Lecture Flashcards

O&P Lecture Flashcards

Why is it good to have a shallow shoulder socket? Provides good flexibility

Why is it bad to have a shallow shoulder socket?

What forces are transmitted through the clavicles?

What are the names for the two joints where the radius and ulna articulate with each other?

What structure connects the radius and ulna?

In anatomical position, which forearm bone is lateral and which is medial?

Which bone contributes heavily to the wrist joint; the radius or ulna?

Which forearm bone moves the hand?

Which forearm bone forms the elbow joint?

Causing stability problems

Compression forces from upper limbs to the axial skeleton

Proximal and distal radioulnar joints

Interosseous membrane

Radius is lateral (thumb side) and ulna is medial

(pinky side)

Radius

Are plane joints considered to be axial joints?

Radius

Ulna

What separates the distal end of the ulna from the carpals?

What is the name of a fracture of the distal end of the radius?

Which row of carpals forms the true wrist?

Fibrocartilage

Colles’ fracture

The proximal row

What type of movement occurs between the carpals? Gliding

What is the medical term for the thumb?

What type of movement occurs in a plane joint?

Pollex

Movement in one plane; either the transverse or frontal plane (called a gliding motion). It does not include the sagittal plane (that is a hinge joint)

No; movement does not occur around an axis.

What type of joints are the carpal bones?

What type of movement do hinge joints have?

Plane joints.

Movement around an axis in the sagittal plane only (uniaxial).

Elbow and interphalangeal joints (IPJ’s) What are examples of hinge joints?

What type of movement do pivot joints have?

What are examples of a pivot joint?

Rotation around a vertical axis (uniaxial)

Proximal radioulnar joint and between the first two cervical vertebrae.

Annular ligament What structure encircles the head of the radius?

What type of movement do condyloid joints have?

What is an example of a condyloid joint?

Movement in two planes (biaxial)

Metacarpal-phalangeal joints (MPJ’s)

What is the definition of a saddle joint? Both sides are concave on one side and convex on the other.

What type of movement is allowed by saddle joints? Movement in two planes (biaxial)

What type of joint allows for an opposable thumb? Saddle joint


What is an example of a saddle joint? At the base of the thumb (between the trapezium and first metacarpal

Movement in three planes (multiaxial) What type of movement does a ball and socket joint have?

What is an example of a ball and socket joint? Shoulder and hip

What is the term for a freely moveable joint, such as the shoulder?

What are the four important shoulder ligaments?

Diarthrotic

Glenohumeral

Coracohumeral

Transverse humeral

Coracoacromial

Sternoclavicular joint What is the name of the joint between the sternum and clavicle?

What is the term for the tissue that surrounds the glenoid cavity, causing the socket to become deeper?

Glenoid labrum

What is the name of the joint between the radius and scaphoid/lunate?

Radiocarpal joint

What is the term for the joints between the carpals? Intercarpal joints

What are the two categories by which disorders of the body are classified?

What is the term for congenital damage to the brachial plexus?

What is crutch paralysis?

Congenital (born with it)

Acquired (happens after birth)

Klumpke’s paralysis

What is claw hand?

Total upper extremity paralysis from leaning on the crutches

Ulnar nerve damage

What is Wrist drop (waiter’s hand)? Radial nerve damage

What nerve is damaged in carpal tunnel syndrome

(Hand of Benediction, Ape hand)?

Medial nerve

What are the 5 major nerves of the upper extremity? Axillary, musculocutaneus, median, ulnar, radial

What two muscles are supplied by the axillary nerve? Deltoid and teres minor

What nerve supplies the anterior arm muscles?

What nerve supplies most of the anterior forearm muscles? Which muscle does it not supply?

What is the name of the ligament that forms the tarsal tunnel?

Why do they call median nerve damage “Ape hand”?

What situation often causes Ape hand? musculocutaneus

Medial nerve; does not supply flexor carpi ulnaris

Transverse carpal ligament

What nerve supplies flexor carpi ulnaris?

What is the layman’s term for this nerve?

They are not able to move the thumb towards the little finger, so it is hard to pick up small objects. Suicide attempts of slitting the wrists often lead to this condition.

Ulnar nerve (“funny bone”)


Why is damage to the ulnar nerve called claw hand? With the flexor carpi ulnaris paralyzed, the extensor carpi ulnaris gains a mechanical advantage, and pulls the two little fingers upward. The person cannot adduct or abduct the fingers, either.

What nerve supplies the posterior arm and forearm? Radial nerve

What are the 5 major arteries of the upper extremity? Subclavian, axillary, brachial, radial, ulnar

What artery supplies all of the arm muscles except triceps brachii?

What artery supplies triceps brachii?

Brachial

Axillary

What artery becomes the axillary artery in the Subclavian armpit?

What artery becomes the brachial artery in the arm? Axillary

What artery divides into radial and ulnar arteries when it reaches the elbow?

Brachial


• Susan reports shoulder pain located at the proximal lateral humerus. The pain is worse when sleeping on the right shoulder, and also when she elevates her arm.

• This location is consistent with pain originating from the shoulder cuff tendons, the long head of biceps femoris, or subacromial bursa.

