Chapter 20: The Knee and Related Structures

Complex joint that endures great amounts of trauma due to extreme amounts of stress that are regularly applied Hinge joint w/ a rotational component Stability is due primarily to ligaments, joint capsule and muscles surrounding the joint Designed for stability w/ weight bearing and mobility in locomotion

Functional Anatomy
Movement of the knee requires flexion, extension, rotation and the arthrokinematic motions of rolling and gliding Rotational component involves the screw home mechanism
As the knee extends it externally rotates because the medial femoral condyle is larger than the lateral Provides increased stability to the knee Popliteus unlocks knee allowing knee to flex

 Capsular ligaments are taut during full extension and relaxed w/ flexion
Allows rotation to occur Deeper capsular ligaments remain taut to keep rotation in check

PCL prevents excessive internal rotation, guides the knee in flexion, and acts as drag during initial glide phase of flexion ACL stops excessive internal rotation, stabilizes the knee in full extension and prevents hyperextension

 Range of motion includes 140 degrees of motion

Limited by shortened position of hamstrings, bulk of hamstrings and extensibility of quads

Patella aids knee during extension, providing a mechanical advantage

Distributes compressive stress on the femur by increasing contact between patellar tendon and femur Protects patellar tendon against friction When moving from extension to flexion the patella glides laterally and further into trochlear groove

 Kinetic Chain
Directly affected by motions and forces occurring at the foot, ankle, lower leg, thigh, hip, pelvis, and spine With the kinetic chain forces must be absorbed and distributed If body is unable to manage forces, breakdown to the system occurs Knee is very susceptible to injury resulting from absorption of forces

Assessing the Knee Joint

Determining the mechanism of injury is critical History- Current Injury
Past history Mechanism- what position was your body in? 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
May cause a combination of problems

Tibial torsion, femoral anteversion and retroversion

 Tibial torsion
An angle that measures less than 15 degrees is an indication of tibial torsion

Femoral Anteversion and Retroversion

Total rotation of the hip equals ~100 degrees If the hip rotates >70 degrees internally, anteversion of the hip may exist INSERT 20-9

 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

Palpation - Bony
Medial tibial plateau Medial femoral condyle Adductor tubercle Gerdys tubercle Lateral tibial plateau Lateral femoral condyle Lateral epicondyle Head of fibula Tibial tuberosity Superior and inferior patella borders (base and apex) Around the periphery of the knee relaxed, in full flexion and extension

Palpation - Soft Tissue

Vastus medialis Vastus lateralis Vastus intermedius Rectus femoris Quadriceps and patellar tendon Sartorius Medial patellar plica Anterior joint capsule Iliotibial Band Arcuate complex Medial and lateral collateral ligaments Pes anserine Medial/lateral joint capsule Semitendinosus Semimembranosus Gastrocnemius Popliteus Biceps Femoris

 Palpation of Swelling
Intra vs. extracapsular swelling Intracapsular may be referred to as joint effusion Swelling w/in the joint that is caused by synovial fluid and blood is a hemarthrosis Sweep maneuver Ballotable patella - sign of joint effusion Extracapsular swelling tends to localize over the injured structure
May ultimately migrate down to foot and ankle

 Special Tests for Knee Instability

Use endpoint feel to determine stability MRI may also be necessary for assessment Classification of Joint Instability
Knee laxity includes both straight and rotary instability Translation (tibial translation) refers to the glide of tibial plateau relative to the femoral condyles As the damage to stabilization structures increases, laxity and translation also increase

Valgus and Varus Stress Tests

Used to assess the integrity of the MCL and LCL respectively Testing at 0 degrees incorporates capsular testing while testing at 30 degrees of flexion isolates the ligaments

 Anterior Cruciate Ligament Tests

Drawer test at 90 degrees of flexion
Tibia sliding forward from under the femur is considered a positive sign (ACL) Should be performed w/ knee internally and externally to test integrity of joint capsule

 Lachman Drawer Test

Will not force knee into painful flexion immediately after injury Reduces hamstring involvement At 30 degrees of flexion an attempt is made to translate the tibia anteriorly on the femur A positive test indicates damage to the ACL

