Knee Injuries. Pro-Am Sports Injury Clinic Telephone Contents

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1 Knee Injuries Contents Page 2 Anatomy of the Knee Joint Page 4 Mechanism of Injury and Site of Pain Page 5 Knee Injuries Explained Jenna Wheatman Bsc.MSST 1

2 Injuries affecting the knee joint can cause considerable disability and time off sport. They are most common in sports that incur twisting and sudden changes in direction and speed. Anatomy of the knee joint The knee contains two joints the tibiofemoral joint (knee joint) which is associated with the collateral ligaments, menisci and cruciate ligaments; it is the joining of the two longest bones in the body the femur and tibia. The patellofemoral joint consists of the patella (knee cap) and femur. It is important to understand the role of the ligaments in the knee joint to help associate the mechanisms of injury and likely consequences. The ligaments passively limit the movement of the joint giving stability. The cruciate ligaments The two cruciate ligaments are called anterior and posterior in relation to where they attach to tibia. The ACL and PCL limit forward and backward movement of the tibia on the femur. The ACL is one of the most important structures in the knee- not least because injury to it may require extensive surgery and rehabilitation. The ACL is essential in pivoting movements and stability whilst landing from a jump. The ACL has a big role in proprioception of the joint so when injured many get the sensation that the knee is weak or giving way. PCL injuries are less common but may have similar symptoms. The collateral ligaments These are called medial and lateral and provide stability to the inside and outside of the knee joint. If a force is placed onto the outside of the joint (as in a tackle) the medial collateral ligament is there to stop excessive lateral tilting of the tibia. It is a broad ligament which attaches to the meniscus. As it attaches to the tibia it fans out leaving it more vulnerable to injury. This is why when testing the medial collateral ligament it should be performed in a straight leg position and at 30 degrees of knee flexion. The lateral collateral ligament is a cord like ligament much stronger and resilient to injury. It attaches to the fibula head with no attachment to the meniscus. Jenna Wheatman Bsc.MSST 2

3 The menisci The menisci are semi-lunar in shape and are split into medial and lateral. They are wedged shaped with the inner edge being thinner. It provides a surface for transmissions of 50% of axial forces across the knee joint. The menisci increases joint stability, assists in nutrition, lubrication and shock absorption. The lateral meniscus is larger than the medial and less firmly adherent to the tibia, resulting in greater mobility. The medial is firmly attached to the capsule and collateral ligament leaving it relatively immobile and susceptible to injury. Bursae The knee joint is surrounded by fluid-filled sacs called bursae, which serve as gliding surfaces that reduce friction of the tendons Tendons These fibrous bands of tissue connect muscles to bones. Your knee has two important tendons, which make it possible for you to straighten or extend your leg: the quadriceps tendon, which connects the long quadriceps muscle on the front of your thigh to the patella, and the patellar tendon, which connects the patella to the tibia. The muscles Knee extension is provided by the big Quadriceps muscles which is split into four muscles. Weakness of this muscle can cause alignment and tracking problems of the patella. The Vastus Medialis is thought to be most important in this. The hamstrings which consists of 3 muscles allow knee flexion to happen. The hamstrings should have 65% strength of the quads, any less and the hamstrings are prone to injury. The hamstrings also need to be relatively supple as they can affect posture. Both the quads and hamstrings help in keeping a neutral pelvis as they work across both the hip and knee. During flexion and extension there will also be activation of the adductors on the inside of the leg and the Illiotibial band along the outside. These can both become injured when there is an imbalance. Having knowledge of the muscles around the hip is also important as referred pain from the hip is a possibility. The knee functions to allow movement of the leg and is critical to normal walking. The knee flexes normally to a maximum of 135 degrees and extends to 0 degrees. Mechanism of Injury and Site of Pain When the patient presents with a history of an acute injury to the knee there are several factors which will indicate the structures injured and the severity of the injury: The mechanism of injury contact, non-contact, foot fixed or free, flexed or extended, valgus or varus force. The amount of pain and disability at the time able to play on or not. The time to onset of swelling and its location. Symptoms and degree of disability since the injury. For chronic injuries the history is important for changes in training volume, training surface or footwear. Recent growth spurts in children can be very important. Many knee injuries are due to overuse, problems with alignment, sports or physical activities, and failure to warm up and stretch before exercise. But they can also result from Jenna Wheatman Bsc.MSST 3

4 trauma, such as a car accident, a fall or a direct blow to your knee. Finding, the exact location of a patient's pain (when possible) and correlating it to potential abnormalities or specific anatomic structures is an essential part of the physical exam. Joint line pain - Can be indicative of a tear of the lining of the joint (the capsule), a meniscus tear, or may indicate abnormalities with the bone or cartilage at the joint line (chondromalacia, arthritis, osteochondritis dissecans, etc). Anterior knee pain - Pain at the inferior pole of the patella is usually indicative of patellar tendonosis. Pain at the quadriceps insertion on the proximal patella may indicate a partial quadriceps tendon tear, quadriceps tendonosis, or the residual of a previous injury or surgery. Pain over the anterior aspect of the knee with deep knee flexion is usually found in patients with patellofemoral dysfunction. In these patients, they may have pain from plica irritation, patellofemoral syndrome (PFS), chondromalacia (needs MRI confirmation), or other anterior joint pathology. Medial knee pain - This can usually indicate a medial collateral ligament sprain. It is very localised to the ligament with little swelling. Tibial tuberosity pain - Tenderness at the tibial tuberosity is primarily due to Osgood- Schlatter's syndrome, or its residual, or deep infrapatellar bursitis. Tenderness in either of these two locations usually goes hand in hand with tight hamstrings. Lateral knee pain - This can indicate a problem with the iliotibial band. It may be due to a lateral collateral ligamnet sprain. Jenna Wheatman Bsc.MSST 4

