Knee Pathologies

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Knee Sprains

 

 

  • A general term used to describe any damage to an isolated structure within the knee, resulting in an instability in one or multiple cardinal planes
  • Depending on what structures are injured, a knee sprain can be considered uniplanar or multiplanar
  • Most knee sprains result from trauma to an isolated structure such as a cruciate (ACL or PCL) or collateral ligament (MCL or LCL).
  • A limited number of knee sprains are due to degenerative changes within the knee

     

     

SIGNS and SYMPTOMS

  • pop
  • buckle sideways
  • pain with activity
  • swelling
  • stiffness
  • pain when bearing weight
  • pain on standing up

     

SPECIAL TESTS

  • Tests to evaluate knee sprains are usually specific to suspected structural injuries (ie. MCL, LCL, PCL, ACL, and meniscal injuries)

 

TREATMENT

  • Rest and avoidance of weight bearing activity
  • Anti-inflammatory drugs (NSAIDS, Ibuprofen)
  • Pain management
  • Immbobilization of the joint
  • Surgical repair of tendons
  • Physical therapy
  • Recovery time varies due to degree of injury and the injured structure

 

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Anterior Cruciate Ligament (ACL) Sprain

 

  • Mechanisms of injury: (1) rotation of the knee while foot is planted followed by a force that drives the tibia anteriorly and the femor posteriorly, or (2) hyperextension
  • Isolated ACL injury is uncommon
  • Trauma to the PCL may provide a false positive for ACL injury
  • Usually injury results from non-contact sport activity in which an athlete cuts or pivots quickly (ie. soccer)
  • Predisposing factors to ACL injury may include: ACL size, joint laxity, muscular and athletic skill coordination, body motions, limb alignment, and menstrual cycle (increased laxity with estrogen and progesterone surges during the luteal phase)
  • Females experience ACL sprains at higher rate than men

     

     

 

SIGNS AND SYMPTOMS

 

  • Pain or “popping sound” from under the kneecap
  • Rapid swelling
  • Isolated ACL injuries do not usually report pain during palpation
  • Limitated movment due to pain during resisted range of motion

     

     

 

SPECIAL TESTS

 

 

TREATMENT

 

  • Rest
  • Restoring of range of motion with therapy
  • Surgery by grafting “new” ACL’s (autograft or allograft)

 

Types of Grafts for ACL Reconstruction

ACL grafts are portions of collagen based tissue that take the place of the compromised ACL and provide the same resistance for anterior translocation of the tibia.

There are two types:

1)An autograft involves the use of the patient’s own tissue from another part of his/her body.

Examples:

o       Portion of the patellar tendon

Advantages – tissue more closely resembles that of the ACL, it is the same length, and there is bone on both sides allowing for better healing

Disadvantages – risk of damaging the patellofemoral joint and associated pain

o       Portion of the hamstrings tendon

Advantages – less pain and smaller incision

Disadvantages – takes longer to heal because there is no bone-to-bone healing

2)An allograft involves the use of donated tissue.

Examples:

o       Donated cadaver ACL

Advantages – simplified surgery, other tissues arent compromised

Disadvantages – reserved for patients with low force requirements, disease transmission and rejection of donor tissue

 

 

 

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Posterior Cruciate Ligament (PCL) Sprain

 

  • MOI: posterior “adjustment” of the tibia on the femur or hyperflexion of the knee

     

     

 

SIGNS AND SYMPTOMS

 

  • Acute hyperflexion or hyperextension of the knee
  • Pain in the posterior knee
  • Weakness to the hamstring and quadriceps
  • Reduced range of motion during flexion
  • Difficulty with posteriolateral rotation

     

 

SPECIAL TESTS

 

  • Posterior drawer test: tests for increased posterior tibial translation
  • Godfrey’s sign: tests for downward displacement of the tibial tuberosity
  • External rotation: externall rotates feet to test for an increase in external rotation greater than 10 degrees when compared to the contralateral leg

     

     

 

TREATMENT

 

  • Rehabilitation for range of motion
  • Surgery
  • Rest
  • Ice

 

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Lateral Collateral Ligament (LCL) Sprain

 

  • Grade 1 to grade 3 sprain on the lateral collateral ligament
  • Results from a varus (medial) force to the knee, or internal tibial rotation
  • Being an extracapsular structure patients may also be evaluated for common and distal peroneal nerve function
  • Injuries to the LCL may also cause injury to the lateral capsule, ACL, and cause anterolateral rotory instability

