HK 302 Exam 4

ROM

  • Flexibility: A Musculotendinous unit’s ability to elongate with application of a stretching force

  • Range of Motion: The amount of mobility of a joint, which is determined by the soft-tissue and bony structures

    • Determined by:

      â—¦Bony structures

      â—¦Soft tissue structures

      â—¦Muscles, tendons, ligaments, capsule, skin

      â—¦Subcutaneous tissues, nerves, blood vessels

  • Collagen: Provides strength and stiffness to tissue

    • Increased binding of collagen fibers = increase tensile strength & stability

  • Elastin: Pro vide extensibility property to a tissue.

    • Tissues with more elastin have greater flexibility

  • Reticulin: Type III collagen fiber. Important during the repair phase following injury.

  • Ground substance: Structureless gel material. Reduces friction between collagen and elastin fibers. Maintains spacing between fibers. Transports nutrients to the fibers.

Three types of connective tissue:

  • Loose Irregular Connective Tissue: Provides tensile strength and pliability (fascia surrounding mm & nn, also fascia of joint capsules)

  • Dense Regular Connective Tissue: More highly organized – with parallel collagen fibers. Able to resist high-tensile loads and still be flexible (tendon best example, also ligaments)

  • Dense Irregular Connective Tissue: Similar to dense regular CT, but fibers are not parallel (Joint capsules, aponeuroses, periosteum)

Effects of immobilization on Connective Tissue:

  • CT is continually replaced and reorganized: As part of this process: CT shortens

  • Normal daily activity maintains normal motion

  • Restriction of motion = changes in structure & function of CT: Motion often restricted following injury to protect the area Changes happen rapidly, and can be reversible or permanent

  • Changes include structural weakness and decreased tissue mobility: Muscle tissue, Articular Cartilage, Periarticular CT

Effects of immobilization on Connective Tissue: Key Point of immobilization Immobilization causes changes that result in loss of motion in all tissues. Increased collagen cross-links and loss of ground substance impair the flexibility of connective tissue.

Determining normal ROM

  • Established “norms” for each joint

  • Measurements are affected by age, gender

  • Measurements are also affected by sport/position

  • Compare bilaterally

  • Need to know what is normal so that you can correct deficiencies

  • Goniometer (a healthcare protractor!)

    • 1. Stationary arm

    • 2. Movable arm

    • 3. Fulcrum / Axis

    • 180 Vs 360

    • Stationary / fulcrum / moving

    • Landmarks

    • Patient position (Start position & End position)

    • Provider position (eye level with fulcrum)

    • Watch for accessory movement

  • Tape Measure

  • Inclinometer

When performing “Special Tests”

  • Perform bilaterally

    • Noninvolved side

    • Involved side

  • Keep impact / influence of “activity” or occupation of the patient in mind!

  • Positive test: Indicates a pathology is present / is likely, and a limitation of movement

  • Negative test: Indicates a pathology does not appear to be present / is not likely, and no limitation of movement

Special Tests

  • Thomas Test: hip flexor tightness

    • Subject lies supine on the table and pulls up one leg and lets other hang

    • positive: femur not parallel with the table, and/or knee is in extension

    • negative: femur parallel with the table and knee at 90 flexion

    • muscles: rectus femoris & iliopsoas

    • ***if positive and knee is passively extended and hip drops then rectus femoris is tight, if knee is passively extended and hip does not drop the iliopsoas is tight

  • 90/90 Straight Leg Raise: hamstring tightness

    • supine on back both legs at 90 flexion, 1 at a time go into extension

    • positive: knee cannot extend to 140

    • negative: knee can extend to 140 and beyond

    • muscles: semimembranosus, semitendinosus, biceps femoris

  • Modified Ober’s: IT band tightness

    • contralateral side lying, upper leg is brought passively behind other leg and allowed to passively drop

