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Knee & Lower Leg

Anatomy Knee & Leg

To better understand how knee problems occur, it is important to understand some of the anatomy of the knee joint and how the parts of the knee work together to maintain normal function.

First, we will define some common anatomic terms as they relate to the knee. This will make it clearer as we talk about the structures later.

Many parts of the body have duplicates. So it is common to describe parts of the body using terms that define where the part is in relation to an imaginary line drawn through the middle of the body. For example, medialmeans closer to the midline. So the medial side of the knee is the side that is closest to the other knee. Thelateral side of the knee is the side that is away from the other knee. Structures on the medial side usually have medial as part of their name, such as the medial meniscus. The term anterior refers to the front of the knee, while the term posterior refers to the back of the knee. So the anterior cruciate ligament is in front of the posterior cruciate ligament.

 

Important Structures

The important parts of the knee include

  • bones and joints
  • ligaments and tendons
  • muscles
  • nerves
  • blood vessels

Bones and Joints

The knee is the meeting place of two important bones in the leg, the femur (the thighbone) and the tibia (the shinbone). The patella (or kneecap, as it is commonly called) is made of bone and sits in front of the knee.

The knee joint is a synovial jointSynovial joints are enclosed by a ligament capsule and contain a fluid, calledsynovial fluid, that lubricates the joint.

The end of the femur joins the top of the tibia to create the knee joint. Two round knobs called femoral condylesare found on the end of the femur. These condyles rest on the top surface of the tibia. This surface is called thetibial plateau. The outside halfl groove formed by the two femoral condyles called the patellofemoral groove.

The smaller bone of the lower leg, the fibula, never really enters the knee joint. It does have a small joint that connects it to the side of the tibia. This joint normally moves very little.

Articular cartilage is the material that covers the ends of the bones of any joint. This material is about one-quarter of an inch thick in most large joints. It is white and shiny with a rubbery consistency. Articular cartilage is a slippery substance that allows the surfaces to slide against one another without damage to either surface. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to facilitate motion. We have articular cart

(farthest away from the other knee) is called the lateral tibial plateau, and the inside half (closest to the other knee) is called the medial tibial plateau. The patella glides through a speciailage essentially everywhere that two bony surfaces move against one another, or articulate. In the knee, articular cartilage covers the ends of the femur, the top of the tibia, and the back of the patella.

Ligaments and Tendons

Ligaments are tough bands of tissue that connect the ends of bones together. Two important ligaments are found on either side of the knee joint. They are the medial collateral ligament (MCL) and the lateral collateral ligament(LCL).

Inside the knee joint, two other important ligaments stretch between the femur and the tibia: the anterior cruciate ligament (ACL) in front, and the posterior cruciate ligament (PCL) in back.

The MCL and LCL prevent the knee from moving too far in the side-to-side direction. The ACL and PCL control the front-to-back motion of the knee joint.

The ACL keeps the tibia from sliding too far forward in relation to the femur. The PCL keeps the tibia from sliding too far backward in relation to the femur. Working together, the two cruciate ligaments control the back-and-forth motion of the knee. The ligaments, all taken together, are the most important structures controlling stability of the knee.

Two special types of ligaments called menisci sit between the femur and the tibia. These structures are sometimes referred to as the cartilage of the knee, but the menisci differ from the articular cartilage that covers the surface of the joint.

The two menisci of the knee are important for two reasons: (1) they work like a gasket to spread the force from the weight of the body over a larger area, and (2) they help the ligaments with stability of the knee.

Imagine the knee as a ball resting on a flat plate. The ball is the end of the thighbone as it enters the joint, and the plate is the top of the shinbone. The menisci actually wrap around the round end of the upper bone to fill the space between it and the flat shinbone. The menisci act like a gasket, helping to distribute the weight from the femur to the tibia.

Without the menisci, any weight on the femur will be concentrated to one point on the tibia. But with the menisci, weight is spread out across the tibial surface. Weight distribution by the menisci is important because it protects the articular cartilage on the ends of the bones from excessive forces. Without the menisci, the concentration of force into a small area on the articular cartilage can damage the surface, leading to degeneration over time.

In addition to protecting the articular cartilage, the menisci help the ligaments with stability of the knee. The menisci make the knee joint more stable by acting like a wedge set against the bottom of a car tire. The menisci are thicker around the outside, and this thickness helps keep the round femur from rolling on the flat tibia. The menisci convert the tibial surface into a shallow socket. A socket is more stable and more efficient at transmitting the weight from the upper body than a round ball on a flat plate. The menisci enhance the stability of the knee and protect the articular cartilage from excessive concentration of force.

Taken all together, the ligaments of the knee are the most important structures that stabilize the joint. Remember, ligaments connect bones to bones. Without strong, tight ligaments to connect the femur to the tibia, the knee joint would be too loose. Unlike other joints in the body, the knee joint lacks a stable bony configuration. The hip joint, for example, is a ball that sits inside a deep socket. The ankle joint has a shape similar to a mortise and tenon, a way of joining wood used by craftsmen for centuries.

Tendons are similar to ligaments, except that tendons attach muscles to bones. The largest tendon around the knee is the patellar tendon. This tendon connects the patella (kneecap) to the tibia. This tendon covers the patella and continues up the thigh.

There it is called the quadriceps tendon since it attaches to the quadriceps muscles in the front of the thigh. Thehamstring muscles on the back of the leg also have tendons that attach in different places around the knee joint. These tendons are sometimes used as tendon grafts to replace torn ligaments in the knee.

Muscles

The extensor mechanism is the motor that drives the knee joint and allows us to walk. It sits in front of the knee joint and is made up of the patella, the patellar tendon, the quadriceps tendon, and the quadriceps muscles. The four quadriceps muscles in front of the thigh are the muscles that attach to the quadriceps tendon. When these muscles contract, they straighten the knee joint, such as when you get up from a squatting position.

The way in which the kneecap fits into the patellofemoral groove on the front of the femur and slides as the knee bends can affect the overall function of the knee. The patella works like a fulcrum, increasing the force exerted by the quadriceps muscles as the knee straightens. When the quadriceps muscles contract, the knee straightens.

The hamstring muscles are the muscles in the back of the knee and thigh. When these muscles contract, the knee bends.

Nerves

The most important nerves around the knee are the tibial nerve and the common peroneal nerve in the back of the knee. These two nerves travel to the lower leg and foot, supplying sensation and muscle control. The large sciatic nerve splits just above the knee to form the tibial nerve and the common peroneal nerve. The tibial nerve continues down the back of the leg while the common peroneal nerve travels around the outside of the knee and down the front of the leg to the foot. Both of these nerves can be damaged by injuries around the knee.

Blood Vessels

The major blood vessels around the knee travel with the tibial nerve down the back of the leg. The popliteal artery and popliteal vein are the largest blood supply to the leg and foot. If the popliteal artery is damaged beyond repair, it is very likely the leg will not be able to survive. The popliteal artery carries blood to the leg and foot. The popliteal vein carries blood back to the heart.

Patellar tendonitis

Alignment or overuse problems of the knee structures can lead to strain, irritation, and/or injury. This produces pain, weakness, and swelling of the knee joint Patellar tendonitis (also known as jumper’s knee) is a common overuse condition associated with running, repeated jumping and landing, and kicking.

Anatomy

What parts of the knee are involved?

The patella (kneecap) is the moveable bone on the front of the knee. This unique bone is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the tibia lower leg bone.

The large quadriceps muscle ends in a tendon that inserts into the tibial tubercle, a bony bump at the top of thetibia (shin bone) just below the patella. The tendon together with the patella is called the quadriceps mechanism. Though we think of it as a single device, the quadriceps mechanism has two separate tendons, the quadriceps tendon on top of the patella and the infrapatellar tendon or patellar tendon below the patella.

Tightening up the quadriceps muscles places a pull on the tendons of the quadriceps mechanism. This action causes the knee to straighten. The patella acts like a fulcrum to increase the force of the quadriceps muscles.

The long bones of the femur and the tibia act as level arms, placing force or load on the knee joint and surrounding soft tissues. The amount of load can be quite significant. For example, the joint reaction forces of the lower extremity (including the knee) are two to three times the body weight during walking and up to five times the body weight when running.

 

Causes

What causes this problem?

Patellar tendonitis occurs most often as a result of stresses placed on the supporting structures of the knee. Running, jumping, and repetitive knee flexion into extension (e.g., rising from a deep squat) contribute to this condition. Overuse injuries from sports activities is the most common cause but anyone can be affected, even those who do not participate in sports or recreational activities.

There are extrinsic (outside) factors that are linked with overuse tendon injuries of the knee. These include inappropriate footwear, training errors (frequency, intensity, duration), and surface or ground (hard surface, cement) being used for the sport or event (such as running). Training errors are summed up by the rule of “toos”. This refers to training too much, too far, too fast, or too long. Advancing the training schedule forward too quickly is a major cause of patellar tendonitis.

Intrinsic (internal) factors such as age, flexibility, and joint laxity are also important. Malalignment of the foot, ankle, and leg can play a key role in tendonitis. Flat foot position, tracking abnormalities of the patella, rotation of the tibia called tibial torsion, and a leg length difference can create increased and often uneven load on the quadriceps mechanism.

