Chapter 20: Chapter 20: The Knee and The Knee and

Related StructuresRelated StructuresJennifer Doherty-Restrepo, MS, LAT, ATCJennifer Doherty-Restrepo, MS, LAT, ATC

Academic Program Director, Entry-Level ATEPAcademic Program Director, Entry-Level ATEPFlorida International UniversityFlorida International University

Acute Care and Injury PreventionAcute Care and Injury Prevention

Functional AnatomyFunctional Anatomy Movement of the knee requires flexion, Movement of the knee requires flexion,

extension, rotation and the arthrokinematic extension, rotation and the arthrokinematic motions of rolling and glidingmotions of rolling and gliding

Rotational component involves the “screw Rotational component involves the “screw home mechanism”home mechanism” As the knee extends it externally rotates As the knee extends it externally rotates

because the medial femoral condyle is larger because the medial femoral condyle is larger than the lateralthan the lateral

Provides increased stability to the kneeProvides increased stability to the knee

Capsular ligaments Capsular ligaments Taut during full extension and relaxed with flexionTaut during full extension and relaxed with flexion

Allows rotation to occurAllows rotation to occur Deeper capsular ligaments remain taut to keep rotation Deeper capsular ligaments remain taut to keep rotation

in checkin check

PCL prevents excessive internal rotation, guides PCL prevents excessive internal rotation, guides the knee in flexion, and acts as drag during initial the knee in flexion, and acts as drag during initial glide phase of flexionglide phase of flexion

ACL stops excessive internal rotation, stabilizes the ACL stops excessive internal rotation, stabilizes the knee in full extension, and prevents hyperextensionknee in full extension, and prevents hyperextension

Patella Patella Aids knee during extension, providing a Aids knee during extension, providing a

mechanical advantagemechanical advantage Distributes compressive stress on the femur by Distributes compressive stress on the femur by

increasing contact between patellar tendon and increasing contact between patellar tendon and femurfemur

Protects patellar tendon against frictionProtects patellar tendon against friction When moving from extension to flexion the When moving from extension to flexion the

patella glides laterally and further into trochlear patella glides laterally and further into trochlear groovegroove

Kinetic ChainKinetic Chain Directly affected by motions and forces occurring at Directly affected by motions and forces occurring at

the foot, ankle, lower leg, thigh, hip, pelvis, and the foot, ankle, lower leg, thigh, hip, pelvis, and spinespine

With the kinetic chain, forces must be absorbed and With the kinetic chain, forces must be absorbed and distributeddistributed

If body is unable to manage the imposed forces, If body is unable to manage the imposed forces, breakdown in the kinetic chain occursbreakdown in the kinetic chain occurs

Knee is very susceptible to injury resulting from the Knee is very susceptible to injury resulting from the absorption of forcesabsorption of forces

Assessment of the Assessment of the Knee JointKnee Joint

Determine MOI - This is critical!!!Determine MOI - This is critical!!! History: Acute InjuryHistory: Acute Injury

Past historyPast history Position of body at time of injury?Position of body at time of injury? Did the knee collapse?Did the knee collapse? Did you hear or feel anything?Did you hear or feel anything? Could you move your knee immediately after Could you move your knee immediately after

injury or was it locked?injury or was it locked? Did swelling occur?Did swelling occur? Where was the painWhere was the pain

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

stairs?stairs? What past treatment have you undergone?What past treatment have you undergone?

ObservationObservation Walking, half squatting, going up and down stairsWalking, half squatting, going up and down stairs Swelling, ecchymosisSwelling, ecchymosis Leg alignmentLeg alignment

Genu valgum and genu varumGenu valgum and genu varum Hyperextension and hyperflexionHyperextension and hyperflexion Patella alta and bajaPatella alta and baja Patella rotated inward or outwardPatella rotated inward or outward Tibial torsion, femoral anteversion and retroversion Tibial torsion, femoral anteversion and retroversion

Tibial torsionTibial torsion An angle that measures less An angle that measures less

than 15 degrees is an than 15 degrees is an indication of tibial torsionindication of tibial torsion

Femoral Anteversion and Femoral Anteversion and RetroversionRetroversion

Total rotation of the hip Total rotation of the hip equals ~100 degreesequals ~100 degrees

If the hip rotates >70 degrees If the hip rotates >70 degrees internally, anteversion of the internally, anteversion of the hip may existhip may exist

Observation cont.Observation cont. Knee Symmetry or AsymmetryKnee Symmetry or Asymmetry

Do the knees look symmetrical? Do the knees look symmetrical? Is there obvious swelling? Is there obvious swelling? Atrophy?Atrophy?

Leg Length DiscrepancyLeg Length Discrepancy Anatomical or functionalAnatomical or functional Anatomical differences can potentially Anatomical differences can potentially

cause problems in all weight bearing jointscause problems in all weight bearing joints Functional differences can be caused by Functional differences can be caused by

pelvic rotations or mal-alignment of the pelvic rotations or mal-alignment of the spinespine

Palpation - BonyPalpation - Bony

Medial tibial plateauMedial tibial plateau Medial femoral condyleMedial femoral condyle Adductor tubercleAdductor tubercle Gerdy’s tubercleGerdy’s tubercle Lateral tibial plateauLateral tibial plateau Lateral femoral Lateral femoral

condylecondyle Lateral epicondyleLateral epicondyle Head of fibulaHead of fibula

Tibial tuberosityTibial tuberosity Superior and inferior Superior and inferior

patella borders patella borders (base and apex)(base and apex)

