still So anyways uh before we get started can anybody tell me what these two X-rays are showing these are kind of more like obscure off thebeaten path pathologies but I guarantee you there will be one BC question maybe on each of them or maybe just one for either one but you will have one It's good just like a deep fact or knowledge to remember Look at that formoral head They're different What do we see here what looks wonky about this is the femoral head wonky or something else wonky the head right where it should be right sitting in the acetabulum But then the neck is not clearly articulated And where I mean is it fractured what's what usually goes here you can kind of see a little bit of one over here Here you can definitely see one right here What is this line growth plate Yeah So this is a fracture right along the whole entire growth plate The epiphysis So does anybody know what this is called there's an official name for this It's almost like the epiphysis epipthesis has slipped from the head of the femur aka the capus of the femur So it's a skippy slipped capital femoral epiphysis There you go Skiffy is more common in uh children or adults Yes Why do we know that for a fact growth plates Absolutely What age do they usually close it's good to know if you're in high school if you have open or closed growth plates for your athletes Depends on depends on the bone and also depends on gender right who closes their growth plates first females or males females Yeah So that's usually in high school at some point And then males are usually in college So it's good to know if you're in a high school setting right now Good morning And you're thinking growth plate injury If they're a senior and it's a girl probably not right they're they probably have already closed their growth plates If it's a guy then there's a legitimate chance they don't fully become mature skeletally uh until like 22 to 26 years old which there it is There was the softball Okay so that's a skiffy What about this one up here also femoral head injury also to children or youth What does it look like is going on it's like we have a nice clean one here So this is your comparison side There's the growth plate We have kind of a growth plate here But do we have a nice clean fully shaped femoral head l So if you thought hypostrophe last names were a thing this is a triple doozy This is leg calf perthesis with two hypothesis right hyphens not hypothesis hyphens Hyphens duh English is hard Okay So leg caps What is this this is the avascular necrosis of the formoral head So there's a little artery that pops out of the formoral head that feeds the inside of the joint because there's no blood flow otherwise And when that artery gets oluded or you know cut off or just dead for whatever reason then you lose blood flow to this area and you can have avascular necrosis aka basically just like a flattened dead cat head of the femur So leg calf heresies disease There is two links in the notes section to that slide if you want to pull up a Mayo Clinic and check it out more But just good to know you will have one of those questions on your BSE and it'll just be a basic like "Hey what do you think this injury is it's a 14-year-old child with diffuse non-specific hip pain and look at this X-ray." And you're like "That looks like the growth plate slipped That must be a slipped growth plate injury." And then there you go You can think back to this moment hopefully Okay moving on Here's our scoreboard Thor is still in the lead And I will say Captain America gained some ground here So good on them We're closing the gap 16 point difference And there's one bonus um miniame today too Oh so we have three chances to earn points Three Yeah So there we are Okay So I'm going to keep the structure similar to how we've been doing it So we'll start with our path anatomy but I printed it out for you guys this time so we can go You don't have to like write all the little things down to save you a couple minutes hopefully Um and then maybe you're not like me trying to like stare at this screen from especially if you back rowers So we'll start with that and then we'll get through these two today Hamstring strains You've already read that article so we don't need to spend too much time on it because you should already know a lot of this or all of it But then we'll go into snapping hip syndrome which is really like a three-part thing because there's three causes of snapping hips So we got to differentiate each one and how to do that And then this is for next week intraarticular pathologies which is laboral tears and hip impingement So between these three things this is probably the vast majority It's going to be like 80% of the hip injuries you ever see for the most part which is really nice So we'll cover all of that um today and next week we will do a little bit of just like skills practice for those special tests And if you remember from the hamstring article it was talking about shrink testing MMT wasn't even brought up because it was so bad It was handheld dynometry right so we brought in two of those so that you guys can just practice using those If you've never used it then I'll show you how I have a vault one and a store brand one um that I bought with my money because vault's expensive Um but otherwise we'll just practice all our other skills So here we go We'll start with this You guys all have your sheets in front of you So go ahead and fill those out Let's take 10 minutes on your own So picture A right b C D There's a couple more today than there usually is There's usually 20 I think I have 25 today So we'll give you extra minute but there's just a lot more anatomy in the hip than there is in like the knee So that's why Sorry about it U but the muscles you should all know Maybe some of the joint stuff give you a little slack on but there's I don't think there's any doozies on this list So I'll give you 10 minutes here and then we'll uh do it as a group Okay here we go You guys can shout them out A1 what do we got a I S A I inferior iliac spine A2 greater chroer Yeah absolutely A3 lesser troanter A4 Oral head Yeah easy Five Six Moral neck Acetabulum I would also take labram if you put that because it's kind of pointing at both Yeah Which one a10 What would it have been a10 was pointing out like articular cartilage of the femoral head So I was like ah curious Hard to differentiate which arrow is which Um okay Good Nice Everybody got that Sounds like B1 What muscle here glute me Yep And then B2 B3 So three Your form is six Max Say those again One is me glute me Two is min Three is pureformis Six is max No I mean they're in there but I didn't pick them Okay screw those things All right the C line Let's do it C3 What do we got here yes Add Magnus Yep C4 C3 Sorry C3 Add Magnus Your fifth hamstring Anybody sore there after deadlifts that's why it's hippensor The only groin that's a hippic sensor C4 graasilus C Yeah All the way through C5 It man Yeah exactly C6 long head Biceps fem long head which means C7 is biceps fem short head Yeah you got it And then C8 and N Right Eight is going to be semi hendinosis And then nine is more medial semimebrosis Yeah What about tendon and then the muscle that white put I mean that is the muscular tendonous junction So you can put either one It's literally halfway in between Even if it's not differentiated between long be long head Yeah Yeah Yeah They say "Hey put the east on the VMO and you put on the on the lateralis muscles last one." Dline Here we go D5 is going to be which hip flexor Soaz major Specifically major What are they gonna put it because so minor is a little I mean so as major there's different muscles D6 is gonna be iliacis So have you guys done uh you've done hip flexor releases right where you get your fingers sinking down After you just did those abdominal palpations doesn't that blow your mind like what we're doing to them We're just like let's just go through depending on what side it is Appendix move Get in here So like Jesus that's intense That's why they're in pain But just know you should