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KIN 191A Advanced Assessment of Lower Extremity Injuries THE PELVIS AND THIGH EVALUATION
INTRODUCTION <ul><li>HISTORY </li></ul><ul><li>INSPECTION </li></ul><ul><li>PALPATION </li></ul><ul><li>ROM TESTS </li></u...
HISTORY <ul><li>Location of symptoms </li></ul><ul><li>Onset of symptoms </li></ul><ul><li>Training techniques </li></ul><...
Location of Symptoms <ul><li>Deep joint pain indicative of joint trauma/injury or may be referred from lumbosacral region ...
Onset of Symptoms <ul><li>Most hip pathologies are overuse/chronic conditions with gradual and insidious onset of symptoms...
Training Techniques <ul><li>Overuse conditions often attributable to </li></ul><ul><ul><li>Surface changes </li></ul></ul>...
Mechanism of Injury <ul><li>Direct trauma </li></ul><ul><ul><li>Iliac crest – hip pointer </li></ul></ul><ul><ul><li>Poste...
Prior History <ul><li>Congenital or developmental hip conditions or abnormalities can alter biomechanics of entire lower e...
INSPECTION <ul><li>Look for external signs of pathology </li></ul><ul><ul><li>Swelling, discoloration (ecchymosis), deform...
<ul><li>Pelvic obliquity – iliac crest height not equal bilaterally </li></ul><ul><li>Imaginary line between PSIS (S2 leve...
PALPATION (Medial Structures) <ul><li>Adductor longus </li></ul><ul><li>Adductor magnus </li></ul><ul><li>Adductor brevis ...
PALPATION (Anterior Structures) <ul><li>Pubic bone </li></ul><ul><li>ASIS </li></ul><ul><li>AIIS </li></ul><ul><li>Sartori...
PALPATION (Lateral Structures) <ul><li>Iliac crest </li></ul><ul><li>Tensor fascia latae </li></ul><ul><li>Gluteus medius ...
PALPATION (Posterior Structures) <ul><li>Median sacral crests </li></ul><ul><li>PSIS </li></ul><ul><li>Gluteus maximus </l...
ROM TESTS <ul><li>AROM </li></ul><ul><ul><li>Flexion (120-130°) </li></ul></ul><ul><ul><li>Extension (10-20°) </li></ul></...
AROM
Hip Flexion <ul><li>Range of motion - 120~130 ° </li></ul><ul><li>End feel - soft (tissue approximation) </li></ul><ul><li...
Hip Extension <ul><li>Range of motion - 10 ~ 20 degrees </li></ul><ul><li>End feel - firm (capsular) </li></ul><ul><li>Pri...
Hip Abduction <ul><li>Range of motion - ~45 ° </li></ul><ul><li>End feel - firm (capsular) </li></ul><ul><li>Primary mover...
Hip Adduction <ul><li>Range of motion - ~30 ° </li></ul><ul><li>End feel - firm (capsular) </li></ul><ul><ul><li>Avoid acc...
Hip Internal Rotation <ul><li>Range of motion - ~45 ° </li></ul><ul><li>End feel - firm (capsular) </li></ul><ul><li>Prima...
Hip External Rotation <ul><li>Range of motion - 45~50 ° </li></ul><ul><li>End feel - firm (capsular) </li></ul><ul><li>Pri...
PROM <ul><li>Flexion </li></ul>
PROM <ul><li>Extension </li></ul>
PROM <ul><li>Abduction  Adduction </li></ul>
PROM <ul><li>Internal Rotation  External Rotation </li></ul>
Goniometry
Goniometry
RROM
RROM
RROM
RROM
ROM <ul><li>SI joint and pubic symphysis have no true range of motion </li></ul><ul><li>Any motion that is present is acce...
SPECIAL TESTS <ul><li>Thomas test </li></ul><ul><ul><li>Evaluates tightness of hip flexors </li></ul></ul><ul><ul><li>Thig...
Thomas Test
Trendelenburg’s Test
Ligamentous Stress Tests <ul><li>No specific stress test for individual ligaments or joint capsule </li></ul><ul><li>Stabi...
