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

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anatomy and injuries of the knee

Anatomy and Injuries of the Knee

Connie Rauser

Sabino Sports Medicine

anatomy bones
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
anatomy joints
Anatomy-Joints
  • Joints
    • Tibiofemoral
      • Hinge joint with synovial lining
        • diarthrodial
    • Patellofemoral
    • Superior Tibiofibular
anatomy meniscus
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 ligaments
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
ligaments
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
ligaments7
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
ligaments8
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
muscles
Muscles
  • Quadriceps
    • Rectus femoris, vastus lateralis, vastus medialis, vastus intermedius
      • Knee extension, hip flexion
  • Hamstrings
    • Biceps femoris, semimembranosus, semitendinosus
      • Knee flexion, hip extension
muscles11
Muscles
  • Gracilis
    • Knee flexion, hip adduction
  • Sartorius
    • Knee flexion, hip flexion, hip external rotation
  • Popliteus
    • Knee flexion
  • Gastrocnemius
    • Knee flexion
muscles12
Muscles
  • Plantaris
    • Knee flexion
  • Pes anserine
    • Goose’s foot
    • Knee flexion, some internal rotation
      • Gracilis, sartorius, semitendinosus
  • Iliotibial Band
    • Thick band on lateral aspect of thigh
      • Attaches at Gerdy’s tubercle on the lateral aspect of tibia
preventing knee injuries
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 injuries14
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?
acl rupture
ACL rupture
  • Mxn:
    • 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
slide17
MXN
  • Hyperextension
inside the knee joint
Inside the knee joint
  • The ACL intact The ACL torn
acl rupture20
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
stress tests
Stress tests
  • Lachman’s test
stress tests22
Stress tests
  • Modified Lachman’s
stress tests23
Stress tests
  • Anterior Drawer test
pcl rupture
PCL Rupture
  • Mxn:
    • hyperflexion
    • falling on bent knee with foot plantar flexed
    • Hit on fixed anterior tibia
  • S/S:
    • “pop” at the back of knee
    • POT and swelling in popliteal fossa
    • + posterior sag test, +sunrise test, + posterior drawer test
pcl rupture25
PCL rupture
  • Tx:
    • RICE
    • Immobilization
    • Crutches
    • Physician referral
    • 6-8 weeks rest/rehab
    • If surgery is elected, 6 weeks immobilization
stress tests27
Stress tests
  • Posterior sag
strest tests
Strest tests
  • Sunrise or posterior sag
mcl sprain
MCL Sprain
  • Mxn:
    • Blow to the lateral side of knee (valgus stress)
    • External rotation of tibia
mcl sprain31
MCL sprain
  • 2nd degree??
mcl sprain32
MCL sprain
  • S/S:
  • 1st degree
    • POT over MCL, stable but pain with valgus stress, mild joint effusion, mild joint stiffness, full ROM
  • 2nd degree
    • Partial tearing-superficial portion, POT over MCL, some instability with valgus stress but solid endpoint, moderate joint effusion, joint stiffness, limited ROM, unable to fully extend knee joint
mcl sprain33
MCL Sprain
  • S/S:
  • 3rd degree
    • Complete tear—superficial and deep portions
    • POT 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
stress tests for mcl
Stress tests for MCL
  • Valgus stress test @ 0 Valgus stress @ 30
mcl sprain35
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
complications
Complications
  • The terrible triad or unhappy triad
    • Torn ACL
    • Torn MCL
    • Torn Medial meniscus
lcl sprain
LCL sprain
  • Mxn:
    • Varus force to medial aspect of knee
    • internal rotation of tibia
  • S/S:
    • POT 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 sprain38
LCL sprain
  • Tx:
    • RICE
    • Crutches
    • Knee immobilizer
    • Physician referral with 2nd or 3rd degree
meniscus tear
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
  • Mxn:
    • Weight bearing with rotational force while extending or flexing the knee
meniscus tear40