 

SIGNS and SYMPTOMS

 

  • Anterolateral instability
  • Pain along the joint line
  • Some loss of motion during active flexion

 

SPECIAL TESTS

 

  • Varus test: tests for laxity and “springy-ness” in the lateral structures and ligaments
  • Slocum drawer test: tests for laxity of the anterolateral capsule

 

TREATMENT

 

  • Surgical repair due to low healing properties of the ligament
  • Rest and rehabilitation
  • Limit weight bearing exercises

 

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Medial Collateral Ligament (MCL) Sprain

  • Grade 1 to Grade 3 sprain of the medical collateral ligament
  • Usually occur in isolation, but trauma leading to the injury of the MCL could also lead to injury to the rupture of the medial joint capsule, tearing of the medial meniscus, and lateral dislocation of the patella
  • Most common mechanisms of injury are lateral blow to the knee of external rotation of the tibia
  • Common injury in contact sports (football)

     

 

SIGNS and SYMPTOMS

 

  • Considered an acute injury
  • Pain along the medial aspect of the knee
  • Popping sound
  • Tenderness from the MCL origin and insertion (the adductor tubercle to the medial tibial flare)

     

     

SPECIAL TESTS

 

  • Valgus Stress Test: tests for MCL laxity, decreased quality, and pain during bilateral manipulation and evaluation
  • Slocum Drawer Test: tests for rotational knee stability. For MCL damage we look for anteromedial instability.

     

 

TREATMENT

 

  • Usually not treated with surgery unless other structural injuries require it (ACL sprain)
  • Rest and rehabilitation
  • Protection from additional valgus stress during healing
  • Pain management

 

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Meniscal Tears

  • Tear of the meniscus (medial or lateral)
  •  There are five types of meniscal tears: 1. Longitudinal tears, 2. Radial tears, 3. Oblique flap tears, 4.Horizontal tears and finally, 5. Complex tears that inlcude more than one of these. These are important to note because it will affect the steps taken to repair, and if surgery is necessary. For example, a vertical tear can be repaired, since it is easily sewn. However, a radial tear or oblique flap requires a meniscectomy, depending on the severity of course. ( Orthopedic Associates of Porltand. "The Meniscus". July 9, 2007. http://www.orthoassociates.com/meniscus.htm#MT_Rx and Emedicine. "Meniscal Injuries". July 9, 2007. http://www.emedicine.com/SPORTS/topic160.htm)

     

     

  • can occur with numerous micro-traumas or concurrently with trauma to other structures

  • Pivoting, cutting, or decelerating may increase the risk of meniscal tear

     

SIGNS AND SYMPTOMS

  •  Stiffness and swelling
  • Tenderness along joint line
  • Collection of fluid
  • Tightness
  • Pain during flexion and rotation of the knee
  • Clicking
  • Knee “giving out”

 

 

SPECIAL TESTS

 

 

TREATMENT

  • Small tears will usually heal on their own, its best to use the RICE treatment (rest, ice, compression, and elevation)
  • If it does not heal on its own, surgery may be an option
  • Rehabilitation

 

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Osteochondral Defects

  • Fractures of articular cartilage and underlying bone due to excessive compressive and shear forces!
  • 80% involve the medial femoral epicondyle, BUT lateral femoral condyle, tibial articulating surface, and patella are also susceptible
  • Males are 3x more likely to suffer these injuries than females! Watch out Guys!

 

SIGNS and SYMPTOMS

  • diffuse pain within the knee
  • "locking" sensation and "giving away" of the knee

    "clunking" sensation

  • PAIN is increased during weight-bearing activities (increase in pain and decrease in strength noted during closed chain exercises vs. open chain)

 

 

SPECIAL TESTS

  • WILSON'S TEST = (start with internally rotated tibia and extend leg; when pain is felt, externally rotate tibia and report any decrease in pain)

 

TREATMENT

  • modified activity to reduce painful stresses
  • surgical treatment may be required (abrasion arthroplasty, microfracture, autogenic chondrocyte transplants)
  • goal is to place newly grown articular cartilage from one area of the knee to the defect
  • post-surgery treatment includes 4-6weeks of protected weight-bearing, passive movement to assist nutrient delivery, and then traditional rehab program to follow

 

 

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Iliotibial (IT) Band Friction Syndrome

 

  • occurs due to contact friction between lateral femoral condyle and IT Band 
  • high occurence in running, rowing, and cycling athletes
  • could involve inflammation of cushioning bursa between distal IT Band and lateral femoral condyle.

