CHAPTER 15
The Knee, Ankle and Foot
Introduction
From the 19th century onwards, the use of manual therapy to treat various musculoskeletal conditions has increased progressively. Although it is still considered a relatively new approach to balance the bones and soft-tissue structures of the body, the use of manipulative techniques, in fact, predates Hippocrates (Dananberg, Shearstone and Guillano, 2000). Today, manual therapy has most commonly been used for the treatment of spinal pathologies, particularly low back pain. However, it has also been successful in treating many structures of the musculoskeletal system, including restrictions at the foot as well as proximal joints (knee and ankle) (Dananberg, 2004).
A number of promising studies have recently indicated that both joint manipulation and soft-tissue mobilisation may significantly improve restricted knee and ankle range of motion (ROM), and provide superior short-term relief from heel and toe pain (Mohammed, Syed and Ahmed, 2009; Andersen, Fryer and McLaughlin, 2003; Grieve et al., 2011; Cleland et al., 2009; Renan-Ordine et al., 2011). Advocates of manual therapy believe that a great majority of patients with knee, ankle and foot pathologies can benefit from joint mobilisations and soft-tissue techniques. In addition, they claim that these techniques are comparatively safe and effective when compared with conventional interventions (Paterson and Burn, 2012).
However, before deciding to apply manipulative techniques to the knee, ankle and foot joints, a practitioner must make sure that no red flags or contraindications are present (Rivett, Thomas and Bolton, 2005). In addition, because adequate knowledge and skill, good handling and proper use of body posture are imperative to apply these techniques accurately and effectively, practitioners must rehearse the techniques repeatedly to apply them with confidence and control in clinical practice (Domholdt, 2000; Hodges and Gandevia, 2000; Dunne, 2001). It is also essential for practitioners to have a thorough understanding of anatomy and body biomechanics, so that they can accurately palpate bony surface landmarks. Therefore, practitioners should have appropriate training and education before they start applying these techniques to their patients (Di Fabio, 1992; World Health Organization, 2005).
The purpose of this chapter is to help practitioners diagnose serious pathologies in the knee, ankle and foot regions. This chapter describes the various joints of these structures, the range of motion in their joints, some common injuries to the regions and the red flags for manipulation.
Joints
In human anatomy, the knee is one of the largest joints in the human body. It comprises bones, cartilage, ligaments and tendons. The knee joint connects the upper and lower leg bones, and is the anatomical region where four bones – the femur, tibia, fibula and patella – meet. Apart from the fibula, these bones are all functional in the knee joint (Tate, 2009).
On the other hand, the ankle and foot are the most distal parts of the lower limb. The bones, ligaments, tendons and muscles of the ankle and foot are highly developed, complex structures. The joints of the ankle and foot are functionally different compared with other joints in the body, because they are at times mobile and at other times quite stable. These structures serve the body by providing mobility and stability, and play diverse roles in our activities of daily living (Riegger, 1988).
Table 15.1 The joints of the knee, ankle and foot | ||
Joint name | Description | Function |
Knee joint | •A synovial (modified hinge) joint, consisting of three distinct and partially separated compartments •Forms a complex hinge between three bones: the femur, the tibia and the patella •Involves two separate articulations: one joining the tibia and femur (tibiofemoral joint), and another joining the patella and femur (patellofemoral joint) •Surrounded by a single articular capsule that encloses the entire joint complex | •Ensures weight-bearing support by allowing flexion and extension of the leg •Allows transmission of body weight in vertical and horizontal directions •Permits a small amount of internal and external rotation when flexed |
Tibiofemoral joint | •A synovial hinge-type joint •Connects the medial and lateral condyles of the femur (thigh bone) with the medial and lateral condyles of the tibia •Supported by two wedge-shaped articular discs: the medial meniscus and lateral meniscus | •Serves as the weight-bearing joint of the knee •Allows flexion and extension of the knee |
Patellofemoral joint | •A saddle-type complex joint of the knee that is often misunderstood •Formed by joining the anterior and distal part of the femur with the patella (kneecap) | •Allows the knee to straighten when standing •Helps to perform the activities of daily living |
