Title: Bone Wizardry / OMM Mastery / 8.Lower Extremities
Tags: #BW_OMM::Region::Lower_Extremity #BW_OMM::Type::Cloze BoneWizardry bonewizardry-free omm omt
On every note of this deck, unless a note says otherwise:
Topic: Lower Extremities
Review Links: - Bone Wizardry lower extremity
- Practice: Lower Extremity QBank
Show outside sources
- MET and counterstrain for piriformis
- AAFP hip evaluation
- AAFP knee evaluation

Q: The primary hip extensor: [...]
A: Gluteus maximus
Q: The primary hip flexor: [...]
A: iliopsoas
Bone Wizardry Lock: Gluteus maximus powers push-off. Iliopsoas lifts the leg to initiate the next step. Weakness in either shifts the whole stride pattern.

Q: Primary extensor of the knee: [...]
A: quadriceps
Q: Primary flexor of the knee: [...]
A: semimembranosus and semitendinosus (hamstrings)
Comment: Quadriceps: rectus femoris, vastus lateralis, medialis and intermedius.
Bone Wizardry Lock: Four muscles converge on the patella to extend the knee. On the flexion side, semimembranosus and semitendinosus do the primary work.

Q: Name the 4 ligaments that make up the femoroacetabular joint:
1. [...]
2. Ischiofemoral
3. Pubofemoral
4. Capitis femoris
A: Iliofemoral
Q: Name the 4 ligaments that make up the femoroacetabular joint:
1. Iliofemoral
2. [...]
3. Pubofemoral
4. Capitis femoris
A: Ischiofemoral
Q: Name the 4 ligaments that make up the femoroacetabular joint:
1. Iliofemoral
2. Ischiofemoral
3. [...]
4. Capitis femoris
A: Pubofemoral
Q: Name the 4 ligaments that make up the femoroacetabular joint:
1. Iliofemoral
2. Ischiofemoral
3. Pubofemoral
4. [...]
A: Capitis femoris
Bone Wizardry Lock: Four ligaments anchor the hip. Iliofemoral is the strongest ligament in the body. Ligament capitis femoris is intra-articular and carries a branch of the obturator artery directly to the femoral head.

Q: The head of the femur will glide [...] with external rotation of the hip.
A: anteriorly
Q: The head of the femur will glide anteriorly with [...] of the hip.
A: external rotation
Q: The head of the femur will glide [...] with internal rotation of the hip.
A: posteriorly
Q: The head of the femur will glide posteriorly with [...] of the hip.
A: internal rotation
Bone Wizardry Lock: The femoral head moves opposite to the rotating leg. Spin the leg out and the head glides anterior in the socket. Roll it in and the head tracks posterior.

Q: Patient complains of pain on their right hip. Physical exam findings show that the hip is restricted in internal rotation. What is the likely somatic dysfunction?
[...]
A: External rotation
Q: External rotation somatic dysfunction of the hip is caused by either a [...] or [...].
A: piriformis; iliopsoas spasm
Bone Wizardry Lock: Hip SD is named for where the joint moves freely, not where it's stuck. Restricted internal rotation means the hip has freedom into external rotation, so it is an external rotation dysfunction. The card names piriformis or iliopsoas spasm as the cause.

Q: Patient presents with pain of the right hip. Physical exam findings show the hip is restricted in external rotation. What is their likely somatic dysfunction?
[...]
A: Internal rotation
Q: What is the main etiology of a hip being held in internal rotation?
Spasm of [...]
A: internal rotators
Comment 2: Gluteus minimus, semimembranosus, semitendinosus, TFL, adductor magnus, adductor longus.
Bone Wizardry Lock: The hip is named for its direction of freedom, not its restriction. Restricted external rotation means the hip is living in internal rotation. The internal rotator list: gluteus minimus, semimembranosus, semitendinosus, TFL, adductor magnus, adductor longus.

