Exam 3 Flashcards Preview

62nd Sem: Movement Science > Exam 3 > Flashcards

Flashcards in Exam 3 Deck (92):
1

1 Short Answer on hip biomechanics problem.
70 ?s multiple choice ?s
Review Lab of hand MMT


Below are flashcards on WRIST and HAND

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2

1) T or F: The hand is very very important to YOU as a PT since you use your hand to treat patients. And it is very important to patients.

2) PT's don't treat hands, OT's do

3) Review numonic to remember carpal bones:

4) What are the carpal bones?

5) How do you remember difference between trapezoid and trapezium?

6) T or F: The pisiform bone is a carpal bone? Why?

7) Function of pisiform bone?

8) So how many bones are part of the proximal row of carpal bones?
- Which ones?



9) Bones of the hand can be divided into 2 functional portions:

10) So what about the proximal row of carpals - what is their function?


11) Digit 1 (or D1) is what finger?

1) True



2) False. Both do

3) So, Long, The, Pinky, Here, Comes, The, Thumb

4) Schaphoid, Lunate, Triquetrum, Pisiform, Hamate, Capitate, Trapezoid, Trapizium

5) TrapeziUM by thumb

6) False. Technically it is a sesamoid bone because it is embedded in a tendon to increase the lever arm for the FCU muscle, and it does NOT articulate at / with the wrist

7) NOT a function of wrist joint movement. It is a sesamoid bone that helps increase lever arm for flexor carpi ulnaris tendon.

8) 3
- Schaphoid, lunate, triquetrum

9)
- Fixed portion: provides a stable base ... includes distal row of carpals and 2nd and 3rd MC bones (D2 and D3)
- Adaptive portion: provides for grasp and manipulation ... they are more mobile. It is MC's 1, 4, 5 and all phalanges (D1, D4, D5) ... and the proximal row of carpals.

10) The proximal row of carpals is associated with motions at the wrist, not the hand.

11) Thumb

3

1) The hand has arches. What is another name for the arches?

2) What is meant by the 'attitude of the hand'

3) What are the 3 arches of the hand:


4) From #3 above,
- where do each of these run
- what fixes it in place
- Does it move












5) If you disrupt or lose mobility in any metacarpal or carpal bone, how does that impact these arches?

1) The "attitude of the hand"


2) The natural position of the hand at rest. Lay your hand dorsally down and let it naturally lie there. Those natural arches (forces on hand) is the 'attitude of the hand'

3)
- Proximal Transverse Arch
- Distal Transverse Arch
- Longitudinal Arch

4)
- Proximal Transverse Arch
- Through carpals
- Flexor retinaculum
- does not move
- Distal Transverse Arch
- Through metacarpal heads
- can flatten or become more curved (since D1, D4, D5
can move, flatten, curve)
- Longitudinal Arch
- It really runs from carpals out through any of the D2-
D5 digits.
- it is mobile and can flatten and curve

5) You lose ability to make any of these arches.

4

1) The 'wrist complex' consists of what:



2) Explain the joints in the 'wrist complex'
- Name of joint
- Type of joint
- Motions of joint




















3) The joint that gives major contribution to radial / ulnar deviation?

4) Outside of those joints listed above, what other unique complex contributes to the wrist complex, and another name for it
- What is this 'joints' function?:


5) How to remember the thumb being in ext/flexion vs. ab/adduction

6) So:
- what are the 'joint cavities' of the wrist
- what is the 'lesser importance' cavity at the wrist
- what is the 'joint complex' of the wrist

7)
- How do you know if you have a pathology of a joint cavity.
- Explain the specifics (bony landmarks / boundaries) of those joint cavities











8) If someone has popping in their wrist, what could that be from?

9) So if you tear your TFCC, what would be limited?

10) Is the proximal or distal row where the movement of the wrist primarily comes from?

1)
- The distal part of the radius, ulna, and TFCC
- The carpal bones
- The proximal (bases) of the metacarpal bones
- All the lig's and joints in that area

2)
- Radiocarpal jt
- Ellipsoid jt
- Flex/Ext, Rad/Ulnar deviation

- Midcarpal jt
- Plane jt
- Flex/Ext, Rad/Ulnar deviation (major contributor!)

- Common carpometacarpal jt
- Plane jt
- Some Flex/Ext
- Gliding of MC down on Carpals (D5 > D4 > D3)

- Thumb carpometacarpal jt
- Saddle jt
- Flex/Ext, Ab/Adduction, Rotation

TECHNICALLY the Pisiform jt (plane joint) that improves moment arm for FCU muscle.


3) Midcarpal jt.


4) TFCC: Triangular fibrocartilage complex
- aka: ulno-menisco-triquetral jt
- Function: helps with pronation and supination, helps with all radio carpal jt movements, primarily to provide stability to the distal radio-ulnar joint, hold ulna into radius, fibers attach to ulnar collateral lig for stability.

5) THUMBS UP is extension.


6)
- Joint Cavities: radiocarpal, midcarpal, common carpometacarpal, thumb carpometacarpal
- Pisiform
- TFCC

7)
- Inject some DYE into a cavity and if there is leakage, then some lig or something has been damaged.
- The radio carpal goes from distal to the radius and TFCC, but proximal to the 3 proximal carpal bones.
- The midcarpal joint cavity runs between the 2 rows of carpal bones, but also projects out between each bone (proximally and distally).
- The common carpometacarpal jt cavity runs between the MC's and the distal row of carpals between D2-D5 (since the thumb has it's own cavity)
- Thumb carpometacarpal around base of D1's MC
- The pisiform also has a slight cavity around it as well.
- There is also one between the distal radio-ulnar joint

8) Could be from many things, but maybe joint capsule releasing pressure, possibly a lig was torn or is getting caught, or the TFCC was torn or is snagging.

9) Pronation and Supination

10) Proximal

5

LIGAMENTS OF THE WRIST:

1) What are 'extrinsic' vs. 'intrinsic' lig's of the wrist ... what is the difference?

2) How many 'extrinsic' lig's of the wrist:

3) Name each from #3 above, and give origin, insertion, surface, and function




























4)
- More lig's of the wrist attach to the radius or ulna?
- More lig's of the wrist are on the dorsal or palmar aspect?


5) Volar means:



1) Extrinsic are ligs that attach outside the actual carpal bones themselves. Intrinsic would be from a carpal bone to a carpal bone.

2) 5

3)
- Radial Collateral Lig:
- o: radial styloid process
- i: schaphoid bone to 1st MC bone
- surface: palmar
- function: prevents ulnar deviation

- Ulnar Collateral Lig:
- o: ulnar styloid process
- i: triquetrum, pisiform, base of 5th MC
- surface: palmar
- function: prevents radial deviation
(it's bigger/thicker)

- Palmar Radiocarpal Ligs:
- o: distal radius (palmar)
- i: scaphoid, capitate, lunate
- surface: palmar
- function: prevents wrist extension

- Palmar Ulnocarpal Ligs:
- o: distal ulna (palmar)
- i: lunate, capitate, triquetral
- surface: palmar
- function: prevents wrist extension

- Dorsal Radiocarpal Ligs:
- o: distal radius (dorsal)
- i: scaphoid, lunate, triquetrum
- surface: dorsal
- function: prevents wrist flexion


4)
- Radius
- Palmar

5) Palmar

6

1) With intrinsic lig's of the wrist, what do the intrinsic lig's of the wrist do?

2) Explain the palmar and dorsal midcarpal lig's











3) These midcarpal lig's are essentially what:


4) Is the proximal or distal row of carpals more stable?

5) What is the 'keystone' of the most stable row of carpals?

6) What are the two unique lig's of the carpal bones? Why?







7) What are the 'Radiate Carpal Lig's'

1) Connect the carpal bones together at the wrist for stability.


2)
- Palmar Midcarpal Lig's
- Multiple bands primarily from the distal
row (capitate) to all other
carpals to hold carpals together.

- Dorsal Midcarpal Lig's
- Multiple bands primarily from the distal
row of carpals (capitate) to all
other carpals. They bind distal row of
carpals to restrain movement of carpal bones.

3) Intercarpal lig's


4) DISTAL

5) Capitate bone. It is the big one in the middle of the stable row of carpals - it gives all the stability at the wrist. The intercarpal lig's all pretty much attach / anchor there.

6) Pisihamate and Pisimetacarpal. Because the pisiform bone is technically not a carpal - it is a sesamoid just like the patella. So the patellar ligament is really just attaching the patella to the tibia (even though it's just an extention of the quadriceps tendon. Same thing with these 2. These two lig's are just an extension of the FCU muscle.


7) “Radiate carpal ligs”
Is a general term referring to the collection of individual Palmar Midcarpal Ligaments that attach to the capitate and pass to another carpal bone

7

The distal row of carpals is very fixed and doesn't move (from the lig's listed above). The proximal row of carpals does move.

1) What is the purpose of the interosseous lig's?

2) The Interosseous Lig's of the proximal row of carpals are named:?

3) What is a FOOSH?

4) If you got a FOOSH injury between scaphoid and lunate interosseous ligament, it would be called:



5) How would you know if you tore or had a lunate-triquetrum dissociation?


5A) What is the most commonly fractured bone of the wrist

5B) What is the most commonly dislocated bone of the wrist


6) Now, let's look at the dorsal side of the wrist ... name the lig's that attach from radius to the carpals:





7) The distal radius has a facet to articulate with the carpals. But the radius has two specific sections of that facet, what are they:

8) Related to the point above, what is the articular facet then for the triquetrum?

9) T or F: The TFCC continues to join the ulnar collateral lig fibers? Why

10)
- What lig goes from ulna to lunate?
- What lig goes from ulna to triquetrum?

11) Review
- what are interosseous lig's of the wrist? And WHY we have them ... what's their purpose?
- what are the "slings" that give stabilization to proximal row of carpals and attach to radius and ulna?




12) What connects carpals to metacarpals?

13) What connects metacarpal bases to each other?

14) Of Digits D2-D5, which intermetacarpal joint would be most stable?


15) Now for the thumb:
- The thumb CMC joint is what type of joint:
- The thumb is unique in that the CMC joint both extends/flexes and ab/adducts and rotates (you can thus do opposition). What makes this possible?
- What are the two lig's allowing this unique movement?
- Are the oblique lig's at the CMC joint or the MCP joint of the thumb?
- He won't ask us to identify them, but just know the twist and one goes on stretch during opposition of the thumb and the other is on slack (and then visa versa during deopposition)


16) SO, in total, how many main groups of intrinsic lig's of the wrist are there?

17) Name them:



Remember it as you need lig's to attach radius and ulna to carpals, carpals to each other, carpals to metacarpals, metacarpals to each other.





1) Connect the proximal row of carpals (the ones that are more mobile). It is like a hammack / shower curtain between the three proximal carpal bones to ensure they move together.

2)
- Scapho-lunate interosseous ligament
- Luno-triquetral interosseous lig

3) Fall on Outstretched Hand

4) Schapo-Lunate dissociation

5) Inject a dye into the radiocarpal joint cavity. If the lunate-triquetrum interosseous lig is in tact, the dye will stay in the radiocarpal cavity space. But if that interosseous lig is torn, the dye will leak through in the radiogram imaging and show in the midcarpal joint cavity, suggesting a tear.

5A) Scaphoid bone

5B) The lunate (from the Schapo-Lunate dissociation)


6)
- Radio-schapho-capitate lig:
- It is on palmar side (a sling/hammack)
- Radio-luno-triquetral lig:
- It is on palmar side (a sling/hammack)


7) Scaphoid facet and lunate facet



8) TFCC


9) True. It stabilizes the ulnar side of the wrist


10)
- Ulno-lunate lig
- Ulno-triquetrum lig :)

11)
- Scapho-lunate interosseous ligament
- Luno-triquetral interosseous lig
- Purpose: Hold proximal row of carpals together since they move a lot.

- Radio-schapho-capitate lig
- Radio-luno-triquetral lig
- Ulno-lunate lig
- Ulno-triquetrum lig :)

12) Dorsal and Palmar Carpometacarpal Lig's

13) Dorsal and Palmar Intermetacarpal Ligs

14) D2-D3 intermetacarpal since that is the stable / fixed portion of the hand.

15)
- Saddle
- It being a saddle joint, and you have 2 oblique ligs that curve and twist around the joint allowing rotational movement
- Dorsal and Volar oblique lig's
- CMC
- Ok






16) 5


17)
- Interosseous Lig's
- Palmar and Dorsal Midcarpal Lig's
- Dorsal and Palmar Carpometacarpal Lig's
- Dorsal and Palmar Intermetacarpal Ligs
- Dorsal and Volar Olique Ligs of 1st CMC

8

1) Let's review the ROM for wrist movements:

- Wrist Extension:
- Wrist Flexion:
- Wrist Radial Deviation:
- Wrist Ulnar Deviation:
- Thumb Abduction:
- Thumb Adduction
- Thumb Extension:
- Thumb Flexion:
- Thumb Rotation:

2) What is thumb abduction vs. thumb extension?

3) Why is Radial deviation less than ulnar deviation?




4) Rotation or opposition of the thumb occurs at what joint?

1)

- Wrist Extension: 70-80 degrees
- Wrist Flexion: 75-80
- Wrist Radial Deviation: 15-20
- Wrist Ulnar Deviation: 30-40
- Thumb Abduction: 65-80
- Thumb Adduction: just return from abduction
- Thumb Extension: 30-40
- Thumb Flexion: Can't really flex (it's just return from extension) and then it goes into rotation
- Thumb Rotation: 90

2) Thumb extension is thumbs up (abduction is other motion)

3) Because radial styloid process hits the scaphoid bone (and ulnar collateral lig / TFCC goes on stretch and they are big fibers). On opposite side, the triquetrum has more space to descend into TFCC space and the radial collateral lig is not as big/strong.

4) CMC jt of thumb (saddle joint)

9

1) Define the boundaries of the carpal tunnel


2)
- What is the 'roof' of the carpal tunnel?
- What is the 'floor' of the carpal tunnel?

3)
- What are the radial attachments of the flexor retinaculum
- What are the ulnar attachments of the flexor retinaculum

4) What runs through the carpal tunnel?

5) Does the ulnar nerve pass through the carpal tunnel?




6) What is the Tunnel of Guyon?

1)
- Volar/Palmar surface: flexor retinaculum
- Dorsally/Deep: carpal bones

2)
- Volar surface (flexor retinaculum)
- Dorsal surface (carpal bones)

3)
- Radial: tubercles of scaphoid and trapezium
- Ulnar: pisiform and hook of hamate

4)
- Median Nerve
- Flexor Digitorum Superficialis
- Flexor Digitorum Profundus
- Flexor Pollicis Longus

5) NO

6) Where your ulnar nerve and artery passes through the wrist (just above / palmar to the carpal tunnel, and more medially). SO - to protect this area, you want large hypothenar m's, wear a glove, don't use it as a hammer, etc. to cause damage to ulnar nerve.

10

1) The MCP joint of the thumb is what type of joints:

2)
- How many sesamoid bones are in the hand
- Where are they in the hand?
- For what muscles?
- Why do we have them?

3)
- MCP joints are stabilized by:
- What are BETTER names for those:




4) What do collateral lig's do?

5) So what does the ulnar lig of thumb do?

6) What are some injuries where you'd see the ulnar collateral lig of thumb injured?

1) Condyloid joint (condyle because it is like the knee) ... but it acts as a hinge joint.

2)
- 2 (3 if you count pisiform)
- In the thumb (head of 1st metatarsal bone)
- Flex pollicis brevis, adductor pollicis
- Increase lever arm ...helps small muscles generate more torque

3)
- Medial and lateral collateral lig's.
- BUT, it gets confusing with those names, so better names are really ulnar/radial collateral ligs so you know for sure what lig / side (joint) you are talking about.

4) Stabilize two bones together, and prevent the distal segment from moving the opposite direction ... prevent ab/adduction or radial/ulnar deviation.

5) Stabilizes two bones together, and prevents radial movement of thumb's proximal phalanx in an extension motion.

6) Driving and get in accident and thumb stays on steering wheel as you go forward, of skiers thumb, or goalkeepers thumb.

11

1) The MCP joints of the fingers are what type of joints

2) Do the MCP joints of the fingers have collateral lig's



3) Technically the collateral lig's at the MCP jts have 3 parts. What are they:

4) What is the Volar Plate:
- What is it's purpose/function

5) So what do the MCP collateral lig's do:

6)
- Are the collateral ligs of MCP joints of D2-D5 on stretch during digit extension or flexion?
- How do you know this?

7) Pretend you make a fist and are going to punch someone ... but you are looking at the fist coming at you, how would the heads of the metacarpals look?
- Why is this important to know?

