Evaluation of Knee Injuries Dr. Alan A. Zakaria, D.O., M.S. 1080 Kirts Blvd., Suite 400 Troy, Mi., 48084 Team Physician United States Soccer Federation University of Michigan Men’s and Women’s Soccer

Objective Identify main anatomic components of the knee Perform basic knee exam along with special tests Identify common knee injury patterns and their physical exam findings.

Anatomy Bony Anatomy Ligaments Cartilage Musculature Other Soft Tissue

Knee Anatomy Two functional joints Femoral condyles Femorotibial Femoropatellar Femoral condyles Flex/extend

Knee Anatomy Patella Sesamoid with two concave surfaces and vertical ridge Increases efficiency of extension

Knee Anatomy: Anterior Cruciate Ligament (ACL) Run inferior, anterior, and medially Arises from medial aspect lateral femoral condyle Insert lateral to medial tibial eminence Restrains anterior subluxation of tibia on femur

Knee Anatomy: Posterior Cruciate Ligament (PCL) Arises from the posterior intercondylar area of the tibia Inserts at the medial condyle of the femur Restrains posterior subluxation of the tibia on the femur

Knee Anatomy: Medial Collateral Ligament (MCL) Postero-superior medial femoral condyle to proximal end of tibia Maximum tension at full extension Restraint to valgus stress

Knee Anatomy: Lateral Collateral Ligament (LCL) Posterosuperior lateral femoral condyle to lateral head of fibula Restraint to varus stress

Knee Anatomy: Meniscus Load bearing, joint stability, shock absorption Peripheral third vascularized

Knee Anatomy: Articular Cartilage Hyaline cartilage that covers the femoral condyles, tibial plateau, and undersurface of the patella Shock absorbing structure that can withstand compression, tension, and shearing forces and dissipate load

Knee Anatomy: Muscles Quadriceps Hamstrings Iliotibial tract Pes Anserine

Knee Anatomy: Pes Anserine Composed of the conjoined tendons of the semitendinosus, gracilis, and sartorius muscles Inserts onto the anteromedial proximal tibial bone

Knee Anatomy: Patellar and Pes Anserine Bursa Synovial fluid-filled sacs that provide a cushion between bones and tendons and/or muscles around a joint Prepatellar bursa located superior to the patella

Patient History. Nature of symptoms Location Timing/Duration Quality and Quantity Trauma or preceding event Exacerbating or relieving factors Past History Age Occupation or recreational activities Clicking or popping Locking or catching Giving Way Swelling

Physical Exam Observation Range of Motion Palpation Strength Testing Special Testing

Observation Anterior view standing Genu valgum/varum, patella position, foot architecture Posterior view standing Genu valgum/varum, foot architecture Anterior and lateral views sitting Patella position/tracking, osgood schlatter’s changes Gait General changes, motion of patella, foot architecture

Palpation Anterior with knee extended Swelling or effusion Prepatellar bursa, patellar tendon, plica Quad and tendon Pes Anserine Lateral Lateral meniscus LCL IT Band Medial Medial meniscus Medial collateral ligament Pes Anserine Posterior Hamstrings Gastrocnemius Popliteal fossa Baker’s Cyst

Range of Motion Flexion – 135 -140 degrees Extension – 0 degrees

Strength Testing (5 point scale) Flexion Hamstring Gracilis, sartorius Popliteus Gastrocnemius Extension Quadriceps Tensor Fasciae Latae

Collateral Ligaments MCL Valgus stress at 0 and 30 degrees LCL Varus stress at 0 and 30 degrees

ACL Lachman Anterior Drawer Pivot Shift

PCL Posterior Sag Posterior Drawer

Meniscus McMurray Apley’s Bounce Home

Patellofemoral Active patellar grind/crepitus Apprehension/hyper mobility

Others Ober’s Test

Diagnostic Imaging X-rays: AP Lateral Sunrise Notch Weight bearing

Diagnostic Imaging CT – More detailed bony evaluation MRI – More detailed bony evaluation and good evaluation of soft tissue structures Ultrasound – Good, detailed evaluation of more superficial soft tissue structures

Summary Knee Anatomy Basic physical exam Special tests

Thank You!