LE Random from Notes Flashcards
What muscles are most frequently injured?
Muscles spanning two joints
Where are tendons most often injured?
Just proximally or distally to the attachment, either in the tenon itself or the bone it attaches to
How do hamstring strains occur?
- usually occur during eccentric contraction of deceleration of the LE during knee extension rather than as a knee flexor
- due to dual innervation and neuron firing time differences, one head of biceps femoris begins lengthening while the other is still contracting
What is crossed pelvic syndrome?
- tight iliosposas and erector spinal with weak abdominals and glutes
- leads to anterior pelvic tilt, increased lumbar lordosis, hip flexion, hyper mobility in the lower lumbar segments, positive trendeleburg
What tests and measures can you use to assess for crossed pelvic syndrome?
- standing posture exam - will see increased anterior tilt, lateral pelvic shift, and possible iliac torsion
- during prone leg extension firing pattern will be abnormal
- modified thomas test for tight muscles
- modified schober test for erector spinal
- sit up
What exercises can be prescribed for crossed pelvic syndrome?
- Start by stretching tight muscles (can be inhibiting weak muscles)
- Strengthen weak muscles
- Prescribe exercises to encourage proper body mechanics
What is the difference between Legg-Calve Perthes disease and slipped capital femoral epiphysis?
- LCP = ages 3-12, peak 6; avascular necrosis to head of femur, tends to flatten out head of femur
- Epiphysis = ages 10-15; ball at the upper end of femur slips off in a backward direction; due to weakness of growth plate, most often occurs during periods of accelerated growth shortly after puberty; patient presents adolescent, sedentary, has knee pain, decr. hip IR
What are the Ottawa knee rules?
- Pt 55 years or older
- Tenderness at head of fibula
- Tenderness at patella
- Unable to bend knee to 90
- Unable to walk 4 steps
What are the Ottawa ankle rules?
- Tenderness at distal 6 cm posterior tibial or tip of medial malleolus
- tenderness at distal 6 cm posterior fibula or tip of lateral malleolus
- tenderness at base of 5th metatarsal
- tenderness at navicular bone
- Unable to walk 4 steps
While performing an ankle exam, what should you always look for with a lateral ankle sprain?
Cuboid syndrome
- will be painful upon palpation and should be mobilized into proper position
How will a person with retroversion present?
- Out-toed gait
- supination
- genu-varum (lower Q-angle)
- increased tibial IR
- increased hip ER, decreased IR
- possible foot pain (stress fx, metatarsalgia, plantar fascitis), LBP, SI dysfunction
What is the normal angle of femoral torsion? What angle is ante version? retroversion?
15; >15; <15
- normal tibial torsion = 20-25
How will a person with ante version present?
- In-toed gait
- pronation
- genu-valgum (higher Q-angle)
- increased tibial ER
- Increased hip IR, decreased ER
- knee pain
What can cause excessive femoral ante version? retroversion?
- W-sitting as a child
- congenital
What is coxa valga? What is coxa vara?
- Valga = >133 in adult
- Vara = <125, may be as low as 90
Normal angle of inclination is 125
What exercises create the most patella-joint reaction forces at the knee?
OC = 30-60 (beneficial to perform rehab in 60-90) CC = 90+ (beneficial to perform rehab 0-30 and creates least amount of shearing forces in CC)
What tests and measures can you use to asses for meniscal lesions?
- Steinmann test - pain anteriorly in extension, posteriorly in flexion
- McMurray’s test - supine, limb in 90/90, ER leg and bring into ER at hip with full extension at knee and hip
- Appleys compression = prone, 90 knee flexion, rotate leg and compress, can add DDV
- Recurvatum
What is trendelenberg’s sign/test?
- Leg length performed in WB position
- Standing on one leg, normal should half pelvis rise on NWB side
- positive test = pelvis drops on NWB side due to weak GM
- patient presents with neurological, hip, or LBP symptoms
What is associated with lateral tibial torsion?
genu valgum
What is the function of PCL? when is it taught? what is the most frequent MOI?
- Prevents posterior displacement of tibia on femur
- flexion
- dashboard injury
What is the function of ACL? when is it taught? what is the most frequent MOI?
- Prevents anterior displacement of tibia on femur
- extension
- partially flexed knee with active quads and IR femoral rotation; hard impact on fully extended knee
Why is the lateral meniscus less frequently injured?
- lacks LCL attachment and is more mobile and coronary ligaments are more lax
- attaches to the popliteus and is more mobile
What are the 3 layers of the medial knee?
- (outer) deep fascia overlying the vastus medalis and MCL and sartorius
- superficial MCL and structure anterior to it
- Capsule, deep MCL, and coronary ligaments
What are the 3 layers of the lateral knee?
