. The ACL may tear away from the femur or tibia; however, tears commonly occur in the midportion of the ligament.
Describe the Overall Shape + Orientation of the Femur - how does this affect strength + stability
shaft of the femur = slight anterior convexity = bows very slightly when subjected to the weight of the body. Consequently, stress along the bone is dissipated through: - compression along posterior shaft - tension along anterior shaft bowing allows the femur to bear a greater load than if it were perfectly straight. the shaft of the femur courses slightly medially = places the knees and feet closer to the midline of the body. ("corrects" for lateral distance created by neck)
Tendonitis of Medial Foot differential dx = what should hurt
should hurt with palpation + PROM + RROM
Saphenous nerve (cutting):
should the saphenous nerve be cut during a saphenous cutdown or caught by a ligature during closure of a surgical wound, the patient may complain of pain along the medial border of the foot.
Time to heal : Bone
squamous = 4 weeks long = 6-12 weeks Bigger bones take longer to heal
Function of Quadratus Plantae + Abductor Hallicus
stabilizes flexor tendons and distal digits in WB
Plantar fasciitis
straining and inflammation of the plantar aponeurosis may result from running and high-impact aerobics, especially when inappropriate footwear are worn. Pain is worst first thing in the morning The pain increases with passive dorsiflexion of the great toe. If a calcaneal spur (abnormal bony process) protrudes form the medial calcaneal tubercle, the plantar fasciitis may produce the "heel spur syndrome." Usually a bursa develops at the end of the spur that may also become inflamed and tender.
What do you do for a Plica Issue in the Knee
strengthen articularis genu
What do you do for IT band tightness
stretch hamstrings + quads bc they attach + ITB does not stretch well
how position of subtalar joint affect stability of the transverse tarsal joint
subtalar joint : - controls the position of the rearfoot - indirectly controls the stability of the more distal joints, especially the transverse tarsal joint Full supination at STJ = restricts the overall flexibility of the midfoot vs. Full pronation of the STJ = increases the overall flexibility of the midfoot ... allow for opposite actions to occur in WB to help balance the foot during stance phasse
Patella : Anatomy embedded in the
superior = Base Inferior = Apex embedded in capsule AND in quadriceps tendon Posteriorly: vertical ridge divides patella into two concavities: medial facet, lateral facet; another ridge medially results in the "odd" facet on the extreme medial border of the medial facet. Females tend to have a slightly greater Genu Valgus = may lead to more patella issues
Supination vs. Pronation : Mobility
supinated = locked + rigid pronated = floppy + mobile
Talocrural Arthrokinematics : OKC Dorsiflexion normally limited by (endfeel)
talus rolls anterior and slides posteriorly increase dorsiflexion = posterior translation of the talus Limited by : Achilles Tendon + Posterior Capsule
Talocrural Arthrokinematics : OKC Dorsiflexion thus how would you manipulate ankle to improve dorsiflexion most limited by
talus rolls anterior and slides posteriorly increase dorsiflexion = posterior translation of the talus Limited by : Achilles Tendon + Posterior Capsule
Talocrural Arthrokinematics : OKC Plantarflexion thus how would you manipulate ankle to improve plantarflexion most limited by
talus rolls posteriorly and slides anteriorly increase plantarflexion = anterior translation of the talus Limited by : Anterior Capsule + ATF (anterior talofibular ligament)
Talocrural Arthrokinematics : OKC Plantarflexion normally limited by (endfeel)
talus rolls posteriorly and slides anteriorly increase plantarflexion = anterior translation of the talus Limited by : Anterior Capsule + ATF (anterior talofibular ligament)
Forces at the Knee During Flexion
the more you flex the greater the forces on the knee
Common fibular nerve injury
the most injured nerve in the lower limb because it winds superficially around the fibular neck. - may be severed during fracture of the fibular neck - severely stretched when the knee joint is injured or dislocated. Severance of the common fibular nerve results in paralysis of all muscles in the anterior and lateral compartments of the leg (dorsiflexors of the ankle and evertors of the foot). The loss of dorsiflexion of the ankle causes foot-drop during gait. Compensation for this may include a high stepping ("steppage") gait, excessive hip to keep the toes from dragging on the ground. In addition, the foot comes down suddenly, producing a "foot slap". The person also experiences a variable loss of sensation on the anterolateral aspect of the leg and the
Tarsal Tunnel Syndrome (Tibial nerve entrapment)
the tibial nerve leaves the posterior compartment of the leg by passing deep to the flexor retinaculum in the interval between the medial malleolus and calcaneus. Entrapment and compression of the tibial nerve (tarsal tunnel syndrome) occurs when there is edema and tightness in the ankle involving the synovial sheaths of the tendons of muscles in the posterior compartment of the leg. The area involved is from the medial malleolus to the calcaneus, and the heel pain results from compression of the tibial nerve by the flexor retinaculum.
