Knee Complex
Normal Ranges and End‐Feels at the Knee: Flexion
0‐140 Tissue approximation or tissue stretch
Normal Ranges and End‐Feels at the Knee: Extension
0‐15 Tissue stretch
Ligament Function: Posterior Cruciate
1. Most fibers resist knee flexion - either excessive posterior translation of the tibia or anterior translation of the femur, or a combination thereof 2. Resists extremes of varus, valgus, & axial rotation
Normal Ranges and End‐Feels at the Knee IR of tibia on femur
20‐30 Tissue stretch
Genu varum
"Bow‐leg" >180 degrees
Excessive genu valgum
"Knock‐knee" <165 degrees
ACL Tear: Etiology
250,000 athletes dx with ACL injuries per year Etiology • Injury factors are intrinsic vs. extrinsic − Intrinsic includes: narrow interchondylar notch, weak ACL, overall joint laxity, LE malalignment (genu valgus, recurvatum etc) − Extrinsic includes: abnormal quadriceps/hamstring interaction; abnormal neuromuscular control, shoe surface interface, athlete's playing style and training • Etiology is multifactorial and difficult to identify • Gender (Sex): women are 2‐8 times more likely to tear ACL − Anatomic alignment/structural differences − Femoral notch − Joint laxity − Hormonal influence − ACL size − Muscular Strength and muscle activation patterns
Pathoanatomy: Articular Cartilage Defects (Read Pg. 907‐920)
A common cause of pain and functional disability Non‐operative rehabilitation and palliative care are frequently unsuccessful Patient's typically opt for surgery Surgical Techniques • Arthroscopic lavage and debridement • Microfracture • Autologous osteochoncral mosaicplasty grafting • Autologous chondrocyte implantation • Osteochondral autograft transfer • Osteochondral allograft transplant
Pathoanatomy: Clinical Practice Guidelines - Meniscal & Articular Cartilage Lesions Risk Factors (C)
Consider the following factors with meniscal injury: • Age and chronicity from time of injury • Participation in high level sports • Increased knee laxity after ACL injury or post‐operative laxity Consider the following factors with chondral lesions: • Age and presence of meniscal tear following ACL injury • Time from ACL injury (greater time = greater chondral lesion)
Clinical Practice Guidelines - Knee Stability Interventions‐Bracing
Functional bracing (C‐D) Post‐operative bracing (B) Utilization of neoprene sleeve and functional bracing for PCL, MCL, and posterior‐lateral corner injuries (F)
Pathoanatomy: Clinical Practice Guidelines - Meniscal & Articular Cartilage Lesions Diagnosis/Classification (C)
Knee pain Mobility impairments Effusion Finding the above can classify with the following ICD categories: • Tear of meniscus/articular cartilage
Pathoanatomy: Patellofemoral Joint- Differential Diagnoses
Medial retinaculitis Meniscus Patellar Tendinitis Bursitis: Superficial/Deep Infrapatellar or Prepatellar Symptomatic Plica Osgood‐Schlatter Disease Patellar Tendinitis (Jumper's Knee) Quad tendon rupture Hoffa's fat pad
What is normal Genu Valgum at the knee
Normal frontal plane alignment of the knee 170‐175 degree
Clinical Practice Guidelines - Knee Stability Diagnosis/Classification (A)
Passive knee instability Joint pain Joint effusion Movement/coordination impairment Any of the above can assist in classifying as follows: • Sprain/strain of collateral ligaments • Sprain/strain of cruciate ligaments • Injury to multiple structures of knee
Pathoanatomy: Patellofemoral Joint- Diagnosis
Patellofemoral Pain Patellofemoral Compression Patellofemoral Osteoarthritis Patellofemoral Instability
Pathoanatomy: Tibiofemoral Joint - Differential Diagnoses
Symptomatic plica Myofascial pain Quadriceps contusion MCL/LCL/PCL Sprains Tendon ruptures Loose body Saphenous nerve involvement Bakers Cyst Breast Stroker's Knee A‐P slide dysfunction Genu recurvatum
Pathoanatomy: Tibiofemoral Joint - Diagnoses
Tibiofemoral Osteoarthritis Tibiofemoral Instability Symptomatic plica Myofascial pain Quadriceps contusion MCL/LCL/PCL Sprains Anterior Cruciate Ligament Tear Meniscal Tears Arthrofibrosis Tendinitis Iliotibial Band Friction Syndrome Bursitis
Complex Regional Pain Syndrome ‐ Reflex Sympathetic Dystrophy
(p. 924)
Myofascial Pain Dysfunction: Vastus Medialis
(p. 924)
Subjective Report: My knee hurts when I get up from a chair or go up steps
Possible Diagnosis: Patellofemoral dysfunction Confirmatory Test(s): Patellofemoral grind test
Subjective Report: I have swelling in the back of my knee
Possible Diagnosis: Popliteal cyst Confirmatory Test(s): Palpation of popliteal fossa
Subjective Report: My knee gives out when I step down from the curb
Possible Diagnosis: Subluxation/dislocation of the patella Confirmatory Test(s): Patellar apprehension test
Patellofemoral Pain
(p. 905)
Patellofemoral Compression Syndromes
(p. 906)
Articular Cartilage Defects
(p. 907)
Tibiofemoral Osteoarthritis
(p. 907)
Total Knee Arthroplasty
(p. 908 - see also online lecture content)
Arthrofibrosis
(p. 909)
Patellofemoral Osteoarthritis
(p. 909)
Anteroposterior Slide Dysfunction: Tibia on Femur
(p. 910)
Anterior Cruciate Ligament Tear
(p. 911 - see also online lecture content)
Genu Recurvatum ‐ "Saber Legs"
(p. 913)
Meniscal Tears
(p. 914)
Posterior Cruciate Ligament Tear
(p. 915)
Patellofemoral Instability
(p. 919)
Symptomatic Plica
(p. 919)
Iliotibial Band Friction Syndrome
(p. 920)
Tendinitis
(p. 920)
Bursitis
(p. 921)
Sindig‐Larson‐Johansson Syndrome and Osgood‐Schlatter Disease
(p. 921)
Baker's Cyst
(p. 922)
Hoffa's (Fat Pad) Syndrome
(p. 922)
Quadriceps Contusion
(p. 922)
Turf Knee or Wrestler's Knee
(p. 922)
Breaststroker's Knee
(p. 923)
Peripheral Nerve Entrapment
(p. 923)
Popliteus Tendinitis
(p. 923)
Tendon Ruptures or Fractures
(p. 923)
Give the criteria for the Ottawa Knee Decision Rule
- Age > 55 years - Tenderness at the head of the fibula - Isolated tenderness of the patella - Inability to flex the knee to at least 90 degrees - Inability to bear weight both immediately & in the emergency department x4 steps. * A (+) test = Any 1 of the above & is an indication for referral for an x‐ray
Patellofemoral Pain Syndrome (PFPS)- impairment based Classification
- Is the problem truly related to the PFJ or related structures? - Is muscle imbalance present? - Is inflammation present? - Is instability present?
