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NYCC Homack Extremit
NYCC TCH6706 Homack Lab final lower extremites
| Question | Answer |
|---|---|
| Palpate the following PRONE hip landmarks: | PSIS, S2 tubercle, L5 (have pt flex), greater trochanter, piriformis, sciatic n., gluteal fold, ischial tuberosity |
| Palpate the following SUPINE hip landmarks: | ASIS, iliac crest, iliac tubercle, inguinal ligament |
| How to verify greater trochanteric contact? | have patient internally and externally rotate leg to verify contact |
| Location technique for piriformis | Bisect greater trochanter and ischial tuberosity |
| Tenderness at ischial tuberosity suggests… | Possible hamstring avulsion fracture |
| Iliac tubercle aka (2) | iliochrystalis or iliochrystal tubercle |
| Confirm inguinal ligament palpation | Pt finds own pubic tubercle; use 4-finger inline palp b/w their landmark and ASIS. Have them cough. IL will pop up into your fingertips. |
| Tenderness 1-1.5" from midline | may indicate Hernia or Meralgia Paresthetica |
| Nerve of meralgia paresthetica | LFCN |
| Perform neurologic eval for nerve root levels L1-S1 | State (+) finding and clinical implication to your patient |
| Trendelenburg sign (+) | (+) pelvis tilts toward lifted leg or shifting of pelvis over supporting leg |
| Trendelenburg sign indicates | Weakness of the gluteus MEDIUS (pos. due to superior gluteal n. injury) |
| Hip POMP | Side posture: include all cardinal ranges (flex, add, internal rotate, external rotate, abduct, extend) |
| Ober's test | IT band: side posture. Maintain abduction of FAJ while bringing hip back to neutral (common error) |
| Ober test (+) | Allow leg to settle; if hangs in air (abducted), (+) for IT contracture. |
| Thomas test | Pt sitting at end of table so 3-4" b/w back of knee and table. Make sure to assist! |
| Thomas test (+) | Confirm 2-joint tight by passive straighten knee. If lowers, then it was the 2-jt (knee) hip flexors. |
| Jansen's test/sign (+) | Inability to place leg in sign of 4 (Patrick-Fabere) due to hip pain |
| Jansen's test/sign indicates | OA or other arthritis of the hip |
| GUILLAND's sign | meningitis: Pt supine w/ legs straight out; doc pinches anterior thigh mm (skin) |
| GUILLAND's sign (+) | Buckling of the opposite hip (rapid hip & knee flexion) |
| GUILLAND's sign indicates | Meningitis. |
| Reverse Lasegue's | Femoral nerve stretch test: pt prone, 90 lift leg like Yeoman's w/ support ipsi PSIS |
| Reverse Lasegue's (+) | Pain or neurologic finding in anterior thigh |
| Reverse Lasegue's indicates | Femoral nerve pathology and/or meralgia paresthetica |
| SOF of diffuse soreness or quad pain in Reverse Lasegue's | Quad tightness - follow up w/ Thomas' test for 1 and 2-jt hip flexors |
| Pyramidalis mm. | Tender just above pubic tubercle/symphysis - mobilize symphyseal jt. |
| Thigh MFTP pattern constellation mm | Quadriceps, Adductor magnus, Hamstrings |
| Tight hams. What to do first? | Adductor magnus split stretch ALWAYS before hamstrings |
| Split stretch for adductor magnus | SLR, note angle. Toes UP (inward hip rot), stand b/w legs and push out, keeping in parallel plane. 3-4x |
| What's the trick to the split stretch for adductor magnus | Hip has to be internal rotation, toes up, in pure abduction to get add mag. |
| After split stretch? | Repeat SLR and see if angle improved. Now, you can stretch the hamstrings! |
| ________ must be addressed before stretching hams! | Adductors |
| Mobilization/Assessment of the hip | Move pt so involved side off table. Inter-genu BELOW knee, reg grip sos near FAJ. Pt protects. |
| Bimanual grasp/Distal Tibia Pull (LAD of the hip) | Supine, Hip flexed 30*, abducted 30* = OPEN pack FAJ. Reg grip above ankle. Pt stabilizes |
| Bimanual grasp/Proximal femur, INferior glide of hip in Flexion | Supine, pt knee over doc shoulder, pt protect and stabilize, Grip near FAJ, vector S-I |
| Bimanual grasp/Proximal femur: INternal ROtation of hip in flexion | Supine, knee over doc shoulder, pt cover & stabilize, PRE-load INTERNAL rotation, vector S-I |