    • positive: leg does not lower beneath the plane of the table

    • negative: leg drops beneath the plane of the table

    • muscle: IT band

  • Ely’s Test: rectus femoris tightness

    • prone lying and passively flex

    • positive: same side hip flexes with knee flexion

    • negative: hip stays relaxed on table

    • muscle: rectus femoris

  • Pectoralis Major - Sternal:

    • supine lying passive arm into “full” flexion over head, palm facing up

    • positive: arm not level with the plane of the table

    • negative: arm level or below the plane of the table

    • muscle: pectoralis major

  • Pectoralis Major - Clavicular:

    • supine lying passive arm into 90 abduction, palm facing up

    • positive: arm not level with the plane of the table

    • negative: arm level or below the plane of the table

    • muscle: pectoralis major

  • Latissimus Dorsi:

    • supine lying, active shoulder flexion

    • positive: arm cannot reach full flexion or come level with the table, back comes off the table to compensate

    • negative: can reach full flexion level with the table without back moving off

    • muscles: latismus dorsi

  • Shoulder rotators:

    • supine lying arm in 90 degrees of abduction and 90 of flexion at the elbow; stabilize the shoulder joint

    • positive: not able to achieve motion or glenohumeral joint raises

    • negative: external rotators - internal rotation, reaches the plane of the table (palm facing down); internal rotators - external rotation, reaches the plane of the table (palm facing up)

    • muscles: subscapularis, teres minor, supraspinatus, infraspinatus

  • Pectoralis Minor:

    • supine lying; acromion distance from the table

    • positive: acromion raised of the plane of the table

    • negative: acromion resting on the plane of the table

    • muscle: pectoralis minor

  • Spinal Mobility - flexion:

    • segmental forward flexion while standing

    • positive: back flat instead of rounded

    • negative: flexion through all segments

    • muscles: abdominal (anterior) muscles

  • Spinal Mobility - extension:

    • segmental extension while standing

    • positive: lack of extension

    • negative: extension through all segments

    • muscles: iliocostalis, longissimus, and spinalis

  • Spinal Mobility - rotation:

    • rotation through cervical, thoracic, and lumbar region

    • positive: no rotation, or pelvis is the origin of rotation

    • negative: rotation

    • muscles: internal oblique abdominals, external oblique abdominals, multifidus

  • Spinal Mobility - lateral flexion:

    • lateral flexion, hands slide down the sides

    • positive: contralateral tightness, shift in weight bearing limb

    • negative: bilateral flexion

    • muscles: internal and external obliques, the quadratus lumborum and the erector spinae

Posture

  • What is posture?: Relative alignment of various body segments.

  • What is good posture?: Posture is a balanced static alignment of body segments so that minimal stress is placed on the segments.

  • Why is posture important?: Poor posture = body alignment is out of balance → exaggerated stresses to segments; Exaggerated stresses over time = anatomical adaptations → changes in ability to perform and impact on the body’s overall efficiency

  • Who is posture important for?:

    • Your clients / patients: Daily activities and sports performance

      • Posture and biomechanics affect performance and risk of injury

    • You: Daily activities and as a clinician

      • Knowledge of proper posture and correct biomechanics will allow you to:

