functional anatomy of the knee and legforms.acsm.org/tpc/pdfs/29 ireland.pdf · functional anatomy...

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

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Mary Lloyd Ireland, MDAssociate Professor Dept. of Orthopaedic Surgery &

Sports MedicineUniversity of KentuckyLexington, Kentucky



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

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

Functional Anatomy of the Knee and Leg




Anatomy and Dissection SourcesAnatomy and Dissection Sources

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

• Interactive Knee• Interactive Functional Anatomy

• Mary Lloyd Ireland, MD

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

• Interactive Knee• Interactive Functional Anatomy

• Mary Lloyd Ireland, MD



Lower Limb model: Lateral ViewLower Limb model: Lateral View

www.primalpictures.com



Lower Limb model: Medial ViewLower Limb model: Medial View




Lower Limb model: Anterior ViewLower Limb model: Anterior View




Lower Limb model: Posterior ViewLower Limb model: Posterior View




Internal/External Rotation of KneeInternal/External Rotation of Knee




Flexion/Extension of KneeFlexion/Extension of Knee



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Knee model: Anterior ViewKnee model: Anterior View



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Left Knee Joint, Ligaments, from aboveLeft Knee Joint, Ligaments, from above



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Knee joint and menisci, from aboveKnee joint and menisci, from above



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Tibial plateau and menisci, from aboveTibial plateau and menisci, from above



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

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


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

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


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Knee model: Medial ViewKnee model: Medial View



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OKU 10: “Soft Tissue Injuries About the Knee,” Kaar et. al., p. 455. Fig. 1A.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

• 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


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Knee model: Lateral ViewKnee model: Lateral View



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OKU 10: “Soft Tissue Injuries About the Knee,” Kaar et. al., p. 455, Fig. 1B.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

• 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


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Knee model: Posterior ViewKnee model: Posterior View



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Anatomic Sources of Leg PainAnatomic Sources of Leg 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 tibialisposterior and soleus.

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

•Periosteum•Inflammation occurs at muscular insertions particular of tibialisposterior and soleus.

© 2002 Mark R. Hutchinson, M.D.


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•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

•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


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•Arteries and Veins• Atherosclerosis can lead to claudication

• Venous phlebitis or thrombosis can occur

• Popliteal artery entrapment and arterial endofibrosishas been described in younger population.

•Arteries and Veins• Atherosclerosis can lead to claudication

• Venous phlebitis or thrombosis can occur

• Popliteal artery entrapment and arterial endofibrosishas been described in younger population.



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Differential Dx of Chronic Leg Pain in AthletesDifferential 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

• CECS• Muscle herniation• Stress fractures• Medial tibial periostitis

(shin splints)• Chronic muscle strain• Popliteal artery entrapment• Referred from spine



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Compartment SyndromesCompartment Syndromes•Traumatic

• Secondary to fracture, crush, and reperfusion injuries

• Surgical emergency• Skin and fascia may both

contribute to compartmental restriction and increased pressure

• Non-physiologic swelling secondary to trauma

•Traumatic• Secondary to fracture,

crush, and reperfusion injuries

• Surgical emergency• Skin and fascia may both

contribute to compartmental restriction and increased pressure

• Non-physiologic swelling secondary to trauma

• Exertional• Consistently exercise-

induced• Generally endurance athletes• No pain at rest, pain

consistently relieved with cessation of sport

• Attributed to restriction of muscle swelling secondary to tight fascial compartments

• Diagnosed with pre and post exercise pressure measurements

• Exertional• Consistently exercise-

induced• Generally endurance athletes• No pain at rest, pain

consistently relieved with cessation of sport

• Attributed to restriction of muscle swelling secondary to tight fascial compartments

• Diagnosed with pre and post exercise pressure measurements


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History and Physical:Clinical Pearls in Athletic Leg Pain