Around the Around the periphery of the periphery of the knee relaxed, in full knee relaxed, in full flexion and flexion and extensionextension

Palpation - Soft TissuePalpation - Soft Tissue Vastus medialisVastus medialis Vastus lateralisVastus lateralis Vastus intermediusVastus intermedius Rectus femorisRectus femoris Quadriceps and patellar Quadriceps and patellar

tendontendon SartoriusSartorius Medial patellar plicaMedial patellar plica Anterior joint capsuleAnterior joint capsule Iliotibial BandIliotibial Band Arcuate complex Arcuate complex

Medial and lateral Medial and lateral collateral ligamentscollateral ligaments

Pes anserinePes anserine Medial/lateral joint Medial/lateral joint

capsulecapsule SemitendinosusSemitendinosus SemimembranosusSemimembranosus GastrocnemiusGastrocnemius PopliteusPopliteus Biceps FemorisBiceps Femoris

Intracapsular swellingIntracapsular swelling May be referred to as joint effusionMay be referred to as joint effusion Swelling within the joint that is caused by Swelling within the joint that is caused by

synovial fluid and blood is called synovial fluid and blood is called hemarthrosishemarthrosis Sweep maneuver – sign of joint effusionSweep maneuver – sign of joint effusion Ballotable patella - sign of joint effusionBallotable patella - sign of joint effusion

Extracapsular swellingExtracapsular swelling Localized over the injured structure Localized over the injured structure May ultimately migrate down to foot and ankleMay ultimately migrate down to foot and ankle

Palpation - SwellingPalpation - Swelling

Special Tests: Special Tests: Knee Knee InstabilityInstability

Valgus Stress TestValgus Stress Test Used to assess the Used to assess the

integrity of MCL integrity of MCL Testing at 0 degrees Testing at 0 degrees

incorporates incorporates capsular testing capsular testing

Testing at 30 degrees Testing at 30 degrees of flexion isolates the of flexion isolates the ligamentsligaments

Special Tests: Special Tests: Knee InstabilityKnee Instability

Varus Stress TestVarus Stress Test Used to assess the Used to assess the

integrity of LCLintegrity of LCL Testing at 0 degrees Testing at 0 degrees

incorporates capsular incorporates capsular testingtesting

Testing at 30 degrees Testing at 30 degrees of flexion isolates the of flexion isolates the ligamentsligaments

Special Tests: Special Tests: Knee InstabilityKnee Instability

Anterior Cruciate Ligament TestsAnterior Cruciate Ligament Tests Drawer test at 90 degrees of flexionDrawer test at 90 degrees of flexion

Tibia sliding forward from under the femur is considered a Tibia sliding forward from under the femur is considered a positive sign positive sign

Should be performed with knee internally and externally Should be performed with knee internally and externally rotated to test integrity of joint capsulerotated to test integrity of joint capsule

Special Tests: Special Tests: Knee InstabilityKnee Instability

Anterior Cruciate Ligament TestsAnterior Cruciate Ligament Tests Lachman Drawer TestLachman Drawer Test

Avoids painful flexion immediately after injuryAvoids painful flexion immediately after injury Reduces hamstring involvementReduces hamstring involvement At 30 degrees of flexion an attempt is made to translate the tibia anteriorly on the At 30 degrees of flexion an attempt is made to translate the tibia anteriorly on the

femurfemur A positive test indicates damage to the ACLA positive test indicates damage to the ACL

Variations for the Lachman Drawer TestVariations for the Lachman Drawer Test May be necessary if athlete is large or May be necessary if athlete is large or

examiner’s hands are smallexaminer’s hands are small

Variations include:Variations include: Rolled towel under the femurRolled towel under the femur Leg off the table with athlete supineLeg off the table with athlete supine Athlete prone on table with knee and lower Athlete prone on table with knee and lower

leg just off tableleg just off table

Special Tests: Special Tests: Knee InstabilityKnee Instability

Pivot Shift TestPivot Shift Test Used to determine anterolateral Used to determine anterolateral

rotary instabilityrotary instability Position starts with knee extended Position starts with knee extended

and leg internally rotatedand leg internally rotated The thigh and knee are then The thigh and knee are then

flexed with a valgus stress applied flexed with a valgus stress applied to the kneeto the knee

Reduction of the tibial plateau Reduction of the tibial plateau (producing a clunk) is a positive (producing a clunk) is a positive signsign

Jerk TestJerk Test Reverses direction of the pivot shiftReverses direction of the pivot shift Moves from position of flexion to extensionMoves from position of flexion to extension Without an ACL the tibia will sublux at 20 Without an ACL the tibia will sublux at 20

degrees of flexiondegrees of flexion

Special Tests: Special Tests: Knee InstabilityKnee Instability

Flexion-Rotation Drawer TestFlexion-Rotation Drawer Test Knee is taken from a position of 15 Knee is taken from a position of 15

degrees of flexion degrees of flexion Tibia is subluxed anteriorly with femur Tibia is subluxed anteriorly with femur

externally rotatedexternally rotated

Knee is moved into 30 degrees of flexion Knee is moved into 30 degrees of flexion where tibia rotates posteriorly and femur where tibia rotates posteriorly and femur internally rotatesinternally rotates

Special Tests: Special Tests: Knee InstabilityKnee Instability

Posterior Cruciate Ligament TestsPosterior Cruciate Ligament Tests Posterior Drawer TestPosterior Drawer Test

Knee is flexed at 90 degrees and a Knee is flexed at 90 degrees and a posterior force is applied to determine posterior force is applied to determine translation of the tibia posteriorlytranslation of the tibia posteriorly