      • Examine technique

      • Examine injuries

      • Conserve energy and prevent injuries for yourself

Correct Standing Alignment: Anterior

  • Plumb line bisects into symmetrical R & L sides

    • Midline of nose, sternum, umbilicus

  • Feet equidistant from plumb line

  • Arms relaxed, palms facing thighs

  • Bilateral structures should be level

    • Earlobes

    • Shoulders

    • Nipples

    • Iliac crests

    • Fingertips

    • Patellae

    • Medial malleoli

  • Patellae face anterior

  • Toes point anterior or slight symmetrical ER

Correct Standing Alignment: Posterior

  • Plumbline bisects into symmetrical R & L sides

    • Midline of posterior head and C → L spinous processes

  • Arms relaxed, palms facing thighs

  • Bilateral structures should be level

    • Earlobes

    • Shoulders

    • Scapulae

    • Posterior Superior Iliac spine

    • Gluteal fold

    • Posterior knee crease

    • Medial malleoli

  • Feet equal distance from plumb line

  • Trunk muscles: Balanced / symmetrical

  • Scapulae: Approx 5 to 6 cm (2 inches) from SPs

  • Elbows: Equal gap between medial elbow and lateral trunk

  • Calcaneus: Line bisecting should be perpendicular to floor

Correct Standing Alignment: Lateral

  • Plumb line should pass through:

    • External auditory meatus

    • Earlobe

    • Bodies of cervical vertebrae

    • Center of shoulder joint

    • Mid-thoracic line

    • Greater trochanter

  • Plumb line should be:

    • just posterior to the hip

    • just anterior to center of knee (just posterior to Patella)

    • slightly anterior to lateral malleolus

  • PSIS and ASIS: Horizontal

  • Appropriate C and L lordosis

  • Appropriate T kyphosis

Correct Sitting Alignment

  • Correct sitting posture (figure 10.4)

    • Normal spinal curves

    • Head should not be forward

    • Shoulders should not be rounded or forward

    • Head and shoulders directly above ischial tuberosities

  • Chair depth and height

    • Front edge of seat does not press back of knees

    • Feet rest comfortably on floor with knees and hips at 900

    • Chair arms supports forearms at 90 degrees

    • Chair back supports L & T spine; reaches inf scapular border

  • Computer position /Desk height

    • Should not change correct sitting posture

  • Scapular Postures

    • Distance from T7-Inferior Angle (increased distance = upward / lateral rotation)

    • “Pseudowinging” (when inferior angle is prominent)

    • To identify scapular winging: Ask your patient/client to load their upper extremity on the wall

Pathological Alignment - Spine

  • Occurs over time

  • Lumbopelvic (A. excessive lordosis, B) flat lumbar spine)

  • Thoracic (C. excessive kyphosis, D. scoliosis, or E. lateral shift)

  • Head and cervical (F. compensatory alignment due to excessive lordosis / kyphosis or posture)

  • Upper Cross Syndrome

    • Tight: Upper Trapezius / Levator Scapulae Pectoralis

    • Weak: Rhomboids, SA, neck flexors

  • Lower Cross Syndrome

    • Tight: Rectus Femoris, Iliopsoas, Erector Spinae

    • Weak: Rectus abdominis, Gluteus maximus, Gluteus medius

Pathological Alignment - Hip

  • Femur: Angle of inclination

    • Normal = 125

    • Coxa Vara = < 125

      • Associated with genu valgum

    • Coxa Valga = > 125

      • Associated with genu varum

  • Femur: Angle of torsion

    • Normal = 15 – 20

    • Femoral Anteversion = > 20

    • Femoral Retroversion = < 15

Patella Alignment

  • Patellae Alta: High-riding patella, + camel sign

  • Patellae Baja: Low-riding patella

  • Squinting Patellae: Patella positioned medially

    • stand in “Chaplin” feat forces patellas forward

  • “Frog-Eyed” Patellae: Patella positioned laterally and high riding

  • Genu Varum: ()

  • Genu Valgum: )(

  • Genu recurvatum: > 5° of knee hyperextension; Congenital, or tear of ACL and PCL

Pathological Alignment - Foot

  • Arch Functions: Shock absorption, Adapt to uneven terrain, Provide space for structures

  • Pes planus: flat feet

  • pes cavus: high arch

  • Hallux valgus / bunion: the proximal phalanx deviating laterally and the first metatarsal head deviating medially and due to the adduction of the first metatarsus

  • Pronated Foot: Calcaneal Eversion (Rearfoot Valgus)

  • Supinated Foot: Calcaneal Inversion (Rearfoot Varus)

