Knee and leg Function Transmission of weight force Mobility to support locomotion in both the horizontal and vertical

planes Dissipation of rotatory movements of hip and feet Force dissipation and transmission Static and dynamic propioception Hinge type of synovial joint 2 femorotibial articulation (femoral condyles articulate with tibial condyles) 1 femoropatellar articulation (intercondylar space and post aspect of the patella) Patello tendon/ligament: Distal part of the quads tendon attaches to tibial tuberosity via this tendon. It receives medial and lateral patella retinaculum, which are formed from aponeurotic expansions of the vastus lateralis and medialis, iliotibial tract laterally and overlying fascia Capsule: Thin with thickening, blends with patella, patella ligaments, retinacula, post to the lat tibial condyle is opening for popliteus to exit Oblique popliteal ligament:Reinforces posterior capsule is a recurrent expansion of insertion of SM, from medial tibial condyle to latero femoral condyle. Arcuate popliteal: From post fibular head, passes over tendon of popliteus Lat collateral ligament: lat femoral condyle to lateral surface of fibular head, stronger that medial, lies deep to biceps femoris tendon, separated from lateral meniscus by popliteus Med collateral ligament:More posterior, two layers (deep and sup), deep attached to medial meniscus. Coronary ligament: Part of capsule, assist tethering the meniscus to the tibia. Transverse ligament: meniscomeniscal ligament is a ligament in the knee

Articular surfaces

Ligaments

joint that connects the anterior convex margin of the lateral meniscus to the anterior end of the medial meniscus.
Meniscofemoral ligament:

Posterio: (ligament of Wrisberg) is a small fibrous band of the knee joint. It attaches to the posterior area of the lateral meniscus and crosses superiorly and medially behind the posterior cruciate ligament to attach to the medial condyle of the femur. Anterior: (ligament of Humphrey) is a small fibrous band of the knee joint. It arises from the posterior horn of the lateral meniscus and passes superiorly and medially in front of the posterior cruciate ligament to attach to the lateral surface of medial condyle of the femur.
ACL: ant intercondylar area of the tibia, attachment extends sup-posteriorly and laterally, attaches lat femoral condyle. PCL: post intercondylar area, extends sup-anteriorly and medially, to the ant part medial femoral condyle Meniscae Function: Increases congruency, increases stability, accommodates to slide and gliding mvmts, shock absorption

Patella

ROM Infrapatellar fat pad Bursae

Structure: medial: C shaped, less mobile,less diameter, attached to MCL/ Lat: O shaped, smaller than medial, more mobile, not attached to LCL Numerous attachments: 1.-coronary lig 2.-transverse meniscomeniscal 3.-MCL 4.-popliteus and SM 5.-ant meniscofemoral (Humphrey), post meniscofemoral (Wrsiberg) Vascularisation: Outer 1/3 Biomechanics: -both slide ant in extension and post in flexion -when squatting increases load in post horn -varus stress: compresses lat meniscus//valgus stress: compresses medial meniscus Patella alta (patellar height: distancia patella and TT): 1.2 < unstable&hypermobile patella//patella baja: 0.8> incongruent articular surfaces Flexion: 135/exte: 15 /IR: 20-30 /ER: 30-40 also known as Hoffa's fat pad, is a cylindrical piece of fat that is situated under and behind the patella bone within the knee. Subcutaneous prepatellar: between the patella and the skin, results in "housemaid's knee" when inflamed. It allows movement of the skin over the underlying patella. Bubcutaneous Infrapatellar bursae: between the patellar tendon and skin Deep infrapatellar bursae: between the upper part of the tibia and the patellar tendon. It allows for movement of the patellar tendon over the tibia. Pretibial bursae: between the tibial tuberosity and the skin. It allows for movement of the skin over the tibial tuberosity Suprapatellar bursae: between the anterior surface of the lower part of the femur and the deep surface of the quadriceps femoris. It allows for movement of the quadriceps tendon over the distal end of the femur Popliteus bursae: Between popliteus, LCL, femoral condyle and biceps femory Fibular bursae: Biceps femoris and LCL Anserine bursae: between the medial (tibial) collateral ligament and the tendons of the sartorius, gracilis, and semitendinosu SM bursae: between the medial collateral ligament and the tendon of the semimembranosus Gastrocnemius bursae: Between the head of the gastrocnemous and the head capsule Ant, post, lat aspect: femoral, tibial, common fibulat Medial aspect: obturator, saphenous Sup medially: ST and SM Sup lat: Biceps femoris Inf medial: Medial head gastrocs Inf lat: Lat head gastrocs and plantaris Floor: knee capsule and popliteus Roof: deep fascia Contents: Popliteal artety, popliteal vein, tibial and common fibular nerves Medial sup geniculate, lat sup geniculate, middle geniculate, lat inf geniculate, medial inf geniculate Plane synovial joint Between the head of the fibula and posterolatinferio aspect of the tibial condyle Ant-post tibiofibular ligaments

