Hip, Thigh, and Knee

ILIUM

Acetabulum

Pubis Ischium Ischial Tuberosity

Greater Trochanter Lesser Trochanter Medial Condyle Lateral Condyle

Lateral Condyle Patella

Anterior Cruciate Ligament Posterior Cruciate Ligament

Medial Meniscus Lateral Collateral Ligament Lateral Meniscus Medial Collateral Ligament

Anatomy Buttocks Gluteus Medius, Minimus, Maximus Piriformis

Anatomy Hip Flexors Psoas Major, Minor Iliacus

Anatomy Quadriceps Rectus femoris Vastus lateralis Vastus medialis Vastus intermedius Abductor Complex Sartorius Tensor Fascia Lata Hamstrings Semimembranosus Semitendinosus Biceps femoris Adductor Complex Adductor Brevis Longus Magnus Gracilis

Quadriceps Rectus Femoris O: Anterior inferior iliac spine I: Patella and Tibial Tuberosity A: flexion of hip, knee extension

Vastus Lateralis O: greater trochanter I: lateral patella, lateral femoral condyle and rectus femoris tendon A: extension of knee

Quadriceps Vastus Intermedius O: proximal 2/3 of anterior femur I: inferior aspect of patella and tendons of vastus lateralis and medialis A: extension of knee

Vastus Medialis O: Between the Greater and Lesser Trochanter I: medial tibial condyle, medial patella and medial aspect of rectus femoris tendon A: extension of knee Vastus Medialis Oblique O: Tendon of Adductor Magnus I: Patellar Tendon/ Tibial Tuberosity A: stabilize patella

ABductors Sartorius Tensor Fascia Latae O: Anterior superior iliac spine I: inferior to medial condyle of tibial A: Flexion, Abduction, and External Rotation of hip; flexion of knee, Tensor Fascia Latae O: Outer lip of iliac crest and between anterior superior and anterior inferior iliac spine I: Greater trochanter of femur, and (as iliotibial band) lateral condyle of tibia A: Abduction

Adductors Adductor Longus Brevis Magnus O: pubic bone I: Middle 1/3 of Femur A: adduction Brevis I: proximal 1/3 of femur Magnus O: pubic bone and ischial Tuberosity I: distal 1/3 of femur

Adductors Gracilis O: pubic symphisis and pubic bone I: distal to medial tibial condyle A: adduction, flexion, and internal rotation of hip, flexion of knee; (Cross legs)

Iliopsoas O: Thorasic and Lumbar Vertebrae (front of spine) and Ilium I: Lesser Trochanter A: Flexion of hip

Hamstrings Biceps Femoris O: ischial Tuberosity I: head of fibula and lateral tibial condyle A: extension of hip; flexion of knee

Hamstrings Semimembranosus Semitendinosus O: ischial Tuberosity I: medial tibial condyle A: hip extension, knee flexion Semitendinosus I: medial condyle of tibia A: hip extension, knee flexion M T

T M

Gluteuses Gluteus Minimus Gluteus Medius O: Ilium I: Anterior Greater Trochanter A: Abducts and Internal Rotation Gluteus Medius I: Lateral Greater Trochanter A: Abduction and Internal Rotation

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

Hip/Thigh Movements Abduction Adduction Extension Flexion Internal Rotation External Rotation What muscles do these movements?

Palpation Hip ASIS Soft Tissue Iliac Crests IT Band PSIS Greater Trochanter Soft Tissue IT Band

What muscles do these movements? List out the muscles that do each movement: Abduction Adduction Hip Flexion Hip Extension External Rotation

Observation Symmetry- hips, pelvis tilt (anterior/posterior) Lordosis or flat back Lower limb alignment Knees, patella, feet Genu Valgum/ Genu Varum Pelvic landmarks (ASIS, PSIS, iliac crest) Standing on one leg Pubic symphysis pain or drop on one side Ambulation Walking, sitting - pain will result in movement distortion

Observation Anteversion (A) and Retroversion (B) Think in terms of the Greater Trochanter

Observation Leg Length Discrepancy Anatomical Functional Actual bone length difference Functional Rotation of pelvis Muscle tightness 1/8 inch or greater = discrepancy

Special Tests Fracture Range of Motion Passive Active Resistive

Thigh Injuries Quadriceps Contusion Mechanism Symptoms Treatment Blow to quads. Symptoms Pain Swelling Bruising Loss of function Treatment RICE Ice bent position

The red is hemorrhaging within the compartment Increased swelling = Increased pressure = decreased healing/ function If hemorrhage gets too large will have to do a compartment release which is done by cutting the fascia to allow the expansion

Thigh Injuries Myositis Ossificans Myo= muscle itis = irritation oss = bone Mechanism Blow to thigh  Hemorrhage  hematoma Symptoms Pain - Hard “bump” Musc weakness - Swelling Loss of function Treatment At first can use Ultrasound Surgical Removal

Practice it! Quad Compression Wrap Start slightly above patella Begin just like all other ACE wrapping techniques. Continue up the thigh halfway overlapping alternating angling up and angling down. Practice it!