 Pivot Shift Test

Used to determine anterolateral rotary instability Position starts w/ knee extended and leg internally rotated The thigh and knee are then flexed w/ a valgus stress applied to the knee Reduction of the tibial plateau (producing a clunk) is a positive sign

 Jerk Test
Reverses direction of the pivot shift Moves from position of flexion to extension W/out and ACL the tibia will sublux at 20 degrees of flexion

Flexion-Rotation Drawer Test

Knee is taken from a position of 15 degrees of flexion (tibia is subluxed anteriorly w/ femur externally rotated) Knee is moved into 30 degrees of flexion where tibia rotates posteriorly and femur internally rotates

 Posterior Cruciate Ligament Tests

Posterior Drawer Test
Knee is flexed at 90 degrees and a posterior force is applied to determine translation posteriorly Positive sign indicates a PCL deficient knee

External Rotation Recurvatum Test

With the athlete supine, the leg is lifted by the great toe If the tibia externally rotates and slides posteriorly there may be a PCL injury and damage to the posterolateral corner of the capsule

 Posterior Sag Test (Godfreys test)

Athlete is supine w/ both knees flexed to 90 degrees Lateral observation is required to determine extent of posterior sag while comparing bilaterally

Instrument Assessment of the Cruciate Ligaments

A number of devices are available to quantify AP displacement of the knee KT-2000 arthrometer, Stryker knee laxity tester and Genucom can be used to assess the knee Test can be taken pre & post-operatively and through rehab

 Meniscal Tests
McMurrays Meniscal Test
Used to determine displaceable meniscal tear Leg is moved into flexion and extension while knee is internally and externally rotated in conjunction w/ valgus and varus stressing A positive test is found w/ clicking and popping response

 Apleys Compression Test

Hard downward pressure is applied w/ rotation Pain indicates a meniscal injury

Apleys Distraction Test

Traction is applied w/ rotation Pain will occur if there is damage to the capsule or ligaments No pain will occur if it is meniscal

 Girth Measurements
Changes in girth can occur due to atrophy, swelling and conditioning Must use circumferential measures to determine deficits and gains during the rehabilitation process Measurements should be taken at the joint line, the level of the tibial tubercle, belly of the gastrocnemius, 2 cm above the superior border of the patella, and 8-10 cm above the joint line

Subjective Rating
Used to determine patients perception of pain, stability and functional performance

 Functional Examination
Must assess walking, running, turning and cutting Co-contraction test, vertical jump, single leg hop tests and the duck walk Resistive strength testing

Q-Angle
Lines which bisects the patella relative to the ASIS and the tibial tubercle Normal angle is 10 degrees for males and 15 degrees for females Elevated angles often lead to pathological conditions associated w/ improper patella tracking

 The A Angle
Patellar orientation to the tibial tubercle Quantitative measure of the patellar realignment after rehabilitation An angle greater than 35 degrees is often correlated w/ patellofemoral pathomechanics

Palpation of the Patella

Must palpate around and under patella to determine points of pain

Patella Grinding, Compression and Apprehension Tests

A series of glides and compressions are performed w/ the patella to determine integrity of patellar cartilage

Prevention of Knee Injuries

Physical Conditioning and Rehabilitation
Total body conditioning is required
Strength, flexibility, cardiovascular and muscular endurance, agility, speed and balance

Muscles around joint must be conditioned (flexibility and strength) to maximize stability Must avoid abnormal muscle action through flexibility In an effort to prevent injury, extensibility of hamstrings, erector spinae, groin, quadriceps and gastrocnemius is important

 ACL Prevention Programs

Focus on strength, neuromuscular control, balance Series of different programs which address balance board training, landing strategies, plyometric training, and single leg performance Can be implemented in rehabilitation and preventative training programs

Shoe Type
Change in football footwear has drastically reduced the incidence of knee injuries Shoes w/ more shorter cleats does not allow foot to become fixed while still allowing for control w/ running and cutting

 Functional and Prophylactic Knee Braces

Used to prevent and reduce severity of knee injuries Used to protect MCL, or prevent further damage to grade 1 & 2 sprains of the ACL or to protect the ACL following surgery Can be custom molded and designed to control rotational forces

