Lecture 3 (L) Flashcards
Which myotome does hip flexion
L2
Knee extension in which myotome?
L3
Ankle dorsiflexion is which myotome?
L4
Great toe extension is which myotome
L5
ankle eversion / plantarflexion is which myotome
S1
plantarflexion / knee flexion is which myotome
S2
L2 myotome does what
hip flexion
L3 myotome does what
Knee extension
L4 myotome does what
ankle dorsiflexion
L5 myotome does what
great toe extension
S1 myotome does what
Ankle eversion / plantar flexion
S2 myotome does what
Plantar flexion, knee flexion
where does L1 dermatome start / where does it go
Starts at L1 and wraps around to the groind area
Where does L2 dermatome start, where does it go
Starts at L2 (so near botom of ribs) - not yet on hip
wraps down to upper anterior leg
Where does L3 dermatome start. Where does it go
Starts at L3
Wraps around and goes to middle of anterior leg
Where does L4 dermatome start?
Where does it go
Starts at L4
Wraps around leg goes right over anterior knee and down medial calf
Where does L5 dermatome start? where does it go
Starts at L5 and wraps around to lateral upper leg (goes lateral knee) then wraps to the middle of the calf then moves to medial 1/2 of dorsal / plantar surface of foot.
Where does S1 dermatome start? Where does it go
S1 dermatome satrts at S1 goes
Goes down the lateral posterior aspect of the hip (litteraly the alteral posterior half of hip) lateral anterior calf and lateral posterior 1/2 of calf then lateral 1/2 plantar/dorsal surface of foot
Where does S2 dermatome start? Where does it go?
Starts at S2
Travels down the medial posterior 1/2 of hip and calf (terminates before the foot)
KNOW S3-5 all on posterior surface of glutes w/ S5 being the most medial and inferior
What is the strongest risk factor that someone will have a fall? what about second most likely factor
Previous history of falling. Followed by fear of falling
Is Hip OA better or worse after activity?
Worse (once the activity is done they stiffen back up)
Is Hip OA better or worse at the end of the day?
Worse - because those msucles are tired / joints are stifening up / inflammed
Does Hip OA get better or worse w/ movement
Better - as long as the movement isnt to intense
What does hip OA feel like in the AM?
Stiff
Does hip OA get better or worse w/ prolonged sitting?
Worse (stiffness)
Why is hip OA associated w/ muscle weakness?
The pain around this joint keeps them from fully using them hip which quickly leads to atrophy - causing the muscle to be weaker
Why does hip OA cause balance issues
Think if they go into a trendelenberg to get away from affected side that causes them to already be off balance
Fear avoidance (fear of falling = increased risk of falling)
Altered joint mechanics - aka joints arent sending great proprioceptive information (because they’ve been damanged from taht general wear and tear) your body won’t know where it is in space - leading to an increased fall risk
Which age group is most likely to get hip OA? Which gender?
Women over 55
Where is pain from hip OA typically located?
Inguinal area (more medial) or trochanteric area. It sometimes extends to the anterior thigh/knee
Seems like its typically more inguinal but think the front of that leg
Does weight bearing increase or decrease hip OA pain?
INCREASE
remember - your distract pt’s w/ arthritis because they are already getting that bone on bone
How would a hip OA pt report their feeling in the hip in the morning?
More stiffness (motion is lotion)
How would someone w/ hip OA report their symptoms after sitting for an extended period of time?
Stiffness pain
What would someone w/ hip OA feel at night when changing positios?
Pain (reduced movement leads to that sutffness and pain)
also at night we have more inflamamtion - so that can also increase pain in the affected area
Why would someone with hip OA have more difficulty outting on socks and shoes?
Because that requires a lot of deep hip movements
A hip OA pt does aggressive exercise. What is the pain outcome
Increased pain - we want that mild EX to alliviate their symptoms
What is an outcome measure
Tool or test that helps doctors measure how well something is doing, It can be a simple questionaire, a test of physical abilities, or something else. - these neasyres guve a ckear way to see changes in health, the impact of treatments, or how something feels
What does the Western Ontario and McMaster Universities Arthritis Index (WOMAC) specifically measure?
