Functional Anatomy of the Knee and Leg Functional Anatomy of The

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

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

FunctionalFunctional AnatomyAnatomy ofof thethe KneeKnee andand LegLeg

Mary Lloyd Ireland, MD Associate Professor Dept. of Orthopaedic Surgery & Sports Medicine University of Kentucky Lexington, Kentucky

ACSM TPC • Feb. 9, 2013 1 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

AnatomyAnatomy andand DissectionDissection SourcesSources

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

• Mary Lloyd Ireland, MD

ACSM TPC • Feb. 9, 2013 2 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

LowerLower LimbLimb model:model: LateralLateral ViewView

www.primalpictures.com

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LowerLower LimbLimb model:model: MedialMedial ViewView

www.primalpictures.com

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LowerLower LimbLimb model:model: AnteriorAnterior ViewView

www.primalpictures.com

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LowerLower LimbLimb model:model: PosteriorPosterior ViewView

www.primalpictures.com

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Internal/ExternalInternal/External RotationRotation ofof KneeKnee

www.primalpictures.com

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Flexion/ExtensionFlexion/Extension ofof KneeKnee

www.primalpictures.com

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ACSM TPC • Feb. 9, 2013 9 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

ACSM TPC • Feb. 9, 2013 10 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

ACSM TPC • Feb. 9, 2013 11 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

ACSM TPC • Feb. 9, 2013 12 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

KneeKnee model:model: AnteriorAnterior ViewView

www.primalpictures.com

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ACSM TPC • Feb. 9, 2013 14 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

LeftLeft KneeKnee Joint,Joint, Ligaments,Ligaments, fromfrom aboveabove

www.primalpictures.com

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KneeKnee jointjoint andand menisci,menisci, fromfrom aboveabove

www.primalpictures.com

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TibialTibial plateauplateau andand menisci,menisci, fromfrom aboveabove

www.primalpictures.com

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ACSM TPC • Feb. 9, 2013 18 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

ScrewScrew homehome mechanismmechanism (Smillie)(Smillie) tibialtibial externallyexternally rotatesrotates inin terminalterminal kneeknee extensionextension

ACSM TPC • Feb. 9, 2013 19 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

JointJoint lineline palpationpalpation withwith kneeknee flexedflexed shouldshould produceproduce painpain ifif meniscusmeniscus isis torntorn

ExternallyExternally rotaterotate tibiatibia foforr medialmedial meniscusmeniscus tears,tears, InternallyInternally rotaterotate forfor laterallateral meniscusmeniscus tearstears

ACSM TPC • Feb. 9, 2013 20 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

ACSM TPC • Feb. 9, 2013 21 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

ACSM TPC • Feb. 9, 2013 22 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

ACSM TPC • Feb. 9, 2013 23 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

ACSM TPC • Feb. 9, 2013 24 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

KneeKnee model:model: MedialMedial ViewView

www.primalpictures.com

ACSM TPC • Feb. 9, 2013 25 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

OKUOKU 10:10: “Soft“Soft TissueTissue InjuriesInjuries AboutAbout thethe Knee,”Knee,” Kaar Kaar et. et. al.,al., p.p. 455.455. Fig.Fig. 1A.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 26 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

KneeKnee model:model: LateralLateral ViewView

www.primalpictures.com

ACSM TPC • Feb. 9, 2013 27 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

OKUOKU 10:10: “Soft“Soft TissueTissue InjuriesInjuries AboutAbout thethe Knee,”Knee,” Kaar Kaar et. et. al.,al., p.p. 455,455, Fig.Fig. 1B.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 28 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

KneeKnee model:model: PosteriorPosterior ViewView

www.primalpictures.com

ACSM TPC • Feb. 9, 2013 29 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

ACSM TPC • Feb. 9, 2013 30 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

ACSM TPC • Feb. 9, 2013 31 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

ACSM TPC • Feb. 9, 2013 32 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

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ACSM TPC • Feb. 9, 2013 34 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

AnatomicAnatomic SourcesSources ofof LegLeg PainPain

•Bone •A continuum of bone trauma exists from bone strain to stress reaction to stress fracture

ACSM TPC • Feb. 9, 2013 35 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

AnatomicAnatomic SourcesSources ofof LegLeg PainPain

•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

ACSM TPC • Feb. 9, 2013 36 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

AnatomicAnatomic SourcesSources ofof LegLeg PainPain

•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.

ACSM TPC • Feb. 9, 2013 37 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

DifferentialDifferential DxDx of of ChronicChronic LegLeg PainPain inin AthletesAthletes

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

ACSM TPC • Feb. 9, 2013 38 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

CompartmentCompartment SyndromesSyndromes ••TraumaticTraumatic •• ExertionalExertional •• SecondarySecondary toto fracture,fracture, •• ConsistentlyConsistently exercise-exercise- crush,crush, andand reperfusionreperfusion inducedinduced injuries injuries •• GenerallyGenerally enduranceendurance athletesathletes • Surgical emergency • Surgical emergency •• NoNo painpain atat rest,rest, painpain •• SkinSkin andand fasciafascia maymay bothboth consistentlyconsistently relievedrelieved withwith contributecontribute toto cessationcessation ofof sportsport compartmental restriction compartmental restriction •• AttributedAttributed toto restrictionrestriction ofof and increased pressure and increased pressure musclemuscle swellingswelling secondarysecondary •• Non-physiologicNon-physiologic swellingswelling toto tighttight fascialfascial compartments compartments secondary to trauma secondary to trauma •• DiagnosedDiagnosed withwith prepre andand postpost exerciseexercise pressurepressure measurementsmeasurements

