Transcript Hip “Click”

Spine, Hip, Knee, & Foot:
Skeletal and muscular considerations
in movement
OVERVIEW
 Role of the region
 Contributions of the boney
structure to stability and mobility
 Contributions of the muscular
structures to stability and mobility
 Impact of each region on other
regions in upright function
Spine & Trunk
Skeletal and muscular considerations
in movement
Spine & Trunk
Skeletal role in posture & movement?
1. Connect the
Upper body
Lower body
2. Position the head for interaction
3. Support and position the UEs for
purposeful function
Role of Boney
Structures in
Movement
A: Frontal Plane
B: Sagittal Plane
C:Transverse Plane
In sitting and standing,
what structure serves as the base for the spine?
vertebrae
vertebral body
pedicles
4
transverse processes
spinous process
3
7
5
2
articular surface for facet
laminae
1
vertebral foramen
From: McMinn’s Color Atlas of Human Anatomy,
Abrahams, Gutchings, Marks, 4th edition
In the spine there are 33
vertebral segments:
Primary Movements?
Cervical
• 7 cervical vertebrae
(C1-7)
• 12 thoracic vertebrae
(T1-12)
Thoracic
• 5 lumbar vertebrae
(L1-5)
• 5 sacral vertebrae
(sacrum)
• 4 coccygeal bones
( coccyx )
Lumbar
Boney structure of the Spine
 Atlanto-occipital:
 Primary action: flexion/extension
 Slight lateral bending
 Almost no rotation
 Atlanto-axial:
 Primary action: rotation (50% of cervical
rotation)
 Seconday: flex/ext
 Almost no lateral flexion
 C2-7:
 Very mobile: flex/ext, lat flex, rotate
Boney structure of the Spine
 T1-12
 Primary actions: flexion/extension,
lateral bending, rotation
 Rotation decreases as you progress
caudally down the thoracic spine toward
the lumbar spine
 T 7-T8 – the point where counter
rotation occurs
Points of transition in the
spine
C7
T1
T7, T8
Point of
counter-rotation in the
Thoracic spine
WHY?
Does this impact
our handling?
“True Ribs”
Ribs 1-7
Diaphragm:
Lowest 4 ribs
Lowest 6 costal cartilages
“False Ribs”
Ribs 8-10
attached to cartilage
Ribs 11, 12
free floating
Role of the Deep
Muscles of the Back

Deepest muscles
(cross 1 segment)
 Interspinalis
 Intertransversarus

Intermediate muscles
 Rotators (cross 1 or 2 segments)
 Multifidi (cross 2-4 segments)
 Semispinalis (cross 6-8 segments
So what is the primary role
of these muscles?
Role of the Deep
Muscles of the Back

The plan for stability
plus mobility:



Diagonal
Horizontal
Vertical
Role of the Muscles of the Back

Erector Spinae
(medial to lateral)
 Spinalis
 Longissimus
 Iliocostalis
What is the primary action
of each of these muscles?
***Note the lateral position of the
iliocostalis & longissimus muscles
Drawings adapted from
Kinesiology of the Musculoskeletal System,
Neumann 2002
Role of Trunk Muscles
 Rectus
abdominus
 External
Obliques
 Internal
Obliques
 Transverse
abdominus
Rectus Abdominus
External Oblique
Internal Oblique
What Movement do we get
from:
 Rectus
 External oblique bilaterally, unilaterally?
 Internal oblique bilaterally, unilaterally?
What Movement do we get
from:
What muscles give us lateral flexion in the frontal plane?
2. What muscles give us rotation with flexion?
1.
3.
What muscles give us rotation with extension?
Stability




The plan for
stability
plus
mobility:
Diagonal
Horizontal
Vertical
What about stability??
Summary:
What does this mean
to our
handling
and our
facilitations?
Hip & Pelvis
Skeletal and muscular considerations
in movement
Hip & Pelvis
Skeletal role in posture &
movement?
1. Weightbearing
2. Movement of the hip joint allows
translation of the trunk unit through
space
3. Pelvis is the base for the spine
Role of Boney
Structures in
Movement
A: Frontal Plane
B: Sagittal Plane
C:Transverse Plane
Are there any boney
limitations to hip
movement in any plane?
Built for
strength
 Ball and socket joint
 Acetabulum covers ½
the head of the femur
 Femur is:
 longest bone in the body
 ¼ total height
 strongest bone in the
body
Hip Structure:
Angle of Inclination
Angle between the:
•long axis
&
•Neck
Typically 126° in
adults
Hip Structure:
Angle of Inclination
Typical : 126°
Coxa Valga:
Coxa Vara:
Increased angle
of inclination
Decreased angle
of inclination
Hip Structure:
Angle of Inclination
The angle of inclination establishes the line of weightbearing
into the acetabulum.
Coxa Valga:
Increased angle of inclination
• favors hip dislocation
• poor angle of pull for the
gluteus medius
Coxa Vara:
Decreased angle of inclination
• hip very stable
• weak pull of hip abductors
• abnormal wear on head
Hip Dislocation
Red Flags:
Uneven gluteal folds
One leg looks shorter or “uneven”
Child appears uncomfortable or
fusses when a hip is moved
Bilateral dislocated hips are much more difficult
to detect clinically than unilateral dislocations
Hip Integrity
Classification:
1. Normal
2. Subluxable – femoral head can
be displaced to the acetabular
rim but is still in the socket
3. Dislocatable -- femoral head is
in the socket but can be dislocated
4. Dislocated but reducible
5. Dislocated and not reducible
Hip Integrity
Hip Integrity: Piston test