1) Condyloid (mainly hinge, but allow some ab/adduction side to side)

2) yes



3) Collateral lig, Accessory lig, Glenoid Lig

4) A dense fibrocartilaginous thickening on the palmar side of each MCP (and PIP and DIP) joint.
- Protects the MCP, PIP, and DIP jt capsules, and ensures as the FDP and FDS tendons run against the joint it provides a cushion (not wear down capsule).

5) Limit Ab/Adduction or Radial/Ulnar deviation of the digits.

6)
- FLEXION
- In extension you can do radial/ulnar deviation. During flexion you can NOT

7) NOT rounded, more trapezoid in shape with the base (closer to palmar side) wider / bigger.
- Because as you flex MCP joints (make a fist) the ligs have to stretch around the broadened head of the metacarpals, which put collateral lig's on more stretch.

12

1) The Interphalangeal joints of digits - what type of joints are they?

2)
- Is there any radial/ulnar deviation at the interphalangeal joints?
- Is there any radial/ulnar deviation at the MCP joints?

3) Do interphalangeal joints have collateral ligs?

4) Are the collateral ligs of interphalangeal joints tight during extension or flexion

5) Is there a volar plate at the PIP and DIP joints?

5A) Why are the volar plates on the palmar/volar side rather than dorsal?

5B) If you injure a volar plate, what happens?
- Are volar plates fibrocartilage?

6) What is rough ROM for PIP and DIP jts of digits

1) Hinge joints


2)
- NO
- Yes


3) Yes

4) FLEXION


5) Yes (on the palmar aspect of the capsule of the joint, with the long digital flexor tendons running superficial to it).

5A) Most trauma and force to our hand is on the palmar aspect, so these plates protect the joint capsule and lig's.

5B) It can get inflammed and lead to a contracture of that joint. Why? Because fibrocartilage is hard to stretch and heal and repairs by scarring.
- YES

6)
- PIP's Flexion: 100-135
- DIP (and thumb IP) Flexion: 80-90
- Extension of PIP and DIP jts D2-D5: very little
- Extension of DIP of thumb: 20 or so

13

1) What is the Least Packed position of the Radiocarpal and Midcarpal joint

2) What is the close packed position of the Radiocarpal and Midcarpal joint. Why?

3) If you want to splint a wrist and hand to put it into a position of function, what would you do?

1) Neutral flex/extension with slight ulnar deviation


2) Max extension. Why ... because most ligs of the wrist are on the volar aspect, so max extension puts those on stretch.

3) Maintain length of muscles crossing wrist ... so do slight extension (10-20 degrees) to ensure long flexors are stretched, and then do slight flexion of fingers at MCP joints, and put thumb between opposition and full deopposition.

14

1) Do the skin and subcutaneous tissue play a role in the movement of the hand?

2)
- Is the skin well attached/fixed on the volar or dorsal side of the hand?
- Why? Name 3 reasons

1) Absolutely


2)
- Palmar/volar is very well attached, dorsal is much more loose.
- (1) To grab things and firmly grasp them, you can't have skin on your palm moving around. (2) Plus, as you make a fist, the dorsal skin moves to fit around curved hand so it needs to move more. (3) You need a place for veins to drain ... that happens on dorsal side.

15

1) We can do power grips. What is the main reason or what allows us to do power grips?


2) Intrinsic muscles of the hand are primarily innervated by what nerve



4) Lumbricals attach to what muscle tendons

5) Dr. T said that ______ nerve is primarily involved in the power grip of hand (althought I'd somewhat disagree). The precision grasp / pinching comes from ______ nerve.

6) If you had an ulnar nerve neuropathy at the elbow, what would be effected?

7) So damage to median nerve means you lose what ability

1) Because the large flexors muscles of the forearm/hand have their muscle belly far up the forearm, creating long tendons that have a pulley system over the wrist that creates long lever arms = more force.

2) Ulnar nerve



4) Flexor digitorum profundus (FDP)

5) Ulnar (but also median, and some radial), Median
- So ulnar nerve is primarily used for POWER, and Median is primarily used for precise pinching manipulation grasps.

6) The muscles innervated by the ulnar nerve (Power Grip).


7) Small object manipulation (pinch, precise grasp, fine motor).

16

1) On the palmar aspect of the hand, you have the superficial and deep arches arteries. The superficial arch comes from ______ artery, and the deep arch comes from ______ artery.

2) Where would you palpate the radial and ulnar artery near the hand?

3) Dorsal side of hand has many veins and they combine into what two veins (and what side are those veins on):
(how to remember)

4) Is there a superficial venous network on palmar surface?

1) Ulnar, Radial



2)
- Radial: in anatomical snuffbox, goes between D1 and D2 through interossei to supply deep arch of hand.
- Ulnar: Through tunnel of guyon (superficial to carpal tunnel and flexor retinaculum) near pisiform to superficial arch of hand.

3) Basilic (medial) and Cephalic (lateral)
(remember: alphabetical, B before C, goes
medial to lateral)\

4) NO

17

1) What are the boundaries of the anatomical snuffbox?

2) If you punch down into anatomical snuffbox, what bone would you feel?

3) What artery is in anatomical snuffbox?

4) Fibers of what nerve are in over these tendons?

1) Extensor pollicis longus and brevis


2) Proximally it is distal radius, but distal it is the Scaphoid bone

3) Radial

4) Radial

18

Flashcards below are unit 2 of the wrist and hand - going into Extensor Hood / Extensor Expansions

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19

1) Extensor Hood or Extensor Expansions go from where to where

2) Starting proximally down near MCP joint, what muscles come in as the first "wings" and through what tendon?

3) Now go to PIP, what muscle comes in and attaches there through what tendon?

3A) So basically what are the proximal and distal wing tendons?

4)
- The middle portion (small band running along middle of dorsal fingers) of the extensor hood is called:
- Down proximally, where the 'central tendon' started ... what attaches into it?
- So the extensor digitorum attaches to extensor hood via the _____ _______

5)
- Now what happens to the central tendon at the PIP joint
- What is it called when it does this?
- After the ______ ______ converge it is called _______ _______

6) So recap of the extensor hood:

















7) Is there an extensor hood and this whole set up on the thumb? Why?




8) The lateral bands are going around what part of the digit?

9) The terminal tendon ends where

10) What joins the lateral bands together
- It goes over what jt?
- Is the triangular lig superficial to central tendon?

11) What is the last wing tendon/lig coming in at the DIP near lateral bands

12) Where does the central (or intermediate) tendon attach?

13) What do the Lumbricals do?

14) What do interossei m's do?

15) Essentially, what is the purpose of the extensor hood?

1) MCP to DIP on the dorsal side of the fingers.


2) Interossei m's (through proximal wing tendon)


3) Lumbricals (through distal wing tendon)

3A) Bands of the extensor hood that wrap around phalanx's to hold extensor hood in place (and allow muscles to connect to help pull taut).


4)
- Central tendon
- Extensor digitorum m.
- Central tendon




5)
- It splits
- Lateral bands
- Lateral bands, terminal tendon



6) Extensor digitorum tendon comes in and attaches to extensor hood starting at the central tendon at the dorsal part of the MCP jt. At MCP jt the interossei muscle tendons join with the proximal wing tendons into the base of the proximal phalanx and into the central tendon. At the PIP jt the lumbrical muscles join into the distal wing tendons into the distal proximal phalanx near PIP on the dorsum / base of the hood via the central tendon. Then the central tendon spits into the lateral bands at PIP and comes back together distally of the PIP to form the terminal tendon which ends at the base of the distal phalanx. The two lateral bands as they come together are bound by the triangular lig. Then distally at the DIP there are the oblique retinacular lig's that come in at the DIP (those are needed to create strain or prevent hyperextension of DIP since central tendon is connected to intermediate phalanx).


7) Not the same, but yes thumb has its own extensor hood. The extensor digitorum only runs from D2-D5. That is why you have 3 muscles strictly for thumb extension/abduction


8) PIP jt


9) Just past the DIP at the base of the distal phalanx

10) Triangular lig
- PIP
- YES

11) Oblique retinacular lig


12) Intermediate phalanx


13) Flexion at MCP jt and extention of PIP and DIP jts

14) Ab/Adduction of the digits (some flexion at MCP jt)

15) Pass tension from many muscles through a long band for distributing forces. Also to extend all digit joints (and allow for muscle attachment).

20

1) Concave and convex members of these joints:
- Radiocarpal
- Metacarpophalangeal
- Carpometacarpal of the thumb
- Interphalangeal


- Radiocarpal: Radius is concave, scaphoid and lunate is convex

- Metacarpophalangeal: Metacarpals heads are convex, and base of proximal phalanx is concave

- Carpometacarpal of the thumb: Metacarpal is convex and trapezium is concave (??? saddle)

- Interphalangeal: proximal part of each phalanx is CONCAVE, distal part (heads) are CONVEX (so bases of phalanx's are concave)

21

Review these motions of the hand:

- Pinch (thumb and index finger tips)
- Tip to Tip pinch
- Pad to pad pinch (pad of thumb to pad of index)
- Pad to side pinch
- Three jaw chuck pinch (holding a pen)
- Lateral pinch (grabing ticket from machine)
- Cylindrical grip (holding pole)
- Spherical grip (holding ball)
- Hook grip (holding brief case)
- Horizontal hook grip (grabbing coffee mug)
- Screwdriver grip



1) What is the stronger side in terms of grip, the medial aspect of hand (ulnar) or lateral (radial/median)?

2) In the power grip, will the ulnar or radial side of the hand be more powerful?



http://images.slideplayer.com
/16/5193949/slides/slide_5.jpg

https://www.researchgate.net/profile/
Cheryl_Metcalf/publication/39997151/
figure/fig1/AS:276488596279312@
1442931426874/Six-prehensile-patterns-enforced-by-the-SHAP-abstract-objects.png







1) Ulnar (medial)

2) Ulnar

22

1) T or F: There is bursa around extensor hood? How do you know?

2) The extensor hood can slide along the MCP jt
- Why?

3) If extensor digitorum contracts, will all phalanges and jts of the digits extend?
- So what causes full extention of all jts / phalanges?



4) So how do the PIP and DIP jts extend

5)
- What is action of lumbricals
- Why or how do they do this strange motion/action?
- So lumbricals are on _______ side of MCP and on _____ side of PIP/DIP

6)
- "Net" torque action of what 3 m's does extension of MCP, PIP, DIP
- Why say "net"

7) If extensor digitorum contracts by itself, what will happen?





8) What if lumbricals and interossei m's contract with OUT the extensor digitorum m - what will result?

1) Yes, at MCP jt (how you get swollen knuckles)


2) True.
- It attaches at middle/intermediate phalanx, so it is mobile else where (like at the MCP jt).

3) No. The proximal phalanx and thus the MCP jt will (as that is where extensor digitorum muscle attaches) but distal finger and joints will be slightly flexed.
- Combination of extensor digitorum with intrinsic m's of the hand

4) Contract the intrinsic muscles (interossei and lumbricals)

5)
- Flex MCP jt, and extend digital PIP and DIP jts
- Because the tendons are palmar to the MCP jt AOR (causing flexion in front of AOR), but then their tendons go up and attach dorsally at PIP to cause extension (sending force down central tendon -> lateral bands -> terminal tendon). This causes extension.
- Palmar/volar, Dorsal

6)
- Extensor digitorum, lumbricals, interossei
- Because lumbricals and interossei tendons are palmar to MCP causing some flexion in that jt.

7) Proximal phalanx will extend at MCP jt, and some force does get distributed distally, but not enough for distal fingers/phalanges at PIP and DIP to fully extend (that is why they will be slightly flexed).

8) Alligator position hand

23

1) What is the 3rd (most distal) portion coming in from the sides on the extensor hood?

2) Where does it insert on the digits?


3) What is it's function





4)
- During finger flexion at all joints, is the oblique retinacular lig on stretch or slack?
- During extension of interphalangeal jts, is the ORL on stretch or slack

1) Oblique retinacular lig

2) Proximally is it down volar of the proximal phalanx (PIP)4. Distally it is near the DIP (on dorsal side) where lateral bands come together.


3)
- Like a rein for a horse, it helps pull the distal phalanx's back (prevent hyperextension) of DIP jts.
- And ALL the tension from central tendon is NOT passed distally to terminal tendon since the extensor hood attaches on intermediate phalanx, thus some of the tension gets disipated. So the oblique retinacular ligament helps prevent too much DIP extension.

4)
- Slack
- Stretch

24

1) What muscles helps flex MCP jts:

2)
- FDS attaches where
- FDP attaches where

3)
- Which one (the FDS or FDP) splits?
- Which one (the FDS or FDP) goes through the split?

4) The FDS and FDP tendons glide over the jts (MCP, PIP, DIP) all the time. What protects the jts from these tendons constantly rubbing on them

5) There are small ligaments that hold the FDS and FDP in place as they glide. What two ligaments are these?

6)
- The very first ligament that holds the FDP and FDS in place is:
- That lig is where?

7)
- The annular lig's are where on fingers?
- So how many total annular lig's?

8)
- How many cruciate ligs in fingers?
- Where are the cruciate ligs?

1) Lumbricals, interossei, and flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP)

2)
- Base of intermediate phalanx
- Base of distal phalanx

3)
- FDS splits (S for SPLIT)
- FDP goes through the split

4) Volar plates.


5) Annular ligs (circular ... act like pulleys) and cruciate ligs (x or cross shaped)

6)
- A1
- Palmar aspect of MCP jt.

7)
- At the jts (MCP, PIP, and DIP), and middle of Proximal and Intermediate phalanx's to hold FDS and FDP tendon's in place
- 5 (A1, A2, A3, A4, A5)

8)
-4 (C0, C1, C2, C3 ... C0 is really not that big)
- Base and heads of proximal and intermediate phalanx's

25

1) Do each of the fingers and FDS and FDP have bursae

2) Do tendons thus get synovial fluid from these bursae?

3) Explain bursae of digits 2-4

4) Do the FDP and FDS each have their own bursae, or do they share bursae?

5) How is D5 bursae different

6)
- So if bursae in palm gets inflammed, will the irritation be felt in D3?
- Will that same irritation in palm be felt in D5

7) Where is 'surgical no man's land' in the hand? Why?

8) If you do get some scarring or inflammation or adhesions, what do you do as a PT?

1) YES

2) NO. They are wrapped in bursae but not bathed in synovial fluid

3) D2-D4 bursae start at MCP jt and go to DIP jt.

4) Have their own

5) D5 bursae doesn't start at MCP jt, it is a continuation of the bursae in the palmar hand (which extends up to D5).

6)
- NOT felt in D3 since the two bursae are seperated
- WILL be felt in D5 since bursae is a continuation up to D5 from the palm.

7) Past the A1 annular lig area (MCP jt) and distal. Why? because injuring the bursae or annular/cruciate ligs would tie down FDP and FDS tendons and inflame them so they couldn't move / can't glide through the sheath.

8) MOVEMENT. Get patient to do tendon gliding to ensure fibrous scarring doesn't result, and to get ROM back.

26

BELOW ARE FLASHCARDS ON LUMBAR SPINE

ok

27

1) What are the big anterior cutaneous nerves of the thigh to remember

2) Go to MY power point doc and review cutaneous nerves of thigh, leg

3) When someone has an ACL tear, what peripheral neuropathy is often a result / damaged in that surgery

4) What are main 3 cutaneous nerves of leg/shank

5) What are the big posterior cutaneous nerves of the thigh to remember

6) Where would you test the sural nerve sensation

7) Cutaneous nerves of foot are:

8)
- Sole of foot (cutaneous) is what nerve
- Medial and Lateral Plantar nerves come from what nerve
- Where do the 2 from above split (roughly)
- And where do they seperate foot?

9) T or F: Diabetes patients often experience neuropathies that are manifested in the foot

1) Lateral femoral cutaneous nerve, anterior femoral cutaneous nerve

2) Ok


3) Infrapatellar nerve from the Saphenous nerve (anteromedial knee) from the femoral nerve

4) Lateral sural, superficial fibular, deep fibular

5) Lateral femoral cutaneous nerve, posterior femoral cutaneous nerve

6) Lateral malleolus


7) Medial and Lateral Plantar nerve



8)
- Calcaneal branch of tibial nerve
- Tibial nerve
- Medial malleolus
- D4

9) TRUE

28

1) You know the osteology of the lumbar vertebrae (review) ... but what sets the lumbar vertebrae apart from other sections of the back:

2) Is lumbar vertebral body thicker anteriorly or posteriorly? Why

3)
- How are the facet joints oriented?
- How are the lumbar facets different than cervical and thoracic

4) What motion can you do in lumbar area, and what motion is limited (because of facet joint orientation)
(how to remember this)

5) "Typical" lumbar vertebra are:

6) During lumbar FLEXION:
- The facet surfaces will gap or compress?
- The IV disc (nucleus pulposus) will bulge anteriorly or posteriorly
- Supraspinous ligs will go on stretch or slack?
- Posterior part of IV disc would be on tension or compression?
- Flexion is limited by _________

7) During lumbar EXTENSION:
- The facet surfaces will gap or compress?
- The IV disc (nucleus pulposus) will bulge anteriorly or posteriorly
- Supraspinous ligs will go on stretch or slack?
- Posterior part of IV disc would be on tension or compression?
- Extension is limited by _________

8)
- During lumbar flexion, the first thing to go on stretch is ______
- During lumbar extension, the first thing to go on stretch is ______

9) If you want the lumbar spine to be as stable as possible, would you put the lumbar spine in flexion or extension? Why?

