Chapter 20: The Knee and
Related Structures
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Complex joint that endures great
amounts of trauma due to extreme
amounts of stress that are regularly
applied
• Hinge joint w/ a rotational component
• Stability is due primarily to ligaments,
joint capsule and muscles surrounding
the joint
• Designed for stability w/ weight bearing
and mobility in locomotion
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-1
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-2
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-3 A-B
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-3 C
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-4
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-5 A & B
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-5C
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-6
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-7
© 2011 McGraw-Hill Higher Education. All rights reserved.
Functional Anatomy
• Movement of the knee requires flexion,
extension, rotation and the
arthrokinematic motions of rolling and
gliding
• Rotational component involves the
“screw home mechanism”
– As the knee extends it externally rotates
because the medial femoral condyle is larger
than the lateral
– Provides increased stability to the knee
– Popliteus “unlocks” knee allowing knee to flex
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Capsular ligaments are taut during full
extension and relaxed w/ flexion
– Allows rotation to occur
• Deeper capsular ligaments remain taut to
keep rotation in check
• PCL prevents excessive internal rotation,
limits anterior translation and posterior
translation when tibia is fixed and non-weight
bearing, respectively
• ACL stops excessive internal rotation,
stabilizes the knee in full extension and
prevents hyperextension
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Range of motion includes 140 degrees of
motion
– Limited by shortened position of hamstrings,
bulk of hamstrings and extensibility of quads
• Patella aids knee during extension, providing a
mechanical advantage
– Distributes compressive stress on the femur
by increasing contact between patellar
tendon and femur
– Protects patellar tendon against friction
– When moving from extension to flexion the
patella glides laterally and further into
trochlear groove
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Kinetic Chain
– Directly affected by motions and forces
occurring at the foot, ankle, lower leg,
thigh, hip, pelvis, and spine
– With the kinetic chain forces must be
absorbed and distributed
– If body is unable to manage forces,
breakdown to the system occurs
– Knee is very susceptible to injury resulting
from absorption of forces
© 2011 McGraw-Hill Higher Education. All rights reserved.
Assessing the Knee Joint
• Determining the mechanism of injury is
critical
• History- Current Injury
–
–
–
–
–
Past history
Mechanism- what position was your body in?
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
© 2011 McGraw-Hill Higher Education. All rights reserved.
• 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?
© 2011 McGraw-Hill Higher Education. All rights reserved.
• 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
– May cause a combination of problems
• Tibial torsion, femoral anteversion and
retroversion
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-10 & 11
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-12 & 13
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Tibial torsion
– An angle that
measures less than 15
degrees is an
indication of tibial
torsion
• Femoral Anteversion
and Retroversion
– Total rotation of the hip
equals ~100 degrees
– If the hip rotates >70
degrees internally,
anteversion of the hip
may exist
Figure 20-9
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-14
© 2011 McGraw-Hill Higher Education. All rights reserved.
– 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
© 2011 McGraw-Hill Higher Education. All rights reserved.
•Palpation - Bony
• Medial tibial plateau
• Medial femoral
condyle
• Adductor tubercle
• Gerdy’s tubercle
• Lateral tibial plateau
• Lateral femoral
condyle
• Lateral epicondyle
• Medial epicondyle
•
•
•
•
Head of fibula
Tibial tuberosity
Patella
Superior and inferior
patella borders (base
and apex)
• Around the periphery
of the knee relaxed, in
full flexion and
extension
© 2011 McGraw-Hill Higher Education. All rights reserved.
