the knee lecture 11. the knee complex the knee is a large complex joint frequently injured during...
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The KneeLecture 11
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The Knee Complex
the knee is a large complex joint frequently injured during sport participation
the knee is positioned between the two longest bones in the body - the femur and the tibia creating potential for high torque’s
this factor coupled with poor bony stability makes the knee very susceptible to injury
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Tibiofemoral Joint
articulation of the distal femur and proximal tibia form a modified hinge joint
movement in 2 planes - Flex /Ext , lnt /Ext rotation
because of the size and shape of the condyles the tibia can rotate on the femur
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this lateral rotation of the tibia on the femur (only a few degrees) provides a locking of the knee or a "screwing-home mechanism"
stability and support provided by menisci and supportive ligaments
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Menisci are fibrocartilage discs that are attached
to the tibia by coronary ligaments and joint capsule
they are thicker along the lateral margin and thinner medially
- the medial meniscus is injured more frequently than the lateral meniscus
blood supply only in outer 1/3 of meniscus
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Medial Meniscus 'C' shaped, strongly
attached to the tibial surface therefore less mobile
one reason injured more often
also attached to the joint capsule (medially)
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Lateral Meniscus more complete
( almost circle shaped) loosely attached to
tibial surface - less commonly injured
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Functions of the Menisci
stability - deepens socket and wedge shaped to prevent A-P motion
-increase surface area of femoral condyles
shock absorption provide nutrition because it promotes
synovial fluid flow and distribution - proprioception function through its innervation
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Meniscal Tears
associated with ligaments disruptions, degenerative changes, repetitive stress secondary to chronic ligamentous laxity, isolated or repetitive rotational stresses
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Ligaments of the Knee
the stabilizing role of the ligaments that cross the knee is very significant
two major ligaments are the anterior and posterior cruciates ( called cruciate because they cross each other inside the knee joint)
two other ligaments are the medial and lateral collateral ligaments
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Anterior Cruciate Ligament separated into to bundles according to
their functions, ( not really separate) spiral around one another, insert as one
board ligament spiral arrangement plus the broad attachment allow ACL to provide stability through out the full ROM
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ACL most common and serious injury to the knee
susceptible to injury with a valgus force, external rotation strong quad contraction of knee hyperextension
ACL is subject to deceleration injuries , internal tibial torque is the most dangerous loading mechanism, particularly when combined with an anterior tibial force
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Posterior Cruciate Ligament
not as commonly injured as ACL stronger and shorter than the ACL prevents posterior tibial translation and
knee hyperextension common mechanism collision or fall on
tibial tuberosity
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Medial Collateral Ligament
provide valgus, external rot support (note ACL is also very imp in this function)
basically a thickening of the medial capsule
superficial layer and a deep layer
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Lateral Collateral Ligament
cord like structure considered to be extra capsular
less commonly injured b/c of varus mechanism and less debilitating
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Dynamic Knee Support
ITB, hamstrings, quads , gracilis , gastroc the key to injury rehab and prevention
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Bursae Suprapatellar, prepatellar, superficial
infrapatellar and deep infrapatellar i) suprapatellar largest in the body lies
between the femur and the quads tendon of the rectus femoris
ii) prepatellar - located between skin and anterior surface of patella
allowing for movement of then skin over the patella
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iii) superficial infrapatellar - located between the skin and the patellar tendon
-inflammation this are due to excessive kneeling referred to as housemaid's knee
iv) deep infrapatellar - located between the tibial tuberosity and the patellar tendon
reduces friction between tendon and bony tuberosity
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Patellofemoral Joint patella articulates
with the femur
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Patella largest sesamiod bone in the body located within the quads tendon articulates with the femoral condyles patella facets -under surface of patella
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Common Injuries to the Knee
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1) Contusions and Bursitis result from a compressive force - a fall ,
a kick generally they are locally tender, with
pain, swelling and ecchymosis Bursitis - may be caused by a direct
trauma or possibly infection swelling usually occurs over a 24 hour
period Rx - PIER - protection - may need
draining but this may add complications
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2) Ligament Injuriesone plane instabilities
i) MCL pain and swelling usually found along
the medial joint line ii) LCL pain and swelling are found on the
lateral aspect of the knee
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MCL injuries
straight lateral forces or valgus causes tension on the MCL
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Signs and symptoms
medial knee pain Swelling Medial joint laxity RX - PIER, hinge knee brace for stability , crutches , most MCL injuries are treated non surgically
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http://www.youtube.com/watch?v=_fxKCDkOiJs&feature=related
http://www.youtube.com/watch?v=ubP-1WaFeEc&feature=related
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LCL injuries
medial forces or varus force produces tension on the LCL
Much rarer injury than MCL
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Signs and symptoms
Lateral knee pain Localized swellingLateral joint laxity RX: PIER, hinge knee brace for stability , crutches , most LCL injuries are treated non surgically
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ACL injuries
ACL prevents forward translation of the tibia on the femur, also assists with controlling valgus and varus forces , and helps prevent hyperextension
MOI : damage to the ACL usually results from a cutting or turning maneuver, landing off balance or a sudden deceleration
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s/s Pain , instability , swelling , may often hear
or fell a pop in the knee, decreased ROM and function
pain described as being felt deep in the knee or on either side of the patellar tendon
joint effusion is usually bloody and fairly rapid onset
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PCL injury
PCl prevents the tibia from moving posterior on the femur
MOI: a direct blow to the anterior tibia ( dashboard injury) , or hyperflexion or hyperextension
s/s Large tense knee effusion Discomfort attempting to flex the knee beyond 90
degrees RX: PIER, crutches , referral to surgeon , however this is
not often repairs..
