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Um Brighton and the fourth one is to be decided, the first session that we're gonna cover today is just brief anatomy of the lower limb. Um So I appreciate you guys being here. And after this short presentation, we'll get onto the Aus prep promptly, cos I know that's what the majority of you guys are here for. So, Vestar, what we'll be going through today is the hip joint the deeper in. Oh, we have another guest or a few guests, the deep and um superficial gluteal muscles, the blood supply to the hip, um the knee joint with functions of the ligaments. Um We'll be going through some pathologies like avascular necrosis, sciatica and ACL ruptures that are quite common and ones that we need to be aware of. And then we'll be going through some examples of consequences of orthopedic injuries um to be more specific, the consequence of ACL injuries because these can have a profound impact on not only people's lives but livelihoods as well. So the hip joint is made up of four components. Um The acetabulum, the acetabular fat pad, the acetabular fossa, and the femoral head and it's a ball and socket joint and the some of the most important functions of the hip joint are uh transmission of weight and movement. Um The hip joint has an extensive blood supply as we'll see later on and it can have dire consequences if this is interrupted. So I know a lot of you guys in the room do Anki. So he wants to volunteer for this image occlusion. OK. So we'll start, we'll start with here Any volunteers, some fossa that you know what? That's a good start. But what fossa is it acetabular fossa? Good, good. That's from the third years, the second years, you got your exam in four days. So can we have some better knowledge? What's what's this referring to uh this image occlusion here? OK. That's not the acetabulum. Mm No, not quite Alan. Come on. I know you've done quite a lot of an reviews. Thanks. OK. Well, um as you can see in this picture, that is the acetabular labrum. So when we're looking at it from the lateral view, this is what it appears like, but when you look at it from the front, it looks like this. So that's the acetabular labrum. Um What's this part? So this um what's that referring to any idea? Anyone? This is this is quite worrying considering some of you have an exam very soon it's the lunate surface. So that's the articular surface of the hip that comes into contact with the femoral head. So when the ace, when the femoral head fits into the acetabular fossa, the superior part of the femoral head comes into contact with the lunate surface. Um What, what ligament is this? Something amazing? Fatima. That's what I like to see. That is indeed the transverse acetaal ligament. And do you know the function of that by any chance I stretching you too far? Ok. So um the transverse ligament is a weight bearing structure and that's responsible for absorbing the weight of the femoral head. Um So that's why that's important. Um What are these, what are these two pointing to? Come on? These are slightly easier. Amazing fatima clearly someone's been doing their revision. Anyone else? Uh what's this one pointing to just to make it easier? Can anyone tell me what, what structure we're looking at here? What's drug, what's drug driving the the acetabular, right? Ok. Cool. So that's the acetabular Foramen Ruben. That's amazing recall from last year. Good, good. So as we can see the acetabular fossa, the acetabular labrum which outlines um the lunate surface and we have the acetabular foramen and the obturator foramen for passenger vessels and then the transverse ob er acetabular ligament to absorb the structures of the femoral head. Sure. So we might have to stop. Um I'm so sorry because we're streaming it online. There's gonna be a few technical conditions. Sorry. We're having some technical difficulties by an awful of our own. There you go. OK. Cool. So, um the blood supply to the hip is actually very important. Um and any disruption in blood supply to, more specifically, the femoral head can cause pathologies like avascular necrosis that can have dire consequences for patients. Um So, in terms of looking at the blood supply of the hip, there, there are five arteries, um five main arteries. So the ob artery, the medial and lateral circumflex arteries, the superior and inferior gluteal arteries and these are the ones that supply blood to the muscles around the hip. Um and the femoral head as well. So, the obturator art supplies the head of the femur and the medial thigh compartment muscles such as the piriformis. Um You have the medial circumflex femoral artery which supplies the femoral head and neck. So, any disruption to this can cause pathologies like avascular necrosis. We have the lateral circumflex femoral artery that supplies blood to the anterior part of the proximal femur. Um the superior, superior gluteal artery to the glu max medius minimus. So, some of the superficial gluteal muscles, um the piriformis which is a deeper um gluteal muscle and then the obturator internus, quadratus femoris, and the head of the femur again. Um and then inferior gluteal artery to the super uh the deeper gluteal muscles, including the piriformis, superior, inferior GME. So who can, who can um label this for me? Given the fact I've just given you what they supply, this should be pretty easy So what's, what's this referring