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TypeQuestionAnswer choicesIncorrect feedbackHintPatient Folder NotesAssetApproved text?Approved Visuals?
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Level 1
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The Case of the Tennis Mom (Bernie)
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B.IIntroduction animation-----B.I: Full-length 2D animation-New Bernie highlight OK. JL
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B.1CheckboxAffected Anatomy

Considering the mechanism of injury, list three structures that could be causing Bernie pain.
Gastrocs
Soleus
Tib ant (wrong!)
Tib post
Flexor digit long
Extensor digit long (wrong!)
Calcaneal tendon (should be one of them)
Posterior Talonavicular ligament
Plantar fascia
If picked anterior structure:
That’s incorrect. Reconsider in which compartment of the leg the injured structures are located.

Incorrect feedback, another posterior structure:
Not quite! Remember muscle, tendons and ligaments can be injured when a joint is taken forcefully to the end of range or beyond.
Watch the animation... REALLY closely!- Injured when lunging to reach tennis ball
- Sudden and severe pain in the ankle and calf
- Loud pop
- Unable to push off on injured foot during walk
B.1: 2D animation; close-up of leg during injuryJLJL
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B.2Multiple choiceAffected Movement

Based on Bernie's limp and injury, what type of movement is she unable to perform?
Dorsiflexion
Inversion
Eversion
Plantar flexion
Look closely at the push-off phase of her affected gait cycle, and compare it to a normal gait cycle.Think about how Bernie’s gait cycle compares to a normal gait cycle. What component looks different? Notes:
- Likely injured structures in posterior compartment of leg
B.2: 2D animation; Bernie limpingJLJL
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B.3CheckboxDominant Plantar Flexors

Out of these five muscles involved in plantar flexion, which are the two dominant ones?
Gastrocnemius
Soleus

Tibialis posterior
FHL
FDL
Almost all these muscles are plantar flexors. Think about what other actions they do and figure out which ones have the least joints to act upon. These muscles would be the strongest plantar flexors. Remember the ‘rule’ of muscles: the more joints that a muscle passes over, the less powerful they are for each action. Consider all the actions of each muscle and this time, choose the two that are the strongest plantarflexors! - Unable to push off on injured foot during walk; unable to plantar flexB.3: 2D illustration; schematic of musculoskeletal anatomy of leg

Slider will toggle between superficial/deep
JLJL
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B.4Multiple choiceKinnect the dots

Since Bernie can’t plantar flex, which tendon has likely been injured?
Calcaneal Tendon
Tibialis posterior tendon
Flexor digitorium longus tendon
Flexor hallucis longus tendon
NoneThink about the location of the pain and which tendon would most likely be in that region. - Gastrocnemius and soleus are the strongest plantar flexors B.3: 2D illustration; schematic of musculoskeletal anatomy of leg

Slider will toggle between superficial/deep
JLJL
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B.CConclusionCase Closed: Calcaneal Tendon Rupture

Summary:
When Bernie lunged to reach the tennis ball, she forcefully pushed off with her foot while her knee was straightened. This caused her calcaneal tendon to become stretched and torn. As with most calcaneal tendon rupture injuries, there was the sound of a loud pop and she felt sudden and severe pain at the back of the ankle and/or calf. Since the calceneal tendon connects the dominant plantar flexors, the soleus and gastrocnemius, to the calcaneus (heel) bone, Bernie is unable to push off (plantar flex) while walking. The calcaneal tendon may become weak and thin with age.

- Calcaneal tendon (Achilles tendon) connects the soleus, gastrocnemius and plantaris muscles to the calcaneus (heel) bone. These muscles act via the tendon to plantar flex the foot at the ankle joint, and flex the knee (except soleus)
- Rule of muscles: the fewer joints a muscles crosses, the stronger the muscle will act on that joint.
- When considering injury with multiple muscles that perform the same actions, the muscles that act most dominantly on that joint are more likely to be injured.
---- Likely to have calcaneal tendon ruptureB.C.F: Flowchart
B.C.S: Summary Figure
JL
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The Case of the Rebel Driver (Van)
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V.IIntroduction Animation-----V.I: Full-length 2D animation-
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V.1CheckboxAnatomy Overview

Considering the force of impact and the plane the movement occurs within, choose the three structures most likely damaged by the impact.
PCL
ACL

LCL
MCL
Patellar ligament
Tibia
Femur
Patella
Fibula
Carefully watch the animation again. The plane of impact informs which structures could be injured.Think about the structures that limit the movement of the knee joint and consider the planes in which they act.- knee hits the dashboard at high velocityV.1: 2Dillustration; knee impact on dashboard with arrows indicating planeJL
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V.23D model drawCruciate Ligaments

Cruciate ligaments were most likely involved. Let’s identify the attachment points for the ACL and PCL. You can zoom, rotate and pan around the 3D model.

