KIN 2236 FINAL EXAM QUESTIONS AND VERIFIED
ANSWERS
The achilles tendon - Answers - the tendons of the gastrocnemius and soleus fuse to
become one tendon, about 5 to 6 cm proximal to the calcaneal insertion, usually 50/50
form gastroc and soleus
-the thickest and strongest tendon in the body
-this tendon has no synovial sheath but is surrounded by paratendon, which wraps
around it and receives blood flow
-so it is a vascular tendon bc it is surrounded by paratenon
Where is the retrocalcaneal bursa - Answers - this is proximal to the achilles tendon
insertion to the calcaneus, between the tendon and the calcaneus
-this can be pinched
What could the cause of posterior heel pain - Answers - -could be achilles tendonitis,
achilles bursitis, or retrocalcaneal bursitis
-we need to look exactly where the pain is
-true tendon pain is only directly on the tendon, not around it
Retrocalcaneal Bursitis - Answers - this is a fluid filled sac that stops the achilles tendon
from rubbing across bone
-this bursa is between the anterior inferior side of the achilles tendon and the
posteriorsuperior aspect of the calcaneus
-this is sometimes seen w insertional tendinopathy, so an issue w the tendon causes
bursa to get irritated
- structural irritants too so tight or pokey
-pain will be just above the insertion of achilles, but not directly on tendon
-pain with squeeze from side and behind tendon
Achilles bursitis (superficial calcaneal bursitis) - Answers - -aka the subcutaneous bursa
-the bursa is located between the calcaneal prominence or achilles tendon and the skin,
so at bottom of achilles
-pain w posterior aspect of heel w solid swelling, so pain below achilles
-this is often due to excessive friction or by wearing shoes that are too tight or too large
-there will be swelling, but wont be soft
Management of an "itis" in posterior heel - Answers - -this is when there is inflammation
-do POLICE/PEACE and LOVE
-address training and equipement issue
-we want to calm down swelling
-Heel lift takes pressure off achilles
-pad around pain w a donut so there is no pressure directly on bursda
,-stretch achilles by stretching gastroc and soleus
What is tendinotis or paratendinitis in ankle - Answers - -tendinitis is inflammation of
tendon, this is pretty rare, from gastroc, soleus or other muscle in ankle
-paratendonitis is inflammation, pain, and crepitattion of the paratendon as it slides over
the structure (creeking noise and feel)
-this is a acute irritation, so too much too soon (increase FITT, not enough rest)
What are the internal and external factors that contribute to tendonitis and paratenonitis
in ankle - Answers - -externla factors like rub from shoe, running down hill (tibialis
anterior bc has to pronate in plantarflexion so added stress) ,rubbing form laces in
tibilais anterior, ot hyperdorsiflexion (achilles from running uphill)
-internal factors could be foot malalignment, so improper rub over bone, cavus or
flat/pronating feet
What are signs and symptoms of tendonitis or paratenonitis in ankle - Answers - -there
is pain and/or crepitation of paratenon of acute onset
-red and hot over involved structure
-usually preciptated by movement around ankle movement that was too much, too soon
-the diagnosis is made on the basis of local swelling
-look at STTT
-there will be pain on palpation only over the direct tendon
What is the usually rehab for ankle paratenonitis - Answers - inflammatory phase:
POLICE/PEACE and LOVE, use heel lift, pad, support
-repair phase: heat to increase blood flow, idealize ROM, so stretch gastroc and soleus
-start strength and proprioception ex as able, could also do balance exercise
-address the training issues
-remodeling phase: idealize strength and do soft tissue work to realign fibres
-begin speed and power training
What is achilles tendinosis - Answers - -this is chronic pathological changes brought by
repetitive micro trauma
-inflammatory cells are absent
-characteristic changes in collagen fibre structure, so fibres start to fray
-abnormal (poor) vascularity, so not getting good blood flow
-usually in midportion of of achille
What is the normal cause of achilles tendinosis - Answers - -most often pain on achilles
is from tendinosis
-predisposing factors include:
-years of running
-excessive pronation, bc this causes increased load on gastroc and soleus to
resupinate, achilles gets twisted )
-poor flexibility
-training in cold climate since tissue is less flexible so more stress on it
,-improper footwear
-may be brought about due to neglect of acute tendinitis
-worsens w increase in FITT and insufficient recovery
