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313 Cards in this Set
- Front
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Review LE Anatomy
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From Anatomy, else p 17-24 of winter OMM book.
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"Hip is Slapping"
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Tenor Fascia Lata
Origin: Anterior External Lip of Iliac Crest Insertion: Gredy's Tubercle of Tibia [Innervation: Superior Gluteal Nerve L4&5] Action: Flexes, medially rotates and abducts hip Dysfnx: Knee, Buttock, Upper Thigh, &/Lateral Hip Pain May present as Sciatica |
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Troublemaker of the Hamstrings
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Biceps Femoris
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Hamstring Injury
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Typically "burst" activity
6-12 weeks recovery minimum the more proximal the injury, the longer the recovery time |
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Congenital Dislocation of the Hip
Presentation, Findings |
Presentation: Asymmetry of Gluteal Skin Folds, One leg seems shorter, limited abduction, +Ortolani's sign.
Ortolani: provocative test trying to dislocate the hip: positive "clocks" with reduction as it is FABER'ed |
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Ortolani's Sign
Pathology, Pt, Findings |
provocative test trying to dislocate the hip: positive "clocks" with reduction as it is FABER'ed
Indicative of Congenital Dislocation of the Hip Presentation: Asymmetry of Gluteal Skin Folds, One leg seems shorter, limited abduction, +Ortolani's sign. |
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Newborn with Assymetrical Gluteal Skin Folds
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Congenital Dislocation of the Hip
Presentation: Asymmetry of Gluteal Skin Folds, One leg seems shorter, limited abduction, +Ortolani's sign. Ortolani: provocative test trying to dislocate the hip: positive "clocks" with reduction as it is FABER'ed |
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Legg-Calve-Perthes' Disease
Pathology, Pt, Findings |
Avascular Necrosis of Femoral Epiphysis
Males 8 yo (±4) Unilateral Antalgic Gait (shortened stance phase = pain on weight bearing) + Elevated Sed Rate Thomas Test Positive Limited Addxn, Extens'n, Internal Rotation; Disuse Atrophy in Upper Thigh "Ratty-Looking" XR |
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Antalgic Gait
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Gait Abnormality wherein stance phase is markedly reduced relative to swing phase. Indicative of pain on weight bearing.
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Avascular Necrosis of Femoral Epiphysis
Disease, Pt, Findings |
Legg-Calve-Perthes' Disease
Males 8 yo (±4) Unilateral Antalgic Gait w/+ Elevated Sed Rate Thomas Test Positive Limited Addxn, Extens'n, Internal Rotation; Disuse Atrophy in Upper Thigh "Ratty-Looking" XR |
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Antalgic Gait in an 8 yo Male
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Legg-Calve-Perthes' Disease: Avascular Necrosis of Femoral Epiphysis
Males 8 yo (±4) Unilateral Antalgic Gait (shortened stance phase = pain on weight bearing) + Elevated Sed Rate Thomas Test Positive Limited Addxn, Extens'n, Internal Rotation; Disuse Atrophy in Upper Thigh "Ratty-Looking" XR |
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Slipped Capital Femoral Epiphysis
Pathology, Pt, Findings, Prognosis |
Obese, Sexually Underdvlpd Male 12 yo (±3) w/ Female Fat Distribution & Antalgic Gait
Generalized limitation of hip motion XR: Frog Leg w/ + Kline Line "looks like Ice Cream falling off a cone" likely bilateral (40%); Progresses to Coxa Vera |
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Limited Addxn, Extensn, Inetrnal Rotation
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Legg-Calve-Perthes' Disease: Avascular Necrosis of Femoral Epiphysis
Males 8 yo (±4) Unilateral Antalgic Gait (shortened stance phase = pain on weight bearing) + Elevated Sed Rate Thomas Test Positive Limited Addxn, Extens'n, Internal Rotation; Disuse Atrophy in Upper Thigh "Ratty-Looking" XR |
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Antalgic Gait in a 12 yo Male
Pathology, Pt, Findings, Prognosis |
Slipped Capital Femoral Epiphysis. Pt is Obese, Sexually Underdvlpd Male 12 yo (±3) w/ Female Fat Distribution & Antalgic Gait
XR: Frog Leg w/ + Kline Line "looks like Ice Cream falling off a cone" Generalized limitation of hip motion likely bilateral (40%); Progresses to Coxa Vera |
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Hip Pain with "Ratty-Looking" XR
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Legg-Calve-Perthes' Disease: Avascular Necrosis of Femoral Epiphysis
Males 8 yo (±4) Unilateral Antalgic Gait + Elevated Sed Rate Thomas Test Positive Limited Addxn, Extens'n, Internal Rotation; Disuse Atrophy in Upper Thigh "Ratty-Looking" XR |
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Kline Line
Pathology, Pt, Findings, Prognosis |
Frog Legged XR Finding: + Kline Line "looks like Ice Cream falling off a cone"
Slipped Capital Femoral Epiphysis: Obese, Sexually Underdvlpd Male 12 yo (±3) w/ Female Fat Distribution & Antalgic Gait Generalized limitation of hip motion likely bilateral (40%); Progresses to Coxa Vera |
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Limitation of Hip Motion in General
Pathology, Pt, Findings, Prognosis |
Slipped Capital Femoral Epiphysis
Obese, Sexually Underdvlpd Male 12 yo (±3) w/ Female Fat Distribution & Antalgic Gait XR: Frog Leg w/ + Kline Line "looks like Ice Cream falling off a cone" likely bilateral (40%); Progresses to Coxa Vera |
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Ischiogluteal Bursitis
Pt, Presentation, DDx |
Sedentary Adults with Point tenderness over ischial tuberosity relieved with standing
DDx: Proximal Hamstring Strain Indication for PLT S/CS: Posterolateral Trochanter Point: near tendinous insertion of Sartorius: 1-2 inches caudad & slightly medial to ASIS, Muscles: Piriformis tendon insertion Tx:Pt prone, doc on same, extend, abduct and extenrally rotate. ExtRot via Doc's knee under thigh and allowing pt's thigh to roll down |
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Sedentary Adults with Point tenderness over ischial tuberosity relieved with standing
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Ischiogluteal Bursitis
DDx: Proximal Hamstring Strain |
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Trochanteric Bursitis
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Point Tenderness over Greater Trochanter
Pain radiates Down Lateral Aspect of Leg, increases w/ Weight Bearing or Walking Causes: ITB Syndrome, Ileocecal Chapman's Point on Right, Sigmoid Chapman's Point on Left; Piriformis Syndrome, Gluteus Medius Insertional Tendonitis Indication for Posterolateral Trochanter (PLT) S/CS or Lateral Trochanter (LT) S/CS |
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Pain Radiating Down Lateral Aspect of Leg which increases w/ Weight Bearing or Walking
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Trochanteric Bursitis: Point Tenderness over Greater Trochanter
Pain radiates Down Lateral Aspect of Leg, increases w/ Weight Bearing or Walking Causes: ITB Syndrome, Ileocecal Chapman's Point on Right, Sigmoid Chapman's Point on Left; Piriformis Syndrome, Gluteus Medius Insertional Tendonitis Indication for Posterolateral Trochanter (PLT) S/CS or Lateral Trochanter (LT) S/CS |
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Meralgia Paresthetica
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Entrapment of Lateral Femoral Cutanous Nerve (L2-3) under the inguinal ligamneta, tensor fascia lata, or the ileopsoas
Classically numbness/paresthesias, occasional pain along lateral and anterior thigh no point tenderness, ± Tinel sign Causes: pregnancy, apron, construxn belt |
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Numbness of anterior thigh
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Meralgia Paresthetica: Entrapment of Lateral Femoral Cutanous Nerve (L2-3) under the inguinal ligamneta, tensor fascia lata, or the ileopsoas
Classically numbness/paresthesias, occasional pain along lateral and anterior thigh no point tenderness, ± Tinel sign Causes: pregnancy, apron, construxn belt |
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Entrapment of Lateral Femoral Cutanous Nerve
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L2&3, Meralgia Paresthetica: under the inguinal ligamneta, tensor fascia lata, or the ileopsoas
Classically numbness/paresthesias, occasional pain along lateral and anterior thigh no point tenderness, ± Tinel sign Causes: pregnancy, apron, construxn belt |
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Osteoarthritis of the Hip Presentation
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XR: Decreased Joint Space
Do not want to internally rotate Pain in groin, worse in morning & w/ weight bearing |
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Pt does not want to internally rotate Hip
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Osteoarthritis of the Hip Presentation
XR: Decreased Joint Space Pain in groin, worse in morning & w/ weight bearing |
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Pain in groin, worse in morning & w/ weight bearing
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Osteoarthritis of the Hip Presentation
XR: Decreased Joint Space Pt does not want to internally rotate Hip |
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SD with externally rotated hip
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common (relative to internally rotated)
usually the piriformis or iliopsoas to blame |
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SD with internally rotated hip
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uncommon (relative to extenrally rotated)
may be glut min, semimembranosus, semitendenosus, TFL, adductors lungus &/or magnus |
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Examination of Gait
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Swing Phase Usually 40%
Stance Phase Usually 60%--where problems are seen |
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What Muscles May Restrict Abduction?