Muscle Imbalances

  • Both a cause of and a result of poor posture

  • Causes: Poor posture, loss of motion / flexibility & associated lengthening / weakening of the opposing muscle or muscle group

  • Treatment: Stretch what is tight; strengthen what is weak

Posture and muscle imbalance-related injuries

  • Lower extremity: ie - Iliotibial Band Syndrome; Stretch: ITB; Strengthen: Gluteus medius, hip lateral rotators, quadriceps

  • Upper extremity: ie - Shoulder impingement; Stretch: Pectoralis minor, Anterior deltoid, latissimus, pectoralis major; Strengthen: Lower and middle trapezius, serratus

    anterior, infraspinatus, and teres minor

Body Mechanics

  • Refers to the way a body is positioned and used during activity

  • Correct body mechanics: makes the most effective use of the body’s forces and lever systems

  • Easier with good posture!

  • Improper body mechanics: increases stresses on body segments and increases workload

Gait

  • Gait = Ambulation = Walking

  • Gait cycle: time from point when one foot touches the ground to the time it touches the ground again

    • Two phases in gait cycle

    • Stance phase: ~60% of cycle

    • Swing phase: ~40% of cycle

Heel Strike

Foot first contacts the ground

Flat Foot

The entire foot contacts the grounds

Midstance

All body weight is borne on the limb and the center of mass is directly over the limb

Heel-off

Center of mass moves forward of the limb

Toe-off

The time from when the heel moves off the ground to the point right before the foot loses contact with the ground

Early Swing

beginning of the non weight bearing phase of stance

Midswing

Middle of the swing phase as the leg is perpendicular to the ground

Late Swing

Last section of the non weight bearing phase when the limb begins to prepare for weight acceptance and contact with the ground

Spatial characteristics of gait: Factors related to space or distance:

  • Stride length: Distance from heel strike of one foot to heel strike of same foot in one gait cycle

  • Step length: Distance from heel strike of one foot to heel strike of other foot in one gait cycle

  • Stride width: Body’s side to side movement as weight shifts from one LE to the other; Distance between midline of one foot at midstance and midline of other foot at midstance

  • Angle of progression: Angle formed between straight line of progression and line bisecting foot; Measure from heel to middle of forefoot, between 2nd and 3rd toes

Determinants of Gait: The trunk, pelvis, and extremities work together to provide efficient gait:

  • Pelvic rotation:

    • Around a vertical axis in the transverse plane

    • As one legs swings forward, that side of the pelvis rotates (max of 4 degrees) forward to increase leg length, as opposite side pelvis rotates (max of 4 degrees) backward.

    • Maximum pelvic rotation (total = 8 degrees) at point of double leg support.

  • Pelvic tilt:

    • During midstance, the pelvis tilts downward around an anterior – posterior axis in the frontal plane from the stance leg

    • Swing-leg side of pelvis slightly lower than the stance-leg side

    • Hip abductors of stance leg control this movement

    • Lowers center of mass during midstance by 50

  • Lateral pelvis motion:

    • Body’s center of mass must shift so it is over the supporting leg.

    • Due to femoral neck angle of inclination and accompanying slight valgus of knees – lateral shift is only about 1.7 inch for an adult.

Muscle Function During Gait: Three primary functions

  • Acceleration: Propels body or segment forward. Concentric.

  • Deceleration or shock absorption: Slows or smooths movement; shock absorption primarily during early contact with ground. Eccentric.

  • Stabilization: Provide support to hold a segment stable. Isometric.

  • Function of a given muscle may vary throughout gait

  • Energy requirement greatest in stance

  • Momentum moves limb forward in swing

  • Accelerators:

    • Primarily concentric activity:

    • Posterior calf: accelerators propel body forward during late stance.

    • Anterior leg (dorsiflexors): accelerators lift foot during swing.

    • Hip flexors: lift hip during early swing.