What is the normal diagnosis of achilles tendinosis - Answers - -history of FITT, pain
that is 2-7 cm from insertion on calcaneus
-there is some swelling and tenderness over large portion of tendon
-faulty biomechanics
-on STTT, both plantar and dorsiflexion cause pain and crepitus, especially w loading
-nodules or bumps may be palpable
-also can see thickening of achilles bc it is frayed
What is the normal treatment of a tendinosis - Answers - -starting in stage 2
-the goals are to idealize ROM, want tissue to be viable again, so use heat to improve
vascularity and figure out training problem
-eccentric strenghening program provide 60-90% improvement in pain and function for
tendinosis
So use both legs to get up on step, then eccentrically strengthen by lowing heel down,
this is painful bc tearing out injured fibres
-can do straight and bent for gastric and soleus
-do NOT use NSAIDS
What are risk factors, and symptoms of an achilles fracture - Answers - -achilles is most
commonly ruptured tendon
-risk factors are males (10:1), use of steroids. Prior rupture on the other side
-patient would report pop or snap like someone kicked them
-pain is immediate then rapidly subsides bc no longer attached, so hard to walk now
-pain is only at site of tear
-clinical signs are a palpable gap, positive thompson test and dorsiflexion when relaxed
Explain inspection of achilles rupture and the thompson's test - Answers - the foot
hangs straight down, there is no plantar flexion
-there is a palpable divot 1-2 inch above insertion, bc it is no linger attached to
calcaneus
-unable to plantarflex, loose on stretch
-may have bruisinh and redness
-the thomspon test is hwne the calf muscle is squeezed, the foot should go up a bit bc
tension on achilles
-so a positive test is NO MOVEMENT bc achilles is ruptures
-can perform surgery or put in boot
What is the tibiofemoral joint - Answers - -this is the articulating surface between medial
and lateral condyles of femur and tibia
-this joint allows transmission of body weight from the femur to the tibia while providing
hinge like, sagittal plane movement w a bit of tibial axial rotation
-so have flexion and extension, and a bit of rotation in screw home mech
, What are the two joints of the knee and the 3 articulating surfaces - Answers - -the
tibiofemoral joint has two articulating surfaces: the medial and lateral condyles of the
femur and the tibia
-the patellofemoral joint is between patella and femur
What is the patellofemoral joint - Answers - this is the articulation between the patella
and the femur
-the patella moves up and down through notched in the femur
-the patella is the largest sesamoid bone in the body
-the quad tendon comes down and attaches to patella, this gives mechanical advantage
for extension
-this is referred to as extensor mechanism
-also works eccentrically during gait to help us take weight and slowly bend the knee
Explain the screw home mechanism - Answers - -rotation occurs during the last few
degrees of extension because the medial femoral condyle is larger than lateral
-if foot is planted, the femur rotated medially
-if femur is fixed, the tibia rotated laterally
-this locks the joint to increase stability, regulated patella alignment
-the popliteus must then contract to externally rotate the femur on the tibia to unlock the
knee
When is the knee the most stable and how does it gain stability - Answers - the knee is
most stable in extension bc there is help from dynamic stabilizers and more bony fit
-knees have relatively poor bony fit when relaxed
-knee has strong fibrous joint capsule
-but knee also needs to relay on other structures for stability like MCL, LCL, ACL, PCL,
muscles
Explain the capsule of the knee - Answers - -the knee is surrounded by a capsule,
anteriorly to suprapatellar pouch and inferiorly to infrapatella fat pad and bursa
-medially it communicates w the deep fibres of MCL
-posteriorly it covers the femoral condyles
-the capsule is also lined by synovial membranes, except posteriorly where it passes in
front of cruciates
Explain the three layers of the lateral support complex in the knee - Answers - 1. There
is superficial layer, which is the illiotibial band and biceps femoris that gives support
2. Middle layer, which holds the paterlla in place
-the patellofemoral ligaments and retinaculum(inert band of tissue that holds patella)
3. Deep layer, which has the Lateral collateral ligament (LCL), the popliteus, the
capsule, and other ligaments like arcuate and fabelofibular
Explain how the lateral portion of the knee is supported by muscles - Answers - -the
