1. The Knee

2. Bony Anatomy The knee is composed of four major bones The Femur Tibia
Bone of the upper leg/thigh
Condyles
Tibia
Medial bone in the lower leg
Tibial plateau
Fibula
Lateral Bone in the lower leg
Patella
“Also known as kneecap”
Sesamoid bone enveloped in the quadriceps tendon

3. Joints of the Knee Tibiofemoral Joint Patellofemoral Joint
Weight-bearing, hinge joint
Held together with joint capsule and several ligaments
Patellofemoral Joint
Helps extend the knee

4. Cartilage Two types of cartilage are found in the knee
Both are bathed in synovial fluid
Produced by the synovial membrane of the knee
Articular cartilage
Covers the ends of the tibia and femur
Covers the retropatellar surface
Meniscus
Wedge shaped cartilage
Aid in shock absorption, distributing forces and improving stability of the joint

5. Cartilage ~ Meniscus Medial Meniscus Lateral Meniscus
Between the medial femoral condyle and medial tibial plateau
“C” - shaped
Lateral Meniscus
Between the lateral femoral condyle and lateral tibial plateau
“U”- shaped

6. Ligaments of the Knee Four major ligaments connect the tibia and femur
Two are located outside of the joint capsule
Medial Collateral Ligament (MCL)
Lateral Collateral Ligament (LCL)
Two are located on the inside of the joint
Anterior Cruciate Ligament (ACL)
Posterior Cruciate Ligament (PCL)

7. Ligaments ~ Collateral
Lateral Collateral Ligament (LCL)
Attaches the femur and the head of the fibula
Provides lateral stability
Only palpable ligament in the knee
Medial Collateral Ligament (MCL)
Attaches the femur to the tibia
Provides medial stability

8. Ligaments ~ Cruciate Anterior Cruciate Ligament
Attaches the to the femur and anterior aspect of the tibial plateau
Prevents anterior translation of the tibia on the femur
Posterior Cruciate Ligament
Attaches to the femur and posterior aspect of the tibial plateau
Prevents posterior translation of the tibia on the femur
Cruciate is derived from Latin word meaning “cross”
ACL running Anterior-to-Posterior-Externally
PCL running Posterior-to-Anterior-Internally
Also help control rotation of the knee and medial/lateral stability

10. Muscular anatomy
Muscles that move the legs are the strongest in the body
Quadriceps
Extend the knee
Hamstrings
Flex the knee joint
Hip Flexors
Assist with knee flexion

11. Muscular Anatomy ~ Quadriceps
4 muscles together join at the distal anterior thigh and attach the patella through the quadriceps tendon
Vatus Lateralis
Vastus Medialis
Vastus Intermedius
Rectus Femoris

12. Muscular Anatomy ~ Hamstrings
3 muscles on the posterior aspect of the thigh are divided into two groups
Medial hamstrings
Semitendonosis
Semimembranosis
Lateral hamstring
Biceps Femoris

13. Muscular Anatomy ~ Hip Flexors
Two additional, long strap-like muscles in the thigh that assist with knee flexion
Sartorius
Gracillis
They attach to the anteriomedial tibia near the attachment of the semitendinosus
Area known as the pes ansurine

14. Knee Injuries
A wide variety of injuries can occur to the knee. Some of the most common are
Patellarfemoral
Patellar tendonitis
Sprains (MCL/LCL)
Ligament Tears (ACL/PCL)
Meniscus Tears
Epiphyseal injuries
Oshgood-Schlatter
Iliotibial Band syndrome
Fractures/dislocations of the patellarfemoral joint

15. Patellofemoral problems
Patellofemoral problems can be very challenging to the ATC and athlete
Usually caused by irregular tracking of the patella
It is not easy to identify the source of the problem
Classic complaints
Anterior pain/aching
Crepitus
Mild, or no swelling
Patella may appear to face inward, instead of forward

16. Patellofemoral Problems ~ Recognition and Treatment
Patellofemoral provocation test will help reproduce the symptoms for the athlete
Forward lunge
Step-down test
Treatment
Correct the suspected cause
Shoe inserts
Low-dye taping
Strengthening exercises
Specialized braces/taping

17. Patellar Tendonitis Inflammation of the patellar tendon
Primarily seen in sports that involve jumping
Also called “jumper’s knee”
Symptoms
Anterior knee pain
inferior to the patella over the patella tendon
Minimal swelling may occur
Treatment
Activity modification
Non-impact activities
cycling, swimming
Stretching for tight quads
Ice after activity
Bracing

18. Fat Pad Syndrome
Involves a region of fatty tissue lying deep to the patellar tendon
Hoffa’s fat pad
When inflammed can become confused with patellar tendonitis
Symptoms
Pain inferior to the patella
Movement aggravates the symptoms
Point tenderness and swelling anteriorly
Treatment
Strengthening exercises
Full extension is contraindicated
Specialized taping
Anti-inflammatory medicines