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Adductors Longus & Brevis (L3)
Gracilis |
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What Muscles May Restrict Adduction
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Gluteus Medius (L5)
TFL |
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What Muscles May Restrict the Straight Leg Raise
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Gluteus Maximus (S1&2)
Hamstrings |
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What Muscles May Restrict Extenral Rotation (with Hip Flexed to 90*)
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Adductor Magnus
Semitendinosus Semimembranosus |
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What Muscles May Restrict Internal Rotation (w/ Hip Flexted to 90*)
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Piriformis (S1)
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What Muscles May Restrict Extension
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(Thomas Test)
Iliopsoas Rectus Femoris Sartorius Not a Muscle but Consider Tight Anterior hip Joint Capsule |
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Trendelenburg Test
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Pt stands on one foot and then the other
Hip drop indicates weakness in hip abductors on standing leg seen in L5 radiculopathies or lesion of superior gluteal nerve |
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Hip Drop while standing on one leg
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Positive Trendelenburg Test
Pt stands on one foot and then the other Hip drop indicates weakness in hip abductors on standing leg seen in L5 radiculopathies or lesion of superior gluteal nerve |
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Ober test
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Pt lies on side, test upper leg
slight extension puts IT behind greater trochanter Doc Abducts Thigh & Flexes Knee, then slowly releases knee Positive if Knee does not drop, means that thigh remains abducted DDx: Neurologic Disorders including Polio and Meningomyelocele, but more commonly a Tight IT Band Tight IT Band Indication for LT S/CS |
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Test for Tight IT Band
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Ober test: Pt lies on side, test upper leg
slight extension puts IT behind greater trochanter Doc Abducts Thigh & Flexes Knee, then slowly releases knee Positive if Knee does not drop, means that thigh remains abducted DDx: Neurologic Disorders including Polio and Meningomyelocele, but more commonly a Tight IT Band Tight IT Band Indication for LT S/CS |
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Pt lies on side, test upper leg
slight extension puts IT behind greater trochanter Doc Abducts Thigh & Flexes Knee, then slowly releases knee |
Ober test: Positive if Knee does not drop, means that thigh remains abducted
DDx: Neurologic Disorders including Polio and Meningomyelocele, but more commonly a Tight IT Band Tight IT Band Indication for LT S/CS |
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Thomas Test
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Pt supine, flattens lordosis by flexing hips and knees
hold one knee and release other, compare distance from knee to table for iliopsoas contracture Iliopsoas contracture may indicate posterior abdominal medical problems such as kiney stones or pancreatitis |
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Patrick Test
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FABERE: Flexion, Abduction, External Rotation and Extension
Positive is Inguinal Pain indicates hip pathology Pain in SI joint as Doc presses down indicates SI pathology |
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Hip Drop Test
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Tests Ability of Lumbar Spine to Sidebend
Pt standing, bends one knee w/o lifting heel Lumbar spine should sidebend opposite Positive if hip does not drop at least 20* (inch or so) |
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Testing Ability of Lumbar Spine to Sidebend
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Hip Drop Test
Pt standing, bends one knee w/o lifting heel Lumbar spine should sidebend opposite Positive if hip does not drop at least 20* (inch or so) |
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Hip Scour Test
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In Patrick's FABER Position, add compressive force through femur into hip joint
pain in groin indicative of hip arthritis pain in SI joint indicates SI pathology |
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Testing for Hip Arthritis vs SI Pathology
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Hip Scour Test: In Patrick's FABER Position, add compressive force through femur into hip joint
pain in groin indicative of hip arthritis pain in SI joint indicates SI pathology |
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ME for Restricted Hip Motions
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See OMM Book P 38-42
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Anterior Hip Joint Capsule Mobilization
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Tight Hip Capsule May Be Restricting Extension
PT Prone, Doc Opposite Restricted Hip Lift Knee, Press down on Femur near hip capsule Articulatory Technique |
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S/CS: AT
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Anterior Trochanter
Sartorius Muscle Point: near tendinous insertion of Sartorius: 1-2 inches caudad & slightly medial to ASIS, Position: Supine, Flex femur to 90*, Moderate Abdxn, Slight Extenral Rotation |
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S/CS: Sartorius
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Point: AT (Anterior Trochanter)near tendinous insertion of Sartorius: 1-2 inches caudad & slightly medial to ASIS,
Position: Supine, Flex femur to 90*, Moderate Abdxn, Slight Extenral Rotation |
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S/CS: PMT
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Posteromedial Trochanter
Indication: Ischiogluteal Bursitis Muscles: Gemelli and Quadratus Femoris Point: 4 cm caudad to trochanter on posteromedial surface of femur, sometimes as far medial as lateral surface of ischial tuberosity Tx: Pt Prone, Doc Opposite TP, Traps Ankle btw arm & chest holding knee: extension, addxn, extenral rotation |
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S/CS: Gemelli
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Indication: Ischiogluteal Bursitis
Point: PMT: Posteromedial Trochanter, 4 cm caudad to trochanter on posteromedial surface of femur, sometimes as far medial as lateral surface of ischial tuberosity Muscles: Gemelli and Quadratus Femoris Tx: Pt Prone, Doc Opposite TP, Traps Ankle btw arm & chest holding knee: extension, addxn, extenral rotation |
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S/CS: Quadratus Femoris
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Indication: Ischiogluteal Bursitis
Point: PMT: Posteromedial Trochanter, 4 cm caudad to trochanter on posteromedial surface of femur, sometimes as far medial as lateral surface of ischial tuberosity Muscles: Gemelli and Quadratus Femoris Tx: Pt Prone, Doc Opposite TP, Traps Ankle btw arm & chest holding knee: extension, addxn, extenral rotation |
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S/CS: PLT
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Posterolateral Trochanter
Indication: Trochanteric Bursitis Muscles: Piriformis tendon insertion Point: postero-superior lateral surface of greater trochanter in region of trachanteric bursa Tx:Pt prone, doc on same, extend, abduct and extenrally rotate. ExtRot via Doc's knee under thigh and allowing pt's thigh to roll down |
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S/CS: LT
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Lateral Trochanter
Indication: Trochanteric Bursitis or IT band dysfnx Point: lateral surface of femoral shaft, commonly 12 cm distal to greater trochanter Tx: Pt prone, doc on same, abduct, fine tune with external rotation |
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S/CS: GM
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Gluteus Medius
Point: 1 cm below iliac crest in an arc 4 cm long Tx: Pt prone, doc on same, extension w/ marked abduxn & internal rotation |
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S/CS: PIR
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Piriformis
Point: belly of piriformis Tx: Pt prone, Doc on same, flex , abdx, extenrla rotation |
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S/CS TP: 4cm arc 1 cm below iliac crest
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GM: Gluteus Medius
Tx: Pt prone, doc on same, extension w/ marked abduxn & internal rotation |
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S/CS TP: lateral surface of femoral shaft, commonly 12 cm distal to greater trochanter
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LT: Lateral Trochanter
Tx: Pt prone, doc on same, abduct, fine tune with external rotation Indications: Trochanteric Bursitis or IT Band Dysfnx |
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S/CS TP: postero-superior lateral surface of greater trochanter in region of trachanteric bursa
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PLT: Posterolateral Trochanter
Muscles: Piriformis tendon insertio Tx:Pt prone, doc on same, extend, abduct and extenrally rotate. ExtRot via Doc's knee under thigh and allowing pt's thigh to roll down Indication: Trochanteric Bursitis |
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S/CS TP: Posteromedial Trochanter, 4 cm caudad to trochanter on posteromedial surface of femur, sometimes as far medial as lateral surface of ischial tuberosity
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PMT: Posteromedial Trochanter,
Muscles: Gemelli and Quadratus Femoris Tx: Pt Prone, Doc Opposite TP, Traps Ankle btw arm & chest holding knee: extension, addxn, extenral rotation Indication: Ischiogluteal Bursitis |
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S/CS TP: near tendinous insertion of Sartorius: 1-2 inches caudad & slightly medial to ASIS,
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AT: Anterior Trochanter
Sartorius Muscle Point: near tendinous insertion of Sartorius: 1-2 inches caudad & slightly medial to ASIS, Position: Supine, Flex femur to 90*, Moderate Abdxn, Slight Extenral Rotation |
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Review the Anatomy of the Knee
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via Anatomy flashcards
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POP goes the ...
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POP goes the ACL:
Planted Out of Position Pivoting |
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Which meniscus is likely to be torn?