STRESS TESTS <ul><li>Pubic symphysis </li></ul><ul><ul><li>Translation (secondary to abnormal palpation or inspection pres...
SI Joint Compression/Distraction <ul><li>Compression </li></ul><ul><ul><li>Patient supine </li></ul></ul><ul><ul><li>“ Spr...
SI Compression (A) / Distraction (B) Tests
Patrick’s (FABER) Test <ul><li>Flexion, abduction, external rotation </li></ul><ul><li>Stabilize opposite ASIS and push on...
Patrick’s (FABER) Test
Gaenslen’s Test <ul><li>Supine on table with involved leg off table side </li></ul><ul><li>Opposite hip fully flexed – inv...
Gaenslen’s Test
Long Sit Test <ul><li>Evaluative for ili um  rotation on sacrum at SI </li></ul><ul><li>Clinician’s thumbs on medial malle...
SI Rocking Test <ul><li>Supine on table </li></ul><ul><li>Involved side – hip flexed with flexed knee, involved knee moved...
Over ’ s  Test <ul><li>Used to determine presence of contracted TFL or IT-band </li></ul><ul><li>Thigh will remain in abdu...
Nobel ’ s  Test <ul><li>Lying supine the athlete’s knee is flexed to 90 degrees </li></ul><ul><li>Pressure is applied to l...
Renne ’ s Test <ul><li>Athlete stands with knee bent at 30-40 ˚ </li></ul><ul><li>Positive response of TFL  / IT band  tig...
Piriformis Test <ul><li>Hip is internally rotated </li></ul><ul><li>Tightness or pain is indicative of piriformis tightnes...
Ely ’ s Test <ul><li>Used to assess tightness of rectus femoris </li></ul><ul><li>Athlete is prone, w/ pelvis stabilized a...
NEUROVASCULAR TESTS <ul><li>Femoral pulse taken in femoral artery at femoral triangle </li></ul><ul><li>Dermatomes/myotome...
<ul><li>Femoral nerve </li></ul><ul><ul><li>D: None </li></ul></ul><ul><ul><li>M: Knee extension </li></ul></ul><ul><li>Ob...
<ul><li>Superior gluteal nerve </li></ul><ul><ul><li>D: None </li></ul></ul><ul><ul><li>M: Hip abduction </li></ul></ul><u...
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Kin191 A.Ch.8. Pelvis. Thigh. Evaluation

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Transcript of "Kin191 A.Ch.8. Pelvis. Thigh. Evaluation"

  1. 1. KIN 191A Advanced Assessment of Lower Extremity Injuries THE PELVIS AND THIGH EVALUATION
  2. 2. INTRODUCTION <ul><li>HISTORY </li></ul><ul><li>INSPECTION </li></ul><ul><li>PALPATION </li></ul><ul><li>ROM TESTS </li></ul><ul><li>STRESS/STREE TESTS </li></ul><ul><li>NEUROGIC TEST </li></ul><ul><li>VASCULAR TEST </li></ul>
  3. 3. HISTORY <ul><li>Location of symptoms </li></ul><ul><li>Onset of symptoms </li></ul><ul><li>Training techniques </li></ul><ul><li>Mechanism of injury (etiology) </li></ul><ul><li>Prior history (medical conditions) </li></ul>
  4. 4. Location of Symptoms <ul><li>Deep joint pain indicative of joint trauma/injury or may be referred from lumbosacral region </li></ul><ul><li>Anterior hip/groin pain typically associated with hip flexor/adductor muscle strain </li></ul><ul><li>Pain to lateral hip often associated with trochanteric bursitis </li></ul>
  5. 5. Onset of Symptoms <ul><li>Most hip pathologies are overuse/chronic conditions with gradual and insidious onset of symptoms </li></ul><ul><li>Insidious onset – unable to specifically identify one mechanism of injury </li></ul>
  6. 6. Training Techniques <ul><li>Overuse conditions often attributable to </li></ul><ul><ul><li>Surface changes </li></ul></ul><ul><ul><li>Footwear </li></ul></ul><ul><ul><li>Training techniques/skills </li></ul></ul><ul><ul><li>Training intensity, frequency and duration </li></ul></ul><ul><li>Tendinitis, bursitis, stress fractures </li></ul>
