Regional pathologies and

evaluation:
Knee – Ankle – Foot
Prof. Dr. İsmet TAMER
İstinye University, Faculty of Medicine
Dept.of Family Medicine
Liv Hospital Bahçeşehir
Anatomy of Lower Limb under the Knees
• The lower limb consists of the thigh (the upper leg), the leg (the
lower leg), and the foot.
• The thigh consists of a single bone, the femur.
• The leg consists of two long bones, the tibia and fibula, and the
sesamoid bone, the patella, that serves as the knee cap.
• The foot consists of 26 bones, which are grouped into
the tarsals, metatarsals, and phalanges.
• The bones of the foot: The calcaneus is the heel bone, and
the talus bone forms the ankle joint with the tibia and fibula.
• The calcaneus and tarsus are two of the 7 tarsal bones that are
posterior to the first long bones of the foot,
the metatarsal bones.
• The bones of the toes are phalanges, the same name used for
finger bones.
Main Muscles & Tendons under the Knees
Normal Knee Anatomy
 The Knee Joint
• The knee is one of the largest and most complex joints in the body. The knee joins the femur to
the tibia. The smaller bone - fibula and the kneecap - patella are the other bones that make the
knee joint.
• Tendons connect the knee bones to the leg muscles that move the knee joint. Ligaments join the
knee bones and provide stability to the knee:
 The anterior cruciate ligament prevents the femur from sliding backward on the tibia (or the
tibia sliding forward on the femur).
 The posterior cruciate ligament prevents the femur from sliding forward on the tibia (or the
tibia from sliding backward on the femur).
 The medial and lateral collateral ligaments prevent the femur from sliding side to side.
• Two C-shaped pieces of cartilage called the medial and lateral menisci act as shock absorbers
between the femur and tibia.
• Numerous bursae, or fluid-filled sacs, help the knee move smoothly.
 Knee Pathologies – 1
• Knee osteoarthritis: Osteoarthritis is the most common
form of arthritis, and often affects the knees. Caused by • Knee effusion: Fluid buildup
aging and wear and tear of cartilage, osteoarthritis inside the knee, usually from
symptoms may include knee pain, stiffness, and swelling. inflammation. Any form of
arthritis or injury may cause a
knee effusion.

CASE: Female, 15-y-old with

pain and swelling left knee
while playing a dancing game.
Lateral view of left knee:
There is a bony fragment
(circle) in the left knee joint
between the femoral
epiphysis and patella.
Moderate amount of knee
joint effusion at the
suprapatellar bursa with
fluid-fluid level (asterisk).
 Medial meniscus
Both horns are triangular in shape and have very sharp
points.

NORMAL MENISCUS
The posterior horn is always larger than the anterior horn.
If this is not the case, then the shape is abnormal, which
can be a sign of a meniscal tear or a partial meniscectomy.

Lateral meniscus
On sagittal images the posterior horn is higher in position
than the anterior horn.
Both horns are about the same size.
NORMAL MENISCUS

The lateral meniscus posteriorly comes up high over the

tibial spine to insert near the posterior cruciate ligament.
This upward position of the posterior horn may be the
reason for the higher signal intensity of the posterior horn
in all planes.
 Knee Pathologies – 2
• Meniscal tear: Damage to a meniscus, the cartilage that cushions the knee, often occurs with twisting the knee. Large tears may
cause the knee to lock.

• MRI images show an extensive displaced tear of the lateral meniscus. The meniscus is deficient laterally and posteriorly with most
of the meniscal tissue displaced anteriorly and centrally into the intercondylar region. The medial meniscus and the articular
cartilage are normal.
Figure A shows a side view of the knee MRI that shows the normal location of the outside, or lateral meniscus.
Figure B shows a similar view that shows a piece of meniscus that has been torn and moved.

A B
Knee Pathologies – 3
• ACL (anterior cruciate ligament) strain or tear: The ACL is responsible for a large part of the knee’s stability. An
ACL tear often leads to the knee “giving out,” and may require surgical repair.
 Sagittal MRI image demonstrating typical appearance of
Sagittal MRI image demonstrating avulsion of ACL from
ACL tear at the mid-substance with fibres discontinuity of
tibial attachment.
ACL.
 Knee Pathologies – 4
• PCL (posterior cruciate ligament) strain or tear: PCL tears can cause pain, swelling, and knee instability. These
injuries are less common than ACL tears, and physical therapy (rather than surgery) is usually the best option.

Sagittal MRI of
posterior cruciate
ligament (PCL) tear
(yellow arrow denotes
torn PCL off the tibia).
 Knee Pathologies – 5
• MCL (medial collateral ligament) strain or tear: This injury may cause pain and possible instability to the inner side of the
knee.
MRI of Left knee
(coronal view: normal
A B
MCL and medial
meniscus)

A – MCL black line

B – MCL highlighted in
yellow

The MCL of the knee is

a ligament that helps
stabilize the knee from
valgus stress and
prevents over
separation of the
medial femoral
condyle from the the
medial tibial plateau.
• The case shows a superficial MCL that is torn from it's attachment on the tibia (yellow
arrow). Normally it should be attached 7 cm below the joint line.

• Deep MCL is also torn, the ligament is absent (orange arrow).

