Professional Documents
Culture Documents
Knee Dislocation
Meniscal Tears
Discoid Meniscus
Meniscal Cyst
Patellofemoral Joint
Chondromalacia Patellae
Patellar Tendinitis
Patellar Fracture
Quadriceps Rupture
Pre-patellar Bursitis
Bipartite Patella
Plica Syndrome
Semimembranous Tendinitis
Loose Bodies
Remember:\
Acute compartment syndrome= Extreme & worsening pain in leg;
Chronic compartment syndrome- Gradual onset muscle pain during
Introduction
The knee is the most commonly injured joint in sport.
Its size, lack of stability and forward prominence makes it prone to contact and injury (Fig.
1).
Biomechanics
It is a complex hinge joint which allows free flexion and some rotation in flexion.
With progressive flexion there is roll-back of the femur on the tibial surface, controlled by
tension in the posterior cruciate ligament.
The articular surfaces of the tibio-femoral joint have relatively poor congruity and little
inherent stability, as is evident on examination of dried bones. The articular congruity is
improved by the menisci, but stability is dependent on ligaments, capsule and muscle
control.
The knee is vulnerable to high torsional and deceleration forces often encountered in
running sports, as well as to contact forces. The key to diagnosis of injury rests with history
and clinical examination. A description of the mechanism of injury often gives a clear
indication to the likely diagnosis (Fig. 2). A sportsman who describes that he felt his knee
dislocate of slip, with pain and a pop when he stepped off it, is providing a fairly classical
history of an isolated rupture of the anterior cruciate ligament.
Ligamentous Injury
The medial and lateral collateral ligaments, and the anterior and posterior cruciate
ligaments constitute the four major ligamentous structures about the knee. Integrity of
these ligaments is important for normal stability and kinematics of the knee, Altered
kinematics may lead to degeneration of the knee.
Examination reveals swelling over the medial aspect of the knee and later bruising may be
seen.
The knee is typically held flexed and there is a painful soft end point limited
extension (pseudo-locking).
There is tenderness along the course of the medial ligament, most commonly at the site of
femoral insertion.
Laxity is assessed with the knee in 30 degrees of flexion and is graded I to III (Figs. 3 and
4). Grade III injury has greater than a centimeter of opening of the medial jointline. If there
is instability in extension a more complex ligamentous disruption should be suspected.
X-rays are usually normal, although an avulsion fragment is rarely seen.
Later, calcification may be seen at the site of femoral insertion (Pellegrini-Stieda lesion).
All isolated medial collateral ligament injuries can be treated conservatively.
Early treatment involves RICE with graded quadriceps strengthening. In normal gait there is
a closing force on the medial jointline and so early weight bearing can be allowed and
bracing is not always required for Grade I to II injury.
Bracing is indicated in Grade III injuries and where the patient feels instability on weight
bearing. Recovery from a Grade I to II injury is usually between 3 and 4 weeks and for a
more significant injury 6 to 8 weeks.
The lateral collateral ligament extends from the lateral femoral epicondyle to the head of the
fibula. Isolated ruptures are rare and the ligament is more commonly injured in association
with disruption of the posterolateral corner. Usually require surgical reconstruction.
Meniscal Tears
Joint line pain with locking.
The menisci are fibrocartilaginous semilunar structures on the tibial surface. Their function
is to improve the congruity of the tibiofemoral articulation and to transmit load. They also
function as shock absorbers and improve knee joint stability. Following meniscectomy the
contact area in the compartment is reduced and contact pressures may be increased by
more than 350%. Shock absorbing capacity is reduced and as a result of these factors
meniscectomy has been shown to lead to development of osteoarthritis. The menisci are
relatively avascular with blood supply limited to the peripheral one quarter to one third (see
Fig. 33, Chapter 18). (Tears in the vascular region have the potential for healing). Medial
meniscal tears are 3 times more common than lateral meniscal tears.
A meniscus is torn by being trapped between the two bone surfaces when a rotary force is
applied to a loaded knee (twisting when rising from a full squat) (Fig. 13).
There is joint line pain, delayed effusion and with a bucket handle tear the knee will
be locked. With less dramatic tears there is usually a history of recurrent clicking and
catching and jointline pain.
‘The signs include effusion, wasting of the quadriceps, pain on forced extension, pain on
forced flexion and a positive McMurray’s test.
Arthroscopy allows good visualization and partial meniscectomy (Fig. 14). Peripheral bucket
handle and incomplete bucket handle tears (in young patients) should be repaired (Fig. 15).
Where there is an associated anterior cruciate ligament rupture this may need to be
reconstructed to decrease the risk of recurrence of the meniscal tear. (Unhappy “Triad” is
medial collateral/anterior cruciate ligament/medial meniscal injury combination).
