Varicose and Spider Veins – What are they and How to avoid them.

anatomy, Common conditions, Exercise, Health

main pic veins

What are Varicose and Spider veins?

Varicose veins are abnormal, dilated blood vessels (veins) caused by a weakening in the vessel wall. They may appear as swollen, twisted clusters of blue or purple veins.

Varicose veins are sometimes surrounded by thin, red capillaries also known as spider veins.

(group of tiny blood vessels located close to the surface of the skin, also called telangiectasias) – Refer Fig 1.

varicose veins
Fig 1: Varicose vs Spider veins

Role of veins and formation of abnormal veins

Veins carry blood back to the heart and have one-way valves that prevent the blood from back-flowing. The calf muscles act as a pump by which the blood is pumped back from the legs towards the heart as shown in Fig 2.

Deep Leg Veins

Fig 2: Normal blood flow through Veins, Calf muscle pump

If those valves of the veins become weak from extended periods of increased pressure and swelling, the blood can back up and collect within the veins. This causes the vein walls to weaken and bulge with blood, causing the veins to appear swollen and twisted as shown in Fig 3.

deformed valves

Fig 3: Normal vs Abnormal blood flow

Who can get it and where does it happen?

Varicose veins and spider veins can occur both in men and women. However, women are known to be affected more than men due to their hormonal predisposition and changes during pregnancy that affect the veins. 

These abnormal veins can develop anywhere, but most often appear on the legs and in the pelvic area because as compared with other veins in the body. This is because, lower limb veins work harder to carry blood back to the heart with forces from the body weight and gravity acting at the same time. This pressure can be stronger than the one-way valves in the veins.

Most varicose veins are seen on the surface of the skin as the superficial veins get swollen with blood collected in it that get raised on the surface and at times above the surface of the skin.  

Signs and Symptoms

Some may not have any symptoms but may be concerned about the appearance of the veins. Symptoms usually worsen after prolonged standing or sitting as the blood pools or collects in the veins of the lower limbs. 

Print

Fig 4: Swelling, Skin changes and Ulcers due to varicose veins

If symptoms occur, they may include:

  • Tiredness, burning, throbbing, tingling or heaviness in the legs
  • Itching around the vein
  • Swollen legs (Refer Fig 4)
  • Muscle cramps, soreness or aching in the legs
  • Brown discoloration of the skin, especially around the ankles (Refer Fig 4)
  • Leg ulcers (Refer fig 4)
  • Rarely varicose veins can form a painful blood clot, referred to as superficial thrombophlebitis (inflammation of a vein).

Risk factors and causes of abnormal veins

Varicose veins are related to increased pressure in the leg veins or defective valves in the veins.

They can happen due to reasons:

  • Idiopathic: The exact cause of this problem is unknown.
  • Heredity: A family history of varicose veins can put a person at risk of developing abnormal veins.
  • Advancing age: With aging veins can lose elasticity causing them to stretch. The valves in your veins may become weak, allowing blood that should be moving toward your heart to back-flow.
  • Prolonged standing or sitting.
  • Being overweight puts extra pressure on your veins, which means damage to the valves, making them more prone to swell.
  • Pregnancy: Pregnancy increases the volume of blood in your body but decreases the flow of blood from your legs to your pelvis. This circulatory change is designed to support the growing foetus but it can produce an unfortunate side effect — enlarged veins in your legs.
  • Hormonal influences during pregnancy, postmenopausal hormonal replacement therapy and use of birth control pills can cause excessive swelling in the lower limbs that hampers blood flow through veins. 
  • Wearing tight clothes can put pressure on the veins which can cause abnormal blood flow.
  • Injury to the veins due to trauma or accidents.
  • Other health conditions that cause increased pressure in the abdomen including liver disease, fluid in the abdomen, previous groin surgery or heart failure.

How is Varicose and Spider veins diagnosed?

A physical examination of the body especially the legs while the person is standing is done. A Doppler ultrasound scan can also check the blood flow in the veins near the skin’s surface and the deep veins. 

When to seek medical care?

  • Walking or standing becomes painful.
  • Soreness develops on or near a varicose vein
  • Your feet or ankles swell up very frequently.

If immediate care is not taken, symptoms may worsen. Complications may develop if there is an underlying disease in the deep veins or in the perforating veins which connect the deep and superficial veins.

  • Chronic venous insufficiency: Untreated venous problems may progress to a chronic condition of abnormal blood flow through the veins.
  • Venous stasis ulcers that result when the enlarged vein does not provide enough drainage of fluid from the skin. As a result, an ulcer (open sore) may form.
  • Fungal and bacterial infections may occur as the result of skin problems caused by the fluid buildup (edema) in the leg. These infections also increase the risk of tissue infection (cellulitis).
  • Thrombophlebitis: Inflammation of the vein due to blood clot formation.
  • Venous hemorrhage: Bleeding through the veins due to micro-tears and ruptures.

How to prevent varicose veins and its complications?

Lifestyle modifications:

  • Losing weight if you are overweight
  • Exercising regularly (especially walking)
  • Avoiding prolonged periods of sitting or standing
  • Avoid wearing tight-fitting undergarments and clothing that constricts the waist, groin or legs.
  • Avoid crossing your legs while seated.
  • Elevating your legs while sitting and sleeping will help.
  • When you need to stand for long periods, take frequent breaks – sit down and elevate your feet.
  • Do ankle pump exercises as shown in Fig 5.

ankle pumps

If you still develop varicose or spider veins, it is best to seek medical attention to know more in details on exercises and lifestyle changes that can be personalized to your needs.  