  • Shock Absorbers and Decelerators:

    • Primarily Eccentric activity

    • Quadriceps: Shock absorbers during early stance (for ground reaction force)

    • Hamstrings: Decelerators during late swing (control swing of leg for smooth initial contact)

    • Ankle dorsiflexors: Decelerators at initial contact (prevent foot from slapping onto the ground)

  • Stabilizers:

    • Primarily isometric activity:

    • hip extensors/abductors and torso muscles (Maintain erect trunk position during weight transfer)

    • Hip adductors during swing (prevent “whipping” of hip during swing)

Pathological Gait:

  • Pathological Gait: A reflection of injury, weakness, loss of mobility, pain, or bad habits.

  • Ambulation continues – but with adjustments / compensation!

  • To correct a pathological gait:

    • Assess

    • Observe specific deficiencies in the gait pattern

    • Perform testing to determine cause(s) of the pathological gait

    • Strength testing

    • Range of motion

  • Trendelenburg gait:

    • Cause: Weak gluteus medius unable to maintain level pelvis during single-leg stance.

    • Result: Pelvis drops on uninvolved (contralateral) non-weight-bearing side during single-leg stance on involved limb.

    • Compensation: Lateral trunk movement over the involved hip and utilization of the quadratus lumborum on the contralateral side to lift the pelvis.

  • Quadriceps gait:

    • Cause: Weak quadriceps due to surgery or severe injury – or bad habits developed when the quadriceps were weak/injured.

    • Result: Patient maintains knee extension at heel strike and through entire stance phase. If quadriceps is very weak, patient will lean trunk forward immediately after heel strike just enough to passively maintain knee extension by positioning the body’s center of mass is ahead of the knee.

    • Compensation: Once in the position above, hip extensors are utilized to stabilize the knee to keep it in full extension after heel strike. May literally use ipsilateral hand to push thigh posterior!

  • Restricted knee motion gait:

    • Cause: Knee does not have full ROM following an injury or surgery. Lack of full extension is particularly problematic for gait.

    • Result: If lacks full extension, will remain in knee flexion throughout stance phase. If lacks sufficient flexion, will use hip hike or circumduction to clear floor with foot during swing phase.

    • Compensation: For lack of extension: shortened stride length with initial contact closer to midfoot rather than heel as unable to reach full knee extension, as well as premature heel-off just after mid-stance. For lack of flexion, use of quadratus lumborum for hip hike, or increased hip flexion or circumduction to allow toes to clear floor during swing phase.

  • Ankle lurch gait:

    • Cause: Decreased ankle motion after ankle sprain or surgery.

    • Result: If decreased DF: At midstance, will rapidly transition (lurch) to heel-off with increased knee extension. If decreased PF: will shorten step length and make contact at midfoot rather than heel.

    • Compensation: If decreased DF: May use hip hike, additional knee and hip flexion, or circumduction to clear toes from floor during swing phase. May use ER of lower extremity in stance phase to allow walking behind foot rather then going over foot. If decreased PF: May also require shortened stride length on uninvolved side due to limited ability to propel body forward with involved foot.

  • Shortened step length:

    • Cause: May result from pain, lack of confidence that the limb will support the patient, fear of falling, reduced hip flexion or extension, reduced knee extension, reduced ankle motion, or muscle weakness or tightness.

    • Result: Change of cadence, change of arm swing (especially if unilateral), and increase width of stance (especially with fear of falling or instability) may all occur.

    • Compensation: Dependent upon cause.

  • Antalgic gait:

    • Cause: Pain

    • Result: Decreased stance time and decreased stride length.

    • Compensation: Typically will weight bear at mid-foot or forefoot, may hip hike involved side or go up on toes of uninvolved leg at midstance to avoid hip and/or knee movement on involved side.

  • Running Gait:

    • Differences from walking gait

    • Shorter stance phase

    • Lengthened swing phase

    • No double support

    • Nonsupport phase = double float phase