lower limb Flashcards
Achilles tendinopathy causes
overuse and poor biomechanics
achilles tendinopathy physical exam
pain with palpation, pain at rest more likely, swelling around tendon, RIMT to plantar flexion
achilles tendinosis
degeneration
achilles tendinitis
inflammation
biomechanics that can cause achilles tendinopathy
pes clavus and pes Planus
achilles tendon rupture physical exam
decrease in active plantar flexion, inflammation/bruising, Thompson test
common achilles tendon rupture history
someone kicked me, Middle Ages male athlete, pivoting and running, burst jumping
where does achilles tendon rupture occur
2 inches above the heel
thompson test
squeeze gastro/soleus and plantar flexion will occur, if achilles tendon is torn no flexion will occur
syndesmosis ligament sprains (high ankle) history
“turned ankle” (lateral rotation) and excessive dorsiflexion
syndesmosis ligament sprains physical exam
swelling/edema, decrease ROM, point tenderness
lateral ligament sprain history
“turned ankle”, common
lateral ligament sprain- ligaments
anterior talofibular
calcaneofibular
posterior talofibular
anterior talofibular ligament (LLS) causes injury
plantar flexed and inverted
calcaneofibular (LLS) causes
in neutral then excessively inverted
posterior talofibular (LLS) physical exam
swelling/edema, decreases ROM, point tenderness, high and low arch
0 degree dorsiflexion
planti grade
medial ligament sprain history
“turned ankle”, eversion
rare- tibionavicular, anterior tibiotalar, tibiocaneal
medial ligament sprain physical exam
swelling/edma, decreased ROM, point tenderness, low arch
plantar fasciosis history
overuse, poor biomechanics, due to small tears and stretching of planter fascia
plantar fasciosis risk factors
flat and high arch, obesity, sudden weight gain, and gastro/soleus and hamstring tightness
plantar fasciosis physical exam
pain with palpation, morning pain, high/low arch, hypo mobility of 1st metatarsal
out of gastro/soleus, hamstring, or BMI which one is the number 1 risk factor
gastro/soleus
arterial supply starting at femoral artery
femoral artery –> popliteal artery –> A. tibial artery or P.tibial artery —-> A. - dorsal pedal or P. M/L plantar artery
femoral artery is also known as
peroneal artery
arcuate artery of foot is also known as
Doral arch
3 bones that make up the hip
ilium, ischium, and pubic
subluxing
comes out of socket and returns back
dislocation
does not go back into socket
ilium pubic bone and the ischium make up the
innominate
socket and femoral head is lined with
hyaline and fibro cartilage
the surface of the acetabulum is covered in
hyaline cartilage
the periphery of the acetabulum is covered by
rim of fibrocartilage
acetabulum labrum is covered in
covered in fibrocartilidge,
labrum provides what
proprioception, stability, and cushioning
labral tears can result from
injury or dislocation of hip joint, “wear and tear” from repetitive movement (twisting or pivoting), and degeneration (osteoarthritis)
labral tears occur where
1 and 2 on the right side
10 and 11 on the left side
with labral tears there may be
locking, clicking or catching sensation in joint, pain in hip or groin, stiffness or limited range of motion
coxa femoral joint has how many degrees of freedom
3 degrees- ball and socket joint
articular capsule is taut when it is placed in what position
extension and internal rotation
a strong and dense, forms a cylindrical sleeve that encloses the hip joint and most of the neck of femur
fibrous capsule
coxa joints 3 degrees of freedom are
flexion/extention, abduction/adduction, internal/external rotation
where is the articular capsule attached
proximally to the edge of acetabulum and transverse acetabular ligament, distally to neck of femur
the capsule is reinforced by
intra articular ligaments and taut in full
increase capsular laxity could result in increase stress to ____ and ____
labrum and articular surface
pubofemoral ligament
limits extension and limits abduction
iliofemoral ligament
limits extension, limits medial rotation, and helps maintain an erect posture
ischiofemoral ligament
limits extension and limits internal rotation
ligaments teres
limits adduction, flexion, and external rotation
what does the ligaments teres artery do
supplies blood flow to the head of the femur in childhood
movement at the hip joints
flexion, extension, adduction, abduction, medial rotation, and lateral rotation
main flexor of the hip
iliopsoas
main extensor at the hip
gluteus maximus
When walking what muscle is being recruited the most
hamstrings
when running, jumping, sprinting what muscle is being recruited the most
glute max
main adductor muscle in hip
adductor Magnus
main abductor of the hip
glue medius
main medial rotator of the hip
glute minimus
main lateral rotation of the hip
glute max
pelvis region includes
ilium, ischium, and pubic bone
obturator foramen
obturator nerve, artery, and vein go through (the lower hole by the ischium of the pelvis)
the coxafemoral joint has how many degrees of freedom
3 degrees ( frontal, transverse, sagittal)
coxafemoral joint is what kind of joint
ball and socket
is the coxafemoral joint stabile?