to here? No, no, all three. So who said that superior gluteal artery? Amazing. So, as we can see, um, the superior gluteal artery is here cos again, it's superior and it supplies the blood supply to head of the femur. What's this one? If that one's superior gluteal, inferior gluteal good. And then fatima, I'm sure you know this one ob obturator artery. Good. So it surrounds obturator foramen. And then we have these two to the remaining ones which are, which one's medial and lateral. Which one's this? Yeah. Good, good, good, good, Ruben, amazing superficial gluteal muscles. What are the superficial gluteal muscles? Alan oh Come on, I just showed you the slide. What, what do show you to your muscles? Ok. Which ones good. So, gluteus maximus, medius minimus, one more that potentially isn't as big but still important for function and assistance of those muscles. A amazing, amazing good. So the superficial gluteal muscles are the gluteus, medius minimus and maximus. Um And I think the main one that you need to remember for um diff differentiation is a glute max. So the gluteus maximus is applied by the inferior gluteal nerve and it has a different function to the other three superficial gluteal muscles. So it extends the femur at the hip rather than um abducting the femur at the hip. Um And the rest are supplied by the superior gluteal nerve, avascular necrosis of the femoral head has anyone heard of this before? Great. That's good to hear considering you've been on orthopedic rotation. Um ok. So there are approximately 10 to 20,000 cases of avascular necrosis that are reported each year. Um The ati how does this occur? It's a disruption to the blood flow more specifically, usually to the proximal femur um the femoral neck, um the site of avian tends to be femoral neck fractures, but you can also have displacement of the femoral head from the acetabulum. And that can also cause avascular necrosis. It's usually investigated using uh as an x-, using an X ray first line. But you can also do MRI S so disruption to the blood supply of the femoral head causes ischemia and prolonged ischemia, um can lead to subsequent necrosis. So this is why it's a surgical emergency and we need to interfere as soon as possible. Um If the restoration of blood flow um Ruben, that is amazing and that's why the next slide is for you. So keep a lookout. Ok. Um So as I was saying, if you don't get restoration of the blood supply to the femoral head, then you're gonna get necrosis and then you're gonna get the death of osteocytes um and then collapse of the arterial uh articular surfaces and then eventually that's gonna lead to osteoarthritis. Um And then that will lead to symptoms of itself. X-ray of the pelvis Ruben. Can you tell me what you see on this x-ray without looking at the that car, I said good. So loss of cartilage and collapse of the femoral head. So as you can see the space here between the femoral head and the acetabulum or the labrum, and we can see that space present, but in um avascular necrosis when you get ischemia, um and then eventually you get death of osteocytes, that space between the femoral head and acetabulum closes and you get complete loss of cartilage. Um And then you can see the collapse of the femoral head here. It's nice and rounded, fits perfectly into the aum. But when you get a collapse, as you can see, it's not, it's not very normal anymore. Um ok, great. What uh how do we treat avascular necrosis? We have to do an arthroplasty. So if there is disruption of blood supply and that leads to avascular necrosis, generally, we have to replace the hip and what type of arthroplasty we do generally depends on the patient. So if you've got a fit young, healthy patient, you're probably gonna do a hemi arthroplasty. So just replacing the femoral head. Um but if you have an older patient who's, you know, likely not gonna go back to playing any sports or uh taking part in difficult activities and you're gonna do a total arthroplasty. So you're gonna resurface the acetabulum and also replace the femoral head as well, the deep muscles as we were talking about earlier, the piriformis obturator internus, uh the gli or the superior, inferior games and then the quadrata femoris. Are you gonna remember the innervation to this? The nerve to the Obr Internus supplies both the obturator internus and also the Gemellus superior. And then the nerve to the quadratus femoris supplies both the quadratus femoris and the Gemellus inferior. Um The pro the actions for all of these muscles are the same. So they laterally rotate the extended femur at the hip joint. Um ok. So that's a superficial and deep gluteal muscles. One of the other pathologies that we need to be aware of that is probably, you probably hear about more than avascular necrosis is sciatica. Um A lot of people say they have sciatica without, you know, extensive investigation, um which is very important. So, sciatica actually happens when the sciatic nerve which runs um down the back of your leg to your feet. If that's irritated or compressed, you get what's what we call sciatica and the symptoms you get with that is pain, tingling, um weakness and numbness and the pain can vary in different people. So some people, it will be a sharp pain, some people will be a mild pain, some people might describe it as an electric shock. Um The pain usually tends to subs subside within 4 to 6 weeks. Um and