Lecture 14 - Knee Anatomy and Lower Leg Issues Flashcards
where is the achilles?
- 5-6 cm proximal to the calcaneal insertion
what structurally makes the achilles a good tendon?
- thickest/strongest in the body
- surrounded by paratenon (which means it is vascular and heals quicker)
what is retrocalcaneal bursitis? what causes it? And how do you test for it?
- bursitis at the achilles tendon insertion point on the calcaneus
- seen with insertional tendinopathy (sometimes)
- structural irritants
- pain just above insertion
- pain with squeeze from the sides
what is achilles bursitis? what causes it?
- bursitis between calcaneus/achilles and skin
- pain with posterior aspect of heel
- swelling
- due to friction from loose/tight shoes
how do you manage ankle itis?
- POLI/ peace and love
- heel lift (to reduce tension)
- donut pad to reduce pressure
- stretch achilles
- break in new shoes/skates
what is tendinitis?
- inflammation of the tendon itself
- rare
- causes by acute irritation (too much too soon)
- caused by external factors (rub/hyper dorsiflexion)
- caused by internal factors (rub over bone, irregular feet)
what is paratenonitis?
- inflammation, pain, and crepitation of the paratenon (as it slides over the structure)
- caused by acute irritation (too much too soon)
- external forces (running down hill, dorsiflexion or rub)
- internal forces (rub over bone, flat/cavus feet)
what are the symptoms/signs of paratenonitis?
- pain/crepitation (acute onset)
- red and hot
- swelling
what is the rehab for paratenonitis?
- inflammation phase = police/peace and love, and heel lift/pad/support
- repair phase = heat, ROM, strength and proprioception (start)
- remodeling phase = strength, soft tissue work, speed and power
what is tendinosis/tendinopathy?
- chronic pathological changes
- caused by repetitive microtrauma
- no inflammation
- poor vascularity
- collagen fibre structure changes
what are the predisposing factors of tendinosis?
- running
- excessive pronation
- poor flexibility
- training in cold climate
- improper footwear
how do you diagnose achilles tendinosis?
- history, FITT, pain (2-7 cm from insertion)
- swelling (thickening) of tendon
- STTT = pain with both plantar and dorsi flexion (especially with loading)
- potential bumps (palpable)
how do you treat achilles tendinosis?
- eccentric strengthening
- rehab
- (avoid NSAIDs) because no swelling
what is the most commonly ruptured tendon?
- the achilles tendon
what are the risk factors for a ruptured achilles?
- male
- use of steroids
- prior rupture on contralateral side
what are the symptoms of an achilles rupture?
- pop or snap
- “like someone kicked them”
- immediate pain - quickly subsides
- pain 1-2 inches above insertion (site of tear)
what are the clinical signs of an achilles rupture?
- palpable gap
- positive thompson test
- dorsiflexed when relaxed
what is the thompson test for achilles tears?
- have the patients knee on a bench/have them lay on their stomach where their foot can hang down
- if unable to plantar flex = positive test
- if foot hangs straight down = positive test
- squeeze calf, if foot doesn’t point = positive test (if there is no movement)
what are the two joints of the knee?
- tibiofemoral –> included in screw home mechanism
- patellofemoral –> eccentric movement during gait
what is the screw-home mechanism?
- rotation during the last few degrees of rotation (medial condyle is larger than the lateral)
- if foot is planted, femur rotates medially
- if femur is fixed, tibia rotates laterally
- “locks” the knee to increase stability
what structures provide knee stability?
- dynamic stabilizers –> muscles
- joint capsule
- MCL/TCL
- LCL/FCL
- ACL
- PCL
what is the knee capsule?
- communicates with deep fibres of the MCL
- covers femoral condyles
- lined by synovial membranes
what are the 3 layers of the lateral support complex?
- superficial = IT band and biceps femoris
- middle = patellofemoral ligaments and retinaculum
- deep = LCL, popliteus, capsule and other ligaments
what 5 structures support the lateral aspect of the knee?
- biceps femoris
- IT band
- popliteus tendon
- capsular ligaments
- LCL
what are lateral knee injuries?
- less common
- injured with varus direct force
- high force = higher grade injury (multiple torn structures)
- isolated LCL tears are uncommon
what is the LCL structure?
- round fibrous cord
- about the size of a pencil
- lateral epicondyle to lateral fibular head
- extracapsular (swells?)
- primary static restraint to varus
what are the 3 layers of the medial support complex?
- superficial = sartorius and fascia
- middle = superficial MCL and semimembranosus
- deep = deep MCL fibres and capsule
what are the stabilizers of the medial support complex?
- MCL (25-30 degrees)
- ACL/PCL (secondary)
- muscles (in full extension) –> medial hamstrings, medial gastroc head, quads
- bony structure is tertiary
what is the structure of the MCL?
- capsular (swells)
- has superficial and deep components
- deep connects to meniscus
- superficial connects to medial femoral epicondyle and tibia
what knee structures are most active at 5 degrees flexion?
- superficial, posterior oblique, then deep
what knee structures are most active at 25 degree flexion?
- superficial, then deep and posterior oblique tied
