5 Lower Limb.pptx

ANATOMY OF MUSCULOSKELETAL SYSTEM: Professor: Prof. Maurilio Marcacci E mail: [email protected] A. RUFFINI 1864-1929 “” SHAPE IS THE EXPRESSION OF FUNCTION” “Biomechanics is the science that examines forces acting upon and within a biological structure and effects produced by such...

ANATOMY OF MUSCULOSKELETAL SYSTEM: Professor: Prof. Maurilio Marcacci E mail: [email protected] A. RUFFINI 1864-1929 “” SHAPE IS THE EXPRESSION OF FUNCTION” “Biomechanics is the science that examines forces acting upon and within a biological structure and effects produced by such forces.” - Jim Hay 2 NEE – FORCE CLOSED MECHANISM IP- SELF CLOSED MECHANISM “Hips don’t lie” • Strong bones • Powerful muscles • Strongest ligaments • Tremendous degree of forces acting around • Mobile as well as stable • “Self closed mechanism” 4 The hip: Mobile and stable • Strong bones • Powerful muscles • Strongest ligaments • Depth of acetabulum , narrowing of mouth by acetabular labrum • Length and obliquity of neck of femur • MOBILITY is due to the long neck which is narrower thanthe diameter of the head Bony anatomy ✤ Ball and socket synovial joint ✤ Acetabulum ✤ Acetabular labrum ✤ Femoral head ✤ Femoral neck 9 Femoral neck • Angulated in relation to the shaft in 2 planes : sagittal & coronal • Neck Shaft angle – 140 deg at birth – 120-135 deg in adult • Ante version – Anteverted 40 deg at birth – 12-15 deg in adults Femoral neck Angulated in relation to the shaft in two planes - sagittal(neck shaft angle) and coronal(ante-version). (a) Normal femoral neck angle, (b) a decreased femoral neck angle (coxa vara) (c) an increased femoral neck angle (coxa valga) 11 Anteversion • Angle between the neck and shaft in the coronal plane(viewed from above) • Axis of the neck and the trans-condylar axis • 15-20 degrees anterior to coronalplane 12 Acetabular version Anteverted(forward) 15 degree Abducted(laterally) 45 degree 13 Muscles 14 Hip biomechanics 16 Centre of gravity In humans- just anterior to S2 17 Hip joint extension through posterior tilting of the pelvis Hip flexion through anterior tilting of the pelvis Joint reaction force • Defined as force generated within a joint in response to forces acting on the joint • In the hip, it is the result of the need to balance the moment arms of the body weight and abductor tension • Maintains a level pelvis 27 28 Biomechanics- HIP • First order lever fulcrum (hip joint) forces on either side of fulcrum i.e, body weight & abductor tension Biomechanics • Forcesacting across hip joint Body weight Abductor muscles force Joint reaction force Biomechanics Tomai ntain st able hip, torques produced by the body weight is countered by abductor muscles pull. Abductor force X lever arm1 = weight X leverarm2 Bi-pedal stance BW ✤ Body weight is equally distributed across both hips ✤ Each hip supports 4/6th or 1/3rd the BW ✤ Little or no muscle force required to maintain equilibrium R R 33 Single leg stance- Right limb M R 34 Abductor force vector- M Body wt vector- K JRF vector- R BW lever arm- h’ Ab lever arm-h h’=3h 35 Coxa Valga ✤ GT is lower than normal ✤ Reduced abductor lever arm ✤ Increased joint reaction force 38 Coxa Vara ✤ GT is higher than normal ✤ Increased abductor lever arm ✤ Decreased joint reaction force ✤ But…abductor inefficiency 39 TRENDELENBURG SIGN Stand on LEFTleg—if RIGHThip drops, then it's a + LEFT Trendelenburg The contralateral side drops because the ipsilateral hip