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Ankle 101

anatomy, Ankle, Foot

ankle joint only

The ankle plays an important role in the pattern of lower limb movements both in weight-bearing and non-weight-bearing positions.

Ankle movements: (Refer Fig 1)

  • Plantarflexion (down)
  • Dorsiflexion(up)
  • Inversion (inwards)
  • Eversion (outwards)
dorsi and plantar flexion

Fig 1: Dorsiflexion, Plantarflexion, Eversion and Inversion

Plantar flexion is the movement that describes the pointing of the toes toward the ground, as in standing on one’s toes.

Dorsiflexion is the opposite of plantarflexion and involves pulling the toes up as in walking on one’s heels.

Inversion is inward rolling of the foot towards the body’s midline and eversion is the exact opposite which involves outward rolling of the foot away from the midline of the body.

Joints in relation to movement

The ankle is made up of three distinct joints namely, 

  • Talo-crural joint (Ankle joint)
  • Subtalar joint 
  • Distal Tibiofibular joint (High ankle)
joints of the ankle

Fig 2: 3 types of ankle joints

Talo-crural joint (Ankle joint): It a hinge type of joint that allows movements of dorsiflexion and plantar flexion along one plane.The articulation of the lower ends of the leg bones and one of the tarsal bones (talus) forms the ankle joint.  

Subtalar joint: The movements of Inversion and eversion take place at this joint. It lies beneath the ankle joint and is formed by the articulation between the talus and the calcaneal bone of the foot. 

Distal tibiofibular joint (High ankle): This is a syndesmosis joint between the lower ends of the bones of the leg(tibia and fibula).  A syndesmosis joint is a joint where the bones are connected by ligaments and have minimal movements.

Muscles that cause ankle movements

The muscles from the leg end as tendons that attach to the foot bones. They contract and transfer forces to cause a movement across the ankle joint.

  • Outer muscles of the leg: The peroneal (Peroneus long and peroneus brevis) muscles are present on the outside aspect of the leg as shown in Fig 3. The contraction of the peroneal muscles help bend the ankle down moving the foot downwards (Plantar flexion) as in fig 3.
Peroneal muscles

Fig 3: Peroneal Muscles and Plantar flexion

The peroneals also help to stabilize the big toe as it attaches behind it. It helps to lift the arch and plantar fascia to produce spring-like effect during running and jumping activities.

  • Back muscles of the leg: The calf muscles (gastrocnemius and soleus) and the tibialis posterior muscles are present at the back of the leg as shown in Fig 4.
back of the leg

Fig 4: Calf and Tibialis posterior muscle.

The calf connects to the heel bone by the Achilles’ tendon. When the calf muscles contract they moving the foot downwards (Plantar Flexion). The posterior tibialis help to turn the foot inwards (Inversion). They help to propel the body forwards as the foot pushes on the ground while walking.

  • Front muscles of the leg: The tibialis anterior present in the front of the leg  and attached in the front of the foot as shown in Fig 5.
tibialis anterior muscle

Fig 5: Tibialis anterior muscle and dorsiflexion

The Tibialis anterior muscle pulls the ankle upwards (Dorsiflexion). It plays a role in striking the heel when you take a step forwards in walking.

Ligaments that support the ankle

Apart from muscles, the ankle is stabilized by many ligaments that surround the ankle. 

  • Lateral ligaments (outer ankle ligaments)
  • Medial ligaments (inner ankle ligaments)
  • High ankle ligaments

Lateral ligaments

Lateral ligaments are present on the outer aspect of the ankle that are attached at the anterior (front), lateral (outer side) and posterior (back) parts of the ankle as shown in Fig 6. 

Outer ligaments of the ankle

Fig 6: Lateral Ligaments

  • The Lateral ligaments play an important role to prevent excessive plantar flexion and inversion movements of the foot. 
  • Along with the medial ligaments, they also provide stability to the ankle during weight bearing movements.

Medial ligaments (Inner Ankle Ligaments) 

The medial ligament otherwise known as deltoid ligament is present on the inner aspect of the ankle, as shown in Fig 7. 

Ligaments of the ankle

Fig 7: Medial ligaments (Deltiod ligament)

  • The medial ligaments function as the main stabilizer of the inner aspect of the ankle against shear and rotational forces.
  • They also act to support the inner arch of the foot.

Distal tibiofibular ligaments

The distal tibiofibular ligaments are located above the ankle and connect the high ankle syndesmosis joint as shown in Fig. 8. 

Syndesmotic ligament complex

Fig 8. High ankle ligaments

  • The high ankle ligaments ensure stability between the lower end of the tibia and the fibula.
  • They resist any force that attempt to separate the tibia and fibula.

Risk of injury to the ankle 

Any inflexibility in the ankle may cause inability to perform a movement properly. For example, poor ankle mobility due to tight soft tissue structures can reduce the range of movement at the ankle causing the knees, hips and trunk to over compensate. This may impair the ability of the trunk to load the joints properly hence increasing the risk an injury.

Temporomandibular (TMJ) Joint and its Disorder

anatomy, Common conditions, Injury, Pain

TMJ

What is the TMJ?

The temporomandibular joint (TMJ) or the jaw joint is a synovial hinge type of joint. This joint is responsible for the movements of our mouth that are needed for chewing, biting, talking and yawning.

To achieve the complex movements needed by the jaw, the TMJ has two articulating surfaces which include the head of the mandible (jaw bone) that fits in the articulating socket of the temporal bone of the skull. In order to prevent friction between the two bones, an articular disc sits between the articulating surfaces which moves with the head of the mandible as one unit.

