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Anatomy and Injuries of the Knee

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

2 Anatomy-Bones Bones Femur Tibia Fibula Patella
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 Anatomy-Bones

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

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 Anatomy-Meniscus

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 Anatomy-Ligaments

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 Ligaments

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 Ligaments

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 Ligaments

9 Ligaments

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

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

12 Muscles Plantaris Pes anserine Iliotibial Band
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 Muscles

13 Anatomy of Knee


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 Preventing knee injuries

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?



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


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

22 ACL rupture MOI: S/S: 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 ACL rupture

23 MOI

24 Hyperextension MOI

25 ACL rupture


27 The ACL intact The ACL torn
Inside the knee joint

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 ACL Rupture

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

30 Lachman’s test Stress tests

31 Modified Lachman’s Stress tests

32 Anterior Drawer test Stress tests

33 PCL Rupture MOI: S/S: 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 PCL Rupture

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

35 PCL rupture

36 Posterior sag Stress tests

37 Sunrise or posterior sag
Stress tests

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

39 MOI

40 2nd degree?? MCL sprain

41 MCL sprain S/S: 1st degree 2nd degree
Pt. Tender over MCL, stable but pain with valgus stress, mild joint effusion, mild joint stiffness, full ROM 2nd 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 MCL sprain

42 MCL Sprain S/S: 3rd 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 MCL Sprain

43 Valgus stress test @ 0 Valgus stress @ 30
Stress tests for MCL

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

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

46 LCL sprain MOI: S/S: 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 1st degree, less stability but solid endpoint with 2nd degree, no endpoint with 3rd degree if “+” varus stress at 0 degrees flexion suspect ACL or PCL injury as well LCL sprain

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

48 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 Meniscus tear

49 Meniscus tear S/S: Effusion w/in 48-72 hours
Pt. Tender over joint line Loss of motion “locking” Giving out Pain with deep knee flexion--squatting Meniscus tear

50 Types of meniscus tears

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

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

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

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) Patella Dislocation

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

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 Dislocation

59 Patella Subluxation MOI: same as for the dislocation S/S: TX:
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 Patella Subluxation

60 Patella fracture MOI: S/S: 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 Patella fracture

61 Patella Fracture

62 Another x-ray

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

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

65 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 Chondro

66 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 Chondro

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 Chondro

68 Osteochondritis Dissecans of Knee

69 Patellar tendonitis Also called “jumper’s knee” MOI: S/S:
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 Patellar tendonitis

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

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) Patellafemoral Pain Syndrome

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 Osgood-Schlatter’s Disease

73 Osgood Schlatter’s S/S: Tx:
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 Osgood Schlatter’s

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 Iliotibial Band Friction Syndrome

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 ITBS

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

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

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

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

80 Bursitis

81 Bursitis

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

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