Download Knee Conditions

Knee Conditions
Chapter 18
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Anatomy
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Anatomy (cont.)
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Anatomy (cont.)
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Tibiofemoral Joint
• Condyles of femur with plateaus of tibia
• Hinge joint—flexion/extension
• Tibia does rotate laterally on femur during last few
degrees of extension
– “Screw-home mechanism”
• Produces a locking of the knee in final degrees
during extension
• Close-packed position of full extension
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Meniscus
• Fibrocartilaginous discs attached to tibial plateaus
– Medial and lateral
• Functions:
– Stabilize joint by deepening the articulation
– Shock absorption
– Provide lubrication and nourishment
– Improve weight distribution
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Joint Capsule and Bursae
• Articular capsule – encompasses both tibiofemoral and
patellofemoral joints
– Suprapatellar bursa
– Subpopliteal bursa
– Semimembranosus bursa
• Bursa outside capsule
– Prepatellar bursa
– Superficial infrapatellar bursa
– Deep infrapatellar bursa
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Ligaments
• ACL
– Prevents:
• Anterior translation of tibia on femur
• Rotation of tibia on femur
• Hyperextension
– Discrete bands
• Knee full extension—posterolateral bundle is taut
• Knee full flexion—anteromedial bundle is taut
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Ligaments (cont.)
• PCL
– Resists posterior displacement of tibia on femur
– Knee full extension—posterior fibers are taut; knee
full flexion—anterior fibers are taut
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Ligaments (cont.)
• MCL
– Resist medially directed (valgus) forces
– Complete extension—taut
midrange—posterior fibers most taut
complete flexion—anterior fibers most taut
• LCL
– Resist laterally directed (varus) forces
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Ligaments (cont.)
• Arcuate-popliteal complex
– Oblique popliteal ligament and arcuate popliteal
ligament
– Supports posterior joint capsule
• Limits anterior displacement of tibia on femur
• Limits hyperextension and hyperflexion
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Iliotibial Band
• Extends from tensor fascia latae to Gerdy’s tubercle on
lateral tibial plateau
• Lateral knee stabilizer
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Patellofemoral Joint
• Patella
–
Superior, middle, and inferior articular surfaces
–
Functions
• Protect femur
• Increase effective power of quadriceps
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Q-Angle
• Q-angle
– Angle between line of resultant force produced by
quadriceps and line of patellar tendon
–
Males 13°; females 18°
–  Q-angle— lateral patellofemoral contact
 Q-angle— medial tibiofemoral contact
• A-angle
– Measures relationship of patella to tibial tubercle
– 35° or greater linked to increased patellofemoral pain
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Muscles
• Produce movement
• Stabilize the knee
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Nerves
• Tibial nerve
– Hamstrings except
short head of biceps
• Common peroneal
– Short head of biceps
• Femoral
– Quadriceps
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Blood Supply
• Femoral artery
• Popliteal artery
• Genicular arteries
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Kinematics
• Knee flexion
– Hamstrings
– Assisted by:
• Popliteus
• Gastrocnemius
• Gracilis
• Sartorius
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Kinematics (cont.)
• Knee extension
– Quadriceps femoris muscle group
• Rectus femoris
• Vastus lateralis
• Vastus intermedius
• Vastus medialis
• Vastus medialis oblique (VMO)
– Screwing-home motion
• Rotation and passive abduction and adduction
– Capability maximal at approximately 90° of knee flexion
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Kinematics (cont.)
• Knee motion during gait
– Midstance – flexed 20°, internally rotated 5°, and
slightly abducted
– Swing phase – flexed 70°, externally rotated 15°, and
5° adduction
• Patellofemoral joint motion
– With knee flexion and extension, patella glides in the
trochlear groove
– Tracking is dependent on the direction of the net
force produced by the attached quadriceps
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Kinetics
• Forces at the tibiofemoral joint
– Compression and shear during daily activities
• Extension—weight bearing and tension in muscles
↑ compression
• Flexion—as angle of joint ↑ to 90 → ↑ shear force
produced by weight bearing
shearing—tendency for the femur to displace anteriorly
• Forces at patellofemoral joint
– Compression during normal walking (50% body weight);
increases with stair climbing
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Prevention of Knee Injuries
• Physical conditioning
– Strength
– Flexibility
• Rule changes
• Footwear
– Cleats vs. flat sole
– Position of cleats and size
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Contusions
• Knee
– Mechanism: compression
– S&S
• Localized tenderness
• Pain
• Swelling
– Management: standard acute
– Caution: excessive swelling could mask other injuries
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Contusions (cont.)