TMJ disc

Fig 1: Normal TMJ when jaw closed

Apart from the disc and articulating structures, there are other supporting structures that provide stability to the TMJ:

  • Joint Capsule
  • Ligaments
  • Muscles

Joint capsule and Ligaments of the TMJ

The capsule is a fibrous cartilaginous membrane that along with the ligaments surrounds the TMJ and attaches all around the articular eminence of the temporal bone, the articular disc and the neck of the mandibular condyle. Both the capsule and the ligaments provide stability to the TMJ during movements. The four ligaments include (Refer Fig 2),

  • The Lateral Ligament (temporomandibular ligament)
  • Sphenomandibular Ligament
  • Stylomandibular Ligament
  • Stylohyoid Ligament
CAPSULE

Fig 2: Showing the attachment of joint capsule, lateral ligament and stylomandibular ligament.

Muscles around the TMJ

The are four main muscles (Refer Fig 3) of the TMJ are,

  • Temporalis
  • Masseter
  • Medial Pterygoid
  • Lateral Pterygoid
muscles of tmj

Fig 3: Prime muscles for TMJ movement

Movements at the TMJ

There is a combination of hinge and sliding motions that can occur in the TMJ due to the movements of the mandible.

  • Protraction (forward) and Retraction (backwards)
  • Elevation (upward) and Depression (downward)
  • Lateral deviation (Side to side movements of the jaw)
MOVEMENT PROTRACTION RETRACTION

Fig 4: The forward and backward movements of the jaw

ELEVATION DEPRESSION

Fig 5: Upward and downward movements of the jaw

lateral deviation

Fig 6: side movement of the jaw

Temporomandibular Joint Disorder 

  • Muscular problem: Pain and discomfort in the muscles of the face during jaw movements.
  • Disc problem: Usually comprises of displaced disc, dislocated jaw, or injury to the mandibular condyle.
  • Joint problem: Degenerative inflammatory joint condition like Arthritis at the temporomandibular joint.

Reasons for TMJ Disorder

  • Genetics

Individuals who have misaligned jaw or teeth which are hereditary can be affected with TMJ disorder.

  • Functional mandibular overload

Normally the jaw is free to move and make contact with the teeth in the right position, (centered occlusion), in anatomical and functional harmony.

Mandibular overload occurs when one sleeps in a wrong position (face down) where the load of the head pushes the mandible to compress the TMJ on one side and attenuation of the ligaments on the other side. Compression obstructs the blood circulation and moves the teeth to a lateral bad occlusion position. In such a situation, swallowing causes the masticatory muscles to overwork to centre the jaw and bring the teeth from forced lateral malocclusion to centred occlusion. This causes a disharmony between the upper and lower teeth. An imbalance of the jaw that can cause bruxism in an attempt to re-position the teeth.

The term bruxism is defined as an involuntary rhythmic or spasmodic non-functional gnashing, grinding or clenching of teeth. The rubbing causes tooth facet to wear out, structural and function damage to the capsulo-ligamentous and muscles around the TMJ. Stress and psychological problems could worsen the condition.

Sudden trauma

Whiplash injury occurs any time when the head is suddenly and unexpectedly distorted from the neck, causing overstretching of the muscles and ligaments that hold the neck and head in alignment. During a whiplash injury, there is also a potential secondary injury of whiplash in the jaw. Jaw dislocation in severe cases can also occur.

  • Inflammatory diseases 

Sometimes infection in the teeth or adjacent structures can cause a spread of infection in the TMJ leading to infectious arthritis.

TMJ could also be affected by osteoarthritis that causes damage in the articular cartilage of the joint and disc degeneration leading to friction between the bones causing inflammation and pain. It usually affects individuals above 50 years of age and is associated with trauma and other muscular and teeth problems.

TMJ disorder could also be present among individuals who are already diagnosed of rheumatic arthritic disease.

Symptoms of TMJ

  • Jaw pain: Pain and tenderness in the jaws. Increasing pain during chewing in the TMJ and in the muscles, radiating pain is also felt in the face, jaw, or neck.
  •  Limited or painful jaw movement: Swelling due to the inflammation lead to joint stiffness and limited movement, wear and tear of the disc leading to locking of the jaw and impaired jaw function.
  • Headache, Neck pain or stiffness: It is generally assumed that headache, neck pain, or painful jaw movement is suggestive of muscular problems. Masticatory and neck muscles may show muscle spasm and myofascial trigger points in the masseter or sternocleidomastoid muscles that refer pain to the head.
  • Clicking or popping: This occurs within the joint during mouth opening and may indicate displacement of the intra-articular disk during mandibular movement.
  • Ear pain and tinnitus (Ringing of the ear): Middle ear muscles have a common embryological and functional origin with masticatory (Chewing muscles) and facial muscles.Having said that, problems with muscles in TMJ disorder could affect the middle ear. In case, other ear problems are not the cause of ear pain and tinnitus a temporomandibular joint dysfunction may be the reason of these symptoms.

Prevention and Treatment

In order to relieve pain and restore the function of the TMJ, a thorough assessment is required to correctly determine the causative factors and to treat the involved structures. Personalized care interventions at an early stage that includes behavioural change and reassurance are important steps for prevention of TMJ disorder.

Anatomy of the Hip

anatomy, Hip, Lifestyle

hip joint

The anatomy of the hip includes the ball-and-socket joint that involve two separate bones namely, the thigh bone and the pelvis.The unique anatomy of the hip enables it to be extremely strong and agile controlling every position of the lower limb in both weight-bearing and non-weight-bearing movements.

