The KNEE, FOOT & ANKLE

Dr. Shamay Ng

29 Jan 2018
Department of Rehabilitation Sciences
The Hong Kong Polytechnic University
Bones of Knee Joint

3 articulations:

•Two femoro-tibial
articulations

•One femoro-patellar
articulation
Radiography of Knee Joint

Moore et al. (2014): B5.85 (7th edition)

 The Knee Joint
• Composed of three bones:
femur, tibia, patella

• Hinge-type condylar synovial

joint

• Movements allowed:
Flexion & extension
Rotation around vertical axis
(limited)
 Femoro-tibial Joint
• 2 concave tibial plateaus

• Medial plateau is larger

surface area

• Covered with fibrocartilaginous

rings – menisci

 Medial meniscus:
semicircular
 Lateral meniscus: nearly a
complete ring
 Menisci

• Medial
– Attachments:
 Peripherally – by coronary
ligament to tibial plateau
 Medially – attached to
capsule and MCL
 Anterior horn – transverse
ligament
 Menisci
• Lateral
– Attachments:
 Peripherally – by
coronary ligament to
tibial plateau
 Anterior horn –
transverse ligament
Menisci
• Functions:
Shock absorbers
Improving congruency & contact area

During movement:
 Rotations: menisci move with femur
 Flexion/extension: menisci move with
tibia
 Stability: Ligaments
• Collaterals
– Medial
 Broad, fan-shaped ligament 10-12cm long
 Passes from medial epicondyle anteriorly to the
medial tibia
 Superficial and deep portions

Functions:
1. Resists excessive abduction of
tibia on femur
2. Limits anterior translation of
tibia on femur, and
hyperextension
 Stability: Ligaments
• Collaterals
– Lateral
 Fibrous cord 5-6cms
 Lateral epicondyle and directed
posterior to the fibular head
 No attachment of menisci

Functions:
1. Resists varus stress during flexion/extension
2. Limits knee hyperextension

Both collaterals help to limit external rotation of the tibia.

 Stability: Ligaments
• Anterior Cruciate
 Starts at anterior tibia
 Passes superiorly,
posteriorly and laterally
 Attaches to inner aspect of
lateral femoral condyle
(posteriorly)

Function:
 Prevents anterior translation of
tibia on femur
 Stability: Ligaments
• Posterior Cruciate
 Starts at posterior intercondylar
tibia
 Passes superiorly, anteriorly, and
medially
 Attaches to inner aspect of medial
femoral condyle

Function:
 Resists posterior translation of the
tibia on femur

Both cruciates limit internal rotation of tibia on femur

 Menisci and Ligaments

Patellar
Ligaments that
surface
Stabilize
the Knee Joint

Posterior cruciate
ligament
Lateral Medial
Anterior cruciate
ligament
condyle condyle
Tibial collateral
ligament Menisci
Medial
Fibular collateral
ligament

Tibia Lateral
Cut tendon of
biceps femoris
muscle

Fibula

Deep anterior view, flexed

Martini 10th Edition

 Dynamic Movement: Muscles

• Extension:
Quadriceps femoris
• Flexion:
Hamstrings
• Special Function: Unlocking
Popliteus
 Locking/Unlocking Mechanism

• The two condyles are not the same length in

the AP direction
• When reaching final extension (in OPEN
CHAIN) the lateral condyle ‘locks in’ to the
tibia first
• Then in order for the medial condyle to reach
the same position, tibia has to rotate laterally a
little bit
 Lateral condyle
locked in, so medial Lateral rotation of
Both plateaus plateau must tibia in the last 20
moving together continue forward degrees

Therefore, when in full extension = locked

To unlock, must medially rotate the tibia - popliteus muscle
accomplishes this
 Capsule
• Common to both
tibiofemoral and Quadriceps
patellofemoral joints tendon
Patella Accessory Structures
of a Knee Joint
Joint capsule
• Surrounds joints like a Femur

tube with a hole anteriorly

Synovial Bursa
membrane
for patella
Fat pad
Joint cavity
Articular Meniscus
cartilage

• Lax structure
Ligaments
Tibia Extracapsular
ligament (patellar)

• Statically stabilized by Intracapsular

ligamentous structures
ligament (cruciate)