Nerve supply Popliteal fossa

Blood supply Proximal TF joint

Middle TF joint

Distal TF joint

Muscles

Fibrous joint between tibia and fibula Fibres pass inferolaterally from tibia to fibula There is a gap superiorly to allow the passage of the ant tibial vessel Syndesmosis fibrous joint Lower end of the tibia and medial aspect of the fibula Ant-post tibiofibular ligaments, transverse tibiofibular ligament Leg: Ant compartment (deep peroneal nerve): TA, EDL, EHL, fibularis tertsus Lat compartment (sup peroneal nerve): FL, FB Post compartment (tibial nerve): TP, FDL, FHL, GN, soleous, popliteus, plataris ACL: -injury results from twisting while changing directions, deceleration with valgus and ER, hyperflexion of the knee -audible pop with immediate swelling (<2h) -intense pain at postlat tibia -unstable in wb Test: Ant drawer test, lachman test //MRI Ttt: conservative, surgery (patella tendon, hamstring tendon arthroscopy) PCL:When a player lands on the tibial tuberosity with the knee bended -minimal swelling, ecchymosis may appear days later -tenderness in popliteal fossa and pain with kneeling -Pt may be able to continue to play Test: posterior drawer test, sag test Ttt: Surgery to repair the posterior cruciate ligament is controversial due to its placement and technical difficulty. Usually a graft taken from the hamstring or Achilles tendon from a host cadaver. LCL: -injury results from varus stress resulting in overstretching or tearing of the LCL. -warm&swollen lateral knee -TTP -ROM may not be affected -Test: varus stress test //MRI//MRI for avulsion MCL: -injury results from valgus stress resulting in overstretching or tearing of the MCL -knee flexion limited to 90 -TTP If deep fibres are torn, knee joint rapidly fills with blood Test: joint gapping//MRI//X-Ray:avulsion

Common problems: Knee ligament injury

Patella dislocation

-knee is slightly flexed but the quadriceps relaxed -Involves direct trauma, often a twisting trauma, that dislocates the patella laterally -Most common in teenagers, especially girls with ligamentous laxity -Patella may rest on lateral femoral buttress. Patella looks laterally and superiorly -Felt a painful pop -clicking and knee giving away -Pt falls to floor as knee collapses - Deformity med femoral condyle uncovered and prominent, patella palpable on lat aspect of leg -Joint may be swollen due to haemarthrosis; med side of patella painful

