(3) Lecture 14: Lower Leg Issues + Knee Anatomy 1 Flashcards
Achilles
- made up of gastroc + soleus fusing proximal to calcaneal insertion
- retrocalcaneal bursa is btwn the tendon and calcaneus
- THICKEST + STRONGEST TENDON in the body
- has NO synovial sheath but is surrounded by paratenon (ONLY VASCULAR tendons are surrounded by paratenon = good healing)
Paratenon
Surrounds only VASCULAR tendons = good healing
Posterior Heel Pain
Could be
- Achilles tendonitis
- Achilles bursitis
- Retrocalcaneal bursitis
True tendon pain is CONFINED to tendon itself = doesn’t hurt around tendon
Retrocalcaneal bursitis
- bursa in recess btwn anterior inferior side of Achilles tendon and posterosuperior aspect of calcaneus
- sometimes seen w/ insertional tendinopathy = tendon thickens + puts pressure
- structural irritants (tight/pokey)
- pain JUST ABOVE INSERTION OF ACHILLES
- pain with SQUEEZE FROM SIDE
Achilles bursitis
Superficial calcaneal bursitis
- bursa btwn calcaneal prominence/Achilles tendon and skin
- pain on POSTERIOR aspect of HEEL with solid SWELLING
- often due to excessive FRICTION or by wearing shoes that are too tight or large
Management of “itis” of the heel
- POLICE/PEACE & LOVE
Address training and equipment issues
- heel lift (takes tension off gastrocs/soleus/Achilles)
- pad or donut
- Achilles stretch
- new shpes
Soleus stretch
stand with BOTH knees bent and involved foot back
gently lean into wall until stretch in calf
Gastroc stretch
2-jt muscle = need to chang position of top muscle to put it on stretch
Keep back leg straight, heel on floor with foot turned slightly inward. Front leg bent. Lean toward wall until stretch in calf
Tendinitis
Tendinitis: inflammation of tendon itself (RARE)
Paratenonitis
Inflammation, pain and crepitation of the paratenon as it slides over the structure
Causes of Tendinitis/Paratenonitis
Acute irritation = too much, too soon
External factors
- rub from shoe/equipment
- running down hill - Tib ant.
- rub from laces - Tib ant.
- hyper dorsiflexion - Achilles
Internal factors like foot malalignment
- rub over bome
- cavus or flat feet
Symptoms and signs of Paratenonitis
- pain or crepitation of paratenon of acute onset
- red and hot over involved structure
- usually precipitated by movement around the ankle joint - too much, too soon
Diagnosis of Tendinitis/Paratenonitis
- local swelling
- STTT - contractile tissues
- palpation over structures
Paratenonitis Rehab
Inflammatory/Destructive
- POLICE/PEACE & LOVE
- heel lift/pad/support
Repair
- heat
- idealize ROM - stretch gastrocs/soleus
- start strength and proprioception
- ADDRESS TRAINING ISSUES
Remodeling
- idealize strength
- soft tissue work to realign fibres
- speed and power training
Tendinosis/Tendinopathy
- chronic pathological changes brought about by repetitive micro-trauma
- NO INFLAMMATION = inflammatory cells are absent
- characteristic changes in collagen fibre structure
- abnormal/poor vascularity
Achilles Tendinosis
- most ppl w/ Achilles tendon pain have tendinosis
- usually in MIDPORTION
- may be caused by neglect of acute tendinitis
- worsens w/ increase in FITT or insufficient recovery
Predisposing factors of Achilles Tendinosis
- years of running
- excessive PRONATION (increased load on gastrocs/soleus to resupinate)
- poor flexibility = micro-tears
- training in COLD climate = muscles are less extensible
- improper footwear
Diagnosis of Achilles Tendinosis
- history, FITT, pain
- pain usually 2-7cm from insertion into calcaneus
Observation
- thickening and tenderness over large portion (NOT red, hot)
- faulty biomechanics
- STTT - both plantar and dorsiflexion cause pain and crepitus (if paratenon involved), especially w/ loading
- NODULES/BUMPS
Treatment of Tendinosis