yes, not a lot of subluxation or dislocations
hip socket is
acetabulum
covers 25% of humeral head
glenoid fossa
which is higher in subluxation/ dislocations coxafemoral joint or glenohumeral joint
glenohumeral due to overlapping of the socket
covered in hyaline cartilage, surrounds socket and femoral head, periphery is covered by fibrocartilage
acetabulum
acetabular labrum
fibrocartilage, horseshoe-shaped, covered in hyaline cartilage,
fibrocartilage of the acetabular labrum has what functions
provides stability, cushion, and proprioception
osteoarthritis of the hip
initial labral tear leads to frictions between femoral head and acetabulum that leads to wearing down of hyalin cartilage at femoral head
labral tears result from (3)
injury to or dislocation of hip, “wear and tear” , degeneration
a patient complains about groin pain with clicking and subjective pain associated with it as well as locking and limited ROM of hip joint then it could be a
labral tear
what part typically tears at the coxafemoral joint and why
anterior superior labrum because of pivoting and twisting
articular capsule of the hip joint
fibrous capsule that is strong and dense, forms a cylindrical sleeve that encloses the hip joint and most of the neck of femur
the articular capsule of the hip joint is reinforced by
intra articular ligaments and taut in hip extension an internal rotation
what can cause stress to labrum and articular surface
increase capsular laxity
Capsule from margins of acetabulum to neck of femur do what
Holds synovial membrane in place
intra articular ligaments are the (4)
pubofemoral
iliofemoral
ischiofemoral
ligamentus teres
what does the pubofemoral ligament do
limits extension and abduction
what does the iliofemoral ligament do
limits extension
limits medial rotation
helps have erect posture
intertrochanteric line
head of femur with a long attachment of tendon
what does the ischiofemoral ligament do
limits extension and limits medial/internal rotation
the ischiofemoral wraps around where
front of femur
what does the ligaments teres do
limits adduction
limits flexion
limits external rotation
provides hip stabilization
ligaments teres location
acetabulum socket to head of femur
what artery supplies blood to the head of femur ONLY in childhood
ligamentus teres artery
ligaments teres medial and lateral circumflex arteries supply what
neck and head of femur in adulthood
a strain is
muscle over lengthen
a sprain is
tears of the muscle ( tendon over lengthen)
fascia lata
aka deep fascia covering muscle groups (whole thigh), tough connective tissue
iliotibial band/tract
thickening/hardening part of the fascia lata, iliac tubercle to gervis tubercle
iliotibial band syndrome
excessive friction on lateral epicondyle that creates pain on the lateral knee
anterior muscles include
psoas major
pectineus
adductor longus/brevis
quadriceps
sartorius
psoas major
one of the main hip flexors, to stretch bring hip into extension
pectineus
spirorami of pectineal line of femur, hip flexor and adductor
linea aspera
bony portion going down posterior side of femur
adductor longus/brevis
innervated by the obturator nerve
quadriceps
extend knee and flexes hip
sartorius
flexes hip, abducts hip, externaly rotates hip ( figure 4 position/ criss cross legs)
adductor muscles
adductor brevis and longus
adductor magnus
gracilis
adductor muscles are ___ to the hip joint
anterior
adductor hiatus
hole in adductor Magnus where the femoral artery and vein goes through
femoral artery goes from
anterior part of thigh, adductor hiatus, posterior part of thigh, popliteal fossa then turns into popliteal artery and vein
gracilis
attaches to Pes anserine
how many muscles attach to pet anserine and which ones
gracilis, semitendinous and sartorius
abductor muscles
tensile fascia lata
glute max
iliotibial band
glute med
glute min
glute medius
