Lecture 14: Lower Leg Issues and Knee Anatomy Part 1

What is the Achilles make up of?

The independent tendons of the gastrocnemius and soleus fuse to become one tendon, approximately 5 to 6 cm proximal to the calcaneal insertion.

Where is the retrocalcaneal bursa located?

Proximal to the insertion, between the tendon and the calcaneus

What is the thickest and strongest tendon in the body?

the achilles

What does the achilles tendon not have?

NO synovial sheath but is surrounded by paratenon

-Only vascular tendons are surrounded by paratenon

If there is posterior heel pain what could it be?

• Achilles Tendonitis, Achilles Bursitis or Retrocalcaneal Bursitis • Need to decide exactly where the pain is!

• True tendon pain is usually confined to the tendon itself

What is Retrocalcaneal Bursitis?

• Bursa in the recess between the anterior inferior side of the Achilles tendon and the posterosuperior aspect of the calcaneus (retrocalcaneal recess)

• Sometimes seen with insertional tendinopathy

• Structural irritants (tight/pokey)

• Pain just above the insertion of the Achilles Tendon

• Pain with squeeze from side

What is Achilles Bursitis (Superficial calcaneal bursitis)?

• Bursa located between calcaneal prominence or the Achilles tendon and the skin

• Pain posterior aspect of heel with solid swelling

• Often due to excessive friction or by wearing shoes that are too tight or too large

What is the management of itis?

POLICE/PEACE & LOVE

-Address training and equipment issues

• Heel lift- shorten achilles

• Pad- donut

• Achilles Stretch

• New Shoes/popped out

What are external factors from Tendinitis/Paratenonitis?

Rub from shoe/equipment Running down hill- Tibialis anterior

Rub from laces- Tibialis anterior

Hyper dorsiflexion- Achilles

What are the internal factors of Tendinitis/Paratenonitis?

as foot malalignment Rub over bone

Cavus or flat/pronating feet

What are the symptoms and signs for Tendinitis/Paratenonitis?

• Pain and/or Crepitation (of Paratenon) of acute onset

• Red and hot over involved structure

• Usually precipitated by movement around the ankle joint - Remember too much , too soon!

What is the diagnosis of Tendinitis/Paratenonitis?

• Made on the basis of local swelling

• STTT- what will that look like?

• Palpation over structures

Paratenonitis Inflammatory/Destructive plan

Police/PEACE &LOVE Heel lift/pad/support

Paratenonitis Repair plan

Heat

- Idealize ROM- Stretch gastrocs/ soleous

- Start strength and proprioception ex. as able

-Address training issues

Achilles Tendinosis predisposing factors?

• Years of running

• Excessive pronation (increased load on Gastrocs/soleus to resupinate)

• Poor flexibility

• Training in cold climate • Improper footwear

Diagnoses of achiles tendonosis

• History FITT, Pain

• Pain usually 2-7 cm from the insertion onto the calcaneus

Observation achiles tendonosis

• More thickening tham Swelling and tenderness over large portion of tendon

• Faulty biomechanics

• On STTT, both plantar and dorsiflexion cause pain and crepitus (if paratenon involved), particularly with loading

• Nodules /bumps may be palpable

What is the treatment of tendinosis?

Which stage of healing are you starting in?

• Goals- idealize ROM and start strengthing

• Good-quality randomized controlled trials indicate that eccentric strengthening programs provide 60 to 90 percent improvement in pain and function - Level of evidence A

• Rehabilitative exercises - Level of evidence B

• Level B evidence NO the use of NSAIDS

What is the most common tendon that is ruptured?

The Achilles tendon is the most commonly ruptured tendon

What are the risk factors of an achilles rupture?

male sex (10:1)

• use of steroids

• prior rupture on the contralateral side.

What is the subjective report (symptoms) of an achilles rupture?

- Patient reports pop or snap like someone kicked them

• Pain may be immediate then rapidly subsides.

