11 The knee

Biomechanics of the extensor mechanism

The patella is the largest sesamoid bone in the body. It is attached above to the quadriceps ten- don,
below to the patellar tendon, and medially and laterally to the patellar retinacula. The breadth of the
pelvis and close proximity of the knee creates a valgus angulation to the femur. Coupled with this,
the direction of pull of the quadriceps is along the shaft of the femur and that of the patellar tendon
is almost vertical (Fig. 11.1). The difference between the two lines of pull is known as the Q angle
and is an important determinant of knee health. Normal values for the Q angle are in the region of
15-20°,

and knees with an angle greater or less than this can be considered malaligned.

As the knee flexes and extends, the patella should travel in line with the long axis of the femur.
However, the horizontal force vector created as a result of the Q angle tends to pull the patella
laterally, a movement which is resisted by the horizontal pull of the lower fibres of vastus media- lis.
These lower fibres can be considered as a functionally separate muscle, the vastus medialis oblique
(VMO) (Speakman and Weisberg, 1977). The quadriceps as a whole have been shown to undergo
reflex inhibition as the knee swells (de Andrade et al., 1965; Stokes and Young, 1984). However, the
VMO can be inhibited by as little as 10 ml effusion while the vastus lateralis and rectus femoris
require as much as 60 ml (Arno, 1990). Minimal effusion occurs frequently with minor trauma and
may go unnoticed by the athlete. However, this will be enough to weaken the VMO and alter the
biomechanics of the patella.

in full extension the patella does not contact the femur, but lies in a lateral position. As flexion
progresses, the patella should move medially. If it moves laterally it will butt against the prominent
lateral femoral condyle, and the lateral edge of the patellar groove of the femur. As flexion
progresses different areas of the patella's undersurface are compressed on to the femur. At 20°
flexion the inferior pole of the patella is compressed and by 45° the middle section is affected. At 90°
flexion, compression has moved to the superior aspect of the knee. In a full squatting position, with
the knee reaching 135° flexion, only the medial and lateral areas of the patella are compressed (Fig.
11.2). Compression tests of the patella to examine its posterior surface must therefore be performed
with the knee flexed to different angles.

Patello-femoral loads may be as high as three or four times body weight as the knee flexes in
walking, and nine times body weight when de- scending stairs (Cox, 1990). While the posterior
surface of the patella is compressed, the anterior aspect receives a tensile force when seen in the
sagittal plane (Fig. 11.3b). The effect of the Q angle is to create both horizontal and vertical force
vectors which tend to compress the lateral aspect of the patella but submit the medial aspect to
tensile stress (Fig. 11.3a). Clearly, alterations in the Q angle will change the pattern of stress
experienced by the patellar cartilage.Knee angles in the stance phase of walking or running will be
altered by foot and hip mechanics through the closed kinetic chain. Excessive foot pronation and hip
internal rotation and adduction (causing a 'knock knee' posture) have been linked to anterior knee
pain (see below).
Anterior knee pain

Pathology

Anterior knee pain is variously called chondromala- cia patellae and patella malalignment
syndrome.It

(a) The Q angle causes the lateral edge of the patellar cartilage to be compressed, while the medial
aspect is subjected to tensile stress

(b) The posterior surface of the patella is compressed. Fo, quadriceps pull; Fp, patellar tendon. From
Cox (1990), with permission.

is a condition affecting the posterior surface of the patella sometimes attributed to cartilage damage
and on occasion incorrectly seen as a direct precur- sor to osteoarthritis. Since hyaline cartilage is
aneural, changes in the patellar cartilage surface itself would not result in anterior knee pain. Fur-
thermore, at arthroscopy cartilage changes are often seen in patients who have no anterior knee
pain. If cartilage degeneration does occur with this

condition, it is to the ground substance and colla- gen at deep levels on the lateral edge of the
patella. This results in a blistering of the cartilage as it separates from the underlying bone, but the
cartil- surface itself is still smooth (Gruber, 1979). In osteoarthritis (see pp. 39-40) the initial changes
age occur to the cartilage surface of the odd facet (medial) and are followed by fibrillation. The
retinacula supporting the patella may be a major source of pain (Fulkerson, 1982), as may be the
subchondral bone of the odd facet (Hertling and Kessler, 1990). As we have seen, the odd facet is
only occasionally compressed in a full squatting position, and so its sub-chondral bone is less dense
and weaker. Lateral movement of the loaded patella could pull the odd facet into rapid contactwith
the patellar surface of the femur, causing pain

The complex mechanical relations of the patella make biomechanical assessment of the lower limb a
necessity in the treatment of anterior knee pain, and static and dynamic posture should be analysed.