Thigh Injuries Hamstring Strain Mechanism Overloading of HS muscles Over stretching Symptoms Pain - swelling - G2 or 3 = palpate deformity Loss of function - “popping” Treatment RIC ROM stretching Compression wrap same as Quad Contusion

Hip Injuries Groin Strain Symptoms Treatment Straining of Adductors Over stretching of the muscle Symptoms Pain in medial hip Pain referred to knee Treatment RIC - light stretching NSAIDs - Strengthening ROM exercises - Compression wrap

Groin wrap Start with roll on lateral side of leg Start ACE at an angle 2 times around with “dog ear” Apply extra tension going medially as to pull the leg into ADduction. Continue your spica until out of wrap. - Athlete should fee leg being pulled in and slightly forward. ****Anytime doing a hip wrap you will pull in the direction that the injured muscles does.

Hip Flexor Strain Rectus Femoris/ Iliopsoas Strain Often due to explosive activities (sprinting) Symptoms “Pop” - Loss of function Pain Treatment Light stretches - rest Compression wrap pulling forward strengthening

Hip Special Tests Kendall / Thomas test Positioning Test Positive Athlete lies supine with ½ of femur off the table Test Athlete hugs opposite knee to chest Positive Knee Extends = Rectus Femoris tightness Hip Flexes = Hip Flexor Contracture

Hip Injuries Contusion (Hip Pointer) Mechanism Symptoms Treatment Blow to iliac Symptoms Bruising Pain Loss of function Treatment RICE

IT Band IT Band Tendonitis Mechanism Symptoms Treatment Repetitive friction over greater trochanter or lateral femoral condyle Pes cavus, Genu varum Symptoms pain at greater trochanter or lateral femoral condyle Positive Ober and Nobles tests Treatment Stretch tendon - Ice Strengthen Abductors - Rest

IT Band Tightness Noble’s Test Position – Test – Positive – athlete supine athlete’s knee is flexed to 90 degrees Test – Pressure is applied to lateral femoral condyle while knee is extended Positive – Pain at lateral femoral condyle IT Band Tendinitis

IT Band Tightness Ober’s Position Test Positive Athlete is lying on side opposite of affected side Tester is behind the athlete at the hip Test Tester holds ankle and knee (flexed to 90) Tester allows knee to adduct. Positive Pain or tightness No drop of the knee

Gluteus Medius and Adductor Weakness *Weakness in these muscle groups can lead to IT band tendonitis, bursitis, and other hip problems. Trendelenburg Position Patient stands with feet together Test Tester stands behind the athlete Athlete lifts knee as to march Positive Drop in the non weight bearing side PSIS/ Iliac Crest

Hip Injuries Trochanteric Bursitis Cause Symptoms Special Test Excessive repetitive irritation at Greater Trochanter Symptoms Hip instability Snapping sensation Pain/ inability to walk Treatment ICE - Stretching NSAIDs - Strengthening Ultrasound (not the kind you see a baby with) Compression wrap Special Test - Range of Motion reproduces the pain

Hip Injuries Dislocated Hip Mechanism Signs and Symptoms Special Tests Result of traumatic force Signs and Symptoms Flexed, adducted and internally rotated hip Palpation reveals displaced femoral head posteriorly Other Soft tissue, neurological damage and possible fx Special Tests none Management EMERGENCY ROOM! 2 weeks immobilization and crutch use for at least one month

Knee Observation Patellar positioning Knee Positioning Swelling Alta Baja Knee Positioning Genu varum Genu valgum Genu Recurvatum Swelling Intracapsular Extracapsular

Observation Patella Alta Patella Baja High Patella Low Patella – tight quad muscles, places extra stress on patellar tendon, causes extra friction on Femoral condyles Patella Baja Low Patella – shorter patellar tendon,

Soft Tissue of the Knee

Observation Genu Varum Genu Valgum Genu Recuvatum Bow legged Stresses lateral structures Genu Valgum Knock kneed Stresses medial structures Genu Recuvatum Hyper-extended knees

Meniscus and Ligaments

Palpation Knee Soft Tissue Medial and Lateral Condyle Tibial Tuberosity Patella Soft Tissue Medial Collateral Ligament (MCL) Lateral Collateral Ligament (LCL) Patellar Tendon IT Band Meniscus (med & lat) Animation

Knee Injuries MCL or LCL sprain Mechanism Symptoms Treatment Lateral (mcl) or medial (lcl) force knee Symptoms Pain laxity Treatment RICE Taping

Knee Special Tests Practice it Valgus and Varus Stress tests Tests MCL (Valgus) or LCL (Varus) Positioning Athlete sitting or lying down in relaxed position Test Apply a medial (varus) or lateral (valgus) pressure to joint line while pulling lower leg in the opposite direction Perform this at 0 degrees and 30 degrees Positive Pain (1st or 2nd degree sprain) Laxity (2nd or 3rd degree sprain Practice it

Knee Injuries ACL sprain Treatment Mechanism Symptoms RICE Plant and twist Symptoms Joint laxity (give way) 1-2 pain Locking swelling Treatment RICE quad strengthening Swelling control ROM SURGERY