• What four things might be causing the pain?

Pain from laying on the shoulder is consistent with pain originating from where?

What actions cause compression of the subacromial bursa? What action may cause a supraspinatus tendon tear, due to pinching of its nutrient vessels?

What muscle participates in humeral elevation throughout its range of motion, and is under tension most of a person’s waking hours and is vulnerable to tensile overload?

What muscle is the most vulnerable of the cuff muscles?

What is the “painful arc” of rotator cuff tendonitis?

Rotator cuff injury

Bursitis

Biceps brachii tendonitis

Upper trapezius strain the subacromial space

In both cases: When the arm is elevated and especially when carrying a load in that position

Supraspinatus

Supraspinatus

Pain between 60-120 degrees of humeral elevation in relation to the trunk. the acromial-clavicular joint. If the pain occurs beyond 120 degrees, it is more likely to be from degeneration of which joint?

What are the symptoms of rotator cuff injuries?

How are rotator cuff injuries diagnosed?

What are 5 causes of rotator cuff injuries?

What is the relationship between trapezius and serratus anterior?

Overuse and damage to trapezius can result in what symptoms?

What can cause an upper-trapezius strain?

Pain and tenderness in the shoulder, especially when reaching overhead, reaching behind the back, lifting, pulling or sleeping on the affected side.

– X-rays

– MRI

– Ultrasound

Normal wear and tear

Poor posture

Falling on the arm

Lifting (esp. overhead) or pulling

Repetitive overhead movement (baseball, swimmers, tennis players, painters, carpenters)

Serratus anterior and trapezius both abduct the arm. Trapezius can abduct the arm through its full range of motion, although it is weaker without serratus anterior. a shoulder shrug motion when trying to elevate the arm, and fatigue and pain in that muscle. consistently overusing the muscle group, even at a low intensity; repetitive motions do not allow the affected tissue to rest between movements


What is a common example of how a desk worker can get an upper trapezius strain?

What movements put stress on trapezius? habitually holding a telephone between the ear and shoulder

Shrugging the shoulders and overhead movements or when the shoulder is elevated and the neck is extended, side-bent and rotated, as when you are cradling a phone between your ear and shoulder.

What movements put stress on the rhomboids?

What are 5 trapezius excersises one can do at the office?

When the shoulders are rounded (poor posture)

1.

Scapular pinches

2.

Shoulder shrugs

3.

Neck side-bending

4.

Neck rotation

5.

Neck stretching

Flexed at about 80 degrees How does a patient naturally hold a sore elbow to minimize the tension of the capsule?

Most elbow pain results from what movements?

What are some activities that cause it?

What is the common cause of elbow dislocations in adults? In children?

What is the location of pain from tennis elbow?

How is it diagnosed?

What is the location of pain from golfer’s elbow?

How is it caused?

What is cubital tunnel syndrome? overuse injuries from sports, hobbies and jobs that require repetitive hand, wrist or arm movements.

Adults: falling

Children: being pulled by the arm (Nursemaid’s elbow)

Lateral epicondylitis. Diagnos by resisting extension of the third finger to reproduce the pain there.

Medial epicondylitis; caused by repeatedly flexing wrists or clenching fingers ulnar nerve on the inside of the elbow is irritated or injured

Little league elbow syndrome (pitcher's elbow) What is an injury mainly affecting children and rapidly growing adolescents involved in throwing sports such as baseball?

What might cause pain at the tip of the elbow?

What is Osteochondritis dissecans?

How does it occur?

Olecranon bursitis

Destruction of bone or cartilage due to reduced blood flow to the end of a bone, occurs most often in young men, particularly after an injury to a joint.

Radial tunnel syndrome In what syndrome does the radial nerve become compressed just beyond the elbow?

What are 8 common treatments for elbow and wrist pain?

• Splinting

• Forearm support bands

• Taping

• Ultrasound

• Manipulation

• Exercise

• Oral anti-inflammatory medicines

•

Cortisone injections


What is Tinel’s sign?

What is a positive Phalen’s test?

What are the first two treatments for Carpal Tunnel

Syndrome?

Are the collateral ligaments of the MPJ’s tight or slack with extension?

What would happen if you immobilized a wrist in an extended position?

In what position should the hand be splinted?

Tapping on the carpal tunnel causes parathesias

(tingling) in the median nerve distribution

Placing the wrist in sustained flexion for one minute also causes the parathesias of carpal tunnel syndrome

Splint the wrist and patient education on proper ergonomics (use a wrist pad while typing)

Slack

It would place the collateral ligaments at risk for adaptive shortening, limiting joint flexion, which impairs grasp.

The MPJ’s should be held in flexion.

The IP joints should be held in extension

The thumb should be placed in slight abduction

Carpal Tunnel Syndrom is damage to which nerve? Median nerve

Cubital Tunnel Syndrome is damage to which nerve? Ulnar nerve

When does this injury (Cubital Tunnel Syndrome) usually occur?

What muscle alone can extend the IP joints of the two small fingers if full MPJ extension is prevented?

How is a splint for ulnar nerve damage shaped?

