Chapter 20: The Knee and Related Structures Jennifer Doherty-Restrepo, MS, LAT, ATC Academic Program Director, Entry-Level ATEP Florida International University Acute Care and Injury Prevention

Assessment of the Knee Joint  Determine MOI - This is critical!!!  History: Acute Injury  Past history  Position of body at time of injury?  Did the knee collapse?  Did you hear or feel anything?  Could you move your knee immediately after injury or was it locked?  Did swelling occur?  Where was the pain?

 History: Recurrent or Chronic Injury  What is your major complaint?  When did you first notice the condition?  Is there recurrent swelling?  Does the knee lock or catch?  Is there severe pain?  Grinding or grating?  Does it ever feel like giving way?  What does it feel like when ascending and descending stairs?  What past treatment have you undergone?

Observation  Walking, half squatting, going up and down stairs  Swelling, ecchymosis  Leg alignment  Genu valgum and genu varum  Hyperextension and hyperflexion  Patella alta and baja  Patella rotated inward or outward  Tibial torsion, femoral anteversion and retroversion

Observation cont.  Knee Symmetry or Asymmetry  Do the knees look symmetrical?  Is there obvious swelling?  Atrophy?  Leg Length Discrepancy  Anatomical or functional  Anatomical differences can potentially cause problems in all weight bearing joints  Functional differences can be caused by pelvic rotations or mal-alignment of the spine

 Intracapsular swelling  May be referred to as joint effusion  Swelling within the joint that is caused by synovial fluid and blood is called hemarthrosis  Sweep maneuver – sign of joint effusion  Ballotable patella - sign of joint effusion  Extracapsular swelling  Localized over the injured structure  May ultimately migrate down to foot and ankle Palpation - Swelling

Recognition and Management of Specific Injuries

Medial Collateral Ligament Sprain  MOI = severe blow or outward twist  Grade I: Signs and Symptoms  Little fiber tearing or stretching  Stable valgus test  Little or no joint effusion  Some joint stiffness and point tenderness on lateral aspect of the knee  Relatively normal ROM

 Grade I: Management  RICE for 24 hours  Crutches if necessary  Rehab  Cryokinetics  Isometrics  Progress to SLRs, bicycle riding, and isokinetics  Return to play when all areas have returned to normal  May require 3 weeks to recover

 Grade II: Signs and Symptoms  Complete tear of deep capsular ligament and partial tear of MCL  No gross instability; laxity at 5-15 degrees of flexion  Slight swelling  Moderate to severe joint tightness  Decreased ROM  Pain along medial aspect of knee

 Grade II: Management  RICE for hours  Crutch use until acute inflammation phase has resolved  Possibly a brace or casting prior to the initiation of ROM activities  Modalities 2-3 times daily for pain  Gradual progression from isometrics (quad exercises) to CKC exercises; functional progression activities

 Grade III: Signs and Symptoms  Complete tear of supporting ligaments  Complete loss of medial stability  Minimum to moderate swelling  Immediate pain followed by ache  Loss of motion due to effusion and hamstring guarding  Positive valgus stress test

 Grade III: Management  RICE  Conservative non-operative versus surgical approach  Limited immobilization (with a brace)  Progressive weight bearing and increased ROM over 4-6 week period  Rehab would be similar to Grade I & II injuries

 MOI = Varus force usually with the tibia internally rotated  Direct blow is rare MOI  If severe enough damage may also occur to  Cruciate ligaments  ITB  Meniscus  Bony fragments may result as well Lateral Collateral Ligament Sprain

 Signs and Symptoms  Pain and tenderness over LCL  Swelling and effusion around the LCL  Joint laxity with varus testing  May cause irritation of the peroneal nerve  Management  Same as MCL injury management

 MOI = tibia externally rotated with a valgus force  Occasionally the result of hyperextension resulting from a direct blow  Research is quite extensive in regards to impact of femoral notch, ACL size and laxity, mal- alignments (Q-angle), and faulty biomechanics  Extrinsic factors may include, conditioning, skill acquisition, playing style, equipment, preparation time  May also involve damage to other structures including meniscus, capsule, and MCL Anterior Cruciate Ligament Sprain

 Signs and Symptoms  Experience pop with severe pain and disability  Positive anterior drawer and Lachman’s  Rapid swelling at the joint line  Other ACL tests may also be positive  Management  RICE; use of crutches  Arthroscopy may be necessary to determine extent of injury  Surgical repair  Without surgery, joint degeneration may result  Surgery may involve joint reconstruction with grafts (tendon), transplantation of external structures  Also requires 4-6 months of rehab

