Anatomy Mondays: The cruciate ligaments of the knee.

Welcome to Anatomy Mondays! This is a new feature which will explain anatomical structures in terms that hopefully are accessible to all.

An recent news report points to a recent NFL study about the rate of knees and ankles injuries during games played on turf and games played on grass. The study shows that there is more incidence of ACL (anterior cruciate knee ligament) injuries is significantly higher (88%) on turf than on grass. While the study does not really draw any conclusions on the reasons why (could it be that players wear the wrong kind of shoes on turf for example) and is just as statistical tally, it is interesting to follow the potential developments from it. Specially considering that all the grass playfields in Seattle are being replaced by turf fields.

The main injurie tracked is a rupture, partial or total of the ACL. ACL injuries are al too common if you are a soccer player or an avid skier. But what exactly is the ACL?

Location:

ACL stands for anterior cruciate ligament. It is a ligament deep inside your knee. It at

taches to the front head of the tibia (to be more precise on the anterior intercondylar area of the t

ibia). It runs up and towards the back of the knee to attach to the femur (the large thigh bone).

To be more precise, it runs postero-(towards the back)-supero-(above)-laterally-(towards the outside of) and attaches to the medial (the interior) aspect of the lateral femoral condyle. A condyle is the round bump of a bone where it forms a joint with another bone. In the case of the femur, there are two condyles, one facing the center line of the body (the medial condyle), the other facing the outside of the body (the lateral condyle).

There is another cruciate ligament, the PCL or posterior cruciate ligament. As its name indicates, the PCL is the opposite ligament to the ACL running from the back of the knee towards the front (from the posterior intercondylar area of the tibia, runs anterisuperomedially and attaches to the lateral surface of the medial femoral condyle).

The two ligaments actually cross, forming an X 'inside' the knee.

Function:

The role of the cruciate ligaments is to resist the hold the tibia and the femur together. Without the ligaments, the tibia could move too much towards the front or the back depending on the movement. The reason why the ligaments actually cross is to allow the joint to flex.

The knee is primarily a hinge joint, allowing for flexion (bringing your heel towards your bottom) and extension (bringing your heel away from your bottom). However to allow for faster reaction and for a more even distribution of forces during movement, the knee also allow for a tiny bit of rotation. During a lateral rotation (your foot is turning out), the cruciate ligaments are slacken somewhat, however during a medial rotation (your foot is turning in), they press against each other and become more taut.

The risk for injury is typically greater to the ACL than the PCL. ACL tears are often the result of either:

• Hyperextending the knee, that is if the knee is straighten more than 10 degrees past the normal fully straighten position. This injury occurs often during skiing, volleyball, basketball, soccer and football.
• Pivoting of the lower leg, particularly inward rotation. This injury is often seen with football, basketball, tennis and soccer.

The treatment for ACL tears is often a long rehabilitation and strengthening program as well as possible reconstructive surgery.

Take care of your knees! It is a complex structure that takes a while to heal.

Illustration taken from the excellent Anatomy of Movement
by Blandine Calais Germain, published by Eastland Press, 1993

Music: Dimunito by Rolf Lislevand et al

A small departure from my usual world beat playlist, I have discovered Dimunito by Rolf Lislevand. I love medieval and renaissance music and this is absolutely sublime.

Lislevand set out to re-actualize the renaissance practice of embellishing a melody with improvisation. Renaissance artists frequently improvised based on familiar tunes for their audience. This practice shines a very different light on the sound we are used to come from specific instruments. I have never heard a lute sound so modern, almost jazz like.

I highly recommend this album!

Enjoy.

Book Review: Pelvic Power by Eric Fanklin

Eric Franklin is head of the Franklin Method Institute in Uster, Switzerland and a member of the International Association of Dance Medicine and Science. In short, he is a movement guy :)

The book: "Pelvic Power: mind/body exercises for strength, flexibility, posture and balance for men and women" is a fantastic resource for all interested in the relationship between core strength and health. The book is organized around a series of exercises designed to raise your awareness of core muscles and a discussion of the anatomy and physiology of those muscles.