ACL Tear Non- Operative treatment: Selection Criteria for Successful Outcome
- No evidence of joint effusion - Full knee PROM compared to the uninvolved side - Full knee extension during a SLR on the involved limb - A quadriceps femoris MVIC force on the involved limb = 75% of that on the uninvolved limb - Tolerance for single-leg hopping on the involved limb without pain - No concomitant ligamentous or meniscal injury
Patellofemoral Pain Syndrome (PFPS)- Treatment
- Patellofemoral Instability, especially if recurrent, often requires surgery - Patellofemoral pain 2o to inflammation or muscle imbalance responds well to conservative intervention • Restore the balance of force production of the medial and lateral stabilizers of the PFJ • Establish or re‐establish the functional control of the VMO(?)
Lateral Patellar Compression Syndrome - Clinically
- Patient complains of pain of pain over the lateral retinaculum - Diagnosis confirmed by a decreased medial patellar glide and evidence of lateral patellar tilt
Pathoanatomy: Clinical Practice Guidelines - Meniscal & Articular Cartilage Lesions Interventions‐Return to Activity
- Progressive return following meniscal repair (C) - Progressive return following articular cartilage surgery (E)
Patellofemoral Pain Syndrome Treatment: Knee & Hip Exercise (KE) Group
- Same protocol as KE group - Hip abduction with weights (sidelying; 3x10 reps)* - Hip abduction against elastic band (standing; 3x10 reps)‡ - Hip lateral rotation against elastic band (sitting; 3x10 reps)‡ - Hip extension (machine; 3x10 reps)* *Load is 70% of 1 RM; †Maintaining the patella off the table; ‡Maximum resistance that enables 10 reps.
Give the orientation of movement (arthrokenimatics) during screw-home
- Screw‐Home is typically described as ER during extension...may be more like an anterior lateral curved translation (axis outside the bone) - Screw‐Home is typically described as IR during Flexion...may be more like a posterior lateral curved translation (axis outside the bone)
ACL Tear Non- Operative treatment: Screening tests for Non-operative Treatment of ACL Injury
- Single, crossover, triple, & timed hop tests: 80% or more of uninvolved limb - Reported number of giving‐way episodes from the time of injury to the time of testing: No more than one episode - The Knee Outcome Survey activities of Daily Living Scale: 80% or more - Subjective global rating of knee function (self‐ assessed 0%‐100%): 60% or more
Patellofemoral Pain Syndrome Treatment: Knee Exercise (KE) Group
- Stretching (hamstrings, plantar flexors, quadriceps, & IT band; 3x30 sec holds) - Seated knee extension from 90o to 45o (3x10 reps)* - Leg press from 0o to 45o (3x10 reps)* - Squatting from 0o to 45o (3x10 reps)* - Hip extension (machine; 3x10 reps)* - Single‐leg calf raises (3x10 reps)* - Prone knee flexion† (3x10 reps)* *Load is 70% of 1 RM; †Maintaining the patella off the table; ‡Maximum resistance that enables 10 reps.
