1. The Knee
Chapter 18

2. Knee Bony Anatomy Lateral Medial Femur Condyles Tibia Tibial Plateau
Fibula
Patella
Largest sesamoid in body
Shape of condyles allows femur to roll and spin on flattened top portion of tibia, called tibial plateau

3. Knee Bony Anatomy

5. Patellofemoral Joint
Point where patella and femur are connected in the trochlear grove

7. Tibiofemoral Joint Tibia meets with femur Weight-bearing joint
Hinge joint
Joint capsule
4 ligaments
Motions:
Flexion
Extension
Rotation of tibia on femur

8. Patella Malalignment Deviations
Genu Varum
Genu Valgum

9. Knee Cartilage & Menisci
Articular cartilage
Thin layer of connective tissue over ends of long bones
Lateral & Medial meniscus
Shock absorption
Distribute forces
Improve stability of femur as it rides on tibia
Synovial membrane
Synovial fluid
Lubricates articulating surfaces of joints
Supplies nutrients to articular cartilage

10. Knee Cartilage & Menisci

11. Menisci Two—medial & lateral Fibrocartilaginous disks
Act as cushions between ends of femur and tibia/fibula
Top of tibia flat
Condyles of femur rounded
Make knee joint more stable

12. Menisci Medial meniscus Lateral meniscus C-shaped
Attached to ligaments on back and medial side of knee
Thus does not move freely
And torn more often than lateral
Lateral meniscus
O-shaped
Attached only at back of knee
Moves more freely as knee flex/extend

15. Ligaments of the Knee Medial Collateral Ligament (MCL)
Lateral Collateral Ligament (LCL)
Anterior Cruciate Ligament (ACL)
Posterior Cruciate Ligament (PCL)

16. Ligament
Attachments
Function
MCL
LCL
ACL
PCL

21. Muscles of the Knee Quadriceps Hamstrings Vastus medialis
Vastus intermedius
Vastus lateralis
Rectus femoris
Hamstrings
Biceps femoris
Semitendinosus
Semimembranosus

22. Quadriceps Rectus Femoris Vastus Lateralis Vastus Medialis
Extend knee
Flex hip
Vastus Lateralis
Vastus Medialis
Vastus Intermedius

23. Hamstrings Biceps Femoris Semitendinosus Semimembranosus Flex knee
Lateral rotate knee
Extend hip
Semitendinosus
Medial rotate knee
Semimembranosus

24. Hamstrings

25. Hamstrings

26. Popliteal space

27. Muscles of the Knee Patellar tendon Sartorius Gracilis Pes Ansurine
Flex hip
ER hip
Flex knee
Gracilis
Adduct hip
Pes Ansurine

28. Patellar Tendon

29. Gracilis
Sartorius

30. Label the Muscles of the Knee

31. Common Knee Injuries

32. Patellofemoral Problems
Symptoms
c/o aching pain in front of knee
Gradual onset
Pain behind kneecap
c/o knee giving way
Pain going up stairs
Crepitus
Pain can increase after prolonged knee flexion

33. Patellofemoral Problems
Causes
Treatment
Femur internally rotated
Squinting patella
Excessive foot pronation
Lowering of the arch
Thigh hip internal rotators
Weak hip external rotators
Orthotics
Muscle strengthening
Muscle stretching
Patellar tracking taping

35. Patellar Tendonitis aka Jumper’s knee
Inflammation of the patellar tendon
Signs & Symptoms
Anterior knee pain
Local tenderness
Local swelling
Treatment
Modify activity
Non-impact activities
Stretching quads
Ice
Specialized bracing & taping

36. Fat Pad Syndrome Signs & Symptoms
Inflammation of infrapatellar fat pad
Fatty tissue lying deep under patellar tendon
Hoffa’s fat pad
Often confused with patellar tendonitis
Pain just below patella
Movement of knee aggravates symptoms
Knee tender to palpation
Swelling in anterior portion of knee

37. Fat Pad Syndrome—Treatment
Strengthening exercises
Avoid full knee extension
Leg press
Specialized taping
Ice
NSAIDs

38. Fat Pad Syndrome—Special Test
Pressure applied to proximal patellar tendon with quadriceps contracted
Stressing only the tendon and not the fat pad
Pressure applied over proximal patellar tendon with relaxed tendon
Allow compression of the fat pad

39. MCL Sprain Signs & Symptoms MOI
Pain & tenderness on medial aspect of knee
Joint line
Bony attachment sites
Limited motion in full flexion and extension
Swelling
Varying degrees of laxity
MCL Sprain
MOI
Valgus force on medial tibiofemoral joint
Blow to lateral aspect of knee
High-energy twisting maneuver

40. MCL Sprain—Treatment PRICE Rehab Gentle active & passive stretching
P: ace, brace, or crutches
Rehab
Submax strengthening in subacute stage, but only if painfree
Bike once gain flex degrees
Gentle active & passive stretching
Avoid valgus & twisting forces

41. LCL Sprain Not frequently involved in sports injuries
MOI: varus stress on lateral tibiofemoral joint
Signs/symptoms & treatment similar to those of MCL sprain

43. MCL/LCL Sprain—Grade 1 Mild tenderness over ligament
Usually no swelling
Pain felt with valgus/varus test but no laxity

44. MCL/LCL Sprain—Grade 2 Significant tenderness over ligament
Some swelling seen over ligament
Pain and laxity in joint with stress test, but definite end point

45. MCL/LCL Sprain—Grade 3 Complete tear of ligament Pain can vary
Sometimes not as bad as Grade 2
When knee stressed, definite joint laxity
Athlete may c/o knee wobbly or unstable

46. ACL Injuries
Females who participate in soccer and basketball 4-6 times more likely than males who play same sport
70% are non-contact injuries
Why incidences higher in females?

