Knee injuries

Chetan Kaushik
M.P.T 2nd year(Ortho)

CONTENTS

ANATOMY OF THE KNEE

MENISCUS
LIGAMENTS
ACL INSTABILITY
PCL INSTABILITY
MCL INSTABILITY
LCL INSTABILITY
PATELLO-FEMORAL PAIN SYNDROME
PLICA SYNDROME

MENISCI
Fibrocartilagenous disks.

Improves
congruency of d joint by
inc. concavity.
Med.& lat. Menisci.
Distributes wt. bearing
forces.
Shock absorber
Reduces friction b/t tibia &
femur.
Located on the top of the
plateau.

 Both r open at the

intercondyler tubercle.
Both have ant. & post.
Horns.
Thick periphery & thin
centrally.
Lat.. Is small then med..
one., so bears more wt.
Wt.is 2 times more
during gait & stair
climbing.
4 times during running.

MED. MENISCUS
C- shaped
Has more lig. & capsular
restrains.
Limited translation so more
inj. They r: Transverse lig.
Patellomeniscal lig.
Coronary lig.
Antero medial meniscus
From med. Capsule, MCL &
reinforced by med.
Retinaculum.

 This thickened
capsule is deep
portion of MCL.
Ant. Horn ACL
Post. Horn- PCL
Semimemb.- to
post. Horn, just
ant. To PCL via
capsule.

LAT. MENISCUS
Oval- of a circle.
Post. Attach to PCL & med.
Condyle by
meniscofemoral lig.
If attach ant. To PCL then
called as lig. Of
HUMPHREY.
If post. Then lig of
WRISBERG.
Popliteus tendon via
poplitial hiatus.
No attachment to the LCL
& less to the capsule.

MENISCAL INNERVATION
Nociceptors-innervates
horns & peripheral part
3 mechanoreceptorsA. Ruffini corpuscles
B. Pacinian corpuscles
C. Golgi tendon organs
. Responsible for. Pain
. Propioception

MECHANISM OF INJURY.
Mechanism of injury is a rotational
force when a flexed knee extends.
In young,it can occur only when weight
is being taken,knee is flexed and there
is twisting strain.
Young active athletes are more prone.
In middle life fibrosis has decreased the
mobility of meniscus and hence tear
occurs with less force.

Meniscal instability
Torn meniscus is the most common causes of
mechanical symptoms in the knee.

Pathomechanics
Turning or twisting on a loaded joint (weight bearing)
may trap the meniscus between the joint surface and
tear the meniscus.
This may occurs in combination with other injuries such
as tear of the ACL that produce excessive tibial
displacement on the loaded joint, causing the meniscus
to displace and tear from its peripheral attachment.
With age the meniscus become less compliant and
stiffer subjecting it injury with less force

 Due to meniscal stiffness there is

mucoid degeneration that comes
with aging, results in older patients
frequently developing meniscal tears
that tend to be more complex in
nature.

Clinical Presentation

History
Pain
Catching
Buckling / Giving Way
Joint Stiffness
Antalgic Gait
Joint Line Pain

Shelbourne et al
1995
Medial joint line pain
is 34.5% predictor of
meniscal injury
Lateral joint line pain
is 49.1 % predictor of
meniscal injury

Effusion
Clicking during ROM
Increased Pain in full
flexion
Pain with Squatting
Duck Walk

Pain with Valgus /

Varus Stress Testing
Rule Out ACL, PCL,
MCL, LCL

Radiograph

Post injury complication

Tear of medial meniscus is more than lateral
meniscus
Meniscal injury occurs with a fragment mobile. The
mobile fragment causes pain, tenderness and local
synovitis by abnotmally pulling on its remaining
attachments
This may causes mechanical complaints such as
catching and locking by dislodging and blocking
joint motion.
Patient may complain snapping and recurrent
effusions
Swelling may occurs and may develop in more than
12hours, after initial injury.

 The shape and location of a meniscal

tear ditermine the symptoms and
findings associated with a particular
meniscal tear.
Localized complaints of pain and joint
line tenderness near the collateral
ligament are probably the most
characteristic findings.

Apleys Distraction Test

Tests for
meniscal or
ligamentous
lesions
(+) test is pain
that is eliminated
(meniscal injury),
or pain that is
increased
(ligamentous)

Apleys Compression Test

Tests for
meniscal lesions
(+) test is
increased pain
during
compression
which may
increase with
rotation in either
direction

ODonohues Test
Tests for meniscal tear or capsular
irritation
(+) test is increased pain, clicking, or
popping in the joint line in either one
or both flexion or extension during
internal or external rotation

McMurrays Test
Tests for meniscal injuries
Tibia IR
Indicates lateral
meniscus injury

Tibia ER
Indicates medial
meniscus injury

(+) test is popping, clicking

or locking of knee;
pain or reproduction of
symptoms
Stratford, et al 1995 & Corea, et
al 1994 found McMurray missed
40% of meniscal injuries

Bounce Home Test

Tests for meniscal tears
(+) test is when extension is not
complete or increased pain
Abnormal springy block at extension

Diagnostic Tools

Aspiration
Radiologic Exam
MRI
90% accurate in
diagnosing meniscal
injury (Bernstein
2000)

Meniscal Injuries

Arthroscopic View

LIGAMENTS
Provides stability to
the joint by restricting Exec. Knee ext.
Varus & valgus stress
Ant& post
Displacement of tibia.
Med& lat. Rotation of
tibia.
Rotatory stability(A-P
P-A & rotation.)