  7. 7. Mechanism of Injury <ul><li>Direct trauma </li></ul><ul><ul><li>Iliac crest – hip pointer </li></ul></ul><ul><ul><li>Posterior hip – gluteal contusion </li></ul></ul><ul><li>Eccentric muscle contraction </li></ul><ul><ul><li>Muscular strain </li></ul></ul><ul><li>Overuse conditions </li></ul>
  8. 8. Prior History <ul><li>Congenital or developmental hip conditions or abnormalities can alter biomechanics of entire lower extremity </li></ul><ul><ul><li>Legg-Calv é -Perthes disease </li></ul></ul><ul><ul><li>Slipped capital femoral epiphysis </li></ul></ul>
  9. 9. INSPECTION <ul><li>Look for external signs of pathology </li></ul><ul><ul><li>Swelling, discoloration (ecchymosis), deformity </li></ul></ul><ul><li>Leg length discrepancy (true vs. apparent) </li></ul><ul><li>Hip angulations </li></ul><ul><ul><li>Angle of inclination (~125 degrees) </li></ul></ul><ul><ul><ul><li>> 125 ° – coxa valga – presents with genu varum </li></ul></ul></ul><ul><ul><ul><li>< 125 ° – coxa vara – presents with genu valgum </li></ul></ul></ul><ul><ul><li>Angle of torsion </li></ul></ul><ul><ul><ul><li>> 15 ° – anteversion – “pigeon toes” </li></ul></ul></ul><ul><ul><ul><li>< 15 ° – retroversion – “duck feet” </li></ul></ul></ul>
  10. 10. <ul><li>Pelvic obliquity – iliac crest height not equal bilaterally </li></ul><ul><li>Imaginary line between PSIS (S2 level) bisects SI joints on both sides </li></ul><ul><li>Line across iliac crests crosses spine between L4 and L5 vertebrae </li></ul><ul><li>“ Sciatic” nerve lays between ischial tuberosity and greater trochanter </li></ul>
  11. 11. PALPATION (Medial Structures) <ul><li>Adductor longus </li></ul><ul><li>Adductor magnus </li></ul><ul><li>Adductor brevis </li></ul>
  12. 12. PALPATION (Anterior Structures) <ul><li>Pubic bone </li></ul><ul><li>ASIS </li></ul><ul><li>AIIS </li></ul><ul><li>Sartorius </li></ul><ul><li>Rectus femoris </li></ul>
  13. 13. PALPATION (Lateral Structures) <ul><li>Iliac crest </li></ul><ul><li>Tensor fascia latae </li></ul><ul><li>Gluteus medius </li></ul><ul><li>IT band </li></ul><ul><li>Greater trochanter </li></ul><ul><li>Trochanter bursa </li></ul>
  14. 14. PALPATION (Posterior Structures) <ul><li>Median sacral crests </li></ul><ul><li>PSIS </li></ul><ul><li>Gluteus maximus </li></ul><ul><li>Ischial tuberosity and bursa </li></ul><ul><li>Sciatic nerve </li></ul><ul><li>Hamstring muscles </li></ul>
  15. 15. ROM TESTS <ul><li>AROM </li></ul><ul><ul><li>Flexion (120-130°) </li></ul></ul><ul><ul><li>Extension (10-20°) </li></ul></ul><ul><ul><li>Adduction (30°) </li></ul></ul><ul><ul><li>Abduction (45°) </li></ul></ul><ul><ul><li>Internal rotation (45°) </li></ul></ul><ul><ul><li>External rotation (50°) </li></ul></ul>
  16. 16. AROM
  17. 17. Hip Flexion <ul><li>Range of motion - 120~130 ° </li></ul><ul><li>End feel - soft (tissue approximation) </li></ul><ul><li>Primary movers </li></ul><ul><ul><li>Iliopsoas, rectus femoris, sartorius </li></ul></ul><ul><li>Affected by knee positioning (flexed vs. extended) </li></ul><ul><ul><li>Active by rectus femoris </li></ul></ul><ul><ul><li>Passive by hamstring restriction </li></ul></ul>