biceps femoris (part of hamstring)
ANSWERS
The achilles tendon - Answers - the tendons of the gastrocnemius and soleus fuse to
become one tendon, about 5 to 6 cm proximal to the calcaneal insertion, usually 50/50
form gastroc and soleus
-the thickest and strongest tendon in the body
-this tendon has no synovial sheath but is surrounded by paratendon, which wraps
around it and receives blood flow
-so it is a vascular tendon bc it is surrounded by paratenon
Where is the retrocalcaneal bursa - Answers - this is proximal to the achilles tendon
insertion to the calcaneus, between the tendon and the calcaneus
-this can be pinched
What could the cause of posterior heel pain - Answers - -could be achilles tendonitis,
achilles bursitis, or retrocalcaneal bursitis
-we need to look exactly where the pain is
-true tendon pain is only directly on the tendon, not around it
Retrocalcaneal Bursitis - Answers - this is a fluid filled sac that stops the achilles tendon
from rubbing across bone
-this bursa is between the anterior inferior side of the achilles tendon and the
posteriorsuperior aspect of the calcaneus
-this is sometimes seen w insertional tendinopathy, so an issue w the tendon causes
bursa to get irritated
- structural irritants too so tight or pokey
-pain will be just above the insertion of achilles, but not directly on tendon
-pain with squeeze from side and behind tendon
Achilles bursitis (superficial calcaneal bursitis) - Answers - -aka the subcutaneous bursa
-the bursa is located between the calcaneal prominence or achilles tendon and the skin,
so at bottom of achilles
-pain w posterior aspect of heel w solid swelling, so pain below achilles
-this is often due to excessive friction or by wearing shoes that are too tight or too large
-there will be swelling, but wont be soft
Management of an "itis" in posterior heel - Answers - -this is when there is inflammation
-do POLICE/PEACE and LOVE
-address training and equipement issue
-we want to calm down swelling
-Heel lift takes pressure off achilles
-pad around pain w a donut so there is no pressure directly on bursda
,-stretch achilles by stretching gastroc and soleus
What is tendinotis or paratendinitis in ankle - Answers - -tendinitis is inflammation of
tendon, this is pretty rare, from gastroc, soleus or other muscle in ankle
-paratendonitis is inflammation, pain, and crepitattion of the paratendon as it slides over
the structure (creeking noise and feel)
-this is a acute irritation, so too much too soon (increase FITT, not enough rest)
What are the internal and external factors that contribute to tendonitis and paratenonitis
in ankle - Answers - -externla factors like rub from shoe, running down hill (tibialis
anterior bc has to pronate in plantarflexion so added stress) ,rubbing form laces in
tibilais anterior, ot hyperdorsiflexion (achilles from running uphill)
-internal factors could be foot malalignment, so improper rub over bone, cavus or
flat/pronating feet
What are signs and symptoms of tendonitis or paratenonitis in ankle - Answers - -there
is pain and/or crepitation of paratenon of acute onset
-red and hot over involved structure
-usually preciptated by movement around ankle movement that was too much, too soon
-the diagnosis is made on the basis of local swelling
-look at STTT
-there will be pain on palpation only over the direct tendon
What is the usually rehab for ankle paratenonitis - Answers - inflammatory phase:
POLICE/PEACE and LOVE, use heel lift, pad, support
-repair phase: heat to increase blood flow, idealize ROM, so stretch gastroc and soleus
-start strength and proprioception ex as able, could also do balance exercise
-address the training issues
-remodeling phase: idealize strength and do soft tissue work to realign fibres
-begin speed and power training
What is achilles tendinosis - Answers - -this is chronic pathological changes brought by
repetitive micro trauma
-inflammatory cells are absent
-characteristic changes in collagen fibre structure, so fibres start to fray
-abnormal (poor) vascularity, so not getting good blood flow
-usually in midportion of of achille
What is the normal cause of achilles tendinosis - Answers - -most often pain on achilles
is from tendinosis
-predisposing factors include:
-years of running
-excessive pronation, bc this causes increased load on gastroc and soleus to
resupinate, achilles gets twisted )
-poor flexibility
-training in cold climate since tissue is less flexible so more stress on it
,-improper footwear
-may be brought about due to neglect of acute tendinitis
-worsens w increase in FITT and insufficient recovery