due to rupture of med ST PF: excessive tibial ER, pronation, patella alta, tight lateral retinaculum, weak hip ER, small medial patella facet, increased Q angle Test: patella apprehension, patella tilt , compression test// X-Ray confirms diagnosis Ttt: -Reduc if necessary; aspiration of the joint if haemarthrosis present -If surg reduc and aspiration required, then joint is immobilised for 4/52 to allow med ST to heal and joint to stabilise -Phytherapy: strength exx of quadriceps to improve stability Recurrent Dislocation -Result of a traumatic initial dislocation -PF: Ligamentous laxity ,abnormalities of the patella or the lateral femoralbuttress, genu valgus -More common in teenagers, esp girls -Sometimes B -Dislocates with minimal trauma usually associated with contraction of quadriceps with knee flexed TTT: -Surgery>3 dislocations and when patient has stopped growing -Surgery can involve: Re-aligning quadriceps by moving TT medially Moving TT distally to pull patella lower into patellar groove Detaching lat structures of patella Tightening med structures of patella Test: Patella apprehension test Meniscal injuries -Can occur with minimal trauma, degeneration, varus/valgus stress, hyperextension, flexion&IR, flexion&ER -Most common in young adults :of sports injury,rotational injuries -Different types of tear, but similar clinical features -Limited blood supply to the periphery, so some scope for repair of peripheral tears, but otherwise avascular -Fragmented part of the meniscus will irritate the synovial membrane, causing local inflammation and pain Clinical presentation: -Pain sometimes severe, rapid onset with associated click or snap -pain localized to the joint line -Knee may become locked/catching in semi-flexion active extension impossible -Swelling may take 12-24h to become apparent, sometimes Baker cyst -Symptoms often improve with rest and NSAIDs, but return after a minor traumatic event, esp another twisting movement -Pain from a medial meniscal tear tends to be localised along the medial joint line, whereas lateral meniscal tears produce a more diffuse pain -On examination, the knee is held in slight flexion and there is a slightly restricted ROM in extension -pain in flexion post part of the meniscus is involved // Pain in extension, ant part of the meniscus is involved -pain at night: extended knee or twisted when turning -Diagnosis is confirmed by MRI or arthroscopic examination. Diagnosis on clinical findings alone is only accurate in 70% of cases -PF:aging, contact sport, family tendency, ligamentous laxity, long periods of weight bearing -Agg: up/down stairs, squatting, hyperextension, hyperflexion, twisting Ttt:

-Once diagnosis is confirmed, torn fragment is excised (preferably by arthroscopy), leaving as much of the meniscus intact as possible -Return to light work is possible after 1 week, heavy work after 2 weeks with arthroscopy recovery takes 3 months following open meniscectomy Test: Appleys compression test, McMurrays test (varus+IR for lateral meniscus //valgus+ ER for medial meniscus) Complications Meniscal injuries and their surgical treatment predispose the patient to early degeneration of the knee

Chondromalacia patellae

-Softening of the cartilage of the patella. Tends to affect the odd facet -Pathophysiology: softening, erosion, fragmentation and scarring of the articular surface of the patella. -Unknown cause, but thought to be associated with a degree of incongruence between femur and patella, leading to a degree of maltracking -More common in teenage girls -Often associated with increased strain on the knee,so may be more common in patients who participate in strenuous sports -Results in swelling and inflammation in the retro-patellar cartilage that may result in medial vastus waisting, weak ER of the hip -Patient presents with anterior knee pain, aggravated by going up/down stairs and prolonged sitting. -Local effusion may be visible/palpable and there may be local tenderness around the patella and on palpation of the posterior patellar surface -crepitus -PF weak hip ER, increased knee valgus, increased Q angle, overpronation of the foot, patella alta/baja, weak vastus lateralis, tight ITB+vastus lateralis. -Complication: it can lead to dislocation of the patella, patelofemoral OA, tibiofemoral OA -Agg: up/down stairs, sitting, prolonged activity Test: Grind test, apprehension test// Confirmed via MRI Ttt: Avoidance of excessive exercise Analgesia If symptoms do not resolve (this can take up to 2 years), surgery may be required. Surgical treatment includes: 1. Shaving the softened area of cartilage 2. Arthroscopic wash-out 3. Re-alignment of the patella 4. Patellectomy

Osgood-Schlatters

-Common condition affecting TT. Excessive Txx on TT from quads (before it is fused to tibia). Traction apophysitis of the TT. -Pathophysiology: 1.-The TT has its own ossification centre (begins to fuse at the age of 16) 2.-Prior to fusion it attaches to the tibia by proliferating cartilage 3.-Deep to the cartilage newly forming bone creates a weak link 4.-The pull of the quads on the tibia stresses this soft new bone 5.-increased tension on quads (increased exx) increases tightness leading to decreased blood supply causing ischaemic necrosis&break down in local bone 6.-revascularisation&irregular calcification 7.-New bone formation leading to hypertrophy of TT

