Objective 3: Recognize common injuries to the lower extremity…

 Bones Femur Patella Tibia  Tibial Tuberosity  Medial Malleolus Fibula  Lateral Malleolus

 Bones Tarsals  Calcaneus  Talus  Metatarsals  Phalanges

 Joints - Knee Tibiofemoral – allows knee flexion/extension Patellofemoral

 Joints – Foot & ankle Tibiotalar (ankle joint)  Allows plantar and dorsiflexion Subtalar  Joint between talus and calcaneus  Allows inversion and eversion Midfoot – where tarsals meet metatarsals Metatarsal Phalengeal (MP)  Allows toe flexion and extension Interphalengeal (PIP & DIP)  Allows flexion and extension of toe segments

 Menisci of the knee Lateral Meniscus – Joint cartilage that deepens the knee joint. Medial Meniscus – Joint cartilage that deepens the knee joint. Has a deep attachment to the MCL. Outer 1/3 has a blood supply, rest is avascular.

 Ligaments of Knee  Medial Collateral (MCL)  Resists valgus forces  Lateral Collateral (LCL)  Resists varus forces  Anterior Cruciate (ACL)  Resists anterior translation of the tibia  Posterior Cruciate (PCL)  Resists posterior translation of the tibia

 Major Tendons Patellar Tendon – attaches the quadricep muscles to the tibia Achilles Tendon – attaches the calf muscles to the calcaneus

 Ankle Ligaments Anterior Tibiofibular – resists forced dorsiflexion and rotation of the talus Anterior Talofibular – resists plantarflexion and inversion forces Deltoid – resists eversion forces

MuscleLocationFunction Quadriceps Femoris  Rectus Femoris  Vastus Medialis  Vastus Lateralis  Vastus Intermedius Anterior ThighExtends the knee Hamstrings  Semimembranosus  Semitendinosus  Biceps Femoris Posterior ThighFlexes the knee Tibialis AnteriorAnterior lower legDorsiflexion of ankle GastrocnemiusPosterior lower legPlantar flexion of ankle; assists in knee flexion SoleusDeep to the gastrocnemiusPlantar flexion of the ankle Tibialis PosteriorPosteromedial lower legInversion of the foot/ankle Peroneus LongusLateral lower legEversion of the foot/ankle Peroneus BrevisLateral lower legEversion of the foot/ankle

 Number #1  Superficial, midline  Crosses the hip

 Number #2  Found on the lateral side  Large Strong muscle

 Number #3  Found on the medial side.  Tear drop shape

 Number #4  Deepest muscle  Found between VMO and VLO

 Medial side  Deep (found under the semitendinosus)

 Medial side  Superficial

 2 Heads (origins)  Found on the lateral side

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies Severe impact to the thigh musculature Pain, loss of function, swelling, decreased ROM Ice, compression with knee flexed. MUST be managed appropriately to avoid complications. Protective equipment Thigh Contusion

Special TestWhat do you feel? Bilateral Comparison Indications Strength Testing Pain, Weakness PalpationWhat do you feel? Bilateral Comparison Indications Over painful area of muscle/tendon Pain, Swelling, deformity, Lack of structure. temperature, Crepitus

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies Sudden stretch or sudden contraction Pain, spasm, loss of function, swelling, possible deformity. RICE, flexibility and strengthening exercises. Proper warm- up, stretching and strengthening. Muscle Strains – Quadricep/Hamstring

PalpationWhat do you feel? Bilateral Comparison Indications Over painful area of muscle/tendon Pain, Swelling, deformity, Lack of structure. temperature, Crepitus Special Test What do you feel? Bilateral Comparison Indications Strength Testing Pain, Decreased Strength

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies Valgus force or tibial external rotation Pain medial knee, mild swelling, joint stiffness, possible joint instability. RICE, ROM and strengthening exercises, restrict activity until asymptomatic. Lower extremity strengthening and conditioning. MCL Sprain

PalpationWhat do you feel? Bilateral Comparison Indications Medial joint line of knee. Medial Proximal portion of tibia Pain, Swelling, deformity, Special TestWhat do you feel? Bilateral Comparison Indications Valgus Stress Test (Place a valgus force on the knee 0 and 30 degrees) Joint Laxity, Pain