1.Select the ligament you want to draw using the ACL/PCL toggle
2.Click on the origin point on the 3D model
3.Then click on the insertion point to draw the ligament
4.Select the other ligament and repeat steps 2 and 3
multiple attachment points on 3D modelNoneRemember that the name of the ligament is the biggest hint to the origin.Notes:
- anterior-posterior plane of injury results in ACL/PCL most likely being injured
V.2: 3D model; of femur and tibia/fibulaJL
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V.3Multiple choiceKinnect the dots

Based on the direction his knee hit the dashboard, which structure must have been damaged?
PCL
ACL
Re-kinnectThe orientation of each ligament affects how it limits movement anteriorly or posteriorly.- ACL origin: lateral femoral condyle
- ACL insertion: anterior tibial plateau
- PCL origin: medial femoral condyle
- PCL insertion: posterior tibial eminence
V.3: 2D illustration; ACL/PCL connecting femur/tibia, arrow shows the directionality of the accidentJL
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V.3.RRe-kinnectUnderstanding the cruciate ligaments

The cruciate ligaments function to limit movement of the tibia relative to the femur. Click and drag the slider to move the tibia either anteriorly or posteriorly, and observe which of the cruciate ligaments are stretched.
----V.3.R: Slider illustration; Slider toggles between anterior and posterior movement of tibia relative to femur
- Schematic diagram: body outline, skeletal anatomy, ligaments (change color when stretched)
- Anterior: ACL stretches and becomes highlighted
- Posterior: PCL stretches and becomes highlighted
JL
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V.CConclusionCase Closed: Torn Posterior Cruciate Ligament

Summary:

When Van Diesel’s knee hit the dashboard, the tibia was push posteriorly relative to the femur. Because the PCL limits the posterior translation of the tibia relative to the femur, Van Diesel’s PCL was torn.

Main Takeaways:
- Ligaments are connective tissue that stabilize joints by limiting motion
- Form and function are interrelated!
- The attachment points and the orientation of each cruciate ligament is connected to its function
- Regardless of relative movement, direction of resistance is the same (posterior translation of the tibia relative to the femur = the anterior translation of the femur relative to the tibia)
----V.C.F: Flowchart
V.C.S: Summary Figure
JL
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The Case of the Volleyball Player (Jenny)
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J.IIntroduction animation-----J.I: Full-length 2D animation-Jenny's CC are Van's. Change Judi's character.
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J.1MatchingAnkle ligaments strains vs. ankle positions

We know that Jenny landed on an inverted ankle. Depending on whether her ankle was positioned in either dorsiflexion, neutral or plantarflexion, different ankle ligaments could have been strained. Drag the ligaments to match the correct ankle position.
Illustration (dorsiflexion + inversion) → posterior talofibular lig
Illustration (neutral + inversion) → calcaneofibular lig
Illustration (plantarflexion + inversion) → anterior talofibular lig
Re-kinnectThink about where the ligaments are attaching around the ankle and foot. The location of each ligament’s attachment points inform what type of movement it restricts.- landed on an inverted ankleJ.1.1: 2D illustration; dorsiflexion and inversion
J.1.2: 2D illustration; neutral and inversion
J.1.3: 2D illustration; plantarflexion and inversion
JL
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J.1.RRe-kinnectReview of Ankle Ligaments

Let’s review how ankle ligaments can become stretched during inversion ankle sprains. View the ankle in plantarflexed, neutral and dorsiflexed positions by clicking on the buttons. Once you've selected a position, click on INVERT to observe which ligament is stretched when the foot moves into inversion.
----J.1.R: Slider illustration; Schematic diagram of ankle bones with ligaments
- Invert + neutral: Calcaneofibular ligament
- Invert + plantar flexion: Anterior talofibular ligament
- Invert + dorsiflexion: Posterior talofibular ligament
JL
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J.2Multiple choiceInjured Ankle Ligament

