KNEE, ANKLE, AND FOOT

(ANATOMY AND KINESIOLOGY)

KNEE JOINT
TIBIOFEMORAL JOINT
TIBIOFEMORAL JOINT
 Tibiofemoral Joint
Resting position 25° flexion

Close pack position Full extension

ER of tibia

Capsular pattern Flexion > extension

 Tibiofemoral Joint
Motion ROM End-feel
Flexion 0-140° Tissue approximation
or tissue stretch

Extension 0-15° Tissue stretch

External rotation of 30°-40° Tissue stretch

tibia on femur
Internal rotation of 20°-30° Tissue stretch
tibia on femur
TIBIA AND FIBULA
SCREW HOME MECHANISM
 TIBIOFEMORAL JOINT

Tibia (OKC) Femur (CKC)

Movement Roll Glide Spin Movement Roll Glide Spin

Flexion Posterior Posterior IR Flexion Posterior Anterior ER

Extension Anterior Anterior ER Extension Anterior Posterior IR

KNEE JOINT MOBILIZATION
 MENISCUS

1. Stability

2. Absorbs and distributes

forces

3. Promote joint lubrication

4. Protect the joint capsule

5. Protect against
hyperextension
MENISCUS
 MENISCUS
Medial meniscus Lateral meniscus

• MCL • PCL
• ACL • Popliteus
• Semimembranosus
MCMURRAY TEST
APLEY’S TEST
THESSALY TEST
LIGAMENTS OF THE KNEE
PATELLAR TENDON
OBLIQUE POPLITEAL LIGAMENT

• Expansion of
semimembranosus
• Protects posterior
knee from
hyperextension
ARCUATE POPLITEAL LIGAMENT
• From popliteal
tendon to the
fibular head
• Protects
posterolateral
capsule from
hyperextension and
rotational forces
 COLLATERAL LIGAMENTS
Lateral Collateral Medial Collateral
Ligament Ligament
VALGUS STRESS TEST FOR MCL
VALGUS STRESS TEST FOR MCL
VARUS STRESS TEST FOR LCL
 VALGUS STRESS TEST

Location of Pain Possibly Injured

Medial MCL

Lateral Meniscus
Lateral

VARUS STRESS TEST

Location of Pain Possibly Injured

Medial Medial Meniscus

LCL
Lateral
CRUCIATE LIGAMENTS
ANTERIOR CRUCIATE LIGAMENT
ANTERIOR DRAWER TEST
LACHMAN MANEUVER
• Ritchie, Trillat, or Lachman-Trillat Test
UNHAPPY TRIAD

• Injury to the MCL,

ACL and medial
meniscus
• MOI
– Valgum
– Flexion
– External rotation
POSTERIOR CRUCIATE LIGAMENT
GODFREY TEST
POSTERIOR SAG SIGN
 Physical
Severity examination Impairment Pathophysiology
findings
Microscopic
Minimal tenderness
Grade 1 Minimal tearing of collagen
and swelling
fibers
Moderate Complete tears of
tenderness and some but not all
Grade 2 swelling Moderate collagen fibers in
Decreased ROM the ligament
Possible instability
Significant swelling Complete
Grade 3 and tenderness Severe tear/rupture of
Instability ligament
KNEE ANATOMY
Anterolateral:
ACL, ITB, lat. Meniscus, LCL

Posteromedial:
PCL, oblique popliteal, medial hamstrings, gracilis, medial
gastroc, MCL

Anteromedial:
MCL , Sartorius, Medial meniscus, ACL

Posterolateral:
PCL, Biceps femoris, Arcuate popliteus, lat. Gastroc,
popliteus, LCL
BURSA
POPLITEAL FOSSA

Contents:

• Popliteal vessels
• Saphenous vein
• CPN
• Tibial n
• Posterior cutaneous
nerve of thigh
• genicular br. of
obturator
• lymph nodes
 Q ANGLE

• Normal: 13-18°
• 0° in sitting (90° knee flex)
Q ANGLE
 NORMAL GENU VALGUM

Standing position
• Articulation between the angled femur and
the relatively upright tibia