Positive sign indicates a PCL deficient Positive sign indicates a PCL deficient kneeknee

Special Tests: Special Tests: Knee InstabilityKnee Instability

Posterior Cruciate Ligament TestsPosterior Cruciate Ligament Tests External Rotation Recurvatum TestExternal Rotation Recurvatum Test

With the athlete supine, the leg is lifted by With the athlete supine, the leg is lifted by the great toethe great toe

If the tibia externally rotates and slides If the tibia externally rotates and slides posteriorly there may be a PCL injury and posteriorly there may be a PCL injury and damage to the posterolateral corner of the damage to the posterolateral corner of the capsulecapsule

Special Tests: Special Tests: Knee InstabilityKnee Instability

Special Tests: Special Tests: Knee InstabilityKnee Instability

Posterior Sag Test (Godfrey’s test)Posterior Sag Test (Godfrey’s test) Athlete is supine with both knees flexed to 90 Athlete is supine with both knees flexed to 90

degreesdegrees Lateral observation is required to determine Lateral observation is required to determine

extent of posterior sag while comparing extent of posterior sag while comparing bilaterallybilaterally

Instrument Assessment of the Instrument Assessment of the Cruciate LigamentsCruciate Ligaments

A number of devices are A number of devices are available to quantify AP available to quantify AP displacement of the kneedisplacement of the knee KT-2000 arthrometerKT-2000 arthrometer Stryker knee laxity tester Stryker knee laxity tester GenucomGenucom

Test can be taken pre & Test can be taken pre & post-operatively and post-operatively and throughout rehabilitationthroughout rehabilitation

McMurray’s Meniscal TestMcMurray’s Meniscal Test Used to determine displaced meniscal tearUsed to determine displaced meniscal tear Leg is moved into flexion and extension Leg is moved into flexion and extension

while knee is internally and externally while knee is internally and externally rotated in conjunction with valgus and rotated in conjunction with valgus and varus stressesvarus stresses

A positive test is found when clicking and A positive test is found when clicking and popping are feltpopping are felt

Special Tests: Special Tests: Meniscal TestsMeniscal Tests

Special Tests: Special Tests: Meniscal TestsMeniscal Tests

Apley’s Compression TestApley’s Compression Test Hard downward pressure is applied with Hard downward pressure is applied with

rotation of the tibiarotation of the tibia Pain indicates a meniscal injuryPain indicates a meniscal injury

Special Tests: Special Tests: Meniscal TestsMeniscal Tests

Apley’s Distraction TestApley’s Distraction Test Traction is applied with rotation of the tibiaTraction is applied with rotation of the tibia Pain will occur if there is damage to the Pain will occur if there is damage to the

capsule or ligamentscapsule or ligaments No pain will occur if there is a meniscal No pain will occur if there is a meniscal

injuryinjury

Girth MeasurementsGirth Measurements Changes in girth may result due to atrophy, Changes in girth may result due to atrophy,

swelling, and conditioningswelling, and conditioning Circumferential measures to determine Circumferential measures to determine

deficits and gains during rehabilitation deficits and gains during rehabilitation

Subjective RatingsSubjective Ratings Used to determine patient’s perception of Used to determine patient’s perception of

pain, stability, and functional performancepain, stability, and functional performance

Other Special TestsOther Special Tests

Functional ExaminationFunctional Examination Assess walking, running, turning, cutting, etcAssess walking, running, turning, cutting, etc Co-contraction test, vertical jump, single leg Co-contraction test, vertical jump, single leg

hop tests, and the duck walkhop tests, and the duck walk Resistive strength testingResistive strength testing

Other Special TestsOther Special Tests

The Q - AngleThe Q - Angle Line which bisect the patella relative to the ASIS and Line which bisect the patella relative to the ASIS and

the tibial tuberclethe tibial tubercle Normal angle is 10Normal angle is 10°° for males and 15 for males and 15 °° for females for females Elevated angles often lead to pathological conditions Elevated angles often lead to pathological conditions

associated with improper patella trackingassociated with improper patella tracking

The A - AngleThe A - Angle Patellar orientation relative to the tibial tuberclePatellar orientation relative to the tibial tubercle Quantitative measure of the patellar realignment after Quantitative measure of the patellar realignment after

rehabilitationrehabilitation An angle greater than 35An angle greater than 35°° is often correlated is often correlated

associated with patellofemoral pathomechanicsassociated with patellofemoral pathomechanics

Other Special TestsOther Special Tests

Patella Grinding TestPatella Grinding Test Determines integrity of patellar cartilage on the Determines integrity of patellar cartilage on the

undersurface of patellaundersurface of patella

Patella Compression TestPatella Compression Test Determines integrity of patellar cartilage on the Determines integrity of patellar cartilage on the

undersurface of patellaundersurface of patella

Apprehension TestsApprehension Tests Patella pushed laterally to determine presence Patella pushed laterally to determine presence

of subluxation/dislocation of subluxation/dislocation

Special Tests: Special Tests: PatellaPatella

Recognition and Recognition and Management of Management of Specific InjuriesSpecific Injuries

Medial Collateral Medial Collateral Ligament SprainLigament Sprain

MOI = severe blow or outward twistMOI = severe blow or outward twist Grade I: Signs and Symptoms Grade I: Signs and Symptoms

Little fiber tearing or stretchingLittle fiber tearing or stretching Stable valgus testStable valgus test Little or no joint effusionLittle or no joint effusion Some joint stiffness and point tenderness on Some joint stiffness and point tenderness on

laterallateral aspect of the knee aspect of the knee Relatively normal ROMRelatively normal ROM