MCL
On med. Side.
2 portions SUPERFICIAL:- fan
shaped
From med condyle to
proximal tibia(distal to
pes anserinus)
DEEP:From med condyle to
tibial plateau.
attaches With joint
capsule.
&to med. Meniscus

FUNCTION OF MCL
Restricts valgus & lat.
Rotation stresses.
Mainly in extended knee.
In absence of ACLrestricts ant. Translation
of tibia.
Post. Oblique lig.oblique fibers to
semimemb, stops antmed rotation of tibia.
Heals faster- rich blood
supply.

LCL
On lat. Side.
From lat condyle
(proximal to poplitial
tendon) to fibula
head(joins biceps
femoris tendon)
Extra capsular lig.
Restricts varus & lat.
Rotation stresses.

ACL
From- ant. Tibial
spine(med,broad
attachment) to the med
surface of lat condyle.
(semicircle- curved at
post side)
GoesPosterosuperolaterally.
(obliquely.)
Average length-38mm
Width-10mm
Thickness- 5mm

 Macroscopically- 2
bundles
Anteromedially(AMB)
Posterolaterally(PLB)
(depends on the
origin 4m tibia)
Increase tension: Knee full ext.-PLB
Knee full flex.- AMB

 So some portion of ACL

remains taut in full ROM.
Tension is more in Int
rotation.
Less with EXT. rotation
Blood supply to ACL by
middle Genicular artery
Restricts ant.
displacement of tibia.
Some valgus & varus
stresses.

PCL
From- post tibial spine to lat
aspect of med condyle.
Goessuperomedioanteriorly
(less oblique than ACL)
Average length-31mm
Width-13mm
Macroscopically-2 bands
AMB
PLB
More tension: Full ext- PLB
Full flex.-AMB

 Restricts post.
Displacement of
tibia.
Some varus&
valgus stresses.
Short ,thick & less
oblique than ACL.
More tension:- int.
rotation(wraps
around ACL)

Anterior cruciate ligament

instability
ACL is primary stabilizer for resisting
anterior translation of tibia on the femur
and serves to control hyperextension of the
knee.
ACL is also serves as secondary stabilizer
to resist internal and external rotation as
well as varus and valgus stress.
Cause of injury may be contact or
noncontact.

Occurrence
75% of ACL rupture occurs in
midstance.
20% are injuries involving the
femoral attachment
5% involve tibial attachment

Pathomechanics
Common mechanism
A valgus force applied to a flexed, externally
rotated knee with the foot planted (or
hyperextension), often combined with
internal rotation.
Less common mechanism
This include hyper flexion or direct valgus
force.
A direct valgus force may produce a tear of
the MCL,ACLand medial meniscus which is
known as the ODonoghue triad.

Associated injury with ACL

It include meniscal tear in 50 to70% of acutely injured
knees and upto 90% in chronic condition orACL
deficient knee.
Chondral injuries in 6 to20% of ACL of injured knee.
Collateral ligament injuries in 40 to 75% of ACL injured
knees.
Occasionally capsular injuries and knee dislocation.
Condition: There is audible crack or pop at the time of initial
injury.
Swelling in first 2to6
Instability to continue the activity.

Grades
Grade 1(sprain): It involves a microscopic partial tear of
the ligament, which over all remains
intact.
Ligament fibers stretched causing
haemorrhage and microscopic disruption
of the structure within the ligament.
No increased laxity compate to
contralateral knee and end points are
firm.

 Grade 2(sprain): It involves a macroscopic and

microscopic tearing resulting in
haemorrage and streching of the
ligament .
But it is still in continuity and function
to some degree.
Positive anterior drawer test
Positive lachmans test
Negative pivot shift test

 Grade 3(sprain): It is complete tear of the ligament.

There is loss of ligament function,
loss of joint stability.
Lachmans test is positive with 2+
to3+
Anterior drawer test is the positive
Positive pivot shift test
Anterior translation of tibia is
excessive and the end point is soft

Post injury complication

The torn ACL doses not heal
ACL deficiency lead to rotatory
instability and lead to functional
disability
Repetitive episode of instability may
result in meniscal tear , which can
result in arthritis
ACL tear without meniscal injury
results to degenerative changes.