An increased Q-angle or femoral anteversion are two common types of malalignment that contribute to patellar tendonitis. The Q-angle is the angle formed by the patellar tendon and the axis of pull of the quadriceps muscle. This angle varies between the sexes. It is larger in women compared to men. The normal angle is usually less than 15 degrees. Angles more than 15 degrees create more of a pull on the tendon, creating painful inflammation.

Any muscle imbalance of the lower extremity (from the hip down to the toes) can impact the quadriceps muscle and affect the joint. Individuals who are overweight may have added issues with load and muscle imbalance leading to patellar tendonitis.

Strength of the patellar tendon is in direct proportion to the number, size, and orientation of the collagen fibersthat make up the tendon. Overuse is simply a mismatch between load or stress on the tendon and the ability of that tendon to distribute the force. If the forces placed on the tendon are greater than the strength of the structure, then injury can occur. Repeated microtrauma at the muscle tendon junction may overcome the tendon’s ability to heal itself. Tissue breakdown occurs triggering an inflammatory response that leads to tendonitis.

Chronic tendonitis is really a problem called tendonosis. Inflammation is not present. Instead, degeneration and/or scarring of the tendon has developed. Chronic tendon injuries are much more common in older athletes (30 to 50 years old).

Symptoms

What does the condition feel like?

Pain from patellar tendonitis is felt just below the patella. The pain is most noticeable when you move your knee or try to kneel. The more you move your knee, the more tenderness develops in the area of the tendon attachment below the kneecap.

There may be swelling in and around the patellar tendon. It may be tender or very sensitive to touch. You may feel a sense of warmth or burning pain. The pain can be mild or in some cases the pain can be severe enough to keep the runner from running or other athletes from participating in their sport. The pain is worse when rising from a deep squat position. Resisted quadriceps contraction with the knee straight also aggravates the condition.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history of your knee problem followed by an examination of the knee, including the patella. There is usually tenderness with palpation of the inflamed tissues at the insertion of the tendon into the bone. The knee will be assessed for range of motion, strength, flexibility and joint stability.

The physician will look for intrinsic and extrinsic factors affecting the knee (especially sudden changes in training habits). Potential problems with lower extremity alignment are identified. The doctor will also check the hamstrings for telltale weakness and tightness.

X-rays may be ordered on the initial visit to your doctor. An X-ray can show fractures of the tibia or patella but X-rays do not show soft tissue injuries. In these cases, other tests, such as ultrasonography or magnetic resonance imaging (MRI), may be suggested. Ultrasound uses sound waves to detect tendon tears. MRIs use magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the knee. Usually, this test is done to look for injuries, such as tears in the quadriceps. This test does not require any needles or special dye and is painless.

pes anserine bursa

Introduction

Bursitis of the knee occurs when constant friction on the bursa causes inflammation. The bursa is a small sac that cushions the bone from tendons that rub over the bone. Bursae can also protect other tendons as tissues glide over one another. Bursae can become inflamed and irritated causing pain and tenderness.

Anatomy

What parts of the body are involved?

The pes anserine bursa is the main area affected by this condition. The pes anserine bursa is a small lubricating sac between the tibia (shinbone) and the hamstring muscle. The hamstring muscle is located along the back of the thigh.

There are three tendons of the hamstring: the semitendinosussemimembranosus, and the biceps femoris. The semitendinosus wraps around from the back of the leg to the front. It inserts into the medial surface of the tibia and deep connective tissue of the lower leg. Medial refers to the inside of the knee or the side closest to the other knee.

Just above the insertion of the semitendinosus tendon is the gracilis tendon. The gracilis muscle adducts or moves the leg toward the body. The semitendinosus tendon is also just behind the attachment of the sartorius muscle. The sartorius muscle bends and externally rotates the hip. Together, these three tendons splay out on the tibia and look like a goosefoot. This area is called the pes anserine or pes anserinus.

The pes anserine bursa provides a buffer or lubricant for motion that occurs between these three tendons and themedial collateral ligament (MCL). The MCL is underneath the semitendinosus tendon.

 

Causes

What causes this problem?

Overuse of the hamstrings, especially in athletes with tight hamstrings is a common cause of goosefoot. Runners are affected most often. Improper training, sudden increases in distance run, and running up hills can contribute to this condition.

It can also be caused by trauma such as a direct blow to this part of the knee. A contusion to this area results in an increased release of synovial fluid in the lining of the bursa. The bursa then becomes inflamed and tender or painful.

Anyone with osteoarthritis of the knee is also at increased risk for this condition. And alignment of the lower extremity can be a risk factor for some individuals. A turned out position of the knee or tibia, genu valgum (knock knees), or a flatfoot position can lead to pes anserine bursitis.

Symptoms

What does the condition feel like?

The patient often points to the pes anserine as the area of pain or tenderness. The pes anserine is located about two to three inches below the joint on the inside of the knee. This is referred to as the anterior knee orproximedia tibia. Proximedia is short for proximal and medial. This term refers to the front inside edge of the tibia.

Some patients also have pain in the center of the tibia. This occurs when other structures are also damaged such as the meniscus (cartilage). The pain is made worse by exercise, climbing stairs, or activities that cause resistance to any of these tendons.

Diagnosis

How do doctors diagnose this problem?

A history and clinical exam will help the physician differentiate pes anserine bursitis from other causes of anterior knee pain, such as patellofemoral syndrome or arthritis. An X-ray is needed to rule out a stress fracture or arthritis. An MRI may be needed to look for damage to other areas of the medial compartment of the knee. Fluid from the bursa may be removed and tested if infection is suspected.

The examiner will also assess hamstring tightness. This is done in the supine position (lying on your back). Your hip is flexed (bent) to 90 degrees. The knee is straightened as far as possible. The amount of knee flexion is an indication of how tight the hamstrings are. If you can straighten your knee all the way in this position, then you do not have tight hamstrings.

Plica syndrome

Introduction

Plica syndrome is an interesting problem that occurs when an otherwise normal structure in the knee becomes a source of knee pain due to injury or overuse. The diagnosis can sometimes be difficult, but if this is the source of your knee pain, it can be easily treated.

This guide will help you better understan

Anatomy

What is a plica, and what does it do?

Plica is a term used to describe a fold in the lining of the knee joint. Imagine the inner lining of the knee joint as nothing more than a sleeve of tissue. This sleeve of tissue is made up of synovial tissue, a thin, slippery material that lines all joints. Just as a tailor leaves extra folds of material at the back of sleeves on a shirt to allow for unrestricted motion of the arms, the synovial sleeve of tissue has folds of material that allow movement of the bones of the joint without restriction.

Four plica synovial folds are found in the knee, but only one seems to cause trouble. This structure is called themedial plica. The medial plica attaches to the lower end of the patella (kneecap) and runs sideways to attach to the lower end of the thighbone at the side of the knee joint closest to the other knee. Most of us (50 to 70 percent) have a medial plica, and it doesn’t cause any problems.

Causes

How does a plica cause problems in the knee?

A plica causes problems when it is irritated. This can occur over a long period of time, such as when the plica is irritated by certain exercises, repetitive motions, or kneeling. Activities that repeatedly bend and straighten the knee, such as running, biking, or use of a stair-climbing machine, can irritate the medial plica and cause plica syndrome.

Injury to the plica can also happen suddenly, such as when the knee is struck in the area around the medial plica. This can occur from a fall or even from hitting the knee on the dashboard during an automobile accident. This injury to the knee can cause the plica, and the synovial tissue around the plica, to swell and become painful. The initial injury may lead to scarring and thickening of the plica tissue later. The thickened, scarred plica fold may be more likely to cause problems later.

Symptoms

What does plica syndrome feel like?

The primary symptom caused by plica syndrome is pain. There may also be a snapping sensation along the inside of the knee as the knee is bent. This is due to the rubbing of the thickened plica over the round edge of the thighbone where it enters the joint. This usually causes the plica to be tender to the touch. In thin people, the tissue that forms the plica may be actually be felt as a tender band underneath the skin. In rare cases where the plica has become severely irritated, the knee may become swollen.

Diagnosis

How will my doctor know it’s plica syndrome?

Diagnosis begins with a history and physical exam. The examination is used to try and determine where the pain is located and whether or not the band of tissue can be felt. X-rays will not show the plica. X-rays are mainly useful to determine if other conditions are present when there is not a clear-cut diagnosis.

If there is uncertainty in the diagnosis following the history and physical examination, or if other injuries in addition to the plica syndrome are suspected, magnetic resonance imaging (MRI) may be suggested. The MRI machine uses magnetic waves to show the soft tissues of the body. Usually this test is done to look for injuries, such as tears in the meniscus or ligaments of the knee. This test does not require any needles or special dye and is painless. Acomputed tomography (CT) scan may also be used to see whether the plica has become thickened. Most cases of plica syndrome will not require special tests such as the MRI or CT scan.

If the history and physical examination strongly suggest that a plica syndrome is present, then arthroscopy may be suggested to confirm the diagnosis and treat the problem at the same time. Arthroscopy is an operation that involves inserting a small fiber-optic TV camera into the knee joint, allowing the surgeon to look at the structures inside the knee joint directly. The arthroscope allows your surgeon to see the condition of the whole knee and determine whether the medial plica is inflamed.

