1
Q
Thoracic Spine Facet Joints
A
- most rigid part of the vertebral column
- ribs, ligaments, muscles
- aligned in a mild kyphosis
- mobile platform for the movement
- upper extremities via scapulothoracic and SC joints
- cervical spine
2
Q
Resting position of Thoracic Spine Facet Joints
A
- midway between flexion and extension
3
Q
Closed pack position of thoracic Spine facet joints
A
- extension
4
Q
Capsular pattern of Thoracic spine facet joints
A
- side flexion and rotation equally limited
- then extension
5
Q
Infrasternal angle above and below 90deg
A
- above 90deg: tightness in internal obliques
- less than 90deg: tightness in external obliques
6
Q
Manubriosternal joint (sternal angle)
A
- 2nd ribs
7
Q
Xiphosternal joint
A
- T9 vertebra
- T6 dermatome
8
Q
Ribs 2-12
A
- most rounded inferior rib felt anterolaterally is the 10th rib and it’s costochondral junction
- inferior and postereolateral to that is the tip of rib 11, ending just anterior to mid-axillary line
- rib 12, inferior and medial to rib 11, it is about an inch or so below rib 11, about 2-4 inches from the spinous process
9
Q
Rib Angles
A
- ribs 2-10
- 1st rib doesnt posses an angle and 11th and 12th are slight if present
- 3-4cm lateral to the tips of the transverse process
10
Q
Root of spine of scapular
A
T3/4
11
Q
Inferior Scap Angle
A
- T7
12
Q
Level of Umbilicus
A
- T10
13
Q
Costovertebral (CV) Joints
A
- ribs and vertebral bodies
- ribs 1,10,11,12 have one vertebral body articulation
- ribs 2-9 articulate with the 2 adjacent vertebra
14
Q
costotransverse (CT) Joints
A
- ribs and transverse processes of the same level
- ribs 1-10
- ribs 11 and 12 do not have these joints
15
Q
Costochondral Joints
A
- ribs and costal cartilage
- ribs 1-7 = true ribs
- ribs 8-10 = false ribs
- ribs 11-12 = floating
16
Q
Thoracic Rules of Threes
A
- T1-3: SP at level with TP
- T4-6: SP are 1/2 level down than TP
- T7-9: SP are one full level down from TP
- T10-12: starts to come back up (T10 is one full level below TP, T11 SP is one half level below TP, T12 SP is even with TP)
17
Q
External Obliques OIA
A
- O: ribs 5-12
- I: iliac crest, pubis, lineal alba
- A: Bilaterally compress abdomen and flex spine. Unilaterally ipsilateral side bending and contralateral rotation
- I: lower intercostal, iliohypogastric, ilioinguinal nn
18
Q
Internal Obliques OIA
A
- O: lateral inguinal lig, middle lip of iliac crest, thoracolumbar fascia
- I: pubis, inferior border of ribs 9-12, linea alba
- A: bilaterally compress abdomen and flexes the spine, unilaterally ipsilaterally flexes and rotates to same side
- I: lower 5 thoracic nn, 1st lumbar n, iliogypogastric, ilioinguinal n
19
Q
Rectus Abdom OIA
A
- O: crest of pubis and pubic tubercle, pubic symphsis
- I: cartilages of the 5-7 ribs and xiphoid process
- A: flexes vertebral column compresses abdomen
- I: spinal nerves T7-12
20
Q
Transverse Ab OIA
A
- O: lateral 3rd of inguinal lig, inner lip of iliac crest, inner cartilage of lower 6 ribs, thoracolumbar fascia
- I: ends in aponeurosis, fron and back of rectus sheath to linea alba and pubis
- A: compresses ab viscera and tenses abdominal wall
- I: lower sic thoracic n, first lumbar n, iliohypograstic and ilioinguinal n
21
Q
Pump Handle Action
A
- move by rotating around their long axis
- rotate up with accompaniment of the manubrium
- T1-6
22
Q
Bucket Handle Action
A
- move upward, backward, and medially
- T7-10
- T2-6 at a much lesser degree
23
Q
Abdominals Double Leg Lowering (Kendall)
A
- patient supine on a firm surface, forearms crossed on chest
- examiner assists patient in raising legs to a vertical position
- patient is instructed to perform a posterior pelvic tilt flattening back to table
- instructed to Hold it flat while patient lowers legs
- ending position is when therapist notices loss of neutral pelvic position
- the ankle between the extended legs and the table determines the strength grade
24
Q
Sahrmann Core Stability Test
A
- ability of a patient to perform specific levels of stability while maintaining a neutral/flat spine
- test is stopped if patient cannot maintain flat spine
- test is graded by the level the patient can perform
25
Sharmann Core Stability Level 1A
- fair
- initial position to be used for rest of levels
- hooklying. tighten your core keeping back flat and slowly lift 1 leg to 90deg keeping knee bent
- keeping 1st leg up, slowly bring 2nd leg to same position
- "up, up position"
26
Sahrmann Core STability Level 1B
- poor (motor training)
- for the patient that cannot performm level 1A
- hooklying. keeping back flat. slide one heel along floor out to straight leg and return to starting position
27
Sahrmann Core Stability Level 2
- fair +
- starting in position 1A (both legs up)
- slowly lower 1 leg down until heel touches table
- slide heel along table out until leg is straight
- slide it back until knee is bent
- return to position 1A
- "one heel slide"
28
Sahrmann Core Stability Level 3
- good
- starting in position 1A (both legs up)
- slowly lower 1 leg until it is a few inches above table
- glide heel above table out until leg is straight
- glide it back until knee is bent
- return to position 1A
- "one heel glide"
29
Sahrmann Core Stability Level 4
- sport level
- starting in position 1A (both legs up)
- slowly lower both legs until heels touch the table
- slide both heels out until both legs are straight
- slide them back until knees bent
- return to position 1A
- "double heel slide"
30
Sahrmann Core Stability Level 5
- Sport Level
- starting in position 1A (both legs up)
- slowly lower both legs until heels are a few inches above table
- glide both legs out until legs are straight
- glide back until knees are bent
- return to position 1A
- "double heel glide"
31
L2 Myotome
- hip flexion
32
L3 Myotome
- knee extension
33
L4 Myotome
- ankle dorsiflexion
34
L5 MYotome
- great toe extension
35
S1 Myotome
- ankle eversion
- hip extension
- plantar flexion
36
S2 Myotome
- knee flexion
37
L3/4 Reflex
- quads
38
S1/2 Reflex
- achilles
39
L5/S1 Reflex
- hamstrings
40
ROM Thoracic Flexion