Special Tests

Lachmans Test
Best acute ACL
test
Best on field test
(+) test is a
mushy or
empty end-feel
False (-) if tibia is
IR or femur is not
properly
stabilized

Anterior Drawer Test

(+) Test is increased
anterior tibial translation
over 6 mm
(+) test indicates:

ACL (anteromedial bundle)

posterior lateral capsule
posterior medial capsule
MCL (deep fibers)
ITB
Arcuate complex

False (-) if only ACL is torn

False (-) if there is swelling
or hamstring spasm
False (+) if there is a
posterior sag sign present

Slocums Test
Tests for multi-planar
instability
ALRI- Anterior lateral
rotary instability
(+) test indicates:
ACL, posterior lateral
capsule, arcuate
complex, LCL & PCL

AMRI- Anterior medial

rotary instability
(+) test indicates:
MCL (superficial),
posterior oblique,
posterior medial capsule,
ACL

Lateral Pivot Shift

Maneuver
Tests for ACL and
posterolateral rotary
instability
Posterolateral
capsule
Arcuate complex

(+) test is the tibia

reduces on the
femur at 30 to 40
degrees of flexion,
subluxation of the
tibia on extension

Diagnostic Imaging

Why perform an MRI after ACL injury?

Posterior cruciate ligament

instability
It is very strong ligament
Injury to PCL is thought to account
for 3 to 20% of all knee injuries.
Injury occurs due to athletic,
motorvehicle or industrial accidents

Pathomechanics
Common mechanism
Mechanism of most athletic PCL injuries is the
fall on the flexed knee with foot and ankle
plantar flexed.
eg. In motor vehicle accident, knee is flexed and
the tibia is forced posteriorly on impact with the
dashboard.
Less common mechanism
Injury by the downwardly directed force
appliedto the thigh while the knee is hyperflexed
eg. When landing from a jump

 Forced hyperflexion can also cause

injury of PCL.
Posteriorly directed force applied to
the anteromedial tibia with knee in
hyperextension may also cause injury
to posteriolateral corner
This results in lateral and posterior
lateral instability.
In varus and valgus stress injuries the
PCL ruptures after appropriate
collateral ligament.

Occurrence
70% PCL disruption occurs on the
tibial side
15% occurs at femoral side.
15% midsubstance tear
Associated injuries with PCL:12% of the chondral
27% of meniscal tear commonly
lateral compartment

Conditions
There is audible crack or pop at the
time of the time of initial injury.
There is mild moderate swelling
within the first 2 to 6 hours
But uplike ACL injuries these
indivdual may return to activity.

Grades
Grade 1(sprain): It involve microscopic tear of the
ligament which overall remains intact.
The ligament fibers are streched,
causing haemorrhage and microscopic
disruption of the structure within the
ligament.
There is no increased laxity compared
with the contralateral knee and the
end point is firm

 Grade 2(sprain): It is partial tear

The injury result in partial loss of
function as determined by a slight
increased in posterior translation
during posterior drawer test
But definite end point is noted
Reverse pivot shift test is nagative

 Grade 3(sprain): It is compete tear of the ligament

There is loss of ligament functioning and
loss of joint stability.
Positive posterior drawer test with 2+
to3+
Positive posterior sag
Godfrey sign
Positive reverse pivot shift test
Posterior tibial translation is excessive
and the endpoint is soft.

Post injury complication

Development of the degenerative
changes involving the medial and
anterior compartment in chronic PCLdeficient knee
PCL deficiency results in increased
medial compartment and
patellofemoral contact pressure that
can result in arthritis of knee.

Posterior Drawer Test

Tests for posterior
instability
Make sure that
there is no anterior
translation prior to
performing test
(+) Test indicates:
PCL
Arcuate Complex
Possibly ACL ???
Rubenstein, et al 1994 found posterior drawer test 90% sensitive for
PCL injury (versus 58% for Quadriceps Active Test & 26% for Reverse
Pivot Shift Test). Clinical exam on whole was 96% effective in
detecting PCL dysfunction

Posterior Drawer Test

Positive Posterior Drawer

Posterior Sag Test

Tests for posterior tibial
translation
Tibia drops back or
sags back on the femur
Medial tibial plateau
typically extends 1 cm
anteriorly
(+) test is when step
is lost
(+) Test indicates:
PCL
Arcuate complex
ACL????

Godfreys Test
Tests for
posterior cruciate
ligament damage
(+) test is a
posterior
displacement of
the tibial
tuberosity

Diagnostic Testing
Radiographs
MRI
96-100% accurate in
detecting PCL injury

Diagnostic Testing
Normal MRI

Torn PCL

Medial collateral ligament

instability
Most commonly injured ligament of
knee
Incidence of injury to the MCL is
lower than those of ACL

Pathomechanics
Common mechanism
The MCL is injured by a valgus stress to the
knee that exceeds the strength of the MCL
This most commonly occurs froma blow to
lateral aspect of knee during sporting
event
Uncommon mechanism
Non contact valgus injury the knee
Such as which occurs in skiing can produce
isolated tear to MCL

Occurrence
65% of MCL injury involve the femoral insertion site
25% involves tibial insertion
10% involve deep portion of the MCL at the level of
jointline
Conditions : The patient complain hit by another person on
lateral aspect and there is pain on the medial acpect
Swelling occurs quickly. There is ecchymosis in 1to3
days.
The walking of patient is with a limp and with the
knee partial flexed because extension streach the
ligament and cause pain.

