AFFECTIONS OF THE

KNEE

Ma. Corazon D. Acosta, MD, FPARM

 Anatomy
 Largest joint in the
body
 Enveloped by an
extensive capsule
 Consists of 3 “joints”
 Tibiofemoral
 Patellofemoral
 tibiofibular
Normal Knee
X-ray of Normal Knee
 Cruciate Ligaments
 Primary static restraint to tibiofemoral
translation
 Described by its attachment to the tibial
plateau
 Anterior Cruciate Ligament (ACL)
 Posterior Cruciate Ligament (PCL)
Cruciate Ligaments
 Anterior Cruciate Ligament (ACL)
 Arises lateral and anterior to the tibial
spine
 Fascicles fan out to form a broad-based
attachment to the posteromedial aspect of
the lateral femoral condyle
 Prevents forward translation of the tibia
relative to the femur
Posterior Cruciate Ligament (PCL)
 Arises between the posterior junction of
the tibial condyles and attaches to the
lateral aspect of the medial femoral
condyle
 Prevents backward translation of the tibia
relative to the femur
Cruciate Ligaments
ACL
 Menisci (Semilunar cartilages)
 Cartilaginous structures which assist the
motion of the femoral condyles at the
tibiofemoral joint
 Deepen the articular surfaces
 Provide a thin layer of lubrication
 Assist in shock absorption
 Limit extremes of flexion and extension
Meniscus
 Medial Meniscus
 Firmly attached to the medial collateral
ligament and the synovial capsule
 Less mobile than lateral meniscus
 Vascular on the peripheral 1/3
 Central portion is avascular
 More prone to injury
 Collateral Ligaments
 Medial (tibial) and lateral (fibular)
 Control varus and valgus moments at the
knee
 Help limit rotation of the tibia
 Medial collateral ligament is attached to
the meniscal periphery
Collateral Ligaments
 ACL tear
 Traumatic rupture
(complete or partial)
 Hyperextension or
rotational strain
 “popping” or audible
snap
 hemarthrosis
ACL Tear
Mechanism of ACL injury
ACL Tear
ACL Tear
 ACL Tear
 Physical Examination
 Palpate for effusion and tenderness
 Evaluate ROM
 Lachman’s maneuver
 Anterior Drawer Test

 Imaging
 MRI
 Arthroscopy
Special Tests
 Treatment of ACL Tear
 Initial treatment include RICE,
immobilization and NSAIDs
 Aggressive reduction of joint swelling
 Cryocuff compression
 Aspiration of hemarthrosis

 Physical therapy and bracing

 Surgical reconstruction
 PCL Tear
 Less common than ACL tears
 Due to direct trauma forcing the tibia
posteriorly, a fall on the flexed knee or
knee hyperflexion
 Less pain, restriction of motion and
hemarthrosis than ACL tear
ACL Repair
ACL Repair
ACL Repair
PCL Tear
 PCL Tear
 Physical Examination
 Reverse Lachman’s test
 Positive sag sign
 Posterior drawer sign

 Imaging studies
 X-ray (to rule out bony avulsion)
 MRI
 Treatment of PCL tears
 Reduce effusion and regain ROM
 Non-operative
 Aggressive rehabilitation
 CKC strengthening of the quadriceps,
hamstrings and hip muscles
Lachman’s Test
 Meniscal Injuries
 Athletic or occupational injury
 May be isolated or in association with a
MCL or ACL tear
 Associated with twisting movement of the
tibia on the femur in a partially flexed knee
 Medial meniscus > lateral meniscus
 Bucket-handle tear most common type
Meniscus Tear
 Meniscus Injury
 Types
 Bucket-handle type
 Tear of the middle third
 Tear of anterior tip
 Longitudinal splitting of anterior third
 Tear of posterior third
 Meniscus Injury
 Clinical Picture
 Acute pain on the inner or outer side of the
knee
 Effusion within 24 – 48 hours
 Sensation of giving way or mechanical locking
 Tenderness on palpation of the joint line
 Locking or unlocking
 Meniscus Injury
 Special Tests
 McMurray Test
 Apley’s compression test

