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183 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Adductor tubercle
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1. Arises off the superior crest of the medial
epicondyle 2. Attachment site to improve mechanical advantage |
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Medial and Lateral Tibial plateaus |
Medial-concave in both frontal and sagittal planes. 50% larger than the the lateral TP
Lateral- concave :frontal convex:sagittal |
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Tibiofemoral- double condyloid joint |
1. flex+ext 2.int+ext rotation 3. abd+add
ant and post translation |
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arthrofibrosis |
hypomobile joint b/c of scar tissue formation in joint |
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MCL: Deep layer |
Thickened part of the joint capsule. Attaches to medial meniscus Taut: slight flexion & Full Extension
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MCL: Anterior/superficial layer |
Separated by bursa from deep layer. Taut: full extension |
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MCL |
Primarily acts to protect the knee from Valgus forces & provides secondary restraint against external rotation of the tibia and anterior translation of the tibia on the femur
O: Just below adductor tubercle I: just below attachment of pes anserine |
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LCL |
-Primary stabilizer of the lateral aspect of the knee -No attachment to joint capsule of the knee -extracapsular structure -Protects knee from varus forces when knee is between 0 deg ext & 30 deg flex |
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What knee system(med or lat) is stronger and why? |
Lateral: subjected to increased stress during the initial contact phase of gait when the knee is extended and WB- placing varus forces on the joint
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Cruciate ligaments |
Located outside of the synovial capsule, even thought intraarticular -help to stabilize the knee vs. valgus and varus forces |
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ACL: Origin & Insertion |
Arises from the anteromedial intercondylar eminence of the tibia, travels posteriorly, and passes lateral to the PCL to insert on the medial wall of the lateral femoral condyle |
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ACL: function |
Static stabilizer vs. -ant translation of the tib on fem -int rot of the tib on fem ext rot of the tib on fem hyperext of the tibiofemoral joint |
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ACL:Biomenchanics of Bundles |
Knee EXT: the femoral attachment site of the anteromedial bundle is proximal to the attachment site of the posterolateral bundle Knee FLEX: attachment sites juxtapose position, causing ACL to wind upon itself
Anteromed: taut when fully flexed Posterolat: taut when fully extended |
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Positions the put great strain on ACL |
-PROM: final 15 deg of ext- int rot tibia Valgus & varus stresses
-Active/Open Chain: the pull of the quad translates the tibia ant the amount of strain is greatest between 0-30 deg of flex + adding resistance through the arc of ext- when the knee extends from 45 to 0 deg of flex
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PCL:Origin and Insertion |
O:Posterior aspect of the tibia and takes superior and anterior course passing medially to ACL
I: Lateral portion of femoral condyle |
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PCL: Function |
Stronger & 120-150% wider than ACL
Primary restraint against post displacement of tibia on femur Secondary restraint against external tibial rotation
augmented by meniscofemoral ligaments |
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PCL: Bundles |
Anterolateral: taut @ knee flex
Posteromedial: lax @ knee flex Tightens @ knee ext |
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PCL: blood supply |
middle geniculate artery (limited) |
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Meniscofemoral ligaments |
Humphrey Wrisberg |
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Primary restraint against posterior displacement of the tibia and femur |
Popliteus posterior capsule Other joint structures |
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Screw home mechanism |
ACL & PCL wind up on each other in FLEX UNwind in EXT |
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PLC |
Posterolateral corner
Provides stability vs. varus stress, ext tib rot, and & post forces
lateral complex/ posterolateral complex
"dark side of the knee" |
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PLC: Superficial Structures |
Lateral fascia IT band Biceps Femoris tendon
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PLC: Middle structures
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Patellar retinaculum Patellofemoral ligament
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PLC:Deep structures |
Joint capsule LCL Arcuate ligament ********* Popliteofibular ligament Fabellofibular ligament Popliteus tendon |
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Popliteofibular ligament |
Y shaped O: Tibia + Fibula I: Femur
Key stabilizer vs. post translation, varus forces and ext rotation |
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Popliteus Complex: structures |
formed by: -popliteus muscle + tendon -popliteofibular ligament -popliteotibial fasicle -popliteomeniscal fasicles
attaches to the post horn and middle post portions of lat meniscus
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Popliteus Complex: function |
resist ext tibial rot between 20 & 130 deg of knee flex |
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Arcuate ligament |
arising from fibular head- passes over popliteus muscle, where it diverges into the intercondylar area of the tibia and post aspect of the femurs lat epicondyle
assists cruciate ligaments in controlling PLRI
Injury to this area- increased ext rot of tib |
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Fabella
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lies within the lateral head of the gastrocnemius muscle; fabellofibular ligament attaches from fabella to fibular head increasing thickness of tissues on posterolateral corner |
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Menisci:functions |
-Deepen articulation and fill the gaps that normally occur during the knee's articulation, increasing load transmission over a greater % of the joint surfaces, -improve lubrication for the articulating surfaces -provide shock absorbtion -increase passive joint stability -limit extremes of flexion and extension -serve as proprioceptive organs |
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Medial meniscus |
half crescent: C shape, wider posteriorly than anteriorly.
