Kinesiology of the hip and knee powerpoint


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Kinesiology of the hip and knee powerpoint

  1. 1. Kinesiology ofthe Hip & KneeA report by:Kenneth Pierre M. Lopez
  2. 2. The Hip Joint Complex
  3. 3. Hip Anatomy OverviewHip Examination Review
  4. 4. Hip joint A.k.a. coxofemoral jt. ROM  Flex 0-1200  Hypertext 0-100  Abd 0-450  Add across 30-400  ER 0-450  IR 0-350 Close-packed  Full ext, IR, Abd
  5. 5. Hip joint Open-packed  300 flex  300 abd  Slight ER Capsular pattern  Flex, abd, IR End feel  Flex soft/firm  Ext firm  Abd soft/firm  Add soft/firm  IR firm  ER firm
  6. 6. End Feels Normal:  Flexion & Adduction  Elastic or Tissue Approximation  SLR  Elastic  Extension & Abduction  Elastic/Firm IR & ER  Elastic/Firm
  7. 7. Hip joint Tonic labyrinthine & optical righting reflexes  Head effectively behaves as if it’s fixed in a vertical position  Maintains head over BOS When hip flexor ms. Is tight, keep LOG w/in BOS  Open-chain response = displacement of head from vertical (Fig. A)  Closed-chain response = maintain head in upright position (Fig. B)
  8. 8. Hip joint Acetabulum of pelvis + head of femur Diarthrodial, ball-and-socket jt. w/ 30 freedom:  flex/ext in sagittal plane  abd/add in frontal plane  IR/ER in transverse plane 10 function of hip  To support wt. of head, arms & trunk (HAT) Also provides pathway for transmission of forces bet. Pelvis & LEs Hip tends to operate in a closed kinematic chain  Proximal end = head  Distal end = foot
  9. 9. Structure Acetabulum  Concave socket  Lateral, inferior, anterior (LIA)  Roundness ↓ w/ age  Inferior = acetabular notch  Central/deepest part = acetabular fossa  Anteversion = anterior orientation of acetabulum  Men = 18.50  Women = 21.5 0  Pathologic ↑ = ↓ jt. stability, risk for anterior dislocation of femoral head
  10. 10. Structure  Acetabular labrum  Fibrocartilage rimming entire periphery  Transverse acetabular ligament  Roofof tunnel passage for blood vessels & nerves entering hip  Has Center Edge angle (CE) or angle of Wiberg  Men = 380  Women = 350  Smaller CE angle (more vertical) = ↓ coverage of head of femur, ↑ risk superior dislocation of femoral head  ↑ w/age
  11. 11. Pelvis  1/5 pubis  2/5 ischium  2/5 ilium  Pelvis full ossification = 15- 25 y.o.
  12. 12. Femur  Circular  Smaller in women  Fovea  Inferior to medial pt. of femoral head  Attachment of ligament of femoral head  Medially, superiorly, anteriorly (SAM)  Neck = 5cm long
  13. 13. Femur  Angulation  Angle of inclination (medial)  Frontal plane bet. Femoral neck & shaft  Early infancy = 1500  Adult = 1250  Elderly = 1200  ↓ in women due to width of female pelvis  Pathologic ↑ = coxa valga  Pathologic ↓ = coxa vara
  14. 14. Femur  Angle of torsion  Transverse plane bet. Femoral neck & condyles  Anterior torsion =relative lateral rotation  ↓ w/age  Newborn = 400  Adult = 150  Anteversion  Pathologic ↑  Internal femoral torsion  ↓ ER  ↑ IR  Retroversion  Pathologic ↓  External femoral torsion
  15. 15. Femur  Frog-leg position  FABER  True physiologic position of hip A congruent fit under low load would lead to incongruence under high load  Periphery of acetabulum in contact, fossa is non- articular
  16. 16. Hip capsule & ligaments  capsule has major contribution to stability  femoral neck = intracapsular  greater & lesser trochanters = extracapsular  thickened anterosuperiorly  thin & loose posteroinferiorly  Iliofemoral ligament  Y ligament of Bigelow  Origin = AIIS  2 arms fan out to insert = intertrochanteric line of femur  Strongest ligament of hip  Taut in hyperextension  Superior fibers taut in adduction  Inferior tense during abduction
  17. 17. Hip capsule & ligaments  Pubofemoral ligament  Origin = anterior pubic ramus  Insertion = anterior intertrochanteric fossa  Taut in hip abd & ext  Ischofemoral ligament  Origin = posterior acetabular rim, acetabulum labrum  Insertion = spiral around femoral neck  Spiral fibers taut during ext, loosen in flex
  18. 18. Hip capsule & ligaments  Position of stability  Full extension of hip  Position of vulnerability  Flex& add (such as sitting w/thighs crossed)  Ligamentum teres  Triangular  Ligament of head of femur