• Infrapatellar fat pad
– Entrapped between the femur and tibia
– S&S
• Locking, catching, giving way
• Palpable pain on either side of patellar tendon
• Extreme pain on forced extension
– Management: standard acute
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Contusions (cont.)
• Peroneal nerve
– Mechanism: blow to the posterolateral aspect of
the knee
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Contusions (cont.)
– S&S
• Radiating pain down lateral aspect of leg and foot
• Severe cases
 Initial pain—not immediately followed by tingling or
numbness
 As swelling ↑ within nerve sheath
 Weakness in dorsiflexion or eversion
 Loss of sensation in dorsum of foot, especially
between 1st and 2nd toes
 May progressively occur days or weeks later
– Management: standard acute; severe S&S—immediate
physician referral
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Bursitis
• Prepatellar
– Mechanism
• Acute: direct blow to anterior patella
• Chronic: repetitive blows
– S&S
• Swelling
• Pain with direct pressure
• Pain with passive knee flexion
• Localized swelling
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Bursitis (cont.)
• Pes anserine
– Mechanism:
• Friction between tendon and MCL
• Direct trauma
– S&S
• Pain with knee flexion
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Bursitis (cont.)
• Infrapatellar
– Mechanism:
• Friction between patellar tendon and fat pad/tibia
• May be associated with patellar tendinitis
– S&S
• Point tender with possible swelling posterior to
patellar tendon
•  pain at end range of resisted knee extension and
passive flexion
• Prolonged knee flexion may symptoms
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Bursitis (cont.)
• Baker’s cyst
– Posterior aspect of knee—most often:
semimembranosus
–  pain with full extension or flexion
• Bursitis management
– Standard acute;  aggravating activities
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Ligamentous Conditions
• AAOS classifies ligamentous knee injuries according to:
– Functional disruption of a specific ligament
– Amount of laxity
– Direction of laxity
• Direction divides laxity into 4 straight and 4
rotatory laxities
• Knowing knee position at impact and direction the
tibia displaces or rotates indicates the damaged
structures
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Ligamentous Conditions (cont.)
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Ligamentous Conditions (cont.)
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Ligamentous Conditions (cont.)
• Straight medial laxity (valgus laxity)
– Involves MCL; posterior medial capsule—possibly PCL
– Lateral forces cause tension on medial aspect of knee
– 1st degree
• Mild pain medial joint line
• Little or no joint effusion/mild swelling at site
• Full ROM with minor discomfort
• Valgus @ 0°—stable; @ 30º—+
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Ligamentous Conditions (cont.)
– 2nd degree
• Valgus @ 30º—+ (with positive end feel)
• Unable to fully extend the leg; often walk on the
ball of foot
– 3rd degree
• Valgus @ 0—+ (with a soft or absent end feel)
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Ligamentous Conditions (Cont’d)
• Straight lateral laxity (varus laxity)
– Involves LCL, lateral capsular ligaments, PCL
– Medial forces produce tension on lateral aspect of
knee
• Not usually isolated—presence of IT band, biceps
femoris, popliteus
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Ligamentous Conditions (cont.)
– S&S
• Similar to MCL
• Swelling minimal—no attachment to capsule
• + varus @ 30º
• Instability may not be obvious if other stabilizers
are intact
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Ligamentous Conditions (cont.)
• Straight anterior laxity (anterior instability)
– Anterior displacement of tibia on femur
– Involves ACL—rarely isolated
– Mechanism: cutting or turning maneuver,
landing, or sudden deceleration
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Ligamentous Conditions (cont.)
– S&S
• Pain
 Minimal and transient to severe and lasting
 Deep in knee difficult to pinpoint
• “Pop”
• Effusion within 3 hours; reports knee giving way—
does not feel right
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Ligamentous Conditions (cont.)
• Straight posterior laxity
– Tibia displaced posteriorly
– Involves PCL
– Mechanism
• Hyperextension force
• Fall on flexed knee (initial contact at tibial
tuberosity)
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Ligamentous Conditions (cont.)