Recognition and Management of Specific Injuries

Medial Collateral Ligament Sprain
Etiology
Result of severe blow or outward twist

Signs and Symptoms - Grade I

Little fiber tearing or stretching Stable valgus test Little or no joint effusion Some joint stiffness and point tenderness on lateral aspect Relatively normal ROM

 Management
RICE for at least 24 hours Crutches if necessary Follow-up care will include cryokinetics w/ exercise Move from isometrics and STLR exercises to bicycle riding and isokinetics Return to play when all areas have returned to normal May require 3 weeks to recover

 Signs and Symptoms (Grade II)

Complete tear of deep capsular ligament and partial tear of superficial layer of MCL No gross instability; laxity at 5-15 degrees of flexion Slight swelling Moderate to severe joint tightness w/ decreased ROM Pain along medial aspect of knee

Management
RICE for 48-72 hours; crutch use until acute 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

 Signs and Symptoms (Grade III)

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

Management
RICE Conservative non-operative versus surgical approach Limited immobilization (w/ a brace); progressive weight bearing for Rehab would be similar to Grade I & II injuries

 Lateral Collateral Ligament Sprain

Etiology
Result of a varus force, generally w/ the tibia internally rotated Direct blow is rare If severe enough damage can also occur to the cruciate ligaments, ITB, and meniscus, producing bony fragments as well

Signs and Symptoms

Pain and tenderness over LCL Swelling and effusion around the LCL Joint laxity w/ varus testing May cause irritation of the peroneal nerve

Management
Following management of MCL injuries depending on severity

 Anterior Cruciate Ligament Sprain

Etiology
MOI - tibia externally rotated and valgus force at the knee (occasionally the result of hyperextension from direct blow) May be linked to inability to decelerate valgus and rotational stresses - landing strategies Male versus female Research is quite extensive in regards to impact of femoral notch, ACL size and laxity, malalignments (Q-angle) faulty biomechanics Extrinsic factors may include, conditioning, skill acquisition, playing style, equipment, preparation time Also involves damage to other structures including meniscus, capsule, MCL

 Signs and Symptoms

Experience pop w/ severe pain and disability Rapid swelling at the joint line Positive anterior drawer and Lachmans Other ACL tests may also be positive

Management
RICE; use of crutches Arthroscopy may be necessary to determine extent of injury Could lead to major instability in incidence of high performance W/out surgery joint degeneration may result Age and activity may factor into surgical option Surgery may involve joint reconstruction w/ grafts (tendon), transplantation of external structures
Will require brief hospital stay and 3-5 weeks of a brace Also requires 4-6 months of rehab

 Posterior Cruciate Ligament Sprain

Etiology
Most at risk during 90 degrees of flexion Fall on bent knee is most common mechanism Can also be damaged as a result of 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 w/ posterior sag test

Management
RICE Non-operative rehab of grade I and II injuries should focus on quad strength Surgical versus non-operative
Surgery will require 6 weeks of immobilization in extension w/ full weight bearing on crutches ROM after 6 weeks and PRE at 4 months

 Meniscal Lesions
Etiology
Medial meniscus is more commonly injured due to ligamentous attachments and decreased mobility
Also more prone to disruption through torsional and valgus forces

Most common MOI is rotary force w/ knee flexed or extended Can be longitudinal, oblique or transverse tears

Signs and Symptoms

Effusion developing over 48-72 hour period Joint line pain and loss of motion Intermittent locking and giving way Pain w/ squatting Portions may become detached causing locking, giving way or catching w/in the joint If chronic, recurrent swelling or muscle atrophy may occur

 Management
If the knee is not locked, but indications of a tear are present further diagnostic testing may be required If locking occurs, anesthesia may be necessary to unlock the joint w/ possible arthroscopic surgery follow-up W/ surgery all efforts are made to preserve the meniscus -- will full healing being dependent on location Menisectomy rehab allows partial weight bearing and quick return to activity Repaired meniscus will require immobilization and a gradual return to activity over the course of 12 weeks

 Knee Plica
Etiology
Irritation of the plica (generally, mediopatellar plica and often associated w/ chondromalacia