Prepatellar bursitis

Introduction

 Prepatellar bursitis is the inflammation of a small sac of fluid located in front of the kneecap. This inflammation can cause many problems in the knee.

 

Anatomy

Where is the prepatellar bursa, and what does it do?

bursa is a sac made of thin, slippery tissue. Bursae occur in the body wherever skin, muscles, or tendons need to slide over bone. Bursae are lubricated with a small amount of fluid inside that helps reduce friction from the sliding parts. The prepatellar bursa is located between the front of the kneecap (called the patella) and the overlying skin. This bursa allows the kneecap to slide freely underneath the skin as we bend and straighten our knees.

Causes

How does prepatellar bursitis develop?

Bursitis is the inflammation of a bursa. The prepatellar bursa can become irritated and inflamed in a number of ways.

In some cases, a direct blow or a fall onto the knee can damage the bursa. This usually causes bleeding into the bursa sac, because the blood vessels in the tissues that make up the bursa are damaged and torn. In the skin, this would simply form a bruise, but in a bursa blood may actually fill the bursa sac. This causes the bursa to swell up like a rubber balloon filled with water.

The blood in the bursa is thought to cause an inflammatory reaction. The walls of the bursa may thicken and remain thickened and tender even after the blood has been absorbed by the body. This thickening and swelling of the bursa is referred to as prepatellar bursitis.

Prepatellar bursitis can also occur over a longer period of time. People who work on their knees, such as carpet layers and plumbers, can repeatedly injure the bursa. This repeated injury can lead to irritation and thickening of the bursa over time. The chronic irritation leads to prepatellar bursitis in the end.

The prepatellar bursa can also become infected. This may occur without any warning, or it may be caused by a small injury and infection of the skin over the bursa that spreads down into the bursa. In this case, instead of blood or inflammatory fluid in the bursa, pus fills it. The area around the bursa becomes hot, red, and very tender.

Symptoms

What does prepatellar bursitis feel like?

Prepatellar bursitis causes pain and swelling in the area in front of the kneecap and just below. It may be very difficult to kneel down and put the knee on the floor due to the tenderness and swelling. If the condition has been present for some time, small lumps may be felt underneath the skin over the kneecap. Sometimes these lumps feel as though something is floating around in front of the kneecap, and they can be very tender. These lumps are usually the thickened folds of bursa tissue that have formed in response to chronic inflammation.

The bursa sac may swell and fill with fluid at times. This is usually related to your activity level, and more activity usually causes more swelling. In people who rest on their knees a lot, such as carpet layers, the bursa can grow very thick, almost like a kneepad in front of the knee.

Finally, if the bursa becomes infected, the front of the knee becomes swollen and very tender and warm to the touch around the bursa. You may run a fever and feel chills. An abscess, or area of pus, may form on the front of the knee. If the infection is not treated quickly, the abscess may even begin to drain, meaning the pus begins to seep out.

Diagnosis

How do doctors identify the condition?

The diagnosis of prepatellar bursitis is usually obvious from the physical examination. In cases where the knee swells immediately after a fall or other injury to the kneecap, X-rays may be necessary to make sure that the kneecap isn’t fractured. Chronic bursitis is usually easy to diagnose without any special tests.

If your doctor is uncertain whether or not the bursa is infected, a needle may be inserted into the bursa and the fluid removed. This fluid will be sent to a lab for tests to determine whether infection is present, and if so, what type of bacteria is causing the infection and what antibiotic will work best to cure the infection

Chondromalacia patella

Introduction

The patella, or kneecap, can be a source of knee pain when it fails to function properly. Alignment or overuse problems of the patella can lead to wear and tear of the cartilage behind the patella. Chondromalacia patella is a common knee problem that affects the patella and the groove it slides in over the femur (thigh bone). This action takes place at the patellofemoral joint.

Chondromalacia is the term used to describe a patellofemoral joint that has been structurally damaged, while the term patellofemoral pain syndrome(PFPS) refers to the earlier stages of the condition. Symptoms are more likely to be reversible with PFPS.

Anatomy

What is the patella, and what does it do?

 

The patella (kneecap) is the moveable bone on the front of the knee. This unique bone is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the lower leg bone. The large quadriceps tendon together with the patella is called the quadriceps mechanism. Though we think of it as a single device, the quadriceps mechanism has two separate tendons, the quadriceps tendon on top of the patella and the patellar tendon below the patella.

 

Tightening up the quadriceps muscles places a pull on the tendons of the quadriceps mechanism. This action causes the knee to straighten. The patella acts like a fulcrum to increase the force of the quadriceps muscles.

 

The underside of the patella is covered with articular cartilage, the smooth, slippery covering found on joint surfaces. This covering helps the patella glide (or track) in a special groove made by the thighbone, or femur. This groove is called the femoral groove.

Two muscles of the thigh attach to the patella and help control its position in the femoral groove as the leg straightens. These muscles are the vastus medialis obliquus (VMO) and the vastus lateralis (VL). The vastus medialis obliquus (VMO) runs along the inside of the thigh, and the vastus lateralis (VL) lies along the outside of the thigh. If the timing between these two muscles is off, the patella may be pulled off track.

 

Causes

What causes this problem?

Problems commonly develop when the patella suffers wear and tear. The underlying cartilage begins to degenerate, a condition most common in young athletes. Soccer players, snowboarders, cyclists, rowers, tennis players, ballet dancers, and runners are affected most often. But anyone whose knees are under great stress is at increased risk of developing chondromalacia patella.

 

Wear and tear can develop for several reasons. Acute injury to the patella or chronic friction between the patella and the femur can result in the start of patellofemoral pain syndrome. Degeneration leading to chondromalacia may also develop as part of the aging process, like putting a lot of miles on a car.

The main cause of knee pain associated with patellofemoral pain syndrome is a problem in the way the patella tracks within the femoral groove as the knee moves. Physical and biomechanical changes alter the stress and load on the patellofemoral joint.

The quadriceps muscle helps control the patella so it stays within this groove. If part of the quadriceps is weak for any reason, a muscle imbalance can occur. When this happens, the pull of the quadriceps muscle may cause the patella to pull more to one side than the other. This in turn causes more pressure on the articular cartilage on one side than the other. In time, this pressure can damage the articular cartilage leading to chondromalacia patella.

Weakness of the muscles around the hip can also indirectly affect the patella and can lead to patellofemoral joint pain. Weakness of the muscles that pull the hip out and away from the other leg, the hip abductor muscles, can lead to imbalances to the alignment of the entire leg – including the knee joint and the muscle balance of the muscles around the knee. This causes abnormal tracking of the patella within the femoral groove and eventually pain around the patella. Many patients are confused when their physical therapist begins exercises to strengthen and balance the hip muscles, but there is a very good reason that the therapist is focusing on this area.

A similar problem can happen when the timing of the quadriceps muscles is off. There are four muscles that form the quadriceps muscle group. As mentioned earlier, the vastus medialis obliquus (the muscle on the inside of the front of the thigh) and the vastus lateralis ( the muscle that runs down the outside part of the thigh) are two of these four muscles. People with patellofemoral problems sometimes have problems in the timing between the VMO and the VL. The VL contracts first, before the VMO. This tends to pull the patella toward the outside edge of the knee. The result is abnormal pressure on the articular surface of the patella.

 

Another type of imbalance may exist due to differences in how the bones of the knee are shaped. These differences, or anatomic variations, are something people are born with. Doctors refer to this the “Q angle”. Some people are born with a greater than normal angle where the femur and the tibia (shinbone) come together at the knee joint. Women tend to have a greater angle here than men. The patella normally sits at the center of this angle within the femoral groove. When the quadriceps muscle contracts, the angle in the knee straightens, pushing the patella to the outside of the knee. In cases where this angle is increased, the patella tends to shift outward with greater pressure. This leads to a similar problem as that described above. As the patella slides through the groove, it shifts to the outside. This places more pressure on one side than the other, leading to damage to the underlying articular cartilage.

 

Finally, anatomic variations in the bones of the knee can occur such that one side of the femoral groove is smaller than normal. This creates a situation where the groove is too shallow, usually on the outside part of the knee. People who have a shallow groove sometimes have their patella slip sideways out of the groove, causing a patellar dislocation. This is not only painful when it occurs, but it can damage the articular cartilage underneath the patella. If this occurs repeatedly, degeneration of the patellofemoral joint occurs fairly rapidly.

Symptoms

What does chondromalacia patella feel like?

The most common symptom is pain underneath or around the edges of the patella. The pain is made worse by any activities that load the patellofemoral joint, such as running, squatting, or going up and down stairs. Kneeling is often too painful to even try. Keeping the knee bent for long periods, as in sitting in a car or movie theater, may cause pain.

There may be a sensation like the patella is slipping. This is thought to be a reflex response to pain and not because there is any instability in the knee. Others experience vague pain in the knee that isn’t centered in any one spot.