When the medial epicondyle is struck while the elbow is flexed extensor digitorum so the flexor digitorum longus can still flex.

Why does ulnar nerve damage cause claw hand?

What is Wartenberg’s sign?

What is trigger finger, and what causes it? because the flexors become weak, giving the extensors a mechanical advantage, pulling the two little fingers into a claw.

The little finger assumes an MPJ abduction position after ulnar nerve damage. repetitive trauma to a flexor tendon results in the formation of nodules on the tendon. Finger flexion may be prevented completely, or the finger may be unable to re-extend.


Which is more common: upper or lower extremity fractures?

When a carpal is fractured, is it more likely to be in the proximal or distal row?

Which three carpals are most often fractured?

Which carpal is the least often fractured?

Which one carpal is most often fractured?

How is the pisiform usually fractured?

Because it is an achor for several other ligamentous attachments, when the pisiform is fractured, there is a 50% chance of what other injury?

What causes a fracture of the scaphoid?

Upper extremity

Proximal

Common: scaphoid, lunate, triquetrum

Uncommon: pisiform

Most common: scaphoid

From a fall on the outstretched hand with the wrist in extension or if the heel of the hand is used like a hammer. injury to the distal radius or to another carpal bone

Where is the anatomical snuffbox? a fall onto an outstretched hand.

It is a triangular deepening on the radial, dorsal aspect of the hand, above the scaphoid and trapezium.

Why is the anatomical snuffbox clinically significant? It is where most of the force goes during a fall on an outstretched hand. Pain there may indicate a fractured scaphoid.

What is unusual about the blood supply to the scaphoid, and why is this clinically significant?

Blood enters the scaphoid distally.

Consequently, in the event of a fracture the

How many of each type of vertebrae are there? proximal segment of the scaphoid will be devoid of a vascular supply, and will—if action is not taken—avascularly necrose (die)

7 cervical, 12 thoracic, 5 lumbar, 5 sacral

What is the outer layer of an intervertebral disc called? What is the inner layer called?

What is one of the reasons why posteriolateral herniations are more common in the lumbar region?

Outer layer: Anulus fibrosus

Inner layer: Nucleus pulposis

Posterior longitudinal ligament ligament in the lumbar region does not provide much support to the intervertebral discs

Increased pain in the flexed position What is the main symptom of a PLL defect with subsequent herniation?

What area of the body is supplied by the cervical plexus?

Skin of the neck, back of head, and upper shoulder, as well as the phrenic nerve


What does the phrenic nerve supply? The diaphragm

What is a lateral curvature of the spine called?

What is a hump-back called?

Scoliosis

Kyphosis

What is a sway-back in the lumbar region called? Lordosis

How can scoliosis mimic asthma?

What is the Boston scoliosis brace?

Rotation of the vertebrae can decrease pulmonary reserve, leading to difficulty breathing upon exertion.

A firmly fitting pelvic girdle that prevents worsening of scoliosis.

What is a drawback of a scoliosis brace?

• Joe is a 33 year old construction worker who, for several months, has been experiencing moderate to severe low back pain which radiates into his right buttock.

• He has pain with carrying, and all lifting activities. He can relieve the pain somewhat when sitting or laying down, but has only been able to work for 4 hours at a time.

• His history includes several episodes of low back pain that were severe but resolved in a few days.

• What are the most likely causes of his pain?

It decreases the ability to breathe by 20% so it cannot be worn during sport activities

1) Sciatica

a) Herniated disc

b) Piriformis syndrome

2) Spondylolisthesis

Is pain from sciatica worse when sitting or standing? Sitting makes it worse

What is sciatica? pain, weakness, numbness, or tingling in the leg. It is caused by injury to or pressure on the sciatic nerve.

What are other things that make sciatic pain worse? Sneezing, coughing, laughing

Bending backwards

Walking more than a few yards

It is worse at night

What are the two most common causes of sciatica? Herniated intervertebral disc

Piriformis syndrome

What are the two most common treatments for herniated discs?

Oral or injected anti-inflammatory meds

Surgery

What is the most common treatment for piriformis syndrome?

What is radiculopathy?

Stretching exercises (lay supine and pull one knee to the opposite shoulder)

Any disease that affects the spinal nerve roots.

A herniated disc is one cause of radiculopathy.

What are the 3 main diagnostic tests that may be performed to diagnos sciatica?

1) Electomyelogram (EMG) to determine the exact nerve root involved

2) Nerve conduction velocity test

3) MRI or CT scan


When you suspect sciatica as a diagnosis except that sitting makes the pain better instead of worse, what other condition would you now suspect?

Why is pain better when sitting with

Spondylolisthesis?

Spondylolisthesis

Flexion activities such as sitting decreases the anterior shear forces on the lumbar spine.

Extension activities are the most painful with this disorder.

What can cause loss of disc height?

What is the most common motion that causes a herniated lumbar disc?

How do the position of the superior and inferior articular facets in the lumbar region predispose some people to herniated discs?

Anterior sheer forces in the lubar region puts stress on what 4 structures?

What two things can be done to control excessive anterior sheer forces?

If you are too tall for your seat, what excess force is being applied to your lumbar discs?

