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END OF SEM ANATOMY

MASTER REVISION

CONTENTS:

1. KNEE & LEGS

2. ANKLE & FOOT

3. VERTEBRAL COLUMN

4. CERVICAL SPINE

5. THORACOLUMBAR SPINE & PELVIS

6. DIAPHRAGM, PELVIC FLOOR & ABDOMINALS

KNEE

KNEE JOINT COMPLEX

TIBIOFEMORAL Joint (femoral condyles + tibial plateau) ❖ Hinge Joint = Predominantly Uniaxial (limited rotation)

❖ Great Stability in E w/ Screw Home Mechanism

❖ F/E along Sagittal Plane on Coronal Axis

❖ Mobility in F (allow foot clearance & optimal orientation of foot)

❖ Poor degree of interlocking joint surfaces (dependent on active & passive structures such as ligaments, menisci & muscles)

❖ Large Lever Arms (therefore, predisposed to injury due to long bones)

❖ Femoral Articular Surface > Tibial Articular Surface (due to differences in condyle size) *5o of HE is critically important for knee function *Can’t rotate tibia & fibula voluntarily *Recurvatum = hyperextension of kneecap

Knee Alignment Q Angle (between axis of tibia & femur): Measured along ASIS Patella (centre)/ Tibial Tuberosity

❖ 14o = Men

❖ 17o = Women 5o Genu Valgus: Tibia is laterally inclined in relation to femur; medial fem condyle extends slightly more distally. Alignment of the femoral condyles on the transverse plane determine the orientation of the F/ E axis of Knee Mechanical Axis of Lower Limb = 2-3o Varus (tibial midline

HOF)

❖ Shortens width of Base of Support to for better weight-bearing & gait

Knee Tendon Attachment ❖ Semimembranosus Tendon attaches posteriorly to

Tibial Medial Condyle, superior to Popliteus

❖ Sartorius, Gracilis & Semitendinosus (Medial Lateral)

❖ Oblique Popliteal Ligament blends in with Posterior Capsule

Synovial Membrane ❖ Synovial surfaces surround all articular areas, capsule

surrounds the entirety of joint

❖ An intracapsular extrasynovial space exists between menisci

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❖ Actively supported by: 1) Quad attachments 2) laterally by ITB 3) medially by Tibial Collateral Ligament 4) posteriorly reinforced by Oblique Popliteal ligament (restricts HE) 5) posterolaterally (pierced by popliteus)

Tibial Meniscal Discs ❖ Circular fibrocartilage pieces that ↑ articular contact & congruency, ↓ compression stress

& protect articular cartilage

❖ After total meniscectomy, contact areas ↓ ~75% & peak local contact stress ↑ ~235%

❖ Medial Menisci (MM) ↑ AP length w/ thicker posterior horn (as the primary coverage over tibial plateau, it bears a large portion of the articular stress). Thus, the Screw Home Mechanism IR to the MM during Knee E for ↑ weight-bearing

❖ LM are narrower, more mobile compared to MM which is anchored to TCL

‘SCREW HOME’ Mechanism ❖ Tibiofemoral Joint initiates ‘screw home’ mechanism by slightly rotates during a primary action

to tighten its ligaments (especially ACL & PCL) for ↑ stability, a ↑ contact area w/ MM

❖ Flexion + LR

❖ Extension + MR

❖ Occurs @ 20oF – 0oE

❖ In terminal extension, this mechanism locks up the knee for greater stability, apart from tightening ligaments, ↑ interlocking between the joints

❖ If tibia is not fixed on the floor, it will LR for the screw home mechanism, if foot is fixed on the ground it will then femur will MR after posteriorly sliding

❖ Popliteus locks TFJ w/ femur IR, to unlock the extended leg it must ER femur during F

Femoral/Tibial Gliding ❖ During movement, the kneecap has two directions of movement, sliding

(AP) & rolling (of either the tibia or femur), both directions will not happen purely but in conjunction