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Multidirectional Instabilities – injuries to multiple structures
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http://www.youtube.com/watch?v=6evRcL3QMns
http://www.youtube.com/watch?v=uuoj_HFG5Z0&NR=1
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First Aid Care ( knee ligaments )
Apply ice and compression immediately , brace to protect , crutches
If knee unstable , have athlete seek proper medical advice
Most ACL tears are referred to a orthopedic surgeon, due to the continued instability of the knee
Repairs….
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3) Meniscal Injuries compression, tensile and shearing force
often cause damage to the mensci tears may be - longitudinal , bucket handle
, horizontal or parrot-beak medial mensicus is more often damaged more common in men between the age of
21-40 and women between 11- 20 joint line pain and general joint effusion,
pain with rotations and extreme flexion
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individual may experience clicking , popping or grinding
the knee may give way or buckle the individual may have difficulty doing
squats and or duck walking the meniscal tear may lodge in the joint
causing locking surgery is usually necessary to unlock this
condition mensici become stiffer and less resilient with age
RX – PIER – rest and time possibly surgery
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First Aid Care
Apply ice and compression immediately ,, crutches
If knee blocked or locked , have athlete seek proper medical advice ASAP
Repairs….
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4) Patellofemoral Stress Syndrome
usually caused by weakness in the VMO or lateral retinaculum is too tight
this condition is more commonly found in women due to a higher Q angle
Q angle is the angle between the line of the quads ( RF) and the patellar tendon
a Q-angle of less than 13 and more than 18 may predispose the athlete to PFS
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pain may be dull and aching generally in the centre of the knee or on lateral edge of patella
point tenderness usually over lateral edge of patella, often associated with anterior knee pain
crepitus or grinding often present - especially upon compression of the patella
Rx - PIER - NSIADS -taping- VMO strengthening , education
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5) Subluxation or Dislocation of Patella commonly occurs during
deceleration or cutting maneuver
patella moves laterally and may tear medial retinaculum
leading to an audible pop and a collapse of the knee
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the patella may remain displaced or reduce itself
may need to be reduced by doctor pain and swelling , Rx- PIER, immobilization, exercise and
education
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First Aid Care
Apply ice and compression immediately , splint leg, crutches
Arrange transportation to nearest medical facility
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6) Patella Tendinitis
aka jumpers knee patellar tendon
becomes inflamed and tender from repeated jumping (eccentric knee extension activities)
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pain located on inferior pole of patella pain increases on stairs, after prolonged
sitting and during resisted knee extension as condition worsens time and duration of
pain may change or worsen Rx- PIER, NSAIDS, modalities, exercise
and stretching..
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7) Osgood-Schlatter Disease traction type injury to the tibial tuberosity
where the patellar tendon inserts more common in boys aged 10-15 pain and swelling are present with
activity usually diminish with rest in cases with long duration the tibial
tuberosity may become enlarged
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condition usually rectifies itself (within 12 to 24 months) with age and closure of the growth plate
Rx – symptomatic and self limiting
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8) Unhappy triad Medial meniscus Anterior cruciate ligament and Medial collateral ligament
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Possible Factors Influencing Increased rate of ACL injuries in Women
Intrinsic Factors Ligament size Ligament laxity Intercondylar notch dimensions Limb alignment ( wider pelvis, genu
valgum , external tibial torsion) Estrogen levels
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Extrinisic Factors Level of skill Level of experience Shoe friction Ankle braces Stylistic differences in sport play
Plant and cut, straight leg landing, one step stop landing , pivoting with sudden deceleration
Muscle strength imbalances (eccentric hamstrings strength relative to eccentric quad strength )