1
Q
3 Joints of the pelvis
A
- L and R SI Joint
- Pubic Symphysis
2
Q
SI Joint Positions
A
- Resting: neutral b/w flexion and extension
- Closed Pack: Nutation
- Capsular: pain when joints are stressed (compression/gap test)
3
Q
2 SI Joints Posteriorly
A
- Synovial articulations with irregular surfaces
- Strong ligamentous support and strong support from bony contour
- Movement? –just a little bit and can have an effect on pain/stretch of ligaments
- -Nutation [forward movement of base] and Counternutation [backward movement of base], shearing
4
Q
Pubic Symphysis
A
- Cartilaginous joint united by a interpubic fibrocartialge disc
- Rotation and translation
- Vertical displacement
- -.08 mm in males
- -1.6 mm in females– More in female than in males [pregnancy]
- Rotation:2 deg for males and females
- AP Translation: 0.5-0.7 mm
5
Q
Hip Joint
A
- type: Multiaxial ball-and-socket joint which is significantly deeper compared to GH joint
- Acetabular labrum increases articular surface area and creates a seal for the central compartment
- -Resists distraction by maintaining a negative pressure
- -Tear labrum = removes seal
6
Q
Hip Positions
A
- Resting: best time to do joint play–30 dg flexion, 30 dg ABD, and slight lateral rotation
- Closed: Full extension, medial rotation, and abduction
- -For sacral intervention: place in this position to prevent damage to this joint
- Capsular Pattern: Flexion, abduction, medial rotation [IR] – order may vary
7
Q
Iliac Crest
A
- most superior aspect of pelvis
- Lay hands flat along the most superior aspect to check for symmetry
8
Q
Iliac Tubercle
A
- 3 in from top of crest
- Widest point of the crest
9
Q
ASIS
A
- Move anterior until you feel the bump
- Drop off and hook under and check for symmtry
- Sartorius and TFL orginates here
10
Q
AIIS
A
- inferior and slightly medial to ASIS
- Rectus femoris originates here
- ask pt to initiate hip flexion with knee extension
11
Q
Pubic Tubercle
A
- superior bony aspect of the pubic symphysis
- 2 approaches:
- -Start with palmar contact, fingers towards belly button and slide down until it bumps against the tubercles and replace your palm with index fingers
- -Have patient find and then replace with your fingers
- -Check for symmetry**
12
Q
Pubic Rami
A
-Laterally from tubercle
13
Q
PSIS
A
- directl under the dimple of the spine just above the butt
- check for symmetry and movement–bending forward
14
Q
SI Joint Palpation
A
- medial to PSIS
- Common location of pain for pts with SI joint dysfunction
15
Q
Spinous Process of S2
A
-medial and inferior to PSIS
16
Q
Sacral Sulcus
A
- Dip b/w the S2 spinous process and the PSIS
- check the dept comparing sides
- -sacral torsion-> rotates to opposite side
17
Q
Inferior Lateral Angle (ILA)
A
- Angle formed at the inferior apex of the sacrum proximal and lateral to the coccyx
- mobilization contact for the SI joint
- can help find sacral torsion
18
Q
Ischial Tuberosity
A
- level of gluteal fold
- palm up, move up until ischial tuberosity rests between the thenar/hypothenar eminences –FINGERS EXTENDED
- pain here could be ischial bursitis or HS strain
- origination of HS (tendinitis)
19
Q
Greater Trochenter
A
- Most prominent lateral aspect of the femur
- Common source of pain due to trochanteric bursa
- -Just posterior to the most lateral aspect
-Used as landmark to clinically check for hip anteversion or retroversion
20
Q
Lesser Trochanter
A
- Located in proximal medial thigh, difficult to palpate
- with pt relxed and supported hip flexion/ER, press down on femur
- Origin of Ilipsoas
21
Q
Posterior and Anterior Tilt
A
Posterior Tilt – ASIS higher
Anterior Tilt – ASIS lower
22
Q
Iliopsoas and Pectineus
A
- Deep! Don’t forget to breathe!
- Patient hooklying or in supported 90/90 position.