•Palpation - Soft Tissue
•
•
•
•
•
•
•
•
•
Vastus medialis
Vastus lateralis
Rectus femoris
Quadriceps and
patellar tendon
Sartorius
Medial patellar plica
Anterior joint
capsule
Iliotibial Band
Arcuate complex
• Medial and lateral
collateral ligaments
• Pes anserine
• Medial/lateral joint
capsule
• Semitendinosus
• Semimembranosus
• Gastrocnemius
• Popliteus
• Biceps Femoris
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Palpation of Swelling
– Intra vs. extracapsular swelling
– Intracapsular may be referred to as joint
effusion
– Swelling w/in the joint that is caused by
synovial fluid and blood is a hemarthrosis
– Sweep maneuver
– Ballotable patella - sign of joint effusion
– Extracapsular swelling tends to localize over
the injured structure
• May ultimately migrate down to foot and
ankle
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Special Tests for Knee Instability
– Use endpoint feel to determine stability
– MRI may also be necessary for
assessment
– Classification of Joint Instability
• Knee laxity includes both straight and rotary
instability
• Translation (tibial translation) refers to the glide
of tibial plateau relative to the femoral condyles
• As the damage to stabilization structures
increases, laxity and translation also increase
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Collateral Ligament
Stress Tests
(Valgus and Varus)
• Used to assess the
integrity of the MCL
and LCL
respectively
• Testing at 0 degrees
incorporates
capsular testing
while testing at 30
degrees of flexion
isolates the
ligaments
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Anterior Cruciate Ligament Tests
• Drawer test at 90 degrees of flexion
– Tibia sliding forward from under the femur is
considered a positive sign (ACL)
– Should be performed w/ knee internally and
externally to test integrity of joint capsule
Figure 20-18
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Lachman Drawer
Test
– Will not force knee
into painful flexion
immediately after
injury
– Reduces hamstring
involvement
– At 30 degrees of
flexion an attempt is
made to translate the
tibia anteriorly on the
femur
– A positive test
indicates damage to
the ACL
Figure 20-19
© 2011 McGraw-Hill Higher Education. All rights reserved.
• A series of variations are also available
for the Lachman Drawer Test
– May be necessary if athlete is large or
examiner’s hands are small
– Variations include
• Rolled towel under the femur
• Leg off the table approach with athlete supine
• Athlete prone on table with knee and lower leg
just off table
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Pivot Shift Test
– Used to determine
anterolateral rotary
instability
– Position starts w/ knee
extended and leg
internally rotated
– The thigh and knee are
then flexed w/ a valgus
stress applied to the
knee
– Reduction of the tibial
plateau (producing a
clunk) is a positive sign
– Slocum’s test is variation
on the pivot shift
Figure 20-20
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Jerk Test
– Reverses direction of the pivot shift
– Moves from position of flexion to extension
– W/out an ACL the tibia will sublux at 20
degrees of flexion
Figure 20-21
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Flexion-Rotation Drawer Test
– Knee is taken from a position of 15 degrees of
flexion (tibia is subluxed anteriorly w/ femur
externally rotated)
– Knee is moved into 30 degrees of flexion
where tibia rotates posteriorly and femur
internally rotates
Figure 20-22
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Losee’s Test
– Similar to flexionreduction drawer test
– Performed side-lying
– Begins with knee at 45
degrees of flexion and
external tibial rotation
– Knee is subluxed
anteriorly
– As the knee is
extended it reduces
Figure 20-22
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Posterior Cruciate Ligament Tests
– Posterior Drawer Test
• Knee is flexed at 90 degrees and a posterior
force is applied to determine translation
posteriorly
• Positive sign indicates a PCL deficient knee
– External Rotation Recurvatum Test
• With the athlete supine, the leg is lifted by the
great toe
• If the tibia externally rotates and slides
posteriorly there may be a PCL injury and
damage to the posterolateral corner of the
capsule
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Posterior Sag
Test (Godfrey’s
test)
– Athlete is supine
w/ both knees
flexed to 90
degrees
– Lateral
observation is
required to
determine extent
of posterior sag
while comparing
bilaterally
Figure 20-25
© 2011 McGraw-Hill Higher Education. All rights reserved.
•Instrument Assessment of the Cruciate
Ligaments
• A number of devices
are available to quantify
AP displacement of the
knee
• KT-2000 arthrometer,
Stryker knee laxity
tester and Genucom
can be used to assess
the knee
• Test can be taken pre &
post-operatively and
throughout rehabilitation
Figure 20-26
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Meniscal Tests
– McMurray’s Meniscal Test
• Used to determine displaceable meniscal tear
• Leg is moved into flexion and extension while
knee is internally and externally rotated in
conjunction w/ valgus and varus stressing
• A positive test is found when clicking and
popping are felt
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-27
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Apley’s
Compression Test
– Hard downward
pressure is applied
w/ rotation
– Pain indicates a
meniscal injury
• Apley’s Distraction
Test
– Traction is applied w/
rotation
– Pain will occur if
there is damage to
the capsule or
ligaments
– No pain will occur if it
is meniscal
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Thessaly Test
– Patient stands on one leg
– Tested with knee flexed to
5 degrees and 20 degrees
– Patient then rotates trunk
and knee into internal and
external rotation, with
clinician supporting patient
– Positive test results in pain
along medial or lateral joint
line
– Perform test on healthy
side first for comparison
Figure 20-29
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Girth Measurements
– Changes in girth can occur due to atrophy,
swelling and conditioning
– Must use circumferential measures to
determine deficits and gains during the
rehabilitation process
– Measurements should be taken at the joint
line, the level of the tibial tubercle, belly of
the gastrocnemius, 2 cm above the
superior border of the patella, and 8-10 cm
above the joint line
• Subjective Rating
– Used to determine patient’s perception of
pain, stability and functional performance
© 2011 McGraw-Hill Higher Education. All rights reserved.