The knee may grind, or you may hear a crunching sound when you squat or go up and down stairs. If there is a considerable amount of wear and tear, you may feel popping or clicking as you bend your knee. This can happen when the uneven surface of the underside of the patella rubs against the femoral groove. The knee may swell with heavy use and become stiff and tight. This is usually because of fluid accumulating inside the knee joint, sometimes called ‘water on the knee’. This is not unique to problems of the patella but sometimes occurs when the knee becomes inflamed.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history of your knee problem followed by an examination of the knee, including the patella. X-rays may be ordered on the initial visit to your doctor. An X-ray can help determine if the patella is properly aligned in the femoral groove. Several X-rays taken with the knee bent at several different angles can help determine if the patella seems to be moving through the femoral groove in the correct alignment. The X-ray may show arthritis between the patella and thighbone, especially when the problems have been there for awhile.

Diagnosing problems with the patella can be confusing. The symptoms can be easily confused with other knee problems, because the symptoms are often similar. In these cases, other tests, such as magnetic resonance imaging(MRI), may be suggested. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the knee. Usually, this test is done to look for injuries, such as tears in the menisci or ligaments of the knee. Recent advances in the quality of MRI scans have enabled doctors to see the articular cartilage on the scan and determine if it is damaged. This test does not require any needles or special dye and is painless.

In some cases, arthroscopy may be used to make the definitive diagnosis when there is still a question about what is causing your knee problem. Arthroscopy is an operation that involves placing a small fiber-optic TV camera into the knee joint, allowing the surgeon to look at the structures inside the joint directly. The arthroscope allows your doctor to see the condition of the articular cartilage on the back of your patella. The vast majority of patellofemoral problems are diagnosed without resorting to surgery, and arthroscopy is usually reserved to treat the problems identified by other means.

There is no clear link between the severity of symptoms and X-ray or arthroscopic findings. Most often, the doctor relies upon the history, symptoms, and results of the examination.

Patellar fractures

The knee comprises of the union of 3 bones – the long bone of the thigh (femur), the shin bone (tibia) and the knee cap (patella) (figure 1). The patella (knee cap) is situated at the front of the knee and lies within the tendon of the quadriceps muscle (the muscle at the front of the thigh). The quadriceps tendon envelops the patella and attaches to the top end of the tibia (figure 1). Due to this relationship, the knee cap sits in front of the femur forming a joint in which the bones are almost in contact with each other.

During certain activities, such as a fall onto the knee cap or following a direct blow to the front of the knee, stress is placed on the patella bone. When this stress is traumatic, and beyond what the bone can withstand, a break in the patella may occur. This condition is known as a patellar fracture.

Because of the large forces required to break the patella bone, a patellar fracture often occurs in combination with other injuries such as patellofemoral joint damage or a quadriceps tear.

Patellar fractures can vary in location, severity and type including stress fracture, displaced fracture, un-displaced fracture, compound fracture, greenstick, comminuted etc.


 

Causes of a patellar fracture

A patellar fracture most commonly occurs due to direct trauma to the knee cap such as a fall onto the knee cap or a direct blow to the patella (e.g. from a hockey stick). Occasionally it may also occur due to a forceful quadriceps contraction such as landing from a height. A stress fracture to the patella, although rare, may occur as a result of overuse, often associated with a recent increase or high volume of jumping. An acute patellar dislocation can also sometimes result in a fracture to the patella.


 

Signs and symptoms of a patellar fracture

Patients with this condition typically experience a sudden onset of sharp, intense pain at the front of the knee at the time of injury. This often causes the patient to limp so as to protect the patella. In severe cases, particularly involving a displaced fracture of the patella, weight bearing may be impossible. Pain is usually felt on the front or sides of the patella and can occasionally settle quickly with rest leaving patients with an ache at the site of injury that may be particularly prominent at night or first thing in the morning. Occasionally patients may experience symptoms in the back of the knee, the thigh or lower leg regions.

Patients with a patellar fracture may also experience swelling, bruising and pain on firmly touching the affected region of bone. Pain may also increase during certain movements of the knee when standing or walking (particularly up or down hills or on uneven surfaces) or when attempting to stand or walk. Squatting or kneeling is also usually painful with many patients being unable to perform these activities. In severe cases (with bony displacement), an obvious deformity may be noticeable. Occasionally patients may also experience pins and needles or numbness in the knee, lower leg, foot or ankle.


 

Diagnosis of a patellar fracture

A thorough subjective and objective examination from a physiotherapist is essential to assist with diagnosis of a patellar fracture. X-rays (including a skyline view of the patella) are usually required to confirm diagnosis and assess the severity of the fracture. Further investigations such as an MRI, CT scan or bone scan may be required, in some cases, to assist with diagnosis and assess the severity of the injury.

Patellofemoral pain syndrome

Patellofemoral pain syndrome is the term given to pain originating from the patellofemoral joint (i.e. the joint between the knee cap (patella) and thigh bone (femur) usually as a result of inflammation or tissue damage to structures of the patellofemoral joint.

The knee comprises of the union of 3 bones – the long bone of the thigh (femur), the shin bone (tibia) and the knee cap (patella) (figure 1). The patella (knee cap) is situated at the front of the knee and lies within the tendon of the quadriceps muscle (the muscle at the front of the thigh). The quadriceps tendon envelops the patella and attaches to the top end of the tibia (figure 1). Due to this relationship, the knee cap sits in front of the femur forming a joint in which the bones are almost in contact with each other. The surface of each bone, however, is lined with cartilage to allow cushioning between the bones. This joint is called the patellofemoral joint.

Normally, the patella is aligned in the middle of the patellofemoral joint so that forces applied to the knee cap during activity are evenly distributed. In patients with patellofemoral pain syndrome the patella is usually misaligned relative to the femur, which therefore places more stress through the patellofemoral joint during activity. As a result this may cause tissue damage and inflammation to structures of the patellofemoral joint (such as cartilage or connective tissue), with subsequent patellofemoral pain. When this occurs, the conditions is known as patellofemoral pain syndrome.

In patients with patellofemoral pain syndrome, the misalignment of the patella may occur for various reasons. One of the main causes is an imbalance in strength between two parts of the quadriceps muscle. The quadriceps muscle comprises of 4 muscle bellies, 2 lie centrally (rectus femoris and vastus intermedius), one lies on the inner leg (vastus medialis) and one lies on the outer leg (vastus lateralis) (figure 2). In the majority of patellofemoral pain syndrome cases, the outer quadriceps (vastus lateralis) is stronger than the inner quadriceps (vastus medialis), resulting in the knee cap being pulled towards the outside of the leg. This may result in abnormal movement of the knee cap when bending and straightening the knee. There are numerous factors which can cause this strength imbalance of the quadriceps (such as abnormal lower limb biomechanics, pain inhibition etc.). These need to be identified and corrected by a physiotherapist.

Patellofemoral pain syndrome is a very common condition that is frequently seen in clinical practice, particularly in runners. It often affects adolescents at a time of increased growth and usually affects girls more than boys. In older patients, patellofemoral pain syndrome is often associated with degenerative joint changes.


 

Signs and symptoms of patellofemoral pain syndrome

Patients with patellofemoral pain syndrome usually experience pain at the front of the knee and around or under the knee cap. Pain can sometimes be felt at the back of the knee or on the inner or outer aspects. Patients usually experience an ache that may increase to a sharper pain with activity. In less severe cases, patients may only experience an ache or stiffness in the knee that increases with rest (typically at night or first thing in the morning) following activities that place stress on the patellofemoral joint. These activities typically include excessive walking (especially up and down stairs or hills or on uneven surfaces), heavy lifting (particularly with knees bent), deep squatting, lunging, kneeling, running, hopping, jumping, or other activities that bend and straighten the knee during weight bearing. The pain associated with this condition may also warm up with activity in the initial stages of injury. As the condition progresses, patients may experience symptoms that increase during sport or activity, affecting performance. Symptoms typically increase on firmly touching the margins of the patellofemoral joint.

Occasionally, patients with this condition may experience pain whilst sitting with the knee bent for prolonged periods. There may also be an associated clicking or grinding sound when bending or straightening the knee. In more severe cases, patients may walk with a limp and sometimes may experience episodes of the knee giving way or collapsing due to pain. In chronic cases there may be evidence of quadriceps muscle wasting (particularly of the vastus medialis).


 

Diagnosis of patellofemoral pain syndrome

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose patellofemoral pain syndrome. Investigations such as an X-ray or MRI may be used to assist with diagnosis.


Prognosis of patellofemoral pain syndrome

Most patients with this condition heal well with appropriate physiotherapy and return to normal function in a number of weeks. Occasionally, rehabilitation can take significantly longer and may take many months in those who have had their condition for a long period of time. Early physiotherapy treatment is vital to hasten recovery in all patients with this condition.

Genu Varum

Bowed legs in a toddler is very common. When a child with bowed legs stands with his or her feet together, there is a distinct space between the lower legs and knees. This may be a result of either one, or both, of the legs curving outward. Walking often exaggerates this bowed appearance.

Adolescents occasionally have bowed legs. In many of these cases, the child is significantly overweight.

Physiologic Genu Varum

In most children under 2 years old, bowing of the legs is simply a normal variation in leg appearance. Doctors refer to this type of bowing as physiologic genu varum.

In children with physiologic genu varum, the bowing begins to slowly improve at approximately 18 months of age and continues as the child grows. By ages 3 to 4, the bowing has corrected and the legs typically have a normal appearance.