5 Knee Injuries explained Meniscus Injury A meniscus tear can result from aggressive pivoting or sudden turns any activity that twists or rotates your knee. Occasionally, you can tear your meniscus while lifting something heavy. Older adults sometimes tear their meniscus during repetitive movements, such as kneeling or squatting, but more often it tears because it has degenerated over time. Meniscus injuries may develop swelling 24 hours after the injury occurred. Cruciate Ligament Injury Most ACL injuries are sports-related. They frequently occur during activities such as football, basketball, hockey and skiing. The mechanism of injury is slowing down suddenly or cutting or pivoting with your foot firmly planted movements that twist or overextend your knee. ACL tears rarely result from contact with other players, but they can develop when you land awkwardly from a jump or fall. If an ACL tear has occured you will probably of heard a pop and swelling will occur within 2 hours. Pain may be less than expected after the initial incident. PCL tears, on the other hand, aren't usually associated with sports. Because the PCL is a strong ligament located deep inside your knee, tears most often result from traumatic injuries, such as those you might receive in a car accident. And because a violent impact is needed to damage the PCL, you're almost certain to injure other ligaments at the same time. Collateral Ligament Injury You're most likely to tear your collateral ligaments in sports that require quick stops and turns, such as tennis, basketball and skiing, or in contact sports when repeated blows to the inside or outside of your knee can cause the opposing ligament to stretch or tear. Collateral ligaments can also be damaged by repeated stress, which causes them to lose their elasticity, much like an overstretched rubber band. There can be little swelling with collateral ligament strains and tend to be very localised. Bursitis Sometimes called housemaid's knee or carpet layer's knee, prepatellar bursitis often occurs after an activity that requires you to kneel for long periods scrubbing floors, gardening, or installing tile or carpet, for example. It can also result from an infection or as one of the signs of arthritis or gout. Dislocated kneecap. Kneecap (patellar) dislocations can occur in contact sports and in activities that require you to change direction while running, such as tennis, racquetball and volleyball. If your knees tend to turn inward or your kneecaps are higher than normal, you may be more prone to this injury. Iliotibial band syndrome This is a common cause of lateral knee pain in runners. Competitive runners are especially susceptible, but amateurs aren't exempt. You're more likely to develop iliotibial Jenna Wheatman Bsc.MSST 5

6 band syndrome if you have biomechanical problems such as unequal leg length or weak hip abductors, the muscles responsible for sideways leg motion. Exercising on concrete surfaces or uneven ground, increasing the intensity or duration of your exercise too quickly, wearing worn or ill-fitting shoes, and excessive uphill or downhill running also can contribute to iliotibial band syndrome. Osgood-Schlatter disease This condition can develop in athletic young people during the years when their bones are growing rapidly usually ages 10 to 15 for boys and 8 to 13 for girls. Osgood- Schlatter disease results from repeated tugging of the patellar tendon on a growth plate at the top of the tibia. This is most likely to occur during activities that involve running, jumping and bending, when the pull of the quadriceps muscle puts tension on the patellar tendon. In time, the tendon may begin to pull away from the tibia, resulting in a small bump you can see. In severe cases, the tendon may come away from the tibia completely. Anterior Knee Pain The alignment of the joint is of great importance as forces need to be absorbed effectively. Factors affecting alignment of the knee include, bony abnormalities, muscles imbalance and foot position. Figure 3b shows what to expect from someone who has PFS. The lower limb is in excessive lateral pelvic translation, internal femoral rotation, external tibial rotation and foot pronation. Giving a bow legged posture with the knee cap facing inwards. These changes can generate abnormal forces in the tissues of the knee, which could trigger Anterior knee pain (AKP). The rotation could be expressed as a torsional load on the patella tendon or altered patella tracking. The increased abduction of the knee changes the angle of pull from the quadriceps, altering patella tracking as it passes through the trochlear groove. Or causes the ITB to bowstring across the lateral aspect of the knee joint. There is an intimate relationship between lower limb alignment and AKP because of the chronic overuse nature of the conditions, which cause AKP. Jenna Wheatman Bsc.MSST 6

7 When alignment problems are present it also means the proprioception of the joint has changed and needs re-training. This will allow correct movements patterns to be completed when getting back into sport. It may be this loss of proprioception that led to the injury, especially if a previous lower limb injury was not treated effectively. Knee pain is likely to effect movements such as squatting, up-hill, down-hill, full flexion, full extension. It is important to take note of which movements are the most aggravating as this will also help to differentiate between conditions. For example pain going down hill may suggest patellofemoral syndrome as where going up hill may suggest quadriceps tendonitis. Plica Syndrome This condition can be hard to diagnose at first. It is usually considered when PFS rehabilitation has failed. An inflamed plica may cause variable sharp pain located on the anterior medial aspect below the patella. If thickened it can be palpated. It is painful on full flexion and can cause a popping or snapping sound. The only differences found between PFS and plica syndrome is the medial glide of the patella may aggravate the condition in the plica. Fat pad Impingement This condition it caused by a direct blow or repetitive micro trauma from repeated hyperextension (swimming, fast bowling). The knee will appear puffy below the knee cap. It will be aggravated by prolonged standing, downhill running, descending stairs. The athlete may not be able to fully extend the knee without pain and discomfort. Jenna Wheatman Bsc.MSST 7

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