Download The Knee

The Knee
Bony Anatomy
 The knee is composed of
four major bones
 The Femur
 Bone of the upper leg/thigh
 Condyles
 Tibia
 Medial bone in the lower leg
 Tibial plateau
 Fibula
 Lateral Bone in the lower leg
 Patella
 “Also known as kneecap”
 Sesamoid bone enveloped in
the quadriceps tendon
Joints of the Knee
 Tibiofemoral Joint
 Weight-bearing,
hinge joint
 Held together
with joint
capsule and
several ligaments
 Patellofemoral
Joint
 Helps extend the
knee
Cartilage
 Two types of cartilage are found
in the knee
 Both are bathed in synovial fluid
 Produced by the synovial membrane
of the knee
 Articular cartilage
 Covers the ends of the tibia and
femur
 Covers the retropatellar surface
 Meniscus
 Wedge shaped cartilage
 Aid in shock absorption,
distributing forces and
improving stability of the joint
Cartilage ~ Meniscus
 Medial Meniscus
 Between the medial femoral condyle and medial tibial plateau
 “C” - shaped
 Lateral Meniscus
 Between the lateral femoral condyle and lateral tibial plateau
 “U”- shaped
Ligaments of the Knee
 Four major ligaments connect
the tibia and femur
 Two are located outside of the
joint capsule
 Medial Collateral Ligament
(MCL)
 Lateral Collateral Ligament
(LCL)
 Two are located on the inside of
the joint
 Anterior Cruciate Ligament
(ACL)
 Posterior Cruciate Ligament
(PCL)
Ligaments ~ Collateral
 Lateral Collateral Ligament
(LCL)
 Attaches the femur and the
head of the fibula
 Provides lateral stability
 Only palpable ligament in
the knee
 Medial Collateral Ligament
(MCL)
 Attaches the femur to the
tibia
 Provides medial stability
Ligaments ~ Cruciate
 Anterior Cruciate Ligament
 Attaches the to the femur and anterior aspect of the tibial
plateau
 Prevents anterior translation of the tibia on the femur
 Posterior Cruciate Ligament
 Attaches to the femur and posterior aspect of the tibial plateau
 Prevents posterior translation of the tibia on the femur
 Cruciate is derived from Latin word meaning “cross”
 ACL running Anterior-to-Posterior-Externally
 PCL running Posterior-to-Anterior-Internally
 Also help control rotation of the knee and medial/lateral
stability
Muscular anatomy
 Muscles that move the
legs are the strongest in
the body
 Quadriceps
 Extend the knee
 Hamstrings
 Flex the knee joint
 Hip Flexors
 Assist with knee flexion
Muscular Anatomy ~ Quadriceps
 4 muscles together
join at the distal
anterior thigh and
attach the patella
through the
quadriceps tendon
 Vatus Lateralis
 Vastus Medialis
 Vastus Intermedius
 Rectus Femoris
Muscular Anatomy ~ Hamstrings
 3 muscles on the
posterior aspect of
the thigh are divided
into two groups
 Medial hamstrings
 Semitendonosis
 Semimembranosis
 Lateral hamstring
 Biceps Femoris
Muscular Anatomy ~ Hip Flexors
 Two additional, long
strap-like muscles in
the thigh that assist
with knee flexion
 Sartorius
 Gracillis
 They attach to the
anteriomedial tibia
near the attachment of
the semitendinosus
 Area known as the pes
ansurine
Knee Injuries
 A wide variety of injuries can occur to the knee. Some of the
most common are
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Patellarfemoral
Patellar tendonitis
Sprains (MCL/LCL)
Ligament Tears (ACL/PCL)
Meniscus Tears
Epiphyseal injuries
Oshgood-Schlatter
Iliotibial Band syndrome
Fractures/dislocations of the patellarfemoral joint
Patellofemoral problems
 Patellofemoral problems can
be very challenging to the
ATC and athlete
 Usually caused by irregular
tracking of the patella
 It is not easy to identify the
source of the problem
 Classic complaints
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Anterior pain/aching
Crepitus
Mild, or no swelling
Patella may appear to face
inward, instead of forward
Patellofemoral Problems ~
Recognition and Treatment
 Recognition
 Patellofemoral provocation test will help reproduce the
symptoms for the athlete
 Forward lunge
 Step-down test
 Treatment
 Correct the suspected cause
 Shoe inserts
 Low-dye taping
 Strengthening exercises
 Specialized braces/taping
Patellar Tendonitis
 Inflammation of the patellar tendon
 Primarily seen in sports that involve
jumping
 Also called “jumper’s knee”
 Symptoms
 Anterior knee pain
 inferior to the patella over the patella
tendon
 Minimal swelling may occur
 Treatment
 Activity modification
 Non-impact activities
 cycling, swimming
 Stretching for tight quads
 Ice after activity
 Bracing
Fat Pad Syndrome
 Involves a region of fatty tissue lying
deep to the patellar tendon
 Hoffa’s fat pad
 When inflammed can become confused with
patellar tendonitis
 Symptoms
 Pain inferior to the patella
 Movement aggravates the symptoms
 Point tenderness and swelling anteriorly
 Treatment
 Strengthening exercises
 Full extension is contraindicated
 Specialized taping
 Anti-inflammatory medicines
Collateral Ligament Sprains
 Results of stretching and a valgus force to the medial
tibiofemoral joint or varus force to the lateral tibiofemoral
joint
 Severity of the sprain is determined by grading scale Grade I –
Grade III
 Signs/Symptoms
 Grade I
 Mild tenderness over ligament
 Usually no swelling
 Pain when ligament is stressed at 30 degrees, but no ligamentous laxity