Q: What are the 3 joints of the knee?
1. [...]
2. [...]
3. [...]
A: Tibiofemoral; Patellofemoral; Tibiofibular
Comment: The tibiofemoral joint is the largest joint in the body. That scale matters when you think about how much load lands there with every step.
Bone Wizardry Lock: Three joints, not two. Most people forget the tibiofibular. It is the one that moves when the foot pronates or supinates.

What are the 4 major ligaments of the knee?
1. ACL
2. PCL
3. MCL
4. LCL
Bone Wizardry Lock: ACL, PCL, MCL, LCL. The two cruciates run inside the joint between the menisci. The collaterals run along the sides. Each has its own named stress test.

Q: The medial and lateral menisci act as [...] and also aid in nutrition.
A: shock absorbers
Bone Wizardry Lock: Menisci do two jobs: absorb compressive load and help distribute nutrition. A torn meniscus disrupts both.

Q: What 2 ligaments are between the 2 menisci and help to stabilize the knee?
[...]
A: ACL and PCL
Bone Wizardry Lock: The cruciates run in the intercondylar notch, between the two menisci. Cruciate means cross. The ACL and PCL cross each other to limit tibial translation in opposite directions.

Q: Which ligament prevents anterior translation of the tibia on the femur?
[...]
A: ACL
Q: Which ligament prevents posterior translation of the tibia on the femur?
[...]
A: PCL
Bone Wizardry Lock: The name tells you which direction of tibial translation each ligament resists. Anterior drawer for the ACL. Posterior drawer for the PCL. The tests follow the same naming logic.

Q: Movement of what joint occurs with pronation and supination of the foot?
[...] joint
A: Tibiofibular
Bone Wizardry Lock: The tibiofibular joint does not move in isolation. It responds to what the foot does. Foot pronation or supination drives fibular head motion up the chain.

Q: Dorsiflexion, eversion and abduction = [...] of the ankle
A: PRONATION
Q: [...] = PRONATION of the ankle
A: Dorsiflexion, eversion and abduction
Q: Plantarflexion, inversion and adduction = [...] of the ankle
A: SUPINATION
Q: [...] = SUPINATION of the ankle
A: Plantarflexion, inversion and adduction
Comment: If you are prone, the DEA may come knocking on your door.
Don't slip little homie
Comment 3: suPINAte
Bone Wizardry Lock: Pronation is a triad: dorsiflexion, eversion, abduction. Supination is the reverse. DEA and suPINAte are the two memory pegs for this card set.

Q: The fibular head will glide [...] with pronation of the foot.
A: anteriorly
Q: The fibular head will glide anteriorly with [...] of the foot.
A: pronation
Bone Wizardry Lock: Foot position drives fibular head position. Pronation pulls the fibular head anteriorly. When you see an anterior fibular head SD, check the foot first before treating the fibula.

Q: The fibular head will glide [...] with supination of the foot.
A: posteriorly
Q: The fibular head will glide posteriorly with [...] of the foot.
A: supination
Bone Wizardry Lock: Supination pulls the fibular head posteriorly. Posterior fibular head SD and a supinated foot often travel together. Treat the kinetic chain, not just the one restriction.

Q: Femoral nerve = [...]
A: L2-L4
Q: What nerve is responsible for flexion at the hip and extension at the knee?
[...]
A: femoral nerve
Q: What nerve provides sensation to the anterior thigh and medial leg?
[...]
A: Femoral nerve (saphenous branch)
Bone Wizardry Lock: Femoral nerve: L2-L4, hip flexion, knee extension, and sensory to the medial leg via the saphenous branch. Hip flexor weakness plus quad weakness plus medial leg numbness points here.