Blount’s Disease

Blount’s disease is a condition that can occur in toddlers, as well as in adolescents. It results from an abnormality of the growth plate in the upper part of the shinbone (tibia). Growth plates are located at the ends of a child’s long bones. They help determine the length and shape of the adult bone.

In a child under the age of 2 years, it may be impossible to distinguish infantile Blount’s disease from physiologic genu varum. By the age of 3 years, however, the bowing will worsen and an obvious problem can often be seen in an x-ray.

Rickets

Rickets is a bone disease in children that causes bowed legs and other bone deformities. Children with rickets do not get enough calcium, phosphorus, or Vitamin D — all of which are important for healthy growing bones.

Nutritional rickets is unusual in developed countries because many foods, including milk products, are fortified with Vitamin D. Rickets can also be caused by a genetic abnormality that does not allow Vitamin D to be absorbed correctly. This form of rickets may be inherited.

 Symptoms

Bowed legs are most evident when a child stands and walks. The most common symptom of bowed legs is an awkward walking pattern.

Toddlers with bowed legs usually have normal coordination, and are not delayed in learning how to walk. The amount of bowing can be significant, however, and can be quite alarming to parents and family members.

Turning in of the feet (intoeing) is also common in toddlers and frequently occurs in combination with bowed legs.

Bowed legs do not typically cause any pain. During adolescence, however, persistent bowing can lead to discomfort in the hips, knees, and/or ankles because of the abnormal stress that the curved legs have on these joints. In addition, parents are often concerned that the child trips too frequently, particularly if intoeing is also present.

 Doctor Examination

Your doctor will begin your child’s evaluation with a thorough physical examination.

If your child is under age 2, in good health, and has symmetrical bowing (the same amount of bowing in both legs), then your doctor will most likely tell you that no further tests are currently needed.

However, if your doctor notes that one leg is more severely bowed than the other, he or she may recommend an x-ray of the lower legs. An x-ray of your child’s legs in the standing position can show Blount’s disease or rickets.

If your child is older than 2 1/2 at the first doctor’s visit and has symmetrical bowing, your doctor will most likely recommend an x-ray. The likelihood of your child having infantile Blount’s disease or rickets is greater at this age. If the x-ray shows signs of rickets, your doctor will order blood tests to confirm the presence of this disorder.

Osgood Schlatters disease

Osgood Schlatters disease is a relatively common condition of the knee affecting adolescents. It refers to an injury to the growth plate at the top of the shin bone (tibia) just below the knee cap.

The muscle group at the front of your thigh is called the quadriceps. The quadriceps attaches to the knee cap (patella) which in turn attaches to the top of the shin bone (tibia) via the patella tendon

In people who have not reached skeletal maturity, a growth plate exists where the patella tendon inserts into the shin bone. This growth plate is primarily comprised of cartilage. Every time the quadriceps contracts, it pulls on the patella tendon which in turn pulls on the tibia’s growth plate. When this tension is too forceful or repetitive, irritation to the growth plate may occur resulting in pain and sometimes an increased bony prominence at the front of the shin. This condition is called Osgood Schlatters disease.

Cause of Osgood Schlatters disease

Osgood Schlatters disease is typically seen in children or adolescents during periods of rapid growth. This is because muscles and tendons become tighter as bones grow longer. As a result, more tension is placed on the tibia’s growth plate. Osgood Schlatters disease is more commonly seen in active children or adolescents who participate in activities requiring strong or repetitive quadriceps contractions such as running or jumping sports.

Signs and symptoms of Osgood Schlatters disease

Patients with this condition typically experience pain at the front of the knee just beneath the knee cap (i.e. the tibial tuberosity). The pain associated with this condition may increase during activities requiring strong quadriceps contractions such as squatting, going up and down stairs, running (especially uphill), jumping or hopping. Patient’s may also experience pain when kneeling or placing firm pressure to the top of the shin bone (just beneath the knee cap). An increased or swollen bony prominence may also be detected at the top of the shin bone, coinciding with the source of pain in patients with this condition.

Diagnosis of Osgood Schlatters disease

 A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose Osgood Schlatters disease. Investigations such as an X-ray, MRI scan or CT scan may be required occasionally to confirm diagnosis.

Treatment for Osgood Schlatters disease

Most patients with this condition heal well with appropriate physiotherapy. The success rate of treatment is largely dictated by patient compliance. A vital aspect of treatment is that the patient rests from any activity that increases their pain. Activities placing large amounts of stress on the tibial tuberosity should also be minimized, particularly squatting, sprinting, jumping and hopping. Resting from aggravating activities ensures the body can begin the healing process in the absence of further damage. Once the patient can perform these activities pain free a gradual return to these activities is indicated provided there is no increase in symptoms.

Ignoring symptoms or adopting a ‘no pain, no gain’ attitude is likely to cause further damage and prolong recovery in patients with Osgood Schlatters disease. Immediate, appropriate treatment in patients with this condition is essential to ensure a speedy recovery.

Whether or not a patient should continue playing sport is dependent on symptoms. Patients with mild symptoms may wish to continue to play some or all sport, others may choose to modify their program. Generally it is recommended that patients with Osgood Schlatters disease keep active provided their symptoms are mild or absent.

Patients should also perform pain-free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. Particular emphasis is often placed on stretching the quadriceps muscles to restore flexibility. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.

Prognosis of Osgood Schlatters disease

Osgood Schlatters disease is a self limiting condition that gradually resolves as the patient moves towards skeletal maturity. This usually takes between 6 to 12 months but may persist for as long as 2 years. With appropriate management, patients with this condition typically improve gradually over time and full function is restored. Osgood Schlatters disease does not interfere with growth. The only long term effect of this condition may be an increased prominence of the tibial tuberosity at the front of the shin.

Contributing factors to the development of Osgood Schlatters disease

There are several factors which may increase the likelihood of developing this condition. These need to be assessed and corrected where possible, with direction from a physiotherapist to ensure an optimal outcome. Some of the factors which may contribute to the development of Osgood Schlatters disease include:

  • a sudden increase in training or sporting activity
  • inappropriate training
  • recent growth spurts
  • inappropriate footwear
  • muscle tightness or weakness (particularly the quadriceps)
  • joint stiffness
  • poor lower limb biomechanics
  • poor foot posture

Shin Splints

What are shin splints?

Shin Splints (Medial Tibial Tenoperiostitis) is a condition characterized by damage and inflammation of the connective tissue joining muscles to the inner shin bone (tibia).

There are several muscles which lie at the back of your lower leg and are collectively known as the calf muscles (figure 1). Several of these muscles lie deep within the calf (tibialis posterior, flexor digitorum longus, flexor hallicus longus and soleus) and attach to the inner border of the shin bone (tibia). The connective tissue responsible for attaching these muscles to the tibia is known as the tenoperiosteum. Every time the calf contracts, it pulls on the tenoperiosteum. When this tension is too forceful or repetitive, damage to the tenoperiosteum occurs. This results in inflammation and pain and is known as medial tibial tenoperiostitis – commonly referred to as shin splints.

Medial tibial tenoperiostitis can sometimes occur in combination with other pathologies that cause shin pain such as compartment syndrome and tibial stress fractures.

Causes of shin splints

Shin splints most commonly occur due to repetitive or prolonged activities placing strain on the tenoperiosteum. This typically occurs due to excessive walking, running or jumping activities (such as an increase in training or running) and is often seen in runners and footballers. It frequently occurs in association with calf muscle tightness or biomechanical abnormalities, such as excessive pronation (flat feet – figure 2) or supination (high arch) or in those with inappropriate footwear. Athletes more commonly develop this condition early in the season following a period of reduced activity (deconditioning) and when training surfaces are generally harder.

Signs and symptoms of shin splints

Patients with shin splints typically experience pain along the inner border of the shin. In less severe cases, patients may only experience an ache or stiffness along the inner aspect of the shin that increases with rest (typically at night or first thing in the morning) following activities which place stress on the tenoperiosteum. These activities typically include excessive walking, running (especially up hills, on uneven surfaces or in poor footwear such as thongs), jumping and general weight bearing activity. The pain associated with this condition may also warm up with activity in the initial stages of injury. As the condition progresses, patients may experience symptoms that increase during sport or activity, affecting performance. In severe cases, patients may walk with a limp although this may also reduce to some extent as the patient warms up.

Patients with this condition typically experience pain on firmly touching the inner border of the shin bone particularly along the lower third of the bone. Areas of muscle tightness, thickening or lumps may also be felt in the area of pain. In severe cases, swelling, redness and warmth may also be present.

Diagnosis of shin splints

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose shin splints. Occasionally, further investigations such as an X-ray, ultrasound, bone scan, CT scan, MRI or compartment pressure testing may be used to assist diagnosis and rule out other conditions, such as compartment syndrome or tibial stress fractures

tibial stress fracture

A tibial stress fracture is a condition characterized by an incomplete crack in the lower leg bone / shin bone (tibia) (figure 1).

During weight-bearing activity (such as running), compressive forces are placed through the tibia. In addition, several muscles attach to the tibia, so that when they contract, a pulling force is exerted on the bone. When these forces are excessive, or too repetitive, and beyond what the bone can withstand, bony damage can gradually occur. This initially results in a bony stress reaction, however, with continued damage may progress to a tibial stress fracture.