  19. 19. Wt. bearing @ hip joint  Medial trabecular system  Medial cortex of upper femoral shaft  Vertically oriented  Medial accessory system is @ medial aspect of upper femoral shaft & fans out to greater trochanter  Lateral trabecular system  Lateral cortex of upper femoral shaft  Responds to forces created during contraction of abductors & tendency of head/neck to bend as wt. is accommodated  Lateral accessory trabecular system runs parallel w/ greater trochanter  Zone of weakness  Thintrabeculae, do not cross each other  @ femoral neck
  20. 20. Arthrokinematics  Movement of convex femoral head on concave acetabulum  Femoral head glides opposite motion of distal femur  Flex = Head spins posterior  Ext = anterior spin  When wt. bearing  Femur fixed, concave acetabulum moves over convex femoral head  Acetabulum glides in same direction
  21. 21. Hip Mobilization Flexion: Femur rolls superior & glides inferiorly on pelvis Extension: Femur rolls inferior & glides superior on pelvis Abduction: Femur rolls lateral/superior & glides inferior on pelvis Adduction: Femur rolls medial/inferior & glides superior on pelvis Internal Rotation: Femur rolls medial & glides lateral on pelvis External Rotation: Femur rolls lateral & glides medial on pelvis
  22. 22. Osteokinematics  Flexion = 900 w/ knee extended  Normal gait on level ground requires  300 hip flexion  100 hyperextension  50 abd/add/IR/ER  Anterior pelvic tilt  Sagittal plane  Hip flexion  ASIS anteriorly & inferiorly, symphisis down
  23. 23. Osteokinematics  Posterior pelvic tilt  Hip extension  Symphisis pubis up  Posterior pelvis closer to femur  Lateral pelvic tilt  Frontal plane  One hip joint serves as pivot/axis  Opposite iliac crest elevates (hip hike) or drop (pelvic drop)  Reference is side farthest from supporting hip  Pelvic rotation  Transverse plane  Occurs in single-limb support around axis of supporting hip jt.  Forward rotation  Side opposite supporting hip moves anteriorly  Backward rotation  Side opposite supporting hip moves posteriorly
  24. 24. Osteokinematics  Lumbar-Pelvic Rhythm  Open-chain  E.g. reaching the floor  Hip flexion up to 900 only  Anterior tilt of pelvis on femurs  Flexion of lumbar spine adds 450  E.g. side-lying abduction  Lateral tilt of pelvis & lumbar spine adds 450  Closed chain response to motions of pelvis  Keeps one or both feet on the ground  Maintain head upright & vertical  Anterior pelvic tilt during hip flexion = head & trunk displaced forward + lumbar extension  Posterior pelvic tilt + lumbar flexion to keep head forward over sacrum
  25. 25. compensatory Osteokinematicspelvic motion co-hip motion lumbaranterior tilt hip flex lumbar extposterior tilt hip ext lumbar flexlateral tilt (drop) right hip add right lateral flexlateral tilt (hike) right hip abd left lateral flexforward rot right hip IR rotation to leftbackward rot right hip ER rotation to right
  26. 26. Hip jt. Musculature Flexors 10  Iliopsoas O = iliac fossa, lateral sacrum, IVD & bodies of T12-L4 vertebra, transverse process of L1-L5  I = lesser troch  Rectus femoris O = AIIS  I = tibial tuberosity  Hip flexion w/knee flexed
  27. 27. Hip jt. Musculature Tensor fascia lata O = anterolateral lip of iliac crest  I = iliotibial band  Abd, IR femur  Maintain tension @ iliotibial band (relieves stress on femur) Sartorius  Straplike O = ASIS  I = upper medial tibia  Flex & abduct hip in either knee flex/ext
  28. 28. Hip jt. Musculature 20 = 40-500 flexion Pectineus Adductor longus Adductor magnus Gracilis
  29. 29. Hip jt. Musculature  Adductors  Pectineus  O = superior ramus pubis  I = femur, below lesser troch  Medial to iliopsoas  Adductor brevis, longus & magnus  O = inferior ramus & body pubis  I = linea aspera  Anteromedially located  Gracilis  O = symphysis pubis  I = medial surface tibial shaft
  30. 30. Hip jt. Musculature  Extensors  Gmax O = sacrum, dorsal sacroiliac ligaments, ilium  I = superior fibers into iliotibial band, inferior fibers into gluteal tuberosity  Hamstrings O = ischial tuberosity  I = biceps femoris into head of fibula, Semimem & ten into medial tibia
