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Chapter 9

HSS2111 Chapter 9: Function & Injuries of Appendicular Skeleton pt.1 lower limbs

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University of Ottawa
Health Sciences
Tien Nguyen

HSS2111 B Professor Tien Nguyen 1. Function and Injuries of Appendicular Skeleton (lower limbs and pelvis) 03.08.2017- 03.15.2017 Functional Anatomy of Lower Limbs and Pelvis Foot – accessory movements allow feet to mold and operate on uneven ground; 3 arches: 1) Medial arch – most elevated (calcaneus, navicular, cuneiform, 1 , 2 , rd and 3 metatarsals) th th 2) lateral arch – talus, cuboid, and 4 & 5 metatarsal 3) transverse arch – 5 metatarsal, cuboid, and cuneiforms  Flat feet is flattened medial arch due to genetic factors – causes issues in knees and pelvis  Natural inversion and slight eversion in all feet regardless of arch flatness Ankle – joints: talocrural joint btwn tibia, fibula, and talus; and subtalar joint btwn talus and calcaneus  Lateral ligaments are most often injured – anterior talofibular ligament, posterior talofibular ligament, calcaneofibular ligament; much easier to invert foot than to evert foot  deltoid ligament (talocrual joint) is thicker and less-likely to be damaged compared to lateral ligaments; can be injured with impact Gastrocnemius – more power and sped (jumping); soleus – less intense movements (walking) Knee – movements include flexion and extension; more rotation possible with more flexion, rotation isn’t possible with fully extended knee  Popliteus plays part in knee rotation – it moves knee out of locked position and allows flexion to occur  3 major bones – femur, tibia, & fibula; femur & tibia form tibifemoral joint (flex, extend, & slight rotation)  Quadriceps – vastus medialis, intermedius, lateralis, and rectus femoris o Plantaris and popliteus muscle – stabilize knee, help flex knee, and evert foot  Hamstring muscles – semitendinosus (medial), semimembranosus, and biceps femoris (later) o Hamstring tension prevents tibial shifting (protect cruciate ligaments) o Medial and lateral hamstrings give medial and lateral rotation respectively  i.e heel strike on left foot – lateral rotation to left; lateral hamstrings cause lateral rotation of femur on the tibia  patellofemoral joint – quadriceps muscles and tendon, patella, and patella tendon  4 major ligaments – MCL, LCL, ACL, and PCL o two crescent shaped menisci (medial and lateral), they absorb shock, distribute force, and provide stability Pelvis – ilium, sacrum, ischium, pubis, and coccyx; obturator foramina, pubic symphsis; strongest joint in the body  Movements: flexion, extension, abduction, adduction, external and internal rotation, circumduction  Muscles of the back, abdomen, hamstrings, quadriceps, adductors, abductors, and gluteus attach at pelvis  Weak hip flexors, person can walk on even group (momentum) but will show difficulty climbing stairs o Hip flexors are used to lift the body upwards against gravity (i.e climbing stairs)  Hip abductors are important in stabilizing the pelvis (i.e during stance phase of walking gait)  More knee problems in women b/c of wider hips  Primary muscles of pelvis, hip, and thigh (often weak but commonly used): o Hip flexors – iliopsoas, Sartorius, pectineus, gracilis, and rectus femoris o Hip adductors: adductor longus, adductor brevis, and adductor magnus o Femur muscles – psoas (minor and major), iliacus, gluteus (maximus, medius, minimus), tensor fasciae latae, abductor brevis, adductor magnus, obturator externus, pectineus Stretches for Buttocks, Hips, and Trunk – lying down open second split, lying down pigeon, sitting pretzel Functions of Lower Limbs and Pelvis Walking Gait; Step: from heel strike of one leg to heel strike of the other leg; Stride: when one foot hits the group to the time it hits the ground again (cycle length of one foot); Strike Angle: the angle at which the foot is placed on floor during walking Gait Cycle (two phases)  Stance phase: time when the foot is in contact with the ground; accounts for ~60% of the gait cycle 1) stance phase begins with heel strike 2) foot flat: When entire foot is on the ground 3) Midstance: When person’s body weight is being transferred over the foot 4) heel off: As foot (heel) begins to come off the ground 5) toe off: When entire foot comes off the ground  Swing phase: time when the foot is off the ground; accounts for ~40% of the gait cycle; when leg is being brought fwd 1) Initial swing (acceleration): phase in which leg is being brought forward 2) Mid-swing: halfway point through the movement 3) Terminal swing (deceleration): just before to heel strike  Two periods of ‘double support’ (when both feet are on the ground) - ~15% of gait cycle; at beginning of gait and at the end; During running, there’s no period of double support Functional Tasks of Limbs During Gait 1) Weight Acceptance – begins at heel strike, followed by load response  Immediate transfer of body weight onto the limb as soon as it contacts the ground requires limb stability and shock absorption while preserving the momentum of progression  When weight acceptance = stable kinetic chain 2) Single-limb support – occurs during midstance; contralateral limb is in swing phase and total body weight is on the stance limb 3) Limb advancement – limb leaves the ground and advances fwd to position itself in preparation for heel strike Running Gait – requires greater balance, muscle strength, and ROM than normal walking  Muscles must generate more force both to raise HAT (head, arms, trunk) higher than normal walking and to balance and support HAT during the gait cycle  Weight of HAT and swinging lower limb, supported by one extremity during single-limb support (COG reaches