Based on Jenny’s ankle position when she fell, which ligament was most likely damaged?
Anterior talofibular ligament
Posterior talofibular ligament
Calcaneofibular ligament
NoneIdentify the positioning of her injury first. Then, review each ligament's role in resisting combined positions of the ankle and subtalar joints. Notes:
- landed on an inverted ankle in plantar flexion
J.2: 2D animation; ankle rollJL
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J.33D model selectAdditional Muscular Injuries

On the 3D model, click and select the leg muscles that are most likely to also be damaged from this ankle sprain.
Fibularis longus
Fibularis brevis

Gastrocnemius
Soleus
Tibialis Anterior
Extensor digitorum longus
Her foot is inverted but not actively. Which muscles are antagonistic for inversion?Think about agonist vs. antagonist relationships. When agonist muscles contract and shorten, antagonist muscles lengthen. - sprained her anterior-talofibular ligament (ATFL)J.3: 3D model; ankle and leg showing the answer choices listedJL
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J.CConclusionCase Closed: Injured Antero-talofibular Ligament

Summary:
When Jenny landed, her foot was inverted and plantarflexed. Thus, her anterior talofibular ligament (ATFL) was torn. Because this ligament limits inversion, Jenny would experience pain when she actively and passively inverts her ankle. Since fibularis longus and brevis act to evert the ankle, their tendons lengthen during inversion. Therefore, they are also susceptible to injury when the ankle is inverted too much. If this happens, Jenny would also experience pain when she actively everts her ankle.

Main Takeaways:
- Ligaments are connective tissue that act to stabilize joints and limit movement.
- When ligaments are stretched beyond their anatomical limit, they can be torn. However, ligaments are not the only structures that may be damaged. As dynamic movers of the joint that may also be overly stretched.
- It is important to not only consider the main affected structure but also the surrounding anatomy such as muscle tendons, vessels and nerves that could also be affected by the injury.
---- also injured her fibularis longus and brevis muscles J.C.F: Flowchart
J.C.S: Summary figure
JL
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Level 2
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The Case of the Weightlifter (Fred)
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F.IIntroduction-----F.I: Full-length 2D animation-
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F.1Multiple choiceAffected Joint

Referring to Fred’s gait cycle in the coronal plane, select the joint where the limp is occurring.
Left hip joint
Right hip joint
Left knee joint
Right knee joint
Left ankle joint
Right ankle joint
NoneThe affected joint should look unbalanced and asymmetric. - lifts heavy objects all the time
- chronic back pain and limp
F.1: 2D animation; Fred’s gait cycle in coronal view (hips/legs only)
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F.2Multiple choiceGait Cycle

By comparing Fred’s affected gait to an unaffected one, which phase of the gait cycle is affected?
Initial contact
Foot flat
Midstance period
Toe off
Pre-swing
Mid-swing
Terminal swing
That's incorrect. What is the gait phase during which the hip joint is the most active? Does the hip drop occur when you have one or both feet on the ground?Notes:
- limp occurs at right hip joint
F.2.1: 2D animation; Fred’s gait cycle in coronal view (hips/legs only)
F.2.2: 2D animation; normal gait cycle in coronal view (hips/legs only)
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F.33D model selectAffected Muscles

During the midstance period of Fred’s gait cycle, his right hip drops abnormally. In a normal midstance period, the hip remain level. Click and select the two muscles that control this action.
Gluteus maximus (R/L)
Gluteus medius (R/L)
Gluteus minimus (R/L)
Iliopsoas (R/L)
Rectus femoris (R/L)
Hip adductors (R/L)
That's not quite right! Remember, muscles on the contralateral side need to contract to abduct the hip in order to keep the pelvis level. There are two muscles involved in this movement. Stand up and try this movement out yourself! Which muscles would you contract to maintain your right hip level?- limp occurs at right hip joint during midstance periodF.3: 3D model; pelvis and femurs with muscles
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F.4Multiple choiceContraction Type