Grade I: ManagementGrade I: Management RICE for 24 hoursRICE for 24 hours Crutches if necessaryCrutches if necessary RehabRehab

CryokineticsCryokinetics Isometrics Isometrics Progress to SLRs, bicycle Progress to SLRs, bicycle

riding, and isokineticsriding, and isokinetics

Return to play when all Return to play when all areas have returned to areas have returned to normalnormal

May require 3 weeks to May require 3 weeks to recoverrecover

Grade II: Signs and SymptomsGrade II: Signs and Symptoms Complete tear of deep capsular ligament and Complete tear of deep capsular ligament and

partial tear of MCLpartial tear of MCL No gross instability; laxity at 5-15 degrees of No gross instability; laxity at 5-15 degrees of

flexionflexion Slight swellingSlight swelling Moderate to severe joint tightness Moderate to severe joint tightness Decreased ROMDecreased ROM Pain along medial aspect of kneePain along medial aspect of knee

Grade II: ManagementGrade II: Management RICE for 48-72 hoursRICE for 48-72 hours Crutch use until acute inflammation phase has Crutch use until acute inflammation phase has

resolvedresolved Possibly a brace or casting prior to the initiation of Possibly a brace or casting prior to the initiation of

ROM activitiesROM activities Modalities 2-3 times daily for painModalities 2-3 times daily for pain Gradual progression from isometrics (quad exercises) Gradual progression from isometrics (quad exercises)

to CKC exercises; functional progression activitiesto CKC exercises; functional progression activities

Grade III: Signs and Symptoms Grade III: Signs and Symptoms Complete tear of supporting ligamentsComplete tear of supporting ligaments Complete loss of medial stabilityComplete loss of medial stability Minimum to moderate swellingMinimum to moderate swelling Immediate pain followed by acheImmediate pain followed by ache Loss of motion due to effusion and Loss of motion due to effusion and

hamstring guardinghamstring guarding Positive valgus stress testPositive valgus stress test

Grade III: ManagementGrade III: Management RICERICE Conservative non-operative versus surgical Conservative non-operative versus surgical

approachapproach Limited immobilization (with a brace)Limited immobilization (with a brace) Progressive weight bearing and increased Progressive weight bearing and increased

ROM over 4-6 week periodROM over 4-6 week period Rehab would be similar to Grade I & II Rehab would be similar to Grade I & II

injuriesinjuries

MOI = Varus force usually with the tibia MOI = Varus force usually with the tibia internally rotatedinternally rotated

Direct blow is rare MOIDirect blow is rare MOI If severe enough damage may also If severe enough damage may also

occur to occur to Cruciate ligamentsCruciate ligaments ITBITB MeniscusMeniscus Bony fragments may result as wellBony fragments may result as well

Lateral Collateral Lateral Collateral Ligament SprainLigament Sprain

Signs and SymptomsSigns and Symptoms Pain and tenderness over LCLPain and tenderness over LCL Swelling and effusion around the LCLSwelling and effusion around the LCL Joint laxity with varus testingJoint laxity with varus testing May cause irritation of the peroneal nerveMay cause irritation of the peroneal nerve

ManagementManagement Same as MCL injury managementSame as MCL injury management

MOI = tibia externally rotated with a valgus force MOI = tibia externally rotated with a valgus force Occasionally the result of hyperextension resulting Occasionally the result of hyperextension resulting

from a direct blowfrom a direct blow Research is quite extensive in regards to impact of Research is quite extensive in regards to impact of

femoral notch, ACL size and laxity, mal-alignments femoral notch, ACL size and laxity, mal-alignments (Q-angle), and faulty biomechanics(Q-angle), and faulty biomechanics

Extrinsic factors may include, conditioning, skill Extrinsic factors may include, conditioning, skill acquisition, playing style, equipment, preparation timeacquisition, playing style, equipment, preparation time

May also involve damage to other structures including May also involve damage to other structures including meniscus, capsule, and MCLmeniscus, capsule, and MCL

Anterior Cruciate Anterior Cruciate Ligament SprainLigament Sprain

Signs and SymptomsSigns and Symptoms Experience pop with severe pain and disabilityExperience pop with severe pain and disability Positive anterior drawer and Lachman’s Positive anterior drawer and Lachman’s Rapid swelling at the joint lineRapid swelling at the joint line Other ACL tests may also be positiveOther ACL tests may also be positive

ManagementManagement RICE; use of crutchesRICE; use of crutches Arthroscopy may be necessary to determine extent of injuryArthroscopy may be necessary to determine extent of injury Surgical repairSurgical repair

Without surgery, joint degeneration may resultWithout surgery, joint degeneration may result Surgery may involve joint reconstruction with grafts (tendon), transplantation Surgery may involve joint reconstruction with grafts (tendon), transplantation

of external structuresof external structures Also requires 4-6 months of rehabAlso requires 4-6 months of rehab

MOI = fall on bent knee (most common)MOI = fall on bent knee (most common) Most at risk during 90 degrees of flexionMost at risk during 90 degrees of flexion Injury may result due to a rotational forceInjury may result due to a rotational force

Signs and SymptomsSigns and Symptoms Feel a pop in the back of the kneeFeel a pop in the back of the knee Tenderness and relatively little swelling in Tenderness and relatively little swelling in

the popliteal fossathe popliteal fossa Laxity with posterior sag testLaxity with posterior sag test

