KRS 420 Exam 4 Study Guide PDF

Pelvis/ Thigh Anatomy ● Bones ○ A total of seven bones form the pelvis ■ Two ischial ■ Two pubic ■ Two iliac bones form each half ■ Posterior border is formed by the sacrum ● Ligaments and Articulations ○ Pubic symphysis ○ Sacroiliac joint ■ Strongest ligaments ○ Coxofemoral joint (femoroacetabular...

Pelvis/ Thigh Anatomy ● Bones ○ A total of seven bones form the pelvis ■ Two ischial ■ Two pubic ■ Two iliac bones form each half ■ Posterior border is formed by the sacrum ● Ligaments and Articulations ○ Pubic symphysis ○ Sacroiliac joint ■ Strongest ligaments ○ Coxofemoral joint (femoroacetabular) ■ Iliofemoral ligament ● Reinforces the anterior joint capsule ● Anterior fibers: Hyperextension ● Superior fibers: Adduction ● Inferior fibers: Abduction ● Allows standing with minimal muscular effort ■ Pubofemoral ligament ● Abduction, hyperextension ■ Ischiofemoral ligament ● Extension, extreme flexion ■ Ligamentum teres (fovea centralis) ● Conduit for passage of artery ■ Inguinal ligament ○ Acetabular labrum ● Muscles ○ Anterior (Flexors) ■ Rectus femoris (2 heads) ● O: AIIS, sup acetabular ridge ● I: Quad tendon ■ Sartorius ● O: Asis to ● I: Pes anserine ■ Illiopsoas group ● Attach at lesser trochanter ● Iliacus, psoas major, psoas minor ○ Medial (Adductors) ■ Pectineus ● Flexion, adduction ■ Adductor magnus ● Extension and adduction ■ Gracilis- pes anserine ■ Adductor brevis ■ Adductor longus ○ Lateral (Abductors) ■ Gluteus ● Medius and minimus ● GT insertion ■ Gluteus maximus ● Ilium/sacrum to femur and ITB ■ Tensor fasciae latae ○ Hip External Rotators (deep hip) ■ Functionally intrinsic muscles ■ Piriformis ■ Quadratus femoris ■ Obturator internus and externus ■ Gemellus superior and inferior ● Femoral Triangle ○ Femoral nerve, artery and vein ● Neurovascular ○ Lumbar plexus (T12–L4) ■ Femoral nerve (L2-4) ■ Obturator nerve (L2-4) ○ Sacral plexus (L4–S4) ■ Sciatic nerve (L4-S3) ● Vascular ○ Medial femoral circumflex arteries ■ Most important for Femoral head ○ Lateral femoral circumflex arteries ■ Inferior femoral neck and trochanteric region ○ Obturator artery ■ Femoral head Clinical Examination ● Hx ○ Intra-articular ■ Not able to be pin-pointed, “c-sign” (i.e. labral damage) ○ Extra-articular ■ Pinpoint location (i.e. bursitis @ GT, rec. Fem. avulsion, etc.) ● Functional Assessment ○ Angle of torsion - angle of femoral condyles with the femoral neck ■ Normal ● ~ 15° (slight twisting inwards of femur) ■ Increased Anteversion - TOE IN ● ~ 45° (shaft of femur is twisting inwards too much) ● Toe points in to neutralize hip ( < ROM in ant. aspect) ■ Retroversion - TOE OUT ● ~ 0° (shaft of femur does NOT twist inwards) ● Toe points outwards to neutralize hip ( > ROM in ant. aspect) ○ Angle of Inclination - angle between femoral neck + shaft ■ Coxa Vara: ~110° (acute, bow-legged) ● Common in older people ● Femoral shaft goes inwards and inc. shear force @ fem. neck ■ Normal: ~130° ● Optimal angle to help with weight transfer/ distribution ● Age 5 AOI increases ~5° as weight bearing increase ■ Coxa Valga: ~140° (obtuse, knock-knee) ● Femoral shaft goes outwards and inc. shear force @ fem. neck ● Palpation ○ Medial: Gracilis, Adductor longus/ magnus/ brevis ○ Anterior: Pubic bone + symphysis, inguinal, ASIS, AIIS, Sartorius, Rec. Fem. ○ Lateral: Iliac crest, TFL, G. Med. + Max, IT band, GT, Trochanteric bursa ○ Posterior: Median Sacral crest, PSIS, G. Max., Ischial Tuberosity, Sciatic N., Hamstrings (4) ● Joint & Muscle Function Assessment ○ AROM & PROM ■ Hip flexion/ extension ■ Hip IR/ ER ■ Hip Abb/ Add ○ MMT ■ Hip Flexion ● Iliopsoas ● Rec fem. ● TFL ■ Hip