Grades
Grade 1(sprain): It involves microscopic tear of the
ligament which overall remains intact
The ligamentous fibres are streched
causing hamorrage and microscopic
disruption
On examination no increase in laxity
compared with the contralateral knee
and the end point are firm

Grade 2(sprain):It is partial tear of ligament

The injury results in partial loss of functioning
A slight degree of increased joint opening with
valgus stress test (3 to 5mm) with knee 30
degree flexion
In full extension, the knee joint opens 2mm more
than contralateral knee
There is macroscopic and microscopic tearing ,
resulting in haemorrhage and stretching of the
ligament, but it is still in continuity and functions
to some degree
Tenderness on palpation.

 Grade 3(sprain): It is complete tear of ligament function

There is 5mm of joit space opening
compared with that of the non involved
knee with valgus stress testing in 30
degree flexion
More than 3mm of opening compared with
the non involve knee in full extension.
There no end point with stress testing
Severity of tenderness does not correlate
whith extent of the injury

Post injury complication

Proximal injuries involving the
femoral insertion tends to have a
higher incidence of stiffness

Valgus Stress Test

Assesses medial instability
Must be tested in 0 and 30
(+) Test in 0

MCL (superficial and deep)

Posterior oblique ligament
Posterior medial capsule
ACL/PCL

(+) Test in 30

MCL (superficial)
Posterior oblique ligament
PCL
Posterior medial capsule

Grading Sprains

McClure et al 1989 found poor intertester reliability on

valgus stress test at 0 and 30 degrees using 3 PT to evaluate

Lateral collateral ligament

instability
LCL injuries are uncommon
Incidence of 2% of injury of knee

Pathomechanics
Common mechanism
The injury occurs as a result of direct varus stress
to the knee, generally with the foot planted and
the knee in extension
The injury to LCL tends to occur as a result of non
sports high energy activities, because a direct blow
to the medial aspect of the knee is unusual
occurrence in sports.
Varus stress to the knee may also occur during the
stance phase of gait, with sudden imbalance and
shift of the center of gravity away from the side of
injury resulting in tension on the lateral structure.

 Less common causes

The less common causes of varus
stress to the knee is a sidewipe
injury, in which one knee has a
valgus stress and the other varus
stress

Occurrence

75% tear from fibular head

20% from the femoral side
5% midstance tear
Associated injury:Upto 24% paroneal nerve injuries occur because
the nerve is tethered as it courses around the
fibular head
These nerve palsies have a poor prognosis for
complete recovery
A severe varus stress results in an LCL disruption
followed by disruption of the posterolateral
capsule and PCL

Condition
There is pop sound in the knee and
lateral knee pain
LCL lesions do not commonly result
in an effusion of the knee.

Grades
Grade 1(sprain): Microscopic partial tearing of the
ligament but ligament overall remains
intact
The ligament fibers are streatched
causing haemorrhage and microscopic
disruption within the ligament
No increase laxity as compare to
contralateral knee, the end point is firm
There is tenderness along the ligament

 Grade 2(sprain): This is a partial tear, but the injury

results in partial loss, of function
There is slight increase in joint opening
Varus stress test shows (3 to 5mm) of
opening as compared to contralateral
knee in30 degree flexion
In full extension knee joint opens 2mm
more than contralateral knee
But it is still in continuity and functions
to some degree.

Grade 3(sprain):It is complete tear of the ligament

There is loss of ligament function
In varus stress test shows more than
5mm of joint space compared to
contralateral knee in full 30 degree
flexion
In full extension 3mm more than the
contralateral knee.

Varus Stress Test

Assesses lateral instability

Must be tested in 0 and
20/30 flexion
(+) Test in 0

LCL
Posterior Lateral Capsule
Arcuate Complex
PCL/ACL

(+) Test in 30
LCL
Posterior lateral capsule
Arcuate complex

Grading Sprains

Unhappy Triad
MCL, ACL, Medial
Meniscus
ODonahue

MCL, ACL, and Lateral

Meniscus
Shelbourne & Nitz 1991

Typically due to a
valgus force with the
foot planted

PFJ Biomechanics
During extension,
patella glides
cranially
During flexion,
patella glides
caudally
Patellar
compression
OKC greatest at end
range (final 30
degrees)
increases in CKC
after 30 degrees of
flexion

Patellofemoral Pain
Syndrome(CHONDROMALACIA
OF THE PATELLA; PATELLOFEMORAL
OVERLOAD SYNDROME))
General term to describe anterior
knee pain
Caused by a variety of factors:
Signs & Symptoms:

Poorly localized P!
Theater sign
Little to no swelling
Pt. Tenderness under lateral patella
Insidious onset

Apprehension Test
Tests for patellar
subluxation or
dislocation
(+) test is verbal
or facial
apprehension
from the athlete,
OR an attempt to
contract the
quadriceps to
avoid dislocation

Grind Test (Clarkes Test)

Tests for
patellofemoral
pain
(+) test is the
athlete
experiences
increased pain,
or cannot hold
the contraction

Chondromalacia of the patella There is no pathognomonic feature on

which to base the diagnosis of
chondromalacia, but several signs are suggestive. (a) Hold the patella
against the femoral condyles and ask the patient to
tighten the thigh muscles; even in normal people this may be uncomfortable,
but patients with chondromalacia experience
sudden acute pain in the patello-femoral joint. (b) A skyline x-ray with
the knee in partial flexion may show obvious tilting
of the patella. (c) In the lateral x-ray, with the knee flexed to 45, the
lengths of the patella and the patellar ligament are
normally about equal (a ratio of 1:1); in patella alta the ratio is less than 1:1.