Muscle strength imbalances

Flexibility and strength of the knee tissues and muscles will often reveal asymmetry. The relation-
ship between the hamstrings and quadriceps (HQ ratio) is particularly important and may require
isokinetic assessment of peak torque values. In cases where genu' recurvatum is present, streng-
thening the hamstrings may be necessary in at- tempting to correct the knee hyperextension. In
addition to knee musculature, hip strength is parti- cularly important. The hip abductors and lateral
rotators warrant special attention, as weakness here has been associated with this condition
(Beckman, Craig and Lehman, 1989). It is common for young athletes to allow the knee to adduct
and medially rotate when descending stairs. This may be due to weakness in the hip abductors,
particularly the gluteus medius, causing the ilio tibial band to overwork and tighten, pulling on the
lateral retina- culum. Manual muscle testing of the gluteus medius in a side-lying position will often
reveal weakness in the affected leg, and tightness in the ITB should be evaluated. Weakness in the
VMO will allow the patella to drift laterally as the quadriceps contract. Streng- thening has
traditionally been achieved by the use of short-range quadriceps exercises and straight leg raising
exercises. However, these are both open chain movements and, as the knee is in closed chain
motion during the stance phase of gait, closed chain actions are more likely to carry over into
functional activities.
Closed chain VMO strengthening may be carried out by performing limited range squats or lunges
moving the knee from 20-30° flexion to full exten- sion. Step downs from a single stair are useful as
they can retrain correct knee motion. The patient should be instructed to keep the knee over the
centre of the foot (avoiding adduction and medial rotation) throughout the movement.

Flexsibility

lexibility should be evaluated against accepted norms and against the contralateral limb. Normal
values of flexibility are highly subjective, but com-parisons with other athletes of a similar stature
whoare performing similar sports will give some gui-dance.Tightness in the quadriceps will increase
com- pression of the patello-femoral joint, while tight hamstrings (which tend to flex the knee
passively) will place a demand on the quadriceps during knee extension. Quadriceps flexibility may
be assessed by passively flexing the knee in a prone-lying position and flexing the knee and
extending the hip in a side-lying position to test the rectus femoris. In the same position the ITB may
be evaluated using the Ober manoeuvre. This is performed by adopt- ing a side-lying position with
the affected limb uppermost. The unaffected limb is flexed and the knee held by the patient to
stabilize the pelvis. The therapist flexes the knee of the affected limb and then passively abducts and
then extends the hip, to pull the knee behind the plane of the body. While maintaining knee and hip
extension, the knee is passively pushed into adduction. Full movement occurs when the hip adducts
far enough to allow the knee to touch the couch. Minimal ITB tight- ness is said to be present if the
knee is unable to touch the couch but will adduct into the horizontal position. If the horizontal
position cannot be reached, the tightness is moderate (Gose and Schweizer, 1989).

Hamstring flexibility may be assessed by actively extending the knee with the hip flexed to 90° in the
sitting or lying position (see p. 69). Failure to extend the knee fully while maintaining 90° hip flexion
constitutes inflexibility. The hip flexors are tested using the Thomas test. The patient lies supine with
the popliteal area of the knee over the couch end. The unaffected limb is flexed and the knee
gripped and pulled in towards the chest (Fig. 11.4a). Normal stretch of the hip flexors will allow the
lower leg to remain in contact with the couch as the flexed limb contacts the patient's chest, but
tightness is indicated if the lower leg starts to lift (Fig. 11.4b). Differentiation between the ilio-psoas
and rectus femoris can be made by assessing the difference made to the movement by further
flexing the knee of the lower leg. If the rectus is tight, the knee will not flex fully The Thomas test.

