Hip/Knee Mechanisms 10/22

Question 1

Flexors of hip (which 5?) Where does Psoas Major inser? whats its innervation?

Answer 1

• Include psoas major, iliacus, pectineus, rectus femoris and sartorius muscles

**Psoas Major Muscle: **

• Originates on the sides of T12-L5 vertebrae, associated intervertebral disks and the transverse processes of L1-L5
  Inserts into lesser trochanter of femur
• Innervated by lumbar nn. L1,2,3
• Dysfunction of this muscle frequently seen with low back pain and hip problems
• Increased tension limits hip extension
• Commonly tight with low back pain
  Pain can be referred to the anterior hip or thigh

Question 2

Hip Ligaments

Answer 2

Iliofemoral ligament (Y ligament)

Ishiofemoral ligament

Ligamentum teres capitis femoris

• these ligaments help guide and limit hip motion - can become stretched/lax with improper use
• Dislocation of the hip damages the joint capsule, ligaments and blood supply and may result in the development of avascular necrosis of the head of the femur

Question 3

Extensor muscles? Gluteus Maximus? Innervation and Insertion/Origin?

Answer 3

• Gluteus Maximus, hamstring muscles (semitendinosus, semimembranosus and biceps femoris)
• if these muscles are tense they will frequently limit hip flexion

**Gluteus Maximus muscle: **

• Origin is widespread and includes posterior gluteal line of ilium, iliac crest, aponeurosis of erector spinae, sacrum and coccyx, sacrotuberous ligament and fascia covering gluteus medius
• Insert into iliotibial tract of fascia latae
• Innervated by L5, S1 and S2 (inferior gluteal nerve)
• May become weak and inhibited with prolonged sitting and sedentary lifestyle and may need to be strengthened with rehabilitative exercises

Question 4

Abductors of Hip? Gluteus Medius? Dysfunction of what is commonly seen with lateral hip and lateral knee pain?

Answer 4

Include gluteus medius and minimus, tensor fascia lata and sartorius muscles

Dysfunction of tensor fascia lata frequently seen with lateral hip and lateral knee pain

Gluteus medius muscle

• Originates on the upper outer ilium
• Inserts into greater trochanter
• Innervated by L5 and S1 (superior gluteal nerve)

Question 5

Adductors of hip? Adductor longus muscle?

Answer 5

Include adductors longus, brevis and magnus, obturator externus and gracilis muscles

Adductor longus muscle

• Originates on anterior aspect of pubis
• Inserts into middle third of femur
• Innervated by L2, L3 and L4 (obturator nerve)
• tightness frequently results in an inferior pubc symphysis shear (dysfunction of symphsis pubis)
• freq. seen with persisten groin pulls

Question 6

Internal rotators of hip? gluteus minimus?

Answer 6

Include tensor fascia lata, gluteus minimus and medius muscles

Gluteus minimus

• Originates from outer surface of ilium and greater sciatic notch
• Inserts into greater trochanter
• Innervated by L5 and S1 (superior gluteal nerve)

Question 7

External rotators of hip? Piriformis muscle?

Answer 7

Include obturators, gemelli, quadratus femoris, gluteus maximus, sartorius and piriformis muscles

Piriformis:

• Originates on anterior surface of sacrum, gluteal surface of ilium, capsule of sacroiliac joint and sometimes sacroiliac and sacrotuberous ligaments
• Inserts into greater trochanter of femur
• Innervated by S1 and S2
• Tightness will decrease hip internal rotation and may irritate the sciatic nerve

Question 8

What is hip dysfunction frequently assosiated with?

Answer 8

• Frequently associated with decreased hip extension due to psoas major muscle tension and decreased internal rotation due to piriformis muscle tension.

Question 9

Signs of torn acetabular labrum?

Answer 9

sharp, deep pain in the anterior thigh and/or groin.

Worsens when rising from a seated to standing position. May also “click” with motion.

Suspect injury to this with hip injuries that are nonresponsive to conservative treatment

Best imaged with MRI

• will need surgery if nonresponsive to conservative care!

Question 10

What is the first motion lost with intraarticular hip problems?

Answer 10

With intraarticular hip problems (fracture or degenerative joint disease), the first motion lost is typically internal rotation!

Question 11

What are major motions of knee? What glide is internal rotation? external rotation?

Answer 11

• flexion and extension
• minor fliding motions of tibial plateau
• Anterior/posterior gliding
• Medial/lateral gliding
• Internal rotation with posterolateral gliding
• External rotation with anteromedial gliding

Question 12

Why does knee passively lock during full extension?

Answer 12

due to medial rotation of the femoral condyles on the tibial plateau

Question 13

Knee ligaments?

Answer 13

Anterior cruciate ligament (ACL) - anterior drawer test, lachman test

Posterior cruciate ligament (PCL) - posterior drawer test

Medial collateral ligament (MCL)-

• Valgus test: move ankle laterally, knee medially - laxity indicates injury

Lateral collateral ligament (LCL)

• Varus Test: move knee laterally, ankle medially - laxity indicates injury

grade 1 and 2 (partial tears) are treated with OMM/rehab

complete tears, grade 3, require surgical repair/reconstruction

Question 14

Menisci? what may indicate a severe tear? what indicates a lateral/medial tear?

