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Foot/Ankle Complex: Main Functions (2)
-stable base of support
-shock absorption
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composition of ankle
held together by...
- -distal tibia
- -distal fibula
- -talus
-interosseous membrane
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mortise of ankle composed of...
malleoli composed of...
-fibula and tibia
-ends of tibia and fibula
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sections of foot (3)
- -hindfoot (talus and calcaneus)
- -midfoot (3 cuneiforms,navicular,cuboid)
- -forefoot (metatarsals and phalanges)
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4 main joints
- -ankle
- -subtalar
- -tarsometatarsal
- -metatarsalphalangeal
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Motions of ankle (2)
- plantarflexion-50*
- dorsiflexion-20*
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ankle talus/mortise
- mortise allows talus to pass through
- talus is wider anteriorly
- talus is narrower posteriorly
- tight at end range in dorsiflexion
- loose at end range in plantarflexion (sprains)
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Talus (injury)
- often fractured in dislocations of ankle
- has upward arterial supply(against gravity, hard to heal)
- prone to necrosis w/sever injury
- Snowboarder's fracture(compression)
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Subtalar joint
- "below the ankle"
- formed between talus and calcaneus
- calcaneus =heel
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subtalar joint movement
- inversion-30*
- eversion-15*
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subtalar neutral
- in the middle
- "optimally aligned foot"
- best stress distribution
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tarsometatarsal joint
- 3 cuneiforms and cuboid with metatarsals
- helps regulate positions of the foot
- -springs,shocks
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metatarsophalangeal joint
- "MTP"
- 5 joints
- primarily flexion an extension
- hinge to allow heel to rise while toes stabilize
- -gait
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6 main movements of foot/ankle complex
- plantarflexion
- dorsiflexion
- inversion
- eversion
- pronation (eversion and dorsiflexion)
- supination (inversion and plantarflexion)
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ankle/foot complex ligaments (4)
- interosseous membrane (force distribution and shock attenuation)
- Deltoid ligament (connects tibia to talus,calcaneus, and navicular)
- *strong(bone(tibia) often fails before ligament ruptures)
- Antierior talofibular ligament (fibula to talus)
- *most often sprained
- Plantar calcaneonavicular ligament (aka spring ligament)
- *helps support medial longitudinal arch
- *helps prevent over pronation
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Arches
- longitudinal
- *medial
- *lateral
Transverse
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Function of arches
- add stability and shock absorption
- supported by ligaments, shapes of bones, tendons, muscles
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Plantar flexors (5 main muscles)
- gastrocnemius
- plantaris
- soleus
- flexor hallucis longus
- flexor digitorum longus
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gastrocnemuis
- Proximal Attachment : posterior condyles of femur
- Distal Attachment: common insertion via achilles tendon
- Action: plantarflexes foot (helps bend knee)
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soleus
- proximal attachment: proximal posterior tibia along soleal line
- Distal attachment: common insertion via achilles tendon
- Attachment: plantar flexes foot (does NOT help bend knee, does not cross)
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plantaris
- proximal attachment: distal posterior femur
- distal attachment: posterior calcaneus
- Action: plantarflexes the foot
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flexor hallicus longus
- proximal attachment: distal 2/3 of posterior fibula
- distal attachment: base pf the distal phalanx of the great toe, plantar surface
- action: plantarflexes foot and big toe
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flexor digititorum longus
- proximal attachment: distal 1/2 of the posterior tibia
- distal attachment: base of distal phalanges of digits 2-5 on plantar surface
- action: plantar flexes foot
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dorsiflexors (3 muscles)
- tibialis anterior
- extensor digitorum longus
- extensor hallicus longus
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tibialis anterior
- proximal attachment: superior 2/3 of anterolatal tibia
- distal attachment: base of 1st metatarsal f the 1st digit, also 1st cuneiform
- action: dorsiflexes foot AND inverts foot
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extensor digitorum longus
- Proximal attacment: superior 3/4 of the fibula, anterior surface
- Distal attachment: via common tendon along the dorsal surfaces of phalanges 2-5
- Action: dorsiflexes foot
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extensor hallicus longus
- Proximal attachment: middle anterior surface of the fibula
- Distal attachment: dorsal surface of the great toe
- Action dorsiflexes foot
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Everters (3 muscles)
- peroneus longus
- peroneus brevis
- preoneus tertius
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peroneous longus
- proximal attachment: head and proximal 1/2 of fibula, lateral side
- distal attachment: dorsal surface of the great toe
- Action: everts foot
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peroneus brevis
- proximal attachment: distal 1/2 of the lateral side of the fibula
