The Knee. Two Joints: Tibiofemoral. Patellofemoral

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1 Evaluating the Knee

2 The Knee Two Joints: Tibiofemoral Patellofemoral

3 HISTORY Remember the questions from lecture #2?

4 Girth OBSERVATION

5 TibioFemoral Alignment What are the consequences of faulty alignment?

6 Leg Length TRUE APPARENT

7 BLOCK METHOD

8 Q-Angle Knee Flexed Knee Extended

9 Patellar Position

10 Where s the swelling?

11 Palpation Four Aspects Anterior Medial Lateral Posterior Start with the Tibial Tuberosity

12 ANTERIOR Tibial Tuberosity Patellar Tendon Patella Quadriceps Tendon Quadriceps Muscles Sartorius

13 Medial Tibial Plateau Meniscus MCL Pes Anserine Semimem Gracilis Femoral Condyle Femoral Epicondyle

14 Lateral Tibial Plateau Meniscus Fibular Head LCL Popliteus Biceps Fem ITB Femoral Condyle Femoral Epicondyle

15 Posterior Popliteal Fossa Hamstrings Heads of Gastroc

16 STRESS

17 Structure Function Injury Mechanism Evaluation Treatment & Rehab

18 Triplanar Knee Motion A simple hinge joint would simply flex and extend This is not a simple hinge joint!!

19 Tibia on a fixed Femur FLEXION Backward Rolling Internal Rotation Varus Posterior Translation EXTENSION Forward Rolling External Rotation Valgus Anterior Translation

20 Femur on a fixed Tibia FLEXION Backward Rolling External Rotation Varus Anterior Translation EXTENSION Forward Rolling Internal Rotation Valgus Posterior Translation

21 Knee Motion Bony Geometry Soft Tissue Constraints Muscle Forces

22 Bony Factors Different size of the medial and lateral femoral condyles Different size of the articular surfaces of the femoral condyles and the tibial condyles Variation in curvature from anterior to posterior

23 Medial Condyle is larger than the Lateral Condyle

24 Larger Femoral Condyles What s the consequence of larger femoral condyles?

25

26 Convex-Concave Concave Rule

27 The Menisci

28

29 The Menisci Tibiofemoral load transmission Shock absorption Lubrication Prevent synovial impingement Distribute synovial fluid Contribute to joint stability Assist in gliding motion

30 My Third Law Levangie and Norkin, 2001

31 during flexion - move posteriorly Movements of menisci during extension - move anteriorly extended R flexing menisci move posteriorly unequally the menisci follow, or stay with the, femoral condyles

32 Movements of menisci during lateral rotation of the tibia the menisci follow the femoral condyles, e.g. they remain with the femoral condyles while the tibia rotates during medial rotation (compare to lateral rotation) Lateral rot. Neutral Medial rot. R the menisci follow, or stay with the, femoral condyles

33 How would you palpate the menisci?

34 Movement of the Menisci Lateral meniscus moves more than medial meniscus (Vedi( Vedi,, 1999) Anterior horns move more than posterior horns (Vedi,, 1999)

35 The menisci attach to the tibia, but move with the femur. What are the consequences?

36 Horizontal Longitudinal Oblique Radial Whiting and Zernicke, 1998

37 Evaluating the Menisci

38 McMurray s Starkey & Ryan, 1996

39 Apley s Starkey & Ryan, 1996

40 Weight bearing with flexion and extension Climbing stairs Rising from a chair

41 Let s Review Different sizes of femoral condyles means triplanar motion. Different sizes of the femoral and tibial condyles means that gliding must accompany rolling. The meniscal reaction force is partially responsible for this gliding.

42 Anterior Cruciate Ligament Prevents anterior translation of the tibia with respect to the femur Or Stabilize in other directions as well

43 Posterior Cruciate Ligament Prevents posterior translation of the tibia with respect to the femur Or Provides stability in other directions as well

44 The Cruciates & Knee Motion ACL assists in anterior glide during flexion PCL assists in posterior glide during extension

45

46 Tibial: Anterior Translation Internal Rotation Valgus or Varus

47 Testing the ACL Greatest forces on ligaments = anterior tib forces + internal tibial torque+valgus/varus Anterior shear loads at 30 degrees of flexion produced greater strain on the AMB than shear loads at 90 degrees. (Beynnon( Beynnon,, 1992)

48 Anterior Drawer Anterior Drawer Starkey & Ryan, 1996

49 Lachman s Starkey & Ryan, 1996

50 Alternate Lachman s Starkey & Ryan, 1996

51 PCL injuries direct impact

52 Testing the PCL Posterior translation was twice as much at 90 degrees of flexion compared to 30 degrees after sectioning PCL (Grood( Grood,, 1988) Test PCL at 90 degrees (posterior drawer and posterior sag test). Internal rotation in this position will decrease laxity (Bergfeld( Bergfeld,, 2001)

53 Posterior Drawer Posterior Drawer Starkey & Ryan, 1996

54 Godfrey s Starkey & Ryan, 1996

55 Let s Review Larger medial condyle produces triplanar motion Larger femoral condyles require a combination of rolling and gliding The menisci and cruciates are largely responsible for these gliding motions

56 Medial Collateral Ligament Restrains valgus loading Checks lateral tibial rotation Back-up anterior displacement

57 Lateral Collateral Ligament Resists varus stress Also limits lateral rotation

58 Testing the Collaterals 57% of valgus load at 5 degrees of flexion 78% of valgus load at 25 degrees of flexion Best position to test the integrity of the collaterals?

59 Valgus Stress Starkey & Ryan, 1996

60 Varus Stress Starkey & Ryan, 1996

61 Rotational Instabilities Relative motion of the tibia on the femur Multiple structures are involved Total may be greater than the sum of the parts

62 Slocum Drawer

63 Crossover Test

64 Pivot Shift

65 ALRI

66 FRD Test

67 External Rotation

68 Osteochondral Defects Fractures of articular cartilage and underlying bone Shear and compressive forces

69 Wilson s Test for OCD

70 Tib-Fib Translation Test

71 Why do we have a patella?

72 Patellar Motions

73 The Effect of the Quads on the Patella

74 Patellofemoral Pain Stress = Force Area

75 Trochlear Depth 60 Flexion

76 Trochlear Depth Full Extension

77 Patellar Glides

78 Patellar Tilt

79 Clarke s Sign

80 Apprehension Test

81 Medial Synovial Plica

82 Stutter Test

83 Range of Motion PASSIVE ACTIVE RESISTED

84 Noble Compression Test

85 Ober s Test

86 A final word of advice The knee is part of a kinetic chain. Don t look at it in isolation!

87 Heh! Heh! It s not my fault!! Heh! Heh!

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