Functional Anatomy of the Knee and Leg. Functional Anatomy of the Knee and Leg

Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD ACSM TPC Part 2 Miami, Florida • February 9, 2013 Functional Anatomy of the Knee and ...
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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

ACSM TPC Part 2 Miami, Florida • February 9, 2013

Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

Associate Professor Dept. of Orthopaedic Surgery & Sports Medicine University of Kentucky Lexington, Kentucky

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Anatomy and Dissection Sources • www.primalpictures.com [3D Human Anatomy Software – London, England] • Interactive Knee • Interactive Functional Anatomy

• Mary Lloyd Ireland, MD

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Lower Limb model: Lateral View

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Lower Limb model: Medial View

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Lower Limb model: Anterior View

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Lower Limb model: Posterior View

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Internal/External Rotation of Knee

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Flexion/Extension of Knee

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Knee model: Anterior View

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Left Knee Joint, Ligaments, from above

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Knee joint and menisci, from above

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Tibial plateau and menisci, from above

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Screw home mechanism (Smillie) tibial externally rotates in terminal knee extension

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Joint line palpation with knee flexed should produce pain if meniscus is torn

Externally rotate tibia for medial meniscus tears, Internally rotate for lateral meniscus tears

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Knee model: Medial View

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

OKU 10: “Soft Tissue Injuries About the Knee,” Kaar et. al., p. 455. Fig. 1A. • Posteromedial corner: • Medial collateral ligament • Superficial and deep layers • Meniscotibial and

meniscofemoral ligaments

• Posterior Oblique ligament • Runs posterior to superficial MCL • Multiple bands attaching to posteromedial capsule, semimembranosus, and proximal tibia

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Knee model: Lateral View

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

OKU 10: “Soft Tissue Injuries About the Knee,” Kaar et. al., p. 455, Fig. 1B. • Posterolateral corner: Static stabilizers Fibular collateral ligament Popliteofibular ligament Posterolateral capsule Popliteus serves as dynamic and static stabilizer • Popliteus femoral attachment in anterior popliteal sulcus, 2cm. anterior and distal to FCL attachment • Upside down muscle: origin distal, insertion proximal • • • •

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Knee model: Posterior View

www.primalpictures.com

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

ACSM TPC • Feb. 9, 2013

Mary Lloyd Ireland, MD

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Anatomic Anatomic Sources Sources of of Leg Leg Pain Pain • Bone • A continuum of bone

trauma exists from bone strain to stress reaction to stress fracture

• Periosteum • Inflammation occurs at

muscular insertions particular of tibialis posterior and soleus.

ACSM TPC • Feb. 9, 2013

© 2002 Mark R. Hutchinson, M.D.

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Anatomic Sources of Leg Pain • Muscles and Compartments • 4-5 muscle compartments • Chronic strains and tendinopathy can occur • Nerves • Proximal nerve entrapment can cause radicular pain • Systemic diseases can lead to neuropathy

© CIBA-Geigy: Permission Applied For

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Anatomic Sources of Leg Pain • Arteries and Veins • Atherosclerosis can lead to

claudication • Venous phlebitis or thrombosis can occur • Popliteal artery entrapment and arterial endofibrosis has been described in younger population.

© CIBA-Geigy: Permission Applied For

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Differential Dx of Chronic Leg Pain in Athletes

• • • • • • •

CECS Muscle herniation Stress fractures Medial tibial periostitis (shin splints) Chronic muscle strain Popliteal artery entrapment Referred from spine

© 2002 Mark R. Hutchinson, M.D.

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Compartment Syndromes •Traumatic

• Exertional

• Secondary to fracture, crush, and reperfusion injuries

• Consistently exerciseinduced

• Surgical emergency

• No pain at rest, pain consistently relieved with cessation of sport

• Skin and fascia may both contribute to compartmental restriction and increased pressure • Non-physiologic swelling secondary to trauma

ACSM TPC • Feb. 9, 2013

• Generally endurance athletes

• Attributed to restriction restriction of of muscle swelling secondary to tight fascial compartments • Diagnosed with pre and post exercise pressure measurements

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

History and Physical: Clinical Pearls in Athletic Leg Pain

• Pain with initial impact • Stress fracture • Periostitis • Muscle strains and tendinitis

ACSM TPC • Feb. 9, 2013

• Focal bone pain • Stress fracture • Diffuse medial bone pain • Medial tibial periostitis • Focal muscle pain • Strain or Hernia

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

History and Physical: Clinical Pearls in Athletic Leg Pain • Pain with resisted

motion

• Muscle strains and

periostitis

• Pain with vibration • Stress fractures • Pain at night • Tumors • Pain with exertion • CECS, Popliteal artery entrapment

ACSM TPC • Feb. 9, 2013

• Paresthesias at rest • Nerve entrapment • Paresthesias with exertion • CECS • Electrical shooting pain • Radicular pain from back

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

History and Physical: Clinical Pearls in Athletic Leg Pain • Diffuse swelling • DVT • CECS • Muscle ruptures • Focal swelling • Muscle herniation • Ganglion • Tumor

© 2002 Mark R. Hutchinson, M.D.

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

80% of CECS involve the anterior or lateral compartments ((Cross-section Cross-section just above middle of leg) Tibialis Flexor digitorum Posterior m. longus m.

Extensor digitorum longus m.

Davey J, Rorabeck C, and Fowler P. The tibialis posterior muscle compartment. Am J Sports Med 12(5):391397, 1984.

Peroneus longus m. Peroneus brevis m. Flexor hallucis longus m. Soleus m.

