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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