If you are too short for your seat, what excess force is being applied to your lumbar discs?

What motions might a person do while sitting that can injure their back?

What are the three directions of force that can injure a "pre-flexed" intervertebral joint?

Extension of discs (L4-L5 and L5-S1) twisting in the chair (to open a file cabinet, etc)

• Over flexing of the Lower Spine

• Anterior Shear of the Lower Spine

• Twisting/Side Bend of the Lower Spine

Sitting in a chair many hours a day What causes Over flexing of the Lower Spine?

What is anterior shear?

Loss of fluid due to damage of the anulus fibrosus

Flexion with rotation (as in lifting a box and then twisting to the side without moving the feet)

If their facets are oriented entirely in the sagittal plane, they offer little bony resistance to anterior sheer forces.

The iliolumbar ligaments

The posterior anulus fibrosus

The PLL

The joint capsules exercises to maximize the ability of the deep erector spinae muscles, and wearing a lumbosacral brace.

Flexion of discs (L4-L5 and L5-S1)

At what level of the vertebral column does most anterior shear force occur? when a vertebra slips forward on the vertebra immediately below it

L4-L5 and L5-S1


Does it takes more or less anterior shear force to damage the flexed intervertebral joint as compared with the same joint in neutral?

When falling on the buttocks while in the “chair sitter” position of lumbar flexion, what happens?

Less

They are 5x more likely to sustain damage from anterior sheer forces

How does lumbar flexion differ from hip flexion?

What muscles in the low and middle back become overworked and painful when subjected to anterior shear forces?

You can flex your hips while keeping the spine straight. This is especially important when squatting. Lumbar flexion is dangerous; hip flexion is not.

Deep errector spinae

For low back injuries, should therapy focus on strengthening or stretching deep errector spinae muscles?

What muscles in the cervical region become overworked and painful when subjected to anterior shear forces (flexion of the neck)?

Strengthening only. Stretching may worsen symptoms

Levator scapulae

For upper back injuries, should therapy focus on strengthening or stretching levator scapulae muscles?

What can help stabilize the trunk?

At what point in rehabilitation of upper back injuries should upper extremity strengthening begin?

Stretching (the anterior shear forces are restrained by other structures)

Exercises that involve strengthening the upper extremity, since they produce tension on the fascia (connective tissue) that connects those muscle groups.

Immediately, since it does not produce trunk movement.


Exercises to increase the strength of the back extensors are often performed in what body position?

What low back exercises produce the lowest compression forces in the low back?

Are sit-ups good or bad for a back injury? prone position single-leg extension while on the hands and knees

Bad

What type of joint is the most moveable? Ball and socket (shoulder and hip)

What holds the head of the femur in the acetabulum? Tranverse acetabular ligament (over the

What are the five major ligaments of the femur? acetabular notch)

Transverse acetabular

Iliofemoral

Which hip ligament is the weakest, and is of little importance in strengthening the hip joint?

Pubofemoral

Ishiofemoral

Ligamentum Teres

Ligamentum teres


What is hip dysplasia?

Longest muscle:

Strongest muscle:

Biggest muscle:

What structure connects the tibia and fibula?

Head of the femur slips out of acetabulum

Longest muscle: Sartorius

Strongest muscle: Gluteus maximus

Biggest muscle: Latissimus dorsi

Interosseous membrane

What is the knee joint also known as? Tibiofemoral joint and patellofemoral joint

Knee joint What is the largest and most complex diarthrosis of the body?

What type of movements are allowed by the knee?

What are the 3 articulations of the knee?

Does the fibula articulate with the femur?

What are the three extracapsular ligaments of the knee?

What structures prevent the knee from rotating when the joint is extended?

What are the two intracapsular ligaments of the knee?

Are they inside the synovial cavity?

Which cruciate ligament is weaker?

It is mainly a Hinge joint, but has movements of gliding, rolling and rotation lateral and medial articulations of femur and tibia; intermediate articulation of patella and femur. Note: Fibula does not articulate with the femur, only with the tibia.

Patellar ligament (patellar tendon)

Medial and lateral collateral

The two collateral ligaments

Anterior and posterior cruciate

They are deep within the joint cavity, but they are not inside the fluid-filled synovial cavity.

Anterior cruciate

Which cruciate ligament is slack when knee is flexed, taut when fully extended?

Which cruciate ligament prevents posterior displacement of femur and hyperextension of knee joint?

Which cruciate ligament is taut during flexion, prevents anterior displacement of femur on the tibia?

Which cruciate ligament is the main stabilizing factor when weight-bearing during flexed knee position (ie.

Walking downhill.)

What type of cartilage are the menisci made of?

Are they thicker laterally or on the inside?

What is their function?

When the knee is extended, what does the ACL do?

When the knee if flexed, what does the PCL do?

Anterior cruciate

Anterior cruciate

Posterior cruciate

Posterior cruciate

Fibrocartilage

Thicker laterally

Shock absorption and prevent the femur from rocking from side to side on the tibia the ACL is pulled tight and prevents hyperextension. the PCL prevents the femur from sliding off the front of the tibia and prevents the tibia from being displaced backward

How are the ACL and PCL named?