- 20deg
41
ROM Thoracic Extension
- 10deg
42
ROM Thoracic Lateral Flexion
- 10deg
43
Thoracolumbar Flexion ROM
- 80deg
44
ROM Thoracolumbar Extension
- 35deg
45
ROM Thoracolumbar lateral Flexion
- 35deg
46
ROM Thoracolumbar Rotation
- 45deg
47
ROM Lumbar Flexion
- 60deg
48
ROM Lumbar Extension
- 25deg
49
ROM Lumbar Lateral Flexion (side bending)
- 25deg
50
ROM Thoracolumbar Lateral Flexion
- 35deg
51
ROM Thoracolumbar Rotation
- 45deg
52
Thoracic Spine Region
- T1-12
53
Thoracolumbar Spine Region
- T1-S2
54
Lumbar Spine Region
- L1-S2
55
Postural Control
- controlling body position in space for stability and orientation
56
Balance
- ability to hold center of mass in relation to base of support
57
Center of Gravity
- vertical projection of the COM (slightly anterior to L2 in standing)
58
Base of Support
- area of body in contact with a support surface
59
Postural Orientation
- ability to maintain an appropriate relation between body segment and between the body and the environment
- involves the active alignment of the trunk and head with respect to gravity, support surfaces, the visual surround and internal references
- sensory information from somatosensory, vestibular and visual systems is integrated, and the relative weights placed on each of these inputs are dependent on the goals of the movement task and the Enviornment context
60
Limits of Stability
- internal representation of how far the body can move over it's base of support before changin the support or losing balance
61
Anticipatory Postural response
- active movement of the body's COM in anticipation of a postural transition from one body position to another
62
Reactionary Postural Responses
- active response to an external perturbation
63
Sensory interaction/prientation
- ability to maintain balance during altering sensory conditions
64
Postural Equilibrium
- involves coordination of movement strategies to stabilize the center of body mass during both self-initiated and externally triggered disturbances of stability
- the specific response strategy selected depends not only on the characteristics of the external postural displacement but also on the individual's expectations, goals, and prior experience
65
What is included in the initial examination?
- taking a history
- systems review
- tests and measures (body structure/function, activity, participation)
66
Taking a History for Balance Exam
- chief complaint
- medical history
- recent history of falls/close falls
- medications
- confidence level (participation level)
67
What is included in the systems review?
- Cardiovascular: Vitals
- Integumentary: skin integ, color, scores
- Neuromuscular: reflexes, gait, tone
- Musculoskeletal: ROM, MMT, posture BMI
68
ICF Model for Balance Examination
- health condition (disorder or disease)
- body functions and structures
- activities
- participation
- environmental factors
- personal factors
69
Ankle Strategy in Balance
- control of postural sway from ankles and feet
- head and hips travel in the same directions at the same time with the body moving as a unit over the feet
- appropriate to use on firm surface, well supported, slow moving with minimal displacement
70
Hip Strategy in Balance
- control of postural sway from pelvis and trunk
- head and hips travel in opposite directions
- appropriate to use when foot not completely supported and when there is quick and large displacements
71
Stepping strategy in Balance
- steps with the feet to establish a new base of support when the center of gravity has exceeded the original base of support
- appropriate to use when other strategies are not sufficient enough to maintain equilibrium
72
Balance Exams for Body Functions and Structure
- modified clinical test for sensory interaction in balance
- balance errors scoring system (BESS)
- single leg stance (eyes open/closed)
- romberg/sharpened romberg
73
CTSIB (Clinical test for sensory interaction in balance)
- clinical version of the sensory organization test that does NOT require computerized force plates
- designed to assess the patient's ability to select and combine sensory information in different environments
- does not measure the integrity of the three sensory systems
74
Sensory weighting on a firm surface
- 70% somatosensory
- 20% vestibular
- 10% vision
75
Sensory weighting on an unstable surface
- 10% somatosensory
- 60% vestibular
- 30% vision
76
CTSIG Conditions
- 1: firm surface, eyes open
- 2: firm surface, eyes closed
- 3: firm surface, dome
- 4: foam surface, eyes open
- 5: foam surface, eyes closed
- 6: foam surface, dome
77
Purpose of the BESS and population
- objective measure of assessing static postural stability (designed for the mild head injury population, to assist in return to sports)
- population tested: concussion, mild TBI, ankle instability, vestibular disorders
78
BESS Conditions
- 6 conditions, barefoot, eyes closed, 20 seconds each
- double leg stance (feet together): firm, foam
- single leg stance (non dom foot): firm, foam
- tandem stance (non dom in back): firm, foam
79
BESS types of errors to be counted
- up to 10 errors in each trial before terminating
- up to 60 errors total
- moving hands off hips
- opening eyes
- step, stumble, or fall
- abduction or flexion of hip beyond 30deg
- lifting the forefoot or heel off of the testing surface
- remaining out of the proper testing position for greater than 5 seconds
80
BESS scores that are good vs. not good
- lower scores = better balance
| - MDC (minimal detectable change) = 7 to 9 points
81
Single Leg Stance Balance Exam (Anticipatory)
- person stands with knee flexed 90deg
- legs should NOT be touching each other
- arms crossed around shoulders
- document # of attemps, time, visual observation during trial
82
Romberg/Tandem Romberg Balance Exam (Anticipatory)
- person stands with feet together (romberg) and eyes open
- repeat the test with eyes closed
- person stands with one foot directly in front of the other (tandem romberg)
- normal is the ability to hold the test position for 30 seconds
- document # of attempts, time, visual observation during trial