Extension ● HS ● G. Max ■ Hip Abduction ● G. Med/ G. Min ■ Hip Adduction ● Flexors ● Extensors ■ Hip IR/ ER ● Seated IR/ ER ● G. Max ER clamshell ○ ST’s ■ Thomas Test - Hip flexor tightness ■ FADIR - Ant. Impingement ■ FABER - LBP vs Labral damage ■ RSLR (IR or ER) - hip flexor/ cam deformity vs. labral tear ■ Hip Scouring test - crepitus/ OA ■ Piriformis Syndrome Test (MMT seated hip abduction) - PS ■ Trendelenburg’s test - weakness in G. Med ■ Ober’s test - IT band tightness ■ Ely’s test - Rec. Fem. tightness Pathologies ● Piriformis Syndrome ● Lumbar Disc Herniation ● Hip pointer - Iliac crest contusion ○ MOI: blunt force to ilium ○ SS: Pain, swelling, discoloration, subsequent LOF ● Muscle strains ○ Common in iliopsoas, quads, adductors, HS ■ HS strain has 33% rate of occurrence ○ MOI: Overstretching or overload during eccentric contraction or loading phase ○ SS: pain, LOF ● Quad. Contusion ○ MOI: Death of muscle fiber ○ SS: pain and spasm limit knee flexion ■ Risk of heterotopic ossification ● Acetabulum & Femoral deformities - angle of torsion, angle of inclination, acetabular dysplasia ● SCFE (slipped capital femoral epiphysis) - Displacement of femoral head relative to femoral neck ○ Common hip disorder in adolescent ○ MOI: gradual onset ○ SS: pain in adductor group or hip increases with walking ■ Possible decrease in IR and hip flexion ● Legg-Calve-Perthes Disease ● ● ● ● ● ● ● ○ Ischemic lesions of the femoral head that develop during the first decade of life ○ SS: Pain in medial thigh, buttock, or suprapatellar region ■ Hip IR and abduction are limited or painful ■ Affected leg may appear shorter CAM deformity - femoral head does not fit into the acetabulum correctly ○ MOI: degenerative or adolescent abnormal growth ○ SS: pn inc. during sitting, dull, decreased overall hip ROM, clicking/ popping “inside” Fem. Neck stress Fx ○ Prevalent in endurance athletes ○ MOI: tensile of compression force fraction ○ SS: Deep aching pain increases with duration and intensity, night pain, limited ROM and painful near end ranges Degenerative Conditions - Arthritis, OD (osteochondral dessicans), Avascular necrosis, HIP OA ○ MOI: obesity, lifting heavy loads, malalignments/ deformities (SCFE, Perthes, abnormal AOT), genetics ○ SS: crepitus, pn during movement, reduced overall ROM Labral Tears ○ MOI: hip dislocations, repeated subluxations, SCFE, Acetabular dysplasia (shallow acetabulum), repeated athletic trauma, femoral acetabular impingement (cam/ pincer deformity) ○ SS: “c- sign,” pn during activity + sitting inc. pn, (+) FADIR test Athletic Pubalgia - inflammation 2 the muscle attachment (usually close to pubic bone pubic symphysis) ○ MOI: insidious or acute, increased loads during adduction and ER (tensile force between adductor muscle group + lower AB muscles) ○ SS: inc. in pn w/ activity and pn decreased when activity stops, PT over pubic region Snapping Hip Syndrome (Coxa saltans) ○ MOI: insidious inflammation of tendons or bursa that cause iliopsoas tendon contacting the fem. head (INTERNAL) or the IT band catching on the GT (EXTERNAL) ○ SS: pn & snapping during activity Bursitis - inflammation of bursa on head of GT, ischial tuberosity, or gluteal fold along iliopsoas ○ MOI: acute or insidious onset (blunt force or friction force between muscle or tendon) ○ SS: PT along area of complaint, ischial bursitis = reduced hip AROM, GT bursitis = pn in loading stance of gait ● Hip Dislocation - medical emergency, possible fx to femoral head/ acetabulum ○ MOI: commonly d/t posterior dislocation (i.e. dashboard accident, post-op in hip replacement) ○ SS: adduction, slight flexion, IR, immediate pn, hip “giving out” ● Femoral Fx - rare fx d/t other weak structures ○ MOI: Torsional/ shear force ○ SS: LOF, pn, obvious deformity Posture ● Clinical Evaluation ○ Tools ■ Plumb lines ■ Goniometer ■ Inclinometer ○ Postural Deviation ■ Mild - 25% deviation ■ Moderate - 50% deviation ■ Severe - 75% deviation ■ Normal ● Evaluating Posture ○ Standing, sitting ○ Static or dynamic positions that produce s/s ● Muscle Balance ○ Muscular length-tension relationship ○ Agonist-antagonist relationship ○ Postural Muscles ■ Support body against forces of gravity ■ Slow twitch ○ Phasic Muscles ■ Body movement ■ Fast twitch ● Causes of Muscle Imbalances ○ Nerve ○ Pain ○ Jt. Effusion ○ Poor Posture ○ Repetitive Activity ○ Soft-Tissue Imbalance ● Inspection of Posture ○ Tips & Guidelines ○ History ■ MOI: Insidious (side of dominance, ADL’s, driving/ sitting/ sleeping posture, posture that aggravate sxs) ○ Body Types ■ Ectomorph, Mesomorph, Endomorph (least to most joint play) ○ Janda’s Lower Cross Syndrome ○ Postural Types ■ Hyperlordotic (lordosis) ● Anterior tilt ■ Kypholordortic (kyphosis) ■ Swayback ■ Flatback ■ Scoliosis ● Bony origin ● Functional origin ■ Leg-length discrepancy ● Structural ○ Measure ASIS to medial malleolus ● Functional ● Palpation ○ Lateral: ASIS + PSIS ■ Ant. Pelvic Tilt ■ Post. Pelvic Tilt ○ Anterior: Iliac crest height, ASIS height, patellar position, Lat. Malleolus, Fib. Head height ○ Posterior: PSIS height, Spinal alignment ● LBP ○ Causes ○ ST’s ■ Hamstring length ● Active and passive knee ext test ■ Hip flexor length ● Thomas test ■ Back muscle endurance ● Keeping legs elevated while prone ■ Core endurance ● Ab endurance test ○ Muscles involved ■ Erector spinae ■ Multifidus ■ G med/max ● Common Postural Deviations ○ Excessive Pronation ○ Excessive Supination ○ Calcaneovalgus (eversion) ○ Calcaneovarus (inversion) ○ Genu recurvatum ■ Hyperextended knee more than 5 degree ○ Genu Valgum ■ Medial angulation at knee ■ Knock knee ○ Genu Varum ■ Lateral angulation at knee ■ Bow legged Gait ● Gait terminology ○ Step - Initial contact of L to IC of R ○ Step length - distance traveled between of IC of R and l foot ○ Step width - distance between the points of contact of both feet ○ Stride - two sequential steps of IC of R to another IC of R ○ Gait cadence - steps taken per time ○ Velocity - distance covered per time (meters/ sec) ○ Stride time - time to complete a single stride ○ Stride length - linear distance covered in one stride ○ Kinematics - characteristics of movements, effects of joint action ○ Kinetics - forces (i.e., ground reaction force, center of mass, center of pressure) ● Gait Evaluation ○ Quantitative - measurements taken normally during research ○ Qualitative - visual analysis ● ● ● ● ○ Finding of Gait analysis + pt.’s functional limitations, impairments identified in examination = Full Examination of Gait Process of Gait ○ Legs alternate between stance and swing phase in which two points of the body is supported by a single leg during midstance and terminal stance Walking Phases ○ Stance (WB) - begins @ initial contact with the surface and ends @ broken contact (contact w/ ground, in which center of mass moves forward until preswing) ■ Initial contact ■ Loading response ■ Midstance ■ Terminal stance ■ Preswing ○ Swing (NWB) - begins @ foot leaving the surface and ends @ right before initial contact (no contact w/ ground, in which center of mass stays in like with NWB foot) ) ■ Initial swing ■ Mid Swing ■ Terminal swing Characteristics of efficient gait ○ Minimal side-to-side motion ○ Max. forward motion ○ ~5 cm of body rising and falling ○ Center of gravity is within a