1. Anatomy and common injuries
KNEE EVALUATIONS
Anatomy and common injuries

2. The Knee Joint Knee joint proper (tibiofemoral joint)
Primarily classified as a ginglymus (hinge) joint
Sometimes referred to as trochoginglymus (pivotal, screw) joint internal & external rotation occur during flexion
Some argue for condyloid (ellipsoid, ovoid)classification
Patellofemoral joint
arthrodial (gliding) classification (patella on femoral condyles)
Femoral condyles articulate with tibial plateaus
Tibia - bears most of the weight
Fibula – attachment for muscles & ligaments

3. The Knee Joint Extends to 180º Flexes to 140º
Hyperextension normal
Flexes to 140º
With knee flexed 30º or >
internal rotation 30º occurs
external rotation 45º occurs

4. The Patella Sesamoid bone Imbedded in quadriceps & patella tendon
Serves similar to a pulley for improving angle of pull (results in greater mechanical advantage in knee extension)

5. Surface Anatomy Patella (A) Femur (B) Tibia (C, E – tuberosity)
Joint Line (D)
Fibula (F)
Gerdy’s Tubercle

6. Internal Knee Anatomy

7. Internal Knee Anatomy Medial Meniscus Lateral Meniscus
Anterior Cruciate Ligament
Posterior Cruciate Ligament
Articular Cartilage

8. Ligamentous Anatomy Hinged Joint ACL: Ant Stability
PCL: Post Stability
Lat/Med Stability: LCL/MCL
Menisci: Medial/Lateral

9. Menisci

10. Cruciate Ligament Movement

11. Bursae & Fat Pad of the Knee

12. Anatomy – Soft Tissue Quadriceps – Hamstrings – Popliteal fossa
Rectus femoris
Vastus lateralis
Vastus intermedius
Vastus medialis (& oblique - VMO)
Hamstrings –
Biceps femoris
Inserts primarily on fibula head
Semitendinosus
Semimembranosus
Inserts posteromedially on medial tibial condyle
Popliteal fossa

13. Muscles Gracilis, Sartorius & Semitendinosus Iliotibial Band
Common attachment
Pes Anscerine
Iliotibial Band
Gastrocnemius heads – lateral & medial

14. The Quadriceps EXTENSOR MECHANISM ORIGINS: Rectus Femoris: AIIS
Vastus Group: Linea Aspera
INSERTIONS:
Patella
Patellar Retinaculum

15. FLEXOR MECHANISM COMMON ORIGIN: Ischial Tuberosity INSERTIONS:
The Hamstring
COMMON ORIGIN:
Ischial Tuberosity
INSERTIONS:
Biceps: Fibular Head
Semimembranosus: Medial Tibial Condyle
Semitendinosus: Pes Anserinus

16. Nerves Femoral Nerve (L2, 3, 4) Lateral femoral cutaneous N.
innervates the knee extensors (quadriceps)
Anterior cutaneous branches of femoral n.
Lateral femoral cutaneous N.
Saphenous N. – infrapatellar branch

17. Nerves Sciatic tibial division common peroneal (fibular) division
semitendinosus, semimembranosus, biceps femoris (long head)
common peroneal (fibular) division
biceps femoris (short head)

18. Vascular Anatomy Femoral Artery & Vein Great Saphenous Vein (medial)
Lesser Saphenous Vein (posterior)
Popliteal Artery & Vein

19. Knee Movements

20. Screw Home Mechanism
Locking mechanism as the knee nears its final extension degrees
Automatic rotation of the tibia externally (approx. 10 degrees) during the last 20 degrees of knee extension
Femoral condyles are a different size
Medial has larger surface area
The tibia glides anteriorly on the femur. As knee extends, the lateral femoral condyle expends its articular distance. The medial articulation continues to glide, resulting in external rotation of the tibia utilizing the lateral meniscus as the pivot point.
ACL & PCL are rotary guides
Forms a close-packed position for the knee joint

21. History MOI - Previous history Pain (levels, types, descriptors)
Position of lower extremity at time of injury (?foot planted, knee extended)
Previous history
Pain (levels, types, descriptors)
Unusual sounds/sensations “pop, clicking, snapping”
Chronic vs. acute
Location of pain “inside the knee”
Surface
Shoes
Type of activity at time of injury
Painful to walk up/down stairs; any clicking, catching
Did it swell immediately, slowly?
Is the swelling located in the knee or in a pocket?

