Select Disorders of the Knee 79 slides--BULK OF FINAL!!

Question 1

Medial Collateral Ligament (MCL)
– Opposes extreme abductive and/or valgus forces
– Most frequently injured ligament in the knee

• Lateral Collateral Ligament (LCL)
– Limits excessive adductive and/or varus pressures

• Anterior Cruciate Ligament (ACL)
– Serves as the primary knee stabilizer, preventing forward displacement
of the tibia on the femur
– Braces against excessive ant. translation in anteroposterior (AP) plane

• Posterior Cruciate Ligament (PCL)
– Braces against excessive post. translation in anteroposterior (AP) plane

Answer 1

KNOW

Question 2

ACL
is small (size of little finger)
More vulnerable then PCL (size of thumb)

Menisci (Medial & Lateral)===Medial meniscus is smaller, more fixed than the lateral meniscus; predisposes it to injury

Answer 2

KNOW

Question 3

Bursae X 5

Answer 3

 Suprapatellar
 Prepatellar
 Superficial and Deep Infrapatellar
 Pes Anserine

Question 4

________ _______

An abnormally high patella in relation to femur

Answer 4

Patella Alta

Question 5

Normal Q-angle:
• Men: \_\_\_ degrees
• Women: \_\_\_\_ degrees
If outside normal ranges, may be a precursor for
overuse injuries

Answer 5

13

18…WOMEN MORE VALGUS DUE TO WIDER HIPS

Question 6

Suspected knee dislocation?

 Relatively rare injury but important to recognize because coexistent vascular injury, if missed, may lead to limb loss

 Assess for discrepancy in ____ _____ compared to the unaffected leg

NOTE: presence of normal pulses does NOT rule out
presence of clinically significant vascular injury *

An ankle-brachial index (ABI) less than ____

____________ can rule out a vascular injury

Answer 6

distal pulses

0.9

Arteriogram

Question 7

Ankle/Arm (Brachial) Index–Measurements usually taken
using Doppler Ultrasound device with a vascular probe,

For example:
• 95 (ankle systolic pressure)
• 130 (brachial systolic pressure) ABI = Ankle systolic/brachial systolic
• 95/130
• The ABI is 0.73

NORMAL = resting ankle-brachial index is—–1 or 1.1
normally LE BP is greater than the UE BP or about the same

A RESTING ankle-brachial index of less than 1 is
____________ (or Borderline)
Indicates Peripheral Artery Disease (PAD)
 Slight drop in ABI with exercise, even with normal ABI at rest, also suggests PAD

Answer 7

abnormal

Question 8

Anterior Knee Pain

1---Patellofemoral Pain Syndrome
AKA:
• Patellofemoral disorder
• Patellar malalignment
• \_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_
– Most common knee problem in clinical practice

—Usually related to _________ not trauma

Clinical Presentation---------------
Anterior knee pain (often diffuse)
Associated crepitus
Pain with squatting
Associated with repetitive activity
Worse with going up stairs and
prolonged sitting
Associated with activities which create high compressive loads
• climbing stairs
• Squatting
• running or jumping

Treatment:—————
1) Patella motor control exercises
short arc, quad sets, mini-squats, rockerboard

Answer 8

Runner’s knee

overuse

**pain is worst between 30-45 degrees of flexion (contact point)

Question 9

Anterior Knee Pain

2—-Chondromalacia Patella
—-Primarily a soft tissue disorder
—-Actual damage to the underlying patellar cartilage
—Degeneration of the _____ ______ on the back
surface of the patella

Answer 9

hyaline cartilage

Question 10

Anterior Knee Pain

3—Patellar Tendinitis
—AKA “________ _______”
Classic Presentation
–

Answer 10

Jumper’s Knee

Question 11

Anterior Knee Pain

4—-Quadriceps Tendinitis
 >30 years of age
 Insidious onset
 Pain anterior knee superior to patella

Staging

Stage 1: Pain after activity, no functional impairment

Stage 2: Pain early in activity that goes away after
warmed up, but returns later in exercise

Stage 3: Constant pain at rest and inability to participate in activity

Stage 4: Complete tendon rupture

Stages 3 or 4 may require ____ for repair

Answer 11

surgery

Question 12

Anterior Knee Pain

5—Prepatellar Bursitis
AKA “_______ ________”
Swelling anterior to patella

Answer 12

Housemaid’s knee

Question 13

Anterior Knee Pain

6--Infrapatellar Bursitis  2 TYPES!!
1) Superficial
 2) Deep
• Both may follow \_\_\_\_\_\_ \_\_\_\_\_\_\_\_
• Both may result in local, painful, fluctuant swelling near the tendon
– Superficial = OVER the tendon
– Deep = BEHIND the tendon