always do both on your release or at least assess which one they need Don't just put your hands somewhere in there because they might be tight in their iliacis which is really easy to find if you just step off the asis But if they're more tight in the so to go a lot more centrally and go a little bit deeper So just assess both before doing your release because you may need to do one or the other or both So just keep that in mind Otherwise let's keep going So we're on D8 right here TFL TFL aka There we go D9 It's an adductor What's that Yeah D10 is a little bit tricky D10's adductor [Music] longus Brevvis sits right in between these two but underneath So brevis it's in there but you can't see it in this picture D11 where we at right here There you go Uh D16 vasis medialis oblus And then 17ad quad There we go Don't just say quad Yeah D3 and D6 D3 is going to be pure form and six is blue max There we go Eight and N was semi glucos Correct Eight and nine for C Yep Yeah you got it Go ahead and add them up and then shout them out once you got them You guys are pretty good Any arguments that happened no in the back corner over What if it's marriage son you know better to be happy than out of 25 Did anybody get all all of them all 25 Look at my mind We did There you go There's that confidence Yeah Let's hear what you get Who else 20 25 Black Widow what we got 20 Thor what you got 21 21 And Hulk good work Good work Okay so we're moving on to the next thing Um before we get into hamstring and anything else we're going to do our MOI differential So I just want you to write the top three to five injuries and only think hip area right so could something happen to this guy's knee or ankle yes for sure But we're just focusing on the hip regions Um you know who that is then that will help a lot A lot a lot It is both of those things All right So let's go as a group Just your top three to five differentials Okay you don't need a whole big list Just top three to five just solely based off of the MOI So this is an acute MOI This is obviously an acute MOI This one would be a chronic overuse related MOI And we're really looking at the hip drop Right Right So when you see that trendelenberg sign when you watch a gate analysis or usually it's more prominent running what's going to happen to the hip area from that over time All right so let's take nine or 10 minutes give or take Does anybody know who this is i can't the worst injury Look great [Music] Yeah we'll talk more about to confession section fix it Yeah Too late That's a good one [Music] Yeah What's going on i will tell you he's getting landed on It's his right hip leg that he injured and he's getting tackled landed on his knees jamming into the ground but then he's going in like imagine like child's pose right it's landing like like that but with the whole body weight then on his like hips and low back Yeah And that's why our job's hard you guys Like it's hard to tell what's going on here looking at it a hundred times Imagine from the sideline with bodies in the way with one shot and then you got to go act like it's hard So it's okay Sometimes you just don't you don't get the whole thing from the sideline That's fine Yeah It's not a great angle You miss like having Come on Zoom down there Yeah And my YouTube is like so branded to just injuries for me now but they filter a lot of those gnarly ones out Yeah Okay so papers Hand it to another group We [Music] cooked our group effort Everybody switch All right Wow There you go Check them off the list if they got them I may have missed one or two These are the biggies But if you think there should be one or two more up there shout them out I'm open to it But at the very least it should have most of these But yeah if you only wrote three to five that's cool That's only okay So the first one we can go through this So he's getting hit lateral hip right helmet to hip That's a big one right so this is going to be a little bit more common hip in football than any other sport just because of the blunt force nature of the helmet But it could happen really in any sport where someone just goes down hard to the ground and lands on their side Especially a court sport like basketball or volleyball where they land on wood That could totally happen as well So hip pointer number one Has anybody ever seen one of those yeah they suck The worst confusion you can have I'm pretty sure that's what they'll tell you You're going to think that they broke their pelvis or their pains just based off their pain levels So you do have to rule those things out But once you do then you're like you're just going to be uh disabled for the next two weeks with this bruise Sounds good So a pelvic or femur fracture So that could be troanteric fracture can potentially be formal head for neck right pelvis like especially iliac crest That would all be fair game Dislocation probably not super common because that would have to be like a anterior medial dislocation Does anybody know what's the most common direction of dislocation for the hip posterior Yeah 85% So it's going to be posterior It's going to dislocate more or less just knock that way because you don't want to get the anterior that throws you off Um but most of the time it's be posterior which would not be the case here That's not truly the MOI but you could uh otherwise glutial contusion or hematoma How would we tell the difference in a patient between two they're very similar right same MOI same kind of injury but hematoma is a little different than a regular contusion Hence the word chemo which indicates what yeah So you have like rupture internal bleeding within the muscle So you're going to have more swelling more pain but you could even have like some hardness or fullness like in the muscle which you're feeling really common with quads People get hit or tackled or take a stick to the quads But it could happen in the you know lateral thigh hamstring glutes too Um just know yeah if it's going to be extra swollen and bruised up it's probably from some internal bleeding That's a hematoma This is going to take two to three times as long to heal So just give it some time Yeah So he told good one Did I miss anything here anybody else have anything okay Number two Tua So what the real injury was was a posterior hip dislocation and a fracture of the pelvic wall of the socket So of the acetapul So it landed on the knee That force pushed the head of the femur up into the acetabulum which broke it which then since it was broken just shot right out the back end So dislocated and you can kind of see when he's laying here for a second his right leg you can see his right leg looks shorter than the left That's because it's posteriorly located or dislocated And so it would then appear that way So kind of similar to you guys have seen pictures like hip dysplasia That's one of the ways to diagnose it in a baby Not that you guys treat babies but that leg length is going to be drastically different for this as well But with that right so we're are we going to reduce that right then no Can you even if you try no And would you want to because there could be pelvic fracture What else could be going on here we could have femur fracture big time If you're doing all that axial load on the femur like that you could easily have femoral shaft fracture as well Moral neck head that's all fair game So you want to stabilize this person right away um after the EMS and hopefully they have some traction splints and good stability for that femur and pelvis there This is immediate emergency Hopefully you never see this otherwise laboral tear whether that uh head of the femur moves in and out of the socket or if it just stays there and just grinds it Labor tear could be a thing or potentially SI dysfunction which you probably had as well as headline on that side shifted I miss anything here Okay Then the last one overuse So chronic runners injuries Um what sports involve running pretty much all of them Everything Yeah So when we think of like runners knee or runner's hip or runners anything just know like