abductors do not stabilizethe pelvis to prevent the droop. Compensatory Lateral Lean of the Trunk • the compensatory lateral lean of the trunk toward the painful stance limb will swing the line of gravity closer to the hip joint, thereby reducing the gravitational moment arm • It does reduce the gravitational torque 1 2 normal affected Cane and Limp • Both decrease the force exerted by the body wt on the loaded hip • Cane: transmits part of the body wt to the ground thereby decreasing the muscular force required for balancing • Limping shortens the body lever arm by shifting the centre of gravity to the loaded hip Cane & Limp ✤ Both decrease the force exerted by the BW on the loaded hip ✤ Cane transmits part of BW to the ground and also provides a counter acting force thereby decreasing the muscular force required for balancing ✤ Limping shortens the body lever arm by shifting the centre of gravity to the loaded hip 41 Use of a Cane Ipsilaterally Body wt passes mainly through cane Use of a Cane Contralaterally Cane assists the abductor muscles in providing counter torque Surface anatomy of the thigh Surface features of • Thigh the – Sartorius muscle – Quadriceps muscle femoris – Adductor longus muscle – Hamstring muscles – Femoral triange Anatomy of the thigh • The anterior compartment muscles of th thigh flex the femur at the hip and exten the leg at the knee. • The posterior compartment muscles of the thigh extend the thigh and flex the leg. the thigh. • The medial compartment muscles all adduct Anterior Compartment Muscles: • Iliopsoas. • Sartorius. • Quadriceps: Rectus femoris. Vastus lateralis. Vastus intermedius. Vastus medialis Anterior Compartment • Innervation: Femoral Nerve: • Action: Hip flexion. Knee extension. Anterior Compartment • Iliopsoas – Origin - Ilia, sacrum, lumbar vertebrae – Insertion – lesser trochanter – Action – flexor of thigh nerve– – femoral Innervation Medial Compartment • Muscles: Gracilis. Adductor longus. Adductor brevis. Adductor magnus. Pectineus Posterior Compartment Posterior Compartment THE LOWER LIMB KNEE AND ANKLE ARTICULAR ANATOMY OF THE KNEE DIARTHROSIS OF DIFFICULT CLASSIFICATION  TIBIOFEMORAL GYGLIMUS (HINGE) a freely moving joint in which the bones are so articulated as to allow extensive movement in one plane ARTHRODIAL (GLYDING) a freely moving joint in which the articulations allow only gliding motions  PATELLOFEMORAL COMPLEX ACTIVITY TWO OPPOSITE FUNCTIONS:  STABLE IN EXTENSION TENSION ACL-PCL-MCL-LCL  MOTILE IN FLEXION 6 DEGREES OF FREEDOM  FLEXION-EXTENSION  ABDUCTION-ADDUCTION  INTERNAL/EXTERNAL ROTATION FEMORAL ARTICULAR SURFACE RAGGI DI CURVATURA DIFFERENTI Part of the patello-femoral joint Part of the tibio-femoral joint MEDIAL FEMORAL CONDYLE Martelli S., Pinskerova 2002 POSTERIOR articular surface (FLEXION FACET) ANTERIOR articular surface (EXTENSION FACET) ARC of 110° with a RADIUS of 22 MM ARC of 50° with a radius of 32 mm LATERAL FEMORAL CONDYLE Martelli S., Pinskerova 2002 POSTERIOR ARTICULAR SURFACE ARC of 114° RADIUS of 21 mm TIBIAL SURFACE LATERAL MEDIAL  POSTERIORLY FLATHORIZONTAL  ANTERIORLY it SLOPES UPWARD  CONVEX MA  THE ARTICULAR SURFACE IS FLAT MENISCI Due dischi di fibrocartilagine The LATERAL meniscus is 4/5 of a ring The MEDIAL meniscus is c-shaped Their principal functions are: -Increasing the contact surface of the femur with the tibia -Reducing friction between the joint segments and serve as a shock absorbing MENISCI sono strutture mobili They move backwards during flexion following the movement of the condyles. During extension it is the opposite. 