Posterior Cruciate Posterior Cruciate Ligament SprainLigament Sprain

ManagementManagement RICERICE Non-operative rehab Non-operative rehab

Appropriate for grade I and II injuries Appropriate for grade I and II injuries Focus on quad strengtheningFocus on quad strengthening

Post-operative rehabPost-operative rehab Surgery will require 6 weeks of Surgery will require 6 weeks of

immobilization in extension immobilization in extension Full weight bearing on crutchesFull weight bearing on crutches ROM after 6 weeks ROM after 6 weeks PRE at 4 monthsPRE at 4 months

Most common MOI is rotary force with Most common MOI is rotary force with knee flexed or extendedknee flexed or extended

Tears may be longitudinal, oblique, or Tears may be longitudinal, oblique, or transverse transverse

Medial meniscus is more commonly Medial meniscus is more commonly injured due to ligamentous attachments injured due to ligamentous attachments and decreased mobilityand decreased mobility Also more prone to disruption through Also more prone to disruption through

torsional and valgus forcestorsional and valgus forces

Meniscal LesionsMeniscal Lesions

Signs and SymptomsSigns and Symptoms Effusion developing over 48-72 hoursEffusion developing over 48-72 hours Pain in joint line Pain in joint line Loss of motionLoss of motion Intermittent locking and giving wayIntermittent locking and giving way Pain with squattingPain with squatting Portions of meniscus may become Portions of meniscus may become

detached causing locking, giving way, or detached causing locking, giving way, or catching within the jointcatching within the joint

If chronic injury, recurrent swelling or If chronic injury, recurrent swelling or muscle atrophy may occurmuscle atrophy may occur

ManagementManagement No locking but indications of a tear are presentNo locking but indications of a tear are present

Further diagnostic testing may be requiredFurther diagnostic testing may be required

If locking occurs, anesthesia may be necessary If locking occurs, anesthesia may be necessary to unlock the joint to unlock the joint Possible arthroscopic surgery Possible arthroscopic surgery

Healing dependent on location of tearHealing dependent on location of tear Menisectomy Menisectomy

Partial weight bearing, quick return to activityPartial weight bearing, quick return to activity

Repaired meniscusRepaired meniscus Requires immobilization, gradual return to activity Requires immobilization, gradual return to activity

over the course of 12 weeksover the course of 12 weeks

MOI = irritation of the plica MOI = irritation of the plica Often associated with chondromalaciaOften associated with chondromalacia

Signs and SymptomsSigns and Symptoms Possible history of knee pain/injuryPossible history of knee pain/injury Recurrent episodes of painful pseudo-lockingRecurrent episodes of painful pseudo-locking Possible snapping and poppingPossible snapping and popping Pain with stairs and squattingPain with stairs and squatting Little or no swellingLittle or no swelling No ligamentous laxityNo ligamentous laxity

ManagementManagement Treat conservatively w/ RICE and NSAID’s if the result of traumaTreat conservatively w/ RICE and NSAID’s if the result of trauma Recurrent conditions may require surgeryRecurrent conditions may require surgery

Knee PlicaKnee Plica

MOI = twisting, sudden cutting, or direct blowMOI = twisting, sudden cutting, or direct blow Signs and SymptomsSigns and Symptoms

Hear a snap Hear a snap Feeling of giving wayFeeling of giving way Immediate swelling Immediate swelling Considerable painConsiderable pain

ManagementManagement Diagnosis confirmed through arthroscopic examDiagnosis confirmed through arthroscopic exam Surgery used to replace fragments in order to avoid joint Surgery used to replace fragments in order to avoid joint

degeneration and arthritis degeneration and arthritis

Osteochondral Knee Osteochondral Knee FracturesFractures

Osteochondritis Osteochondritis DissecansDissecans

MOI = partial or complete separation of MOI = partial or complete separation of articular cartilage and subchondral bonearticular cartilage and subchondral bone

Exact cause is unknown but may include: Exact cause is unknown but may include: Blunt trauma, Blunt trauma, Possible skeletal or endocrine abnormalities, Possible skeletal or endocrine abnormalities, Prominent tibial spine impinging on medial Prominent tibial spine impinging on medial

femoral condyle, or femoral condyle, or Impingement due to patellar facetImpingement due to patellar facet

Signs and SymptomsSigns and Symptoms Aching pain and point tendernessAching pain and point tenderness Recurrent swelling Recurrent swelling Possible lockingPossible locking Possible quadriceps atrophy Possible quadriceps atrophy

ManagementManagement Rest and immobilization for childrenRest and immobilization for children Surgery may be necessary in teenagers and adults Surgery may be necessary in teenagers and adults

Drilling to stimulate healing, pinning, or bone graftsDrilling to stimulate healing, pinning, or bone grafts

MOI = repeated traumaMOI = repeated trauma May result due to osteochondritis dissecans, meniscal May result due to osteochondritis dissecans, meniscal

fragments, synovial tissue damage, or cruciate ligaments fragments, synovial tissue damage, or cruciate ligaments injuryinjury

Signs and SymptomsSigns and Symptoms May become lodged and cause locking or poppingMay become lodged and cause locking or popping Pain Pain Sensation of instabilitySensation of instability

ManagementManagement If not surgically removed it can lead to conditions causing If not surgically removed it can lead to conditions causing

joint degenerationjoint degeneration

Loose Bodies Loose Bodies

MOI = direct blow MOI = direct blow Signs and SymptomsSigns and Symptoms

Severe painSevere pain Acute inflammationAcute inflammation Loss of movement Loss of movement SwellingSwelling

