Knee complex Tibiofemoral Patellofemoral Prox tibiofibular

TF - largest joint in body Lat. Femoral condyle o More anterior

Med condyle o More distally displaced

Tibia o Shorter than fibula (compensation) Knee joint Modified hinge 2 DOF o Flex/ex o Int.rot/ext.rot OF TIBIA o Rotation only when flexed Stability Ligamentous & muscular o NOT osseous PF On saddle fem condyle o Concave (med-->lat) o Slightly convex (front-->back) 2 DOF o Sup/inf o Med/lat o Tilting not included 5 articular facets o + odd facet Not contacting (only after 90 deg flex) Site of osteonecrosis

Fxns of patella Inc leverage of quads Protect joint surfaces of fem condyles Dec pressure Prevent damaging compression forces of quads tenson Ratio of insal & salviti Patellar tendon length vs patellar length 1:1 Patella Rests @ patellar grove/trochlear surface of femur (resting pos'n) Greatest compression - 90 def closed chain flexion (deep squat) Articulation Medially

Superiorly VMO Patellofemoral lig Meniscopatellar lig

Laterally Vastus intermedi us Rectus fem

Vastus lateralis Superficial & deep retinacula IT band

Lateral patellar tracking - strengthen VMO

Prox TF Pain @ joint manifest @ knee Aka FORGOTTEN JOINT Syndesmosis o Connected by fibrous sheath Palpable Epicondyle Condyle Patella Tibial crest Tibial tubercle

Edges of plateau Med & lat collateral Medial meniscus (int rot)

Motions: Flex/ex Axial rotation Accessory o Rolling o Sliding/gliding Terminal knee extension o 15-20 deg Axis of motion o Center of lat & med condyle forming evolute o 2 cm above condyles o Rouleau - intersection of ACL & PCL ROM measurement o Lat epicondyle

Screw home mechanism Aka terminal rot of knee Last 15-20 deg of terminal knee ext o Open chain Tibia rot lat on femur o Closed chain Femur rot med on tibia

ACL

Most stable, more injured Orig: ant intercondylar fossa Course: sup & lat Ins: medial lip lat condyle Prevents: o Ant dislocation/translation of tibia o Int & ext rot of tibia

o o

Seldom in closed-chain Torn if sulcus present (anterior drawer sign)

PCL

Orig: post intercondylar fossa Course: sup & med Ins: lateral lip med condyle Prevents: o Post translation of tibia o Closed-chain Ant displacement of femur on tibial condyles (post drawer)

Stabilizing comp Menisci o Medial C More susceptible to injury More fixed to tibia o Lateral O Where popliteus attaches Popliteus - readily locate meniscus post during flexion o Avascular central; vascular peripheral o Jump: compressed inner portion o Knee flexed: Injury to medial condyle Ligaments o Cruciate o Collateral o Patellofemoral o Patellotibial Tendon o Quads o Patella Muscular o Semi o Popliteus Joint capsule - most impt stabilizer

Cruciates Above II Front X Relatively constant length Collateral lig Frontal movt Only in ext Limit valgus & varus (ext) Shortened if flexed Prevents o Ant & post displacement of femur (flexed) o Rotational forces Medial collateral usually injured o Valgus stresses Unhappy triad of ODonoghue Medial meniscus Anterior cruciate Medial collateral Menisci Aid in o Lubrication and ______ o Shock absorption o Improve weight distribution o Dec friction

Intercondylar eminence bet menisci Limits hyperextension

Bursae Suprapatellar quads & ant femur Subpopliteal popliteus & lat condyle Gastroc med head & med condyle (bakers) Prepatellar skin & ant patella (nuns/maids) Subcutaneous-infrapatellar skins & patellar lig Deep infrapatellar patellar lig & tibial tubercle Observations & Measurements Patellar orientation

o Patella alta Overriding Longer patellar tendon o Patella baja Inferior o Both measured in knee extension Grasshoppers eye/frog eyes patella laterally Patella external rotation (internet) Squinting medially Patella internal rotation (internet) Osgood schlatter osteonecrosis of odd facet irritation of the patellar tendon at the tibial tuberosity (internet) Camel sign Patellar override Directly observable Q angle, quads angle From femoral shaft and perpendicular line through center of patella o Males:___ (10) o Females 18 (18) >18 o Chondromalacia patella o Displaced laterally o Inc fem anteversion o Genu valgum o Rtibial tubercle displaced lat o Tibial torsion o Bayonets sign (+) Q angle when seated Subluxed patella <10 o Patella alta o Chondromalacia patella Obliterated if knee flexed Swelling of bursae Pes anserinus bursitis o Gracilis

o Semiten o Sart Bakers cysts o Gastroc bursae

Posterior knee Lateral semimem Medial semiten Lift leg: pes anserinus palpated Muscles acting on knee Knee extensors o Rectus femoris o Vastus lat o Vastus med o Vastus intermedius sitting quads (ecc); hams (silent) standing quads (con); hams (con) o Gmax- stabilize hip Closed chain o Quads, hamstrings both extend o Gastroc/soleus from squatting >90 deg Knee flexors Hamstrings Gracilis Sartorius Gastrocnemius popliteus

Closed-chain quads gastroc wont contract until >90 deg NO HAMSTRINGS Gmax extend hip (ecc) o Move knee posteriorly

Range for normal gait: 60 deg Downstairs: 96 deg Upstairs: 83 deg Tying shoes: 103 deg Picking objects: 117 deg Referred pain: common peroneal, saphenous, etc. Knee internal rotators (pes, semimem, popliteus) PSP Semiten Sart Gracilis Semimem Popliteus

Knee external rotators Biceps femoris Tibiofemoral shaft angle Lines through shaft of femur & shaft of tibia 6 deg Inc - genu valgum Dec - genu varum Newborn: mod genu valgum 6 mos: min g valgum 1 yr 7 mos: straight leg 2 yr 6 mos: phys g val 4 yrs 6 mos: legs straight (normal out toeing) VVSVS KNEE FLEX, hip extended passive insufficiency RECTUS KNEE EX, hip flex passive insufficiency HAMSTRINGS KNEE FLEX, plantarflex full action gastrocsoleus KNEE EX, plantarflex good length-tension of gastroc

Tiptoe Gastrocsoleus

 Flexor hallucis longus Heelraise Gastrocsoleus Ascending stairs Quads Hams Descending Quads gastroc