Signs and Symptoms

Possible history of knee pain/injury Recurrent episodes of painful pseudo-locking Possible snapping and popping Pain w/ stairs and squatting Little or no swelling, and no ligamentous laxity

Management
Treat conservatively w/ RICE and NSAIDs if the result of trauma Recurrent conditions may require surgery

 Osteochondral Knee Fractures

Etiology
Same MOI as collateral/cruciate ligaments or meniscal injuries Twisting, sudden cutting or direct blow

Signs and Symptoms

Hear a snap and feeling of giving way Immediate swelling and considerable pain

Management
Diagnosis confirmed through arthroscopic exam, w/ surgery to replace fragment to avoid joint degeneration and arthritis

 Osteochondritis Dissecans
Etiology
Partial or complete separation of articular cartilage and subchondral bone 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 with recurrent swelling and possible locking Possible quadriceps atrophy and point tenderness

Management
Rest and immobilization for children Surgery may be necessary in teenagers and adults (drilling to stimulate healing, pinning or bone grafts

 Loose Bodies w/in the Knee

Etiology
Result of repeated trauma Possibly stem from osteochondritis dissecans, meniscal fragments, synovial tissue or cruciate ligaments

Signs and Symptoms

May become lodged, causing locking or popping Pain and sensation of instability

Management
If not surgically removed it can lead to conditions causing joint degeneration

 Joint Contusions
Etiology
Blow to the muscles crossing the joint (vastus medialis)

Signs and Symptoms

Present as knee sprain, severe pain, loss of movement and signs of acute inflammation Swelling, discoloration Possible capsular damage

Management
RICE initially and continue if swelling persists Gradual progression to normal activity following return of ROM and padding for protection If swelling does not resolve w/in a week a chronic condition (synovitis or bursitis) may exist requiring more rest

 Peroneal Nerve Contusion

Etiology
Compression of peroneal nerve due to a direct blow

Signs and Symptoms

Local pain and possible shooting nerve pain Numbness and paresthesia in cutaneous distribution of the nerve Added pressure may exacerbate condition Generally resolves quickly -- in the event it does not resolve, it could result in drop foot

Management
RICE and return to play once symptoms resolve and no weakness is present Padding for fibular head is necessary for a few weeks

 Bursitis
Etiology
Acute, chronic or recurrent swelling Prepatellar = continued kneeling Infrapatellar = overuse of patellar tendon

Signs and Symptoms

Prepatellar bursitis may be localized swelling above knee that is ballotable Swelling in popliteal fossa may indicate a Bakers cyst
Associated w/ semimembranosus bursa or medial head of gastrocnemius Commonly painless and causing little disability May progress and should be treated accordingly

Management
Eliminate cause, RICE and NSAIDs

 Patellar Fracture
Etiology
Direct or indirect trauma (severe pull of tendon) Forcible contraction, falling, jumping or running

Signs and Symptoms

Hemorrhaging and joint effusion w/ generalized swelling Indirect fractures may cause capsular tearing, separation of bone fragments and possible quadriceps tendon tearing Little bone separation w/ direct injury

Management
X-ray necessary for confirmation of findings RICE and splinting if fracture suspected Refer and immobilize for 2-3 months

 Acute Patella Subluxation or Dislocation

Etiology
Deceleration w/ simultaneous cutting in opposite direction (valgus force at knee) Quad pulls the patella out of alignment Some athletes may be predisposed to injury Repetitive subluxation will impose stress to medial restraints

Signs and Symptoms

W/ subluxation, pain and swelling, restricted ROM, palpable tenderness over adductor tubercle Dislocations result in total loss of function

 Management
Reduction is performed by flexing hip, moving patella medially and slowly extending the knee Following reduction, immobilization for at least 4 weeks w/ use of crutches and isometric exercises during this period After immobilization period, horseshoe pad w/ elastic wrap should be used to support patella Muscle rehab focusing on muscle around the knee, thigh and hip are key (STLRs are optimal for the knee) Possible surgery to release tight structures Improve postural and biomechanical factors

 Injury to the Infrapatellar Fat Pad

Etiology
May become 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 (especially during knee extension) May display weakness, mild swelling and stiffness during movement