83
Activity Balance Measures
- Berg Balance Score
- Tinetti Performance Oriented Mobility Assessment
- Functional Reach test
- TUG, TUG manual, TUG cognitive
84
Participation Balance Measures
- activities based confidence scale
85
Berg Balance Score Conditions
- 14 test items intended to assess a person's ability to perform common ADLs safely
- items are scored from 0 to 4, max score is 56
- min detec change: 3-8 points
86
Berg Balance Score cut offs in older adults
- history of falls and Berg <51
- no history of falls and Berg <42
- predictive 91% sensitivity, 82% specificity
- score of <40 on Berg associated with almost 100% fall risk
- CVA risk 45/56
87
Tinetti Performance Oriented Mobility Assessment (POMA) Conditions
- consists of 2 subscales to screen for balance and mobility skills in older adults and determine likelihood of falls (balance (9), gait (7))
- 16 items total
- scored 0-2
88
Cutoff scores for Tinetti
- chronic stroke <20
- older adults 19-21
- PD <20 (AUC 72%, sensitivity 76%, specificity 66%)
89
General Tinetti scores
- score 19-24 are at moderate risk of falls
- score <19 are considered high risk for falls
- minimal detectable change: 4
90
Functional Reach Test Conditions
- define max distance one can reach forward beyond arm's length while maintaining fixed base of support in standing
- examines limits of stability in forward direction
- person stands near wall with feet parallel
- raises arm nearest wall to 90deg of shoulder flex
- makes fist and leans as far forward as possible
- three trials, average of the last 2!!
91
Cutoffs with Functional Reach Test
- less than or equal to 6 inches predictive of increased risk of falls in community dwelling elderly
- <18.5cm in frail elderly (75% sensitivity, 67% specificity)
- PD 25.4cm (30% sensitivity, 92% specificity)
- PD 30.1 cm (56% sensitivity, 77% specificity)
92
Activities Based Confidence Scale Conditions
- 16 item questionnaire
- measure of balance self-efficacy
- subjects rate their confidence performing a variety of in-home and community based functional activities such as walking in a variety of environments, reaching, picking things up from the floor
- scores range 0-100 where higher scores indicate greater balance confidence
93
Activities Based Confidence (ABC) scale cut-offs
- <67% fallers and non-fallers
- <69% PD
- <81% CVA
- MDC for PD: 11-13%
94
TUG
- individuals are given instructions to stand up from chair
- walk 3 meters as quickly and safely as possible
- cross a line on floor
- turn
- walk back as quickly and safely as possible
- sit down
- patient may use assistive device
- time patient
95
TUG Manual
- does the TUG
| - patient must walk holding a cup filled with water
96
TUG Cognitive
- do the TUG
- patient asked to complete test while counting back by 3s from a randomly selected # between 20 and 100
- or could ask patient to do alternating letters of alphabet
97
TUG scores interpretation
- >15 seconds = 90% prediction rate for faller
98
Documentation of Balance
- subjective: history of falls, close falls, fear of falling
- objective: name of test, trials, assistive device
- assessment: interpretation of score
- Plan: implementation of balance into plan of care
99
Balance exams looking at body structure/function
- CTSIG
- BESS
- single leg stance
- romberg
- tandem romberg
100
Balance exams looking at activity
- Berg
- Tinetti
- Functional reach
- TUG
- TUG manual
- TUG cognitive
101
Balance exams looking at participation
- ABC scale
102
What sense dominates when doing CTSIG Condition 1
- firm, eyes open
| - somatosensory dominates
103
What sense dominates in CTSIG Condition 2
- firm, eyes closed
| - somatosensory dominates
104
What sense dominates in CTSIG Condition 3
- firm, dome
| - vestibular dominates
105
What sense dominates in CTSIG Condition 4
- foam, eyes open
| - vision dominates
106
What sense dominates in CTSIG Condition 5
- vestibular dominates
107
Berg Balance test what score indicates a fall risk close to 100%
- scores less than 36
108
What does SPLATT stand for, and why do you use it?
- helps to get overall idea of fall/fall risk of patient
- Symptoms before fall
- Previous falls
- Location of fall
- Activity during fall
- Time of fall
- Trauma
109
Tinetti scores at moderate and high risk of falls
- scores 19-24 are moderate risk for falls
| - scores under 19 are high risk
110
3 Joints of Pelvis
- 2 posterior: left and right SI joint
| - 1 anterior: pubic symphysis
111
SI Joints
- synovial articulations with irregular surfaces
- strong ligamentous support and strong support from bony contour
- some movement. can have effect on pain, stretch, muscle gaurding
112
Nutation and Counter-nutation
- nutation: base (top) of sacrum moves forward
| - counternutation: base (top) of sacrum moves backwards (causes shearing)
113
Resting Position of SI Joint
- neutral between flexion and extension
114
Closed Pack Position of SI Joint
Nutation
115
Capsular pattern of SI Joint
- pain when joints are stressed (compression/gap test)
116
Pubic Symphysis
- cartilaginous joint united by an interpubic fibrocartilage disc
- movement = rotation and translation
117
Rotation of pubic symphysis in males and females
- 2deg for males and females
118
Vertical displacement of pubic symphysis for males and females
- .08mm males
| - 1.6mm females
119
Anterior/Posterior Translation in Pubic Symphysis
- 0.5-0.7
120
Hip Joint
- acetabulum and femur
- one of largest and most stable joints in body
- multi-axial ball and socket joint
- significantly deeper than GH joint
- acetabular labrum increases articular surface area and creates a seal for the central compartment (resists distraction by maintaining a negative pressure)
121
Resting position for the hip joint
- 30deg fledxion
- 30deg abduction
- slight lateral rotation
122
Closed pack position for hip joint
- full extension
- medial rotation
- abduction
123
Capsular pattern for hip joint
- flexion > abduction > medial rotation
| - order of restriction may vary
124
What is the most superior aspect of the pelvis?