(a) Normal stretch. The lower leg remains on the couch as the upper hip is flexed to the chest.

(b) Hip flexor tightness causes the lower leg to lift off the couch.

(c) Rectus femoris tightness prevents the lower knee from flexing fully. From Saunders (1989),
with permission.

Satisfactory scores of knee flexion to 80° have been quoted for industrial workers, and if the lower
hip flexes 10° or more off the table, and/or the lower knee does not flex to at least 70, tightness is
present (Saunders, 1989). If the lower leg drifts into abduction the ITB may be tight, and should be
tested by pressing the leg into adduction. This position mimics the Ober manoeuvre.

A tight gastrocnemius will affect the sub-talar joint and can increase pronation, a condition which in
turn will affect the patello-femoral joint. The gastrocnemius is assessed using a forward lunging
position against the wall whilst mainting full knee extension.
Foot biomechanics

During normal running gait (pp. 152-154) the sub-taloid joint (STJ) is slightly supinated at heel strike.
As the foot moves into ground contact, the joint pronates, pulling the lower limb into internal
rotation and unlocking the knee. As the gait cycle progresses, the STJ moves into supination, ex-
ternally rotating the leg as the knee extends (locks) to push the body forward. This biomechanical
action combines mobility and shock absorbtion (STJ pronation and knee flexion) with rigidity and
power transmission (STJ supination and knee ex- tension), and shows the intricate link between foot
and knee function.

If STJ pronation is excessive or prolonged, ex- ternal rotation of the lower limb will be delayed. At
the beginning of the stance phase, STJ pronation should have finished. But, if it continues, the tibia
will remain externally rotated and prevent the knee from locking. The leg must compensate to
prevent excessive strain on its structures, and so the femur rotates instead of the tibia, and the knee
is able to lock once more. As the femur rotates internally in this manner, the patella is forced to
track laterally.

In certain circumstances the patella can cope with this extra stress, but if additional malalign- ment
factors exist, they are compounded. Antever- sion of the femur (internal rotation), VMO weak- ness,
and tightness of the lateral retinaculum may all increase the lateral patellar tracking causing
symptoms (Tiberio, 1987). For anterior knee pain to be treated effectively
therefore, a biomechanical

assessment of the lower limb is mandatory. If hyperpronation is present, it must be corrected. This
will involve assessment of sports footwear, patient education and orthotic prescription.

Patella position

Quantifying the position of the patella is important because, as described above, excessive pressure
on the odd facet may result if the patella position is at fault. McConnell (1986) described four
different patellar position faults which could be assessed with the patient in the supine position with
the quadriceps relaxed. By using the patellar poles as landmarks and comparing their position with
the planes of the femur any malalignment becomes evident. In addition, accessory patellar
movements can be assessed with particular emphasis on medial and lateral gliding. Patellar glide
occurs when the patella moves from a neutral position. The distance from the centre of the patella
to the medial and lateral femoral condyles is assessed (Fig. 11.5a). Tightness in the lateral
retinaculum, a frequent occurrence in anterior knee pain sufferers, will cause lateraliza tion of the
patella. Patellar tilt evaluates the position of the medial and lateral facets of the patella,with patello-
femoral pain patients frequently showing a more prominent medial facet (Fig. 11.5b). Patellar
rotation occurs when the inferior pole of the patella deviates from a neutral position. In- ternal
rotation is a change to the medial side position (Fig. 11.5c). The anterior-posterior relates to the
position of the inferior pole as the quadriceps contract. During this movement, the inferior pole
should remain inferior and not tilt above the plane of the superior pole (Fig. 11.5d). Arno (1990)
attempted to quantify the patellar position with a description of the A angle. This relates patellar
orientation to that of the tibial tubercle. The poles of the patella are palpated and a line is drawn
bisecting the patella. Another line is drawn from the tibial tubercle to the apex of theinferior pole of
the patella and the angle of intersec-tion forms the A angle (Fig. 11.5e). The sameauthor argued that
an A angle greater than 35°constituted malalignment when the Q angle re-mained constant. DiVeta
and Vogelbach (1992)showed A angle measurement to be reliable, withaverage values of 12.3° for
normals and 23.2° forpatients with patellofemoral dysfunction.Pain relief may often be provided by
temporarilycorrecting any underlying fault in patella positionthrough strapping. Excessive lateral tilt
is cor-rected by passively medially tilting the patella andapplying adhesive taping from the midpoint
of thepatella to the medial aspect of the knee. Decreasedmedial glide is corrected with a similar
tapingmethod, but this time extending from the lateralborder of the patella to the medial knee. If
theinferior pole of the patella lies posterior to thesuperior pole, taping is applied to the upper half
ofthe patella to compress it. Patella rotations are corrected by placing the patella in a neutral posi-
tion.