22. Observation Bilateral comparison
Gait (limp, walking on toes, do they not want to extend knee, do they keep the knee stiff)
Swelling (girth measurements)
Discoloration
Deformity (squinting patellae, “Frog-eyed” patellae, Patella alta, Patella baja)
Genu valgum, genu varum, recurvatum
Musculature – defined/mushy

23. Q-angle
The quadriceps angle (Q-angle) is the angle formed between a line drawn through the tibial tuberosity and the center of the patella and another line drawn from the anterior superior iliac spine (ASIS) of the pelvis through the center of the patella.

24. 1) ASIS to center of Patella and 2) Patella to Tibial Tubercle
Quadriceps Angle
(Q Angle) =
The Angle between:
1) ASIS to center of Patella
and
2) Patella to Tibial Tubercle
Men <10°
Women <15°
NORMAL

25. Q-angle Knee in extension Knee in 90 degrees flexion
Normal – males 13 degrees
Normal - females – 18 degrees
Knee in 90 degrees flexion
Both genders – 8 degrees

27. Palpation Tibia – tibial plateau, tibial tuberosity, Gerdy’s Tubercle
Fibula – head
Medial joint line
Medial collateral ligament
Lateral joint line
Lateral collateral ligament
“Windows”
Medial & Lateral femoral condyles & epicondyles
Pes anserine tendon
Semitendinosus tendon
Patella – inferior pole
Patellar tendon
Quadriceps muscle group
Biceps femoris tendon
Iliotibial band
Popliteal fossa
Gastrocnemius heads

28. Range Of Motion

29. Stress/Special Tests On-field vs. Off-field eval
Check for fractures, blood, deformities, neurological
Valgus Stress Test – MCL
Varus Stress Test - LCL
Lachman’s – ACL
Anterior Drawer – ACL
McMurray’s - meniscus

30. Stress/Special Tests Check for swelling Check ROM Ely’s Test
Sweep Test, Ballotable Patella
Check ROM Ely’s Test
Check integrity of ligaments & joint stability
Valgus, Varus, Lachman’s, Anterior/Posterior Drawer, Godfrey’s Test, Posterior Sag Test, Crossover Test, Slocum Drawer Test, External Rotation Test, Pivot Shift
Check integrity of meniscus
McMurray’s, Apley’s Compression/Distraction, Duck Walk, Bounce home
Check integrity of patella
Patellar Apprehension, Q Angle, Clarke’s Sign, Patellar glide, tilt, rotation
Check integrity of Iliotibial Band
Ober’s Test, Noble’s Compression Test

31. Now What?
? Crutches
? Referral
? RICE

32. Osgood-Schlatter’s Disease

33. Osgood-Schlatter’s Disease Clinical Features
History
young athlete complains of painful enlargement of the tibial tuberosity
pain worse with activity, esp. run/jump
Exam
tender tibial tuberosity
tight quads +/- hamstrings
Imaging: usually not necessary

34. Osgood-Schlatter’s Disease Imaging
Use in severe or persistent cases to rule out other problems
Not used to make the diagnosis in most cases
May show fragmentation of the anterior tibial tuberosity

35. Osgood-Schlatter’s Disease Treatment
Relative rest; cross-training
Ice
Hamstring stretching
Strapping of patellar tendon
Rare: temporary immobilization
Return to play:
Pain-free with sports activity