 

PREDISPOSING FACTORS

  • lateral projection of lateral femoral condyle due to gena varum (increased friction)
  • leg length differences, pronated feet, other conditions causing internal rotation of the tibia

 

SYMPTOMS

  • "burning" pain over lateral femoral condyle that radiates distally; point tenderness where IT Band passes over the condyle
  • Resisted ROM may result in PAIN approaching 30 degrees knee flexion, HOWEVER NO PAIN may be present during active or passive ROM
  • downhill running may produce pain

 

 

TESTS

  • Ober's Test

 

Patient is in decubitus position with injured side up. The examiner will take leg that is flexed and abduct. Examiner releases leg. In instances of tight iliotibial band there will be a resistance to normal falling. 

 

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Figure 24 Ober's test for Iliotibial Band a.set up before release b. positive. c negative (normal) for iliotibial band tightness

 

TREATMENT PLAN

  • correct biomechanical faults (orthotics may help)
  • use of NSAIDS and local modalities to decrease inflammation at the bursa and IT Band
  • static stretching at TFL and IT Band as well as other associated tight musculature
  • GOAL is to return patient PAIN-FREE to full activity

 

 

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Popliteus Tendinitis

 

  • tendinitis arises as secondary to repetitive stress or biomechanical changes.
  • popliteus muscle is often injured in conjunction with other knee injuries
  • manifests similar to IT Band friction syndrome
  • EXCEPTION = location of PAIN (immediately posterior to LCL in proximal portion of tendon)

 

 

  • excessive foot pronation will predispose one to this condition
  • worsens with downhill running since popliteus acts to prevent posterior tibial shift (exactly what downhill running induces!)

 

 

 

SPECIAL TESTS

* "FIGURE 4" TEST for Popliteus tendinitis: Sit with the side of your injured heel resting on the knee of the opposite leg. Tenderness can be felt just in front of the fibular collateral ligament.

 

The popliteus tendon is best examined in the ‘figure of 4’ position, where it is found just anteriorly to the lateral collateral ligament on the joint line. Pulling the ankle at the buttock in this position often causes pain.

 

 

TREATMENT

  • correction of abnormal biomechanical patterns
  • use of NSAIDS
  • use of local modalities (i.e ice and heat) to control inflammation

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 Lower Limb Nerve Damage

COMMON PERONEAL

  • damage occurs secondary to the following: fracture of the fibular head, contusion to the superior lateral portion of lover leg, compression from knee braces or elastic wraps, prolonged squatting, exertional compartmental syndromes, varus stress to knee, knee hyperextension, plantar flexion of the ankle, or inversion of the ankle
     

FEMORAL

  • damage occurs secondary to pelvis fracture, damage to the femoral triangle region, or femur fracture
     

SCIATIC

  • damage secondary to pelvis fracture, femur fracture, and compression of the nerve

 

SACRAL

  • damage secondary to pelvis fracture, sacrum fracture, and nerve compression

 

LUMBAR

  • damage secondary to compressed vertebra, injury to or fracture of the spine, nerve compression, trauma to the spinal cord, pelvis fracture, and sacral fracture

 

SIGNS and SYMPTOMS

  • numbness or tingling in portion of leg innervated
  • lack of sensation in portion of leg innervated
  • lack of/ limited function of the innervated muscle groups

 

AFFECT ON KNEE

  • lack of mobility/ stability due to limited or non-existant muscle function

 

SPECIAL TESTS

*Test sensation and function of innervated muscles. Patellar tendon reflex testing, partial tendon reflex testing, and achilles tendon reflex testing can also indicate damage

 

TREATMENT

  • isolation of damaged area to allow healing (when applicable)
  • Alieve other symptoms that may be affecting nerves (i.e. compression)

 

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  • Recent comments:
    Ian Metzler:I added info about what the options for ACL grafts were and a few advantages and disadnatages of each. I used http://orthopedics.about.com/cs/aclrepain/a/aclgrafts_2.htm for some of the info.
    Dianna Sampietro:I added information about IT pathologies including running on slanted surfaces, because many people are not aware that they are causing damage to one side of their body, causing IT tightness.
    lydia ohlmann:I added types of miniscal tears because it seems like that would be a huge determinant of the surgery required. I know there are some examples in the picture but just thought it would be good to mention.
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