attached by at peripheries to the tibia via coronary ligaments |
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Lateral meniscus |
Circular in shape
smaller and more mobile- attached to femur via meniscofemoral ligaments and popliteus muscle via the joint capsule and coronary ligament
attached by at peripheries to the tibia via coronary ligaments |
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The _______________ of each meniscus are joined by the _______________ ligament and connected to the patellar tendon via _________________ ligaments |
1. anterior horns 2. transverse 3. patellomeniscal |
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When does the meniscus become avascular and what portion? |
9 months old. 1/3 |
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Pes anserine |
gracilis, sartorius, semitendinosis
-flexes knee and internally rotates tibia when foot is not planted on the ground
- foot is fixed- they externally rotate the femur on the fixed tibia
-sartorius assists in flexion, ext rot, abd of the hip |
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Line of pull of IT band |
Full extension of the knee: that of a knee extensor
Flexed past 30 degrees: assumes angle of a flexor |
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IT band |
I:Gerdy's tubercle
Relatively insignificant knee motion
(deep distal fibers) Plays a significant role in lateral knee stabilization |
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What unlocks the knee during WB? |
contraction of: Popliteus, semimembranosis, semitendinosis muscles |
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To initiate flexion in the knee_______________ |
it must be unlocked by the tibia internally rotating relative to the femur (popliteus) |
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Nerve roots that supply the knee |
L3, L4, L5, S1, S2 |
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Anterior nerve innervations |
anterior cutaneous branches of the Femoral nerve infrapatellar branch of Saphenous nerve |
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Medial nerve innervations |
Saphenous nerve
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Posterior nerve innervations |
posterior cutaneous branches of the Cluneal nerve |
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Lateral nerve innervations |
Sural cutaneous |
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______ Pain that may mimic that caused by a strain of the medial or lateral origin of the gastroc |
PCL |
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sensation of giving way without buckling is usually related to... |
pain quad weakness/ inhibition patellofemoral joint disease
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true locking (inability to extend the knee) indicates |
unstable meniscal tear subluxation of post horn of meniscus loose body like osteochondral fragment within the joint that wedges between the femur and tibia -- locking the joint |
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catching or crepitation more accurately indicated... |
patellofemoral joint disease |
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chronic onset of injury arises secondary to... |
training errors foot type shoe type postural deviations hip pathology foot biomechanics |
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following injury- what is the relaxed position that maintains the knee in resting position |
30 degrees of flexion- shortens stance phase and minimize stress on involved structures |
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Ruptured patellar tendon |
unilateral high riding patella + quad spasm |
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Indicators of intra-articular effusion |
LOSS of: concave depressions on both sides of the patella when the patient is supine & knee is extended |
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Patellar Tendon Pathologies |
Swelling over or directly around: Tendonopathy or Bursitis
Swelling on both sides that masks definition: inflammation of underlying fat pad |
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Normal angle of Tibia on Femur |
180-185 |
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baker's cyst |
only involve bursa of semimembranosus and medial head of gastroc |
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Palpation of anterior structures |
Patella Patellar tendon Tibial tuberosity Quadriceps Quad tendon Sartorius |
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Palpation of medial structures
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Medial meniscus Medial joint line MCL Medial femoral condyle + epicondyle Medial tibial plateau pes anserine tendon + bursa Semitendinosus tendon gracilis
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Palpation of lateral structures |
Joint line Fibular head LCL popliteus biceps femoris IT band lateral femoral condyle |
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Palpation of posterior structures
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popliteal fossa Hamstring muscle group
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Acute injury aspiration |
dark red -- bleeding |
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Cyclops lesion |
Scar tissue formation in anterior intracondylar notch
fibrous nodules creating a mechanical block/ capsulitis |