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Medial Meniscus is more likely to be injured
Medial Tears in Young Lateral Tears in Elderly |
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Recovery from ACL tear
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7/10 return w/o surgery
99% return with surgery Cadaveric ACL transplant: lower pain, 4 mo recovery time |
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Ligament torn when Tibia is driven anteriorly
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ACL
runs from anterior intercondylar area of tibia to postero-medial aspect of lateral condyle of the femur. |
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Ligament torn when Femur is driven posteriorly
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ACL
runs from anterior intercondylar area of tibia to postero-medial aspect of lateral condyle of the femur. |
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Ligagment torn with knee hyperextension
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ACL
runs from anterior intercondylar area of tibia to postero-medial aspect of lateral condyle of the femur. |
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Terrible Triad
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Lateral Blow to Knee tears:
ACL, Medial Meniscus, Medial Collateral Ligament Slightly Controversia: may be lateral meniscus rather than medial |
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Nutrient supply to cartilage of the knee
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peripheral margins supplied by popliteal artery; interior aspects supplied by diffusion only
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Ligament torn when the Tibia is driven posteriorly
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PCL
runs from posterior intercondylar area of tibia to anterior portion of medial femoral condyle |
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Ligament torn when the Femur is driven anteriorly
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PCL
runs from posterior intercondylar area of tibia to anterior portion of medial femoral condyle |
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Ligament torn when the Knee is hyperflexed
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PCL
runs from posterior intercondylar area of tibia to anterior portion of medial femoral condyle |
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ACL Tear
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Typically causes immeidate swelling, tested via Drawer or Lachman's Test
Tears when Tibia is driven anteriorly, femur is driven posteriorly, or with hyperextension of the knee |
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Why do women tear ACL more than men
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Estrogen produces laxity
women on birth control have fewer tears |
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Knee ligament tear which swells immediately
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ACL
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PCL tear
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Tears when tibia is driven posteriorly, femur is driven anteriorly, or knee is hyperflexed
tested via drawer test and Tibial Sag Test Quad firing compensates but does require surgery |
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Medial Collateral Ligament Tear
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Tears with blow to lateral side of knee
can do okay non-surgically, must sleep at 30* of flexion |
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Lateral Collateral Ligament Tear
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Tears with blow to medial side of knee. Injury may also sever the common peroneal nerve
Should go to surgery |
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Osgodd Schlatter Disease
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Pain and Swelling of the infrapatellar tendon insertion into the tibial tubercle
More common in boys from active growth or sports Tx: NSAIDS, relative rest, ice, Cho-Pat strap |
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Pain and Swelling of the infrapatellar tendon insertion into the tibial tubercle
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Osgodd Schlatter Disease
More common in boys from active growth or sports Tx: NSAIDS, relative rest, ice, Cho-Pat strap |
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Cho-Pat Strap
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Used to change the fulcrum for Osgodd Schlatter Disease: Pain and Swelling of the infrapatellar tendon insertion into the tibial tubercle
More common in boys from active growth or sports |
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Prepatellar Bursitis
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Housemaid's Knee, product of chronic kneeling
Tx; NSAIDS, relative rest, ice Avoid temptation to needle, risk infection and will refill rapidly |
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Housemaid's Knee
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Prepatellar Bursitis, product of chronic kneeling
Tx; NSAIDS, relative rest, ice Avoid temptation to needle, risk infection and will refill rapidly |
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Pes Anserine Bursitis
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Posterior Medial Knee Pain, typically with overuse (not acute trauma)
Provocative maneuvers to determine which muscle |
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Posterior Medial Knee Pain without Acute Trauma
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Pes Anserine Bursitis, typically with overuse (not acute trauma)
Provocative maneuvers to determine which muscle |
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Patellofemoral Pain Syndrome
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Imbalance between medial and lateral quadriceps group causes "lateral tracking" ie abnormal patella glide with motion
tenderness at facets, plica bands positive theater sign: knees ache after sitting positive stair sign: fine on flat surface, pain on stairs Special tests: Patella Grind, Apprehension, Q angle, Garrett's Hamstring Inflexibility Test |
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Theater Sign
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knees ache after sitting
Indicative of Patellofemoral Pain Syndrome: Imbalance between medial and lateral quadriceps group causes "lateral tracking" ie abnormal patella glide with motion tenderness at facets, plica bands positive theater sign: knees ache after sitting positive stair sign: fine on flat surface, pain on stairs Special tests: Patella Grind, Apprehension, Q angle, Garrett's Hamstring Inflexibility Test |
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Stair Sign
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fine on flat surface, pain on stairs
Indicative of Patellofemoral Pain Syndrome: Imbalance between medial and lateral quadriceps group causes "lateral tracking" ie abnormal patella glide with motion tenderness at facets, plica bands positive theater sign: knees ache after sitting positive stair sign: fine on flat surface, pain on stairs Special tests: Patella Grind, Apprehension, Q angle, Garrett's Hamstring Inflexibility Test |
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Patella Apprehension Test
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I bet there's more to this
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Q angle
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Difference in between line from ASIS through patel and line from patella through ankle
Men should be 18* Women should be 22* Wider indicates Lateral tracking, ie Imbalance between medial and lateral quadriceps group causes "lateral tracking" ie abnormal patella glide with motion, which causes Patellofemoral Pain Syndrome |
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garret's Test
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the fuck is this shit?
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Gastrocnemius-Semimenbranosus Bursitis
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Baker's Cyst, A Sx of Another Problem
Usually painless, mobile firmness typically located on medial side of popliteal fossa Tx: Treat Underlying Problem; Don't ever put a needle in it ("unless you've got a CV Surgeon right there ready to go" |
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Baker's Cyst
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Gastrocnemius-Semimenbranosus Bursitis, A Sx of Another Problem
Usually painless, mobile firmness typically located on medial side of popliteal fossa Tx: Treat Underlying Problem; Don't ever put a needle in it ("unless you've got a CV Surgeon right there ready to go") |
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3 degrees of ligament sprains
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1: Microscopic
2: Laxity with Endpoint 3: Complete Rupture |
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Go back and made sure you've got a card for each of the "Important Tests of the Knee"
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page 59 OMM book
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Drawer Test
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Pt Supine, Knees flexed at 90*, feet flat on table
Doc sits on foot Pull tibia anteriorly to assess the ACL Push Tibia posteriorly to assess the PCL Small amt of mot'n normal if present in other knee |
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Lachman Test
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For the ACL
BEST TEST for ACL integrity because joint capsule is relaxed Pt supine, 30* flex'n at knee, Doc stabilizes femur with one hand and uses opposite to draw proximal tibia anteriorly. (Modified: Doc's knee under pt's thigh) Hard end point is negative "Mushy" soft end is positive |
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Testing for ACL integrity
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Best Test is Lachman test because Joint Capsule is Relaxed
Pt supine, 30* flex'n at knee, Doc stabilizes femur with one hand and uses opposite to draw proximal tibia anteriorly. (Modified: Doc's knee under pt's thigh) Hard end point is negative "Mushy" soft end is positive |
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Testing Medial Collateral Ligament
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Pt supine, flexed just enough to unlock (else false negative), secure angle under arm, place one palm on fibular head and with that hand push medially while pushing laterally with other hand against the ankle (Valgus stress)
don't roll the femur |
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Testing the Lateral Collatera Ligament
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Pt supine, flexed just enough to unlock (else false negative), secure angle under arm, place one palm on medial tibial plateau and with that hand push laterally while pushing medially with other hand against (Varus stress)
don't roll the femur |
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Apley's distraction test
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helps to distinguish between meniscal and ligamentous damage
pt prone, leg flexed to 90*, doc puts cephelad knee on pt's thigh to stabalize, grasps dorsal and posterior portions of pt's foot and applies traction while rotating tibia internally and externally If ligaments are damaged: pt will complain of pain; ---lateral pain = lateral collateral ligament, medial pain = medial collateral ligament If only meniscus is torn, there will be no pain |
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pt prone, leg flexed to 90*, doc puts cephelad knee on pt's thigh to stabalize, grasps dorsal and posterior portions of pt's foot and applies traction while rotating tibia internally and externally
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Apley's distraction test: helps to distinguish between meniscal and ligamentous damage
If ligaments are damaged: pt will complain of pain; ---lateral pain = lateral collateral ligament, medial pain = medial collateral ligament If only meniscus is torn, there will be no pain |
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Distinguishing between meniscal and ligamentous damage in knee
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Apley's distraction test: pt prone, leg flexed to 90*, doc puts cephelad knee on pt's thigh to stabalize, grasps dorsal and posterior portions of pt's foot and applies traction while rotating tibia internally and externally
If ligaments are damaged: pt will complain of pain; ---lateral pain = lateral collateral ligament, medial pain = medial collateral ligament If only meniscus is torn, there will be no pain |
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Childress' Sign
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Squat Test: ask Pt to duck walk
positive if pt will not squat all the way down at 70%, most sensitive test for meniscal injury assoc w/ torn ACL |
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Most Sensitive Test for Meniscal Injury
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Childress' Sign (Squat Test): ask Pt to duck walk
positive if pt will not squat all the way down at 70%, most sensitive test for meniscal injury assoc w/ torn ACL |
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Pt unable to squat and walk like a duck without pain
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Positive Childress' Sign (Squat Test)
at 70%, most sensitive test for meniscal injury assoc w/ torn ACL |
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Apley's Compression Test
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Pt prone, knee flexed to 90*, stabilize thigh with doc's knee. Compress knee via foot, internally and externally rotate.