Patellar Examination
• Palpation of the Patella
– Must palpate around and under patella to
determine points of pain
• Patella Grinding, Compression and
Apprehension Tests
– A series of glides and compressions are
performed w/ the patella to determine
integrity of patellar cartilage
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Patella Grinding, Compression and Apprehension Tests
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Q-Angle
– Lines which bisect the patella relative to the
ASIS and the tibial tubercle
– Normal angle is 10 degrees for males and 15
degrees for females
– Elevated angles often lead to pathological
conditions associated w/ improper patella
tracking
• The A - Angle
– Patellar orientation to the tibial tubercle
– Quantitative measure of the patellar realignment
after rehabilitation
– An angle greater than 35 degrees is often
correlated w/ patellofemoral pathomechanics
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Functional Examination
– Must assess walking, running, turning and
cutting
– Co-contraction test, vertical jump, single
leg hop tests and the duck walk
– Resistive strength testing
– Tests should be performed at speed w/out
limping or favoring injured limb
– Use baseline for comparison if available
© 2011 McGraw-Hill Higher Education. All rights reserved.
Prevention of Knee Injuries
• Physical Conditioning and Rehabilitation
– Total body conditioning is required
• Strength, flexibility, cardiovascular and
muscular endurance, agility, speed and
balance
– Muscles around joint must be conditioned
(flexibility and strength) to maximize stability
– Must avoid abnormal muscle action through
flexibility
– In an effort to prevent injury, extensibility of
hamstrings, erector spinae, groin, quadriceps
and gastrocnemius is important
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Decreasing the Risk for ACL Injury
– Focus on strength, neuromuscular control,
balance
– Series of different programs which address
balance board training, landing strategies,
plyometric training, and single leg
performance
– Can be implemented in rehabilitation and
preventative training programs
• Shoe Type
– Change in football footwear has drastically
reduced the incidence of knee injuries
– Shoes w/ more short cleats does not allow foot
to become fixed - still allows for control w/
running and cutting
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Functional and
Prophylactic Knee Braces
– Used to prevent and
reduce severity of knee
injuries
– Used to protect MCL,
or prevent further
damage to grade 1 & 2
sprains of the ACL or
to protect the ACL
following surgery
– Can be custom molded
and designed to control
rotational forces
Figure 20-37
© 2011 McGraw-Hill Higher Education. All rights reserved.
Recognition and Management
of Specific Injuries
• Medial Collateral Ligament Sprain
– Etiology
• Result of severe blow from lateral side (valgus
force)
– Signs and Symptoms - Grade I
• Little fiber tearing or stretching
• Stable valgus test
• Little or no joint effusion
• Some joint stiffness and point tenderness on
lateral aspect
• Relatively normal ROM
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Management
• RICE for at least 24
hours
• Crutches if necessary
• Follow-up care will
include cryokinetics w/
exercise
• Move from isometrics
and STLR exercises to
bicycle riding and
isokinetics
• Return to play when all
areas have returned to
normal
• May require 3 weeks to
recover
Figure 20-38
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Signs and Symptoms (Grade II)
• Complete tear of deep capsular ligament and partial tear of
superficial layer of MCL
• No gross instability; laxity at 5-15 degrees of flexion
• Slight swelling
• Moderate to severe joint tightness w/ decreased ROM
• Pain along medial aspect of knee
– Management
• RICE for 48-72 hours; crutch use until acute 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
© 2011 McGraw-Hill Higher Education. All rights reserved.
