1. Anatomy and Injuries of the Knee
Adapted from Connie Rauser
Sabino Sports Medicine

2. Anatomy-Bones Bones Femur Tibia Fibula Patella
Medial/lateral femoral condyles articulate w/ tibia
Tibia
Tibial plateau is flat-articulates w/ femoral condyles
Fibula
Articulates w/ tibia
Patella
Sesamoid bone protects anterior joint
Enclosed in quadriceps/patellar tendon
Anatomy-Bones

3. Anatomy-Joints Joints Tibiofemoral Patellofemoral
Hinge joint with synovial lining
diarthrodial
Patellofemoral
Superior Tibiofibular
Anatomy-Joints

4. Anatomy-Meniscus Meniscus Medial and lateral Fibrocartilaginous disks
Thicker on outside than inside (poor blood supply)
Lie on top of tibial plateau
Increase stability
Make condyles fit better
Shock absorbers
Anatomy-Meniscus

5. Anatomy-Ligaments ACL-anterior cruciate ligament
Runs from anterior tibia to posterior femur
Prevents anterior displacement of tibia on fixed femur
Prevents femur from moving posterior during weight bearing
Stabilizes tibia against excessive internal rotation
Anatomy-Ligaments

6. Ligaments PCL-posterior cruciate ligament
Runs from posterior tibia to anterior femur
Prevents posterior translation of tibia on fixed femur
Prevents femur from moving anterior during weight bearing
Both ACL and PCL “cross” or wrap around each other—taut when in extension and looser when in flexion
Ligaments

7. Ligaments MCL-medial collateral ligament
Attaches on the medial femoral epicondyle & anteromedial tibia
Thickened portion of joint capsule
Two parts-superficial and deep
Deep portion attaches to medial meniscus
Stabilizes against valgus stress applied to lateral aspect of joint capsule
Ligaments

8. Ligaments LCL-lateral collateral ligament
Attaches to lateral femoral epicondyle and head of fibula
Stabilizes against varus stress when force is applied to medial aspect of joint
Both the MCL and LCL are tightest during full extension of knee and relaxed during flexion
Ligaments

9. Ligaments

10. Quadriceps
Rectus femoris, vastus lateralis, vastus medialis, vastus intermedius
Knee extension, hip flexion
Hamstrings
Biceps femoris, semimembranosus, semitendinosus
Knee flexion, hip extension
Muscles

11. Muscles Gracilis Sartorius Popliteus Gastrocnemius
Knee flexion, hip adduction
Sartorius
Knee flexion, hip flexion, hip external rotation
Popliteus
Knee flexion
Gastrocnemius
Muscles

12. Muscles Plantaris Pes anserine Iliotibial Band Knee flexion
Goose’s foot
Knee flexion, some internal rotation
Gracilis, sartorius, semitendinosus
Iliotibial Band
Thick band on lateral aspect of thigh
Attaches at Gerdy’s tubercle on the lateral aspect of tibia
Muscles

13. Preventing knee injuries
Conditioning
Strength, flexibility, cardiovascular and muscular endurance
Hamstring strength 60% of quad strength
Rehabilitation
Strengthen all muscles around knee joint
Shoes
proper type for surface
Length of cleats
Turf vs grass
Preventing knee injuries

14. Preventing knee injuries
Knee braces
Functional vs. prophylactic
Functional—used to provide support to an unstable knee
Usually custom fitted to some degree
Uses hinges and supports to control excessive rotational stress and tibial translation
Prophylactic-worn on lateral aspect knee to protect MCL.
Usefulness questioned—does it cause more injuries?