Pain = meniscal damage located on side of pain |
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Pt prone, knee flexed to 90*, stabilize thigh with doc's knee. Compress knee via foot, internally and externally rotate
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Apley's Compression Test
Pain = meniscal damage located on side of pain |
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McMurray's test
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Pt supine, hold pts ankle with caudad hand, flex leg fully. Externally Rotate leg and place valgus (medially oriented) stress at knee. Extend the knee: if click is palpable or audible, test is positive for torn medial meniscus, usually in posterior position
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Testing for Joint Effusion
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Pt Supine, Knee extended. "Milk" fluid from suprapatellar pouch and lateral side of knee into medial side of knee. Then gently tap medial side of knee and palpate the lateral side for fullness.
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Patellar Femoral Grinding Test
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Tests quality of articulating surfaces of patella and trochlear groove of femur
Pt supine, Legs relaxed. Doc grasps patella and pushes distally. Pt told to tighten quadracepts, doc offers resistance. Movement should be smooth and glinding roughneess causes palpable crepitation. Positive if pain or discomfort |
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Testing Quality of Patellar Articulation
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Patellar Femoral Grinding Test: Tests quality of articulating surfaces of patella and trochlear groove of femur
Pt supine, Legs relaxed. Doc grasps patella and pushes distally. Pt told to tighten quadracepts, doc offers resistance. Movement should be smooth and glinding roughneess causes palpable crepitation. Positive if pain or discomfort |
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Patella Apprehension Test
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Determines if patella is prone to lateral dislocation
Pt supine, quads relaxed. Doc presses patella laterally. Positive if pt becomes distressed |
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Determining if patella is prone to lateral dislocation
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Patella Apprehension Test: Pt supine, quads relaxed. Doc presses patella laterally.
Positive if pt becomes distressed |
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Anterior Fibular Head HVLA
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Pt supine,
Place a pillow beneath pt's knee place heel of cephalad hand over anterior distal fibular head grasp ankle with caudad hand superior to maleoli corrective force: downward pressure vs. head of fibula with heel of cephelad hand combined with internal rotation of tibia with caudad hand. |
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Posterior Fibular Head HVLA
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Pt supine,
lateral portion of the proximal end of cephelad index finger directly behind head of left fibula with thumb projecting over anterior tibia caudad hand holds ankle superior to malleoli position knee in extreme flexion corrective motion: forward pressure against head of fibula with index finger, increased flexion, and external rotation of tibia. |
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S/CS: MM
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Medial Meniscus
Indications: "Lame Knee," Knee Pain, Unable to Extend Knee TP: Medial Surface of Tibia at level of knee joint Tx: Pt supine with leg off table, flex knee to 40*, marked internal rotation of tibia and mild varus strain on knee |
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S/CS: MH
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Medial Hamstring
TP: Proximal posteromedial surface of tibia at site of MH insertion Tx: Pt supine, knee flexed to 60* with extenral rotation of tibia on femur. fine tune with addxn |
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S/CS: ACL
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Anterior Cruciate Ligament
Indications: Knee Instability, Pain in Deep Knee TP: On Hamstrings Medial and Lateral to Popliteal Area Tx: rolled pillow under distal femur, apply force antero-->posteriorly on proximal tibia w/ internal rotation |
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S/CS: PCL
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Posterior Cruciate Ligament
Indications: Knee Instability, Pain in Deep Knee TP: Middle of Popliteal Space Tx: pillow under proximal end of tibia, apply pressure to distal femur antero-->posteriorly w/ internal rotation to tibia at ankle |
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S/CS: FH
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Fibular Head
TP: posterior surface of proximal fibular head Tx: usually 2ndry to ankle SD, check for and correct lateral ankle tenderpoint |
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S/CS: PAT
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Patella
Indications: acute tender site on extensor msucle group, chondromalacia patella TP: Perimeter of patella Tx: Pt supine, knee extended, apply pressure on opposite side of patella |
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S/SC: LM
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Lateral Meniscus
TP: Lateral tibia on lateral knee joint line near lateral collateral ligament Tx: Pt supine with leg abducted off table, knee flexted to 40*. Some combination of Tibial rotation, abduction, or adduction w/ valgus force on knee (Very Similar to Lateral Hamstring) |
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S/SC: LH
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Lateral Hamstring
TP: Insertionof lateral hamstring into poterolateral tibia Tx: Pt supine with leg abducted off table knee flexed to 30*, external rotation of tibia with mild abudction. (Very similar to lateral meniscus) |
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"Lame Knee" S/CS
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Medial Meniscus
TP: Medial Surface of Tibia at level of knee joint Tx: Pt supine with leg off table, flex knee to 40*, marked internal rotation of tibia and mild varus strain on knee |
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Knee Pain S/CS
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Medial Meniscus
TP: Medial Surface of Tibia at level of knee joint Tx: Pt supine with leg off table, flex knee to 40*, marked internal rotation of tibia and mild varus strain on knee |
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Unable to Extend Knee S/CS
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Medial Meniscus
TP: Medial Surface of Tibia at level of knee joint Tx: Pt supine with leg off table, flex knee to 40*, marked internal rotation of tibia and mild varus strain on knee |
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Knee Instability S/CS
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ACL or PCL
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Pain in Deep Knee S/CS
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ACL or PCL
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Acute Tender Site on Extensor Muscle Group S/CS
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PAT: Patella
TP: Perimeter of patella Tx: Pt supine, knee extended, apply pressure on opposite side of patella |
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Condromalacia Patella S/CS
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PAT: Patella
TP: Perimeter of patella Tx: Pt supine, knee extended, apply pressure on opposite side of patella |
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TP: Medial Surface of Tibia at level of knee joint
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MM: Medial Meniscus
Indications: "Lame Knee," Knee Pain, Unable to Extend Knee Tx: Pt supine with leg off table, flex knee to 40*, marked internal rotation of tibia and mild varus strain on knee |
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TP: Proximal posteromedial surface of tibia
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At site of MH insertion
MH: Medial Hamstring Tx: Pt supine, knee flexed to 60* with extenral rotation of tibia on femur. fine tune with addxn |
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TP: On Hamstrings Medial and Lateral to Popliteal Area
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ACL: Anterior Cruciate Ligament
Indications: Knee Instability, Pain in Deep Knee Tx: rolled pillow under distal femur, apply force antero-->posteriorly on proximal tibia w/ internal rotation |
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TP: Middle of Popliteal Space
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PCL: Posterior Cruciate Ligament
Indications: Knee Instability, Pain in Deep Knee Tx: pillow under proximal end of tibia, apply pressure to distal femur antero-->posteriorly w/ internal rotation to tibia at ankle |
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TP: posterior surface of proximal fibular head
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FH: Fibular Head
Tx: usually 2ndry to ankle SD, check for and correct lateral ankle tenderpoint |
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TP: Perimeter of patella
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PAT: Patella
Indications: acute tender site on extensor msucle group, chondromalacia patella Tx: Pt supine, knee extended, apply pressure on opposite side of patella |
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TP: Lateral tibia on lateral knee joint line near lateral collateral ligament
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LM: Lateral Meniscus
Tx: Pt supine with leg abducted off table, knee flexted to 40*. Some combination of Tibial rotation, abduction, or adduction w/ valgus force on knee (Very Similar to Lateral Hamstring) |
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TP: Poterolateral proximal tibia
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LH: Lateral Hamstring
Tx: Pt supine with leg abducted off table knee flexed to 30*, external rotation of tibia with mild abudction. (Very similar to lateral meniscus) |
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S/CS: Pt supine with leg off table, flex knee to 40*, marked internal rotation of tibia and mild varus strain on knee
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MM: Medial Meniscus
Indications: "Lame Knee," Knee Pain, Unable to Extend Knee TP: Medial Surface of Tibia at level of knee joint |
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S/CS: Pt supine, knee flexed to 60* with extenral rotation of tibia on femur. fine tune with addxn
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MH: Medial Hamstring
TP: Proximal posteromedial surface of tibia at site of MH insertion |
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S/CS: rolled pillow under distal femur, apply force antero-->posteriorly on proximal tibia w/ internal rotation
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ACL: Anterior Cruciate Ligament
Indications: Knee Instability, Pain in Deep Knee TP: On Hamstrings Medial and Lateral to Popliteal Area |
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S/CS: pillow under proximal end of tibia, apply pressure to distal femur antero-->posteriorly w/ internal rotation to tibia at ankle
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PCL: Posterior Cruciate Ligament
Indications: Knee Instability, Pain in Deep Knee TP: Middle of Popliteal Space |
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S/CS: usually 2ndry to ankle SD, check for and correct lateral ankle tenderpoint
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FH: Fibular Head
TP: posterior surface of proximal fibular head |
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S/CS: Pt supine, knee extended, apply pressure on opposite side of patella
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PAT: Patella
Indications: acute tender site on extensor msucle group, chondromalacia patella TP: Perimeter of patella |
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S/CS: Pt supine with leg abducted off table, knee flexted to 40*. Some combination of Tibial rotation, abduction, or adduction w/ valgus force on knee
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LM: Lateral Meniscus
TP: Lateral tibia on lateral knee joint line near lateral collateral ligament Very Similar to Lateral Hamstring |
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S/CS: Pt supine with leg abducted off table knee flexed to 30*, external rotation of tibia with mild abudction.