Causes of a tibial stress fracture

A stress fracture of the tibia is an overuse injury that typically develops gradually over time due to activities placing large amounts of stress through the tibia beyond what it can withstand. These activities usually involve excessive weight bearing activity such as running, sprinting or jumping. The condition often occurs following a recent increase in activity or change in training conditions.

Signs and symptoms of a tibial stress fracture

Patients with this condition typically experience a gradual onset of localized pain at the inner aspect of the shin bone. The pain is often sharp or acute in nature and typically increases with impact activity and decreases with rest. Occasionally pain may be felt with rest or even at night. In severe cases, walking may be enough to aggravate symptoms. Patients with this condition typically experience tenderness on firmly touching the inner aspect of the shin bone. Occasionally, a tibial stress fracture may present as calf pain or pain located at the front of the shin (rather than the inner aspect of the bone).

Diagnosis of a tibial stress fracture

A thorough subjective and objective examination from a physiotherapist may be sufficient to diagnose a tibial stress fracture. Further investigations such as an X-ray, bone scan and CT scan are usually required to confirm diagnosis and determine the severity of injury.

calf cramp

A calf cramp is an involuntary and painful contraction of the calf muscle that can occur suddenly and may prevent the individual from continuing activity. Research suggests the mechanism of cramps is related to disturbances within the nerves and muscles.

The muscle group at the back of the lower leg is commonly called the calf. The calf comprises of 2 major muscles one of which originates from above the knee joint (gastrocnemius) the other of which originates from below the knee joint (soleus). Both of these muscles insert into the heel bone via the Achilles tendon (figure 1).

The calf muscle is one of the most commonly affected by cramp. This typically affects the gastrocnemius muscle although occasionally the soleus may also be involved.

Causes of a calf cramp

There are a number of factors which may in isolation or combination predispose patients to developing a calf cramp. These factors should be assessed and corrected with direction from a physiotherapist, podiatrist, nutritionist and/or doctor. Some of these factors may include:

  • Dehydration
  • Low salt levels (potassium and sodium)
  • Inadequate carbohydrate intake
  • Excessive muscle tightness
  • Neural tightness
  • Muscle weakness
  • Muscle or neural fatigue
  • Excessive training or activity (particularly running or running sports)
  • A lack of fitness or conditioning
  • Joint stiffness (particularly of the ankle, heel or foot)
  • Poor biomechanics of the foot (such as flat feet)
  • Inappropriate footwear, equipment or training surfaces
  • Certain medications
  • Poor recovery strategies between training sessions or matches
  • A lack of sleep

Signs and symptoms of a calf cramp

Patients with a calf cramp usually experience a sudden, intense involuntary contraction or tightening of the calf muscle. This is usually associated with significant pain and a pulling sensation in the calf that may be temporarily disabling. Calf cramps can often spontaneously resolve as quickly as they have developed, particularly if appropriate stretching is applied to the calf muscle.

Diagnosis of a calf cramp

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a calf cramp and exclude other conditions. Occasionally further investigation such as an ultrasound may be required to rule out other injuries.

alf strain

A calf strain is a common injury affecting the lower leg characterized by tearing of one or more of the calf muscles and typically causes pain in the back of the lower leg.

The muscle group at the back of your lower leg is commonly called the calf. The calf comprises of 2 major muscles one of which originates from above the knee joint (gastrocnemius) the other of which originates from below the knee joint (soleus). Both of these calf muscles insert into the heel bone (calcaneus) via the Achilles tendon (figure 1). The soleus muscle lies deeper than the gastrocnemius.

During contraction or stretch of the calf, tension is placed through the calf muscle. When this tension is excessive due to too much repetition or high force, the calf muscle can be torn. When this occurs and the injury involves the deeper calf muscle, it is known as a calf strain of the soleus muscle.

A strained calf can range from a small partial tear whereby there is minimal pain and minimal loss of function, to a complete rupture of the calf which may require surgical reconstruction.

Calf strains range from grade 1 to grade 3 and are classified as follows:

  • Grade 1 Tear: a small number of fibres are torn resulting in some pain, but allowing full function.
  • Grade 2 Tear: a significant number of fibres are torn with moderate loss of function.
  • Grade 3 Tear: all muscle fibres are ruptured resulting in major loss of function.

The majority of calf strains are grade 2.


Causes of a calf strain

A strained calf commonly occurs due to a sudden contraction of the calf muscle (often when the muscle is in a position of stretch). This frequently occurs when a patient attempts to accelerate from a stationary position or when lunging forwards such as while playing tennis, badminton or squash. They are also commonly seen in running sports such as football and athletics.

A calf strain involving the soleus muscle may also frequently occur due to gradual wear and tear associated with overuse. This may be due to activities such as distance running, repetitive jumping or walking excessively (especially up hills or on uneven surfaces).


Signs and symptoms of a calf strain

Patients with a strained calf usually feel a sudden sharp pain or pulling sensation in the calf muscle at the time of injury. Occasionally, the patient may experience increasing tightness in the calf muscle in the lead up to their injury. Swelling, tenderness and bruising are often present in the calf muscle following the injury. When the soleus muscle is involved, symptoms tend to present more commonly in the outer (lateral) aspect of the muscle. In minor strains, pain may be minimal allowing continued activity. In more severe cases, patients may experience severe pain, muscle spasm, weakness, and an inability to continue activity. Patients with a severe calf strain may also walk with a limp or be unable to weight bear on the affected leg.

Patients with this condition usually experience pain in the calf that may increase during activities such as walking (especially uphill or on uneven surfaces), going up and down stairs, running, jumping, hopping, or standing on tip toe (particularly with the knee bent). It is also common for patients with a strained calf to experience pain or stiffness after these activities with rest, especially upon waking in the morning. Occasionally, walking and jogging may actually be more painful than fast running in patients with a calf strain involving the soleus muscle.


Diagnosis of a calf strain

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a calf strain. Further investigations such as an MRI scan or Ultrasound may be required, in rare cases, to confirm diagnosis, assess the severity of injury and/or rule out other pathologies

popliteal cyst

Introduction

popliteal cyst, also called a Baker’s cyst, is a soft, often painless bump that develops on the back of the knee. A cyst is usually nothing mohese cysts occur most often when the knee is damaged due to arthritis, gout, injury, or inflammation in the lining of the knee joint. Surgical treatment may be successful when the actual cause of the cyst is addressed. Otherwise, the cyst can come back again.

Anatomy

What is a popliteal cyst?

re than a bag of fluid. T

The knee joint is formed where the thighbone (femur) meets the shinbone (tibia). A slick cushion of articular cartilage covers the surface ends of both of these bones so that they slide against one another smoothly. The articular cartilage is kept slippery by joint fluid made by the joint lining (the synovial membrane). The fluid is contained in a soft tissue enclosure around the knee joint called the joint capsule.

A popliteal cyst is a small, bag-like structure that forms when the joint lining produces too much fluid in the knee. The extra fluid builds up and pushes through the back part of the joint capsule, forming a cyst. The cyst squeezes out toward the back part of the knee in the area called the popliteal fossa, the indentation felt in the back part of the knee between the two hamstring tendons and the top part of the calf muscle. Most people will be able to feel the cyst in the hollow area right behind the knee joint.

 

Causes

Why does a popliteal cyst develop?

A popliteal cyst may form after damage to the joint capsule of the knee. The weakening of the joint capsule in the damaged area can cause the small sac of fluid to form. This can lead to a bulging of the joint capsule, much like what occurs when an inner tube bulges through a weak spot in a tire. The cyst may become larger over time.

A popliteal cyst can actually be a response to other conditions that cause swelling in the knee joint. This swelling is most often from problems of osteoarthritis or rheumatoid arthritis in the knee joint. It can also be caused by trauma, either from a direct blow to the knee or from repetitive activities that lead to overuse in the knee joint. A popliteal cyst is not from a blood clot in the leg, although sometimes it can be mistaken for a blood clot.

Symptoms

What does a popliteal cyst feel like?

The symptoms caused by a popliteal cyst are usually mild. You may have aching or tenderness with exercise or your knee may feel unsteady, as though it’s going to give out. You may feel pain from the underlying cause of the cyst, such as arthritis, an injury, or a mechanical problem with the knee, for instance a tear in the meniscus. Along with these symptoms, you may also see or feel a bulge on the back of your knee. Anything that causes the knee to swell and more fluid to fill the joint can make the cyst larger. It is common for a popliteal cyst to swell and shrink over time.

Sometimes a cyst will suddenly burst underneath the skin, causing pain and swelling in the calf. A ruptured popliteal cyst gives symptoms just like those of a blood clot in the leg, called thrombophlebitis. For this reason, it is important to determine right away the cause of the pain and swelling in the calf. Once the cyst ruptures, the fluid inside the cyst simply leaks into the calf and is absorbed by the body. In this case, you will no longer be able to see or feel the cyst. However, the cyst will probably return in a short time.

Diagnosis

How do doctors identify a popliteal cyst?

Your doctor will ask you to describe the history of your problem. Then the doctor will examine your knee and leg. A physical exam is usually all that is needed to diagnose a popliteal cyst. Unless the cyst has ruptured, further testing is typically not needed.

