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The Knee - revision
Anatomy
Joints:
1. Tibio-femoral joint
2. Patello-femoral joint
3. Superior Tib-Fib joint (not really part of the knee)
Tibiofemoral joint
Main Movements:
Accessory movements:
Observation:
Active Examination:
Passive Examination:
Special tests
Palpation
Flexion (0-135), Extension (0-15), Rotation (25 medially restricted by the
cruciates winding around each other), >25 laterally)
Abduction, Adduction, Anterior and Posterior glide, Longitudinal
Standing and Lying
Centre of gravity
Orientation (flexed, extended, rotated)
Valgus (KK), Varus (BL), Normal
Q angle
Angle of Antiversion
Patella – size (1/2 diameter of joint), position (lower pole at joint line),
height
Muscle bulk
Swelling – hot?,where?
Colour – bruising, varicosities, scarring
Assess gait. Limp?
Balance on 1 leg and rotate
Squat with and without heels down
Ranges
Gapping:
1. Medial: full extension, just off, and 30 degrees
2. Lateral: full EXT and 30 degrees. Stresses postero-lateral capsule,
arcuate-popliteal complex and biceps femoris
Cruciates:
1. Anterior at 90 Also tests posterio capsule, deep MED collateral lig.
2. Anterior at 25 degrees, takes supporting tissues off stretch
3. Anterior with internal rotation (slocum’s test) specific to ANT
4. Posterior at 90 also tests posterior restraining tissues
5. Posterior sag test
Apleys Grind – Prone, knee flexed to 90. +ve with pain
Mc Murrays – Tibial External rotation with varus/Valgus strain
Patella grind. +ve with palpable click/thud
Joint effusion
Patella tap (retro patella effusion)
Patella tracking
Popliteus can be an indicator or the intra-articular tissues
The Knee - revision
Knee essential anatomy
Fibrous capsule – posterior opening to allow popliteus tendon to attach to the Tibia. Anteriorly the
Quad tendon and Patella tendon replace the fibrous layer
Synovium – reflects around the infra-patella fat pad and Cruciate ligaments so they are extra
capsular
Popliteus – an intra-articular muscle. The tendon passes under Lat collateral lig
Extracapsular ligaments: Med/Lat collateral, Patella lig, Oblique popliteal lig (recurrent
Semimembranosis), Arcuate popliteal lig (strengthens capsule posteriorly)
Collateral ligaments are taut on full EXT. Lat collateral lig splits Biceps tendon in half
Coronary lig attach the meniscus to the Tibia at the periphery and the joint capsule.
Muscle sips deep to vastus intermedius from the articular muscle of the knee which retract the
bursa in EXT.
Intra-articular lig: Cruciates (but outside the synovium), Menisci, Popliteal tendon
The Knee - revision
Disorders VINDICATOR
Vascular – Haemarthrosis, DVT
Inflammatory/infective - RA, Reactive arthritis
Neoplastic – secondary cancer, sarcoma,
Degenerative –
 OA,
 Chondromalacia patella – softening, erosion, fragmentation and scarring of the articular
surface of the patella. Who gets it: All ages, More often elderly, Felames>Males with
increased Q angle, Traumatic, Repetitive stress, Biomechanical/Anatomical, Iatrogenic. Risk
factors: Trauma, Anatomical (Qangle, Alta, Baja, Muscle imbalance, LLD, Collapsing Arches,
Growth spurt. Exam: look at patella tracking, Quad balance, Patella size and position,
crepitus
 Osteochondritis desicans
Developmental –

Genu recurvatum – Hyperextension of knees beyond 5’. Congenital or Aquired. Who gets it:
Females>Males, Any age but often young. Causes: Congenital, Postural, Post trauma, Muscle
contracture, LLD. TTT: Stretch quads and psoas, strengthen hams and abs, Heel lift.

Genu varum,

Genu valgum
Iatrogenic – Bursitis, Bakers cycst

Patella dislocation – dislocates laterally. More common in women (greater Q angle).
Counter balanced by vastus medialis

Prepatella bursitis – inflammation of the prepatella bursa. Knee pain with walking, unable to
kneel. Common in carpet layers manual workers on their knees.
Congenital – Genu valgum/varum
Autoimmune – monoarthropathy (enteric, psoriatic, AS)
Trauma –

Meniscal tear – Pain, swelling, locking, Clicking, Giving way. Pain turning in bed at night
(Coopers sign), ttp joint line, redness, unable to squat. Onset: traumatic or degenerative,
Hyperextension, Hyperflexion with rotation, Valgus/Varus force. Risk factors: Age, Contact
sports, Repetitive activity and long periods load bearing. Family hxx, Ligamentous laxity.
The Knee - revision

Ligament strain (MCL, LCL, ACL, PCL) Unhappy triad = MCL, ACl, Medial meniscus. Risk
factors: Contact sports, Slipped, Balance/Strength issues, Previous lig damange (reduced
proprioception). Causes: Valgus or Varus force with or without rotation, Hyperextension,
Posterior force. X-ray if: 55YOA+, Unable to weight bear >2 steps, Unable to flex 90’.
Grading: Grade 1 – minimal tenderness, no bruising, no limp, Grade 2 – moderate pain, mild
bruising, some swelling, 11-50% fibers damaged, Grade 3 – 50-100% fibres damaged, severe
pain, rapid swelling, suspect haemarthrosis, refer for surgery! Treatment PRICE, Ice,
Mobility, Strengthening, Nutrition, ROM exx

Muscle strain, Meniscal tear, Coronal lig strain, Stress #

MCL or LCL strain/rupture – Pain, instability, loss of function, swelling, bruising,

Iliiotibial band syndrome

Bursitis
Endocrine – oosgood schlatters

Jumpers Knee (osteochondritis) (aka Sindling Larson Johansson synrome) – vague anterior
knee pain. Pain following activity. Tenderness to inferior border of patella. Common in
teenagers and <16 during growth spurt. Ttt rest, stretching

Oosgood Schlatters (osteochondritis)
Metabolic

Gout – Urate crystals accumulate in affected joints. Onset: acute. Progression: Reoccurring
Who gets it: Males>Females 30-60 YOA. Urica acid is the end product of purine metabolism
(beef, pork, bacon, lamb, seafood, Beer, Bread). Causes: increased uric acid, decreased
ability to clear uric acid from the kidneys or a combination. Risk factors: Hypertension, renal
insufficiency, Obesity, Diabetes, Genetic predisposition, African Americans, Diet, Hxx of
kidney stones. Treatment: NSAIDS, Cholchacine, Allopurinol only once an acute episode has
resolved
Rheumatoid

RA of the knee – Female > Male, Joint pain, stiffness, flu symptoms, fatigue, swelling of
joints
1. Patellofemoral syndrome – pain deep to the patella. Repetitive micro trauma from
abnormal tracking. Causes: direct blow, OA. Ttt to stretgthen VMO.
2. Cruciate ligament strain/rupture
3. Haemarthrosis
The Knee - revision
4. OA of the knee
5. RA of the knee
6. Popliteal cyst