highest point)  As pelvis (ipsilateral) rotates fwd with the swinging lower limb (hip joint of the weight-bearing limb serves axis of rotation), the thorax on the opposite (contralateral) side rotates fwd  Swinging arm (ipsilateral) provides a counterbalance to the fwd swinging of the leg and helps to decelerate rotation of the body (due to rotating pelvis) Float period: both feet are out of contact with the supporting surface; ~15% of gait cycle Common Injuries to the Foot and Ankle Ankle Sprains – most common is inversion and plantar flexion (~80% of cases), injure anterior talofibular ligament  Signs and symptoms o Mild – point tenderness, little (or no) swelling and pain; ~3-week recovery o Moderate – pain, swelling, point tenderness, affects walking gait o Severe – joint instability, extreme pain (no pain if nerve damaged), point tenderness, loss of function, and possible fracture; ~4-month recovery  Treatment – RICE for first 24 hrs (15min on, 90min off); cease movements with splint, tape, brace, or wrap  Rehabilitation – stretching and strengthening program anterior talofibular ligament - attaches fibula to anterior talus; most commonly torn  ATF ligament Palpation – apply pressure in an anterior-medial motion to anterior talofibular ligament  Anterior Drawer Test – tests integrity of anterior talofibular ligament; stabilize top of ankle with one hand and pull up on heel with the other hand – if there’s fwd motion of foot, ATF ligament may be torn Posterior Talofibular Ligament – from mid lateral malleolus and runs almost horizontally to posterior talus  Palpate behind lateral malleolus; foot in dorsiflexed position as you medially rotate ankle to stress PTFL Calcaneofibular Ligament – connect distal tip of malleolus to calcaneus  Palpate under lateral malleolus; Talar Tilt Test – apply direct inversion stress, if talus tilts out from lateral malleolus indicates sprain Deltoid Ligament – distal tibia to anterior talus, navicular, calcaneus, and posterior talus (form large fan-shape)  Palpate groove of medial malleolus to posterior portion Plantar Fasciitis: plantar fascia is a wide ligamentous tissue that extends from anterior portion of calcaneus to the heads of metatarsals; supports longitudinal arches of foot  Causes – overuse, footwear, tight Achilles tendon, hard running surface o Most common is chronic irritation from running and jumping  Pain and point tenderness on bottom of foot near heel; can lead to muscle strains, shin splints, heel spurs  Treatment – correcting biomechanics, massage, ice, cushioned footwear  Palpate with tap test along fibrous band through arch of foot from medial tubercle of calcaneus to metatarsal heads Heel Spur: bony growth on the calcaneus, pain and inflammation of soft tissue; aggravated by exercise  Foot flattens, plantar fascia is stretched and pulled at attachment to calcaneus o Over time, calcaneus reacts to irritation by forming bony material; located by pressing on heel  Treatment – taping arch of foot, shoe inserts to reduce plantar’s pull on the calcaneus Great Toe Sprain: great toe is most important for balance and speed; sprain of ligaments of toe (‘turf toe’)  Occurs when foot slips bwd on a slippery surface causing hyperextension of metatarsalphalangeal joint  Treatment – protection, RICE, support; may need x-ray to rule out more severe injury, AT may suggest foot/toe support Blisters: due to skin rubbing (friction), results in separation of skin layers where fluid forms; pain felt b/c it creates pressure on nerve endings; broken blister may create open wound – bandage to prevent infection Arch Sprains: can affect any one of the 3 arches in the foot; most common with medial arch and lateral  Causes from overuse, overweight, fatigue, hard surfaces, improper foot wear  Treatment – RICE, tapping to prevent excessive movement of arch  Prevent with stretches, massages, or just to relieve weight off of feet Common Injuries of Lower Leg Contusion: (bruises) most often over the tibia (very sensitive) to direct trauma; can also involve muscles and nerves (peroneal nerve) Strains: due to repetitive and explosive dynamic force; most common is calf muscles and insertion of Achilles tendon into calcaneus Muscle Cramps: factors that contribute are fatigue, atrophy of muscles, dehydration, diet and nutrient deficiencies (electrolyte imbalance, sodium, calcium, magnesium, and K), poor flexibility (ROM), improper fitted equipment Achilles Tendonitis: usually occurs where tendon attaches to the heel but can occur at any point along the tendon  Overpronation can cause medial arch to flatten and cause leg to twist = gastrocnemius and soleus to stretch more than normal o Force sustained by tendon and calcaneus = pain and inflammation  Signs and symptoms – discomfort is minor at first then worsens as movement continues; repeated overstress increases inflammation; pain, crepitus (popping sounds), redness  Treatment – prevent with stretching; rest, slow-gradual return to regular activity, may need podiatrist to observe biomechanics; icing, anti-inflammatory drugs, physical therapy o Palpate medial and lateral edges and center of tendon at back of ankle Achilles Rupture: usually ruptures about 1-2 inches proximal to the insertion point of tendon into the calcaneus  May result from poor conditioning and/or overexertion o sudden and excessive eccentric contraction to a dorsiflexed foot  Must be surgically repaired; rehabilitation may take up to 1 yr before regular activity can resume  Thompson Test – patient lying on stomach, knee bent at 90 degrees, athletic trainer places hands and fibers around lower leg (thumbs on gastrocnemius) and squeezes lower leg muscles o Achilles is intact if fo
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