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LH: Lateral Hamstring
TP: Insertionof lateral hamstring into poterolateral tibia |
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Sesamoid bones
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allow for strong lever of 1st ray flexors
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LIgaments of the Ankle
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Deltoid Ligament medially: prevents eversion and A-P displacement of tibia
Lateral: Anterior talofibular, posterior talofibular and calcaeofibular prevent excessive inversion and A-P displacement of the fibula |
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Muscles of the foot
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Twelve extrinsic muscles
19 intrinsic muscles |
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Arterial Supply of the Foot
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Popliteal Artery divides in the poplitieal fossa into the anterior and posterior tibial artery
Posterior tibial artery follows same coruse as tibial nerve supplying posterior leg muscles and lateral leg as peroneal artery Anterior tibial artery supplies anterior compartment of the leg becomes dorsalis pedis Porstalis pedis and posterior tibial artery are palpated for ankle PE |
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Venous Return of the Foot
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Superficially: small saphenous and Great saphenous
Deep: venae comitantes to the arterial branches in lower extremities Perforating veins run between deep and superficial veins, valves direct blood into deep veins pulsations of arteries and large muscles within the LE help move blood up the leg |
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Arches o the foot
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dense connective tissue suspended between calcaneus and 1st and 5th metatarsals. weight distributed along the arches to create a CT pyramid
Longitudinal arches supported by Tibalis posterior ataching to navicular and 1st cuneiform. Transverse arch supported by pereoneus longus, tibalis anterior and shoes. Medial Longitudinal Arch: Calcaneus, Talus, Navicular, Cuneiforms, and first three metatarsals; Navicular is the keystone. Lateral Longitudinal Arch: Calcanius cuboid, 4th and 5th metatarsals Transverse Cuboid Navicular, cuneiforms and proximal ends of the metatarsals |
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Medial Longitudinal Arch
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Calcaneus, Talus, Navicular, Cuneiforms, and first three metatarsals; Navicular is the keystone.
Longitudinal arches medial and lateral supported by Tibalis posterior ataching to navicular and 1st cuneiform. Most common dysfnx: dropped navicular: head of the talus moves medially on the navicular which drives the medial aspect of the navicular inferiorly. |
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Lateral Longitudinal Arch
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Calcanius cuboid, 4th and 5th metatarsals
Longitudinal arches supported by Tibalis posterior ataching to navicular and 1st cuneiform Common dysfnx is dropped cuboid, usually 2ndry to talocalcaneal dysfnx w/ Talus anterior and calcanus internally rotated. |
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Transverse Arch
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Cuboid Navicular, cuneiforms and proximal ends of the metatarsals
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Foot Diaphragm
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Fibrous connective tissue arches of the foot fnx as a diaphragm
weight distributed through 3 equal points like the base of a pyramid base acts as shock absorber and stabilizer, also pumping action which aids in lymphatic and venous flow |
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Gait Cycle
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Stance Phase 65%
Contact, heel strike to forefoot landing: 27% Midstance: 40% Propulsion: heel off to toe off: 33% Swing Phase 35% |
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Proper footwear
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supportive soft cushion w/ good ventilation. Not too small or narrow, with flexible inner sping arch to permit normal arch descent, heel no greater than 1.5 prevents lumbar lordosis.
primitive people's feet are flat when static and become highly ached iwth action. Modern feet have a pronouned medial longitudinal arch faily static with gait as borner shoes effectively place the foot in a splint |
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Problems assoc with improper foot wear
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Ingrown toenails
Hallux valgus Achiles tendon contracture Claw toes and hammer toes fungal infxn calluses metatarsalgia painful heel |
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When evaluating the foot and ankle osteopathically
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also look at the knee, sacrum, pelvis and lumbar spine
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Pes Cavus, Pes Planus
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Cavus- abnormally high arch
Planus- Valgus. talar head displaced medially and plantarward. |
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Hallux Valgus
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lateral deviation of big toe
bunion if sesemoid bones drift laterally too (btw 1st & 2nd digits) |
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Ankle Sprain
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Inversion most commmon: order of occurance: ATF, CF, PTF. Evaluate for Jones fx: fx of prximal 5th metatarsal
Type 1: ATF Type 2 ATF + CF Type 3: ATF + CTF + PTF Eversion sprain: deltoid ligament: avulsion fx of medial maleolus. maisonnevue fx. of proximal fibula |
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Type 1 2 and 3 Ankle Sprains
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1: ATF
2 ATF + CF 3: ATF + CTF + PTF |
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Anterior Drawer Testing the Foot
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Primarily Tests anteiro Talofibular Ligament
Positive w/ pain welling and bruishing 96% sensitive and 86% specific confirm with ultrasound |
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Ottowa ankle rules
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very sensitive to ankle injuries (to justify X ray)
1) Inability to bear weight and take more than 4 steps at time of injury and in ED 2) tender at lateral malleolus 3) tender at medial malleolus |
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High Ankle Sprains
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Squeeze test: tests the anterior tibiofibular ligament/tibiofibular syndesmoisis injury
improtant because longer recovery period |
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Squeeze test
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tests the anterior tibiofibular ligament/tibiofibular syndesmoisis injury: High Ankle Sprains
improtant because longer recovery period |
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eversion sprains
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medial malleuolus has boney articulation with talus
also deltoid ligament strength few eversion sprains: when occur occur with fractures: -Avulsion fx of medial malleolus maisonnevue spiral fracture of proximal fibula |
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PRICE
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Protection
Rest Ice Compression Elevation |
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Treating Ankle Sprains
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No minor ankle Sprains!
Look for SD of fibula and ipsilateral 3rd rib Tx: PRICE, non weight bearing, tx axial skeleton and diaphragm for venous/lymphatic flow. Treat fibular dysfnx and look for 3rd rib. locally look for S/CS points along with other indirect methods 1-2 weeks later: tx mortise joint and look for cuboid/navicular dysfnx. Tx pelvis 2-3 wks later start proprioceptive balance training |
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Achilles tendonitis
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Pain at insertion Point usually due to improper stretching or increased physical activity
Thompson Test for Rupture |
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Thompson Test
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Squeeze Calve, Foot should plantarflex. Tests for Achilles Tendon Rupture by compressing gastrocnemius.
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Posterior tibilalis tendonitis
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Posteriormedial ankle/foot pain
progresses to loss of arch, more common in women can't stand on toes. "Too many toes." |
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Too many toes
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Posterior tibilalis tendonitis:Posteriormedial ankle/foot pain
progresses to loss of arch, more common in women can't stand on toes. |
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Tarsal Tunnel Syndrome
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Posterior & Inferior to tibia roofed by flexor reinaculum from medial malleolus to calcaneus
Posterior Tibial Nerve, Tendons, N-AV Paresthesias, numbness, pain on plantar surface of foot. |
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Paresthesias, numbness, pain on plantar surface of foot.
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Tarsal Tunnel Syndrome
Posterior & Inferior to tibia roofed by flexor reinaculum from medial malleolus to calcaneus Posterior Tibial Nerve, Tendons, N-AV |
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Morton's Neuroma
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Entrapment Vasoneuropathy of interdigital Nerve
Tx: Take shoes off, support the transverse arch in wide shoes OMM, metatarsal pads, surgery |
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Metatarsaligia
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Painful metatarsal heads
most commonly occurs after wt gain in middle age Tx: weight reduxn, metatarsal pads, OMM to restore strx/fnx |
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Plantar Fascia
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From calcaneus to metatarsal heads: bowsring for longitudinal arch, supports plantar muscle of foot
plantar fasciitis = infalm --> painful tendonosis worse in morning and with activity. Tx: night splints, PRICE [exercises, heel cups, OMT, prolotherapy/PRP, orthotripsy] Cuse caution with steroids. |
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painful plantar foot worse in morning and with activity.
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Plantar Fasciitis = infalm --> painful tendonosis worse in morning and with activity.