• Lateral angle of 170-175°

• Medial angle of 5-10 °
• <170° lateral angle = genu valgum
• >180° lateral angle = genu varum
TIBIOFEMORAL ANGLE
MALALIGNMENT
 Possible Compensatory Motions
Possible Correlated Motions or
Malalignment or Postures
Postures
(pelvis & foot)
Lumbar spine contralateral Ipsilateral lateral pelvic
rotation rotation
Excessive hip adduction Excessive subtalar supination
Ipsilateral hip excessive to allow the lateral heel to
medial rotation contact the ground
Genu Valgum Forefoot varus
Lateral patellar subluxation In-toeing to decrease pelvic
Lateral tibial torsion sway during gait
Excessive subtalar pronation
Pes planus
Excessive hip abduction Ipsilateral medial pelvic
Ipsilateral hip lateral rotation rotation
Forefoot valgus
Genu Varum Medial tibial torsion Excessive subtalar pronation
Excessive lateral angulation to allow the medial heel to
of the tibia in the frontal contact the ground
plane; tibial varum
PATELLOFEMORAL JOINT
 PATELLA
1. Improve efficiency
2. Centralize forces
3. Provide a smooth gliding
mechanism
4. Stability
5. Protection
PATELLA
PATELLA
 PATELLOFEMORAL JOINT

Movement Glide
Flexion
Inf
Extension Sup
PATELLAR MOBILIZATION
 PATELLOFEMORAL JOINT
Knee Range of Facet Contact
Flexion
0° No contact

15°-20°(25) Inferior Pole

45° Middle Pole

90° All facets
115

Full flexion Odd Facet and

lateral aspect
PATELLAR LOADING WITH ACTIVITY
• Walking: 0.3 times the body weight

• Climbing stairs: 2.5 times the body weight

• Descending stairs: 3.5 times the body weight

• Squatting: 7 times the body weight

 PATELLAR MALALIGNMENT &
TRACKING PROBLEMS
1. Increased Q angle

– Wide pelvis
– Femoral anteversion
– Coxa vara
– Genu valgum
– Laterally displaced tibial tuberosity
 PATELLAR MALALIGNMENT &
TRACKING PROBLEMS
2. Muscle and fascial tightness at the knee

3. Laxity and weakness at the knee

4. Hip muscle weakness

5. Ankle and foot

MUSCLES OF THE KNEE
 KNEE EXTENSORS
1. Rectus Femoris
2. Vastus Lateralis
3. Vastus Medialis
4. Vastus intermedius

Nerve supply- Femoral n.

Nerve root- L2-L4
QUADRICEPS LAG
GENU RECURVATUM
 KNEE FLEXORS
1. Hamstrings (L5, S1,
S2)

2. Gracilis (L2,3)

3. Gastrocnemius (S1,
S2)
4. Plantaris (S1, S2)

5. Popliteus (L4,5, S1)

6. TFL (L4,5)
KNEE FLEXORS
KNEE FLEXORS
 KNEE FLEXORS
Popliteus
Unlocks the knee

OKC: ____

CKC: ____

Nerve supply: Tibial

nerve
Nerve Root: L4-S1
 HAMSTRINGS AND QUADRICEPS
TORQUE
QUADRICEPS TORQUE HAMSTRINGS TORQUE

Maximum torque Greatest torque

• When muscles are
• 60° of knee flexion
elongated at both
the hip and knee

Decreased Lowest torque

• Further extension • When muscles
of the knee contract in its
shortened position
 ACTIVE INSUFFICIENCY VS PASSIVE
INSUFFICIENCY

• Knee flexion Combined with Hip extension

• Knee extension Combined with Hip Flexion

Lower Leg, Ankle and Foot
FUNCTIONS OF THE ANKLE AND FOOT

• Acts as a support
base
• Provides a
mechanism for
rotation
• Provides flexibility
• Acts as a lever
ANKLE AND FOOT
 ANKLE AND FOOT

Range of Motion Functional ROM

– Descend stairs: 20 DF
DF 0-20 deg – Walk: 20 PF, 10 DF
PF 0-50 deg
Eversion 0-15 deg Forces
Inversion 0-35 deg – Walk 1.2 x BW
– Run 2 x BW
– Jump 5 x BW
 ANKLE AND FOOT