Surgery

Before surgery is considered, conservative management must be attempted. Indeed, Insall (1979)
stated that surgery was only indicated when continuous pain limited normal activities for at least
sixmonths and the condition had not responded to management. The comple differentconsondition
has led to a number of e of theapproaches. carried out Release of tight lateral retinaculum is
performed through a small incision or arthroscopy to divide the retinaculum from the lower fibres of
the vastus lateralis. Patellar debridement/shaving has been o remove degenerate articular cartilage
on the patella undersurface. Small areas of cartilage may be removed en bloc or larger areas shaved.
Realignment procedures involve structural transfer to reduce or alter compression forces on the
patella. The Maquet operation elevates the tibial tubercle to reduce patella reaction forces and the
Hauser manoeuvre uses distal and medial transfer to reduce the valgus vector acting on the patello-
femoral joint. Realignment of the attach- ment of the vastus medialis aims to increase the
mechanical advantage of the VMO.

Patellar fracture

Patellar fractures in sport occur most frequently in adolescent athletes, usually as a result of
jumping. Fracture may occur at the pole of the patella, or as transverse, vertical, or comminuted
injuries. Stress fracture at the distal third of the patella has been reported after sprinting (Jerosch,
Castro and Jantea, 1989). Conservative treatment, consisting of immobilizing the limb in a cast for
two to three weeks, is sufficient in 50-60% of cases (Exler, 1991). Surgical treatment involves internal
fixation of the patellar fragments, and hemipatellectomy or total patellectomy in the case of
comminuted injuries, combined with immobilization in a cast. Following immobilization, mobility
exercises and quadriceps strengthening are started. Streng-thening begins with straight leg raising.
An extension lag is common in these patients. The leg is locked from a long sitting position and, as it
is raised, the tibia falls 2-3 cm as the patient is unable to maintain locking. Re-education of the knee
locking mechanism may be achieved in a side-lying (gravity eliminated) position. This is followed by
knee bracing with a rolled towel under the knee, the patient being instructed to 'push down' on the
towel with the back of the knee and at the same time to lift the heel from the couch surface. Short
range movements over a knee block using a weight bag is the next progression. When 60-90° knee
flexion is achieved, light weight training on universal machine with a relaxation stop, or isokinetic
training, is used before closed chain activities.

Patellar dislocation

Patellar dislocation may occur traumatically with any athlete, but is more frequently seen in children
between the ages of 8-15 years and middle-aged women who are overweight and have poor
muscular development of the quadriceps. Biomechanically, the individual is more susceptible to this
condition if they demonstrate genu valgum, excessive femoral anteversion or external rotation of
the tibia, and if the VMO is weak. The injury usually occurs when the knee is externally rotated and
straightened at the same time, such as when the athlete turns to the left while pushing off from the
right foot. In this position the tibial attachment of the quadriceps moves laterally in relation to the
femur, increasing the lateral force component as the muscle group contracts. The patella almost
always dislocates laterally and is accompanied by a ripping sensation and excruciating pain, causing
the knee to give way. As the knee straightens, the patella may reduce spontaneously with an audible
click. Swelling is rapid due to the haemarthrosis, causing the skin to become taught and shiny.
Bruising forms over the medial retinaculum, and the athlete is normally completely disabled by pain
and quadriceps spasm. Initial treatment is to immobilize the knee com- pletely and apply the RICE
protocol. Aspiration may be required if pain is intense, but swelling usually abates with non-invasive
management. Quadriceps re-education plays an important part in the rehabilitation process, with
VMO strengthening being particularly important. The medial retinaculum must be allowed to heal
fully, and it is a mistake to allow these athletes to mobilize unprotected too soon. Only when 90°
knee flexion isachieved and the patient is able to perform atstraight leg lift with 30-50% of the
power of the The knee 175 uninjured leg are they ready to walk without support.