Good at looking at hip OA (but i think it does arthritis in general)
Why wouldnt we use the LEFs test when assessing OA? (2)
Its not specifically for OA but the entire lower exteremity (LE)
Also, some of the stuff on here is realtively active (running / jumping) and pt’s w/ OA are typically older and can’t do these movements
Would someone with hip OA be good at sit to stand? Why or why not
No
Because they arent good at those deep motions
Could someone w/ hip OA have a positive trendelenburg? Why
Yes
Because trenedelnburg is caused by poor hip abductor (think glute med) strength. These muscles atrophy from disuse misuse w/ hip OA leading to this sign
What muscles atrophy the most with OA
Glutes
Patient is sitting with leg in what position clues us in that its an OA thing
Leg pointed out
ER/ABDUCTION/FLXN
Anything to try and open up that joint capsule
How many CM is leg length discrepency?
1.5 CM
KNOW: Hip OA pt’s can have leg length discrepencys
KNOW: Hip OA pt’s can present with genu valgum (knees in) or genu varum (knees out)
Ask and make sure it hasnt been there since childhood but some kind of boney change due to a change in posturing
What two motions are most limited w/ hip OA? which one is more limited?
Internal rotation is the most limited movement followed by hip flexion
NOTE: AB / EX is also somewhat limited (probs don’t memorize)
This is because these two motions close down the most on that joint capsule
Could we rule hip OA out if their hip can get full ROM (not motion resitrction) in every direction?
Yes
How many planes of motion need to be limited for us to be clued in that its hip OA?
3 or more
We would normally see limitations in IR/FLXN and Abduction or Extension
A patient is asked to go into hip flexion and stops because they can’t go any further. What is my next question?
What’s limiting you (pain vs tightness). Then where is that pain or tightness. How would you describe the pain. Is it the pain you came in with? (compariable sign)
Which two accessory movements are typically limited w/ hip OA? why?
Posterior / inferior glide
This makes sense. The hip is a convex on concave (opp). Internal rotation = anterior roll = posterior slide (joint assessment). Flexion/abduction = superior roll = inferior slide (asses)
which 3 muscles would we do MLT on for hip OA?
Hip Flexors
IT band
Piriformis
Which 2 muscles would we MMT for
Glute med (abduction) / glute max
atrophy of these two muscles are highly correlated w/ hip OA
We flex or hips a lot more than we extend them meaning glute max could be atrophing (+ extension is one of those movements we won’t be doing as much w/ hip OA)
Glute med because we stop abducting because it hurts and when we stop using it we start losing it.
Would we do a trendelenburg test for hip OA? Why
Not the best test
All it tells us is that the glutes are weak. It tests for that glute med abduction but nothing specific to OA
What movements are in the FABER test?
Flexion
Abduction
External rotation
Would we use a FABER test for hip OA? Why?
It kind of tests it but not specific to hip OA
What is a Scour test? Is it good for hip OA
Them jamming the hip in the acetabulum and then grinding the hip from a 12 a clock position to a 2 a clock position back and forth (out in out in)
Think a scouring pad to clean a dish
It’s good for figuring out if someone for sure doesnt have hip OA. If we do this test and there is no pain then the person almost def doesnt have hip OA. However, a posititve doesnt mean it is hip OA (could be a 100 other things)
What two imaging is done for hip OA
x-ray and MRI
What is the Clinical prediction rule for hip OA? How many factors do we need
1) Self-reported squatting as an aggravating factor (closing down the hip space - cramming down on the hip joint)
2) PASSIVE IR of involved side less than or equal to 25 degrees
3) Active hip flexion causes lateral hip pain (think about head moving laterally)
4) Active hip extension causes hip pain
5) Postitive Scour test w/ adduction (not when you scour out but when you scour in [maxiamlly closes down hip joint]) in the ground or lateral hip
NOTE: Hip OA pain is typically in the groin (anterior hip) or lateral hip (trochanteric area)
We need 4/5 of these to be posititve to rule in hip OA
If I move the lumbar spine and it doesnt reproduce latearl hip pain, then i bring the knee into deep flexion and have latearl hip pain and I thinking lumbar or hip issues?
Hip
What does CPR stand for?
Clinical prediction rule
Who gets femoral stress fractures more, men or women?