If the cyst has ruptured, additional tests will be required. Regular X-rays will not show the cyst since it is a soft tissue, and X-rays show mostly bones. A cyst can be seen with a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to create pictures that look like slices of the area your doctor is interested in. This test requires no needles or special dye and is painless. Your doctor may order an ultrasound test. This test uses sound waves to allow the doctor to see the outline of the cyst and determine whether it is filled with fluid or solid tissue. This is useful in determining whether the lump could actually be a tumor instead of a fluid-filled cyst.

Baker’s cysts

A Baker’s cysts is a condition characterized by local swelling situated behind the knee and typically occurs as a result of, and in association with, knee joint injuries (such as a meniscal tear or knee osteoarthritis).

The knee joint comprises of the union of two bones: the long bone of the thigh (femur) and the shin bone (tibia) (figure 1). Between the bone ends are 2 round discs made of cartilage, called the medial (inner) and lateral (outer) meniscus (figure 1). Each meniscus acts as a shock absorber cushioning the impact of the femur on the tibia during weight-bearing activity. Wrapping around the entire knee joint is strong connective tissue known as the knee joint capsule which effectively forms a container within the knee joint. Behind the knee lie several small fluid filled sacs known as bursa. Bursa are designed to reduce friction between adjacent bony or soft tissue layers and often communicate with the knee joint.

Structures within the knee joint such as the medial and lateral meniscus may be damaged suddenly due to a specific incident or gradually over time due to repetitive or prolonged activities placing strain on tissue. This may be due to excessive weight bearing or twisting forces, a fall or an awkward landing from a height and may over time lead to knee osteoarthritis. When injury occurs to structures within the knee joint such as the menisci, swelling typically accumulates within the knee joint capsule and sometimes into the bursa (usually at the back of the knee) that communicate with the knee joint. This condition is known as a Baker’s cyst.

Causes of a Baker’s cyst

A Baker’s cyst most commonly occurs secondary to degenerative changes to the knee (knee osteoarthritis) or meniscal injuries (either acutely or due to gradual overuse). Meniscal injuries often occur traumatically in sports that require sudden changes of direction and twisting movements (sometimes in combination with excessive straightening or bending of the knee). These sports may include football, soccer, basketball, netball and snow skiing. Meniscal tears frequently take place when the foot is fixed on the ground and a twisting force is applied to the knee (e.g. when another player’s body falls across the leg, or when a player is tackled) or following a forceful jump or landing.

Meniscal injuries may also occur over time through gradual wear and tear associated with overuse (e.g. excessive distance running). This may be associated with, or lead to, degenerative changes within the knee joint over time (osteoarthritis), particularly in older patients.

Signs and symptoms of a Baker’s cyst

Patients with a Baker’s cyst typically experience a firm, lumpy swelling located at the back of the knee. In patients with a minor Baker’s cyst little or no symptoms may be present. As the condition worsens patients may experience pain or an ache located at the back of the knee and often a feeling of tightness, particularly when attempting to bend or straighten the knee fully. Sometimes this tightness may extend into the calf. Tenderness may also be experienced when firmly touching the Baker’s cyst at the back of the knee.

Patients with a Baker’s cyst may also experience other symptoms associated with the underlying cause of the Baker’s cyst. These symptoms may include clicking, grinding, locking, sharper pains, an audible sound at the time of injury, pain during certain activities (such as weight bearing activity, kneeling, twisting or squatting), knee weakness or collapsing, night or morning pain or ache, and, a limp or inability to weight bear on the affected limb.

Diagnosis of a Baker’s cyst

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a Baker’s cyst and the underlying cause of the condition. An ultrasound investigation is usually the most appropriate investigation to identify the presence of a Baker’s Cyst. Other investigations, such as X-ray, MRI and CT scan are sometimes used to assist or confirm diagnosis and to determine the cause of the Baker’s cyst. In rare cases, where appropriate investigations have proven inconclusive, an investigative arthroscope may be performed to assist with diagnosis.

Compartment syndrome

What is compartment syndrome?

Compartment syndrome is a condition characterized by a variety of symptoms (such as pain and muscle tightness), which occurs in the lower leg as a result of exercise-induced muscle swelling and a subsequent increase in local tissue pressure.

There are several muscles which lie at the front of the shin (tibialis anterior, extensor digitorum longus, extensor hallicus longus and peroneus tertius). These muscles are responsible for moving the foot and toes towards the shin (dorsiflexion) and are enveloped in a layer of connective tissue (fascia), which encloses them, therefore forming a compartment. This compartment is known as the anterior compartment (figure 1).

Occasionally, the compartment’s enveloping layer of connective tissue becomes tight and inflexible resulting in an increase in pressure within the compartment. This may be due to an inflammatory process whereby the connective tissue loses its elasticity. In addition, activity requiring repeated use of muscles within the anterior compartment (such as excessive walking or running) results in a local increase in blood flow, causing the muscles to swell. Subsequently, the pressure within the compartment may increase excessively during activity resulting in a variety of lower leg symptoms such as tightness, pain, weakness, pins and needles or numbness. When this occurs, the condition is known as anterior compartment syndrome. Occasionally, compartment syndrome may occur in combination with other conditions that cause shin pain such as shin splints and stress fractures.

Causes of compartment syndrome

Compartment syndrome is usually associated with overuse (such as a sudden increase in training or running) and is often seen in runners and footballers. It frequently occurs in association with muscle tightness, an increase in size and volume of muscles within the compartment or biomechanical abnormalities, such as excessive pronation (flat feet – figure 2) or supination (high arch). Patients often develop this condition early in the season following a period of reduced activity (deconditioning) and when training surfaces are generally harder.

Signs and symptoms of compartment syndrome

Patients with anterior compartment syndrome typically experience pain and tightness along the outer aspect of the front of the lower leg. Symptoms generally increase with exercise and decrease with rest and can occur in one or both legs.

Patients with this condition may experience an ache, tightness or busting sensation that can progress to chronic pain with excessive activity. In severe cases, patients may experience weakness, pins and needles in the foot, numbness or a ‘dead’ feeling in the leg that develops with ongoing activity. Usually symptoms will disappear relatively quickly upon resting.

Patients usually do not experience pain on firmly touching the affected area, however, if other conditions are present, such as shin splints, there may be tenderness evident along the border of the shin bone. Areas of muscle tightness, thickening or lumps may also be felt in the area of pain.

Diagnosis of compartment syndrome

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose compartment syndrome. Compartment pressure testing can be used to confirm the diagnosis and identify the muscle compartment involved. Investigations such as an X-ray, bone scan, CT scan or MRI may sometimes also be used to assist with diagnosis and exclude the presence of other pathologies

Achillis Bursitis

Heel pain is a common symptom that has many possible causes. Although heel pain sometimes is caused by a systemic (body-wide) illness, such as rheumatoid arthritis or gout, it usually is a local condition that affects only the foot. The most common local causes of heel pain include:

  • Plantar fasciitis — Plantar fasciitis is a painful inflammation of the plantar fascia, a fibrous band of tissue on the sole of the foot that helps to support the arch. Plantar fasciitis occurs when the plantar fascia is overloaded or overstretched. This causes small tears in the fibers of the fascia, especially where the fascia meets the heel bone. Plantar fasciitis may develop in just about anyone but it is particularly common in the following groups of people: people with diabetes, obese people, pregnant women, runners, volleyball players, tennis players and people who participate in step aerobics or stair climbing. You also can trigger plantar fasciitis by pushing a large appliance or piece of furniture or by wearing worn out or poorly constructed shoes. In athletes, plantar fasciitis may follow a period of intense training, especially in runners who push themselves to run longer distances. People with flat feet have a higher risk of developing plantar fasciitis.

  • Heel spur — A heel spur is an abnormal growth of bone at the area where the plantar fascia attaches to the heel bone. It is caused by long-term strain on the plantar fascia and muscles of the foot, especially in obese people, runners or joggers. As in plantar fasciitis, shoes that are worn out, poorly fitting or poorly constructed can aggravate the problem. Heel spurs may not be the cause of heel pain even when seen on an X-ray. In fact, they may develop as a reaction to plantar fasciitis

  • Calcaneal apophysitis — In this condition, the center of the heel bone becomes irritated as a result of a new shoe or increased athletic activity. This pain occurs in the back of the heel, not the bottom. Calcaneal apophysitis is a fairly common cause of heel pain in active, growing children between the ages of 8 and 14. Although almost any boy or girl can be affected, children who participate in sports that require a lot of jumping have the highest risk of developing this condition.
  • Bursitis — Bursitis means inflammation of a bursa, a sac that lines many joints and allows tendons and muscles to move easily when the joint is moving. In the heel, bursitis may cause pain at the underside or back of the heel. In some cases, heel bursitis is related to structural problems of the foot that cause an abnormal gait (way of walking). In other cases, wearing shoes with poorly cushioned heels can trigger bursitis.
  • Pump bump — This condition, medically known as posterior calcaneal exostosis, is an abnormal bony growth at the back of the heel. It is especially common in young women, in whom it is often related to long-term bursitis caused by pressure from pump shoes.
  • Local bruises — Like other parts of the foot, the heel can be bumped and bruised accidentally. Typically, this happens as a “stone bruise,” an impact injury caused by stepping on a sharp object while walking barefoot.
  • Achilles tendonitis — In most cases, Achilles tendonitis (inflammation of the Achilles tendon) is triggered by overuse, especially by excessive jumping during sports. However, it also can be related to poorly fitting shoes if the upper back portion of a shoe digs into the Achilles tendon at the back of the heel. Less often, it is caused by an inflammatory illness, such as ankylosing spondylitis (also called axial spondylarthritis), reactive arthritis, gout or rheumatoid arthritis.
  • Trapped nerve — Compression of a small nerve (a branch of the lateral plantar nerve) can cause pain, numbness or tingling in the heel area. In many cases, this nerve compression is related to a sprain, fracture or varicose (swollen) vein near the heel.