Plantar fascia: bowsring for longitudinal arch from calcaneus to metatarsal heads, supports plantar muscle of foot Tx: night splints, PRICE [exercises, heel cups, OMT, prolotherapy/PRP, orthotripsy] Cuse caution with steroids. |
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OMT for Foot/Ankle Problems Gneeral Approach
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Tx pelvis and lumbar spine
look for tight hams, peroneals, and gastrox/soleus, Tx w/ muscle energy Tx fibular head, talocrural, navicular/cuboid dsyfnx, metatarsals Look for s?CS points and tx |
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Orthoses
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look fo revidenc ebased on condition being treated
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Hiss Whip
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For Dropped Cuboid or Navicular
Prone, dysfnx leg off table. Doc's thumbs V at dropped c or n. Downward force with thumbs while "whipping" pt.s ankle and knee: medial for navicular, lateral for cuboid. |
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Tarsometatarsal Joint Play
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For restoration of Dorsal-to Plantar Glide: Thumbs on metatarsal undersides, fingers on top. Glide on metatarsal relative to the other repeatedly. If restricted, articulatory technique.
For restoration of medial and lateral ortations: Doc's hand stabalizes cuneiform bones. other induces inversion and eversion of the forefoot. mobilize against barrier. |
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Cuneiform Dysfnx
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Grasp two cunieforms on the top and bottom: test motion of one against the other. Then with thumbs on dorsum and giners on plantar surface, test springing.
Joint play by grasping one and moving the other in dorsal-planar fashion. |
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Metatarsal Heads Joint Play
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Grasp one move the one next to it, not the first though.
Should dorisflex and plantarflex, plus rotate ina nd out. |
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Metatarsophalangeal Joints and Interphalangeal Joints Joint Play
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Exactly what you would think: can HVLA w/ traction force.
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Plantarflexed Talus
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ME: One hand under foot, other hand over talus. Dorsiflex to engaged the barrier.
HLVA: Fingers over foot, thumbs under foot. Dorsiflex and traction. Thrust with long axis extnsion. |
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Testing and Mobilizing: Talocalcaneal Joint
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test: One hand over ankle with fingers and thumb on malleoli. Other hand on calcaneus: test for anteromedial to posterolateral glide.
HVLA: take calcaneus into the barrier. Traction tug through the barrier. |
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S/CS: MAN
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Medial Ankle (Tibialis Anterior
TP: 2 cm below maleolus Tx: pt lies dysfnx up, knee flexed foot off table. rolled up towel beneath distal tibia. Induced marked inversion from lateral aspect of the ankle. |
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S/CS: MCA
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Medial Calcaneus (Abductor Hallucis)
S/CS: MCA TP: On medial aspect of calcaneus 3 cm caudad and posterior to medial malleolus. Tx: pt lies dysfnx up, foot off table. medial pressure at heel around end of table to markedly invert calcaneus. evert distal aspect of foot. |
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S/CS: LAN
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Lateral Ankle (Peroneus Longus and Brevis)
S/CS: LAN TP: in depression 3 cm anterior and slighly caudad form alteral malleolus Tx: Pt lies dysfnx down, ankle off edge of table. marke deversion via force form medial foot. pad ankle with rolle dup towel. |
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S/CS: LCA
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Lateral Calcaneus
S/CS: LCA TP: 3 cm caudad and posterior to lateral malleolus Tx: pt lies dysfnx down ankle over edge. induce eversion at heel and invert distal foot. |
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S/CS: NAV
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Plantar Navicular (Tibialis Posterior)
S/CS: NAV TP: plantar surface of foot on navicular Tx: pt prone knee flexed. wrap index finger around navicular bone and reinforce w/ 3rd finger. thnar eminence of other hand induce inversion of navicular |
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S/CS: CUB
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Cuboid (Extensor digitorum brevis)
S/CS: CUB TP: plantar surface of foot on cuboid bone, must probe deeply 3 cm proximal and medial to promenence of 5th metatarsal. Tx: Pt prone w/ knee flexed. grasp lateral half of metatarsals and press towards table w/ 2nd MCP joint at pts proximal 5th metatarsal inducing evrsion and some extension of the cuboid relative to the foot |
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S/CS: FCA
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Flexion Calcaenus (quadratus plantae)
S/CS: FCA TP: plantar surface of thefoot on teh anteiror border of calcanus in the plantar fascia Tx: Pt prone, flex knee, grasp calcaneus and induxe flexion with the rest of the foot by forcing dorusm against thigh, wrap around point |
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S/CS: FMC
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Flexion Medial Calcaneus (Soleus)
S/CS: FMC TP: Posterior to medial aspect of tibia on the fibers ofthe muscle TX; Pt prone, flex knee, dorsal arch on thigh, marked extension of ankle by pushing on plantar surface of thehell towars the calve, angle medially to fine tune. |
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TP: 2 cm below maleolus
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Medial Ankle (Tibialis Anterior
S/CS: MAN Tx: pt lies dysfnx up, knee flexed foot off table. rolled up towel beneath distal tibia. Induced marked inversion from lateral aspect of the ankle. |
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TP: On medial aspect of calcaneus 3 cm caudad and posterior to medial malleolus.
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Medial Calcaneus (Abductor Hallucis)
S/CS: MCA Tx: pt lies dysfnx up, foot off table. medial pressure at heel around end of table to markedly invert calcaneus. evert distal aspect of foot. |
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TP: in depression 3 cm anterior and slighly caudad form alteral malleolus
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Lateral Ankle (Peroneus Longus and Brevis)
S/CS: LAN Tx: Pt lies dysfnx down, ankle off edge of table. marke deversion via force form medial foot. pad ankle with rolle dup towel. |
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TP: 3 cm caudad and posterior to lateral malleolus
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Lateral Calcaneus
S/CS: LCA Tx: pt lies dysfnx down ankle over edge. induce eversion at heel and invert distal foot. |
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TP: plantar surface of foot on navicular
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Plantar Navicular (Tibialis Posterior)
S/CS: NAV Tx: pt prone knee flexed. wrap index finger around navicular bone and reinforce w/ 3rd finger. thnar eminence of other hand induce inversion of navicular |
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TP: plantar surface of foot on cuboid bone, must probe deeply 3 cm proximal and medial to promenence of 5th metatarsal.
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Cuboid (Extensor digitorum brevis)
S/CS: CUB Tx: Pt prone w/ knee flexed. grasp lateral half of metatarsals and press towards table w/ 2nd MCP joint at pts proximal 5th metatarsal inducing evrsion and some extension of the cuboid relative to the foot |
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TP: plantar surface of thefoot on teh anteiror border of calcanus in the plantar fascia
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Flexion Calcaenus (quadratus plantae)
S/CS: FCA Tx: Pt prone, flex knee, grasp calcaneus and induxe flexion with the rest of the foot by forcing dorusm against thigh, wrap around point |
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TP: Posterior to medial aspect of tibia on the fibers ofthe muscle
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Flexion Medial Calcaneus (Soleus)
S/CS: FMC TX; Pt prone, flex knee, dorsal arch on thigh, marked extension of ankle by pushing on plantar surface of thehell towars the calve, angle medially to fine tune. |
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Tx: pt lies dysfnx up, knee flexed foot off table. rolled up towel beneath distal tibia. Induced marked inversion from lateral aspect of the ankle.
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Medial Ankle (Tibialis Anterior
S/CS: MAN TP: 2 cm below maleolus |
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Tx: pt lies dysfnx up, foot off table. medial pressure at heel around end of table to markedly invert calcaneus. evert distal aspect of foot.
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Medial Calcaneus (Abductor Hallucis)
S/CS: MCA TP: On medial aspect of calcaneus 3 cm caudad and posterior to medial malleolus. |
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Tx: Pt lies dysfnx down, ankle off edge of table. marke deversion via force form medial foot. pad ankle with rolle dup towel.
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Lateral Ankle (Peroneus Longus and Brevis)
S/CS: LAN TP: in depression 3 cm anterior and slighly caudad form alteral malleolus |
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Tx: pt lies dysfnx down ankle over edge. induce eversion at heel and invert distal foot.
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Lateral Calcaneus
S/CS: LCA TP: 3 cm caudad and posterior to lateral malleolus |
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Tx: pt prone knee flexed. wrap index finger around navicular bone and reinforce w/ 3rd finger. thnar eminence of other hand induce inversion of navicular
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Plantar Navicular (Tibialis Posterior)
S/CS: NAV TP: plantar surface of foot on navicular |
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Tx: Pt prone w/ knee flexed. grasp lateral half of metatarsals and press towards table w/ 2nd MCP joint at pts proximal 5th metatarsal inducing evrsion and some extension of the cuboid relative to the foot
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Cuboid (Extensor digitorum brevis)
S/CS: CUB TP: plantar surface of foot on cuboid bone, must probe deeply 3 cm proximal and medial to promenence of 5th metatarsal. |
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Tx: Pt prone, flex knee, grasp calcaneus and induxe flexion with the rest of the foot by forcing dorusm against thigh, wrap around point
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Flexion Calcaenus (quadratus plantae)
S/CS: FCA TP: plantar surface of thefoot on teh anteiror border of calcanus in the plantar fascia |
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TX: Pt prone, flex knee, dorsal arch on thigh, marked extension of ankle by pushing on plantar surface of thehell towars the calve, angle medially to fine tune.
