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Hip, Thigh, and Knee

Hip, Thigh, and Knee. ILIUM Acetabulum Ischium Ischial Tuberosity Pubis

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Hip, Thigh, and Knee

ILIUM

Acetabulum

IschiumIschial Tuberosity

Pubis

Greater Trochanter

Lesser Trochanter

Lateral Condyle

Medial Condyle

Lateral Condyle

Patella

Posterior Cruciate Ligament

Anterior Cruciate Ligament

Medial Meniscus

Lateral Meniscus

Medial CollateralLigament

Lateral

Collateral

Ligament

Anatomy

• Buttocks

• Gluteus – Medius, – Minimus, – Maximus

• Piriformis

Anatomy

• Hip Flexors

• Psoas Major, Minor

• Iliacus

Anatomy

• Quadriceps• Rectus femoris• Vastus lateralis• Vastus medialis• Vastus intermedius

• Abductor Complex• Sartorius• Tensor Fascia Lata

• Hamstrings• Semimembranosus• Semitendinosus• Biceps femoris• Adductor Complex• Adductor

– Brevis– Longus– Magnus

• Gracilis

Quadriceps• Rectus Femoris

– O: Anterior inferior iliac spine

– I: Patella and Tibial Tuberosity

– A: flexion of hip, knee extension

• Vastus Lateralis– O: greater trochanter– I: lateral patella, lateral

femoral condyle and rectus femoris tendon

– A: extension of knee

Quadriceps• Vastus Intermedius

– O: proximal 2/3 of anterior femur– I: inferior aspect of patella and tendons of

vastus lateralis and medialis– A: extension of knee

• Vastus Medialis– O: Between the Greater and Lesser

Trochanter– I: medial tibial condyle, medial patella and

medial aspect of rectus femoris tendon– A: extension of knee

• Vastus Medialis Oblique– O: Tendon of Adductor Magnus– I: Patellar Tendon/ Tibial Tuberosity– A: stabilize patella

ABductors• Sartorius

– O: Anterior superior iliac spine– I: inferior to medial condyle of tibial – A: Flexion, Abduction, and External

Rotation of hip; flexion of knee,

• Tensor Fascia Latae– O: Outer lip of iliac crest and between

anterior superior and anterior inferior iliac spine

– I: Greater trochanter of femur, and (as iliotibial band) lateral condyle of tibia

– A: Abduction

Adductors• Adductor

– Longus• O: pubic bone• I: Middle 1/3 of Femur• A: adduction

– Brevis• O: pubic bone• I: proximal 1/3 of femur• A: adduction

– Magnus• O: pubic bone and ischial Tuberosity• I: distal 1/3 of femur• A: adduction

Adductors

• Gracilis– O: pubic symphisis and pubic bone – I: distal to medial tibial condyle – A: adduction, flexion, and internal rotation of

hip, flexion of knee; (Cross legs)

Iliopsoas

O: Thorasic and Lumbar Vertebrae (front of spine) and Ilium

I: Lesser Trochanter

A: Flexion of hip

Hamstrings

• Biceps Femoris–O: ischial Tuberosity

– I: head of fibula and lateral tibial condyle

–A: extension of hip; flexion of knee

Hamstrings

• Semimembranosus– O: ischial Tuberosity – I: medial tibial condyle – A: hip extension, knee flexion

• Semitendinosus– O: ischial Tuberosity – I: medial condyle of tibia– A: hip extension, knee flexion

T

M

T

M

Gluteuses• Gluteus Minimus

– O: Ilium– I: Anterior Greater Trochanter– A: Abducts and Internal

Rotation

• Gluteus Medius– O: Ilium– I: Lateral Greater Trochanter– A: Abduction and Internal

Rotation

• Gluteus Maximus– O: Ilium Sacrum– I: Posterior Greater Trochanter and IT Band– A Extension and External Rotation

Hip/Thigh Movements

• Abduction • Adduction• Extension• Flexion• Internal Rotation• External Rotation

• What muscles do these movements?

Palpation Hip• ASIS• Iliac Crests• PSIS • Greater Trochanter

Soft Tissue• IT Band

What muscles do these movements?

