Musculoskeletal: LE Flashcards
hip joint
ball and socket synovial joint
- head of femur (ball)
- Acetabulum (socket) is part of pelvis
Hip and Pelvis: anterior landmarks
- Iliac crest: at level of approx. L4
- Iliac tubercle: widest part of the crest
- Anterior superior iliac spine (ASIS)
- Pubic symphysis
Hip and Pelvis: posterior landmarks
- Posterior superior iliac spine: at level of S2
- Sacroiliac joint
- Ischial tuberosity (“sits bone”)
- Greater trochanter of the femur and trochanteric bursa
hip bursae
- trochanteric bursa is largest
- ischial bursa posterior
ischial bursitis
pt. has history of tenderness with sitting on hard surface on the sits bone; usually thin, boney frame
trochanteric bursitis
enderness of the bursa with radiation into the anterior/lateral thigh
Sciatic nerve
- Sciatic nerve: exits posteriorly via the sacroiliac notch just below sacroiliac joint
- “Hip pain” may actually be referred from the back
- True sciatica radiates pain below the knee
- Check straight leg raise for lumbar radiculopathy
inspection of the hip
gait; symmetry, atrophy, skin, deformity; leg length discrepancy
If patient is not ambulatory and/or in severe pain inspect for one leg shorter and hip rotated (hip displaced)
palpation of the hip
iliac crest, ASIS, greater trochanter, inguinal ligament, PSIS, SI joints, ischial tuberosity, bursae
active ROM and strength of hip
flexion, extension, abduction, adduction, internal and external rotation
movement of the hip
- Flexion
- -Iliopsoas
- Extension
- -Gluteus maximus
- Abduction
- -Gluteus minimus/medius
- Adduction
- -Adductor muscles
- Internal Rotation
- -Gluteus medius/minimus
- External Rotation
- -Lateral rotator group
Knee joint consists of three bones
femur, tibia, patella
three compartments to knee
- Medial compartment
- Lateral compartment
- Patellofemoral compartment
patellar tendon
- Inserts on tibial tuberosity
- Patellar tendon tenderness or inability to extend knee may suggest complete or partial tear of patellar tendon
- -High riding patella
- Patellar tendon tear most often associated with running and jumping activities and higher risk if a person has pre-existing tendonitis (if you are told you have patellar tendonitis– rest, don’t run or jump!)
ligaments of the knee
- Medial collateral (MCL)
- Lateral collateral (LCL)
- Anterior cruciate (ACL)
- Posterior cruciate (PCL)
meniscus
- Crescent shaped fibrocartilaginous disc: medial and lateral
- Palpable along joint line
- Medial meniscus more commonly injured-usually valgus stress
exam of the knee
- Inspection: swelling, deformity, quadriceps atrophy
- Palpation: femoral and tibial condyles, joint line (medial and lateral), patella, tibial tuberosity, posterior aspect of knee
- ROM & Strength: flexion (hamstrings), extension (quads)
- Special Tests:
- -Balloon, Ballottement or Bulge Signs if suspect effusion
- -McMurray’s Sign
- -Ligament Stability Tests
effusions
- Joint Effusion: fluid in synovial joint cavity
- Assess for Balloon, Ballottement, and Bulge signs
- Differentiate from Pre-patellar bursitis: fluid in patellofemoral compartment (not an effusion) or swelling associated with osteoarthritis
bulge sign
milk effusion inferiorly and laterally then tap on the lateral margin to assess for fluid bulge toward the medial margin
balloon sign
compress suprapatellar pouch downward and feel for fluid wave around the patella (medially and laterally)
ballottement sign
compress suprapatellar pouch then push “ballot” patella and watch for return of fluid to the pouch
special test for the knee
- Test for patellofemoral syndrome:
- -Patellofemoral grind test
- Tests for effusion:
- -Bulge Sign
- -Balloon Sign
- -Balloting the patella
- Tests for ligament stability:
- -Varus and Valgus stress tests: LCL, MCL
- -Lachman’s: ACL
- -Anterior drawer: ACL
- -Posterior drawer: PCL
- -McMurray’s: meniscus
patellofemoral syndrom
nonspecific term for pain in front/center of knee, can be from chondromalacia patella, patellar tendonitis; to perform grind test, have patient extend leg fully, put pressure on the knee and have the patient flex the quadriceps; a positive test will cause grinding and pain under the patella.