Bones of the Hip 

The Bones of the Hip include,

  • Pelvic bones (Ilium, Ischium, Pubis)
  • Femur (Thigh bone)

Fig 1: Shows the two Hip bones, sacrum, the acetabular socket of the hip joint, the entire Hip.

Pelvis

As shown in Fig.1, the pelvis is made up of two halves or two hip bones. Each hip bone is formed from the fusion of three bones: ilium, ischium and pubis. Fusion of these three bones, form one solid pelvic bone. The Pelvic bone contributes to the hip socket or acetabulum. Each pubic bone connect in front at the symphysis pubis.

Between the two hip bones, lies the foundation for the pelvis, the sacrum. The sacrum is a triangular-shaped bone that comprise of five fused bones at the lower end of the spine.

Fig 2. The Femur (thigh bone)

Femur

As shown in fig 2, the femur is more commonly known as the thigh bone which consists of the round head, the neck, the shaft and two condyles (lateral and medial) at the base of the femur.

The HIP joint

Like the shoulder, the hip joint is also a ball-and-socket joint, where the ball is the head of the femur, and the socket is the acetabulum.

Fig 3: Ball and socket hip joint

HIP JOINT 1

Articular Cartilage and labrum

The articular cartilage is a protective material that covers the articular surfaces of the hip joint (refer Fig.4).  It is about one-quarter of an inch in thickness with a rubbery consistency.The function of the cartilage is related to its structure and thus acts as a shock absorber by allowing better transmission of forces. It also helps prevent friction between the bones and is slippery enough to allow the joint surfaces to slide against one another without causing any damage.

The Labrum is a fibrous rim of cartilage around the acetabular socket that holds the femoral head in the joint providing stability.

Fig 4: Shows articular cartilage and labrum

cartilage and labrum

Joint capsule and ligaments of the Hip joint

The joint capsule is a watertight sac that surrounds the hip joint. The capsule is reinforced by three major ligaments, which are denser bands of connective tissue.

Fig 5: Shows Capsule and reinforced ligaments of the hip joint

capsule and lig

The attachments of each of these ligaments can be identified by its name- the iliofemoral ligament extends from the ilium on the pelvis to the femur, the pubofemoral ligament connects the pubic bone to the femur, and the ischiofemoral ligament extends from the ischium to the femur.

A small ligament called ligamentum teres connects the very tip of the femoral head to the acetabular socket. It accommodates a small artery within itself that brings an important blood supply to part of the femoral head.

Muscles around the hip joint:

Back muscles of the hip 

These Muscles are responsible for hip joint extension (backward movement)

They include,

  • Gluteus maximus
  • Hamstrings (long head of biceps femoris, semitendinosus, semimembranosus)

Fig 6: Extensor muscles

gluteal and hamstring muscles

These muscles cause the hip to move backwards in extension (Fig 7), it also causes knee flexion (bending the knee by bringing the heel towards the buttock). Hip extension is important during gait especially to propel your body forwards.

Fig 7: Hip extension movement of the hip joint

hip extention

Gluteus maximus contraction is a powerful action that opposes the force of gravity. The action of gluteus maximus is to move the hip bone(thigh) backward from a position of full flexion(bent), as in climbing stairs, or rising from a squatting or sitting position.

Fig 8: Action of Gluteus Maximus muscle

Gluteus max sit to stand

Front muscles of the pelvis

These muscles are responsible for hip joint flexion (forward movement).They include,

  • Iliopsoas (iliacus and psoas)
  • Rectus femoris
  • Tensor fasciae latae
  • Sartorius

Fig 9: Hip Flexor muscles

fllexor muscles

The hip flexors help you to draw your leg towards your chest and also helps to you move your legs from side to side and backwards. It serves to stabilize your hips, keeping the joints of your pelvis and lower back strong.

Fig 10: Hip flexion movement

hip flexion

Hip flexion movement is also important during the gait cycle in order to bring you leg forwards for heel strike.

Inner thigh muscles

These muscles are responsible for hip joint adduction (inward movement).They include,

  • Pectineus
  • Adductor brevis
  • Adductor longus
  • Gracilis
  • Adductor magnus.

Fig11: Aductor muscles of the hip joint

hip adductors

When the foot is not planted on the ground, the adductors will bring the leg toward the midline of the body. Also known as an open kinetic chain movement (open kinetic chain is defined as a combination of successively arranged joints in which the terminal body segment can move freely).

Fig 12: Adduction movement

adductors

Apart from the adduction movement in open kinetic chain, adductors also contributes during closed kinetic chain movements (In a closed kinetic chain movement, the distal end of the extremity is fixed, emphasizing joint compression and, in turn, stabilizing the joints).

A simple example would be during bilateral stance (standing on both legs) movement like squatting, adductors of both the hip joints help contribute to the stability in the pelvis. These adductors work with abductor muscles synergistically to provide side-to-side stabilization of the pelvis.

During walking, adductors also contribute throughout the gait cycle. For example, when you foot is move forwards before striking on the ground, the adductors will bring the leg towards the midline. Similarily, adductors with help in flexing the hip when the thigh is in an extended position as in the swing phase of the gait (walking) cycle.

Fig 13: Action of adductors during gait

Gait cycle

They are not the prime movers but function in reflex response to gait activities.

The only two-joint muscle of the adductor group, the gracilis, functions as an inner knee stabilizer and helps stabilize both the hip and knee during weight-bearing.

