KNEE JOINT COMPLEX

BY: Dr. Sana Saifi, MPT (Sports)

Former senior sports Physio at Sporting ethos pvt ltd
 INTRODUCTION
• The joint is made up of bones femur, tibia, patella and fibula as well
as the ligaments, tendons, muscles, bursa and joint [Link] is a
type of modified hinge joint as with flexion and extension it also
offers some lateral and medial rotation. The stability of the joint is
through its bony configuration and its ligaments.
• Modified hinge joint/ Double condyloid joint
• It is consist of:
• Joints: medial and lateral tibio-femoral and the patellofemoral joints
• Articular cartilage: underlies the femur, tibia and patella to provide a smooth
movement by preventing the direct contact between the bones
• Menisci: medial and lateral fibrocartilagenous structures over the tibial condyles
that absorbs shock, increase the contact area and thus reducing the contact
pressure and distribute the load.
• Ligaments:
• Anterior and posterior cruciate ligament
• Medial and lateral collateral ligament
• Medial and lateral patellofemoral ligaments
• Transverse ligament and coronary ligaments
• Anterolateral ligament (ALL)
• Wrisberg ligament
• Muscles: quadriceps, hamstrings, TFL, IT band, gastrocnemius attaches directly
around the joint and provides the dynamic stability.
•
POPLITEAL FOSSA

SAVNB (Serve And Volley Next Ball) to remember the popliteal fossa anatomy medial-
to-lateral in arrangement. Semimembranosus, Artery, Vein, Nerve, Biceps femoris
Knee locking mechanism:
• During end 15-30 degrees of extension
• Medial rotation of the femur on tibia
• Helped by Vastus medialis
Unlocking:
• During beginning of flexion
• Lateral femoral rotation of femur on tibia
• Helped by popliteus
 Ligaments and their injuries
Ligaments Function MOI Special tests
ACL Prevents anterior tibial Pivoting Anterior drawer
translation landing from a jump Lachman
decelerating Pivot shift
suddenly
twisting force
on a semi-flexed
knee
PCL Prevents posterior tibial Backward force on Posterior drawer
translation tibia
MCL Prevents valgus stress Valgus force Valgus stress test at 30 degrees
of knee flexion

LCL Prevents varus stress Varus force Varus test at 30 degrees of knee
flexion
Mneumonic: LAMP lateral condyle to ACL and Medial condyle
to PCL
Early phase of post ACLR rehab, focuses on:
1- Flexion
2- Gait training
3- Extension
4- immobilization
Females are more prone to get ligament injuries:
Intrinsic Factors Extrinsic Factors
Intercondylar notch size: smaller in females Kinematics
ACL size: smaller due to smaller notch size Kinetics
Wider pelvis Muscle strength
Greater Q angle Muscle endurance
Physiologic laxity (generalized joint and ligamentous laxity) Muscle activation
Hormonal fluctuations: increased estrogen levels during the
ovulatory and luteal phases of the menstrual cycle may increase
ACL laxity.
• OKC V/S CKC
OKC exercises beyond 60 degrees of knee flexion produces less
detrimental forces on the new graft whereas CKC exercises in less than 30
degrees of knee flexion produces least affects on new graft.
Return to sports test after ACLR:
1- Lachman test
2- Anterior drawer test
3- Pivot shift
4- triple hop test
MEDIAL COLLATERAL LIGAMENT
• Grade I injury: no increase in medial joint line opening compared to
the opposite knee at 30 degrees of knee flexion and tenderness along
the ligament
• Grade II injury: more generalized tenderness with 5 to 10 mm of joint
line opening on examination but a moderately firm endpoint
• Grade III injury: complete disruption of the ligament

• To assess the integrity of the MCL and posteromedial capsule, valgus

stress testing is done with the knee in full extension. Increased laxity
with the knee in full extension suggests a severe injury of the MCL
and the posteromedial capsule and a possible injury to one or both of
the cruciate ligament
 MENISCI
Menisci (medial and lateral) performs the following functions:
- Protects the underlying articular cartilage
- Work as shock absorber
- Increases the contact area between femur and tibia
The medial meniscus and the posterior horn of the meniscus has less
mobility than lateral meniscus and anterior horn and that is why in most
sporting activities posterior horn of medial meniscus gets injured
(PHMM).
 Blood supply to the menisci
Arnoczk and Warren, in 1982 explained the microvasculature of the
menisci. In adults, the vessels provides blood to only the outer 6 mm or
about an outer third of the width of the meniscus. In this highly
vascularised region healing of a meniscal tear is greatest. This healing
impairs as the tear progresses deep from the periphery. Healing is also
influenced by the pattern and type of the tear as longitudinal tears have
more potential of healing compared with radial tears. Simple tear
patterns heals than complex tears similar Traumatic tears have higher
healing rates than degenerative tears and acute tears heals better than
chronic tears
TEARS
ROM of the knee before 60 degrees of flexion has little effect on meniscal
displacement, but flexion angles greater than 60 degrees translate the
menisci posteriorly. This increased translation may place detrimental
stresses across a healing meniscus
Repair Menisectomy
-when the patient is young In Degenerative tears
-In longitudinal tears in the Tears with Flap.
peripheral zone of meniscus horizontal cleavages in the
because of its high meniscus
vascularisation complex meniscal tears
-when knee is stable
Dropback sign is seen in:
1- ACL
2- PCL
3-MCL
4-LCL
Posterior sag sign is for:
• 1- ACL
• 2-MCL
• 3-PCL
• 4-LCL