15. ACL rupture MOI: S/S: fixed foot and external rotation of femur
knee in valgus position
hyperextension
S/S:
“pop”,
knee gives out
instability of knee joint
swelling within knee joint—hemarthrosis
intense pain initially but still able to walk
“+” Lachman’s test
“+” anterior drawer test
ACL rupture

16. MOI

17. Hyperextension
MOI

18. ACL rupture

19. The ACL intact The ACL torn
Inside the knee joint

20. ACL Rupture Tx: RICE, knee immobilizer, crutches, Physician referral
Requires surgical reconstruction
Timing of surgery decided by athlete, parents, doctor
Grafts used are patellar tendon, hamstring tendon, cadaver graft, allograft
3-5 weeks in brace, 6-9 months return to activity
ACL Rupture

21. ACL Rupture Knee post-ACL tear Test for Swelling
Ballotable Patella Test
ACL Rupture

22. Lachman’s test
Stress tests

23. Modified Lachman’s
Stress tests

24. Anterior Drawer test
Stress tests

25. PCL Rupture MOI: S/S: hyperflexion
falling on bent knee with foot plantar flexed
Hit on fixed anterior tibia
S/S:
“pop” at the back of knee
Pt. Tender and swelling in popliteal fossa
+ posterior sag test,+ posterior drawer test
PCL Rupture

26. PCL rupture Tx: RICE Immobilization Crutches Physician referral
6-8 weeks rest/rehab
If surgery is elected, 6 weeks immobilization
PCL rupture

27. PCL rupture

28. Posterior sag
Stress tests

29. Sunrise or posterior sag
Stress tests

30. MCL Sprain MOI: Blow to the lateral side of knee (valgus stress)
External rotation of tibia
MCL Sprain

31. MOI

32. 2nd degree??
MCL sprain

33. MCL sprain S/S: 1st degree 2nd degree
Pt. Tender over MCL, stable but pain with valgus stress, mild joint effusion, mild joint stiffness, full ROM
2nd degree
Partial tearing-superficial portion, Pt. Tender over MCL, some instability with valgus stress but solid endpoint, moderate joint effusion, joint stiffness, limited ROM, unable to fully extend knee joint
MCL sprain

34. MCL Sprain S/S: 3rd degree Complete tear—superficial and deep portions
Pt. Tender over MCL
Moderate to severe effusion
Severe pain
Loss of motion due to pain, effusion, muscle guarding
“+” valgus stress in 0 and 30 degrees, no endpoint
MCL Sprain

35. Valgus stress test @ 0 Valgus stress @ 30
Stress tests for MCL

36. MCL Sprain Tx: RICE Crutches Knee immobilizer/brace
1st degree 1-2 weeks
2nd degree 2-4 weeks
3rd degree 4-6 weeks
Physician referral for 2nd degree or greater
MCL Sprain

37. Complications The terrible triad or unhappy triad Torn ACL Torn MCL
Torn Medial meniscus
Complications

38. LCL sprain MOI: S/S: Varus force to medial aspect of knee
internal rotation of tibia
S/S:
Pt. Tender over LCL,
pain,
swelling,
loss of motion,
“+” varus stress at 30 degrees—solid endpoint with 1st degree, less stability but solid endpoint with 2nd degree, no endpoint with 3rd degree
if “+” varus stress at 0 degrees flexion suspect ACL or PCL injury as well
LCL sprain

39. LCL sprain Tx: RICE Crutches Knee immobilizer
Physician referral with 2nd or 3rd degree
LCL sprain

40. Medial: more often torn than later due to attachment to MCL
Lateral: doesn’t attach to joint capsule making it more mobile, less prone to injury
MOI:
Weight bearing with rotational force while extending or flexing the knee
Meniscus tear

41. Meniscus tear S/S: Effusion w/in 48-72 hours
Pt. Tender over joint line
Loss of motion
“locking”
Giving out
Pain with deep knee flexion--squatting
Meniscus tear

42. Types of meniscus tears

43. Meniscus Tears Special Test
McMurray Test
Positive Sign: Pain and/or clicking
Meniscus Tears Special Test

44. Meniscus tears Tx: RICE Crutches if necessary Physician referral
If knee is “locked” by displaced meniscus, go to ER
Arthroscopic surgery to fix
Meniscus tears

45. Injuries to the Patella
Dislocation
Subluxation
Fracture
Chondromalacia
Patellar tendonitis
Injuries to the Patella

46. Patella Dislocation MOI:
Foot planted, deceleration, and cutting in opposite direction from the weight bearing foot
Thigh rotates internally while leg rotates externally
Strong forceful contraction of quads (vastus lateralis)
Patella Dislocation

47. Dislocation S/S: loss of motion/function at the knee Pain Swelling
Deformity
Pt. Tender over medial aspect of knee joint
Dislocation