Arthroscopy
Cartilage softening is common in asymptomatic knees, and painful
knees may show no abnormality.
However, arthroscopy is useful in excluding other causes of
anterior knee pain; it can also serve to gaugepatello-femoral
congruence, alignment and tracking
Differential diagnosis
Other causes of anterior knee pain must be excludedbefore finally
accepting the diagnosis of patellofemoral pain syndrome (see Table
20.1). Even then,the exact cause of the syndrome must be
establishedbefore treatment: e.g. is it abnormal posture,
overuse,patellar malalignment, subluxation or some abnormality in the
shape of the bones?

 Treatment
CONSERVATIVE MANAGEMENT
In the vast majority of cases the patient will be
helpedby adjustment of stressful activities and
physiotherapy,combined with reassurance that
most patients eventuallyrecover without
physiotherapy.
Exercises aredirected specifically at
strengthening the medialquadriceps so as to
counterbalance the tendency tolateral tilting or
subluxation of the patella.
Somepatients respond to simple measures
such as providingsupport for a valgus foot.
Aspirin does no more thanreduce pain, and
corticosteroid injections should beavoided.

 OPERATIVE TREATMENT
Surgery should be considered only if (1)
there is ademonstrable abnormality that is
correctable by operation,or (2)
conservative treatment has been tried for
at least 6 months and (3) the patient is
genuinely incapacitated.
Lateral release.
Proximal realignment.
Distal realignment.
Distal elevation of the patellar ligament.
Chondroplasty.
Patellectomy.

Plica Syndrome
An anomaly or fold in the
synovial membrane
Usually found along the
anterior, superior medial
border of the patella

Only becomes
symptomatic if inflamed
or taut
Signs & Symptoms:
Snapping, Clicking, or
jumping of the patella
during flexion
p! along medial border of
the patella
Swelling

Pathology
The plica in itself is not pathological.
But if acute trauma, repetitive strain
or some underlying disorder(e.g. a
meniscal tear) causes inflammation,
the plica may become oedematous,
thickened and eventually fibrosed; it
then acts as a tight bowstring
impinging on other structures in the
joint and causing further synovial
irritation.

Diagnosis
There is still controversy as to whether plica
syndrome constitutes a real and distinct clinical
entity. In some quarters, however, it is regarded
as a significant cause of anterior knee pain. It
may closely resemble other conditions such as
patellar overload or subluxation; indeed, the
plica may become troublesome only when those
other conditions are present.
The diagnosis is often not made until arthroscopy
is undertaken. The presence of a chondral lesion
on the femoral condyle secondary to plica
impingement confirms the diagnosis.

Hughstons Plica Test

Tests for medial plicas
(+) test is pain and/or popping of the
plical band under the clinicians
fingers on the medial aspect of the
knee

TREATMENT
The first line of treatment is rest,
anti-inflammatory drugs and
adjustment of activities.
If symptoms persist, the plica can be
divided or excised by arthroscopy.

Loose bodies,knee

Loose bodies are fragments of bone

and/or cartilage that freely float in the
joint space.
They may occur singly or in groups and
typically affect only one joint.
Loose bodies are classified as either
stable or unstable.
STABLE loose bodies are in a fixed
position and are generally well tolerated
by the individual.
UNSTABLE loose bodies are free to move
about the joint and cause symptoms.

Loose bodies are classified into

three types
Fibrinous, Cartilaginous, and
Osteocartilaginous.
Fibrinous loose bodies result from bleeding
within the joint or from the death of the
tissue lining of joints (synovial membrane)
associated with tuberculosis,
osteoarthritis, and rheumatoid arthritis.
. Cartilaginous loose bodies are fragments
of cartilage and are caused by injury (
trauma) to the joint and osteoarthritis.

 Osteocartilaginous loose bodies are

fragments of cartilage and bone
caused by fractures, bone and
cartilage inflammation (
osteochondritis dissecans),
osteoarthritis, and benign tumors of
the synovial membrane (synovial
chondromatosis). Cartilage is
nourished by the fluid within the joint
(synovial fluid) so loose bodies often
increase in size and become
smoother over time.

Clinical features
knee pain and swelling, with intermittent
locking or catching of the joint.
The locking disappears spontaneously, only
to recur.
Individuals may report hearing a grating
sound (crepitus) with joint movement.
They may also report that the joint
intermittently "gives way" or "goes out,"
causing them to fall.
Any history of osteoarthritis or injury should
be taken into consideration while making a
diagnosis.

 tenderness, soft tissue swelling, or a

grating sound in the affected joint.
There may be evidence of fluid
buildup (effusion) in the joint. Loose
bodies are rarely felt by touch
(palpation).