If not resolved within a week then a chronic condition may exist (synovitis or If not resolved within a week then a chronic condition may exist (synovitis or bursitis) bursitis)

EcchymosisEcchymosis Possible capsular damagePossible capsular damage

ManagementManagement RICE RICE Progress to normal activity following return of ROM Progress to normal activity following return of ROM Padding for protectionPadding for protection

Joint ContusionsJoint Contusions

MOI = compression due to a direct blowMOI = compression due to a direct blow Signs and SymptomsSigns and Symptoms

Local pain and possible shooting nerve painLocal pain and possible shooting nerve pain Numbness and paresthesia Numbness and paresthesia Added pressure may exacerbate conditionAdded pressure may exacerbate condition Generally resolves quickly Generally resolves quickly

In the event it does not resolve, it could result in drop footIn the event it does not resolve, it could result in drop foot

ManagementManagement RICE RICE Return to play once symptoms resolve and no weakness is Return to play once symptoms resolve and no weakness is

presentpresent Padding for fibular headPadding for fibular head

Peroneal Nerve Peroneal Nerve ContusionContusion

MOI = acute, chronic, or recurrent swellingMOI = acute, chronic, or recurrent swelling Prepatellar = continued kneelingPrepatellar = continued kneeling Infrapatellar = overuse of patellar tendonInfrapatellar = overuse of patellar tendon

Signs and SymptomsSigns and Symptoms Localized swelling that results in ballotable patellaLocalized swelling that results in ballotable patella Swelling in popliteal fossa may indicate a Baker’s cystSwelling in popliteal fossa may indicate a Baker’s cyst

Associated with burse over the semimembranosus or medial head of Associated with burse over the semimembranosus or medial head of gastrocnemiusgastrocnemius

Commonly painless and causing little disabilityCommonly painless and causing little disability May progress and should be treated accordinglyMay progress and should be treated accordingly

ManagementManagement Eliminate causeEliminate cause RICE and NSAID’sRICE and NSAID’s Aspiration and steroid injection if chronicAspiration and steroid injection if chronic

BursitisBursitis

MOI = direct or indirect trauma MOI = direct or indirect trauma Semi-flexed position with forceful contraction, which may occur Semi-flexed position with forceful contraction, which may occur

while falling, jumping or runningwhile falling, jumping or running

Signs and SymptomsSigns and Symptoms Hemorrhaging and joint effusion Hemorrhaging and joint effusion Possible capsular tearing, separation of bone fragments, and Possible capsular tearing, separation of bone fragments, and

possible quadriceps tendon tearing due to bone fragmentspossible quadriceps tendon tearing due to bone fragments

ManagementManagement X-ray necessary for confirmation X-ray necessary for confirmation RICE and splinting if fracture suspectedRICE and splinting if fracture suspected ReferRefer Possible immobilize for 2-3 monthsPossible immobilize for 2-3 months

Patellar FracturePatellar Fracture

MOI = deceleration with simultaneous cutting in MOI = deceleration with simultaneous cutting in opposite direction (valgus force)opposite direction (valgus force) Quad pulls the patella out of alignmentQuad pulls the patella out of alignment Repetitive subluxation will impose stress to medial Repetitive subluxation will impose stress to medial

restraintsrestraints

Signs and SymptomsSigns and Symptoms SubluxationSubluxation

Pain, swelling, restricted ROM, and palpable tenderness over Pain, swelling, restricted ROM, and palpable tenderness over adductor tubercleadductor tubercle

Dislocations Dislocations Total loss of functionTotal loss of function

Patella Subluxation or Patella Subluxation or DislocationDislocation

ManagementManagement Reduction Reduction

Performed by flexing hip, moving patella medially, and slowly extending the Performed by flexing hip, moving patella medially, and slowly extending the kneeknee

Following reduction, immobilize for at least 4 weeks Following reduction, immobilize for at least 4 weeks Use crutches Use crutches Isometric exercises Isometric exercises

After immobilization period, horseshoe pad with elastic wrap should After immobilization period, horseshoe pad with elastic wrap should be used to support patellabe used to support patella

Rehab focuses on strengthening the muscles around the knee, thigh, Rehab focuses on strengthening the muscles around the knee, thigh, and hip and hip

Possible surgery to release tight structuresPossible surgery to release tight structures Improve postural and biomechanical factorsImprove postural and biomechanical factors

MOI = becomes wedged between the tibia and MOI = becomes wedged between the tibia and patellapatella Irritated by chronic kneeling, pressure, or traumaIrritated by chronic kneeling, pressure, or trauma

Signs and SymptomsSigns and Symptoms Capillary hemorrhaging and swellingCapillary hemorrhaging and swelling Chronic irritation may lead to scarring and Chronic irritation may lead to scarring and

calcificationcalcification Pain below the patellar ligament during knee Pain below the patellar ligament during knee

extensionextension May display weakness, mild swelling, and stiffness May display weakness, mild swelling, and stiffness

during movementduring movement

Infrapatellar Fat PadInfrapatellar Fat Pad

ManagementManagement Rest Rest

Avoid irritating activities until inflammation has subsidedAvoid irritating activities until inflammation has subsided

Utilize therapeutic modalities for inflammationUtilize therapeutic modalities for inflammation Heel lift to prevent irritation during extensionHeel lift to prevent irritation during extension Hyperextension taping to prevent full extensionHyperextension taping to prevent full extension

MOI = softening and deterioration of the MOI = softening and deterioration of the articular cartilagearticular cartilage