Jumpers kneeinfrapatellar tendonitis

- May be bilateral -Insiduous onset, becomes chronic until tuberosity fuses -May start after vigorous exx, kicking -Results in local inflammation and pain -TTP, enlargement of the TT -Affects teenagers (mainly boys), esp. those participating in lots of sport -TT may be enlarged and is often tender -Agg: Exx, ARMT knee ext, kneel, passive stretching of quads/ Relv:rest Test: X-Ray: avulsion -TTT: -Initial: rest, NSAID, ice, strap, avoid quads stretching -Later quads stretches warm up/down -Normally full resolution. Fragment excision at TT. One exx type bad for teens. Infrapatella tendonitis RSI of the infrapatellar tendon ( jumping, kicking, running activities) Mechanism of injury similar to that of tennis elbow, Osgood Site of injury normally at inferior border of patella where tendon inserts -Pathophysiology: low grade inflammation &histological bone changes at the tendon bone junction. Often becomes chronic and can lead to tendon rupture Insidous onset: vague ant knee pain for month -gradual progression -localised swelling and crepitus, bruising, TTP over tendon PF: overpronation, structural fault, hip muscle imbalance, increased IR and ADD hip, sloped surface, improper shoes, sudden increased distance, hill training, direct trauma, weight lifting, patellar maltracking. Agg: ARMT knee ext, post activity, up/down stairs, sitting (movie sign), strenuous activity, sitting to standing Test: difficulties squatting, kneeling, sitting to standing, end range flexion, +trendelenburg (weak hip abd), + patella compression test (false positive chondromalacia), Test: MRI Ttt: -Rest, NSAIDs -Up to three injections of cortisone into region of tendon (not into tendon itself) -Surgical intervention is indicated if conservative treatment fails

Osteochondritis dissecans

-Affects posterolateral medial femoral condyle. Lesions of the subchondral bone& overlying articular cartilage leading to fragmentation and fracture -insidious onset -Occurs in children of 8 12 yoa -6 times more common in boys -knee efussion -knee crepitus with knee flexion and extension -poorly localized knee pain -causes pain which is aggravated by walking and hyperextension (decreased ext end ROM) -antalgic gait (ER tibia) -TTP over medial condyle with knee flexion (medial joint line) -in later stages, a loose body in the joint can cause the knee to lock -complications include later development of secondary O/A as a result of the condition itself and the trauma of the surgical removal of the fragment

-Test: Wilson test: ext knee with IR of the tibia//ER tibia should take the pain away -Test: MRI, bone scan Patellofemoral O/A Bursitis

-Inflammation of one bursa of the knee;saclike cavities filled with synovial fluid, located at tissue sites where friction occurs (tendon, muscles, bony prominences). Facilitates mvnt, minimizes friction. -Bursitis is considered nonarticular. However several knee bursae are connected with articular cavity, when swollen may indicate an articular pathology Prepatella: common in sport, falling on knee or kneeding (housemaids knee) Infrapatella: kneeling Pes anserine: prevalent in long distance running or middle age women with knee OA. PF: lat tibial rotation, pronation Gastrocnemious -localised heat to palpation -localised swolling -radiating pain 2-4 cm bellow the bursa -crepitus -disconfort with active and passive ROM Test: MRI An acute or chronic bone infection due to bacteria or rarely fungi. Bones can become infected in a number of ways: Infection in one part of the body may spread into the bone, or an open fracture that exposes bone to may get infected. P.F: diabetes, haemodyalisis, injecting drugs, local recent trauma/surgery Symptoms: local bone pain, malaise, fever, sweating, swelling, redness Test: X-Ray, MRI, blood culture (ESR, CRP) - a progression of shin splints resulting in a loss of microcirculation in shin muscles -This is an emergency situation Front of the leg, preceded by intense athletic activity. Oedema and swelling occur and it can lead to ischaemia and necrosis of the muscles. Leg is swollen and tender. TA and EHL are first affected, with weakness and later an inability to extend the ankle and first toe (foot drop). The dorsalis pedis pulse may be absent and there may be sensory loss in the first web space from ischaemic changes in the deep peroneal nerve. -skin feels warm and firm Ttt: decompression to avoid necrosis Popliteal aneurysm: DVT: Lymph node swelling: Baker cyst: The synovial sac of the knee joint can, under certain