ACL tear
common in sports injuries, usually associated with effusions immediately following the injury
For the anterior drawer test, the patient assumes a supine position with the injured knee flexed to 90 degrees. The physician fixes the patient’s foot in slight external rotation (by sitting on the foot) and then places thumbs at the tibial tubercle and fingers at the posterior calf. With the patient’s hamstring muscles relaxed, the physician pulls anteriorly and assesses anterior displacement of the tibia (anterior drawer sign).
lachman test
assessing the integrity of the anterior cruciate ligament. The test is performed with the patient in a supine position and the injured knee flexed to 30 degrees. The physician stabilizes the distal femur with one hand, grasps the proximal tibia in the other hand, and then attempts to sublux the tibia anteriorly. Lack of a clear end point indicates a positive Lachman test.
posterior drawer test
patient assumes a supine position with knees flexed to 90 degrees. While standing at the side of the examination table, the physician looks for posterior displacement of the tibia (posterior sag sign). Next, the physician fixes the patient’s foot in neutral rotation (by sitting on the foot), positions thumbs at the tibial tubercle, and places fingers at the posterior calf. The physician then pushes posteriorly and assesses for posterior displacement of the tibia
valgus stress test
performed with the patient’s leg slightly abducted. The physician places one hand at the lateral aspect of the knee joint and the other hand at the medial aspect of the distal tibia. Next, valgus stress is applied to the knee at both zero degrees (full extension) and 30 degrees of flexion. With the knee at zero degrees (i.e., in full extension), the posterior cruciate ligament and the articulation of the femoral condyles with the tibial plateau should stabilize the knee; with the knee at 30 degrees of flexion, application of valgus stress assesses the laxity or integrity of the medial collateral ligament.
varus stress test
physician places one hand at the medial aspect of the patient’s knee and the other hand at the lateral aspect of the distal fibula. Next, varus stress is applied to the knee, first at full extension (i.e., zero degrees), then with the knee flexed to 30 degrees. A firm end point indicates that the collateral ligament is intact, whereas a soft or absent end point indicates complete rupture (third-degree tear) of the ligament.
McMurray test
physician grasps the patient’s heel with one hand and the knee with the other hand. The physician’s thumb is at the lateral joint line, and fingers are at the medial joint line. The physician then flexes the patient’s knee maximally. To test the lateral meniscus, the tibia is rotated internally, and the knee is extended from maximal flexion to about 90 degrees; added compression to the lateral meniscus can be produced by applying valgus stress across the knee joint while the knee is being extended. To test the medial meniscus, the tibia is rotated externally, and the knee is extended from maximal flexion to about 90 degrees; added compression to the medial meniscus can be produced by placing varus stress across the knee joint while the knee is being extended. A positive test produces a thud or a click, or causes pain in a reproducible portion of the range of motion.
ankle joint anatomy
hinge joint
tibia
fibula
talus
landmarks of the ankle
Medial malleolus (tibia) Lateral malleolus (fibula) Calcaneus (heel)
ankle and foot joints
Ankle (Tibiotalar) joint
Subtalar (Talocalcanea) joint
Transverse Tarsal joint
Metatarso-phalangeal (MTP) joints
ankle and foot ligaments
- Medial
- -Deltoid ligament
- Lateral
- -Anterior talofibular ligament
- -Calcaneofibular ligament
- -Posterior talofibular ligament
- Posterior
- -Achilles tendon
Most common injury is ankle sprain with inversion and tear of lateral ligaments (usually ATFL)
inspection of the ankle and foot
Inspection: swelling, deformity, callus or wound
palpation of the ankle and foot
Palpation: malleoli, ligaments (medial and lateral), Achilles tendon, joints of ankle and toes
ROM of ankle and foot
ROM: dorsiflexion, plantar flexion, inversion and eversion of the ankle; flexion, extension, abduction, adduction of the toes
Strength of ankle and foot
Strength: dorsiflexion, plantarflexion, inversion and eversion of the ankle; dorsiflexion, plantarflexion of the great toe
movement of ankle: dorsiflexors
Tibialis anterior
Extensor digitorum and hallucis
movement of ankle: plantarflexors
Gastrocnemius
Flexor digitorum and hallucis
movement of ankle: everters
peroneus muscles
movement of ankle: inverters
tibialis anterior and posterior
thompson test
assesses integrity of achilles tendon
anterior drawer test
ATFL stability
