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Anatomy and Injuries of the Knee Adapted from Connie Rauser Sabino Sports Medicine.

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Presentation on theme: "Anatomy and Injuries of the Knee Adapted from Connie Rauser Sabino Sports Medicine."— Presentation transcript:

1 Anatomy and Injuries of the Knee Adapted from Connie Rauser Sabino Sports Medicine

2 Anatomy-Bones Bones ◦Femur  Medial/lateral femoral condyles articulate w/ tibia ◦Tibia  Tibial plateau is flat-articulates w/ femoral condyles ◦Fibula  Articulates w/ tibia ◦Patella  Sesamoid bone protects anterior joint  Enclosed in quadriceps/patellar tendon

3 Anatomy-Joints Joints ◦Tibiofemoral  Hinge joint with synovial lining ◦ diarthrodial ◦Patellofemoral ◦Superior Tibiofibular

4 Anatomy-Meniscus Meniscus ◦Medial and lateral ◦Fibrocartilaginous disks  Thicker on outside than inside (poor blood supply) ◦Lie on top of tibial plateau ◦Increase stability ◦Make condyles fit better ◦Shock absorbers

5 Anatomy-Ligaments ACL-anterior cruciate ligament ◦Runs from anterior tibia to posterior femur ◦Prevents anterior displacement of tibia on fixed femur ◦Prevents femur from moving posterior during weight bearing ◦Stabilizes tibia against excessive internal rotation

6 Ligaments PCL-posterior cruciate ligament ◦Runs from posterior tibia to anterior femur ◦Prevents posterior translation of tibia on fixed femur ◦Prevents femur from moving anterior during weight bearing  Both ACL and PCL “cross” or wrap around each other—taut when in extension and looser when in flexion

7 Ligaments MCL-medial collateral ligament ◦Attaches on the medial femoral epicondyle & anteromedial tibia ◦Thickened portion of joint capsule ◦Two parts-superficial and deep  Deep portion attaches to medial meniscus ◦Stabilizes against valgus stress applied to lateral aspect of joint capsule

8 Ligaments LCL-lateral collateral ligament ◦Attaches to lateral femoral epicondyle and head of fibula ◦Stabilizes against varus stress when force is applied to medial aspect of joint  Both the MCL and LCL are tightest during full extension of knee and relaxed during flexion

9 Ligaments

10 Muscles Quadriceps ◦Rectus femoris, vastus lateralis, vastus medialis, vastus intermedius  Knee extension, hip flexion Hamstrings ◦Biceps femoris, semimembranosus, semitendinosus  Knee flexion, hip extension

11 Muscles Gracilis ◦Knee flexion, hip adduction Sartorius ◦Knee flexion, hip flexion, hip external rotation Popliteus ◦Knee flexion Gastrocnemius ◦Knee flexion

12 Muscles Plantaris ◦Knee flexion Pes anserine ◦Goose’s foot ◦Knee flexion, some internal rotation  Gracilis, sartorius, semitendinosus Iliotibial Band Apart of the tensor fascia latae ◦Thick band on lateral aspect of thigh  Attaches at Gerdy’s tubercle on the lateral aspect of tibia

13 Anatomy of Knee

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15 Preventing knee injuries Conditioning ◦Strength, flexibility, cardiovascular and muscular endurance  Hamstring strength 60% of quad strength Rehabilitation ◦Strengthen all muscles around knee joint Shoes ◦proper type for surface ◦Length of cleats ◦Turf vs grass

16 Preventing knee injuries Knee braces ◦Functional vs. prophylactic  Functional—used to provide support to an unstable knee  Usually custom fitted to some degree  Uses hinges and supports to control excessive rotational stress and tibial translation  Prophylactic-worn on lateral aspect knee to protect MCL.  Usefulness questioned—does it cause more injuries?