Iliac crest
125
Size of the Iliac Tubercle?
- widest point of the crest
| - 3 inches from top of crest
126
What originates at the ASIS?
- Sartorius
- Transverse Abdominis
- Internus Abdominis
- TFL
127
What originates at the AIIS?
- rectus femoris
128
What is just lateral the pubic tubercle?
- pubic rami
129
What is at the level of the gluteal fold?
- Ischial tuberosity
130
What common sources of pain are found at the Ischial tuberosity?
- muscle pain
| - bursitis
131
What is the most prominent lateral aspect of the femur?
- Greater Trochanter
132
What is a common source of pain at the Greater Trochanter?
- trochanteric bursa
| - just posterior to most lateral aspect
133
What landmark is used clinically to check for hip anteversion or retroversion?
Greater Trochanter
134
What is found between the PSIS
- spinous process of S2
135
What is the innervation of the Semimembranosus and Semitendinosus?
- sciatic nerve (tibial division)
136
Biceps femoris Long Head Origin and Insertion
- O: ischial tub and sacrotuberous ligament
- I: head of the fibula
- N: sciatic (tibial division)
137
Biceps Femoris Short Head Origin and Insertion
- O: linea aspera of femur
- I: head of fibula
- N: sciatic nerve (common peroneal division)
138
TFL and ITB Origin and Insertion
- TFL: anterior outer lip of iliac crest and ASIS to ITB
- ITB: anterolateral iliac tubercle to lateral condyle of tibia
- nerve: superior gluteal nerve
139
Glut Med and Min innervation
- superior gluteal nerve
140
Glut Max O/I/N
- O: posterior gluteal line and crest of ilium, dorsal sacrum, lateral coccyx and ST lig
- I: ITB and gluteal tuberosity
- N: inferior gluteal n
141
Piriformis O/I/A
- anterior sacrum and gluteal surface of ilium to superior greater trochanter
- nerve to piriformis
142
Borders of the Femoral Triangle
- superior: inguinal ligament
- lateral: sartorius
- medial: adductor longus
- inferior: pectineus, adductor longus, iliopsoas
143
Contents of Femoral Triangle Medial to Lat
- femoral Canal (lymphatics, lymph nodes)
- femoral vein
- femoral artery
- femoral nerve
144
True leg length discrepancy
- actual bone length inequality
145
Apparent Leg length discrepency
- no true LLD
| - may stem from pelvic obliquity or deformity from the hip
146
Weber-Barstow Maneuver
- patient hooklying, look at femur/tibia length
| - position in prone with knees, look at bottom of feet heights
147
Tape measure for True LLD
- ASIS to medial malleolus
- ASIS to lateral epicondyle
- lateral epicondyle to lateral malleolus
148
Tape measure for apparent LLD
- umbilicus to medial malleolus
149
Total Hip Precautions with new hip replacements
- no flexion beyond 90deg
- no adduction
- no IR
- no crossing legs
- don't bend at hip over sitting position
- use pillow between legs at night when sleeping
150
AROM for hip flexion
- 120deg
151
End feel for hip flexion
- soft (muscle contact with lower ab)
152
Goni placement for hip flexion
- F: greater trochanter
- P: lateral midline of pelvis
- D: lateral midline of femur (lat epicondyle for reference)
153
AROM Hip Abduction
- 40deg
154
end feel for hip Abduction
- firm
| - tension in inferior/medial joint capsule and inferior band oliofemoral lig
155
Goni placement for Hip Abduction
- F: ASIS
- P: horizontal line extending ASIS to other
- D: anterior midline of femur (patella as reference)
156
AROM Hip Adduction
- 20deg
157
End feel Hip Adduction
- firm
| - tension in superior lateral joint capsule
158
Goni placement for Hip Adduction
- F: ASIS
- P: line between ASIS
- D: anterior midline of femur (patella as reference)
159
AROM Hip Extension
- 20deg
160
End Feel Hip Extension
- firm
| - anterior joint capsule and ligaments
161
Goni placement for Hip Extension
- F: greater troch
- P: lateral midline of pelvis
- D: lateral midline of femur (lateral epicondyle of femur as reference)
162
AROM Hip Internal Rotation
- 45deg
163
Endfeel of hip Internal Rot
- firm
| - tension in posterior joint capsule and ischiofemoral ligament
164
Goni placement for Hip internal rotation
- F: anterior aspect of patella
- P: perpendicular to floor or parallel to supporting surface
- D: anterior midline of lower leg (use crest of tibia and point midway between malleoli
165
AROM Hip External Rotation
- 45deg
166
Hip external rotation end feel
- firm
| - tension from anterior joint capsule, iliofemoral lig, pubofemoral lig
167
Goni placements for Hip external rotation
- F: anterior aspect of patella
- P: perpendicular to floor or parallel to supporting surface
- D: anterior midline of lower leg (use crest of tibia and point midway between malleoli)
168
Faber Test
- hip flexin, abduction, and external rotation with knee flexion
- taken by measuring tape from surface of table to knee
- compare to other leg
- normal = parallel to table
- man-cross leg over other while laying supine
169
Thomas Test
- muscle length test of hip flexors
- pt supine
- have pt bring knee to chest
- have hold it tight to stomach
- some pull prior to posterior pelvic tilt
- opposite thigh should stay down on table
170
Modified Thomas Test
- pt resting against end of table with glutes against edge then lay down with resting leg off table
171
Ober Test
- TFL and ITB mm length test
- patient side lying with hip and knee both flexed to 90deg
- while stabilizing pelvis with contact on iliac crest, passively abduct and extend hip to neutral keeping knee at 90
- with hip in neutral, drop leg slowly into adduction (towards table)
- 10deg adduction is normal
- can be modified by keeping knee straight (23deg normal)
172
Functional Hip ROM needed for walking
- 0-30deg flexion
| - 0-15deg extension
173
Function hip ROM for stairs
- ascending: 65deg flexion
| - descending: 40-45deg flexion
174
Function hip ROM for sitting
- 90-112 flexion
175
Functional Hip ROM for putting on socks
- 120deg flexion
- 20deg abduction
- 20deg lateral rotation
176
Functional Hip ROM for squatting
- 115deg fleixon
177
If ASIS is lower, what pelvic tilt do you have?