Management
Rest from irritating activities until inflammation has subsided and therapeutic use of cold Heel lift to prevent irritation during extension Hyperextension taping to prevent full extension

 Chondromalacia patella
Etiology
Softening and deterioration of the articular cartilage Possible abnormal patellar tracking due to genu valgum, external tibial torsion, foot pronation, femoral anteversion, patella alta, shallow femoral groove, increased Q angle, laxity of quad tendon

Signs and Symptoms

Pain w/ walking, running, stairs and squatting Possible recurrent swelling, grating sensation w/ flexion and extension Pain at inferior border during palpation

Management
Conservative measures
RICE, NSAIDs, isometrics, orthotics to correct dysfunction

Surgical possibilities

 Patellofemoral Stress Syndrome

Etiology
Result of lateral deviation of patella while tracking in femoral groove
Tight structures, pronation, increased Q angle, insufficient medial musculature

Signs and Symptoms

Tenderness of lateral facet of patella and swelling associated w/ 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

 Osgood-Schlatter Disease and LarsenJohansson Disease

Etiology
Osgood Schlatters is an apophysitis occurring at the tibial tubercle
Begins cartilagenous and develops a bony callus, enlarging the tubercle Resolves w/ aging Common cause = repeated avulsion of patellar tendon

Larsen Johansson is the result of excessive pulling on the inferior pole of the patella

Signs and Symptoms

Both elicit swelling, hemorrhaging and gradual degeneration of the apophysis due to impaired circulation

 Signs and Symptoms (continued)

Pain w/ kneeling, jumping and running Point tenderness

Management
Conservative
Reduce stressful activity until union occurs (6-12 months) Possible casting, ice before and after activity Isometerics

 Patellar Tendinitis (Jumpers or Kickers Knee)

Etiology
Jumping or kicking - placing tremendous stress and strain on patellar or quadriceps tendon Sudden or repetitive extension

Signs and Symptoms

Pain and tenderness at inferior pole of patella
3 phases - 1)pain after activity, 2)pain during and after, 3)pain during and after (possibly prolonged) and may become constant

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

 Patellar Tendon Rupture

Etiology
Sudden, powerful quad contraction Generally does not occur unless a chronic inflammatory condition persist resulting in tissue degeneration Occur 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 care of jumpers knee can minimize chances of occurring If steroids are being used, intense knee exercise should be avoided due to weakening of collagen

 Runners Knee (Cyclists Knee)

Etiology
General expression for repetitive/overuse conditions attributed to mal-alignment and structural asymmetries

Signs and Symptoms

IT Band Friction Syndrome
Irritation at bands insertion - commonly seen in individual that have genu varum or pronated feet

Pes Anserine Tendinitis or Bursitis

Result of excessive genu valgum and weak vastus medialis Due to running w/ one leg higher than the other

Management
Correction of mal-alignments Ice before and after activity, proper warm-up and stretching Avoidance of aggravating activities NSAIDs and orthotics

Knee Joint Rehabilitation

General Body Conditioning
Must be maintained with non-weight bearing activities

Weight Bearing
Initial crutch use, non-weight bearing Gradual progression to weight bearing while wearing rehabilitative brace

Knee Joint Mobilization

Used to reduce arthrofibrosis Patellar mobilization is key following surgery CPM units

 Flexibility
Must be regained, maintained and improved

Muscular Strength
Progression of isometrics, isotonic training, isokinetics and plyometrics Incorporate eccentric muscle action Open versus closed kinetic chain exercises

Neuromuscular Control
Loss of control is generally the result of pain and swelling Through exercise and balance equipment proprioception can be enhanced

 Bracing
Variety of braces for a variety of injuries and conditions Typically worn for 3-6 weeks after surgery -used to limit ranges for a period of time Some are used to control for specific injuries while others are designed for specific forces and stability

Functional Progression
Gradual return to sports specific skills Progress w/ weight bearing, move into walking and running, and then onto sprinting and change of direction

 Return to Activity
Based on healing process - sufficient time for healing must be allowed Objective criteria include strength and ROM measures as well as functional performance tests