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19 Muscle Strains MOI: Sudden contraction of muscle or muscle being overstretched S/S: -Stretching/pulling sensation -Pain with active movement and passive stretching

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21 Tx: RICE, modalities, alternative training exercises to allow muscle to rest

22 ACL rupture MOI: ◦fixed foot and external rotation of femur ◦knee in valgus position ◦hyperextension S/S: ◦“pop”, ◦knee gives out ◦instability of knee joint ◦swelling within knee joint—hemarthrosis ◦intense pain initially but still able to walk ◦“+” Lachman’s test ◦“+” anterior drawer test

23 MOI

24 MOI Hyperextension

25 ACL rupture

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27 Inside the knee joint The ACL intactThe ACL torn

28 ACL Rupture Tx: RICE, knee immobilizer, crutches, Physician referral Requires surgical reconstruction ◦Timing of surgery decided by athlete, parents, doctor ◦Grafts used are patellar tendon, hamstring tendon, cadaver graft, allograft ◦3-5 weeks in brace, 6-9 months return to activity

29 ACL Rupture Knee post-ACL tear Test for Swelling Ballotable Patella Test

30 Stress tests Lachman’s test

31 Stress tests Modified Lachman’s

32 Stress tests Anterior Drawer test

33 PCL Rupture MOI: ◦hyperflexion ◦falling on bent knee with foot plantar flexed ◦Hit on fixed anterior tibia S/S: ◦“pop” at the back of knee ◦Pt. Tender and swelling in popliteal fossa ◦+ posterior sag test,+ posterior drawer test

34 PCL rupture Tx: ◦RICE ◦Immobilization ◦Crutches ◦Physician referral ◦6-8 weeks rest/rehab ◦If surgery is elected, 6 weeks immobilization

35 PCL rupture

36 Stress tests Posterior sag

37 Stress tests Sunrise or posterior sag

38 MCL Sprain MOI: ◦Blow to the lateral side of knee (valgus stress) ◦External rotation of tibia

39 MOI

40 MCL sprain 2 nd degree??

41 MCL sprain S/S: 1 st degree ◦Pt. Tender over MCL, stable but pain with valgus stress, mild joint effusion, mild joint stiffness, full ROM 2 nd degree ◦Partial tearing-superficial portion, Pt. Tender over MCL, some instability with valgus stress but solid endpoint, moderate joint effusion, joint stiffness, limited ROM, unable to fully extend knee joint

42 MCL Sprain S/S: 3 rd degree ◦Complete tear—superficial and deep portions ◦Pt. Tender over MCL ◦Moderate to severe effusion ◦Severe pain ◦Loss of motion due to pain, effusion, muscle guarding ◦“+” valgus stress in 0 and 30 degrees, no endpoint

43 Stress tests for MCL Valgus stress 0 Valgus 30

44 MCL Sprain Tx: RICE Crutches Knee immobilizer/brace ◦1 st degree 1-2 weeks ◦2 nd degree 2-4 weeks ◦3 rd degree 4-6 weeks Physician referral for 2 nd degree or greater

45 Complications The terrible triad or unhappy triad ◦Torn ACL ◦Torn MCL ◦Torn Medial meniscus

46 LCL sprain MOI: ◦Varus force to medial aspect of knee ◦internal rotation of tibia S/S: ◦Pt. Tender over LCL, ◦pain, ◦swelling, ◦loss of motion, ◦“+” varus stress at 30 degrees—solid endpoint with 1 st degree, less stability but solid endpoint with 2 nd degree, no endpoint with 3 rd degree ◦if “+” varus stress at 0 degrees flexion suspect ACL or PCL injury as well

47 LCL sprain Tx: ◦RICE ◦Crutches ◦Knee immobilizer ◦Physician referral with 2 nd or 3 rd degree

48 Meniscus tear Medial: more often torn than later due to attachment to MCL Lateral: doesn’t attach to joint capsule making it more mobile, less prone to injury MOI: ◦Weight bearing with rotational force while extending or flexing the knee

49 Meniscus tear S/S: ◦Effusion w/in hours ◦Pt. Tender over joint line ◦Loss of motion ◦“locking” ◦Giving out ◦Pain with deep knee flexion--squatting

50 Meniscus tear Types of meniscus tears

51 Meniscus Tears Special Test McMurray Test Positive Sign: Pain and/or clicking

52 Meniscus tears Tx: RICE Crutches if necessary Physician referral If knee is “locked” by displaced meniscus, go to ER Arthroscopic surgery to fix

53 Injuries to the Patella Dislocation Subluxation Fracture Chondromalacia Patellar tendonitis Patella Femoral Pain Syndrome

54 Patella Dislocation MOI: ◦ Foot planted, deceleration, and cutting in opposite direction from the weight bearing foot ◦Thigh rotates internally while leg rotates externally ◦Strong forceful contraction of quads (vastus lateralis)

55 Dislocation S/S: loss of motion/function at the knee Pain Swelling Deformity Pt. Tender over medial aspect of knee joint