Grade 1
Grade 2
Grade 3
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Signs and Symptoms (Grade III)
•
•
•
•
•
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
– Management
• RICE
• Conservative non-operative versus surgical
approach
– Limited immobilization (w/ a brace);
progressive weight bearing and increased
ROM over 4-6 week period
• Rehab would be similar to Grade I & II injuries
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Lateral Collateral
Ligament Sprain
– Etiology
• Result of a varus force,
generally w/ the tibia
internally rotated
• If severe enough damage
can also occur to the
cruciate ligaments, ITB, and
meniscus, producing bony
fragments as well
Figure 20-41
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Lateral Collateral Ligament Sprain
– Signs and Symptoms
•
•
•
•
Pain and tenderness over LCL
Swelling and effusion around the LCL
Joint laxity w/ varus testing
May cause irritation of the peroneal nerve
– Management
– Follows management of MCL injuries depending on
severity
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Anterior Cruciate Ligament Sprain
– Etiology
• MOI - tibia externally rotated and valgus force at the
knee (occasionally the result of hyperextension
from direct blow)
• May be linked to inability to decelerate valgus and
rotational stresses - landing strategies
• Male versus female
• Research is quite extensive in regards to impact of
femoral notch, ACL size and laxity, malalignments
(Q-angle) & 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
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Signs and Symptoms
– Experience pop w/ severe
pain and disability
– Positive anterior drawer and
Lachman’s
– Rapid swelling at the joint
line
– Other ACL tests may also be
positive
Figure 20-42
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Management
– RICE; use of crutches
– Arthroscopy may be necessary to determine
extent of injury
– Could lead to major instability in incidence of
high performance
– W/out surgery joint degeneration may result
– Age and activity may factor into surgical option
– Surgery may involve joint reconstruction w/
grafts (tendon), transplantation of external
structures
• Will require brief hospital stay and 3-5
weeks of a brace
• Also requires 4-6 months of rehab
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Posterior Cruciate
Ligament Sprain
– Etiology
• Most at risk during 90
degrees of flexion
• Fall on bent knee is most
common mechanism
• Can also be damaged as
a result of a rotational
force
• Sometimes referred to as
a “dashboard injury”
– May result when flexed
knee of car driver or
passenger hits the
dashboard
Figure 20-43
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Signs and Symptoms
• Feel a pop in the back of the knee
• Tenderness and relatively little swelling in
the popliteal fossa
• Laxity w/ posterior sag test
– Management
• RICE
• Non-operative rehab of grade I and II injuries
should focus on quad strength
• Surgical versus non-operative
– Surgery will require 6 weeks of immobilization in
extension w/ full weight bearing on crutches
– ROM after 6 weeks and PRE at 4 months
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Meniscal Lesions
– Etiology
• Medial meniscus is more
commonly injured due to
ligamentous attachments
and decreased mobility
– Also more prone to
disruption through torsional
and valgus forces
• Most common MOI is
rotary force w/ knee flexed
or extended
• Tears may be longitudinal,
oblique or transverse
Figure 20-44
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Signs and Symptoms
•
•
•
•
•
Effusion developing over 48-72 hour period
Joint line pain and loss of motion
Intermittent locking and giving way
Pain w/ squatting
Portions may become detached causing
locking, giving way or catching w/in the joint
• If chronic, recurrent swelling or muscle atrophy
may occur
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Management
• If the knee is not locked, but indications of a
tear are present further diagnostic testing may
be required
• If locking occurs, anesthesia may be necessary
to unlock the joint w/ possible arthroscopic
surgery follow-up
• W/ surgery all efforts are made to preserve the
meniscus -- with full healing being dependent
on location
• Meniscectomy rehab allows partial weight
bearing and quick return to activity
• Repaired meniscus will require immobilization
and a gradual return to activity over the course
of 12 weeks
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Knee Plica
– Etiology
• Irritation of the plica (generally,
mediopatellar plica and often associated
w/ chondromalacia)
– Signs and Symptoms
• Possible history of knee pain/injury
• Recurrent episodes of painful pseudolocking
• Possible snapping and popping
• Pain w/ stairs and squatting
• Little or no swelling, and no ligamentous
laxity
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Management
– Treat
conservatively w/
RICE and
NSAID’s if the
result of trauma
– Recurrent
conditions may
require surgery
Medial
Patellar Plica
Figure 20-45
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Osteochondral Knee Fractures
– Etiology
• Same MOI as collateral/cruciate ligaments or
meniscal injuries
• Twisting, sudden cutting or direct blow
• Fractures of cartilage and underlying bone
varying in size and depth
– Signs and Symptoms
• Hear a snap and feeling of giving way
• Immediate swelling and considerable pain
• Diffuse, pain along joint line