Outer muscles of the thigh

These muscles are responsible for hip joint abduction (outward movement). They include,

  • Gluteus medius
  • Gluteus minimus
  • Tensor fascia latae

Fig 14: Abductor muscles of the hip

abductors

In open kinetic chain movement when standing on one leg, the abductors move the leg away from the midline of the body.

Fig 15: Abduction in single leg stance

hip abduction

The gluteus medius however, is more of a lower extremity dynamic stabilizer than it is a pure hip abductor.  If the gluteus medius and minimus are weak or atrophied, the pelvis will drop to the opposite side when you bear full weight on the same side during walking. This dysfunctional postural pattern is referred to as the Trendelenburg sign.

Fig 16: Pelvic stabilization (strong Gluteus medius) and pelvic drop (weak Gluteus medius)

Gluteus medius

As you can see in fig 16, weakness of the right gluteus medius will cause the left hip to drop when standing on the right leg. Thus, during walking the primary function of the gluteus medius is to stabilize the pelvis when weight is shifted from one side to the other.

External rotators of the hip joint

Muscles of the thigh responsible for hip joint external rotation (twisting hip outwards) include,

Primary External Rotators:

  • Obturatorius internus and externus
  • Gemellus superior and inferior
  • Quadratus femoris
  • Piriformis

Secondary External Rotators:

  • Gluteus Maximus (lower fibres)
  • Gluteus Medius and minimus muscles when the hip is extended
  • Psoas Major Muscle
  • Psoas Minor Muscle
  • Sartorius

In the open kinetic chain the primary and secondary external rotators turn the lower limb outwards in relation to a fixed pelvis. This action is seen with the movement of the hip with knee flexion as seen in Fig 17.

Fig 17: External rotation

hip-external-rotation

However, in the closed kinetic chain scenario, with the foot fixed on the ground, the activation of these same muscles will cause the same movement at the hip-pelvis interface will cause the pelvis/torso to rotate.  For example, refer Fig 18. a closed chain right lower limb, upon activation of the external hip rotators the person’s pelvis and trunk will rotate to the left simultaneously (counterclockwise rotation) along the vertical body axis about the fixed right limb.

Fig.18 external rotation of right hip

Standing twist

This rotation can occur from activation of not only the hip rotators but also from the muscles of the abdomen, thoracic spine and rib cage.

Role in Hip stabilization

The deep external rotators (quadratus femoris, obturator internus and externus and the gemelli) are also active stabilisers of the hip and, along with the internally rotator gluteus minimis, they are also described as the “rotator cuff muscles” of the hip. The quadratus femoris,

During weight bearing, the deep rotators having a short moment arm and smaller in area there is minimal capacity of rotational force and more of  a horizontal line of force, which is more important in the compression of the joint surfaces.Thus creating more stability in the hip joint during movements.

Hip Internal Rotators

The muscles that are responsible for twisting the leg inwards (Internal Rotators) are,

  •  Anterior portion of the gluteus medius
  • Tensor fasciae latae

The head of thigh bone (femur) rotates inwards within the hip joint. It also occurs in standing when the lower limb is fixed and the trunk/pelvis rotates as already seen in hip external rotation. Internal rotation is the exact opposite.

In the open kinetic chain, the internal rotators turn the lower limb inwards in relation to a fixed pelvis. This action is seen with the movement of the hip with knee flexion as seen in Fig 19.

Fig 19: Open chain internal rotation of hip joint

Hip Internal roation

Similarily, Fig 20 shows a closed chain right lower limb, upon activation of the internal hip rotators driven by the person’s pelvis and rotation to the Right side simultaneously (clockwise rotation) along the vertical body axis about the fixed right limb.

Fig 20: Right hip internal rotation and right side pelvic rotaion

Twist IR

Role of internal rotators

During walking, in order to sufficiently extend the hip toward the end of the gait cycle, there has to be enough hip internal rotation (Fig 21). Without sufficient internal rotation, the pelvis will move as far forward over the stance leg, and we instinctively shorten our stride.

Fig 21: Hip extension and internal rotation of left hip joint in the final phase of the gait cycle.

gait IR

In conclusion, a thorough understanding of pelvic and hip anatomy is important for undermining any cause of dysfunction or injury. Even a lack of range of motion due to tightness in the soft tissue structures can put you at risk of involving compensatory movements that can lead to postural problems. Always seek medical advice when in doubt.

Shoulder 101

anatomy, Exercise

shoulder

The main joint of our upper limb is the shoulder joint which can be moved in various positions when looked at in a three-dimensional perspective. In order to be able to have these movements, many other components help in order to maintain a stable shoulder. In short, there is a complex interplay between the shoulder joint, other joints, muscles and ligaments that make the shoulder a complex and unique part of our body.

Anatomy of the Shoulder Complex

The Shoulder complex consists:

  • The true joint called the Shoulder joint (Glenohumeral joint – GH)
  • The Clavicular joint with the scapula (Acromioclavicular joint – AC)
  • The Scapular joint with the body wall (Scapulothoracic joint – ST)
  • The Clavicular joint with the breastbone sternum (Sternoclavicular joint – SC).