List out the muscles that do each movement:

• Abduction

• Adduction

• Hip Flexion

• Hip Extension

• External Rotation

Observation

• Symmetry- hips, pelvis tilt (anterior/posterior)– Lordosis or flat back

• Lower limb alignment – Knees, patella, feet

– Genu Valgum/ Genu Varum

• Pelvic landmarks (ASIS, PSIS, iliac crest)• Standing on one leg

– Pubic symphysis pain or drop on one side

• Ambulation– Walking, sitting - pain will result in movement distortion

Observation

• Anteversion (A) and

• Retroversion (B)

• Think in terms of the Greater Trochanter

Observation

• Leg Length Discrepancy– Anatomical

• Actual bone length difference

– Functional• Rotation of pelvis• Muscle tightness

– 1/8 inch or greater = discrepancy

Special Tests

• Fracture

• Range of Motion– Passive– Active– Resistive

Thigh Injuries• Quadriceps Contusion

– Mechanism• Blow to quads.

– Symptoms• Pain• Swelling• Bruising• Loss of function

– Treatment• RICE

– Ice bent position

• The red is hemorrhaging within the compartment

• Increased swelling = Increased pressure = decreased healing/ function

• If hemorrhage gets too large will have to do a compartment release which is done by cutting the fascia to allow the expansion

Thigh Injuries• Myositis Ossificans

• Myo= muscle itis = irritation oss = bone– Mechanism

• Blow to thigh Hemorrhage hematoma

– Symptoms• Pain - Hard “bump”• Musc weakness - Swelling• Loss of function

– Treatment• At first can use Ultrasound• Surgical Removal

• Quad Compression Wrap– Start slightly above patella – Begin just like all other ACE wrapping

techniques.– Continue up the thigh halfway overlapping

alternating angling up and angling down.

–Practice it!

Thigh Injuries• Hamstring Strain

– Mechanism• Overloading of HS muscles• Over stretching

– Symptoms• Pain - swelling - G2 or 3 = palpate deformity• Loss of function - “popping”

– Treatment• RIC• ROM• stretching

• Compression wrap same as Quad Contusion

Hip Injuries• Groin Strain

– Straining of Adductors– Over stretching of the muscle

• Symptoms– Pain in medial hip– Pain referred to knee

• Treatment– RIC - light stretching– NSAIDs - Strengthening– ROM exercises - Compression wrap

Groin wrap• Start with roll on lateral side of leg

• Start ACE at an angle– 2 times around with “dog ear”

• Apply extra tension going medially as to pull the leg into ADduction.

• Continue your spica until out of wrap.

- Athlete should fee leg being pulled in and slightly forward.

****Anytime doing a hip wrap you will pull in the direction that the injured muscles does.

Hip Flexor StrainRectus Femoris/ Iliopsoas Strain

- Often due to explosive activities (sprinting)

- Symptoms- “Pop” - Loss of function- Pain

- Treatment- Light stretches - rest- Compression wrap pulling forward- strengthening

Hip Special Tests

• Kendall / Thomas test– Positioning

• Athlete lies supine with ½ of femur off the table

– Test• Athlete hugs opposite knee to chest

– Positive• Knee Extends = Rectus Femoris tightness• Hip Flexes = Hip Flexor Contracture

Hip Injuries

• Contusion (Hip Pointer)– Mechanism

• Blow to iliac

– Symptoms• Bruising • Pain• Loss of function

– Treatment• RICE

IT Band

• IT Band Tendonitis– Mechanism

• Repetitive friction over greater trochanter or lateral femoral condyle

• Pes cavus, Genu varum

– Symptoms• pain at greater trochanter or lateral femoral condyle• Positive Ober and Nobles tests

– Treatment• Stretch tendon - Ice• Strengthen Abductors - Rest

IT Band Tightness

• Noble’s Test– Position –

• athlete supine• athlete’s knee is

flexed to 90 degrees

– Test – • Pressure is applied to lateral femoral condyle while

knee is extended

– Positive – • Pain at lateral femoral condyle• IT Band Tendinitis

IT Band Tightness

• Ober’s– Position

• Athlete is lying on side opposite of affected side• Tester is behind the athlete at the hip

– Test• Tester holds ankle and knee (flexed to 90)• Tester allows knee to adduct.