main abductor, external rotation, main stabilizer of the coxafemoral joint
glute minimus
attaches to greater trochanter, abducts and internal rotation of hip
glute minimus and medius are part of what nerve
superior gluteal nerve
glute max borders
superior- greater trochanter and PSIS
inferior- coccyx to ischial tuberosity
hamstrings
one of the main flexors of knee
deep posterior muscles
obturator externus
gemellus superior/inferior
obturator internus
quadratus femoris
most inferior deep posterior muscle
quadratis femoris
hip replacement with a posterior approach could cause what
drop foot because moving piriformis could hurt the common peroneal nerve
bursas behave like
contractile lesions (stretching or contraction causes pain)
trochanteric bursa are where
gluteus minimus
sub gluteus max
sub gluteus medius
trochanteric bursitis causes
repeated movement like climbing stairs, sleeping on same side, overrecruiting glutes, falling on hip by greater trochanter
what muscle is most affected by bursitis
sub gluteus maximus
ischial bursitis
between hamstring origin and ischial tuberosity
ischial bursitis causes
overuse
trauma
running/jumping
prolonged sitting
how to tell ischial bursitis
tenderness of ischial tuberosity, pain when weightbearing, and pain with contraction of hip extensors
iliopectineal bursitis causes
same as ischial bursitis
how to tell iliopectineal bursitis
tenderness to femoral triangle
pain when power walking and running
pain with resistive hip flexion and adductions
greater sciatic foramen- superior to piriformis
superior gluteal vessels and superior gluteal nerve
greater sciatic foramen- inferior to piriformis
pudendal nerve, sciatic nerve, posterior femoral cutaneous, nerve to obturator internus and quadrates femoris
sacral plexus comes out from
inferior to piriformis
pudenal nerve flow
inferior to piriformis, wraps around, and goes backin to the lesser sciatic Foramen
lesser sciatic foramen
internal pudendal vessels
pudenal vessels
obturator internus
nerve to obturator internus
pudendal nerve affects
sensation of external genitalis and anus, some muscles of pelvis
obturator internus flow
from obtruator membrane, lesser sciatic Foramen, to greater trochanter
trendelenberg sign
weakness and absence of hip abductor mechanism, hip drop on contralateral side
what muscle makes sure pelvis is level
glute medius
floor of femoral triangle
lateral: iliopsoas
medial: pectinous
borders of femoral triangle
superior: inguinal ligament
lateral: sartorius
medial: adductor longus
femoral hernia
loop of intestine forces out through femoral triangle due to weakness or tear in abdominal wall: risk of strangulation
inferior vena cava splits into
common iliac vein left and right, then becomes external iliac vein then the femoral vein
aponeurosis from anterior iliac spine forms what
canal
inguinal hernia
abdominal contents (intestines) want to go into the deep ring to the inguinal canal (indirect hernia) and eventually the scrotum
direct hernia
abdominal contents go directly to superficial ring and eventually could go into scrotum
femoral hernia
abdominal contents go into femoral triangle- can compress femoral nerve - extreme pain in groin
sports hernia
tear of covering of inguinal canal
supplies most of the blood to head and neck of femur, can be torn in femoral neck fracture or hip dislocations
medial circumflex
comes out of the internal iliac artery
superior and inferior gluteal arteries and obturator artery
legg- calve-perches disease
injury to ligamentus teres artery - femoral head does not get nutrition- necoris/fracture- total hip replacement
blood supply of hip starting at the aorta
aorta - common iliac artery- internal and external iliac artery - internal splits into 2- external iliac artery goes under inguinal ligament and canal and femoral triangle - splits into superfical and Deep femoral artery - superficial becomes popliteal artery