The shoulder joint (GH) is made of two main bones that articulate with each other forming the ball and socket joint. The ball of the arm bone(humerus) and the glenoid cavity of the shoulder blade(scapula) is articulated at the shoulder joint (GH joint). Similarly, on the inner chest, the clavicle articulates with sternum to form the SC joint while on the outer end towards the shoulder the clavicle articulates with the acromion process of the scapula bone to form the AC joint. Both GH, SC and AC are true joints with union by fibrous, cartilaginous or synovial tissues. Lastly the ST joint, while this is not a true bony joint, its muscular attachments create a shoulder joint complex.SHOULDER

The humeral head (ball) is about three times larger than the glenoid fossa. Actually, only 25 percent of the humeral head articulates with the glenoid fossa. Glenoid cavity (fossa) forms a very shallow socket as compared to the hip socket of the hip joint. Therefore, the humeral head articulates with a smaller open and shallow saucer- type of articulation, lacking stability in its own. However, it is with all the soft tissue structures both inside and outside the joint that are responsible for the overall stability of the arm during movements.

Soft tissue structures that support the Shoulder Joint

The important soft tissue structures are:

  • Articular Cartilage
  • Labrum
  • Joint Capsule
  • Ligaments
  • Muscles

Articular Cartilage

A smooth, white tissue that covers the humeral head (ball) and the glenoid fossa to make it easier for the two bones to move at the joint. It allows the bones to glide over each other with very little friction.

Articular cartilage

Labrum 

Since the head(ball) of the upper arm bone is larger than the glenoid fossa, the articular cartilage forms a soft fibrous tissue rim called the labrum which surrounds the socket to help fit the head into it thus stabilizing the joint.

labrum

The socket can be divided into four regions namely anterior (front), posterior ( back), superior (the upper end near your head), and inferior (the lower end which is towards the elbow). Based on these regions the labrum is also called as superior, inferior, anterior and posterior labrum.

labrum 2

Joint Capsule

The shoulder joint capsule is a membranous sac that encloses the entire joint. The joint capsule of the shoulder is attached along the outside rim of the glenoid labrum of the glenoid cavity and attaches to the neck of the arm bone. The capsule by itself is quite loose and it is the surrounding reinforcement by the muscles, tendons, and ligaments that are largely responsible for keeping the shoulder joint stable.

capsule of the shoulder

Ligaments

In the shoulder, there is a group of ligaments that is responsible for the stability of the shoulder.

ligaments

Glenohumeral Ligaments (GHL)

This ligament attaches from along the outer glenoid socket covering the joint to the upper part of the arm bone.

  • Superior (upper) GHL
  • Middle GHL
  • Inferior (lower) GHL

Coraco-acromial Ligament (CAL)
This ligament attaches from the coracoid process to the acromion process of the shoulder blade (Scapula).

Coraco-clavicular Ligaments (CCL)
These two ligaments (trapezoid and conoid ligaments) attaches from the clavicle to the coracoid process of the scapula. This ligament can carry the load and is extremely strong. These tiny ligaments (with the AC joint) keep the stability between the scapula and the clavicle and thus keeping your shoulder ‘square’.

Transverse Humeral Ligament (THL)

This ligament protects the long head of biceps tendon muscle in the groove of the arm bone.

Muscles for the stability of the Shoulder Joint

Muscles of the shoulder connect the shoulder girdle, the clavicle and arm bone.

  • Muscles that origin from the spine and attaches to scapula and/or clavicle
  • Muscles that origin from the clavicle or scapula and/or body wall(ribs) to the top end of the humerus.

Trapezius, Levator scapulae, Rhomboids and Serratus Anterior

Originate from the base of the skull and/or spine and connect the scapula and clavicle to the trunk of the body.

traps, levator...

  • Trapezius forms cross-shaped web along the neck and run from the spinal column out to the shoulder blade and clavicle bone. It helps to shrug the shoulders.
  • Rhomboids and levator scapulae are important muscles that join the shoulder blade to the spinal column helping the scapular movements.
  • Serratus anterior muscle helps to stabilize the shoulder blade on the chest wall. When this muscle is weak, winging of the scapula occurs which is when the shoulder blade protrudes from the back.
winged scapula

Winged Scapula

Deltoid, Pectoralis major, Pectoralis minor, Latissimus dorsi, Teres major, Serratus Anterior

These arise from the clavicle and/or scapula and/or body wall and connect to the upper end of the arm (humerus) and anchor the shoulder joint to our body.

MUSCLES PECS

  • Deltoid muscle is a muscle that is responsible for overhead activities. It helps to move the arm sideways up.
  • Pectoralis major muscle like the deltoid is another powerful muscle which is the main muscle when doing push-ups. It originates from the front of the chest and collar bone and inserts on the upper part of the arm bone (humerus).
  • Latissimus dorsi is another powerful muscle that together with the teres major muscle pulls the arm down to the side. We use this muscle when doing chin-ups.

What are the Shoulder blade movements?

The muscles of the shoulder complex work together to perform a particular action. The Scapula and arm bone move together in a pattern to perform a movement.

The movements of the Scauplo-thoracic joint includes,

  • Depression – Downward arm and shoulder girdle movement
  • Elevation – Upward arm and shoulder girdle movement
  • Retraction – backward shoulder girdle movement
  • Protraction – forward shoulder girdle movement

movements in shoulder

Rotator cuff muscles- small in size, big in importance

The four rotator cuff muscles are important for the stability and movements of the shoulder joint. They are,

  • Subscapularis
  • Supraspinatus
  • Infraspinatus
  • Teres minor

Rotator cuff

These muscles connect the shoulder blade (Scapula) to the arm bone (Humerus) supporting the entire shoulder joint during movements.

The major function of the four rotator cuff muscles is to work simultaneously with each other to allow the arm to move freely in numerous positions. They do all this while pulling the humeral head downward and inward within the glenoid fossa.