– S&S
• Sense of stretching to posterior knee
• “Pop”
• Rapid joint effusion
• ↓ knee flexion due to effusion
• + reverse Lachman’s test; posterior sag
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Ligamentous Conditions (cont.)
• Anteromedial instability
– Anterior external rotation of medial tibia condyle on
femur
– Involves MCL and oblique popliteal ligament,
potentially ACL and medial meniscus
– S&S
• + valgus @ 0 & @ 30°
• + Slocum drawer test; + Lachman’s test
• ↑ anterior translation of the medial tibial plateau
(w/ special tests)
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Ligamentous Conditions (cont.)
• Anterolateral instability
– Anterior internal subluxation of lateral tibial condyle on
femur
– Caused by a sudden deceleration and cutting maneuver
– Involves ACL, IT band, lateral capsule
– S&S
• ↑ anterior translation of the lateral tibial plateau (with
special tests)
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Ligamentous Conditions (cont.)
• Posteromedial instability
– Medial tibial plateau shifts posteriorly on the femur
and opens medially
– Involves superficial MCL, ACL, PCL, posteromedial
capsule, and oblique popliteal ligament
– S&S: + posteromedial drawer test and posteromedial
pivot shift test
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Ligamentous Conditions (cont.)
• Posterolateral instability
– Lateral tibial plateau rotates posteriorly
– Due to hyperextension with varus
– Involves PCL, arcuate–popliteal complex, posterolateral
capsule, and LCL
– S&S
• Soft end point with varus stress at 0° and 30°
• + posterolateral drawer and external rotation
recurvatum tests
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Instabilities of the Knee
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Ligamentous Conditions (cont.)
• Management
– Standard acute; NSAIDs
– Physician referral—timing dependent on severity
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Knee Dislocation/Subluxation
• Minimum of 3 ligaments must be torn for knee to dislocate
– Most often—ACL, PCL, and one collateral ligament
• Concern: damage to other structures; especially
neurovascular
• S&S
– Individual describes severe injury
– “Pop”
– Deformity (unless spontaneously reduced)
• Management: standard acute
– Spontaneous reduction—physician referral
– Not reduced—activate EMS
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Meniscal Conditions
• Classified according to location
• Involve compression, tension, shearing forces
• Longitudinal
– Twisting motion when foot fixed and knee flexed
• Produces compression and torsion on posterior
peripheral attachment
– Bucket-handle tear
• Longitudinal segment displaced medially toward
center of tibia
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Meniscal Conditions (cont.)
• Horizontal tear
– Due largely to degeneration
– Shearing from rotational forces
• Tears the inner surface of the meniscus
– Parrot-beak tear
• 2 tears; commonly in middle segment of lateral
meniscus
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Meniscal Conditions (cont.)
• S&S
–
Initial symptoms may be vague or limited
• Limited sensory nerve supply—minimal pain
• Minimal disability
• Minimal swelling
–
Understand mechanism
–
Delayed swelling
–
Joint line pain
–
Classic: clicking/locking (not acutely) leads to knee buckling
or giving way
–
+ McMurray; Apley’s compression; “bounce home”
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test
Meniscal Conditions (cont.)
• Management
– Standard acute; treat symptoms
– Physician referral
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Patellar Conditions
• Patellofemoral pain
– Causes
• Mechanical (e.g., patellar subluxation or
dislocation)
• Inflammatory (e.g., prepatellar bursitis, patellar
tendinitis)
• Other causes (e.g., reflex sympathetic dystrophy,
tumors)
– Dynamic stabilizer— extensor mechanism
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Patellar Conditions (cont.)
• Patellofemoral stress syndrome
– Mechanism
• Poor patellar tracking due to weak VMO or tight
lateral structures
– S&S
• Dull, aching pain, ↑ with sitting, squatting, and
descending stairs
• Point tenderness—lateral facet of the patella
• Pain with manual patella compression into trochlear
groove
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Patellar Conditions (cont.)
– Management:
• Standard acute; NSAIDs
• Lower extremity assessment
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Patellar Conditions (cont.)
• Chondromalacia
–
Degeneration in articular
cartilage of patella
–
Due to abnormal excursion and
compressive forces
–
S&S:
• Localized tenderness
• Anterior knee pain
• + Clarke’s test; + Waldron
test
–
Management
• Standard acute
• Activity modification
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Patellar Conditions (cont.)
