Osteology, ligaments, gluteal musculature Lower Extremity Osteology, ligaments, gluteal musculature

Which of the following is most likely pertaining to the two pelves depicted? The left is male and the right is female The right is male and the left is female The left is from a younger person than the right The right is from a younger person than the left A

LE Unit Overview Superficial fascia, veins, lymph Skeletal structures / joint surfaces Ligamentous support Musculature / vasculature Nerves Forces and injuries Again building from inside out Potentially most important region / unit for physical therapists Highest forces, mobility still essential for function -> precarious balance between stability and mobility Injuries common Also, nerve supply is farthest from the brain (the source) Spinal cord injuries, nerve injuries, affect leg and mobility function

Objectives Describe the gross anatomy for each system (circulatory, muscular, nervous, and skeletal) in the lower extremity. Integrate the systems to discuss the lower extremity stability and mobility functions. Analyze common injuries in the lower extremities. For each muscle, describe how the attachment sites result in an action around a joint. For each muscle, identify the innervation (peripheral nerve and nerve roots). Pulled from syllabus

LE Overview Joints: hip – ball and socket (reinforced with ligament… tbd) knee – modified hinge (hinge with rotation) tibiotalar and talofibular (ankle) – hinge names of joints and ligaments = tibia wins, talus comes in second, fibula loses talocalcaneal (subtalar) – condyloid Common understanding: ankle joint is commonly thought of as the tibiotalar, talofibular, and subtalar joints together. Musculature: extensors for each joint are powerful and essential Neurovasculature: tends to run on the flexion side for protection and reduced stretching femoral artery and nerve anterior to hip popliteal artery and sciatic branches posterior to knee sciatic nerve is an exception – commonly in trouble!! tibial nerve and posterior tibial artery are posterior to ankle Line of force: straight through each joint ideally – postural variations, skeletal variations, muscular strength/weakness may change the normal line of force (tbd) hip flexors, ankle plantarflexors regularly active like the back extensors

For reference

Fascia latae, crural fascia holds muscles in place, creates pressure for returning blood to the heart Superficial veins – venous drainage of extremities is both superficial and deep medium veins, with valves not necessary for proper drainage – great saphenous is sometimes used in surgeries as a vessel replacement

Top is R leg, bottom is R leg Intermuscular septa – bone to superficial fascia Reduce muscles rubbing against each other, serve as attachment sites (short head of bicep for example), maintain pressure for each compartment medial and lateral in thigh anterior, posterior and transverse in leg

Superficial veins and lymphatic flow Great saphenous dives deep in femoral triangle Small saphenous dives deep in popliteal fossa

During development, three bones are very distinct notice: separation between ilium and pubis/ischium, and femoral head growth plate

Coxae (Pelvis) Obturator Membrane Anatomical Position Coxal joint, coxa vara, coxa valga Obturator membrane is tough but thin and serves as an attachment site for two muscles: ?? obturator internus obturator externus Also allows passage of obturator nerve which innervates ??? adductors Asis and pubic tubercle should vertically line up Anatomical Position

True vs. false pelvis – true pelvis is cavity for reproductive organs, bladder, and rectum. False pelvis is actually in the abdominal region but serves as essential surface area for hip muscles – iliacus, glutes, TFL Side note: angle of sacrum, sacral promontory

Sacroiliac Joint - Ligaments Primary: Anterior Sacroiliac Interosseus Short and long posterior sacroiliac Secondary: Sacrotuberous Sacrospinous Anterior sacroiliac – thickened joint capsule this part of sacroiliac joint is also strengthened by piriformis and psoas Interosseus ligament – short, strong fibers between sacrum and ilium along margins strongest bond Posterior sacroiliac ligaments (short and long) short – extensive but thin, many fibers bind with interosseous long – 3rd-4th sacral segments -> PSIS Sacrotuberous – does not cross joint! PSIS -> ischial tub Sacrospinous – does not cross joint! sacrum -> ischial spine (creates greater and lesser sciatic foramen for piriformis & sciatic, and obturator internus muscles)

Sacroiliac Joint - Motions Anterior Tilt and Posterior Tilt Nutation (sacral flexion) and Counternutation (sacral extension) Stability vs. Mobility http://www.youtube.com/watch?v=elo2_sWBXaM Nutation is more stabilizing – stretches interosseous and sacrotuberous ligaments, compresses joint