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies Varus force or tibial internal rotation. Pain lateral knee, mild swelling, possible joint laxity. RICE, ROM and strengthening exercises, restrict activity until asymptomatic. Lower extremity strengthening and conditioning. LCL Sprain

Special TestWhat do you feel? Bilateral Comparison Indications Varus Stress Test (Place a varus force on the knee 0 and 30 degrees) Joint Laxity, Pain PalpationWhat do you feel? Bilateral Comparison Indications Lateral joint line of knee. Pain, Swelling, deformity,

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies Noncontact: - decellereation - foot planted - rotation - valgus stress Contact: hyperextension w/foot planted Hears or feels a “pop”, rapid swelling, joint instability. RICE, restore ROM and strength, surgery required to reconstruct the ligament. Lower extremity strengthening and conditioning. ACL Sprain ACL Injury Video

PalpationWhat do you feel? Bilateral Comparison Indications Anterior Joint Line Pain, Swelling, Special TestWhat do you feel? Bilateral Comparison Indications Lachman TestPain, Joint laxity, soft end feel

Special TestWhat do you feel? Bilateral Comparison Indications Anterior Drawer Test Pain, Joint laxity, soft end feel

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies -Falling on bent knee - direct force to front of knee - rotational forces Hears or feels a “pop”, minimal swelling, posterior tibial sag. RICE, restore ROM and strength. Surgery is controversial. Lower extremity strengthening and conditioning. PCL Sprain

PalpationWhat do you feel? Bilateral Comparison Indications Posterior of knee. Anterior portion of knee Pain, Swelling, deformity. Step Deformity Special Test What do you feel? Bilateral Comparison Indications Posterior Sag Sign Pain, Step deformity,

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies Weight bearing with rotational force. Swelling, joint line pain, loss of motion, locking or giving way. RICE Avascular area: Surgically trimmed and smoothed. Vascular area: Surgically repaired. Lower extremity strengthening and conditioning. Meniscus Tear Medial Meniscus Injury and Surgery Video Link

PalpationWhat do you feel? Bilateral Comparison Indications Knee bent to 45 degrees. Anterior joint line. Medial/Lateral Pain, Swelling, Special TestWhat do you feel? Bilateral Comparison Indications Compression Distraction Pain, Pinching

Special TestWhat do you feel? Bilateral Comparison Indications Mcmurray’sPain, Pinching, Instability Special TestWhat do you feel? Bilateral Comparison Indications Thessely’s (0 – 30 degrees bend at knee) Pain, Pinching

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies Combination of foot planted, deceleration, and change of direction. Obvious deformity, pain, swelling, limited ROM. RICE and immobilization initially, then ROM and strengthening exercises. McConnell taping or bracing. Lower extremity strengthening and conditioning. Patellar Subluxation/Dislocation

PalpationWhat do you feel?Bilateral Comparison Indications Structures medial and slightly superior to patella. Lateral femoral condyle Pain, Swelling, deformity, Pain (indicates bruising from patella) Special Test What do you feel? Bilateral Comparison Indications Apprehension Test Excessive lateral tracking, pain (medial or lateral)

Mechanism of Injury Signs and SymptomsTreatmentPrevention Strategies Repetitive deceleration Vague pain and tenderness of patellar tendon that worsens with running/jumping activities. Rest, ice, NSAID medications, patellar strap, friction massage, and lower extremity strengthening. Progressive increase in frequency/intensity of training. Lower extremity strengthening and conditioning. Patellar Tendinitis – “Jumper’s Knee”

PalpationWhat do you feel? Bilateral Comparison Indications Patellar Tendon. Infrapatellar Fat pad. (behind patellar tendon) Pain, Swelling, deformity, Strength Testing MeasurementBilateral Comparison Indications Knee extensionDecrease ROM, Pain over patellar tendon

Mechanism of Injury Signs and SymptomsTreatmentPrevention Strategies -Tight hamstring and calf muscles -Increased Q-angle -Weak quadriceps muscles -Poor foot mechanics Tenderness of one or more patellar edge, dull ache, crepitus, pain with compression, positive Apprehension test. NSAIDs, quadricep strengthening, sleeve with buttress and/or McConnell taping, orthotic foot insert. Lower extremity strengthening and conditioning. Patellofemoral Syndrome

PalpationWhat do you feel? Bilateral Comparison Indications Patellar tendon and soft tissue structures around the patella. Pain, Swelling, deformity, Point tenderness Special TestMeasurementBilateral Comparison Indications Patellar Orientation (Tilt, Glide, Rotation) Pain in glide, maltracking patella

Mechanism of Injury Signs and SymptomsTreatmentPrevention Strategies Repetitive running activities. Diffuse pain in distal medial tibia, increasing with activity. Correct faulty foot mechanics with footwear, or orthotic foot insert, calf stretching Appropriate footwear for activity, lower leg flexibility and strengthening, orthotic foot inserts. Medial Tibial Stress Syndrome – “Shin Splints”

PalpationWhat do you feel?Bilateral Comparison Indications Posterior Medial Portion of tibia Pain, Swelling, Gait AnalysisWhat do you See?Bilateral Comparison Indications Watch Patient walk, Pay attention to foot, Knee, and hip mechanics Abnormal Gait, Pronation, Toe out Gait

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies Inversion: forced inversion and plantar flexion “rolling” Pain, swelling, decreased ROM, possible joint laxity. RICE, symptomatic modalities, taping and/or bracing. Appropriate footwear for activity, lower leg strengthening, proprioceptive training, taping and/or bracing of joint. Ankle Sprains – Lateral

PalpationWhat do you feel?Bilateral Comparison Indications Anterior Inferior of lateral Malleolus (lateral ankle bone) “Sinus Tarsi” Pain, Swelling, Special TestWhat do you feel? Bilateral Comparison Indications Anterior Drawer (ankle plantar flexed degrees) (anterior slide of talus) Pain, Joint laxity

Special TestWhat do you feel? Bilateral Comparison Indications Talar tilt (10-20 degrees) Tilt talus inward Pain, Joint laxity

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies Eversion: forced eversion of ankle – high risk for fracture. Pain, swelling, decreased ROM, possible joint laxity. RICE, symptomatic modalities, taping and/or bracing. Appropriate footwear for activity, lower leg strengthening, proprioceptive training, taping and/or bracing of joint. Ankle Sprains – Medial

PalpationWhat do you feel?Bilateral Comparison Indications Inferior to medial malleolus (medial ankle bone) Pain, Swelling, Special TestWhat do you feel? Bilateral Comparison Indications Medial Talar tilt (10-20 degrees) tilt talus outward Pain, Joint Laxity

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies Syndesmosis (high): forced inversion with rotation of the talus. Pain, swelling, decreased ROM, possible joint laxity. RICE, symptomatic modalities, taping and/or bracing. Appropriate footwear for activity, lower leg strengthening, proprioceptive training, taping and/or bracing of joint. Ankle Sprains – Syndesmotic (High)

PalpationWhat do you feel?Bilateral Comparison Indications Distal portion of Tibia and Fibula Pain, Swelling, Special TestWhat do you feel? Bilateral Comparison Indications Kliegers Test (Dorsiflexion and Eversion Pain, Possible laxity.

Special TestWhat do you feel? Bilateral Comparison Indications Squeeze Test (Squeeze mid Tibia/Fibula) Pain over distal aspect of Anterior Tibiofibular Ligament

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies Tight calf muscles, poor arch support, possible leg length discrepancy, over striding while running. Medial heel pain, particularly in the morning; pain with forced dorsiflexion of the toes. Calf stretching, plantar fascial stretching, heel cup, orthotic foot inserts. Calf flexibility, correction of faulty foot mechanics. Plantar Fasciitis

Special TestWhat do you feel? Bilateral Comparison Indications Extension of toes with Dorsiflexion Pain PalpationWhat do you feel?Bilateral Comparison Indications Medial Longitudinal Arch (Common Arch of foot) Pain, Swelling,

Mechanism of Injury Signs and Symptoms TreatmentPrevention Strategies Hyperextension sprain of the great toe. MP joint. Can be related to either trauma or overuse. Pain at MP joint of great toe, increasing with extension of the joint. Steel toe insoles or taping, symptomatic modalities. Appropriate footwear, correction of faulty foot mechanics. “Turf Toe”

Special TestWhat do you feel? Bilateral Comparison Indications Extension/ Flexion of Toe Active and Passive Pain PalpationWhat do you feel?Bilateral Comparison Indications Metatarsal Phalangeal joint (Base of big toe) Pain, Swelling