Women
Whats a big disease thats associated w/ femoral stress fractures?
osteoprosis
**What kind of pain is with femoral stress fracture? where is this pain?
proximal anterior or latearl hip and groin region (almost exactly the same pattern as OA). Deep aching pain
Is femoral stress fracture pain better w/ EX or rest?
Better with rest (EX hurts - its a fracture)
Whats a huge differeinating factor with hip OA and femoral stress fracture?
Femoral stress fracture has a traumatic MOI while OA is a degenerative disease.
NOTE: They both have the same pain pattern - anterior and lateral thigh / groin
What would be two good outcome measures to use for a 45 year old male with a hip fracture?
LEFS and Hip outcome score (more functional)
What outcome measure would we use for a 67 year old sedentaory female w/ femoral stress fracture?
Hip outcome score
We wouldnt use LEFS because it involves more active stuff (jumping / running)
We wouldnt use HOOS because it tests specifically for OA
How would someone w/ a femoral stress frature be expected to hold their hip in the clinic?
Would come in with hip flexion, abduction, external rotation (most open packed position)
what motion would have weakness w/ a femoral stress frature? (Post OP)
abduction
they would cut glutes to repair causing this motion to be weakened
What two tests would we do to rule out femoral fractures?
Fulcrum test
Patellar pubic percussion test
would a femoral neck fracture or a trochanteric fracure look better from the outside?
Femoral neck fracture
It is intracapsular meaning that swelling will be compressed within that joint
Does severe swelling normally happen w/ trochanteric fractures?
Yes, because it is extra capsular
With a trochanteric fracture the leg goes into what position
Which makes it appear ______
External rotation
Shorter
KNOW: theres lots of swelling in the surrounding tissue
What is the most problematic femoral fracture? (not hard)
femoral neck fracture
are most femoral neck fractures displaced?
95% are - think about it - its a tiny neck meaning it will easily slide apart when broken
KNOW: Femoral neck fractures mess up the integrity of the joint itself (because they’re intracapsular)
Which way does the hip dislocate with dashboard injuries?
Posterior fracture dislocation
Posterior Hip Dislocations are assocaited w/ what MOI
typically dashboard injuries
Are anterior or posterior hip dislocations more common?
Posterior
When a hip has a posterior displacement or dislocation what 3 positions is it in (after the fact)
flexion, adduction, IR
What motion causes an anterior dislocation of the hip?
Exterme extension pushes the head out forward
far less common than posterior
This pt was found on the floor unconscious. By looking at them we can insantlly tell whats wrong. Whats wrong and how do we know?
This person has a posterior hip fracture dislocation
We know this because they present with an internally rotated adducted flexed leg
What population is typically affected by femoral acetabulum impingement?
Young healthy active population (20-40)
What kind of FAI affected the femoral head and neck?
Cam
What kind of FAI affects the acetabulum?
Pincer
What age group typically gets FAI?
Young adult active population (20-40)
What position is the worst for FAI? (brings on symptoms)
flexion, IR, ADD (closes down joint space - or pinch the labrum between it)
Is FAI gradual onset?
Yes (boney deformitites take time to form)
What is a precursor to labral tears?
FAI (because those boney deformitites pinch down on it over and over again and cause it to break)
repetitive activities + FAI =
Labrum tear (constatly pinching labrum until it breaks)
KNOW: Sudden twist or pivot / hyperflexion or forced squat can cause that labral tear / impingement (especially when the pt already has FAI)
C-Shape pain is constisten w/ what?
FAI
traditionally inner groin but can radiate laterally to the inner thigh
What is pain like w/ FAI?
* what is it like w/ deep squats?
Dull achy pain (labrum is constantly being compressed) - however w/ deep rotation / flexion / cutting movements we can bring on sharp pain (being compressed)
Hip pain is clicking - what do we think it is? Why?
Clicking = labral issue
This is due to decreased pressure in the joints because the labrum is not doing its job and keeping all the pressure in
W/ a labral issue would we have increased or decreased joint laxity?
increased.
Because the labrum is not doing its job so the joint can slide all over the place (aka why there is also clicking)
pt might say “my hip doesnt feel stable”
pt comes in and says hip feels unstable. What is the most likely pathology and why?
labral issue
Because the hip sits in a deep acetabulum and should never feel unstable. However, if the labrum is affected that would cause the clicking / sliding out of place
For instance w/ hip OA I would never have an unstable joint just a painful one.