Nutation and the effects of sacrotuberous and sacrospinous ligaments

None of these would be stretched Your patient has significant posterior tilt in his pelvis but when palpating, you notice his sacrum is nutated. What ligament would be most stretched? Posterior Sacroiliac Anterior Sacroiliac Sacrospinous None of these would be stretched C

Your female patient has anterior pelvic tilt due to excessive lumbar lordosis. Which of the following is TRUE? She must be in nutation She must be in counternutation She is at risk for posterior disc herniation None of these D

Femur line of force Condyles are horizontally in line, shaft is angled inferomedially, force over time will impact the angle of inclination (of neck of femur)

Femur: Torsion Angle Averages: 7 degrees in males 12 degrees in females Discussion question: What effect does this difference have? Angle of acetabulum matches torsion angle

Femur: Angle of Inclination Change in bone structure over lifespan

The part of the femur that is most susceptible to fracture in conjunction with osteoporosis is: mid-shaft. medial condyle. along the intertrochanteric line. neck. intercondylar area. D

In the following radiograph of the hip, the arrow points to the: greater trochanter. lesser trochanter. ischial spine. femoral neck. B

Coxa vara refers to: an abnormal decrease in the angle between the shaft of the femur and the tibia. an abnormal decrease in the angle between the head and neck of the femur and its shaft (angle of inclination). an abnormally short distance between the anterior superior iliac spine and the center of the acetabulum. an abnormally short distance between the iliac crest and the greater trochanter. an abnormally short femur. B

Hip ligaments: iliofemoral (Y) – covers anterior femoral head ischiofemoral – covers posterior femoral head pubofemoral – covers inferior femoral head All resist distraction, medial rotation, and extension of hip Strongest joint position is extended & medially rotated Ligament of head of femur (carries an artery) Subluxation of hip can result in avascular necrosis

Hip musculature Gluteal region Anterior hip Gluteus maximus Iliopsoas Gluteus medius Pectineus Gluteus minimus Sartorius TFL Rectus femoris Piriformis Obturator internus Gemelli Obturator externus Quadratus femoris

Gluteus maximus ilium, sacrum -> IT band (3/4) & gluteal tuberosity (1/4) ¾ of this muscle crosses the knee joint strongest hip extensor from flexed position Gluteus medius ilium -> greater troch hip abductor line of pull – active during walking Trendelenburg test, Trendelenburg gait Gluteus minimus ilium -> anterior greater troch similar action to medius, also internally rotates in flexed position TFL anterior iliac crest -> IT band counteracts glut max pulling posteriorly

Piriformis anterior sacrum -> greater troch through greater sciatic foramen when tight and short, can impinge sciatic nerve in the greater sciatic foramen Obturator internus obturator membrane -> trochanteric fossa Gemelli superior: ischium above OI (spine) -> fossa inferior: ischium below OI (tuberosity) -> fossa Obturator externus obturator membrane -> fossa Quadratus femoris ischial tuberosity -> intertrochanteric crest

Bursa Ischial Obturator internus Trochanteric Gluteofemoral Bursa = sac of synovial fluid to reduce friction of muscles on bones or for cushioning from external forces

Iliopsoas Psoas from lumbar vertebrae -> lesser trochanter iliacus from iliac fossa -> lesser trochanter strong hip flexors cross sacroiliac & hip joints psoas can cause low back pain if tight and short Pectineus adductor muscle – supports anterior hip Sartorius ASIS -> pes anserine weak support for anterior hip joint Rectus femoris AIIS -> quad tendon Hip flexion accomplished mostly with iliopsoas, Sartorius and rectus femoris. Flexion and extension are vastly different

Important vasculature: Femoral artery (no blood supply around posterior hip) branches supply pelvis Profunda Femoris artery branches supply head of femur, trochanters, shaft of femur Lateral and medial circumflex femoral arteries (both branch off profunda) anastomosis – when arteries connect together to supply blood from multiple sources, insurance policy against reduced blood flow Popliteal artery Geniculate arteries – more anastomoses Tibial arteries

The iliotibial tract is the conjoint distal aponeurotic attachment of which of the following pairs of muscles? gluteus medius and minimus gluteus medius and maximus gluteus maximus and the tensor of the fascia lata the tensor of the fascia lata and rectus femoris rectus and biceps femoris C

Which of the following is incorrect pertaining to the great saphenous vein? It passes posterior to the medial malleolus. It passes posterior to the medial condyle of the femur. It drains into the femoral vein. It has a nearly uniform diameter because blood is shunted to deeper veins. It traverses the saphenous opening in the fascia lata. A

For Monday Readings in Moore Study for lab quiz