23
Q
Psoas only
A
- 2 inches lateral and then to inches inferior to umbilicus
- -Lateral to rectus
- Must go deep (breathe), ask patient to initiate hip flexion to feel it contract
24
Q
Iliacus only
A
- Palpate medial to ASIS and deep
- As patient breathes out attempt to go deeper and press in and laterally
- Ask patient to attempt to flex hip to feel contract
- “Paddy touch” bc tips will be too hard for pts
25
Semimembranosus
- O --> I: Ischial tuberosity to medial tibial condyle
| - Nerve: Sciatic nerve (tibial divison) L5-S2
26
Semitendinosus
- O--> I: Ischial tuberosity to medial tibia via tendon of pes anserinus
- Nerve: Sciatic nerve (tibial division) L5-S2
27
Biceps Femoris
-O-->I:
LH – Ischial tuberosity and sacrotuberus ligament to head of fibula
SH – Linea aspera of femur to head of fibula
-Nerve:
LH – Sciatic nerve (tibial division) L5-S2
SH – Sciatic nerve (common peroneal division) L5-S2
28
Palpation of the HS
- palpate their common origins: pt lay sidelying and bring knee to chest --> tenderness could be damage to HS or ischial bursitis
- pt lay prone and resist knee flexion
29
TFL
- Origin to Insertion: Anterior outer lip of iliac crest and ASIS to ITB
- Innervation: Superior gluteal nerve (L4-S1)
30
ITB
-Origin to Insertion: Anterolateral iliac tubercle to lateral condyle of tibia “Gerdy’s tubercle”.
31
Palpation of TFL / ITB / Sartorius / RF
Palpate ASIS in supine, ER the hip slightly & resist flexion.
A “V” is formed
TFL laterally
Sartorius medially
Space between and distally is rectus femoris
Work you way down the lateral thigh/leg to knee palpating and attempting to “bend” ITB.
32
Gluteus Medius
- Origin -> Insertion: Outer surface of the ilium inferior to crest to lateral/superior greater trochanter
- Innervation: Superior gluteal nerve (L4-S1)
33
Gluteus Minimus
-Origin -> Insertion: Outer surface of ilium between inferior and anterior gluteal lines, margin of greater sciatic notch to anterior greater trochanter
Go through medius to get to minimus
-Innervation: Superior gluteal nerve (L4-S1))
34
Palpation of Gluteus Medius/Minimus
In side lying or standing, palpate below iliac crest asking the patient to perform 1st few degrees of abduction.
Palpate down towards greater trochanter.
Minimus is deep to medius and originates distally.
35
Gluteus Maximus
- Origin -> Insertion: Posterior gluteal line and crest of ilium, dorsal sacrum, lateral coccyx and ST ligament to ITB and gluteal tuberosity
- Innervation: Inferior gluteal nerve (L5-S2
36
Piriformis
-Origin -> Insertion: Anterior sacrum and gluteal surface of ilium to superior greater trochanter
Go through maximus to get to it
-Innervation: Nerve to piriformis (S1-S2)
37
Gluteus Maximus Palpation
- Most posterior and superficial glut muscle
| - Resist hip extension with knee bent to feel it contract.
38
Piriformis Palpation
- Palpate deep to gluteus maximus.
- One finger on the sacrum just inferior to PSIS and the other on the uppermost aspect of the greater trochanter marks the line of pull. Work deep and run fingers perpendicular to the fibers to feel.
39
Palpation of the Sciatic Nerve
-Will feel “spongy” not as firm as we think
-Prone: Approximately half way to a third the distance of the piriformis and distal/deep to that
-Sidelying with hip flexed:
Midway between greater trochanter and ischial tuberosity.
40
Femoral Triangle surface Palpation
- Superior Border: Inguinal ligament
- Lateral Border: Sartorius
- Medial Border: Adductor longus
- Floor:
- -Medial: Pectineus, Adductor longus
- -Lateral: Iliopsoas
41
Femoral Triangle Contents
- Femoral Vein
- Femoral Artery
- Femoral Nerve
- Femoral Canal
--Van Uphill
42
True LLD
- actual bone length inequality
| - Femur, tibia, or both
43
Apparent LLD
- May stem from pelvic obliquity or deformity from the hip.
| - May be from muscle tightness or rotational component
44
Screening LLD
- Excessive movement comes from the lumbar spine where there is extra available movement
- Imaging is most accurate
- -Standing AP computed radiograph
45
Leg Length Evaluation
- Perform Weber-Barstow Maneuver –realign spine by pulling down on legs -Want thumbs on inferior aspect of malleoli - look at knee height
- Palpate Standing: Iliac Crest, ASIS, PSIS
- Palpate Supine: Iliac Crest Height, ASIS (hook underneath), PSIS
46
Leg Length Evaluation with Tape Measure
-True LLD:
ASIS to Medial Malleolus
ASIS to Lateral Epicondyle
Lateral Epicondyle to Lateral Malleolus
-Apparent LLD:
Umbilicus to medial malleolus
47
Total Hip Precautions
General- know open and closed chains– posterior lateral hip approach
- No flexion beyond 90°
- No adduction- pillow between knees
- No IR
- “Do not cross your legs.”