19. Collateral Ligament Sprains
Results of stretching and a valgus force to the medial tibiofemoral joint or varus force to the lateral tibiofemoral joint
Severity of the sprain is determined by grading scale Grade I – Grade III
Signs/Symptoms
Grade I
Mild tenderness over ligament
Usually no swelling
Pain when ligament is stressed at 30 degrees, but no ligamentous laxity
Grade II
Significant tenderness over the ligament
Some swelling
Pain and some ligamentous laxitiy when stressed, but definite end point
Grade III
Complete tear of the ligament
Pain can vary
When the ligament is stressed, there is significant ligamentous laxity
Knee feels wobbly or unstable

20. MCL/LCL Sprains Treatment of acute injuries with PRICE Special Test
After acute phase, rehab should begin
Special Test
Valgus/Varus stress test

21. ACL Tears
An ACL tear is when the ligament is completely torn and is no longer intact
ACL tears are more common among female athletes than make athletes
1 of 10 college athletes, 1 of 100 high school athletes
Usually due to women using the quads more than men
Some athletic shoes can increase the risk of injury
There seems to be no connection of ACL size to injury

22. ACL Tears ~ MOI ACL tears can be from contact or non-contact causes
Contact that causes a blow to the lateral knee or valgus force
Non-contact
Situations where the knee is loaded and combined with flexion, valgus force and rotation of the tibia on the femur can rupture the ACL in a non-contact manner

23. ACL Tears ~ Signs & Symptoms
Symptoms include the following
Hearing a “pop”
Rapid effusion
Nasuea
Pain
Many times if the ligament is tested within 5 minutes of injury, the examiner can get a better result
Lachman’s maneuver and Anterior Drawer test the integrity of the ligament
Positive signs usually indicate rupture
Diagnosis and MRI by orthopedic will confirm the injury

25. ACL Tears ~ Treatment Acute Treatment Surgical Reconstruction PRICE
Use an immobilizer that prevents movement of the joint
Athlete should be non-weight bearing
Referral to orthopedic physician for diagnosis
Surgical Reconstruction
Allograft vs. Autograft replacement
Rehabilitation from ACL reconstruction is typically 6+ months

27. PCL Tears
Occur when athlete’s fall on the flexed knee with the foot in plantarflexion
The tibia hits the ground first and is pushed back
Occurs less often than ACL tears
Signs & Symptoms
A positive sag test is a good indication that the PCL has been torn

28. PCL tear ~ treatment Immediate care is PRICE
Referral to a physician if suspected
Surgery can be avoided in most cases
A strong rehab program and physical therapy are important
Specific quadriceps strength and endurance training can compensate for the torn PCL

29. Meniscus Tears
Can be torn when the knee is suddenly twisted and one or both menisci become trapped between the femur and tibia

30. Meniscus Tears ~ S & S/Treatment
Signs and Symptoms
Gradual swelling
Pain
Popping
Locking
Giving away
Treatment
Immediate care is ice and compressive wrap
Use of crutches may be necessary
Referral to physician if suspected for MRI
Surgery is not always required

31. Meniscus Tears ~ Treatment/Special Test
Non-surgical management
Physical Therapy
Increase muscles strength
Increases range of motion
Modified activity
NSAISDs
Time
Special Tests
McMurrays

32. Epiphyseal growth-plate injuries
Normally seen in skeletally immature athletes
Forces that would normally cause ligamentous injuries in adults could potentially damage the growth-plate injury in children and younger athletes.
These injuries can be quite serious so athletes may only return to play upon approval of the physician.

33. Osgood-Schlatter
This condition is a group of symptoms involving the tibial tubercle epiphysis
A small bump of the anterior tibia where the patella tendon attaches
The tibial tubercle is a growth center
Affects males and females 10-14
Usually caused by a inflammation of the layers of the tubercle
Fibrocartilage lines the layer underneath the tibial tubercle
Layers are loosely held together during the active growth years

34. Osgood-Schlatter Signs & Symptoms Pain Swelling Weakness in the Quads
Increased pain/swelling with activity
A visible lump
Sensitive to palpation

35. Osgood-Schlatter ~ Treatment
Management of this condition can be managed as long as the pain, swelling and flexibility are managed.
Additional treatment include
Prevention of progression
Knee pad
Neoprene sleeve
Icing after activity
Anti-inflammatory medicines
Stretching the hamstrings
Should pain continue or increase, refer to physician

36. Iliotibial Band Syndrome
IT Band syndrome involves inflammation of the thick band of fibrous tissue that runs down the side of the tibia, just below the knee
Bursa between the mucles/bones and IT band becomes inflamed and makes movement painful
Usually affects people who suddenly increase level of activity
Ex. Runners increasing mileage
Others who are prone are
People who overpronate
Have leg-length discrepancies
Are bowlegged

37. IT Band Syndrome ~ Treatment
Analyze athlete's gait and training program
Rule out mechanical problems
Proper footwear
Icing the painful area
Stretching
Reduce or modify activities until symptoms subside

38. IT Band ~ Stretches

39. Fractures Usually a result of high-energy trauma Patella fractures
Can occur from direct impact to anterior knee
Distal femoral or proximal tibia
Can occur with violent twisting or falls from heights