Why would prolonged periods of sitting affect FAI?
Because of that deep hip flexion
KNOW: We typically get inguinal pain (anterior) w/ labral issues (however it might also precent as deep C-shape pain)
KNOW w/ labral issues prolonged sitting, standiing, walking hurt. If we just had this we might be thinking FAI or OA. However he’ll give us pt demographics that will clue us one direction or another (aka saying that theres cliking or that its a 63 year old female w/ osteoporosis)
KNOW: We don’t really treat FAI and labral tears very different so its not that important for us to be differentaite them - we treat them both w/ conservative PT
KNOW: if theres trauma involved more likely to be labral tear than labral irritation (both have clicking)
For labral issue PT’s what questionaires?
Hip Outcome Score (HOS)
LEFS - for someone more functional
Someone has chronic labral issues. Is there leg going to be in varus or valgus? Why?
Valgus
Because they’re taking wt off that leg and it will cause it to collapse in
Does someone w/ chronic labral issues have an anterior pelvic tilt or posterior? Why?
What other back issue would they have?
Anterior pelvic tilt. Because if I go fully upright thats going to stretch that anterior hip capsule (most labral issues anterior)
That anterior pelvic tilt is accompanied by increased lumbar lordosis (do it yourself to see) which is common w/ chronic labral pts
Why is FAI increased w/ increased body mass?
because were adding in more weight on those bones (wolfs law) causes those bones to build up and be deformed
What position is the hip held in w/ FAI (or any hip joint issues that invovle effusion or swelling)
typical of pts w/ hip pain
Flexion, slight abduction, external rotation (takes pressure off hip)
note: this is how most hip pts sit so we can typicaly rule out lumbar spine if they are sitting like this
KNOW: someone w/ labral issues are more likely to have decreased IR
What 3 motions are limited in labral pts?
**Hip flexion, internal rotation, adduction **
NOTE: the other one was the way they were seated this is about their limited motion
This is anything closing down on that joint capsule or pushing on it
Becuase labral pts dont like internal rotation or or adduction they are typically held in ER and ABD. Which muscles are adaptively shortened?
Because they are held in ER / ABD those muscles are adaptively shortened - so they don’t produce as much strength
Hip flexor weakness is also common
* they typically stay in some hip flexion as to not stress the anterior joint capsule which causes the hip flexors to adaptively shorten and weakened
Which special test would be used to rule out FAI / labral tears?
FADIR (Anterior labral tear test)
especially when combined w/
Posterior labral tear test (drop from DAIR inro hip ext, abd, ER)
However - labrum is typically more anterior pain
KNOW: Hip scour is often posititve for FAI/Labral tears because it puts you in a lot of the other posititve positions
Would a person w/ labral issues want to swquat more w/ ER or IR?
They would want to squat w/ ER (helps it not be closed down as much)
KNOW: W/ OA proably both ER/IR is going to such but w/ this only one is stretching the joint capsule
Whats the best way to differentiteate labral tears and FAI?
MOI (traumatic vs non-traumatic)
- think piviting twisting causing the traumatic event
KNOW: FAI is a precursor for OA (and labral tears)
Do labral pts have tenderness w/ palpation?
No, its a really deep area
what two scans are best for labral issues?
MRI –> CT
What is the most common cause of a greater troachanter bursitits or tendinopathy?
Direct trauma
(other related causes are mechanical overload / obesity)
KNOW: greater trichanteric bursitits can be brough on by changing up something from normal (think new shoes)
KNOW: Females are more likely to get bursitits / gluteal tendinopathy
KNOW: A middle aged secretary thats over weight w/ a trendenlberg = every greater trochanteric bursitits pt ever
KNOW: female is more common for this than men
especially if they have lateral hip pain
KNOW: greater trochanter pain is lateral
KNOW: Greater troachnteric bursitits will be tender to palpation over the greater trochanter
How would you differentiate hip OA and greater trochanteric bursitits?