Normal
Subluxable
Dislocatable
Dislocated but reducible
Dislocated and not reducible
Hip Integrity: Hart’s Sign
Unequal hip abduction





Normal
Subluxable
Dislocatable
Dislocated but reducible
Dislocated and not reducible
Parents often notice it during diapering or dressing.
Hip Integrity: Galeazzi
Sign
Uneven Knees
Can also be done with
the femurs perpendicular
to the surface and the
feet off the surface
Hip Integrity: Galeazzi
Sign
Uneven Knees





Normal WHY?
Subluxable
Dislocatable
Dislocated but reducible
Dislocated and not
reducible
Hip Integrity: Ortolani’s Sign
Hip “Click”
Parents may notice
it when dressing or moving
the child.
Hip Integrity: Ortolani’s Sign





Normal WHY?
Subluxable
Dislocatable
Dislocated but reducible
Dislocated and not reducible
Deceptive: A soft click
may be the iliofemoral
ligament moving over
the anterior surface of
the head of the femur
Femoral Torsion: a twisting
of the femoral bone
Angle between:
the transcondylar axis of the knee
the axis of the femoral neck
newborn 50° (disputed)
adult 15°
Femoral Antetorsion
Femoral
Retroversion
Measuring Torsion:
Ryder test
What alternative if
hip flexion contractures are present?
2 issues:
1. twisting of the femur
Torsion
2. functional position of the
femoral neck and head
in relation to the acetabulum
Version
Antetorsion
Anteversion
Retrotorsion
Retroversion
Version
Internal
femoral rotation
External
femoral rotation
Hip/Pelvic
Musculature
 Hip Flexors




Iliopsoas
Tensor facia latae
Rectus femoris
Sartorius
Anterior view
Right lower extremity
Hip Flexion Contracture
Thomas Test
What might make the test difficult
or mask the results?
Concept:
Free segment moves on the fixed
segment
 Movement of hip
flexors:
Pelvis on Femur
or
Femur on pelvis
Hip/Pelvic
Musculature
 Hip Extensors
 Gluteus maximus
 Hamstrings
• biceps femoris
• semitendinosus
• semimembranosus
 Adductor magnus
(posterior head)
Posterior view
Left lower extremity
Clinically, what problem
would we see with hip
extensor tightness?
Hip/Pelvic
Musculature
 Hip Abductors
 Gluteus medius
 Gluteus minimus
 Tensor fascia latae
Posterior view
right lower
extremity
Anterior view
right lower
extremity
Free segment moves on the fixed
segment
 Movement of hip
abductors:
Pelvis on Femur
or
Femur on pelvis
Posterior view
Of left hip
What happens when abductors are:
 Tight?
 Weak?
Concept:
Muscle action may change
depending on joint position
 Gluteus medius
 Gluteus minimus
Hip/Pelvic
Musculature
 Hip Adductors
 Adductor brevis
 Adductor longus
 Adductor magnus
(both heads)
Anterior view
right lower extremity
Muscle action may
change depending
on joint position
 Adductor Longus
Anterior right
Pelvis & femur
Posterior right
femur
Hip/Pelvic
Musculature
 Hip External Rotators







Gluteus maximus
Piriformis
Gemeilus superior
Obturator internus
Gemeilus inferior
Quadratus femoris
Sartorius
Posterior view
Left lower extremity
Hip/Pelvic
Musculature
 Hip Internal Rotators
Hip/Pelvic
Musculature
 Secondary Hip Internal Rotators






Gluteus minimus (anterior fibers)
Gluteus medius (anterior fibers)
Tensor fascia latae
Adductor longus
Adductor brevis
Medial hamstrings (semimembranosus,
semitendinosus)
(Arnold 2000, 2001), (Lynn 2009) (Delp 1999)
Important Points:
1. Facilitate muscles…not bones Stay off the
pelvis!
2. Mobile segments move on the fixed
segments…2 sides to every coin.
3. Muscle function can change with joint
position…ALIGNMENT IS ESSENTIAL TO
FUNCTION!!!
4. Challenge your assumptions!!!!
Surface Anatomy
Find:
• Spinous Processes: Kyphosis, Lordosis, Scoliosis
• C7 Spinous Process
• T7 –T8
• Sacrum
• ASIS
• PSIS
• Head of the Trochanter