Loose bodies (a) This loose body slipped away from the
fingers when touched; the term joint mouse seems
appropriate. (b) Which is the loose body here? Not the large
one (which is a normal fabella), but the small lower one
opposite the joint line. (c) Multiple loose bodies are seen in
synovial chondromatosis, a rare disorder of cartilage
metaplasia
in the synovium.

Tests
Larger loose bodies are typically calcified and
thus easily visible on a plain film x-ray of the
affected joint.
Loose bodies that are small or contain little or
no bone may not be visible with an x-ray and
are typically diagnosed using either CT or
arthrography.
MRI may be useful in determining whether
associated bone changes have occurred.
Ultrasound scans may be performed to
determine the presence and location of loose
bodies.

Treatment
To encourage the best possible
management, whenever possible the
underlying cause of loose bodies should
be identified.
For small loose bodies, treatment may be
directed at relief of symptoms.
If pain and swelling are present,
analgesics or nonsteroidal antiinflammatory medications (NSAIDs) may
be prescribed.
In general, any loose body that is causing
symptoms should be removed.

 Large loose bodies may require removal by use of an

arthroscope (arthroscopy).
A small suction tip may be used to help draw out the
loose body, or it may be held in place by a small needle
and grasped with a special tool.
Some loose bodies may not be retrievable due to their
position in the joint space, and an instrument
(mechanical burr or resector) may be used to break the
loose body apart. Once it is in small pieces, it can be
easily reabsorbed through the body's normal means of
elimination (enzyme degradation).
Very large loose bodies and those located in the back of
the knee need to be removed by open surgery
(arthrotomy). Large osteocartilaginous loose bodies can
be realigned (reduced) and secured using pins or screws.
In some cases, such as synovial chondromatosis, part of
the synovium may be removed (partial synovectomy).

Rehabilitation

The focus of rehabilitation for loose bodies in the

knee is to control pain and restore function. The
rehabilitation program will depend on whether or not
the individual has had surgery or has plans for
surgery (Clarke).
The first goal is gait training with an assistive device
as needed for independent ambulation, with weight
bearing as indicated by the physician.
Initially, if pain and edema are a problem, modalities
such as heat and cold may be used (Braddom). After
the initial injury or postoperative period, common
clinical practice includes a heat treatment before
exercise (to relax the tissues around the knee) and a
cold treatment after exercise (to control the pain and
swelling).

 The next goal is to restore motion and strength to the

involved knee.
In a nonoperative knee, full range of motion may be difficult
to achieve, and the joint may lock intermittently throughout
the available range. Postoperatively, full range of motion
should be expected.
In both situations, exercise may be progressed based on the
recommendations of the physician.
Therapy should progress to strengthening exercises as
tolerated.
It may also be necessary to strengthen the adjacent joints.
Therapy should include flexibility exercises throughout the
period of strengthening. Although strong muscles around the
joint are critical, flexibility of the same muscle groups must
be considered. Generally, both open and closed kinetic chain
exercises are emphasized.
When full, pain-free motion is regained and the individual has
sufficient strength for all activities of daily living, therapy may
progress to balance and proprioceptive exercises.

 Prior to discharge from

physical therapy, individuals may
receive instruction emphasizing
strength and flexibility exercises and
joint-protective activities.
The desired degree of knee loading
must be considered prior to return to
work and leisure activities.
An ergonomic assessment may be
indicated for those individuals whose
job demands place the knees at risk for
injury.

Osteochondritis Dissecans of the Knee

Osteochondritis Dissecans, although an uncommon
injury, is one injury that can have long term effects on
the ability to participate in sports.
Defined as loss of adequate blood supply to the bone
and supporting cartilage resulting in possible fracture
or fissuring of the cartilage causing loose bodies and
cartilage fragments causing pain, swelling and locking.
The knee is the most commonly affected joint, but
Osteochondritis Dissecans (OD) can also occur in the
elbow, hip and ankle. The majority of the people
diagnosed with symptomatic OD are older children,
teenagers and young adults and particularly those who
participate in sports.

causes and signs and symptoms

OD is generally caused by the result of a direct trauma
to the knee or a series of repetitive stresses over time.
Typically the signs and symptoms include pain, joint
locking, and decreased range of motion, swelling and
tenderness, joint stiffness and giving way and loose
bodies in the joint.
Early diagnosis and treatment of Osteochondritis is
essential to minimizing the long-term affects. If caught
early enough, especially in young growing children the
condition will most likely heal itself.
However, if improperly diagnosed or missed the
condition can cause joint surface damage in older
teenagers and young adults, even with surgery.
OD can produce future disability including
degenerative arthritis and osteoarthritis.

Evaluation
Diagnosis begins with a proper
physical examination followed by XRays.
a bone scan or MRI to aid in the
diagnosis and to pinpoint the extent
of damage of the area affected.

Medical Management
By minor cases rest can prescribed.
The patient has to stop activities for
three to six months.
Stages three and four are always
treated surgically, and also when the
conservative treatment in stages one
and two was inadequate.

