Chapter 20: The Knee and Related Structures

1
Chapter 20 The Knee and Related Structures

• Jennifer Doherty-Restrepo, MS, LAT, ATC
• Academic Program Director, Entry-Level ATEP
• Florida International University
• Acute Care and Injury Prevention

2
(No Transcript)
3
(No Transcript)
4
(No Transcript)
5
(No Transcript)
6
Assessment of the Knee Joint

• Determine MOI - This is critical!!!
• History Acute Injury
• Past history
• Position of body at time of injury?
• Did the knee collapse?
• Did you hear or feel anything?
• Could you move your knee immediately after injury
  or was it locked?
• Did swelling occur?
• Where was the pain?

7

• History Recurrent or Chronic Injury
• What is your major complaint?
• When did you first notice the condition?
• Is there recurrent swelling?
• Does the knee lock or catch?
• Is there severe pain?
• Grinding or grating?
• Does it ever feel like giving way?
• What does it feel like when ascending and
  descending stairs?
• What past treatment have you undergone?

8

• Observation
• Walking, half squatting, going up and down stairs
• Swelling, ecchymosis
• Leg alignment
• Genu valgum and genu varum
• Hyperextension and hyperflexion
• Patella alta and baja
• Patella rotated inward or outward
• Tibial torsion, femoral anteversion and
  retroversion

9
(No Transcript)
10

• Observation cont.
• Knee Symmetry or Asymmetry
• Do the knees look symmetrical?
• Is there obvious swelling?
• Atrophy?
• Leg Length Discrepancy
• Anatomical or functional
• Anatomical differences can potentially cause
  problems in all weight bearing joints
• Functional differences can be caused by pelvic
  rotations or mal-alignment of the spine

11
Palpation - Swelling

• Intracapsular swelling
• May be referred to as joint effusion
• Swelling within the joint that is caused by
  synovial fluid and blood is called hemarthrosis
• Sweep maneuver sign of joint effusion
• Ballotable patella - sign of joint effusion
• Extracapsular swelling
• Localized over the injured structure
• May ultimately migrate down to foot and ankle

12
Recognition and Management of Specific Injuries
13
Medial Collateral Ligament Sprain

• MOI severe blow or outward twist
• Grade I Signs and Symptoms
• Little fiber tearing or stretching
• Stable valgus test
• Little or no joint effusion
• Some joint stiffness and point tenderness on
  lateral aspect of the knee
• Relatively normal ROM

14

• Grade I Management
• RICE for 24 hours
• Crutches if necessary
• Rehab
• Cryokinetics
• Isometrics
• Progress to SLRs, bicycle riding, and isokinetics
• Return to play when all areas have returned to
  normal
• May require 3 weeks to recover

15

• Grade II Signs and Symptoms
• Complete tear of deep capsular ligament and
  partial tear of MCL
• No gross instability laxity at 5-15 degrees of
  flexion
• Slight swelling
• Moderate to severe joint tightness
• Decreased ROM
• Pain along medial aspect of knee

16

• Grade II Management
• RICE for 48-72 hours
• Crutch use until acute inflammation phase has
  resolved
• Possibly a brace or casting prior to the
  initiation of ROM activities
• Modalities 2-3 times daily for pain
• Gradual progression from isometrics (quad
  exercises) to CKC exercises functional
  progression activities

17

• Grade III Signs and Symptoms
• Complete tear of supporting ligaments
• Complete loss of medial stability
• Minimum to moderate swelling
• Immediate pain followed by ache
• Loss of motion due to effusion and hamstring
  guarding
• Positive valgus stress test

18

• Grade III Management
• RICE
• Conservative non-operative versus surgical
  approach
• Limited immobilization (with a brace)
• Progressive weight bearing and increased ROM over
  4-6 week period
• Rehab would be similar to Grade I II injuries

