Knee Injures & Knee Examination

Bursitis Etiology

Acute, chronic, or recurrent swelling Prepatellar - continued kneeling (house maid's knee) Infrapatellar - overuse of patellar tendon

Plica Syndrome

Anomaly or fold in the synovial membrane on the anterior aspect of the knee Most common site along the superior medial border of the patella Sign and symptoms include a snapping or clicking as the knee moves into flexion

Osgood-Schlatter's Disease

Apophysistis and also labeled as a syndrome Due to repetitive traction by the patellar tendon to a weaker epiphysis Caused by muscle tightening and running and jumping during significant growth spurts Focused anterior knee pain and increased prominance over the tibial tuberosity Sign and symptoms also include crepitus, swelling, and pain consistent with activity Treatment includes ice, modify activity, pad Larsen Johnasson Disease is the result of excessive pulling on the inferior pole of the patella

Osteochondritis Dissecans (OCD)

Avascular neurosis of the osteochondral surface of the knee Occurs most often in adolescents and to the medial femoral condyle Gradual onset of pain, periodic swelling after activity, clicking or catching, and palpable joint line tenderness

Patellar Tendon Rupture

Caused by a violent, rapid quad contraction rupturing the infrapatellar or suprapatellar tendons Can be a single injury or a chronic inflammatory mechanism Generally does not occur unless a chronic inflammatory condition persists resulting in tissue degeneration Signs and symptoms include immediate and severe pain and swelling, loss of function, possible audible snap, lack of knee extension, and palpable defect

Chondromalacia Patella

Characterized by softening, roughening, and eventual degeneration and defects on the articular surface of the patella Results from direct or repetitive trauma, patella malalignment, or previous trauma such as a dislocation or subluxation Signs and symptoms include general anterior knee pain, crepitus, minor swelling, and increased pain with patellofemoral compression (excessive flexion or extension against resistance)

Chondral & Osteochondral Fractures

Chondral fractures go through the articular cartilage Osteochondral fractures extend through articular cartilage and bone Mechnism is compression combined with a valgus, varus, or rotational force Can result in loose bodies (joint mice) Signs and symptoms include pain, immediate swelling, locking or clicking Pt may be unable to bear weight or move the knee

Bursitis Management

Eliminate cause, RICA, NSAIDs Aspiration and steroid injection if chronic

Joint Contusions

Etiology - blow to the muscles crossing the joint (vastus medialis) Signs & Symptoms - present as knee, sever pain, loss of movement and signs of acute inflammation; swelling, discolorartion (ecchymosis); 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 within a week a chronic condition (synovitis or bursitis) may exist requiring more rest

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 parasthesia 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

Loose Bodies Within the Knee

Etiology - result of repeated trauma; possibly stem from osteochondritis dissecans (OCD), meniscal fragments, synovial tissue, or cruciate ligaments Signs & Symptoms - may become lodged causing locking or popping; pain and sensation of instability Management - If not surgically removed it can lead to conditions of joint degeneration

Iliotibial Band Friction Syndrome (ITB tendonitis)

Excessive friction between ITB and lateral femoral condyle At 30 degrees flexion, the ITB changes from an extensor to a flexor Irritation occurs with repetitive activity Increased probability with genu varum (bow legged), excessive pronation, leg length discrepancy, and training errors Signs and symptoms include pain and point tenderness over the lateral femoral condyle as knee flexes to 30 degrees

Patellofemoral Pain Syndrome

General term to describe anterior knee pain Can result in patellar malalignment, increased patellofemoral compression, or poor tracking Result of anatomical and biomechanical abnormalities, muscle weakness, or imbalance, and training errors Signs and symptoms include poorly localized anterior knee pain exacerbated by activity Vague history Variety of symptoms

Collapsing Knee

Giving way of knee Weak quads Chronic instability of ligamentous structures Torn meniscus Loose bodies within the knee Subluxing patella Chondromalcia Due to pain

Patellar Tendonitis Management

Ice, phonophoresis (ultrasound to drive medicine through tissues), iontophoresis, ultrasound, heat Exercise - quad strengthening Patellar tendon bracing Transverse friction massage

Meniscal Lesion 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 with possible anthroscopic surgery followup With surgery all efforts are made to preserve the meniscus-full healing depends on location Menisectomy 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

Patellar Tendonitis Etiology

Jumping or kicking - placing temendous stress and strain on patellar or quad tendon Sudden or repetitive extension

Anterolateral Rotary Instability

Lateral tibial plateau subluxes with anterior translation and medial rotation of the tibia (Hughston) Results in injury to the ACL, LCL, and lateral capsule

Pes Anserine Tendinitis

Mechanisms similar to bursitis Causes irritation on medial tibial plateau Result of excessive genu valgum (knocked knee) and weak vastus medialis Often occurs due to running with one leg higher than the other Signs and symptoms include pain, swelling, palpable tenderness over the anteromedial tibial plateau and crepitus Passive extension and active or resistive flexion can cause pain

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 with knee flexed or extended Tears may be longitudinal, oblique, or transverse

Anteromedial Rotary Instability

Most common type of rotary instability Medial tibial plateau subluxes on the femur Mechanism of injury is lateral rotation of the tibia with a valgus force (slocum) Results in injury to the ACL, MCL, medial capsule, and possibly the meniscus