  31. 31. Hip jt. Musculature  Abductors  Gluteus medius O = lateral wing of ilium  I = greater troch  Anterior fibers flex & IR  Posterior ext & ER  All abduct  Gluteus minimus O = outer ilium  I = greater troch  Stabilize pelvis in unilateral stance
  32. 32. Hip jt. Musculature  Lateral Rotators = all insert into greater troch  Obturator internus  O = inside of obturator foramen  Obturator externus  Close to gemelli  Gemellus superior  O = ischial spine  Gemellus inferior  @ inferior border of obturator internus  Quadratus femoris  O = Ischial tuberosity  I = posterior femoral head  Piriformis  O = anterior sacrum  Superior to sciatic nn
  33. 33. Hip jt. Musculature  Medial rotators  Anterior gluteus medius  Tensor fascia lata
  34. 34. Hip jt. Pathology  Arthrosis  OA  Tissue changes in aging  Fx  Due to abnormal ↑ of magnitude of force or weakening of bone  Usually @ zone of weakness  Femoral neck  Bony abnormalities of femur  Coxa valga  Functionally weakened abductors  ↓ hip stability  Predispose to hip dislocation
  35. 35. Hip jt. Pathology  Coxa vara  ↑ hip stability  Femoral head deeper in acetabulum  ↑ risk for femoral neck fx  Slipped capital femoral epiphysis = slide femoral head inferiorly  Retroversion  stable  Out-toeing  Anteversion  Unstable, predispose to andterior dislocation of head of femur  In-toeing  Hip abductors fall posterior, functionally weak  Paraplegia Y ligament permits standing balance when knee & ankle stabilized w/ orthosis
  36. 36. The Knee Joint Complex
  37. 37. Knee Joint OverviewKnee Examination Review
  38. 38. Knee Joint3 bones  Femur, tibia, patella3 articulating surfaces  Medial tibiofemoral, lateral tibiofemoral, patellofemoral all enclosed in the joint capsule Mobility is primarily by the bony structure Stability is primarily by the soft tissues * the knee complex is responsible for moving and supporting the body in sitting and squatting activities and for support for transfers and locomotive activities
  39. 39. Knee JointA double condyloid joint with 2degrees of freedom  Flexion and extension / Medial and lateral rotation  0-120-150 degrees for flexion; Hyperextension 15 degrees
  40. 40. LigamentumpatellaeContinuation of the tendon ofthe quadriceps femoris muscleAttached above to the lowerborder of the patella andbelow to the tubercle of thetibiaGives the patella is mechanicalleverage
  41. 41. Lateral Collateral Ligament Aka fibular collateral ligament Cordlike structure attached to the lateral condyle of the femur and below to the head of the fibula Separated from the lateral semilunar cartilage by the tendon of popliteus muscle Taut during full knee extension & slack during full knee flexion Protects the lateral side from an inside bending force (a varus force).
  42. 42. Stabilizing role of thelateral collateralligamentPrimary restraint toadduction of the kneeSecondary restraint toanterior and posteriordrawer, when thedrawer displacementsare large. Combinedwith the other lateralstructures the lateralcollateral ligament is asignificant restraint toexternal rotation of thetibia.
  43. 43. Medial Collateral Ligament Flat band that is attached above the medial condyle of the femur and below to the medial surface of the shaft of the tibia Strongly attached to the medial semilunar cartilage Taut during full knee extension and slack during full knee flexion Composed of three groups of fibers, one stretching between the two bones, and two fused with the medial meniscus. Partly covered by the pes anserinus and the tendon of the semimembranosus passes under it Protects the medial side of the knee from being bent open by a stress applied to the lateral side of the knee (a valgus force).
  44. 44. Medial collateral ligamentfunctional unitsThe medial collateralligament is the primaryrestraint to abduction andinternal tibial rotation.Secondary role of MCL:Provides anterior kneestability, which isenhanced by externaltibial rotation.With anterior cruciatedisruption the medialcollateral ligamentprovides most of theanterior stability of theknee.