Surgical techniques
In stages one and two the articular cartilage is
still intact, through retrograde operation trying
to tap into to the affected bone from behind
and clear it. The advantage of this surgical
technique is that the articular cartilage stays
intact .
Not yet dissected fragment will be fixed by
means of an operation .
Repair of blood supply by drilling arthroscopic
through the cartilage and the hearth of
osteochondrosis into the healthy bones ,
Stabilization of the fragment through pinning or
through screw fixation

 Osteochondral autograft
transplantation (OATS).
Osteochondral allograft
transplantation.
Autologous chondrocyte implantation
(ACI)

Physical Therapy Management

In stages one and two the condition is localized in the
subchondral bone, the cartilage is still intact and gets
its nourishment from synovial fluid. In these two stages
conservative therapy can be applied [2].
The goals of the conservative therapy are: pain
reduction, repair the continuity of the surface of the
cartilage and to prevent degeneration of the surface of
the knee joint.
Adaption of the strain is needed so the bone can heal.
2 weeks of immobilization and partly support is
recommend by an acute injury.
Long-term immobilization has to be prevented,
because joint motion is necessary for the nutrition and
strengthening of the cartilage. Sport activities should
be stopped temporally

 First exercises: closed chain exercises, low impact

activities like cycle and swimming.
straight leg raises and ankle tubing exercises,
strength can be maintained.
Coactivation or setting of the quadriceps and
hamstring can be performed while in an immobilizer
or cast.
Using neuromuscular electrical stimulation to the
quadriceps and hamstrings for coactivation
contractions can further augment the strength
maintenance program.
Following immobilization should be continued, range
of motion exercises, as well as progressive quadriceps
and hamstring strengthening should be performed.
Weight-bearing progression throughout rehabilitation
should be to patient tolerance.

 In facilitating the return to full-weight-bearing status is

aquatic therapy very beneficial.
To adress any gait deviations that developed during the
immobilization and decreased weight-bearing phases of
rehabilitation gait training techniques may be used, such as
manual facilitation and visual feedback tot the patient via a
full length mirror.
Additional exercises to restore ankle joint and normal knee
proprioception, such as biomechanical ankle platform
systems (BAPS board) exercises or unilateral stance, are also
beneficial to the athlete planning to return to competition.
After this period the sport activities can be partly restart.
An operative treatment is indicated if, after the treatment no
recovery has occurred .
After surgery conservative therapy is recommend.
Continuous passive motion is used very early after surgery.
Immediate weight-bearing restrictions for up to 6 weeks for
minor lesions

Osteochondritis dissecans imaging The lesion

is often missed in the standard anteroposterior x-ray and is
better seen in the tunnel view, usually along the lateral
side of the medial femoral condyle (a). Here the
osteochondral fragment has remained in place but
sometimes it appears as a separate body elsewhere in the
joint. (b) MRI provides confirmatory evidence and
shows a
much wider area of involvement than is apparent in the

Osteochondritis dissecans Intraoperative pictures showing

the articular lesion (a) and the defect left after removal
of the osteochondral fragment (b).

Blounts disease
This is a progressive bow-leg deformity associated
with abnormal growth of the postero -medial part
of the proximal tibia.
The children are usually overweight and start
walking early; the condition is bilateral in 80 per
cent of cases.
Children of negroid descent appear to be affected
more frequently than others.
Deformity is noticeably worse than in
physiological bow legs and may include internal
rotation of the tibia.
The child walks with an outward thrust of the
knee; in the worst cases there may be lateral
subluxation of the tibia.

INVESTIGATION(X-ray)
The proximal tibial epiphysis is flattened medially
and the adjacent metaphysis is beak-shaped.
The medial cortex of the proximal tibia appears
thickened; this is an illusory effect produced by
internal rotation of the tibia.
The tibial epiphysis sometimes looks
fragmented; occasionally the femoral epiphysis
also is affected.
In the late stages a bony bar forms across the
medial half of the tibial physis, preventing further
growth on that side. The degree of proximal tibia
vara can be quantified by measuring the
metaphyseo-diaphyseal angle

Treatment
Spontaneous resolution is rare and, once itis clear that the
deformity is progressing, a corrective osteotomy should be
performed, addressing both the varus and the rotational
components.
A preoperative(or peroperative) arthrogram, to outline the
misshapen epiphysis, will help in planning the operation.
Slight over-correction should be aimed for as some recurrence
is inevitable.
In severe cases it may be necessary also to elevate the
depressed medial tibial plateau using a wedge of bone taken
from the femur.
If a bony bar has formed, it can be excised and replaced by a
free fat graft. In older children it may be easier to perform a
surgical correction and then (if necessary) lengthen the tibia
by the Ilizarov method.
All these procedures should be accompanied by fasciotomy to
reduce the risk of a postoperative compartment syndrome.

SYNOVIAL
CHONDROMATOSIS
This is a rare disorder in which the joint comes to

contain multiple loose bodies, often in pearly

clumps resembling sago (snowstorm knee).
The usual explanation isthat myriad tiny fronds
undergo cartilage metaplasia at their tips; these
tips break free and may ossify.
It has ,however, been suggested that
chondrocytes may be cultured in the synovial fluid
and that some of the products are then deposited
onto previously normal synovium, so producing
the familiar appearance (Kay et al., 1989).
X-rays reveal multiple loose bodies; on
arthrographythey show as negative defects.