venous system starting at inferior vena cava
left and right common iliac vein
external and internal iliac vein
internal- branches of S/I iliac vein, pudendal, obtruator vein
external - femoral vein
superficial and deep femoral veins
deep- blood to posterior vein
superficial- becomes popliteal vein
superficial veins are in the
hypodermis
great saphenous vein
runs medially in lower leg and empties into femoral vein
small saphenous vein
lower leg posterior side and empties into popliteal vein through popliteal fossa to femoral vein
2 deep inguinal lymph nodes
vertical in orientation, lateral to great saphenous vein, main collectors of the lymph nodes
superficial lymph nodes dumps into…..then….
superficial lymph nodes- deep nodes- external iliac nodes- vessels -venous angle to bring back some to venous system
popliteal lymph nodes
drains lymph into deep inguinal lymph nodes- external lymph nodes- venous angle (towards subclavian vein)- into venous system
signs/symptoms of hip osteoarthritis
joint pain, morning stiffness lasting less than 60 minutes, loss of function, mian with nothing, antalgic gait, bony enlargement at affected joints, limited ROM
hip osteoarthritis causes
hyalin cartilage is worn down from excessive friction and labral tears
crackling/graveling sound
crepitus
painful gait
antalgic gait
where are the 2 articulation of the knee joint
between patella and femur
between femoral and tibial condyles
where is the meniscus
between tibia and femoral condyles
sesamoid bone in quadriceps tendon
patella
patella function
biomechanics advantage for pull of quads by increasing distance of quads from axis of knee
what attaches to the apex of patella
patellar tendon
normal sulcus angle
128 degrees
if femoral condyles make an angle of 145 degrees, patella has a higher chance of what
dislocation
where does the patella normally dislocate and why
laterally because there are not condyles to keep it in place
patellar movement
knee flexion- patella inferiorly glides
knee extension- patella superiorly glides
articular capsule of knee
strong fibrous capsule, especially where it forms instrinsic and extrinsic ligaments which are continuous with the fibrous capsule
what does the articular capsule of the knee not include
ACL and PCL
synovial capsule of knee
-lines the inner aspect of the fibrous capsule
-more extensive than nay other joint
what happens when the knee is inflamed
synovial fluid increases and aspirate fluid to relieve pressure, remove blood that has entered the joint
why would you aspirate the knee
if the joint is swollen the capsule can push on nerves and causes pain
knee ligaments
-patellar ligament
-fibular collateral ligament
-tibial collateral ligament
-oblique popliteal ligament
-arcuate popliteal ligament
extracapsular ligaments
-patellar ligament/tendon
-lateral collateral ligament
-medial collateral ligament
- oblique popliteal ligament
-arcuate popliteal ligament
patellar ligament
strong band continuation from quad tendon, runs from patella to tibial tuberosity, helps generate force
osgood schlatter disease
patellar ligament is overly recruited in childhood and it pulls on insertion of the ligament bone is added to try to adapt= more pain
lateral collateral ligament
head of fibula to lateral epicondyle, prevents excessive varus movement
varus
distal end of joint pointing in (bowlegged <>)
valgus
distal end of joint point out (knocked knees ><)
how is LCL injured example
football player squatting and being tackled so someone hitting medial knee and pushing outward
medial collateral ligament
strong flat band, continuous with tendon of adductor Magnus, deep fibers are attached to medial meniscus and fibrous capsule of knee joint
lateral collateral ligament
disruption of lateral side of knee joint, common peroneal nerve wraps around head of fibula, resists varus stress