if it doesn't, then it requires further investigation. Some of the risk factors for sciatica are age. Um obesity, uh occupation, prolonged sitting and diabetes. Um, if the, as I said, if the pain doesn't improve in 4 to 6 weeks, then we're gonna require further investigation, um, in the form of x rays, MRI or CT scans just to see what's pressing on the nerve. If there's a mass present or anything more sinister that we need to be aware of the treatments for sciatica. Aren't, there's, there aren't, um, extensive approved treatments, but generally they include anti-inflammatory steroid injections and when symptoms are more severe and people have symptoms like incontinence or loss of perianal sensation, then we can perform surgery as well. Um Another thing that we need to be aware of and make sure we ask the patient for is symptoms of corda equina. So we need to make sure we screen for corda equina. Um and some of those are urinary incontinence, um Sado anesthesia, uh and so on and then we have the knee joint. So I'm moving on from the hip. You have the knee, which is the next joint of the lower limb that we're gonna go through today. That's made up the made up of bones, joints, ligaments and menisci. The bones are the femur tibia and patellar that all meet at the knee joint. Um and the type of joint, it's a hinge joint. So typically for flexion and extension. Um and then we have menisci. So we have two menisci and in our knees and they act as shock absorbers when we're playing football or when we jump and then land. Um the medial meniscus is c shaped, it's er fixed and then the lateral meniscus is more mobile and it's smaller. And then we have four ligaments in our knees, which are the anterior posterior cruciate ligaments, the medial and lateral collateral ligaments. What ligament in the knee is most commonly injured? Do you think ACL? Very good. So what are the functions of these ligaments? Your medial and lateral collateral ligaments control your side to side motion and brace against any abnormal movement. So, in your day to day, your medial and lateral collateral ligaments are being used to stabilize you when you walk in. Um And when you're playing sports, especially football or sports that require high um levels of agility, your medial and lateral collateral ligaments are very important. The Antero cruciate ligaments runs in the middle of your knee and that prevents your tibia from sliding out in front of your femur um and provides rotational stability. So, again, important for agility and commonly um ruptured in high intensity sports, the posterior cruciate ligaments keeps your shin bone from moving back too far. It's stronger than the ACL and it's ruptured far less often. Does anyone know any common injury mechanisms of ACL ruptures? Yeah, good. So, twisting injury, anything else, what do we do in sports? Typically in football, you're trying to get past a player. One, yeah, tackled. So tackles um can often lead to acr ruptures and are one of the most common cause of acr ruptures in sports and then rapid changes of direction, um can also cause acr ruptures. Several studies have shown that females can have a higher incidence of ACL ruptures any reasons for this. Does anyone know any reasons for this because they're worse at sports? No. Abdullah, that's not true. Cos what? Sorry. No question Rubin. You know what? That's an interesting hypothesis theory that I think you could conduct some research into. But at this point in time I'm not sure how much data exists on that, but it's, it's, um, some of the common reasons found from studies are due to physical conditioning differences in men and women, um, or male and female athlete, should I say, uh, muscular strength tends to exceed, er, be higher in men. Um, which means that they're less prone to these injuries and also on neuromuscular control just generally speaking as well. Um, ok. So the symptoms that we're gonna get with the ACL rupture, swelling, loss of range of movement tenderness along the joint and discomfort while we're walking. And all of these are, um, common presentations to orthopedic clinics and GPS as well. Um, does anyone know how many, how many people in the UK present every year with a painful joint? Mhm. That's a good guess. Alan, but not quiet, higher. Oh, yeah. Higher, slightly less. It's about 8.5 million people in the UK. Present every, every year with a painful joint. So whether that be knee, shoulder and um ACL S are just one of those. Um, although x-rays can't show any injury to your Antero cruciate ligaments, they can show if it's associated with a bone break, which often is the case. Um MRI scans can get a better image of soft tissues like the ACL. Um However, usually that's not required to make a diagnosis of the ACL. Um the treatment varies. So for a young athlete that's involved in any agility, sports, footballers, NFL, athletes, um they'll most likely require surgery to safely return to sports. And it's important to note that the majority of players don't return to the level that they were playing um prior to the surgery, a less active older adult may just be able to, you know, not have surgery and get by on conservative treatment, painkillers, steroids, um exercise and physiotherapy. So this is an interesting, this is something I found quite interesting what the consequences of orthopedic injuries like an ACL rupture, for example. Well, it's important