Dashboard injury is the injury to the:

• 1-ACL
• 2-PCL
• 3-MCL
• 4-LCL

In early phases of rehabilitation, the main focus is to:

• 1- Restore quads strength
• 2- protect the healing graft
• 3- restoration of ROM
• 4- Restoration of gait
-- The PCL is often referred to as the "dashboard injury" because it can
be injured in:
• A. Car accidents
• B. High-impact sports
• C. Tripping and falling
• D. All of the above
--What type of bracing or support is often used to provide stability to
the knee during PCL rehabilitation?
• A. Knee immobilizer
• B. Patellar tendon strap
• C. Functional knee brace
• D. Wrist splint
-- The PCL is often referred to as the "dashboard injury" because it can
be injured in:
• A. Car accidents
• B. High-impact sports
• C. Tripping and falling
• D. All of the above
--What type of bracing or support is often used to provide stability to
the knee during PCL rehabilitation?
• A. Knee immobilizer
• B. Patellar tendon strap
• C. Functional knee brace
• D. Wrist splint
 Patellar related injuries
• Patellar dislocation:
• Patella is displaced laterally in patellar dislocation. It can be acute or traumatic and
atruamatic as often seen in young girls with hyper ligamentous laxity.
• Primary stability of the patella is by medial patellofemoral ligament (MPFL) which provides
stability around 53% to 67% and by structures like medial and lateral retinaculars and
hence during lateral displacement, the MPFL ligament gets sprained, torn easily.
• This injury could also results in osteochondral avulsion fracture that always should be
treated with surgery.

Factors predispose to the dislocation of the patella are:

• Femoral anteversion
• Shallow femoral groove (trochlea dysplasia)
• Genu valgus
• Loose or weak medial retinaculum
• Tight lateral retinaculum
• Vastus medialis dysplasia
• Increased quadriceps vector (O angle)
• Patella alta
• Excessive Subtalar pronation
• Patellar dysplasia
• General Hypermobility
• PATELLAR DISLOCATION: which is the most common dislocation in patella?

• -how to differentiate acute patellar disclocation from ACL tear?

• 1- Hemarthrosis
• 2-pain in walking
• 3- positive stroke test
• 4- positive apprehension test

• Lateral side pain: IT band

• Retropatellar pain: PFPS
• Inferior patellar pain: Patellar tendinopathy/ fat pad impingement
• b/l anterior pain: PFPS / Patellar tendinopathy
Following are present as intrinsic factors contributing to PF pain,
except:
1 increased femoral internal rotation
2 increased apparent knee valgus
3 increased tibial rotation
4 pronated foot type
5 increase laxity
PATELLOFEMORAL PAIN SYNDROME
• Pain in and around the patella is termed as patellofemoral pain
syndrome. It starts often because of the abnormal loading on the PFJ.
Supraphysiological loads either one episode of the load with maximal
loading or small magnitude of repetitive load on the patella can cause
this abnormal loading.
• ELPS and GPPS
Extrinsic factors Intrinsic factors Work load
GRF Increased femoral internal Type of load
Body mass rotation Frequency of loading
Speed of gait Increased apparent knee Intensity of loading
Surfaces valgus
Foot wears Increased tibial rotation
Pronated foot type
Inadequate flexibility.
NERVE SUPPLY
 OA Knee
• Not an inflammatory disorder but the disease of wear and tear of hyaline
cartilage followed by the reactive bone formation in the for of osteophytes.
• Also called as osteoarthosis
• Clinical features:
- old age
-weight bearing joint
-mechanical pain
Medial joint tenderness
-crepitus
-painful restricted ROM
Miscellaneous conditions in knee joint:
Jumpers knee: overuse injury of the patella
Osgood schatter disease: Osgood-Schlatter lesion is an osteochondrosis
Sinding-Larsen-Johansson syndrome
GPPS and ELPS
Hoffa’s disease: inflammation in the fat pad
Bassett Sign: to check patellar tendinitis: tenderness at 0 degrees and
resolution of tenderness at 90 degrees
Housemaid knee: prepatellar bursistis
Bakers cyst
 THANKYOU

BY: Dr. Sana Saifi, MPT (sports)

Clinical sports physio
Former Senior sports Physiotherapist at Sporting Ethos pvt ltd
Expert in ligament injuries and post surgical rehabilitation
Contact at: sanasaifi14@[Link]
9582933992