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OA 1.13 Please have your binder out and ready for notes. 1.

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Presentation on theme: "OA 1.13 Please have your binder out and ready for notes. 1."— Presentation transcript:

1 OA 1.13 Please have your binder out and ready for notes. 1

2 The Pelvis & Thigh Chapter 18 (pp )

3 Objectives Identify… The bones of the hip & thigh The ligaments of the hip & thigh The muscles of the hip & thigh Other structures

4 Skeletal anatomy

5 The pelvic girdle Illium, pubis, ischium –Two innominate bones Acetabulum –Portion of all 3 bones Sacrum –5 fused vertebrae Coccyx –4-6 fused vertebrae

6 The pelvic girdle

7 Ilium –Forms upper 2/5 of acetabulum Ischium –Forms posterior 2/5 of acetabulum Pubis –Forms anterior 1/5 of acetabulum

8 The pelvic girdle The ilium –Anterior Superior Iliac Spine (ASIS) –Anterior Inferior Iliac Spine (AIIS) –Posterior Superior Iliac Spine (PSIS) –Posterior Inferior Iliac Spine (PIIS)

9 The pelvic girdle The ilium –Iliac fossa (not shown) –Iliac crest –Greater sciatic notch

10 The pelvic girdle The ischium –Ischial tuberosity –Obturator foramen Obturator foramen

11 The pelvic girdle The pubis –Pubic symphysis –Pubic tubercle –Obturator foramen

12 The pelvic girdle The sacrum –Connects spine to pelvis –Stabilizes pelvis –Coccyx connects inferiorly –Fused vertebra

13 The femur Largest, strongest bone in the body –Head –Neck –Greater trochanter –Lesser trochanter

14 Articulations

15 ARTICULATIONS Sacroiliac Joint Pubic Symphysis Acetabular Joint

16 Sacroiliac joint Fusion of the sacrum and posterior ilium Immobile

17 Pubic symphysis Joining of the two sides of the pelvic girdle Dense, fibrous connective tissue Immobile

18 Acetabular joint Ball and socket joint –Very stable –Relatively immobile Fibrous capsule –Encloses the head and most of the neck of the femur

19 Ligaments & Joint Capsule

20 Hip joint ligaments Ligamentum teres Ligamentum capitis Round ligament Ligament to the head of the femur All same thing!

21 Inguinal ligament From ASIS to the pubic tubercle Functions to contain soft tissues as they pass from the trunk to the lower extremities

22 Joint capsule Synovial joint Reinforced by: –Iliofemoral ligament “Y” ligament Ligament of Bigelow Strongest ligament –Pubofemoral ligament –Ischiofemoral ligament

23

24 Joint capsule The acetabulum is surrounded by a labrum –Extension of cartilage to deepen the joint

25

26

27 Muscular anatomy

28 Anterior hip & thigh Muscles that cross the hip Iliacus Psoas major Rectus femoris (crosses hip & knee) Sartorius (crosses hip & knee) Pectineus Muscles that don’t cross the hip Vastus Medialis Vastus Intermedius Vastus Lateralis Vastus Medialis

29

30

31 Lateral hip & thigh Tensor Fascia Latae Gluteus Medius Gluteus Minimus

32

33 OA 1.14 How are the anterior muscle of the hip & thigh categorized? List them into their respective categories. 33

34 Posterior hip & thigh Gluteus Maximus Biceps Femoris Semitendinosus Semimembranosus Posterior fibers of Adductor Magnus

35 Deep posterior hip & thigh EXTERNAL ROTATORS Piriformis Obturator Internis Gemellus Superior Gemellus Inferior Quadratus Femoris Obturator Externis

36

37 Medial hip & thigh Adductor Longus Adductor Brevis Adductor Magnus Gracilis

38 Other structures

39 bursa Iliopsoas bursa Trochanteric bursa

40 Circulatory anatomy Iliac artery Femoral artery Femoral circumflex arteries –Surrounds the head & neck of the femur

41 Neural anatomy Femoral nerve –Anterior thigh Sciatic nerve –Posterior thigh –Tibial and common peroneal Obturator nerve –Medial thigh

42 Femoral triangle Superior: inguinal ligament Lateral: sartorius Medial: adductor longus Femoral artery, femoral vein, femoral nerve, and lymph nodes run through Palpate femoral pulse

43 OA 1.21 A basketball player was going up for a lay up and got her feet taken out from under her. She lands hard on her left hip. What questions would you ask to gather clues about what is going on? What are some relevant observations to make regarding their body?