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Limited knee flexion occurs when |
Hip is fully extended |
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Lachman's test tends to isolate what? |
posterolateral bundle of ACL |
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Grading systems for PCL |
I- palpable but diminished step off between tibia and femur 0-5mm of displacement
II- Step off is lost, tibia can't be pushed beyond medial femoral condyle; 5-10 mm displacement
III- step off is lost; tibia can't be pushed beyond medial femoral condyle; >10 mm displacement |
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Primary structure for resisting Valgus forces: Knee flexed 25 degrees |
MCL
Extended- indicator of MCL sprain or fracture of femoral epiphysis in younger patients |
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Primary structure for resisting Varus forces: knee flexed 25 degrees |
LCL
Extended- indicator of LCL or distal femoral epiphysis fracture in younger patients |
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(SUPINE) special tests |
Anterior Drawer Posterior Drawer Quad Active Test External Rotation Recurvatum Posterior Sag / Godfreys Slocum Drawer Hughstons Posterolateral Hughstons Posteromedial Hughstons Plica Flexion Rotation drawer Lachman's Valgus Varus Pivot Shift (Jerk) Reverse Pivot Shift Dynamic Posterior shift Steinmans tenderness displacement McMurray Nobels compression Sweep Ballotable
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(SIDE LYING) special tests |
Slocum ALRI Obers |
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(PRONE) special tests |
Apley's compression and distraction External Rotation (Dial) Prone Lachman's |
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(SHORT SITTING) Special tests |
Wilson's
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(STANDING) special tests |
Crossover Thessaly Renne's |
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Lateral joint play
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Proximal Tibiofibular syndesmosis |
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MOI: Valgus force |
MCL Medial joint capsule pes anserine muscle group Medial meniscus
(compressive forces - lateral meniscus) |
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MOI: Varus |
LCL Lateral joint capsule IT band Biceps femoris
(compressive forces- medial meniscus) |
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MOI: Anterior Tibial displacement |
ACL IT band LCL MCL Medial and lateral joint capsules
(compressive forces: posterior portion of the medial and lateral meniscus)
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MOI: Posterior Tibial Displacement |
PCL Meniscofemoral ligaments Popliteus Medial and lateral joint capsules
(compressive forces: Anterior portion of the medial and lateral meniscus) |
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Internal tibial Rotation |
ACL Anterolateral joint capsule Posteromedial joint capsule Posterolateral joint capsule LCL
(compressive forces: Anterior horn of medial meniscus & Posterior horn of lateral meniscus)
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External tibial rotation |
Posterolateral joint capsule anteromedial joint capsule MCL PCL LCL ACL
(Compressive forces: Anterior horn of lateral meniscus, Posterior horn of medial meniscus) |
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Hyperextension |
ACL Posterior Joint Capsule PCL
(Compressive forces: Anterior portion of the medial and lateral meniscus) |
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Hyperflexion
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ACL PCL
(compressive forces: Posterior portion of the medial and lateral meniscus) |
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Deltoid ligament |
Anterior Tibiotalar Tibiocalcaneal Posterior Tibiotalar Tibionavicular |
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Anterior Tibiotalar |
Anteromedial portion of the tibias malleolus to superior portion of the medial talus |
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Tibiocalcaneal |
apex of the medial malleolus to calcaneus directly below medial malleolus |
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Posterior tibiotalar |
spans posterior aspect of medial malleolus attaching on the posterior portion of the talus |
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Tibionavicular |
inserts on the medial surface of the navicular to limit lateral translation and lateral rotation of the tibia on the foot |
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What is TAUT in the subtalar joint when plantarflexed |
ATT TN |
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What ligaments tighten during dorsiflexion |
TC PTT |
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Immobile joint which 2 bones are bound together by ligaments |
Syndesmosis joint |
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Stieda's process |
appears 8-13 y/o
7% of population |
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When is Os trigonum formed? |
Steida's process separates from the talus |
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Distal tibia joint play: Implications |
Sprain of the distal tibiofibular syndesmosis |
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Distal tibia joint play: Extensor mechanism |
formed by the quads and patellafemoral joint responsible for causing extension of the lower leg at the knee joint |