to know that all ACL injuries result in negative health outcomes. So there's never a case really where an ACL is beneficial to anyone in any regard. And one of the biggest things that it can have major financial implications, especially for athletes. So in sports like the NFL, where your next contract isn't guaranteed. This is especially true. Um A study was conducted that found that ACL injured players earned $2 million less than salary match controls over four years after injury. So 2 million quid, that's, that's quite a lot. That's like a New Bhatti or 10 Lamborghinis just to put it into context. Um, and yeah, so if you have an ACL, you're less likely, you're gonna make less money, most likely, er, and you're not gonna get back to playing how you were playing before. Thank you very much for watching. I think Safa has got a short presentation that we'll go on to and then we'll go on to Os prep. So, yeah, thank you. Um, if we take like a five minute break, you guys can help yourself to refreshments and drinks and we'll just change over the slides and if you have any questions about anatomy, um, ask Rae, please. Excuse me. I was last time. It's good, you know, I know. Take a look. No, thank you. Be like I said it. Ok. Right on Tuesday. Mhm. Ok. So, so just uh, I'm sorry, I'm sorry. Hi, I can change, you know. Yeah. Right. You OK. I think we're gonna start the akie stuff if you guys wanna sit down the brain. Cool. So we're gonna start. Um, so R has already covered the anatomy and now we're gonna cover the hip, knee for an ankle exam. Um, before that though, we got a question, this was just a question I came across um, doing passed and I thought it was interesting and it relates to lower limb. Um, we've not particularly covered it, but you should be able to figure it out. Hopefully. So, a 46 year old woman, I turn to the GP complaining of intermittent pain in her right thigh. The pain is sharp and is relieved by sitting down on examination, you know, that she is obese, but there's no deficit in tone or power of the limbs out of the four options on the slides. Which one do you think is most likely one? What, what do you guys think? So, we've had obturator nerve impingement two. It's two. If you said two, you're right. So it's entrapment of the lateral femoral cutaneous nerve. Um So that nerve goes through the inguinal ligament as well as the obs foreman. And that can be impinged in pregnant or obese patients. Um And that presents as a pa pain or burning sensation often caused by long periods of standing. Um The key bits in the slide in the question are there's no deficit in tone or power. So it's not going to be a Cordner. It definitely is nerve impingement. Um And yeah, the fact that the patient is obese is kind of pathognomonic of this nerve impingement. Um ok. So, oy, so when I start with the hip before I start though, can anybody tell me what the four kind of main things you cover in any musculoskeletal osk are? What's your structure. Yeah, perfect. So when you're looking at the hip, what we're looking for, just shout out varus valgus of the hip. Yeah, absolutely. So you always look at the joint above and the joint below. Um Yeah. So in your hip examination, you always ask the patient to walk a few steps. Um So you assess their gait, you assess all phases of the gait cycle. And when you're examining, you always do it standing and then lying um because you'll get different joint bearing and it will look different. So you do it from the front, the sides and the back, always no matter what examination you're doing. Um And then particularly for the hip, you need to inspect and measure the leg length and we'll talk about how to do that later. Um And what are you gonna feel for in the hip? What A R has already told you what joints there are what? Bones? Yeah. Um So you palpate the greatest of cancer and then you, I'm not sure if they'll do, ask you to do this in the OSC cos it's a bit intimate. Um but femoral in inguinal region for lymph nodes and then move, what are the movements of the hip? Yeah. Flexion extension two. Yeah, abduction addiction. And you do all of these movements passively and actively. So you ask the patient to do them on their own and then you do it against resistance. And then the special tests for the hip. Does anybody remember them? 20 thomas'? Mhm. Yeah. I think there's one more, there was one more no more. What was that? Yeah. Turn down and b so again, like I said, you look when they're walking does even know what that picture shows. Yeah. Cliff and got it. Trendelenberg ate and the sound side sides. So, you examine range of movement. If they've got any limping, if they've got any abnormal leg length, they're turning, particularly, you'll get that in like Parkinson's patients. If they're really struggling, they'll have like a shuffling gait and a really slow turning. Um And then trend gait, you'll kind of see them waddling. Um And then you also want to assess the patient's footwear and then you look for scars, bruising swelling, you guys. Ok. Yeah. Yeah, cool. Um And you also look for quadriceps racing, the leg length, discrepancy and pelvic tilt. So when you feel for the greatest cancer, you go along the side of the hip um and palpate the bone and you wanna say that you're palpating for this bone. So it sounds like you know what you're talking about basically, um ss for pain, tendon tenderness and temperature