48. dislocation

49. dislocation

50. Dislocation Tx: immobilize in position you find it Ice ER visit
After reduction, immobilize in extension about 4 weeks—use crutches
Strengthen muscles of knee, thigh and hip
Dislocation

51. Patella Subluxation MOI: same as for the dislocation S/S: TX:
same as for the dislocation except there will be no deformity
Pt. Tender over the medial knee joint
Pain with movement
TX:
RICE
Knee Immobilizer and crutches
Physician referral
Patella Subluxation

52. Patella fracture MOI: S/S: direct impact or trauma to patella
Indirect trauma in which a severe pull of the patellar tendon occurs against the femur when the knee if semi-flexed
S/S:
hemorrhage which results in significant swelling
pain
Pt. Tender over Patella
extreme pain with weight bearing/movement
Patella fracture

53. Patella Fracture

54. Another x-ray

55. Patella Fracture Tx: RICE Immobilize Crutches ER
Possible surgery depending on type of fracture
Patella Fracture

56. Softening and deterioration of the articular cartilage on the posterior side of the patella
Chondromalacia

57. MOI:
related to abnormal movement of the patella within the femoral groove as the knee flexes and extends
Lateral tracking patella as quads contract usually associated with weak quads (VMO) or in females a wider pelvis
Chondro

58. S/S:
Pain on the anterior aspect of the knee (behind the patella) while walking, running, ascending or descending stairs, sqatting or sitting with knees flexed for a long period of time
Pain with compression of patella in femoral groove
Chondro

59. Chondro Tx: remove from activities that cause the pain
Strenghtening exercises for the quads, especially the VMO
Knee sleeve with patellar support
Ice, heat
Surgery to smooth the posterior side of patella
Chondro

60. Patellar tendonitis Also called “jumper’s knee” MOI: S/S:
excessive running, jumping or kicking causing extreme tension of the knee extensor muscle complex
S/S:
Pain at the patellar tendon
Pt. Tender over the distal pole of patella
Pain increases with activity
Thickening of tendon
crepitus
Patellar tendonitis

61. Patellar tendonitis TX: Rest Ice Heat Ultrasound
Cross-friction massage
NSAIDS
Patellar tendon strap/taping
Modify activity
Patellar tendonitis

62. Osgood-Schlatter’s Disease
Condition common in adolescent knee
MOI:
Repeated pull of patellar tendon at tibial tuberosity apophysis due to excessive running, jumping, kicking, etc.
S/S:
pain and Pt. Tender at the patellar tendon attachment on tibial tuberosity
Excessive bony formation over tubersity as tendon continues to pull at the apophysis
Osgood-Schlatter’s Disease

63. Osgood Schlatter’s S/S: Tx:
usually resolves itself when the athlete reaches years of age
Enlarged tibial tuberosity remains
Tx:
Modify activity
Ice
Tape/patellar tendon strap
Padding
Strengthening of quads and hamstrings
Osgood Schlatter’s

64. Iliotibial Band Friction Syndrome
MOI:
Overuse injury that occurs in runners or cyclists attributed to the malalignment and structural asymmetries of the foot and lower leg
Irritation develops over lateral femoral epicondyle or at the band’s insertion at Gerdy’s tubercle on the lateral side of the tibia
Iliotibial Band Friction Syndrome

65. ITBS S/S: Pt. Tender over the lateral femoral epicondyle Swelling
Increased pain with activity especially distance running and starts and stops and change of direction
ITBS

66. ITBS Tx: Stretching the ITB Ice pack/massage
Transverse friction massage ITB
Modify activity
Correct foot/lower leg malalignment
ITBS

67. Bursitis Can be acute, chronic, or recurrent
Numerous bursae involved but most commonly injured are the prepatellar or the deep infrapatellar
Bursitis

68. Bursitis MOI: falling directly on knee Continuous kneeling
Overuse of patellar tendon
Bursitis

69. S/S:
Localized swelling that is similar to a water balloon and is outside the knee joint
Pain especially with pressure
Bursitis

70. Bursitis

71. Bursitis

72. Bursitis Tx: Rest Ice Compression NSAIDS
Padding for protection when returning to activity
Bursitis