When gluteus medius and minimus are unaffected, what type of contraction normally occurs during the midstance period of the gait cycle?
Eccentric
Concentric
Isometric
Re-kinnectWhat kind of contraction of any muscle is typical when you need to resist gravity?- left gluteus medius and minimus aren’t contracting to abduct the right hipF.4: 2D animation; animation of gluteus med/min contracting normally during walk cycle (coronal view)
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F.4.RRe-kinnectGluteus Medius and Minimus Contraction

Let’s compare how the gluteus medius and minimus act during concentric vs. eccentric contractions. Drag the slider to toggle between the two types of contractions.
----F.4.R: Slider illustration; Slider toggles between concentric and eccentric contraction
- Schematic diagram: body outline, skeletal anatomy, muscle strings (lengthen/contract)
- Eccentric: left leg lifts and hip is level
- Center: both legs on the ground, hip level
- Concentric: right leg abducts and right hip hikes up
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F.5Multiple choiceNerve Supply

If the gluteus medius and minimus are not contracting eccentrically, perhaps the issue is neural. Which nerve innervates these muscles?
Superior gluteal n.
Sciatic n.
Inferior gluteal n.
Pudendal n.
NoneRefer to your notes. Pretty sure you know this.- left gluteus medius and minimus aren’t contracting eccentrically to abduct the right hipNone
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F.CConclusionCase Closed: Trendelenburg Gait

Summary:
After several months of repetitive heavy lifting from powerlifting and construction work, Fred has been experiencing chronic back pain and limping. Specifically, Fred’s right hip drops abnormally in the mid stance period. Normally, the left gluteus medius and minimus contract eccentrically to abduct the right hip. Since the superior gluteal nerve supplies these muscles, dysfunction of this nerve can explain why these muscles are weakened.
Watch the following animation to see how repetitive heavy lifting can lead to superior gluteal nerve dysfunction and explain Fred’s symptoms!

Main Takeaways:
- Phases of the gait cycle, eccentric contraction, nerve dysfunction
- Activities that involve repetitive bending and heavy lifting (flexion and extension of the back), including weightlifting and shovelling, can lead to disc problems. Disc protrusion can occur, pushing and moving laterally to pinch nerve roots
- Trendelenburg gait is an abnormal gait characterized by hip dropping in the midstance period of the gait cycle. It is caused by weakness of the gluteus medius and gluteus minimus muscles, which can result from superior gluteal nerve dysfunction.
----F.C: Full-length 2D animation
F.C.F: Flowchart
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The Case of the Soccer Player (Alex)
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A.IIntroductionA.I: Full-length 2D animation
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A.1MatchingMuscles for Wind-up vs. Kick

What are the main muscles involved in the wind-up and kicking movement. Click and drag to match the muscle to the movement type.
For Wind-up:
Hamstring
Gluteus maximus

For Kick:
Quadriceps (VI, VL, VM)
Iliopsoas
Rectus Femoris
Not quite! Think about what muscles are involved in hip extension and knee flexion. Now link these actions to the muscles. Try standing up and going through the motions with your own leg! Think about the muscles involved as you try it for yourself. - kicked the ball with high velocity and forceA.1.1: 2D illustration of wind-up
A.1.2: 2D illustration of kick
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A.2MatchingWind-up vs. Kicking Contractions

Can you identify what type of contraction is involved in the beginning and end of the wind up and kicking phase?
Quadriceps - CON (kick/start)
Quadriceps - ECC (wind-up/finish)
Hamstrings - CON (wind-up/start)
Hamstrings - ECC (kick/finish)
Glutes - CON (wind-up/start)
Glutes - ECC (kick/finish)
Hip Flexors - CON (kick/start)
Hip Flexors - ECC (wind-up/finish)
Re-kinnectThe muscle needs to rapidly accelerate in the beginning and rapidly decelerate at the end of the contraction. Think about what type of contractions would be needed to do so. Notes:
- Hamstrings and glutes are main wind-up muscles involved in hip extension and knee flexion
- Quads, iliopsoas, and rectus femoris are main kicking muscles involved in hip flexion and knee extension
A.2.1: 2D illustration of wind-up with start and finish arrows
A.2.2: 2D illustration of kick with start and finish arrows
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A.2.RRe-kinnectEccentric vs. Concentric Contractions