Q: Sciatic nerve = [...]
A: L4-S3
Q: What are the 2 divisions of the sciatic nerve?
[...]
A: Tibial and Peroneal
Q: What nerve controls the actions of the hamstrings (except for the short head of the biceps femoris)?
[...]
A: Tibial nerve
Q: What nerve controls the actions of the short head of the biceps femoris?
[...]
A: Peroneal nerve
Q: What nerve is responsible for foot inversion and plantar flexion?
[...]
A: Tibial nerve
Q: What nerve provides sensation to the sole of the foot?
[...]
A: Tibial nerve
Q: What nerve is responsible for foot eversion and dorsiflexion?
[...]
A: Peroneal (fibular) nerve
Q: What nerve provides sensation to the area between the 1st and 2nd toes?
[...]
A: Deep peroneal (fibular) nerve
Q: What nerve provides sensation to the dorsum of the foot?
[...]
A: Superficial peroneal (fibular) nerve
Comment 3: "TIPs": Tibial Inversion Plantarflexion
Comment 7: "PEDs": Peroneal Eversion Dorsiflexion
Bone Wizardry Lock: Sciatic = L4-S3. Lock in two mnemonics: TIPS = Tibial does Inversion, Plantarflexion, Sole sensation. PEDS = Peroneal does Eversion and Dorsiflexion. Deep peroneal narrows to just the web space between toes 1 and 2.

Q: The normal angle between the neck and shaft of the femur is [...].
A: 120°-135°
Q: If the angle between the neck and shaft of the femur is < 120° this condition is called [...].
A: coxa vara
Q: If the angle between the neck and shaft of the femur is [...] this condition is called coxa vara.
A: < 120°
Q: If the angle between the neck and shaft of the femur is > 135° this condition is called [...].
A: coxa valga
Q: If the angle between the neck and shaft of the femur is [...] this condition is called coxa valga.
A: > 135°
Bone Wizardry Lock: Vara = angle below 120 degrees, the neck falls toward the shaft. Valga = angle above 135 degrees, the neck rises away from the shaft. Think of vara as the neck caving inward.

Q: A normal Q angle is [...]
A: 10°-12°
Q: An increased Q angle is referred to as [...].
A: genu valgum
Q: An [...] Q angle is referred to as genu valgum.
A: increased
Q: A decreased Q angle is referred to as [...].
A: genu varum
Q: A [...] Q angle is referred to as genu varum.
A: decreased
Comment 2: The patient will appear more knocked kneed.
Comment 3: The patient will appear more knocked-kneed.
Comment 4: The patient will appear more bowlegged.
Bone Wizardry Lock: Q angle measures the quad pull on the patella. High Q = patella pulls lateral = knock-knees (genu valgum). Low Q = bowlegs (genu varum). Normal is 10-12 degrees. Track Q angle whenever the patella misbehaves.

Q: Patient presents for knee pain. Physical exam findings include proximal fibular head resists anterior spring and distal fibula is anterior. What is the likely diagnosis?
[...]
A: Posterior fibular head
Q: Patient presents for knee pain. Physical exam findings include proximal fibular head resists posterior spring and the distal fibula is posterior. What is the likely diagnosis?
[...]
A: Anterior fibular head
Q: In a posterior fibular head SD, the talus is [...], causing the foot to invert and plantarflex.
A: internally rotated
Q: In a posterior fibular head SD, the talus is internally rotated, causing the foot to [...].
A: invert and plantarflex
Q: In an anterior fibular head SD, the talus is [...], causing the foot to evert and dorsiflex.
A: externally rotated
Q: In an anterior fibular head SD, the talus is externally rotated, causing the foot to [...].
A: evert and dorsiflex
Q: A posterior fibular head may disturb the function of what nerve?
[...]
A: Common peroneal nerve
Comment: the proximal and distal fibular head move in opposite directions.
Bone Wizardry Lock: Fibular SD is named for the direction the proximal head cannot spring toward. Posterior head = proximal resists anterior spring. The common peroneal nerve wraps around the fibular neck and is at risk with posterior fibular head dysfunction.