Movements at the shoulder joint

The main movemnts at the GH joint are:

  • Flexion-Extension
  • Abduction-Adduction
  • Internal and External rotation

MOVEMENTS AT THE SHOULDER

  • Supraspinatus assists with lifting the arm with the deltoid above the head (abduction). This is the most common muscle / tendon to tear in the shoulder.
  • Subscapularis twists the arm behind (Internal rotation) the back.
  • Infraspinatus and the teres minor twists the arm outwards(External rotation) and sideways from the body.
  • Subscapularis assists with Deltoid, Biceps, coracobrachialis, Tere major to bring about shoulder forward flexion movement.
  • Triceps, latissimus dorsi, pectoralis major, teres major brings the arm backwards (Extension).

Why is the Rotator cuff is so important?

In order to prevent upward dislocation of the arm or tear within the inner soft tissue structures like labrum and capsule of the shoulder, balanced rotator cuff strength and function are necessary.  All the rotator cuff muscles work together stabilizing the humeral head within the glenoid while the larger muscles like the ltissimus dorsi, pectoralis major and deltoid produce the forces necessary for movements.

Common Injuries to the shoulder

  • Broken collar bone (Clavicle)
  • Dislocations of the shoulder
  • Frozen shoulder (Adhesive capsulitis)
  • Rotator cuff injury or strain (tendonitis or tendinopathy)
  • Acromioclavicular joint sprain
  • SLAP Tear (Superior Labrum Anterior Posterior tear)
  • Bankart’s lesion (Anterior inferior Labral tear, sometimes a part of the genoid cavity bone is also broken)

Most injuries to the shoulder are due to sudden trauma or repetitive trauma to the soft tissues and bones. Some of the injuries occur because of improper exercise selection, faulty technique, lack of warm-up, lack of dynamic stretches, dehydration and many more. However, knowing the anatomy and functions of the joints and soft tissue structures of the shoulder complex not only gives you a better understanding of it but will possibly give you a prospective as to how important is their role in maintaing the stability of the shoulder.

Functions of the Patella – Knee Cap

anatomy, Common conditions, knee, Lifestyle, Pain

knee cap

The only time feeling weak at the knees would be a normal phenomenon is when you are standing at the edge of a cliff or doing a bungee jump.

Experiencing weak knees with joint pain can be quite debilitating. We can sit, stand, walk, run and move about easily because of our knees. What we should know is that our kneecap is a part of the knee joint and it should remain ‘in the groove’  for optimal function.

The kneecap, also called the patella bone, is a sesamoid bone in the front of your knee. It’s called the sesamoid bone as it has the shape of a sesame seed. The sesamoid bone is a bone that grows within a tendon. The patella has many biomechanical functions which are responsible for the protection, support and movements at your knees.

Anatomy of the knee cap

anatomy

The knee joint (Patellofemoral joint) is comprised of the three bones. The thigh bone (Femur), the shin Bone (Tibia) and the patella (Kneecap). The patella  lies in a groove at the lower end of the femur and acts as an attachment point for the four main muscles of the thigh (quadriceps). The lowest part of the patella continues on as a tendon that attaches to the tibia. The muscles pull on the patella and the patella pulls on the tibia allowing you to straighten your knee from a bent position.

knee extension action

Cartilage of Patella

articular cartilage of patella

The cartilage is a taut protective structure underneath the kneecap. It found to be among the thickest cartilage in the body providing cushioning for the patella bone. The cartilage helps to prevent friction and acts as a shock absorber protecting the bony surfaces.

Why is the patella so important?

  • Patella functions as a natural pulley

The kneecap plays an important role, it increases the leverage of the quadriceps tendon (thigh muscle tendon) and protects the front of the knee from direct trauma.

lever arm quads

The quadriceps muscle is providing the force like the man in the picture, the patella bone acts as a fulcrum to provide more leverage for lifting the stone.

In real life though, the patella is a little more complicated by not only providing increased force, but also by aiding in balancing forces as well as providing a direction for the forces.

  • Prevents excessive weight-bearing compressive stress 

As weight bearing stress falls on our knees, the patella acts as a spacer protecting the quadriceps tendon and bone from coming into compression and creating a frictional force. The patella also allows for smoother movements when bending and straightening the leg.

  • Maintaining the Quadriceps Angle

Q angle

The quadriceps angle or the Q angle is determined by drawing one line from the hip bone (anterior superior iliac spine) through the center of the patella and a second line from the center of the patella through the leg bone (tibial tuberosity).

normal Q angle

As the Q angle increases above 15 degrees, it potentially could cause the patella bone to move out of its groove. This is as if the Q angle is increased, forceful contraction of the quadriceps muscle can cause the patella to move outwards and possibly dislocate. Slight changes in the Q angle would cause imbalances in the muscle forces causing compression stress, symptoms of pain and inflammation at the knee joint.

Knee Pain related to the Patella 

Although patellar dislocation, fracture, and patellar tendon inflammation are the common sports-related injury. Many patella related problems may also occur during daily activities.

  • Runner’s knee/ Patellofemoral pain syndrome 

Patellofemoral joint pain is a condition seen in runners causing pain during running or while at rest. Pain usually occurs in the front of the knee.

  • Condromalacia Patellae (“soft cartilage under the knee cap”)

This often affects young, otherwise healthy athletes. Chondromalacia patella is one of the conditions that cause pain in front of the knee. When pain exists in the absence of cartilage softening, it can be referred to as patellofemoral pain syndrome (Runner’s knee). Although it’s common to sporting individuals, it can also affect individuals with weak quadriceps muscles. It is common among individuals engaging in activities like football, cycling, tennis, weightlifting, runners. In other words, any sport that involves running, jumping, squatting and landing on the knees.