Management
• Ultrasound, Ice, Stretching, CMT

Answer 13

direct trauma

Question 14

Anterior Knee Pain

7–Osgood-Schlatter’s Disease

Classic Presentation
• 11-15 y.o.
• males > females
• history of a single violent injury or repetitive knee flexion & extension
• Localized pain, tenderness & swelling about the _______ _____(almost pathognomonic)
• Pain with resisted quad contraction
• 25-50% of cases are bilateral
• May have chronic course over months or years, but usually ceases by age 18

Answer 14

tibial tuberosity

***Often associated with tight quadriceps

Question 15

Anterior Knee Pain

8—-Plica Syndrome
Plica:
 Synovial folds of the knee
 Embryonic remnant
 Reabsorbed by birth but present in 20-50% of knees
• Can mimic _______ pathology
• Suprapatellar Plica
• Medialpatella Plica
 Snapping & pain with repetitive flexion & extension
 Tender to palpation medial to patella with knee flexed
 Stretching, corticosteroids, surgery if persistent
(8 weeks)
 X-rays normal & often missed on MRI

Answer 15

meniscus

Question 16

Medial Knee Pain

1—-Partial MCL Sprain:
Hyperpronation & overuse will cause chronic sprain
Follows twisting strain of the flexed knee or valgus force
Pain, tenderness, & swelling along the medial joint line

2---MCL Sprain
First Degree (Grade 1)– up to 5 mm of motion
Second Degree (Grade 2)– 6 to 10 mm of motion 
Third Degree (Grade 3)– up to 15 mm of motion

3—Complete MCL Tear:
– Follows marked _______ & _________ of the leg with
the knee partially flexed, or abd with knee extended
– Hematoma, pain, & edema over the medial joint
line

Answer 16

abd & ext rotation

Question 17

Medial Knee Pain

4—Medial Meniscus Tear

Medial Meniscus
• Partially flexed knee suffers a twisting injury
• ______ is often fixed to the ground, while the thigh is
violently twisted
• Audible pop, tearing sensation, or severe pain
• Warmth, swelling (develops over many hours), and tenderness at the medial joint line
• Weight bearing is often intolerable, and pain is concentrated at joint line
• ________ _______ that may be relieved by pulling,
twisting, or shaking the leg
• MRI for definitive DX
• Degenerative tear is slower in onset and milder in symptoms

Answer 17

Foot

Locking sensation

**Recall:
• Menisci are without pain fibers
• the tearing and bleeding into peripheral attachments,
as well as the traction on the joint capsule, causes
discomfort

Question 18

Medial Knee Pain

5–Terrible Triad (aka. O’Donoghue’s Triad):
_____&_____ and medial meniscus tear
The classic “terrible triad” involves valgus stress to the
knee with resultant acute injury to the ACL and MCL
NOTE: The medial meniscus tear is now thought to
occur later, as a result of chronic ACL deficiency

6—_________ Test—High diagnostic accuracy rate:
94% in the detection of tears of the medial meniscus
96% in the detection of tears ofthe lateral meniscus
Low rate of false-positive and false-negative

Answer 18

MCL, ACL

Thessaly

Question 19

Medial Knee Pain

7—Bursitis
A. MCL Bursitis
Pain without locking along the medial joint line
Tenderness to palpation of MCL, INCREASED pain with ________ stress
Often diagnosed as med meniscus tear and treated with arthroscopy
23% may show unassociated meniscus tear

B. Pes Anserine Bursitis
Pain at the insertion of the sartorius, gracilis, and semitendinosus
Pain, local tenderness, and swelling over the anteroMEDIAL, PROXIMAL tibia _________ the joint line
Intensified by climbing stairs and walking
Generally NO increase in pain with valgus stress in 30 degrees knee flexion
Often mistaken for OA

Answer 19

valgus

below

Question 20

Medial Knee Pain

8—Tendinitis

A. Gastrocnemius Tendinitis:
 Causes _____ knee pain that mimics pes anserine bursitis
 Pain is located b/w the pes anserine tendons and the gastrocnemius

B. Semimembranosus Tendinitis:
 Aching pain over the __________ aspect of the knee just inferior to the joint line
 Provoked by walking, bending, lifting, climbing, running
 Often associated with hyperpronation of the ipsilateral foot

Answer 20

medial

posteromedial

Question 21

Lateral Knee Pain

1—LCL Strain
 Fall or blow to the knee with the leg ______ rotated and varus stress applied
 Pain over the LCL, minimal joint effusion
 Walking causes some pain, but running or cutting
cause pain and a sense of “giving way”
 Varus stress at 30 degrees (+)