LCL does what
stabilizes lateral knee and limits external rotation of knee
what happens if LCL tears
head of fibula can tear off, common peroneal nerve can also be stretched which can cause drop foot,
how to determine if LCL is in tact
varus test- put lower extremity in 30 degrees and create varus stress in knee
MCL does what
prevents disruption of medial side of knee joint , resists against valgus stresses, external tibia rotation and resist translation of tibia anterior on femur
what is the unhappy triad
ACL,MCL, and meniscus
what happens if the MCL is torn
meniscus and ACL may also be damaged due to the MCL being attached to medial meniscus
oblique popliteal ligament
lateral condyle and epicondyle of femur to posterior medial tibial condyle
- reinforces posteriormedial knee
arcuate popliteal ligament
head of fibula to lateral epicondyle and the oblique popliteal ligament
- strengths capsule posterior lateral
intracapsular (intrinsic) knee ligaments
ACL
PCL
medial meniscus
lateral meniscus
coronary ligaments
transverse ligaments
Cruciate ligaments of knee joint
essental to the anteroposterior stability of the knee joint- especially when flexed
- prevents excessive anterior or posterior movement of knee
cruciate ligaments join what
tibia and femur
ACL
weaker ligament, slack when knee is flexed and taut when fully extended
ACL function
prevent excessive anterior movement of tibia on the femur, provides valgus stability
prevents excess IR/ER of tibia
ACL injury causes
-MCL tear
- excessive anterior movement of tibia on femur
- hyperextension of knee
- excess IR/ER of tibia
ACL injury test
anterior drawer test
gastrocnemius muscle affect on ACL
gastro has more protective effect on PCL bc of orgin and insertion guards tibia from moving posteriorly
PCL
-stronger ligament
-rarely torn
-tightens during flexion of the knee
PCL function
-prevents hyper flexion of knee (stabilizes femur when going downhill
- prevents anterior displacement of the femur on tibia
PCL injury causes
-knee flexed and superior tibia is struck
- tibia is driven posterioir on femur
- knee joint is severely hyperflexed
PCL injury test
posterior drawer test
coronary ligaments
capsular fibers that attach the menisci to the tibial condyles
transverse ligament of the knee
joins the anterior edges of the 2 menisci, goes through the menisci horns
menisci function
stability, cushion, proprioception and acts as a shocket absorber
peripheral margins of menisci are ____ and interior portions are _____
vascularize, avascular
medial meniscus
bigger, C-shaped, firmly attached to deep surface of MCL, more likely to tear
lateral meniscus
smaller, horseshoe shaped, very moveable/adaptable, popliteus muscle seperates it from LCL, harder to treat becuase it moves more
outer (anterior) of menisci is
1/3, vascular, injury here can be reattached
inner of menisci
2/3, avascular, low chance of repair
common mode of injury for menisci
pivoting and twisting when leg is flexed
what can happen if medial mensci detaches from fibrous capsule
knee can be in a “locked” flexed position
menisci injury test
thessalys test
what can be used for a ACL/PCL graft
part of hamstring to patellar ligament
bursae around the knee that are connected
supra patellar (quads)
popliteus bursa
gastrocnemius bursa
most important bursa of knee
suprapatellar bursa
suprapatellar bursa
articulates menu attaches to bursa and when contracted bursa moves up, when relaxed bursa moves down
decreases friction between quads and femur
popliteus bursa
decreases friction between popliteus and lateral femoral condyle
Pes anserine bursa
between SGT (sartorius, gracilis, and semitendinosis)
housemaids knee
inflamed subcutaneous pre patellar bursa
subcutaneous prepatellar bursa
between skin and anterior surface of patella, allows movement of skin over patella when flex/ext of knee