sinusoidal curve Running Phases ○ Stance (WB) ■ Hip: flexed to 50° @ IC going into extension ■ Knee: flexed to 30°, moves to 50° of flexion, then moves into extension ■ Ankle: dorsiflexed to 25° going into plantarflexion ○ Swing (NWB) ■ Hip: extended to 10°, then to 50°-55° of flexion ■ Knee: full extension, then to 125° of flexion, and to 40° of flexion before contact with surface ■ Ankle: 25° of plantarflexion to 20° of dorsiflexion ○ Triplanar GRF’s ■ Measuring of initial contact, midstance, and push off ■ Walking TGRF: Two humps indicate that GRF are increased @ initial contact and push off ■ Running TGRF: Two humps indicate that GRF are increased @ initial contact and push off (push off ground reaction force is increased) ■ Both walking & running produce braking forces but minimized during running ● Difference of Running Gait vs. Walking Gait ○ Flight phase - neither foot is in contact w/ surface ○ No period of limb support ○ Increased ground reaction force ○ Shortened stance phase time ○ Loading response and midstance occur more rapidly in stance phase ○ Swing phase during running gait can cause more injury d/t mistiming of hamstring eccentric contraction to slow knee extension ● Interventions ○ Guided Cue words/ phrases ○ Strength training ○ Flexibility/ ROM exercises ○ Different shoes ● Gait Deviations/ Malalignments ○ Retroversion (toe out) ■ Stress on medial and plantar structures ○ ○ ○ ○ ○ ○ ○ ○ ○ ● semitendinosus, semimembranosus, gastrocnemius, etc.) Anteversion (toe in) - found in midstance/ after push off ■ Stress on lateral soft tissues ● Biceps femoris, gastrocnemius, peroneals Shortened step length ■ Causes: pain in back, hip, knee, ankle that causes step length to decrease to reduce forces and symptoms ■ Inadequate push off and pull Shortened stance time (limp) ■ Causes: pain (acute or chronic) ■ Using crutches Unequal hip/ pelvic positions ■ Causes: leg length discrepancy ■ Important to assess lumbo-pelvic-hip complex ● Tightness or muscle weakness in hip flexors, back muscles, gluteus medius & minimus, sacroiliac joint pain Asymmetrical arm swing ■ Arm swing allows for hip and pelvis ■ Causes: Upper extremity injury, leg length discrepancies, spine dysfunction, exaggerate motion in hip/ pelvis Excessive PF Ankle @ IC ■ Causes: gastrocnemius spasticity (only keeping the ankle in plantar flexion), hamstring pathology, drop foot (nerve injury to deep peroneal nerve) Inadequate PF Ankle @ TO - inadequate ankle plantar flexion @ push off ■ Causes: muscle weakness in triceps surae, acute ankle sprain with effusion, forefoot pathology Leg Stiffness ■ Excessive origin: bony injury ● Less ROM = less efficiency = GRF going into bones ■ Deficient origin: soft tissue injury ● Less ROM + less MUSCLE efficiency = GRF going into soft tissues Excessive Knee Flx. @ IC - knee is near full extension @ contact during running ■ Causes: pain, hamstring strain/ tightness, hip adductor strain, sciatic nerve pathology ○ Inadequate Knee Flx. @ Stance - knee is not flexed to 20° during stance ■ Causes: quadriceps pathology, knee joint pain ○ Inadequate Knee Flx. @ Swing - during swing phase knee is not flexed to 30° to 60° during walking and > 90° during walking ■ Causes: hamstring pathology, stains, spasms, sciatica ○ Inadequate Hip Ext. @ TO - hip does not extend @ end of stance ■ Causes: contracture or injury of hip flexors ○ Forward Trunk Lean - changing knee external forces from flexion to extension ■ Causes: low back pathology, weak/ painful hip flexors/ quads/ ankles ○ Lateral Trunk Lean - trying to reduce work of unilateral lumbar-pelvic-hip complex ■ Causes: weak glute medius, low back injury