Answer 14

Crescent-shaped plates of fibrocartilage found on the articular surface of the tibia

• provide some stability
• play role in shock absorption
• provide proprioceptive feedback regarding joint motion
• Outer 1/3 – vascular and more likely to heal
• Inner 1/3 – avascular and less likely to heal

Joint locking may indicate a very significant meniscal tear and is an indication for an MRI and probable surgery. You can have a less severe meniscal tear without joint locking!

Lateral joint line tenderness or palpable tissue texture changes may indicate a lateral meniscal tear

Medial joint line tenderness or tissue texture changes may indicate a medial meniscal tear

Tenderness in the popliteal fossa may indicate a tear of the posterior horn of either meniscus

Question 15

What are some PCM tests for Meniscal tears?

Answer 15

Thessalys test: have patient do rotation while standing, creating grind on menismus * most sensitive *

McMurrays test: internal and external rotation of knee while joint is flexed

Question 16

“Terrible Triad”

Answer 16

unhappy triad or O’Donoghue’s triad

injury to the anterior cruciate ligament, medial collateral ligament and medial meniscus

Question 17

What are flexors of the knee? biceps femoris muscle?

Answer 17

Include biceps femoris, semimembranosus, semitendinosus, popliteus (also functions as a dynamic tensioner of lateral meniscus) and gastrocnemius muscles

• dysfunction of these muscles may be associated with **posterior knee pain **

**Biceps Femoris Muscle: **

• Originates on ischial tuberosity, sacrotuberous ligament and femur
• Inserts into fibular head, lateral collateral ligament and lateral condyle of tibia
• Innervated by L5, S1 and S2 (sciatic nerve)

Question 18

What are major extensors of the knee? Where will pain be associated with? Rectus Femoris? What will limit flexion/extension?

Answer 18

Include the rectus femoris, vastus lateralis, vastus medialis, vastus intermedius

Dysfunction may be associated with anterior knee pain

Rectus femoris?

• Originates on anterior inferior iliac spine, groove above acetabulum and capsule of hip joint
• Inserts into base of patella (and ultimately tibial tuberosity via patellar tendon)
• Innervated by L2, L3 and L4 (femoral nerve)

Excessive tension (tightness) in the knee flexors will limit knee extension

Excessive tension (tightness) in the knee extensors will limit knee flexion

Question 19

Proximal tibiofibular joint: what are two types of gliding? how is fibular head associated with the malleolus? what attaches to fibular head? What strain results in restriction of fibular head? what nerve runs near fibular head (damage to this nerve)?

Answer 19

Allows for anterolateral and posteromedial gliding of the fibular head

Fibular head moves in combination with lateral malleolus

• When the fibular head glides anteriorly, the lateral malleolus glides posteriorly
• When fibular head glides posteriorly, the lateral malleolus glides anteriorly

Inversion ankle sprains may result in restriction of the lateral malleolus and fibular head (covered later)

• the lateral collateral ligament and lateral hamstring muscle (biceps femoris) attaches to fibular head
• Frequently find fibular head restrictions with hamstring strains and injuries to the lateral collateral ligament
• If a fibular head restriction persists despite treatment, may be associated with injury to lateral meniscus
• restriction of the tibiofibular joint – produces lateral knee pain
• The common peroneal (common fibular) nerve runs near the fibular head
• A posterior fibular head may affect the function of this nerve and contribute to foot drop

Question 20

What is the arterial supply to the lower extremity? lower extremity venous drainage?

Answer 20

femoral a.

Any somatic dysfunction affecting the femoral triangle and/or subsequent fascial restriction associated with somatic dysfunction of the lumbar spine, innominates, sacrum and lower extremities can reduce arterial supply to lower extremity

• venous drainage through femoral v. also courses through femoral triangle.

Question 21

Where is lymphatic drainage of the lower extremity?

Answer 21

• The majority courses through the superficial and deep inguinal nodes in route ultimately to the left lymphatic (thoracic) duct
• Tension affecting the various functional diaphragms (popliteal, pelvic, respiratory and thoracic inlet) impairs lymphatic drainage
• The various diaphragms must work in synchrony!

Question 22

Sympathetic innervation of Hip/Knee?

Answer 22

Cell bodies of preganglionic neurons concerned with the lower extremity are located T10-L3 (NBOME)

• Smooth muscle in walls of lymphatic vessels contract when sympathetic nerves are stimulated
• Reduces size of lumen, thereby impairing lymphatic drainage

**Somatic dysfunction at the thoracolumbar junction increases sympathetic tone to lower extremity **

• results in decreased lymphatic drainage
• may result in increased swelling within the lower extremity, impairing function and recovery

Question 23

CS points with hip inuries? knee injuries?