Special Tests Practice it Anterior Drawer Tests ACL Position Test Athlete supine on table with knee bent to 90 degrees Tester sits on foot to stabilize lower leg Place thumbs on the tibial plateau (tibial joint line) Test Pull lower leg anteriorly in line with thigh in a jerking motion Positive Pain or laxity Note: if the athlete does have an ACL injury it is likely that you will only have one chance to correctly do this test because they may guard against you after that. Practice it

Special Tests Practice it Lachman Drawer Test This test is less painful and more precise after a knee injury Position Athlete is supine on the table with legs straight Tester places their knee under femur in order to bend the knee to 30 degrees Test Tester pulls the tibia directly upward and presses the femur downward in a jerking motion Positive Pain (1st and 2nd degree tear) Laxity (2nd and 3rd degree tear) Practice it

ACL Surgery

Post. Cruciate Lig. sprain Mechanism Blow to anterior tibia Symptoms Pain Swelling Joint laxity Treatment Strengthening RICE Surgery

Special Tests Practice it Posterior drawer Tests PCL Position Test Athlete supine on table with knee bent to 90 degrees Tester sits on foot to stabilize lower leg Place thumbs on the tibial plateau (tibial joint line) Test Push lower leg posteriorly in line with thigh in a jerking motion Positive Pain or laxity Note: if the athlete does have an PCL injury it is likely that you will only have one chance to correctly do this test because they may guard against you after that. Practice it

Special Tests Posterior Sag Test (Godfrey’s test) Positioning Test Athlete is supine w/ both knees flexed to 90 degrees Test Lateral observation to see if either tibia has moved posteriorly

Meniscal Tears Mechanism Treatment Symptoms Cutting Forcefully extended Rotation Treatment Surgery Bracing Strengthening ROM Symptoms Joint pain locking swelling Loss of motion giving way cracking/popping

Meniscus and Ligaments

Special Tests Practice it McMurray’s Test Used to determine displaceable meniscal tear Position Athlete is supine on table Test Leg is moved into flexion and extension while knee is internally and externally rotated in conjunction w/ valgus and varus stressing Positive clicking and popping are felt Practice it

Special Tests B A D C

Special Tests Practice it Apley’s Compression Test Athlete prone Hard downward pressure is applied w/ rotation Positive - Pain indicates a meniscal injury Apley’s Distraction Test Traction is applied w/ rotation Pain will occur if there is damage to the capsule or ligaments No pain will occur if it is a meniscus tear Practice it

Special Tests Apley Compression

Meniscus Tear Surgery http://www.youtube.com/watch?v=_QLalb PVP4c&edufilter=ZfvWoTQoe9wnoR5AG PfSjA

Plica tear of the fascia under the patella Mechanism Excessive Shock Symptoms Snap/popping Pain when sitting for long time Treatment Rest Heat NSAIDs Surgery

Special Tests Practice it Patellar Compression test Position Test Athlete seated or lying in a comfortable position Test Tester presses patella down into the femoral groove, then moves it up and down to feel for any abnormalities Positive Pain or grinding sensation Practice it

Special Tests Practice it Patellar Grind Test Position Test Positive Athlete supine either seated or lying Test Tester places Thumb web-space just above the patella Tester then asks athlete to contract their quad forcefully Positive Pain and/or grinding. Practice it

Patellofemoral Stress Syndrome Chondromalacia or any condition associated with the patella on the femur Chondro = Cartilage Malacia = softening of Mechanism Patella not tracking within femoral groove correctly. Signs and Symptoms Tenderness of lateral patella Swelling Dull ache in center of knee Patellar compression will elicit pain and crepitus Apprehension when patella is forced laterally Management RICE - Tape patella to aid in tracking Stretch ITB - Strengthen Medial structures 81

Knee Injuries Patella Dislocation Mechanism Non-contact, quick forceful contraction of the lateral quads Symptoms Deformity - slightly flexed knee Pain Treatment Straighten leg - Splint I.C.E. - Send for x-rays Can cause damage to cartilage or fracture patella

Patellar subluxation Apprehension Test Position Test Positive Athlete supine and relaxed with knee extended Test Tester places a lateral stress on the patella Positive Athlete has pain or tightens quads in “fear” of dislocation

Osgood-Schlatter Disease Mechanism Begins as cartilage and develops a bony callus, enlarging the tubercle Resolves w/ aging Common cause = repeated avulsion of patellar tendon Signs and Symptoms Swelling - Point tenderness Pain w/ kneeling, jumping and running Management Reduce stressful activity (6-12 months) Possible casting, ice before and after activity Isometerics 84

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Patellar Tendinitis (Jumper’s or Kicker’s Knee) Mechanism Jumping or kicking - placing tremendous stress and strain on patellar or quadriceps tendon Sudden or repetitive extension Signs and Symptoms Pain and tenderness at inferior pole of patella 3 phases - 1)pain after activity, 2)pain during and after, 3)pain during and after (possibly prolonged) and may become constant Management Ice, ultrasound, heat Exercise Patellar tendon bracing Transverse friction massage 86

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