19
Lateral Collateral Ligament Sprain

• MOI Varus force usually with the tibia
  internally rotated
• Direct blow is rare MOI
• If severe enough damage may also occur to
• Cruciate ligaments
• ITB
• Meniscus
• Bony fragments may result as well

20

• Signs and Symptoms
• Pain and tenderness over LCL
• Swelling and effusion around the LCL
• Joint laxity with varus testing
• May cause irritation of the peroneal nerve
• Management
• Same as MCL injury management

21
Anterior Cruciate Ligament Sprain

• MOI tibia externally rotated with a valgus
  force
• Occasionally the result of hyperextension
  resulting from a direct blow
• Research is quite extensive in regards to impact
  of femoral notch, ACL size and laxity,
  mal-alignments (Q-angle), and faulty biomechanics
• Extrinsic factors may include, conditioning,
  skill acquisition, playing style, equipment,
  preparation time
• May also involve damage to other structures
  including meniscus, capsule, and MCL

22

• Signs and Symptoms
• Experience pop with severe pain and disability
• Positive anterior drawer and Lachmans
• Rapid swelling at the joint line
• Other ACL tests may also be positive
• Management
• RICE use of crutches
• Arthroscopy may be necessary to determine extent
  of injury
• Surgical repair
• Without surgery, joint degeneration may result
• Surgery may involve joint reconstruction with
  grafts (tendon), transplantation of external
  structures
• Also requires 4-6 months of rehab

23

Posterior Cruciate Ligament Sprain

• MOI fall on bent knee (most common)
• Most at risk during 90 degrees of flexion
• Injury may result due to a rotational force
• Signs and Symptoms
• Feel a pop in the back of the knee
• Tenderness and relatively little swelling in the
  popliteal fossa
• Laxity with posterior sag test

24

• Management
• RICE
• Non-operative rehab
• Appropriate for grade I and II injuries
• Focus on quad strengthening
• Post-operative rehab
• Surgery will require 6 weeks of immobilization in
  extension
• Full weight bearing on crutches
• ROM after 6 weeks
• PRE at 4 months

25
Meniscal Lesions

• Most common MOI is rotary force with knee flexed
  or extended
• Tears may be longitudinal, oblique, or transverse
  
• Medial meniscus is more commonly injured due to
  ligamentous attachments and decreased mobility
• Also more prone to disruption through torsional
  and valgus forces

26
(No Transcript)
27

• Signs and Symptoms
• Effusion developing over 48-72 hours
• Pain in joint line
• Loss of motion
• Intermittent locking and giving way
• Pain with squatting
• Portions of meniscus may become detached causing
  locking, giving way, or catching within the joint
• If chronic injury, recurrent swelling or muscle
  atrophy may occur

28

• Management
• No locking but indications of a tear are present
• Further diagnostic testing may be required
• If locking occurs, anesthesia may be necessary to
  unlock the joint
• Possible arthroscopic surgery
• Healing dependent on location of tear
• Menisectomy
• Partial weight bearing, quick return to activity
• Repaired meniscus
• Requires immobilization, gradual return to
  activity over the course of 12 weeks

29
Knee Plica

• MOI irritation of the plica
• Often associated with chondromalacia
• Signs and Symptoms
• Possible history of knee pain/injury
• Recurrent episodes of painful pseudo-locking
• Possible snapping and popping
• Pain with stairs and squatting
• Little or no swelling
• No ligamentous laxity
• Management
• Treat conservatively w/ RICE and NSAIDs if the
  result of trauma
• Recurrent conditions may require surgery

30
Osteochondritis Dissecans

• MOI partial or complete separation of articular
  cartilage and subchondral bone
• Exact cause is unknown but may include
• Blunt trauma,
• Possible skeletal or endocrine abnormalities,
• Prominent tibial spine impinging on medial
  femoral condyle, or
• Impingement due to patellar facet