• Patellar instability and dislocation
– Displacement of patella due to internal or external
forces
– Mechanism: deceleration combined with a cutting
motion
– S&S subluxation
• Transient partial displacement; acute or
intermittent with spontaneous reduction
• Feeling of patella slipping when cutting, twisting, or
pivoting
• + apprehension test
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Patellar Conditions (cont.)
– S&S dislocation
• “Pop”
• Violent collapse of the knee
• Localized tenderness—medial extensor retinaculum
• Effusion
– Management: standard acute; immediate physician
referral
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Patellar Conditions (cont.)
• Patella plica syndrome
– Asymptomatic until trauma
– S&S
• Gradual onset of anterior knee pain
• Pain with prolonged sitting; individual stands and begins
to walk, sharp pain for 8–10 steps, then disappears
• Slight joint effusion
• Palpable pain and crepitus – medial and lateral
retinacular regions
• + medial synovial plica and stutter tests
– Management: treat symptoms; activity modification
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Patellar Conditions (cont.)
• Patellar tendinitis
– Due to repetitive or eccentric knee extension activities
– S&S
• Initial—pain after activity on inferior pole of patella
or distal attachment of patellar tendon
• Progression—pain at start of activity, subsides with
warm-up, reappears after activity
• Pain ascending and descending stairs
• Pain with passive knee flexion beyond 120° and
resisted knee extension
– Management: standard acute; NSAIDs
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Patellar Conditions (cont.)
• Osgood- Schlatter disease
– Inflammation or partial avulsion of tibial apophysis
due to traction forces
– S&S
• Individual points to tibial tubercle as source of
pain
• Tubercle appears enlarged
• Pain during activity and relieved with rest
• Pain at extreme knee extension and forced
flexion
– Management: treat symptoms; self-limiting
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Patellar Conditions (cont.)
• Sinding-Larsen-Johansson disease
– Inflammation or partial avulsion of apex of patella due to
traction forces
– S&S
• Gradual onset of pain
• Pain with palpation of inferior patellar pole with
patient’s knee extended and patellar tendon relaxed
– Management: treat symptoms; self-limiting
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Patellar Conditions (cont.)
• Extensor tendon rupture
– Due to powerful eccentric muscle contractions
– S&S
• Partial rupture—pain and weakness in knee extension
• Total rupture distal to patella
 High-riding patella
 Palpable defect over the tendon
 Inability to extend knee extension or perform a
straight leg raise
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Patellar Conditions (cont.)
• Total rupture from superior pole with extensor
retinaculum still intact
 Knee extension is possible, but weak and painful
– Management: standard acute; knee immobilizer and
crutches; immediate referral to a physician
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Iliotibial Band Friction Syndrome
• Band drops behind lateral femoral epicondyle with knee
flexion, then snaps forward over epicondyle during
extension
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Iliotibial Band Friction Syndrome (cont.)
• Due to excessive compression and friction
• Associated with overuse, abnormal biomechanics, and poor
flexibility
• S&S
– Pain with exercise progresses from not restrictive to
restrictive even with ADLs
– Extreme point tenderness 2–3 cm proximal to lateral
joint line over epicondyle with leg flexed at 30°
– + Noble’s and Ober’s compression tests
• Management: standard acute; NSAIDs; preventative
conditioning program
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Fractures and Associated Conditions
• Avulsion fracture
– Due to direct trauma, excessive tensile forces, overuse
– S&S: localized pain and tenderness over the bony site
• Epiphyseal and apophyseal fracture
– Tibial tubercle fracture
• Mechanism
 Forced flexion of knee against a straining
quadriceps contraction
 Violent quadriceps contraction against a fixed foot
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Fractures and Associated Conditions
(cont.)
• S&S
 Pain, ecchymosis, swelling, and tenderness
 Difficulty going up and down stairs
– Distal femoral epiphyseal fracture
• Mechanism: varus or valgus stress applied on a fixed,
weight-bearing foot
• S&S: pain around knee; unable to bear weight
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Fractures and Associated Conditions
(cont.)
• Stress fractures
– Common areas
• Femoral supracondylar region
• Medial tibial plateau
• Tibia tubercle
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Fractures and Associated Conditions
(cont.)