- anterior pelvic tilt
178
If PSIS is lower, what pelvic tilt do you have?
- post pelvic tilt
179
What attaches at the lesser trochanter?
- iliopsoas
180
Tibiofemoral Joint
- modified hinge joint with 2 DOF
- convex femur
- concave tibia
181
Resting Position of Tibiofemoral Joint
- 25deg flexion
182
Closed Pack Position Tibiofemoral joint
- full extension
| - lateral rotation of the tibia
183
Capsular Pattern Tibiofemoral Joint
- flexion
| - extension
184
Patellofemoral joint
- modified plane joint
185
Resting position of patellofemoral joint
- full extension
186
Closed packed position
- full flexion
187
Capsular Pattern of Patellofemoral joint
- flexion > extension
188
Patella
- sesamoid bone within the patellar tendon
- thickest layer of cartilage
- 5 facets: superior, inferior, medial, lateral, and off
- improves efficiency of extension during last 30deg of extension
- bony shielf for the articular cartilage of the femoral condyles
- improves moment arm, reduce tibiofemoral shear stress
189
Osgood-Schlatter Disease
- distal end of patellar tendon may have excessive overgrowth due to this
190
What is the highest point of the femoral condyles?
- trochlear grove
191
What is the attachment site for LCL and biceps femoris
- fibular head
192
What is the attachment site for the adductor magnus
- adductor tubercle
193
What is the attachment site for medial meniscus
- medial tibial plateau
194
Pes Anserene from Superior to inferior
- sartorius
- gracilis (slightly medial to semitend)
- semitendinosus (post and inferior)
195
Where does the ITB insert?
- onto lateral tibial tubercle
196
Where does biceps femoris tendon insert?
- onto fibular head
197
Popliteal Fossa Borders
- superior lateral: biceps femoris
- superior medial: semiten, semimem
- inferior medial: medial head gastrocs
- inferior lateral: lat head of gastrocs
198
Popliteal fossa contents (deep to superficial)
- Popliteal artery
- popliteal vein
- posterior tibial nerve
199
AROM knee flexion
- 150deg
| - can vary: 132deg ranch and miles
200
Normal end feel knee flexion
- soft (muscle contract between posterior calf and thigh or heel and buttocks)
201
Goni for Knee Flexion
- F: lateral epicondyle of the femur
- P: lateral midline of femur, greater trochanter for reference
- D: lateral midline of fibula, lateral malleolus, and fibular head for reference
202
AROM knee extension
- 0deg
- children as young as 2-8 can be up to 7deg, >10deg in infants
- >5deg in adults = hyperextension/genu recuvatum
203
Normal end feel for knee extension
- firm
| - posterior capsule and ligaments
204
Goni for Knee Extension
- F: lateral epicondyle of femur
- P: lateral midline of femur, greater troch for reference
- D: lateral midline of fibula, lateral malleolus and fibular head for reference
205
Functional knee ROM for stairs
- descending: 80-170deg
| - ascending stairs: 105deg
206
Functional knee ROM for sitting in chair
- depends on seat height
- standard chair: 90-95deg
- low seat/toilet: 110deg
207
Functional Knee ROM for tieing shoes
- up to 106 deg
208
Functional knee ROM to lift objects up from floor
- up to 117deg
209
Hamstrings Muscle Testing
- "90/90"
- patient supine with hip flexeds to 90deg
- passively extend knee as straight as possible
- look for compensation at hip joint
- to quantify the muscle length measure the amount of knee flexion contracture is taken
210
Rectus Femoris Muscle Length Testin
- "Ely's Test"
- patient prone
- passively flex the patient's knee by bringing the heel as close to buttocks
- look for compensation at the hip joint
- hip flexion, hip rotation
- measure the amount of knee flexion that occurs
211
Take knee circumferential measures at
- joint line
- suprapatellar line
- infrapatellar line
212
Where is the tragus located?
just anterior to the external auditory meatus
213
Zygomatic Arch
- anterior to ear canal
- merges with orbit
- formed by temporal and zygomatic bones
214
Movement of mandibular condyle
- 1st motion of opening: rolling
| - 2nd motion of opening: anterior glide (disc glides with mandible)
215
Overbite vs OVerjet
- overbite: verticle overlap (front teeth are literally overing the bottom teeth)
- overjet: horizontal overlap (front teeth are just further anterior than bottom teeth)
216
AROM Mandibular Depression (mouth opening)
- normally 40-50mm
- 3 stacked fingers
- check for any lateral deviations (S or C-shaped)
217
Functional ROM for mandibular depression (opening)
- 30-50mm
- 3-4 fingers
- 2-3 knuckles
218
AROM TMJ LAteral Excursion
- 8-10mm
- varies between 8 and 15
- measured using distance between upper and lower central incisors
- avoid cervical compensation
219
AROM TMJ Protrusion
- 6-9mm
- varies between 3-10mm
- avoid cervical compensation
220
TMJ MMT Grades
- F: functional
- WF: weak functional
- NF: non-functional
- 0 = absent
221
What facial motion activates the Occipitofrontalis?
