The Knee
MSC MANUAL THERAPY
SEPT 2011
JANE ASHBROOK
Msc Manual Therapy
The Knee
FUNCTIONAL ANATOMY AND CLINICAL
PRESENTATIONS
Anterior Cruiate Ligament
ACL
 Normal
 Partial tear
Treatment
Conservative Management
ACL Reconstruction
Indications for ACL reconstruction
 Professional athletes must have surgery.
 Prevents meniscal tears and OA.
 Recreational athletes will benefit, especially activities
involving twisting and turning eg. Skiing, tennis,
squash.
 90% of patients achieved normal or nearly normal
function following ACLR (Ardern et al, 2011).
Medial Collateral Ligament
MCL
•Indications
 Valgus stress test less give in ext suggests
ACL/PCL/POL/PMC intact.
 DMCL tighten with ER.
 SMCL primary valgus restraint throughout flex.
 PMC/POL controls valgus, IR and post drawer in ext.
(Coen et al, 2010)
 Total ruptures usually occur with associated injury,
including ACL, med or lat meniscus (Nakamyra et al,
2003).
Management
Conservative:
Grade 1,2 and acute 3.
 Protected weight bearing
 Early active movement
 Hinge brace (gr 3)
 Progressive strength
 Functional rehab
 Good outcomes
(Cohen et al, 2010)
Surgical:
Combined SMCL +/- DMCL
and POL injuries causing
severe instability.
 Anatomic recontruction of
SMCL and POL.
 Concurrently with coexisting ACLR.
 May require arthroscopy
before or after if chondral
defect or meniscal tear
present.
Posterior Cruciate Ligament
PCL
Indications
 Accounts for only 0.65% of all knee injuries (Majewski
et al, 2006)
 50% MVA (Dandy and Pusey, 1982).
 Rupture well tolerated ?meniscofemoral ligaments
resist post drawer up to 40% (Malone et al, 2006).
Management
Conservative:
 ?Immobilised in ext
brace 6 weeks.
 Functional rehab.
 V little evidence.
Surgical:
 Avulsion # can be
repaired.
 Little evidence for PCLR.
 No evidence regarding
long term OA.
 If instability present then
likely to be other
ligaments involved and
multiple repair required.
Lateral Collateral Ligament
LCL
 1.1 % of athletic knee injuries (Majewski et al, 2006)
 Common peroneal nerve injured in conjunction in 15% of
cases- meta analysis of 139 patients (Malone et al,2006)
 If LCL sectioned then small increase in varus is seen on
testing.
 If large movement detected on varus testing then multiple
ligament injury should be suspected.
Postero-Lateral Corner
PLC
Indications
 Rarely injured in isolation (Malone et al, 2006).
 May present with +ve Dial, +ve postlat drawer and varus
opening at 0-30˚ flex.
 Unstable knee, ?failed ACLR.
 Post and lat thrust on stance phase of gait.
Management
Conservative:
 Knee very unstable.
 Chronic instability or
failed ACL
reconstruction.
Surgical:
 Early repair best: 48hrs7 days (La Prade et al,
1997).
 Larson (sling ITB) or
LaPrade (TA allograft)
technique.
 Correction of lat thrust.
 Can’t replace normal
PLC function.
Meniscal Injuries
Meniscal tears
Tear posterior horn medial
meniscus with meniscal cyst
Radial tear lat meniscus
Indications
 Twisting, change of direction on loaded knee.
 Acceleration/deceleration.
 Degen tears spontaneous/minor incident.
 Composite testing most effective.
 Accuracy difficult in degen tears and associated lig
injuries.
 Torn discoid lat meniscus: children.
 Post horn lat meniscus: instability and detachment,
PLC.
 (McDermott, 2011.)
Tears
Management
Conservative:
 Can be asymptomatic.
 Less mechanical
symptoms in degen tears.
 Rehab AROM and
functional strength.
(McDermott, 2011)
Surgical:
 Arthoscopy.
 Repair: vertical, some
horiz, 25% under 40.
Sutures.
 Rehab: PWB, 90* brace 6
weeks. Start impact 3
months.
 Resect: flap, ragged,
complex.
 Rehab: very quick.
 New tech: replacement.
Chondral Surface Injury
Indications
 Rotational forces cause stress fracture in
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subchondral bone, fails to heal, necrosis.
Common in adolescents, usually stable.
Unstable in adults, can cause loose body.
Classified dependent on extent and depth.
Need WB x-ray and MRI.
 (Cole and Cohen, 2011)
Management
Conservative:
 NSAIDs
 Corticosteroids
 Chondroprotective
agents.
 Activity
modification/avoidance.
 Brace.
 Strength and flexibility.