Let’s simplify the kicking movement and just focus on knee extension. When you extend your knee, the quadriceps concentrically contract to lift your leg. Depending on the speed of the kick, however, the muscle activations will change at the end of the kick. When the leg is kicked really fast, the hamstrings must contract eccentrically to ensure that the leg doesn’t hyperextend past its anatomical limit and cause injury. Explore different scenarios of knee extension by adjusting the speed of the kick.
----A.2.R.1: 2D animation (Slow: only quadriceps contract concentrically, lines shorten to indicate contraction)
A.2.R.2: 2D animation (Fast: quadriceps contract concentrically, hamstrings contract eccentrically at end)
A.2.R.3: 2D animation (Too Fast: quadriceps contract concentrically, hamstrings contract eccentrically at end, but leg hyperextends beyond anatomical limit)
- 3 speeds: Slow, Fast, Too Fast + play button
- Schematic diagram of person sitting on chair and extending leg, lines to represent hamstrings and quadriceps
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A.3Multiple choiceAlex's Muscle Strain

Based on the mechanism of Alex’s injury, choose the muscle most likely to be strained.
Hamstrings
Quadriceps
Glutes
Iliopsoas
Rectus Femoris
NoneDuring their kick, Alex hyperextends during knee extension. Which muscle normally contracts eccentrically to prevent the knee from hyperextending?- chart from exercise 2A.3: 2D animation; Alex’s kick (clearly showing hyperextension)
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A.4CheckboxHamstring Strain

Which coupled actions are going to aggravate the hamstring again?
Choose all that are correct.
Knee flexion and hip flexion together
Knee flexion and hip extension together
Knee extension and hip flexion together
Knee extension and hip extension together
Sit on the floor and stretch your hamstring. Now stand up and contract your hamstring. Now you know what may aggravate it!When a muscle is injured, pain could be produced by either contracting or fully stretching the muscle- hyperextended during knee flexion, resulting in hamstring strainNone
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A.5CheckboxActivities of Daily Living

Poor Alex, their hamstring is going to be sore for a while. What other daily activities will aggravate their injury?
Picking something off the ground
Climbing up stairs
Bending over with knees straight
Running

Sitting in a chair
Figure four stretch
Laying in a bed (netflixing)
Standing
NoneFor each activity, think about what happens at the joints. Stand up and try each movement! - hamstring strain aggravated by either knee flexion/hip flexion or knee extension/hip flexionA.5.1-8: 8 2D illustrations
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A.CConclusionCase Closed: Hamstring Strain

Summary:
When Alex scored her winning goal, she also hyperextends during knee extension. Normally, the hamstrings contract eccentrically at the end of a kick to decelerate and prevent the leg from from hyperextending past its anatomical limit. Because she kicked too hard and too fast, she ends up straining her hamstrings. Due to Alex’s injury, they will feel pain during activities involving hip flexion/knee extension or hip flexion/knee flexion such as running, or bending over with knees straight.

Main Takeaways:
- Normally, movement is initiated by concentric contraction. At high speeds, antagonist muscles on the opposite side of the joint contract eccentrically to prevent the agonist muscle from extending beyond its anatomical limit.
- Muscles are usually damaged when they are extended past their anatomical limit forcefully and rapidly.
- When muscles are damaged, any activity that contracts and fully stretches the muscle causes pain and affects daily activities.
---- hamstring strain aggravated by either knee flexion/hip flexion or knee extension/hip flexion, including activities such as:
Picking something off the ground
Climbing up stairs
Bending over with knee straight
Running
A.C.F: Flowchart
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Level 3
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The Case of the Alpine Skier (Maryem)
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M.IIntroduction-----M.I: Full-length 2D animation
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M.1Multiple choiceAbnormal Gait Cycle

What part of Maryem’s gait cycle is abnormal in the sagittal plane?
Heel strike
Foot flat
Toe off
Pre-swing
Mid-swing
Terminal swing
NoneNone- Broke right tibia skiing
- Cast and wheelchair for three months, recently removed
- Left knee pain during walking, but not sitting
- Gets tired easily , trouble walking
M.1: 2D animation; gait cycle lateral view
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M.2Multiple choiceNormal Gait Cycle

Based on a normal gait cycle, at which joint does the heel strike occur?
Hip
Knee
Talocrural
Subtalar
Talocalcaneonavicular
NoneNoneNotes:
Right Foot Drop:
Abnormal gait, no right heel strike
None
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M.3CheckboxTalocrural Joint