that can obviously happen in pretty much any sport especially that is heavy right so don't just think that's only for cross country and track stuff Uh but it van syndrome And why would we see that there with a hip drop it would be we'd be looking at the left side Would this be the activity of the knee or the hip it's a little different how that works We were saying is from which he doesn't have any but what's happening at the hip to that IT band Yeah Yeah With that hip drop the shorter is then jutting out to the side and it's basically bow stringing that IT band over it And so that could be one of your sources of snacking syndrome So you could have IT band syndrome that revving what's right in between the band and the greater troer is the troant versa So you could have that chronic inflammation and friction So tantric pcitis really hard to differentiate the two and I think a lot of people would say hey they're probably both happening in most cases because why wouldn't there be they're both friction issues So just they kind of treat both the same anyways Otherwise pureformis syndrome So same thing with the hip drop weak glutes uh glutial tendonopathy that can be pretty common on and around the greater chroma where all of those tendons come together And then also just chronic degradation of FAI so injury or label tear I missed anything on that one Stress fracture a stress fracture It wasn't on the board Yes Yes Okay we're good Add them up and get your scores and then we'll move on Okay we got both Huh good Yeah your problems that would be more like Yeah like you probably had surgery while it's Yeah So that's good questionis for one you guys Did anybody else put that for number one what was your thoughts there oh did we not no we didn't He's getting tackled right over that versa And the way we think of bers versus usually is how do they get inflamed trauma or friction So usually the ones though that we see blow up the most from trauma are very superficial It's like a leon one maybe the knee one like superella three Since this one sits underneath a lot of musculature and a lot of tendons it's very rarely gonna blow up from trauma Um it's usually more from the friction But if you put it like watching I don't care But just know that that would be like in reality All right 10 Nice Hulk what did you guys get let's go Okay Iron Man Five And then Captain America Or sorry Thor 12 Okay Cool Thor I honestly agree with you Okay What was that i said honestly I agree with you Did anybody put skiffy on them those are so I like you were thinking that skiffy or leg caps So those are going to be more of your youth athletes which you know this might be high school Um but they're usually more chronic non-traumatic They're just kind of like developmental issues So that's why they're also kind of hard to diagnose because you're like "What's your MOI?" And you're like "I don't have one." You're like "Sick." All right that helps me zero Um so anyways kudos to you for having it but not for this case Okay so we're getting into hamstring Um and then if you guys need a break we'll you can have a little bathroom break after this But for hamstring this should be pretty much review MOI Common MOI for this excessive eccentric contraction So usually when someone's running or kicking it's when that leg is fully stretched out right and they're reaching forward in their stride or they're following through in their kick So you get the stretching effect right so the eccentric contraction and then you're pulling it back through So that transition from the fully lengthened phase to the fully shortened phase that's the hardest part of muscular contraction You have the highest load you have high speeds at sprinting it can get up to levels that we can't always replicate in the gym So that's usually our MOI So that being said um otherwise it's a pretty easy diagnosis Yeah like muscle strains in general aren't too bad especially if you're not having to tease out which exact muscle it is It's just hey it's hamstring You can kind of get into is it medial hamstring or lateral hamstring with you know towing the foot in or out for your strength testing But in general you're going to treat it the same So do you really need to do that right you can debate probably not So what are we looking for this kind of MOI it's usually non-cont right unless someone gets like overstretched or something Uh and then their pain's going to be in the posterior thigh somewhere Could be distal tendonous area could be belly could be proximal tendonous area anywhere in between But there's only one muscle group that lives there So it's a fairly clean look u with your exam And this is the biggie Since it's a muscle strain pain is easily reproduced with active contraction and passive stretch Easy peasy So if you're going out onto the field let's say athlete goes down and you're not sure if they have hamstring cramping or maybe a grade one strain How are you just a quick and easy test right because there's no special tests for the hamstring Just something really quick and easy maybe two things that you can do on the field to just tease it out and see can you keep going because if they have a strain they probably should not keep going They're just going to get worse Yeah Yeah 100% So stretch because that would that feel good for a cramp or bad that'd feel good but would that feel good for a strain or bad yeah exactly So there you go And then contraction is probably not going to feel good for either one right if you're cramping that's just going to make you cramp harder So but you can still check it just to get like a quick like little break test MMT just to see how much pain are you in Are you just tightening up or are you truly like weak and painful still worth a check Um if you're really worried about them and they can't do a quick MMT they probably shouldn't be playing So right it's all relative Uh but I would do both of these things on the field maybe start with this and then end with that So that way you can see hey I'm either going to make you feel better and give you this treatment for your hamstring I'm going to hold you this and your stretch give you some electrolytes and you're good to go Or I'm going to finish with this stretch and that's going to be painful and that tells me you're coming off anyways So like let's just go So but that's up to you I just like to go here first and then here for that reason Um because then this is going to be where you make the call Cool Otherwise so pretty big predictors but maybe a little bit surprising some of them So this one shouldn't be uh number one predictor of any injury hamstrings different is previous history of that injury It's almost too good to be true and like think sometimes we like truly forget that sometimes because it's so obvious and like in our face Um but for hamstrings two to six times more likely to have another hamstring strain if you've just had one before And how many times do people just have one hamstring in their life hamstring strain Is that Yeah Because they're pretty chronic and recurrent kind of like ankle sprains which is annoying Um but this is part of the reason why you're so much more likely is because they're very highly repetitive Um and then it'll go up into that close to that six times range if your athlete already had a hamstring train that season or within the past two to three months Yeah So if you're in that window it's a very vulnerable time for the muscle And so some people can play through some of those lighter grade strains but just know they're up to six times more likely to fully strain it So it's just you know it's a risk So modifi non modifiable risk factor Otherwise older age younger athletes our high schoolers a little less likely to have the strains They're probably more likely to have our cramps So that's why that's a good test to run through them Um not judging their hydration habits but it's probably not great right what did we do great in high school probably not much Uh except getting here maybe a few things but hydration is definitely not on my