Surface Anatomy of Lower LimbClick to edit Master text styles
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Inguinal lig
Inguinal fold
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Apex of sacrum in male Apex of coccyx in female
Highest point of Iliac crest
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Anterior Superior Iliac Crest , Pubic Tubercle , Pubic Symphysis ASIS,PSIS,S2,Sacroiliac joint,Lower part ofSubarachnoid space
PSIS
(S2)
pg 755
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Sacral hiatus
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Ischial tuberosity
Greater Trochanter
Lesser trochanter
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Lateral malleolus
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Head of talus
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Bony Landmarks
Anterior Superior Iliac Crest
Tubercle of Iliac crest
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Knee joint
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Ok – Next week is a bit more about function of the knee in relation to sports, and as part of that we’re going to look at muscles. Before next week, I want you to get a bit of a handle on where everything is in your own knee. This makes it so much easier to understand what’s going on when the knee is moving. Now because there’s a fair bit of muscle surrounding the knee, they do make up some of the land marks, so we will mention some of them here, but we’ll talk about what they do next week.
Ok. Here are a nice wee pair of legs. And we’re looking at them from the anterior aspect.
If you’ve got half decent quads, which I should hope you all have being sports science students, you should be able to see and feel two firm bumps of muscle which represent different parts of your quads muscles, known as the VMO or the vastus medialis oblique muscle on the medial part of the knee, and the VL, Vastus lateralis on the lateral side of the knee – easy isnt it. See how the lateral muscle belly is higher up, more superiorly placed than the medial muscle belly.
Now all but the most obese people on the planet should be able to feel their knee caps, and just beneath the patella is where the joint line runs – remember the joint line is where the femur meets the tibia. It runs round emdially to laterally.
If we runs our hand vertically down beneath the patella, we can feel the patella ligament, which attaches at a bony prominence called the tibial tuberosity – this may be more pronounced on some people than others.
2.5-3.5cm
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Meniscal Cartilage
Ankle joint
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Metatarsophalangeal joint
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Prof. Monsees
Bones of foot do not lie flat in single plane
Longitudinal + transverse arches of the foot
Arches are flexible; absorb and transmit forces during standing and walking
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-usually it goes posterior into notch
-position typically flexion, adduction, and internal rotation
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And just in case you track and field people out there thought you were safe, here’s a nice compound tibial facture – which ended this long jumper’s career – compound fractures are those whereby the skin is breached – and here we can see the pointy end of his broken tibia popping out. Lovely!
Palpate
Click on patella tap – effusion (NB tense effusion – negative)
Localised tenderness along joint line commonest in meniscus, collateral ligament + fat pad injuries –seen in OA/ Pre-menstrual fluid retention (cured by fat pad excision)
Tibial tuberosity – osgood schlatters (10-16y.os, usually settles with epiphyseal closure) / acute avulsion patella ligament
Femoral condyles – osteochondritis dissecans, esp medial condyle. – teenage males, impingement of fem condyle against tibial spines/ cruciate ligs – AVN.
– image carpenters knee (or parson’s knee to pray)– infrapatellar bursitis
suprapatellar bursitis ‘housemaid’s knee’
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Swelling –
-confined to synovial cavity (effusion, haemarthrosis, pyarthrosis/ SOL)
- generalised (infection/ tumour/ major injury)
Bruising – soft tissues, not normally with meniscal linjuries
Rash – psoriasis
Bursae – in popliteal region, cystic swelling – most commonly semi-membranous bursa
Feel heat with back of hand
Hand under knee – press leg against hand - ? Quads function ok
SLR – to check extensor apparatus with knees hanging over edge of couch
Knee Injection
suprapatellar bursa
Aspiration + culture of fluid
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Cruciate ligament
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ACL
ACL is actually smaller in cross section and weaker than the posterior cruciate – and as a result it gets damaged more often.ACL cane be torn or ruptured during hyperextension, particularly if combined with rotation
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Here’s another way to bust your ACL – this time with a little help from your friends. His leg would already into hyperextension- ahave been at full extension before matey here shoved it way nd he doesn’t appear to be enjoying it too much
Phantom Foot / ACL Injury
hips in a position which is lower than your knees
Anterior cruciate ligament
Or Lachman test
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So firstly we’ll look at the ACL – the anterior cruciate ligament – what do we mean by “anterior”, after all, they’re both in the middle of the knee aren’t they?
The term “anterior” relates to where this ligament inserts, or plugs in, on the tibia. In other words it actually inserts on the anterior part of the intercondylar eminence, which is that little bony ridge that runs anterior to posterior along the top flat surface of the tibia, between the 2 tibial plateaux.
On the femur the acl starts off on the medial aspect of the LATeral femoral condyle and then it runs down and medially to attach onto the anterior portion of the intercondylar ridge on one of the spines that we looked at yesterday. just posterior to where the anterior part of the medial mensicus attaches – we’ll see that on anther view.
We know that the anterior ACl is made up of 2 bundles of fibres that twist on themselves and tighten up when the knee goes from a flexed to an extended position. The ACL is actually smaller in cross section and weaker than the posterior cruciate – and as a result it gets damaged more often. (Trent et al, 1976).
It actually has four roles, but its main role is to prevent excessive anterior displacement of the tibia on the femur when your leg is off the ground. But when your foot is firmly planted on the ground, the acl actually prevents your femur moving excessively posterior relative to the tibia. The ACL doesn’t get much help with resisting excessive anterior tibial movement on the femur – in fact it is 85 % of this kind of restraint is performed by the acl.