Risk Factors for PFJ OA: Joint based risk factors
1. Coarse crepitus 2. Previous ACL injury 3. Patella malalignment 4. Quadraceps, hip, abductor & rotator weakness 5. ITB & hamstrings tightness 6. Lower limb alignment & kinematics (varus/valgus alignment; femoral IR; tibial ER)
Risk Factors for PFJ OA: Personal based risk factors
1. Age > 40 2. Female gender 3. Obesity 4. Activities that load the PFJ (e.g. descending stairs)
Red Flags Requiring Immediate Medical Referral: Signs/Symptoms and Common Cause
1. Angina pain not relieved in 20 min - myocardial infarction 2. Angina pain with nausea, sweating, and profuse sweating - myocardial infarction 3. Bowel or bladder incontinence and/or saddle anesthesia - Cauda equina lesion 4. Anaphylactic shock - Immunological allergy or disorder 5. Signs/symptoms of inadequate ventilation - Cardiopulmonary failure 6. Patient with diabetes who is confused, is lethargic, or exhibits changes in mental function - Diabetic coma 7. Patient with positive McBurney's point or rebound tenderness - Appendicitis or peritonitis 8. Sudden worsening of intermittent claudication - Thromboembolism 9. Throbbing chest, back, or abdominal pain that increases with exertion accompanied by a sensation of a heartbeat when lying down and palpable pulsating abdominal mass - Aportic aneurysm or abdominal aortic aneurysm
Ligament Function: Anterior Cruciate
1. Most fibers resist extension - either excessive posterior translation of the tibia or anterior translation of the femur or a combination thereof 2. Resist extremes of varus, valgus, & axial rotation
Give the Capular support for the Posterior Knee (See slide 26)
1. Origin of the gastrocnemius muscle, medial head 2. Origin of the gastrocnemius muscle, lateral head 3. Origin of the plantaris muscle 4. Tendon of the popliteus muscle 5. Popliteus muscle 6. Popliteus muscle, fibers to the posterior horn of the lateral meniscus 7. Lateral collateral ligament 8. Arcuate popliteal ligament 9. Tendon of the Semimembranosus Muscle (PAP) a. Anterior Branch (ant/med tibia) b. Central Branch (post/med tibia) c. Oblique Popliteal ligament (arcuate ligament) d. Medial Branch (med meniscus) e. Inferior Branch (popliteus)
Infrapatellar Compression Syndrome - Three Progressive stages:
1. Prodromal Stage: between weeks 2‐8; painful knee ROM; decreased PF mobility; extensor lag present; usually in failed postoperative management; only stage amenable to nonsurgical intervention (Early recognition of this is critical!) 2. Active Stage: between weeks 6‐20; loss of extensor lag; tissue change in patellar tendon; (+) Shelf sign 3. Residual Stage: 8 months or years later; significant PF arthrosis and low riding patella either due to (primary) infrapatellar contraction or (secondary) as a result of surgical intervention or post‐op immobilization; >10o loss of extension, > 25o loss of flexion and reduced patellar mobility
Ligament Function: Medial collateral
1. Resists valgus 2. Resists knee extension 3. Resists extremes of axial rotation (esp. external rotation)
Ligament Function: Lateral collateral
1. Resists varus 2. Resists knee extension 3. Resists extremes of axial rotation
Give the components of the IT band (see slide 29)
1. Tract 2. Lateral intermuscular septum 3. Kaplan fibers 4. Patellar insertion 5. Tibial insertion 6. Lateral femorotibial ligament
Normal Ranges and End‐Feels at the Knee ER of tibia on the femur
30‐40 Tissue stretch
Arthrofibrosis: Type I
< or = 10 degrees of knee extension loss with normal knee flexion
Arthrofibrosis: Type II
> or = 10 degrees of knee extension loss with normal knee flexion
Arthrofibrosis: Type III
>10 degrees of knee extension loss with >25 degrees of flexion loss without patella infera but with patella tightness
Arthrofibrosis: Type IV
>10 degrees of knee extension loss with >30 degrees of flexion loss accompanied by patella infera & with patella tightness
Medial Retinaculitis
?
Tibiofemoral Instability
?
Iliotibial Band Friction Syndrome: Etiology
A repetitive stress injury that results in friction of the IT band as it slides over the lateral femoral epicondyle at about 30o of flexion
At what positions is the ACL taught?
ACL is tight in extension; however... Anteromedial fibers of ACL are taught in flexion Posterolateral fibers of ACL are taught in extension
Give the colon cancer red flags
Age over 50 yr Bowel disturbances (e.g. rectal bleeding or black stools) Unexplained weight loss History of colon cancer in immediate family Pain unchanged by positions or movement
Patellofemoral Compression Syndromes (PCS) - Etiology
An overconstrained patella where motion is severely restricted
Closed-chain Extension: Distal‐on‐Proximal - Meniscotibial Joint
Anterior Meniscus translates Anterior on the Tibia (getting out of the way of the rolling femur)
Open-chain extension: Distal‐on‐Proximal - Meniscotibial Joint
Anterior Meniscus translates on Tibia
Periarticular Tissue: Bursa
As many as 14; for at inter-tissue junctions that encounter high friction during movement
Periarticular Tissue: Fat Pads
Associated with bursa around the knee
Patellofemoral Instability: Bracing
Bracing has no significant influence on lateral patellar tilt; however, bracing has been shown to have a significant effect on lateral patellar displacement.
Clinical Practice Guidelines - Knee Stability Interventions‐Early Weight‐bearing (C)
Can be used in post‐operative ACL reconstruction patients
Clinical Practice Guidelines - Knee Stability Interventions‐Cryotherapy (C)
Can be used to decrease postoperative pain
Pathoanatomy: ITB Friction Syndrome Treatment - Return to Function Phase
Chronic Goal: Strengthen the gluteus medius muscle including multiplanar closed chain exercises 1. Exercises should be pain free 2. Repetitions & sets of exercises are 8‐15 reps & 2‐3 sets 3. Recommend the exercises of sidelying hip abduction, single leg activities, pelvic drops, & multiplanar lunges
Clinical Practice Guidelines - Knee Stability Interventions‐Immediate vs Delayed Mobilization (C)
Consider immediate mobilization to improve ROM, reduce pain, and limit adverse soft tissue adaptation
Chondromalacia: Grade 1
Closed disease. Spongy intact joint surface; reversible; a blister or raised area of the articular surface may be seen
What is the cpp and opp of the tibiofemoral joint
Close‐Packed Position: Full extension and external rotation of the tibia Open‐Packed Position: 25 degrees of flexion
Clinical Practice Guidelines - Knee Stability Risk Factors (B)
Consider the following factors with non‐contact ACL injury: • Shoe‐surface interface • Increased BMI • Narrow femoral notch width • Increased joint laxity • Preovulatory phase of menstrual cycle • Combined loading pattern (flexion, valgus, ER) • Strong quadriceps contraction (eccentric loading phase)
Pathoanatomy: Clinical Practice Guidelines - Meniscal & Articular Cartilage Lesions Intervention‐Progressive Knee Motion (C)
Consider using early progressive knee motion following meniscal or articular cartilage surgery
Clinical Practice Guidelines - Knee Stability Interventions‐Eccentric Strengthening (B)
Consider using in ACL recovery and those with PCL injury to improve strength and functional performance
Clinical Practice Guidelines - Knee Stability Intervention‐CPM (C)
Consider using in post‐operative knee patients
What are the qualities of copers VS non-copers?