mind Uh okay Modifiable risk factors So these are things we can change right can't change your age You can't change your injury history What's done is done It is what it is But these things you can change So these are things you want to look for maybe in preseason screens um just to pick up risk factors right hey who's prone for certain things on this team or for whatever this school so validated hamstring weakness and high-speed running demands So this one the high speeded running demands basically just lines up with what's the common MOI People that are going to be doing a lot of sprinting jumping and kicking are going to get more hamstring strains than people who aren't doing a lot of high speeded running jumping and kicking Right if you're a jogging athlete or if you're just not doing high volume of running then there you go Right so then by definition um baseball players are going to be less exposed to this type of injury than say soccer players They're just doing less high-speed running All the running they do is high speed but there's just less of it overall right so they still are going to have it because they go zero to 100 after sitting for an hour So that's what happens My brother police officer out in Denver he almost pulls his hamstring like monthly I'm pretty sure because they get out of their car and they go like "Dude that's that's terrible I feel so bad for all of your muscles especially in the cold winter air out there That's awful Uh but anyway so the hamstring weakness that makes sense right why Why would weakness of the hamstring be a risk factor for the strain because going back to this is it more of a flexibility tightness issue or is it more of a strength issue in the first place of why they get injured strength issue Yeah Do we all have tight hamstrings in this room raise your hand Yes or no do you all have hamstring strains right now no No So just because you have tight hamstrings does not mean you have or will get a hamstring strain Um granted if you have a hamstring strain you will present with tightness That's a big difference So we can see tightness in the eval after the injury is done That doesn't mean that they had tightness going into it that caused this We just treat it because okay we need to get this back to normal Symmetrical symmetricalize your body U but this is not a risk factor hamstring flexibility is not going to make any difference because no matter how long your muscle is you still need to be strong enough to go through these demands So if you think about if you're doing a lot of stretching and you're getting more loose and mobile and that's all you're doing great Now your legs can go even further into your uh sprint cycle right your legs can reach out even further get a bigger swing phase But if you don't do any more strengthening especially eccentrically to strengthen it now you're going to be even more prone to hamstring injury because now you can go even further with even less strength to control that range That end range is very uh vulnerable with all that high load So we need a lot of eccentric strength So as a result uh Nordics right you guys know Nordic hamstrings those are one of the most proven things to help prevent hamstring strains just from an injury prevention protocol standpoint So this is why a lot of people do preseason screening because you can pick up on people especially like say you're working football Well okay your linemen aren't going to be doing a lot of this but your receivers your running backs they're going to be doing a lot of this And if they also have hamstring weakness and history they're super prone right they have the non-modifiable factors and the modifiable factors So you need to work on this You need to get them stronger with Nordics in order to prevent their odds a little bit And then maybe if they are starting to tighten up and cramp early in the preseason let's modify their practice load a little bit so that they can drop their demands and then basically get the capacity back up Okay other little highlights from the article So I just thought this was interesting grading it like this is kind of difficult to grade a strain from clinical eval Usually it's a little easier from MRI And why is that for grade one two and three for muscle strength Yeah Yeah Because we're looking for pain with stretch pain and weakness with uh with strength test But does that tell you the muscle is fully intact or 50% intact or fully right it'll tell you maybe if it's fully gone maybe but that's about it So our test is it's more specific to maybe what muscle is involved what kind of injury is it aka it's a hamstring strain to the biceps fem but we are not always going to know in the clinic is it grade one two three and then the pluses and minuses in there like we don't always know So it's educated guesswork based off of some of these things until where if they get an MRI where you can actually see is there any tearing and then they don't even usually use a lot of this language They're just going to say it's 20% tear That's way more accurate than saying is that a grade one plus or a two minus or where is that 20% there there it is That's your number which is kind of nice to just talk about it that way But this is something that we can do to just look at it So when we are assessing their mobility post injury right so this is not for risk factor testing but after they're injured we can get there's different names for it but popial angle measurement right did you guys do that in lower extrem measure okay we're going to do that today Um this study was looking at it actively So you can do it passively which is what they're doing or you just lift the leg up and then you're measuring You can either me measure this big angle or you can measure this little angle Doesn't matter as long as you just know what numbers you're looking for Um but you're just seeing how high can this tibia go That's going to tell you a good indicator of what's the flexibility of that hamstring if you can imagine that Right so when we do actively or passively the normal amount that we're looking for is about 155 degrees which is obviously if we measure the big angle or that'd be 25 if you're up at the top Cool This is something you do have to go to because if you're going to make a call on you know is this a 5 10 degree difference you need to actually measure that But there's little cut offs here between grade one two and three and ranges So if there's less than a 15% or 15 degree uh discrepancy or um deficit in that leg then there you go It's probably a grade one because that's not that much You guys might even have a 10 to 15 degree um deficit when we check each other today That's not that crazy But when you get up into the higher ranges 16 to 25 for grade two 26 to 35 and up for grade three then it just helps you kind of like put into perspective what's the severity of this injury like how much range of motion have they actually lost that can clue you into what's the grade This is not the whole thing right this is just part of it but we can also use this information right here So other than range of motion we're doing strength testing What would we expect if someone has a grade one strain what would we expect their MMT scores would be yeah No lower than a four right right So either a four maybe a four plus Um yeah but with with pain Yeah probably Especially if you're going max right grade two What are we thinking four minus Sure Four minus Could you be a three plus potentially Could you be a three potentially if they're limited A lot of people aren't going to push when they have that much pain And if they have a grade two they're going to have a lot of pain Um what if it's a grade three would you have a zero i mean think about it If you're doing knee flexion MMT let's say I fully tore my biceps fe them short head how many other hamstrings do I still have three Raise your hand if you've had an ACL repair Anybody no Okay Well you've worked with them Don't they usually take the short head of the biceps hamstring tendon to use the graph do they