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Management
• Diagnosed through use of CT and MRI
• Treatment dependent on stability of fracture
• If stable the patient will be casted
• If fragment is loose surgical reattachment will occur
or removal via arthroscopic
• Microfracture procedures used to repair defects in
underlying bone
– Generates small amounts of bleeding to
stimulate bone growth and healing
• Rehabilitation is dependent on location of fracture
• ROM is typically initiated early after surgery with
active strengthening beginning after
6 weeks
• Return to activity at 3-6 months
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Osteochondritis Dissecans
– Etiology
• Partial or complete separation of articular
cartilage and subchondral bone
• 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
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Signs and Symptoms
• Aching pain with recurrent swelling and
possible locking
• Possible quadriceps atrophy and point
tenderness
– Management
• Rest and immobilization for children
• Surgery may be necessary in teenagers and
adults (drilling to stimulate healing, pinning or
bone grafts)
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Joint Contusions
– Etiology
• Blow to the muscles crossing the joint (vastus
medialis)
– Signs and Symptoms
• Present as knee sprain, severe pain, loss of
movement and signs of acute inflammation
• Swelling, discoloration
• Possible capsular damage
– Management
• RICE initially and continue if swelling persists
• Gradual progression to normal activity following
return of ROM and padding for protection
• If swelling does not resolve w/in a week a chronic
condition (synovitis or bursitis) may exist requiring
more rest
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Peroneal Nerve Contusion
– Etiology
• Compression of peroneal nerve due to a direct blow
– Signs and Symptoms
• Local pain and possible shooting nerve pain
• Numbness and paresthesia in cutaneous
distribution of the nerve
• Added pressure may exacerbate condition
• Generally resolves quickly -- in the event it does not
resolve, it could result in drop foot
– Management
• RICE and return to play once symptoms resolve
and no weakness is present
• Padding for fibular head is necessary for a few
weeks
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Bursitis
– Etiology
• Acute, chronic or recurrent swelling
• Prepatellar = continued kneeling
• Infrapatellar = overuse of patellar tendon
– Signs and Symptoms
• Prepatellar bursitis may be localized swelling above
knee that is ballotable
• Swelling in popliteal fossa may indicate a Baker’s
cyst
– Associated w/ semimembranosus bursa or medial
head of gastrocnemius
– Commonly painless and causing little disability
– May progress and should be treated accordingly
– Management
• Eliminate cause, RICE and NSAID’s
• Aspiration and steroid injection if chronic
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-47
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Patellar Fracture
– Etiology
• Direct or indirect trauma (severe pull of
tendon)
• Semi-flexed position with forcible
contraction (falling, jumping or running)
– Signs and Symptoms
• Hemorrhaging and joint effusion w/
generalized swelling
• Indirect fractures may cause capsular
tearing, separation of bone fragments
and possible quadriceps tendon tearing
• Little bone separation w/ direct injury
– Management
Figure 20-47
• X-ray necessary for confirmation of
findings
• RICE and splinting if fracture suspected
• Refer and immobilize for 2-3 months
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Acute Patella Subluxation or
Dislocation
– Etiology
• Deceleration w/ simultaneous cutting
in opposite direction (valgus force at
knee)
• Quad pulls the patella out of alignment
• Some individuals may be predisposed
• Repetitive subluxation will stress
medial restraints
– Signs and Symptoms
• W/ subluxation, pain and swelling,
restricted ROM, palpable tenderness
over adductor tubercle
• Results in total loss of function
Figure 20-49
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Management
• Reduction is performed by flexing hip, moving
patella medially and slowly extending the knee
• Following reduction, immobilization for at least
4 weeks w/ use of crutches and isometric
exercises during this period
• After immobilization period, horseshoe pad w/
elastic wrap should be used to support patella
• Muscle rehab focusing on muscle around the
knee, thigh and hip are key (STLR’s are optimal
for the knee)
• Possible surgery to release tight structures
• Improve postural and biomechanical factors
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Injury to the Infrapatellar Fat Pad
– Etiology
• May become 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 (especially
during knee extension)
• May display weakness, mild swelling and
stiffness during movement
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Injury to the Infrapatellar Fat Pad
(continued)
– Management
• Rest from irritating activities until inflammation
has subsided
• Utilize therapeutic modalities for inflammation
• Heel lift to prevent irritation during extension
• Hyperextension taping to prevent full extension
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Chondromalacia patella
– Etiology
• Softening and deterioration of the articular
cartilage
• Undergoes 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
© 2011 McGraw-Hill Higher Education. All rights reserved.