Figure 18
Anterior Knee Pain Syndrome
Patellofemoral problem= Pain after sitting & with stars
climbing with patella creptitus and patella grind,
∙ Trauma (Osteochondral injury)
∙ Malalignment
Anatomical predisposition
Muscle imbalance
Patellar subluxation
Patella dysplasia
∙ Compressive
Excessive lateral pressure syndrome
Hamstrung patella
∙ Overuse
Patellar tendinitis
Medial plica syndrome
Rentinacular irritation
OsgoodSchlatter’s disease
Bipartite patella
∙ Degenerative/Inflammatory
∙ Idiopathic
Primary chondromalacia
Eighty percent of patients with anterior knee pain syndrome respond to non-operative
measures. Precipitating and aggravating activities should be identified and avoided. A
physiotherapy programme should include quadriceps strengthening and in particular vastus
medialis toning, together with hamstring stretching. Patellar taping may be of benefit. A
response is usually seen within 6 to 8 weeks, but if not the diagnosis should be reassessed
and onward referral or further investigation undertaken.
This is softening of the patella cartilage either from a direct blow or mal-alignment (with
patellar subluxation). Typically seen in young overweight girls with knock-knees. The
cartilage damage can be classified (Fig. 20).
A tense haemarthrosis may be drained for pain relief. The knee should be immobilized in
extension and a removal splint is usually adequate. The patient is instructed in isometric
quadriceps exercises and may weight bear as comfort allows. As the effusion resolves
graduated flexion may be commenced and the knee immobilizer can usually be discarded by
three weeks. The patient should not return to sport until they have regained normal
quadriceps muscle tone and bulk and a negative apprehension test.
Recurrent Dislocation
Recurrent dislocation is usually clear on history and if there is not a response to an
extensive quadriceps strengthening programme surgery is indicated (a lateral release and
repair or advancement of the medial retinacular tissue and vastus medialis, if
intraoperatively this does not achieve stability a distal bony re-alignment may be indicated).
Recurrent Subluxation
Symptoms include anterior knee pain and giving way. Examination may reveal anatomical
features predisposing to patellar subluxation, including increased Q angle (line of pull of the
quadriceps) due to valgus or rotational factors, out-turned patellae or patellar alta. The
patella may track in a J-curve (Fig. 21). The patella may be subluxable or dislocatable, and
lateral retinacular tightness may be evident. X-rays (with skyline views) and CT scan may
show patella dysplasia or subluxation. If there is no improvement with a protracted
conservative programme, surgery is necessary (with soft tissue or bony re-alignment).
Patellar Fracture
Injury with dorsiflexed foot.
Caused by direct impact on the patella as in a fall on a flexed knee or a dashboard injury.
May also occur following violent resisted contraction of the extensor mechanism. If there is
disruption of the extensor mechanism (indicated by a lag on examination or a significant
gap on x-ray) surgical repair is essential (Fig. 22). Undisplaced or minimally displaced
fractures with preservation of the extensor mechanism may be treated non-operatively, by
splinting in extension for 6 weeks.
Quadriceps Tendon Rupture (Bill Clinton’s injury)
Caused by sudden resistance to a strong quadriceps contraction. Seen in the older patient
group (as with other tendon degeneration conditions). There is pain with loss of quadriceps
function, a lag and a palpable gap. When the diagnosis is unclear and particularly when
presentation is delayed MRI can define the integrity of the tendons. To restore good
quadriceps function operative repair is required.
Pre-patellar Bursitis
Severe pain with subtle signs of crpitus. Surtgery often helps.
The bursa over the anterior aspect of the patella is prone to injury and inflammation from
repetitive contact (seen in football players and gymnasts). Once a significant episode has
occurred there is a tendency to become recurrent. Examination reveals enlargement of the
thickened bursa with crepitus. Acute cases have signs of inflammation and there may be
secondary infection with cellulitis.
Inflammatory bursitis is treated with RICE and NSAIDS. Padding and protecting the area on
return to sport is important to minimize the risk of recurrence. Where there is secondary
sepsis antibiotics are needed and surgical draining of an abscess. Recurrent or chronic
bursitis will eventually require excision of the thickened bursa.
Plica Syndrome
Synovial plicas are common and often seen at arthroscopy (Figs. 23 and 24). They may
become a source of symptoms following a direct injury causing thickening and scarring of
the plica, or from over use. There is an anterior knee pain syndrome with occasional
clicking and snapping and tenderness over the medial femoral condyle.
Those that do not settle with rest and a conservative programme may be treated by
arthroscopic resection.
Treatment involves rest and a set of exercises to stress the ilio-tibial band and hamstring
muscles. A break of three months from distance running is usually required.
Semimembranous tendinitis
This is seen in male athletes and may be difficult to diagnose (postero-medial knee joint
pain with hamstring spasm). A cyst may occur which is difficult to excise (Fig. 26).
Loose Bodies
Loose bodies cause mechanical symptoms of locking and recurrent effusions. Occasionally
they can be palpated. They can be due to a meniscal fragment or osteochondral fragment
(traumatic, degenerative, osteochondritis dissecans) or synovial chondromatosis (Fig. 27).
X-rays will demonstrate radio-opaque loose bodies. Treatment by arthroscopic removal is
usually successful.