Copers: - A subset of individuals who are better at actively stabilizing the ACL‐ deficient knee through complex neuromuscular patterns - They are unique in their ability to return to full activity with no instability for at least 1 year - They adopt various compensatory patterns of muscle activation that appear unrelated to quadriceps strength Non‐Copers: - Individuals who are not able to return to full activity & tend to demonstrate a joint‐stiffening strategy or a nonadaptive generalized co‐ contraction of the muscles that stabilize the knee
Arthrokinematics: Rotation ER
During Rotation, the menisci stay with the femur - External Rotation • Lateral Meniscus translates anterior on tibia • Medial Meniscus translates posterior on tibia
Arthrokinematics: Rotation IR
During Rotation, the menisci stay with the femur - Internal Rotation • Lateral Meniscus translates posterior on tibia • Medial Meniscus translates anterior on tibia
Periarticular Tissue: Articular Capsule
Encloses the medial and lateral compartments of the tibiofemoral joint and the patellofemoral joint
Pathoanatomy: Clinical Practice Guidelines - Meniscal & Articular Cartilage Lesions Interventions‐Supervised Rehabilitation (D)
Evidence is not clear regarding in‐clinic use of strengthening exercises to return to functional performance in meniscus and cartilage pathology
Give the criteria for the Pittsburg Knee rule
Fall or Blunt Trauma mechanism of injury: 1. Inability to ambulate initially or in the emergency department x4 steps 2. Age: Younger than 12 or >50 years old * A (+) test = A history of blunt trauma or fall & 1 of either the 1st or 2nd criteria, & is an indication to refer for x‐ray.
Closed-chain Extension: Proximal‐on‐Distal - Tibiofemoral Joint
Femur rolls anterior and slides the tibia
Closed-chain Flexion: Proximal‐on‐Distal - Tibiofemoral Joint
Femur rolls posterior and on the tibia
What is the capsular pattern of the tibiofemoral joint
Flexion > extension (+5:1)
Pathoanatomy: Clinical Practice Guidelines - Meniscal & Articular Cartilage Lesions Interventions‐Therapeutic Exercise (B)
For meniscal surgery, consider using therapeutic exercise to restore strength and endurance to quadriceps and hamstrings
Periarticular Tissue: Plicae
Formed by incomplete resorption of mesenchymal tissue during development
Chondromalacia: Grade 4
Full‐thickness fibrillation extending down to bone; extent depends on size of the lesion
Pathoanatomy: ITB Friction Syndrome Treatment - Sub‐Acute Phase
Goal: Achieve flexibility in the iliotibial band as a foundation to strength training without pain 1. Iliotibial band stretching 2. Soft‐tissue mobilization to reduce myofascial adhesions
Pathoanatomy: ITB Friction Syndrome Treatment - Acute Phase
Goal: Reduce inflammation of the iliotibial band at the lateral femoral epicondyle 1. Control extrinsic factors, such as rest from running & cycling 2. In severe cases patients should avoid any activities with repetitive knee flexion‐extension & swim using only their arms & a pool buoy 3. The use of concurrent therapies is advised (i.e. ice, phonophoresis, iontophoresis, etc...) 4. Oral, nonsteroidal anti‐inflammatory medication is recommended 5. Corticosteroid injection, if no response to the above methods 6. Up to 2 pain‐free weeks before return to running or cycling in a graded progression
Differential Diagnosis of Medial Knee Pain: Remote neuromuscular
Hip dysplasia Lumbosacral pathology Obturator neuropathy
Give the osteonecrosis of the femoral head (avascular necrosis) red flags
History of long‐term corticosteroid use (e.g. in patients with rheumatoid arthritis, systemic lupus erythematous, or asthma) History of avascular necrosis of the contralateral hip Trauma
Patellar Tenditis: Clinically
History; painful palpation; painful resistive testing (may need to have them activate prior to resistance testing)
Patellofemoral Osteoarthritis: Etiology
Idiopathic or traumatic (determined by history)
What is normal tibial declination orientation at the tibiofemoral joint? (See slide 6)
In weight bearing tends to shift the femur posteriorly on tibia. 10 + or - 3 degrees
Give the Predictor Variables + Radiography (moderate shift in probability) for knee osteoarthritis
Knee pain and osteophytes on knee radiograph plus at least 1 of the following 3 clinical findings - Age>50 - Morning stiffness < 30 min - Crepitus with active motion
Give the Predictor Variables (small shift in probability) for knee osteoarthritis
Knee pain plus at least 3 of the following 6 items: - Age>50 - Morning stiffness < 30 min - Crepitus with active motion - Bony tenderness - Bony enlargement - No palpable warmth
Periarticular Tissue: Synovial Membrane
Lines internal surface of the capsule
Patellar Tenditis: Treatment Stage 3
Loading: Energy storage loading Indication to initiate: a) Adequate strength** & consistent with other side b) Load tolerance with initial level energy storage exercise (i.e. minimal* pain during exercise & pain on load tests returning to baseline within 24 hours) Dosage: Progressively develop volume & then intensity of relevant energy storage exercise to replicate demands of sport
Patellar Tenditis: Treatment Stage 1
Loading: Isometric loading Indication to initiate: More than minimal* pain during isotonic exercise Dosage: 5 repetitions of 45 seconds, 2‐3x/day, progress to 70% maximal voluntary contraction as pain allows
Patellar Tenditis: Treatment Stage 2
Loading: Isotonic loading Indication to initiate: Minimal* pain during isotonic exercise Dosage: 3‐4 sets at a load of 15 RM progressing to a load of 6 RM, every 2nd day, fatiguing load
Patellar Tenditis: Treatment Stage 4
Loading: Return to sport Indication to initiate: Load tolerance to energy storage exercise progression that replicates demands of training Dosage: Progressively add training drills then competition when tolerant to full training
What is the screw-home mechanism?