Aetiology

Tightness of the ITB can occur in a number of patient groups. The tall, lanky teenager who has
recently undergone the adolescent growth spurt may experience pain if soft tissue elongation lags
behind long bone development. Tightness in adole- scent females is a frequent cause of anterior
knee pain. The second major group of sufferers are adult athletes, particularly distance runners. A
number of factors can contribute to problems within this group. Running on cambered roads and
using shoes worn on their lateral edge will increase varus knee angulation and may overstretch a
tight ITB. Rapid increases in speed or hill work can place excessive stress on the structure. In
addition, imba- lances of muscle strength and flexibility around the knee and hip may lead to the
gradual onset of symptoms. flexes to 30° and back, the ITB will pass over the lateral femoral condyle
and may cause friction and pain which builds in intensity. Flexibility tests, particularly the Ober
manoeuvre and Thomas test (p. 172) often reveal pain and a lack of flexibility. Management

The initial inflammation responds to anti- inflammatory modalities, but the underlying cause must
be addressed. Modifications include altera- tions of running surface and footwear, and changes to
training intensity, frequency, duration and con- tent. Where limited-range motion is identified,
stretching procedures are called for. Hip flexor and extensor flexibility is regained by using exercises
previously described, and the ITB itself is stretched using an adaptation of the Ober manoeuvre.

The ITB insertion at the knee is first heated with hot packs or diathermy. The pelvis is stabilized by
the patient flexing and holding the lower knee. The affected upper leg is initially abducted and ex-
tended at the hip and flexed at the knee. From this position, hip extension is maintained and the leg
is pushed downwards into adduction, and held for 30-60 seconds, with the stretch being repeated
four or five times. As adduction commences, the patient's pelvis will tend to tilt, and an assistant
should press down on the rim of the ilium to stabilize the pelvis and increase the stretch. Between
treatment sessions the patient should attempt this procedure at home. The weight of the leg may be
used to press it into adduction, and a weight bag on the knee will assist this. In addition, training
partners or family members can be taught to help. Weakness in the hip abductors may allow the
pelvis to tilt or 'dip' during the stance phase of walking or running. This often gives the impres- sion
of a mild trendelenberg gait, and may be habitual following lower limb injury. Gait re- education and
abductor strengthening are called for. The abductors may be strengthened from an open chain or
more functional closed chain starting position. Open chain strengthening is performed using a
weight bag in a side-lying hip abduction exercise. Closed chain strengthening is carried out with the
athlete standing on the affected leg, and keeping it locked. The unaffected leg is flexed a the knee.
From this position the pelvis is allowed to at drop towards the unsupported side and pulled back to
the horizontal position by hip abductor action

Collateral ligament injuries

The medial collateral ligament (MCL) is a broad flat band about 8 or 9 cm in length. It travels
downwards and forwards from the medial epicon- dyle of the femur to the medial condyle and
upper medial shaft of the tibia. The ligament has both deep and superficial fibres, with the deep
fibres attaching to the medial meniscus, and the super- ficial fibres extending below the level of the
tibial tuberosity. The superficial fibres have anterior, middle and posterior portions.

