Lecture 3: Clinical anatomy if the knee

Ege's Test is performed in order to test for?

Meniscus tear

Ege's Test is also known as...

weight bearing McMurray's test

Patella grind test is used for...

Identify pathological changes in retropatellar cartilage by exerting a compressive force to the patella. Patellofemoral disorders

When is the Ege's Test POSITIVE?

In the presence of pain and/or when a click is felt or heard. pain can be felt while squatting or while getting out of the squat.

What is the Thessaly test for?

meniscus lessions

vastus medialis obliquus

oblique portion of VM that attaches to medial patella

how do we know with the Ege's Test that the tear is in the anterior horn?

pain in early knee flexion

how do we know with the Ege's Test that the tear is in the posterior horn?

pain in late knee flexion

What is a positive result for Patella grind test?

pain with movement or inability to complete the test.

During a Gait analysis the following observations were made to the patient of the study: •Bilateral pes planus •Increased Q-angle •Genus valgus •Patella seems to track more laterally with knee extensions compared to the right knee AND... X-rays (ap, lateral, skyline) taken and were unremarkable, a lateral patellar tilt was noted on the sunrise view What was the diagnosis?

patellofemoral pain syndrome

At 30⁰ the IT band is...

posterior to the femoral epicondyle,

Genu recurvatum is an abnormality of which plane?

sagital

What is a mechanical axis?

straight line connecting the center points of the proximal and distal joints.

Q- angle Reflects the lateral pull of the quadriceps in relation to

the patella

Posterior surface of the patella has ...

thick layer of hyaline cartilage up to 7mm

What Increases Q-angle:

Femoral anteversion External tibial torsion Genu valgus

Is pain indicative of POSITIVE McMurray's test

NO

Patella apprehension test is used for...

patella dislocation

Does McMurray's test by itself have good diagnosis accuracy?

NO (it has to be combined with other tests)

What is another name for Patellar tendinitis?

"Jumper's knee"

Muscles that stabilize the knee, also stabilize the Patellofemoral Joint. Which ones are them?

- Quadriceps muscles (especially vastus medialis obliquus) - Pes anserine muscles - hamstring muscles

Increased Q-angle causes

- excessive lateral tracking - lateral subluxation forces on patella - Increases patellofemoral contact pressure, can cause pain, cartilage wear

What is a POSITIVE Apley's compression test?

- pain -clicking - restriction

How is the Patella grind test performed?

- patient in supine position. - place the webspace of the hand on the superior border of the patella (affected side) - ask patient to contract the quadriceps as if they were to extend the knee. - apply downward and inferior pressure on the patella.

How is McMurray's test performed?

- patient in supine position. - take affected leg into near maximum hip and knee flexion. - palpate medial and lateral tibiofemoral joints. - internally rotate the tibia while providing a valgus force. - increase valgus force and take the patient into extension of hip and knee - Repeat with external rotation of Tibia with Varus force

What is a POSITIVE Patella grind test?

- patient is surprised, and feels uncomfortable with the lateral displacement of the patella. - patient may reach for your hand to stop you or attempt to return the patella to the normal position

Apley's compression test

- patient lies prone with the knee flexed to 90 degrees. - examiner places both hands on the plantar aspect of the subjects foot and heel. - examiner medially and laterally rotates the tibia while applying an axial load to it. - test is repeated with distraction force

how is the Patella grind test performed?

- patient lies supine or sitting on a bench with the knees flexed to 30 degrees. ** quadriceps should be relaxed to allow passive movement of the patella. - With the thumbs of both hands press on the medial side of the patella to exert laterally directed pressure.

How is the Ege's Test performed?

- patient stading with the feet 30-40cm apart - patient has to squat with both legs in maximal external rotation (for medial meniscus tear) - patient has to slowly stand up after every squat. -patient squats with both legs internally rotated (for lateral meniscus tear)

How is the Thessaly test performed?

- patient stands ont eh injured leg flexed to 20 degrees. - rotate over the tibia 3x on each side.

What is the best diagnosis for meniscus session?

-Apply a combination of tests: Apley's + McMurray's + Thessaly. -Send your patient for an MRI

What is Chondromalacia Patella?

1. Degeneration of the articular cartilage of patella caused by trauma and/or microtrauma •Softening, erosion, fraying and fissuring 2. Cartilage loss can reach down to subchondral bone

Patellar tendinitis can be caused by...

1. Tendons heals poorly(inadequate reapair) 2. patellar ligament

Navicular drop test is to assess...

1. positioning of the talus. 2. overpronation of forefoot

What is the typical presentation of Chondromalacia Patella?

1•Anterior knee pain that is aggravated by activities the increase patellofemoral contact •Squatting, sitting with knees flexed for a prolonged time, climbing stairs, going from sitting to standing 2•Tenderness around patella borders 3•Can have mild swelling 4•Grinding sensation or crunching/crackling sound with squatting/stairs

Musculoskeletal abnormalities causing gene recurvatum?