 Diagnostic tests
 MRI
 arthroscopy
McMurray Test
 Treatment of Meniscus Injury
 If locking and/or instability is absent:
 RICE
 Short course of NSAIDs
 Immobilization in extension
 Patella-setting exercise, hamstring and ITB
stretching
 Gradual return to activity
 Treatment of Meniscus Injury
 Recurrent catching, popping or effusion
may need surgical debridement, repair or
excision of the torn portion.
 Arthroscopy
 Open arthrotomy

 Physical therapy
 Quads and hamstring strengthening
 Mobility training
Arthroscopy
Arthroscopy
 Degenerative Meniscal Tears
 Occur in 50% of population above 65
 Horizontal cleavage tears
 Part of aging
 Treated conservatively
 Limited excision of the torn portion may be
done
 Discoid Meniscus
 Uncommon developmental anomaly
 Mostly involving the lateral meniscus
 Presents as loud clicking on joint
movement
 No locking
 Widening of the cartilage space between
the lateral condyle and the tibia
 Treated by excision
Discoid Meniscus
 Ligamentous Injuries
 Due to valgus or varus stresses applied to
the knee
 Medial collateral ligament more commonly
injured than the lateral collateral ligament
 May be isolated or may occur with injuries
to other ligaments
Collateral Ligament Injuries
Medial Collateral Ligament Injuries
 Etiology
 Direct trauma
 overuse

 Clinical Picture
 Pain and rapid swelling
 Tenderness on the medial side
 (+) valgus stress test
 Grading of MCL Injuries and
Treatment
 Grade I (Mild)
 Ice packs, NSAIDs
 Locked brace Hinge brace
 Strengthening and flexibility program
 Grade II (Moderate)
 Characterized by inability to extend the knee because
of pain and inflammation
 Rupture of the extracapsular fibers of the MCL
 Mild to moderate valgus instability
 Grading of MCL Injuries and
Treatment
 Grade II
 (+) swelling and hemorrhage
 Initial treatment include icing and compression
 Knee orthosis that restricts last 20 – 30o of extension
during the 1st week
 Early mobilization within pain-free limits
 FWB in brace with full flexion/extension after 4 weeks
 Strengthening of hip girdle muscles and knee
stabilizers
 Grading of MCL Injuries and
Treatment
 Grades III (Severe) Injury
 Instability to valgus stress in both flexion and
extension
 Hemarthrosis within a few hours
 Treated surgically if associated with meniscal
or cruciate tears
Medial Collateral Ligament Tear
And ACL Tear
 Ossification of the Tibial Collateral
Ligament (Pellegrini-Stieda Disease)

 Men between 25 – 40 years of age

 New bone usually overlie the medial
femoral condyle and the tibial collateral
ligament
 May be caused by trauma
 Ossification of the Tibial Collateral
Ligament (Pellegrini-Stieda Disease)

 Clinical Picture
 Tenderness over the medial aspect of the
knee after trauma
 Pain on extremes of flexion and extension
 Knee usually held in slight flexion
 Slight swelling of the knee
 Ossification of the Tibial Collateral
Ligament (Pellegrini-Stieda Disease)
 Prognosis and
treatment
 Symptoms subside
spontaneously
 Rest and support
during acute stage
 Osgood – Schlatter Disease
 Minimal partial separation of the
tonguelike epiphysis of the tibial tuberosity
 Common in boys 10 – 14 years of age
 Frequently bilateral
 May be caused by continued or sudden
strain applied by the patellar tendon
Osgood – Schlatter Disease
 Osgood – Schlatter Disease
 Clinical Picture
 Pain
 Enlargement of the tibial tuberosity
 Tenderness