• Usually pain only at site of tear.

• Usually occurs 1-2 inches above the insertion

What are the clinical signs of an achilles rupture?

• Palpable gap

• Positive Thompson test

• Dorsiflexed when relaxed

What is the Inspection/palpation of an achilles tendon rupture?

• Foot hangs straight down - No plantar flexion

• Palpable divot 1-2"above insertion

• Unable to plantar flex. Relatively loose on stretch

• May have bruising/redness, if seeing the patient the following day

What the the thompson's test?

Repture achilles

Positive test is no movement

What is the tibiofemoral joint?

• Articulating surfaces between the medial and lateral condyle of the femur and tibia (Tibiofemoral joint)

• The tibiofemoral joint allows transmission of body weight from the femur to the tibia while providing hinge-like, sagittal plane joint rotation along with a small degree of tibial axial rotation

What is Patellofemoral joint?

• Is the articulation between the patella and femur

• The patella is the largest sesamoid bone in the body.

• Referred to as the extensor mechanism

• Also works eccentricelly during gait

When is the knee most stable?

• More stable in extension

• Help from dynamic stabilizers

• Knees have relatively poor bony fit when flexed

• Knee has a strong fibrous joint capsule

What structure does the knee rely on?

• MCL

• LCL

• ACL

• PCL

• Dynamic stabilizers

What is the capsule of the knee?

• Anteriorly to suprapatellar pouch

• Inferior to infra patellar fat pad and bursa

• Medially it communicates with the deep fibers of the MCL

• Posteriorly covers femoral condyles

• Lined by synovial membranes, except posteriorly where it passes in front of the cruciates

What is the Superficial Lateral Support Complex of the knee?

• Iliotibial band and biceps Femoris

What is the middle Lateral Support Complex?

Patellofemoral ligaments and retinaculum

What is the deep Lateral Support Complex?

• Lateral (Tibial) Collateral Ligament (LCL)

• Popliteus tendon

• Capsule

• Other ligaments (Arcuate, Fabelofibular, etc.)

Lateral aspect of the knee is significantly supported by?

Muscles

- Biceps Femoris

- IT band

- Popliteus tendon

- Capsular ligaments (lateral capsule)

- Lateral Collateral Ligament

What are lateral knee injuries?

• Injuries of the lateral compartment of the knee are less common than injuries of the medial compartment.

• Injured with varus directed force

• High grade injuries require higher forces which usually injures multiple structures

• Isolated high grade LCL tears are uncommon

What is the lateral collateral ligament?

• Round fibrous cord about the size of a pencil.

• Extends from the lateral epicondyle of the femur to lateral fibular head

• Extra capsular (generally less swelling)

• Primary static restraint to varus

When is there the greatest load on the knee?

Load at 25-30 degrees greater than at 90

What is the Superficial of the medal support complex of the knee?

Sartorius and fascia

What is the middle of the medial support complex of the knee?

Contains superficial MCL and Semimembranosus

What is the deep of the medial support complex of the knee?

Contains Deep fibers of MCL and capsule

What is Medial Support Complex stability?

• MCL primary stabilizer -25-20 degrees

• ACL/PCL secondary vs. valgus

• Muscles help in full extension

• Medial hamstrings (Sartorius, semimembranosus + semitendinosus)

• Medial head of gastrocs.

• Quad muscles (vastus med.)

• Bony structure is tertiary support

What is the medial collateral ligament?

•A capsular ligament (swelling)

•Has superficial and deep components

• Deep portions connect directly to the medial meniscus

• Superficial portions run from medial femoral epicondyle to superomedial surface of tibia

What is medial view of the knee flexion and extension?

most active resisting valgus loading when knee is 25-30 degrees of flexion

at 5 degrees

- superficial 57%

- Deep 8%

- Posterior oblique 18%

At 25 degrees

- superficial 78%

- Deep 4%

- Posterior oblique 4%