- (outer) IT band and biceps femoris
- quadriceps, patellar retinaculum, patellofemoral ligaments
- lateral collateral ligament, joint capsule, fibulloarticular ligaments
What are the attachments of the pes anserine tendon?
- Semitendinosus attaches posterior and lateral
- Gracilis is anterior and medial to ST
- Sartorius is more superficial and has a broader insertion site
What is the function of the popliteus m?
- flexes and rotates the knee medially
- unlocks the nee by IR of the tibia on femur
What is the primary medial stabilizer of the patella?
VMO
What are the 3 functions of the superficial MCL?
- Chief restraint against valgus deformity
- Prevents ER of tibia on femur
- Helps as a secondary restraint to anterior tibial translation if the ACL is absent
What are the functions of the deep MCL?
- Thickening of joint capsule
2. Secondary restraint to valgus opening
Where does the patella lie in full flexion?
In the intracondylar groove
- in full extension, only the inferior part of the patella is in contact with the femur
What are the functions of the patella?
- lengthens the lever arm of the quads
- increases the are a of contact between the patellar tendon and the femur allowing a wider distribution of compressive stress on the femur
Where do you palpate the posterior tibial artery? dorsalis pedis artery? What does this indicate if you cannot find a pulse?
- posterior and inferior to the medial malleolus
- lateral to the tendon of TA
- indicative with diabetic and peripheral vascular disease, and indicative of compartment syndrome
How do you palpate for a leg length discrepancy?
- PSIS height difference is found in standing, but disappears with sitting
- can measure from ASIS to medial malleolus in WB position to confirm
- to fix, a heel lift is inserted
What is the correct sequence of hip extensor muscle firing?
- Hamstrings/ glut max
- Contralateral lumbar extensors
- Ipsilateral lumbar extensors
- contralateral thoracolumbar extensors
- ipsilateral thoracolumbar extensors
What is the role of the lumbopelvis?
absorb forces and transfer forces to surrounding tissues from ground reaction focuses transmitted superiorly at heel strike
What are the stabilizers of the lumbopelvis?
- Thoracolumbar fascial and lats
- IAO, EAO, transversus and recuts abdominos
- iliopsoas
- mulitifidus
- lat iliocostalis lumborum
What are the movers of the lumbopelvis?
- Superficial Erector spinae - iliocostalis lumborum and longissimus thoracis
- deep erector spinal - lateral iliocostalis pars lumborum
What are the monitors of the lumbopelvis?
- Multifidus
- intertransversarii medialis
- interspinalis lateral intertransversarii
What muscles of the lumbopelvis are prone to weakness?
Glut max, med and min
rectus abdominis
What muscles are the primary flexors of the hip?
- psoas major and minor
- iliacus
- rectus femoris
What muscles are the primary extensors of the hip?
- gluteus maximus
2. hamstrings
What muscles are the primary abductors of the hip?
gluteus medius and minimus
What muscles are the primary adductors of the hip?
- adductor magnus
- longus and brevis
- gracilis
What muscles are the primary external rotators of the hip?
- piriformis
- obturator externus and interns
- gemellus superior and inferior
- gluteus maximus
What muscles are the primary internal rotators of the hip?
- gluteus minimus
- tensor fasciae
latae
What movement of the hip is not done specifically by a particular muscle group, but as a secondary action of muscles belonging to other groups?
internal rotation
Are hip flexors or extensors stronger?
extensors
- 3x stronger due to fxn in upright standing posture and walking
Are IRs or ERs stronger?
ER
- IRs are ⅓ as strong
What is the compensatory posture due to hip flexor contracture (or ankylosis)?
increased anterior pelvic tilt and lumbar lordosis (to create hip extension), and increased transverse rotation of the pelvis and increased knee flexion (to lengthen step on fixed side)
What could adductor or abductor contractors cause? what condition do they usually take place in?
- Adduction = high ipsilateral iliac crest and apparent short leg
- abduction = low ipsilateral iliac crew and apparent long leg
- advanced osteoarthritis
What is seen during stance with an anterior pelvic tilt? posterior?
- anterior = longer length (fxn’l lengthening)
- posterior = shorter length (fxn’l shortening)
A hip that is low, extended, or externally rotated could cause fxn’l ______. A hip that is elevated, flexed, or internally rotated could cause fxn’l ______.
Lengthening; shortening
What weak muscle may cause fxn’l shortening in an athlete or heavy patient?
Glut med
- rarely, weak piriformis allows internal rotation also causing shortening
What is the estimated minimum range of hip motion necessary for common ADLs?
100 flexion
20 abduction
20 ER
What does a capsular pattern PROM indicates?
osteoarthritis
What are the two types of athletic soft tissue hip injuries?