Divided into 4 functional

regions:
A. Ankle joint
– Proximal tibiofibular
joint
– Distal tibiofibular joint
– Talocrural joint
B. Hindfoot
– Subtalar joint
 ANKLE AND FOOT

C. Midfoot joint
– Calcaneocuboid joint
– Talonavicular joint
– Naviculocuboid joint
– Intercuneiform joint

D. Forefoot joint
– Tarsometatarsal joint
– Intermetatarsal joint
– Metatarsophalangeal joint
– Interphalangeal joint
TIBIA AND FIBULA
 PROXIMAL TIBIOFIBULAR JOINT

• “Forgotten joint”
• Plane synovial joint
• Articulation of the head
of the fibula and
posterolateral aspect of
the tibia
• Reinforced by the
anterior and posterior
tibiofibular ligaments
 DISTAL TIBIOFIBULAR JOINT

• Syndesmosis joint
• Between the concave facet
of the tibia and the convex
facet of the fibula

• Supported by the anterior

and posterior tibiofibular
ligament and interosseous
membrane
 DISTAL TIBIOFIBULAR JOINT

Open pack
Plantar flexion
position
Close pack
Maximum dorsiflexion
position
Capsular
Pain when joint is stressed
pattern
 TALOCRURAL JOINT

• Uniaxial, modified hinge

joint

• Between the medial and

lateral malleolus, and
body of the talus

• Movements:
– Dorsiflexion/Plantarflexion
 TALOCRURAL JOINT

NORMAL ROM

Dorsiflexion 0-20

0-50
Plantarflexion
 TALOCRURAL JOINT

Open pack 10° plantarflexion, midway between

position maximum inversion and maximum eversion

Close pack
Maximum dorsiflexion
position
Capsular
Plantarflexion > Dorsiflexion
pattern
 TALOCRURAL JOINT

Increase MOBILIZATION (TALUS)

Posterior
Dorsiflexion
Anterior
Plantarflexion
TALOCRURAL JOINT
 SUBTALAR JOINT

• Synovial, multiplanar
joint

• Movements:
– Abduction/Adduction
– Inversion/Eversion
– Dorsiflexion/Plantarflexion
SUBTALAR JOINT OKC
SUBTALAR JOINT
 Open Kinematic Chain (NWB)
Calcaneal Adduction
Supination Calcaneal Inversion
Calcaneal Plantarflexion
Calcaneal Abduction
Pronation Calcaneal Eversion
Calcaneal Dorsiflexion

Close Kinematic Chain (WB)

Calcaneal Inversion
Talar Abduction
Supination Talar Dorsiflexion
External Tibial Torsion
Calcaneal Eversion
Talar Adduction
Pronation Talar Plantarflexion
Internal Tibial Torsion
 SUBTALAR JOINT

NORMAL ROM

Inversion 0-35

Eversion 0-15
 SUBTALAR JOINT

Open pack Midway between extremes of range of

position motion

Close pack
Supination
position
Capsular
Limited ROM (varus, valgus)
pattern
 SUBTALAR JOINT

Increase MOBILIZATION

Inversion Lateral

Medial
Eversion
SUBTALAR JOINT
Midfoot and Forefoot joints
 MIDFOOT (Mid Tarsal Joints)

• Calcaneocuboid joint
• Talonavicular joint

• Naviculocuboid joint
• Naviculocuneiform joint
• Intercuneiform joint
 MIDTARSAL JOINT

Open pack Midway between extremes of range of

position motion

Close pack
Supination
position
Capsular Dorsiflexion > Plantarflexion > Adduction >
pattern Medial Rotation
 TARSOMETATARSAL JOINT

• Plane, synovial joints

• Formed by the distal
row of tarsal bones
and bases of
metatarsals
• Movement: Gliding
 TARSOMETATARSAL JOINT

Open pack Midway between extremes of range of

position motion

Close pack
Supination
position
Capsular
None
pattern
 INTERMETATARSAL JOINT

• Plane, synovial joints

• Movement: Gliding
 METATARSOPHALANGEAL JOINT

• Condyloid synovial
joints

• Movements:
– Flexion/Extension
– Abduction/Adduction
 METATARSOPHALANGEAL JOINT