Q: An imbalance of the musculature of the quadriceps can lead to [...] syndrome.
A: patello-femoral
Q: How does the patella present in patello-femoral syndrome?
Deviates [...]
A: laterally
Bone Wizardry Lock: VMO weakness lets the patella drift lateral. That lateral tracking stress is the core mechanism of patello-femoral syndrome. Wider pelvis drives a larger Q angle, which increases lateral pull.

Q: Patient presents with deep knee pain, especially when climbing stairs. Physical exam findings include atrophied vastus medialis, patella crepitus, and a laterally displaced patella. What is the likely diagnosis?
[...]
A: Patello-femoral syndrome
Q: What is the treatment of patello-femoral syndrome?
[...]
A: Strengthen the vastus medialis muscle
Comment: Mostly in women. A wider pelvis often results in a larger Q angle.
Bone Wizardry Lock: The exam picture: deep anterior knee pain on stairs, VMO atrophy, patellar crepitus, lateral patellar shift. More common in women because a wider pelvis increases Q angle. Treatment is VMO strengthening to recenter the patella, not surgery.

Q: [...] ligament sprain: ligament is intact, tensile strength is preserved, no laxity on stress testing.
A: First degree
Q: [...] ligament sprain: partial tear with weakened tensile strength and mild to moderate laxity.
A: Second degree
Q: [...] ligament sprain: complete rupture, no tensile strength remaining, severe laxity on exam.
A: Third degree
Comment: Treat conservatively.
Comment 3: In most cases, third degree sprains may require surgery, while first and second degree sprains generally can be treated conservatively.
Bone Wizardry Lock: Grade by structural integrity: 1st = intact and stable (conservative), 2nd = partial tear and mildly lax (conservative), 3rd = complete rupture with severe laxity (may need surgery). Laxity tracks directly with grade.

What are the 4 compartments of the leg?
1. Anterior
2. Lateral
3. Deep posterior
4. Superficial posterior
Q: Which leg compartment is most often affected by compartment syndrome?
[...]
A: Anterior compartment
Comment 2: This often results in severe unrelenting pain after and during exercise.
Bone Wizardry Lock: Four leg compartments: anterior, lateral, deep posterior, superficial posterior. Anterior is the tightest and most vulnerable to compartment syndrome. Classic presentation: pain out of proportion to injury, pain with passive toe stretch, tense compartment on palpation.

Q: [...] consists of injury to the ACL, MCL and medial meniscus.
A: O'Donahue's triad (terrible triad)
Q: O'Donahue's triad (terrible triad) consists of injury to the [...], [...] and [...].
A: ACL; MCL; medial meniscus
Bone Wizardry Lock: Terrible triad comes from a valgus blow on a flexed knee. ACL and MCL fail together, and the medial meniscus tears because the MCL attaches directly into it. The three structures are mechanically linked, so valgus stress takes all three.

Q: [...]
A: Calcaneus
Q: [...]
A: Talus
Q: [...]
A: Cuboid
Q: [...]
A: Navicular
Q: [...]
A: Cuneiform
Bone Wizardry Lock: Seven tarsals in two functional rows. Hindfoot: calcaneus and talus. Midfoot: navicular and cuboid. Forefoot row: three cuneiforms. The talus perches on top of the calcaneus and transmits all body weight into the foot.

Q: 80% of ankle sprains occur in [...].
A: plantar flexion
Q: The ankle is more stable in [...].
A: dorsiflexion
Bone Wizardry Lock: Plantarflexion narrows the mortise because the talar dome is wider anteriorly. Less bony contact means less stability and an easier roll. Dorsiflexion wedges the widest part of the talus into the mortise, locking the ankle tight. That is why 80% of sprains happen in plantarflexion.