 MOI = fall on bent knee (most common)  Most at risk during 90 degrees of flexion  Injury may result due to a rotational force  Signs and Symptoms  Feel a pop in the back of the knee  Tenderness and relatively little swelling in the popliteal fossa  Laxity with posterior sag test Posterior Cruciate Ligament Sprain

 Management  RICE  Non-operative rehab  Appropriate for grade I and II injuries  Focus on quad strengthening  Post-operative rehab  Surgery will require 6 weeks of immobilization in extension  Full weight bearing on crutches  ROM after 6 weeks  PRE at 4 months

 Most common MOI is rotary force with knee flexed or extended  Tears may be longitudinal, oblique, or transverse  Medial meniscus is more commonly injured due to ligamentous attachments and decreased mobility  Also more prone to disruption through torsional and valgus forces Meniscal Lesions

 Signs and Symptoms  Effusion developing over hours  Pain in joint line  Loss of motion  Intermittent locking and giving way  Pain with squatting  Portions of meniscus may become detached causing locking, giving way, or catching within the joint  If chronic injury, recurrent swelling or muscle atrophy may occur

 Management  No locking but indications of a tear are present  Further diagnostic testing may be required  If locking occurs, anesthesia may be necessary to unlock the joint  Possible arthroscopic surgery  Healing dependent on location of tear  Menisectomy  Partial weight bearing, quick return to activity  Repaired meniscus  Requires immobilization, gradual return to activity over the course of 12 weeks

 MOI = irritation of the plica  Often associated with chondromalacia  Signs and Symptoms  Possible history of knee pain/injury  Recurrent episodes of painful pseudo-locking  Possible snapping and popping  Pain with stairs and squatting  Little or no swelling  No ligamentous laxity  Management  Treat conservatively w/ RICE and NSAID’s if the result of trauma  Recurrent conditions may require surgery Knee Plica

Osteochondritis Dissecans  MOI = partial or complete separation of articular cartilage and subchondral bone  Exact cause is unknown but may include:  Blunt trauma,  Possible skeletal or endocrine abnormalities,  Prominent tibial spine impinging on medial femoral condyle, or  Impingement due to patellar facet

 Signs and Symptoms  Aching pain and point tenderness  Recurrent swelling  Possible locking  Possible quadriceps atrophy  Management  Rest and immobilization for children  Surgery may be necessary in teenagers and adults  Drilling to stimulate healing, pinning, or bone grafts

 MOI = repeated trauma  May result due to osteochondritis dissecans, meniscal fragments, synovial tissue damage, or cruciate ligaments injury  Signs and Symptoms  May become lodged and cause locking or popping  Pain  Sensation of instability  Management  If not surgically removed it can lead to conditions causing joint degeneration Loose Bodies

 MOI = direct blow  Signs and Symptoms  Severe pain  Acute inflammation  Loss of movement  Swelling  If not resolved within a week then a chronic condition may exist (synovitis or bursitis)  Ecchymosis  Possible capsular damage  Management  RICE  Progress to normal activity following return of ROM  Padding for protection Joint Contusions

 MOI = compression due to a direct blow  Signs and Symptoms  Local pain and possible shooting nerve pain  Numbness and paresthesia  Added pressure may exacerbate condition  Generally resolves quickly  In the event it does not resolve, it could result in drop foot  Management  RICE  Return to play once symptoms resolve and no weakness is present  Padding for fibular head Peroneal Nerve Contusion

 MOI = acute, chronic, or recurrent swelling  Prepatellar = continued kneeling  Infrapatellar = overuse of patellar tendon  Signs and Symptoms  Localized swelling that results in ballotable patella  Swelling in popliteal fossa may indicate a Baker’s cyst  Associated with burse over the semimembranosus or medial head of gastrocnemius  Commonly painless and causing little disability  May progress and should be treated accordingly  Management  Eliminate cause  RICE and NSAID’s  Aspiration and steroid injection if chronic Bursitis

 MOI = direct or indirect trauma  Semi-flexed position with forceful contraction, which may occur while falling, jumping or running  Signs and Symptoms  Hemorrhaging and joint effusion  Possible capsular tearing, separation of bone fragments, and possible quadriceps tendon tearing due to bone fragments  Management  X-ray necessary for confirmation  RICE and splinting if fracture suspected  Refer  Possible immobilize for 2-3 months Patellar Fracture

 MOI = deceleration with simultaneous cutting in opposite direction (valgus force)  Quad pulls the patella out of alignment  Repetitive subluxation will impose stress to medial restraints  Signs and Symptoms  Subluxation  Pain, swelling, restricted ROM, and palpable tenderness over adductor tubercle  Dislocations  Total loss of function Patella Subluxation or Dislocation