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Medial Knee joint reinforcements |
MCL Medial patellofemoral ligaments medial patellar retinaculum
laterally augmented: the LCL lateral patellar retinaculum lateral patellofemoral ligament IT band
Posteriorly by the posetrolateral corner
anteriorly by the patella tendon |
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McMurray's special test |
Positive test: popping, clicking or locking of the knee, pain eminating from the menisci or sensation to that experienced with ambulation
Implications: meniscal tear on the side of the reported symptoms |
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Predisposing factors to ACL Ligament injuries Extrinsic to the knee |
Sport specific body motions muscle strength muscle fatigue muscular activation and coordination athletic skill coordination the shoe surface interface hyperpronation of the foot anterior pelvic tilt anteroverted femur wider pelvis to femoral length ratio menstral cycle history of an immediate family member female
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Predisposing factors to ACL ligament injuries Intrinsic to the knee
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joint laxity
limb alignment narrow intercondylar notch width small size of the ACL genu recurvatum |
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Kleiger's |
External rotation test Used to determine injury to the deltoid ligament caused by ROTATIONAL stress + syndesmosis sprain + deltoid ligament involvement: medial joint pain- examiner may feel displacement of the talus away from the medial malleolus
syndesmosis involvement: pain is described in the anterolateral ankle at the site of the distal tibiofibular syndesmosis |
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Kleiger's implications |
Medial pain: trauma to deltoid ligament
Pain in the area of the anterior or posterior tibiofibular ligament should be considered syndesmosis pathology unless determined otherwise
fracture to the distal fibula |
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Anterior Drawer Test |
used to determine the integrity of the ATF |
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Inversion stress trest |
used to determine if the calcaneofibular ligament has been injured- also stresses the anterior and posterior talofibular ligaments |
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Eversion stress test |
used to evaluate injury to the deltoid ligament |
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Synostosis |
union of 2 bones through the formation of connective tissue |
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Maisoneuve fracture |
Spiral fracture of the proximal 1/3 of the fibula with concurrent disruption of the distal tibiofibular syndesmosis |
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Pott's fracture |
bimalleolar fracture |
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Tarsal coalition |
bony, fibrous, or catoliginous union between 2 or more tarsal bones |
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Peroneal spastic flat foot |
lowering of the medial foot caused by spasm of the peroneous longus muscle |
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Tarsal coalition clinicall exhibited as |
rigid flat foot with calcaneal valgus and abduction of the forefoot that is unchanged when the patient is in a WB position |
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Bony surface of the TARSAL TUNNEL |
tibia talus calcaneus
roof formed by the flexor retinaculum |
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Trarsal tunnel syndrome caused by |
entrapment of the posterior tibial nerve or one of its medial or lateral branches as it passes through the tarsal tunnel |
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What predisposes TTS |
Rear foot varus coupled with excessive pronation increased internal rotation of the tibia hypermobility of the medial longitudinal arch
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Pivot shift implications |
ACL Anterolateral capsule LCL Biceps femoris Lateral meniscus Popliteus Posterolateral capsule |
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Positive test for Pivot shift test |
Tibia's postion on the femus reduces as the leg is flexed in the range 30-40 degrees
jerk test: during extension, the anterior subluxation is felt in the same range |
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Slocum drawer |
Rotational knee instability
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Slocum drawer positive test |
increased amount of anterior tibial translation compared to the opposite side OR lack of a firm endpoint |
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Implications of Slocum drawer |
Test for ALRI: damage to ACL Anterolateral capsule LCL ITband Popliteus tendon Posterolateral complex lateral meniscus
test for AMRI: damage of the MCL anteromedial capsule pes anserine medial meniscus |
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5 P's describe signs and symptoms of compartment syndrome |
Pain Pallor Pulselessness Paresthesia Paralysis |
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Anatomic factors that predispose someone to have CCS |
Herniation of the muscle, occluding the neurovascular network as it transverses the interosseous membrane
Fascia's failing to accomodate the increase on the muscle volume during exercise
