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Evaluating the KneeEvaluating the Knee
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The KneeThe Knee
Two Joints:Two Joints:
TibiofemoralTibiofemoral
PatellofemoralPatellofemoral
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HISTORYHISTORY
Remember the questions from
lecture #2?
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OBSERVATIONOBSERVATION
GirthGirth
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TibioFemoralTibioFemoral AlignmentAlignment
What are the consequences of
faulty alignment?
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Leg LengthLeg Length
APPARENTTRUE
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BLOCK METHODBLOCK METHOD
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QQ--AngleAngle
Knee Flexed
Knee Extended
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Patellar PositionPatellar Position
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Where’s the swelling?Where’s the swelling?
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PalpationPalpation
Four AspectsFour AspectsAnteriorAnterior
MedialMedial
LateralLateral
PosteriorPosterior
Start with the Tibial Start with the Tibial TuberosityTuberosity
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ANTERIORANTERIORTibial Tibial TuberosityTuberosity
Patellar Patellar TendonTendon
PatellaPatellaQuadriceps Quadriceps TendonTendonQuadriceps Quadriceps MusclesMusclesSartoriusSartorius
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MedialMedialTibialTibialPlateauPlateau
MeniscusMeniscusMCLMCLPesPesAnserineAnserineSemimemSemimemGracilisGracilis
Femoral Femoral CondyleCondyleFemoral Femoral EpicondyleEpicondyle
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LateralLateralTibialTibial PlateauPlateau
MeniscusMeniscus
Fibular HeadFibular HeadLCLLCLPopliteusPopliteusBiceps FemBiceps FemITBITB
Femoral Femoral CondyleCondyleFemoral Femoral EpicondyleEpicondyle
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PosteriorPosteriorPoplitealPoplitealFossaFossaHamstringsHamstringsHeads of Heads of GastrocGastroc
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STRESSSTRESS
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Structure Function
InjuryMechanism
EvaluationTreatment
&Rehab
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TriplanarTriplanar Knee MotionKnee Motion
A simple hinge joint would simply flex and A simple hinge joint would simply flex and extendextend
This is not a simple hinge joint!!This is not a simple hinge joint!!
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Tibia on a fixed FemurTibia on a fixed Femur
FLEXIONFLEXION
Backward RollingBackward Rolling
Internal RotationInternal Rotation
VarusVarus
Posterior Posterior Translation
EXTENSIONEXTENSION
Forward RollingForward Rolling
External RotationExternal Rotation
ValgusValgus
Anterior Anterior TranslationTranslation Translation
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Femur on a fixed TibiaFemur on a fixed Tibia
FLEXIONFLEXION
Backward RollingBackward Rolling
External RotationExternal Rotation
VarusVarus
Anterior Anterior Translation
EXTENSIONEXTENSION
Forward RollingForward Rolling
Internal RotationInternal Rotation
ValgusValgus
Posterior Posterior TranslationTranslation Translation
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Knee MotionKnee Motion
Bony GeometryBony Geometry
Soft Tissue ConstraintsSoft Tissue Constraints
Muscle ForcesMuscle Forces
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Bony FactorsBony Factors
Different size of the medial and lateral femoral Different size of the medial and lateral femoral condylescondyles
Different size of the Different size of the articulararticular surfaces of the surfaces of the femoral condyles and the femoral condyles and the tibialtibial condylescondyles
Variation in curvature from anterior to posteriorVariation in curvature from anterior to posterior
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Medial Medial CondyleCondyle is larger than the is larger than the Lateral Lateral CondyleCondyle
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Larger Femoral CondylesLarger Femoral Condyles
What’s the consequence
of larger femoral
condyles?
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ConvexConvex--Concave RuleConcave Rule
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The MenisciThe Menisci
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The MenisciThe Menisci
TibiofemoralTibiofemoral load transmissionload transmissionShock absorptionShock absorptionLubricationLubricationPrevent Prevent synovialsynovial impingementimpingementDistribute Distribute synovialsynovial fluidfluidContribute to joint stabilityContribute to joint stabilityAssist in gliding motionAssist in gliding motion
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My Third Law
Lev
angi
ean
d N
orki
n, 2
001
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Movements of menisciMovements of menisci
during flexion during flexion --move posteriorlymove posteriorly
during extension during extension --move anteriorlymove anteriorly
extended flexing… menisci moveposteriorly unequally
R
…… the menisci follow, or stay with the, femoral condylesthe menisci follow, or stay with the, femoral condyles
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Movements of menisciMovements of menisci
during lateral rotation of the tibia during lateral rotation of the tibia the menisci follow the femoral condyles, e.g. they the menisci follow the femoral condyles, e.g. they remain with the femoral condyles while the tibia remain with the femoral condyles while the tibia rotates rotates
during medial rotation during medial rotation (compare to lateral rotation)(compare to lateral rotation)
Lateral rot. Medial rot.Neutral
R
…… the menisci follow, or stay with the, femoral condylesthe menisci follow, or stay with the, femoral condyles
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How would you palpate the menisci?
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Movement of the MenisciMovement of the Menisci
Lateral meniscus moves more than medial Lateral meniscus moves more than medial meniscus (meniscus (VediVedi, 1999), 1999)
Anterior horns move more than posterior horns Anterior horns move more than posterior horns ((VediVedi, 1999), 1999)
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The menisci attach to the tibia, but The menisci attach to the tibia, but move with the femur.move with the femur.
What are the consequences?
