NU505- Anatomy and Physiology Wk 2- Lower limb, continued

Components of the femoral triangle

Lateral- Contains the femoral arteries
Middle- Contains the femoral veins
Medial- Contains the lymph vessels

Bursa’s at the Hip

Trochanteric bursa
Gluteus medius
Iliopsoas bursa
Ischiogluteal bursa
Obturator internus bursa
Gluteus maximus bursa

Trochanteric/Gluteus Medius bursa

Attaches beneth tendon as muscle attachment at greater trochanter

Iliopsoas bursa

Attaches at lesser trochanter

Ischiogluteal bursa

Attaches at distal ischial tuberosity

Articulations of the knee

Tibiofemoral joint (medial and lateral compartments)
Patellofemoral joint
Proximal tibial-fibular joint (not really a true joint)

Tibiofemoral joint

Condyles of the femur (convex) to the tibial plateaus (concave)

Patellofemoral joint

Condyles of the femur to the pateller surface

Capsular and support structures

Articular and synovial capsules
Infrapatellar synovial fold
Alar folds (plica)

Articular and synovial capsules

Provide synovial fluid
Ligamentous tissue
Very vascularized

Infrapatellar synovial fold

Part of synovial capsule

Structure/Function of the medial and lateral menisci

Deeper articular surface of tibia (wedges, build up side of tibial condyles)
Distribute weight bearing forces
Distribute synovial forces
Contribute to knee stability in extension

Ligaments of the knee

Medial/Tibial collateral (MCL)
Lateral collateral (LCL)
Anterior cruciate (ACL) (provides axis)
Posterior cruciate (PCL)
Anterolateral (same proximal attachment as LCL, runs just off)

Varus/Valgus stress test

PT supports medial/lateral knee (lateral, valgus) (medial, varus) and medial/lateral at the ankle (opposite of the knee) to test movement and stability of the knee
Can be done in complete knee extension or at 30 degrees flexion

Genu valgus

Knees in
“Knock kneed”

Genu varus

Knees out
“Bow legged”

Testing for ACL tear

Wrap hands underneath knee and pull anteriorly (away) from patient

Testing for PCL tear

Wrap hands around tibia and push posteriorly (toward) patient

Accessory ligaments and supporting structures

Medial/Lateral patellar retinacula
Patellar ligament
Oblique popliteal
Arcurate popliteal
ITB (contributes to lateral retinacula)

Bursa at the knee

Pre-patellar
Suprapatellar
Infrapatellar
Pes anserine
Gastrocnemius
Semimembranosis

Knee movements

Flexion/Extension
Transverse rotation
Instant center-axis
Lock-knee mechanism

What two knee movements are conjoined

Knee flexion/extension and transverse rotation:

Rotation starts at 30-40 degrees flexion and is acting upon the tibial plateus

Open chain lock knee mechanism

As knee approaches terminal 20 degrees extension from flexed position, tibia externally rotates on fixed femur, due to longer medial tibial and femoral articular surfaces compared with the lateral articular surfaces
Results in full seating of menisci, tibia, femur, and ligamentous tension
Ex: Extending knee from sitting position

Closed chain lock knee mechanism

As knee approaches terminal 20 degrees of extension from flexed position, femur internally rotates on fixed tibia
Ex: Extending knee during sit to stand

Vasculature structures of the thigh and knee

Femoral arteries and veins in anteromedial thigh (adductor canal) enter adductor haitus and exits as poplietal artery and vein

Function of the patella

Protection of the anterior knee
Provide mechanical advantage to the quadriceps for knee extension by lifting quad tendon away from axis during extension/flexion and increasing angle of insertion of the patellar ligament into the tibia

Vastus Lateralis

P- Anterior/inferior aspects of greater trochanter, lateral lip of linea aspera
D- Superolateral aspect of patella, lateral condyle of tibia
N- Femoral nerve
S- L2, L3, L4
A- Knee extension

Vastus intermedius

P- Proximal 2/3 anterior aspect femur, distal ½ lateral lip of linea aspera
D- Base of patella (under rectus femoris)
N- Femoral nerve
S- L2, L3, L4
A- Knee extension

Vastus medialis

P- Intertrochanteric line, medial lip of linea aspera
D- Superomedial border of patella, medial tibial condyle
N- Femoral nerve
S- L2, L3, L4
A- Knee extension

Anterior compartment muscles

Vasti muscles (lateralis, medialis, intermedius)
Rectus femoris
Sartorius
Articularis genu

Articularis Genu

P- Anterior aspect distal femur
D- Proximal aspect of synovial membrane of knee capsule
N- Femoral nerve
S- L3, L4
A- Draws capsule anteriorly

Posterior compartment muscles

Hamstring group (Bicep femoris, semimembranosis, semitendanosis)
Bicep femoris (short head)
Popliteus
Gracilis (can also flex knee)

Bicep femoris (short head)