1) The knee axis Normal range 5-6° di valgus (7-8° femoral valgus + 1-2° tibial varus) Genu VALGUM : Compression and damage of the lateral compartment. The bearing axis passes through the lateral condyle and the lateral half of the knee joint is overloaded. Genu VARUM : Compression and damage of the medial compartment. The bearing axis passes through the medial condyle and the medial half of the knee joint is overloaded. . 2) Anatomical and mechanical axis of the knee ANATOMICAL AXIS: Coincide with the axis of the diaphysis. It forms an angle of 6-7° in valgus with respect to the mechanical axis. MECHANICAL AXIS: It connects the rotation center of the head of the femur with the intercondylar fossa. 3) Anatomical and mechanical axis of the tibia They coincide, 1-2° of varus Epiphyseal axis of the tibia It is the line connecting Varus Knee 1) The middle of the tibial joint line and 2) The middle of the line connecting the tibial epiphysis This line forms a constant angle of 90 +/- 2 degrees to the lateral tibial plateau. - In a knee with a normal axis it corresponds to the line of the anatomical or mechanical axis - In a tibia vara it passes externally to the mechanical axis - In a tibia valga it passes internally to the mechanical axis = epiphyseal axis = mechanical axis = epiphyseal line FLEXION-EXTENSION XX AXIS´ (sagittal plane) ± TEA (transepicondylar axis) ACL/PCL MCL/LCL BIOMECHANICS OF FLEX/EXT MAX FLEXION  Resultant of a complex muscular mechanism, involving a number of muscles in the posterior compartment of the thighE SEMIMEMBRANOSO BIOMECHANICS OF FLEX/EXT FLEXORS HAMSTRINGS - Bicep femoris muscle - Semitendinosus - Semimembranosus They are assisted by: - Gracilis - Sartorius - Popliteus - Gastroctemius BIOMECHANICS OF FLEX/EXT EXTENSORSS QUADRICEPS FEMORIS - Rectus femoris - Vastus lateralis - Vastus intermedius - Vastus medialis BIOMECHANICS FLEX/EXT MAX FLEXION Detension LCA, LCP, LCL Partial tensioning of LCM Tibio-patellar contact BIOMECHANICS FLEX/EXT MAX EXTENSION  LIMITED BY THE TENSIONING OF LCA/LCP  PROXIMALIZATION OF THE PATELLA  5° OF HYPEREXTENSION ARE ALLOWED WITH EXTENDED THIGH BIOMECHANICS FLEX/EXT Si realizza FORWARD ROLL + ROLL BACK of femoral condyles ROLL BACK IN CASE OF ROLLING IT WOULD DISLOCATE IN CASE OF GLIDING FLEXION WOULD BE POOR ROLLING + GLIDING= + STABILITY and + FLEXION THE FIRST BIOMECHANICAL MODEL 4 BARS LINKAGE  BASED ON THE ROLL-BACK MODEL  IT INCREASES FLEXION DELAYING THE CONTACT OF THE FEMUR WITH THE TIBIA.  IT IMPROVES THE LEVER ARM OF THE EXTENSION APPARATUS WITH A FLEXED KNEE 4 BARS LINKAGE ACL and PCL should be:  ISOMETRIC IN THE ENTIRE ROM  STIFF AND NOT EXTENDIBLE  ISOTROPIC  UNIPLANAR BIOMECHANICS FLEX/EXT LEGAMENTI CROCIATI PRIORITY ROLE IN ROLL-BACK FLEX ACL is responsible for the forward gliding of the condyle and the roll back. EXT PCL is responsible for the back gliding with roll forward. BIOMECHANICS FLEX/EXT There is a movement of automatic rotation  extension = external rotation  flexion =internal rotation BIOMECHANICS FLEX/EXT SCREW-HOME Screw-home rotation allows for full knee extension and flexion. During the last 20° of knee extension the tibia must externally rotate of about 10°. The foot tip externally rotate in the last 15-20° of knee extension. PATELLO-FEMORAL JOINT THE PATELLA INCREASES THE INSERTION