When the knee is in full extension, it is in close pack formation. The medial femoral condyle is
pushed backwards, and the medial epicondyle lifts away from the tibial plateaux, tightening the
poste- rior part of the MCL. As the knee is flexed, the posterior part of the ligament relaxes, but the
anterior and middle parts remain tight. By 80-90° flexion, the middle of the ligament is still tight, but
the anterior and posterior portions are lax. In this way, the strong middle section of the ligament
remains tight for most of the range of movement. The changing distribution of tension strain in the
ligament means that the section which is affected Hip abductor strengthening. (a) Athlete stands on
affected leg. (b) Allowing the opposite hip to drop and then pulling it up works the abductors of the
weight-bearing limb. through injury will depend on the knee angle when the injury occurred, so an
accurate history is extremely helpful.

The lateral collateral ligament (LCL) is a round cord about 5 cm long, which stands clear of the joint
capsule. It travels from the lateral epicondyle of the femur to the lateral surface of the head of the
fibula. The ligament splits the tendon of biceps femoris, and is separated from the joint capsule by
the popliteus muscle, and the lateral genicular vessels and nerve (Palastanga, Field and Soames,
1989). The lower end of the lateral ligament is pulled backwards in extension and forwards in flexion
of the knee.

Damage to the MCL can result from excessive valgus angulation of the knee coupled with external
rotation, while LCL damage is normally through varus strains coupled with internal rotation. MCL
damage usually leads to pain over the medial epicondyle of the femur, the middle third of the joint
line, or the tibial insertion of the ligament. With LCL damage, pain is normally over the head of the
fibula or lateral femoral epicondyle. The integrity of the ligaments is tested by applying a varus and
valgus stress to the knee flexed to 30°. It is ineffective to the same test with the knee locked, as this
is the close pack position, and nearly 50% of medial and lateral stability is provided by the cruciate
ligaments and joint capsule. The easiest way to perform the varus/ valgus test is with the patient's
hip abducted, the thigh supported on the couch and the lower leg over the couch side. First and
second degree injuries are generally treated conservatively. Third degree injuries (com- plete
rupture) have been treated surgically, but some authors argue that stability of the knee is not
improved to a greater extent than with non- operative intervention (Keene, 1990). First degree
injuries are generally treated partial or full weight bearing with the ligament supported by strapping.
Second and third degree injuries are managed non-weight bearing. Initially, the aim is pain relief,
swelling reduc- tion and the start of mobile scar formation. Isome- tric quadriceps drill is begun and
modalities used to reduce pain and swelling. At night a knee brace may be used to protect the
ligament. By the third or fourth day after injury (sometimes earlier with a first degree and later with
a third degree injury) gentle mobility exercises are begun either in a side-lying starting position or in
the pool. Gentle transverse frictions are used to encourage mobile scar formation. The sweep should
be quite broad and a large section of the ligament treated. Free, or light resisted exercises are begun
to the knee, hip and calf musculature within the pain-free range. Isokinetics may be used, with the
aim of restoring the HQ ratio to that of the uninjured limb.

When 90° of pain free movement is obtained (usually 10-14 days after injury with a grade three
sprain) the rehabilitation programme can be pro- gressed further to include more vigorous activities,
and increased mobility and strength training. An exercise cycle or light jogging may be used, and
swimming (not breast stroke) started. Weight training is progressed to use leg machines, and some
power training is added. Towards the end of this period, depending on pain levels, shallow jumping,
bench stepping, circle running and zig- zagging in the gym are used to gradually introduce rotation,
shear, and valgus stress to the knee. In addition to improving strength and power, these exercises
build confidence and provide an assess- ment of knee stability.

Cruciate ligaments

The cruciate ligaments are strong rounded cords within the knee joint capsule, but outside its
synovial cavity. The ligament fibres are 90% colla- gen and 10% elastic tissue, arranged in two types
of fasciculi. The first group travel directly between the femur and tibia as would be expected, but the
second set spiral around the length of the ligament. This structure enables the ligament to increase
its resistance to tension when loaded. Under light loads only a few of the fasciculi are under tension,
but as the load increases, the spiral fibres unwind bringing more fasciculi into play and effectively
increasing the ligament strength. The anterior cruciate ligament (ACL) is attached from the tibia,
anterior to the tibial spine. Here, it blends with the anterior horn of the lateral menis- cus and passes
beneath the transverse ligament. Its direction is posterior, lateral and proximal to attach