1•Connective tissue disorders causing knee ligaments laxity 2•Quadriceps muscle weakness 3•Quadriceps spasticity 4•Conditions that cause quad weakness or spasticity •CP, Muscular dystrophy, polio 5•Malformation of tibia (increased slope)

Q-angle has 2 lines, which ones are them?

1•Line from the ASIS to the patella center •Corresponds to force of quadriceps 2•Line from the patella center to the tibial tuberosity

When is the Ege's Test more efficient ?

ACL diffusion knees and knees with fusion.

Rearfoot angle:

Angle between a line that bisects the distal 1/3 of the leg and a line that bisects the calcaneus

McMurray's test purpose

Assess for potential meniscus tear

Q-angle

Assess overall line of pull of the quadriceps relative to the patella.

Normal ranges of Q-angle vary by source (~10-20ᵒ). What are the values?

Females: 15-18 > males: 10-13

What is the diagnosis for the following observations on an MRI? Signs of cartilage loss of the patellar cartilage and patellar subcondral edema

Chondromalacia patella 9requires surgical treatment)

Patella grind test is also known as...

Clarke's sign

POSITIVE McMurray's test

Clicking or popping

Navicular drop definition

Difference in height of the navicular tuberosity from a subtalar neutral position to a relaxed standing position •Measures sagittal mobility

During jumping, who is the higher load on patellar tendon/ligament?

During landing

What can cause Genu recurvatum?

Injuries or musculoskeletal abnormalities

What is a POSITIVE Apley's compression test with distraction indicates?

Ligamentus pathology

Can the Ege's Test be performed on every patient?

No, because the patient has to be able to stand up, and squat in a limiting rang of motion

"Jumper's knee" can be described as...

Overload/overuse injury that is more common in sports involving repetitive jumping

What is Iliotibial Band Syndrome?

Overuse injury that is caused by repetitive knee flexion and extension •Cyclist and runner

Patellofemoral pain syndrome definition

Overuse musculoskeletal disorder that causes anterior knee pain and is aggravating by activities that increase patellar load.

What is a POSITIVE Thessaly test?

Pain in the join line during the rotations

Patellofemoral joint (Part of knee joint) is formed by

Posterior surface of patella and trochlear surface (groove) of femur

How do we know when a patient can have snapping of ITBand?

Presents with pain over lateral femoral condyle that can extend into lateral thigh/calf

Pain at the inferior pole of patella indicates...

Problems with the patellar ligament (patella to tibial tuberosity)

What does the stability of the patellofemoral articulation depends on?

Sufficient depth of trochlear sulcus

What does a POSITIVE Apley's compression test represents?

Tear of medial or lateral meniscus, depending on position of symptoms

What is another name for the inverted U-shaped patellar surface found on Distal femur?

Trochlear sulcus or intercondylar groove

What clinical value can be attributed to the Patella grind test.

Weak

At 0⁰ the IT band is...

anterior to the femoral epicondyle,

When is the Ege's Test less efficient ?

degenerative arthritis and patellofemoral disease

What is Genu recurvatum?

knee deformity where the knee angulates backwards; knee extension of > 5⁰ (past 0)

The trochlear sulcus extends further on which condyle?

lateral

Which ones are the Patella facets?

• Lateral •Medial •Odd facet: far medial

What happens when Tendons heals poorly(inadequate reapair)?

•Thicker but collagen more disorganized •Can eventually result in tenoncyte cell death and tendon degeneration

Injuries causing genu recurvatum?

•Tibia growth plate trauma •Knee ligaments injury (ACL + posterior/lateral capsule)

What causes Chondromalacia Patella?

•Abnormal patellar tracking •Q-angle •Pes planus •VMO to VL imbalance in strength or timing •VMO: inferior fibers of VM, have more horizontal orientation •Weak hip abductors •Femoral anteversion, tibial torsion, Genu valgum •Trochlear dysplasia •Patella alta

What is Patella Alta?

•Abnormally high patella •Associated with patellofemoral pain and instability •Chondromalacia patella and Knee OA

Mechanical axis of the lower limb...

•Center of femoral head to center of ankle •Crosses center of knee joint

Which ones are the soft tissue structures of the Patellofemoral articulation?

•Medial and lateral retinacula •Medial and lateral patellofemoral ligaments •Medial and lateral patellotibial ligaments •Iliotibial band •Crural fascia •Quadriceps aponeurosis

Angle of inclination

•Normal range in adult is 125-135⁰ •Coxa valga > 135⁰ (some say 140⁰) •Can cause genu varum (bow-legged) •Coxa vara < 120⁰ •Can cause genu valgum (knocked knee) •Coxa vara and valga can increase risk of knee osteoarthritis

Patellofemoral pain syndrome characteristics

•Pain can be peripatellaror retropatellar. •Also called "Runners knee" •Pain occurs during running, going up or down stairs, squatting, sitting w/flexed knees for prolonged periods of time

Biomechanical abnormalities associated with patellofemoral pain

•Pes planus •Increased Q-angle

What causes patella Alta?

•Rupture of patellar ligament •Congenitally long patellar tendons