- raise eyebrows
222
What activates the Corrugator supercilli and procerus muscles?
- pull eyebrows medially
223
What activates the Orbicularis Oculi (orbital)?
- scrunch up eyelid
| - squint(?)
224
What activates the Orbicularis Oculi (palperbral)?
- close the eyelids
225
What activates the Orbicularis Oris?
- close lips
226
What activates the Buccinator?
- cheeck compression
| - fishy face
227
What activates the Levator Anglui Oris?
- smile and sneer
228
What activates the levator labii superior alaeque nasi?
- elevate upper lip
229
What activates the levator labii superioris?
- protract and elevate upper lip
230
What activates zygomaticus major
- laughing
231
What activates the Matalis?
- protrude lower lip
232
What activates depressor anguli oris?
- pull mouth down and laterally?
233
What activates depressor labii inferioris
- curls lip down and laterally
234
What activates platysma
- expression of horror
235
What activates procerus muscle?
- pulls eyebrows medially
236
What are the muscles of masticatoin?
- masseter
- temporalis
- lateral and medial pterygoid
- mylohyoid
- stylohyoid
- geniohyoid
- anterior and posterior digastrics
237
What muscles do jaw opening?
- lateral pterygoid
| - suprahyoid muscles
238
What muscles do lateral jaw deviation?
- lateral and medial pterygoids
- deviation to R: R lateral and L medial pterygoids
- deviation to L: L lateral and R medial pterygoid
- when mouth opens, if naturally deviates, it deviates towards the side of weakness
239
What muscles close the jaw?
- masseter
- temporalis
- medial pterygoid
240
What muscle do jaw protrusion?
- lateral and medial pterygoids
| - with unilateral lesion, protruding jaw deviates to weak side
241
Distal Tibiofibular Joint
- fibrous/syndesmosis joint type
- movement is minimal
- small amount of movement with 1-2mm at ankle to allow full DF
- DF causes fibula to move superiorly which can also stress the proximal tibiofibular joint
- when lose this joint, lose a lot of ankle stability
242
Ligamentous support at Tibiofibular joint
- anterior tibiofibular
- posterior tibiofibular
- inferior transverse
- interosseous/syndesmosis
243
Resting position of distal tibiofibular joint
- plantar flexion
244
Closed packed position of distal tibiofibular joint
- maximum DF
245
capsular pattern of distal tibiofibular joint
- pain when joint is stressed
246
High ankle sprain injures what?
- lose talocrural jt
| - worst ankle sprain
247
Talocrural (ankle) joint
- modified hinge, synovial joint
- talus: wider anteriorly (more mobile in PF, less in DF)
- lateral malleolus of fibula (extends down to almost subtalar level)
- medial malleolus of tibia (extends down to mid-talus)
- responsible for DF and PF!
248
Resting position of talocrural (ankle) joint
- 10deg PF
| - midway between inversion/eversion
249
Closed packed position of Talocrural (ankle) joint
- maximum DF
250
Capsular pattern for talocrural (ankle) joint
- PF, DF
251
Subtalar Joint
- synovial joint
- 3 DOF/tri-planar motion
- inversion/eversion are responsible for alignment of transverse tarsal joint axes (locking and unlocking mid-foot)
- held rigid = at risk for stress fracturs (pes cavus - supinated foot)
252
What happens with a pronated hind foot in subtalar joint
- parallel axes
| - causes increased movement / flexibility
253
What happens with supinated hind foot in subtalar joint?
- axes are not parallel
| - decreased movement (rigid)
254
3 articular facets in subtalar joint
- posterior: talus concave, calcaneus convex
| - 2 anterior: talus is conves, calcaneus is concave
255
Resting position of subtalar joint
- midway between extremes of motion
256
Closed packed position of subtalar joint
- supination
257
capsular pattern of subtalar joint
- varus, valgus
258
Mid-tarsal joints (midfoot)
- talonavicular and calcaneocuboid joints
- minimal movement in isolation
- significant movement when work together, allowing foot to adapt to nany positions
259
Chopart joint
- midtarsal joints between talus-calcaneous and navicular-cuboid
260
Resting position of midfoot (mid tarsal jts)
- midway between extremes of ROM
261
closed packed position for midfoot (mid tarsal jts)
- supination
262
Capsular pattern of f=midfoot (midtarsal jts)
- DF, PF, adduction, medial rotation
263
Joints of the forefoot
- tarsometatarsal joint
- metatarsalpholangeal joints
- interphalangeal joints
264
Resting position of tarsometatarsal joint
- midway between extremes of ROM
265
Closed packed position of tarsometatarsal joint
- supination
266
capsular pattern of tarsometatarsal joint
- NONE
267
Resting position of Metatarspphalangeal joints
- 10deg extension
268
Closed packed position of metatarsophalangeal joints
- full extension
269
Capsular pattern of metatarspphalangeal joints
- big toe: extension, flexion
| - 2-5th toes: variable
270
Resting position of interphalangeal joints
- slight flexion
271
Closed packed position of interphalangeal joints
- full extension
272
capsular pattern of interphalangeal joints
- flexion, extension
273
Movement at talocrural joint
- PF and DF
274
Movement at subtalar joint
- Inversion and eversion
275
Movement at midtarsal joints
- adduction and abduction
276
What is the most distal aspect of the fibula?