- the friction type- caused by repetitive friction of the iliotibial band on the superficial trochanteric bursa
- the failure type - caused by stressing of collagen fibers of tendons and muscles beyond their ultimate yield strength and resulting in a range of lesions
Bursae are affected by all inflammatory conditions that affect synovial joints (RA, gout, infection), macrotrauma or repetitive microtrauma; usually presents with nonspecific symptoms (pain with 2-3 tests and PROM); generally, a combo of various nonspecific resisted and passive tests should indicate acute or subacute condition
Hip bursitis
Presents limited IR of hip and reflex tightening of hip ERs (IT band tightening), deep, dull or sharp ache on lateral hip/thigh; Positive over test is often related to irritation of the bursa bc the band moves forward during flexion an posterior during extension (glut max pulls it back); caused by persistent lifting from a flexed lumbar position back to extension with the knees straight, or overuse causation, especially in female runners who have a broad pelvis and an excessive Q angle, in runners who have a crossing gait, Leg length discrepancy, excessive foot pronation, and poor running surfaces
Trochanteric bursa
- composed of 2 bursa (below glut med and below TFL and glut max)
Pt will complain of painful gait (esp during extension), point tenderness, pain in groin and anterior thigh
Iliopectinial and iliopsoas bursitis
- iliopectinial = palpation near head of femur
- iliopsoas = pt supine with hip flexed to 90, palpation just below inguinal lig while passively abducting hip
What is Osgood-schlatter disease?
enlarged, tender tibial tubercle
Distal fibular fracture from talus hitting fibula in a DF and inversion sprain
Pott’s fx
Fibularis brevis avulsion fracture of 5th metatarsal tubercle; occurs in PF/inversion injury
Jone’s fx
What muscles act as secondary stabilizers that are often injured? What is their action at the foot?
- Fib long - main everted of ankle
- Tib ant - DF
- Post tib - inverts and PF foot (achilles tendon also acts in PF)
What nerve entrapment happens when the nerve is pushed up against the fibular neck; runners often get this (stretching during inversion and PF); knee crossing, tight knee band or cast; may present with lateral ankle sprain
Superficial fib nerve entrapment
Nerve entrapment: occurs in distal foot areas (under inferior extensor retinaculum and under tendon of hallucis brevis); history of ankle sprains, tight-fitting shoes or skiboots
Deep fib nerve entrapment
Nerve entrapment: occurs in adductor canal, fascia of vastus medals, sartorial, and adductor longus; caused by excessive knee extensions or squats, pos anserine bursitis, direct trauma to the canal, post-surgical knee, venous thromophlebitis
Saphenous nerve entrapment
Nerve entrapment: most commonly occurs in ankle-foot (fascia above ankle, lateral mall, 5th MT after displaced fx); also baker’s cyst, lipoma, scars, crural fascial; tight boots and lacing may cause compression
Sural nerve entrapment
Flexor retinaculum entraps of the contents of the tarsal tunnel (posterior tibialis, FDL, FHL tendons, tibial nerve, artery and vein); pts present with burning pain and paresthesia in ankle or foot with or without paresthesias in the sole
Tarsal tunnel syndrome
What nerve gets entrapped in tarsal tunnel?
Tibial nerve
- splits into MP and LP n’s in or just past the canal
What causes shin splints?
- hyperpronation and tight heel cords especially in joggers and runners (posterior tib)
A finding of a restricted SLR with concurrent limited hip flexion and a non-capsular pattern of restriction of ROM; signs may indicate the presence of serious pathology in pelvic or gluteal region
“sign of the buttock”
soft tissue and osseous deformities of sup-post-lat calcareous due to pronation; causes same area of the calc to hit shoe resulting in hyperplasia of the skin (callus formation) and/or exostosis (bone formation)
Haglund’s deformity
AKA pump bumps
What can occur as a compensation (specific adaptation to imposed demands) for excessive pronation?
abductor hallucis brevis hypertrophy
-only dynamic stabilizer of the ML arch
Clinical prediction rule: pt with painful knee OA; 2of the 5 following:
- pain with ipsilateral hip distraction
- ipsilateral knee passive flexion <122
- ipsi hip passive IR <17
- pain or parestesia in ipsi hip or groin
- ipsi anterior thigh pain
hip mobilization
Clinical prediction rule: pt with patellofemoral pain;
- pt has IR assymetery > or = 14, OR 3 of the 4 following:
1. ankle DF (knee flexed) > 16
2. navicular drop > 3mm
3. no self reported stiffness with sitting >20 mins
4. squatting reported as most painful activity
lumbopelvic manipulation
Clinical prediction rule: pt with patellofemoral pain; 1 of the 2 following:
- positive patellar tap test
- tibial varum > 5
patellar taping
Clinical prediction rule: pt with patellofemoral pain; 1 of the 3 following:
- forefoot valgus alignement > or equal to 2
- great toe extension of < 78
- navicular drop < 3 mm
foot orthosis use and modified activity