What is the normal diagnosis of achilles tendinosis - Answers - -history of FITT, pain
that is 2-7 cm from insertion on calcaneus
-there is some swelling and tenderness over large portion of tendon
-faulty biomechanics
-on STTT, both plantar and dorsiflexion cause pain and crepitus, especially w loading
-nodules or bumps may be palpable
-also can see thickening of achilles bc it is frayed
What is the normal treatment of a tendinosis - Answers - -starting in stage 2
-the goals are to idealize ROM, want tissue to be viable again, so use heat to improve
vascularity and figure out training problem
-eccentric strenghening program provide 60-90% improvement in pain and function for
tendinosis
So use both legs to get up on step, then eccentrically strengthen by lowing heel down,
this is painful bc tearing out injured fibres
-can do straight and bent for gastric and soleus
-do NOT use NSAIDS
What are risk factors, and symptoms of an achilles fracture - Answers - -achilles is most
commonly ruptured tendon
-risk factors are males (10:1), use of steroids. Prior rupture on the other side
-patient would report pop or snap like someone kicked them
-pain is immediate then rapidly subsides bc no longer attached, so hard to walk now
-pain is only at site of tear
-clinical signs are a palpable gap, positive thompson test and dorsiflexion when relaxed
Explain inspection of achilles rupture and the thompson's test - Answers - the foot
hangs straight down, there is no plantar flexion
-there is a palpable divot 1-2 inch above insertion, bc it is no linger attached to
calcaneus
-unable to plantarflex, loose on stretch
-may have bruisinh and redness
-the thomspon test is hwne the calf muscle is squeezed, the foot should go up a bit bc
tension on achilles
-so a positive test is NO MOVEMENT bc achilles is ruptures
-can perform surgery or put in boot
What is the tibiofemoral joint - Answers - -this is the articulating surface between medial
and lateral condyles of femur and tibia
-this joint allows transmission of body weight from the femur to the tibia while providing
hinge like, sagittal plane movement w a bit of tibial axial rotation
-so have flexion and extension, and a bit of rotation in screw home mech
, What are the two joints of the knee and the 3 articulating surfaces - Answers - -the
tibiofemoral joint has two articulating surfaces: the medial and lateral condyles of the
femur and the tibia
-the patellofemoral joint is between patella and femur
What is the patellofemoral joint - Answers - this is the articulation between the patella
and the femur
-the patella moves up and down through notched in the femur
-the patella is the largest sesamoid bone in the body
-the quad tendon comes down and attaches to patella, this gives mechanical advantage
for extension
-this is referred to as extensor mechanism
-also works eccentrically during gait to help us take weight and slowly bend the knee
Explain the screw home mechanism - Answers - -rotation occurs during the last few
degrees of extension because the medial femoral condyle is larger than lateral
-if foot is planted, the femur rotated medially
-if femur is fixed, the tibia rotated laterally
-this locks the joint to increase stability, regulated patella alignment
-the popliteus must then contract to externally rotate the femur on the tibia to unlock the
knee
When is the knee the most stable and how does it gain stability - Answers - the knee is
most stable in extension bc there is help from dynamic stabilizers and more bony fit
-knees have relatively poor bony fit when relaxed
-knee has strong fibrous joint capsule
-but knee also needs to relay on other structures for stability like MCL, LCL, ACL, PCL,
muscles
Explain the capsule of the knee - Answers - -the knee is surrounded by a capsule,
anteriorly to suprapatellar pouch and inferiorly to infrapatella fat pad and bursa
-medially it communicates w the deep fibres of MCL
-posteriorly it covers the femoral condyles
-the capsule is also lined by synovial membranes, except posteriorly where it passes in
front of cruciates
Explain the three layers of the lateral support complex in the knee - Answers - 1. There
is superficial layer, which is the illiotibial band and biceps femoris that gives support
2. Middle layer, which holds the paterlla in place
-the patellofemoral ligaments and retinaculum(inert band of tissue that holds patella)
3. Deep layer, which has the Lateral collateral ligament (LCL), the popliteus, the
capsule, and other ligaments like arcuate and fabelofibular
Explain how the lateral portion of the knee is supported by muscles - Answers - -the
biceps femoris (part of hamstring)