Locking of the knee in full extension • Requires about 10 degrees of external rotation • Occurs during the last 30 degrees of extension • Conjunct rotation (i.e. mechanically linked to flexion and extension) - can't be performed independently • The combined external rotation and knee extension maximizes the overall contact area • Increases joint congruency and favors stability
What is the osteological orientation of the medial and lateral plateau of the tibiofemoral joint?
Medial plateau: Convex femur on concave tibia Lateral Plateau: Convex femur on convex tibia (allows for spin movement which supports screw home mechanism
Pathoanatomy: Clinical Practice Guidelines - Meniscal & Articular Cartilage Lesions Interventions‐Progressive Weight‐bearing (D)
No clear decisive method on weight‐bearing progression in this population
Tibiofemoral Osteoarthritis: Etiology
OA regarded as "wear and tear" or "degenerative" condition that is often related to activity
Give the pathological fractures of the femoral neck red flags
Older women (>70 yr) with hip, groin, or thigh pain History of fall from a standing position Severe, constant pain that is worse with movement A shortened and externally rotated lower extremity
Chondromalacia: Grade 2
Open disease. Fissures that may or may not be obvious initially
Differential Diagnosis of Medial Knee Pain: Tumors
Osteochondroma Chondroblastoma Giant cell tumor Osteoid osteoma Osteosarcoma Ewing sarcoma Chondrosarcoma Fibrosarcoma Pigmented villonodular synovitis (PVNS) Localized nodular synovitis (LNS)
Patellar Tenditis: Etiology
Overuse injury resulting from a mismatch between stress on a given structure and the ability of that structure to dissipate the forces resulting in inflammatory changes
At what positions is the PCL taught?
PCL is tight in flexion; however... Anterolateral fibers of PCL are taught in flexion Posteromedial fibers of PCL are taught in extension
Differential Diagnosis of Medial Knee Pain: Local Musculoskeletal Syndrome
Patellofemoral syndrome Medial meniscus tear Patellar tendinitis Lateral patellar subluxation Pes anserine tendinitis Pes anserine bursitis Vastus medialis strain Saphenous neuropathy Medial collateral ligament sprain Medial tibial plateau fracture Proximal tibia stress fracture
Subjective Report: I cannot straighten my knee out
Possible Diagnosis: • Fluid in the knee • Torn meniscus Confirmatory Test(s): Meniscus tests, patellar ballottement test, bounce home test
Subjective Report: I have bow legs and they hurt
Possible Diagnosis: • Osteoarthritis • Ligamentous instability Confirmatory Test(s): Range of motion (capsular), Patellofemoral grinding test, Ligament stability tests
Subjective Report: I landed heavily on the front of my knee and it hurts
Possible Diagnosis: • Patellar fracture • Fat pad syndrome • Prepatellar bursitis • Infrapatellar bursitis Confirmatory Test(s): Radiograph, Palpation
Subjective Report: My knee locks
Possible Diagnosis: • Torn medial meniscus • Loose body within the knee joint Confirmatory Test(s): McMurray test and Apley grinding & distraction tests
Subjective Report: My knee buckles; it gives out
Possible Diagnosis: • Unstable knee joint (torn collateral or cruciate ligament) • Torn medial meniscus Confirmatory Test(s): Valgus & Varus stress tests, anterior drawer, Lachman, Posterior Sag, Strength testing (neuro screen), Meniscus tests
Subjective Report: My knee feels swollen and tight
Possible Diagnosis: Fluid within the knee Confirmatory Test(s): Patellar effusion tests
Subjective Report: I cannot move my knee in any direction without pain
Possible Diagnosis: Infected knee joint Confirmatory Test(s): Joint aspiration
Subjective Report: I have pain on the inside of my leg
Possible Diagnosis: Torn medial collateral ligament, Bursitis, pes anserinus bursa Confirmatory Test(s): Valgus stress test, palpation of the pes anserinus bursa
Subjective Report: I made a quick turn while playing sports while my foot was planted, & my leg suddenly collapsed & the knee became swollen
Possible Diagnosis: Torn medial meniscus Confirmatory Test(s): Apley test and McMurray test
Closed-chain Flexion: Proximal‐on‐Distal -Meniscotibial Joint
Posterior Meniscus translates Posterior on of the way of the Tibia (getting out rolling femur)
Open-chain Flexion: Distal‐on‐Proximal - Meniscotibial Joint
Posterior Meniscus translates Tibia
during your systems review what should considerations should one make concerning referred pain?
Referred pain to the hip is common and should be considered in the absence of acute trauma or when symptoms do not clearly originate from the hip Viscerogenic Vasculogenic Neurogenic Psychogenic Spondylogenic
Lateral Patellar Compression Syndrome - Treatment
Responds well to conservative management: • Stretching to lateral retinaculum • Patellar taping • Stretching to the hamstrings, quadriceps and ITB • Strengthening of the VMO (?) • Anti‐inflammatory measures • Activity modification (stair climbing and deep knee squats)
Differential Diagnosis of Medial Knee Pain: Vascular/inflammatory
Rheumatoid arthritis Reiter's syndrome Saphenous thrombophlebitis Deep vein thrombosis
Clinical Practice Guidelines - Knee Stability Differential Diagnosis (B)
Same as others with no change in symptoms when addressing interventions targeted at findings listed above.
Pathoanatomy: Clinical Practice Guidelines - Meniscal & Articular Cartilage Lesions Differential Diagnosis (C)
Same as others with no change in symptoms when addressing interventions targeted at findings listed above.