– Positive• Pain or tightness• No drop of the knee

Gluteus Medius and Adductor Weakness

• Trendelenburg – Position

• Patient stands with feet together

– Test• Tester stands behind the

athlete• Athlete lifts knee as to march

– Positive• Drop in the non weight bearing

side PSIS/ Iliac Crest

*Weakness in these muscle groups can

lead to IT band tendonitis, bursitis,

and other hip problems.

Hip Injuries• Trochanteric Bursitis

– Cause• Excessive repetitive irritation at Greater Trochanter

– Symptoms• Hip instability• Snapping sensation • Pain/ inability to walk

– Treatment• ICE - Stretching• NSAIDs - Strengthening• Ultrasound (not the kind you see a baby with)• Compression wrap

Special Test

- Range of Motion reproduces the pain

Hip Injuries

• Dislocated Hip– Mechanism

• Result of traumatic force

– Signs and Symptoms• Flexed, adducted and internally rotated hip• Palpation reveals displaced femoral head posteriorly• Other

– Soft tissue, neurological damage and possible fx

– Special Tests• none

– Management• EMERGENCY ROOM!• 2 weeks immobilization and crutch use for at least one month

Knee Observation

• Patellar positioning– Alta– Baja

• Knee Positioning– Genu varum– Genu valgum– Genu Recurvatum

• Swelling– Intracapsular– Extracapsular

Observation

• Patella Alta– High Patella

• tight quad muscles, • places extra stress on patellar tendon, • causes extra friction on Femoral condyles

• Patella Baja– Low Patella –

• shorter patellar tendon, • causes extra friction on Femoral condyles

Soft Tissue of the Knee

Observation

• Genu Varum– Bow legged– Stresses lateral structures

• Genu Valgum– Knock kneed– Stresses medial structures

• Genu Recuvatum– Hyper-extended knees

Meniscus and Ligaments

Palpation

Knee• Medial and Lateral

Condyle• Tibial Tuberosity• Patella

Soft Tissue• Medial Collateral

Ligament (MCL)• Lateral Collateral

Ligament (LCL)• Patellar Tendon• IT Band• Meniscus (med & lat)

Animation

Knee Injuries

• MCL or LCL sprain– Mechanism

• Lateral (mcl) or medial (lcl) force knee

– Symptoms• Pain• laxity

– Treatment• RICE • Taping

Knee Special Tests

• Valgus and Varus Stress tests– Tests MCL (Valgus) or LCL (Varus)– Positioning

• Athlete sitting or lying down in relaxed position

– Test• Apply a medial (varus) or lateral (valgus) pressure to joint

line while pulling lower leg in the opposite direction• Perform this at 0 degrees and 30 degrees

– Positive• Pain (1st or 2nd degree sprain)• Laxity (2nd or 3rd degree sprain

Practice itPractice it

Knee Injuries

• ACL sprain– Mechanism

• Plant and twist

– Symptoms• Joint laxity (give

way)• 1-2 pain• Locking• swelling

– Treatment• RICE• quad strengthening• Swelling control• ROM• SURGERY

Special Tests• Anterior Drawer

– Tests ACL– Position

• Athlete supine on table with knee bent to 90 degrees• Tester sits on foot to stabilize lower leg• Place thumbs on the tibial plateau (tibial joint line)

– Test• Pull lower leg anteriorly in line with thigh in a jerking motion

– Positive• Pain or laxity

– Note: if the athlete does have an ACL injury it is likely that you will only have one chance to correctly do this test because they may guard against you after that.

Practice itPractice it

Special Tests

• Lachman Drawer Test– This test is less painful and more precise after a knee

injury– Position

• Athlete is supine on the table with legs straight• Tester places their knee under femur in order to bend the

knee to 30 degrees– Test

• Tester pulls the tibia directly upward and presses the femur downward in a jerking motion

– Positive• Pain (1st and 2nd degree tear)• Laxity (2nd and 3rd degree tear) Practice itPractice it

ACL Surgery

Post. Cruciate Lig. sprain–Mechanism

• Blow to anterior tibia

–Symptoms• Pain• Swelling• Joint laxity

–Treatment• Strengthening

• RICE

• Surgery

Special Tests• Posterior drawer

– Tests PCL– Position

• Athlete supine on table with knee bent to 90 degrees• Tester sits on foot to stabilize lower leg• Place thumbs on the tibial plateau (tibial joint line)

– Test• Push lower leg posteriorly in line with thigh in a jerking motion

– Positive• Pain or laxity

– Note: if the athlete does have an PCL injury it is likely that you will only have one chance to correctly do this test because they may guard against you after that.

