Knee Joint Complex: Orthopedic Assessment and Management PDF

KNEE JOINT COMPLEX: COMMON DIAGNOSES DPTV 755: Orthopaedic Assessment and Management I Soft Tissue Components-ligamentous structures Anterior and Posterior Cruciate Ligaments Cruciate-”cross-shaped” describes...

KNEE JOINT COMPLEX: COMMON DIAGNOSES DPTV 755: Orthopaedic Assessment and Management I Soft Tissue Components-ligamentous structures Anterior and Posterior Cruciate Ligaments Cruciate-”cross-shaped” describes relationship of the ligaments in intracondylar notch of the femur Intracapsular Covered by synovial lining Blood supply is via small vessels located in the synovial membrane Named according to their attachment on the tibia Soft Tissue Components Anterior Cruciate Ligament Runs from anterior tibia to the medial side of the lateral femoral condyle Runs superior, lateral and posterior Fibers form 2 indistinct spiraling bundles Named according to their tibial attachments Anteriomedial bundle (AMB) Posteriolateral bundle (PLB) ACL Injury Subjective Exam History Primary contributing factors Physical Exam Loss of end range knee extension Positive Diagnostic Testing Lachmann, Anterior Drawer, etc.. Noncontact ACL injuries are more likely to happen during deceleration/acceleration with excessive quad contraction and reduced hamstring co-activation at or near full extension Soft Tissue Components-ligamentous structures Soft Tissue Components Posterior Cruciate Ligament With prone knee flexion, the hamstrings slide the tibia posterior The posterior slide is limited by passive tension in the PCL Hamstrings are called “PCL antagonists” PCL Injury Subjective Exam History Localized knee pain with kneeling or deceleration Physical Exam Loss of knee extension during gait or ROM Positive Diagnostic Tests Posterior drawer, Posterior sag, “Dial” Test Often associated with injury to posterolateral corner Soft Tissue Components-ligam entous support Medial and Lateral Collateral Ligaments Function: Limit excessive knee motion in the frontal plane MCL protects against a valgus force LCL protects against a varus force Collateral Ligament Injury Subjective Exam History Physical Exam Localized effusion Palpable tenderness Pain and laxity with testing at 30° flexion (not inclusive) Soft Tissue Components Menisci Medial: “C” shaped Lateral: 4/5 of complete circle Anchored at anterior and posterior horns. External ends attached to tibia and capsule by coronary ligaments. Relatively loose allowing motion (lateral>medial) Transverse Ligament (anterior) General Discussion of Meniscal Injuries Subjective Exam History Delayed effusion “catching”/”locking” Physical Exam Symptoms present at extremes of motion Positive Diagnostic Tests Joint line tenderness, McMurray, Apley, Thessaly Pain at maximal end range flexion and pain with forced hyperextension High incidence of meniscal tears with ACL injuries Terrible or “Unholy” Triad Patellofemoral Joint-Kinematics Tibial on Femoral Movements Patella slides relative to fixed intercondylar groove of femur Patella follows the direction of the tibia during knee flexion (due to the bony attachment of the patellar tendon to tibial tuberosity) Femoral on Tibial Movements Intercondylar groove of femur slides relative to fixed patella Patellofemoral Joint Patellar Contact on the Femur As the knee extends through the last 20-30° of flexion, primary contact point is the inferior pole Patella loses much of its mechanical engagement with intercondylar groove In full extension, the patella rests completely proximal to the groove against the suprapatellar fat pad Position of mobility assessment Patellofemoral Joint Kinetics Subjected to high magnitudes of compression force: Walking on level surfaces: 1.3x body weight Climbing stairs: 3.3x body weight Deep knee bends: 7.8x body weight Factors Affecting Patellar Tracking During Knee Extension Quadriceps pull the patella superiorly in the intercondylar groove There is also a pull laterally and posteriorly Factors Affecting Patellar Tracking Factors Affecting Patellar Tracking Global Factors Alignment of LE Factors that resist excessive valgus or the extremes of axial rotation of the tibiofemoral joint Often associated with joints other than the knee (i.e. Hip and Foot/Ankle) Excessive Genu Valgum Increased Q angle, and increased “bowstring” force at the patella  Patellofemoral Dysfunction In the past broad, inclusive terms were used Chrondromalacia Patellae Patellofemoral Pain Syndrome (PFPS) Classification Systems Patellar Compression Syndromes Patellofemoral Instability PF Pain with Malalignment or Biomechanical Dysfunction PF Pain without Malalignment Wilk et al. Patellofemoral Disorders: A Classification System and Clinical Guidelines for Nonoperative Rehabilitation, 1998 Examination of the Patellofemoral Joint, Manske and Davies, 2016 Patellofemoral Dysfunction Classification Systems Patellar Compression Syndromes Patellofemoral Instability PF Pain with Malalignment or Biomechanical Dysfunction PF Pain without Malalignment Patellofemoral Dysfunction Knee Osteoarthritis Subjective Exam Gradual Onset Behavior: stiff in am, eased w/activity Risk Factors Excess weight, previous history Capsular Pattern Physical Exam Posture/Observation Genu Varum Instability/”Buckling” Often pain inhibition of quadriceps Muscle Weakness Patellar Tendinopathy Symptoms Intervention Pain localized to inferior pole of patella Assessing pain irritability is a fundamental part Pain that increases with increased load on knee Inflammatory control extensors Eccentric exercise, if used in isolation Particularly during plyometric type activities involving the knee (e.g. jumping) Strengthening and lengthening of involved muscle groups. Tendon pain occurs instantly with loading and usually ceases almost immediately when the load Multi-angle isometrics OKC and CKC is removed Reduced strength in gluteus maximus,, quadriceps, and calf bridging single-leg squat resisted knee extension repeated calf raises. Foot posture/alignment Quadriceps and hamstring flexibility Weight-bearing ankle dorsiflexion range of motion Nerve Injuries at the Knee Nerve Injuries at the Knee Common Fibular (Peroneal) Nerve (L4-S2) Saphenous Nerve Figure 12-52 Pediatric Knee Conditions Other pediatric conditions with knee pain Slipped Capital Femoral Epiphysis (SCFE) Legg-Calve-Perthes Disease Red flag Conditons Cellulitis Compartment syndrome DVT Fractures Peripheral arterial occlusive disease Septic arthritis