Three stages:Three stages: Swelling and softening of cartilageSwelling and softening of cartilage Fissure of softened cartilageFissure of softened cartilage Deformation of cartilage surfaceDeformation of cartilage surface

Often associated with abnormal trackingOften associated with abnormal tracking Abnormal patellar tracking may be due to genu Abnormal patellar tracking may be due to genu

valgum, external tibial torsion, foot pronation, valgum, external tibial torsion, foot pronation, femoral anteversion, patella alta, shallow femoral femoral anteversion, patella alta, shallow femoral groove, increased Q angle, laxity of quad tendongroove, increased Q angle, laxity of quad tendon

Chondromalacia patellaChondromalacia patella

Signs and SymptomsSigns and Symptoms Pain with walking, running, stairs, and squattingPain with walking, running, stairs, and squatting Possible recurrent swellingPossible recurrent swelling Grating sensation with flexion and extensionGrating sensation with flexion and extension Pain at inferior border during palpationPain at inferior border during palpation

ManagementManagement Conservative measuresConservative measures

RICE, NSAID’s, isometrics, orthotics to correct dysfunctionRICE, NSAID’s, isometrics, orthotics to correct dysfunction

Surgical possibilitiesSurgical possibilities Altering muscle attachmentsAltering muscle attachments Shaping and smoothing of surfacesShaping and smoothing of surfaces DrillingDrilling Elevating tibial tubercleElevating tibial tubercle

MOI = lateral deviation of patella while tracking in femoral MOI = lateral deviation of patella while tracking in femoral groovegroove May result due to tight structures, pronation, increased Q angle, May result due to tight structures, pronation, increased Q angle,

insufficient medial musculatureinsufficient medial musculature Signs and SymptomsSigns and Symptoms

Tenderness at lateral facet of patella Tenderness at lateral facet of patella Swelling associated with irritation of synoviumSwelling associated with irritation of synovium Dull ache in center of kneeDull ache in center of knee Patellar compression will elicit pain and crepitusPatellar compression will elicit pain and crepitus Apprehension when patella is forced laterallyApprehension when patella is forced laterally

ManagementManagement Correct imbalances (strength and flexibility)Correct imbalances (strength and flexibility) McConnell tapingMcConnell taping Lateral retinacular release if conservative measures failLateral retinacular release if conservative measures fail

Patellofemoral Stress Patellofemoral Stress SyndromeSyndrome

Osgood Schlatter’s is apophysitis at the tibial Osgood Schlatter’s is apophysitis at the tibial tubercle tubercle MOI = repeated avulsion of patellar tendonMOI = repeated avulsion of patellar tendon Bony callus develops enlarging the tibial tubercleBony callus develops enlarging the tibial tubercle Resolves with agingResolves with aging

Larsen Johansson is the result of excessive Larsen Johansson is the result of excessive pulling on the inferior pole of the patellapulling on the inferior pole of the patella

Osgood-Schlatter Osgood-Schlatter Disease, Larsen-Disease, Larsen-Johansson DiseaseJohansson Disease

Signs and SymptomsSigns and Symptoms SwellingSwelling Hemorrhaging Hemorrhaging Gradual degeneration of the apophysis due to Gradual degeneration of the apophysis due to

impaired circulationimpaired circulation Pain with kneeling, jumping, and runningPain with kneeling, jumping, and running Point tendernessPoint tenderness

ManagementManagement ConservativeConservative Reduce stressful activity Reduce stressful activity Possible castingPossible casting Ice before and after activityIce before and after activity IsometericsIsometerics

MOI = sudden or repetitive extensionMOI = sudden or repetitive extension Jumping or kicking places tremendous strain on patellar or Jumping or kicking places tremendous strain on patellar or

quadriceps tendonquadriceps tendon Signs and SymptomsSigns and Symptoms

Pain and tenderness at inferior pole of patellaPain and tenderness at inferior pole of patella 3 phases: 3 phases:

1) pain after activity, 1) pain after activity, 2) pain during and after activity,2) pain during and after activity, 3) pain during and after activity that may become constant3) pain during and after activity that may become constant

ManagementManagement Ice, phonophoresis, iontophoresis, ultrasound, heatIce, phonophoresis, iontophoresis, ultrasound, heat ExerciseExercise Patellar tendon bracingPatellar tendon bracing Transverse friction massageTransverse friction massage

Patellar TendinitisPatellar Tendinitis (Jumper’s or Kicker’s Knee)(Jumper’s or Kicker’s Knee)

MOI = sudden, powerful quad contractionMOI = sudden, powerful quad contraction Rare unless a chronic inflammatory condition exists Rare unless a chronic inflammatory condition exists

resulting in tissue degenerationresulting in tissue degeneration Occurs primarily at point of attachmentOccurs primarily at point of attachment

Signs and SymptomsSigns and Symptoms Palpable defectPalpable defect Lack of knee extensionLack of knee extension Considerable swelling and pain (initially)Considerable swelling and pain (initially)

ManagementManagement Surgical repair is neededSurgical repair is needed Proper conservative treatment of jumper’s knee can Proper conservative treatment of jumper’s knee can

minimize chances of occurringminimize chances of occurring

Patellar Tendon RupturePatellar Tendon Rupture

MOI = repetitive/overuse conditions attributed to MOI = repetitive/overuse conditions attributed to mal-alignment and structural asymmetriesmal-alignment and structural asymmetries

Signs and SymptomsSigns and Symptoms IT Band Friction SyndromeIT Band Friction Syndrome