Chondromalacia: Grade 3
Severe exuberant fibrillation or "crabmeat" appearance
Differential Diagnosis of Medial Knee Pain: Systemic disease
Thyroid disorder (Grave's disease) Lymphoma Leukemia Myeloma
Open-chain extension: Distal‐on‐Proximal - Tibiofemoral Joint (see slide 40)
Tibia rolls and slides anterior
Open-chain Flexion: Distal‐on‐Proximal - Tibiofemoral Joint
Tibia rolls and slides posterior
Lateral Patellar Compression Syndrome - Etiology
Tight lateral retinaculum responsible for patellar tilt and excessive pressure on the lateral patellar facet
Pathoanatomy: Clinical Practice Guidelines - Meniscal & Articular Cartilage Lesions Examination‐Activity Limitation (C)
Use objective testing deficits • Single limb hop, 6 minute walk test, or timed up and go
Clinical Practice Guidelines - Knee Stability Examination‐Activity Limitation (C)
Use objective testing deficits (Single limb hop, timed hop for distance, cross‐over triple hop, etc...)
Pathoanatomy: Clinical Practice Guidelines - Meniscal & Articular Cartilage Lesions Examination/Outcome Measures (C)
Use validated measures to assess change in function
Clinical Practice Guidelines - Knee Stability Examination/Outcome Measures (A)
Use validated measures to assess change in function and restrict participation. (e.g. Lysholm, Functional testing sequence, etc...)
Meniscal Tears: Etiology
Usually occurs turning, twisting or changing directions during WB
Patellar Tenditis: Treatment overview
Usually self limiting: responds to rest, stretching, eccentric strengthening, bracing; balance between tissue strength and inflammation.
Clinical Practice Guidelines - Knee Stability Interventions‐Supervised Rehabilitation (B)
Utilization of in‐clinic exercise with HEP is beneficial in patients with knee instability and movement coordination impairment
Clinical Practice Guidelines - Knee Stability Interventions‐Therapeutic Exercise (A)
Utilize both open and closed chain exercise based on stages of healing and patient response to exercise
Clinical Practice Guidelines - Knee Stability Interventions‐Neuromuscular Re‐education (B)
Utilize neuromuscular training (balance/proprioceptive) as a supplement to strength training
Pathoanatomy: Clinical Practice Guidelines - Meniscal & Articular Cartilage Lesions Interventions‐NMES (B)
Utilize to increase muscle strength in meniscal and articular cartilage post‐operative patients
Clinical Practice Guidelines - Knee Stability Interventions‐NMES (B)
Utilize to increase muscle strength in post‐operative patients or those with poor motor control
General Rehabilitation for Patellafemoral Pathology: Phase I (protection - acute phase)
Weeks: 1 Goals: - Independent ambulation - Decreased effusion - Pain & inflammation reduction Precautions: Avoid - kneeling - Deep squatting - Prolonged positioning - Other aggravating activities Treatment: - Relative rest - Cryotherapy, anti-inflammatory modalities - LE stretching - Grade I & II mobilizations Clinical Milestones: - Full ROM - Normalization gait - Minimal effusion - Minimal pain
General Rehabilitation for Patellafemoral Pathology: Phase II (Intermediate - Subacute/ controlled motion)
Weeks: 2 to 6 weeks Goals: - Pain reduction - Normal patellar mobility - Normal LE flexibility - LE strengthening, including thigh, hip, and calf musculature - Maintenance of cardiovascular conditioning Precautions: Avoid - Kneeling - Deep Squatting - Flexed-Posture cycling - Running (esp. hills) - Other aggravating activities Treatment: - Continued cryotherapy and modalities at indicated - Patellar glides and tilts - LE stretching - IT band, quadriceps, hamstrings, calf - LE and core progressive strengthening - Quadriceps, hip abduction, hip ER, hip extension strengthening - OKC exercises 60 to 90 degrees - CKC exercises 0 - 45 degrees - Orthotic needs evaluation - Proprioceptive and cardiovascular training Clinical Milestones: - > 80% LE Strength, balance, & proprioception - Normalized patellar mobility & LE flexibility
General Rehabilitation for Patellafemoral Pathology: Phase III (Chronic/Return to Function)
Weeks: 6+ Goals: - Return to pain-free ADL - Full LE strength, balance, and proprioception - Tolerance for return-to-sport progression initiation Precautions: Avoid - hill running - Aggravating activities Treatment: - Advanced strength and balance training - Continued flexibility exercises - Endurance exercises - Bracing or taping as indicated Clinical Milestones: - No pain during ADL - Equal LE strength, and proprioception bilaterally - Return to sport
Perturbation training involves . . .
applying potentially destabilizing forces to the injured knee to enhance the neuromuscular awareness, neuromuscular response, & dynamic stability of the knee to stabilize the joint."
Bursitis: Treatment
inflammation management; stretching; activity management and protection; mobilizations
Meniscal Tears are the most common source of?
mechanical symptoms in the knee
Patellofemoral Pain Syndrome (PFPS)- Characterized by
̶ Pain in the anterior knee that worsens with sitting and stair climbing • Women (2:1) who are not athletic may be predisposed • Higher incidence in male athletes (4:1)
Patellofemoral Pain Syndrome (PFPS)- Etiology
̶ Symptoms are set off by a trigger, or combination of structural and dynamic factors, which vary from patient to patient • Anatomic Variance • Gender • Tibial Rotation • Subtalar Joint Position • Femoral Rotation
Meniscal Tears: Characterized by
• Asymptomatic MRI study: 16% have tears (36% in older patients) • Posterior meniscal tears may return into position with extension • Lateral meniscus more mobile...less likely to be involved in locking but predisposed to tearing • Degenerative tears are usually horizontal in nature and older patient. • Vertical tears: bucket handle can lead to locking in a flexed position
Patellofemoral Instability: Clinically
• Must differentiate between a "subluxation" or "giving way" • Palpation to medial or distal pole structures as well as the distal quadriceps may be painful • Is this a matter of Recurrence? − First time subluxators should be managed conservatively − Chronic subluxators or dislocators may need surgical management *Note regarding surgical management: lateral release may not be successful • Cruciate ligament instabilities may lead to 2o patellofemoral pain • Inappropriate relocation can lead to chondral defects...