- Do not let patients cross midline.
- “Do not bend your hips more than 90°.”: Actively or passively.
- Do not sit in a low chair, be careful getting up from a chair.
- When taking ROM stop patient at 90° even if they can go beyond it.
- “Do not turn your feet excessively inward/outward.”
48
Hip Flexion ROM
- Normal: 120
- End Feel: Soft
- F= greater trochanter
- S= lat. midline of pelvis
- M=lat. midline of femur (lat. epicondyle of femur)
- Pt supine w/ knees extended & no hip abd/add and rotation.
- Keep CL LE flat
- Also use hand to prevent posterior tilting of pelvis
- As pt flexes hip allow knee to bend
- -Reduces HS tension.
- -MML test
- -Don’t want sciatic nerve problems either
- When ROM is complete, move hand stabilizing pelvis to hold/position proximal arm.
49
Hip Abduction
- Normal: 40
- End Feel: Firm-tension in inferior/medial joint capsule and inferior band iliofemoral ligament
- F: ASIS
- S: From ASIS to CL ASIS
- M: Anterior midline of femur (patella=reference)
- Pt supine w/ knees extended & hips in neutral abd/add and rotation.
- Starting position is 90° on the goni
- Position pt to opposite end of table of leg being tested
- Lets the table support the moving leg.
50
Hip Adduction
-Normal: 20dg
-End Feel: Firm-– tension in superior lateral joint capsule [Superior band of iliofemoral ligament
Tension from gluteus medius, minimus, and TFL may contribute.]
-F= ASIS of leg measured
-S= CL ASIS
-M=midline of femur
- Pt supine w/ knees extended & hips in neutral abd/add and rotation.
- -Starting position is 90°
- Position CL extremity in abd
- -Provides sufficient space to complete full add ROM.
51
Hip Extension
- Normal: 20dg
- End Feel: Firm-anterior joint capsule and ligaments [Iliofemoral > ischialfemoral, and pubofemoral]
- F= greater trochanter
- S= lat. midline of pelvis
- M= lat. midline of femur
- Pt prone with both knees ext. and neutral abd/add and rotation
- Stabilize pelvis with one hand while pt extends hip raising it from the table
- Keep CL leg flat on table.
- Keep knee in extension
- -Reduce tension on rectus femoris.
- At end ROM the PT can use distal hand to support the femur and keep distal goni in alignment.
52
Hip IR
- Normal: 45
- End Feel: Firm-[tension in posterior joint capsule and ischiofemoral ligament]
- F=anterior aspect of patella
- S=perpendicular to floor
- M= midline of lower leg
- Pt short sitting with knees flexed to 90°
- -Place towel under knee if it needs to stay at 90dg
- Place hip in 0° abd/add & in 90° of flexion.
53
Why do you stabilize the distal femur in hip IR/ER AROM?
Prevents compensations
Abd/adduction
Flexion
Lateral tilting of pelvis
54
Hip ER
- Normal: 45dg
- End Feel: Firm-[tension from anterior joint capsule, iliofemoral and pubofemoral lig.]
- F= anterior patella
- S=perpendicular to floor
- M=midline of lower leg
- Pt short sitting with knees flexed to 90°
- -Place towel under knee if it needs to stay at 90dg
- Place hip in 0° abd/add & in 90° of flexion.
55
Faber [Figure 4 Test]
- Hip Flexion, Abduction, and ER with Knee Flexion
- Taken by measuring with tape measure from surface of table to knee.