- distal attachment: tuberosity of the lateral side of the 5th matatarsal
- Action: everts foot
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peroneus tertius
- proximal attachment: distal 1/3 of the anterior surface of fibula
- Distal attachment: dorsal surface of the base of the 5th metatarsal
- Action: everts foot
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Inverters (2 muscles)
- tibialis anterior
- tibialis posterior
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tibialis posterior
- proximal attachment: lateral side of the posterior tibia proximally
- distal attachment: navicular tuberosity, three cuneiforms, cuboid, metatarsal 2-4
- Action: inverts foot
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muscles of the foot are mostly....
intrinsic
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ankle sprain
- inversion w/plantarflexion
- *tear to ATF
- *severe inversion may fracture distal fibula
- Eversion (rare)
- *tear to deltoid ligament
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plantar fascitis
- inflammation of plantar fascia
- fascia usually tears near its calcaneus calcaneus attachment
- cardinal sign symptom: pain worst with first few steps in morning
- MOI: repetitive overuse,over pronation, poor shoe support
- Calf stretching good for remodleing scar tissue
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fibular fracture (2 types)
- low energy: ground level falls and athletic injuries
- high energy injuries: motor vehicle injuries, pedestrians struck by vehicle and gunshot wounds
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Fibular fracture
- ambulation is often still possible:fibula 10%-15% of weight and tibia 85%-90% of weight
- Surgical options: open reduction and internal fixation
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achilles tendonitis
- 1-2" above attachment to calcaneus
- "critical zone of avascularity"
- pronation increases LENGTH of achilles tendon
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achilles tendon rupture
- violent start or stop
- over age 30
- audible pop or snap
- needs to be repaired right away
- **strengthen hip to decrease pain
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shin splints
- repetitive microtrauma to tibia and its muscular attachments
- microtears to the tibialis posterior muscle or soleus muscled (medial tibial pain)
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shin splits (causes)
- torsion on the tibia bone
- excess pronation
- poor shock absoprtion
- poor foot alignment
- sudden increase in activity levels
- muscle imbalances
- poor warmup
- poor conditioning
- tight achiles tendon
- toe running
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talar avascular necrosis
- following fracture or dislocation
- inverted arterial supply
- NO MUSCULAR ATTACHMENTS
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Planes of motion (3)
- sagittal plane
- frontal plane
- transverse plane
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sagittal plane
- bisects body in left and right halves
- motion: flexion and extension (bicep curl)
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frontal plane
- divides body front to back
- motion: adduction and abduction
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transverse plane
- divides body horizontally into superior and inferior halves
- motion: rotational, pronation, supination and spinal rotation
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Axes of rotation
- sagittal plane: lateral
- frontal plane: anteroposterior
- transverse plane:vertical
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anteroinferior
front and down
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anterolateral
front and away from midline
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anteromedial
front and towards midline
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anteroposterior
front and back
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anterosuperior
front and up
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contralateral
opposite sides
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lateral
away from midline
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posterioinferior
back and down
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posterolateral
back and away
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posteromedial
back and to midline
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posterosuperior
back and above
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proximal
closer to midline
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superficial
closer to surface
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volar
palms and bottoms of feet
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types of bones (5)
- long bones
- short bones
- flat bones
- irregular bones
- sesamoid bones
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long bones
- long cylindrical shaft
- wide protruding ends
- function: serve as lever
- femur, tibia, fibula
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short bones
- small, cube shaped, solid bones
- function: shock abosrption
- wrist and ankle
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flat bones
- curved surface
- can be thick or thin
- function: protection
- cranial, ribs, pelvis
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irregular bones
- serve a variety of purpose
- bones of entire spine, ischium, pubis and maxilla
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sesamoid bones
- small bones embedded within the musculoskeletal tendon that provide protection
- free floating: do not attach to other bones
- also serve to improve mechanical advantage o muskulotendious unit
- hyoid, patella, thumb and big toe