 Grade II
 Significant tenderness over the ligament
 Some swelling
 Pain and some ligamentous laxitiy when stressed, but definite end point
 Grade III
 Complete tear of the ligament
 Pain can vary
 When the ligament is stressed, there is significant ligamentous laxity
 Knee feels wobbly or unstable
MCL/LCL Sprains
 Treatment of acute injuries with PRICE
 After acute phase, rehab should begin
 Special Test
 Valgus/Varus stress test
ACL Tears
 An ACL tear is when the ligament is completely torn and is
no longer intact
 ACL tears are more common among female athletes than make
athletes
 1 of 10 college athletes, 1 of 100 high school athletes
 Usually due to women using the quads more than men
 Some athletic shoes can increase the risk of injury
 There seems to be no connection of ACL size to injury
ACL Tears ~ MOI
 ACL tears can be from contact
or non-contact causes
 Contact
 Contact that causes a blow to
the lateral knee or valgus force
 Non-contact
 Situations where the knee is
loaded and combined with
flexion, valgus force and
rotation of the tibia on the
femur can rupture the ACL in a
non-contact manner
ACL Tears ~ Signs & Symptoms
 Symptoms include the following
 Hearing a “pop”
 Rapid effusion
 Nasuea
 Pain
 Many times if the ligament is tested within
5 minutes of injury, the examiner can get a
better result
 Lachman’s maneuver and Anterior Drawer
test the integrity of the ligament
 Positive signs usually indicate rupture
 Diagnosis and MRI by orthopedic will
confirm the injury
ACL Tears ~ Treatment
 Acute Treatment
 PRICE
 Use an immobilizer that
prevents movement of the joint
 Athlete should be non-weight
bearing
 Referral to orthopedic
physician for diagnosis
 Surgical Reconstruction
 Allograft vs. Autograft
replacement
 Rehabilitation from ACL
reconstruction is typically 6+
months
PCL Tears
 Occur when athlete’s fall on the flexed knee with the foot in
plantarflexion
 The tibia hits the ground first and is pushed back
 Occurs less often than ACL tears
 Signs & Symptoms
 A positive sag test is a good indication that the PCL has been
torn
PCL tear ~ treatment
 Immediate care is PRICE
 Referral to a physician if suspected
 Surgery can be avoided in most
cases
 A strong rehab program and
physical therapy are important
 Specific quadriceps strength and
endurance training can compensate
for the torn PCL
Meniscus Tears
 Can be torn when the knee is suddenly twisted and one or
both menisci become trapped between the femur and tibia
Meniscus Tears ~ S & S/Treatment
 Signs and Symptoms
 Gradual swelling
 Pain
 Popping
 Locking
 Giving away
 Treatment
 Immediate care is ice and
compressive wrap
 Use of crutches may be necessary
 Referral to physician if suspected
for MRI
 Surgery is not always required
Meniscus Tears ~
Treatment/Special Test
 Non-surgical management
 Physical Therapy
 Increase muscles strength
 Increases range of motion
 Modified activity
 NSAISDs
 Time
 Special Tests
 McMurrays
Epiphyseal growth-plate injuries
 Normally seen in skeletally immature athletes
 Forces that would normally cause ligamentous injuries in
adults could potentially damage the growth-plate injury in
children and younger athletes.
 These injuries can be quite serious so athletes may only
return to play upon approval of the physician.
Osgood-Schlatter
 This condition is a group of symptoms
involving the tibial tubercle epiphysis
 A small bump of the anterior tibia
where the patella tendon attaches
 The tibial tubercle is a growth center
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Affects males 12-16 and females 10-14
 Usually caused by a inflammation of
the layers of the tubercle
 Fibrocartilage lines the layer
underneath the tibial tubercle
 Layers are loosely held together during the
active growth years
Osgood-Schlatter
 Signs & Symptoms
 Pain
 Swelling
 Weakness in the Quads
 Increased pain/swelling
with activity
 A visible lump
 Sensitive to palpation
Osgood-Schlatter ~ Treatment
 Management of this condition can be managed as long as the
pain, swelling and flexibility are managed.
 Additional treatment include
 Prevention of progression
 Knee pad
 Neoprene sleeve
 Icing after activity
 Anti-inflammatory medicines
 Stretching the hamstrings
 Should pain continue or increase, refer to physician
Iliotibial Band Syndrome
 IT Band syndrome involves inflammation of the
thick band of fibrous tissue that runs down the
side of the tibia, just below the knee
 Bursa between the mucles/bones and IT band
becomes inflamed and makes movement painful
 Usually affects people who suddenly increase
level of activity
 Ex. Runners increasing mileage
 Others who are prone are
 People who overpronate
 Have leg-length discrepancies
 Are bowlegged
IT Band Syndrome ~ Treatment
 Analyze athlete's gait and
training program
 Rule out mechanical problems
 Proper footwear
 Icing the painful area
 Stretching
 Reduce or modify activities
until symptoms subside
IT Band ~ Stretches
Fractures
 Usually a result of high-energy trauma
 Patella fractures
 Can occur from direct impact to
anterior knee
 Distal femoral or proximal tibia
 Can occur with violent twisting or falls
from heights