have a zero see where I'm going with this so this this is not the most accurate means of grading things which is good to know That's why we rely on imaging as well right so this gets you close but just look for pain and weakness And then you can kind of use this to hone in a little bit more on on the grading based off the range of motion Another big one that I like to do personally uh is these two right here which is pretty simple because you're just looking at them You're not actually doing too much But if there's bruising would that likely be a grade one if there's discoloration and bruising and swelling Yeah probably not Unless this person is like literally I don't What's the word doesn't matter Doesn't matter But yeah most grade ones are not going to have significant versioning but your grade twos and threes sure could right so just look for those things to help you just judge this because this is going to determine how heavy you go on treatment at the beginning and also what's your timeline that you're telling because they're going to ask you how long am I going to be out for Never tell them one number Always give a range because we don't fully know right like there is truly a range with injuries And also if you're having a hard time day one to differentiate exactly what how severe do I think it is well one just tell them I think it's going to be six to eight weeks and then but let's re-evaluate in a week and see how you're going Then we can kind of hone in Then is it more like four to six is it more like 8 to 10 we can go from there Cool The other one is gate There's a good rule of thumb It's not perfect rule of thumb but I do like it If someone like a lot of times people are going to have pain just with walking after hamstring strain that is going to indicate a little bit more serious of an injury because if they have pain with running duh right that's how they probably did it But if they have pain with walking especially one to two days post injury they most likely have at least a grade two strain and they will at least miss two weeks time which is kind of good to know right one or two days post still have pain probably a grade two or more Probably going to miss miss two weeks or more right so don't tell them you're only going to miss two weeks Two weeks or more probably more but still just good to know Again not a perfect rule of thumb for these two but really helpful especially because these aren't the most accurate things to strength So how can we make it more accurate right because we just said for strength testing it already wasn't great And I think you guys um already know that MMTs are very subjective and how we grade them And it's also subjective from the patient in terms of how hard they're pushing and are they understanding where we want them to push and you know there's a lot of factors to it that make it not the most reliable of measures So as you probably remember from the article the handheld dynamometry was the go-to So there was other ways to do it You guys might have seen like single leg bridge testing for hamstring strength especially with the heel up on a box Um that's a good workout but it's not as validated as something like this where we're actually getting a number So the big difference with this is not that it's fancy and it's looks cool and flashy It's that you get an objective number It actually measures what's the peak strength Usually we're talking about it in terms of Newtons So going back to physics physics is fun Um but you could most units you can switch it over to being in pounds or kilos or whatever you prefer talking about but just know all of your normative values are going to come in newtons So if you do use one of these devices you should just leave it in that That way you don't have to do conversions to try to figure out is this normal Um but that's it So day one we do want to check it and compare it to the other side And then we also want to check it um within that first week to see is it getting any better If they're not improving in strength within that first week you can probably bet that there's not full union of those muscle fibers right there's some tearing which would then mean there's some strength loss right but if they're improving in strength already within one or two days there's probably not a lot of this going on It's probably a little overstretched maybe more of a grade one so you're a little bit shorter on the return play timeline So that's why this is key because one what's the difference between a 3+ today and a four minus tomorrow you That's the difference right just how much pressure you put or what kind of mood you're in But this is not going to change This is going to be the same every day No matter who's testing it no matter how hard they're pushing right you can get a clean real number Okay So last thing for the group activities today I want you guys with your There should be a sheet of scratch paper Maybe flip it over There's two little mini cases here What I want you guys to do is tell me a few things I want you to tell me what grade you think each cases There's two right this is case one This is case two Uh what grade do you think this hamstring injury is um what's the prognosis right so what's the return to play timeline how's it going to look okay And then just think about what are the things that really queued me in on this Cool So let's take just five minutes Shouldn't take too long We'll just go through that We know the norm What's the normative value for the active knee extension 155 There we go Uh we haven't talked about the normative value for the strength testing but I'll give you a hint This is really close for males So we can just assume for these just to make it easier these can both be males You can do it in your group or if you want to do it solo that's cool either way But it's going to count for uh group points Do we know what all this means ttp What's that hx Beautiful Active knee extension Cool Just making sure It says it doesn't know that you Also it doesn't say timeline but just assume that these are pretty acute within about let's call it 24 hours You see them next day 24 hours Thank you Isaiah say that louder Name of injury Prognosis and imaging Yeah Do they need imaging thank you Making sure I know what we're doing Yeah he already back in college Yes One more minute One more minute One more minute Just grade your hand strength Give me a prognosis on timeline and then yes or no for imaging [Music] I don't think that's something at all [Music] Yeah Yeah Okay Grade of injury grade your strain prognosis on your timeline and then referral Yes or no question restraint one you can do plus you want your timeline and then referral So just three questions Three for each They don't want and they do Okay let's talk about it Case one this is for points too So obviously these are both hamstring strains right yeah you can keep them It's okay I trust you I think should we switch switch them up switch them up Switch up Switch them up Like last place That's why they got what the game always tell you Okay so number one Did anybody put anything besides one no Okay Did anybody try to plus or minus it or did you just put one one One That is correct But why what clued you in on that tell me it still has good strength Strength is Yeah So what is that that's like a 5% strength loss Yeah Give or take 2.5 It doesn't matter Pain as well right so pain with active contraction No pain with stretch But where we at on those limitations 17 degrees Where where does that put us in that spectrum from the last slide question Actually it's the second category right so 15 to 25 16 to 25 grade two category but there's no pain right and it's like barely there So it doesn't always be just straight in the bucket So that is a decent amount of range of motion loss Um no bruising tender palpation over the muscle belly approximately Um no history right so that's that's good And then painfree walk Cool Yeah So grade one if you wanted to put you could probably make the argument for grade one plus just because of this range