Irritation at band’s insertion Irritation at band’s insertion Commonly seen in individual that have genu varum or Commonly seen in individual that have genu varum or

pronated feetpronated feet Pes Anserine Tendinitis or BursitisPes Anserine Tendinitis or Bursitis

Result of excessive genu valgum and weak vastus medialisResult of excessive genu valgum and weak vastus medialis Often occurs due to running with one leg higher than the Often occurs due to running with one leg higher than the

other other Running on a slope or crowned roadRunning on a slope or crowned road

Runner’s Knee & Runner’s Knee & Cyclist’s KneeCyclist’s Knee

ManagementManagement Correction of mal-alignmentsCorrection of mal-alignments Ice before and after activityIce before and after activity Utilize proper warm-up and stretching techniquesUtilize proper warm-up and stretching techniques Avoidance of aggravating activitiesAvoidance of aggravating activities NSAID’s NSAID’s OrthoticsOrthotics

Giving way of knee Giving way of knee Result of… Result of…

Weak quadricepsWeak quadriceps Chronic instability of ligamentous structuresChronic instability of ligamentous structures Torn meniscusTorn meniscus Loose bodies within the kneeLoose bodies within the knee Subluxating patellaSubluxating patella ChondromalaciaChondromalacia Due to painDue to pain

The Collapsing KneeThe Collapsing Knee

Prevention of Knee Prevention of Knee InjuriesInjuries

Total body conditioning is requiredTotal body conditioning is required Strength, flexibility, cardiovascular and Strength, flexibility, cardiovascular and

muscular endurance, agility, speed and muscular endurance, agility, speed and balancebalance

Muscles around joint must be conditioned Muscles around joint must be conditioned to maximize stabilityto maximize stability Flexibility and strengtheningFlexibility and strengthening

Must avoid abnormal muscle action Must avoid abnormal muscle action through flexibilitythrough flexibility

ACL Prevention ProgramsACL Prevention Programs Focus on strength, neuromuscular control, Focus on strength, neuromuscular control,

and balanceand balance Series of different programs which address Series of different programs which address

balance board training, landing strategies, balance board training, landing strategies, plyometric training, and single leg plyometric training, and single leg performanceperformance

Can be implemented in rehabilitation and Can be implemented in rehabilitation and preventative training programspreventative training programs

Shoe TypeShoe Type Change in football footwear has drastically Change in football footwear has drastically

reduced the incidence of knee injuriesreduced the incidence of knee injuries Shoes with more short cleats does not allow Shoes with more short cleats does not allow

foot to become fixed foot to become fixed Still allows for control during running and cuttingStill allows for control during running and cutting

Functional and Prophylactic Functional and Prophylactic Knee BracesKnee Braces Used to protect MCLUsed to protect MCL Used to prevent further Used to prevent further

damage to grade 1 and grade damage to grade 1 and grade 2 ACL sprains 2 ACL sprains

Used to protect the ACL Used to protect the ACL following surgeryfollowing surgery

Can be custom molded and Can be custom molded and designed to control rotational designed to control rotational forcesforces

Knee Joint Knee Joint RehabilitationRehabilitation General Body ConditioningGeneral Body Conditioning

Must be maintained with non-weight bearing activitiesMust be maintained with non-weight bearing activities Weight BearingWeight Bearing

Initial crutch use, non-weight bearingInitial crutch use, non-weight bearing Gradual progression to weight bearing while wearing Gradual progression to weight bearing while wearing

rehabilitative bracerehabilitative brace Knee Joint MobilizationKnee Joint Mobilization

Used to reduce arthrofibrosisUsed to reduce arthrofibrosis Patellar mobilization is key following surgeryPatellar mobilization is key following surgery CPM unitsCPM units

FlexibilityFlexibility Must be regained, maintained, and improvedMust be regained, maintained, and improved

Muscular StrengthMuscular Strength Progression of isometrics, isotonics, Progression of isometrics, isotonics,

isokinetics, and plyometricsisokinetics, and plyometrics Incorporate eccentric muscle actionIncorporate eccentric muscle action Open vs. closed kinetic chain exercisesOpen vs. closed kinetic chain exercises

Neuromuscular ControlNeuromuscular Control Loss of control is generally due to pain and Loss of control is generally due to pain and

swellingswelling Through exercise and balance equipment Through exercise and balance equipment

proprioception can be enhanced and regainedproprioception can be enhanced and regained

BracingBracing Variety of braces Variety of braces

Some used to control for specific injuries while Some used to control for specific injuries while others are designed for specific forces, stability, others are designed for specific forces, stability, and providing resistanceand providing resistance

Typically worn for 3-6 weeks after surgeryTypically worn for 3-6 weeks after surgery Used to limit ROM for a period of time Used to limit ROM for a period of time

Functional ProgressionFunctional Progression Gradual return to sports specific skillsGradual return to sports specific skills Progress with weight bearing, move into Progress with weight bearing, move into

walking and running, and then onto sprinting walking and running, and then onto sprinting and change of directionand change of direction

Return to ActivityReturn to Activity Based on healing process Based on healing process

Sufficient time for healing must be allowedSufficient time for healing must be allowed

Objective criteria should include…Objective criteria should include… Strength assessmentStrength assessment ROM measuresROM measures Functional performance testsFunctional performance tests

SummarySummary

Review anatomyReview anatomy AssessmentAssessment

History, observation, palpationHistory, observation, palpation Special TestsSpecial Tests

Injury preventionInjury prevention Injury recognitionInjury recognition RehabilitationRehabilitation