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Joint
- articulation of 2 or more bones
- enable movement to occur
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join classification
- structure/function
- fibrous/synarthrodial (no movement)
- cartilaginous/amphiarthrodial(some movement)
- synovial/diarthrodial (a lot of movement)
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fibrous joints
- joined together by connective tissue
- general IMMOVABLE
- examples: sacroiliac joint, sternoclavicular
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cartilaginous
- joined together by hyaline cartilage or fibrocartilage
- allows VERY SLIGHT MOVEMENT
- examples: costochondral joints of ribs, intervertebral discs
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synovial joints
- freely moveable
- contain a joint capusle
- contain synovial fluid
- generally DIARHTROIDAL
- examples: knee, shoulder
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amphiarthrodial
- slightly movable
- three types
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syndemosis
- held together by strong ligament structures
- amphiarthrodial joint
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symphisis
- joint separated by a fibrocartilage pad
- amphiarthrodial
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synchrosis
joint separated by hyaline cartilage
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diarthrodial joints
- freely movable
- contains a joint capsule (sleeve-like covering)
- joint capsule surrounds bony ends
- contain synovial fluid: lubricates joint cavity
- examples: knee, shoulder
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motion in one plane
- 1 degree of freedom
- knee and elbow
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motion in two planes
- 2 degrees of freedom
- wrist
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motion in three planes
- 3 degrees of freedom
- shoulder, lumbar spine,neck, hips
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arthrodial joint (gliding joint)
- two flat bony surfaces
- butt against each other
- permits limited gliding motion
- 1 degree of motion
- example: carpal bones of wrist
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condyloidal joint (biaxial ball and socket joint)
- bones permit movement in two planes without rotation(2 degrees of freedom)
- example: wrist between the radius and proximal row of the carpal bones
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enarthrodial joint (multiaxial ball and socket joint)
- permits movement in all three planes (3 degrees of freedom)
- examples: hip and shoulder
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ginglymus joint (hinge joint)
- one plane of motion
- wide range of motion in that plane
- examples: elbow (≃150°) and knee
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sellar joint (saddle joint)
found only in thumb
permits ball and socket movement, except rotation
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general joint motions
- abdution
- adduction
- circumduction
- diagonal abduction
- diagonal adduction
- flexion
- extension
- external rotation
- internal rotation
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abduction
- lateral movement away from the body
- frontal plane motion
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adduction
- movement medially toward the midline of the trunk
- frontal plane motion
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circumduction
- circular movement of a limb that delineates an arc
- combination of flexion, extension, abduction and adduction
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diagonal abduction
- movement by a limb through a diagonal plane
- away from midline of body
- drawing a sword
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diagonal adduction
- movement by a limb through a diagonal plane
- toward and across midline
- sheathing a sword
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flexion
- bending movement of a limb
- results in a decreased joint angle by moving bones together
- usually occurs in the sagittal plane
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extension
- straightening movement of a limb
- results in an increased joint able by moving bones apart
- usually occurs in the sagittal plane
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external rotation
- rotary movementaround a longitudinal axis of a bone
- movement is away from the body
- transverse plane motion
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internal rotation
- rotary movement around the longitudinal axis of a bone
- movement is towards the midline of the body
- transverse plane motion
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muscles
- 600+
- 40-50% of body weight
- responsible for movement of body and joints
- provide protection, posture and support
- provide major portion of body heat
- many different shapes and sizes
- different fiber types and arrangements
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intrinsic muscle
- pertaining to muscles within or belonging solely to the body part on which they act
- example: small intrinsic muscles of the hand
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extrinsic muscles
- pertaining usually to muscles that arise or originate outside the body part in which they act
- example: forearm muscles that attach to distal end of humerus and insert on the fingers
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action
- the specific movement of the joint resulting from a concentric (shortening) contraction of a muscle which crosses the joint
- usually action is caused by a group of muscles working together
- a particular muscle may cause more than one action, either at the same joint or a different joint.