and those things might suggest trochanteric bursitis. So measuring leg length, does anybody know the difference between measuring apparent versus true leg length? Yeah. So I think the ones I looked at on, uh I think it's on the K MS notes as well is apparent being from the umbellus to the tip of the medial malleolus and then true leg length being from the ASIS to the medial malleolus. So they both go to the maybe on the it says, but this was methods anyway. Um yeah. So you have to do that and then movements, abduction and abduction. You ask the patient to do this actively and passively. Um you do hip flexion and extension. So on the notes, it wants you to do hip extension with a patient prone. Um And that can take a bit of time to explain. But yeah, and then your special tests, Thomas's test like you talked about SS is for a fixed flexion deformity. So basically, if patients got a fixed flexion on one side of the hip, they compensate by having an exaggerated lumbar lo dosis and the Thomas's test, ask the patient to lie down and you put a hand under their lumbar region and you ask them to flex one hip and if they have a flexion deformity, one side of the hip will raise and that's an abnormal test. And then Tranberg, you asked the patient to stand in front of you um and to hold your hands and you ask them to stand on one leg um and the sound side sides. So this is testing your hip abductors. Um and on the side where the abductors are working, that side will drop down. And now if you guys wanna practice, um you don't have to practice physically if you don't want to, but you can talk through it and then mark yourselves on this sheet. Probably like, 34 minutes. If you wanna do that, you don't have to 10 minutes. Yeah, we'll do the exam. Yeah. Ok. So, um, 10 minutes to practice the hip exam, you can use this checklist or if you have access to K MS and use that one, you can do it in threes or however you want to do it. And if you're watching online, just practice on your own. Does that make sense? Cool. So, I hope that was useful. We're gonna start the knee now and of course, it's the same structure. Look, feel moving and special tests. What are you gonna look for in the knee? The what? Yes. What would septic arthritis look like? Yes, a hot swollen unilateral knee. Um Again, it's the same structure, scars, swelling, asymmetry and any deformity and you do it from the front, the back and the sides and you do it standing and supine. That's with most of the examinations as well. We'll come, no, we'll come to that. We'll come to that. Um What would you feel for in the knee? Yeah. Popliteal patella. You do it systematically basic. Yeah, as well as for temperature, knee joint and the knee. The specific thing to remember is for a fusion and there's two different tests to do that. Movements of the knee like she extension Yep, that's it. Um, and you also do an active straight leg raise and you assess pain and range of all the movements. Special tests for the knee. There's quite a few. Yeah. Yeah. Yeah. So medial collateral, lateral collateral PCL, ACL and the patella apprehension test which is for subluxation or dislocation that they've had previously. So when you're looking, I've put in a few pictures of what you might expect to see because I don't, I don't know about second years, but for 3rd, 4th and above, you might get pathology. So you might get patients who've had previous knee operations and replacements. Um Top picture shows a total knee replacement scar. Bottom one is arthroscopy if they've had any internal work done. And does anybody know what that last picture shows? Yeah, Baker cyst and it's a pop or swelling more than that. Um Yes, us for asymmetry, leg length, muscle bulk and rotation and that's the valgus and virus as well in the knees. Um And the swelling when you feel for the knee, this is how you feel for the knee. So you remember your anatomy and you feel systematically, you start at the top at the suprapatellar pouch, which is where you'll feel the indent where it's really soft. Um And then you'll feel around the patella, the condyles and all the way around to the insertion. And then that is the patella tap that you do for knee fusion. But you can also do the swipe test, which is where you hold down on one knee and swipe the fluid across and see if there's any bulge and then movements. So the straight leg raises, you just ask the patient to lift the leg off the bed and you don't do that passively. And then there's only two movements of the knee flexion and extension. And the easiest way to explain it to a patient is to access if they're kicking a football and then bring in the heel into the bottom. And then for the special test, it's really important and ask you that you ask the patient if they have any pain because for these tests, you're gonna be sitting on their foot for a lot of it. And obviously, if you've got any pain, it's gonna make it worse. So the first ones you do are your medial collateral ligaments, stress test and your lateral collateral. So what you do is you ask the patient to lie supine and you grab their leg, you kind of put it under your armpit if that makes sense and you push immediately and laterally to assess the ligaments. And then the PCL is the SAG sign. So you ask them to bring when he's close to get that in and if there was damage to the PCL, you would see a SAG and then for the anterior draw test, that's