 Management  Reduction  Performed by flexing hip, moving patella medially, and slowly extending the knee  Following reduction, immobilize for at least 4 weeks  Use crutches  Isometric exercises  After immobilization period, horseshoe pad with elastic wrap should be used to support patella  Rehab focuses on strengthening the muscles around the knee, thigh, and hip  Possible surgery to release tight structures  Improve postural and biomechanical factors

 MOI = becomes wedged between the tibia and patella  Irritated by chronic kneeling, pressure, or trauma  Signs and Symptoms  Capillary hemorrhaging and swelling  Chronic irritation may lead to scarring and calcification  Pain below the patellar ligament during knee extension  May display weakness, mild swelling, and stiffness during movement Infrapatellar Fat Pad

 Management  Rest  Avoid irritating activities until inflammation has subsided  Utilize therapeutic modalities for inflammation  Heel lift to prevent irritation during extension  Hyperextension taping to prevent full extension

 MOI = softening and deterioration of the articular cartilage  Three stages:  Swelling and softening of cartilage  Fissure of softened cartilage  Deformation of cartilage surface  Often associated with abnormal tracking  Abnormal patellar tracking may be due to genu valgum, external tibial torsion, foot pronation, femoral anteversion, patella alta, shallow femoral groove, increased Q angle, laxity of quad tendon Chondromalacia patella

 Signs and Symptoms  Pain with walking, running, stairs, and squatting  Possible recurrent swelling  Grating sensation with flexion and extension  Pain at inferior border during palpation  Management  Conservative measures  RICE, NSAID’s, isometrics, orthotics to correct dysfunction  Surgical possibilities  Altering muscle attachments  Shaping and smoothing of surfaces  Drilling  Elevating tibial tubercle

 MOI = lateral deviation of patella while tracking in femoral groove  May result due to tight structures, pronation, increased Q angle, insufficient medial musculature  Signs and Symptoms  Tenderness at lateral facet of patella  Swelling associated with irritation of synovium  Dull ache in center of knee  Patellar compression will elicit pain and crepitus  Apprehension when patella is forced laterally  Management  Correct imbalances (strength and flexibility)  McConnell taping  Lateral retinacular release if conservative measures fail Patellofemoral Stress Syndrome

 Osgood Schlatter’s is apophysitis at the tibial tubercle  MOI = repeated avulsion of patellar tendon  Bony callus develops enlarging the tibial tubercle  Resolves with aging  Larsen Johansson is the result of excessive pulling on the inferior pole of the patella Osgood-Schlatter Disease, Larsen-Johansson Disease

 Signs and Symptoms  Swelling  Hemorrhaging  Gradual degeneration of the apophysis due to impaired circulation  Pain with kneeling, jumping, and running  Point tenderness  Management  Conservative  Reduce stressful activity  Possible casting  Ice before and after activity  Isometerics

 MOI = sudden or repetitive extension  Jumping or kicking places tremendous strain on patellar or quadriceps tendon  Signs and Symptoms  Pain and tenderness at inferior pole of patella  3 phases:  1) pain after activity,  2) pain during and after activity,  3) pain during and after activity that may become constant Patellar Tendinitis (Jumper’s or Kicker’s Knee)

 Management  Ice, phonophoresis, iontophoresis, ultrasound, heat  Exercise  Patellar tendon bracing  Transverse friction massage

 MOI = sudden, powerful quad contraction  Rare unless a chronic inflammatory condition exists resulting in tissue degeneration  Occurs primarily at point of attachment  Signs and Symptoms  Palpable defect  Lack of knee extension  Considerable swelling and pain (initially)  Management  Surgical repair is needed  Proper conservative treatment of jumper’s knee can minimize chances of occurring Patellar Tendon Rupture

 MOI = repetitive/overuse conditions attributed to mal-alignment and structural asymmetries  Signs and Symptoms  IT Band Friction Syndrome  Irritation at band’s insertion  Commonly seen in individuals who have genu varum or pronated feet  Pes Anserine Tendinitis or Bursitis  Result of excessive genu valgum and weak vastus medialis  Often occurs due to running with one leg higher than the other  Running on a slope or crowned road Runner’s Knee & Cyclist’s Knee

 Management  Correction of mal-alignments  Ice before and after activity  Utilize proper warm-up and stretching techniques  Avoidance of aggravating activities  NSAID’s  Orthotics

 Giving way of knee  Result of…  Weak quadriceps  Chronic instability of ligamentous structures  Torn meniscus  Loose bodies within the knee  Subluxating patella  Chondromalacia  Due to pain The Collapsing Knee