Answer 21

internally

Question 22

Lateral Knee Pain

2—Lateral Meniscus Tear
 Follows twisting injury with knee FLEXED
 Local tenderness over lateral joint line
 Locking that prevents full ________ may occur, but is
less common than with medial tears
 Joint effusion

Answer 22

extension

Question 23

Lateral Knee Pain

3—Popliteus Tenosynovitis
Inflammation of the tendon sheath lining**
 Popliteus: Flexes and medially rotates the tibia in
the open chain (non-wt bearing), laterally rotates the femur (closed)
 Lateral knee pain during weight bearing with the knee flexed 15 -30 degrees
 Similar complaints to _____ ________
 Downhill running or walking aggravates, especially banked surfaces
 Less or no pain up hill because the muscle does not have to prevent forward tibial displacement
 Rest relieves
 Pain may be perceived as arising in the knee since a portion of the tendon is intraarticular

Answer 23

ITB syndrome

Question 24

Lateral Knee Pain

4—Iliotibial Band Friction Syndrome
• Common in runners (sedentary may also develop)
• Pain on the _______ side of the knee that can refer to the insertion at Gerdy’s tubercle
• Pain gradually INCREASES over days to weeks
• Worse with downhill running (esp. with knee extension just before heel strike) may cause runner to stop
• REST relieves, returns upon resuming activity
• Tender at __________ epicondyle
• Increased tenderness while flexing and extending knee (Noble’s)
• Friction between ITB and condyle over bursa causes irritation (30-40 degrees flexion)
• Common causes: Tight ITB, running and hyperpronation

Answer 24

lateral

lateral

Question 25

Posterior Knee Pain

1---Baker’s Cyst
AKA: popliteal cyst
• Not considered to be a true bursitis
• Synovial cyst:
• located \_\_\_\_\_\_\_ to the MEDIAL femoral condyle, between tendons of the gastrocnemius and semimembranosus muscles

**Usually seen in patients with RA or DJD
***Compression of the tibial nerve or venous obstruction
mimicking thrombophlebitis or peripheral neuropathy

Answer 25

posterior

Question 26

Posterior Knee Pain

2—Gastrocnemius Strain
Tearing or ripping pain after a sudden start or turn
Pain may come and go with walking or running
Local tenderness and swelling
• MC cause of “_______ _________”
Tearing of musculotendinous junction of MEDIAL head of
gastrocnemius

Answer 26

Tennis Leg

Question 27

Posterior Knee Pain

3—Hamstring Strain
—Forced ____________ of knee
– Tenderness and swelling to muscle

Answer 27

extension

Question 28

Biomechanics of ACL Tears

Associated with anterior blows that _________ the knee, excessive noncontact hyperextension of the knee, and extreme deceleration forces to the knee (sudden stopping or cutting)

78% result from _________ deceleration & change in direction at the knee
• Swelling within 1-2 hrs
• Pain may be mild or absent in 30% (rupture)
• “______ _________” in 36% of cases and moderate to severe anterior knee pain in 70%
• Exam of the knee with painful acute ________ unreliable
• Midsubstance tears often rupture the middle geniculate artery resulting in hemarthrosis
• MRI or scope is most diagnostic

Answer 28

hyperextend

sudden

Popping sensation

hemarthrosis

Question 29

ACL Tear

• -Patient presents in either acute or chronic phase
• –An acute knee injury heralded by a ____ OR_____, followed by a rapidly evolving effusion, almost always affirms a rupture of the ACL

Answer 29

pop or snap

Question 30

Biomechanics of PCL Tears—-Posterior directed force applied to the proximal tibia with the knee flexed

PCL tears typically report falling on a ____ knee or
sustaining a severe direct blow to the _______ aspect of the knee.

 This injury pattern displaces the tibia backward and pulls apart the PCL
eg. when the knee strikes the dashboard in a motor vehicle accident

 Patellar injury with disruption of normal articulation or fracture may also result

 Look for abrasions, contusions, or lacerations over the knee region

 Onset of edema & pain tends to occur within the first 3 hrs after injury

 PCL harm often signifies a major injury and rarely occurs
as an isolated injury

Answer 30

flexed

anterior

Question 31

Osteochondritis Dissecans (OD)

Classic Presentation
• 14-yo male athlete (may occur in adults too)
• Insidious onset, ant knee pain, causing patient to limp,
occasionally locks and swells
• B/L in 20% of cases

Cause
• ______ _______ separates and can dislodge into the joint
• Thought to be due to disturbed vascular supply &/or trauma

Management
• Rest and protection – partial or complete remission in 30%
• Surgical excision indicated if healing does not occur
• OA is a common long-term complication

Answer 31

Bone fragment