36. Osgood Schlatter’s Disease Surgery Indications
Persistent, painful os after growth complete

37. Housemaid’s knee

38. Joint Stability Testing
MCL: Valgus Load
LCL: Varus Load
ACL: Lachman, Ant drawer, Pivot Shift
PCL: Posterior Drawer, Sag sign, Quadriceps Active
Postero-lateral complex: Ext Rot

39. MCL Stability
Apply Valgus or Medial Stress
Test in 30° flexion
LCL Stability
Apply Varus or Lateral Stress

41. Grading collateral ligament injuries
Grade I: mild; no laxity
Grade II: partial tear; laxity w/ firm end-point
Grade III: complete tear; laxity w/o firm endpoint
Why does it matter? Prognosis

42. Treatment of MCL/LCL injuries
Grades I-II
knee immobilizer until pain gone
ROM/strength ex’s as pain allows
Grade III:
r/o associated injuries
knee immobilizer at 30° NWB 3 weeks
knee immob ° NWB 4 wks
progressive ROM/strength ex’s

43. ACL anatomy

46. Tests of ACL At 90° Flexion At 20-30 ° Flexion (more sensitive)
+ is increased translation or soft end point

47. Lachman test

48. Pivot Shift: ACL Injury
1. Knee extended
2. Internally rotate tibia
3. Apply valgus load
4. Flex Knee
5. At 20-30°, if you feel a jerk at Ant/Lat proximal tibia, test +

49. Management of ACL tears
PRICEMM
ROM/strength ex’s as pain allows
MRI
Referral to Orthopedics
Surgery once edema gone
Graft options
Bone-patella-bone autograft
Hamstring autograft
Cadaver allograft

50. PCL Tear

51. PCL TESTS: Posterior Sag
Quad Active Test
Posterior Drawer

52. Management of PCL tears
Immobilize; refer to Ortho
If no associated injuries:
ROM /strength ex’s as pain allows
If associated with other injuries:
Surgical repair
MCL
Postero-lateral corner

53. Popliteus Tendonitis Function: resists posterior translation of tibia
Pain postero-lateral
Garrick Test: pain with resisted ext rotation of leg
Seen w/ downhill running
Treatment:
Modify running
NSAID/ice
Hamstring stretching
Eccentric quad strength
Refer for injection if not responding
Popliteus

54. Flexibility testing Inflexeruse Hamstring Quadriceps
Ilio-tibial band (ITB)
Gastro-soleus complex
Patellar glide and tilt

55. Quadriceps flexibility

56. Hamstring flexibility: Popliteal Angle Goal: 0°

57. Gastro-soleus flexibility

58. Ober test ITB flexibility: Tight ITB will remain Abducted
Pain = ITB injury

59. Ilio-Tibial Band Friction Syndrome

60. Management of ITB Friction Syndrome
Reduce run mileage/hills/banked surfaces
NSAID/ice massage/phonopheresis
ITB stretching
Correct overpronation
Gradual return-to-running program
Referral for injection if fail above

61. Miscellaneous Tests McMurray: Meniscal injury
Apley Test: Meniscal vs ligament injury
Bounce Home Test: meniscal injury, effusion
Patellar grind test: PFS, chondromalacia

62. Normal Meniscus
Meniscal Tear

63. McMurray Test MEDIAL MENISCUS: Flex knee maximally
Externally rotate tibia
Varus stress
Extend Knee
LATERAL MENISCUS:
Flex knee
Internally rotate tibia
Valgus stress
Extend knee
+ is painful pop over Medial or Lateral Joint Line

64. McMurray Test

65. Apley test Compression for Meniscal Injury
Distraction for Ligamentous Injury

66. Full Flexion Test Pain at full flexion suggestive of posterior horn tear

67. Bounce Home Test Normal 1. Flexion 2. Passive Extension
Abnormal is lack of full extension (meniscal tear, loose body, effusion)

68. Management of Meniscal Tears
Weight-bearing as tolerated
ROM/strength ex’s as pain allows
MRI to confirm if recovery not prompt
Indications for referral:
Elite athletes
Symptomatic after 3 months
Locking
Unable to fully extend knee