10) T or F: You can move lumbar lordosis into kyphosis

1)
- Huge vertebral bodies to bear weight of trunk
- Large transverse processes for all the major back muscles that attach
- Large spinous process
- Sup and Inf articular processes are more spread out

2) Anterior. That is why there is lordosis

3)
- Superior art. process face medially and posteriorly, inf. art. process faces laterally and anteriorly
- Lumbar facets have the sup facet displaced from inferior (inferior being more posterior). So pars interarticularis area is larger / more spread out.

4) Can do flexion/extension well, can not do rotation well
(you don't want to do flexion in thorax and squeeze your
lungs)

5) L2-L4

6)
- GAP
- Posteriorly
- Stretch
- Tension
- SOFT TISSUE (ligs and muscles)


7)
- Compress (apposition)
- Anteriorly
- Slack
- Compression
- Bony apposition of facet jt surfaces and kissing spinous processes (a little from ant. long. lig)

8)
- Supraspinous lig (and then it moves interiorly from there)
- Anterior longitudinal lig


9) EXTENSION. So weight of body is between facet jt bones hitting each other (bear the weight), rather than putting weight on IV discs or ligs.


10) False (unless some extreme injury or pathology)

29

1) During R sided lumbar sidebending, what limits that motion

2) What happens to the IV disc during RIGHT side bending

3) What happens to both the R and L facet joints during RIGHT side bending of lumbar spine

4)
- Cervical side bending (coupling) is to the same side or opposite?
- Thoracic side bending (coupling) is to the same side or opposite?
- Lumbar side bending (coupling) is to the same side or opposite?

5) T or F: Side bending to the RIGHT in the lumbar spine is coupled to the opposite side (rotation to the left)
- EXPLAIN WHY this happens



6) Remember how the fibers of the IV discs are oriented in opposite directions (perpendicular) for the varying layers ... when would IV disc be most vulnerable for a herniated disc / tear of IV disc?

1) Right Facet jt. apposition, and Left Intertransverse ligs stretch, and eccentric muscle contractions

2) The IV disc bulges to the left


3) The RIGHT side facet will apposition / jam together. The LEFT side will gap or pull apart.

4)
- Cervical: SAME
- Thoracic: Can't determine
- Lumbar: Opposite



5) TRUE (sidebending and rotation in lumbar spine are OPPOSITE sides/directions)
- As you side bend to the right, the right facet joint experiences apposition and eventually won't move. The left facet glides up and then at that point where it can't move, it moves POSTERIOR (gaps) and this creates the LEFT rotation of vertebral body to create more side bending motion.

6) During flexion (since your facet joints are open and weak, and then you do some torsion / rotation movement and cause more tension on disc.

30

1) Innomenent bones are:

2)
- What is the lumbosacral angle?
- That angle should be about what:

3)
- What is the sacral angle?
- That angle should be about what:
- What would happen to the sacral angle during anterior pelvic tilt?

4) What is anterior vs. posterior pelvic tilt?

5)
- What is the pelvic inlet angle?
- That angle should be about what:
- What would happen to the pelvic inlet angle during anterior pelvic tilt?

1) Hip bones

2)
- Vertical long axis through L5 and the vertical long axis through S1 (Sacrum)
- 140 degrees

3)
- If pt is standing up, draw a straight horizontal line parallel to floor, and then take the angle of the sacral promontory and that is the angle where those 2 meet
- 30 degrees
- it would get bigger (increase the angle)

4) Anterior pelvic tilt is the ENTIRE PELVIC GIRDLE going anterior. It basically looks like the iliac crest (or ASIS) is rotating ANTERIOR and slightly caudally.

5)
- Draw a line from sacral promontory down to pubic symphysis/tubercle ... that line intersects with the horizontal line
- 60 degrees
- it would get bigger (increase the angle)

31

1) Now moving down to sacrum where sacral vertebrae and lumbar vertebrae meet ... how are sup articular facets oriented on sacrum (S1)
- WHY

2) Review bony landmarks of sacrum






3) Is spinal cord in sacrum area?

4) Explain how L5 sits on S1 and the forces involved








5) T or F: The sup and inf art. processes of L5 are attached to the Lamina at different places?
- Where are sup and inf processes located on L5

6)
- What is the pars articularis
- Why do we need to know this?





7)
- What is Spondylolysis
- What is Spondylolisthesis




8)
- So a pars interarticularis fracture could result in:
- What is another name for this fracture
- In order to view this fracture on a radiograph, would you want a lateral or an oblique view of lumbar spine?

9)
- Can a spondylolysis or spondylolisthesis happen at any level of the vertebral column?
- What area does it typically happen at?

10) You can grade the severity of a spondylolisthesis (actual movement). What is the grading system:







11) If you get spondylolisthesis, what restrains the movement. Or why doesn't the "free" vertebral body just move forward quickly and fall off it's base?
- Can erector spinae m's help prevent anterior glide?

12) What happens to surrounding anatomy as spondylolisthesis further progresses to more severe grades:

13) About what grade do you start to see neurological symptoms (neuropathy, impingement pain)

1) They are vertical (superior) and POSTERIORLY facing (slightly medial)
- So the lumbar spine doesn't fall off / forward.


2)
- Ala (wings)
- Sacral promontory (top and anterior of S1 body)
- Intervertebral foramina (ant and post)
- Median Sacral Crest (spinous processes)
- Base vs. Apex (apex is bottom portion)
- Sacral canal, and sacral hiatus (for cauda equina)

3) NO - that ended in L2 area. It is spinal rootlets coming down from cauda equina to exit sacrum (through intervertebral foramina) as lumbosacral plexus.

4) L5 vertebral body sits on S1 base at an angle (sacral angle), and S1 superior articular processes hold L5 (and weight of trunk) by preventing inf. art. processes of L5 to slide down (combined with muscles and ligaments, etc.). That sup art. facet of S1 is a "block of the tire" concept for weight of upper body.

5) TRUE
- Sup is near pedicle (on the lamina), and inf. is near junction of spinous process (on the lamina)

6)
- Part between the sup and inf articular processes. It is area that connects the posterior part (spinous process) of vertebrae with the anterior part (body).
- Cause it can be fractured. Typically a fracture happens on both sides, so the post. portion of vertebrae is seperated from anterior portion.

7)
- What is Spondylolysis: fracture (of the pars interarticularis of a vertebrae) with NO seperation yet
- What is Spondylolisthesis: fracture (of the pars interarticularis of a vertebrae) WITH seperation/movement (of L5/S1)

8)
- Spondylolysis (no movement), or Spondylolisthesis (with movement)
- Scottie Dog fracture
- Obliques give you view in intervertebral foramen in lumbar spine

9)
- YES
- L5 on S1


10)
- Normal: If posterior part of L5 is on posterior part of S1 (which would be a spondylolysis if there's a fracture)
- Grade 1: When L5 has moved forward 25% anteriorly with respect to S1 vertebral body
- Grade 2: " 50%
- Grade 3: " 75%
- Grade 4: L5 is off and not sitting on S1

11) Disc (and it's ligaments), several large muscles, several lig's (but over time these deform and get stretched).
- Yes, but over time they get stretched and lose their ability to hold that weight, so erector spinae can't fully stop the anterior movement/displacement.

12) Muscles and lig's go on more and more stretch, and the cauda equina and nerves get impinged (and thus lose sensation and motor movement of LE and even bowel genital areas.

13) Grade 2

32

1) What is the purpose of the iliolumbar ligaments


2)
- T or F: The iliolumbar lig's are essentially BIG intertransverse lig's between L4 and L5 and pelvis?
- What is the difference between these at L5 and L4 vs. other areas of spinal column?

3) Side bending to the RIGHT will cause the LEFT iliolumbar ligs to go on stretch or slack?

4) How much sidebending ROM can you get at the L5 / S1 junction?

1) These help distribute the force of the upper body weight down to LE's. It is not just through vertebral body and IV disc of L5, but also through these large ligs that help distribute the forces.

2)
- True
- Intertransverse lig's are not that strong above L3 ish area, but the intertransverse ligs / iliolumbar ligs of L4 and L5 are large and very strong and important.

3) Stretch

4) Basically none (very little)

33

1) If you have annulus fibrosus break down, where typically does it occur (or where does herniated disc happen)
- Why is that area so dangerous?


2)
- If nucleus pulposus begins to move but it is still contained well within the annular fibers, it is called:
- If nucleus pulposus now moves to edge of annulus fibrosus but it is still contained within the outer annular fibers, it is called:
- What is it called if nucleus pulposus exits through a ruptured annulus fibrosus

3)
- Why wouldn't someone feel or know if they had an early prolapse?
- Would someone feel a late prolapse? Why
- Why are herniated discs so painful

4)
- If there is a L4/L5 herniation, what nerve root is impinged?
- L5 herniation would press against what nerve root, but feeling would be lost where?
- If someone couldn't feel or had loss of sensation to S3 part of limb innervation, what level of spine might have nerve root herniation?

5) *** Quickly review the DERMATOMES of the LE's

6) Make sure you know the MUSCLES of the LE

7) Get netter anatomy flashcards and review bony landmarks of LE bones

1) Postero-lateral corner(s)
- It impinges the spinal nerve



2)
- Early prolapse
- Late prolapse
- Herniation (herniated disc)





3)
- Because there are no nerves within inner portion of IV disc.
- Yes. Outer annulus fibrosus fibers are innervated. They get sensory fibers from post. long. lig. and periosteum of surrounding bone.
- Because nucleus pulposus is pinching the spinal nerve

4)
- L5. Remember the nerve root LOWER then the herniation/impingement is where the pain / neuropathy is felt.
- L5, S1
- S2

5) ok

6) ok

7) ok

34

1) What is the straight leg test and why is it done?





















2)
- Maximal stretching of sciatic nerve is lifting leg to what degree?
- This moves the nerve at the intervertebral foramen about how much?

1) Helps with nerve impingement pain in back, or sciatic nerve pain. Patient will lift leg to 60 degrees off the table (symptoms should occur before or at 60 degrees ... if symptom occurs after, may be hamstring tightness). Patient should keep knee extended, and ankle in neutral or even slight dorsiflexion. Make sure leg is slightly adducted (to create more stretch of sciatic nerve). Then tuck chin. This elongates the spinal cord and sciatic nerve (called nerve flossing) to hopefully break up any impingement. This moves the spinal nerve within the intervertebral foramen about 1/2 inch relieving any impingement/pressure/pain. If pain only occurs at back or thigh, it didn't work. If pain goes all the way past the knee, the test worked (positive result) and this suggests there is some impingement (herniated disc, osteotic growth, tumor).

Compare both sides. If pain is only unilateral it would suggest positive test indicated above. If it is bilateral, that is much more worrysome, suggesting some spinal cord legion (now legion is in spinal cord, not spinal root at the intervertebral foramen).

But you never know for sure unless patient gets an MRI.

2)
- 60 degrees.
- 12 mm (1.2 cm, or half an inch)

35

1) When you increase the inter-thoracic, inter-abdominal, inter-pelvic pressure and hold air in, this is called:

1) Valsalva manuever

36

1) For lumbopelvic rhythm, explain the steps of bending over / flexing trunk down to the ground and what happens in sequence and why











2) T or F: It is possible to flex without flexing any flexor m's:

3)
- If someone had inflexible hip extensors, how would it look bending forward to pick up a dollar bill off the ground?
- If someone had inflexible lumbar muscle extensors, how would it look bending forward to pick up a dollar bill off the ground?
- So someone doing forward bending and demonstrates hyper-kyphosis =
- So someone doing forward bending and demonstrates straight back and a lot of hip motion =

4) So what are the 3 different strategies to accomplish same thing of forward bending:



5)
- If someone bends forward and then goes back up to neutral standing position, what is that called:
- Explain muscle contraction steps of this action

1)
- The AOR is just posterior to hip, so you first need to flex abdominal m's to move trunk forward.
- Then, once you are moving forward, if you did nothing, you'd fall on your face as HAT unit falls forward with gravity
- So erector spinae m's then eccentrically contract to hold HAT up.
- Then eventually all the lig's go on stretch (supraspinous,s interspinous, etc.) and at that point the erector spinae m's aren't doing as much to hold up body.
- Hip extensor m's also contract eccentrically to control and restrain the hip from too much rotation forward.

2) True. You can bend forward and the eccentric back extensor and hip extensor m's are just lowering you down withOUT any flexor m's concentrically contracting. (Or, just fall and let gravity pull you down with no reaction :)

3)
- Pelvis would not rotate as much (because hamstrings are holding down ischial tuberosity), and thus the patient would have to do more back curving / flexion of thorax and create more thoracic and lumbar kyphosis
- The pelvis would rotate much more anteriorly but the lumbar spine would be more straight causing back to look straight. More motion needs to come at the hips (hamstrings, glutes).
- Tight hamstrings and glutes (weak hip extensors)
- Tight lumbar erector spinae m's and flexible hip extensors

4)
- Normal back bending and hip flexion
- Increased thoracic kyphosis due to tight hamstrings
- Increased hip flexion ROM with tight erector spinae m's (allowed by flexible hamstrings)

5)
- Return from flexion
- First you do hip extension since the moment arm is much less than the moment arm of the thorax chest area since it's COM is so far from the AOR. Once the hip extensors (concentric hamstrings, gluteus m's) move the body up as much as they can and the moment arm decreases, the erector spinae m's of the back kick in to concentrically contract.

37

1)
- Now, if you imagine the muscles surrounding the lumbar spine, how many fascial layers / muscle layers are there around lumbar vertebrae?
- What are the names of those ___ layers:
- Starting most anterior and internally, and moving externally and posteriorly, name the muscle groups of those layers:

2) Do these 3 fascial layers surrounding these 3 groups of muscles converge? Where?

3)
- Where does that fascial layer go from there?
- What are layers called now?

4) Where do layers go from there.



5)
- What is most superficial layer of muscle on lumbar back section (posterior to vertebrae)?
- What is middle layer of lumbar back muscles (just deep to lats, but posterior to vertebrae)?
- What is inner layer of lumbar back muscles (deep to the 2 mentioned above, but still posterior to vertebrae)?

6)
- T or F: There is a lumbar and thoracic portion of the longissimus muscle

7) 3 actions of the erector spinae m's

8) When erector spinae m's contraction, what orthogonal forces are acting on spine:

9) 3 things posterior rami nerves innervate:

1)
- 3
- Posterior, middle, and anterior fascial layers
- Most Anterior / Interior Layer: Psoas Major/Minor
- Intermediate / Middle layer: Quadradus lumborum
- Superficial / Posterior Layer: Erector Spinae and Multifidus

2) Yes. Lateral to the erector spinae muscle group.


3)
- It then goes laterally and heads anteriorly where it splits again between the 3 lateral abdominal m's (ext. oblique, int. oblique, transversus abdominis).
- Superficial, middle, and deep

4) Superficial goes anterior rectus abdominis, and the middle and deep converge to go posterior the rectus abdominis.

5)
- Latissimus dorsi
- Erector spinae (spinalis, longissimus, iliocostalis)
- Transversospinalis (semispinalis, multifidus, rotatores)


6)
- True


7) Back extension (bilaterally), sidebending (unilaterally), and eccentric contraction to control sidebending to the opposite side)

8) One component of the angled muscle causes spine to go straight posterior (extension), and the other causes vertebrae to go into compression (down).

9) Posterior spinal m's like erector spinae and transversospinalis, skin over posterior spine, and facet joints.

38

1)
- The major muscle mass surround spinous processes (right next to them) are what muscle:
- What is largest muscle of the transversospinalis muscle group?

2)
- With the psoas major muscle and quadratus lumborus, are their proximal attachments more on ventral or dorsal aspect of lumbar vertebrae?
- So what are they innervated by?

3) T or F: Psoas major causes lumbar flexion and extension? Explain
- So how would someone look who had a tight psoas major

4)
- What are the 'guy wires' of cervical area
- What are the 'guy wires' of the pelvic area

5)
- Can you palpate the quadratus lumborum or psoas?
- Could you dry needle the quadratus lumborum or psoas?
- Can you push intestines aside / out of the way to get to psoas?