•A plane-type synovial joint formed by joining the lateral edge of the tibia with the head of the fibula •Composed of two facet joints: one on the posterolateral aspect of the tibial condyle and one on the medial upper surfaces of the head of the fibula | •Dissipates torsional stresses applied at the ankle •Dissipates lateral tibial bending movements | |
Inferior tibiofibular joint | •A syndesmosis formed by joining the distal end of the fibula with the lateral side of the tibia •Is supported by strong interosseus ligament | •Permits slight movements to allow the lateral malleolus to rotate laterally when the ankle dorsiflexes •Helps to maintain the ankle joint integrity |
Ankle or talocrural joint | •A hinge joint formed superiorly by the distal tibia and fibula and inferiorly by the dome of the talus •Involves articulation between three bones (the tibia, fibula and talus) •Is supported by strong ligamentous structures that provides stability to the ankle | •Allows dorsiflexion and plantar flexion movements via axis in talus |
Subtalar or talocalcaneal joint | •A modified multiaxial joint formed between two of the tarsal bones: the talus and the calcaneus (heel bone) •Involves three articulations between talus and calcaneus: anterior, middle and posterior | •Permits inversion and eversion motions of the foot |
Talocalcaneo-navicular joint | •A compound, multiaxial joint formed when the rounded head of the talus connects with the navicular and the calcaneus •Includes two articulations: an anterior talocalcaneal and a talonavicular | •Allows plantar flexion of talus on the navicular |
Calcaneocuboid joint | •A biaxial joint that is considered among the least mobile joints of the foot •Involves articulation between the heel bone and the cuboid bone | •Allows a movement, which is best referred to as obvolution-involution |
Tarsometatarsal or lisfranc joints | •Arthrodial joints that are formed between the tarsal bones of the mid-foot (the 1st, 2nd and 3rd cuneiform bones and the cuboid bone) and the bases of the metatarsal bones •Are strengthened by strong interosseus dorsal, and plantar ligaments | •Allow slight gliding movements at the feet |
Intermetatarsal joints | •Synovial joints that involve articulations between the bases of the metatarsal bones •Are strengthened by strong interosseus dorsal and plantar ligaments | •Allow slight gliding movements at the feet |
Metatarsopha-langeal joints | •Ellipsoid joints formed by joining the heads of the metatarsal bones with the bases of the proximal bones (proximal phalanges) •Are strengthened by collateral and plantar ligaments | •Allow a variety of movements at the toes, including flexion, extension, abduction, adduction and circumduction |
Interphalangeal joints | •Ginglymoid (hinge) joints formed by the articulations between the superior surfaces on the phalangeal heads and the adjacent phalangeal bases •Subdivided into two sets of articulations: proximal interphalangeal joints and distal interphalangeal joints | •Permit flexion and extension movements |
Sources: Tate (2009); McCann and Wise (2011); Standring (2008); Riegger (1988); Norkin and White (2009) | ||
Range of Motion
Knee
The knee joint is well constructed for the transmission of body weight in vertical and horizontal directions. It allows flexion and extension, with slight internal and external rotation about the axis of the lower leg in the flexed position. The stability and normal movements at the knee are essential for performing many daily activities, including walking, running, kicking, sitting and standing (Mader, 2004). The range of motion of the knee is typically measured using a hand goniometer. However, visual estimation and radiographic goniometry are also used to measure the range of motion.
Table 15.2 Normal range of motion of the knee | |
Movement type | Range of motion |
Flexion | 120–150° |
Extension | 5–10° |
Lateral rotation (knee flexed 90°) | 30–40° |
Medial rotation (knee flexed 90°) | 10° |
Source: Schünke et al. (2006) | |
Table 15.3 Range of motion of the knee in different age groups (in degrees) | |||
Age | Motion | Males | Females |
2–8 years | Flexion | 147.8 (146.6–149.0) | 152.6 (151.2–154.0) |
Extension | 1.6 (0.9–2.3) | 5.4 (3.9–6.9) | |
9–19 years | Flexion | 142.2 (140.4–44.0) | 142.3 (140.8–143.8) |
Extension | 1.8 (0.9–2.7) | 2.4 (1.5–3.3) | |
20–44 years | Flexion | 137.7 (136.5–138.9) | 141.9 (140.9–142.9) |
Extension | 1.0 (0.6–1.4) | 1.6 (1.1–2.1) | |
45–69 years | Flexion | 132.9 (131.6–134.2) | 137.8 (136.5–139.1) |
Extension | 0.5 (0.1–0.9) | 1.2 (0.7–1.7) | |
Numeric variables expressed as degree (range). Source: Soucie et al. (2011) | |||
The ankle allows dorsiflexion and plantar flexion movements at the foot. However, the axis of rotation of the ankle is dynamic because of the complex morphology of the talocrural joint.