Osteomyelitis

Ant compartmental syndrome of the leg

Swelling of the popliteal fossa

circumstances, produce a posterior bulge, into the popliteal space. When this bulge becomes large enough, it becomes palpable and cystic. -golf ball-size, swelling at SM tendon, med GN, popliteus -best palpated in full flexion -stiff, tender with limited knee ROM -A Baker's cyst can rupture and produce acute pain behind the knee and in the calf and swelling of the calf muscles. -Cause: Intra or extra articular cause: Repeated irritation of GN, SM or popliteus muscles/intraarticular cause (meniscus, loose body, OA), knee joint sweeling

Infrapatellar fat-pad

Medial tibial stress syndrome (MTSS), tibial periostitis Or shin splints

Test: MRI -Pt with hyperextension or genu recurvatum. -In the case of a forceful direct impact to the kneecap, the fat pad can become impinged (pinched) between the femoral condyle and the patella. -As the fat pad is one of the most sensitive structures in the knee, this injury is known to be extremely painful -Agg: ext knee Test: Hoffas test -Caused by repeated trauma to the connective muscle tissue surrounding the tibia -may result in a more serious condition such as a stress fracture. Females are 1.5 to 3.5 times more likely to progress to stress fractures from shin splints. -If an athlete begins running a lot after not running for a long period of time -Increasing activity, intensity, and duration too quickly leads to shin splints because the tendons and muscles are unable to absorb the impact of the shock force as they become fatigued -Agg: runnig uphill, downhill or uneven surfaces

PF: Excessive pronation at subtalar joint

Excessively tight calf muscles (which can cause excessive pronation) Engaging the medial shin muscle in excessive amounts of eccentric muscle activity Undertaking high-impact exercises on hard, noncompliant surfaces (ex: running on asphalt or concrete) Smoker and low fitness

Iliotibial band syndrome

Ottawa knee rule

Irritation &inflammation of the distal ITB near femoral condyle of femur. Overuse syndrome, bursa may also be swollen Anatomy &biomechanics: -ASIS to lat tibial condyle (Gerdys tubercle), small expansion to superolateral patella -Gluteus maximus and TFL contribute ITB -When knee is extended ITB ant to lat femoral condyle//knee flexed more than 30 ITB post to condyle -ITB rubs with condyle between 30-40 of flexion -Diffuse lat knee pain -increased pain with downhill running -increased pain during swing forward phase -repetitive snapping -lat tenderness ITB Test: + Obers test and + Renners test X-Ray series is only required if the pt presents any of the following criteria: -55 yo -isolated tenderness of the patella -tenderness of the head of the fibula

- inability to flex >90 -inability to wb less than 4 steps

Rheuma: Unilateral: Gout Pseudogout Enteropathic Reiters Psoriatic OA Billateral: RA

Other conditions: DVT

DVT develops as a combination effect of 1 Change in coagulation 2 Damage to endothelium 3 Decreased blood flow 4 Fibrinolytic state of the patient Risk factors for DVT: Immobility Age over 40yrs History of DVT Varicose veins Obesity Malignant disease Pregnancy Oral contraception Surgery Trauma Flying long haul Connective tissue disorders

Presentation
-Tender painful swelling in the calf, signs of veins on surface, skin discoloured. -Agg: standing and walking/ Rel: rest. -There is no sudden onset, unlike with a muscle tear where pain is marked on walking. Pain is only generated on contracting the damaged muscle and therefore is generally not painful when standing. More than half of DVT are silent. Conversely less than half patients with local tenderness or Homan's sign have DVT. Note that a muscle tears may also cause pain on full ankle dorsi-flexion, since this also causes a stretch of the painful muscle. If in any doubt it is wise not to perform soft tissue treatment on the calf, and to refer to GP who will see DVT more often. GPs will tend to refer rapidly for further investigation if in any doubt.

-Osteopathic test: Homans sign, increased circumference >1.2 -Medical test: Doppler ultrasound -Complication: PE

Vascular claudication Neural claudication