  18. 18. Hip Extension <ul><li>Range of motion - 10 ~ 20 degrees </li></ul><ul><li>End feel - firm (capsular) </li></ul><ul><li>Primary movers </li></ul><ul><ul><li>Gluteus maximus, hamstrings </li></ul></ul><ul><li>Affected by knee positioning </li></ul><ul><ul><li>Active by hamstrings </li></ul></ul><ul><ul><li>Passive by rectus femoris </li></ul></ul>
  19. 19. Hip Abduction <ul><li>Range of motion - ~45 ° </li></ul><ul><li>End feel - firm (capsular) </li></ul><ul><li>Primary movers </li></ul><ul><ul><li>Glutues medius, gluteus minimus </li></ul></ul>
  20. 20. Hip Adduction <ul><li>Range of motion - ~30 ° </li></ul><ul><li>End feel - firm (capsular) </li></ul><ul><ul><li>Avoid accessory motions </li></ul></ul><ul><li>Primary movers </li></ul><ul><ul><li>Adductor longus/magnus/brevis </li></ul></ul>
  21. 21. Hip Internal Rotation <ul><li>Range of motion - ~45 ° </li></ul><ul><li>End feel - firm (capsular) </li></ul><ul><li>Primary movers </li></ul><ul><ul><li>Adductor longus/magnus/brevis </li></ul></ul><ul><ul><li>Gluteus medius/minimus </li></ul></ul>
  22. 22. Hip External Rotation <ul><li>Range of motion - 45~50 ° </li></ul><ul><li>End feel - firm (capsular) </li></ul><ul><li>Primary movers </li></ul><ul><ul><li>6 external rotators (piriformis, S.G., I.G., O.E., O.I., Q.F.) </li></ul></ul><ul><ul><li>Sartorius </li></ul></ul><ul><ul><li>Gluteus maximus </li></ul></ul>
  23. 23. PROM <ul><li>Flexion </li></ul>
  24. 24. PROM <ul><li>Extension </li></ul>
  25. 25. PROM <ul><li>Abduction Adduction </li></ul>
  26. 26. PROM <ul><li>Internal Rotation External Rotation </li></ul>
  27. 27. Goniometry
  28. 28. Goniometry
  29. 29. RROM
  30. 30. RROM
  31. 31. RROM
  32. 32. RROM
  33. 33. ROM <ul><li>SI joint and pubic symphysis have no true range of motion </li></ul><ul><li>Any motion that is present is accessory in nature and minimal </li></ul>
  34. 34. SPECIAL TESTS <ul><li>Thomas test </li></ul><ul><ul><li>Evaluates tightness of hip flexors </li></ul></ul><ul><ul><li>Thigh and knee position evaluated to differentiate tightness in iliopsoas vs. rectus femoris </li></ul></ul><ul><li>Trendelenburg’s test/sign </li></ul><ul><ul><li>Weakness or neurological injury associated with gluteus medius </li></ul></ul><ul><ul><li>The pelvis lowers on the opposite side of the affected leg </li></ul></ul>
  35. 35. Thomas Test
  36. 36. Trendelenburg’s Test
  37. 37. Ligamentous Stress Tests <ul><li>No specific stress test for individual ligaments or joint capsule </li></ul><ul><li>Stabilizing structure integrity assessed by end range passive range of motion </li></ul>
  38. 38. STRESS TESTS <ul><li>Pubic symphysis </li></ul><ul><ul><li>Translation (secondary to abnormal palpation or inspection presentation – i.e. elevation or depression) </li></ul></ul><ul><li>SI joint </li></ul><ul><ul><li>Compression/distraction </li></ul></ul><ul><ul><li>Patrick’s (FABER) test </li></ul></ul><ul><ul><li>Gaenslen’s test/sign </li></ul></ul><ul><ul><li>Long sit test </li></ul></ul><ul><ul><li>SI rocking test </li></ul></ul>
  39. 39. SI Joint Compression/Distraction <ul><li>Compression </li></ul><ul><ul><li>Patient supine </li></ul></ul><ul><ul><li>“ Spread” ASIS – compresses SI joint/s </li></ul></ul><ul><li>Distraction </li></ul><ul><ul><li>Side laying – do from both sides </li></ul></ul><ul><ul><li>Compress ilium to distract SI joint/s </li></ul></ul>