Practice itPractice it

Special Tests

• Posterior Sag Test (Godfrey’s test)– Positioning

• Athlete is supine w/ both knees flexed to 90 degrees

– Test• Lateral observation

to see if either tibia

has moved posteriorly

Meniscal Tears

• Mechanism– Cutting– Forcefully extended– Rotation

• Treatment– Surgery– Bracing– Strengthening– ROM

• Symptoms– Joint pain– locking– swelling– Loss of motion– giving way– cracking/popping

Meniscus and Ligaments

Special Tests

– McMurray’s Test• Used to determine displaceable meniscal

tear• Position

– Athlete is supine on table

• Test– Leg is moved into flexion and extension while

knee is internally and externally rotated in conjunction w/ valgus and varus stressing

• Positive – clicking and popping are felt

Practice itPractice it

Special TestsA B

C D

Special Tests• Apley’s Compression Test

– Athlete prone– Hard downward pressure is applied w/ rotation– Positive - Pain indicates a meniscal injury

• Apley’s Distraction Test– Athlete prone– Traction is applied w/ rotation– Pain will occur if there is damage to the capsule

or ligaments– No pain will occur if it isa meniscus tear Practice itPractice it

Special Tests

• Apley

Compression

Plica tear of the fascia under the patella

• Mechanism–Excessive Shock

• Symptoms–Snap/popping

–Pain when sitting for long time

• Treatment–Rest

–Heat

–NSAIDs

–Surgery

Special Tests

• Patellar Compression test– Position

• Athlete seated or lying in a comfortable position

– Test• Tester presses patella down into the femoral

groove, then moves it up and down to feel for any abnormalities

– Positive• Pain or grinding sensation

Practice itPractice it

Special Tests

• Patellar Grind Test– Position

• Athlete supine either seated or lying

– Test• Tester places Thumb web-space just above the

patella• Tester then asks athlete to contract their quad

forcefully

– Positive• Pain and/or grinding.

Practice itPractice it

– Chondromalacia or any condition associated with the patella on the femur

• Chondro = Cartilage Malacia = softening of

– Mechanism• Patella not tracking within femoral groove correctly.

– Signs and Symptoms• Tenderness of lateral patella• Swelling• Dull ache in center of knee• Patellar compression will elicit pain and crepitus• Apprehension when patella is forced laterally

– Management• RICE - Tape patella to aid in tracking• Stretch ITB - Strengthen Medial structures

Patellofemoral Stress Syndrome

Knee Injuries• Patella Dislocation

– Mechanism• Non-contact, quick forceful contraction of the lateral

quads

– Symptoms• Deformity - slightly flexed knee• Pain

– Treatment• Straighten leg - Splint• I.C.E. - Send for x-rays

• Can cause damage to cartilage or fracture patella

Patellar subluxation

• Apprehension Test–Position

• Athlete supine and relaxed with knee extended

–Test• Tester places a lateral stress on the patella

–Positive• Athlete has pain or tightens quads in “fear”

of dislocation

• Mechanism– Begins as cartilage and develops a bony callus,

enlarging the tubercle– Resolves w/ aging– Common cause = repeated avulsion of patellar

tendon• Signs and Symptoms

– Swelling - Point tenderness– Pain w/ kneeling, jumping and running

• Management– Reduce stressful activity (6-12 months)– Possible casting, – ice before and after activity– Isometerics

Osgood-Schlatter Disease

• Patellar Tendinitis (Jumper’s or Kicker’s Knee)– Mechanism

• Jumping or kicking - placing tremendous stress and strain on patellar or quadriceps tendon

• Sudden or repetitive extension

– Signs and Symptoms• Pain and tenderness at inferior pole of patella

– 3 phases - 1)pain after activity, 2)pain during and after, 3)pain during and after (possibly prolonged) and may become constant

– Management• Ice, ultrasound, heat• Exercise• Patellar tendon bracing• Transverse friction massage