14.7 - adult acquired flatfoot deformity due to damage to which muscle / tendon results in ... think unopposed actions
tibialis posterior = very active during stance phase = inversion + plantarflexion (supination) = rapid changes - concentric = to push off - eccentric = to slow pronation during loading + support medial arch very susceptible to strains tendon rupture = collapse of medial longitudinal arch. = adult acquired flatfoot deformity (stages 1-4) - dropped navicular head = along with calcaneonavicular (spring) ligament trauma - eversion of the rearfoot - splaying of the forefoot into excessive abduction - Marked eversion and lateral instability of the mortise can also stress the tibial nerve within the tarsal tunnel, =neuropathy , weakness of intrinsic mms of the foot loss of the dominant inversion force at the rearfoot = eversion forces produced by the fibularis longus and brevis are left significantly unopposed = strong rearfoot eversion · The chronically and severely pronated foot never locks in late stance, which significantly reduces the stability needed during push off
Transverse Arch Support - transverse
transverse = tib posterior + fibularis longus
Layers of the Foot name layers + mm in each
trick for Mm layers 3 Mm 2Mm + 2 tendons 3 Mm 2Mm + 2 tendons Superficial layer Skin + plantar fascia Second layer Flexor digitorum brevis Abductor digiti minimi Abductor hallucis Third layer Quadratus plantae Flexor digitorum longus Flexor hallucis longus Fourth Layer Adductor hallucis (oblique and transverse) Flexor hallucis brevis Longitudinal ligament Fifth Layer (Deepest) Transverse ligament Interossei and lumbricales fibularis longus + posterior tibialis tendons
The KNEE joint how many articulations weak or strong ... explain
two joints within one joint capsule The bony articulation appears to be quite unstable BUT the joints are stabilized by strong ligaments, tendons, and a strong joint capsule. difficult to differentiate between which joint is injured based on symptoms because injury to one will cause pain , bruising , etc in the entire area
Acquired dislocation of the hip joint
uncommon because the articulation is so strong and stable. Dislocation may occur during an automobile accident when the hip is flexed, adducted, and medially rotated - the position of the lower limb when a person is seated in a car. Posterior dislocations are most common. A head-on collision that causes the knee to strike the dashboard may dislocate the hip when the femoral head is forced out of the acetabulum. The fibrous capsule ruptures inferiorly and posteriorly, allowing the femoral head to pass through the tear in the capsule and over the posterior margin of the acetabulum onto the lateral surface of the ilium, shortening and medially rotating the affected limb. Because of the close relationship of the sciatic nerve to the hip joint, it may be injured (stretched and/or compressed) during posterior dislocations or fracture-dislocations of the hip joint. This kind of injury may result in paralysis of the hamstrings and muscle distal to the knee and supplied by the sciatic nerve. Sensory changes may also occur in the skin over the posterolateral aspects of the leg and over much of the foot because of injury to sensory branches of the sciatic
Popliteus Action OKC vs. CKC
unlocks extended knee joint = to allow for flexion closed chain (weightbearing) - ER of femur vs. open chain - IR of tibia
Time to heal : Tendon
up to 12 weeks = poor blood supply + don't response well to stresses
Gout what causes it symptoms normally seen in the foot how do you treat it
urate crystal accumulation in joint - inflammation (5 signs) - intense pain Your body produces uric acid when it breaks down purines - found in naturally in our bodies + in certain foods, such as steak, organ meats and seafood. + alcoholic beverages, especially beer, and drinks sweetened with fruit sugar (fructose). Swelling + Redness 1st MTP Limited ROM 1st MTP Pain with ANY motion Other Joints in Body May Be Involved (thumb, elbows, etc) Avoidance Until the Body Decreases Inflammation Genetic = you have it for life
Prepatellar bursitis
usually a friction bursitis caused by friction between the skin and the patella; however, the bursa may be injured by compressive forces resulting from a direct blow or from falling on the flexed knee. If the inflammation is chronic, the bursa becomes distended with fluid and forms a swelling anterior to the knee. This condition has been called "housemaid's knee"; however, other people who work on their knees without knee pads, such as hardwood floor and rug installers, also develop prepatellar bursitis. Suprapatellar bursitis: abrasions
MCL of Knee - prevents ________ - how do you find it via palpation
valgus stress medial meniscus direct attachment RUNS PAST THE PES DISTALLY to medial border of tibia
Forefoot : varus vs. valgus - what does each cause at the hindfoot
varus = toes angled inward ... causes hindfoot (calcaneous) valgus vs. valgus = toes angled outward ... causes hindfoot (calcaneous) varus
LCL of Knee - prevents ________ - how do you find it via palpation
varus stress Is DEEP to IT band = put varus stress on it by having them cross their legs to find it
Pes Equinus
walking/standing on forefoot-toes (heel off ground)
Lateral Patellar Tracking is often due to ____________ -> think Mms / bony alignment
with knee near full extension MM if pull of vastus lateralis > VMO = can cause lateral subluxation / dislocation Alignment Coxa Varus --> Genu Valgus --> dislocation