• Dynamically stabilized by
muscle tendons Knee joint, sagittal section

Martini 10th Edition

 Patellar Retinacula
• Fibrous expansions of the
vastus medialis and lateralis
muscles
• Retinacula extends distally
towards tibial plateaus &
posteriorly to collateral
ligaments
• Laterally, the retinaculum
contains expansion of the
ITB
 Patellofemoral Joint
• Femur
– Anterior surfaces of femoral condyles and femoral sulcus
(intercondylar groove)
– Steep lateral condyle prevents lateral dislocation of patella

• Patella
‒ Medial and lateral
facets divided by a
vertical ridge
‒ Odd facet (most
medial aspect)
 Patellofemoral Joint

• Stability
Longitudinally:
 Quadriceps tendon superiorly
 Patella tendon inferiorly
Transversely:
 Medial and lateral patellar
retinaculae (indirectly VM & VL)
 Patellofemoral Joint
Movement:
 Full extension: no contact between
femur & patella
 10-90° of flexion both facets in
contact
 90-135° gradually less medial facet
contact until only lateral/odd

135°
Arterial Anastomoses Around Knee

• Genicular anastomosis
(genu=knee)
 Branches of femoral,
popliteal,
anterior/posterior tibial
arteries
Popliteal Fossa
Arteries of Leg and Foot

Moore et al. (2014): B.5.58 (7th edition)

Nerves of Leg and Foot

Moore et al. (2014): Fig 5.57 (7th edition)

Superficial Venous Drainage of Lower Limb

Femoral triangle

Long (Great) Saphenous vein

Popliteal fossa

Short (Small)
Saphenous vein
Ankle and Foot
Bones of the Foot

tarsal bones (7)

metatarsal bones (5)

Phalanges (14)
Tarsal Bones
 Ankle joint
• Hinge type of synovial joint
• Proximal
– Distal ends of tibia + fibula +
inferior transverse part of the
posterior tibiofibular ligament
 mortise (deep socket)
• Distal
– Trochlea (L. pulley) of the
talus
 Fibrous Capsule of Ankle joint
• Fibrous capsule
– Thin anteriorly and posteriorly
– Lateral collateral ligament
• Anterior talofibular ligament
• Posterior talofibular ligament
• Calcaneofibular ligaments

Moore et al. (2014): B5.97 (7th edition)

Ankle joint
• Medial collateral ligament
 Deltoid ligament
 Talocrural (ankle) Joint
• Movements of the ankle joint
Dorsiflexion
Plantarflexion
 Joints of Foot

• Subtalar joint
• Talocalcaneonavicular
• Calcaneocuboid
• Cuneonavicular
• Tarsometatarsal
• Intermetatarsal
• Metatarso-phalangeal
• Interphalangeal
Transverse Tarsal Joints

Moore et al. (2014): 7th edition, Fig 5.11

 Transverse Tarsal &
Subtalar Joints
• Transverse tarsal joint
 Calcaneocuboid and
talonavicular joints

• Subtalar joint
 Between talus and calcaneus

• Inversion and eversion

take place in these joints
 Ligaments of the Foot
• Plantar calcaneonavicular
ligament (spring ligament)
 Connects sustentaculum
tali to the postero-
inferior surface of the
navicular
 Ligaments of the Foot
•Long plantar ligament
 From plantar surface of the calcaneus to
groove on the cuboid, bases of metatarsals
 Important in maintaining the arches of the
foot

• Plantar calcaneocuboid ligament

(short plantar ligament)
 Deep to the long plantar ligament
 From anterior aspect of the inferior surface
of the calcaneus to inferior surface of the
cuboid
Arteries of Foot

Moore et al. (2014): B5.73 (7th edition)

Nerves of Foot
Foot Arches & Weight-Bearing Areas of Foot

Moore et al. (2014): B5.102 (7th edition)

Transverse Arch

Metatarsals 1-5,
Cuneiform 1-3, Cuboid
 Longitudinal Arches

Medial:
Lateral:
MT 1-3, Cuneiform 1-3,
MT 4 -5, Cuboid &
Navicular
Calcaneus
Talus & Calcaneus
 Mechanisms of Arch Support