ACSM TPC • Feb. 9, 2013 39 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

HistoryHistory andand Physical:Physical: ClinicalClinical PearlsPearls inin AthleticAthletic LegLeg PainPain

•Pain with initial impact •Focal bone pain • Stress fracture • Stress fracture • Periostitis •Diffuse medial bone pain • Muscle strains and • Medial tibial periostitis tendinitis •Focal muscle pain • Strain or Hernia

ACSM TPC • Feb. 9, 2013 40 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

HistoryHistory andand Physical:Physical: ClinicalClinical PearlsPearls inin AthleticAthletic LegLeg PainPain

•Pain with resisted •Paresthesias at rest motion • Nerve entrapment • Muscle strains and •Paresthesias with exertion periostitis • CECS •Pain with vibration •Electrical shooting pain • Stress fractures • Radicular pain from back •Pain at night • Tumors •Pain with exertion • CECS, Popliteal artery entrapment

ACSM TPC • Feb. 9, 2013 41 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

HistoryHistory andand Physical:Physical: ClinicalClinical PearlsPearls inin AthleticAthletic LegLeg PainPain

•Diffuse swelling •DVT •CECS •Muscle ruptures

•Focal swelling •Muscle herniation •Ganglion •Tumor

ACSM TPC • Feb. 9, 2013 42 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

80%80% ofof CECSCECS involveinvolve thethe anterioranterior oror laterallateral compartmentscompartments (Cross-section((Cross-section justjust aboveabove middlemiddle ofof leg)leg) ExtensorExtensor digitorumdigitorum TibialisTibialis FlexorFlexor digitorumdigitorum longuslongus m.m. PosteriorPosterior m.m. longuslongus m.m.

PeroneusPeroneus Davey J, longuslongus m.m. Rorabeck C, and Fowler P. PeroneusPeroneus The tibialis brevisbrevis m.m. posterior FlexorFlexor hallucishallucis muscle longuslongus m.m. compartment. Am J Sports SoleusSoleus m. m. Med 12(5):391- 397, 1984.

GastrocnemiusGastrocnemius m. m. GastrocnemiusGastrocnemius m. m. (lateral(lateral head)head) (medial(medial head)head) © CIBA-Geigy: Permission Applied For

ACSM TPC • Feb. 9, 2013 43 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

NervesNerves (Cross-section(Cross-section justjust aboveabove middlemiddle ofof leg)leg)

AnteriorAnterior tibialtibial a.a. andand SuperficialSuperficial v.v. andand deepdeep PeronealPeroneal n. n. peronealperoneal n. n.

PosteriorPosterior tibialtibial a.a. andand vv.vv. andand tibialtibial n.n.

LateralLateral suralsural CutaneousCutaneous n. n. MedialMedial suralsural CutaneousCutaneous n. n.

ACSM TPC • Feb. 9, 2013 44 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

AnteriorAnterior andand LateralLateral CompartmentsCompartments

ExtensorExtensor digitorumdigitorum TibialisTibialis anterior anterior m.m. longuslongus m.m. ExtensorExtensor hallucishallucis IntermuscularIntermuscular longuslongus m.m. septumseptum

PeroneusPeroneus longuslongus m.m.

PeroneusPeroneus brevisbrevis m.m.

ACSM TPC • Feb. 9, 2013 45 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

PosteriorPosterior Compartments:Compartments: DeepDeep andand SuperficialSuperficial

TibialisTibialis PosteriorPosterior m.m.

FlexorFlexor digitorumdigitorum FlexorFlexor hallucishallucis longuslongus m.m. longuslongus m.m.

SoleusSoleus m. m.

GastrocnemiusGastrocnemius m. m. GastrocnemiusGastrocnemius m. m. (lateral(lateral head)head) (medial(medial head)head) © CIBA-Geigy: Permission Applied For

ACSM TPC • Feb. 9, 2013 46 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

AnteriorAnterior tibialtibial a.a. andand SuperficialSuperficial v.v. andand deepdeep PeronealPeroneal n. n. peronealperoneal n. n.

Know the anatomy before performing compartment testing or surgical releases.

ACSM TPC • Feb. 9, 2013 47 Functional Anatomy of the Knee and Leg Mary Lloyd Ireland, MD

TheThe EndEnd ...... Thank Thank You!You!

FunctionalFunctional AnatomyAnatomy ofof thethe KneeKnee andand LegLeg

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 48

FUNCTIONAL ANATOMYOF THE Mary Lloyd Ireland, M.D. KNEE AND LEG UK Healthcare - Orthopaedics ACSM TPC II & Sports Medicine Miami, Florida 601 Perimeter Drive #200 February 9, 2013 Lexington, KY 40517 (859) 218-3131 Fax: (859) 323-2255 ______

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