- Compare to other leg
- Normal = parallel to table
- Neg=no problem
- + = could be a lot of things
56
“Thomas Test”-Hip Flexors
-Pt supine
-Ask pt to bring their knee to chest (non-tested leg)
--Some hold it tight to stomach
--Some pull just prior to a posterior pelvic tilt
-Can assist the pt by holding the knee toward chest to maintain a flat back
-Thigh should be down in contact with table
+ = CL comes up -> hip flexion
-To quantify the ML use same landmarks as measuring hip flexion/extension
57
“Modified Thomas Test” -Hip Flexors
- Pt resting against end of table with glutes against edge then lay down with resting leg off table
- May need to straighten knee to reduce tightness of rectus – 80 deg of flexion considered normal
- See how much knee bends down
- Bend knee -> hip flexion = tight rectus
58
“Ober Test”- TFL and ITB
- Pt side lying with hip and knee both flexed 90 deg
- While stabilizing the pelvis with contact on the iliac crest, passively abduct slightly and extend the hip to neutral keeping the knee at 90 deg.
- With the hip in neutral, drop the leg slowly into adduction (bring it toward table).
- -Don’t allow hip to flex, pelvis to laterally tilt or hip to IR
- 10 deg of adduction is considered normal
- Can be “Modified” by keeping the knee straight, ~23 deg being normal with the modification: Changes length of ITB
To quantify the muscle length use same landmarks as measuring hip abduction/adduction
59
Hip Flexion MMT
- Psoas Major and Iliacus
- Pt sitting, thighs supported on table, legs hanging over the edge.
- Arms can provide trunk stability
- Therapist standing next to pt
- One hand gives downward force over distal thigh proximal to knee.
Grade 2:
Completes ROM in side-lying position with uppermost limb (testing limb) supported by PT
60
Hip Flexion, Abduction, and ER with knee flexion MMT
- Sartorius
- Pt sitting with thighs supported on table, legs hanging. Arms may be used for support. Have pt assume position
- Therapist standing lateral to patient
- -One hand on lateral knee –push into extension
- -One hand on medial/anterior surface of distal leg
Grade 2:
Supine, place heel of limb on CL shin (support if necessary to maintain alignment)
“Slide your heel up to your knee”
61
Hip Extension MMT**
-Gluteus Maximus & HS
-Patient prone
Isolate Gluteus Max by bending knee and resisting proximal to knee
-Therapist to side of leg being tested
--One hand provides resistant to posterior leg just above ankle
--Other hand stabilized pelvis or maintains alignment at PSIS
Grade 2
Completes ROM in side-lying position with uppermost limb (testing limb) supported by PT
62
Hip ABD MMT
-Gluteus Medius and Minimus
-Patient side-lying with test leg “up”, pelvis rotated slightly forward, bottom leg flexed for stability.
Start test with limb slightly extended beyond midline.
-PT standing behind patient
--Have pt close to PT
--One hand on lateral surface of distal thigh/knee or ankle
--Other hand palpation gluteus medius proximal to greater trochanter.
--5=hold leg against strong force on distal leg
WATCH FOR COMPENSTATIONS!
Hip hiking, hip flexion, and/or hip ER
-Grade 2:Completes ROM in supine with no resistance and minimal to 0 friction
63
Hip Abduction (Flexed Position) MMT
- TFL
- Pt side-lying, upper leg flexed to 20-45° and in ER and lies across lower leg, foot resting on table.
- PT standing behind pt.
- -One hand giving resistance on lateral surface of thigh just above knee into adduction and extension
- -Other hand providing stabilization on crest of ilium.
Grade 2
Pt able to abduct to 30 deg long sitting
64
Hip Adduction MMT
- Adductors, Pectineus, and Gracilis
- Pt side-lying with test leg on “bottom”,
- PT behind patient
- -One hand giving resistance to test leg at medial thigh just proximal to knee.
- -Other hand supporting “top” leg at 25° abduction.
Grade 2
Pt adducts limb through full range in supine
65
Hip ER MMT
- Deep ERs, piriformis, and posterior gluteus maximus
- Pt sitting, trunk may be supported by hands at sides.
- PT sitting on stool/kneeling beside testing limb
- -One hand resists at medial ankle just above the malleolus
- -Other hand offers counter pressure over lateral aspect of distal thigh
Grade 2
Patient able to roll leg out in supine
66
Hip IR MMT
- Gultei Minimus and medius, TFL
- Pt sitting, trunk may be supported by hands at sides.
- PT sitting on stool/kneeling in front of patient
- -One hand grasps lateral ankle just above the malleolus
- -Other hand offers counter pressure over medial aspect of distal thigh
Grade 2
Able to roll leg in with patient in supine
Test and Measures
flashcards
Decks in class (8)
# Cards