Q: The medial longitudinal arch is composed of the [...], [...], [...], 1st-3rd metatarsals.
A: talus; navicular; cuneiforms
Q: The [...] longitudinal arch is composed of the talus, navicular, cuneiforms, 1st-3rd metatarsals.
A: medial
Q: The lateral longitudinal arch is composed of the [...], [...], and 4th and 5th metatarsals.
A: calcaneus; cuboid
Q: The [...] longitudinal arch is composed of the calcaneus, cuboid, and 4th and 5th metatarsals.
A: lateral
Q: The transverse arch is composed of the [...], [...] and [...].
A: navicular; cuneiforms; cuboid
Q: The [...] arch is composed of the navicular, cuneiforms and cuboid.
A: transverse
Bone Wizardry Lock: Two longitudinal arches, one transverse. Medial longitudinal is the tall arch (talus, navicular, cuneiforms, metatarsals 1-3). Lateral longitudinal is the low outer pillar (calcaneus, cuboid, metatarsals 4-5). Transverse arch runs side to side across the navicular, cuneiforms, and cuboid.

Q: Which arch of the heel is most likely to have SD?
[...]
A: Transverse
Comment: Transverse arch SD runs in long distance runners. Repetitive loading without proper arch support concentrates stress there, and the transverse arch takes the hit before the medial or lateral arches.
Bone Wizardry Lock: Runner or prolonged-standing history with foot pain: transverse arch SD is the OMM answer. Repetitive axial load is the mechanism. Treat the foot dysfunction at the source.

Q: Name the lateral stabilizing ligaments of the ankle:
1. [...]
2. [...]
3. [...]
A: Anterior talofibular ligament; Calcaneofibular ligament; Posterior talofibular ligament
Q: What is the most common ligament injury of the ankle?
[...]
A: Anterior talofibular ligament
Bone Wizardry Lock: The ATF sits at its worst mechanical angle when the foot is plantar flexed and inverted, so it tears first. The three lateral ligaments follow a sequence: ATF, then calcaneofibular, then posterior talofibular. Injury severity tracks that order.

Q: 3 classifications of ankle sprains:
Type I: involves the [...]
A: anterior talofibular ligament
Q: 3 classifications of ankle sprains:
Type [...]: involves the anterior talofibular ligament
A: I
Q: 3 classifications of ankle sprains:
Type II: involves the [...]
A: ATF and the calcaneofibular ligament
Q: 3 classifications of ankle sprains:
Type [...]: involves the ATF and the calcaneofibular ligament
A: II
Q: 3 classifications of ankle sprains:
Type III: involves the [...]
A: ATF, calcaneofibular ligament and the posterior talofibular ligament
Q: 3 classifications of ankle sprains:
Type [...]: involves the ATF, calcaneofibular ligament and the posterior talofibular ligament
A: III
Comment: 3 classifications of ankle sprains:
Type I: involves the anterior talofibular ligament
Type II: involves the ATF and the calcaneofibular ligament
Type III: involves the ATF, calcaneofibular ligament and the posterior talofibular ligament
Bone Wizardry Lock: Type I = ATF only. Type II adds the calcaneofibular. Type III completes the lateral set with the posterior talofibular. Severity climbs one ligament at a time. The posterior talofibular almost never tears in isolation.

Q: Which ankle ligament is considered the medial stabilizer?
[...]
A: Deltoid ligament
Bone Wizardry Lock: The deltoid is broad and strong enough that eversion injuries tend to avulse the medial malleolus before tearing the ligament. Medial ankle pain after trauma means rule out fracture before calling it a sprain.

Q: If you have an MCL injury then you will have a [...] deformity.
A: valgus
Q: If you have an LCL injury then you will have a [...] deformity.
A: varus
Q: ACL injury will cause anterior displacement of the [...].
A: tibia
Comment: Creates a knock-kneed appearance.
Comment 2: Remember that Varys from Game of Thrones is a fat character
So a varus deformity is obtuse/fat.
Bone Wizardry Lock: MCL is the medial restraint: valgus stress tears it, knee goes into valgus. LCL is the lateral restraint: varus stress, knee goes into varus. ACL resists anterior tibial translation: anterior drawer positive. Match the force direction to the restraint it overcomes.