-start in REPAIR stage (no inflammation)
- goals: idealize healing environment (heel lift), heat, realigning tissue
- eccentric strengthening programs provide 60-90% improvement in pain and function - level of evidence A
- rehab exercises - level of evidence B
- NO NSAIDS - level B evidence
Achilles Rupture Risk Factors
- most commonly ruptured tendon
Risk Factors
- male sex (10:1)
- prior rupture on contralateral side
- use of steroids (break up tendons and attachments on bone)
Achilles Rupture Symptoms
- POP or snap LIKE SOMEONE KICKED THEM
- pain may be IMMEDIATE then rapidly subsides = pain only at site of tear
- usually occurs 1-2 inches above insertion
Achilles Rupture Signs
- palpable gap
- positive Thompson tets
- DORSIFELEXED when relaxed
Thompson’s Test
squeeze calf
negative test = foot moves
POSITIVE test = NO movement
Best test for Achilles Rupture
Single leg heel raise
Achilles Tendon inspection/palpation
- foot hangs straight down = no plantar flexion (when Achilles is attached and someone lays on their front, foot is slightly plantar flexed)
- palpable divot 1-2 inches above insertion
- unable to plantar flex
Tibiofemoral joint
- articulating surfaces btwn medial and lateral condyles of femur + tibia
- allows transmission of body weight from femur to tibia
- provides hinge-like, sagittal plane rotation (rotation is important for screw-home mechanism)
Patellofemoral joint
- articulation btwn patella and femur
- patella is largest sesamoid bone
- EXTENSOR MECHANISM
- works eccentrically during gait
Screw Home Mechanism
Rotation happens during last few degrees of extension b/c medial femoral condyle is larger than lateral
- foot planted = femur rotates medially
- femur fixed = tibia rotates laterally
Locks joint to increase stability
- ensures knee stability
- regulates patellar alignment
Popliteus contracts to externally rotate femur on tibia to unlock kneeq
Knee Stability
- knee is more stable in extension
- during flexion, knees have poor bony fit
- has strong fibrous joint capusle
- need to rely on: MCL, PCL, ACL, LCL, dynamic stabilizers (muscles)
Knee Capsule
- anterior to suprapatellar pouch
- inferior to infrapatellar bursa
- medially communicates with MCL
- posteriorly covers femoral condyles
lined by synovial membranes except posteriorly where it passes in front of cruciates
Lateral Support Complex
3 layers
- Superficial
- ITB and biceps femoris - Middle
- patellofemoral ligs and retinaculum - Deep
- LCL
- popliteus tendon
- capsule
- other ligs
Main support of lateral knee
MUSCLES
order of injury:
1. biceps femoris
2. IT band
3. popliteus tendon
4. capsular ligaments (lateral capsule)
5. LCL
Lateral knee injuries
- LESS common that injuries of medial compartment
- injured w/ VARUS DIRECTED force
- high grade injuries need higher forces which injure multiple structures
- isolated high grade LCL tears are UNCOMMON
LCL
Lateral Collateral Ligament
- round cord about the size of pencil
- extends from lateral epicondyle of femur to lateral fibular head
- primary STATIC restraint to varus
Medial Support Complex layers
3 layers
- Superficial
- sartorius and fascia - Middle
- superficial MCL and semimembranosus - Deep
- deep fibres of MCL and capsule
Medial Knee Stability
- MCL is primary stabilizer
- 25-30 degrees
- ACL/PCL secondary vs valgus - Muscles help in full extension
- medial hamstrings (sartorius, semimembranosus + semitendinosus)
- medial head of gastrocs
- quad muscles (vastus med) - Bony structure is tertiary support
MCL
- capsular lig = SWELLING
Has superficial and deep components
- deep portions connect directly to medial meniscus
- superficial portions run from medial femoral epicondyle to superomedial surface of tibia
Most active resisting valgus