❖ *ACL/PCL tightens during flexion or gliding, pulling femur back into a slide backwards or forwards

❖ For tibial extension, tibia will slide & roll anteriorly

❖ For femoral extension, it will slide backwards but still roll anteriorly

❖ To prevent excessive knee F, the ACL will tighten, forcing the femur into an anterior slide

PATELLOFEMORAL Joint ❖ Patellar glides upon Patella Groove on the Femur

❖ ↑ Leverage of Quads by altering its LOA & ↑ distance from axis (thus moment arm). Net pull towards HOF (in a slightly valgus direction)

❖ Provides protection to the exposed cartilage of femoral condyles in Knee F

❖ Distributes forces & pressure placed on the femur

❖ ↓ Friction of Quads Tendon as it will rub upon the fem condyles w/o Patella

❖ Patella is most inclined to dislocate laterally even w/ the VMO’s medial pull resistance and the greater height of the lateral portion of the Patella Groove

❖ Patellectomy = ↓ Quads Moment Arm, ↓ Knee ROM, Anterior Instability & Loss of Trochlea Protection

❖ Patella glides distally permitted by the unfolding of the Suprapatellar Pouch

Translations

❖ Glides distally on femur during Knee F

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❖ Glides medially during 0-30oF then lateral during 30-90oF Rotations

❖ Laterally tilts during flexion Contact Area

❖ w/ increasing knee flexion, the patella moves proximally to ↑ contact area

Patella Bursae & Spaces Bursae Location

Suprapatellar Above patellar, deep to the patellar tendon

Subcutaneous Prepatellar Superficial to patellar

Subcutaneous Infrapatellar Superficial to patellar tendon, below patellar

Deep Infrapatellar Inferior to patellar, deep to patellar tendon

Infrapatellar Fat Deep to Infrapatellar bursae

Semimembranosus Behind femorotibial joint

Subsartorial (pes anserinus) On medial side of the tibia

❖ Fat Pad separates Quads Tendon from Femur (↑ moment arm)

❖ Articular Genus pulls Suprapatellar Bursae back from being pinched during Knee E

❖ Bursae promotes frictionless Knee movement, but pain sensitive and susceptible to inflammation

Knee Movement Range ❖ Motion Range

o Gait: 60-70o o Stairs: >110o o Sitting: 93o o Shoe Tying: 106o

❖ Loading o Level Ground: 3x BW o Stairs: 4.25x BW

Movement Range

Flexion 140o

Hyperextension 5o

Accessory Movements

AP Glide

Medial/ Lateral Rotation

Medial/ Lateral (Transverse) Glide

ABD/ADD

Superior Tibiofibular Joint Arthrodial (Plane) Joint

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KNEE MUSCLE COMPLEMENT Action Muscles

Extension Quads

Flexion Hamstrings (weak contribution from gastro, soleus & sartorius)

Internal Rotation Semitendinosus, Semimembranosus, Popliteus, Gracilis & Sartorius

External Rotation Biceps Femoris & TFL

*popliteus unlocks knee from screw mechanism as well as assisting the PCL w/ resisting anterior gliding

Muscle Origin Insertion Innervation Function

Anterior Compartment (Knee E)

Rectus Femoris (deep to satorius)

AIIS

Patellar via Quadriceps Tendon

Femoral N (L2-4)

Knee E Hip F

Vastus Medialis Medial Lip of Linea Aspera & Intertrochanteric Line

Knee E Vastus Intermedius (deep to RF)

Anterior surface of femur

Vastus Lateralis Greater Trochanter & Lateral Lip of Linea Aspera

Sartorius ASIS Pes Anserinus Femoral N (L2-3) Hip F, ADD & LR Knee MR

Medial Compartment (Adduction)

Adductor Longus (anterior)

Superior Ramus of Pubis

Linea Aspera Obturator N (L2-4) Hip ADD & F (Hip E only @ 90oF)

Adductor Brevis (superior)

Pectineal Line & Inferior Pubic Ramus

Adductor Magnus (posterior, largest)