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LongitudinalHorizontal
Oblique Radial
Whiting and Zernicke, 1998
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EvaluatingEvaluatingthethe
MenisciMenisci
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McMurray’sMcMurray’s
Star
key
& R
yan,
199
6
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Apley’sApley’s
Star
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199
6
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Weight bearing with flexion and Weight bearing with flexion and extension…extension…
Climbing stairsClimbing stairs
Rising from a chairRising from a chair
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Let’s Review…Let’s Review…
Different sizes of femoral condyles means Different sizes of femoral condyles means triplanartriplanar motion.motion.
Different sizes of the femoral and Different sizes of the femoral and tibialtibial condyles condyles means that gliding must accompany rolling.means that gliding must accompany rolling.
The The meniscalmeniscal reaction force is partially reaction force is partially responsible for this gliding.responsible for this gliding.
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Anterior Anterior CruciateCruciate LigamentLigament
Prevents anterior Prevents anterior translation of the tibia translation of the tibia with respect to the with respect to the femur femur Or…Or…Stabilize in other Stabilize in other directions as welldirections as well
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Posterior Posterior CruciateCruciate LigamentLigament
Prevents posterior Prevents posterior translation of the tibia translation of the tibia with respect to the with respect to the femurfemurOr…Or…Provides stability in Provides stability in other directions as other directions as wellwell
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The The CruciatesCruciates & Knee Motion& Knee Motion
ACL assists in anteriorglide during flexion
PCL assists in posteriorglide during extension
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Tibial:
•Anterior Translation
•Internal Rotation
•Valgus or Varus
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Testing the ACLTesting the ACL
Greatest forces on ligaments = anterior Greatest forces on ligaments = anterior tibtibforces + internal forces + internal tibialtibial torque+valgus/varustorque+valgus/varus
Anterior shear loads at 30 degrees of flexion Anterior shear loads at 30 degrees of flexion produced greater strain on the AMB than shear produced greater strain on the AMB than shear loads at 90 degrees. (loads at 90 degrees. (BeynnonBeynnon, 1992), 1992)
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Anterior DrawerAnterior Drawer
Star
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199
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Lachman’sLachman’s
Star
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199
6
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Alternate Alternate Lachman’sLachman’s
Star
key
& R
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199
6
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PCL injuries…direct impactPCL injuries…direct impact
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Testing the PCLTesting the PCL
Posterior translation was twice as much at 90 Posterior translation was twice as much at 90 degrees of flexion compared to 30 degrees after degrees of flexion compared to 30 degrees after sectioning PCL (sectioning PCL (GroodGrood, 1988), 1988)Test PCL at 90 degrees (posterior drawer and Test PCL at 90 degrees (posterior drawer and posterior sag test).posterior sag test).Internal rotation in this position will decrease Internal rotation in this position will decrease laxity (laxity (BergfeldBergfeld, 2001), 2001)
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Posterior DrawerPosterior Drawer
Star
key
& R
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199
6
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Godfrey’sGodfrey’s
Star
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199
6
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Let’s Review…Let’s Review…
Larger medial Larger medial condylecondyle produces produces triplanartriplanar motionmotion
Larger femoral condyles require a combination Larger femoral condyles require a combination of rolling and glidingof rolling and gliding
The menisci and The menisci and cruciatescruciates are largely responsible are largely responsible for these gliding motionsfor these gliding motions
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Medial Collateral LigamentMedial Collateral Ligament
Restrains Restrains valgusvalgusloadingloading
Checks lateral Checks lateral tibialtibialrotationrotation
BackBack--up anterior up anterior displacementdisplacement
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Lateral Collateral LigamentLateral Collateral Ligament
Resists Resists varusvarus stressstress
Also limits lateral Also limits lateral rotationrotation
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Testing the CollateralsTesting the Collaterals
57% of 57% of valgusvalgus load at 5 degrees of flexionload at 5 degrees of flexion
78% of 78% of valgusvalgus load at 25 degrees of flexionload at 25 degrees of flexion
Best position to test the integrity of the collaterals?
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ValgusValgus StressStress
Star
key
& R
yan,
199
6
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VarusVarus StressStress
Star
key
& R
yan,
199
6
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Rotational InstabilitiesRotational Instabilities
Relative motion of Relative motion of the tibia on the femurthe tibia on the femurMultiple structures Multiple structures are involvedare involvedTotal may be greater Total may be greater than the sum of the than the sum of the partsparts
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Slocum DrawerSlocum Drawer
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Crossover TestCrossover Test
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Pivot ShiftPivot Shift
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ALRIALRI
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FRD TestFRD Test
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External RotationExternal Rotation
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OsteochondralOsteochondral DefectsDefects
Fractures of Fractures of articulararticularcartilage and cartilage and underlying boneunderlying bone
Shear and Shear and compressive forcescompressive forces
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Wilson’s Test for OCDWilson’s Test for OCD
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TibTib--Fib Translation TestFib Translation Test
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Why do we have a patella?
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Patellar MotionsPatellar Motions
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The Effect of the Quads on the The Effect of the Quads on the PatellaPatella
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PatellofemoralPatellofemoral PainPain
Force
AreaStress =
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TrochlearTrochlear Depth Depth –– 6060°° FlexionFlexion
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TrochlearTrochlear Depth Depth –– Full ExtensionFull Extension
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Patellar GlidesPatellar Glides
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Patellar TiltPatellar Tilt
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Clarke’s SignClarke’s Sign
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Apprehension TestApprehension Test
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Medial Medial SynovialSynovial PlicaPlica
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Stutter TestStutter Test
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Range of MotionRange of Motion
PASSIVEPASSIVE
ACTIVEACTIVE
RESISTEDRESISTED
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Noble Compression TestNoble Compression Test
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Ober’sOber’s TestTest
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A final word of advice…
The knee is part of a kinetic The knee is part of a kinetic chain.chain.
Don’t look at it in isolation!
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It’s not my fault!!
Heh! Heh!
Heh! Heh!