- example: bicps brachii has the action of flexion at the elbow
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proximal insertion (origin)
- generally considered the least moveable part
- usually the part that attaches closes to midline of the body
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distal insertion (insertion)
- generally considered the most moevable part
- usually the part that attaches farthest from the midline
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innervation
- the segment of the nervous system defines as being responsible for providing a stimulus to muscle fibers within a specific muscle or portion of the muscle
- a particular muscle may be innervated by more than one nerve
- a particular nerve may innervate more than one muscle
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types of muscle contraction
- isometric
- isotonic
- concentric
- eccentric
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isometric
- no movement (pusing against the wall)
- tension is developed within the muscle but the joint angle remains constant
- static contractions
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isotonic
- involve the muscle developing tension to either cause or control joint movement
- Dynamic contraction: causes the joint angle to change
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concentric
involves the muscle developing tension as is shortens
occurs when the muscle develops enough force to overcome applied resistance - can be thought of as causing movement against gravity or resistance
- described as positive contraction
- results in the joint angle being changed in the direction of the applied muscular force
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eccentric
- involves muscle lengthening under tension
- occurs when the muscle gradually lessens tension to control the descent of the resistance
- control movement with gravity or resistance
- called negative contractions
- results in a change in the joint angle in the direction of the resistance or external force
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agonist
- muscles that, when contracting concentrically cause joint motion through a specified plane of motion
- known as prime movers
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antagonist
- muscles that are usually located on the opposite side of the joint from the agonist
- have the opposite concentric action
- known as contralateral muscles
- work in cooperation with agonistic muscles bu relaxing and allowing movement
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synergist
- muscles that surround the joint or body part
- contract to fixate or stabilize the area to enable another limb or body to exert more force or move
- proximal stability---->distal mobility
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synergist
- muscles that assist in the action of agonists
- not necessarily in the prime movers for the action
- known as guiding muscles
- assist in refining movement
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knee
- largest joint in body
- structural: synovial joint
- functional: diarthroidal joing
- Provides: stability, mobility, shock absorption
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joints
- tibiofemoral (knee)
- patellofemoral
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tibiofemoral joint
- synovial
- diarthroidal
- functions as a hinge
- flexion and extension
- some internal and external rotaion
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patella
- kneecap
- embedded in the quadriceps tendon
- function: to increase force of quadriceps muscle
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MCL (medial collateral ligament)
- medial knoww
- femur to tibia
- thick and wide
- protects against lateral blows to the knee
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LCL (lateral collateral ligament
- lateral
- femur to fibula
- thin and narrow
- protects against medial forces to the knee
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ACL (anterior cruciate ligament)
- femur to anterior tibia
- protects excessive anterior tibial movement
- goes through notch of femur
- hands in pockets
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PCL (posterior cruciate liga)ment
- femur to posterior tibia
- protects posterior tibial movement
- opposite of hands in pockets
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knee movements
- flexion (155°)
- extension (0-20°)
- internal rotation
- external rotation
- ***foot has slight external rotation in extension due to shape of meniscus and bones
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IT band syndrome
- sharp or burning pain 2cm prox. to lateral joint line
- symptoms develop after reproducible distance run
