Knee Notes and SPT valgus force (c or s rot): MCL c injury to
Applied Ana posteromedial capsule, med meniscus & ACL (unhapy
Tibiofemoral jt. triad)
-largest jt. hyperextension: ACL c meniscus tears
-modified hinge c 2 deg of freedom flexion c post trans: PCL
-cruciate lig - intracapsular, extrasynovial varus force: LCL, posterolateral capsule & PCL
-OPP: 25 deg of flexion torsion (compression & rot): meniscus (more
commonly med)
-CPP: Full extension & ER of tibia
-tibial tubercle apophysis/traction epiphysis - osgood-
-CP: Flex, ext
schlatter disease (enlargement of tibial tuberosity)
-lat fem condyle - more ant to prevent lat disloc of
-less injury if LE is in OKC
patella
-distinct pop: ACL tear/osteochondral fx , lat aspect -
-MCLO - Med meniscus:C , Lat meniscus:O
snapping of popliteus tendon
-ext to flex: both meniscus moves post (med
-acceleration & twisting - meniscus; deceleration -
menisccus:2mm, lat meniscus:10 mm)
cruciate lig; constant speed c cutting- ACL
-meniscus are inner 2/3 avascular & outer 1/3 vascular
Pain:
-coronary lig = meniscotibial lig are longer on lat
-aching - degeneration
Patellofemoral jt.
-catching - mechanical prob
-modified plane
-arthritic pain - stiffness in morning & eases c
-sesamoid bone
act
-facets/ridges: sup, inf, lat, med, odd
-ant knee pain - patellofemoral prob, pre &
-odd facet - most frequently affected in chondromalacia infrapatellar patho, fat pod patho, tendinosis, OS
patellae disease
-chondromalacia patellae - premature degeneration of -patellofemoral pain - insidous and spontaneous
patellar cartilage
-pain at rest - usually not mechanical prob
-odd facet - contacts fem condyle at 135 deg of knee
pain during act - structural abnormalities
flexion
-pain after act or c overuse - inflammatory d/o
-malalignment of patellar mvmt = patellofemoral
(eg. tendinosis/paratenosis leading to jumper's
arthralgia
knee/Sinding-Larsen-Johansson syndrome)
Patella
-generalized pain - contusions, partial tears of
-improves efficiency of extension during last 30 deg (30- mm or lig
0 deg ext)
-instability rather than pain - complex lig
-patellar loading: disruptions or mm dysfunction
walking: 0.3 x bw -pain in knee an ankle movements - sup
climbing stairs: 2.5 x bw tibiofemoral jt.
descending stairs: 3.5 x bw -constant pain unrelated to act, time or posture
squatting: 7 x bw - serious patho (eg. tumor)
Superior Tibiofibular jt. Giving way:
-plane synovial -knee instab
-fibula bears 1/6 of bw -meniscus patho
-10% of pop - cont. of tibiofemoral jt. -patellar sublux
-undisplaced osteochondritis dissecans
Pt. Hx -patellofemoral syndrome
MOI: -plica/loose body
-when walking uphill/downhill - retro patellar -inc foot pron
lesion -excessive lordosis - knee hyperextension = post knee
-"slips out of place" - patellar sublux, plica patho pain
Locking: -intracapsular swelling - 15-25 deg of knee flexion
-locking - knee can't fully ext c flex normal & is related -intracapsular swelling - evident over the entire jt.