 X-ray
 Slight separation of the epiphysis(early stage)
 Fragmentation of the epiphysis (Later stage)
Osgood-Schlatter Disease
 Osgood-Schlatter Disease
 Treatment
 Mild – restriction of activities
 Use brace to restrict flexion
 Severe – cast immobilization in extension
 Avoid full flexion for several months
 surgery
 Genu Varum
 Bowleg
 Normal in infancy up to 2 years of age
 May be caused by rickets or Blount’s
disease
 OA is most common cause of
bowleggedness in adults
Genu Varum
 Blount’s Disease
 Also known as tibia vara
 Results from retardation of the growth on
the medial side of the proximal tibial
epiphyseal plate
 Onset between 1 – 3 years
 Bilateral > unilateral
Blount’s Disease
Blount’s Disease
Blount’s Disease
 Blount’s Disease
 Treatment
 Osteotomy of the tibia and fibula
 Advisable to do surgery early (before 8 years)
for better maintenance of reduction
 If done later than 8 years of age, frequently
followed by recurrent deformity
 Recurrent Patellar Dislocation
 Common in young women
 Usually unilateral
 Associated factors:
 Fibrous attachment of the vastus lateralis
 External tibial torsion
 Shallow patellar groove
 Joint laxity
 Recurrent Patellar Dislocation
 Associated factors:
 Hypoplasia of the lateral femoral condyle
 Underdevelopment of the patella
 Patella alta
 Genu valgum
 Recurrent Patellar Dislocation
 Clinical Picture
 Lateral displacement of the patella
 (+) sharp pain
 Sense of instability
 Mild to moderate effusion
 Knee weakness
 Recurrent Patellar Dislocation
 Physical Findings:
 Abnormal patellar tracking
 Abnormally high patella
 Abnormal patellar mobility
 (+) apprehension test
 Incrased “Q” angle
Recurrent Patellar Dislocation
Recurrent Patellar Dislocation
Recurrent Patellar Dislocation
 Recurrent Patellar Dislocation
 Treatment
 Strengthening of the vastus medialis
 Brace
 Surgery
 Release of the quadriceps retinaculum
 Tightening of the medial capsule
 Osteotomy to correct genu valgum
Recurrent Patellar Subluxation
 Chondromalacia Patella
 Common degenerative process of unknow
etiology
 Degenerative changes in the undersurface
of the patella
 Common in young adults, especially
women
 Chondromalacia Patella
 Pathology
 Fibrillation and fissuring
 Erosion
 Clinical Picture
 (+) Hx of trauma followed by temporary
disability and relief
 Pain on climbing and descending stairs
 Tenderness
 Subpatellar crepitation
 Chondromalacia Patella
 Treatment
 Mild cases – rest and heat with bracing
 Quadriceps strengthening with knee extended
 For persistent cases – arthroscopic shaving of
fibrillated cartilage or drilling of subchondral
bone
 Release of lateral retinaculum
Patellar Tendinitis (Jumper’s knee)
 Common affection of athletes
 Pain and tenderness over the patellar
tendon
 Pain on forceful extension of the knee
 Treated by rest and restriction of forxeful
knee extension
Patellar Tendinitis (Jumper’s knee)
 Bursae Around the Knee Joint
 Clinical significance:
 Prepatellar
 Deep infrapatellar
 Superficial pretibial
 popliteal
Bursitis
 Prepatellar Bursa
 Lies anterior to the lower half of the
patellar ligament
 Acute bursitis may be caused by puncture
wounds
 Chronic bursitis occurs from prolonged
kneeling (housemaid’s knee or nun’s knee)
Prepatellar Bursitis
 Deep Infrapatellar Bursa
 Between the lower
portion of the patellar
ligament and the tibia
 (+) pain and limitation
on active knee flexion
and extension
 Superficial Pretibial Bursa
 Overlies the insertion
of the patellar
ligament into the tibial
tuberosity
 Popliteal Bursa
 Gastrocnemiosemime
branosus bursa
 Baker’s cyst
Baker’s Cyst
Baker’s Cyst
 Bursitis
 Treatment
 Rest and application of heat
 If pyogenic, aspiration and antibiotics may be
needed
 If chronic, bursa may be excised