What action(s) does the talocrural joint allow?
Dorsiflexion
Plantarflexion

Inversion
Eversion
NoneNone- Abnormal gait from lack of right heel strike at talocrural jointNone
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M.4Multiple choiceAbnormal Heel Strike

In Maryem’s case, she is unable to do what action during the heel strike?
Dorsiflex
Plantarflex
Invert
Evert
NoneNone- Abnormal gait, no right heel strike at talocrural joint (dorsiflexion and plantar flexion)M.4: 2D animation; Maryem's gait cycle with close-up on just the heel strike part
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M.5CheckboxDorsiflexion Muscles

Yes, instead of dorsiflexing, Maryem is dropping her right toe and dragging it abnormally during the heel strike. So, what are the muscles responsible for dorsiflexion?
Gastrocnemius
Soleus
FDL
FHL
Tib. Post.
FL
FB
Tib Ant.
EHL
EDL
NoneNone- Unable to dorsiflexNone
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M.6Multiple choiceFoot Drop Cause

Which of the following could be a possible cause of Maryem’s right foot drop?
Muscle Stiffness (post-cast)
Ligament restriction
Muscles not producing movement
Denervation
NoneNone- Dorsiflexion: TA, EHL, EDL None
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M.7CheckboxDenervation

Considering Maryem is unable to dorsiflex, which nerve(s) could be dysfunctional in Maryem’s right leg? Think about the relationships between nerves and how they connect to one another.
common fibular nerve
superficial fibular nerve
deep fibular nerve

tibial nerve
sural nerve
NoneNone- Potential denervation None
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M.8Multiple choiceKinnect the dots

Considering that denervation could explain Maryem’s symptoms, what is a possible explanation for how she damaged her nerve?
- Maryem tore the nerve during her skiing accident.
- The cast compressed the common fibular nerve on the fibular head and damaged the nerve
- From being confined to wheelchair, Maryem’s dorsiflexors atrophied and subsequently caused the superficial fibular nerve to atrophy as well
- Compression from the cast decreased the blood supply to the common fibular nerve, which injured the nerve
NoneNone- Potential denervation of right common fib., sup. fib. n and/or deep fib. nervesNone
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M.9Multiple choiceAbnormal Gait (part 2)

Great job! Maryem’s cast compressed her common fibular nerve causing weakness of her dorsiflexors and subsequent foot drop. The common fibular nerve’s superficial position makes it vulnerable to injury. But we haven’t fully analyzed Maryem’s limp. Now let’s determine what part of Maryem’s gait cycle is abnormal in the coronal plane.
Foot flat
Toe off
Heel Strike
Swing phase
NoneNone- Denervation of right common fibular nerve due to compression of castM.9: 2D animation; Maryem walking in coronal view (legs only)
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M.10Multiple choiceSwing Phase

Which joint is affected in the swing phase?
Hip
Knee
Talocrural
Subtalar
Talocalcaneonavicular
NoneNone??????:
- Abnormal gait, right swing phase
M.10: 2D animation; Maryem walking in coronal view
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M.11Multiple choiceSwing Phase Action

More specifically, which of the following actions is responsible for the abnormal swing phase in Maryem’s gait?
Adduction
Extension
Flexion
Hip hike
Hip drop
External rotation
Internal rotation
NoneNone- Affected right hip joint M.11: 2D animation; Maryem walking in coronal view (legs only)
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M.12Multiple choiceHip Hike Joint(s)

Across which joint(s) is the hip hike movement produced? If you are having trouble, try this movement out yourself!
Vertebral
Left Hip
Right Hip
Left Knee
Right Knee
NoneNoneRight hip hike:
- Affected right hip joint, hip hike
None
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M.13CheckboxVertebrae to Pelvis Muscles

Correct! Maryem’s hip hike involves lateral flexion of the lumbar spine. So, what are muscles that connect the vertebrae to the pelvis?
Trapezius
Rhomboids
Latissimus dorsi
Quadratus lumborum

Erector spinae
Iliopsoas
NoneNone- Affected right hip joint, hip hike across vertebral joints None
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M.14Multiple choiceHip Hike Muscle

