Pelvis And Thigh 2
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Transcript of Pelvis And Thigh 2
Quadriceps group
Rectus femoris
Vatus lateralis
Vastus medialis
Vastus intermedius
Qduariceps group
Action All: Extend the knee Rectus femoris: Flex the hip
Origin RF: ASIS VL: Lateral lip of linea aspera, gluteal
tuberosity VM: Medial lip of linea aspera VI: Anterior and lateral shaft of the femur
Insertion Tibial tuberosity
Innervation Femoral (L2-4)
Quadriceps as a group
Seated
Lay the flat of your hands on the ant. Surface of the thigh
Ask pt. to alternately extend and relax his knee slowly
Test for quadriceps femoris
• Patient:Patient: Sitting, with the knee over the side of the table and holding on to the table
• Fixation:Fixation: The examiner may put a hand under the distal end of the thigh to cushion that part against table pressure.
• Test:Test: Full extension of the knee joint, without rotation of the thigh
• Pressure:Pressure: Against the leg, above the ankle, in the direction of flexion
Rectus femoris
Supine with knee bolstered
Locate the AIIS and the patella
Draw imaginary line b/w these two point
Palpate along this line and strum across the rectus fibers
Rectus femoris
Ask pt. to flex his hip
and hold his foot up
off the table
Vastus medialis
Supine with the knee bolstered
Ask pt. to fully contract his quadriceps by extending knee
Palpate just medial and proximal to the patella
Locate the rectus and sartorius – “teardrop” shape
Vastus lateralis
Sidelying
Place the flat of your
hand on the lat. side
of the thigh while pt.
slowly extends and
relaxes his knees
Gluteal muscles
1. Gluteus maximus
2. Gluteus medius
3. Gluteus minimus
4. Tensor fasciae
latea
Gluteus maximus
Action All fibers: extend the hip,
laterally rotate the hip, abduct the hip
Lower fibers: adduct the hip
Origin Coccyx, edge of sacrum,
posterior illiac crest, sacrotuberous and sacroilliac ligaments
Insertion Gluteal tuberosity and
iliotibial tract
Innervation Inferior gluteal (L5-S2)
Gluteus maximus
Ask pt. to extend his hip
Palpate the bulging fibers that lead to the gluteal tuberosity
Gluteus maximus Prone
Locate coccyx, the edge of sacrum, PSIS and the post. 2 inches of the iliac crest
Locate the insertion of maximus at the gluteal tuberosity
Connect its origin to its insertion and then palpate
Gluteus medius
Action All fibers: abduct the hip Anterior fibers: flex the
hip, medially rotate the hip Posterior fibers: extend
the hip, laterally rotate the hip
Origin Gluteal surface of the ilium
b/w iliac crest and the post. and ant. gluteal lines
Insertion Greater trochanter
Innervation Superior gluteal (L4-S1)
Gluteus minimus
Action Abduct the hip, medially
rotate the hip, flex the hip
Origin Gluteal surface of the
ilium b/w the anterior and inferior gluteal lines
Insertion Ant. border of greater
trochanter
Innervation Superior gluteal (L4-S1)
Gluteus medius and minimus
Sidelying
One hand along the iliac crest (PSIS~nearly ASIS) while other hand locates the greater trochanter
Pie-shaped outline of the gluteus medius
Sink your fingers deep to the gluteus medius lto explore the gluteus minimus
Adductor group
1. Obturator externus
2. Pectineus
3. Adductor longus
4. Adductor brevis
5. Adductor magnus
6. Adductor minimus
7. Gracilis
Obturator externus
Action Adduction and external
rotation of the hip joint Stabilizes the pelvis in the
sagittal plane
Origin Outer surface of the
obturator membrane and its bony boundaries
Insertion Trochanteric fossa of the
femur
Innervation Obturator nerve (L3-4)
Pectineus
Action Adduction, external
rotation, and slight flexion of hip joint
Origin Pecten pubis
Insertion Pectineal line and the
proximal linea aspera of the femur
Innervation Femoral, obturator nerve
(L2,3)
Pectineus Supine with the hip slightly
flexed and laterally rotated
Place hand on the middle of medial thigh
Ask pt. to adduct his hip slightly
Locate the prominent tendon of adductor longus or gracillis
Slide off laterally toward ASIS
Slowly sink into the belly of pectineus
Adductor longus
Action Adduction and flexion (up to
70°) of the hip joint (extends the hip past 80° of flexion)
Stabilize the pelvis in the coronal and sagittal plane
Origin Superior puic ramus and
anterior side of the symphysis
Insertion Linea aspera: mediallip in
the middle third of the femur
Innervation Obturator nerve (L2-4)
Adductor brevis
Action Adduction and flexion (up to
70°) of the hip joint (extends the hip past 80° of flexion)
Stabilize the pelvis in the coronal and sagittal plane
Origin Inrefior pubic ramus
Insertion Linea aspera: mediallipin
the upper third of the femur
Innervation Obturator nerve (L2-4)
Adductor magnus
Action Adduction, external rotation,
and extension of the hip joint
Origin Inferior pubic ramus, ischial
ramus, and ischial tuberosity
Insertion Deep part: Medial lip of
lenea aspera Superficial part: Medial
epicondyle of the femur
Innervation Deep part: Obturator (L2-4) Superficial part: Tibial
nerve (L4)
Adductor magnus Sidelying with top hip flexed
Begin by locating ischial tuberosity
Ask pt. to adduct his hip slightly
Locate the prominent tendon of adductor longus or gracillis.