Open pack
10° extension
position
Close pack
Full extension
position
Capsular Big toe: Extension > Flexion
pattern Second to fifth: Variable
 INTERPHALANGEAL JOINT

• Synovial hinge joints

• Movements:
– Flexion/Extension
 INTERPHALANGEAL JOINT

Open pack
Slight flexion
position
Close pack
Full extension
position
Capsular
Flexion > Extension
pattern
LIGAMENTS OF THE ANKLE
 LIGAMENTS OF THE ANKLE

• Lateral collateral
ligament
– Anterior talofibular
ligament
– Calcaneofibular
ligament
– Posterior talofibular
ligament
 LIGAMENTS OF THE ANKLE

• Medial collateral
ligament
– Tibionavicular
ligament
– Tibiocalcaneal
ligament
– Posterior tibiotalar
ligament
– Anterior tibiotalar
ligament
ANTERIOR DRAWER TEST
PRONE ANTERIOR DRAWER TEST
TALAR TILT
EXTERNAL ROTATION TEST
 GRADING OF ANKLE SPRAIN
The West Point Ankle Sprain Grading System
Criterion Grade I Grade II Grade III
Location of Anterior talofibular Anterior talofibular Anterior talofibular
tenderness ligament ligament ligament
Calcaneofibular Calcaneofibular
ligament ligament
Posterior talofibular
ligament
Edema and Slight and local Moderate and local Significant and
ecchymosis diffuse
Weight-bearing Full or partial Difficult without Impossible without
ability crutches significant pain

Ligament damage Stretched Partial tear Complete tear

Instability None None or slight Definite
CLASSIFICATION OF ANKLE SPRAIN
 Severity Pathology Signs and Symptoms Disability
Grade I Mild stretch No hemorrhage No or little limp
(mild) stable Min swelling Min functional loss
No instability
Point tenderness Difficulty hopping
Single ligament involved No ant drawer sign Recovery in 8 days (2-
(Usually ATFL) No varus laxity 10)
Grade II Large spectrum of Some hemorrhage Limp with walking
(moderate) injury Localized swelling Unable to toe raise
stable (margins of Achilles Unable to hop
Mild to moderate
tendon less defined) Unable to run
instability
Ant drawer sign may be Recovery in 20 days
Complete tear of ATFL/ present (10-30)
Partial tear of ATFL +CFL No varus laxity

Grade III Significant instability Diffuse swelling on both Unable to bear weight
(severe) two- sides of Achilles tendon fully
ligament Complete tear of Early hemorrhage Significant pain
unstable anterior capsule, ATFL, (+) Ant drawer’s sign inhibition
and CFL (+) varus laxity Initially almost complete
loss of ROM
Recovery in 40 days (30-
90)
 PLANTAR FASCIA

• Plantar Aponeurosis
• A broad, dense band of
longitudinally arranged
collagen fibers
• medial calcaneus to
phalanges
• Tightens with
dorsiflexion of the MTP
joints
WINDLASS EFFECT
WINDLASS TEST
ARCHES OF THE FOOT
MEDIAL LONGITUDINAL ARCH
LATERAL LONGITUDINAL ARCH

Abductor Digiti Minimi

FDB
TRANSVERSE ARCH
TYPES OF FOREFOOT
TYPES OF FOOT
 TYPES OF FOOT

Forward Progression of Toes

2>1>3>4>5 Morton’s Foot

Index minus
1>2>3>4>5 Egyptian Foot
Most common
Index plus
1=2>3>4>5 Squared Foot
Index plus-minus type
MUSCLES OF LOWER LIMB AND FOOT
 ANTERIOR COMPARTMENT
• Tibialis anterior (L4-L5)

• Extensor digitorum longus

• Peroneus tertius
• Extensor hallucis longus
• Extensor digitorum brevis
– All (L5-S1)
 LATERAL COMPARTMENT
• Peroneus longus

• Peroneus brevis

– (L5, S1, S2)

– PF & Evert
 POSTERIOR COMPARTMENT
Superficial layer:

• Gastrocnemius
• Plantaris
• Soleus
– S1,S2
SIMMOND’S/THOMPSON’S TEST
MATLES TEST
 POSTERIOR COMPARTMENT
Deep layer:

• Tibialis posterior
– (L4-L5)

• Flexor digitorum longus

– (S2,S3)
• Flexor hallucis longus
– (S2,S3)
MUSCLE OF THE SOLE OF THE FOOT
First layer Innervation

Abductor hallucis MPN

Flexor digitorum brevis MPN

Abductor digiti minimi LPN

Second layer Innervation

Quadratus plantae LPN

Lumbricals 1st: MPN; remainder: LPN

Third layer Innervation

Flexor hallucis brevis MPN

Adductor hallucis LPN

Flexor digiti minimi brevis LPN

Fourth layer Innervation

Interossei LPN
LUMBAR PLEXUS
SKIN SENSATION
LUMBOSACRAL PLEXUS
1. SGN
2. IGN
3. Sciatic
a. Tibial
• Sural (S1,S2)
• Medial Plantar nn (L4,5)
• Lateral Plantar nn (S1,S2)
b. Common Peroneal nn
• Deep peroneal nn (L4,5, S1,2)
• Superficial peroneal nn (L4,5,S1)
SKIN SENSATION
SKIN SENSATION
 Lumbar Root Syndromes
Reflexes/Special
Root Dermatome Muscle Weakness Paresthesias
Test Affected
Back, over trochanter, None None Groin, after
L1 groin holding posture,
which causes pain
Back, front of thigh to Psoas, hip adductors None Occasionally front
L2 knee of thigh

Back, upper buttock, Psoas, quadriceps – Knee jerk sluggish, Inner knee,
L3 front of the thigh and thigh wasting PKB positive, pain on anterior lower leg
knee, medial lower leg full SLR
Inner buttock, outer Tibialis anterior, SLR limited, neck- Medial aspect of
thigh, inside of leg, extensor hallucis flexion pain, weak or calf and ankle
L4
dorsum of foot, big toe absent knee jerk, side
flexion limited
Buttock, back and side of Extensor hallucis, SLR limited to one Lateral aspect of
thigh, lateral aspect of peroneals, gluteus side, neck-flexion leg, medial three
leg, dorsum of foot, medius, ankle pain, ankle jerk toes
L5
inner half of sole and dorsiflexors, decreased, crossed-
first, second and third hamstrings – calf leg raising -- pain
toes wasting
 Lumbar Root Syndromes
Reflexes/Special
Root Dermatome Muscle Weakness Paresthesias
Test Affected
Buttock, back of Calf and hamstrings, SLR limited, Lateral two toes,
thigh, and lower leg wasting of gluteals, Achilles reflex lateral foot,
S1 peroneals, plantarflexors weak or lateral leg to
absent knee, plantar
aspect of foot
Same as S1 Same as S1 except Same as S1 Lateral leg, knee,
S2
peroneals heel
Groin, inner thigh None None None
S3
to knee
Perineum, genitals, Bladder rectum None Saddle area,
S4 lower sacrum genitals, anus,
impotence
 Deep Tendon Reflexes
Pertinent
Reflex Site of Stimulus Normal Responses CNS
Segment
Patella Patellar tendon Leg extension L3-L4
Medial Semimebranosus Knee flexion/
L5, S1
Hamstrings tendon Muscle contraction
Lateral Biceps femoris Knee flexion/
S1-S2
Hamstrings tendon Muscle contraction
Tibialis posterior
Tibialis Plantarflexion of
tendon behind L4-L5
Posterior foot with inversion
medial malleolus
Plantarflexion of
Achilles Achilles tendon S1-S2
foot
Myotomes of the Lower Limb
Nerve Root Test Action
L1-L2 Hip flexion
L3 Knee extension
L4 Ankle dorsiflexion
L5 Big toe extension
Ankle plantarflexion
S1 Ankle eversion
Hip extension
S2 Knee flexion
No specific test action;
S3
intrinsic foot muscles
 Now we see things imperfectly as in a
cloudy mirror, but then we will see
everything with perfect clarity. All that
I know now is partial and incomplete,
but then I will know everything
completely, just as God now knows me
completely.

1 Corinthians 13:12