Shape of stones: “keystone” Tie beam: tendons

Staples: ligaments Suspension bridge: muscles

Example: Active and Passive Support of
Medial Longitudinal Support
MUSCLES
4 Layers on the bottom of the foot:
1. Abductor digiti minimi, flexor digitorum
brevis, abductor hallucis
2. FHL, FDL, four lumbricals, quadratus
plantae
3. Flexor digiti minimi brevis, adductor
hallucis, flexor hallucis brevis
4. Plantar & dorsal interossei, tendons of
peroneus longus & tibialis posterior
Four Layers of Plantar Muscles
Nerves of Foot

• Adductor Hallucis*
• Quadratus Plantae
• Abductor digiti
minimi
• Lumbricals (2 lateral)
• Flexor Digiti Minimi
Brevis
• Interossei
Nerves of Foot

•Abductor Hallucis
•FDB
•Lumbricals (2 medial)
•Flexor Hallucis Brevis
Clinical Implications
 Unhappy Triad of Knee Injuries

• TCL attach firmly to medial meniscus

• Tearing of TCL frequently results in
concomitant tearing of the medial meniscus
and ACL = “Unhappy triad”
Moore et al. (2014): B5.33 (7th edition)
Anterior & Posterior Drawer Sign

Anterior drawer sign

• Tibia slide anteriorly
under femur
• Tested via Lachman test

Posterior drawer sign

• Tibia slide posteriorly
under femur

Moore et al. (2014): B 5.33 (7th edition)

Ankle Sprain
• Mostly ankle inversion injury
• Twisting of the weight-
bearing, plantarflexed feet
• Lateral collateral ligament
(anterior talofibular
ligament) is most
commonly injured

Moore et al. (2014): B5.39 (7th edition)

Pott Fracture-Dislocation of Ankle
• Forcefully everted foot

• Pull strong on medial

ligament results in medial
malleolus fracture

• Break the fibula superior

to the tibiofibular
syndesmosis

Moore et al. (2014): B5.40 (7th edition)

 Palpation of Dorsalis Pedis Pulse

• Lateral to the EHL tendons

• Absence of pulse suggests vascular insufficiency
resulting from arterial disease

Moore et al. (2014): B5.27 (7th edition)

 Palpation of Posterior Tibial Pulse

• Between the posterior surface of the medial malleolus

and the medial border of the calcaneal tendon

Moore et al. (2014): 7th edition, B5.25

 Calcaneal Tendon Jerk

• Normal result: plantarflexion

• Tests the S1 and S2 nerve roots

Moore et al. (2014): 7th edition, B5.22

 Plantar Fasciitis
• Inflammation of the
plantar fascia
 Overuse from running
and high-impact
aerobics
 Inappropriate footwear

• Pain on the plantar

surface of the foot and
heel

Moore et al. (2014): B5.26 (7th edition)

Calcaneal Bursitis

• Inflammation of the
deep bursa of the
calcaneal tendon

• Pain posterior to the heel

• Caused by excessive
friction on the bursa as
the tendon continuously
slides over it

Moore et al. (2014): B5.23 (7th edition)

 Hallux Valgus
L : Lateral deviation

• By pressure from footwear and degenerative joint

disease
Moore et al. (2014): 7th edition, B5.41
 Hammer Toe & Claw Toes
Hammer toe
• Proximal phalanx dorsiflexed at the metatarsophalangeal joint
• Middle phalanx plantarflexed at the proximal interphalanged joint
• Hyperextended distal phalanx

Claw toes
• Hyper extension of the metatarsophalanged joints
• Flexion of the distal interphalangeal joints of lateral 4 toes

Moore et al. (2014): B5.42 (7th edition)

 Pes Planus (Flatfeet)
• Flexible:
 flat when weight-bearing but normal when no weight
 More common, from degenerated intrinsic ligaments

• Rigid:
 flat with or without weight

Moore et al. (2014): B5.42 (7th edition)

Injury of Common Fibular Nerve & Footdrop

• Toes fail to clear the ground

during the swing phase

• Causes:
 injury of the common fibular nerve
 Flaccid paralysis of all dorsiflexors
and evertors

Moore et al. (2014): B5.20 (7th edition)

 Injury of Common Fibular Nerve & Footdrop
Compensations for “Footdrop”:

(D) Steppage gait

• Extra flexion at
hip and knee to
raise the foot
(B) Waddling gait
• Leans to the
side opposite
the long limb

(C) Swing-out gait

• Long limb abducted to allow
the toes to clear the ground
Moore et al. (2014): B5.20 (7th edition)
 The End

Any Questions?