6)
- Early prolapse =
- Late prolapse =


1)
- Multifidi
- Multifidi


2)
- Ventral
- Ventral rami



3) True. Most of the fibers are anterior the AOR in lumbar spine, causing flexion. But some extend up higher on lumbar vertebrae posterior to AOR so contracting those fibers causes some slight extension.
- Obviously some hip flexion (contracture), but also potentially more lumbar lordosis as well.

4)
- Cervical: Scalenes anteriorly with levator scapulae posteriorly - they work together to stabilize cervical spine
- Quadratus lumborum and iliopsoas in pelvic area - they both provide ant and post stabilization of lumbar spine.

5)
- No. (Maybe you could get deep into femoral triangle to get to psoas, but very hard.
- Technically yes, but I wouldn't. It would be so easy to puncture the abdominal cavity - too risky
- Abdominal cavity is very much affixed to abdominal wall. They don't move.

6)
- If nucleus pulposus begins to move but it is still contained well within the annular fibers.
- If nucleus pulposus now moves to edge of annulus fibrosus but it is still contained within the outer annular fibers.

39

Below is the 'extra' class he did on Extensor Hood

ok

40

1) Generally the AOR is where on a convex/concave member of a jt

2) T or F: Lateral bands are volar to the DIP jt's AOR

3) Explain a buttonhole / central tendon laceration injury and what would happen

4) What is the swan neck deformity of extensor hood?
- Will DIP also hyperextend? Why?
- How to remember

5) So are buttonhook and swan neck deformity opposites?








6) What is Mallot finger:

7) Explain what happens to flexor tendons during Rheumatoid Arthritis
- What is 'Ulnar Drift'
- What is back up within hand that prevents too much ulnar drift

1) Center of Convex member

2) False. They are DORSAL, and dorsal to the PIP jt.

3) If dorsal part of central tendon got cut, but the intrinsic m's are still intact, they will pull the distal phalanx back (extention), but the middle phalanx will buckle and go into flexion since the intrinsic muscles tendons force is volar to AOR (since they can't distribute force up to dorsal side now with a cut central tendon).

4) When PIP jt volar plate becomes elongated (creating hyperextension of PIP). So if the volar plate is ruptured or elongated, the PIP gets hyperextended, but DIP goes into flexed position.
- NO. Because you are stretching deep digital flexor tendons past point (passive insufficiency) and they will resist.
- Finger looks like a swan neck formation

5) Exact opposites

6) Disruption to terminal tendon at dorsal DIP jt. So this makes you lose extensor ability at distal phalanx, and yet flexors still work, so distal phalanx is flexed down abnormally (looks like a mallot).

7) Based on orientation of both FDS and FDP through carpal tunnel, they have a natural slight pull to ulnar side of hand. So if A1 annular lig gets injured (RA degenerates that lig/knuckle area), FDS and FDP tendons pull fingers more ulnarly.
- Where proximal phalanx is pulled ulnarly compared to metacarpals.
- Collateral ligs

41

NOW WE GO BACK TO LUMBAR SPINE

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42

He said this over and over and over ... the Lumbar spine is associated with the pelvis which is associated with the hip .... they all move and function together.

1) T or F: A neurologic or functional dysfunction of the hip could be from neurologic or functional dysfunction at lumbar spine (and visa versa). Explain?

2) What are muscles of anterior and lateral abdominal wall:

3) What are the m's from #2 above innervated by?

4)
- Dermatome for the inguinal region
- Dermatome for nipple line
- Dermatome for xiphoid process
- Dermatome for umbilical

5)
- Movement or action of rectus abdominis muscle in OPEN chain is (open meaning pelvis is not fixed):
- Movement or action of rectus abdominis muscle in CLOSED chain is (closed = pelvis fixed):
- If the rectus abdominis moves the pubis up to chest, would that create anterior or posterior pelvic tilt?

6)
- 1 joint hip flexor muscles are:
- 2 joint hip flexor muscles are:

7)
- If pelvis is fixed, what is action of one side of the Ext. Oblique muscle?
- If pelvis is not fixed (but back is on ground), what is action of Ext. Oblique muscle?
- Both ext and int obliques contracting together - what happens (what is action)

8) Is it possible to contract a portion of the oblique m's, or is it all or nothing?

9)
- What is main purpose of transversus abdominis muscle?
- Which muscle(s) is the transversus abdominis tied to closely?
- Explain the above point ... why?
- SO if someone had low back pain and multifidus muscle atrophies, how can you retrain?
- TRY SOMETHING ... flex abs ... you are actually also flexing transversus abdominis, and a few miliseconds later you will feel your lower back also contract and tighten. This illustrates the point.

10)
- Besides contracting erector spinae m's, what is another way to tighten the thoracolumbar fascia
- Is the above point's option possible to do often?





11) What muscles help pull / connect the trunk to the pelvis?

12) T or F: The abdominal m's on the anterior portion of the trunk help with lumbar stabilization? Explain

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1) True. Forces from LBP get distributed to pelvis and hip area (and visa versa).



2) Rectus abdominis, ex. oblique, int. oblique, transversus abdominins

3) Ventral rami, segmentally innervated (thoracoabdominal)

4)
- L1
- T4
- T7
- T10

5)
- Open: Bring pelvis up to chest
- Closed: Bring chest to pelvis (trunk flexion)
- Posterior pelvic tilt




6)
- 1: Iliopsoas (and pectineus, adductor brevis and magnus)
- 2: Rectus femoris (and sartorius)

7)
- Pull ribs to opposite ASIS (contralateral trunk rotation)
- Pull ASIS toward opposite ribs
- The diagonal pull (to both sides) of both m's cancels each other out and and resultant vector is straight down (crunch)


8) They are segmentally innervated, so you can technically contract a portion of the muscle belly.

9)
- It's the container around abdominal contents to help PRESSURIZE and protect the abdominal cavity. Strengthen the core.
- Multifidis
- They have a reflex relationship together. So the transversus abdominis muscle fires, and about .2-.3 seconds later the multifidi fire as well. Both work together to stabilize the core/trunk/lumbar spine area.
- Get them to contract transversus abdominis muscle (to fire multifidi). Activation of transversus abdominis activates multifidi SO THE WHOLE TRUNK GETS STABILIZED.

10)
- Tighten the Lats and the glutes bilaterally and they thus pull in 4 directions (4 corners) to tighten fascia of lower back. (Try it ...)
- If you stand erect and don't move, it works well. But it is pretty impractical unless you are just standing erect with no motion. But if you bend down to pick up a box, you need to stretch arms out (stretching lats), and stand back up (which elongates glutes). So the concept of contracting glutes and lats together is not functionally possible most the time.

11) MANY ... but specifically the psoas and quadratus lumborum and the ant/lat abdominal muscles (even erector spinae do).

12) True. They contract pulling ribcage toward pelvis to stabilize, and that stabilizes the spine as a result (plus the transversus abdominis contracting triggers multifidi, etc.).

43

1) Explain the 'Abdominal Curl' test and why you'd do it

2) What is the 4 point kneeling arm/leg lift

3) What is side bridging test
- Would the erector spinae and ext oblique muscles be contracting on the right (downhill) side or the left (uphill) side? Why?
- If knee is proping him up, would his right hip AB/ADductors be contracting?

4) Goal of these 2 tests above:

5) What stretch could you have patient do to get some ROM in lumbar spine with low weight bearing?
- To get major kyphosis, what muscle should you activate to get lumbar kyphosis?
- To get major lordosis, what muscle should you activate to get lumbar lordosis?

6) T or F: You can not contract the erector spinae without compressing spinal column?

1) The McGill Curl Up ... place hand behind lower lumbar area while laying supine, and do a slight curl up and push lumbar back down to tighten abdominal m's (anteriorly) and fire posterior back m's (erector spinae and multifidi) to strengthen core and help alleviate LBP.

2) Kneel and kick one leg out and bring out opposite arm. Helps with core/pelvic/lumbar stabilization training (same point as above).

3) Kneel sideways proping yourself up on your elbow
- Right (downhill). If the top muscles contracted it would pull trunk up a little but force pelvis down. The downhill ones contract and pull trunk back to pelvis to keep it straight and tight and prevent it from slumping down.
- ABductors.

4) Strengthen core to help train lumbar stabilization.

5) The "Cat" stretch: On all 4's and move lumbar spine from extreme lordosis to extreme kyphosis to stretch that lumbar spine area and get some ROM.
- Rectus abdominis and ext/int oblique m's
- GRAVITY (and some Psoas, Erector spinae)

6) TRUE

44

BELOW ARE FLASHCARDS ON PELVIS

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45

1) What is the Pelvic Girdle:

2) What is the main purpose of the pelvic girdle?
- What are other purposes?

2A) What is main difference between Pelvic girdle vs. shoulder girdle
- Why it's important to know this:

3) Another name for hip bones that Dr. T uses? The ilium, ischium, and pubic bones together are known as the:

4) Where do the ilium, ischium, and pubic bones join together:
- What is the area of bones fuzing together there called where there is cartilage
- When does it ossify?

5) Explain how weight or a force gets distributed from trunk to leg
- Is weight (force) ever distributed from LE's to trunk?
- Describe bony architecture in that area and how forces are distributed






6) What if you are not standing, but rather sitting - explain how force is distributed?


7) What could you palpate on most patients of the innominate bones



8) What is the bony landmark on the ilium where the sacrum articulates (at the SI joint)?

1) Hip bones, sacrum (and coccyx)

2) Transmit body weight, and stability
- Connect lumbar spine to LE's
- Contain viscera / organs
- Attachment site for trunk and LE muscles
- Allows mobility

2A) The shoulder girdle only attaches at one spot to a fixed bone: S/C joint. The pelvic girdle is solid all the way around.
- This is important since the large muscles that attach to pelvic girdle are thus big and strong since they attach to a fixed bone. Lots of torque generated, so muscles/bones need to come from a stable base.

3) Innominate bones

4) Acetabulum
- Triradiate (or Tripartate) cartilage
- Age 12-14

5) Weight force goes from L5 to Sacrum (through vertebral body and IV disc, and iliolumbar ligs) and that force is distributed through SI joint to ilium down to acetabulum and then it is transmitted to head of femur through neck and down long axis of femur.
- Yes, all day every day as we walk or run
- It is primarily cancellous bone in the middle of each bone (vertebrae, sacrum, ilium, femur) and the force is transmitted through the longitudinal lines of the cancellous bone.

6) Now it goes from vertebra down into sacrum (same way as above), down through the ilium, but now from ilium to the ischium to the ischial tuberosity (sit bone).

7)
- ASIS
- PSIS
- SI joint area (posteriorly)
- Iliac crest
- Ischial tuberosity
- Pubic tubercle/crest

8) Auricular surface (iliac tuberosity just above that space)

46

1) Does the base of the sacrum articulate with the coccyx or the L5 vertebrae?

1A) Joint name between sacrum and coccyx

2) Essentially, what are the ala of the sacrum?

3) Middle hole going down the middle of sacrum is:
- What goes through there?
- They exit anteriorly and posteriorly through:
- They exit distally through:
- What is different about the intervertebral foramina in sacrum compared to other vertebrae:







4) Does sacrum have spinous processes?
- What is that ridge called?
- Can you palpate them?

5) The main superior articular processes of the sacrum (S1) face what direction and why?

6) Area of sacrum that articulates with hip / innominate bones is called:
- The joining surface on the ilium that articulates here (SI jt area) is called:

7) Explain the base and sacral promontory of the sacrum (and their difference)
- So anterior portion of L5 should be aligned with:
- What is sacral promontory used for:

8) Most distal cauda equina rootlets exit through:

1) L5

1A) Sacrococcygeal jt


2) Wings ... the fused transverse processes like other normal vertebra

3) Sacral canal
- Spinal nerve ROOTLETS from cauda equina (lumbosacral plexus)
- Intervertebral foramina
- Sacral hiatus
- Up top the dorsal and ventral root come out laterally through the intervertebral foramen as 1 spinal nerve. In the sacrum there are 2 openings / exits / intervertebral foramina ... and they are anterior and posterior on sacrum (vs. lateral) ... and so the ventral and dorsal root exit their respective opening.

4) Yes
- Medial sacral crest
- Not really

5) Superior, slightly medial, and POSTeriorly, to block the L5 from moving to far ANteriorly.

6) Articular surfaces
- Auricular surfaces



7) Base of the sacrum is the entire top (cranial) portion of the sacrum ... all of it. The sacral promontory is the ANTERIOR portion of the projecting part (articular surface that L5 vertebral body sits on) where the articular surface of L5/S1 is.
- Sacral promontory
- To determine lining / tilt of pelvis (in radiographs) to determine pelvic tilt, sacral angle, pelvic inlet angle.

8) Sacral hiatus

47

1) The 2 projecting antlers that project up from the coccyx are called:

1A) How many vertebrae make up the coccyx

2) From #1 above, those articulate where?

3) T or F: the cornua articulates with sacrum at a diarthrodial joint?
- Why does this even matter to know?

4)
- T or F: There is not a disc between S5 and C1 (coccyx)
- What is unique /different about question above's answer:

5) Is the coccyx innervated? Explain

6) What is MAIN role of the coccyx
- What other muscle attaches on coccyx

7) Does it move during childbirth? Bowel movements?

8) If you hurt your coccyx, what do you do?

9) Sometimes Dr's opt to remove coccyx. Why is this problematic?
- What results from this?

1) Cornua (meaning "crown")


1A) Usually 4, but could be 3-5

2) Two bumps on apex area of sacrum

3) True
- They act as facet joints, so they can get dislocated, inflammed, etc.

4) False. There is
- There is NO nucleus pulposus in that disc.


5) YES. If you fall on your coccyx, it hurts = its innervated.

6) Attachment point for muscles of the pelvic diaphragm.
- Gluteus max has fibers that attach there.

7) Yes, Yes

8) Do NOT do weight bearing. Get a donut cushion to take weight bearing off of it. You can also do surgery and remove it.

9) Removing coccyx removes a major attachment point for pelvic diaphragm.
- Pelvic floor dysfunction is the result.

48

1) Explain the iliolumbar lig's

2) Does iliolumbar lig interact with SI joint or SI lig's

3) Explain lig's of SI joint

4) What are the ligs that connect sacrum to coccyx?

5) What are the BIG 2 L.A.A.D. at sacrum area that connect sacrum to hip bones to prevent sacral nutation?

1) They pass from L4 and L5 transverse processes and go down to the brim of the pelvis (iliac crest) to distribute weight from L4/L5 to ilium, and provide lots of stability. (They are big strong intertransverse ligs)

2) L5 portion of the iliolumbar lig attaches down near top portion of SI joint. So SI joint pain can get distributed up to L5, and L5 pain can get distributed down to SI joint and ilium.

3) Anterior and Posterior SI lig's (and interosseous SI ligs posteriorly at the non-synovial portion of the SI joint)

4) Yes. Superficial sacrococcygeal lig's

5) Sacrotuberous, Sacrospinous

49

1) Is the SI joint a diarthrodial joint?
- Does it thus have synovial fluid and hyaline cartilage?

2) So, we know SI joint has the anterior and posterior SI lig's, but explain what is between those:





3)
- Explain the details of the auricular surface of the ilium and the articular surface of the sacrum, and how the connect / articulate:
- So which one is the valley, which one is the ridge:









4)
- What is the iliac tuberosity (and where)
- What is it's function

5)
- Is the sacrum wider at the base or apex?
- Is the sacrum wider anteriorly at the base, or wider posteriorly at the base?
- Why is this important to know for function / movement of sacrum


6) Can you palpate the SI joint? How
- PSIS is at what level of the spine?
- PIIS is at what level of the spine?
- Iliac crest highest point is about what level of spine
- Inferior angle of scapula is what level of spine:

7)
- What ties the pelvic girdle together posteriorly?
- What ties the pelvic girdle together anteriorly?

8) Pubic Symphysis is composed of what:

9) What holds pubic symphysis in place?





10) What muscle inserts at pubic symphysis?

11) Explain Sacral Nutation and Counternutation
- What happens to innominate bones during nutation and counternutation?















11A) Why would we even care about knowing about / looking for nutation or counternutation?



11B) Why (or how) do innominate bones move IN during nutation and OUT during counternutation






11C) Is coccyx moving toward pubis during nutation or counternutation?

11D) With 11C above, would this motion make SI joint more loose or taut?

12) What are the main ligs that prevent too much sacral nutation?