where you sit on that and you call me in months. And those are some pictures showing you what you would do and then the patella apprehension test again for this one. You wanna make sure the patient doesn't have any pain. Um And in practice, you can ask if they've ever previously dislocated or subluxed the patella because if this was a positive test, they would quite literally jump off the couch if they'd done this injury before. I know you got some practice again. A OK. Mhm A you this one. OK. So we're gonna do for an ankle which is the last one and I know we're over time. So I'm gonna make it quick. Ok? For an ankle again, it's the same structure that we followed for this whole session. Look for your move and special tests. When you're looking, you are looking in the patient's shoes, you need to make sure that you do this for for an ankle. You're looking for any insoles um or abnormal patterns of wear. And you also need to examine the ankle and the foot separately and you need to voice that you're examining them separately while the patient's standing and also while they're super and then feeling you wanna feel for temperature tenderness and swelling. You also wanna feel for all the joint lines as well as looking for the achilles and then for the foot, you wanna um verbalizer you're examining for the heel, the mid foot and the forefoot and you also wanna do an MTP J squeeze which would be painful in conditions like rheumatoid arthritis and then movements. You've got active and passive dorsiflexion and plantar flexion. And then for the foot, you've got passive aversion and inversion and then for the toes, you've got extension and flexion. Does anybody know the special test that we do in the foot and ankle? Squeeze simmons test with achilles, Babinski's N you do the anterior draw test and then for completion, you would always say that you would do a lower limb neurovascular assessment and examine the knee um joint above. So, like I said, you wanna look for insoles, patterns of wear and while they're standing, you can say that you're examining, examining for asymmetry, valgus virus, skin changes, you might see uh I can't even say that word virus swelling of the medial and lateral malleoli and then for the foot again, front side and back symmetries, calluses ulcers bunion, and particularly particularly in the foot. You want to look at the transverse arch because in people with flat foot, which is pe anus, they can get um the transverse arch is basically diminished. So you wanna put your hand under the arch to make sure it's there. And then you also look at the media and natural arches and you look at it's a post tendon. Um And then there's a sign called too many toes sign, which is for a valgus heel, which looks like that. So that's when you're looking from the back of the patient. Um And basically that patient's left leg shows too many toes. And you would also look for swelling of the achilles as well as for calf bulk, that's showing the valgus and barriss deformity of the foot. And that's also why you look for the patterns of wearing the shoe on the bottom. And if they did have a deformity, the pattern would be different. And then when you're feeling, you always feel the temperature with the back of your hand. Um and think back to your anatomy and palpate systematically. And again, because this is foot and ankle, it's two joints. You need to say that you're palpating at the ankle, media or natural and then you're palpating the foot along all the joints. And then when you're moving, you've got Dorty flexion and plantar flexion, inversion and eversion and then toes, you've got extension and flexion. So the hardest part about these movements is explaining them to the patient um because they can be really complicated to explain. But I think the best way to do it is to practice on your peers. Um and also use phrases that the patient understands. For example, for plantar flexion, like pushing your foot down on the gas dorty flexion, bring your toes to the sky. And then e inversion e version, if you show the patient the movements passively and then ask them to do it actively, it can make it a bit easier. And then your special test. That's your anterior jaw test. Um, and that hand placement is exactly how you would do it. You would stabilize at the ankle joint and then push the heel upwards. Yes. What I've always down. Yeah, you said by myself you can also do it that way. Um, or you can do it this way, you can do it either. So, what Rachel said was ask the patient to bend their knees and have the feet on the bed stabilize the knee joint and bring the forward. Um Yeah, if they're really digging their feet into the couch, it can be a little bit harder to bring it forward, but it doesn't matter. And then the bottom one is a simmons test. Um So you squeeze each of the calves and you watch for ankle plantar flexion and if there was injury to the achilles tendon, you wouldn't get that movement. Um And that picture just shows what the case and then rupture might look like and that's it. Uh If you guys wanna practice, we'll give you 10 minutes um to practice, but I know we run out over time. So you're free. I just also about combination of the, uh because it says basically, um, and for anyone attending online, if you can fill out the feedback for me, we'll get your certificate. Um But yeah, I hope you've enjoyed it and thank you for attending