ANGLE OF THE PATELLAR TENDON AND ALSO THE EFFICACY OF THE QUADRICEPS TENSION PRODUCED DURING EXTENSION. PATELLAR STABILIZERS OSTEOARTICULAR (ANATOMICAL)  PASSIVE (STATIC)  ACTIVE (DINAMIC) Q ANGLE (or patello-femoral) Is the angle formed by the quadriceps muscle (mainly the rectus) and the patellar tendon. It is formed by a line drawn from the anterior superior iliac spine (ASIS) to the center of the patella. A second line is drawn from the center of the patella to the tibial tubercle. The angle formed by the two angles is called the Q-angle. The patello-femoral joint is affected by the axial and torsional deformities of the whole lower limb. ANATOMY AND BIOMECHANICS OF THE FOOT AND ANKLE PROF. M. MARCACCI ANKLE GINGLYMUS JOINT HINGE ANKLE TALUS •BICONCAVE DOME, CENTRAL SULCUS (1,2) – WIDER ANTERIORLY THAN POSTERIORLY 1. 2. Close JR., Inman, VT (1952). “The action of the ankle joint”. Prosthetic Devices Research Project, Institute of Engineering Research, University of California, Berkeley, Ser. 11, Issue 22. Inman, VT: “The Joints of the ankle” Williams and Wilkins, Baltimor, 1976 ANKLE TALUS •BIOCONCAVE DOME, CENTRAL SULCUS (1,2) – AXIALLY, WIDER ANTERIORLY THAN POSTERIORLY – RADIUS OF CURVATURE GREATER LATERALLY 1. 2. Close JR., Inman, VT (1952). “The action of the ankle joint”. Prosthetic Devices Research Project, Institute of Engineering Research, University of California, Berkeley, Ser. 11, Issue 22. Inman, VT: “The Joints of the ankle” Williams and Wilkins, Baltimore, 1976 ANKLE • LATERAL ANKLE LIGAMENTS (1-4) – ATFL (5 and 6) • Strain in plantar flexion, inversion, and internal rotation – CFL (10) • Strain in dorsiflexion and inversion – PTFL 1. Goláno et al: “Anatomy of the ankle ligaments: a pictorial essay” KSSTA (2016) 24:944–956 2. Fong BL, Brunet ME. The leg, ankle, and foot. Perrin DH, ed. The Injured Athlete. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1999. 432-9. 3. Jayanthi N. Lower leg and ankle. McKeag DB, Moeller J, eds. ACSM's Primary Care Sports Medicine; 2007. 4. Magee D. Lower leg, ankle, and foot. Orthopedic Physical Assessment. 4th ed. Toronto, Canada: Elsevier Sciences; 2006 ANKLE • LATERAL ANKLE LIGAMENTS (1-4) – ATFL • Strain in plantar flexion, inversion, and internal rotation – CFL • Strain in dorsiflexion and inversion – PTFL (6) • Talar dislocation ANKLE DELTOID LIGAMENT – Fan-shaped – Descriptions vary widely – Superficial layer • Tibionavicular (1) • Sup post tibiotalar – Deep layer • Deep ant tibiotalar • Tibiocalcaneal (3) • Deep post tibiotalar (4) 1. 2. Milner CE, Soames RW (1998) Anatomy of the collateral ligaments of the human ankle joint. Foot Ankle Int 19:757–760 Goláno et al: “Anatomy of the ankle ligaments: a pictorial essay” KSSTA (2016) 24:944–956 ANKLE • SYNDESMOSIS – Incisura fibularis – Fibular facet – Ligaments • Ant inf tibiofibular lig. (35%) • Post inf tibiofibular lig. (43%) • Interosseous lig. (22%) – Interosseous membrane 1. 2. Goláno et al: “Anatomy of the ankle ligaments: a pictorial essay” KSSTA (2016) 24:944–956 Hoefnagels EM, Waites MD, Wing ID et al (2007) Biomechanical comparison of the interosseous tibiofibular ligament and the anterior tibiofibular ligament. Foot Ankle Int 28:602–604 ANKLE - BIOMECHANICS BIMALLEOLAR AXIS (1) – CORONAL 82° ± 4° – AXIAL 13-18º 1. Inman V: The joints of the ankle. 1976 Williams & Wilkins Baltimore ANKLE - BIOMECHANICS BIMALLEOLAR AXIS ROM (1,2) – DORSIFLEXION 10-25º • 10º TO RUN – PLANTARFLEXION 2050º • WALKING 24º 1. 