13) The sacrum and ilium rotate around each other at the:

1) YES and NO. The anterior portion is synovial yes, but posterior portion is fibrous filled with connective tissue (interosseous ligs)
- YES (the anterior portion)

2) Anteriorly is the synovial joint portion of the SI joint. It is like all diarthrodial joints (capsule, synovial membrane, synovial fluid, cartilage, etc.). The posterior portion is essentially a gap between sacrum and ilium and it is filled with fibrocartilage and the interosseous lig's. The ant and post SI lig's are the sandwich (peices of bread) with those two different portions of the SI jt between.

3)
- Ilium's auricular surface is shaped in a C or L shape, and the middle portion of it is RIDGED (or raised) to where the sides (going ant and post) slope down from the ridge.
- Sacral articular surface is also shaped in the similar C or L shape (since these articulate together), and the middle portion of it is CONCAVELY dipped in (or lowers / caves in) to where the sides (going ant and post) raise UP from the caved in portion.
- VALLEY is the sacrum portion (articular surface) of SI joint, and RIDGE is the ilium portion

4)
- In the region of the SI joint, just above auricular surface of the ilium, ... the auricular surface of the ilium has a projection called the iliac tuberosity.
- AOR for SI joint

5)
- Wider at BASE
- Wider ANTERIORLY
- Because it is wider anteriorly, it is easier for sacrum to go forward (nutation), but it can't go backward as easily because of that shape (counternuation).

6) Yes. Find PSIS and move just medially to palpate SI joint
- S2
- S3/S4
- L5
- T7

7)
- Posterior: Sacrum, with all the lig's (post SI lig, sacrotuberous, sacrospinous, etc)
- Anterior: Pubic symphysis (and its lig's)

8) Fibrocartilage

9)
- Superiorly it is the sup. pubic ligament
- Inferiorly it is the arcuate pubic lig
- Anterior: Anterior pubic lig
- Posterior: Posterior pubic lig

10) Rectus abdominis

11) Nutation of the sacrum is the sacrum nodding forward, or the sacral promontory going forward (anterior and caudal) and apex going back (posterior and cranial).
- Innominate bones during this rotation ... the top or iliac crests move IN or medial toward sacrum during Nutation, and ischial tubercles move OUT or laterally during Nutation (Remember this happens because of the wedge shape of the sacrum).

- CounterNutation of the sacrum is the sacrum nodding backward, or the sacral promontory going backward (posterior and caudal) and apex going forward (anterior and cranial). PLUS ... innominate bones during this rotation ... the iliac crests move OUT or laterally from sacrum, and ischial tubercles move IN or medially.

11A) If both sides are hypo/hyper mobile, or if unilaterally you have hypo/hyper mobility of a SI joint (or weak lig's), etc. ... it could create back pain, lack of stability at the hip, inproportionate distribution of weight from low back down to hips.

11B) Remember the wedge shape of the sacrum. Because it is wider anteriorly, it easily falls into nutation (with weight of L5 bearing down to help too). If the wedge (sacrum) goes forward (nutation), the innominate bones will naturally go in. BUT, with counternutation (or return from nutation) the wedge drives back and pushes innominate bones out.

11C) Counter

11D) Taut



12) Sacrotuberous and Sacrospinous ligs (combined with ant / post SI ligs)

13) Iliac tuberosity (SI joint)

50

1) Can you have pt create sacral nutation motion by themselves?

2) How would you create posterior torsion on the left innominate bone?
- Doing this would essentially create what movement at the sacrum?

3) The return of sacral nutation is known as:

4) How can you as a PT create the motion of counternutation of one of the innominate bones (since pt can't do it themselves)
- Why pull knee up?




5)
- Is anterior torsion of innominate bone same as anterior pelvic tilt?
- Is anterior torsion of BOTH innominate bones the same thing as sacral counternutation?

6) Is nutation and counternutation referring to movement of sacrum or innominate bones?

7) What is average ROM of the SI joint

8) Do both innominate bones ever act in opposite torsion / directions from each other? Explain
- What does that do to pubic symphysis?








9) REVIEW:
- Explain differences between
- anterior/posterior pelvic tilt
- anterior/posterior innominate bone torsion
- sacral nutation vs. counternutation

10) What happens to lumbar spine during anterior pelvic tilt?

10A) Does sacrum move with innominate bones during pelvic tilt (ant or post)?




11) AOR for:
- SI joint movement (sacral nutation)
- Ant/Post pelvic tilt

12) Weight of body coming down on L5 will naturally push sacrum into what type of movement?
- What stops that movement?
- During sacral nutation, will the ligs from the last point be on stretch or slack?

13) What prevents too much counternutation movement?




14) What happens to ASIS during anterior torsion of R innominate bone?

1) NO


2) Place pt supine and bring leg up (knee flexed) and push leg into iliac crest to push innominate bone posteriorly.
- Sacral nutation


3) Counter-nutation

4) Place pt prone, grab leg with knee flexed, and pull knee up to ceiling while using other hand to push pelvis forward on one side. This is creating anterior pelvic torsion of the innominate bone, which creates sacral counternutation.
- Pulling knee up pulls the rectus femoris up, which pulls AIIS down, which helps create a force couple to bring innominate bone forward.

5)
- NO. Anterior pelvic tilt refers to BOTH innominate bones moving together with the sacrum (the entire pelvic girdle). Anterior torsion refers to just ONE of the innominate bones moving.
- Yes

6) SACRUM

7) 3-6 degrees (so not much)

8) YES. During normal gait. On your RIGHT stance leg, the ground reaction force pushes R femur up into lip of R innominate bone which pushes the R acetabulum up and creates posterior torsion of R innominate bone. BUT the left leg is in swing phase, so all the weight on L side is creating a weight/gravity force down and that pulls the L innominate bone down into anterior torsion. So both innominate bones are acting opposite to each other (opposite torsions) during gait.
- Causes a shearing force on the pubic symphysis.

9)
- Ant/Post Pelvic Tilt: The entire pelvic girdle moving ant or post. Includes sacrum and both innominate bones moving as a unit.
- Ant/Post innominate bone torsion is when just ONE innominate bone moves
- Sacral nutation is when sacral promontory goes forward, and counternutation is when sacral promontory goes backward.

10) It would be in MORE LORDOSIS

10A) YES. Entire pelvic girldle moves together during ant/post pelvic tilt

11)
- Iliac tuberosity
- Coxafemoral jt.

12) NUTATION
- Sacrotuberous and sacrospinous lig's (and partially the ant/post sacroiliac ligs), as well as muscles.
- Stretch

13) Bony apposition. Remember the sacrum is shaped like a wedge where anterior portion is wider. Because it is wider anteriorly, it goes into nutation easier (and plus weight of body helps push it forward/down). But it can't move posterior as easy given anterior portion of sacrum is wider. Plus the Posterior SI ligs help.

14) It would move anterior and caudally.

51

1) T or F: When looking at or palpating a patient, both ASIS's should be at the same horizontal level?

2) From #1 above, if they are not, what might be happening?
- Pretend the ASIS on the LEFT side is HIGH, what is happening?
- How do you know which side has pathology?

1) True


2) Some pathologic innominate torsion ... meaning one is either in posterior torsion or the other is in anterior torsion
- The left innominate bone is probably in some posterior torsion (or R could be anterior torsion)
- Whichever side they hurt on :)

52

1) Above we talked about how the axis of the sacrum is at the ______ ________. But is this the only axis of the sacrum?
- What is L/R oblique axis
- How might you palpate to know whether this is happening or not?
- How would you fix it?






2)
*** He said the only science proving axis's of the sacrum is:

1) Iliac tuberosity
- Well, in some people or pathologies, it's proposed there may be another axis lower on sacrum as well. But Dr. T said he doesn't really think this one exits.
- He argued that if in some pathologies there is a lower axis, then the top right and lower left axis work to give rotational movement of sacrum.
- Find PSIS and then go to area between to feel space of SI joint. If one side projects more posterior and superior with the opposite corner more anterior and inferior, then it would confirm this is the case (but Dr. T said it is highly unlikely).
- YOu push high side (if it is the one more posterior) and push it back or in (anterior) since you can't grab the low side which is too far in. If the low side is more back or dorsal, push that in.

2)
- ** The SI joint up at normal Iliac tuberosity around level of S2

53

1) We know the ant and post SI lig's hold the sacrum in place. But what else contributes to holding the sacrum in place?

2) If you tear the pubic symphysis, what would happen?

3) How well do you weight bear if you have a hypermobile sacrum?


4) What are options to fix a broken pubic symphysis

1) The pressure of the two innominate bones actually push into the sacrum, squeezing it into place essentially (like a nutcracker or wrench can wedge something in the middle). Innominate bones are lever arms squeezing sacrum, creating friction to hold it in place.

2) It releases tension of innominate bones, releasing pressure, so pressure is released from the sacrum so sacrum isn't compressed into hip bones. Sacrum thus becomes more free and floating = inable to bear weight of upper body.

3) YOU DON'T

4)
- Sling around pelvic area (you wear for months till it heals, and no weight bearing ... so it is torture)
- Screws in place of pubic symphysis, but then you don't allow innominate bones to move/rotate at that joint, so walking is very difficult
- Some external brace where bones are screwed to brace, but still allow movement at pubic symphysis.

54

1) What is a scleratome



2) T or F: Synovial joints have sensory nerves within connective tissue:

3) When you break a bone, what actually is the thing that causes pain?

4) *** What is Hilton's Law

5) How does Hilton's Law apply to the posterior arm vs. the sacral area?

1) Sensory innervation of the connective tissue overlying bones and joints (dermatomes are innervation of skin areas, myotomes are group of muscles innervated by a nerve)

2) TRUE

3) NOT the bone breaking, it is the periosteum that is well innervated that gets damaged and hurts as it gets sensory fibers from nerves there.

4) ANY NERVE THAT SUPPLIES A MUSCLE THAT CROSSES A JOINT ALSO SENDS SENSORY FIBERS TO THAT JOINT AND THE SKIN OVER THAT JOINT.

5) For posterior arm, it is just the triceps and the radial nerve. Sacral area has TONS of nerves in that region. So injuring a muscle tendon or lig there impacts MANY nerves in that area.

55

1) What is Last's Rule












2) So if you had an injury at L3, what function would you have and what would you NOT have?


L2 L3 L4 L5 S1 S2
H A A P P
K A A P P
A A A P P

H=Hip
K=Knee
A=Ankle

Above is the MAIN root levels. So for Hip flexion (of L2 and L3) you do get some L1 and a little L5. But it is mainly L2 and L3

2) You'd have everything from L3 and up. But you'd lose L4 and down.

56

BELOW ARE FLASHCARDS ON PELVIC FLOOR KINESIOLOGY

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57

1) Explain the difference between the pelvic diaphragm and the perineum:
(how to remember)

2) From #1 above, which one is the DEEP / INTERNAL layer, which is the superficial layer?

3)
- Muscles of Pelvic Diaphragm:
- Muscles of Perineum:

4) Which of those 2 are palpable?




5)
- What is the function of the pelvic diaphragm?
- Laughing, speaking, whistling, and valsalva maneuver is controlled by (inferiorly):

6)
- What m's are part of levator ani:
- Are the m's of levator ani anterior or posterior on the pelvic floor?
- From the point above, then what forms the other side
- Levator ani are innervated by:


7) Explain the attachment points for levator ani muscle
- T or F: Anteriorly and medially, the levator ani (specifically the iliococcygeus portion) is attached to another muscle? Explain

7A) What is the arcus tendineous

8)
- T or F: The levator ani is one big muscle, or is it seperated at midline?
- There are holes in between both levator ani muscles, what are those holes
- What is the unique name for those holes (from point above)?

9) If you were a dog, what muscle helps you wag tail from side to side

10) Coccygeus muscle is innervated by:

11) What muscle helps close off the rectum?

1)
- Pelvic diaphragm: The pelvic floor that supports the internal organs (uterus, bladder, rectum) and maintains internal pressure.
- Perineum: Superficial muscle layers that includes sphinctes and urogenital muscles for external openings.
(Remember: diaphragm is INSIDE ... so pelvic diaphragm
is INSIDE)

2)
- Deep: Pelvic diaphragm (pelvic floor muscles)
- Superficial: Perineum

3)
- Pelvic Diaphragm: Levator Ani (posterior portion is coccygeus and piriformis)
- Perineum: Deep transverse perineus, bulbospongiosus, ischiocavernosus, Superficial transverse perineus

4) Perineum

5)
- Regulate internal pressure (with help of glottis), and help with inferiorly hold in the internal organs.
- Pelvic floor m's

6)
- Puborectalis, Pubococcygeus, iliococcygeus
- Anterior
- The posterior side is formed by the coccygeus muscle and piriformis muscle
- Ventral rami S3-S4

7) As their names suggest ... the pubis, coccyx, and iliac bones.
- True. It attaches to the obturator internus muscle fascia.

7A) That is the name for that piece of fascia of the obturartor internus where part of the levator ani (iliococcygeus) muscle attaches.

8)
- It is seperated at midline by fascia between two levator ani m's on both sides
- Anus in men/women, and vagina and urethral opening in women.
- Special name = effulence.

9) Coccygeus muscle

10) S4/S5

11) Puborectalis (with external sphincters)

58

1) The perineum is deep to or superficial (external) to the pelvic diaphragm?

2) What are the 2 portions of the perineum?

3) From #2 above, which one is anterior, which is posterior?

4) Everything in perineum are innervated by:

5) What does the urogenital triangle contain:







6) What does the anal triangle contain:

7) What muscle transversely divides the urogenital and anal triangles?

8) What is perineal body
- Why is it so important?
- What is another name for it
- What often happens to it during childbirth
- How is the point above graded?
- How is it fixed?






9) The external urethral sphincter would be part of what triangle?

10) What is the thin "ligament" or band between superficial (perineum) and deep (pelvic diaphragm) layers:

11)
- Are Pelvic diaphram muscles (except sphincters) Type I (slow twitch) or Type II (fast twitch) muscle fibers?
- Are Sphincters Type I (slow twitch) or Type II (fast twitch) muscle fibers?

1) Superficial (external)


2) Urogenital and anal triangles

3)
- Anterior: Urogenital
- Posterior: Anal

4) Pudental nerve

5)
- Sphincters for genital function
- Opening for vagina and urethra for women (nothing for men)
- Ischiocavernosus
- Bulbospongiosus
- Posteriorly the superficial transverse perineum
- Deep layer is deep transverse perineum

6) Sphincters for GI (external anal sphincter)
- Anal opening

7) Superficial transverse perineus muscle

8) Point between urogenital and anal triangles where superficial perineus muscle attaches. It is between anal and vaginal opening. It is connective tissue that connects everything in pelvic floor together
- It connects / anchors the pelvic diaphragm to the perineum, and the urogenital triangle to the anal triangle (of the perineum)
- Central tendon of the Perineum
- It gets torn (or cut)
- Grade 1 is mild, grade 4 goes all the way to rectum
- Lots of stitches :)

9) Urogenital

10) Deep transverse perineum

11)
- Type I
- Type II

59

1) Explain "Force Closure" of SI joint, and how this is done

2) T or F: Contraction of the pelvic diaphragm stabilizes the SI joint?

1) Contract transversus abdominis muscle to pull both iliac crests medially ... this will 'force close' the SI joint.

2) TRUE

60

Below are flashcards on the pathokinesiology of the pelvic floor

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61

1) The pelvic diaphragm muscles are:

2) Where do the levator ani m's attach on their lateral sides?

3) Name for the specific attachment point on the lateral side for levator ani m's is:

4) One of the most common pathologies of the pelvic floor is:
- What would happen in this case? Let's say the Left arcus tendineus got torn.
- So would bladder get pushed to injured or the intact side in this injury?

5) What anchors the pelvic floor to the perineum

6) What is the band between the anus (anal opening) and coccyx bone?
- What is its function

7) So, we know the puborectalis goes from pubis to rectum --- but what does it do?
- This only works if what is functioning?
- So what is the purpose of the perineal body in connection with the analcoccygeus lig?
- What is a pathology where this is ruined?



8)
- Where is the pudental canal
- What is compression of the pudental canal
- Where (when or who) does it most often happen with?
- How does it happen?





9) Pudental nerve originates from what nerve fibers?
- Injury to pudental nerve results in:

1) Levator ani (the 3)

2) Obturator internis muscle (that fascia)


3) Arcus tendineus


4) Tearing the arcus tendineus (during childbirth or pelvis fractures)
- The left arcus tendineus gets torn, so the intact right side pulls the contents over to the right side.
- The bladder goes to the INTACT side.