Iliotibial Band Friction Syndrome: Treatment
• Conservative − Activity modification ↓ mileage Changing bike seat position Changing training surfaces • New running shoes • Modalities: heat or ice • Therapeutic exercise: Strengthening of the hip abductors, and stretching the ITB • Surgical − Resection of the posterior half of the ITB (recalcitrant cases)
Tibiofemoral Osteoarthritis: Treatment
• Conservative management: − NSAID's, cortisone, patient education, weight loss, therapeutic exercise, modalities, and shoe inserts/orthotics (medial compartment) − LE strengthening (emphasis on quads); LE ROM; Cardiovascular endurance activities (walking; swimming; bicycling) • Balance and coordination activities • Manual therapy (Deyle et al 2000) • See Slides 133, 134
Meniscal Tears: Treatment
• Conservative management: resolution of impairments such as swelling, restricted ROM, and strength by using exercises, bracing, and oral meds • Surgical management: menisectomy; meniscus repair; allograft transplantation; (Open vs. Arthroscopic) • Relative avascularity in the middle and inner third of the meniscus create limited healing potential; outer third tears have a better healing potential (about 1/3 of meniscal tears)
Arthrofibrosis: Treatment
• Conservative: ROM exercises; Stretching of specific structures • Surgically: Gentle manipulation under anesthesia, Arthroscopic debridement − If manipulation is vigorous: Could cause ↑ tibiofemoral and patellofemoral compression risking chondral damage or fracture, Could rupture patellar ligament or femoral fracture Been linked to CRPS.
Arthrofibrosis: Etiology
• Dense proliferative scar formation intra and extra articular that may spread and progressively limit motion • May occur as an inflammatory cascade post surgery but the reason for proliferation of scaring in some is unclear
Patellofemoral Osteoarthritis: Clinically
• Diagnosis by correlating patellofemoral pain with radiographic changes • Chondromalacia presents in <20% of those with anterior knee pain − Most common in those 12‐35 years of age − Predominance in females − Two types: Surface degeneration (age dependent) or Basal degeneration (trauma)
Arthrofibrosis: Clinically
• Diagnosis by exclusion (rule out other reasons for limitation first i.e., fracture, meniscal tear, loose body, non‐isometric graft placement) − ACL reconstruction within 3 weeks of injury may precipitate; poor or unsupervised rehab post surgery may also play a role • Stiffness is the primary symptom and is worse in the morning hours. • If Globally: − Marked limitation of flexion, extension, and patellar glide − Widespread joint inflammation as well as intra‐articular formation of fibrous tissues • Patient presents with an antalgic gait
Tibiofemoral Instability: Treatment
• Direction of laxity determines intervention • Muscle strengthening, correction to muscle imbalances • Passive restraints such as bracing or orthotics • NOT listed in text: Neuromuscular Re‐education (NMR) or Proprioceptive Re‐education...often it is not the STRENGTH...but the CONTROL that is the issue.
Tibiofemoral Instability: Clinically
• Giving Way, locking or catching are symptoms that may be associated with laxity or instability • Examination reveals laxity
Tibiofemoral Instability: Etiology
• Intrinsic and extrinsic trauma (microtrauma, macrotrauma, genetics, gender, ethnic factors)
Arthrofibrosis: Characterized by
• Involves either the parapatellar recess; suprapatellar recess; interchondylar notch, articular surface • Patella infera and chronic patellar entrapment may develop
Tibiofemoral Instability: Characterized by
• Knee laxity leads to more displacement and shear within the joint and may contribute to OA; Should be addressed quickly to limit internal damage to articular structures
Patellar Tenditis: Characterized by
• Known as patellar tendinitis (jumpers knee) or quadriceps tendinitis • Typically Injuries associated with eccentric overloading during deceleration activities
Anterior Cruciate Ligament Tear: Clinically
• Mechanism of Injury − Downhill skiing: Phantom foot (flexion and tibial internal rotation); Quadriceps and boot causes anterior translation; Valgus rotation − Other sports: valgus force; ER with extension with fixed foot; hyperextension − Contact versus Non‐contact injuries • Signs and Symptoms − History: knee popping out or giving way; decrease in functional ability − Hemarthrosis: blood in joint or synovial cavity; clouds clinical examination (often need to deal with this prior to being able to dx an ACL tear) − Quad atrophy is common; torque differences between Quads/HS − (+) Anterior drawer and/or Lachman • Imaging and Arthrometer − KT‐1000 used to objectify the A‐P instability in millimeters − Radiograph: avulsions, arthritic changes − MRI: diagnose ligament tears
Tibiofemoral Osteoarthritis: Characterized by
• Most common cause of disability in the US; affects functional ability • 33% of those age 63‐94 are affected by OA of the knee • May affect one or more of the 3 compartments of the knee: medial/lateral tibiofemoral and/or patellofemoral
Patellofemoral Osteoarthritis: Characterized by
• OA is most associated with bony changes • Chondromalacia ("catch‐all" term) is a softening of the cartilage on the posterior aspect of the patella
Infrapatellar Compression Syndrome: Treatment - Prodromal Stage
• Patellar mobilizations (1‐12 min holds) • Stretching of the hamstrings, hip flexors, quadriceps, gastrocnemius, and ITB • Emphasis placed on restoring full knee extension • Active ROM • Multiangle isometric strengthening of the quadriceps • Neuromuscular stimulation • TENS • NSAIDs
Meniscal Tears: Clinically
• Patient history of swelling; popping or clicking; joint line pain, locking • Pain presentation??? (Dutton suggests Menisci not innervated)
Open-chain extension: Distal‐on‐Proximal - Meniscofemoral Joint
• Posterior Meniscus ̶ Anterior‐distal on the femur • Anterior Meniscus ̶ Anterior‐proximal on the femur
Closed-chain Extension: Distal‐on‐Proximal - Meniscofemoral Joint