Franklin uses his intensive knowledge of movement based therapies with a interesting insight on energy based anatomy (qi) to create a fascinating, highly useable manual on one of the most important part of our bodies. I recommend it!

Enjoy...

Would you like fries with that? A comment on prices and massage.

Regularly I am being asked if the price for my session is for regular work or deep tissue. This is an interesting question. I like to answer it is the price for the session you want or need.

Often when looking at the different options offered by spas, prices differ based on modalities. This is a typical up-selling technique. If you want more than oil spread on you and for the practitioner to really start working with you, you need to pay extra. While this make some sense when selling cars, it is harder to quantify when it comes to services, specially when the service cannot be standardized. And I consider massage to be one of those services. Everybody coming to my office is unique. Each body is different. Each pain pattern, stress pattern, life pattern is unique to every one of us. So it is therefore impossible, in my opinion, to standardize a massage.

Sometime you hear some 'enlightened' spa owner talking about how much harder a deep tissue massage is for the practitioner. While this might be accurate, it is also harder to work with someone who doesn't hydrate enough or is particularly tall or small. And really, how do you quantify what a deep massage is? Depth is one of those interesting metric that everybody talks about but no one can really measure, partly because it is unique to each of us.

Maybe a better metric than duration and depth should be the intent of the session. If you want the great, overall relaxation session, we would use particular payment scale. If you come for help with your back/neck/ankle or other (more treatment oriented session), we would use a different scale. And if you come with a post/pre event related goal (running a marathon or training for the curling event in the olympics) we could use a different scale all together.

Food for thoughts I guess... Any opinions?

Jamie Oliver's talk at TED

Nutrition as medicine is a concept I believe very strongly in. I am convinced that the best medicine is a combination of diet and movement (to paraphrase Thomas Edison). Alas, it seems we are losing the battle on the diet front.

The need to reform our eating habits is a topic discussed by many people from the scientific community or journalists. This is the first time I hear it coming from a "food" personality.

Jamie Oliver is a British chef better known for his books and TV shows. During his talk at T.E.D. he introduced himself as someone who is trying to save lives. With his typical fast pace and emotional delivery, he is really talking plainly about the need for food education for our kids.

Absolutely a must... Go watch it (it is only 19 minutes)...

Running without shoes? Good or bad for you?

The latest trend in the running world is to run without shoes. New designs for minimal footwear are coming out from all the major athletic shoe brands along with a plethora of opinions in the media and blogosphere about the benefits or problems with them.

From all the reading I've done on the subject, it seems like the current athletic shoe design and our current way of life shapes the way we have been running lately. The cushioning of the shoe seems to have lull the runner into a false sense of comfort, allowing for a heavier heel strike while running. While running barefoot, the whole foot is used to cushion the impact of the stride, not just the heel. This really how the foot is "designed" to function. In the long run, it seems that running with minimal footwear would minimize the opportunity for injury. There is also a need to learn how to run barefeet. This sounds a little counter intuitive but since we spend most of our lives in shoes (leather coffins as Tom Meyers likes to call them) and we certainly have invested quite some time running with athletic shoes on, it is important to re-learn the proper techniques to absorb the stride with the whole foot. Otherwise, injuries will occur running barefoot or with shoes.

For more information, the Skeletal Biology Lab at Harvard University as devoted a great web site on the topic. Another interesting resource is the web site Running Barefoot which has some good tips and resources.

Keep moving!

A conversation with Dr. Abraham Verghese

Dr Abraham Verghese, author of "Cutting for Stone" and "My Own Country" is talking to KUOW's Steve Scher about life and the practice of medicine.

This is probably one of the most moving and thoughtful discussion about the practice of medicine I have heard in a very long time. From the need to go beyond the iPatient and the need for hands-on, bedside medicine to the need for reform of the medical education, this talk is an absolute must. One of those moments where radio is not a background noise and makes you stop and listen.

Treat yourself. Listen to it.