Knee

Colgan Osteopath in Kettering Northamptonshire

Knee exercise

Meniscal tear

 

MCL sprain

Knee pathologies

Meniscal tear

medial 75%, lat 25%. MCL attached to med meniscus, LCL not attached to lat men. no nerves in menisci but a lot in transition zone b/n men and capsule. weight 50%standing, 90%with knee flexed, male X3>fem. tears 1. trauma, 2. degenerative. risk – ligament laxaty, deep knee bent, repetitive rotation force. SSx – joint line P, locking, catching,  swelling, +/-Bakers, incr P on hyperflexion/hyperextension, decr ROM on extension, often P at night, DDx joint mice

Infrapatellar tendinitis ( jumper knee)

degenerative tendinopathy of infrapatellar tendon (Often together with chondromalacia patella) due to overuse. Risk: overpronation, structural (e.g. patella alta, genu varus/valgus, leg length), mm imbalance – VMO vs ITB + Vas. Lat. Maintaining – weight lifting, hill training. SSx – P ant knee (esp after activity), +ve movie sign, P when arising from sitting, P on palpation. DDx – (<16) Osggood, bursitis, chondromalacia (grinding)

Chondromalacia patella

erosion of articular surface of patella due to repetitive stress, Q angle, mm imbalance, anatomical (pat alta or bassa). Risk – pronation (incr LSp lordosis), tight ITB. SSx – incr P going down stairs, kneeling, prolonged sitting, crepitis. DDx – jumpers knee (no crepitis), meniscus, bursitis

MCL sprain

injury on lat rot of femur on tibia or valgus force. grade 1 mild (no laxaty, but P) <6mm gapping. SSx P & swelling on med knee. DDx – med meniscus, ACL, PCL, pes anserinus

ACL sprain

attached to ant tib and lat condyle femur. highest rate during ovulation, hypermobility. pronation syndrom (incr pronation led int rot of tibia led incr tension on ACL). Unhappy triad – ACL, MCL, med menis. valnerable in all rotation (int & ext), hyperextension, valgus force and hit from behind. SSx may dissapear in several weeks but lig takes up to 1 year to regain strength

PCL sprain

post tibia and med condyle of femur. x2 stronger than ACL, stabilise post shift of tibia. Risk – hit dashboard, collision sport. tibia translation <1 cm – conservative. ttt > 1cm – surgery. Test – post drawer (back into normal position). if untreated – 4-5 years OA + meniscal

LCL sprain

least frequent of 4 ligs. – ACL 50%, MCL 40%, PCL 7%, LCL3%. Best palpated in Zikov position. grade 1 & 2 no gapping at 0 degree and 30 degree, 3 – gapping. Prognosis 1 – 6/52, 2-nd grade 12/52

Pes Anserinus tendinopathy (& bursitis)

cause: too much lat tibial rot, over pronation, direct pressure on med knee (motorbike, roofer). SSx pin point P at bursa, incr P with running (may be able to run through P, but worse after), warm.

ITB syndrome

irritation and inflammation of distal ITB (bursa may be swallen) due to overuse. Tibial attachment of ITB is Gerby’s tubercle and superiorlateral patella. Tension of ITB – post Glut Max, ant TFL. Risk – over/ under pronation, valgus/varum (gives anatomicaly thicker ITB), leg lenth, bicycle seat too high. SSx – P diffuse lat (esp going downhill). Test – Renne test (palpation while rising on chair or squating)

Baker`s cyst (also known as popliteal bursitis, gastrocnemius bursitis)

inflam of bursa post to knee (it communicate with join cavity). not always visible. Causes 1. irritation from gastrocs, poplitius or/and semimembranosis 2. int knee joint derangement, OA, meniscus. joint infl – overfill – goes to bursa. SSx – can not flex knee fully, incr P at the end of flexion. incr P when strenghtening leg after prolonged sitting. DDx – popliteal aneurism (pulsating mass), fat, tumor. ttt – cyst aspiration and filling it with corticosteroid