motion but who cares you're treat It's going to be first independent So grade one that's a point Um timeline What did you guys think for that four to six weeks Four to six Two to six Four to six Probably closer to four You would hope So I personally I would say like three to five but four to six is fine Yeah When you're looking at the degrees of difference do you go based off of the 155 normative or do you go off of like Yes No Yes I got off on that Yeah So this is plus five Thank you for this is 12 degrees So this isn't the grade one You do typically also want to compare it to the other side but for that rule that's off of the norm Thank you But that's where the the degrees come from Like less than 15 It's the difference from the norm Sorry I had that backwards My bad So this is it's 17 degrees different from the other side It's 12 difference from the norm So that would be in the grade one category Which then it just tracks with the rest Even if this was 17 degrees it would still be grade one because everything else fits grade one right does that make sense thank you for that Uh in case sorry before we move on So timeline 4 to six referral yes or no We need imaging No What if the athletes like one of those and they're like can I you think should I go should I go sure What's your What's your insurance there you go You wear your parents But maybe it's just a we need to learn to trust things But they just want to hear it from someone else somehow So whether it's another AT in the clinic or whether it's a physician a team doc an imaging like it's not the end of the world if you have them just for their own peace of mind It's not the end of the world But that's on them That's totally on them Okay Case two What grade would this be two plus Two Yeah Not a grade one right like so between two and three Did anybody think three or we all thinking somewhere in the two range three minus Three minus Okay Oh no sorry So so this one is let's see 22 degrees below norm with pain Is that in the grade two category or three two That's in the grade two category What's our strength loss here yeah almost 20% Right We're 54 pounds under that So it's almost give or take almost 20% difference with pain which is significant but that's not that crazy So hard to say Um bruising yes Tender palpation muscle belly um history no pain So hard to say Hard to say Is it grade two or is it grade three you just got high There you go So this is the case where you could refer for imaging But the thing is you could also try to get a little bit deeper into your eval Remember that hook test that we had with the biceps tendon you could do that like hamstring tendons are pretty easy Yeah So if you can feel this is semimebrosis Can you like these two are right next to each other semime if you can feel two tendons right there and while they're doing an MMT if you can feel it still there it's not you know going curtain style going up the leg like a pop eye Is it fully torn probably not So then you should be fine But if there's any doubt you can always refer this person out Um but interesting thing if you guys remember from the article MRIs for hamstring strains don't add that much clinical accuracy to our clinic Game changer You're smarter than you think So yeah it's probably a grade two or three Either way um the only way treatment's going to change is if it's truly a full clean tear and they need to surgically repair it If it's a grade two they're not going to do surgery to fix it So if there's any integrity left most surgeons are going to say "Yeah rehab that just go super slow So if you can feel the muscle still being integral and that's why your palpations are important then you're probably going to rehab this case Grade three is okay because you can't rule it out because without more information that we don't have So grade three or two is fine That's a point Um timeline for grade two What were you guys thinking six to eight Okay And then grade three if you put that what was your timeline six to 10 Yeah probably like four to six months probably maybe more Yeah especially with hamstrings And then referral yes or no you could go either way Um really we would want a little bit more information before making that call which you could do in real life Just I just wanted you to get thinking about all the answers Okay so there's three points available for each one So six total Um so just add those up and then send them all back He literally do sometimes Also just so you guys know we haven't talked about a lot of timelines that's okay In theex you will get a lot So if you're ever wondering like four weeks how the heck it is four weeks and you will know It's coming soon A little different but like what's our score five for America Hulk what do we got five Did every five no Six There we go Yes we got six Okay Um we're gonna practice These two things we're going to practice but I want to get through the snapping hip stuff first and then we'll just practice everything Okay so we'll come back to this slide So snapping hip this is our last thing for today before we do some hands-on Um three main causes You should be moderately familiar with all three Also if you need to go to bathroom feel free Um but let's see So external internal intraarticular Those are good terms to know for the BOC but I feel like correct me if I'm wrong but I feel like when we're in the clinic we don't always say those exact terms We just say it's snapping hip of the and then you would say either so as usually it's not so it's probably the least common it band's very common right you can feel that thing clunking right there and then labroom is the most serious and just yeah you know it can be common as well so but they're going to be categorized from out to in in these pictures so external it's called that because it's the most external to the hip joints right the IT band all the way out here right and then the soaz actually runs right over the hip joint right So it's more internal It's not in the joint but it's closer And then intraarticular which literally means in the joint that's labor right so snapping can be a lot of things What the thing is that's snapping just depends on where it's coming from So you're not always going to know unless it's IT band You can kind of feel that right but don't just assume don't just put your hand on someone's IT band like "Oh there's snapping." Like "Yeah got it Eval over." Because what if they have a laboral tear and that twisting weight bearing twist is causing you know critus in the joint you don't know for sure You think you can feel exactly where some of these things are coming from And usually you can like I'll give it to you but don't just put all of your faith in just a touch thing right so with this we went over this already with that runner's picture This is a lot of times like our chronic uh hip drop patients Tindel glute me weakness that are going to be susceptible to this a lot of overuse runners maybe even some bikers Soaz the soaz right so not iliacis the soaz muscle is going to come down insert on the lesser trocanter it's going to run over this pubic ramis okay when we move into flexion and extension then that can have a tendency to roll over this little bony nodule on the front of the pubic ramis is not always painful just like this is not always painful you can have a clunk and little little catch without being an injury right some of you guys probably have that sometimes you just feel Same thing here Like if I do flutter cakes I get like a thunk dunk I'm like good lord I know what that is And it just like it's unsettling but it doesn't hurt at all Um so this is usually just due to soass tightness And so when that muscle gets tighter it's going to then get a little bit more bound down towards the bone And then as you move from flexion to extension with your leg then this is going to get caught and fling over that little bone similar to what's happening over here Different muscle different spot Okay so if someone's describing their clunking or snapping as anterior it's not it band It's going to be