14.1 ankle injury resulting from the extremes of dorsiflexion or plantar flexion
· Extreme and violent dorsiflexion of the ankle (leg over foot) can cause the mortise to "explode" outward, injuring several tissues - widening of the mortise - displacement of the fibula = ligaments of the distal tibiofibular joint + interosseus membrane = high ankle / syndesmotic sprain - mechanism of injury common to many high ankle sprains involves dorsiflexion + excessive abduction (external rotation) + version to the mortise · Highest ligamentous strains - anterior tibiofibular ligament + anterior fibers of the deltoid ligament · Because of the likelihood of trauma of multiple tissues, the recovery time following high ankle sprains often exceeds that required for the more common inversion sprain
Stress Fx of Femur (top side vs. bottom side) = very important causes how to dx how to rehab
•Caused by OVER (load, stress, strain, distance, time) Won't show for up to 2 weeks So don't take x-rays for t least 2 weeks bc they wont show up Causes •Amenorrhea in females •Low aerobic fitness when starting intensive exercise program •Smoking •Steroid use (corticosteroid) Signs and Symptoms •Exercise induced pain in the hip, groin, or thigh •Referred pain to the knee Rehab •Restore ROM/strength following pinning/rest •Correct any muscle imbalances that may have lead to abnormal stresses •Recommend modification of activities that may have lead to abnormal stresses •Insufficiency fractures require addressing the source of the insufficiency •Dietary, hormonal management
MSK Ankle Sprain Grade II including tests
•Moderate swelling •Possible eccymosis •Moderate point tenderness •Loss of function •Ant. Drawer - pos •Talor tilt - neg
Morton's Neuroma differential dx how do you rule it out
•More than one inter space involved •Involved in more areas than just the forefoot •Not a friction injury in this person •Most of their pain is in the heel not the forefoot •Common Only with Distal Pain Complaints •Tender Between Distal Metatarsals (2-4...1 only) •Easy to Reproduce with Pressure •Check for Inter-Metatarsal Mobility •Biomechanics of NWB to FWB in Forefoot
MSK Ankle Sprain Grade III including tests
•Severe swelling •Eccymosis •Major loss of function •Ant. Drawer - pos •Talor rock - pos
Sciatic Nerve Glide (sliders)
•Sliders can be defined as moving neural tissue in one direction, and at the same time slackening it at the other axis of movement - i.e., SLR with neck extension. The principle is to allow neural tissue to move without putting mechanical strain on it. •Sliders should be comfortable, pain-free movements. Treatments usually involve few repetitions, but done frequently - i.e., 10 times, every hour.
MSK Ankle Sprain Grade I including tests
•Slight/no swelling •Slight point tenderness •No loss of function •Ant. Drawer - neg •Talor tilt - neg
Nerve Tensioner
•Tensioners can be defined as moving neural tissue in one direction, and then at the same time move it in an opposite direction, thus putting some mechanical load/"stretch" to the system. Example - SLR with neck flexion. •Patients may feel a slight stretch at end-ROM. To avoid any ischemic reaction, these movements should "tease" the end-ROM, rather than produce a sustained stretch. •Fewer repetitions/sets per day will be needed •It is recommended to first use some "sliders" before tensioners, to "prime the nervous system." The same may be done following tensioners, to alleviate any ischemic reaction. •Slight tingling may be present, but numbness should be avoided.
Fibular Fractures commonly occur at __________ how do you dx this? / signs
•The weakest area is the one that fails •Typically in the malleolus or just superior to the malleolus •Avulsions of ligament can also occur •Decide on x-ray through Ottawa Ankle Rules and through manual testing Fracture •Point sensitivity •Vibration response •Stress on bone creates response •X-rays positive
Double Crush Syndrome what is it how do we treat it
•When a nerve is compressed or injured, the nerve has an increased excitability and will affect other tissues it contacts in the distal aspects of its course. These tissues will be enhanced in excitability in conjunction with the nerve and will further compress the nerve causing a secondary More Common in UE but possible in LE
24 Hour Activity Program
•Working 10 minutes stretch/hour •Working 10 minutes of strengthening/hour •Working 10 minutes of rocking/ hour •OUT OF EVERY WAKING HOUR AND WHEN WAKE FROM SLEEP
Rehab of Cemented vs. Cemenetless hip replacements
● Cementless hips: ○ Protected weight-bearing early ○ Use of walker for the first few weeks ○ Limited ROM for the first few weeks ● Cemented hips: ○ Immediate weight-bearing ○ Limitations in the range from incision early
Icing vs. Heating for Healing
● Icing: ○ Cools while on body ○ Reflex circulation for 2 to 3 hours to warm after the end of cooling ○ Blood flow THROUGH the area ● Heating: ○ Warms the area ○ Blood comes TO the area ○ Pooling of blood and protective response
Total knee arthroplasty (TKA) when to do it primary causes
● TKA is highly cost effective Primary pain complaint and functional limitation - Impairment in quality of life - Deformities in alignment or range - One compartment arthritic changes - Failed with non-operative treatment Osteoarthritis of Knee = Most common type of arthritis (10-13% over 60 years) - Obesity - Poor Biomechanics Other Reasons for Degeneration ● Rheumatoid Arthritis ● Psoriatic Arthritis ● Hemophilic Arthropathy ● Pseudogout: Calcium Pyrophosphate (CPPD) ● Gout ● Osteonecrosis (diabetes)