By their attachment to the tibia

What is the “unhappy triad”? After a blow to the lateral side of the knee, the

ACL, tibial collateral ligament, and medial meniscus are torn


What are the two main nerves of the lumbosacral plexus?

Femoral (anterior)

Sciatic (posterior)

What are the 7 major nerves of the lower extremity? Obturator

Sciatic

Femoral

Tibial

Common, superficial, and deep peroneal

What muscles are supplied by the obturator nerve? Adductor muscles of the thigh


What muscles are supplied by the femoral nerve? Anterior Thigh (Quadriceps femoris)

What muscles are supplied by the sciatic nerve?

What muscles are supplied by the tibial nerve?

What muscles are supplied by the superficial branch of the common peroneal nerve?

What muscles are supplied by the deep branch of the common peroneal nerve?

Injury to what nerve causes “foot drop”?

Back of the thigh (hamstrings)

Leg, and foot

Posterior leg and foot, eg. Gastrocnemius,

Soleus, Tibialis Posterior

Lateral leg (peroneal muscles)

Anterior leg deep branch of the common peroneal nerve

What are the main arteries to the lower extremity?

Which arteries are superficial enough to detect a pulse or draw blood?

Which artery becomes the femoral artery?

External iliac

Femoral

Popliteal

Anterior and posterior tibial

Dorsalis pedis

Femoral (groin)

Popliteal (behind the knee)

Posterior tibial (medial ankle)

Dorsalis pedis (top of foot)

External iliac

Which artery becomes the popliteal artery?

Which artery becomes the tibial artery?

What artery supplies all the muscles of the thigh?

What arety supplies the leg muscles?

What artery is on top of the foot, where you can feel a pulse?

What is Peripheral Vascular Disease (PVD)?

What are the 4 symptoms of PVD?

What is claudication?

Femoral

Popliteal

Femoral

Tibial

Dorsalis pedis obstruction of large arteries, frequently in the lower extremity. Usually caused from atherosclerosis (fatty plaques).

Claudication

Slow healing wounds

Change in color and temperature

Diminished hair and nail growth pain, weakness, numbness, or cramping in muscles due to decreased blood flow


Where is the center of mass (CoM)? What does its precise location depend on? Does it change location as the body moves in space?

Anterior to S2

Depends on the person’s weight distribution

It does not change

Where is the line of gravity (LoG)? Does it change? Between the feet, parallel to the trunk and limbs. If a person bends over, it changes.

What permits a wide excursion of the LoG without falling over?

A wide base of support

What forms the CoM for the lower limbs?

What forms the CoM for the entire body?

The CoM for the left leg + CoM right leg

CoM for lower limbs + CoM for trunk

How do weights affect the CoM?


What is a Grade I sprain?

It shifts the CoM. A cast on the leg or carring a load on the shoulder will shift CoM

Injury to a few fibers of the ligament

What is a Grade II sprain?

What is a Grade III sprain?

Partial tear of the ligament

Complete rupture of the ligament

What is an abnormal range of motion (ROM)?

What problems does that cause?

What is hypermobility?

What causes hypomobility?

Sam Alexander is 20 years old. His foot was caught in a gopher hole while golfing. He suffered a tear in the medial collateral ligament, a partial tear of the ACL, and partial tear of the medial meniscus. What should his treatment plan include? when a joint exceeds or fails to reach the normal anatomic limits of motion. It causes undesirable effects at the affected and adjacent joints.

Failure to limit motion by either boney or soft tissues. May lead to instability.

Caused by boney or cartilaginous blocks, or inability of the capsule, ligaments, or muscles to elongate sufficiently. A contracture

(shortening of soft tissues near a joint) may also cause hypomobility. strengthening of the quadriceps, using a legpress machine and a free weight boot.

What are some causes of immobilization, and what problems does it cause?

What effect does immobilization have on ligaments and tendons? How long does recovery take?

Caused by a cast, bed rest, denervation, or as a reaction to pain. The joint capsule will adapt

(shorten) and contractures will develop in the surrounding soft tissues. Resumption of a normal ROM will be difficult.

Decreases their tensile strength and increases stiffness up to 50% after 8 weeks of immobilization. Recovery can take weeks to 2 years.

What other problems are there from immobilization? can also cause adhesions between the folds of synovium, atrophy of cartilage, regional osteoporosis, weakening of ligaments at their insertion sites as a result of osteoclastic resportion of bone, and an increase in the water content of articular cartilage.


What joints are particularly affected by immobilization?

• When the cast is removed from George’s leg, he has 10° dorsiflexion and 20 ° plantarflexion, and his subtalar motion is restricted.

• How will his activities be affected?

• How can we restore his subtalar joint (STJ) range of motion?

How do all tissues respond to gradual progressive loading?

What does the tissue response depend on?

Knee joints

This will affect his ability to squat, walk, adapt to uneven surfaces.

Stretching

They respond favorably by adapting to meet the increased mechanical demands the nature of the stimulus, the amount, type, and frequency of loading increase cartilage formation. What does low frequency compressive loading do to tissues?

What does high frequency compressive loading do to tissues?

What does higher magnitude or sustained loading do to tissues?