 Knee Pathologies – 6
• Knee bursae are sacs surrounding the knee joint that are filled with synovial fluid. They facilitate movement and
reduce friction where tendons or muscles pass over bony prominences. The knee bursae can be either
communicating or non-communicating with the knee joint itself.
• Knee bursitis: Pain, swelling, and warmth in any of the bursae of the knee. Bursitis often occurs from overuse or
injury.
An elliptical region of marked signal hypointensity is seen in the midline subcutaneous tissues superficial to the
anterior tibial tuberosity and patellar tendon (arrows), with mild prepatellar and infrapatellar subcutaneous edema.
The underlying tendon and osseous structures are normal.
Knee Pathologies – 7
• Patellar fracture is one of the common knee injuries usually post direct trauma to the patella or sudden forceful
contraction of the quadriceps muscles in the context of a sports injury.
Knee Pathologies – 8
• Baker’s cyst: Collection of fluid in the back of the knee. Baker’s cysts usually develop from a persistent
effusion as in arthritis or repeating injuries.
 The Ankle
• The ankle is a large joint made up of three bones:
• The tibia, fibula and talus.

• The ankle joint allows up-and-down movement of

the foot.
• The subtalar joint sits below the ankle joint, and
allows side-to-side motion of the foot.
• Numerous ligaments (made of tough, moveable
tissue) surround the true ankle and subtalar joints,
binding the bones of the leg to each other and to
those of the foot.
ANKLE

The bony bumps (or protrusions) seen and felt on the

ankle have their own names:
 The medial malleolus, felt on the inside of the
ankle is part of the tibia's base,
 The posterior malleolus, felt on the back of
the ankle is also part of the tibia's base,
 The lateral malleolus, felt on the outside of the
ankle is the low end of the fibula.
 Ankle Pathologies – 1
• Sprained ankle: Damage to one of the
ligaments in the ankle, usually from an
accidental twist or turn of the foot.
Rehabilitation can prevent pain and swelling
from becoming a long-term problem.
Edema
 Ankle Pathologies – 2
• High ankle sprain: The ligament joining the two bones of the lower leg (tibia and fibula), called the syndesmotic
ligament, is injured. A high ankle sprain causes pain and swelling similar to a true ankle sprain, but can take
longer to heal.
The axial MR image
through the distal
tibiofibular
syndesmosis
demonstrates buckling
and anterior protrusion
of the anterior inferior
tibiofibular ligament
(arrow). Part of the
posterior inferior
tibiofibular ligament
(arrowhead) is also
visualized and appears
intact.

High ankle sprain

The coronal MR image

through the anterior
inferior tibiofibular
ligament shows
irregular wavy
morphology and
increased signal in the
ligament (arrow), with
adjacent soft tissue
edema.
 Ankle Pathologies – 3
• Ankle fracture: A break in any of the three bones in the ankle. Most commonly, the bones of the
lower leg (tibia or fibula) is fractured.
• Types of Ankle fractures: The level of the fracture directs the treatment – fractures can be classified
according to the Salter-Harris classification.
• Ankle fractures:
Ankle Pathologies – 4
• Ankle arthritis: While it’s not common, osteoarthritis, the most common form of arthritis, can
affect the ankle.
Ankle Pathologies – 5
• Gout: A form of arthritis in which crystals periodically deposit in joints, causing severe pain and
swelling. The ankle may sometimes be affected by gout.
Foot: The feet are flexible structures of bones, joints, muscles, and soft tissues that let us stand upright
and perform activities like walking, running, and jumping.

The feet are divided into three

sections:
• The forefoot contains the five
toes (phalanges) and the five
longer bones (metatarsals).
• The midfoot is a pyramid-like
collection of bones that form the
arches of the feet. These include
the three cuneiform bones, the
cuboid bone, and the navicular
bone.
• The hindfoot forms the heel
and ankle. The talus bone
supports the leg bones (tibia and
fibula), forming the ankle. The
calcaneus (heel bone) is the
largest bone in the foot.
Common Foot Pathologies – 1
Gout: An inflammatory condition in which crystals periodically deposit in joints, causing severe pain and
swelling. The big toe is often affected by gout.
Common Foot Pathologies – 2
Bunions (hallux valgus): A bony prominence next to the base of the big toe that may cause the big toe to turn
inward. Bunions may occur in anyone, but are often caused by heredity or ill-fitting footwear.
Common Foot Pathologies – 3
Achilles tendon injury: Pain in the back of the heel may suggest a problem with the Achilles tendon. The injury
can be sudden or a nagging daily pain (tendinitis).
Common Foot Pathologies – 4
Diabetic foot: People with diabetes are vulnerable to infections of the feet, which can be more severe than
they appear. People with diabetes should examine their feet daily for any injury or signs of developing infection
such as redness, warmth, swelling, and pain.
 An untreated
diabetic foot
with
secondary
osteomyelitis
and necrosis

Stages of a
surgically
treated
diabetic foot
Common Foot Pathologies – 5
Heel spurs: An abnormal growth of bone in the heel, which may cause severe pain during walking or standing.
People with plantar fasciitis, flat feet, or high arches are more likely to develop heel spurs.

Normal foot
Common Foot Pathologies – 6
Fallen arches (flat feet): The arches of the feet flatten during standing or walking, potentially causing other feet
problems. Flat feet can be corrected with shoe inserts (orthotics), if necessary.
Common Foot Pathologies – 7
Fracture: The metatarsal bones are the most frequently broken bones in the feet, either from injury or
repetitive use. Pain, swelling, redness, and bruising may be signs of a fracture.
Thank you for joining!

ismet.tamer@istinye.edu.tr
: 0(532)332 09 29
@profdrismettamer