1. The major structural and functional anatomical features of the knee: Bones: The knee joint complex consists of the femur, the tibia, the fibula, and the patella. On the distal end of the femur there’s a lateral and medial condyle which are designed to articulate with the tibia patella. Anteriorly, the condyles form a hollowed femoral groove to receive the patella. On the proximal end of the tibia, tibial plateau articulates with the condyles on the femur. On the flat tibial plateau there are too shallow concavities that articulate with their respective femoral condyles. Patella- The patella is the largest sesamoid bone in the human body. Its located on the tendon of the quadriceps femoris muscle. The lateral aspect is wider than the medial aspect. The patella articulates between the concavity provided by the femoral condyle. Articulations: The knee joint consists of four articulations between the femur and tibia, the femur and the patella, the femur and the fibula, and the tibia and fibula. Menisci: These are two oval fibrocartilages that deepen the articular facets of the tibia, cushion any stress placed on the knee joint, and maintain spacing between femoral condyles and tibial plateau. The menisci are like intervertebral discs. Location: Medially and laterally on the tibial plateau. The menisci help stabilize the knee, when its flexed at 90°. Medial meniscus- This meniscus is C-shaped fibrocartilage. It is attached to the medial articular facet of the tibia in the joint capsule by the coronary ligaments. It is also attached to fibers of the semimembranous muscle. Lateral meniscus- This meniscus is O-shaped and attach the lateral articular facet on the superior side of the tibia. It also attaches loosely to the lateral articular capsule and popliteal tendon. Stabilizing ligaments: The major stabilizing ligaments of the knee are the cruciate ligaments, the collateral ligaments, and the capsular ligaments. Cruciate ligaments- These ligaments account for a lot of the knee stability. They are too ligamentous bands that cross over one another within the joint capsule of the knee. The ACL attaches below and in front of the tibia then going backwards. It attaches laterally to the inner surface of the lateral condyle. The PCL crosses from the back of the tibia and an upward, forward, and medial direction. It attaches to the anterior portion of the lateral surface of the medial condyle. It is also stronger than the ACL. The ACL has three twist bands which are the anteriomedial, intermediate, and posteriolateral bands. The ACL prevents the femur from moving posteriorly during weight-bearing, limits anterior translation of the tibia and non-weightbearing, Stabilizes the tibia against excessive internal rotation and says of the secondary restraint for vagus/varus stress with collateral ligament damage. The ACL works in conjunction with the hamstring muscle group to stabilize the knee joint. The PCL resists internal rotation of the tibia, prevents hyperextension of the knee, limits anterior translation of the femur during weight-bearing, and limits posterior translation of the tibia and non-weightbearing. Capsular and collateral ligaments- these function as additional stabilization. They also direct movement in the correct path. They also move synchronized and are divided into the medial and lateral complexes. The MCL is separate from the deeper capsular ligament at the joint line. It is attached above the joint line on the medial epicondyle and below on the tibia. Deep medial capsular ligaments: Is divided three parts which are anterior, medial, and posterior capsular ligaments. The anterior one connects with the extensor mechanism and the medial meniscus through the coronary ligaments. It works out to relax the knee during extension and tighten during knee flexion. The medial capsular ligaments attach the medial meniscus to the femur and allow the tibia to move on the meniscus inferiorly. The posterior capsular ligament, sometimes called the posterior oblique ligament, attaches to the posterior medial aspect of the meniscus. The LCL is a round, fibrous cord close to the size of a pencil. It’s attached to the lateral epicondyle of the femur and the head of the fibula. It’s taut during knee extension but relaxed during flexion. Joint capsule: It extends upward underneath the patella to form a suprapatellar pouch. It also forms 2 pouches that cover over the femoral condyles and tibial plateau. The capsule thickens immediately to form the posterior oblique ligament and laterally to form the arcuate ligament. The joint capsule is divided into 4 regions: the posteriolateral, posteriomedial, anterolateral, and anteriomedial. Knee musculature: for knee flexion, the knee uses the video femoris, semitendinosus, semimembranous, gracilis, sartorious, gastrocnemius, popliteus, and plantar is muscles. For knee extension, the knee uses the quadriceps. For external rotation, the biceps femoris is used. For internal rotation, the popliteal, semitendinosus, semimembranous, sartorious, and gracilis are used. Bursae: it reduces the friction between anatomical structures. It’s found between muscle and bone. Fat pads: there are many fat pads. The largest one is the infrapatellar fat pad. These serve as cushion to the front of the knee and separates the patellar tendon from the joint capsule. 