44 History & Observation

45 objectives Identify… Pertinent information to gather during a hip & thigh evaluation Important observations to make during a hip & thigh evaluation

46 introduction Must understand anatomy & biomechanics Examination process is on-going –Initial  rehab  RTP Must be systematic and methodical Must understand differential diagnosis (DDx) –Options that a specific injury could be –Pathologies often have similar S&S Rule out emergency situations quickly err on side of caution –If unsure, err on side of caution

47 history Start with generic history questions –Chief complaint –Age –Occupation / sport / position etc. –General health condition –Activity level –Medications

48 history History of previous injuriesHistory of previous injuries –What happened? –Who did you see? –What did they tell you? –How long were you out? –Has it fully resolved?

49 history Mechanism of injury –How did it happen? strainTension = sprain; fracture; strain sprain/labrumTorsion = sprain/labrum; fracture contusionfractureCompression = contusion; fracture fractureShear = fracture; sprain

50 history Mechanism of Injury – Hip & Thigh specific –Compression –Internal/External rotation –Internal/External rotation of the femur –Overuse

51 history Ask these questions regarding PAIN P-rovocation – what causes it? what makes it better? Q-uality – what does it feel like? neurological symptoms? R-egion – where does it hurt? can you point w/one finger? 1-10S-everity – how bad does it hurt? (1-10) T-iming – when does it hurt? how long?

52 history Type of PainStructure Cramping, dull, achingMuscle Dull, achingLigament, joint capsule Sharp, bright, lightning-like, burningNerve Deep, nagging, dullBone Sharp, severe, intolerableFracture Throbbing, diffuseVasculature

53 history Sounds & sensations –Did you hear any sounds? Did you hear any pops, crackles, snaps, clicking? What could this indicate???What could this indicate??? –Did you feel anything unusual?

54 history Specific to the HIP & THIGH –Link the anatomy to the pathology Where it hurts = what is injuredAKA: Where it hurts = what is injured –Focus on the onset/duration changes in activity, training, etc.Link the start of symptoms to changes in activity, training, etc. –Prior medical conditions abnormalitiesCongenital abnormalities

55 observation When does this begin? Compare each side bilaterally to identify what is normal for that person We look for: asymmetry ecchymosisDeformity, asymmetry, edema, ecchymosis

56 observation Gross motor function –Can the athlete move the limb on their own through normal function? bear full body weight? –Can they bear full body weight?

57 observation Leg alignment knocked knee’d –Genu valgum – knocked knee’d bow-legged –Genu varum – bow-legged points medially –Squint eye patella – points medially points laterally –Frog eye patella – points laterally

58

59 observation Additional examinations: valgus anterior hip –Q-angle – degree of valgus alignment between anterior hip & tibia –Leg Length –Gait analysis

60 Q-Angle

61 Critical thinking… A hurdler comes to see you about pain she is having in her anterior hip. She was at practice yesterday and on her last hurdle she felt a “funny pull” in her lead leg. There was an immediate shot of pain to the front of her hip bone, and she immediately had to stop running. She iced it when she got home and took some meds for the pain. Today she felt worse. She could barely walk and wasn’t able to lift her leg to go up/down the stairs. Now her hip is all bruised and is very tender to the touch. What anatomy would you consider inspecting & palpating? List all possibilities—bones, landmarks, muscles, ligaments, etc. What other history questions would you ask? List 5. What injury/injuries do you think this is? How would you treat this athlete initially?

62 Critical thinking… A hurdler comes to see you about pain she is having in her anterior hip. She was at practice yesterday and on her last hurdle she felt a “funny pull” in her lead leg. There was an immediate shot of pain to the front of her hip bone, and she immediately had to stop running. She iced it when she got home and took some meds for the pain. Today she felt worse. She could barely walk and wasn’t able to lift her leg to go up/down the stairs. Now her hip is all bruised and is very tender to the touch. What anatomy would you consider inspecting & palpating? List all possibilities—bones, landmarks, muscles, ligaments, etc. What other history questions would you ask? List 5. What injury/injuries do you think this is? How would you treat this athlete initially?

63 Critical thinking… A hurdler comes to see you about pain she is having in her anterior hip. She was at practice yesterday and on her last hurdle she felt a “funny pull” in her lead leg. There was an immediate shot of pain to the front of her hip bone, and she immediately had to stop running. She iced it when she got home and took some meds for the pain. Today she felt worse. She could barely walk and wasn’t able to lift her leg to go up/down the stairs. Now her hip is all bruised and is very tender to the touch. What anatomy would you consider inspecting & palpating? List all possibilities—bones, landmarks, muscles, ligaments, etc. What other history questions would you ask? List 5. What injury/injuries do you think this is? How would you treat this athlete initially?