What induces tissue formation in tendons and ligaments? enhance bone synthesis. induce fibrocartilage formation.

Tensile loads

What does maintenance of these physical therapy techniques require?

Overuse damage can occur in what two ways? repetitive loading beyond a threshold level.

Sudden application of large loads

Repeated application of low loads

Rupture of tendons and bone fractures What injurys do sudden application of large loads cause?

What injuries are caused by repeated application of low loads? deformities, including chronic back pain or tendon injuries. Ligaments may lengthen excessively.

What might happen to the knee after loss of the ACL? Knee hypermobility

What happens to cartilage that is subjected to constant compressive loading?

Why are joints and their supporting structures injured when they are subjected to repetitive loading?

What types of activities are prone to repetitive injuries?

Are women or men more prone to repetitive injuries?

Why?

It will creep and deform because they do not have time to recover their original dimensions before they are subjected to another loading cycle athletes, dancers, farmers, musicians, computer users

More common in women, perhaps because collagen deposition decreases during hormone cycles.


• Gloria is 78 years old, having increasing problems with hip pain, localized in the left groin. When she was a teenager, her doctor told her she would have problems with her hip when she got older. X-rays show a shallow acetabulum. What is her diagnosis?

What structure deepens the acetabulum? developmental hip dysplasia with osteoarthritis on the left hip

The acetabular labrum

Tears in the acetabular labrum are a starting point for what?

• Gloria walks with asymmetrical toe-out, with the right greater than the left. She has a slight left lateral lean during left stance. There is a

1” leg length discrepancy, with the left leg shorter.

• In the supine position, medial rotation of the left hip is much greater than lateral rotation.

This asymmetry is not evident on the right.

She finds passive hip flexion with medial rotation painful on the left. What structure is

probably damaged?

When a person has a damaged acetabular labrum how does this affect the hip joint?

What does varus mean?

What does valgus mean?

What is the angle of inclination of the femur? degenerative changes

The superior portion of the acetabular labrum

The stress distribution within the joint is concentrated in a smaller weight-bearing area throughout the gait cycle. That leads to degenerative changes over time. inward angulation of the distal segment of a bone or joint. outward angulation of the distal segment of a bone or joint.

The angle between the anatomical neck and the diaphysis of the femur

Who has a larger angle of inclination of the femur, men or women?

Women


If the angleof inclination of the femur is larger than

126°, what is it called?

If the angle of inclination of the femur is smaller than

126°, what is it called?

What is the angle of torson of the femur?

Coxa valga

Coxa vara

The angle of the anatomical neck with the axis of the femoral condyles.

What is the term if the angle of torsion of the femur is too high?

What is the term if the angle of torsion of the femur is too low?

Gloria’s structural deviations of femoral anteversion, coxa valga, and shallow acetabulum result in what problems?

What could have been done for Gloria in infancy?

Anteversion

Retroversion increased exposure of the femoral head, less congruence, and reduced stability of the hip joint when weight bearing. frog-leg positioning might have been maintained using a Pavlik harness.The position of flexion, abduction, and rotation improves articular contact.

What is the zone of weakness in the femur?

Gloria walks with asymmetrical toe-out, with the right greater than the left. What structural abnormality does this correspond with?

How do you test for femoral anteversion?

An area of spongy bone in the anatomical neck.

It may be a factor in hip fractures.

Femoral anteversion

In the supine position, hip extended, she has more hip joint medial rotation than lateral rotation.


With an anteverted femur, in which direction does the affected hip rotate during gait?

The affected side rotates medially, called medial femoral torsion. It is done unconsciously to minimize stretch on the capsule. in-toe stance and gait Femoral anteversion results in what type of stance and gait?

What is tibial torsion?

If a person has medial femoral torsion with an equal amount of lateral tibial torsion, what position would the foot be in?

How would this affect the knee joint?

What are two motions in the sagittal plane, producing hip flexion and extension while the feet are on the ground?

What is a motion of the pelvis in the frontal plane called?

What does lateral pelvic tilt do to the other side?

When the distal end of the tibia is twisted either medially or laterally.

If both torsions were in the same proportion, the foot would not be rotated too far medially or laterally; the opposite torsions would cancel each other out. However, there would be stress on the knee joint. When the patient stands straight, the patella will face medially although the foot points straight ahead.

• Anterior pelvic tilt  Hip flexion

• Posterior pelvic tilt  Hip extension

• Lateral pelvic tilt

What effect does pelvic tilt have on the femur?

Pelvic hiking (elevation of the opposite side) or

Pelvic dropping (dropping of the opposite side).

When the pelvis is shifted to the right when standing, the right hip joint will be adducted and the left will be abducted.

What is pelvic motion in the transverse plane called? Pelvic rotation

What does forward rotation of the pelvis around the right hip joint results in?

What does backward rotation of the pelvis around the right hip joint results in? medial rotation of the right hip joint. lateral rotation of the right hip joint


In a leg length discreptancy (LLD), will the pelvis drop to the short side or the long side?

In a leg length discreptancy, will the lumbar spine be laterally flexed towards the short side or away from the short side?