  45. 45. Oblique Popliteal Ligament Tendinous expansion of the semimembranosus muscle Strengthens the back of the capsule
  46. 46. Anterior Cruciate Ligament Attached below to the anterior intercondylar area of the tibia Courses superiorly, posteriorly & laterally; attaches to the lateral femoral condyle Prevents anterior dislocation of the tibia on a fixed femur or prevents posterior dislocation of the femur on a fixed tibia Checks lateral rotation of the tibia in flexion and to a lesser extent, check extension & hyperextension at the knee Helps to control the normal rolling and gliding movement of the knee Anteromedial bundle is taut in both flexion & extension, while the posterolateral bundle is taut on extension only
  47. 47. ACL:Primary restraint to anteriortranslation of the tibia andcontributes the most at 30°flexion.-Prevents hyperextensionof the knee- Secondary restraint tointernal tibial rotation- Resists adduction andabduction at full extension- guides the screw homerotation of the knee jointas it approaches terminalextension
  48. 48. Posterior Cruciate Ligament Attached below to the posterior intercondylar area of the tibia Courses superiorly, anteriorly and medially; attaches to the medial femoral condyle Stoutest ligament in the knee Prevents posterior dislocation of the tibia on a fixed femur or prevents anterior dislocation of femur on a fixed tibia Checks extension & hyperextension, and in addition, helps to maintain rotary stability and functions as the knee’s central axis of rotation Bulk of the fibers are tight at 30 degrees flexion and the posterolateral fibers are loose in early flexion
  49. 49. PCL:Primary restraint posterior translationof tibiaSecondary restraint external tibialrotation at 90° flexion,which reduces uponknee extensionNear full knee extension, theanterior bundle of the PCLslackens, and theposterolateral structuresbecome the primaryrestraint.
  50. 50. PCL footprintNo fan out like theACLThe fibers arealmost parallel tobone
  51. 51. Meniscofemoral Ligaments The ligaments of Humphrey and Wrisberg are meniscofemoral ligaments which run from the posterior horn of the lateral meniscus to the lateral aspect of the medial femoral condyle The anterior meniscofemoral ligament is known as the ligament of Humphrey The posterior meniscofemoral ligament is known as the ligament of Wrisberg In about 70 % of knees, there is either anterior meniscofemoral ligament of Humphrey or posterior meniscofemoral ligament of Wrisberg
  52. 52.  Humphreyligament: (anterior meniscofemoral)  isless than 1/3 the diameter of the PCL  arises from the posterior horn of the lateral meniscus, runs anterior to the to the PCL and inserts at the distal edge of the femoral PCL attachment Wrisbergs ligament: (posterior meniscofemoral)  usuallylarger than ligament of Humphrey (upto 1/2 the diameter of the PCL diameter)  extends from the posterior horn of lateral meniscus to medial femoral condyle
  53. 53. Semilunar Cartilages (Menisci) Sheets of fibrocartilage with a thick peripheral convex border and a thin inner concave border which is attached to the capsule Upper surfaces are in contact with the femoral condyles and the lower surfaces are in contact with the tibial condyles Increase the congruency of the tibiofemoral articulations & distribute the pressure Lateral meniscus is “O” shaped Medial meniscus is “C” shaped and is thicker posteriorly than anteriorly
  54. 54. MENISCUS:Lateral meniscusMedial meniscusTransverse meniscalligamentPosterior menisco-meniscal ligamentAnterior/Posterior horn-attached to intercondylartibial plateau-vascular like periphery
  55. 55. Meniscal biomechanics andFunctional anatomyMedial meniscus has a firmbond to MCLLateral meniscus has noattachment to LCLBecause the popliteus tendonattaches to the posterolateralcorner of the lateral meniscus,there is some additionalmobility and decreasedvascularity in this location.The transverse ligament joinsthe anterior horns of the twomenisci.
  56. 56. Synovial Membrane Linesthe capsule Forms a pouch that extends up beneath the quadriceps femoris to form the suprapatellar bursa, anteriorly Extends downward on the tendon of the popliteus muscle forming the popliteal bursa, posteriorly
  57. 57. Bursa Related to the Knee Joint Suprapatellar Bursa Liesbeneath the quadriceps muscle Largest bursa and always communicates with the knee joint Prepatellar Bursa Lies between the patella and the skin Infrapatellar Bursa Superficial infrapatellar bursa: lies between the ligamentum patellae & the skin Deep infrapatellar bursa: lies between the ligamentum patellae and the tibia
  58. 58. Suprapatellar, Prepatellar, InfrapatellarBursae
  59. 59. Popliteal Bursa Surround the tendon of the popliteus; always communicates with the joint cavity Semimembranosus Bursa Liesbetween the tendon of this muscle and the medial condyle of the tibia May communicate with the joint cavity
  60. 60. The Screw Home Mechanism Refers to the terminal external rotation of the leg at the last 20 degrees of extension due to unequal condylar configuration, muscle torque action & ligamentous guidance During the last 20 degrees of knee extension, the tibia externally rotates about 20 degrees on the fixed femur Also called the terminal rotations of the knee In closed kinematic chain motion, terminal rotation is seen as internal rotation of the femur on the fixed tibia In open kinematic chain motion, terminal rotation is seen as the external rotation of the tibia on a fixed femur Rotation between the tibia and femur occurs automatically between full extension (0˚) and 20˚ of knee flexion. These figures illustrate the top of the right tibial plateau as we look down on it during knee motion.
