Download Knee - Liberty Union High School District

Hip, Thigh, and Knee
ILIUM
Acetabulum
Pubis
Ischial
Tuberosity
Ischium
Sacrum
Greater
Trochanter
Lesser
Trochanter
Medial
Condyle
Lateral
Condyle
Lateral
Condyle
Patella
Posterior
Cruciate
Ligament
Anterior
Cruciate
Ligament
Medial
Meniscus
Lateral
Lateral
Meniscus
Collateral
Ligament
Medial
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 and
rectus femoris tendon
– A: extension of knee
Quadriceps
• Vastus Intermedius
– O: proximal 2/3 of anterior femur
– I: inferior aspect of patella and patellar
tendon
– A: extension of knee
• Vastus Medialis
– O: Between the Greater and Lesser
Trochanter
– I:medial patella and rectus femoris tendon
– A: extension of knee
• Vastus Medialis Oblique
– O: Tendon of Adductor Magnus
– I: Patellar Tendon/ Tibial Tuberosity
– A: stabilize patella
• Sartorius
ABductors
– 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
• Adductor
Adductors
– 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;
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
M
T
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 and Sacrum
– I: Posterior Greater Trochanter
– 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)
• Gait
– 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
• ME H
– 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
– Mechanism
oss = bone
• Blow to thigh  Hemorrhage  hematoma
– Symptoms
• Pain
• Musc weakness
• Loss of function
- Hard “bump”
- Swelling
– Treatment
• At first can use Ultrasound
• Surgical Removal
Thigh Injuries
• Hamstring Strain
– Mechanism
• Overloading of HS muscles
• Over stretching
– Symptoms
• Pain
deformity
- swelling
- G2 or 3 = palpate
- Loss of function - “popping”
– Treatment
– Heat
- light stretching
– NSAIDs
- Strengthening
– ROM exercises - Compression wrap
Hip Injuries
• Groin Strain
– Straining of Adductors
– Over stretching of the muscle
• Symptoms
– Pain in medial hip
– Pain referred to knee
• Treatment
– Heat
– NSAIDs
– ROM exercises
- light stretching
- Strengthening
- Compression wrap
Groin wrap
• Start with roll on MEDIAL 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 Strain
Rectus Femoris/ Iliopsoas Strain
- Often due to explosive activities
(sprinting)
- Symptoms
- “Pop”
- Pain
- Loss of function
- Treatment
– Heat
– NSAIDs
– ROM exercises
- light stretching
- Strengthening
- Compression wrap
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 = Iliopsoas tightness
Hip Injuries
• Trochanteric Bursitis
– Cause
• Excessive repetitive irritation at Greater Trochanter
– Symptoms
• Hip instability
• Snapping sensation
• Pain/ inability to walk
– Treatment
•
•
•
•
Special Test
- Range of Motion
reproduces the
pain
ICE
- Stretching
NSAIDs
- Strengthening
Ultrasound (not the kind you see a baby with)
Compression wrap
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
IT Band
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 lying on unaffected side
• athlete’s knee is flexed to 45 degrees
– Test –
• Pressure is applied to lateral femoral condyle while
knee is extended and flexed
– Positive –
• Pain at lateral femoral condyle
• IT Band Tendinitis
https://www.youtube.com/watch?v=l5upmuAnRYE
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
https://www.youtube.com/watch?v=U-BBaQyner4
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.
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
Animation
Soft Tissue
• Medial Collateral
Ligament (MCL)
• Lateral Collateral
Ligament (LCL)
• Patellar Tendon
• IT Band
• Meniscus (med & lat)
Knee Ligament 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 lateral (valgus) or medial (varus) 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 it
Knee Injuries
• ACL sprain
– Mechanism
• Plant and twist
– Symptoms
• Joint laxity (give
way)
• pain
• Locking
• swelling
– Treatment
•
•
•
•
•
METH
quad strengthening
Swelling control
ROM
SURGERY
https://www.youtube.com/watch?v=t63QH2
mv1CM#t=130.701
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 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 it
ACL Reconstruction Surgical
Technique
https://www.youtube.com/watch?v=5yiWPb9
_hNc
ACL Surgery
Post. Cruciate Lig. sprain
– Mechanism
• Blow to anterior
tibia
– Symptoms
• Pain
• Swelling
• Joint laxity
–Treatment
• Strengthening
• METH
• 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 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
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 it
Special Tests
A
C
B
D
Special Tests
• Standing Compression Test
– Athlete stands on one leg
– Athlete performs a slight squat then rotates to
each side.
– Positive is pain and/or locking

Practice it
Meniscus Tear Surgery
• https://www.youtube.com/watch?v=WAdTn
rI_VUE
Chondromalacia patella
- Softening and deterioration of the articular cartilage
Often associated with abnormal tracking
Signs and Symptoms
Pain w/ walking, running, stairs and squatting
Possible recurrent swelling, grating sensation w/
flexion and extension
Pain at inferior border during palpation
Management
Conservative measures
RICE, NSAID’s, isometrics, orthotics to correct dysfunction
Surgery
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 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 it
Knee Injuries
• Patella Dislocation
– Mechanism
• Non-contact, quick forceful contraction of the lateral
quads
– Symptoms
• Deformity
• Pain
- slightly flexed knee
– 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
Osgood-Schlatter Disease
• Mechanism
– Begins as cartilage and develops a bony callus,
enlarging the tuberosity
– 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
• 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
Bursitis
Acute, chronic or recurrent swelling
Prepatellar = continued kneeling
Infrapatellar = overuse of patellar tendon
Signs and Symptoms
Prepatellar bursitis may be localized swelling above
knee that is ballotable
Management
Eliminate cause, RICE and NSAID’s
Aspiration and steroid injection if chronic
Other Conditions/ Injuries
Shin splints
– Catch-all term for anterior pain
Stress fractures, muscle strains and chronic
compartment syndrome
Medial Tibial Stress Syndrome
– Due to repetitive microtrauma
– Weak muscles
- Poor shoes
– Overtraining
-Running surface
– Malalignment
Grades of MTSS
Grade 1
– pain after activity
Grade 2
– pain during and after activity
– No performance affects
Grade 3
– Before during and after
– Affects performance
Grade 4
– Activity impossible/ too painful
Management
Medial Tibial Stress Syndrome (MTSS)
– Modification of activity
– Gait analysis
– massage
– Stretching
– Arch taping
– Compression
http://www.youtube.com/watch?v=ea4cInVmIv4
Compartment
Syndrome
– Acute – secondary to
trauma
– Exertional – activity
related
– Symptoms
Deep Aching Pain
Tightness and Swelling
Pain w/ stretching
Reduced circulation and
sensation