Treatment
The loose bodies should be removed
arthroscopically. At the same time an
attempt shouldbe made to remove
all abnormal synovium.

DISLOCATION OF PATELLA
if the intercondylar groove is unusually shallow, or the
patella seated higher than usual, or the ligaments are
abnormally lax, dislocation is not that difficult.
Mechanism of injury:
While the knee is flexed and the quadriceps muscle
relaxed, the patella may be forced laterally by direct
violence; this is rare. More often traumatic dislocation
is due to indirect force: sudden, severe contraction of
the quadriceps muscle while the knee is stretched in
valgus and external rotation.
Typically this occurs in field sports when a runner
dodges to one side.
The patella dislocates laterally and the medial
patellofemoral ligamentand retinacular fibres may be
torn.

 In a first-time dislocation the patient may experience a tearing

sensation and a feeling that the knee has goneout of joint; when
running, he or she may collapse and fall to the ground. Often the
patella springs back into position spontaneously; however, if it
remains unreduced
there is an obvious (if somewhat misleading)deformity: the
displaced patella, seated on the lateral side of the knee, is not
easily noticed but the uncovered
medial femoral condyle is unduly prominent and maybe mistaken
for the patella.
Neither active nor passive movement is possible (Fig. 30.16). In
the rare intraarticular(downward) dislocation the patella is stuck
between the condyles and there is a marked prominence on the
front of the knee.
If the dislocation has reduced spontaneously, the knee may be
swollen and there may be bruising and tenderness on the medial
side.
If there is fluid in the joint, aspiration may show that it is blood
stained; the presence of fat droplets suggests a concurrent

DIAGNOSIS
Anteroposterior, lateral and tangential
(skyline)x-ray views are needed.
In an unreduced dislocation,the patella is
seen to be laterally displaced and tilted or
rotated. In 5 per cent of cases there is an
associated osteochondral fracture
MRI may reveal a soft-tissue lesion (e.g.
disruptionof the medial patellofemoral
ligament) as well as articularcartilage
and/or bone damage.

Dislocation of the patella (a)

The right patella has dislocated laterally;
the flattened appearance is typical.
(b,c) Anteroposterior and lateral films of
traumatic dislocation of the patella.

TREATMENT
In most cases the patella can be pushed back into place
without much difficulty and anaesthesia is not always
necessary; the exception is an intra-articular
(intercondylar) dislocation, which may need open
reduction.
If there are no signs of soft tissue rupture i.e.
there is minimal swelling, no bruising and little tenderness
cast splintage alone will usually suffice.
The knee is aspirated and then immobilized in almost full
extension; a small pad along the lateral edge of the patella
may help to keep the medial soft tissues relaxed.
The cast is retained for 2 or 3 weeks and the patient then
undergoes a long period (23 months) of quadriceps
strengthening exercises.

 However, if there is much bruising,

swelling and tenderness medially,
the patellofemoral ligaments and
retinacular tissues are probably torn
and immediate operative repair will
reduce the likelihood of later
recurrent dislocation.

OPERATIVE TREATMENT
The area is approached through a medial incision. If
the patellofemoral ligament is avulsed from the
femur,it is reattached with suitable anchors.
Mid-substance tears of the ligaments are sutured
directly. At the same time, if the lateral retinaculum is
tight it is released.
Osteochondral fragments are removed unless they
are single, large and amenable to reattachment.
Postoperatively a padded cylinder cast is applied with
the knee in extension; this can be renewed when the
swelling has subsided.
A hinged brace is substituted,which provides control
for weight bearing and allows knee movement.
Quadriceps exercises are encouraged

Osgood-Schlatter
Disease
Osgood-Schlatter disease used to be considered a

form of osteochondritis associated with a partial

avulsion of the patellar tendon at its insertion into
the tibial tubercle before this apophysis unites.
Almost all patients 'with this condition have some
mechanical inefficiency of the extensor mechanism.
In fact, it is now thought that this is not really a
"disease," but a form of tendinitis of the knee
tendon.
In young athletes, the tendon is attached to
prebone, which is weaker than normal adult bone.
With excessive stresses on the tendon from running
and jumping, the structure becomes irritated and a
tendinitis begins.

Objective findings include:

A tender swelling over the tibial
tubercle
Pain is reproduced on resisting
quadriceps extension;squatting may
also reproduce the pain.
Decreased flexibility. Most patients
have significant restriction in the
hamstrings, triceps surae, and
quadriceps muscles.

TREATMENT
The mechanical inefficiencies of the extensor
mechanism should be treated by appropriate
rehabilitative exercises.
Inflexibility should be addressed throughstretching
and ankle dorsiflexion .
strengthening if weakness is found .
This condition usually resolves without any
significant additional treatment.
Complete immobilization is neither necessary nor
practical.
A simple patellar support, such as a Neoprene
rubber, knee sleeve, may help.

THANX..
THANX