Inferior Ramus & Ischiopubic Ramus & Ischial Tuberosity

Linea Aspera & Adductor Tubercle

Obturator N (L2-4) & Tibial N (L4)

Gracilis Inferior Pubic Ramus & Pubic Symphysis

Pes Anserinus Obturator N (L2-3) Hip ADD

Pectineus Pecten Pubis (like superior pubic ramus)

Pectineal Line Femoral N (L2-3) & Obturator N (L3-4)

Hip ADD, F & MR

Posterior Compartment (Knee Flexion)

Biceps Femoris *Long Head (left) *Short Head (right)

Long: Ischial Tuberosity Short: Lateral Lip of Linea Aspera

Head of Fibula & Lateral Condyle of Tibia

Tibial N (L5-S2)

Knee F & LR Hip E (long head only) *Tibial ER

Semitendinosus (lateral, more posterior to semimembranosus) Ischial Tuberosity

Pes Anserinus Knee F & MR Hip E *Tibial IR

Semimembranosus Medial Condyle of Tibia

*posterior thigh muscles are biarticular (crosses two joints)

KNEE LIGAMENT STRUCTURES Ligament Attachments Resists

Anterior Cruciate Ligament (ACL) Anterior Tibial Head Posteriorly below Lateral Menisci

Posterolateral Band (PLB): largest, tightest in E

Anteromedial Band (AMB): tightens in F

Posterior Cruciate Ligament (PCL)

Posterior Tibial Head > Anteriorly below Medial Menisci

Anterior Gliding (during Tibial/ Femoral E)

Tibial (medial) Collateral Ligament (TCL)

Medial Femoral Condyle Midline of Medial Tibia

Superficial (longer): Valgus Force (throughout F)

Medial Femoral Condyle Posterior Edge of Medial Tibial Condyle

Deep (shorter): Anterior Displacement of Tibia

Anterolateral Ligament (ALL) Posterior Edge of Lateral Condyle Lateral Head of Tibia

Tibial IR @ 30oF + Anterolateral Stability

Fibular (lateral) Collateral Ligament (FCL)

Posterior Edge of Lateral Condyle Head of Fibula

Varus Force

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Posterior Tibiofibular Ligament (PTL) Inferior Posterior Tibia Fibula Stability of TFJ

Oblique Popliteal Ligament (OPL) Lateral Femoral Epicondyle Medial Tibial Condyle

Knee HE

Transverse Ligament Connects Anterior Lateral & Medial Menisci

Anterior Gliding of Anterior Menisci Horns (as they are somewhat mobile & being pinched by the femur OR tibia)

Coronary Ligaments Inferior edges of LM & MM Knee Capsule

Anchors Menisci @ four points onto the tibia

Posterior Meniscofemoral Posterior Horn of LM Femur ???

*TCL tends to be part of capsule while the FCL is more prominently outside the capsule

ANTERIOR CRUCIATE LIGAMENT

❖ Resists anterior translation of tibia on femur

❖ Resists posterior translation of femur on tibia

❖ ↑ rotation stability

❖ Resists valgus forces

❖ Tightens @ terminal E (but not main restraint)

❖ Tightens @ 10oIR & 30oER

Injury

❖ Large valgus moment that creates excessive knee ABD & tibial ER

❖ Commonly caused by pivoting sports w/ females being 3-5x more likely to suffer from this injury

ACL Deficiency Test: Lachman’s Test (done @ 15o knee F) & Anterior Drawer Test (@ 90o knee F) done by gliding the tibia in an AP manner, lack of resistance = compromised ACL

POSTERIOR CRUCIATE LIGAMENT

❖ Resists posterior translation of tibia on femur

❖ Resists anterior translation of femur on tibia

Injury

❖ Throw against “dashboard” during car crash

❖ Hyperflexion or HE

PCL Deficiency Test: Sag Test by placing the knee @ 90oF, if there is a deficiency than the knee should have a slight backwards bend to it (meaning that the tibia is gliding posteriorly & the femur is anterior translating)