- lateral malleolus
277
What are the 3 main ligaments that attach on the lateral malleolus
- anterior talofibular ligament
- calcaneofibular ligament
- posterior talofibular ligament
- can be strained or torn with inversion sprain!
278
What are the ligaments that attach onto the medial malleolus?
- deltoid ligament!
| - includes tibionavicular, tibiocalcaneal, and tibiotalar
279
In what position does the talus move out in?
- plantar flexion b/c talus is wider anteriorly!!
280
What is the small canal under the talus on the outer lateral aspect?
- sinus tarsi
- soft tissue depression just anterior to lateral malleolus
- swelling and pain can occur here
281
What muscle goes through the sinus tarsi?
- extensor digitorum brevis
282
What separates peroneus brevis and longus?
- calcaneus / peroneal tubercle (bump on lateral aspect of calcaneous)
283
What inserts onto the base of the 5th MET
- peroneus brevis
284
What ligament attaches onto the medial tubercle of talus?
- posterior portion of deltoid ligament
285
What attaches at the sustentaculum tali?
- spring ligament!
286
Where is the navicular tubercle?
- most medial prominence distal the sustentaculum tali
287
What 3 main things attach to the medial calcaneal tubercle?
- medially: abductor hallucis
| - anteriorly: flexor digitorum brevis, plantar fascia
288
1st MTP restriction can lead to what
- hallucis rigidis/limitis
| - site of grout
289
What is embedded within flexor hallucis brevis?
- sesmoid bones
290
Where does the deltoid ligament exist?
- anterior to navicular
- inferior to calcaneus
- posterior to talus
291
How to feel tibialis posterior tendon (what position do you put foot/ankle in?)
- invert and PF
292
How to feel flexor digitorum longus tendon? (What position do you put foot in?)
- flex toes
293
how to put ATFL on tension
- PF and invert
| - usually the first ligament "to go" in ankle sprain
294
How to put CFL on tension
- invert with foot in neutral
| - will be posterior to peroneal tubercle
295
how to put PTFL on tension
- resist ankle DF, adduction, medial rotation, AND medial translation of talus
296
Where does the peroneus longus insert?
- inserts onto 1st cuneiform and base of 1st ,et
297
where does the peroneus brevis insert?
- onto the styloid process of the 5th met
298
How to contract peroneus longus and brevis
- eversion
299
What foot position to feel tibialis anterior?
- DF and invert
300
Where is the dorsal pedal artery?
- between EHL and EDL on dorsum of foot
301
Abductor Hallucis
- most medial aspect of the plantar aspect of foot
| - if unable to abduct great toe, shorten foot in standing
302
AROM DF
- 20deg
303
endfeel for DF
- firm
304
Goni placement for DF
- F: lateral aspect of lateral malleolus
- P: lateral midline of fib, head of fib for reference
- D: parallel to lateral aspect of 5th met
305
AROM PF
- 50deg
306
endfeel for PF
- firm
307
Goni placement for PF
- F: lateral aspect of lateral malleolus
- P: lateral midline of fib, head of fib for reference
- D: parallel to lateral aspect of 5th met
308
AROM Inversion
- 35deg
309
endfeel for inversion
- firm
310
Goni placement for inversion
- F: anterior aspect of ankle midway between malleoli
- P: anterior midline of lower leg, tibial tub
- D: anterior midline of second met
311
AROM Eversion
- 15deg
312
Endfeel for eversion
- HARD
313
Goni placement for eversion
- F: anterior aspect of ankle, midway between malleoli
- P: anterior midline of lower leg, tibial tub
- D: anterior midline of second met
314
AROM 1st MTP flexion
- 45deg
315
endfeel for 1st MTP flexion
- firm
316
Goni placement for 1st MTP flexion
- F: dorsal aspect of 1st MTP joint
- P: dorsal midline of met
- D: dorsal midline of proximal phalanx
317
AROM 1st MTP extension
- 70deg
| - can be 80 for athletes
318
endfeel for 1st MTP extension
- firm
319
Goni placement for 1st MTP extension
- F: dorsal aspect of 1st MTP joint
- P: dorsal midline of met
- D: dorsal midline of proximal phalanx
320
Fucntional ankle ROM for gait
- 10-15deg DF for normal stance
321
Functional Ankle ROM for stairs
- acsending: 11-27deg DF
| - descending: 21-36deg DF
322
Functional Ankle ROM for squatting
- 38deg DF
323
Functional ankle ROM for sit to stand
- full DF
324
Landmarks for ankle figure 8 measurement with tape measure
- patient long sitting with ankle off edge
- midway between tibialis anterior and lateral malleolus
- navicular tub
- base of 5th
- distal medial malleolus
- distal lateral malleolus
325
Why do PTs need to know how to view x-rays
- more comprehensive eval is obtained
- PT will look at an x-ray for different reasons than a radiologist (alignment, fracture)
- new vision by APTA helps
326
History of Plain Film Radiography
- discovered by Wilhelm Roentgen in 1895
- named "x-rays" due to uncertain nature of rays
- led to one of the most significant advancements in medical history
- Marie Curie discovered radioactive elements
- awarded nobel prize 1901
- made without contrast enhancement
- form of electromagnetic radiation
327
X-ray Wavelength
- shorter wavelength = the higher the energy and greater penetration of dense substances
- produces ionization of atoms and molecules (loss of electrons)
- results in a gray image on the radiograph
328
Production of a radiograph, requirements:
- an x-ray beam source
- a patient
- an x-ray film or image receptor
329
X-Ray Tube
- cathode (negative) and anode (positive) enclosed in glass envelope which maintains a vacuum (heated thoriated tungsten filament in cathode assembly)
- high voltage current passes through vacuum
- electrons are driven from cathode and strike anode (decelerate and create x-rays via energy consumption)
330
Making a Radiograph
- current is beamed through a series of shutters and directed toward the body (at or near a 90deg angle)
