Evaluation of Knee Injuries

Dr. Alan A. Zakaria, D.O., M.S. 1080 Kirts Blvd., Suite 400 Troy, Mi., 48084 Team Physician United States Soccer Federation University of Michigan Men’s and Women’s Soccer Objective

Identify main anatomic components of the knee Perform basic knee exam along with special tests Identify common knee injury patterns and their physical exam findings. Anatomy

➢ Bony Anatomy ➢ Ligaments ➢ Cartilage ➢ Musculature ➢ Other Soft Tissue Knee Anatomy

Two functional joints – Femorotibial – Femoropatellar Femoral condyles – Flex/extend Knee Anatomy

Patella – Sesamoid with two concave surfaces and vertical ridge – Increases efficiency of extension Knee Anatomy: Anterior Cruciate Ligament (ACL)

Run inferior, anterior, and medially Arises from medial aspect lateral femoral condyle Insert lateral to medial tibial eminence Restrains anterior subluxation of tibia on femur Knee Anatomy: Posterior Cruciate Ligament (PCL) Arises from the posterior intercondylar area of the tibia Inserts at the medial condyle of the femur Restrains posterior subluxation of the tibia on the femur Knee Anatomy: Medial Collateral Ligament (MCL) Postero-superior medial femoral condyle to proximal end of tibia Maximum tension at full extension Restraint to valgus stress Knee Anatomy: Lateral Collateral Ligament (LCL) Posterosuperior lateral femoral condyle to lateral head of fibula Restraint to varus stress Knee Anatomy: Meniscus

Load bearing, joint stability, shock absorption Peripheral third vascularized Knee Anatomy: Articular Cartilage Hyaline cartilage that covers the femoral condyles, tibial plateau, and undersurface of the patella Shock absorbing structure that can withstand compression, tension, and shearing forces and dissipate load Knee Anatomy: Muscles

Quadriceps

Hamstrings

Iliotibial tract

Pes Anserine

Knee Anatomy: Pes Anserine

Composed of the conjoined tendons of the semitendinosus, gracilis, and sartorius muscles Inserts onto the anteromedial proximal tibial bone Knee Anatomy: Patellar and Pes Anserine Bursa Synovial fluid-filled sacs that provide a cushion between bones and tendons and/or muscles around a joint Prepatellar bursa located superior to the patella Patient History.

➢ Nature of symptoms ➢ Age ➢ Location ➢ Occupation or ➢ Timing/Duration recreational activities ➢ Quality and Quantity ➢ Clicking or popping ➢ Trauma or preceding ➢ Locking or catching event ➢ Giving Way ➢ Exacerbating or ➢ Swelling relieving factors ➢ Past History Physical Exam

➢ Observation ➢ Range of Motion ➢ Palpation ➢ Strength Testing ➢ Special Testing Observation

Anterior view standing ➢ Genu valgum/varum, patella position, foot architecture

Posterior view standing ➢ Genu valgum/varum, foot architecture

Anterior and lateral views sitting ➢ Patella position/tracking, osgood schlatter’s changes

Gait ➢ General changes, motion of patella, foot architecture

Palpation

Anterior with knee extended Medial ➢ Swelling or effusion ➢ Medial meniscus ➢ Prepatellar bursa, patellar ➢ Medial collateral ligament tendon, plica ➢ Pes Anserine ➢ Quad and tendon ➢ Pes Anserine Posterior ➢ Hamstrings Lateral ➢ Gastrocnemius ➢ Lateral meniscus ➢ Popliteal fossa ➢ LCL ➢ Baker’s Cyst ➢ IT Band Range of Motion

➢ Flexion – 135 -140 degrees

➢ Extension – 0 degrees Strength Testing (5 point scale)

Flexion ➢ Hamstring ➢ Gracilis, sartorius ➢ Popliteus ➢ Gastrocnemius

Extension ➢ Quadriceps ➢ Tensor Fasciae Latae Collateral Ligaments

MCL ➢ Valgus stress at 0 and 30 degrees

LCL ➢ Varus stress at 0 and 30 degrees ACL

➢ Lachman ➢ Anterior Drawer ➢ Pivot Shift PCL

➢ Posterior Sag ➢ Posterior Drawer Meniscus

➢ McMurray ➢ Apley’s ➢ Bounce Home Patellofemoral

➢ Active patellar grind/crepitus

➢ Apprehension/hyper mobility Others

Ober’s Test Diagnostic Imaging

X-rays: ➢ AP ➢ Lateral ➢ Sunrise ➢ Notch ➢ Weight bearing Diagnostic Imaging

➢ CT – More detailed bony evaluation ➢ MRI – More detailed bony evaluation and good evaluation of soft tissue structures ➢ Ultrasound – Good, detailed evaluation of more superficial soft tissue structures Summary

Knee Anatomy Basic physical exam Special tests Thank You!