5. Collateral ligament sprains: there is pain and tenderness over the LCL. You can palpate it when the knee is flexed and internally rotated. There is swelling over the LCL, and there is laxity while doing the varus stress test. The way this sprain happens is internally rotating the tibia. Cruciate ligament sprains: these are more serious. The sprain ca occur by externally rotating the tibia while the knee is in valgus position. The patient will also hear or feel a pop when it happens, followed by immediate disability. It will also produce rapid swelling at the joint line. 6. Meniscal lesion: a valgus force can adduct the knee, tearing and stretching the MCL while the fibers twist the medial meniscus outwards. It happens if someone makes a cutting motion while running. Or if the knee is forcefully extended from a flexed position while the femur is internally rotated. It’s hard to determine the injury. Once the tear occurs, the ruptured edges harden and may atrophy. The patent may feel a sense of the knee collapsing, a popping sensation, or having the inability to squat or change direction quickly without pain. Knee plica: it’s usually from blunt force, like falling on the knee or twisting with the foot planted. The patient will complain about painful pseudo locking of the knee while sitting for a long time. A snap may be felt or heard. There is no swelling or laxity. 9. Patellar fractures occur by either indirect or direct trauma. Indirect trauma- a severe pull of the patellar tendon occurs against the femur when the knee is semiflexed. Falling, jumping or running may result in a fracture too. Patellar dislocations occur when the quadriceps muscles attempts to pull in a straight line, pulling the patella laterally. 10. Causes of patellofemoral arthralgia: from lateral deviation of the patella as it tracks in the femoral groove. 12. Iliotibial band friction syndrome: from repetitive and overuse conditions. It commonly occurs in runners and cyclists who have genu varum and pronated feet.where the band creates friction, becomes irritated. Pes anserine tendinitis or bursitis: inflammation results from excessive genu valgum and weakness of the vastus medialis muscle. These 2 things compare by they both happen to runners and cyclists. 13. What causes the knee to collapse is knee locking, knee ligament damage, recurrent patella dislocation, discoid lateral meniscus, chrodromalacia patella, and osteochondritis.
1. The anatomy of the ankle and lower leg.
Bones- lower leg: There are two bones which is the tibia and fibula. Ankle: distal portion of the tibia, the distal portion of the fibula and talus.
Tibia- The tibia is the longest bone in the body. It serves as the principal weight-bearing bones of the leg. It’s located on the medial side of the lower leg. It’s triangular shaped and it’s upper second and third, But rounded and more constructed in the lower third. Surfaces of the shaft of the tibia: posterior, medial and lateral.
Fibula- It is long and slender. It’s located along the lateral aspect of the tibia. Its main function is to provide for the attachment of muscles. There are two malleoli: a medial and lateral one.
Talus- This is the second largest tarsal and the main weight-bearing bones of the articulation. It rests on the calcaneus and receives articulating surfaces of the lateral and medial malleolus. The talus forms a link between the lower leg and foot.
Calcaneous: This is the bone forms the hill and it supports ligaments of the ankle and achilles tendon.
Superior and inferior tibiofibular joints: The superior one allows some gliding movement. The interior one is a fibrous articulation. It’s reinforced by the ankle ligaments.
Talocrural joint: It is a hinge joint that is formed by the articular face, on the distal portion of the tibia. Ankle movements that occur at this joint include plantar and dorsiflexion.
Subtalar joint: It consists of the articulation between the talus and calcaneus. The movement that occurs that this joint included inversion, eversion, pronation and supination.