excessive hypertrophy of the muscles within an otherwise normal fascial network
Increased capillary permeability
Post exercise fluid retention
decreased venous return |
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Tibiofemoral alignment |
genu valgum- tibia angled medially more than 5 degrees relative to the femur
genu varum- tibia angled laterally more than 5 degrees relative to the femur
genu recurvatum- tibiofemoral extension freater than 0 |
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Quadriceps active test |
+ anterior translation of the tibia on the femur
Impications- grade II or III PCL sprain |
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ALRI = |
trauma to both ACL and lateral extraarticular restraints( LCL, IT Band, Biceps femoris, and lateral meniscus) |
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ALRI specific tests |
pivot shift test slocum ALRI Flexion rotation drawerSL |
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Slocum drawer + crossover test |
used to determine ALRI & AMRI |
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Slocum- isolates |
AM or AL joint capsule |
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Anteromedial structure instability |
ACL AM capsule MCL pes anserine medial meniscus posteromedial capsule |
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Anterolateral structural instability
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ACL
Anterolateral capsule LCL IT band biceps femoris lateral meniscus popliteus posterolateral capsule |
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Posteromedial structural instability |
posterior oblique ligament MCL semimembranosis anteromedial capsule |
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posterolateral structural instability |
posterolateral complex LCL Biceps femoris
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Crossover test |
used to determine rotational instability of the knee |
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Allograft |
tissue used to replace ligament are harvested from a CADAVER |
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Autograft |
the tissues used to replace the ligament harvested from the PATIENTS body |
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Example of MOI of PCL |
landing on anterior tibia while the knee is flexed can drive the tibia posteriorly |
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Reliable tests for PCL |
Posterior drawer Sag test
*reliable and sensitive in ID presence of chronic PCL sprains |
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Slocum ALRI |
Appreciable "clunk" or instability as the lateral tibial plateau subluxes or pain/instability |
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Slocum ALRI implications |
tear of ACL LCL anterolateral capsule arcuate ligament complex biceps femoris tendon IT band
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vascular (RED zones) of menisci |
outer rim and anterior and posterior horns
10-25% lateral meniscus 10-30% medial meniscus |
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avascular (white zones) of menisci |
inner portion |
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What joins the anterior horns of each meniscus |
transverse ligament and connected to patellar tendon via patellomeniscal ligaments |
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Knee extension patellomeniscal ligaments pull... |
lateral meniscus anteriorly; early stages of flexion popliteus puls lateral meniscus posteriorly; later ROM meniscofemoral ligament pulls posterior horn medially and anteriorly |
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Classifications of meniscal tears |
vertical longitudinal oblique degenerative transverse (radial) horizontal |
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Osteochondral defects |
fractures of the articular cartilage and underlying bone that are typically caused by compressive and shear forces |
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Wilson's test |
used for presence of OCD on knee's articular surface |
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Nobel's compression test |
+ pain under thumb - most commonly when knee is 30 degrees of flexion |
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Implications of Nobel's test |
Inflammation of the IT band associated burse Inflammation of the lateral femoral condyle |
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Lateral compartment of the ankle |
-Peroneous longus- most superficial -peroneous brevis lies beneath PL (both peroneals are held in place by superior and inferior peroneal retinaculum) -superficial peroneal nerve Peroneal artery arises off tibial artery
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Dial test |
External rotation |
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Dial test (positive findings)
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increase in external rotation greater than 10 degrees |
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Dial test implications |
difference of 30 degrees of flexion but not at 90 degrees: injury isolated to the posterolateral corner of the knee
30degree: PCL, posterolateral knee structures, posterolateral corner
90degree: isolated PCL sprain |
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Paratenon |
HIGHLY vascular structure |