5) Perineal body

6) Analcoccygeal lig
- It helps anchor the pelvic floor to the coccyx


7) Puborectalis essentially hugs rectum, and when it contracts, it squeezes rectum to kink it (to not let contents pass through).
- If the perineal body is solidly in place, and the analcoccygeal lig is firm and working, this will allow puborectalis to pull and squeeze off rectum without rectum moving.
- To hold rectum in place
- If perineal body or coccygeal lig are ruined or weak, you can't use puborectalis muscle to squeeze off rectum to stop bowel movement. This = incontenence

8)
- Just medial to ischial tuberosity by the obturator internus muscle
- When this area of pudental n, a, v get compressed
- Bike riders sitting long periods on that area.
- If bike seat is NOT wide enough, it will compress area between the two ischial tuberosities and compress the pudental canal area.

9) S2-S4
- Lose motor innervation to perineum area and muscles, plus the external genitalia of both sexes, as well as external sphincters for the bladder and the rectum.

62

Below are flashcards of the HIP

*** Obviously review bony landmarks of hip, femur, and muscles of hip, and dermatomes, etc.

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63

1) What is another name for hip joint

1A) What type of joint is it?

1B) How many degrees of freedom does the hip joint have?

1C) Is the glenohumeral joint or coxafemoral joint more stable?

1D) Is the acetabulum and femoral head very congruent together?

2) The hip joint is composed of what bony articulations

3) Is there a capsule over the hip joint?

4) Explain the uniqueness of the cartilage of the hip joint
- What is it called?
- Why does this cartilage NOT go all the way around?
- So what does that area contain?


5) What is the purpose of the transverse acetabular lig?


6)
- The ligament that connects head of femur into acetabulum is the:
- Another name for that lig:
- Where does it attach (on both sides)
- What is it's function





7) So if you stand in front of someone's pelvis and look at it from anterior side, what is the direction / orientation of the acetabulum?

8) Is the superior lip of the acetabulum more laterally projecting, or the inferior lip?
- Why?

1) Coxafemoral joint

1A) Ball and socket

1B) 6 degrees

1C) Coxafemoral joint (shoulder has more mobility, hip joint has mobility too but more stability than shoulder).


1D) Very congruent yes


2) Acetabulum and femoral head

3) Yes

4) There is of course articular cartilage over the femoral head. And the acetabulum is lined with a labrum, partial circle (2/3rds) of cartilage (but it does NOT go all the way around full circle).
- Lunate surface
- Because weight bearing during standing or walking doesn't utilize that lower area of the acetabulum for weight bearing, so no need for articular cartilage.
- The Transverse Acetabular Lig

5) It completes inferior portion of acetabulum. The acetabulum is the bone portion (with lunate surface of cartilage covering it) and it is shaped in a C and doesn't close / join at the bottom. This lig completes the circle and closes off the area.

6)
- Ligament of the head of the femur
- Ligament capitis femoris or ligamentum teres femoris
- Into the acetabular fossa, and then into the fovea of the head of the femur.
- You might think it holds the head in place, but it doesn't really. It is a embryological remnant, and it especially is a blood supply to head of femur (umbilical cord for blood supply to head of femur).

7) It points anterolaterally and slightly caudally.

8) The superior lip is much more laterally oriented
- Because it needs to weight bear between it and head of femur to pass weight up/down

64

1) The head of the femur is a sphere, but is it a full sphere?

2) T or F: Head of femur is covered with articular cartilage?

3) T of F: The interior portion of the head and neck of the femur bone is cancellous bone?
- Explain why

4) What are the 3 main ligs of the hip joint






5) Which of the 3 from above is the Y shaped lig?
- Will this lig be on stretch or slack during hip extension
- T or F: the iliofemoral lig has 2 portions, a medial and lateral?
- During hip ABduction, will the medial or lateral band go on stretch?
- During hip ADduction, will the medial or lateral band go on stretch?
- Is Y lig (iliofemoral) more on the anterior or posterior side of the capsule?

6) Which lig is primarily on the posterior side of the capsule?
- It will get tight during flexion or extension of the femur?
- Will it tighten on ER or IR of femur?

6A) Explain where pubofemoral lig attaches proximally and distally?
- Does it go tight during femoral flexion or extension?
- It also resists what movement of the femur?

7) Important to know the boundaries of the hip jt capsule, or from where these ligs start and go distally to attach

8) What is the final lig down at the neck of the femur holding the base of the capsule in place:
- What is it's function

1) No, about 2/3 sphere

2) True


3) True
- Just like every other bone, the epiphyseal end portions of bone are filled with cancellous bone to help distribute forces (so with femur, force from innominate bones are passed down through femur head into shaft/long axis of femur which is stronger cortical bone).

4)
- Iliofemoral
- Ischiofemoral
- Pubofemoral

5) Iliofemoral
- Stretch
- True
- Medial
- Lateral
- Anterior




6)
- Ischiofemoral
- Extension
- IR

6A) From pubic bone down to base of the neck of the femur
- Extension
- ABduction

7) The start of the jt capsule proximally is just above acetabular rim (and transverse acetabular lig on inf portion), and then it goes down just past neck of the femur near the intertrochanteric line.

8) Zona Orbicularis (or zonular band, ring ligament, and orbicular zone).
- To squeeze of the base of the capsule to hold the femoral head in place.

65

1) Where is the true AOR for flexion/extension of hip joint (compared to where we use goni to measure)
- AOR for AB/ADduction of hip joint is:
- AOR for IR and ER of hip joint is:

2)
- HIP Flexion PROM is checked by:
- HIP Extension PROM is checked by:
- HIP ABduction PROM is checked by:
- HIP ADduction PROM is checked by:
- HIP IR PROM is checked by:
- HIP ER PROM is checked by:





3)
- T or F: Head of femur (and acetabular area) is bathed in synovial fluid?
- T or F: The neck of the femur is bathed in synovial fluid?

4) The head and neck of femur are supplied with blood by:
- Do these arteries supply the femoral head? Explain
- So how does head of femur get blood supply?
- Is the lig of head of femur (ligamentum teres) an umbilical cord, if you will? Explain

1) True AOR is tip of greater trochanter and draw a line from there straight into head of femur. BUT, you can't palpate tip of greater trochanter, so we use the lateral side that projects out ... close enough :)
- Imagine a pin going anterior to posterior through middle of femoral head (since that is the convex member)
- Imagine a pin going from sup to inf (vertical) through femoral head ... and then down into knee between condyles (remembering femur is angled)

2)
- Flexion: Hip extensor m's stretching, posterior capsule stretching, and soft tissue of thigh hitting soft tissue of abdomen (even slight active insufficiency of psoas muscle)
- Extention: Femor flexor m's, and 3 capsular ligs
- ABduction: Pubofemoral lig, adductor m's
- ADduction: Lateral portion of Y lig, glut mid/med stretch (abductor m's)
- IR: Stretching ER m's and ischiofemoral lig
- ER: Pubofemoral lig, obturator internus muscle

3)
- True
- False

4) Circumflex femoral arteries (ant and post, med and lat circumflex arteries).
- They do branch up through neck towards head yes, but they can't penetrate INTO the bone of the femoral head.
- A branch from obturator artery sends blood through ligamentum teres (lig of head of femur) to internal portion of bone of head of femur.
- Much like umbilical cord, the lig of head of femur is more like an umbilical cord to get blood supply?

66

1) Femoral angulation means what:
- It should be about what (how many degrees)
- If it is MORE than 125 degrees, it is called _____
- If it is LESS than 125 degrees, it is called _____
- How would these happen?

2) If you have too much coxa valga, why would that be bad?


3)
- Can coxa valga happen as an adult?
- When does it normally happen?
- Is coxa vara a developmental result? Explain
- How might you fix this?















4) What is Aseptic Necrosis

1) The angle between the head/neck of the femur and the long axis of the femur
- 125 degrees
- Coxa Valga
- Coxa Vara
- Development (coxa valga), injury or weight bearing (coxa vara)

2) Means the head of the femur is not properly articulating with the acetabulum so it can't bear as much weight, so you can easily dislocate hip or even develop a pseudoarthrosis (false joint). Or with dislocation, the muscles and lig's just hold it in place and that alters ones gait substantially (and is painful).

3)
- It could possibly, but usually does not
- Probably during development
- NO, usually it is a result of a fracture. So if epiphyseal growth plate of femoral head in a child is fractured, weight of acetabulum (and upper body) pushes the weak femoral head DOWN, and it thus heals at a lower angle due to weight bearing down on it.
- Ideally get Xray and catch it early on, and then get patient on crutches to take weight bearing off leg while it heals. BUT, if you don't get it in time and bone is dying and reforming, surgeon cuts hole through neck and head of femur to allow growth of new vessels to provide new blood supply. Or put a pin/screw in it (but can only due that if bone is not still in growth = child)

4) Death of bone tissue due to loss of blood supply

67

1) What is NORMAL anteversion of the femur
- What is the angle of normal anteversion

2) So explain pathologic anteversion and retroversion
- Does retroversion mean the head of the femur must be posterior the frontal plane axis of the body?
- Is a 5 degrees angle anteversion or retroversion
- Is 20 degrees angle anteversion or retroversion
- Is 1 degree change a concern? When is it a concern?
- Does retroversion ever get past midline?

3)
- Is pathologic anteversion or retroversion more common?
- Does anteversion change over one's life?





4) Review - what direction is the acetabulum facing?
- What way is femoral head facing?
- Why is that odd?

5)
- If you have too much anteversion at the hip, what will be your natural compensation?
- If you have too much retroversion at the hip, what will be your natural compensation?
- Why do they do this?

6) Can exercise change anteversion or retroversion?

7) You as a clinician obviously can't measure the angle of ante/retroversion. So how do you get that angle?
- How can you 'eye ball' and tell if there is ante/retroversion?
- If patellas are excessively medial, that would =
- If patellas are excessively lateral, that would =
- If patellas are excessively medial, then how might their feet appear?
- From point above, how might someone compensate for that (and what you'd see)

1) The head of the femur is angled slightly anteriorly (anteversion). So if you place femur flat on a table, the head is up off table. Or if you look at femur in it's anatomical position, the head is angled slightly anteriorly.
- 15 degrees

2) If normal anteversion is 15 degrees, pathologic anteversion is if femoral head is angled MORE than that, and pathologic retroversion is angled LESS than that.
- No. It is just more posteriorly angled than the normal 15 degrees.
- Retroversion
- Anteversion
- Change of 5+ degrees is when it becomes concerning
- Typically retroversion never goes past midline

3)
- Anteversion
- Yes. As we age we get less and less anteversion as we weight bear

4) Anterolaterally and caudally
- Anteromedially and cranially
- They are NOT exact opposites (for congruence). The femoral head you'd think would face more posteriorly to fit into acetabulum perfectly, but it too faces more anteriorly.

5)
- Toeing in (pigeon toed)
- Toeing out
- They are trying to put head of femur back into the most stable position in the acetabulum.

6) Exercise can NOT change bony alignment issues (like tibial torsion)

7) From an MRI or some imaging scan
- Look at their patellas ("patella squinting")
- Anteversion (think of it this way ... if the femoral head is anteverted, that rotates femur laterally and you need to compensate with toeing in, making the patella medial)
- Retroversion
- The feet will be angled medially (normally big toe is pointing slightly lateral, but in this case it would be slightly medial).
- Tibial bowing (torsion) to bring feet back to normal position (despite having anteversion and patella medial squinting).

68

1) What is normal hip PROM for:
- Flexion:
- Extension:
- ABduction:
- ADduction:
- IR:
- ER:

2) What ROM is required for normal ambulation?
- Flexion:
- Extension:
- ABduction:
- ADduction:
- IR:
- ER:

3) Why can you do much more flexion than extension at the hip?
- A tight hip capsule limits what during gait?
- Besides stretching hip flexors or extendors, what can someone do to get more hip flexion or extension

4) You think you can get much more than 10-20 degrees of hip extension ... why?

5) What is the least packed position of the hip jt?

6) What is the close packed position of the hip jt?

7) If we think of motions at the hip from the MOST restricted to the least ... how would you rank all the movements of the hip from MOST restricted to LEAST

8) Position of femur that results in a hip dislocation

1)
- Flexion: 120 (with knee flexed), 80 (with knee extended)
- Extension: 10 (with knee flexed), 20 (with knee extended)
- ABduction: 40-45
- ADduction: 20-30
- IR: 30-45
- ER: 30-45

2)
- Flexion: 30
- Extension: 10
- ABduction: 5
- ADduction: 5
- IR: 5
- ER: 5

3) Remember the capsule that all 3 ligs limit extension
- Extension ... The PUSH OFF portion of gait as leg is extended pushing off.
- Do some PELVIC TILTING with lumbar spine movement to create extra ROM

4) Well if you involve lumbar spine to help create pelvic tilt you certainly can get more. BUT if we just look at hip jt extension only, it is much less than if you involve pelvic rotation and lumbar compensation.

5) 30 degrees of flexion, 30 degrees of ABduction, slight ER

6) Max extension, max abduction, internal rotation

7) IR, Extension, Abduction, Flexion, ER

8) Flexion, ER, Adduction (crossing knee/leg over other knee)

69

1) If you flex hip and run into active insufficiency, what does that mean?
- What would you need to do at this point to get more hip motion?

2) Imagine standing on your right leg (so it is fixed) and then you are swinging your left leg forward (during swing phase of gait). Is the LEFT hip bone doing protraction or retraction in this motion?
- What is the RIGHT hip bone doing during that same motion?
- Where does this motion occur?

3) So in same example from above (right leg is fixed during gait) ... if right leg is fixed and left leg is swinging forward, is the Right femur doing IR or ER?
- T or F: Protraction of L hip bone creates ER at right hip? bone
- Retraction of hip bone of L leg creates IR or ER at right leg?

4)
- How many places around hip have bursa
- Review what those places are:


5) Which of those bursa is in communication with the hip jt capsule (like the subscapularis bursa was within glenohumeral jt capsule)

1) Means as you flex iliopsoas, eventually you get to point where that muscle can NOT keep flexing and creating movement of the thigh. This = active insufficency.
- Do posterior pelvic tilt with lumbar spine.

2) Protraction
- Retraction
- Right hip





3) IR
- False. Protraction of L hip bone creates IR at right hip bone.
- ER




4)
- 4
- Iliopsoas bursa (iliac bursa): seperates psoas from pubis
- Trochanteric bursa: on top of greater trochanter beneath gluteus max
- Gluteofemoral Bursa: Between gluteus max and vastus lateralis
- Ischial Bursa: on ischial tuberosity beneath glut max (WE SIT ON IT)

5) Iliopsoas bursa

70

GO review the dermatomes slide where you have to draw pinpoint dermatomes

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71

Continuation of hip

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72

1) What is the same concept of the subscapularis bursa for the hip joint?
- What is it and why do we have it?


2) The very top most portion of the femoral head when you stand erect in neutral is called:
- What is it?

3) If standing in normal position with both legs on ground, what % of upper body weight (HAT unit) would be on each Zenith?
- How much on a Zenith during single leg stance?
- So 50% WB means what?

4) T or F: When standing still erect, you will not sway or have any postural sway?
- Is there ever a time where all your muscles are silent or not working?

5) If you lose balance or sway slightly and go anteriorly, what action corrects this?
- What muscles activate to do the ankle strategy to restore balance / posture?
- Can you control yourself more or less if you fall / sway backwards? Why?
- So what muscles help prevent backward sway?
- So do older people fall more frontwards or backwards?

6) How do we prevent or compensate for losing balance / postural sway medially and laterally?

7) Lets pretend you have been standing for a while and shift to your RIGHT leg to have MOST of the weight on your RIGHT leg. What muscles need to work to bring hips/pelvis back to a neutral position where you have 50% of the weight on both Zenith's

8) Remember the practice problems you did. Rank the ones below that would create the most force in the R hip ABductor muscles (rank from least amount of force on ABductor muscles to most):
- Standing with cane on contralateral side of weak hip ABductors
- Standing with cane on ipsilateral side of weak hip ABductors
- Single leg stance on weak hip ABductors with no body weight shift
- Single leg stance on weak hip ABductors with body weight shift so COG is over leg

1) Iliopsoas bursa
- As iliopsoas comes down to attach into the lesser trochanter, this bursa projects from the hip capsule to act as a friction reducing device at that junction between the capsule and tendon.

2) Zenith
- It is the part that is the MOST WEIGHT BEARING

3) 50%
- 100%
- You can stand normally, but don't put all weight on one leg.


4) False. Everyone has a little (granted it is very little) sway even when standing still erect.
- Possibly during deep sleep (or when you are dead :), but most times throughout the day some muscles are activating to prevent too much sway and keep balance.

5) Ankle strategy (dorsiflexion with balls of feet going into ground ... closed chain dorsiflexion)
- Posterior shank muscles (plantarflexors)
- You can control FORWARD sway better because of the long lever arm of the foot. Backwards you only have calcaneus and COG goes behind AOR quick and easy and you lose balance and have no lever arm to help correct.
- Anterior shank muscles (dorsiflexors)
- Backwards

6) Hip sway ... hip muscles and movement (ab/adductors).

