Knee Injuries Chetan

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- ¾ 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 mechanoreceptors-A. Ruffini corpusclesB. Pacinian corpusclesC. 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.

Apley’s Distraction Test

• Tests for meniscal or ligamentous lesions

• (+) test is pain that is eliminated (meniscal injury), or pain that is increased (ligamentous)

Apley’s Compression Test

• Tests for meniscal lesions

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

O’Donohue’s 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

McMurray’s 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 ACL- restricts

ant. Translation of tibia.• Post. Oblique lig.- oblique

fibers to semimemb, stops ant-med 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)

• Goes- Posterosuperolaterally. (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. rotationBlood supply to ACL by

middle Genicular arteryRestricts ant. displacement

of tibia.Some valgus & varus

stresses.

PCL• From- post tibial spine to lat

aspect of med condyle.• Goes- superomedioanteriorly (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 O’Donoghue 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 lachman’s 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.• Lachman’s 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

Lachman’s 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

Slocum’s 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 PCL- deficient 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????

Godfrey’s 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.

GradesGrade 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 50 patients

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– O’Donahue

• 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(CHONDROMALACIAOF 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 (Clarke’s 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 ofchondromalacia, but several signs are suggestive. (a) Hold the patella against the femoral condyles and ask the patient totighten the thigh muscles; even in normal people this may be uncomfortable, but patients with chondromalacia experiencesudden acute pain in the patello-femoral joint. (b) A ‘skyline’ x-ray with the knee in partial flexion may show obvious tiltingof the patella. (c) In the lateral x-ray, with the knee flexed to 45°, the lengths of the patella and the patellar ligament arenormally about equal (a ratio of 1:1); in patella alta the ratio is less than 1:1.

ArthroscopyCartilage 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 diagnosisOther 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– possible locking sensation

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.

Hughston’s Plica Test

• Tests for medial plica’s• (+) test is pain and/or popping of the plical

band under the clinician’s 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’ seemsappropriate. (b) Which is the loose body here? Not the large one (which is a normal fabella), but the small lower oneopposite the joint line. (c) Multiple loose bodies are seen in synovial chondromatosis, a rare disorder of cartilage metaplasiain 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 anti-inflammatory 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 X-Rays.

• 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 lesionis often missed in the standard anteroposterior x-ray and isbetter seen in the ‘tunnel view’, usually along the lateralside of the medial femoral condyle (a). Here theosteochondral fragment has remained in place butsometimes it appears as a separate body elsewhere in thejoint. (b) MRI provides confirmatory evidence and shows amuch wider area of involvement than is apparent in the plane x-ray.

Osteochondritis dissecans Intraoperative pictures showing the articular lesion (a) and the defect left after removalof the osteochondral fragment (b).

Blount’s 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 gone‘out 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 osteochondral fracture.

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 oftraumatic 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 fullextension; 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 (2–3 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.

• 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

OPERATIVE TREATMENT

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…..