Lecture 14 - Knee Anatomy and Lower Leg Issues

Question 1

where is the achilles?

Answer 1

• 5-6 cm proximal to the calcaneal insertion

Question 2

what structurally makes the achilles a good tendon?

Answer 2

• thickest/strongest in the body
• surrounded by paratenon (which means it is vascular and heals quicker)

Question 3

what is retrocalcaneal bursitis? what causes it? And how do you test for it?

Answer 3

• 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

Question 4

what is achilles bursitis? what causes it?

Answer 4

• bursitis between calcaneus/achilles and skin
• pain with posterior aspect of heel
• swelling
• due to friction from loose/tight shoes

Question 5

how do you manage ankle itis?

Answer 5

• POLI/ peace and love
• heel lift (to reduce tension)
• donut pad to reduce pressure
• stretch achilles
• break in new shoes/skates

Question 6

what is tendinitis?

Answer 6

• 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)

Question 7

what is paratenonitis?

Answer 7

• 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)

Question 8

what are the symptoms/signs of paratenonitis?

Answer 8

• pain/crepitation (acute onset)
• red and hot
• swelling

Question 9

what is the rehab for paratenonitis?

Answer 9

• 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

Question 10

what is tendinosis/tendinopathy?

Answer 10

• chronic pathological changes
• caused by repetitive microtrauma
• no inflammation
• poor vascularity
• collagen fibre structure changes

Question 11

what are the predisposing factors of tendinosis?

Answer 11

• running
• excessive pronation
• poor flexibility
• training in cold climate
• improper footwear

Question 12

how do you diagnose achilles tendinosis?

Answer 12

• 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)

Question 13

how do you treat achilles tendinosis?

Answer 13

• eccentric strengthening
• rehab
• (avoid NSAIDs) because no swelling

Question 14

what is the most commonly ruptured tendon?

Answer 14

• the achilles tendon

Question 15

what are the risk factors for a ruptured achilles?

Answer 15

• male
• use of steroids
• prior rupture on contralateral side

Question 16

what are the symptoms of an achilles rupture?

Answer 16

• pop or snap
• “like someone kicked them”
• immediate pain - quickly subsides
• pain 1-2 inches above insertion (site of tear)

Question 17

what are the clinical signs of an achilles rupture?

Answer 17

• palpable gap
• positive thompson test
• dorsiflexed when relaxed

Question 18

what is the thompson test for achilles tears?

Answer 18

• 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)

Question 19

what are the two joints of the knee?

Answer 19

1. tibiofemoral –> included in screw home mechanism
2. patellofemoral –> eccentric movement during gait

Question 20

what is the screw-home mechanism?

Answer 20

• 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

Question 21

what structures provide knee stability?

Answer 21

• dynamic stabilizers –> muscles
• joint capsule
• MCL/TCL
• LCL/FCL
• ACL
• PCL

Question 22

what is the knee capsule?

Answer 22

• communicates with deep fibres of the MCL
• covers femoral condyles
• lined by synovial membranes

Question 23

what are the 3 layers of the lateral support complex?

Answer 23

• superficial = IT band and biceps femoris
• middle = patellofemoral ligaments and retinaculum
• deep = LCL, popliteus, capsule and other ligaments

Question 24

what 5 structures support the lateral aspect of the knee?

Answer 24

1. biceps femoris
2. IT band
3. popliteus tendon
4. capsular ligaments
5. LCL

Question 25

what are lateral knee injuries?

Answer 25

• less common
• injured with varus direct force
• high force = higher grade injury (multiple torn structures)
• isolated LCL tears are uncommon

Question 26

what is the LCL structure?

Answer 26

• round fibrous cord
• about the size of a pencil
• lateral epicondyle to lateral fibular head
• extracapsular (swells?)
• primary static restraint to varus

Question 27

what are the 3 layers of the medial support complex?

Answer 27

• superficial = sartorius and fascia
• middle = superficial MCL and semimembranosus
• deep = deep MCL fibres and capsule

Question 28

what are the stabilizers of the medial support complex?

Answer 28

• MCL (25-30 degrees)
• ACL/PCL (secondary)
• muscles (in full extension) –> medial hamstrings, medial gastroc head, quads
• bony structure is tertiary

Question 29

what is the structure of the MCL?

Answer 29

• capsular (swells)
• has superficial and deep components
• deep connects to meniscus
• superficial connects to medial femoral epicondyle and tibia

Question 30

what knee structures are most active at 5 degrees flexion?

Answer 30

• superficial, posterior oblique, then deep

Question 31

what knee structures are most active at 25 degree flexion?

Answer 31

• superficial, then deep and posterior oblique tied