- pain with walking or sitting in sever cases
- tests: pain with palpation, positive noble's test, positive obers test
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knee musles
- extensors: quadricepss (4 parts)
- flexors: hamstrings (3 parts)
- internal knee rotators: popliteus
- external knee rotators: none
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quadirceps
- 4 distinct parts:
- rectus femoris
- vastus lateralis
- vastus intermedius
- vastus medialis
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rectus femoris
- proximal attachment: iliac spine
- distal attachment: tibial tuberosity
- action: extends the knee
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vastus lateralis
- proximal attachment: lateral femur
- distal attachment: tibial tuberosity
- action: knee extension
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vastus medialis
- PA: medial femur
- DA: tibial tuberossity
- A: knee extension
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vastus intermedius
- PA: femur
- DA: tibial tuberosity
- A: knee extension
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hamstrings (3 muscles)
- biceps femoris
- semimembranosis
- semitendinosus
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biceps femoris
- PA: ischial tuberosity
- DA: lateral condyle of tibia and head of fibula
- A: knee flexion
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semimebranosis
- PA: ischial tuberosity
- DA: proximal media tibia
- A: knee flexion
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semitendinosis
- PA: ischial tuberosity
- DA: proximal medial tibia
- A: knee flexion
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popliteus
- PA: posterior lateral femur
- DA: medial tibia
- A: knee internal rotation and knee flexion
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external rotation
- tibia externally rotates on the femur
- happens when knee extends
- due to shapes of bones and meniscus
- called: Screw Home Mechanism
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Internal rotation
- popliteus "unlocks" the knee
- popliteus internally rotates the knee
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MCL Sprain
- can be minor to major (grade I-gradeIII)
- MOI: lateral stress/force t knee
- Signs and Symptoms: pain on inner side ningof knee, feeling of knee giving way
- may hear or feel pop
- Tests and measures: medial ligamentous stress test
- rehab: bracing. ROM and, strengthe
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"Terrible Triad"
ACL, MCL and meniscus
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Osteoarthritis (OA)
- MOI: insidious onset caused by breakdown and eventual lloss of joint carilate
- common sites: hands, feet, spine and large wt. bearing joints
- cause: with age
- signs and symptoms: pain and stiffness of joint, usually effects medial knee compartment
- Rehab: ROM and strengthening
- Surgery: TKA or hemi TKA (total or partial knee arthoplasty(replacement)
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Total Knee replacement
- preferred surgery for end stage of OA
- 300,000/year in US
- may replace medial compartment only
- Rehab: strengthening and ROM
- 6 months to year for complete rehab
- unable to squat or kneel
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patellofemoral pain
- MOI: usually repetitive stressful knee maltracking of the patella
- signs and syptoms: retropatella(under) or peripatella(around) pain
- etiology: probably multifactorial, biomechanical, muscular overuse therories
- rehab: quad strengthining hamstring, IT band calf stetching
- hip etiology?
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Q angle
- large Q angle may be predisposing factor for developing patellofemoral pain
- increased incidence in females vs. males
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patellar tendinitis/osis
- MOI: sports and activity involving frequent jumping
- also called "jumper's knee"
- signs and symptoms: pain usually below patella to insertion of patellar tendon
- itis=inflammation
- osis=degeneration
- treatment: modification of avtivity, stretching/strengthening quadricep muscles, patellar strap
- surgery: pain>6 months
- 6-12 month recovery period
- 25% no recovery
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osgood-schlatter disease
- MOI: running jumping activity during rapid bone growth( soft tissue cant keep up with growth)
- higher frequency in athletes: 20%
- signs and symptoms: pain swelling and tenderness at tibial tuberosity
- sever cases: patellar tendon may actually detach at its insertionh:
- Rehab: quad stretching, activity modification
- usually resolves after growth spurt 11-12 females, 13-14 males
- surgery" if patellar ligament ruptures
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