  61. 61.  DURING KNEE EXTENSION, the tibia glides anteriorly on the femur.
  62. 62.  During the last 20 degrees of knee extension, anterior tibial glide persists on the tibias medial condyle because its articular surface is longer in that dimension than the lateral condyles.
  63. 63.  Prolonged anterior glide on the medial side produces external tibial rotation, the "screw- home" mechanism.
  64. 64. The Screw Home Mechanism Reverses during knee flexion When the knee begins to flex from a position of full extension, posterior tibial glide begins first on the longer medial condyle.
  65. 65.  Between 0 deg. extension and 20 deg. of flexion, posterior glide on the medial side produces relative tibial internal rotation, a reversal of the screw-home mechanism.
  66. 66. Closed Kinematic Chain Motion Aka proximal-on-distal segment kinematics A series of segment link motion with the distal end fixed on the ground or some immovable point e.g. standing up, squatting down Open Kinematic Chain Motion Aka distal-on-proximal segment kinematics A series of segment link motion with the distal end free in space e.g. raising lower leg, throwing a ball Kinematics A branch of mechanics that describe the position and motion of body in space, without regard to the forces or torques that may produce the motion
  67. 67. Osteokinematics Normal ROM: Flexion >130 Rotation: 10 OPP: 25 flexion CPP: Maximal Extension &tibial external rotation Normal End feels  Flexion: Tissue approximation  Extension: Elastic/Firm  SLR: Elastic  *Femoral condyles begin to contact the patella inferior at 20 of knee; flexion; progresses superior at 90 & medial/lateral at 135 of knee flexion
  68. 68. Arthrokinematics Concave Surface: Tibial Plateau Convex Surface: Femoral Condyles To facilitate extension:  OKC: tibia rolls and glides anterior on femur  CKC: femur rolls anterior and glides posterior on the tibia To facilitate knee flexion:  OKC: tibia rolls & glides posterior on the femur  CKC: femur rolls posterior and glides anterior on the tibia
  69. 69. Functions of KneeMuscles & theirChange of Actions
  70. 70. Leg movements by compartment (inleg all nn are branches of sciatic)
  71. 71. Anterior Leg (deep fibular n.)  Fibularis (peroneus) longus  Extensor digitorum longus  Extensor hallicus longus  Tibialis anteriorus
  72. 72. Lateral Leg (superficial fibular n.)  Fibularis brevis/longus
  73. 73. Posterior Leg (tibial n.) Gastrocs and soleus Flexor digitorum longus Flexor hallucus longus
  74. 74. Vastus Intermedius Mostefficient knee extensor with least demand of force
  75. 75. Vastus Medialis Plays an important role in keeping the patella on track in gliding on the femoral condyles (tracking mechanism)
  76. 76. Vastus Medialis Oblique Themedially directed forces of the VMO counteract the laterally directed forces of the vastus lateralis, thus preventing lateral displacement of the patella in the trocklear groove
  77. 77. Biceps Femoris Externally rotates the tibia with respect to the femur
  78. 78. Popliteus Considered as knee flexor but has a poor leverage for this motion Medially rotates the tibia on the femur to initiate unlocking of the flexed knee
  79. 79. Quadriceps Muscles When coming to standing from sitting position, these act concentrically to extend the knee When coming to sitting from standing position, these act eccentrically to control the rate of knee flexion
  80. 80. Gastrocnemius Flexesthe knee simultaneous with plantar flexion of the ankle
  81. 81. Knee Alignment & Deformities Tibio-femoral shaft angle is seen anteriorly on an extended knee which is about 170 degrees in a normal adult Genu Valgum or Knock Knee: refers to an angle that is less than 170-165 degrees >195 if ant Genu Varum or Bowleg: refers to an angle that approaches 180 degrees or greater <180 if ant Q Angle: an angle formed by the tendons of the quadriceps femoris and ligamentum patellae; N= 15˚ Genu Recurvatum: an excessive hyperextension that develops from weight bearing on an unstable knee