Tibiofibular ligament: a strong Interosseous membrane. It’s an oblique arrangement. It aids in diffusing the forces placed on the leg.
-Lateral ligaments: anterior talofibular, the posterior talofibular and calcaneofibular
-Medial ligaments: The deltoid ligament is triangular
2. Ankle injuries can be prevented by stretching the Achilles tendon, strengthening key muscles, learning neuromuscular and proprioceptive control, wearing proper footwear, and being properly taped.
3. Steps that should be taken when assessing ankle and lower leg injuries: One: ask the patient history questions, two: Observe for any postural deviations, difficulty in walking, deformity, swelling, bony deformity, color and texture of the skin, abnormal sounds of the ankle joint, if there’s any heat or redness, and is there obvious pain and if the patient is able to walk. Three: palpate to determine obvious structural deformities, areas of swelling, or points of tenderness. Four: Use special stress tests.
4. The three different types of ankle sprains:
-Inversion sprains: these are the most common types of ankle sprains. The injury results to the lateral ligaments. Its main function is to stop forward subluxation of the talus. It’s possible that inversion can cause both an avulsion of the lateral malleolus and fracture of the medial malleolus. For this sprain, you have the inability to bear weight for four steps, there’s tenderness over the interior and posterior pole of either Malleolus, you have the inability to bear weight at the time of injury and at the time of have evaluation, and there’s tenderness along the base of the fifth metatarsal. Grade one ligament sprain is the most common type of sprain. Signs and symptoms of this sprain is there is very mild pain and disability occurs, It is very tender and swells a lot.
A grade two ligament sprain causes a great deal of disability. The patient complains about how much it hurts and feeling or hearing a pop in the ankle- lateral side.
A grade three ligament sprain Is relatively uncommon, but when it does happen is extremely disabling.
-eversion ankle sprains: these are less common than inversion ankle sprains because of the bony ligamentous anatomy. The patient usually complains about the pain in the lower leg and foot. The patient is usually unable to bear weight. Adduction and abduction cause pain but pressing directly up against the bottom of the foot does not cause pain.
-high ankle sprains: The anterior and posterior tibiofibular ligaments are torn with increased external rotation or forced dorsiflexion and are often injured in conjunction with a severe sprain of the medial or lateral ligament complexes. The patient complains about severe pain in the Ankle region. Pain normally occurs along the anterolateral leg.
13. The appropriate progression of treatment that should be used in the rehabilitation of ankle and lower leg injury: The typical progression begins early in the rehab process as the patient becomes partially weight-bearing. Full weight-bearing should be started when the activity is performed with no limp. Running can start when ambulation is pain-free. The patient should jog restraints and walk the curbs and then progress to jogging the entire track. You should also start with a slow speed and then progressively increase to a sprint in a straight line. The cutting sequence should begin with circles of diminishing diameter. You can set up cones for the patient to run around as the next cutting progression. Next is the sidesteps. Next the patient sprints to a predesigned spot and cuts/sidesteps abruptly. When that is accomplished the patient should be able to do this without warning. Jumping/hopping activities/exercises are to be started on both legs simultaneously and gradually reduced to only the injured ankle. Once the upper levels of all sequences are reached, the patient can return to a limited practice which may include early training and fundamental drills.
The anatomy of the foot:
Bones: there are 26 bones, 14 phalangeal, five metatarsal and seven tarsals. Some people have 2 sesamoid bones.
Toes: They’re similar to fingers, but shorter and have a different function. They designed to give a wider base both for balance and for propelling the body forward. The hallux has two phalanges and others have three. Sesmoid bones are located under the hallux. The purpose is to bear weight and act as sliding pulleys for tendons.
Metatarsals: They’re the five bones that lie between and articulate with the tarsals and the phalanges. They have little movement. The ligamentous arrangements give elasticity to the foot and weight-bearing. The metatarsophalangeal joints permit hinge action found between the phalanges, which is similar the action found between the hand and fingers. The first metatarsal’s largest and strongest. The Medial and lateral sesamoid bones are located on the plantar aspect of the metatarsophalangeal joint of the great toe within the flexor hallucis tendon. Purpose; (one) to increase the mechanical efficiency of the tendon & (2) to decrease frictional stress.