64 Range of Motion

65 Remember… History –Asking questions to gather information regarding what happened & what the patient is experiencing –Clues to solve the puzzle of diagnosing the issue

66 remember… Observation –Deducing relevant signs of problems –Uses our senses of sight & sound to gather more clues

67 From SKILLS LAB… Palpation –Allows us to feel what is going on –Comparison of normal to abnormal

68 Range of motion For the hip… coxofemoral –ROM occurs at the coxofemoral joint Acetabular joint acetabulum femurArticualtion between the acetabulum & femur

69 Movements Primary movements Flexion Extension AdductionAdduction Abduction Internal Rotation External Rotation

70 Hip movements pelvic girdleFlexion – decreasing the joint angle between the femur and pelvic girdle Tested with & without knee flexion Aka: straight leg raise knee to chestAka: knee to chest Normal: 120 o

71

72 Hip movements Extension– increasing the joint angle between the femur and pelvic girdle with & withoutTested with & without knee flexion Aka: straight leg raise Aka: lift foot off table Normal: o

73

74 Hip movements away from the midlineAbduction– movement of the leg away from the midline sidelyingTested in sidelying Aka: straight leg raise Normal: 45 o

75 Hip movements towardsADDuction– movement of the leg towards the midline bent in front of test legTested in sidelying with opposite knee bent in front of test leg Normal: 30 o

76 Hip movements External Rotation– Rotation of the femur away from the midline ated positionTested in a seated position with the knee bent oppositeToes move opposite of hip movement Normal: 50 o

77

78 Hip movements Internal Rotation– Rotation of the femur towards the midline Tested in a seated position with the knee bent Toes move opposite of hip movement 45 oNormal: 45 o

79

80 Range of motion Definition: –Range of motion refers to the distance and direction a joint can move between the flexed position and the extended position In true clinical settings, we use a goniometer to measure ROM

81 Range of motion Types –Active range of motion (AROM) –Passive range of motion (PROM) –Resistive range of motion (RROM)

82 Range of motion AROM –The patient’s ability to move a joint under their own strength PROM –The joint’s ability to be moved through a range of motion RROM –Measurement of the muscle strength of a joint through the ROM

83 Range of motion Performed bilaterally on the uninjured side first –Why?? Allows us to get a look at what is normal for that athlete!

84 Testing order R flexion – Straight Leg & Bent Knee L flexion – SL & BKL flexion – SL & BK R abduction – sidelying adductionL adduction – sidelying R extension – SL & BK L extension – SL & BK abductionL abduction – sidelying R adduction – sidelying R ER & IR - seated L ER & IR - seated

85 Testing order Test AROM, PROM, RROM for all patient positions before moving into a new position AROM flexion, PROM flexion, RROM flexion THEN move the sidelyingAKA: AROM flexion, PROM flexion, RROM flexion THEN move the sidelying

86 Active Range of motion Have the patient move their knee through the movements face up –Lay face up: lift your leg straight up; now drive your knee to your chest right right left –Lay on your left side: lift your right leg up; plant your right knee and lift your left leg up

87 Active Range of motion Have the patient move their knee through the movements bend your knee –Lay face down: lift your leg straight off the table; now bend your knee and lift your foot into my hand –Lay on your right side: life your left leg up; now plant your left knee and lift your right leg up

88 Active Range of motion Have the patient move their knee through the movements –Sit at the end of the table –Sit at the end of the table: rotate your right leg in, then out; repeat with the left leg

89 Passive range of motion The examiner will move the hip through the ROMs to the extreme end – why?? –I am going to move your hip/leg for you. Just try to relax and let me know if you feel discomfort, pain, or anything unusual.

90 Resistive range of motion The athlete will move through each ROM as the examiner places resistance against the movement –Repeat the ROM with resistance placed at or below the knee

91 Muscles & tendons Anterior aspect – flex & IR the hip (and extend the knee) –Quadriceps femoris group –Sartorius –Iliacus –Psoas major –TFL

92 Muscles & tendons Posterior aspect – extend the hip* (and flex the knee) –Hamstrings group maximus –Gluteus maximus

93 Muscles & tendons Lateral aspect – abduct & ER the hip* TFL MediusGluteus Medius MinimusGluteus Minimus

94 Muscles & tendons Medial aspect – adduct & IR the hip* Adductor Longus BrevisAdductor Brevis Adductor Magnus Gracilis

95 Muscles & tendons EXTERNAL ROTATORS Piriformis Obturator Internis GemellusGemellus Superior GemellusGemellus Inferior Quadratus Femoris Obturator Externis

96 Items to note: When assessing, make note of: –differences in AROM –Pain during PROM –Decreased strength during RROM But WHY??

97 Grading ROM AROM & PROM are graded as within normal limits (WNL) or decreased/limited & why –AROM: R = WNL, L = decreased DF due to pn

98 Grading ROM graded on a 0-5 scaleRROM is graded on a 0-5 scale

99 Documenting ROM When documenting ROM, each movement must be listed & assessed. AROM: R = WNL, L = WNL PROM: R = WNL, L = WNL with Pn RROM: R = 5/5DF, 5/5PF, 5/5INV, 5/5EV; L = 5/5DF, 3/5PF due to Pn, 3/5INV due to Pn, 2/5EV due to Pn


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