Gastrocnemius m. (lateral head)

ACSM TPC • Feb. 9, 2013

© CIBA-Geigy: Permission Applied For

Gastrocnemius m. (medial head)

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Nerves Nerves (Cross-section (Cross-section just just above above middle middle of of leg) leg) Anterior tibial a. and v. and deep peroneal n.

Superficial Peroneal n.

Posterior tibial a. and vv. and tibial n. Lateral sural Cutaneous n.

Medial sural Cutaneous n.

© CIBA-Geigy: Permission Applied For

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Anterior Anterior and and Lateral Lateral Compartments Compartments Extensor digitorum longus m.

Tibialis anterior m. Extensor hallucis longus m.

Intermuscular septum Peroneus longus m. Peroneus brevis m.

© CIBA-Geigy: Permission Applied For

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Posterior Posterior Compartments: Compartments: Deep Deep and and Superficial Superficial Tibialis Posterior m.

Flexor digitorum longus m.

Flexor hallucis longus m. Soleus m.

Gastrocnemius m. (lateral head)

ACSM TPC • Feb. 9, 2013

© CIBA-Geigy: Permission Applied For

Gastrocnemius m. (medial head)

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Functional Anatomy of the Knee and Leg

Mary Lloyd Ireland, MD

Superficial Peroneal n.

Anterior tibial a. and v. and deep peroneal n.

Know the anatomy before performing compartment testing or surgical releases.

ACSM TPC • Feb. 9, 2013

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Functional Anatomy of the Knee and Leg

The End . . .

Mary Lloyd Ireland, MD

Thank You!

Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

Associate Professor Dept. of Orthopaedic Surgery & Sports Medicine University of Kentucky Lexington, Kentucky ACSM TPC Part 2 Miami, Florida • February 9, 2013

ACSM TPC • Feb. 9, 2013

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FUNCTIONAL ANATOMYOF THE KNEE AND LEG ACSM TPC II Miami, Florida February 9, 2013

Mary Lloyd Ireland, M.D. UK Healthcare - Orthopaedics & Sports Medicine 601 Perimeter Drive #200 Lexington, KY 40517 (859) 218-3131 Fax: (859) 323-2255 _________________________________________________________________________ BIBLIOGRAPHY

Amis AA, Dawkins GP. Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br 1991;73(2):260-267. Dodds JA, Arnoczky SP. 1994;10(2):132-139.

Anatomy of the anterior cruciate ligament :

a blueprint for repair and reconstruction.

Arthroscopy

Friederich NF et al. Clinical application of biomechanic and functional anatomical findings of the knee joint. Orthopade 1992;21(1):41-50. Goodfellow J et al. Patello-femoral joint mechanics and pathology. 1. Functional anatomy of the patello-femoral joint. J Bone Joint Surg Br 1976;58(3):287-290. Goodfellow J et al. Patello-femoral joint mechanics and pathology. 2.Chondromalacia patellae. J Bone Joint Surg Br 1976;58(3):291-299. Harner CD, Xerogenanes JW, Livesay GA, et al. The human posterior cruciate ligament complex. An interdisciplinary study. Ligament morphology and biomechanical evaluation. Am J Sports Med 1995;23:736-745. Hughston JC, Andrews JR, Cross MJ, Moschi A: Classification of knee ligament instabilities: Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg 1976;58A:159-172 Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities: Part II. The lateral compartment. J Bone Joint Surg 1976;58A:173-179. LaPrade RF, Terry GC. Injuries to the posterolateral aspect of the knee: Association of anatomic injury patterns with clinical instability. Am J Sports Med 1997;25:433-438.

FUNCTIONAL ANATOMY OF THE KNEE AND LEG Mansour JM, Pereira JM. Quantitative functional anatomy of the lower limb with application to human gait. J Biomech 1987;20(1):5158. Muller W. Current aspects of functional anatomy of the knee joint. Hefte Unfallheilkd 1997;129:131-137. Muller W. Functional anatomy and clinical findings of the knee joint. Helv Chir Acta 1984;51(5):505-514. Neurath M, Stofft E. New aspects of the functional anatomy of the menisci. Unfallchirurg 1992;95(1):17-20. Norwood LA, Cross MJ. Anterior cruciate ligament: functional anatomy of its bundles in rotatory instabilities. Am J Sports Med 1979;7(1):23-26. Robichon J, Romero C. The functional anatomy of the knee joint, with special reference to the medial collateral and anterior cruciate ligaments. Can J Surg 1968;11(1):36-40. Rorabeck C, Fowler P. The tibialis posterior muscle compartment. Am J Sports Med 1984;12(5):391-397. Stäubli HU, Birrer S. The popliteus tendon and its fascicles at the popliteal hiatus: Gross anatomy and functional arthroscopic evaluation with and without anterior cruciate ligament deficiency. Arthroscopy 1990;6:209-220. Staubli HU, Rauschning W. Knee injuries in alpine sports. Schweiz Z Med Traumatol 1994;1:30-37. Terry GC, LaPrade RF. The biceps femoris muscle complex at the knee: Its anatomy and injury patterns associated with acute anterolateral rotatory instability. Am J Sports Med 1996;24:2-8. Trelease RB et al. Going virtual with quicktime VR: new methods and standardized tools for interactive dynamic visualization of anatomical structures. Anat Rec 2000;261(2):64-77. Veltri DM, Deng XH, Torzilli PA, Warren RF, Maynard MJ: The role of the cruciate and posterolateral ligaments in stability of the knee: A biomechanical study. Am J Sports Med 1995;23:436-443. Wagner M. Functional anatomy of the knee joint. Orthopade 1987;16(2):88-99. Watanabe Y et al. Functional anatomy of the posterolateral structures of the knee. Arthroscopy 1993;9(1):57-62.

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