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Paeritendinitis |
inflamation of a paratenon |
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tendinosis |
degeneration of the tendon's substance starting with microscopic tears and necrotic areas within the tendon as a result of decreased blood flow throughthe paratenon |
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Achilles degeneration |
peritendinitis or tendinosis to tendon rupture |
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ANatomic factors that leaf to onset of Achilles pathology |
tibial varum Calcaenovalgus hyperpronation tightness of triceps surae+hamstrings |
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Inversion stres test |
TALAR TILT |
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TALAR TILT positive tests |
Talus tilts or gaps excessively compared with the uninjured side or pain is produced
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Talar tilt implications |
calcaneofibular ligament anterior talofibular and posterior talofibular ligament |
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Prone lachmans can be used to differentiate |
abnormal tibiofemoral glide caused by tears of the ACL from that caused by PCL deficiencies |
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Test for posterior instability |
posterior sag posterior drawer test Godfrey's |
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Test for medial instability |
valgus stress test (full ext+30 deg flexion)t |
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tests for lateral instability |
varus stress test (extended and 30 degrees of flexion (isolates LCL))
Fully extended may indicate distal femoral epiphysis in a younger patient |
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Patellar dislocation usually occur |
laterally |
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Subluxating peroneal tendons caused by rupture of stretching of retinaculum... |
change the angle of pull to that of a dorsiflexor |
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Reverse pivot shift test |
+: (clunk) of the tibia on the femur
implications: posterolateral rotary instability and/ or trauma to the posterolateral corner |
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Predisposition to IT band friction syndrome |
genu varum pronated feet LLD lateral heel strike conditions causing internal tibial rotation activities causing overstriding large lateral femoral epicondyle |
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Ober's test |
IT band tightness |
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CCS |
Chronic exertional compartment syndrome
recurrent or intermittent claudication occurs secondary to anatomic abnormalities obstructing blood flow in exercising muscles |
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claudication |
pain caused by inadequate venous drainage or poor arterial innervation sy |
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subcutaneous calcaneal bursa |
located between the posterior aspect of the Achilles tendon and the skin;;;;
forms PUMP BUMPS |
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Retrocalcaneal bursitis |
forms pump bumps |
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Talocrural joint must provide |
10 degree of dorsiflexion and 15 degree during running as te opposite limb goes from stance phase to swing phase |
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AROM plantar flexion |
50 degrees |
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AROM Dorsiflexion |
0-20 degrees |
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Ankle mortice |
distal articular surface of tibia and its medial malleolus fibulas lateral malleolus talus |
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Achilles insertion site |
Calcaneal tubercle |
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Navicular serves |
Insertion of post tibialis supports medial longitudinal arch via plantar calcaneonavicular spring ligament |
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Calcaneofibular ligament |
extracapsular structure |
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Ligaments in the joint capsule of ankle |
anterior and posterior talofibular |
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Only fibular shaft is fractured |
Hugier or High Dupuytren fracture |
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Anatomic and physiologic ankle sprain predisposition |
decreased proprioceptive ability decreased muscular strength lack of muscular coordination all factors are associated with a history of multiple sprains |
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Where can a chondral defect be present |
articulating surfaces of the superior portion of the anteromedial talus and ot the inferior portion of the anteromedial tibia |
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Sinus tarsi |
after injury to the ATF or fractures about the ankle this area fills up with fluid resulting in a loss of normal indentation in the proximal foot |
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Iliopsoas |
Pain in the femoral triangle or anterior hip |
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Adductor Tubercle |
1. Arises off the superior crest of the medial epicondyle 2. Attachment site to improve mechanical advantage |
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