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ANKLE

ANKLE JOINT COMPLEX

Stability & Mobility Demands ❖ Support of Entire Body Weight

❖ Control of Leg & Stabilisation over Foot

❖ Adjustment over irregular surfaces

❖ Elevation of Body

❖ Shock Absorption *function is dependent upon 3 intrinsic foot arches, ligament support & dynamic muscle contractions

3 Axes of Movement ❖ Dorsiflexion (300)/ Plantarflexion (50-600) only happens @ talocrucial joint (sagittal plane)

❖ ABD/ADD happens @ forefoot (transverse plane)

❖ Inversion/Eversion (40o total ROM, may be more on one side than other) happens at subtalar joint (on coronal plane)

❖ Pronation (DF + Eversion + ABD)/ Supination (PF + Inversion + ADD) (triplanar movement, requires all three joints)

Close-Packed Positions

❖ Ankle – DF (end feel is firm) ❖ Tarsal Joints – full inversion

❖ Metatarsophalangeal (MTP) – extension

❖ Interphalangeal (IP) – extension

Force Transfer ❖ Largest distally & proximally, force transfer thru tibia

❖ Anterior Tibia under tension forces

❖ Posterior Tibia under compression forces

▪ 90% of Tibial Stress Fractures is located posteromedial

▪ 20-40o External Tibial Torsion

❖ Navicular Stress Fractures occurs @ the central zone of force between the medial & intermediate cuneiform whereupon medial & lateral compressive forces are directed thru 1st & 2nd Ray, this can cause hypovascularity (lack of blood supply)

FIBULA ❖ Muscle Attachment

❖ Ligament Attachment

❖ Talocrural Joint Stability

*not a structural bone, only for the attachments of important active structures

Regions of Foot

❖ Rearfoot (talus & calcaneal)

❖ Midfoot (navicular, cuboid, lateral, intermediate & medial cuneiform)

❖ Forefoot (phalanges)

• 1st, 2nd & 3rd Ray: corresponding cuneiform w/ phalange

• 4th & 5th Ray: just 4th & 5th phalange *2nd ray is least mobile while 1st ray provides stable medial side for

push-off during gait

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Tendons ❖ 2 sesamoid bones in tendons of FHB under 1st MTP prevents weight-

bearing from compressing the tendon & aligns tendon

❖ fibularis tendon sulcus on lateral calcaneus facilitates passing of the fibularis tendons

DISTAL TIBIOFIBULAR Joint (DTFJ) ❖ Fibrous Syndesmosis Joint

❖ Stability of Distal Tibiofibular Joint is crucial for the stability of the Talocrural Joint

❖ Consists of: o Anterior Tibiofibular Ligament (ATL) o Posterior Tibiofibular Ligament (PTL) o Interosseous Membrane (IOM)

TALOCRUCAL Joint ❖ Synovial Hinge

❖ Widest part of the talus firmly fits into the mortise (inverted cup formed by the tibia & fibular) in DF, if ER of the foot is experienced the talus’s widest side is angled & jammed into the mortise, possibly causing separation of the distal fibula & tibia OR tearing anterior tibiofibular ligament OR fractures fibula OR fractures at the corners of the talar dome

❖ DF is the close-packed position of the talocrural joint, providing most stability

❖ In PF, the talus’s narrow part is moved into the mortise

SUBTALAR (Talocalcaneal) Joint (STJ) ❖ 3 articular facets between talus & calcaneus, vital for supination & pronation

❖ Translates movements of the foot to the leg, i.e. foot pronation = tibial IR

❖ Inclined ~45o anterior to posterior, slightly medial to the long axis of the foot Transverse Tarsal Joint = Talonavicular & Calcaneocuboid forms joint between rearfoot & midfoot

Arches of the Foot - Medial Longitudinal Arch (stabilised by fibularis longus, abductor hallucis, TA & TP) - Lateral Longitudinal Arch (stabilised by fibularis brevis) - Transverse Arch *arches serve as shock absorbers & energy returners (during gait)