Meniscus tear
  • S/S:
    • Effusion w/in 48-72 hours
    • POT over joint line
    • Loss of motion
    • “locking”
    • Giving out
    • Pain with deep knee flexion--squatting
meniscus tear41
Meniscus tear
  • Types of meniscus tears
meniscus tears
Meniscus tears
  • Tx:
  • RICE
  • Crutches if necessary
  • Physician referral
  • If knee is “locked” by displaced meniscus, go to ER
  • Arthroscopic surgery to fix
injuries to the patella
Injuries to the Patella
  • Dislocation
  • Subluxation
  • Fracture
  • Chondromalacia
  • Patellar tendonitis
patella dislocation
Patella Dislocation
  • Mxn:
    • 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)
dislocation
Dislocation
  • S/S: loss of motion/function at the knee
  • Pain
  • Swelling
  • Deformity
  • POT over medial aspect of knee joint
dislocation48
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
patella subluxation
Patella Subluxation
  • Mxn: same as for the dislocation
  • S/S:
    • same as for the dislocation except there will be no deformity
    • POT over the medial knee joint
    • Pain with movement
  • TX:
    • RICE
    • Knee Immobilizer and crutches
    • Physician referral
patella fracture
Patella fracture
  • Mxn:
    • 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
    • POT over Patella
    • extreme pain with weight bearing/movement
patella fracture53
Patella Fracture
  • Tx:
  • RICE
  • Immobilize
  • Crutches
  • ER
  • Possible surgery depending on type of fracture
chondromalacia
Chondromalacia
  • Softening and deterioration of the articular cartilage on the posterior side of the patella
chondro
Chondro
  • Mxn:
    • 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
chondro56
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
chondro57
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
patellar tendonitis
Patellar tendonitis
  • Also called “jumper’s knee”
  • Mxn:
    • excessive running, jumping or kicking causing extreme tension of the knee extensor muscle complex
  • S/S:
    • Pain at the patellar tendon
    • POT over the distal pole of patella
    • Pain increases with activity
    • Thickening of tendon
    • crepitus
patellar tendonitis59
Patellar tendonitis
  • TX:
    • Rest
    • Ice
    • Heat
    • Ultrasound
    • Cross-friction massage
    • NSAIDS
    • Patellar tendon strap/taping
    • Modify activity
osgood schlatter s disease
Osgood-Schlatter’s Disease
  • Condition common in adolescent knee
  • Mxn:
    • Repeated pull of patellar tendon at tibial tuberosity apophysis due to excessive running, jumping, kicking, etc.
  • S/S:
    • pain and POT at the patellar tendon attachment on tibial tuberosity
    • Excessive bony formation over tubersity as tendon continues to pull at the apophysis
osgood schlatter s
Osgood Schlatter’s
  • S/S:
    • usually resolves itself when the athlete reaches 18-19 years of age
    • Enlarged tibial tuberosity remains
  • Tx:
    • Modify activity
    • Ice
    • Tape/patellar tendon strap
    • Padding
    • Strengthening of quads and hamstrings
iliotibial band friction syndrome
Iliotibial Band Friction Syndrome
  • Mxn:
    • 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
slide63
ITBS
  • S/S:
    • POT over the lateral femoral epicondyle
    • Swelling
    • Increased pain with activity especially distance running and starts and stops and change of direction
slide64
ITBS
  • Tx:
  • Stretching the ITB
  • Ice pack/massage
  • Transverse friction massage ITB
  • Modify activity
  • Correct foot/lower leg malalignment
bursitis
Bursitis
  • Can be acute, chronic, or recurrent
  • Numerous bursae involved but most commonly injured are the prepatellar or the deep infrapatellar
bursitis66
Bursitis
  • Mxn:
    • falling directly on knee
    • Continuous kneeling
    • Overuse of patellar tendon
bursitis67
Bursitis
  • S/S:
    • Localized swelling that is similar to a water balloon and is outside the knee joint
    • Pain especially with pressure
bursitis70
Bursitis
  • Tx:
    • Rest
    • Ice
    • Compression
    • NSAIDS
    • Padding for protection when returning to activity