let’s take stock of … the lower limb !

Hello everybody! Since the number of daily readers (and followers) of my blog is (surprisingly) increasing day after day (Thank you everybody!), I thought it could be useful to take stock of some important posts I wrote about the lower limb. Let’s start from the top -the hip- and go down to the bottom -the ankle-, with 9 posts that got many views and some funny comments 🙂

Obviously, since my PhD project is about a knee prosthesis, most of the posts (5 out of 9) are about the knee joint. But in general I tried to give an overall view of some interesting topics related to the biomechanics of the lower limb. Enjoy! 🙂

the Hip Joint: some hints

hammers, screws and Intramedullary nails

the Knee Bursae: some hints

the Meniscus: some hints

the Patella: some hints

Knee Alignment Conditions

Patellar Reflex

How many limbs do you actually perceive?

the Ankle Joint: some hints

the Knee Bursae: some hints

The bursae of the knee can be defined in a very simple way: they are fluid sacs, or synovial pockets. This second definition comes from the sinovial fluid that fills them.

Synovial fluid is made of hyaluronic acid and lubricin, proteinases and collagenases. Its main functions are reducing friction by lubricating the joint, absorbing shocks and properly “feeding” joint cartilage. In the case of the knee, the Knee Capsule encloses the Knee Cavity which is filled with synovial fluid. Knee Bursae surround and sometimes communicate with the Knee Cavity, as we can see in the picture.

Usually Knee Bursae are thin-walled and represent the weak point of the joint. At the same time, their presence is really important since they enlarge the joint space. They can be grouped according to:

• their characterization as communicating and non-communicating bursae. A communicating bursa is when a bursa is located adjacent to a joint, thus having the synovial membrane in communication with the joint itself.
• their location (frontal, lateral, medial).

In pathological conditions, such as excessive local friction, infection, arthritides or direct trauma, fluid and debris collect within the bursa or fluid extends into the bursa from the adjacent joint. As a consequence, the walls of the bursa thicken as the bursal inflammation becomes longstanding. The term bursitis refers to pathological enlargement of the bursa. Clinically, bursitis mimics several peripheral joint and muscle abnormalities.

   

<–prepatellar bursitis

          elbow bursitis–>

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sources: Wikipedia and this website

Patellar Reflex

definition _

Patellar Reflex, also called knee-jerk, is a stretch reflex associated with quadriceps femoris muscle stretching.

how it works _

The stretch is created by a blow upon the patellar tendon (positioned just below the Patella). This blow, usually performed with a specific tendon hammer, activates the muscle spindle in the quadriceps femoris muscle.

Muscle spindle is a particular type of sensory receptor, normally embedded in muscle fibers, able to detect changes in the length of the muscle itself. Once “activated” by the external blow, this receptor sends a signal to the spinal cord. Instead of involving higher nervous centres (it would take too long), at the level of the spinal cord an alpha-motor neuron is immediately activated.

The alpha-motor neuron conducts an efferent impulse directly back to the quadriceps femoris muscle, leading to its contraction. At the same time, an inhibitory interneuron relaxes the hamstring muscle, which is the quadricep’s antagonistic muscle.

The result of such coordinated contraction-relaxation, causes the “kick movement” of the leg. In normal health conditions, the leg extends once and then comes back to rest. It only takes about 50 milliseconds between the tap and the start of the leg kick.

why it is useful _

Patellar Reflex is a proprioceptive reflex which helps keeping posture and balance. The fact that everything “happens” at the level of the spinal cord, without involving higher nervous centres, allows for instance to keep balance without effort (actually, one does not have to focus on keeping an upright position). Energies are saved for more complex activities. Moreover, Patellar Reflex helps avoiding strong muscle contractions which could tear the tendon.

clinical interest _

As said, there is no interneuron in the pathway leading to contraction of the quadriceps muscle. Patellar Reflex can be used, for example, to check the conditions of the connections between the spinal cord and the muscles.

The absence or decrease of the Patellar Reflex is known as Westphal’s sign. On the other hand, multiple oscillation of the leg following the blow may be a symptom of cerebellar diseases.

source: contents taken from Wikipedia’s page

the Patella: some hints

The patella (also known as knee cap) is a thick, circular-triangular bone which articulates with the femur and covers and protects the anterior articular surface of the knee joint.

It is the largest sesamoid bone in the human body. In the adult the articular surface is about 12 cm² and covered by cartilage, which can reach a maximal thickness of 6 mm in the centre at about 30 years of age.

The patella is attached to the Quadriceps tendon (of the quadriceps femoris muscle), which contracts to extend/straighten the knee. The vastus lateralis and vastus medialis are attached to lateral and medial borders of patella respectively. The vastus intermedialis muscle, not showed in this picture, is attached to the base of patella.

The patella is stabilized by the insertion of vastus medialis and the prominence of the anterior femoral condyles, which prevent lateral dislocation during flexion. The retinacular fibres of the patella also stabilize it during exercise.

The primary functional role of the patella is knee extension. The patella increases the leverage that the Quadriceps tendon can exert on the femur by increasing the angle at which it acts.

Patellar problems are among the most common causes of knee pain. This disease may be associated with other symptoms, such as instability or giveaway, dislocation, catching, grinding (crepitation), and/or swelling. These symptoms may present spontaneously or following injury (such as subluxations, blows to the front of the knee etc.). In general terms, patellar problems can be organized as:

1. Pain alone – “patellofemoral syndrome”,
2. Pain from malalignment – tilt and/or displacement,
3. Instability – subluxation and dislocation,
4. “Wear and tear” – arthritis,
5. Other problems – synovial plica, tendonitis, bursitis, Osgood Schlatter’s disease, etc.

Surgery is rarely necessary, and must be carefully considered. For example, for the “pain alone” case, surgery is rarely indicated since it may even make pain worse. In these terms, surgery is best used as a last resort, after all other techniques fail (normally: conservative care trials).

Arthroscopy is the very best way to evaluate the patella and surrounding portions of the knee joint. Surgery will vary depending upon the type of patellar problem.  Of course it has risks, such as infection, stiffness, continued instability, weakness, pain, blood clots, fracture, impaired bone healing, etc. Recovery ranges from 6 weeks to 6 months, or even longer, depending upon the type of surgery, healing rates and limitations, and patient rehabilitation and efforts.

sources: two websites, this one and this one