    Symptoms

    The heel can be painful in many different ways, depending on the cause:

    • Plantar fasciitis — Plantar fasciitis commonly causes intense heel pain along the bottom of the foot during the first few steps after getting out of bed in the morning. This heel pain often goes away once you start to walk around, but it may return in the late afternoon or evening.
    • Heel spur — Although X-ray evidence suggests that about 10% of the general population has heels spurs, many of these people do not have any symptoms. In others, heel spurs cause pain and tenderness on the undersurface of the heel that worsen over several months.
    • Calcaneal apophysitis — In a child, this condition causes pain and tenderness at the lower back portion of the heel. The affected heel is often sore to the touch but not obviously swollen.
    • Bursitis — Bursitis involving the heel causes pain in the middle of the undersurface of the heel that worsens with prolonged standing and pain at the back of the heel that worsens if you bend your foot up or down.
    • Pump bump — This condition causes a painful enlargement at the back of the heel, especially when wearing shoes that press against the back of the heel.
    • Local bruises — Heel bruises, like bruises elsewhere in the body, may cause pain, mild swelling, soreness and a black-and-blue discoloration of the skin.
    • Achilles tendonitis — This condition causes pain at the back of the heel where the Achilles tendon attaches to the heel. The pain typically becomes worse if you exercise or play sports, and it often is followed by soreness, stiffness and mild swelling.
    • Trapped nerve — A trapped nerve can cause pain, numbness or tingling almost anywhere at the back, inside or undersurface of the heel. In addition, there are often other symptoms — such as swelling or discoloration — if the trapped nerve was caused by a sprain, fracture or other injury.

    Diagnosis

    After you have described your foot symptoms, your doctor will want to know more details about your pain, your medical history and lifestyle, including:

    • Whether your pain is worse at specific times of the day or after specific activities
    • Any recent injury to the area
    • Your medical and orthopedic history, especially any history of diabetes, arthritis or injury to your foot or leg
    • Your age and occupation
    • Your recreational activities, including sports and exercise programs
    • The type of shoes you usually wear, how well they fit, and how frequently you buy a new pair

    Your doctor will examine you, including:

    • An evaluation of your gait — While you are barefoot, your doctor will ask you to stand still and to walk in order to evaluate how your foot moves as you walk.
    • An examination of your feet — Your doctor may compare your feet for any differences between them. Then your doctor may examine your painful foot for signs of tenderness, swelling, discoloration, muscle weakness and decreased range of motion.
    • A neurological examination — The nerves and muscles may be evaluated by checking strength, sensation and reflexes.

    In addition to examining you, your health care professional may want to examine your shoes. Signs of excessive wear in certain parts of a shoe can provide valuable clues to problems in the way you walk and poor bone alignment. Depending on the results of your physical examination, you may need foot X-rays or other diagnostic tests.​

Calf Strain (Soleus)

A calf strain is a common injury affecting the lower leg characterized by tearing of one or more of the calf muscles and typically causes pain in the back of the lower leg.

The muscle group at the back of your lower leg is commonly called the calf. The calf comprises of 2 major muscles one of which originates from above the knee joint (gastrocnemius) the other of which originates from below the knee joint (soleus). Both of these calf muscles insert into the heel bone (calcaneus) via the Achilles tendon (figure 1). The soleus muscle lies deeper than the gastrocnemius.

 

During contraction or stretch of the calf, tension is placed through the calf muscle. When this tension is excessive due to too much repetition or high force, the calf muscle can be torn. When this occurs and the injury involves the deeper calf muscle, it is known as a calf strain of the soleus muscle.

A strained calf can range from a small partial tear whereby there is minimal pain and minimal loss of function, to a complete rupture of the calf which may require surgical reconstruction.

Calf strains range from grade 1 to grade 3 and are classified as follows:

  • Grade 1 Tear: a small number of fibres are torn resulting in some pain, but allowing full function.
  • Grade 2 Tear: a significant number of fibres are torn with moderate loss of function.
  • Grade 3 Tear: all muscle fibres are ruptured resulting in major loss of function.

The majority of calf strains are grade 2.


Causes of a calf strain

A strained calf commonly occurs due to a sudden contraction of the calf muscle (often when the muscle is in a position of stretch). This frequently occurs when a patient attempts to accelerate from a stationary position or when lunging forwards such as while playing tennis, badminton or squash. They are also commonly seen in running sports such as football and athletics.

A calf strain involving the soleus muscle may also frequently occur due to gradual wear and tear associated with overuse. This may be due to activities such as distance running, repetitive jumping or walking excessively (especially up hills or on uneven surfaces).


Signs and symptoms of a calf strain

Patients with a strained calf usually feel a sudden sharp pain or pulling sensation in the calf muscle at the time of injury. Occasionally, the patient may experience increasing tightness in the calf muscle in the lead up to their injury. Swelling, tenderness and bruising are often present in the calf muscle following the injury. When the soleus muscle is involved, symptoms tend to present more commonly in the outer (lateral) aspect of the muscle. In minor strains, pain may be minimal allowing continued activity. In more severe cases, patients may experience severe pain, muscle spasm, weakness, and an inability to continue activity. Patients with a severe calf strain may also walk with a limp or be unable to weight bear on the affected leg.

Patients with this condition usually experience pain in the calf that may increase during activities such as walking (especially uphill or on uneven surfaces), going up and down stairs, running, jumping, hopping, or standing on tip toe (particularly with the knee bent). It is also common for patients with a strained calf to experience pain or stiffness after these activities with rest, especially upon waking in the morning. Occasionally, walking and jogging may actually be more painful than fast running in patients with a calf strain involving the soleus muscle.


Diagnosis of a calf strain

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a calf strain. Further investigations such as an MRI scan or Ultrasound may be required, in rare cases, to confirm diagnosis, assess the severity of injury and/or rule out other pathologies

Compartment Syndrome(Deep Posterior)

What is compartment syndrome?

Compartment syndrome is a condition characterized by a variety of symptoms (such as pain and muscle tightness) which occur in the lower leg as a result of exercise-induced muscle swelling and a subsequent increase in local tissue pressure.

There are several muscles which lie at the back of the lower leg and are collectively known as the calf muscles (figure 1). Several of these muscles lie deep within the calf (flexor hallicus longus, flexor digitorum longus and tibialis posterior) and are enveloped in a layer of connective tissue (fascia) which encloses them, therefore forming a compartment. This compartment is known as the deep posterior compartment.

Occasionally, the compartments’ enveloping layer of connective tissue becomes tight and inflexible resulting in an increase in pressure within the compartment. This may be due to an inflammatory process whereby the connective tissue loses its elasticity. In addition, activity requiring repeated use of muscles within the deep posterior compartment (such as running) results in a local increase in blood flow, causing the muscles to swell. Subsequently, the pressure within the compartment may increase excessively during activity resulting in a variety of lower leg symptoms such as tightness, pain, weakness, pins and needles or numbness. When this occurs, the condition is known as deep posterior compartment syndrome.

Occasionally, compartment syndrome may occur in combination with other conditions that cause shin pain such as shin splints and stress fractures.

Causes of compartment syndrome

Compartment syndrome is usually associated with overuse (such as a sudden increase in training or running) and is often seen in runners and footballers. It frequently occurs in association with calf muscle tightness, an increase in calf muscle size or biomechanical abnormalities, such as excessive pronation (flat feet – figure 2) or, less commonly, supination (high arch). Patients often develop this condition early in the season following a period of reduced activity (deconditioning) and when training surfaces are generally harder.

Signs and symptoms of compartment syndrome

Patients with deep posterior compartment syndrome typically experience pain and tightness along the inner aspect of the shin and / or back of the lower leg. Symptoms generally increase with exercise and decrease with rest and can occur in one or both legs.

Patients with this condition may experience an ache, tightness or bursting sensation that can progress to chronic calf pain with excessive activity. In severe cases, patients may experience weakness, pins and needles in the foot, numbness or a ‘dead’ feeling in the leg that develops with ongoing activity. Usually symptoms will disappear relatively quickly upon resting.

Patients usually do not experience pain on firmly touching the affected area, however, if other conditions are present, such as shin splints, there may be tenderness along the inner border of the shin bone. Areas of muscle tightness, thickening or lumps may also be detected in the area of pain.

Diagnosis of compartment syndrome

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose compartment syndrome. Compartment pressure testing can be used to confirm the diagnosis and identify the exact muscle compartment involved. Investigations such as an X-ray, bone scan, CT scan or MRI may sometimes also be used to assist with diagnosis and exclude the presence of other pathologies.

Diseases

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