47. Female Factors & ACL Biomechanical factors Hormonal influences
Use quads more than hamstrings
Land on flat foot vs toes
Hormonal influences
Estrogen levels
Environmental factors
Anatomic risk factors

48. ACL Tear Contact or non-contact Low to lateral knee
Knee joint in combined position of flexion, valgus, and rotation of tibia on femur
Once stretched or ruptured, will not heal
Often accompanied by meniscus tears and/or MCL sprains

49. ACL Tear—Signs/Symptoms
Heard or felt “pop”
Rapid effusion
Knee “buckles” or “gives way”
Special testing—Lachman’s or Anterior Drawer
Test’s ligaments integrity
Within first 5 min to avoid protective muscle guarding
Often false-negative testing
F/u with orthopedist
MRI to confirm

50. Lachman’s Test

51. ACL Tear—Treatment Acute: splint, ice, compressive wrap, crutches
Reconstructive surgery necessary to replace ACL
Patellar tendon
Hamstring tendon (Gold standard)
Cadaver
Comprehensive rehab (6 months)

52. http://physiomed. patientsites

54. PCL Injuries Account for 3-20% of all injuries
Less researched because injured less often (compared to ACL)
MOI: tibia strikes ground/object and is pushed backward
Motor vehicle accident
Industrial accident
Fall on flexed knee with foot plantar flexed
Hyperflexion of knee

55. PCL Signs & Symptoms Treatment PRICE Rehab Surgery usually avoided
Positive Posterior Drawer
Positive Godfrey’s (Sag) Test
Athlete in supine position, knee bent at 90⁰
Treatment
PRICE
Rehab
Strength
Quadriceps
Proprioception
Surgery usually avoided

56. Meniscus Tears Knee twisted suddenly Ligaments in & around knee torn
One or both menisci become trapped between femur and tibia
Ligaments in & around knee torn
As ages, menisci lose their rubbery consistencywill soften and fray
Weakened structures torn more easily

57. Meniscus Tears

58. Meniscus Tears Treatment Ice Compressive wrap/knee support
Crutches prn
Rehab (non-surgical)
Streength
ROM
Activity modification
NSAIDS
Support sleeve
Surgery
MRI
Signs & Symptoms
Mild knee swelling over several hours or more
Pain
Popping
Locking
Giving way of knee

59. Meniscus Tears—Special Tests
McMurray’s
Apley’s Compression & Distraction

60. Epiphyseal (Growth Plate) Injuries

61. Epiphyseal (Growth Plate) Injuries

62. Osgood-Schlatter
Group of symptoms involving the tibial tubercle epiphysis
Tibial tubercle: small bump on tibia where patellar tendon attaches
Condition result of traction
Femur growing faster than quadriceps muscle
Result: quad will exert undue pressure on growth center of tibia (at tubercle)
Most likely affect males yo and females yo

63. Osgood-Schlatter

64. Osgood-Schlatter—Signs & Symptoms
Pain over tibial tubercle
Swelling over tibial tubercle
Weakness in quad muscles
Increased pain & swelling with activity
Visible lump
Point tenderness over affected area
Susceptible to avulsion fx

65. Osgood-Schlatter—Treatment
Address pain, swelling, flexibility
During practice/competitionwear protective padding
Volleyball knee pad
Combine with neoprene sleeve
After activityice (even if not painful) & NSAIDs
Hamstring tightness cause quads to pull harder during athletic activity
Avoid quad stretching (or try gentle stretch)
Limit or restrict activity (decrease intensity)

66. Osgood-Schlatter—Rehab
Exercises to minimize strength loss rather than increase strength
SLR
Body weight squats
Hamstring curls
Calf raises
AVOID:
Knee extension
Heavy squats
Power cleans
Plyometrics
Maintain aerobic fitness
Cycling
Slide board
Swimming

67. Iliotibial Band Syndrome
Irritation usually at femoral lateral epicondyle
Bursa facilitate smooth gliding motion of ITB, when inflamed ITB not glide easily
Pain worsens with continued movement

68. Iliotibial Band Syndrome
Sudden increase in activity level
i.e. runners who increase mileage
Mechanical problems:
Over-pronate
Leg-length discrepancies
Bowlegged

69. Iliotibial Band Syndrome
Treatment
Gait analysis
Review training program
Proper footwear
Ice
Stretch
Modify training program
Reduce activity level
Cross-train
Special Test
Ober’s

70. Fractures High-energy trauma Rare in athletes
Fx to patella result of direct impact to anterior knee
Distal femoral & proximal tibial fxs occur from violent twisting injuries
Fall from height (pole vaulter who misses landing pit)

71. Patella Dislocation MOI Signs/Symptoms
Plants foot, decelerates, Internally Rotates thigh
Signs/Symptoms
Obvious deformity
Pain
Swelling
Loss of function

72. Patella Dislocation Management Patella apprehension test Gently extend
Immobolize
Rule out: osteochondral fx
Patella apprehension test

73. Bursitis

75. Rehab
Wall squat
Step-up
Resisted terminal knee extension