31

• Signs and Symptoms
• Aching pain and point tenderness
• Recurrent swelling
• Possible locking
• Possible quadriceps atrophy
• Management
• Rest and immobilization for children
• Surgery may be necessary in teenagers and adults
• Drilling to stimulate healing, pinning, or bone
  grafts

32
Loose Bodies

• MOI repeated trauma
• May result due to osteochondritis dissecans,
  meniscal fragments, synovial tissue damage, or
  cruciate ligaments injury
• Signs and Symptoms
• May become lodged and cause locking or popping
• Pain
• Sensation of instability
• Management
• If not surgically removed it can lead to
  conditions causing joint degeneration

33
Joint Contusions

• MOI direct blow
• Signs and Symptoms
• Severe pain
• Acute inflammation
• Loss of movement
• Swelling
• If not resolved within a week then a chronic
  condition may exist (synovitis or bursitis)
• Ecchymosis
• Possible capsular damage
• Management
• RICE
• Progress to normal activity following return of
  ROM
• Padding for protection

34
Peroneal Nerve Contusion

• MOI compression due to a direct blow
• Signs and Symptoms
• Local pain and possible shooting nerve pain
• Numbness and paresthesia
• Added pressure may exacerbate condition
• Generally resolves quickly
• In the event it does not resolve, it could result
  in drop foot
• Management
• RICE
• Return to play once symptoms resolve and no
  weakness is present
• Padding for fibular head

35
Bursitis

• MOI acute, chronic, or recurrent swelling
• Prepatellar continued kneeling
• Infrapatellar overuse of patellar tendon
• Signs and Symptoms
• Localized swelling that results in ballotable
  patella
• Swelling in popliteal fossa may indicate a
  Bakers cyst
• Associated with burse over the semimembranosus or
  medial head of gastrocnemius
• Commonly painless and causing little disability
• May progress and should be treated accordingly
• Management
• Eliminate cause
• RICE and NSAIDs
• Aspiration and steroid injection if chronic

36
Patellar Fracture

• MOI direct or indirect trauma
• Semi-flexed position with forceful contraction,
  which may occur while falling, jumping or running
• Signs and Symptoms
• Hemorrhaging and joint effusion
• Possible capsular tearing, separation of bone
  fragments, and possible quadriceps tendon tearing
  due to bone fragments
• Management
• X-ray necessary for confirmation
• RICE and splinting if fracture suspected
• Refer
• Possible immobilize for 2-3 months

37
Patella Subluxation or Dislocation

• MOI deceleration with simultaneous cutting in
  opposite direction (valgus force)
• Quad pulls the patella out of alignment
• Repetitive subluxation will impose stress to
  medial restraints
• Signs and Symptoms
• Subluxation
• Pain, swelling, restricted ROM, and palpable
  tenderness over adductor tubercle
• Dislocations
• Total loss of function

38

• Management
• Reduction
• Performed by flexing hip, moving patella
  medially, and slowly extending the knee
• Following reduction, immobilize for at least 4
  weeks
• Use crutches
• Isometric exercises
• After immobilization period, horseshoe pad with
  elastic wrap should be used to support patella
• Rehab focuses on strengthening the muscles around
  the knee, thigh, and hip
• Possible surgery to release tight structures
• Improve postural and biomechanical factors

39
Infrapatellar Fat Pad

• MOI becomes wedged between the tibia and
  patella
• Irritated by chronic kneeling, pressure, or
  trauma
• Signs and Symptoms
• Capillary hemorrhaging and swelling
• Chronic irritation may lead to scarring and
  calcification
• Pain below the patellar ligament during knee
  extension
• May display weakness, mild swelling, and
  stiffness during movement

40

• Management
• Rest
• Avoid irritating activities until inflammation
  has subsided
• Utilize therapeutic modalities for inflammation
• Heel lift to prevent irritation during extension
• Hyperextension taping to prevent full extension