*arches protect the blood vessels, neural & musculoskeletal structures underneath the foot during weight-bearing *the medial arch can be tested w/ the Navicular Drop Test, comparing the differences in height between the arch and the floor when load is placed on the foot

Arch Muscular Support Medial Arch - TA, TP, FHL, FDL & Fibularis Longus,

Plantar Aponeurosis, Long & Short Plantar Ligament + Spring Ligament (for medial arch)

Lateral Arch - Fibularis Longus & Brevis, FDL

Transverse Arch - Fibularis Longus, TP & Adductor Hallucis

ANKLE MUSCLE COMPLEMENT Action Muscles

Inversion TA/ TA

Eversion FB & FL

Dorsiflexion TA/ EHL & ED

Plantarflexion Triceps Surae (Gastro, Soleus, Popliteus, Plantaris)

Calcaneocuboid Saddle Joint (Convex Concave)/ Plane Joint

Debate between function of joint & its actual range Talonavicular

Talocalcaneonavicular Ball & Socket Joint *rest are plane joint*

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Muscle Origin Insertion Innervation Action

Anterior Compartment (DF & Inversion)

Tibialis Anterior Lateral Tibia Condyle Medial Cuneiform & 1st MT Deep Fibular N

(L4-5)

DF (agonist) Midfoot Inversion (contributes)

Extensor Hallucis Longus

Fibula & Interosseous Membrane

Base of Distal Phalanx of 1th Digit

PF Extensor Digitorum Longus

Lateral Tibia Condyle + Interosseous Membrane

Distal Phalanges of 2nd-5th Digit

Deep Fibular N (L5-S1)

Posterior Compartment (PF & Knee Flexion)

Popliteus Lateral Femoral Condyle Posterior Tibia Tibial N (L4-S1) Knee MR & F

Tibialis Posterior Posterior Interosseous Membrane

Navicular Tuberosity, All Cuneiforms & 2nd-4th MT

Tibial N (L4-5) Inversion (agonist) & PF (slight contribution)

Gastrocnemius Lateral & Medial Femoral Condyles

Calcaneal Tendon (Archimedes tendon)

Tibial N (S1-2)

PF (agonist) & Inversion (small contribution as it is aligned medially) (Knee F only for Gastro)

Soleus (deep to plantaris)

Posterior Head of Fibula

Plantaris (deep to Gastrocnemius)

Posterior Lateral Femoral Condyle

Flexor Digitorum Longus

Posterior Tibia Plantar 2nd-5th DP

Tibial N (S2-3) PF (agonist)

Flexor Hallucis Longus Interosseous Membrane & Posterior of Fibula

Base of Distal 1st Phalanx

Lateral Compartment (Eversion)

Fibularis Brevis

Lateral Fibula

5th MT Tuberosity Superficial Fibular N (L5-S2)

Eversion (agonists) PF (small contribution)

Fibularis Longus Base of 1st MT (wraps underneath foot)

Intrinsic Foot (supports arches)

Extensor Hallucis Brevis (medial to EDB) Superolateral surface of

Calcaneus

Dorsal 1st MTP Deep Fibular N (L5-S1)

1st Ray E

Extensor Digitorum Brevis

Dorsal 2nd-4th PIP 2nd-4th Ray E

Flexor Digitorum Brevis

Calcaneal Tuberosity & Plantar Aponeurosis

Plantar 2nd-4th MP

Medial Plantar N (S2-3)

2nd-5th Ray F

Flexor Hallucis Brevis Plantar Cuboid, Lateral Cuneiform & medial 1st MTT

Plantar 1st PP 1st Ray F

Flexor Digiti Minimi Brevis

Base of 5th MT 5th PP 5th Ray F

Abductor Hallucis Medial Calcaneal Tuberosity

Dorsal 1st MTP 1st Ray ABD

Adductor Hallucis Oblique: Base of MT Transverse: 2nd-4th MTP

Lateral Base of 1st PP

Lateral Plantar N (S2-3)

