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Lecture 12 (final)

اخر محاضره gait 🥳🔥
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🔹Hip flexion (anterior thigh muscles) :

🔸Psoas major
Nerve supply : lumbar plexus,
Problem in this nerve causes compression or external trauma leading to weakness or paralysis.

🔸Iliacus
Nerve supply : femoral nerve.

🔹Acessory hip flexors :
- Rectus femoris
- Sartorius
- Tensor fasciae latae
- Pectineus

🔸ROM : from Zero to 115 or 125

🔹Limitations :
1- contact of thigh on abdomen with knee flexed.
2- tension of hamstring with knee extended.

🔸Notice that
1- Knee flexed or extended to prevent the substitution.
2- Hamstring is a two jointed muscle which has a passive insufficiency.
3- To get the exercise more difficult increase the lever arm.

🔹Palpation of
1- Psoas major : distal to inguinal ligament.
2 - Iliacus : slide in iliac crest.

🔸Notice that inguinal ligament presents in the medial side of sartorius.

🔹Substitution by 2 muscles :
1- Sartorius in hip flexion causes lateral rotation and abduction of thigh.
2- Tensor fasciae latae in hip flexion causes medial rotation and abduction of thigh.

🔸To avoid the substitution, we should keep the thigh toward the med line (other leg)

🔹Weakness of hip flexors :
1- Disability in climbing stair, walking, bringing the trunk forward in sitting position.
2- Marked weakness in walking because the patient should do propulsion of hip (bringing the leg forward by pelvic motion) which comes from anterior and lateral abdominal muscles action rather than hip flexion.

🔸Notice that :
1- In propulsion of hip there is :
🔹Anterior pelvic tilt
🔹Hyper lordosis (extension in lumber)

2- Also weakness in hamstring causes inability to stand up strightly
و دا يحصل اما اجيب حاجه من ع الأرض، وعندي ضعف في ال hamstring، فـ هطلع بال trunk extensors و مش هكمل الحركه هفضل معوج كدا لان اللي مفروض تكمل الحركه فيها weakness و هي ال hamstring.

🔹Contracture of hip flexors:
1- Unilateral causes flexion, abduction, external rotation.
2- Bilateral causes lower cross syndrome which is :
🔹Anterior pelvic tilt (hip flexion deformity)
🔹Lumber hyper lordosis

🔹Hip extension (posterior thigh muscles)

🔸Gluteus maximus
Nerve supply : inferior gluteal nerve.

🔸Notice that if iliotibial band is :
- tight causes lateralization of patella.
- weak causes knee rocking

🔹Biceps femoris
Nerve supply :
🔸Long head : tibial branch of Sciatic nerve
🔸Short head : pernoeal branch of Sciatic nerve.

🔹Semitendinosus and Semimembranosus
Nerve supply : Sciatic nerve

🔹ROM :
- from 115 or 125 to Zero
- Or It's 10 to 15 degrees beyond the mid line.

🔸The ROM of hip extension can be limited by tension in :
🔸The ilifemoral ligament
🔸The hip flexor muscles

🔸Fixation :
🔹Contraction of iliocustalis
🔹Quadratus lumborum
🔹Weight of trunk

🔸Palpation of gluteus maximus through iliac crest from posterior

🔹Substitution by lumber spine to rise the thigh, the patient do hyperlordosis which is not a compound action (It's just carrying the weight)

🔸Notice that in flat lumber curve there is :
🔹Flexion in abdomen
🔹Posterior pelvic tilting

🔸To isolate the gluteus maximus muscle, all the test tasks must be performed with knee in flexion.

🔹Weakness of hip extensors :
🔸Bilateral marked weakness of the gluteus maximus muscle makes walking extremely difficult, and necessitates the aid of crutches.
🔸Postero-lateral displacement of the trunk over the femur (hyperextension of hip joint )
🔸Patients must push themselves to an upright position by using their arms.

🔹Hip Abduction

🔸Gluteus Medius and minimus nerve supply : superior gluteal nerve.

🔹Acessory muscles :
-Tensor fasciae latae
-Gluteus Maximus (upper fibers)

🔸Notice that :
- The anterior fibers of gluteus medius medially rotate and may assist in hip flexion.
- The posterior fibers of gluteus medius laterally rotate and may assist in hip extension.

🔹ROM :
From med line to full ROM, the hip joint can abduct for 45 degrees.

🔸 This ROM can be limited by :
- Tension of of distal band of iliofemoral ligament and of the pubocapsular ligament.
- Tension of hip adductors.

🔹Notice that in fixation and substitution :
When testing the abductors as a group in side lying position, the stabilization is necessary, but often difficult, As it requires :
🔸Strong fixation by many trunk muscles.
🔸Stabilization given by the PT.
🔸The slight flexion of hip and knee of the under leg aids in stabilizing the pelvis against anterior and posterior tilt.
🔹Any shift in position of pelvis may be result from :
🔸 trunk weakness
🔸Substitute by anterior or posterior hip muscles
🔸Substitute by lateral abdominals.

🔹Hip adduction :

🔸Pectineus

Nerve supply : Femoral and Obturator Nerves.

🔸Adductor Magnus

Nerve supply : Obturator and Sciatic Nerves.

🔸Gracilis, Adductor Brevis and Adductor longus nerve supply : Obturator Nerve.

🔹ROM : from the hip abduction position to the mid line the ROM is 45 degrees.

🔸The ROM can be limited by :
- contact with the other leg
- when hip is flexed, tension of ischio-femoral ligament.

🔹Substitutions :
- Anterior pelvic tilt or flexion of hip allows substitution by the hip flexors.
- Forward rotation of the pelvis with extension of hip shows attempt to hold with lower fibers of gluteus maximus.

🔸Notice that excessive tightness of adductors cause avulsion fracture (like in excessive jumping).

🔹When person has a two striped pirformis, the Sciatic Nerve is between them (1)
🔹Or when sciatic nerve under the pirformis (2)

In (1) or (2) compression on sciatic nerve occurs which leads to inflammation or spasm.