either soaz or laboral Okay and then this one you could rule it in with your soaz test which how can we test for soaz tightness thomas test Yeah Easy That would probably be tight And then we'd rule this out in order to further rule this in right because anterior clunking and clicking from the hip you want to rule out labor to make sure it's not that before you rule in soaz So this is our third cause intraarticular laboral tears That can be acute or chronic Here's a little breakdown for you guys So MOIS just big u big picture key things that you're going to see in your evals and then the special test to confirm So with the uh IT band we're going to talk about overuse It's that friction that slides over the greater troanter There's actually some good studies um saying like is it actually IT band like what's actually inflamed there is it Versa or is it the IT band and it just kind of depends where you look where you read which is why I say it's probably a combination of both So just know that it's probably those two things If you're doing an eval and you're like I don't know which one is it Just move forward with your treatment You you got it Um but your tenative palpation is going to be here right it's not going to be down here at the knee That's going to be a completely different thing That's not snapped again This is snapped again Cool Um these people are usually gonna have a TFL dominance over a glute dominance What I mean by that is their glutes are going to be weak relative to their TFL being overactive right so if we think about our runners people do a lot of running when you do maybe a abduction MMT and they feel the burn in their TFL you already know you're why are you using your TFL and not your primary abductor that would be a TFL dominance That just tells you every time they move in sports and function they're using this a lot And so they're getting a lot of you know compression through there And they're under using their glute which leads to that hip drop Cool So when you do your MMT especially in the hip I like to feel the muscles with uh and that way when you're giving resistance where are they actually pushing from like when you think is it from the glute lead or is it from the TFL that's really important to know And then when you give them you know band exercises now I need to queue them like "Hey you were all TFL I don't want you to go more strength than your TFL with these band blocks We need to queue you to get a little bit more posterior." Same thing when you do hip extension You want to make sure they're not too hamstring dominant They probably are They just strain their hamstrings Can you actually squeeze your butt um how many times you guys done like a glute MMT and they hamstring cramp on you that's hamstring balance right that should be a glute test but if they're cramping in their hamstring that means they're using way too much of their hamstring Um special tests for IT band pretty straightforward Obsers it's good for the for the hip These two are more at the knee right where you're pushing down here but you can still do it just to recreate it Maybe their it man syndrome is so bad Otherwise Thomas test you can see if their knee flares out for so um repetitive uh flexion extension So think people I mean really any athlete but runners bikers people that are just doing core all day long swimmers anybody can have that kind of clunking in there TTP not over the iliacis right so their tendation will be more over the soaz inferiorly as it runs here So basically if you find that ingenal ligament that we were palpating in 6088 and then you just come down a little bit onto that pubic ramis they'll probably have tenis palpation on the bone and through the muscle They might have a little bit of pain with a hip flexion manual muscle test and a stretch Who knows but they would probably definitely have clunking and you know snapping when they go through those motions So that's what we're looking for If their hip flexor is tight which it usually is for this they're going to be here That's another thing to look for Um Thomas test will tell you And then this is not an official special test but Faber you guys know that position you take them from here to EA which is just the opposite So right flexion abduction er to extension a deduction IR then you're basically giving the soass tenant a chance to snap over the bone So you can you can try to reproduce that motion for them and then you can then if you're reproducing the clunking and the snapping you're like yeah sweet yes that's the one perfect what I'm doing is literally just taking that tendon right over the bone So just keep that in mind You don't have to just rely on this And then for labum this could be acute or chronic joint compression with twisting right it's cartilage So it doesn't like too much compression or torsion Um and it can also be injured if you have any subluxation or relaxation coming in out socket but that's really rare in the hip So it's usually more from compression and or uh twisting All right So a lot of times somebody will like land from a rebound the lamb with a stiff leg in like kind of a twisted position no shock absorption through the knee and through the ankle and so their their labum just takes it all Um there's no give there right it's just bone to socket So could potentially tear This one's going to be interesting Um pain is pretty general Have you guys ever seen a label tear before on a patient positive scour test all that good stuff They're not going to be able to pinpoint their pain because can you touch your label no it's pretty it's pretty deep in there and it's kind of anterior but it's kind of like it's just in there right like your hip is literally a pretty meaty joint Um so they're not going to be able to pinpoint It's be non-specific So they could be pointing kind of anywhere generally around the area whereas these is not the case They can pinpoint exactly where that's coming from and they can probably put their finger right on it This is not only diffuse and general but you can have some referred pain So not just organs that refer the pain but some of our joints can do that too So the hip famously refers pain to the groin and to the lateral truck injury area So if you're thinking you kind of have like a twisting injury you have a lot of groin pain looked at your groin and it's completely fine don't be thrown off That's the number one most common place to feel pain when you have a internal hip joint injury Okay so really where you'll see that a lot which maybe not for you guys is older folks that are about to need to go get hip replacements because they have arthritis All their pain is like medial thigh and like lateral butt And there's why is it hurt so bad here like should I need a hip replacement it's just shooting pain out That's what it's doing You can't localize it So it's just doing one of these Yeah So that's Don't be surprised when you see pain in here or out here or something internal to the hip joint Otherwise you have a lot of special tests for intraarticular issues Scour twist I don't think you guys learned but favor you you did fader Did you guys learn that one yeah we'll we'll go over that today too Arlington is just these two combined so that's fine Cool So let's do it Um before we get into these let's do the hamstring ones So let's grab some tables and set them up We'll take 15 minutes to run through all of our stuff and then we're good for today So we'll do two hamstrings and then we will go through the hip stuff You're going to need to go down here set up I'm going to show how to do these two using model and then you guys can practice these two Okay let's do range of motion first Okay so with this with any gon assessment you need to vote in landmarks That's where you're going to line it up If you don't know those it's not going to be accurate Don't do it So bony landmark Same thing when we do knee flexion extension So lateral epicondile for the fulcrum What's our landmark up here for the stationary yep And then what's our landmark down here for the moving