to meniscus patho -extracapsular swelling - localized
-catching - momentary locking or giving way due to -patella tilt outward - grasshopper eyes/frog eyes
reflex inhibition or pain -patella tilt inward - squinting patellae = med
-true locking - rare femoral/lat tibial torsion= patellofemoral instab
-recurrent locking - loose bodies Lat, standing:
-spasm locking - hamstring mm spasm -genu recurvatum - hyperextended knee
Clicking/grating: -if habitual - PCL tear
-degeneration, structures are snapping -if hyperextension of only one knee - meniscus
Swelling & tightness: patho
-swelling c act - instability -patella alta - high patella
-tightness at rest - arthritic changes, -ant knee pain
patellofemoral dysfunction -camel sign - patella alta & infrapatellar fat pad
-swelling c pivoting - meniscus problems, or inflamed infrapatellar bursa
tibiofemoral jt. instab -patella baja/infera - low patella
-recurrent swelling c climbing or descending -osteoarthritic lipping or synovial hypertrophy (RA) -
slopes - patellofemoral dysfunction may also limit movements
-localized swelling - inflamed bursa Post, standing:
*deep infrapatellar bursa - ant knee pain -abnormal swellings
-synovial swelling - 8-24 hrs. after injury - popliteal (Baker's) cyst - caused by herniation
-swelling caused by blood - immediately of synovial tissue
Ant & Lat, sitting:
Observation -tibia torsion - med:varum ; lat:valgum
Ant, standing: -med tibial torsion - pigeon-toed
-malalignment - genu varum (bowleg), genu valgum -excessive tibial torsion - chondromalacia
(knock knee) patellae, patellofemoral instab, fat pad entrapment
children: -fick angle - patella faces straight ahead while foot faces
-varum (18-19 mos) to valgum (3-4 y/o) slightly laterally
adult: -5 deg in babies
-knee - aprox 6 deg of valgus (normal tibiofemoral shaft -18 deg in adults
angle) *tailor's pos - maintains normal med tibial torsion
-genu valgum - knees touch but ankles do not (9-10 cm Gait:
excesssive) -weak hip abd - trendelenburg sign
-genu varum - ankles touch but knees do not (2 fingers -trendelenburg sign c med tibial torsion - patellofemoral
bet or 4 cm syndromes
-miserable malalignment syndrome: -tight heel cords - gait c knee flexed = stress on
-ant pelvic tilt patellofemoral jt
-inc hip anteversion -foot pronation & lat tibial torsion - patellofemoral
-dec tibiofemoral angle patho or anteromedial jt pain
-genu recurvatum -tight hamstrings - inc knee flexion, inc ankle
-navicular drop dorsiflexion
-if no further dorsiflexion is possible, foot -duck waddle - inc symptoms of meniscal & ligamentous
pronates to compensate = inc dynamic Q-angle lesions
-single-leg hop for distance - instability; distance of
Examination affected leg is less than normal leg
Active modifications:
-sitting or supine -single-leg hop timed
-full knee flexion - 0-135 deg; full kne extension - 135-0 -triple hop
deg (but can be -15 deg esp in women) -crossover hop
-normal patellar pattern - med in early flexion to lat -agility hop
-inverted "J" sign - presence of pathological patellar -stair hop test (stairs hopple test)
tracking & patellar instab -deceleration test - rot instability
-quadriceps lag - quads mm are not strong enough to -limb symmetry index (LSI) - any functional deficit bet
extend knee two limbs
-med rot of tibia - 20-30 deg; lat rot of tibia - 30-40 deg -disco test - rot instability
Passive -Merke's sign - if there is pain on joint line -
-end feel - all tissue stretch except flexion (tissue meniscus pathology
approx) -leaning hop test - rotary instability
-deg of knee flexion needed for act:
-117 deg - squatting to ties shoelaces Ligament Stability
-90 deg - sitting -acts as primary stabilizers; guide the movements of
-80 deg - climbing stairs bones in relation to one another
-motion palpation test - severe damage Collateral lig:
Resisted Isometric -medial (tibial) collateral lig (MCL) - lies more post on
-supine medial aspect of tibiofemoral jt
-PFPS - patellofemoral pain syndrome -all fibers - tight on full ext
- hip abd & lat rot are weak -ant fibers - flexion
-testing quadriceps - 0,30, 60,90 deg while observing -post fibers - mid range of ROM
any tibial movement (lig instability) or excessive pain -medial capsular lig - deep layer; blends c med meniscus
from patellar compression (patellofemoral syndrome) -lateral (fibular) collateral lig (LCL) - round; lies under
-testing hamstrings - prone tendon of biceps fem; more post
-90 deg knee flexion, heel out - greatest stretch - tight in extension
on lat hamstring (biceps fem) Cruciate lig:
-90 deg knee flexion, heel in - greatest strech on -primary rotary stabilizers
med hamstring (semimembranosus & semitendinosus) -intracapsular but extrasynovial
-anterior cruciate lig (ACL) - sup, post, lat
Functional Assessment -posterior cruciate lig (PCL) - sup, ant, med
-functional tests: -oblique popliteal lig - prevents hyperextension
-figure-eight running to straight running - ACL
deficiencies
Testing of Ligaments
-Timed "Up and Go" Test (TUG Test) - total knee
-left-right difference of 3 mm - pathological
arthroplasty
-soft/indistinct end feel - ligamentous injury
-sit-to-stand test - biomechanical function test
-squatting - limitations of flexion & impingement c
meniscal lesions