• Posterior Meniscus ̶ Femur moves past the meniscus Posterior‐proximal in a direction • Anterior Meniscus ̶ Femur moves past the meniscus Posterior‐distal direction
Open-chain Flexion: Distal‐on‐Proximal - Meniscofemoral Joint
• Posterior Meniscus ̶ Posterior‐proximal on the femur • Anterior Meniscus ̶ Posterior‐distal on the femur
Closed-chain Flexion: Proximal‐on‐Distal -Meniscofemoral Joint
• Posterior Meniscus: ̶ Femur moves past the meniscus in an Anterior‐distal direction • Anterior Meniscus: ̶ Femur moves past the meniscus in an Anterior‐proximal direction
Pathoanatomy: Articular Cartilage Defects - Postsurgical Rehabilitation
• Proliferation phase (lasts 4‐6 weeks) − Protect the repair − Decrease swelling − Gradually restore PROM, weight‐bearing, and volitional control of quads • Transition phase (4 through 16 weeks) − Progression from partial to full weight‐bearing − Achieve full ROM and soft‐tissue flexibility • Remodeling phase (3‐6 months) − Normal range of motion − Low‐to‐moderate impact activities (bike riding, golfing, walking, etc...) • Maturation phase (begins ~4‐6 months & lasts up to 15‐18 months)
Patellofemoral Joint: Function
• Provide the articulation with low friction • Protect the distal aspect of the femur from trauma and the quadriceps from attritional wear • Improve cosmetic appearance of the knee • Improve the moment arm of the quadriceps • Decrease the amount of anteroposterior tibiofemoral shear stress
Iliotibial Band Friction Syndrome: Clinically
• Rarely traumatic; stairs are often painful; • Patients do not complain of pain with sprinting or higher speed activity • Diffuse lateral knee pain; painful with palpation at lateral epicondyle or Gerdy's tubercle • (‐) Resistive tests • (+) Ober's; Noble compression test for pain, or crepitus, or both especially at 30o degrees of weight‐bearing knee flexion • Biomechanical changes throughout chain should be evaluated − Gluteus medius weakness or fague → ↑ thigh adducon → Internal rotation at midstance → ↑ Valgus at the knee → ↑ tension on the ITB
Patellofemoral Instability: Treatment: Acute first‐time subluxation or dislocation
• Reducing swelling • Early ROM • Muscle strengthening − Quads/VMO (at least 80% as strong as uninvolved side before returning to sport) 0 to 30 degree arc initially (allows decreased contact pressures) − Gluteal muscles − External rotators • Patellar Bracing: Functional Brace or Patellar stabilization bracing
Tibiofemoral Osteoarthritis: Clinically
• Risk factors: physically demanding occupations (kneeling, squatting etc...), certain sports, older age, female sex, OA in other joints, obesity, previous knee surgery • Patients present with minimal to severe swelling, warm to the touch, pain with WB activity and possibly at rest, loss of motion (capsular pattern), muscle weakness • See slide129
What is the screw-home mechanism driven by?
• Shape of the medial femoral condyle* • Passive tension in the ACL • Slight lateral pull of the quadriceps muscle
Patellofemoral Instability: Etiology
• Small patella • Shallow patellar groove (trochlea dysplasia) • Abnormal patellar position • Muscle imbalance b/w VMO and ML • Generalized Ligament laxity
Bursitis: Etiology/Clinically
• Superficial and deep infrapatellar bursitis − Mechanical irritation from direct trauma or compression • Prepatellar bursitis − Recurrent microtrauma to the anterior knee; long periods of compression such as from kneeling − Pain and swelling present on palpation • Superficial pes anserinus bursitis − Common in novice swimmers and long‐distance runners − Medial knee pain distal to the joint line, and an externally rotated tibia • Medial collateral ligament bursitis − Inflammation of the bursa deep to the MCL often misdiagnosed as Medial meniscus pathology − Confirmed by palpation of a painful mass; painful with valgus loading
Infrapatellar Compression Syndrome: Treatment - Active Stage
• Surgical intervention: open intra‐articular and extra‐articular debridement • CPM, full AROM, and extension splints at night post‐ operatively
Anterior Cruciate Ligament Tear: Characterized by
• Tear categorization − Grade1,2or3tears • Midsubstance tear: tear in central ligament as opposed to the insertion site of the ligament − Most are midsubstance tears • Young athletes may have an avulsion fracture; controversy as to most common in young athletes (midsubstance vs. avulsion), but young injuries may predispose to degenerative conditions during aging • Posterolateral portion is the most commonly injured portion • Associated Injuries − Other ligaments, meniscus, degenerative, deafferentiation
Osteokinematics: Patellofemoral Joint
• Tibial‐on‐femoral movements - patella slides relative to the fixed femur • Femoral‐on‐tibial movements - femur slides relative to the fixed patella
Patellofemoral Instability: Characterized by
• Usually defined through history of dislocation of subluxation • Direction of instability is usually lateral • Medial instability is almost always 2o to iatrogenic causes
Iliotibial Band Friction Syndrome: Characterized by
• Usually involved at the posterior portion of the IT band • Bursal formation may occur • Considered the most common overuse syndrome of the knee and is common in long‐distance runners (terrain considerations) • Many activities can predispose one to ITBFS − Any activity that requires repetitive knee flexion and extension • Faster speed of running...less time spent in contact with epicondyle
Patellofemoral Osteoarthritis: Treatment - Conservative
− Quadriceps strengthening − Lateral patellar retinaculum stretching − ROM as needed
Infrapatellar Compression Syndrome - Characterized by
− Restriction of patellar movement due to excessive tightness of both the medial and lateral retinaculum − Direct trauma usually involved → fibrous hyperplasia of peripatellar tissues − Secondary to prolonged immobilization post surgery
Patellofemoral Osteoarthritis: Treatment - Surgical
− Soft‐tissue realignment of the extensor mechanism − Osteotomies of the tibial tubercle − Autologous chondrocyte implantation − Patellectomy (a salvage procedure) − Patellofemoral replacement − Total knee arthroplasty