Popliteal tendinitis

Inflam of popliteal tendon often due to running downhill. SSx – P when running downhill in post knee. DDx – menisci . ttt – rest, NSAIDs, ice, no downhill running for 6/52

Osgood`s – Schlatter disease

Traction lesion due to excersive pull of patellar lig on tib apophysis. Ptn male 10-15, U/L P, swelling, hypertrophy of tib tuberosity. ttt – P relief, avoiding sport with deep bending untill 16. Prognosis – spontaneous resolution after course of weeks or months

Sindling-Larsen-Johanson

Traction epiphysitis of inferior pole of patella. often with calcification if chronic in adult. ptn 8-16 or adult athlet running and squating. SSx P on palpation, no crepitis, no swelling. in teenage resolves spontaneously with rest

Fat pad impingement (Hoffa’s pad)

P in the eyes of knee on palp. P on hyperextension in ant knee. Hx of trauma and hyperextension. ttt – PRICE, avoid P-full activities

Plica syndrome

Prepatellar bursitis

Quads tendinitis (distal patella)

Osteochondritis

separation of subchondrial bone and art cartilage from end of bone that extrudes fragment into joint cavity. age 11-20, Hx of overuse. SSx – joint locking / crepitis, P agg by balistic activities, myospasm. ttt – mobilization is contraindicated. osteochondrosis if no inflamation

 

RED FRIC 3 REF

Vascular – popliteal aneurysm

“Fracture” – stress # of tibia, meniscus tear, osteochondritis

Rheumatic- OA, (RAPE – RA, Ankispon, Psoriatic, enteropathic A (fem with Chron or Ulc.C.)), Reiters (yong male), Vessels, Nerves and Cristalls: SLE (90% joints), pseudogout (CPPD- old fem, Ca2O7P2 calcium pirophosphat deposit), chondrocalcinosis – chronic pyrophosphate arthropathy

Infection – septic A, osteomyelitis

Cancer – osteosarcoma (<30), osteochondroma (ptn 10-30 yo)

Referral –

1.biomech – from hip (medial knee), ankle

2. neural –  L3, saphenous N (entrapted  between Adductor magnus and vastus medialis (bodybuilders) or while penetrating pes anserinus tendon), common peronial N (excessive icing), obturator N, femoral N.

Knee Exam

I am going to examen your knee, this involves having a look, a feel and asking you to do a few exercise

Gait– symmetry, antalgic

Observation –

standing–

front- alighment. varus, valgus, q angle, mm waist (vastus medialis)

side – recurvatum

posterior – baker cyst, popliteal aneurism

feet – cavus, planus (PFPS), big toe

supine – skin, scars, colore, temperature, swelling

Active movement – bend and straight

Passive movement – now i will do the same movement but i need you to relax and let me take the full weight of your leg- can you make your leg go nice and floppy

flex, extend, rotate

look for hyperextension (>5grad) and feel for crepitus

General Palpation

  1. tibial tubercle-osgood schlatter
  2. infra patelar lig – jumpers knee
  3. fat pad- press for pain
  4. joint line – meniscus, OA,
  5. border of patella
  6. quads tendon
  7. popleteal fossa – baker cyst, aneurism

medial 8. MCL

9. pes anserinus

lateral 10. ITB syndrome (fem condyle)

11. LCL femcondyle – tibial head

12. tibial femoral join

Patella

1. tracking + crepitis with passive movement

2. stability – side to side

3. patella tap 1. move fluid upwards and hold it there 2. wait till it fill up 3. if it does press with 3 fingers to see if it bounds back

4. aprehension  – try to push patella laterally with leg slightly bend over the edge of a table

ACL + PCL

  1. drawers test alternatevly
  2. femur stabilised on bent knee of Dr and tibia up and down

MCL + PCL

knee bent 15dgr

knee straight

ITB

Nobel test,if +ve – Ober test

Menisci

McMurray

Appley compression

Thesally – disco

Hyperextension

if P anteriorly it is Hoffa sign of fat pad impingement

Joint above and below

screening Ankle and Hip