 Ineffective.
Surgical:
 Palliative: debridement
and lavage.
 Reparative: marrow
stimulating technique.
 Restorative: ACI,
osteochondral grafting.
Patello femoral Pain Syndrome
Forces
Patellofemoral Joint Reaction Force
Patellofemoral Joint Stress=
PJRF ÷ PF contact area.
Unreliable clinical measurement.
Increase in angle will increase
Lateral patella displacement.
Biomechanics
Angle of knee flexion
Event
0-10*
No patella contact with femur
10-30*
Patella aligns and enters intercondylar
notch
0-50*
Tension in patella tendon greater than
tension in quads
0-90*
Contact zone moves proximally
>50*
Tension in patella tendon lower than
tension in quads
0-60*
PJRF and PJS increase
60 ±5*
Peak PJS, quads neutral, critical angle
85-90*
Quads wrap
(Selfe, 2004)
Indications
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Controversy in literature: overloaded with theories.
Subchondral bone deformation(Goodfellow et al, 1998,
Naslund et al, 2005)
Intermedullary pressure changes (Arnoldi, 1991)
Lateral retinacular neuroma formation (Sanchis-Alfonso
et al, 1998)
Vascular dysfunction (Sanchis-Alfonso et al, 2007, Selfe
– work ongoing)
The tissue homeostasis theory/the biological
inflammatory cascade (Dye et al, 1999
Risk Factors
 Lower limb malalignment (Shelton, 1991).
 VMO:VL muscle imbalance (McConnel, 1986).
 VM considered single anatomical unit (Hubbard, 1998).
 Conflicting evidence of delayed onset VMO (Selfe, 2004).
 VMO onset delay in runners with PFPS (Ng et al, 2011).
 VMO-VL timing rations vary between healthy subjects
and patients (Selfe, 2004).
 Effusion inhibits quads: VM (Torry, 2000).
Risk Factors
 Reduced quads flexibility, VM reflex response time,
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explosive strength and vertical jump ability (Witrouw,
2000).
Weakness of hip lateral rotators and abductors (Robinson,
2007 and Ireland, 2003).
PFPS subjects sig difference in ITB length in symptomatic
and asymptomatic sides(Hudson and Darthuy, In Press)
ITB tightness increases pressure on lateral patella facet
(Merican et al, 2009)
PFPS subjects had significantly shorter hamstrings than
asymptomatic controls (White et al, In Press)
Treatment
 Poor prediction of recovery if pain persists for 2 years
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(Price, 2000).
Combination of CKC and OKC exercises required.
OKC avoided in 1st 30* flex (Doucette, 1996).
Exercises can be performed in controlled pain.
Proprioception (Callaghan, 2008, 2010, 2011).
Mobilisation and manipulation.
Acupuncture.
Taping/bracing .
Combined (Mason, 2010).
Orthotics (Vincenzino, 2010 and Barton, 2009).
Patella Instability
Indications
 Functional valgus: if lat force of eccentric quads



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overcomes VMO and MPFL, patella can dislocate
(Greiwe, 2009).
Articular geometry: patella alta-increased translation
prior to trochlear engagement (Greiwe, 2009).
Dynamic limb alignment: femoral anteversion,
decreased hip abd and IR strength (Ireland, 2003).
Dynamic stability: VMO injury in acute dislocation.
Static stability: MPFL fails at low load, 50% increase
lat displacement patella (Greiwe, 2009).
Management
Conservative:
 Dynamic neuromuscular
control: hip, knee, core.
 Proprioception.
 Orhtotics.
 Rehab remains reduced
in a proportion of
patients (Smith, 2010).
 VMO activity and onset
timing uncertain (Smith,
2010).
Surgical:
 Tibial tubercle
osteotomy: alter Q-angle.
 Distal tubercle
osteotomy: decrease
patella alta.
 Trochleoplasty: Increase
trochlear groove.
 Quadsplasty: suture
VMO to add magnus.
 MPFL recon: gracilis
aotgraft.
Osteoarthritis
Risk factors
Post menisectomy:
 Younger patients.
 Decrease contact surface
area 75% and increase
contact pressures 235%
(McDermott, 2010)
 1400% increased
prevalence 21 years after
menisectomy (Roos,
1998).
Degenerative:
 Older patients.
 Obesity.
 Repetitive strain, wear
and tear.
 Genetic predisposition.
Management
Conservative:
 Decrease effusion.
 Increase AROM and
flerxibility.
 Increase muscle strength
and propriocetion.
 Activity modification.
 NSAIDs.
Surgical:
 Corticosteroid injections.
 Hyaluronic acid
injections.
 Wash out and
debridement.
 TKR.