  40. 40. SI Compression (A) / Distraction (B) Tests
  41. 41. Patrick’s (FABER) Test <ul><li>Flexion, abduction, external rotation </li></ul><ul><li>Stabilize opposite ASIS and push on crossed knee </li></ul><ul><li>Pain in posterior hip/SI joint area indicative of SI pathology </li></ul>
  42. 42. Patrick’s (FABER) Test
  43. 43. Gaenslen’s Test <ul><li>Supine on table with involved leg off table side </li></ul><ul><li>Opposite hip fully flexed – involved hip pushed into hyperextension by clinician </li></ul><ul><li>Pain indicative of SI joint dysfunction due to rotational stress to joint </li></ul>
  44. 44. Gaenslen’s Test
  45. 45. Long Sit Test <ul><li>Evaluative for ili um rotation on sacrum at SI </li></ul><ul><li>Clinician’s thumbs on medial malleoli </li></ul><ul><li>Patient “sets” pelvis with bridge maneuver and then performs active long sit </li></ul><ul><li>Clinician indicates any change in orientation of medial malleolus relationship </li></ul><ul><ul><li>Involved goes longer to shorter – anterior rotation </li></ul></ul><ul><ul><li>Involved goes shorter to longer – posterior rotation </li></ul></ul>
  46. 46.
  47. 47. SI Rocking Test <ul><li>Supine on table </li></ul><ul><li>Involved side – hip flexed with flexed knee, involved knee moved toward opposite shoulder and “rocked” </li></ul><ul><li>Pain in SI joint indicative of pathology </li></ul>
  48. 48. Over ’ s Test <ul><li>Used to determine presence of contracted TFL or IT-band </li></ul><ul><li>Thigh will remain in abducted position, not falling into adduction </li></ul>
  49. 49. Nobel ’ s Test <ul><li>Lying supine the athlete’s knee is flexed to 90 degrees </li></ul><ul><li>Pressure is applied to lateral femoral condyle while knee is flexed/ extended </li></ul><ul><li>Pain at 30 degrees at lateral femoral condyle indicates a positive test </li></ul>
  50. 50. Renne ’ s Test <ul><li>Athlete stands with knee bent at 30-40 ˚ </li></ul><ul><li>Positive response of TFL / IT band tightness occurs when pain is felt at lateral femoral condyle </li></ul>
  51. 51. Piriformis Test <ul><li>Hip is internally rotated </li></ul><ul><li>Tightness or pain is indicative of piriformis tightness </li></ul>
  52. 52. Ely ’ s Test <ul><li>Used to assess tightness of rectus femoris </li></ul><ul><li>Athlete is prone, w/ pelvis stabilized and knee on the affected side is flexed </li></ul><ul><li>If hip on that side extends as the knee is flexed, rectus femoris is tight </li></ul>
  53. 53. NEUROVASCULAR TESTS <ul><li>Femoral pulse taken in femoral artery at femoral triangle </li></ul><ul><li>Dermatomes/myotomes associated with L1-S2 </li></ul><ul><li>Peripheral nerves </li></ul><ul><ul><li>Femoral </li></ul></ul><ul><ul><li>Obturator </li></ul></ul><ul><ul><li>Superior gluteal </li></ul></ul><ul><ul><li>Inferior gluteal </li></ul></ul>
  54. 54. <ul><li>Femoral nerve </li></ul><ul><ul><li>D: None </li></ul></ul><ul><ul><li>M: Knee extension </li></ul></ul><ul><li>Obturator nerve </li></ul><ul><ul><li>D: None </li></ul></ul><ul><ul><li>M: Hip adduction </li></ul></ul>
  55. 55. <ul><li>Superior gluteal nerve </li></ul><ul><ul><li>D: None </li></ul></ul><ul><ul><li>M: Hip abduction </li></ul></ul><ul><li>Inferior gluteal nerve </li></ul><ul><ul><li>D: None </li></ul></ul><ul><ul><li>M: Hip extension </li></ul></ul>
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