2. Berry FJ: Angle variation patterns of normal hip, knee and ankle in different operations. Univ Calif Prosthet Devices Res Proj Rep. 1952 Ryker NJ: Glass walkway studies of normal subjects during normal walking. Univ Calif Prosthet Devices Res Proj Rep. 1952 ANKLE - BIOMECHANICS MALLEOLAR AXIS OM (1,2) – CLOSED KINETIC CHAIN • DORSIFLEX  tibia IR • PLANTAR FLEX  tibia ER 1. 2. Berry FJ: Angle variation patterns of normal hip, knee and ankle in different operations. Univ Calif Prosthet Devices Res Proj Rep. 1952 Ryker NJ: Glass walkway studies of normal subjects during normal walking. Univ Calif Prosthet Devices Res Proj Rep. 1952 ANKLE - BIOMECHANICS BIMALLEOLAR AXIS ROM SYNDESMOSIS MOVEMENT – FIBULA ER – FIBULA PROX / DISTAL MIGRATION 1. 2. Goláno et al: “Anatomy of the ankle ligaments: a pictorial essay” KSSTA (2016) 24:944–956 Hoefnagels EM, Waites MD, Wing ID et al (2007) Biomechanical comparison of the interosseous tibiofibular ligament and the anterior tibiofibular ligament. Foot Ankle Int 28:602–604 ANKLE - BIOMECHANICS BIMALLEOLAR AXIS ROM SYNDESMOSIS MOVEMENT 85-90% 10-15% AXIAL LOAD 1. 2. Goláno et al: “Anatomy of the ankle ligaments: a pictorial essay” KSSTA (2016) 24:944–956 Hoefnagels EM, Waites MD, Wing ID et al (2007) Biomechanical comparison of the interosseous tibiofibular ligament and the anterior tibiofibular ligament. Foot Ankle Int 28:602–604 HINDFOOT and MIDFOOT • CHOPART JOINT (TRANSVERSE TARSAL) – TALONAVICULAR • SPRING LIGAMENT(1,2) – Superomedial CNL – Inferoplantar CNL – Medioplantar oblique CNL 1. Davis, WH; Sobel, M; DiCarlo, EF; Torzilli, PA; Deng, X; Gep- pert, MJ; Patel, MB; Deland, JT: Gross, histological and micro- vascular anatomy and biomechanical testing of the spring ligament. Foot Ankle Int. 17(2):95 – 102, 1996. 2. Mengiardi et al: “Spring Ligament Complex: MR Imaging–Anatomic Correlation and Findings in Asymptomatic Subjects” RSNA Radiology, 237, 1, 2005 HINDFOOT and MIDFOOT • CHOPART JOINT (TRANSVERSE TARSAL) – TALONAVICULAR • Spring ligament (1,2) • Acetabulum pedis (3) – Ball and socket 3. Sarrafian SK: Biomechanics of the subtalar joint complex. Clin Orthop Relat Res. 290:17-26 1993 MUSCLES • DEEP POSTERIO COMP – Tarsal tunnel: AM  PL • Tom – PTT • Dick – FDL • Very – Vein • Angry – Post tibial artery • Nervous - Tibial nerve • Harry - FHL MUSCLES • LATERAL COMP – Fibro-osseous tunnels • SPR FOOT BIOMECHANICS DURING GAIT (STEP CYCLE) THE FOOT IS PASSING CONTINUOUSLY FROM SUPINATION TO PRONATION: • PRONATION IS MAINLY ACHIEVED DURING THE PHASE OF CONTACT WITH THE SOIL • SUPINATION IS MAINLY ACHIEVED DURING THE PUSH PHASE FOOT BIOMECHANICS • DURING PRONATION THE FOOT BEHAVES AS A FLEXIBLE STRUCTURE THAT CAN BETTER ADAPT TO THE GROUND • DURING SUPINATION THE FOOT BECOMES A RIGID STRUCTURE IN ORDER TO PROVIDE ADEQUATE PROPULSION FOOT BIOMECHANICS PRONATION SUPINATION FOOT BIOMECHANICS PRONATION FOOT BIOMECHANICS SUPINATION FOOT BIOMECHANICS PRONATION AND SUPINATION, BOTH IN STATIC AND IN DYNAMIC PHASE, ALTERNATE IN A MORE OR LESS RHYTHMIC WAY SO THAT THE FOOT IS IN A CONTINUOUS STATE OF “VARIABILITY “ FOOT BIOMECHANICS DURING WALKING, IN THE ADAPTATION TO THE GROUND, THE FOOT BECOMES FLEXIBLE WITHOUT KNOWING WHAT THE ENVIRONMENT RESERVES AND OBTAINS THE APPROPRIATE INFORMATION THROUGH ITS RICH PROPRIOCEPTIVE APPARATE. FOOT BIOMECHANICS MUSCLES CONTRIBUTES TO THE STABILIZATION OF THE STRUCTURE AND ALLOW THE COMPLEX THREEPLAN MOTION OF