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Flexion Medial Calcaneus (Soleus)
S/CS: FMC TP: Posterior to medial aspect of tibia on the fibers ofthe muscle |
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S/CS: Tibialis Anterior
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Medial Ankle (Tibialis Anterior
S/CS: MAN TP: 2 cm below maleolus Tx: pt lies dysfnx up, knee flexed foot off table. rolled up towel beneath distal tibia. Induced marked inversion from lateral aspect of the ankle. |
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S/CS: Abductor Hallucis
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Medial Calcaneus (Abductor Hallucis)
S/CS: MCA TP: On medial aspect of calcaneus 3 cm caudad and posterior to medial malleolus. Tx: pt lies dysfnx up, foot off table. medial pressure at heel around end of table to markedly invert calcaneus. evert distal aspect of foot. |
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S/CS: Peroneus Longus and Brevis
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Lateral Ankle (Peroneus Longus and Brevis)
S/CS: LAN TP: in depression 3 cm anterior and slighly caudad form alteral malleolus Tx: Pt lies dysfnx down, ankle off edge of table. marke deversion via force form medial foot. pad ankle with rolle dup towel. |
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S/CS: Tibialis Posterior
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Plantar Navicular (Tibialis Posterior)
S/CS: NAV TP: plantar surface of foot on navicular Tx: pt prone knee flexed. wrap index finger around navicular bone and reinforce w/ 3rd finger. thnar eminence of other hand induce inversion of navicular |
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S/CS: Extensor digitorum brevis
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Cuboid (Extensor digitorum brevis)
S/CS: CUB TP: plantar surface of foot on cuboid bone, must probe deeply 3 cm proximal and medial to promenence of 5th metatarsal. Tx: Pt prone w/ knee flexed. grasp lateral half of metatarsals and press towards table w/ 2nd MCP joint at pts proximal 5th metatarsal inducing evrsion and some extension of the cuboid relative to the foot |
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S/CS: quadratus plantae
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Flexion Calcaenus (quadratus plantae)
S/CS: FCA TP: plantar surface of thefoot on teh anteiror border of calcanus in the plantar fascia Tx: Pt prone, flex knee, grasp calcaneus and induxe flexion with the rest of the foot by forcing dorusm against thigh, wrap around point |
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S/CS: Soleus
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Flexion Medial Calcaneus (Soleus)
S/CS: FMC TP: Posterior to medial aspect of tibia on the fibers ofthe muscle TX; Pt prone, flex knee, dorsal arch on thigh, marked extension of ankle by pushing on plantar surface of thehell towars the calve, angle medially to fine tune. |
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Glenohumoral joint
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fossa covers 1/3 of head
stability mostly from soft tissue primary motion: rotation Minor mot'ns: rolling and translation, increases with injury |
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Acromioclavicular Joint
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fibrocartilage
protract'n/retract'n, elevation/depression, rotation |
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Sternoclavicular Joint
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Synovial saddle joint
transfers motion of arm to axial skeleton, rarely luxed, may be subluxed Motion: 4 degrees/10 degrees of arm elevation moves reciprocally to AC joint |
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Scapulothoracic Articulation
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Musclar attachment only: 18 muscles attach to the scapula
2ndry boney attachment via AC joint protraction/retraction, elevation/depression, rotation |
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SITS Muscles
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S -supraspinatus
I-Infraspinatus T-Teres minor S-subscapularis |
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Palpating Greater/Lesser Tubercle
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must put arm into external rotation
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Blood Supply of Arm
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Subclavian bexomes axillary becomes Brachial becomes radial and ulnar
subclavian artery passes between anterior and middle scalene: thoracic outlet syndrome venous supply runs anterior, will not be compromised |
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Brachial Plexus
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R- roots
T- trunks D- divisions C- cords B- branches Most common injury is Erb Duchenne palsey |
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Erb Duchenne Palsey
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Injury to C5-C6 results in upper arm paralysis: deltoid, extenral rotators, biceps, brachioradialis and supinator msucles
Waiter position |
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Injury to C5 & C6
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Erb Duchenne Palsey
Upper Arm Paralysis: deltoid, extenral rotators, biceps, brachioradialis and supinator muscles Waiter position |
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Waiter Arm Position
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Erb Duchenne Palsey: Injury to C5 & C6
Upper Arm Paralysis: deltoid, extenral rotators, biceps, brachioradialis and supinator muscles Waiter position |
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Klumpke's Palsy
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Claw Hand: Arm constantly supinated w/ wrist in extension
Injury to C8-T1 Affects intrinsic muscles of hand common injury: grab a branch/rung to prevent fall, football player grabs opponents Jersey and holds on |
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Arm constantly supinated w/ wrist in extension
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Klumpke's Palsy (Claw Hand): Injury to C8-T1
Affects intrinsic muscles of hand common injury: grab a branch/rung to prevent fall, football player grabs opponents Jersey and holds on |
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Injury to C8-T1
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Klumpke's Palsy (Claw Hand): Arm constantly supinated w/ wrist in extension
Affects intrinsic muscles of hand common injury: grab a branch/rung to prevent fall, football player grabs opponents Jersey and holds on |
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Bursitis and Tendonitis of the Shoulder
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Reptitive overuse, esp just started using joint more
Most common shoulder diagnosis Worse with overhead motion, no pain with passive mot'n Dx: positive Jobe's Test or Impingement Tx: Ice, Rest, NSAIDS |
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Adhesive Capsulitis
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Frozen shoulder from inflammation of rotator cuff
Cause: trauma/repetivie overuse followed by disuse correlated with diabetes Sx: decreased ROM over years Dx: positive Hawkin's or Neers Tx: OMT, stretching, Spencer's ROM exercises Steroid injxn/anti-inflamatory meds |
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Rotator Cuff Tear
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Tendon separates from bone.
Causes: may happen without trauma at all Sx: weakness, pain in deltoid often at night Dx: Positive Job's Test Tx: PT, NSAID, Steroids, surgery (some do great with conservative tx) |
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Shoulder Separation
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AC Joint separation or coronoid/clavicle
Causes: direct trauma, FOOSH SSx: Pain Dx: Swelling, positive corssover test Treatmetn: Ice, NSAID, Rest, grade dependent surgery |
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Shoulder Disolocation
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Displaced Humeral Head, 95% humorous moves anterior
Cuases: injury Ssx: Arm held at side, anatomy changes Dx: Positive apprehension test Tx: reduction, rest, strengthening maybe surgery |
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Scaular Y view
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X ray angle, humerus should be in center
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With any shoulder dysfnx always consider
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Cervical radiculopathy
AC3 or C4 tenderpoints Scapular Dysfnx Postural Imbalance Orthopedic Pathology (joint Dysfnx) |
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Quick Test
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Abduct arms and birng back of hands together over top of head
ROM Test |
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Abduct arms and birng back of hands together over top of head
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Quick Test
ROM Test |
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Apley Scratch Test
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Each behind head to scratch opposite shoulder with one arm and at the same time rech behind body to touch opposite scapula
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Each behind head to scratch opposite shoulder with one arm and at the same time rech behind body to touch opposite scapula
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Apley Scratch Test
Tests ROM internal rotation, extenral rotation |
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Deltoid Motor Innervation
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C5-6
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Supraspinatus Motor Innervation
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C5-C6
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Terres Major Motor Innervation
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Extension
C5-C6 |
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Sensory Dermatomes of the Arm
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C4 Top of Shoulder
C5 Lateral Arm T1 Medial Arm |
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Dermatome Top of Shoulder
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Top of Shoulder
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Dermatome Lateral Arm
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Lateral Arm
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Dermatome Medial Arm
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Medial Arm
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C4 Dermatome
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Top of Shoulder
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C5 Dermatome
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Lateral Arm
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T1 Dermatome
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Medial Arm
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Jobe's sign
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supraspinatus tendonitis
Empty beer chan stance, Doc pushes down and asks for resistance pain OR weakness is positive |
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Empty beer chan stance, Doc pushes down and asks for resistance
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Jobe's sign
supraspinatus tendonitis Empty beer chan stance, Doc pushes down and asks for resistance pain OR weakness is positive |
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supraspinatus tendonitis orthopedic test
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Jobe's sign
Empty beer chan stance, Doc pushes down and asks for resistance pain OR weakness is positive |
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Drop Arm Test
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Tears in rotator cuff
Pts arm pasively abducted to 90*. Pt asked to lower slowly. Tear in supraspinatus will drop to pts side. |
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Pts arm pasively abducted to 90*. Pt asked to lower slowly.
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Drop Arm Test: Tear in supraspinatus will drop to pts side.