arm so that stays the same Um I'm going to have you do it actively I'm just going to keep you at 90 degrees right here I'm going tell you to straighten your leg as far as you can And then just hold back for me Again I want to make sure That's lined up Okay we're good Some people like do this whole thing and all the way up Just let her go and then line up when you're done Now you're not fighting with it the whole time So you are at 172 She good Absolutely Right What's the norm 155 Yep So let's just always measure both sides Right Go ahead and raise it up Make sure she stays at 90 That's even better somehow 174 Nice So within good enough symmetry Yeah And she's well over the norm which makes sense because she now check your strength So let's go on your stomach So for MMTs you can test hamstring strength a lot of ways right you can do prone with 90 degrees That's probably the most common one But you can do it seated like how we do the lower quarter screen Like there's no right or wrong way to do I guess techn Well that's right Officially you're supposed to go against gravity right so for the PLC remember that all I'm going to use is against gravity But instead of me just using my hand and doing the brake test here this would just be for the brake test portion I can use one of these I'll show you both and then you get to try them out This is my little UFO Um and it just gives you a reading right here of what's the heat force So instead of just using my hand this is a foam pad I'm just going to put that right here So I don't want it to be an uncomfortable spot And I'm going to say don't let pull you down And this is quite rain yesterday Is that good she's like cramp for real 23 That's bad Does you get affected yeah Well yes because I'm going to give her the counter pressure So I have to make sure it stays as isometric which So that's the limitation to this If your athlete can overpower you then that's not going to get their peak force because you can't constrain their peak force So go ahead and sit up for me That's where this comes into play So the bald ones you can set this up to where you have them pushing into it For the bald ones um sit here and then you're just going to put your foot here You don't have to So this is where it's I'm going to Nice [Music] 21 So I got my number from here We'll see if they're the same That was 123 Different testing position here We go to knee knee flexion seated We'll do 60° 90 degrees knee fction That's your right leg And then we're ready to go This thing is the easiest thing So if you guys have one on side don't be afraid of it just Okay Um are you ready bring a little bit closer That way you can sit off the edge Cool So same thing It's just going to be a max ISO And this is not going to let her move right so just go as hard as you But this you can't break this right like she can maybe break my resistance but this you can't So that's kind of more foolproof Go ahead and go Oops And then it'll keep your it'll keep your peak value right there So 108 So pretty consistent This was 123 Maybe a different position But she also probably went too hard on the prone one and immediately felt it And now she was a little bit more guarded So fairly consistent 108 And then you can just compare you know left to right Let's just do that real quick So you can do I like this you can do any muscle this right like you flip around you got quad pull it up you got hip flexor okay 112 so 108 112 she's good on that's good um for the female norm she's at about 50% But she's recovered So sorry That's how you do it So I want you guys to practice with the gonies Grab one of these as well Take five minutes We have another one too sources Okay I pushed out one day No It's like Okay makes sense Now we can't wait for you know we didn't know like You're not You're not See Hey guys I know we only have 10 minutes but still we're gonna practice some more stuff after this too Okay two more minutes I'm gonna show you the hip side We got your mom We if we if you need anything from us you know what I mean you let us know No you will Yeah you're Where are you forion all right All right Don't mind Okay I'll be there Go and gather around CP Everybody gather around Gather around Okay So you guys learn the other three So quickly review scour one spot So I got a windshield wiper grip coming inside top They call this like the hip quadrant test almost because you can go like all four corners Okay Favor's easy You should never ever forget what position this is because it's in the name right the flexion abduction external rotation Yeah So there's your favorite position Okay Um favorite position is just the opposite Flexion a deduction internal rotation If you guys have tight hips right no one likes IR right is your knees okay right Any IR test or measurement of the hip Look what we're doing to his knee So you always have to ask first is your cell okay is your cell okay if that is bothering him at all then just move your hands Come onto the femur and move his hip this way That way it's a lot safer and you can get more hip and less knee So for faded we're going to go flexion IR across the body If we think about the angul of the acetabulum it's sitting like this right so they're like little bowls So it's anterior right but the rim of it that we're going to impinge on is anterior superior So as we come across the body up and with IR that's where we're jamming the head into the labum and the tabular rim most So this is not just a laboral test this is a test too Yeah So if you feel a clicking or anything like that you're thinking lab If it's just stiff and tight it'll be either So favor is position Favor disposition Arlington is just going from one to the other And they found higher specificity with that as the highest one So you should just do both None of these tests are perfect As you can see like specificity there's only one that's pretty good They appear zero to 100 What the heck that's just ridiculous means nothing to me It's worthless U worthless information Maybe it's a good test I don't know But sensitivity same thing It's kind of all over the board but none of these are great And the whole point of why I put this up there for you guys and this story just came out this year I was like none of these tests are your go-to There is no gold standard So use combos like use like multiple in order to confirm your findings So that's why I like because that is you go from fader to fader to fader back and forth a couple times and you see do either of these positions pick up anything that's going to be more accurate than just doing one of the positions Cool First one scour and twist Scour Isaiah had that twist test That's the only one we haven't showed Go and stand up for me That's weight bearing which makes sense for lab because there's lunch compression So that's why you add the compression with scour So it's a two-part test It's kind of like the but for the kick So go ahead and face me And you're going to get a little bit of a of a knee bend Are you a good dancer and then with that with a little hip flexion we're going to approximate more head So with this I want you to shake your knees in and out but keep your hips still So he's just pointing his knees internal external rotation So we're creating rotation or torsion in the hip socket Okay if there's no pain with that then I'm going to do it again Single leg So it's two-part test Double leg and then single leg So you can just do that Both your hands table and then just one leg right leg Right So again limitation special test if he has knee pain it's probably going to hurt it but we're looking for pain and clicking in the hip right cool That's okay If you guys can practice that would be good But just so you guys know real quick because I don't want to make you stay guys I don't want to make you stay any longer than you have to And we're almost out of time but I think you should practice these Uh for next week we're coming back to hip and thigh For homework it's light We just have the journal for the clinicals this weekend right and then we have quiz