They both cause lateral hip pain
However, greater trochanteric bursitits has tenderness over the latearl hip while hip OA doesnt
What is the biggest red flag for greater trochanteric bursitits?
fracture because the MOI is direct trauma
Gluteal tendinopathy = greater trochanteric pain syndrome = greater trochanteric bursitits
What age group are gluteal tendinopathies most common in?
40-60
How would we bring about the pain for a gluteal tendinopathy?
MMT –> stress the muscle pull the tendin and bring on the pain
What two things like cause gluteal tendinoatphies
traumatic event or repetitive load
What tendin is affected by gluteal tendinopathies?
glute med
also the IT band runs over the greater trochanter here and is involved
What two motions flare gluteal tendinoapthies?
Flexion and adduction
it pinches down on the greater trochatner / bursa (causing imflammation of tendin and bursa)
What causes snapping hip syndrome?
Tight ilipsoas
feels like its snapping / strumming w/ flexion
What kind of people are likely to get gluteal tendinopathies - sedentary or active?
Sedentray (muscle stays weak then they go into that pelvic drop causing more issues in that area)
Why would someone w/ gluteal tendinopathy have trouble going up stairs?
Because they struggle w/ hip flexion / adduction (goes over the bursa and makes it tight) –> so this motion would be painful for them
What kind of pain is gluteal tendinopathy described as?
Deep ache
What position is someone w/ gluteal tendinopahy likely to have when resting
flexion (because they’re sitting)
ER
abd
(this is the common hip pattern for sitting)
most open packed position
also it takes them out of that position that tightens up around their greater trochanter (think abd)
Would you be able to feel swelling w/ acute greater troachteric syndrome
probaly
What motions would cause pain w/ greater troachteric pain syndrome? (actively)
We said that glute med’s tendin is involved so the motions of glute med (for abd)
**abd / ER / extension **(they have weakness w/ these motions)
* I think its because all the glutes are involved (not just glute med) that these motions are as such
* Theres weakness w/ these motions as well
(would also present w/ decreased extension)
What position would cause pain w/ greater trochatneric pain syndrome w/ passive motioun (you’re moving them)
add, IR, Flexion (were stretching it causing pain over greater troachnter)
Both FAI and greater troachnteric bursitits are capable of causing latearl hip pain. What are 2 ways we can differentiate the two?
1) Greater troachnteric pain syndrome is more pinpointed and palpable
2) Greater trochanteric bursitits as weakness w/ extension / ER / abd (because of glute involvement) while FAI does not have this weakness
What test would cause pain for gluteal teinopathiy (special test)
Ober test
think about the abduction the pt needs to go into for that
What muscle group is involved in gluteal teindopathy?
Glutes (not just glute med but i’d say thats the most involved)
Why might a trendelnburg gate be involved w/ greater trochanteric bursitits?
because it invovles a weak glute med
also IT band tightness can be involved because it crosses over
Why might gerdys tubercle be painful w/ greater trochanteric burstits?
Because the IT band is affected (tight) w/ this and it inserts on gerdys
20 year old pt walks into clinic complaining of lateral hip pain. What do they most likely have
We know that FAI presents in pts that are younger so we would pick this instead of the greater troachnteric pain syndrome (those pts are typically 40-60 and more obese)
20 year old pt walks into clinic complaining of latearl hip pain after traumatic fall. What do they most likely have.
Greater trochanteric pain syndrome
while they are part of the younger population that traumatic MOI makes clues us in here
What nerve passes deep to the piriformis?
Sciatic nerve
Pregnant indivudal has pressure on a nerve. which one is it?
Obturator (think about where it comes out / innervates)
Femur / pelvis fractures / dislocations would most likely affect which nerve?
femoral nerve
Weakness in knee flexion is led back to what nerve?
sciatic nerve tibial division
what nerve causes adductor weakness / sensory loss medial thigh if damaged?
obturator
pt has obturator nerve damage. What gait pattern do they use and why
circumduction
this is a typical pattern fro adductor weakness (take it out wide so that gravity pulls it back in)
What most likely causes damage to femoral n
gynecological intervention (urologic / pregnancy)
this is because its put on stretch w/ this
pt presents w/ weak hip flexion / knee extension. What nerve problem do they most likely have
femoral
What special test do we do to test femoral n?
Elys test (this is the test that does rec fem)