Slide off the tendon posteriorly
Palpate the wide tendon of adductor magnus as it stretches to the ischial tuberosity
Gracilis
Action Hip joint: Adduction and
flexion Knee joint: Flexion and
internal rotation
Origin Infrior pubic ramus below
the symphysis
Insertion Medial border of the tibial
tuberosity
Innervation Obturator nerve
Test for hip adductionrange of motion
Test The movable arm of the aliper is held in line with the
thigh as the left leg is passively and slowly moved into adduction without any rotation.
At the moment the pelvis starts to move downward on the side of the adducted leg, the movement of the leg in adduction is stopped.
Sartorius
Action Flex, laterally rotate
and abduct the hip, flex the knee, medially rotate the flexed knee
Origin ASIS
Insertion Proximal, medial shaft
of the tibia at pes anserinus tendon
Innervation Femoral (L2,L3)
Sartorius
Supine
Ask pt. to position his foot resting his opposite knee
Place your hand along the middle of the medial thigh
Ask pt. to raise his knee toward the ceiling (contracting sartorius)
Test for sartorius
Test for sartorius
• Patient:Patient: Supine
• Test:Test: Lateral rotation, abduction, and flexion of the thigh, with flexion of the knee
• Pressure:Pressure: Against the anterolateral surface of the lower thigh,, in the direction of hip extension, adduction, and medial rotation, and against the leg, in the direction of knee extension.
Adductor group
Supine with the hip
slightly flexed and
laterally rotated
Place your hand along
the med. thigh
Ask pt. to adduct his
hip against your
resistance
Gracillis and adductor longus
Supine with the hip slightly flexed and laterally rotated
Ask pt. to adduct his hip slightly
Slide your fingers proximally to the pubic bone and locate the prominent tendons extending off of the pubic tubercle
Tensor fasciae latae
Action Tenses the fascia lata Hip joint: abduction,
felexion, internal rotation
Origin ASIS
Insertion Iliotibial track
Innervation Superior gluteal (L4-S1)
Tensor fasciae latae
Supine
Locate ASIS
Place hand posterior and distal to the ASIS and iliac crest
Ask pt. to alternate medial rotation with relaxation of the hip
Upon medial rotation, TFL will contract into a solid, oval mound
Iliotibial tract• Sidelying
• Locate biceps femoris tendon just proximal to the back of the knee
• Slide anteriorly from the biceps femoris tendon to the lateral thigh
• Follow it distally as it disappears toward the tibial tubercle
Test for tensor fasciae latae & iliotibial track
Ober test The right leg is flexed to a right angle at the knee The right thigh is abducted widely then
hyperextended in the abducted position
Test for tensor fasciae latae & iliotibial track
Modified Ober test Knee extended
Piriformis
Action External rotation,
abduction, and extension of the hip joint
Origin Pelvic surface of the
sacrum
Insertion Apex of the greater
trochanter of the femur
Innervation Direct branches from the
sacral plexus (L5-S2)
Piriformis
Prone
Locate the coccyx,
PSIS and greater
trochanter. These
landmarks form a “T”.