| Why not use torque during internal/external rotation of hip in flexion? | All the torque is already in the PRE LOAD! Do not twist on impulse. Vector is S-I |
| Bimanual Grasp/Proximal femur; EXternal RO of hip in flexion | Supine, knee over doc shoulder, pt cover & stabilize, PRE-load EXTERNAL rotation, vector S-I |
| Hypothenar/Proximal femur, Palmar Distal femur grasp; P-A glide hip Prone shifted to side of adj; Knife edge at gluteal fold, lift knee; Vector P-A to table | |
| Alt hand contact on P-A femur at gluteal fold? | Calcaneal; must reinforce w/ leaning contact hand into doc hip. Rough on wrist |
| Somatic exercises for the abdomen part I: | Supine, hooklying position: xyphoid-p.symph contact, bring together. Neutral - sit up 6x |
| Somatic exercises for the abdomen part II: | Supine, hooklying position: one hand on ipsilateral raised knee, resistance to obliques 6x |
| Somatic exercises for the abdomen part III | Supine, hooklying position: one hand on contralateral raised knee, resistance to obliques 6x |
| Somatic exercises for the abdomen part IV | Supine, hookyling position: p.symp hand shifts to behind head, attempt to touch elbow to ipsi knee |
| Somatic exercises for the HIP part 1 | Supine, neutral pelvic tilt: External rotation, drag heel up opposite leg w/o touching table or leg, return. 10x |
| Somatic exercises for the HIP part 2 | Supine, neutral pelvic tilt: INTERNAL rotation, drag toe up opposite leg w/o touching table or leg, return. 10x. |
| Schedule for somatic exercises for abdomen and hip | Each set 3x for 3 days, 5x for 5 days, 10 times thereafter. Advise what to expect and stop if sx exacerbate |
| Palpate knee: Tibial tubercle, inferior pole of patella, borders of patella | Head & neck of fibula (dorsi/plantarflex), Common peroneal n., GERDY's tubercle, Adductor tubercle, Vastus medialis, Biceps femoris tendon |
| GERDY's tubercle location | between fibular head and tibial tuberosity - Insertion for ITB |
| Sensory pure patches for femoral, obturator, and common peroneal n. | F: anterior thigh, Ob: over adductor tubercle, CPN: at fib head |
| Patellar Apprehension Test | Supine, knees straight. Stand opposite! Gently push patella med - lateral |
| Patellar Apprehension Test (+) and indication | Discomfort or apprehension indicates ligamentous pathology |
| Varus Stress test knee | Abduction: Closed then Open packed. Hand medial knee, gap outside lateral |
| Varus Stress test knee (+) and indication | Pain or excessive motion of injured knee (**MUST KNOW BOTH POSITIVES) Ligament instability |
| Valgus Stress test knee | ADDuction: Closed then Open packed. Hand lateral knee, gap inside medial |
| Valgus Stress test knee (+) and indication | Pain or excessive motion of injured knee (**MUST KNOW BOTH POSITIVES) Ligament instability |
| McMurray's valgus TEST | Hand on lateral knee, Internally rotate tibia, pressure and slowly extend knee (no winding) |
| McMurray's valgus TEST (+) and indication | Pain, locking or popping/clicking. Indicates LATERAL meniscus tear (valgus) |
| McMurray's varus TEST | Hand on medial knee, EXternally rotate tibia, pressure and slowly extend knee (no winding) |
| McMurray's varus TEST (+) and indication | Pain, locking or popping/clicking. Indicates MEDIAL meniscus tear (varus) |
| During McMurray's TEST, do not… | do not snap the knee into hyperextension = injury to mensicus |
| Sag sign | Knees up for comparison supine. One tibia slides posteriorly like step sign of shoulder |
| Sag sign (+) | Tibia slides posterior/inferior on distal femur |
| Sag sign indicates | Partial or complete tear of PCL |
| If the sag sign is present, do not perform… | do not perform A-P stress on knee (duh) |
| Lachman's test | supine, knee flexed 20-30*. Stabilize femur, pull up on prox tibia P-A |
| Lachman's test (+) | Pain or excessive motion of injured knee (**MUST KNOW BOTH POSITIVES) Ligament instability |
| Lachman's test indicates | Complete or partial tear of ACL |
| DROP leg Lachman's | Instead of pulling up on distal femur, doc thumb/web contacts and pushes it down, into FCJ |
| DROP leg Lachman's (+) | Pain or excessive motion of injured knee (**MUST KNOW BOTH POSITIVES) Ligament instability |
| DROP leg Lachman's indicates | Complete or partial tear of ACL |
| A-P and P-A drawer tests | Movement refers to direction of distal tibia (push or pull, PCL or ACL) |
| A-P and P-A drawer tests (+) and indicates | Pain or excessive motion indicates either PCL/push or ACL/pull partial or complete meniscal tear |
| Noble compression test | supine and knee in air 90* Doc inside thumb on lateral femoral condyle/GERDY's tubercle, pt slow straightens knee off the table |
| Noble compression test (+) | Pain under the contact at ~ 30* flexion, described similar to pain when running |
| Noble compression test indicates | distal ITB tendinosis |
| Plica | redundant folds or pouches in the synovial capsule of the knee |
| Plica pinching most often occurs where? | medial to patella, extendin superiorly under quadriceps. Pain, inflammation, crepitus |
| Why do plica band pinching sx get worse over time? | Becomes thick and fibrotic, increasing sx. Surgery may be necessary |
| MEDIOpatella plica test | supine, knee flexed 30* Stand same side. Move patella lateral to medial against medial femoral condyle |
| MEDIOpatella plica test (+) and indicates | Pain - plica band adhering to medial border of patella or being pinched aga. medial femoral condyle |
| HUGHSTON plica test | Supine. Doc flexes knee 90* and internally rotates ankle, applies lateral to medial pressure, extend and flex knee a couple of times |
| HUGHSTON plica test (+) and indicates | Crepitus, popping, clicking indicates INFLAMED plica |
| Trigger point constellation pattern mm of knee area | Vastus medialis, Adductor Magnus, Proximal gastrocnemius |
| Cross friction massage muscles of knee | LCL's, Infrapatellar tendon, Quad insertion on patella, Distal ITB above knee then across to Gerdy's tubercle (ITB insertion) |
| Postural considerations of knee | Q-angle, Genu recurvatum (hyperextended knees), Patellar position (alta, baja) |
| Bimanual grasp/Prox tibia w/ knee Extension LAD of tibiofemoral jt | Supine, pt slide to side, brace. Ankle b/w doc knees, reg grip below knee, vector S-I in LAD |
| How to isolate knee for LAD | Externally rotate FAJ w/ toes pointing upwards |
| Bimanual grasp/Proximal Tibia: INTternal or EXternal rotation of tibfib | Doc bent knee, foot on table. Rest pt. ankle on knee. Reg grip and twist internal or external just inferior to knee. |
| Reinforced web/proximal tibia PUSH; A-P glide of tibfib in flexion | Supine: doc bent knee, foot on table, pt ankle on knee (90*). Reg grip at eyes of knee, impulse A-P to table |
| Bimanual Grasp/Prox Tibia: P-A glide tibfib (supine) | Sit on or stabilize their foot. Reg grip at eyes of knee, lean back for P-A preload and impulse P-A (side slap) |
| Index/Prox Fibula, Palmar ankle PUSH (supine) | the tibia crank |
| Reinforced MID-hypothenar (knife edge)/Proximal TIBIA pull; P-A glide of tibfib in flexion | Prone: Pt stabilizes, doc kneels, pt tib against inside shoulder. Create torque at fib head w/ reg grip, preload P-A, impulse P-A (looks like S-I along table vector) |
| Reinforced MID hypothenar (knife edge)/Prox fibula PULL. P-A glide tib fib Prone: pt stabilizes. Doc kneels w/ pt shin against inside shoulder. Reg grip M-L (torque) & P-A preload, vector is P-A only because no twisting during adjustment | |
| Both prone tibia pull and prox fibula pulls have vector of | P-A |
| Meniscal release maneuver is also called | McMurray's RELEASE |
| Meniscal release maneuver | supine, hip/knee flexed way past 90* GAP side you want to release! Clockwise or counterclock wind down, pressing lateral or medial side of knee (closed side) |
| Valgus meniscal release maneuver would gap the ____ side | medial side |
| Varus meniscal release maneuver would gap the ____ | lateral side |
| Quad sets for knee rehab | Pt seated on table, legs straight out. Inflatable/ball under knee. Pt presses ball to table w/ knee. |
| Leg extension exercises for knee rehab | Pt seated. Resistance band strapped to table. Extend leg against resistance while band looped over ankle. |
| Terminal leg (knee) extension exercise for knee rehab | Seated, externally rotate FAJ so vastus med on top, leg flexed to just past 10* (barely bent). Fully extend to zero. |
| Wall sits knee rehab | Back against wall. Slide down to 'chair' position 90/90. Hold up to 15 min. |
| How to increase load on medial quads in wall sits? | externally rotate tibias/feet |
| Palpate the ankle and foot landmarks part I | Dome & head of talus, medial and lateral malleoli, sinus tarsi, sustentaculum tali, posterior & anterior tarsal tunnels, navicular tubercle, 1st cuneiform, base of 1st metatarsal |
| Palpate the ankle and foot landmarks part II | Inferior pole of lateral malleolus, peroneal tubercle, cuboid, styloid 5th metatarsal, anteromedial tubercle of calcaneus, all three cuneiform, dorsum of navicular, pulses of dorsalis pedis and post tibial a. |
| A-P and P-A drawer test ankle | pt supine, hip & knee @ 90*, grasp tibia at malleoli, foot across talar dome, push foot A-P (tests posterior talofibular ligament). Now push tibia towards table or ask pt to lie prone w/ foot off table & push ankle P-A for ATFL test. |
| Tinel tap at the ankle | ONCE. (+) is sustained paresthesias along tibial and plantar nerves |
| Duchenne's sign | Supine. Pt "presses the gas pedal" around doc pressure on medial metatarsal heads. |
| Duchenne's sign (+) and indicates… | Foot wraps around doc thumb press. Indicates weak peroneus long & brev. d/t injur or denervation of superficial peroneal n. |
| Hoffa's sign | prone, feet off table. Observe if one foot is more dorsiflexed than other d/t Achilles rupture |
| Hoffa's sign (+) and indicates... | One foot more dorsiflexed d/t Achilles rupture |
| Matles' sign | same as Hoffa's but pt prone w/ knees bent, feet in air. Look for dorsiflexed foot |
| Matles' sign (+) and indicates | One foot more dorsiflexed d/t Achilles rupture |
| Hoffa's vs. Matles | Hoffa is dead face down. His Achilles heel finally got him. Matles' is alive and watching tv on his belly, w/ an Achilles rupture. |
| Homan's sign | for DVT: pt prone, feet off table. Dorsiflex ankle like clonus test, add pressure w/ flat hand to calf. |
| Homan's sign (+) and indicates… | Pain is positive. Indicates DVT |
| Thompson twins sign | Looks like Moses' test. Pt prone, bend knee to 90*, squeeze calf to isolate Achilles' rupture/calcaneal injury |
| Thompson twins sign (+) and indicates… | (+) is lack of plantarflexion when calf squeezed. Ruptured Achilles or calcaneal injury |
| Thompson's test looks like | Moses test for phebitis, but TT is for Achilles' rupture/calc fx - squeeze calf, no plantarflex (+) |
| Postural observation of ankle | Internal/external rotation, path pronation/supination, Valgus stress (deviation of Achilles) |
| MFTP lower extremity | Anterior tibialis, Gastrocs, Soleus, Posterior tibialis, Peroneus long and brev |
| Stretching the anterior talofib ligament results in | greater ability to DORSIflex |
| Bimanual reinforced interphalangeal/Anterior talus PULL; LAD of tibiotalar jt | Supine, open pack hip, Doc outside hand talar dome/dorsiflex OR regular grip, Sideslap. LAD |
| Bimanual/Anterior Talus-Calcaneus PULL: LAD of subtalar joint (supine, calcaneal contact) | Supine, outside hand cup calcaneus, inside dorsiflexes subtalar (dorsal) area, Sideslap. LAD |
| Inferior Web/Talus PUSH; A-P of tibiotalar joint (mortis) | supine, foot off end. Stabilize w/ hand on shin, grasp talar dome and impulse A-P to floor |
| Inferior Web/Calcaneus PUSH; P-A tibtalar (prone) prone: foot off end of table. Grasp malleoli stablize, grasp calcaneus and impulse P-A to floor | |
| Inside Web/Calcaneus LAD of subtalar (prone) LAD means stretch so stand ipsilateral, face feet, pt prone w/ feet off table. Reach across and outside hand on calc induces LAD while inside hand stabilzes calf. Dr arm at or below 45* | |
| Interlaced Bimanual Grasp/Calcaneus: Subtalar glide L-M, M-L, P-A, A-P prone | supine, face feet, place pt ankle in your armpit and cradle calcaneus. Distract slightly and move through 4 ranges |
| Foot drills directions | Outside of foot, toe in on toes, backwards on toes, flatfooted, external rotation, in shoes on heels |
| How many foot drill patterns and how far? | 6 patterns (Out, Tin, Toe, Back, Flat, Ex, Heel) 25 meters ea. |
| Benefits of foot drills | Lessen, reduce, prevent ankle sprains, shin splints, knee prob, plantar fascitis |
| Balance work ankle | Wobble board and beams for rehab and proprioception |
| Elastic resistance ankle | Theraband - all ranges of motion. Trace alphabet or phrases w/ toe on resistance. Rehab + injury prevention |
| Towel drills ankle foot | scrunch towel on smmot surface w/ toes feet |
| Always advise patients to | What to expect and to stop if increasing sx |
| Strunsky's sign | pt prone, bend knee, face feet, passively flex toes towards you and push calc/ankle away |
| Strunksy's sign (+) and indicates... | Pain in MTP or IP positive for DJD or Rheumatoid arthritis |
| Morton's squeeze | Supine. Two hand grasp forefoot and reverse anterior transverse arch, sqeeze ball of foot together |
| Morton's squeeze (+) | Pain in distal metatarsals indicates Morton's neuroma |
| Muldar's click | Audible or palpable clicking b/w metatarsals during Morton's squeeze - enlarged neuroma slipping dorsal and plantar |
| Tinel tap at tarsal tunnel | ONCE. (+) is sustained paresthesias along tibial and plantar nerves |
| Plantar fascia and Windlass effect | Great toe extended/dorsiflexed and tension applied to fasica all the way to anterior medial tubercle of calcaneus. Tension creates posterior calc tilt and increases long arch of foot |
| Soft tissue stretches ankle | Calf on book/step, on wall. Plantar fascia on tennis ball, etc. |
| Long distance runner | High medial longitudinal arch, slender build. Stress on dorsum, navicular. Windlass makes worse. |
| Hypothenar/Cuboid w/ Forefoot distraction; Plantar to dorsal glide | Prone, knee bent. Grasp foot, apply pisiform pressure to sole at cuboid, support w/ distraction of forefoot by hand on dorsum of foot |
| Hypothenar/Navicular w/ Forefoot distraction; Plantar to dorsal glide | Prone, knee bent. Grasp foot, apply pisiform pressure to sole at navicular, support w/ distraction of forefoot by hand on dorsum of foot |
| What else can you do to move navicular or cuboid plantar to dorsal? | thumb on thumb, pisiform on thumb, speeder board |
| Reinforced thumbs/Cuneiform (Cuboid, Navicular) w/ forefoot distraction; Plantar-dorsal glide of... | Pt prone, Thumb on thumb, preload and distract, impluse plantar to dorsal |
| Reiforced middle phalangeal/Cuneiform (Navicular, Cuboid) PULL; A-P/or Dorsal-Plantar glide | Pt supine, stabilizes. Reinforced index contact on dorsum of foot, dorsiflex. Step back and side slap |
| Bimanual Thenar/METAtarsal grasp SHEAR: A-P, P-A glide of intermetatarsal jts | Breaking crackers. Use Central Ray (middle toe/2nd) as stable fulcrum for great toe, then so on across foot, stabilizing the next over. |
| Bimanual web/Tarsals, LAD | Breaking a stick. Pt supine. Grasp entire hindfoot w/ one hand, forefoot w/ other and shear across midfoot at desired articulation. |
| Thumb Index Grasp/Phalanx: LAD | Pulling toes. Pt supine. Grasp forefoot, thumb under distal metatarsal head. Pincer grip to distract LAD each toe. |
| Plantar-Dorsal glide of metatarsal-phalangeal joints | Prone. Grasp forefoot w/ both hands, thumb on thumb reinforced to move MTP joints from plantar surface to dorsal. |
| Thumb index grasp/Phalanx: Plantar-dorsal (flexion of toes) glide | Grasp forefoot in one hand w/ thumb support under metatarsal head. Bend each toe over into flexion, impulse is flexion vector. |
| Web Metatarsal/Finger grasp phalanx: M-L glide (of great toe) w/ PENDULAR distraction | Grasp great toe close to MTP. Rest foot on your outside thigh, web contact at that valgus toe and whammo! Just kidding. Vector is M-L. |
| Rehab home instructions for foot | marble pick up, alphabet, towel drills, foot drills |
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