- x-ray beam passes through the body and undergoes a process of attenuation (defined as the gradual loss of intensity as a result of passing through a medium)
- human body absorbs rays in various amounts dependent on tissue characteristics
- x-ray film sensitive to light and radiation, chemical reaction occurs causing an image to be produced in shade of gray in black film
- final image is representation of radio density of anatomical structures the x-rays have passed through
331
Radiodensity
- refers to the amount of blackening on the radiograph
| - determines how much radiation will be absorbed
332
Radiolucent Radiodensity
- does not absorb much radiation
- appears dark grey or black
- air and fat
333
Radiopaque Radiodensity
- absorbs a lot of radiation
- appears more white
- metal and bone
334
Radiodensity is determined by what
- atomic weight or composition (the greater the atomic weight, the greater the radiodensity)
- lead used as shielding device (high atomic weight)
- thickness of object (thicker the object, the more radiation absorbed = more radio dense)
335
Densograph
- radiographs are not photographs, but densographs
- they represent tissue density
- normal tissues are grey, with any observed density changes, one can assume pathology is present
- 75% of film-reading skill is knowledge of anatomy
336
Density of Tissues
- the greater the density of the tissue, the less penetration of the x-rays
- highest density tissues appear white
337
Lowest Density on X-rays
- air
- black
- lungs, trachea, bowel, thin fat, thin connective tissue, adipose
338
Lower Density on X-rays
- fat
- dark grey
- thicker adipose, multiple layers of thin tissue, osteoporotic bone
339
Neutral Density on X-rays
- watery
- mid-density
- mid-gray
- muscle, tendon, thin bones, overlapping soft tissues, blood
340
Higher Density on X-rays
- mineral
- light grey
- cancellous bone, thinner muscle, tendon, organ tissues, superimposition of thin, soft tissues, large blood vessels
341
Highest Density on X-ray
- heavy metals
- white
- thick cortical bone, dental fillings, jewelry, orthopedic hardware, zippers, buttons
342
Third Dimension x-ray Perception
- need more than one radiograph to get info about a structure
- one view is not enough
- two projections are taken at 90deg orientation
- minimizes 2D error
343
Body positioning with radiographs
- specific positioning
- provides best visualization of body area with least number of radiographs
- routine views of skeletal system
344
Viewing Radiographs
- place film on view box as if viewer are X-ray beam
- consider area x-rayed
- consider this area must be closest to film to get accurate picture
- consider the x-rays must pass through the person to get the film
345
Film Markers
- patient ID
- anatomical side markers
- Int / Ext
- WB
- erect, upright
- decubitus
- Insp / exp
- radiographers initials
346
Radiographic Density as a Quality factor
- controlled by varying the milliamperage (mA) and exposure time
- distance of body part from beam affects this well
- under or over exposure
347
Radiographic Contrast as a Quality Factor
- anatomical detail more visible on the x-ray
- greater the variation in anatomical structures, the higher the contrast
- chest radiograph = low contrast
- skeleton = high contrast
348
Contrast
- controlled by kilovoltage (kVp)
- higher the kVp, the greater the energy of the x-ray beam which causes greater entertain through the body parts
- more penetration, more uniform is the picture and will have less variation in tissue absorption and a low contrast radiograph occurs
349
General Rule with radiography Contrast
- use the highest kVp and lowest mA which will yield the best diagnostic info necessary for patient intervention
350
Radiographic Distortion
- difference between the actual object and it's recorded image
- radiographs are 30% larger than actual structure
- shape distortion: unequal magnification of structure (central ray accurate, more inclined the structure = greater distortion)
351
Radiographic Distortion causes
- beam source
- patient
- film
- alignment
- position of central ray
352
Superimposition
- occurs when anatomic structures are stacked or superimposed on one another so that the x-ray beam must penetrate multiple structures before arriving at the film plate
- this may create artificial lines, shapes, and forms that appear unrecognizable or pathological in nature
353
Evaluating Pain Film Radiographs
- ABCD'S
- alignment
- bone density
- cartilage space
- disc space
- soft tissue
354
What to look at when reviewing the Alignment
- general structural architecture
- general contour of bone
- alignment of bone relative to adjacent bones
355
What to look at when reviewing bone density
- general bone density
- texture abnormalities
- local bone density changes
356
What to look at when reviewing cartilage space
- joint space width
- subchondral bone
- epiphyseal plates
357
Epiphyseal plates
- AP ankle radiograph demonstrate medial malleolar epiphyseal fracture, posterior metaphyseal fracture (arrows) with fracture of anterolateral growth plate
- this is a triplane fracture which is a form of Salter Harris type 4 injury
- aka like a growing plate/area
358
What to look at when reviewing disc space
- eval cervical, thoracic, or lumbar spine pathology
359
What to look at when reviewing soft tissue
- muscles
- fat pads
- joint capsules
- periostreum
- miscellaneous soft tissue findings
360
Contrast-Enhanced Radiographs
- contrast medium injected or injested into the body (improves visualization in areas with low contrast)
- can be radiolucent (air)
- can be radiopaque (barium sulfate, Iodide)
- can be dual (see gastrointestinal dual-contrast examination)
Tests and Measures
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