7) You need to contract your RIGHT hip ABductors, and your LEFT hip ADductors (with eccentric muscle contraction of the opposites as well). And you can argue that you'd use your left erector spinae to laterally bend trunk back over.

8)
- Standing with cane on contralateral side of weak hip ABductors
- Single leg stance on weak hip ABductors with body weight shift so COG is over leg
- Single leg stance on weak hip ABductors with no body weight shift
- Standing with cane on ipsilateral side of weak hip ABductors

73

1) What would the action of the iliopsoas be during:
- Open Chain
- Closed Chain:
- What does 'closed chain' mean in this example?
- T or F: The iliopsoas during hip flexion will get to a point of active insufficiency? Explain
- If you have bilateral psoas tightening, how might someone compensate?
- Can you get unilateral shortening of a psoas muscle?
- From last point, if so, how would someone compensate?
- T or F: Iliopsoas plays a major role in LBP

2) We know the glut max is a powerful hip abductor and extensor, but does it do any adduction?
- What is GM's role during gait

3) What is a Gluteus Maximus Lurch

4) We know the Glut med/min muscles help with hip ABduction, but what else do they do? WHY?



5) Explain the difference between a compensated vs. an uncompensated action
- So explain compensated vs. uncompensated action of a weak hip ABductor muscle





6) What is the Trendelenburg test, and why would you do it?




7) So of the two actions below (with regards to gait), which is compensated and which is uncompensated:
- Leaning towards injured side to shift body weight
- Falling down on opposite the effected side

8) Can a muscle like the hip ABductors get too tight?
- How would this look / result in?

9) Can ADductor muscles help with hip flexion? When?

10) Pectineus is in the adductor group, but how do we know it also assists in hip flexion?



11) A "groin pull" is usually what muscle being torn?

12) What is 'scissors gait'
- Why would this happen?

13) What are several muscles that are LATERAL ROTATORS of the hip

14) T or F: The piriformis acts as both a ER and IR of the hip?
- HOW



15) Where does the sciatic nerve run with respect to the piriformis muscle?
- Why is this important to know?



16) What muscles do IR of the hip?
- Is there a muscle dedicated ONLY to IR of the hip?

17) T or F: The hamstrings also help with IR of hip?

1)
- Open: Hip flexion
- Closed: Trunk flexion
- Leg (and pelvis) is fixed and can't move
- True. It doesn't contract any more (at end point of it's ability to contract).
- Increase lumbar lordosis to keep COG even
- Yes
- Bend knee slightly (do more tippy toe walk/stand)
- TRUE


2) Lower fibers do adduction, upper fibers do abduction
- To bring leg back (extend it)



3) When GM muscle gets weak and you can't extend it during gait, you lurch or lunge your body back during gait to get leg back.

4) Help with hip IR and ER. Because the ant fibers can fire during IR, and posterior fibers can fire during ER

5) Uncompensated is what will naturally happen if you do NOT compensate (gravity). Compensate is how your body compensates for an injury or pain, etc.
- Compensated is lateral rotation of trunk over weak hip to reduce lever arm of hip ABductors (and maybe hike hip). UNcompensated would be the opposite side of hurt ABductors would just collapse.

6) Have patient stand on one leg to test the strength of the hip abductor muscles. A POSITIVE test can indicate an unstable hip on the unsupported side or a weak gluteus medius muscle of the standing leg. People who have a positive Trendelenburg test mostly walks with 'dipping gate'

7)
- Compensated
- Uncompensated

8) Of course
- Leaning trunk to effected/involved side.

9) Yes but only if your leg is in extension, so fibers run from pubis to femor, and if femor is in extension, contracting will help with flexion.

10) Cause it's innervation if the femoral nerve, so it must assist in hip flexion

11) Adductor longus

12) When a person's leg crosses the midline
- Tight hip ADductors, neuropathy

13) Glut max, post portions of Glut med/min, piriformis, gemelus', obturator externus, obturator femoris

14) TRUE. It does ER like all the other ER's of the hip. But, when hip is flexed, it helps with IR
- When you flex hip, the tip of the greater trochanter goes posterior and the tendon of piriformis slides over that tip to that anterior side so it is anterior of the AOR.

15) Just caudal to the muscle, just above the sup. gemellus muscle (in greater sciatic notch).
- If the piriformis gets inflammed, it can impinge the sciatic nerve.

16) TFL, Anterior portions of Glut med/min, some adductor m's
- NO

17) True. The MEDIAL portion of hamstrings assist a little in IR of hip.

74

1) REVIEW: As you do normal gait, you obviously try to keep your toe pointed forward. BUT, in order to do that:
- If RIGHT leg is fixed (during gait), and LEFT leg is back fully extended trailing, will the RIGHT hip be in ER or IR?
- If RIGHT leg is fixed (during gait), and LEFT leg now is swinging and in front leading, will the RIGHT hip be in ER or IR?
- If RIGHT leg is fixed (during gait), and LEFT leg is back fully extended trailing, will the LEFT hip bone be in protraction or retraction?
- If RIGHT leg is fixed (during gait), and LEFT leg is back fully extended trailing, will the LEFT hip be in ER or IR?

1)
- ER
- IR
- Retraction
- IR

75

BELOW ARE FLASHCARDS ON THE KNEE:

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76

1) What bones are involved at knee joint
- Is the fibula part of knee joint?

2) What is the 'medial tibiofemoral jt'

3) How many articulations are at the knee joint:
- Explain them



4) What type of joint is the knee jt

5) What are the 2 longest levers in the body?
- Why is knowing that important?

6) The knee is the 'torsion link' ... what does that mean?

1) Distal femur, proximal tibia, and patella
- NO

2) Refers to the medial portion of the knee joint where the medial tibial plateau articulates with the medial femoral condyle

3) 3
- Medial and lateral tibiofemoral jts and the patellofemoral articulation

4) Condylar joint (bicondylar) ... modified hinge joint

5) Femur and tibia
- Because of that, the knee joint takes A LOT of torsion and torque

6) During gait, running, twisting ... you plant foot into the ground so it is fixed, and then rotate at the hip/pelvis/trunk. What takes the brunt of all that twisting and torsion? THE KNEE. Thus, it absorbs a lot of different forces between the stationary ground (ankle) and moving body above.

77

1) The femur distally has two condyles with grooves in between anteriorly and posteriorly. What are those grooves

2) Is the lateral or the medial condyle oriented more diagonally?

3) Looking at the condyle from ant. to post. aspect, which one is longer (or protrudes out more anteriorly)? Lateral or medial condyle?
- Why ... for what?

4) Does the lateral or medial condyle have a groove on the OUTER side of it? Why?

5) Name the top portion of the tibia:
- What are the two major attachment points / landmarks on the proximal part of the tibia where muscles attach?

6) T or F: The head of / proximal part of the fibula plays a role in the knee joint?
- What is the role of the proximal tibiofibular jt?

7) Will the medial or the lateral meniscus be more straight up/down or ant/post? Why?
- Will medial or lateral meniscus have thicker cartilage?
- Does the lateral or medial meniscus take more force? How do you know?

8) Explain the uniqueness of the synovial lining of the knee joint
- So does the ACL or PCL get synovial fluid?
- How do you know if you tear the synovial membrane lining?




9) How is the knee jt capsule different compared to synovial membrane lining?
- Where does capsule go anteriorly?
- What is the suprapatellar pouch?
- Is the knee capsule in front of or behind patella and patellar lig (quad tendon)



10) The two articular surfaces of the tibial plateau are seperated by _______________, and it has two bony landmarks called: ____________, and these protrude superiorly into ___________ of the femur

11) Which tibial plateau is concave ant/post and med/lat?
- Which plateau is larger?

12) When standing, what is the angle between the long shaft of the femur and the long shaft of the tibia?
- Why
- What is this angle 'called'
- Bowing the tibia (knee) laterally is called:
- Bowing the tibia (knee) medially is called:
- So is 'physiologic valgus' pathological?

13)
- Genu Varus' degree is:
- Genu Valgus' degree is:
- "Knocked Knee" is =
- "Bow Legged" =


14) What is it called when someone has too much hyperextension of the knee:
- What is the angle / degrees for that:

15) What is the "Q Angle"
- Is this the same as Physiological Valgus?
- Is it the same as Genu Valgus?
- What is the angle typically in males vs. females
- So how are Q angle and physiological valgus different?

16) If quads contract, which way to they pull the patella?
- If Q angle (in males) is greater than 5 degrees, what would happen during quad contraction?
- What is stopping the patella from jumping off the femur?

1) Patellar groove (or sulcus) anteriorly, and intercondylar notch posteriorly.


2) Medial condyle is diagonal, and lateral condyle is much more straight.

3) Lateral. The lateral side has a really protruded / bulging forward or anterior to
- RESTRAIN THE PATELLA from too much lateral dislocation

4) Lateral one does for the tendon of the popliteus


5) Tibial plateau
- GERDY's tubercle is on the anterior part of the LATERAL tibial condyle ... where IT band inserts, and PES ANSERINE insertion point is antero-lateral portion of the MEDIAL tibial condyle where SGT muscles insert.

6) False
- Help with movement at the ankle

7) The LATERAL menisus is more straight (compared to medial meniscus) ... to match the more straight up/down or ant/post femoral condyle.
- Medial
- Medial (it has more thicker cartilage - meniscus, and it's attached to more ligs and muscles to tear it)

8) It surrounds the meniscus, but it goes IN between the condyles from the posterior aspect and does NOT include the ACL or PCL, but then curves around them and back down to include both menisci.
- NO
- If you tear your ACL and it swells immediately, that means that lining was also damaged and now fluid and blood is getting into knee joint cavity.

9) It likewise covers the knee, but does NOT go up into intercondylar area. It covers the ACL and PCL as well.
- Anteriorly: Follows patellar lig down around tibial tuberosity, and then up above around the two condyles (it actually goes a little above condyles ... suprapatellar pouch).
- Area above femoral condyles where the capsule extends superiorly above patella
- BEHIND

10) Intercondylar eminence, intercondylar tubercles, intercondylar notch



11) Medial
- Medial

12) About 170-175 degrees
- Remember the femur comes off the hip at a slight angle. The width of the hips are wider than where knees are placed.
- Physiological Valgus
- Genu varus
- Genu valgus
- NO - that 170-175 degree angle is the NORM. Anything outside that becomes genu valgus/varus

13)
- >180
- <165
- Genu valgus
- Genu varus

14) Genu Recurvatum
- > 5 degrees of hyperextention

15) Measure the angle between the long axis of the Quads and the long axis of the patellar lig.
- Usually it is the same yes
- NO
- Males it is 5 degrees, and females it is 10 degrees
- One is 175 degrees, the other is 5 degrees

16) LATERALLY
- More lateral push of the patella.
- Anterior lip of the lateral femoral condyle (plus the obliqe part of vastus medialis, and medial patellar retinacular fibers)

78

Stability of the knee is provided by what:

1) What are the ANTERIOR reinforcements of the knee joint:

2) What are the POSTERIOR reinforcements of the knee joint:

3) What are the LATERAL reinforcements of the knee joint:

4) What are the MEDIAL reinforcements of the knee joint:

5) Is the medial or lateral collateral lig of the knee actually part of the jt capsule? Which is a capsular lig?

6) Which lig restricts valgus stress

7) Which lig restricts varus stress

8) What is the biggest contributor to supporting the lateral / posterior part of the knee jt capsule

Muscles, ligs, and the capsule

1) Quad tendon, patella, patellar lig, ant capsule, patellar retinacular ligs, portion of VMO, transverse lig of the knee


2) Gastrocs, hamstrings, arcuate lig, meniscofemoral lig, Popliteus muscle, oblique popliteal lig, post capsule


3) Popliteus muscle, oblique popliteal lig, biceps femoris, lateral collateral lig, IT band, lateral capsule

4) SGT, medial collateral lig, medial capsule

5) MEDIAL

6) Medial collateral lig of knee (tibial collateral lig)

7) Lateral collateral lig of knee (fibular collateral lig)

8) Popliteus muscle

79

1) ACL and PCL are named based on where they attach on the femur or tibia?
- So is ACL or PCL attached posteriorly on the tibia?

2) Which meniscus is smaller and more C shaped

3)
- Lig of Humphrey =
- Lig of Wrisberg =
- Which one runs ANTERIOR to the PCL
- Which one runs POSTERIOR to the PCL









4) Purpose of the menisci

5) Do they have a blood supply and heal? Why

6) What is the anterior lig of the knee jt that is connecting anterior portions of menisci

7) Is the distal / inferior (bottom) portion of the menisci that sits on the tibial plateau actually attached to the tibial plateau's cartilage?
- Where or how do menisci get anchored down?

8) Is the patella connected to the menisci?
- What is the name of the lig that attach the patella to the menisci?

9) Is the medial collateral lig of the knee attached to or part of the capsule?
- Is the MCL attached to the medial meniscus?
- Is the semimembranosus muscle attached to capsule?
- Is the semimembranosus muscle attached to medial meniscus?
- Is the popliteus muscle attached to capsule?
- Is the popliteus muscle attached to the meniscus? Which one?

1) TIBIA
- PCL


2) Lateral

3)
- Anterior meniscofemoral lig: ... small fibrous band of the knee joint. It arises from the posterior horn of the lateral meniscus and passes superiorly and medially in front of the posterior cruciate ligament to attach to the lateral surface of medial condyle of the femur.
- Posterior meniscofemoral lig: ... small fibrous band of the knee joint. It attaches to the posterior area of the lateral meniscus and crosses superiorly and medially behind the posterior cruciate ligament to attach to the medial condyle of the femur.
- L. of Humphrey (ant. to PCL)
- L. of Wrisberg (post. to PCL)

4) Shock absorption, reduce friction, and weight distribution (or distributes forces from femur through tibial plateau more evenly)

5) WELL - they are fibrocartilage, so no blood supply, but OUTER portions get blood supply from the capsule and surrounding ligs and muscles.

6) Transverse lig of the knee

7) NO
-The coronary ligaments of the knee are portions of the joint capsule which connect the lateral edges of the fibrocartilaginous menisci to the periphery of the tibial plateaus.

8) Yes (well ... via lig fibers)
- Meniscopatellar fibers

9) Yes
- Yes
- Yes
- Yes
- Yes
- Yes, lateral

80

1) Closed packed position of the knee is:

2) Open packed position of the knee is:

3) Stability of the MEDIAL knee (from anterior to central to posterior) part of the medial knee is supported by or stabilized by:
- Anterior:
- Central:
- Posterior:

4) Stability of the LATERAL knee (from anterior to central to posterior) part of the lateral knee is supported by or stabilized by:
- Anterior:
- Central:
- Posterior:

5) Stability of the ANTERIOR-POSTERIOR movement of the knee is supported by or stabilized by:







6)
- Where does ACL attach anteriorly?
- What direction does ACL go from it's anterior attachment point?
- Where does ACL attach posteriorly?
(HOW TO REMEMBER point above)
- Does ACL prevent tibia going anterior (with respect to femur) or femur going anterior (with respect to tibia):
- Does ACL prevent IR or ER of the tibia on femur
- Does ACL tighten on knee flexion or extension

6A)
- Where does PCL attach posteriorly?
- What direction does PCL go from it's posterior attachment point?
- Where does PCL attach anteriorly?
- Does PCL prevent tibia going anterior (with respect to femur) or femur going anterior (with respect to tibia):
- Does PCL tighten on knee flexion or extension
- Does PCL tighten on ER?

6C) TRY THIS: Put D3 forward and D2 down, and then place them both on top of your knee. D3 is ACL, and D2 is PCL
- Does ER wind or unwind the ACL and PCL?
- Does IR wind or unwind the ACL and PCL?

6D) Do the MCL and LCL of the knee help contribute to restricting IR and ER of the tibia with respect to the femur?