Bursitis

Most often affects the prepatellar , infrapatellar, suprapatellar, and pes anserine bursae Caused by repetitive trauma or friction over the bursa Signs and symptoms include pain, redness, localized swelling, involved area warm to the touch, and limited ROM A chronic bursitis can also include crepitus and thickening of the bursal fluid

Patellar Tendonitis (Jumper's Knee)

Overloading of the extensor mechanism Causes microtearing or inflammation at either inferior or superior pole Signs and symptoms include pain, inflammation, mild swelling, palpable tenderness, and possible crepitus Passive stretching or active or resistive knee extension causes pain Chronic injury can weaken the tendon (possible rupture)

Patellar Tendonitis Signs & Symptoms

Pain and tenderness at inferior pole of patella 3 phases - 1. pain after activity 2. pain during and after activity 3. pain during and after (possibly prolonged) and may become constant

Posterolateral Rotary Instability

Posterior subluxation of the lateral tibial plateau Results from an anterior blow to the tibia with the foot laterally rotated and the knee under varus stress Results in injury to the PCL and posterolateral compartment

Bursitis Signs & Symptoms

Prepatellar bursitis may be localized swelling above knee that is ballotable Swelling in popliteal fossa may indicate Baker's cyst - associated with semimembranosus bursa or medial head of gastrocnemius; commonly painless and causing little disability; may progress and should be treated accordingly

Patellofemoral Subluxation & Dislocation Management

Reduction is performed by flexing hip, moving patella medially and slowly extending the knee Following reduction, immobilization for at least 4 weeks with use of crutches and isometric exercises during this period After immobilization period, horseshoe pad with elastic wrap should be used to support patella Muscle rehab focusing on muscle around the knee, thigh, and hip are key Possible surgery to release tight structures Improve postural and biomechanical factors

Patella Fracture

Results from a fall on a flexed knee or severe traction caused by a forceful quad contraction Sudden and severe pain and unwillingness to contract the quadriceps or to extend knee Signs and symptoms also include rapid swelling and crepitus over the patella Fractures through the articular surface can lead to chronic pain, chondromalacia patella, and considerable and prolonged disability

Femur Fracture

Results from a severe direct blow to the midthigh or occurs secondary to torsional forces Signs and symptoms include immediate and severe pain, muscles spasms, inability to move, hemorrhage, and deformity (shortened, laterally rotated leg) Potential for the athlete to go into shock from the above hemorrhage Don't forget to R/O distal femoral fractures

Popliteal Artery or Nerve Injury

Results from a severe fracture or tibiofemoral dislocation Check distal pulse and sensory distribution Treat as a medical emergency

Posteromedial Rotary Instability

Results from an anterior blow to the tibia with the knee partially flexed and the knee under valgus stress Results in injury to the PCL,MCL, and medial joint capsule

Patellofemoral Subluxation & Dislocation

Results from direct blow to the medial patella and indirect quadricep forces Decleration with simultaneous cutting in opposite direction (valgus force at knee) and quad pulls the patella out of alignment Predisposing factors include a shallow femoral groove, an excessive Q angle, a hypermobile patella, a weak medial quadriceps, and a patella alta Signs and symptoms include a sharp pain or pop in the anterior knee and a feeling of giving way Obvious deformity If the patella spontaneously reduces after a dislocation, there should be palpable tenderness along the medial border and anterior knee swelling Patella apprehension test

Popliteal Cyst (Baker's Cyst)

Results from herniation of the synovial cavity and accumulation of fluid in the politeal space Palpable fluid-filled cyst May restrict knee flexion Commonly associated with meniscal tears and arthritic conditions

Tibial Plateau Fracture

Results from severe varus, valgus, or rotational force in combination with axial compression with the foot firmly planted Patient is unable to move the knee and complains of severe and immediate pain, swelling, tenderness, crepitus, and possible deformity

Tibiofemoral Dislocation

Serious and potentially limb threatening Results from large direct forces that force the joint beyond its normal limit Often tears multiple primary ligaments and causes significant damage to the soft tissue High risk of neurovascualr injury

Chondromalacia Patella Etiology

Softening and deterioration of the articular cartilage Undergoes three stages - swelling and softening of cartilage, fissure(crack) 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 (these often go together), patella alta, shallow femoral groove, increased Q angle, laxity of quad tendon

Epiphyseal Fractures

Typically occur through the proximal tibial epiphysis Result from rotational and shearing forces at the knee Mechanisms include a twisting, valgus, or varus force with foot firmly planted Signs and symptoms include immediate pain, swelling, tenderness, loss of function, and deformity Suspect fracture when examining valgus or varus injury in adolescent population

Peroneal Nerve Palsy

Vulnerable near the head of the fibula Injured secondary to a direct blow, severe cold (ice application), or traction from a varus force Signs and symptoms include pain and tenderness over the distal fibula, numbness, and burning and tingling down the lateral lower leg and dorsum of the foot Also include motor weakness of the dorsiflexors, everters, and toe extensors (drop foot) Added pressure may exacerbate condition Generally resolves quickly - in the event it does not resolve, it could result in drop foot