In a leg length discreptancy, will the shoulders tilt in the same direction as the hips or in the opposite direction?

In a leg length discreptancy, will the cervical spine laterally flex towards or away from the short side?

Short side

Away from the short side

Opposite direction (if the short side is the left, the shoulder will drop on the right). The shoulders tilt downward on the long side.

Towards the short side

If the pain is on the left, what side is the cane used Right on?

Left (the side with the pain) If the pain is on the left, on what side should groceries and other loads be carried?

What percent of a person’s body weight is the 25% maximum they should carry?

What term means “on the same side”? Ipsilateral

What term means “on the opposite side”?

The longitudinal axis of the femur is oblique. That places more force on what side of the knee?

Contralateral

Medial side


The longitudinal axis of the tibia is what? Vertical

What is the normal anterior angle of the femur and tibia at the knee? What is this position called?

180-185° at the knee joint (so normally there is a slight valgus of the knee, up to 5°)

Greater than 185° at the knee is called what?

Less than 175° at the knee is called what?

During gait, the line of force shifts where?

This medial shift causes what forces at the knee? genu valgum (knock-kneed) genu varum (bow-legged) medially to the knee joint center increases the compressive stresses medially and increases the tensile stresses laterally.

Genu valgum shifts the weight-bearing line where?

What forces does it cause?

What effect does genu valgum have on the knee cartilage? onto the lateral compartment, increasing lateral compression while increasing the tensile forces on the medial collateral ligaments.

Damages lateral cartilages.


Genu varum shifts the weight-bearing line where?

What forces does it cause? onto the medial compartment, increasing medial compression while increaseing the tensile forces on the lateral collateral ligaments.

Damages medial cartilages What effect does genu varum have on the knee cartilage?

Describe a valgus stress test on the knee. • The examiner places his hands over the medial joint line while the other hand holds the foot/ankle.

• A valgus stress is applied to the joint through the foot, while the fingers palpate for any increase in joint line opening.

During a valgus stress test, a significant increase in Medial collateral ligament tear valgus opening indicates what injury?

Lateral Which knee meniscus covers a greater percentage of the tibia’s articular cartilage?

What effect does this have on the medial condyle? The medial condyle has enormous compressive loads during daily activities

How are forces at the knee changed during gait and stair climbing?

Compressive forces may reach twice the body weight

How are forces at the knee changed during running? Compressive forces may reach 4x the body

Where are these forces absorbed? weight

In the menisci

How is the medial meniscus affected in genu varum? The greater the degree of genu varum, the greater the compression on the medial meniscus.

What part of the menisci is vascularized in a young adult? In a person over 50?

The outer 1/3 is vascularized in a young adult.

Only the periphery is vascularized in a person over 50.

How does the central portion of the menisci get nutrients?

How does immobilization affect the menisci? must rely on the diffusion of synovial fluid. This diffusion requires intermittent loading by either weight-bearing or muscular contractions the meniscus may not receive appropriate nutrition, and the central portion of the meniscus may not heal after an injury.


What structure the primary restraint against anterior displacement of the tibia on the femur and also hyperextension of the knee?

In what position is the knee when injury occurs to the

ACL?

Contraction of what two muscles results in greater strain on the ACL than either muscle alone would produce?

What muscle group can contract to mitigate these forces?

What must a patient be careful about after a torn

ACL?

What is the best treatment for ACL tears?

ACL

When the knee is slightly flexed and the tibia is rotated in either direction in weight-bearing both the gastrocnemius and quadriceps muscles

Hamstrings

Knee buckling with weight bearing.

Surgery right away

What happens if surgery is delayed for several months?

They will have excessive shear and compressive forces during that time, causing narrowing of the knee joint space, which may lead to arthritis and future knee replacement.

PCL What is the primary restraint to posterior displacement of the tibia beneath the femur?

The PCL resists forces best when the knee is in what position?

The ACL resists forces best when the knee is in what position?

Why are ski boots designed to hold the foot in dorsiflexion?

Flexion

Full extension

To protect the PCL.

What is the function of the patella?

When is the mechanical advantage provided by the patella is diminished?

What happens if the quadriceps are damaged?

What are the 5 motions of the patella?

• The patella increases the mechanical advantage of the quadriceps by increasing the distance of the muscle from the axis of the knee joint.

• The patella acts as a pulley, increasing the angle of pull and the ability of the muscle to generate and extension force. in the final stages of knee extension they may not be able to complete the last 15° of knee extension

Flexion (moving downward in the groove)

Extension (moving upward in the groove)

Tilt (medial and lateral)

Rotation (medial and lateral)

Shift (frontal plane medial/lateral)


Describe the Patellar Mobility (glide) Test

What is chondromalacia patella?

What causes it?

What is the treatment?

• Technique

– Patient lies supine

– Grasp Patella and move it medially

– Measure the extent of displacement

• Patella width divided in

4 quadrants

• Estimate number of quadrants of medial glide

• Interpretation

– Tight lateral structures: <1 quadrant of movement

– Hypermobility: >3 quadrants of movement

Pain under the patella because it is pulled out of the condylar groove of the femur.

The vastus lateralis muscle is stronger than the vastus medialis muscle.