Tarsal bones: The foot has seven tarsal bones which are located between the bones of the lower leg and metatarsals. The importance is to support the body and it’s locomotion.
Calcaneus: The calcaneous is the largest tarsal bone. It supports the talus And shapes the heel. The function is to convey the bodyweight to the ground, and serve as an attachment For the achilles tendon and locations of the Plantar surface.
Talus: The talus is the most superior of the tarsal bones. It is above the calcaneus. The talus consist of a body, neck and head.
Navicular: It is positioned anterior to the talus on the medial aspect of the foot. It articulates with the three cuneiform bones.
Cuboid: It is on the lateral aspect of the foot. It articulates posteriorly with the calcaneous and anteriorly with the fourth and fifth metatarsal.
Cuneiforms: The three of them are located between navicular and base of the three metatarsals on the medial aspect of the foot.
Arches- Arches assist the foot in supporting the bodyweight, in absorbing shock of the weight-bearing, and providing space on the plantar aspect for nerves, blood vessels and muscles. There are four arches.
Metatarsal arch: It’s shaped by the distal heads of the metatarsals. Semi ovoid appearance. Stretching from the first to the fifth metatarsal.
Transverse arch: It extends across the transverse tarsal bones. It forms a half Dome. It gives protection to soft tissue and increases mobility.
Medial longitudinal arch: It originates along the medial border of the calcaneus and extends forward to the distal head of the first metatarsal. The main supporting ligament is the planter calcaneonavicular ligament which acts as a spring by returning the arch to its normal position after being stretched.
Lateral longitudinal arch: it is on the outer aspect of the foot and follows the same pattern as that of the medial longitudinal arch. Formed by the calcaneus, cuboid and fifth metatarsal bones. It’s lower and less flexible than the inner longitudinal arch.
Plantar fascia- It is a thick white band of fibrous tissues. It originates from the medial tuberosity of the calcaneus and ends at the proximal heads of the metatarsal heads. It supports the foot against downward forces.
Articulations- These are the joints.
Interphalangeal joints: These are located at the distal extremities of the proximal the middle phalanges at the base of the adjacent middle and distal phalanges. These designed for flexion and extension. They all have collateral ligaments on the medial and lateral sides.
Metatarsophalangeal joints: They are the condyloid types with permits flexion, extension, abduction and abduction. They also have collateral ligaments like the interphalangeal joints on each medial and lateral side.
Intermetatarsal joints: These are sliding joints. They had two sets of articulations. They permit slight gliding movements.
Tarsometatarsal joint: These are formed by the junction of the bases of the metatarsal bones with the cuboid and all three cuneiforms
Subtalar joint: The articulation between the talus and calcaneus. It’s Normal movement is inversion, eversion, pronation and supination.
Metatarsal joint: This consists of calcaneocuboid and the talonavicular joint.
2. The foot functions during the gait cycle in phases. The stance phase, which starts with an initial contact of the heel on the ground and ends when the toe breaks contact with the ground which is toe-off. Swing phase: The time between toe off and the initial contact, which is a period of non-weightbearing. The foot’s function during stance phase of running is two fold. At heel strike, the foot acts as a shock absorbers to impact forces and adapts to uneven surfaces. At toe off the function of the rigid lever to transmit the explosive force from the lower extremity to the running surface.
3. An injury on the plantar surface of the foot can cause soreness and pain in the knee because the transverse plane rotation occurs at the knee joint because of tibial rotation.
4. An appropriate procedure for assessing injuries up the foot: you need to ask history questions, observe if the patient is favoring the foot, if the foot is swollen, deformed or discolored, if it changes color when walking, if the person flat-footed or has a high arch, or if the toes have abnormalities, Check their footwear, and then palpate to determine and evaluate circulation. After that use special tests.
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