Chondromalacia
Figure 20-51
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Signs and Symptoms
• Pain w/ walking, running, stairs and squatting
• Possible recurrent swelling, grating sensation
w/ flexion and extension
• Pain at inferior border during palpation
– Management
• Conservative measures
– RICE, NSAID’s, isometrics, orthotics to correct
dysfunction
• Surgical possibilities
–
–
–
–
Altering muscle attachments
Shaping and smoothing of surfaces
Drilling
Elevating tibial tubercle
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Patellofemoral Stress Syndrome
– Etiology
• Result of lateral deviation of patella while tracking in
femoral groove
– Tight structures, pronation, increased Q angle, insufficient
medial musculature
– Signs and Symptoms
• Tenderness of lateral facet of patella and swelling
associated w/ 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
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Osgood-Schlatter Disease and LarsenJohansson Disease
– Etiology
• Osgood Schlatter’s is an apophysitis occurring at
the tibial tubercle
– Begins cartilaginous and develops a bony callus,
enlarging the tubercle
– Resolves w/ aging
– Common cause = repeated avulsion of patellar tendon
• Larsen Johansson is the result of excessive
pulling on the inferior pole of the patella
– Signs and Symptoms
• Both elicit swelling, hemorrhaging and gradual
degeneration of the apophysis due to impaired
circulation
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-53
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Signs and Symptoms (continued)
• Pain w/ kneeling, jumping and running
• Point tenderness
– Management
• Conservative
– Reduce stressful activity until union occurs
(6-12 months)
– Possible casting, ice before and after activity
– Isometrics for quadriceps and hamstrings
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Patellar Tendinitis (Jumper’s or Kicker’s Knee)
– Etiology
• Jumping or kicking - placing tremendous stress and strain
on patellar or quadriceps tendon
• Sudden or repetitive extension
– Signs and Symptoms
• Pain and tenderness at inferior pole of patella
– 3 phases - 1)pain after activity, 2)pain during and after,
3)pain during and after (possibly prolonged) and may
become constant
– Management
•
•
•
•
Ice, phonophoresis, iontophoresis, ultrasound, heat
Exercise
Patellar tendon bracing
Transverse friction massage
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-54
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Patellar Tendon Rupture
– Etiology
• Sudden, powerful quad contraction
• Generally does not occur unless a chronic
inflammatory condition persists resulting in tissue
degeneration
• Occur 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 care of jumper’s knee can
minimize chances of occurring
• If steroids are being used, intense knee exercise
should be avoided due to weakening of collagen
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Iliotibial Band Friction Syndrome (Runner’s
Knee or Cyclist’s Knee)
– Etiology
• General expression for repetitive/overuse
conditions attributed to mal-alignment and
structural asymmetries
– Signs and Symptoms
• IT Band Friction Syndrome
– Irritation at band’s insertion - commonly seen in individual
that have genu varum or pronated feet
– Positive Ober’s test
• Pes Anserine Tendinitis or Bursitis
– Result of excessive genu valgum and weak vastus
medialis
– Often occurs due to running w/ one leg higher than the
other (running on a slope or crowned road)
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Management
• Correction of malalignments
• Ice before and after
activity
• Utilize proper warmup and stretching
techniques
• Avoidance of
aggravating
activities
• NSAID’s and
orthotics
Figure 20-5
© 2011 McGraw-Hill Higher Education. All rights reserved.
Knee Joint Rehabilitation
• General Body Conditioning
– Must be maintained with non-weight bearing
activities
• Weight Bearing
– Initial crutch use, non-weight bearing
– Gradual progression to weight bearing while
wearing rehabilitative brace
• Knee Joint Mobilization
– Used to reduce arthrofibrosis
– Patellar mobilization is key following surgery
– CPM units
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Flexibility
– Must be regained, maintained and improved
• Muscular Strength
– Progression of isometrics, isotonic training,
isokinetics and plyometrics
– Incorporate eccentric muscle action
– Open versus closed kinetic chain exercises
• Neuromuscular Control
– Loss of control is generally the result of pain and
swelling
– Through exercise and balance equipment
proprioception can be enhanced and regained
– The patient must be challenged
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 20-59
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Bracing
– Variety of braces for a variety of injuries
and conditions
– Typically worn for 3-6 weeks after surgery
• Used to limit ranges for a period of time
– Some are used to control for specific
injuries while others are designed for
specific forces, stability, and providing
resistance
• Functional Progression
– Gradual return to sports specific skills
– Progress w/ weight bearing, move into
walking and running, and then onto
sprinting and change of direction
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Return to Activity
– Based on healing process - sufficient time
for healing must be allowed
– Objective criteria should include strength
and ROM measures as well as functional
performance tests
© 2011 McGraw-Hill Higher Education. All rights reserved.