Selectively strengthen the vastus medialis muscle by using a muscle stimulator

In-toed In what position is the foot on a person with internal tibial torsion?

In what position is the foot on a person with external tibial torsion?

What is the Q angle? (Quadriceps angle) What is normal?

Out-toed

The Q angle is formed from a bisection of the femur and the tibia. 10-15° is normal.


What problems does a high Q angle cause? Problems with tracking of the patella, leading to chondromalacia patella

Pronation What deformity of the feet also places additional strain on the Q angle due to excessive internal rotation of the tibia?

What is the treatment for someone with a high Q angle?

What are the four major ligaments of the ankle?

Strengthen the vastus medialis muscle.

Anterior and Posterior talofibular

Calcaneofibular

Deltoid

What are the three arches of the foot? Medial and lateral longitudinal arches

Transverse arch

What is the keystone of the medial longitudinal arch? Talus

What is the keystone of the lateral longitudinal arch? Cuboid

What is ankle mortis? Measurement of a line drawn from the tip of the medial malleolus to the tip of the lateral malleolus, compared to a line drawn parallel to the ground. Normal is 14°

How is the Longitudinal Arch Evaluated? Talar declination angle and

Calcaneal Inclination Angle

What is the Talar Declination Angle? What is normal? A line drawn on a lateral x-ray that bisects the talus, compared to the ground. It should go through the first metatarsal

What does a low talar declination angle indicate? indicates excessive pronation and a low arch.

What is the calcaneal inclination angle? What is normal?

A line drawn on a lateral x-ray that bisects the calcaneus. Normal calcaneal inclination is about

25°


What is the term for a high calcaneal inclination angle?

Pes cavus (high arch)

What is the term for a low calcaneal inclination angle? Pes planus (low arch)

What is the largest ligament in the body?

Where is its origin and insertion?

How do heel spurs form?

What is calcaneovalgus?

What is calcaneovarus?

Calcaneal ligament

Calcaneal tubercle to metatarsal heads

With excess pronation, the longitudinal arch collapses, pulling on the calcaneal ligament. It pulls a shelf of bone with it, causing a heel spur.

An increase in the medial angle between the calcaneus and posterior leg.

An decrease in the medial angle between the calcaneus and posterior leg.

How do you evaluate the forefoot plane?

What is forefoot valgus?

What is forefoot varus?

When the subtalar joint is in neutral position, and the midtarsal joint is locked by loading the

5 th metatarsal by pushing on it with your thumb, the forefoot should be parallel to the rearfoot.

When the subtalar joint is in neutral position,

Forefoot is everted to the rearfoot.

When the subtalar joint is in neutral position,

Forefoot is inverted to the rearfoot

How are bunions first evaluated on x-ray?

What is the IM angle? What is normal?

By drawing the intermetatarsal (IM) angle

The angle between a line drawn through the first metatarsal compared to a line drawn through the second metatarsal. Normal is is 8-

10°


How does a high IM angle affect the hallux?

What is the medical term for a bunion?

What are the names of the two sesamoid bones under the first metatarsal head?

How are these sesamoid bones affected by hallux abductovalgus?

It causes the hallux to become abducted, and also twists into a valgus position.

Hallux abductovalgus

Tibial (medial) and fibular (lateral) sesamoids.

The first metatarsal moves medially, leaving the sesamoids behind. The tibial sesamoid no longer fits into the groove of the metatarsal.

Instead, the ridge of the first metatarsal hits the tibial sesamoid, causing pain.

What is a Tailor’s bunion? What causes it?

What is metatarsus adductus?

How is metatarsus adductus treated?

What happens if it is not treated?

What is a club foot?

How is club foot treated?

How is the transverse arch evaluated?

What is a plantarflexed metatarsal, and what problems does it cause?

When the 5 th metatarsal deviates laterally.

It is caused by forefoot varus.

The foot lands harder on the lateral side when walking, causing the 5 th met to loosen. all the metatarsals are adducted at birth.

Serial casting or splints it will present as an in-toed gait. They learn not to trip by externally rotating the foot. That causes knee and back pain.

The foot is rotated internally at the ankle

Serial casting and surgery is usually required

The 1 st and 5 th metatarsal heads should be on the same plane. There should also be no plantarflexed metatarsals 2-4.

A plantarflexed 1 st or 5 th metatarsal will bear too much weight, causing it to become abducted (bunion). A plantarflexed metatarsal

2, 3, or 4 will also bear too much weight, causing a callous on the bottom of the foot.

Orthotics are required.


When a metatarsal becomes plantarflexed, what happens to the proximal phalanx?

What else also causes a hammertoe?

It becomes dorsiflexed (hammertoe)

Hallux abductovalgus

What is the angle of gait?

What is the base of gait? the measurement of the longitudinal bisection of the foot, compared to the midline of the body when the patient is walking. The angle of gait could be normal, wide, or narrow. how far apart the feet are from each other when the person is walking. The base of gait could be normal, wide, or narrow.

How does foot pronation affect the rest of the body? When the foot is pronated, it rotates the knee medially, so the person compensated by rotating the hip laterally, and the hip and back are stressed.

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