Lecture 12 (final)

اخر محاضره gait 🥳🔥
شرح دكتور سرحان
#gait

🔹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.

🔸Hip external rotation

🔹Pirformis, Quadratus femoris, Obturator internus and gemellus superior :-
Nerve supply is sacral plexus.

🔹Obturator Externus nerve supply is Obturator Nerve

🔹ROM :
- with knee in flexion the hip lateral rotation is 45 degrees of motion
-with knee in extension the ROM will have tendency to be less amplitude.

🔸The ROM can be limited by :
- Tension of lateral band of iliofemoral ligament.
- Tension in the hip medial rotator muscles.

🔹Weakness of hip lateral rotators causes :-
- Medial rotation of femur
- Pronation of foot
- Tendency toward Knock-knee position

🔸Contracture in lateral rotators of hip :-
- Usually occurs in an abducted position of hip.
- The ROM of medial rotation will then be limited in standing position and toes are outwardly directed.

🔸Hip internal rotation :-

🔹Gluteus minimus and Tensor fasciae latae :-

Nerve supply is superior gluteal nerve.

🔸Acessory muscles :
- Gluteus Medius
- Semitendinosus
- Semimembranosus

🔹ROM like lateral rotation

🔸The ROM can be limited by :-
-Tension in the iliofemoral ligament when the hip is extended.
- Tension in the ischio-capsular ligament when hip is flexed.
- Tension of hip lateral rotator muscles.

🔹Weakness of hip medial rotators :-
result in lateral rotation of the lower extremity in standing and walking.

🔹Trunk flexion :-

🔸Rectus abdominis :

🔹Nerve supply : lower intercostal nerves.

🔹Acessory muscles :
Internal and external oblique muscles.

🔹Factors limiting motion :
- Tension of spinal extensor ms
- Tension of posterior longitudinal ligament, interspinal and supraspinal ligament and legmenta flava m
- opposition of lower lip of vertebral bodies.
- compression of intervertebral fibrocartilages in front.
- contact of lower ribs on abdomen (obesity).

🔹Fixation (Prevent Substitution) :
- Hip flexors
- weight of legs and pelvis

🔸Notice that in trunk flexion :-
- Grade 3 is partial range of grade 4 (In scapular motion from plence)
- Grade 2 is static contraction (poor).
- Ambilicus deviation occurs if it :-
- Upward, the upper part is more stronger.
- Downward the lower part is more stronger.
- If there is no deviation, so there is equal tone between upper and lower.

🔹Trunk Extension :

🔸Erector spinae (sacrospinalis) :

1- Iliocostalis dorsi and Spinalis dorsi nerve supply is dorsal rami of spinal nerves.
2- longissimus dorsi
3- iliocostalis lumborum
4- Quadratus lumborum


🔸Acessory muscles :
- semispinalis
- multifidus
- Rotators

🔸ROM :
Lumber extension is more than thoracic extension.

🔸Factors limiting motion :
🔹Tension of anterior longitudinal ligament of spine.
🔹Tension of anterior abdominal muscles.
🔹Contact of spinous processes
🔹Contact of inferior articular margins with laminae.

Fixation :
- Hip extensors
- weight of legs and pelvis

🔹Trunk Rotators :-
نقول تريكايه بسيطه كدا في الأكشن :
Internal ➡️ Same Direction
External ➡️ opposite Direction

يعني أما اقولك بعمل Right rotation بـ ايه تقولي بال
- Right internal oblique (same)
- left external oblique (opposite)

🔸External and internal oblique nerve supply is mainly : lower intercostals.

🔹ROM :
full clearance of scapula from plence in opposite direction.

🔸Factors limiting motion :
1- Antagonist
2- Tension of annulus fibrosis between vertebrae.
3- Tension of costovertebral ligaments in thoracic area.
4- In lumber area, interlocking of articular facets (Rotation negligible).

🔹Fixation:
Reverse action of hip flexor muscles.

🔸Acessory muscles :
- latissimus dorsi
- semispinalis
- Multifidus
- Rotators
- Rectus abdominis (combined trunk rotation and flexion).

🔸Elevation of pelvis :

🔹Quadratus lumborum :

🔸Nerve supply : lumbar plexus

🔸Action :
- Hip hiking
- Elevates the pelvis laterally by producing a lateral rotation of the lumbar spine.

🔹ROM :
In standing position, the pelvis raised on one side until the foot is well clear of floor.

🔸ROM may be limited by :
- Tension of spinal ligaments on the opposite side.
- Contact of iliac crest with thorax.

🔹Sartorius :

🔸Nerve supply : Femoral nerve.

🔹Function : flexion, abduction, external rotation with knee flexed position.

🔹Acessory muscles :
- Hip and knee flexors
- External rotators of hip
- Hip abductors

🔹ROM : combined range

🔹Postion : sitting with thighs on table and legs dangling off desired motion.

🔹Resistance :
- On lateral aspect of knee (resist hip flexors)
- On medial aspect of ankle
(resist external rotation and knee flexion)

🔹Substitution (pure hip flexion):

Iliopsoas and rectus femoris in this movement is evidence by straight hip flexion without abduction and lateral rotation.

🔹Effect of weakness :
Impaired contribution to anteromedial stability of knee joint.

🔹Effect of contracture :
Patient walks with anterior pelvic tilit and hip flexion, abduction, external rotation.

🔸Tensor fasciae latae :

🔸Nerve supply : superior gluteal nerve

🔸Action : flexion, abduction, internal rotation with flexed knee.

🔸ROM is also combined and on asking the patient to abduct the hip, ROM is approximately 30 degrees.

🔸Effect of weakness :
Thrust to the direction of bow leg position and the extremity tends to rotates laterally from hip.

🔸Effect of shortness :
If the tightness :
1- Bilateral : causes anterior pelvic tilt, Sometimes bilateral Knock knee.
2- Unilateral : the abductors and fasciae latae are tight along with tensor and this causes lateral pelvic tilt on side of tight, knee on that side will tend toward a Knock knee position.

🔸Notice that :
If tensor fasciae latae is tight as a hip flexor, this causes anterior pelvic tilt and a medial rotation of femur, as Indicated by patella position.