56 dislocation

57 dislocation

58 Dislocation Tx: immobilize in position you find it Ice ER visit After reduction, immobilize in extension about 4 weeks—use crutches Strengthen muscles of knee, thigh and hip

59 Patella Subluxation MOI: same as for the dislocation S/S: ◦same as for the dislocation except there will be no deformity ◦Pt. Tender over the medial knee joint ◦Pain with movement TX: ◦RICE ◦Knee Immobilizer and crutches ◦Physician referral

60 Patella fracture MOI: ◦direct impact or trauma to patella ◦Indirect trauma in which a severe pull of the patellar tendon occurs against the femur when the knee if semi-flexed S/S: ◦hemorrhage which results in significant swelling ◦pain ◦Pt. Tender over Patella ◦extreme pain with weight bearing/movement

61 Patella Fracture

62 Another x-ray

63 Patella Fracture Tx: RICE Immobilize Crutches ER Possible surgery depending on type of fracture

64 Chondromalacia Softening and deterioration of the articular cartilage on the posterior side of the patella

65 Chondro MOI: ◦related to abnormal movement of the patella within the femoral groove as the knee flexes and extends ◦Lateral tracking patella as quads contract usually associated with weak quads (VMO) or in females a wider pelvis

66 Chondro S/S: ◦Pain on the anterior aspect of the knee (behind the patella) while walking, running, ascending or descending stairs, sqatting or sitting with knees flexed for a long period of time ◦Pain with compression of patella in femoral groove

67 Chondro Tx: ◦remove from activities that cause the pain ◦Strenghtening exercises for the quads, especially the VMO ◦Knee sleeve with patellar support ◦Ice, heat ◦Surgery to smooth the posterior side of patella

68 Osteochondritis Dissecans of Knee

69 Patellar tendonitis Also called “jumper’s knee” MOI: ◦excessive running, jumping or kicking causing extreme tension of the knee extensor muscle complex S/S: ◦Pain at the patellar tendon ◦Pt. Tender over the distal pole of patella ◦Pain increases with activity ◦Thickening of tendon ◦crepitus

70 Patellar tendonitis TX: ◦Rest ◦Ice ◦Heat ◦Ultrasound ◦Cross-friction massage ◦NSAIDS ◦Patellar tendon strap/taping ◦Modify activity

71 Patellafemoral Pain Syndrome MOI: Overuse and Overload and we just don’t know… Signs and Symptoms: ◦Dull achy pain on or around anterior knee ◦ Pain with walking up or down stairs ◦Pain with descending inclines ◦Mild Swelling is possible Tx: ◦RICE ◦Strengthening and stretching exercises to help support the tendon ◦Active Rest (biking, swimming)

72 Osgood-Schlatter’s Disease Condition common in adolescent knee MOI: ◦Repeated pull of patellar tendon at tibial tuberosity apophysis due to excessive running, jumping, kicking, etc. S/S: ◦pain and Pt. Tender at the patellar tendon attachment on tibial tuberosity ◦Excessive bony formation over tubersity as tendon continues to pull at the apophysis

73 Osgood Schlatter’s S/S: ◦usually resolves itself when the athlete reaches years of age ◦Enlarged tibial tuberosity remains Tx: ◦Modify activity ◦Ice ◦Tape/patellar tendon strap ◦Padding ◦Strengthening of quads and hamstrings

74 Iliotibial Band Friction Syndrome MOI: ◦Overuse injury that occurs in runners or cyclists attributed to the malalignment and structural asymmetries of the foot and lower leg ◦Irritation develops over lateral femoral epicondyle or at the band’s insertion at Gerdy’s tubercle on the lateral side of the tibia

75 ITBS S/S: ◦Pt. Tender over the lateral femoral epicondyle ◦Swelling ◦Increased pain with activity especially distance running and starts and stops and change of direction

76 ITBS Tx: Stretching the ITB Ice pack/massage Transverse friction massage ITB Modify activity Correct foot/lower leg malalignment

77 Bursitis Can be acute, chronic, or recurrent Numerous bursae involved but most commonly injured are the prepatellar or the deep infrapatellar

78 Bursitis MOI: ◦falling directly on knee ◦Continuous kneeling ◦Overuse of patellar tendon

79 Bursitis S/S: ◦Localized swelling that is similar to a water balloon and is outside the knee joint ◦Pain especially with pressure

80 Bursitis

81 Bursitis

82 Bursitis Tx: ◦Rest ◦Ice ◦Compression ◦NSAIDS ◦Padding for protection when returning to activity


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