3. Knee
◈ Stability of the knee is based on its soft tissue constraint rather than
on its bony configuration
◈ The massive femoral condyles articulate with the nearly flat proximal
articular surfaces of the tibia, held in place by extensive ligaments,
join capsule and menisci, and large muscles
◈ With the foot firmly in contact with the ground, these soft tissues are
often subjected to large forces from both muscles & external sources
injury
5. Distal Femur
◈ Distal femur: lateral & medial condyle
◈ Lateral & medial epicondyle
� project from each condyle
� providing elevated attachment sites for the collateral ligaments
� Seperated by intercondylar notch, forming a passage way for the cruciate ligament narrower
than average notch increase anterior cruciate ligament injury
◈ The Femoral condyles fuse anteriorly to form Intercondylar (trochlear) groove
� Articulate with the posterior of patella Patelofemoral joint
7. Proximal Tibia & Fibula
◈ Fibula
� has no direct function at the knee maintain tibia’s alignment
� The head of fibula attachment for the biceps femoris & collateral ligament
� Attached to the lateral side of tibia proximal & distal tibiofibular joint
◈ Tibia
� Function: transfer weight across the knee and to the ankle
� Proximal end tibia flare into median & lateral epicondyles (distal femur)
� Tibial plateau: medial condyle & lateral condyle separated by intercondylar eminence (attachment
place for The cruciate ligament & menisci)
� Anterior tibia: tibial tuberosity distal attachement for m. quadriceps femoris via the patellar
tendon
9. Patella
◈ Triangular bone embedded within the quadriceps tendon curved
base superiorly & pointed apex inferiorly
◈ Thick patellar tendom: between apex of the patella & tibial tuberosity
◈ Posterior articular surface of the patella (covered cartilage up to 4 – 5
mm to disperse the large compression forces) articulate with the
intercondylar groove of the femur Patellofemoral joint
◈ 3 Facet: medial, lateral, odd facet
◈ Between medial and lateral facet Vertical Ridge
18. Bursa
• Subcutaneous prepatellar bursa
• Subcutaneous infrapatellar bursa
• Deep infrapatellar bursa
• Suprapatellar bursa
• Subsartorial bursa
• Semimembranosus bursa
19. Menisci
◈ Function:
� Reduce compressive stress across the tibiofemoral joint
� Stabilizing the joint during motion
� Lubricating the articur cartilage
� Providing proprioception
� Helping to guide the knee’s arthrokinematics
◈ Common mechanism of injury: (medial meniscus 2 times more often than lateral
meniscus)
� Meniscal tears associated with a forceful, axial rotation of the femoral condyles over a
partially flexed and weight-bearing knee.
� Bucket-handle tear: dislodged / folded flap meniscus e.c axial torsion within the compressed
knee
� Valgus force: axial rotation + external forces from lateral aspect of knee
24. Osteokinematics at Tibiofemoral Joint
◈ The medial-lateral axis of rotation for
flexion and extension is not fixed
migrates within the femoral condyles
◈ The curved path of the axis Evolute
37. nspection
• Observe the patient’s gait
• Abnormal movement
(pain/joint stiffness)
• Soft tissue swelling
• Inspect the symmetry of
muscle contours above the
knee for any visible
muscular atrophy
Anterior view, standing
• note any malalignment/
deformity :Genu valgum
/varum
• Patella : should be
symmetrical and level
• Normally, the tibia has a
slight valgus angulation in
Bursitis
synovitis
Quadricep
atrophy
46. Active Movement
• In non–weight-bearing, active medial
rotation of the tibia on the femur should be
20° to 30°, whereas active lateral rotation
should be 30° to 40° at 90° flexion in non–
weight-bearing
48. PALPATION
Bony prominence
1. Infrapatellar tendon
• Place your hands upon the
knee joint so that your
fingers curves around to the
posterior popliteal area
• Place your thumbs on
anterior portion of the
knee and press into the soft
tissue depressions on
either side of the
infrapatellar tendon
49. Palpation : Medial Aspect
2. Medial Tibia Plateau
• Push thumb inferiorly
into the soft tissue
depression until you
can feel sharp upper
edge of medial tibial
plateau
50. Medial aspect
3. Tibial Tubercle
• Follow the infrapatellar
tendon distally to where
it insert into the tibial
tubercle
51. Medial aspect
4. medial femoral
condyle
• More palpable if the
knee flexed more than
90°
• The condyle is palpable
along its sharp medial
angle, proximally as far
as the superior portion
of the patella and
distally to the junction
of the tibia and femur
52. Medial aspect
5. Adductor tubercle
• On medial surface of
the medial femoral
condyle and move
further posteriorly
until you locate the
adductor tubercle in
the distal end of the
natural depression
between vastus
medialis and hamstring
muscle
53. Lateral aspect
1. Lateral femoral
condyle
• Palpable laterally
onto the sharp
edge of the lateral
femoral condyle
54. Lateral aspect
2. Head of fibula
• From lateral femoral
condyle, move your
thumb inferiorly and
posteriorly across the
joint line. Situated at
the same level as
tibial tuberosity
55. Soft tissue palpation
1. M. Quadriceps femoris
• Vastus medial and
lateral form visible
bulges on medial and
lateral sides of the knee
and easily palpable
• Defect are most often
found distally in rectus
femoris or vastus
intermedius just
proximal to the patella
• Look for any sign of
atrophy
56. Soft tissue palpation
1. m. quadriceps
femoris
• Measuring the
circumference of
each thigh about 3
inches above knee
57. Sof tissue palpation
2. Infrapatellar tendon
• Palpable to its insertion into the tibial
tubercle
• Runs from inferior border of patella
to tibial tubercle
• Tenderness is often here in young
individuals (Osgood-Schlatter
Syndrome)
• The infrapatellar fat pad lies
immediately posterior to the
infrapatellar tendon at the level of
joint line.
• Tenderness -> may be evidenced of
hypertrophy or contusion of the fat
pad.
58. Soft tissue palpation
3. Medial meniscus
• Anterior margin of the
medial meniscus itself
just barely palpable
deep within the joint
space
• When the tibia is
internally rotate, its
medial edge becomes
more prominent and
palpable
59. Soft tissue palpation
4. Medial collateral
ligament
• Relocate the
medial joint line.
• As you move
,medially and
posteriorly along
the joint line, the
ligament lies
directly under
your fingertips
60. Soft tissue palpation
5. Sartorius, gracilis, and
semitendinosus tendons
• To palpate, stabilize the patient’s
leg by holding it securely with your
own legs.
• Cup your finger around the knee
and feel the tautness of the
tendons
• Semitendinosus tendon is the most
posterior and inferior you can feel;
gracilis lies slightly anterior and
medial to the semitendinosus
• Wide, thick band of the muscle just
above the gracilis tendon is the
61. Soft tissue palpation
6. Biceps femoris tendon
• Knee flexed, palpate near its
insertion (fibular head)
62. Soft tissue palpation
7. Iliotibial band
• Palpable to the
point where it
insert to the lateral
tibial tubercle
63. Soft tissue palpation
8. Common peroneal nerve
• Palpable where it crosses the neck of
the fibula
• Nerve can be rolled gently between
the tip of your finger and neck of the
fibula, slightly inferior to the
insertion of the biceps femoris
muscle.
64. Soft tissue palpation
10. Popliteal artery
• Because covered by the
fascia, the nerve and
the vein, it may be
difficult to feel the
popliteal pulse.
• Absence of this pulse
may be due to vascular
occlusive disease
65. Soft tissue palpation
11. Popliteal fossa
• Swelling in the fossa may
indicate a popliteal cyst,
palpable when the knee
extended
66. Test for joint stability
1. Medial collateral ligament
• Secure his ankle with one hand,
other hand around the knee so
that your thenar eminence is
against fibular head
• Push medially against the knee
and laterally against the ankle
in an attempt to open knee
joint on inside (valgus stress)
• palpate the medial joint line for
gapping
• When stressed of injured joint
is relieved, fell the tibia and
femur “clunk” together as they
close
67.
68.
69. Test for joint stability
2. Lateral collateral ligament
• Push laterally against the knee
and medially against the ankle
to open the knee joint on lateral
side (varus stress)
70.
71. Test for joint stability
3. Cruciate ligament
• Cup your hands around his knee, with your fingers on the area of insertion of
the medial and lateral hamstring and yor thumbs on medial and lateral joint
lines
• Draw the tibia toward you. Positive -> it slides forward from under the femur
• Posterior cruciate ligament -> conversely
72. Anterior Drawer Test
• Normal: shift up to 6 mm
• Audible snap or palpable jerk
(Finochietto jumping sign) 🡪
meniscus lesion + torn
anterior cruciate ligament
• Arcuate Spin Test
– Tibia is pushed backward, the
examiner forcefully rotates the
tibia laterally 🡪 excessive
movement occurs
– (+) 🡪 Posterolateral instability
Posterior Drawer Test
73. Active Anterior Drawer Test
• To test anterior and posterior
cruciate ligament. Posterior >>
anterior
• Hold dorsum pedis, ask patient
to strengthen the leg
🡪 tibia move anteriorly
• Ask patient to contract
hamstring isometrically 🡪 tibia
move posteriorly
76. Special test
Mc Murray test
• Examine of meniscus tear
• Lie supine, legs flat in neutral
position. One hand hold his heel
and flex his leg fully
• Place free hand on knee joint
• Rotate the leg internally and
externally loosen the knee joint
• Push on lateral side to apply
valgus stress to the medial side of
the joint, at same time , rotating
the leg externally.
• Maintain valgus stress and
external rotation , and extend the
leg slowly as you palpate the
medial joint line
• If palpable or audible “click’
within the joint -> medial
meniscus tear
77.
78. Reduction click
• Applicable for patients with
locked knee due to torn,
dislocated, or heaped up
meniscus
• To reduce the displaced or torn
portion of meniscus by clicking
it back into place
• To unlock a locked knee (by
torn meniscus) & permit full
extension
• Position = McMurray test
• Flex knee while it is rotated
internally & externally
• Then rotate & extend leg until
you hear “click”, as meniscus
slips back to its proper position
79. Apley compression test/grinding test
• To aids diagnosing meniscal tear
• patient lie prone with one leg flexed
to 90O
• Gently kneel on the back of his thigh
to stabilize it
• While leaning hard on the heel to
compress medial & lateral menisci
• Rotate tibia internally & externally on
femur as you maintain firm
compression
• Positive = pain + = meniscal tear
• Pain on medial side = medial
meniscal tear
• Pain on lateral side = lateral meniscal
tear
80. Apley’s Distraction Test
• To distinguish between meniscal &
ligamentous problem of knee joint
• Should follow Apley’s compression
test
• Remain in the same position after
Apley’s compression test
• Maintain stabilization of posterior
thigh
• Apply traction to leg
• While rotating tibia internally &
externally on femur
• Positive = pain + = damaged
ligaments
• Negative = pain - = only the
meniscus were torn, ligaments not
damaged
81. Bounce home test
• To evaluate lack of full knee
extension, secondary by torn
meniscus, loose body within
knee joint, intracapsular joint
swelling
• Patient supine
• Cup his heel on your palm
• Bend his knee into full flexion
• Passively allow knee to extend
• Positive = knee extend
completely/ bounce home
with sharp end point = normal
• Negative = knee falls short,
offering rubbery resistance to
further extension = probably
torn meniscus or other
blockage
82. Patellar Femoral Grinding Test
• To determine quality of
articulating surfaces of patella
and trochlear groove of femur
• Patient supine with legs relaxed
in neutral position
• Push patella distally in trochlear
groove
• Instruct him to tighten his
quadriceps
• Palpate & offer resistance to
patella as it moves under your
fingers
• Negative = patella moves
smooth & gliding
• Positive = pain/ discomfort +
83. Apprehension Test for Patellar Dislocation &
Subluxation
• To determine whether patella is
prone to lateral dislocation
• If you suspect patient has
recurrent dislocating patella,
attempt to manually dislocate it
while observing his reaction face
• Patient lie supine with legs flat &
quadriceps relaxed
• Press medial border of patella with
your thumb
• Negative = little reaction = normal
• Positive = expression on patients
face becomes one of apprehension
& distress = patella begins to
dislocate
84. Tinel Sign
• To elicit pain from tapping
for neuromata on the end
of a cut nerve
• To the provocation of pain
on the leading edge of a
regenerating nerve
• tap area around medial side
of tibial tubercle
(infrapatellar branch
saphenous nerve)
• Positive = tenderness over
bulbous end of the severed
nerve if neuroma has
developed.
• In knee surgery, this nerve
frequently cut during
85. Test for Major Effusion
• To examine effusion on knee
joint
• When joint distended by large
effusion
• Carefully extend patient’s knee
• Instruct him to relax
quadriceps m.
• Push patella into trochlear
groove & quickly release it
• Positive = ballotable patella;
large amount of fluid under
patella first forced to the joint
sides, then flows back to its
former position, forcing patella
to rebound
86. Test for Minor Effusion
• Keep patient’s knee
extended
• Milk the fluid from
suprapatellar pouch &
lateral side into medial
side of knee
• Positive = Gently tap
the joint over the fluid,
which will traverse knee
to create fullness on
lateral side