7) What is the 'drawer test' of the knee

1) Full extention

2) Slight flexion (about 25 degrees)

3)
- Anterior: Fibers from vastus medialis (VMO), sartorius, gracilis, media meniscopatellar lig
- Central: MCL,
- Posterior: Semimembranosus and semitendinosus tendons (and medial gastroc)


4)
- Anterior: Vastus lateralis, IT band, meniscopatellar lig
- Central: IT band, LCL, popliteus
- Posterior: Popliteus, Biceps femoris tendon



5)
- ACL
- PCL
- Quad tendon
- IT band
- Sartorius and gracilis
- Patellar ligament (and patella)
- Gastroc m's
- Popliteus
- Hamstring tendons

6)
- Anterior tibial plateau (in intercondylar eminence area)
- Superior, posterior, and laterally
- Medial aspect of the LATERAL femoral condyle
- Dr T's 2 fingers on knee trick
- Restricts anterior tibial gliding (or posterior femur gliding)
- Restricts IR of tibia on femur
- Extension

6A)
- Posterior tibial plateau (in intercondylar eminence area)
- Superior, anterior, medial
- Lateral aspect of medial condyle
- Prevents tibia going posterior (with respect to femur) or femur going anterior
- Flexion
- Not really. Just IR is when ACL goes taut


6C)
- Unwind
- Wind



6D) YES



7) Pushing ant or post on tibial plateau to get an idea of any laxity of ACL vs. PCL

81

1) How much AROM of the knee can you get:
- Knee flexion (with hip flexed)
- Knee flexion (with hip extended)
- Why is it less for knee flexion with hip extended
- Can you get more ROM with PROM?
- Typical hyperextension of the knee
- Can tibia / femur / knee joint do more IR or ER. WHY?
- Do you have any AB/ADduction at knee jt?

2) How much FLEXION ROM do you need for normal functional activities, like:
- Gait:
- Stairs:
- Sitting / Rising from a chair:
- In/Out of Bath:
- Full Squat:

3) A successful TKA recovered ROM for knee flexion is

4) AOR for the knee joint is:
- Is the AOR from point abaove the same point during the full ROM?
- We use what as the most accurate AOR to do goni measurments?

1)
- 140
- 120
- Quads are on stretch more
- Yes (about 160)
- 1-3 degrees
- ER (because ACL and PCL tighten during IR, and popliteus helps a little)
- A little (about 10 degrees)


2)
- Gait: 20 degrees during stance phase, 60 during swing phase
- Stairs: 90-100 degrees
- Sitting / Rising from a chair: 90 degrees
- In/Out of Bath: 130 degrees
- Full Squat: 160 degrees

3) 90 degrees

4) A pin through the femoral condyles
- NO, the joint is evolute, meaning the AOR changes throughout the ROM
- Lateral condyle of femur

82

1) For forces acting at the tibiofemoral joints, how much weight is passed through this joint during normal level walking?
- What about if you walk up stairs or a ramp/incline?

2) What is the "screw-home mechanism of the knee"
- T or F: Flexion and extension of the knee is always combined with relative internal and external rotation between the femur and the tibia.
- So when the tibia is free, knee flexion will produce IR or ER of tibia?
(HOW to rememeber)
- So when the tibia is free, knee extension will produce IR or ER of tibia?
- When tibia is fixed, knee flexion will produce IR or ER of femur?
- When tibia is fixed, knee extension will produce IR or ER of femur?
- So as tibia is free and fully extends, does it do slight IR or ER

3) So what does the politeus do?
- Explain how it does that
- Is it on slack or stretch during knee extension?
- If tibia is fixed, what will popliteus do?

1) 3x your body weight
- 5x body weight



2) When the knee gets screwed into it's locked (close packed) position.
- True
- IR
(3 muscles medially pull into IR, vs 1 laterally pulls ER)
- ER
- ER
- IR
- ER







3) UNlocks the knee (unlocks femur when tibia is fixed, and unlocks tibia when tibia is free)
- It attaches proximally on lateral aspect of knee, and goes down to posterior part of proximal tibia. So if it contracts, it slightly pulls tibia (from behind) into IR to unlock the knee. OR if tibia is fixed, it pulls femur into ER to unlock it.
- Stretch
- Move femur into slight ER to unlock the knee

83

1) Do the menisci move?
- So in full extension where are menisci
- In full flexion are the menisci more anterior or posterior on tibial plateau (if tibia is fixed)
- If the tibia does ER, will the medial meniscus move anterior or posterior?
- If the tibia does ER, will the lateral meniscus move anterior or posterior?

2) T or F: The femoral condyles are like your fingers, and they sit in these menisci that are "washers" that move as your fingers move?

3) Which meniscus gets damaged or injured more, and why?

4) What is a terrible triad?
- Would someone be hit from medial or lateral side to cause this?

5) What are the 4 bursa associated WITH the knee jt capsule
- Which of these is the BIG bursa of the knee?

6) What are some other bursa associated with the knee jt. but NOT part of the capsule







7) Can you feel / palpate bursa?

8)
- If you do full knee extension, will the posterior capsule be slack or pulled tight?
- What happens to inter-capsular fluid during extension?
- If you do full knee flexion, will the posterior capsule be slack or pulled tight?
- What happens to inter-capsular fluid during flexion?

1) YES
- More anterior
- The menisci move posterior
- Posterior
- Anterior




2) TRUE



3) Medial. It gets entraped since it is bigger, and it attaches to MCL, so it can get torn easier. It bears more weight/force.

4) Torn MCL (of knee), one of the meniscus, torn ACL (could be medial or lateral meniscus) ***
- Lateral

5)
- Suprapatellar bursa (below quad tendon, above femur)
- Gastrocnemius bursa
- Semimembranosus bursa
- Politeus bursa (under popliteus)
- Suprapatellar bursa

6)
- Prepatellar bursa (superficial to patella beneathe skin)
- Infrapatellar bursa (superficial, above patellar lig, just above tibial tuberosity)
- Deep infrapatellar bursa (below patellar lig between lig and bone)
- Pes Anserine bursa

7) NO

8)
- Pulled tight
- Gets shoved anteriorly
- More slack than extension, but mid flexion is where open pack position is.
- Gets shoved posteriorly

84

1) Do knees have fat pads?
- What is the purpose of fat pads





2) What are the 4 fat pads of the knee

1) YES
- The knee capsule is really big (43 sq inches). So the fat lies beneath the skin, but above capsule. It pushes capsule down to minimize the space / reduce joint volume (otherwise you'd have huge space full of synovial fluid). It also gives a bit more structure/support.

2)
- Anterior Suprapatellar fat pad
- Posterior Suprapatellar fat pad
- Infrapatellar fat pad
- Popliteal fat pad

85

1) During a Terrible Triad, does medial or lateral meniscus get torn more

2) But in general, what meniscus gets damaged or injured more often?
- Why

3) How are the menisci attached to the tibial plateau?
- Where are those lig's located?
- T or F: The coronary lig is an extention of the knee jt capsule

4) Do the menisci get a blood supply? Explain
- So middle portions of the menisci (and thus articular cartilage in the inter-capsular space) is nourished by:

5) Talk about how menisci heal / repair

6) How do we as PT's help with meniscal healing?
- Will the menisci, after being torn, ever get back to 100%




7) Can you palpate coronary lig to assess a tear? Where?

1) It is a toss up


2) Medial
- It gets put on stress during ER as it rotates posterior ... AND, it is attached to the medial collateral lig, so can tear easier.

3) Coronary ligs
- OUTside borders
- True

4) The outside borders do (since they but up to the capsule), but the INSIDE part of the menisci do NOT get a blood supply.
- Synovial fluid

5) The outer portions (that have a blood supply) can most likely repair. The inner portions do not get a blood supply, so they often do NOT repair.

6) At first, have pt stay OFF of it and not do weight bearing, to allow fibroblasts to repair as much as possible. Then help strengthen ROM and strength. Maintain movement to generate synovial fluid to nourish it.
- The menisci will never fully recover and be the same.

7) You can anterolaterally (just lateral to patella lig on both sides). But both medially and posteriorly they are burried behind lots of other tissue.

86

1) T or F: The patella is a sesamoid bone?

2) What is the purpose / function of the patella

3) Where does it articulate?

4) T or F: Inside the patella is filled with cancellous bone

5) TOP (superior) portion is called _______, and bottom (inferior) portion is called _______
- That is just like what other bone?

6) Looking at the posterior side of the patella, which side has the larger or more broad facet? Why?
- How are the medial and lateral facets seperated, by what?

7) How is the medial facet subdivided

8) T or F: The patella is in contact with the femur during full ROM of the knee jt

9)
- If you flex the knee, which way does the patella move?
- If you extend the knee, which way does the patella move?

10) Looking sagittally at the knee, the length of the patella (from sup to inferior), compared with the length of the patellar tendon ... that ratio should be?
- What does that ratio mean?
- If the patella is too high (meaning the patellar lig is long), that is called:
- If the patella is too low (meaning the patellar lig is short), that is called:
- The ratio for a patella alta (a/b ratio) =
- The ratio for a patella baja (a/b ratio) =
- What is wrong with both, or what results?

1) True

2) Increase lever arm of the quad tendon (and protect anterior knee jt)

3) Patellar sulcus / groove of femur

4) True

5) Base, Apex
- Sacrum

6) Lateral. The lateral condyle of the knee is larger and is the lip to hold patella in place.
- A central ridge

7) Most of it is the medial facet, but on medial side is the 'odd facet' (which is very small)

8) 90% of the time it does articulate with the femur, except right at the end of full extension (top part).

9)
- Flexion: down
- Extension: up

10) 1
- The length of patella (from sup to inf) is SAME length of patellar lig.
- Patella Alta
- Patella Baja
- < 0.8
- > 1.2
- A patella alta means patella is too high above femoral groove, so it can "jump the track" and dislocate. The patella baja means it is deep in the sulcus so it won't dislocate, but it will take more force/weight.

87

1) What is the 'sulcus angle' of the knee


2) What is the 'patellar tilt' angle of the knee





3) If someone has an anteverted hip, what will they do with femur to compansate:
- How will this impact the knee?

4) Would the patella be deeper / lower in femoral patellar groove during 20 degrees of knee flexion of 130 degrees of knee flexion?

5) What is 'patellar tracking'
- Patella goes UP or DOWN during extension?
- During full flexion does the patella slide over to cover more of the lateral or medial condyle?

6) If knee is flexed to 20 degrees, would the base or the apex of the patella be articulating with the femur in the femoral groove
- During knee flexion, the smallest contact of the patella with the femur occurs at approximately ____ degrees (often just the _____ facet and proximal portion of the_____ facet is in contact with femoral groove)
- The greatest contact of the patella with the femur occurs between _______ degrees
- T or F: The odd facet is in contact with the femur during full ROM of knee movement

7) What is PLICA of the knee
- If plica get inflammed or injured, what happens?

1) From the tip of the anterior medial condyle, to the lowest point in the sulcus, back up to the anterior/highest point of lateral condyle. It is the angle of the sulcus of the knee.

2) Draw a line from the anterior tip of the lateral condyle and draw line down to anterior tip of the medial condyle (remembering lateral protrudes out anteriorly more), then draw a line horizontal / transverse through max width of patella.

3) IR
- Decrease Q angle, and press patella laterally against the lateral condyle within the sulcus.

4) 130 degrees


5) How patella glides and moves during flexion/extension of the knee.
- UP
- Lateral condyle

6) Apex
- 135
- Odd, lateral
- 60-90
- False - only during extreme flexion


7) Plica is a term used to describe when the joint capsule of the knee fold and unfold. Imagine the inner lining of the knee joint as nothing more than a sleeve of tissue. This sleeve of tissue is made up of synovial tissue, a thin, slippery material that lines all joints. Just as a tailor leaves extra folds of material at the back of sleeves on a shirt to allow for unrestricted motion of the arms, the synovial sleeve of tissue has folds of material that allow movement of the bones of the joint without restriction.
- They inflame and scar, then when two bands fold onto each other they scar together, which reduces flexibility and volume of jt capsule, so then it hardens and pushes the patella laterally (since the plica are MEDIAL and sup/inf to patella).

88

1) Can the patella get dislocated?
- If so, which way will it most often get dislocated?
- If it does dislocate, can you just push it back into place?
- Why would you NOT want to do that

2) Does the force pulling up on the patella align with the alignment of the patellar lig?
- What is this force angle called?
- Why is Q angle important to know regarding the patella

2A) What else contributes to LATERAL pull of the patella besides quad force

3) So what 3 things stop the patella from too much lateral pull and dislocating?

4)
- What amount of the body weight (force) is acting on patellofemoral jt during normal level walking?
- What amount of the body weight (force) is acting on patellofemoral jt during going up stairs?

1) Yes
- Laterally
- Technically, yes (and you could do this with any dislocated joint and shove it back into place)
- Shoving it back into place could tear cartilage (which doesn't heal) then you've created another problem.

2) NO
- Q angle
- Its pull is natrually laterally, which could dislocate patella out of the groove.

2A) IT band, and lateral patellar retinacular fibers

3)
- the higher (protruding) lateral lip of the lateral condyle of the femur
- the pull of the vastus medialis muscle (oblique portion)
- the medial patellar retinacular fibers

4)
- 1/2 body weight
- 3.3 times body weight

89

1) In the popliteal space we have the politeal artery. How and where does that artery descend and become?
- Ant tibial artery becomes:
- Where would you palpate the dorsalis pedis and post. tibial a.

2) In popliteal fossa, the sciatic nerve splits to become:

3) Why is the infrapatellar nerve so important to know about:
- It is a branch of what nerve
- Can a nerve grow back

1) It splits just above interosseous membrane between tibia and fibula to become both ant and post tibial arteries.
- Dorsalis pedis a.
- Top (dorsal) of foot, and medial malleolus


2) Tibial n. posteriorly and then common fibular nerve splits laterally to become superficial and deep fibular n.

3) This area is often an entry point for a scope into the knee, so it is often cut and that area loses sensation.
- Saphenous n
- It is possible. It's a 50/50 ... it has to find the distal portion and regrow/connect between. A high chance it won't.

90

1) Thinking of the knee extensors (quads), how much torque is generated at these degrees of knee flexion:
- 15 degrees:
- 60-70 degrees:
- 90 degrees:
- 140 degrees:

2) The rectus femoris only makes up about what % of the quad mass:

3) What would be better to strengthen (or test strength) the rectus femoris, and why ... do knee extension with no hip flexion, or do knee extension without hip flexion

4) If you have a tight rectus femoris and want to stretch it, would you want to keep femur straight down or abduct femur out? Why?

5) If you have weak quad muscles, why is bending down lower (into a chair or a squat) even harder to flex and contract those muscles (to come out of a chair or a deeper squat?
- So how can you help a pt with this problem?

6) T or F: Tight quad muscles cause patellar tracking and Q angle issues?

- 15 degrees: small
- 60-70 degrees: MOST
- 90 degrees: average
- 140 degrees: little



2) 15%


3) You want to do knee extension WITH hip flexion since the RF is a 2 joint muscle. Just doing knee extension with NO hip flexion doesn't really strengthen RF muscle.

4) Keeping the femur straight down when stretching the RF puts more stretch on it. People naturally compensate by abducting leg out which gives more slack. So people should NOT abduct, but keep femur pointing straight down.

5) The lower you go, the larger the lever arm, so the harder to overcome with enough force.
- Teach them to sit on chairs that don't require 90 degree knee flexion, get a stool to prop them up.

6) True

91

1) Is the gastroc a knee flexor?

2) What is the main one joint knee flexor
- This muscle's main function is to:

3) Do the medial or lateral hamstrings interact with and rub up against jt capsule of the knee

4) T or F: Regarding SECONDARY actions, the medial hamstrings can also ADduct hip and medially rotate, and lateral hamstrings can ADduct hip and laterally rotate

5) What do hamstrings do eccentrically to control movement

6) What essentially controls the placement of the tibia during gait
- So weak hamstrings =
- Also, if you are running and have weak hamstrings, what is another issue you'd run into?

7) Why would you want to contract the hamstrings WITH contracting quads during an ACL / meniscus injury




8) If someone has significant posterior pelvic tilt, it might indicate what issue:

1) Yes

2) Popliteus
- UNLOCK the knee.

3) Medial


4) True



5) Prevent pelvis (trunk) from too much flexion, prevent too quick of knee extension, and slow down tibia during running, pull tibia back when walking/running.


6) Hamstrings (medial and lateral) to do slight ER and IR to keep tibia aligned
- Unable to extend hip and flex knee yes, but also unable to rotate and control tibia.
- Unable to deccelerate tibia before hitting the ground (eccentric contraction).

7) To limit the shearing force of femur sliding on tibia. Contracting hamstrings counteracts the shearing on meniscus to limit shear force.
- PEOPLE typically can use a machine to do this. Instead of contracting both quads and hamstrings (which your body naturally wants to shut hamstrings down when quads contract), you use a machine that as quads push against it, machine pushes back.

8) Tight hamstrings

92

1) Will popliteus unlock the femur from the tibia during open or closed chain?

2) Which muscle is a supplemental PCL

3) What is the tailors muscle

4) Would the Pes Anserine limit varus or valgus stress
- So, essentially the Pes Anserine can act as a back up

5) What is the knee flexor / extensor muscle balance (ratio or amount of force each muscle group takes relative to the other):
- What does that mean?

1) Closed


2) Popliteus

3) Sartorius (tailor sitting position)

4) Valgus
- MCL of the knee

5) .45 / .65 (hams/quads)
- QUADS are stronger than hamstrings