Mohsen Mardani-Kivi, M.D.Orthopedic Department, Guilan University Of Medical Sciences

Anatomy

Bones:FemurTibiapatella

ligaments MCL LCL ACL PCL

Anatomy

Extensor muscles :

Muscles:Quadriceps:

Vastus medialis Vastus lateralis Rectus femoris Vastus

intermedius

Flexor muscles:

Semimembranosus

Semitendinosus Biceps femoris gastrocnemius

Biomechanics:

Tibiofemoral Joint

Patello-femoral joint

Patella :

largest sesamoid bone

The primary functional role: knee Extension

Femoral condyles

The medial condyle is larger and lower than the lateral condyle.

Valgus and Varus Genu

Flexion : 120-150°

Extension : 5-10°

Internal rotation : 10°

External rotation : 30-40°

Major Movements

Inspection :

Baker's cyst genu recurvatum Valgus deformity (knock-kneed) Varus deformity (bowlegged)

Physical Examination

Palpation :

Temperature change Joint line tenderness

Physical Examination

Motion :

The patient should be asked to move their knee

Full ROM is 0-135 degrees Examination of crepitus : clicking of

the joint with motion

Physical Examination

Physical Examination

• Valgus or varus stress test:• One hand at the lateral aspect of the

knee joint and the other hand at the medial aspect of the distal tibia.

•Valgus or varus stress is applied to the knee at both zero degrees (full extension) and 30 degrees of flexion.

1-Anterior Drawer Test

Anterior force applied at 90 degrees of flexion

Examination

2-Posterior Drawer Test

Most accurate test for PCL tear. Patient in supine position with knee flexed 90°. Apply a posteriorly directed force to proximal tibia.

Examination

3-Lachman Test: best test for ACL laxity. 

Knee placed in 20-30 degrees of flexion, the femur is stabilized, and an anteriorly directed force  applied to proximal calf. 

Examination

4-Pivot-Shift TestConfirms complete ACL tear. Based on very early flexion causing anterior subluxation of the tibia that is reduced with further flexion (20-40 degrees) due to the posterior pull of the iliotibial tract.

Examination

Mc. Murray’s Test

Examination

ACL

• Etiogenesis: • Sports-related injurySports-related injury (80%

non-contact!)• Motor-vehicle collisions• Falls• Work-related injuries.

• occur when pivoting or landing from a jump. The knee gives-out from under the athlete when the ACL is torn.

ACL injury

How is the ACL injured

• ACL injuries in Female athletes:• higher risk while

participating in competitive sportscompetitive sports.

ACL injury

NoncontactAudible pop (usually a hyper-Ext.+ pivot combinationHemarthrosisUnable to return to play.

Contact and high-energy traumaOften associated with other ligamentous and meniscal injuries.A valgus stress to the knee The classic "terrible triadterrible triad": ACL, MCL, and medial meniscus tears

Clinical feature

Signs and Symptoms

AcuteMarked pain and popSwellingDifficulty at bearing weight on the affected knee

ChronicThe knee feels looseloose“buckling”, “giving waygiving way” or instabilityPain and swelling

Radiography

Diagnosis

HistoryPhysical examX-rays normal (only to R/O fracture)MRI (Gold Standard) (Gold Standard) excellent for evaluating not only the ACL but also the meniscus, articular cartilage and other knee ligaments

In adult with bone fractureWith other lesion Just ligament tearing :

General Population

Athlete Chronic tearing

Treatment

What is the treatment for an acuteacute ACL tear?

Rest Ice ElevationCompressionProtected Weight BearingBrace

Treatment

SurgerySurgery

Reconstruction of the ACL by drilling tunnels in your femur and tibia

Tunnel in thigh bone for graft passage

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Meniscal Tear

Functions of the menisci

Lubrication and nutrition of the jointShock absorbersEvenly distribute weight throughout the kneeAllows for smoother motions between the femur and tibia

The inner 2/3 of the menisci are avascularOnly! outer 1/3 is vascular (with blood supply)

Anatomy

Mechanisms of injury

Sport injury:Usually the foot stays fixed on the ground and the rest of body rotatesGetting up from a squatting or crouching positionLoading the knee from a fixed position

Types of Meniscal Tear

Types:Vertical Radial HorizontalDegenerateComplex Horn

A loss of any part of the meniscus causes uneven weight distribution and can lead to early wear of the knee

Torn meniscus Suture repair of meniscus

Treatment

MCL SPRAIN

MCL SprainMCL Sprain

• Usual cause: • Contact sports Contact sports • Force applied to

the outside of the knee, which pushes the knee inwards and beyond its normal range of motion.

• Inside knee Pain • Swelling • Instability• Perhaps a popping sound heard at the

moment of injury

Sprained MCL SymptomsSprained MCL Symptoms

Medical history Ph/Ex. X-ray imaging R/O fractures MRI

MCL Sprain Diagnosis

• Usually respond to conservative treatment, • Ice pack• Resting the knee joint• Bandage and Bracing• NSAIDs

• Surgery is rarely required.

MCL Sprain Treatment

MCL Tear

MCL Tear

May occur: isolated or complex injury (most commonly: ACL and/or Meniscal tear).

Pain Swelling Limitated ROM positive valgus stress test

Symptoms

Simple Radiography Stress Film Ant. Graphy in Abd

Diagnosis

Cast Brace Surgery

Treatment

LCL Tear

LCL Tear

Etiogenesis:• direct blow to

the inside of the knee

Pain Swelling Limited ROM positive varus stress test Drop foot: Weakness in the foot, if the

peroneal nerve is stretched during the injury or is pressed by swelling in surrounding tissues

Symptoms

Rest NSAIDs Ice Knee Exercises

Treatment

Rehab

physical therapy

The first few sessions of PT more modalities / fewer manual techniques:

Heat/iceUltrasoundElectrical stimulationManual stretchingPassive ROM for full knee flexion and extension

Once pain and swelling are reduced mainly focus on increasing the strength and flexibilityVary depending on the individual

physical therapy

StretchingHamstrings

Quadriceps

Calf muscles

Stretching continuedHip flexors

Hip adductors

StrengtheningFocusing on strengthening the muscles around the knee is essential in rehabilitation Quad sets Straight leg raises (in all planes)

Heel raises Leg Curl

Leg extension

Balance

Balance can sometimes be compromised after an injury or surgery

Here are some balance exercises that can help

Dynamic exercises

Progression to more dynamic sports specific exercises helps with the transition back into sports