Piriformis is located
along the base of the
“T”
Quadratus femoris
Action Laterally rotate the hip
Origin Lateral border of ischial
tuberosity
Insertion Intertrochanteric crest,
b/w the greater and lesser trochanters
Innervation Branch of sacral plexus
Quadratus femoris Prone
Locate the distal, posterior aspect of the greater trochanter and the ischial tuberosity
Place finger b/w these two landmarks
Pressing through the gluteus maximus fibers
Flex knee and ask pt. to laterally rotate his hip against your resistance
Test for lateral rotators
• Patient:Patient: Sitting on a table, with the knees bent over the side and the subject holding on to the table
• Test:Test: Lateral rotation of the thigh, with the leg in a position of completion of the inward arc of motion
• Pressure:Pressure: With one hand, the examiner applies counter pressure at the lateral side of the lower end of the thigh. With the other hand, the examiner applies pressure to the medial side of the leg, above the ankle, pushing the leg outward in an effort to rotate the thigh medially
Posterior thigh
1. Biceps femoris
2. Semimembranosu
s
3. Semitendinosus
4. Popliteus
Biceps femoris
Action Hip joint (long head): Extend
the hip, stabilize the pelvis in the sagittal plane
Knee joint(entire muscle): Flexion and external rotation
Origin Long head: Ihchial tuberosity,
sacrotuberous ligament (common head with semitendinosus)
Short head: Lateral lip of the linea aspera in the middle third of the femur
Insertion Head of fibula
Innervation Long head: Tibial nerve (L5-S2) Short head: Common fibular
nerve (L5-S2)
Semimembranosus
Action Hip joint: Extends the hip,
stbilize the pelvic in the sagittal plane
Knee joint: Flexion and internal rotation
Origin Ischial tuberosity
Insertion Medial tibial condyle,
oblique popliteal ligament, popliteus fascia
Innervation Tibial nerve (L5-S2)
Semitendinosus
Action Hip joint: Extends the hip,
stabilize the pelvis in the sagittal plane
Knee: Flexion and internal rotation
Origin Ischial tuberosity and
sacrotuberous ligament (comon head with long head of biceps femoris)
Insertion Medial to the tibial
tuberosity in the pes anserinus (along with the tendons of gracilis and sartorius)
Innervation Tibial nerve (L5-S2)
Popliteus
Action Flexion and internal
rotation of the knee joint (stabilizes the knee)
Origin Lateral femoral condyle,
posterior horn of the lateral meniscus
Insertion Posterior tibial surface
(above the origin of soleus)
Innervation Tibial nerve (L4-S1)
Hamstrings as a group
Prone
Ask pt. to flex his
knee, holding his
foot off the table
As the hamstrings
contract, explore
their mass and width
Hamstrings as a group
Locate ischial
tuberosity
Slide distally one
inch and strum
across the tendon of
hamstrings
Test for shortness of hamstring
• Normal hamstring length
• Excessive hamstring length
Test for shortness of hamstring
• Apparently short, actually normal
• Apparently normal, actually excessive
Test for semimembranosus and semitendinosus
Test for semimembranosus and semitendinosus
• Patient:Patient: Prone
• Fixation:Fixation: The examiner should hold the thigh down firmly on the table.
• Test:Test: Flexion of the knee between 50° and 70°, with the thigh in medial rotation and the leg medially rotated on the thigh
• Pressure:Pressure: Against the leg, proximal to the ankle, in the direction of knee extension. Do not apply pressure against the rotation compartment.
Tendons of the post. knee
Lateral tendons Prone
Ask pt. to flex and hold his knee at 45°
The most prominent tendons : biceps femoris
Move laterally 1 inch from biceps and palpate the iliotibial tract
Medial tendons Supine
Palpate thin, prominent semitendinosus tendon
Slide off anteriorly and palpate
gracillis tendon
Situated anterior to gracillis : sartorius
Follow the three tendons distally as they blend together to become the pes anserinus tendon
Psoas major
Action Hip joint: Flexion and external
rotation Lumbar spine: Unilateral
contraction bends the trunk laterally to the same side,bilateral contraction raises the trunk from the supine position
Origin Bodies and transverse processes
of lumbar vertebraeInsertion
Common insertion on the lesser trochanter of the femur as the iliopsoas
Innervation Direct branches from the lumbar
plexus (L1-3)
Psoas major Supine with hip
slightly flexed and laterally rotated
Locate the navel and ASIS, placing your fingerpads hand-on-hand b/w these point
Slowly compress into abdomen
Ask pt. to flex hip slighlty
Psoas major
Sidelying with hip
flexed: less invasive
position
Iliacus
Action Hip joint: Flexion and
external rotation Lumbar spine: Unilateral
contraction bends the trunk laterally to the same side,bilateral contraction raises the trunk from the supine position
Origin Iliac fossa
Insertion Common insertion on the
lesser trochanter of the femur as the iliopsoas
Innervation Femoral nerve
Iliacus Supine with hip slightly
flexed and laterally rotated
Located anterior portion of iliac crest
Place your finger pads an inch medial to its ridge
Slowly curl your fingers into the iliac fossa
Ask pt. to flex his hip slightly and feel the contraction
Iliacus
Test for iliopsoas
Test for iliopsoas
• Patient:Patient: Supine
• Fixation:Fixation: The examiner stabilizes the opposite iliac crest.
• Test:Test: Hip flexion in a position of slight abduction and slight lateral rotation.
• Pressure:Pressure: Against the anteromedial aspect of the leg, in the direction of extension and slight abduction, directly opposite the line of pull of the psoas major from the origin of the lumbar spine to the insertion on the lesser trochanter of the femur
Other structures of the pelvis and thigh
Sacrotuberous ligament Post. Sacroiliac ligaments
Other structures of the pelvis and thigh
Iliolumbar ligament Prone
Locate PSIS
Slide thumb straight superior from the PSIS to the level of L4 and L5
Other structures of the pelvis and thigh
Trochanteric bursa Post/lat aspect of
greater trochanter
Reduce friction b/w trochanter and gluteus maximus
Normally impalpable