Answer 23

• hip injuries/trochanteric bursitis: lateral trochanter tender point
• knee injuries: medial and lateral meniscal tender points

Question 24

What are the minor motions of the hip/knee?

Answer 24

External rotation of the hip creates anterior glid of the femoral head in the acetabulum

internal rotation creates posterior glide

Question 25

minor motions of the knee?

Answer 25

flexion creates an anterior glide of the tibia on the femur extension creates posterior glide of the tibia on femur - medial glide can be induced with valgus pressure to joint sapce, lateral glide can be induced with varus pressure to the joint space **- External rotation of leg: anteromedial glide of the tibial plateau (turning foot laterally)** **- Internal rotation of leg: posteriorlateral glide (turning foot medially)**

Question 26

Minor motions of fibula?

Answer 26

superior portion: fibular head; distal portion: lateral malleolus - motion of fibular head and lateral malleolus are reciprocal: anterior and posterior External rotation of tibia: * lateral malleolus: posterior * fibular head: anterior glide Internal rotation of tibia: * lateral malleolus: anterior * fibular head: posterior - if fibular head or lateral malleolus are restricted - there is a good chance that the interosseous membrane is affected.

Question 27

Minor motions of ankle (tibiotalar)? subtala/talocalcaneal joint?

Answer 27

posterior glide with dorsiflexion anterior glide with plantar flexion - asymmetric movment indicates somatic dysfunction of the tibiotalar joint - Note: the achilles tendon can also restrict dorsiflexion of the ankle Taocalcaneal joint: inversion and eversion

Question 28

Inversion ankle sprain cascade

Answer 28

inversion = lateral malleolus moves anterior, pushing fibular head posteriorly = tibia externally rotates= femur internally rotatesipsilateral innominate rotates anteriorly, sacrum goes into forward torsion toward the ankle that was sprained i.e. a right inversion ankle sprain usually results in a right on right torsion of the sacrum

Question 29

Tenderpoints? Iliacus/Psoas? Piriformis?

Answer 29

Iliacus/Psoas: near sacrum in internal portion of the pelvis * 1 inch medial to ASIS, patient in supine, legs flexed to 90 degrees, sedebend and internally rotate towards TP. Piriformis: posterior pelvic bone - near middle butt. * 8-9cm medial and slightly superior to greater trochanter, pateitn prone, flex affected leg to 135 degress, abduction, internal/external rotation

Question 30

ACL/MCL TP's

Answer 30

ACL tenderpoints: * on lateral/ posterior epicondyles: distal aspect of the biceps femoris tendons bilaterally: * initial position - posterior pressure on proximal tibia. * Muscles involved: biceps femoris, ACL PCL tenderpoint: * in middle of epicondyles: midline in popliteal fossa * initial position: posterior pressure on distal femur * Involved muscles: biceps femoris, PCL

Question 31

Lateral trochanter TP

Answer 31

supine or prone abduction and slight flexion of the thigh, involves IT band

Question 32

TP for

Question 33

Medial/Lateral Meniscus TPs

Answer 33

Lateral meniscus: * anterior, lateral: lateral aspect of knee along joint line * initial position: slight knee flexion, slight abduction of thigh, external rotation of tibia * Muscles: IT band, possible LCL Medial meniscus: * anterior, medial: medial aspect of knee along joint line * Initial position: knee flexed to 40 degrees, abduction/adduction, and internal/external rotation of the thig as needed * Involved muscles: Pes anserinous muslces (sartorius, gracillis, semitendenosus) possibly MCL

Question 34

HVLA/MET for anterior fibular head

Answer 34

quick thrust posteriorly directed with cephalad hand from thenar eminence, while caudal hand provides a slight internal rotational counterforce to the ankle MET: posterior malleolus, prefers external rotation. Engage feather boundary by internally rotating the patient's ankle while applying posterior force on the fibular head.

Question 35

HVLA/MET for posterior fibular head

Answer 35

externally rotate lower leg, and move fibular head anteriorly final corrective force is a quick, flexing of the knee with caudal hand against the pressure of your index finger MET: posterior fibular head = anterior malleolus = likes internal rotaton engage feather boundary by externally rotating the patients ankle, with flexed knee, and applying anterior force on fibular head.

Question 36

HVLA for posterior Talus and Anterior Talus

Answer 36

Posterior Talus: likes dorsiflexion, doesn't like plantar flexion: provide force thurst down posteriorly on tibia, while pulling ankle anteriorly Anterior Talus: likes plantar flexion, doesn't like dorsiflexion: provide quick J motion: while pulling the foot inferiorly while increasing dorsiflexion

Question 37

MET for externally rotated tibias

Answer 37

prefers external rotation, and anteromedial glide To treat provide internal rotation and induce posterolateral glide

Question 38

MET for internally rotated tibias

Answer 38

prefers internal rotation and posteriolateral induce external rotation and medial/posterior glide of proximal tibia instruct patient to internally rotate leg