– Occur when:
• Load on the bone is increased
• Number of stresses on the bone increases (e.g.,
changes in training intensity, duration, frequency)
• surface area of the bone receiving load decreases
– S&S: localized pain before and after activity, relieved
with rest and non–weight bearing
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Fractures and Associated Conditions
(cont.)
• Chondral fracture (involves
articular cartilage)
• Osteochondral fracture (involves
articular cartilage and
underlying bone)
–
Due to compression from
direct blow to knee causing
shearing or forceful
rotation
–
S&S
• Painful “snap”
• Considerable pain and
rapid swelling
• Displaced fracture:
locking; crepitus
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Fractures and Associated Conditions
(cont.)
• Osteochondritis dissecans
–
Bone fragment due to localized area of avascular necrosis
–
Due to:
• Direct and indirect trauma
• Skeletal abnormalities
• Prominent tibial spine
• Generalized ligamentous laxity
–
S&S
• Aching, diffuse pain, or swelling with activity
• As disease progresses, knee locking or giving way
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Fractures and Associated Conditions
(cont.)
• Fracture management
– Standard acute
– Immobilization
– Immediate physician referral
• Stress fracture management
– Physician referral
– Rest
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Assessment
• History
• Observation/inspection
• Palpation
• Physical examination tests
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Patella Palpation
• Patellar glide
– Hypomobile
• < 1 quadrant of
displacement
– Hypermobile
• 3+ quadrants (greater
than one-half of
patellar width)
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Palpation for Swelling
• Brush or stroke test
(milking)
• Patellar tap test
(“ballotable patella”)
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Range of Motion (ROM)
• AROM
– Flexion (0–135°)
– Extension (0–15°)
– Medial rotation of tibia on femur (20–30°) with knee
flexed at 90°
– Lateral rotation of tibia on femur (30–40°) with knee
flexed at 90°
• PROM
– Normal end feel
• Flexion—tissue approximation
• Extension; medial and lateral rotation—tissue stretch
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ROM (cont.)
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ROM (cont.)
• RROM
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Stress Tests
• Anterior drawer test
• Lachman’s test
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Stress Tests (cont.)
• Modified Lachman’s
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Stress Tests (cont.)
• Posterior sag (gravity) test
• Posterior drawer test
• Reverse Lachman’s test
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Stress Tests (cont.)
• Valgus stress
• Varus stress
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Stress Tests (cont.)
• Slocum drawer test
– Anteromedial rotary instability
– Anterolateral rotary instability
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Stress Tests (cont.)
• Lateral pivot shift
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Stress Tests (cont.)
• Jerk test
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Stress Tests (cont.)
• Slocum ALRI test
• Cross-over test
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Stress Tests (cont.)
• Flexion–rotation drawer
• Posteromedial drawer
• Posteromedial pivot
shift
• Posterolateral drawer
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Stress Tests (cont.)
• Reverse pivot shift
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Stress Tests (cont.)
• External rotation
recurvatum
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Special Tests
• Meniscal tests
– McMurray’s test
– Apley’s compression/
distraction test
– “Bounce home” test
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Special Tests (cont.)
• Tibiofibular instability
– Proximal tibiofibular syndesmosis test
• Plica tests
– Mediopatellar plica test
– Stutter test
– Hughston’s plica test
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Special Tests (cont.)
• Tests for patellofemoral dysfunction
– Patella compression or grind
– Clarke’s sign
– Waldron test
– Patellar apprehension
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Special Tests (cont.)
• IT band syndrome tests
– Noble compression test
– Ober’s test
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Neurologic Tests
• Myotomes
– Hip flexion—L1, L2
– Knee extension—L3
– Ankle dorsiflexion—L4
– Toe extension—L5
– Ankle plantarflexion, foot eversion, or hip extension—S1
– Knee flexion—S2
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Neurologic Tests (cont.)
• Reflexes
– Patella—L3, L4
– Achilles tendon—S1
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Neurologic Tests (cont.)
• Dermatomes
• Peripheral nerve
distribution
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Rehabilitation
• Restoration of proprioception and balance
– Closed-chain exercises
• Muscular strength, endurance, and power
– Open-chain exercises
– PNF-resisted exercises
• Cardiovascular fitness
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Rehabilitation (cont.)
• Range of motion
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Rehabilitation (cont.)
• Patellar self-mobilization
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Rehabilitation (cont.)
• Closed-chain terminal extension
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins