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NYCC Homack Extremit

NYCC TCH6706 Homack Lab final lower extremites

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
Created by: hecutler