Considering the attachment points of the two muscles, which one is more likely responsible for the hip hike?
Left Latissimus dorsi
Right Latissimus dorsi
Right Quadratus lumborum
Left Quadratus lumborum
NoneNone- Lat. dorsi and Quad. Lumborum connect vertebrae to pelvis None
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M.15Multiple choiceKinnect the dots

Considering Maryem’s injury and recovery, what is a possible reason for her right hip hike?
- Maryem’s right hip hikes to clear her right foot drop in the swing phase
- After being confined to a wheelchair, her right hamstring has become weak and Maryem right hip hikes to compensate
- Maryem’s right tibia healed abnormally so that her right leg is now longer than her left. Maryem’s right hip hikes to compensate for leg length discrepancy
- Maryem developed arthritis in her left hip after being confined in a wheelchair. Consequently, she has reduced range of movement during left swing phase which causes an exaggeration of movement in the opposite limb, shown as 'hip hiking’.
NoneNone- Right Quad. Lumborum acts to hip hike None
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M.16CheckboxKnee Structures Causing Pain

Awesome deduction! Yes, Maryem’s right hip hikes to compensate for her right foot drop in the swing phase. Now we’ve accounted for all of Maryem’s symptoms except her left knee pain. What structures in the knee are most likely to be causing pain?
Menisci
ACL
PCL
LCL
MCL
Joint capsule
Fatpad
Bursa
Bony joint
Tendon
NoneNone- Hip hike compensates for ipsilateral foot drop None
63
M.17Multiple choiceKinnect the dots

Considering Maryem’s injury and recovery, what is a possible reason for her left knee pain? Remember the left knee pain only manifests when Maryem walks, but not when she is sitting or lying down.
- Due to her abnormal gait, Maryem has been relying on her healthy left leg as compensation. Overtime, the added load lead to overuse and inflammation in the joint.
- Maryem also injured her left knee cartilage during the skiing accident.
- Skiing is considered a high impact sport that can put a lot of stress on the knee joint. Due to her intense training schedule as a competitive skiier, Maryem has developed anterior knee pain due to overuse.
- Stress on the knee joint from skiing all the time has causesd degenerative arthritis in Maryem’s left knee. Overuse has grinded down her knee cartilage and the bone to bone contact is painful.
NoneNoneLeft Knee pain:
- Likely due to bursa, bony joint, tendon
None
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M.CConclusionCase Closed: Compression Neuropathy

Summary
Due to the tightness of Maryem’s cast, it compressed the common fibular nerve on the fibular head. Pinched nerve causes numbness and weakness of the muscles. In Maryem’s case, the common fibular nerve becomes the deep fibular nerve which supplies the dorsiflexors. Consequently she is unable to dorsiflex during the heel strike phase, resulting in a right foot drop. To compensate and clear her dropped foot, her right hip hikes in the swing phase. Due to her abnormal gait, Maryem has increasing the weightbearing load on her unaffected left leg. Over time, this leads to overuse and inflammation in the knee joint causing her left knee pain.

Main Takeaways:
- Injuries that occur over a period of time are complicated and can result in major-life altering functional changes and losses.
- Sometimes the management of an injury (in this case, the application of a cast on a swollen limb) can actually cause an injury while simultaneoulsy resolving another. - Compressed nerves fail to send their motor information to the target muscle, Over time, this can result in faulty mechanics, weakness or even loss of movement of the target muscle.
- Overcompensation occurs when a person starts to develop different motor patterns elsewhere to compensate for a change. This often leads to over usage and injury.
----M.C.F: FlowchartJL
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Draft Judi Wrote (do not delete):
Injuries are not always a simple issue....especially when they develop over time. Sometimes the management of an injury (in this case, the application of a cast on a swollen limb) can actually cause an injury while simultaneoulsy resolving another. When a nerve is compressed, motor information fails to reach the target muscle and over time, this can result in faulty mechanics or weakness or even loss of movement. Since this takes time, it may not be evident to anyone (including the injured person) that they are starting to develop different motor patterns elsewhere to compensate for a change in typical mechanics. In this case, there were more than one abnormal development over a short time...even though her fractured leg healed, she ended up with weakness in that leg, an altered gait pattern and too much weight bearing on the other side. It is no wonder that longer term injuries (think: arthritis or larger nerve damage) can result in major life-altering functional changes or losses!
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