May be painless |
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Scapular Winging
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Serratus Anterior
Long Thoracic Nerve C5-C7 |
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Shoulder Aprehension Test
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Anterior Dislocatoin
Arm Abducted, Elbow Flexed, Arm Extenrally Rotated all to 90 (Friendly wave position). Continue externally rotating. Apprehension/Guading is positive. Posteriorly directed forc eon shoulder will decrease pain and apprehension |
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Arm Abducted, Elbow Flexed, Arm Extenrally Rotated all to 90 (Friendly wave position). Continue externally rotating.
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Shoulder Aprehension Test
Anterior Dislocatoin Apprehension/Guading is positive. Posteriorly directed forc eon shoulder will decrease pain and apprehension |
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Speeds Sign
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Biceps Tendinitis
Arms out in Front Supinated, Doc pushes Down while Pt pushes up Positive is pain along long head of biceps |
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Arms out in Front Supinated, Doc pushes Down while Pt pushes up
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Speeds Sign
Biceps Tendinitis Positive is pain along long head of biceps |
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Crossover Test
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AC Joint Pathology
Adduct Pts arm across chest to touch opposite shoulder Pain over AC joint may indicate problem |
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Adduct Pts arm across chest to touch opposite shoulder
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Crossover Test
AC Joint Pathology Pain over AC joint may indicate problem |
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Impingement Sign
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Abduct arm to 180
positive if shoulder will not abduct beyond 90* w/wo pain (one of three) Hawkin's test: Flexing internally rotating shoulder, placing a downward pressure on wrist; positive pain in pt with shoulder: Impingement Sign Neers test: Flex the arm while placed in internal rotation; positive pain: Impingement Sign |
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Hawkin's test
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Flexing internally rotating shoulder, placing a downward pressure on wrist
positive pain in pt with shoulder: Impingement Sign |
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Neers test
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Flex the arm while placed in internal rotation
positive pain: Impingement Sign |
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Doc flexes the arm while placed in internal rotation
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Neers test
positive pain: Impingement Sign |
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Doc Flexes and internally rotates shoulder, placing a downward pressure on wrist
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Hawkin's test
positive pain in pt with shoulder: Impingement Sign |
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Sulcus Test
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Pt seated or standing, shoulder in neutral, doc grabs arm proximal to elbow. inferior traction, obvserve for dimpling. palpation reveals space
tests of rglenohumor instability possible AC joint separation |
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Spencer Technique
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Articulatory Technique: Pt lying on side shoulder up, doc stabalizing clavicle and scapula
Order not crucial, does progress to more complex motions 1. Extension 2. Flexion 3. Abduction to 90, flexed elbow, cricumduction 4. Extened elbow circumduction 5 Elbow flexed, induce abduction beyond 90 6 Internal rotation 7 traction/distraction Spencer technique itself does not adress external rotation |
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Weird muscles atatached to scapula:
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omohyoid
long head of triceps brachii coracobrachialis |
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Hypertonic shoulder Muscles
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Levator Scaps, Lats
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Inhibited Shoulder Muscles
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Serratus anterior from stacked alternating ERS's in the mid-scapular area
Middle and Lower Traps form FRS's in lower T spine |
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Restricted Posterior Shoulder Capsule Stretch
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Pt lying dysfnx down
flex elbow and abduct to 90 degrees hodlign arm at barrier, roll pt forward and then back over shoulder repatedly |
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S/CS: Subdeltoid Brusa and Deltoid Muscle
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TP: Under Acromion Process high on the anterolateral humerous found by abducting arm
Tx: Statue of Liberty: Abduction to 90*, forward flexion 30*, Int/Ext fine tuning For: Bursitis of the shoulder |
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S/CS: Coracoid
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TP: Over Coracoid Process
Tx: Addxn across chest to touch hand to opposite shoulder For: Biceps tendonitis/strain |
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S/CS: Long head biceps
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TP: Bicipital Groove
Tx: Woe is me, head away For: biceps tendonitis/strain |
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S/CS: Infraspinatus
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TP: ~2" below spine of scapula 1/2" lateral to medial margin
Tx: 160*+ of pure abduction |
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S/CS: Supraspinatus
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TP: Supraspinatus Fossa
Tx: 45* flexion/abduction |
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S/CS: Trapezius
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TP: Middle portion of upper fibers of trapezius behind first rib pressing anteriorly
Tx: sidebend pts head towards tenderoitn side, abduct shoulder to 180 |
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S/CS: Subscapularis
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TP: Anteiror surface of scapula in posteior axillary fold
Tx: extension 30 degrees, abduction 30 degrees and marked internal rotation of the shoulder |
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S/CS: Pectoralis Minor
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TP: 3cm inferior and medial to coracoid
Tx: Adduct the pts arm obliquely across the body and add caudal traction Same as Anteiror aspect of AC Joint |
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S/CS: Anteior aspect of AC Joint
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TP: Anteior Acromioclavicular
Tx: Adduct the pts arm obliquely across the body and add caudal traction; same as pect minor |
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Levator Scapular
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TP: Superior edial angle of scapula
Tx: prone, head turned away, extend and externally rotate shoulder via wrist w/ caudal traction. Tx: supine, neck sidepent to TP, w/ elbow flexed, cephalad force through shaft of humerous |
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TP: Under Acromion Process high on the anterolateral humerous found by abducting arm
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S/CS: Subdeltoid Brusa and Deltoid Muscle
Tx: Statue of Liberty: Abduction to 90*, forward flexion 30*, Int/Ext fine tuning For: Bursitis of the shoulder |
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TP: Over Coracoid Process
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S/CS: Coracoid
Tx: Addxn across chest to touch hand to opposite shoulder For: Biceps tendonitis/strain |
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TP: Bicipital Groove
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S/CS: Long head biceps
TP: Bicipital Groove Tx: Woe is me, head away For: biceps tendonitis/strain |
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TP: ~2" below spine of scapula 1/2" lateral to medial margin
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S/CS: Infraspinatus
Tx: 160*+ of pure abduction |
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TP: Supraspinatus Fossa
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S/CS: Supraspinatus
Tx: 45* flexion/abduction |
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TP: Middle portion of upper fibers of trapezius behind first rib pressing anteriorly
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S/CS: Trapezius
Tx: sidebend pts head towards tenderoitn side, abduct shoulder to 180 |
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TP: Anteiror surface of scapula in posteior axillary fold
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S/CS: Subscapularis
Tx: extension 30 degrees, abduction 30 degrees and marked internal rotation of the shoulder |
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TP: 3cm inferior and medial to coracoid
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S/CS: Pectoralis Minor
Tx: Adduct the pts arm obliquely across the body and add caudal traction; same as anterior AC |
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TP: Superior medial angle of scapula
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Levator Scapular
Tx: prone, head turned away, extend and externally rotate shoulder via wrist w/ caudal traction. Tx: supine, neck sidepent to TP, w/ elbow flexed, cephalad force through shaft of humerous |
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TP: Anteior Acromioclavicular
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S/CS: Anteior aspect of AC Joint
Tx: Adduct the pts arm obliquely across the body and add caudal traction; same as pect minor |
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Tx: Statue of Liberty: Abduction to 90*, forward flexion 30*, Int/Ext fine tuning
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S/CS: Subdeltoid Brusa and Deltoid Muscle
TP: Under Acromion Process high on the anterolateral humerous found by abducting arm For: Bursitis of the shoulder |
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Tx: Addxn across chest to touch hand to opposite shoulder
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S/CS: Coracoid
TP: Over Coracoid Process For: Biceps tendonitis/strain |
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Tx: Woe is me, head away
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S/CS: Long head biceps
TP: Bicipital Groove For: biceps tendonitis/strain |
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Tx: 160*+ of pure abduction
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S/CS: Infraspinatus
TP: ~2" below spine of scapula 1/2" lateral to medial margin |
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Tx: 45* flexion/abduction
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S/CS: Supraspinatus
TP: Supraspinatus Fossa |
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Tx: sidebend pts head towards tenderoitn side, abduct shoulder to 180
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S/CS: Trapezius
TP: Middle portion of upper fibers of trapezius behind first rib pressing anteriorly |
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Tx: extension 30 degrees, abduction 30 degrees and marked internal rotation of the shoulder
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S/CS: Subscapularis
TP: Anteiror surface of scapula in posteior axillary fold |
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Tx: Adduct the pts arm obliquely across the body and add caudal traction
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S/CS: Pectoralis Minor
TP: 3cm inferior and medial to coracoid S/CS: Anteior aspect of AC Joint TP: Anteior Acromioclavicular |
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Tx: supine, neck sidepent to TP, w/ elbow flexed, cephalad force through shaft of humerous
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Levator Scapular
TP: Superior medial angle of scapula |
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Tx: prone, head turned away, extend and externally rotate shoulder via wrist w/ caudal traction.
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Levator Scapular
TP: Superior medial angle of scapula |