1st Ray ADD

Flexor Digiti Minimi Plantar 5th MMT

Plantar 5th MTP

5th Ray F

Abductor Digiti Minimi (lateral to FDB)

Calcaneal Tuberosity & Plantar Aponeurosis

5th Ray ABD

Lumbricals Medial side of FDL Tendons

Medial side of MTP Medial & Lateral Plantar N (S3)

IP E while MTP F

Quadratus Plantae Calcaneal Tuberosity & Long Plantar Ligament

Tendon of FDL

Lateral Plantar N (S2-3)

Assists FDL w/ F (also realigns angle of FDP pull)

Plantar Interossei Medial side of 3rd-5th MT Medial Side of 3rd-5th PP ADD 2nd – 4th Ray

Dorsal Interossei Between all MT Both sides of 2nd PP, but only on lateral side of 3rd & 4th PP

ABD 2nd – 4th Ray

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ANKLE LIGAMENT STRUCTURES Ligament Attachments Resists

Fibular Ligaments

Anterior Tibiofibular Ligament (ATL) Distal Anterior Tibia Distal Anterior Fibula (consists of 2 separate superior & inferior bands)

Separation & Stability of TFJ

Posterior Tibiofibular Ligament (PTL) Distal Posterior Tibia Distal Posterior Fibula

Interosseous Membrane (IOM) Within the Tibiofibular Joint

Anterior Talofibular Ligament (ATFL) Lateral Posterior Lateral Talus Posterior Distal Fibula

TCJ Stability & Excessive Inversion Posterior Talofibular Ligament (PTFL)

Lateral Anterior Talus Anterior Distal Fibula

Calcaneofibular Ligament (CFL) Lateral Calcaneus Apex of Fibula

Intrinsic Ligaments

Flexor Retinaculum Medial Malleolus Calcaneus Creates the Tarsal Tunnel, anchors flexor & TP tendons

Talocalcaneal Interosseous Lateral Anterior Calcaneus Lateral Anterior Talus (w/ sinus tarsi)

Talar – Calcaneal Stability

Dorsal Calcaneonavicular Dorsal Calcaneus Posterior Lateral Navicular

Calcaneus – Navicular Stability Bifurcated Ligaments ↑ ↓

Dorsal Calcaneocuboid Dorsal Calcaneus Cuboid (x3 bands) Calcaneus – Cuboid Stability

Cervical Ligament Calcaneus Talus (much like CFL but anterior)

Resists Inversion & Stability of Calcaneus/ Talus

Long Plantar Ligament Base of 4th & 5th MT Plantar Calcaneus

Maintains Lateral Arch Short Plantar Ligament

Plantar Lateral Cuneiform Plantar Calcaneus

Plantar Calcaneonavicular (Spring) Ligament

Plantar MTP Capsules Plantar Calcaneus (medial side)

Stores energy during gait & releases energy as a spring during push-off phase

Plantar Fascia Plantar PIP Plantar Medial Calcaneal Tuberosity

2x tensile strength of plantar ligaments, rich in proprioceptors, maintains rigid foot during step-off in gait (during MTP HE & PF pushes calcaneal tuberosity posteriorly

Tibial Ligaments (Deltoid Ligaments)

Anterior Tibiotalar Ligament (ATTL) Anterior Distal Tibia Anterior Talar

Excessive Inversion

Posterior Tibiotalar Ligament (PTTL) Posterior Distal Tibia Posterior Talar

Tibiocalcaneal (& Tibiospring) Ligament

Medial Distal Tibia Medial Calcaneal

Tibionavicular Ligament Distal Tibia Dorsal Navicular

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Ankle Osteology ❖ Subtalar joint is formed by posterior,

lateral & anterior talar articular surfaces

between the calcaneus & talus

❖ Sustentaculum Tali is a shelf between the

lateral & posterior articular surfaces

❖ Tarsi Sinus is the cavity created between

the calcaneus & talus