Table 15.4 Approximate range of motion of the ankle | ||
Movement type | Range of motion | Reference |
Normal dorsiflexion | 0–50° | Clarkson (2000) |
Normal plantar flexion | 0–20° | |
Dorsiflexion, knee extended | 14–48° | Spink et al. (2011) |
Dorsiflexion, knee flexed | 16–60° | |
Foot
The movement of the foot joints is complex. The motion of the subtalar joint is triplanar. It permits pronation and supination movements and allows 1° of freedom. The transverse tarsal joint, though, permits some degrees of inversion and eversion motions, but it mainly serves to amplify the motions of the talocrural joint and the subtalar joint (Oatis, 1988). The motion of the tarsometatarsal joints is translatory or planar. They continue the compensatory movement produced at the transverse tarsal joint when it reaches its maximum range of motion. The metatarsophalangeal joints allow 2° of freedom, providing motion in the sagittal and transverse planes. The interphalangeal (IP) joints permit motion in the sagittal plane, allowing pure flexion and extension (Norkin and White, 2009).
Table 15.5 Range of motion of the foot joints | ||
Joint name | Movement type | Range of motion |
Subtalar joint | Inversion | 0–50° |
Eversion | 0–26° | |
Flexion (great toe) | 0–45° | |
Extension (great toe) | 0–80° | |
Flexion (lesser toes) | 0–40° | |
Extension (lesser toes) | 0–70° | |
Interphalangeal joints | Flexion (great toe) | 0–90° |
Flexion (lesser toes) | 0–30° | |
Extension (great toe and other toes) | 0–80° | |
Sources: Oatis (1988); Norkin and White (2009) | ||
Common Injuries
Knee, ankle and foot injuries are the most common musculoskeletal injuries. Most injuries to these regions are caused by a fall, motor vehicle accident, violent activity, sport accident or penetrating trauma. These injuries are common in all populations, including male and female, the very young and the old, and participants of numerous sports. In athletes, the knee, ankle and foot are the most commonly injured parts of the body. These injuries are linked to both short-term and long-term disability and can significantly upset activities of daily living.
Table 15.6 Common injuries of the knee, ankle and foot | |
Injury | Characteristics |
Anterior cruciate ligament sprain | •One of the most common knee injuries •Involves tearing of the anterior cruciate ligament – a ligament that keeps the knee stable •Occurs most commonly in athletes who actively participate in demanding sports such as football, soccer, tennis, downhill skiing, volleyball and basketball •Often occurs with a ‘popping’ noise •Causes include slowing down when running, rapid changing of direction, stopping suddenly or landing from a jump •About 50% of these injuries potentially damage other structures in the knee, including meniscus, articular cartilage or other ligaments |
•One of the most commonly injured ligaments of the knee •Involves tearing of the medial collateral ligament – a ligament that prevents the knee from bending inward •Occurs most commonly in athletes who participate in contact sports such as wrestling, judo, rugby, hockey and football •Often occurs due to a hit or direct blow to the outer aspect of the knee •Common causes include bending, twisting or rapid changing of direction while running •Symptoms include a ‘popping’ noise, pain, swelling, tenderness and locking or catching in the knee | |
Meniscal tear | •One of the most common injuries to the knee •Involves rupturing of the meniscus – a rubbery, C-shaped fibrocartilaginous structure that cushions the knee •Common causes include forceful twisting, quick turning or hyperflexion of the knee joint •High-risk group: individuals who participate in contact sports •Symptoms include pain, swelling, a ‘popping’ noise and tenderness in the knee Related posts: Stay updated, free articles. Join our Telegram channel
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