Basically the ACL cane be torn or ruptured during hyperextension, particularly if combined with rotation. But funnily enough most ACL ruptures aren’t inflicted on you by other players, they’re usually caused by you twisting internally whilst you’re standing on your planted leg, e.g.playing a game of squash or putting your foot in a pot hole
The problem with a torn acl is that it allows the femoral condyle to roll excessively during flexion. Unfortunately this means that the femoral condyle can skid on the mensicus, which can often lead to meniscal tears, particularly of the lateral meniscus. You also can’t lock out your knee if and so your knee will frequently give way.
Injuries
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PCL is thicker in cross section and stronger than the ACL, so we don’t see it damaged so often.
When off the pitch, we see PCLs being damaged by dashboards. If you’re driving along with your kneeflexed and then youre in a high velocity smash, the front end of the car is often shunted backwards, ramming the dashboard into you shin, which takes your tibia posteriorly and pops your PCL
Posterior cruciate ligament
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*********** don’t forget to talk about what we mean by “Deficient”************************
Ok, well proximally it’s attached to the anterior part of the lateral aspect of the medial femoral condyle, and then it runs down and laterally to plug in at the intercondylar ridge of the medial meniscus, behind the attachment of the posterior horns of the medial and lateral menisci.
Its main role is the opposite to that of the anterior cruciate, in other words it is designed to prevent excessive posterior displacement of the tibia on the femur – AND 95 % of this resistance is provided by the PCL. We can see on this draw test that the PCL isnt doing its job, as the tibia moves a long way back.
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*********** WHAT I WANT YOU TO DO NOW IS THINK OF A WAY THAT YOUR ACL AND PCL MIGHT BE DAMAGED DURING A RUGBY MATCH, IN TERMS OF HOW YOU MIGHT BE TACKLED*************AND THE MECHAMISM OF IT.
When off the pitch, we see PCLs being damaged by dashboards. If you’re driving along with your kneeflexed and then youre in a high velocity smash, the front end of the car is often shunted backwards, ramming the dashboard into you shin, which takes your tibia posteriorly and pops your PCL
Movements of the knee
5-10 deg of hyperextension
30 deg int rotation
45 deg ext rotation
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Ok, so how do we describe the range of movements possible in our knee?
When our knee is extended we call that zero degrees
- in other words it can extend so that the entire leg forms a straight line, but most of us can hyperextend our knees a little bit – in the region of 5 or even 10 degrees.
************ so in otherwords if our knee is fully flexed, we can extend it through 135 degrees and we also have an additional 5 or even 10 degrees of hyperextension******************************
So what’s stopping us from flexing our knees any further????
Any comments?
(tight quads, and heel hitting the bum if they’re flexible)
When we have a slightly flexed knee, the knee obviously isnt locked out – in otherwords, it’s in an unlocked position.
If our knee is flexed to 35 degrees or more, we can actually internally and externally rotate at the knee to move the lower leg. ? How is this possible?
Well although flexion and extension occur at the joint made up of the femur and the tibia meeting,
Internal and external rotation can occur because rotation can take place between the menisci and the tibia.
With the knee flexed to more that 35 degrees, we can usually achieve around 30 degrees of internal rotation and 45 degrees of external rotation – up on your feet again and give it a try – we wouldn’t be able to do the twist if you couldn’t internally and externally rotate at the knee joint.
Move
Hyperextension – Ehlers danlos syndrome, Charcot’s disease + polio (rare), girls esp. – high patella, chondromalacia patellae, recurrent dislocation, sometime tears ant. Cruciate, medial meniscus or medial ligament. Ballet + high-heels – retard upper tibial epiphyseal growth.
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- Rigid block – arthritic (fixed flexion deformity)
Hyperextension – Ehlers danlos syndrome, Charcot’s disease + polio (rare), girls esp. – high patella, chondromalacia patellae, recurrent dislocation, sometime tears ant. Cruciate, medial meniscus or medial ligament. Ballet + high-heels – retard upper tibial epiphyseal growth.
Menisci
McMurrays test – medial + lateral menisci
Medial McMurray’s – leg flexed, foot EXTERNALLY rotated, hip abducted, - clicks + grating felt while leg smoothly extended
Lateral McMurray’s – lef flexed, foot INTERNALLY rotated, hip abducted – as above.
Meniscal injuries – meniscal tears in young adult, degenerative lesions in middle age
Meniscal cysts – firm on palpation joint line, tender on deep pressure – usually lateral side.
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Medial McMurray’s – leg flexed, foot EXTERNALLY rotated, hip aBducted, - clicks + grating felt while leg smoothly extended
Lateral McMurray’s – lef flexed, foot INTERNALLY rotated, hip abducted – as above.
Meniscal injuries – meniscal tears in young adult, degenerative lesions in middle age
Meniscal cysts – firm on palpation joint line, tender on deep pressure – usually lateral side.
Move - instability
2) Varus stress test ( +ve lat lig torn)
Knee Arthroscopy
Small incisions
Small instruments trim and smooth cartilages
Operate using a video monitor
Surgical Treatment
Knee Arthritis
Roughens increasing gliding friction
Improves with rest, anti-inflammatory medicines, low impact exercise
Knee Replacement
Larger incision
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Muscles of Extension
Muscles of Adduction
Muscles of Abduction
Lateral Rotation
Medial Rotation
Gluteus minimus
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Lateral depression
Medial depression
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Femoral Triangle
Sartorius (lateral)
pg 746
pg 752
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Leg movements by compartment (in leg all nn are branches of sciatic)
Frolich, Human Anatomy, Lower LImb
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