History and Physical:Clinical Pearls in Athletic Leg Pain

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

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

•Focal bone pain• Stress fracture

•Diffuse medial bone pain• Medial tibial periostitis

•Focal muscle pain• Strain or Hernia

•Focal bone pain• Stress fracture

•Diffuse medial bone pain• Medial tibial periostitis

•Focal muscle pain• Strain or Hernia


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History and Physical:Clinical Pearls in Athletic Leg PainHistory 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

•Pain with resisted motion

• Muscle strains and periostitis

•Pain with vibration• Stress fractures

•Pain at night• Tumors

•Pain with exertion• CECS, Popliteal artery entrapment

•Paresthesias at rest• Nerve entrapment

•Paresthesias with exertion• CECS

•Electrical shooting pain• Radicular pain from back

•Paresthesias at rest• Nerve entrapment

•Paresthesias with exertion• CECS

•Electrical shooting pain• Radicular pain from back


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History and Physical:Clinical Pearls in Athletic Leg PainHistory and Physical:Clinical Pearls in Athletic Leg Pain

•Diffuse swelling•DVT•CECS•Muscle ruptures

•Focal swelling•Muscle herniation•Ganglion•Tumor

•Diffuse swelling•DVT•CECS•Muscle ruptures

•Focal swelling•Muscle herniation•Ganglion•Tumor



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80% of CECS involve the anterior or lateral compartments (Cross-section just above middle of leg)80% of CECS involve the anterior or lateral 80% of CECS involve the anterior or lateral compartments compartments ((Cross-section just above middle of leg)

Flexor digitorumlongus m.Flexor digitorumlongus m.

TibialisPosterior m. TibialisPosterior m.


Gastrocnemius m.(medial head)Gastrocnemius m.(medial head)

Flexor hallucislongus m.Flexor hallucislongus m.

Soleus m.Soleus m.

Gastrocnemius m.(lateral head)Gastrocnemius m.(lateral head)

Extensor digitorumlongus m.Extensor digitorumlongus m.

Peroneuslongus m.Peroneuslongus m.

Peroneusbrevis m.Peroneusbrevis m.

Davey J, Davey J, RorabeckRorabeck C, C, and Fowler P. and Fowler P. The The tibialistibialisposterior posterior muscle muscle compartment.compartment.Am J Sports Am J Sports MedMed 12(5):39112(5):391--397, 1984.397, 1984.


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Nerves (Cross-section just above middle of leg)Nerves (Cross-section just above middle of leg)

SuperficialPeroneal n.SuperficialPeroneal n.

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


Posterior tibial a. and vv. and tibial n.

Posterior tibial a. and vv. and tibial n.

Lateral suralCutaneous n.Lateral suralCutaneous n.

Medial suralCutaneous n.Medial suralCutaneous n.



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Anterior and Lateral CompartmentsAnterior and Lateral Compartments

IntermuscularseptumIntermuscularseptum


Tibialis anterior m.Tibialis anterior m.

Extensor hallucislongus m.Extensor hallucislongus m.

Extensor digitorumlongus m.Extensor digitorumlongus m.

Peroneuslongus m.Peroneuslongus m.

Peroneusbrevis m.Peroneusbrevis m.


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Posterior Compartments: Deep and Superficial Posterior Compartments: Deep and Superficial

TibialisPosterior m. TibialisPosterior m.


Flexor digitorumlongus m.Flexor digitorumlongus m.

Gastrocnemius m.(medial head)Gastrocnemius m.(medial head)

Flexor hallucislongus m.Flexor hallucislongus m.

Soleus m.Soleus m.

Gastrocnemius m.(lateral head)Gastrocnemius m.(lateral head)


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SuperficialPeroneal n.SuperficialPeroneal n.



Know the anatomy before performing Know the anatomy before performing compartment testing or surgical releases.compartment testing or surgical releases.


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



The End . . . Thank You!The End . . . Thank You!

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

_________________________________________________________________________

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. Anatomy of the anterior cruciate ligament : a blueprint for repair and reconstruction. Arthroscopy 1994;10(2):132-139. 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 2 Mansour JM, Pereira JM. Quantitative functional anatomy of the lower limb with application to human gait. J Biomech 1987;20(1):51-58. 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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