subcutaneous infrapatellar bursitis
between skin and patellar ligament, allows skin to glide over tibial tuberosity and withstand pressure when kneeling with trunk upright
clergymans knee
infrapatellar inflammation and occurs in roofer/floor tilers
knee extension is due to what muscle
quads (femoral nerve L2-L4)
knee flexion is due to what muscles
bicep femoris, semitendin and semi membran (sciatic nerve- tibial nerve)
lateral rotation of femur is what muscles
popliteal muscles (popliteus)
open kinematic chain activity
body prefers to move tibia, distallimb is not fixed against stable surface
when knee is locked what happens (open chain)
tibia is externally rotates
when the knee is unlocked what happens (open chain)
popliteus is recruited by internally rotating tibia or externally rotating femur
closed kinematic chain
distal part of limb is fixed against a stable surface, body moves the femur
how does the knee unlock in a closed chain
popliteus muscle externally rotates the femur
chondromalacia patella
softening of cartilage ,rubs agaisnt the femur instead of gliding
what causes cohndromalacia patella
bone mislaignment or muscle imbalance
creates popliteal fossa
bicep femoris going to tibial head
semimemb and semitend going to proximal tibia
heads of gastro on medial and lateral sides
contents of popliteal fossa
small saphenous vein
popliteal arteries and veins
tibial and common fibular nerves
posterior cutaneous nerves of thigh
popliteal lymph nodes and lymphatic vessels
arterial supply to knee
femoral artery- popliteal artery- genicular artery- genicular anastomosis
geni means
knee
angulation of knee -normal
185 - slightly valgus
angulation of knee - genus varus bowleg
<175, patella moves laterally when leg is extended
angluation of knee- genus valgus
> 185, more tensile stress on medial side, more compressive stress on lateral side
tensile stress
when you pull apart attached surfaces
osteoarthritis of knee would lead to varus or valgus?
varus- medial compression and lateral tensile
components of the ankle/foot complex
28 bones, 25 joints
rear, mid, and forefoot
body weight when walking, running and jumping
walking- 1.2.x
running- 2x
jumping- 5x
rear foot consists of
distal tibiofibular joint
talocrural joint
subtalar joint
Distal tibiofibular joint:
between tibia and fibula
dosriflexion and plantar flexion
talocrural joint
between tibia dn fibula with talus
dorsiflexion and plantar flexion
subtalar joint
between talus and calcaneus
inversion and eversion
mid foot is also known as
choparts joint
main midfoot joints
talocaneonavicular and calceocuboid
what do the main midfoot joints do
supination (planter flex, invert, and adducts) and pronation (dorsiflex, eversion, and abduction)
forefoot contains
tarsometatarsal joint
inter metatarsal
metatarsophalangeal
interphalangeal
ankle ligaments
anterior inferior tibiofibular ligament
anterior talofibular
calcaneofibular
posterior inferioridistalfibular liga
poserior talofib
calcaneus navicular ligament
Anterior inferior (distal) tibiofibular ligament
Tears with high ankle strains
Anterior talofibular
Most common ligament to tear/sprain at ankle/foot
Posterior inferior (distal) tibiofibular ligament
-Part of ligaments surrounding tibia and fibular distally
-Can tear with high ankle strain
Calcaneus navicular ligament (aka spring ligament)
-Calcaneus to navicular bone
-Important for stability of medial arch
4 deltoid ligaments
anterior tibiotalar
tibiocalcaneal
posterior tibiotalar
tibionavicular
long plantar ligament
calcaneus to cuboid bone
fibular retinaculum
holds brevis and longus in place
spring ligament
Important for stability of medial arch
Long plantar ligament
-Calcaneus to cuboid to 2nd-4th metatarsal heads (with extensions
-Stabilizes arch laterally w/ short one
short plantar ligament
-Calcaneus to cuboid
-Stabilizes arch laterally w/ long one