41
Chondromalacia patella

• MOI softening and deterioration of the
  articular cartilage
• Three stages
• Swelling and softening of cartilage
• Fissure of softened cartilage
• Deformation of cartilage surface
• Often associated with abnormal tracking
• Abnormal patellar tracking may be due to genu
  valgum, external tibial torsion, foot pronation,
  femoral anteversion, patella alta, shallow
  femoral groove, increased Q angle, laxity of quad
  tendon

42

• Signs and Symptoms
• Pain with walking, running, stairs, and squatting
• Possible recurrent swelling
• Grating sensation with flexion and extension
• Pain at inferior border during palpation
• Management
• Conservative measures
• RICE, NSAIDs, isometrics, orthotics to correct
  dysfunction
• Surgical possibilities
• Altering muscle attachments
• Shaping and smoothing of surfaces
• Drilling
• Elevating tibial tubercle

43
Patellofemoral Stress Syndrome

• MOI lateral deviation of patella while tracking
  in femoral groove
• May result due to tight structures, pronation,
  increased Q angle, insufficient medial
  musculature
• Signs and Symptoms
• Tenderness at lateral facet of patella
• Swelling associated with irritation of synovium
• Dull ache in center of knee
• Patellar compression will elicit pain and
  crepitus
• Apprehension when patella is forced laterally
• Management
• Correct imbalances (strength and flexibility)
• McConnell taping
• Lateral retinacular release if conservative
  measures fail

44
Osgood-Schlatter Disease, Larsen-Johansson Disease

• Osgood Schlatters is apophysitis at the tibial
  tubercle
• MOI repeated avulsion of patellar tendon
• Bony callus develops enlarging the tibial
  tubercle
• Resolves with aging
• Larsen Johansson is the result of excessive
  pulling on the inferior pole of the patella

45
(No Transcript)
46

• Signs and Symptoms
• Swelling
• Hemorrhaging
• Gradual degeneration of the apophysis due to
  impaired circulation
• Pain with kneeling, jumping, and running
• Point tenderness
• Management
• Conservative
• Reduce stressful activity
• Possible casting
• Ice before and after activity
• Isometerics

47
Patellar Tendinitis (Jumpers or Kickers Knee)

• MOI sudden or repetitive extension
• Jumping or kicking places tremendous strain on
  patellar or quadriceps tendon
• Signs and Symptoms
• Pain and tenderness at inferior pole of patella
• 3 phases
• 1) pain after activity,
• 2) pain during and after activity,
• 3) pain during and after activity that may
  become constant

48

• Management
• Ice, phonophoresis, iontophoresis, ultrasound,
  heat
• Exercise
• Patellar tendon bracing
• Transverse friction massage

49
Patellar Tendon Rupture

• MOI sudden, powerful quad contraction
• Rare unless a chronic inflammatory condition
  exists resulting in tissue degeneration
• Occurs primarily at point of attachment
• Signs and Symptoms
• Palpable defect
• Lack of knee extension
• Considerable swelling and pain (initially)
• Management
• Surgical repair is needed
• Proper conservative treatment of jumpers knee
  can minimize chances of occurring

50
Runners Knee Cyclists Knee

• MOI repetitive/overuse conditions attributed to
  mal-alignment and structural asymmetries
• Signs and Symptoms
• IT Band Friction Syndrome
• Irritation at bands insertion
• Commonly seen in individuals who have genu varum
  or pronated feet
• Pes Anserine Tendinitis or Bursitis
• Result of excessive genu valgum and weak vastus
  medialis
• Often occurs due to running with one leg higher
  than the other
• Running on a slope or crowned road

51

• Management
• Correction of mal-alignments
• Ice before and after activity
• Utilize proper warm-up and stretching techniques
• Avoidance of aggravating activities
• NSAIDs
• Orthotics

52
The Collapsing Knee

• Giving way of knee
• Result of
• Weak quadriceps
• Chronic instability of ligamentous structures
• Torn meniscus
• Loose bodies within the knee
• Subluxating patella
• Chondromalacia
• Due to pain