P- Distal 2/3 lateral lip linea aspera
D- Posterolateral aspect of head of fibula
N- Common fibular nerve
S- L5, S1, S2

A- Knee flexion

Popliteus (intrinsic knee muscle)

P- Lateral aspect of lateral femoral condyle
D- Posterior aspect of tibia above soleal line
N- Tibial nerve
S- L4, L5, S1
A- Knee derotation, posterior knee stabilization

Branches of Poplietal artery

Medial superior genicular artery
Medial inferior genicular artery
Lateral superior genicular artery
Lateral inferior genicular artery

Popliteal Fossa Bounderies

Superomedial- Hamstrings
Superolateral- Biceps femoris
Inferomedial- Gastroc
Inferolateral- Gastroc/Poplietus
“Diamond shape”

Poplietal Fossa Floor

Popliteus, femur, tibia

Popliteal Fossa roof

Skin and fascia

Contents in popliteal fossa roof

Popliteal arteries and veins
Medial and lateral superior/inferior genicular arteries (aa)

Tibial nerve

Common fibular nerve
Fat and lymph nodes

Osteology of the Leg

Tibia, fibula, interosseus membrane

Osteology of Ankle and Foot

Calcaneus

Talus

Navicular

Cuboid

Medial cuneiform (1)
Intermediete cuneiform (2)
Lateral cuneiform (3)
Metatarsals 1-5 (medial to lateral)
Phalanges

Phalanges

Proximal and distal phalanges for hallux (great toe)
Proximal, middle, and distal phalanges for toes 2-5

Anterior department muscles of the leg

Tibialis anterior

Extensor digitorum longus

Extensor hallicus longus

Peroneus tertius

Tibialis anterior

P- Proximal 2/3 anterolateral tibia, membrane, lateral tibial condyle
D- Medial aspect base of first metatarsal, medial/plantar aspects medial cuneiform
N- Deep fibular nerve
S- L4, L5
A- Ankle dorsiflexion

Extensor digitorum longus

P- Proximal 2/3 anterior fibula & fibular head, lateral condyle of tibia
D- By 4 tendons to middle and distal phalanges of toes 2-5, expansion hood
N- Deep fibular nerve
S- L4, L5, S1
A- Extension metatarsals and phalanges 2-5

Extensor Hallicus longus

P- Middle 1/3 anterior fibula
D- Dorsal aspect base of distal phalynx of great toe
N- Deep fibular nerve
S- L4, L5, S1
A- Extension of great toe

Peroneus tertius

P- Distal 1/3 anterior aspect of fibula and tendon of extensor digitorum longus
D- Dorsal aspect base of fifth metatarsal
N- Deep fibular nerve
S- L4, L5, S1
A- Ankle dorsiflexion with eversion

Musculature of the Leg lateral compartment

Peroneus longus
Peroneus brevis

Peroneus longus

P- Proximal ½ lateral aspect fibula and fibular head
D- Lateral aspect base of 1st metatarsal and lateral aspect of 1st cuneiform
N- Superficial fibular nerve
S- L5, S1
A- Ankle eversion

Peroneus brevis

P- Distal ½ lateral aspect of fibula
D- Lateral aspect of tuberosity of 5th metatarsal

N- Superficial fibular nerve
S- L5, S1

A- Ankle eversion

The deepest muscle of the leg in the posterior compartment

Tibialis posterior

Tibialis posterior

P- Proximal 2/3 posterolateral aspect of tibia, posteromedial fibula, membrane
D- Tuberosity of navicular

N- Tibial nerve
S- L4, L5, S1
A- Ankle inversion

Musculature of the leg Posterior compartment Middle layer

Flexor hallicus longus

Flexor digitorum longus

Flexor hallicus longus

P- Distal 2/3 posterior fibula
D- Plantar aspect of base of distal phalynx of great toe
N- Tibial nerve
S- S1, S2, S3
A- Flexion of great toe

Flexor digitorum longus

P- Proximal 2/3 posterior aspect of tibia
D- By 4 tendons to plantar aspect bases of distal phalanges 2-5
N- Tibial nerve
S- S1, S2, S3

A- Flexion toes 2-5

Musculature of the leg Posterior compartment Superficial layer

Soleus
Gastrocnemius
Plantaris

Soleus

P- Proximal 1/3 posterior aspect of fibula, fibular head, 1/3 medial border tibia
D- Posterior aspect of calcaneus
N- Tibial nerve
S- S1, S2
A- Ankle plantarflexion

Gastrocnemius

P- Lateral head: Posterior aspect lateral femoral condyle; Medial head: Posterior aspect medial femoral condyle
D- Posterior aspect calcaneus
N- Tibial nerve
S- S1, S2
A- Ankle plantar flexion, knee flexion

Plantaris

P- Lateral femoral condyle and lateral linea aspera
D- Posterior aspect calcaneus
N- Tibial nerve
S- L5, S1, S2
A- Insignificant actions on knee nor ankle