PRONATION AND SUPINATION FOOT BIOMECHANICS MUSCLES ACT AS COMPARTMENT IN HARMONY WITH ARTICULAR CONSTRAINTS AND DEPENDING ON THEIR RELATIONSHIP WITH JOINT AXES MEDIAL LATERAL SUPINATOR PRONATOR Anterior Compartment Anterior compartment contains the muscles that dorsiflex the ankle and extend the toes. • Contains Anterior Tibial Nerve • Contains Anterior Tibial Artery. Anterior Compartment Tibialis anterior (TA) • Origin -lateral condyle of tibia, upper half/lateral surface of tibia, interosseous membrane • Insertion - medial st cuneiform, base of 1 metatarsal • Nerve - deep fibular (peroneal) (L4-5) • Action - ankle dorsiflexion, forefoot inversion Anterior Compartment Extensor Digitorum Longus (EDL) • Origin - lateral condyle of tibia, ant surface of fibula, interosseous membrane • Insertion - dorsum of base of middle phalanx, dorsum of base of distal phalanx • Nerve - deep fibular (peroneal) (L5-S1) • Action - extension of toes, dorsiflexion of ankle Anterior Compartment Extensor Hallucis Longus (EHL) • Origin - middle ½ of ant fibula, IM • Insertion - distal phalanx of the great toe • Nerve - deep fibular (peroneal) (L5-S1) • Action - extend the great toe, dorsiflex ankle Anterior Compartment Fibularis (Peroneus) Tertius • Origin - distal 1/3 ant fibula, interosseous membrane • Insertion - dorsum shaft of 5thmetatarsal • Nerve - deep fibular (peroneal) (L5-S1) • Action - forefoot eversion, weak ankle dorsiflexion Lateral Compartment Lateral compartment contains the muscles that Everters of the foot (turns foot outward) Contains the superficial peroneal nerve Lateral Compartment Fibularis (Peroneus) Longus (FL) • Origin - head, upper 2/3 lateral surface of fibula Its tendon courses behind lateral malleolus, underneath the fibular trochlea, and lies in the groove in the cuboid bone before going to its place of insertion • Insertion - inferolateral surface of medial cuneiform , metatarsal 1st on its inferior surface • Nerve - superficial fibular (peroneal) (L5-S1) • Action - forefoot eversion, ankle plantar flexion Lateral Compartment Fibularis (Peroneus) Brevis (FB) • Origin - lower 2/3 lateral fibula Courses behind lateral malleolus and underneath the fibular trochlea • Insertion - tuberosity on base of 5thmetatarsal • Nerve - superficial fibular (peroneal) (L5-S1) • Action - forefoot eversion, ankle plantar flexion Superficial) Posterior compartme Posterior compartment contains the plantar flexors muscles. Contains: • Short saphenous vein • Peroneal communicating branch of the common peroneal nerve • Medial cutaneous nerve of the calf • Sural nerve Superficial) Posterior compartme Muscles: • Gastrocnemius • Plantaris • Soleus Deep Posterior Compartment Blood supply: The posterior tibial artery Innervation: Tibial nerve. Deep Posterior Compartment Muscles: • Popliteus • Flexor digitorum longus • Flexor hallucis longus • Tibialis posterior Deep Posterior Compartment • Popliteus –Origin - lateral condyle of femur and lateral meniscus –Insertion– proximal shaft of tibia –Nerve -Tibial nerve –Action– flex and medially rotate leg Deep Posterior Compartment • Flexor digitorum longus –Origin - shaft of tibia –Insertion - distal phalanges of toe 2-5 –Nerve -Tibial nerve –Action – plantarflex and invert foot, flex toe Deep Posterior Compartment • Flexor hallucis longus –Origin - shaft of fibula –Insertion - base of distal phalanx of big toe. –Nerve -Tibial nerve –Action - plantarflex and invert foot, flex toe