  • Prepatellar bursitis (between patella bone and skin)

Prepatellar bursitis has historically been referred to as “housemaid’s knee”, which is derived from a condition that was commonly associated with individuals whose work necessitated kneeling for extended periods of time. Prepatellar bursitis is common in professions such as carpet layers, gardeners, roofers, and plumbers.

  • Infrapatellar Bursitis (Below the Kneecap)

This is common among individuals who engage in activities that involve kneeling down for long hours causing inflammation of the bursa below the patellar tendon. It can also occur conjunctively with a condition called jumper’s knee.

  • Suprapatellar Bursitis (Above the kneecap)

Injuries such as direct trauma and overuse injury to the bursa beneath the quadriceps tendon cause inflammation of this bursa.Overuse injuries caused due to running on uneven surfaces or doing jobs that require crawling on the knees.

  • Osteoarthritis 

Patellofemoral arthritis occurs when the articular cartilage on the underside of the patella wears down causing friction between the patella and the end of the thigh bones. It gets extremely painful during weight bearing with swelling, inflammation around the knee. It is generally a degeneration condition which requires immediate medical attention to manage the condition.

  • Patellar Dislocation 

This type of injury happens when the kneecap (patella) moves out of its groove due to the sudden change in direction engaging in high impact sports. It most commonly occurs among young girls or hypermobile individuals due to laxity and increased hip angle. Direct trauma to the kneecap could also cause dislocations.

As a precautionary measure, using knee pads during sports and regular exercises of your knee muscles will have great benefits for your patella. Generally, most of the injury conditions can be managed with appropriate treatment and rehabilitation.

However, if you’ve only begun to feel pain while doing activities or just by standing, you might like to seek medical attention to prevent long-term pain or further damage to your patella.

 

Anatomy of the Knee – A simple understanding

anatomy, knee, Lifestyle

Anatomy knee pic

Have you ever imagined your bodies to be like a robot’s? Detaching a part and replacing it as and when we want to? Probably it would be the best idea for those who wish to get rid of their knee aches and pains. But the complexity of being human is that we know our body parts aren’t detachable and that the more we learn about our body, the more there is left to learn.

The way we all understand our body, is that everything is connected. By having basic anatomy knowledge, we can actually help ourselves find the source of our injury and problems.

The Knee Joint

The knee Joint is the largest weight-bearing joint in our body that forms an important part of our lower limbs. It is responsible for the movements of our leg and is basically the foundation on which our body performs complex moves.

The Knee model:

The Knee joint is made of three components; the lower part of the thigh bone (Femur), the upper part of the leg bone or shin bone (Tibia) and the kneecap (Patella).

knee bone anatomy

What’s in between the two bones?

Between the thigh and the shinbone are structures that provide easy joint movements and prevent the two bones to rub against each other. These structures are the articular cartilage and the meniscus.

  • Articular Cartilage

cartillages of knee

Articular cartilage is a slippery structure on the bone surfaces that help the two bones glide against each other without causing any damage to the bones during movement.

  •  Meniscus

Knee meniscus

There are two thick C-shaped rubber-like menisci that are present between the articulating ends of the thigh and shin bone. The one on the inner side of the knee is called the medial meniscus and the one on the outer side of the knee is called the lateral meniscus. Both the menisci act like cushion pads and are great shock absorbers preventing weight bearing stresses to affect the knee.

What’s supporting the knee?

The knee joint has strong supporting structures like the ligaments and tendons that help keep the femur, tibia and the patella bones in place. These structures not only support the joint during movements but also prevent any dislocations at the knee joint.

  • Ligaments

These are fibrous band-like structures that connect one bone to another. There are two types of very important ligaments of your knee namely, the cruciate and the collateral ligaments.

ligaments of the knee

1. Cruciate ligaments (the “X” Structure in between) 

These are called cruciate because they cross each other in between the thigh and shin bone inside the knee joint. The anterior cruciate ligament (ACL) is the one that is seen in the front and the posterior cruciate ligament (PCL) is present at the back. They hold the two bones, the femur and tibia together when the leg is bending and straightening.

2. Collateral ligaments

The medial collateral ligament (MCL) is present on the inner side of the knee and the lateral collateral ligament (LCL) is present on the outer side of the knee. Both the MCL and LCL support the knee joint during side and rotation movements of the leg.

  • Tendons

Muscles end as tendons and attach to bones. Two such important tendons of the knee are the tendon of the quadriceps muscle (the main muscle on the front of the thigh) and the patellar tendon.

Quadriceps tendon attaches itself to the upper part of the patella bone. While the patellar tendon starts from the lower part of the kneecap to the front of the shin bone.

tendons

Both the quadriceps and the patellar tendons help to straighten the leg.

Damage to the knee structures

Knee injuries can happen suddenly or gradually over time. Maybe you’re into sporting activities that require plenty of sharp rotation/pivoting actions of your knee. Maybe you’re lifting weights incorrectly or just lifting too much with poor form. Any such strenuous activities could actually cause damage to the supporting structures of your knee which could lead to painful knee conditions.

But sometimes you may not have participated in any strenuous activities at all and yet have knee pains. A simple understanding of this would be that our body acts as a unit and everything is connected, weak muscles and improper mobility around the hip, knee and/or ankle could also create great amount of stress on the knee joint.

So always listen to your body and stop overworking your muscles at any given point in time. Of course, if you start having any knee pain, the best thing for you to do is meet the experts who will help you recover and save your knee from further damage.