knee joint physical exam relevant anatomy

2. It is a term used to cover a group of disorders
involving disruption of the normal functioning
of the ligaments or cartilages (menisci) of the
knee joint.

3. Bones & Articulations
Largest joint in the body
Synovial hinge type of a
joint
Mainly articulation of four
bones ;femur, tibia, patella,
fibula
Each articulation covered
with hyaline cartilage;
The primary articulation
between Condyles of
femur & tibia

4. LIGAMENTS
Dense structures of
connective tissue that
fasten bone to bone &
stabilise the knee.
Inside the knee are
two major ligaments-
anterior & posterior
cruciate ligaments

5. • Two other ligaments are
located outside the knee –
Medial & Lateral collateral
ligaments. They act to stabilise
knee sideways motion.
• The patellar tendon connects
lower part of patella with
upper part of tibia. Part of this
tendon is used in
Reconstructing a torn ACL

6. • MENISCI
Two menisci are in
each knee.
• Act as shock
absorbers & also help
in spreading weight .
• A meniscus is
frequently torn at the
same time as ACL
tears during injury.

7. • The following disorders may be met with:-
• Sprain or tear of the medial collateral ligament.
• Sprain or tear of the lateral collateral ligament.
• Partial or complete rupture of the anterior cruciate ligament.
• Rupture of the posterior cruciate ligament.
• Tear of the medial semilunar cartilage. This may take the
form of a longitudinal spilt (bucket handle tear), or an
anterior or posterior horn tear.
• Tear of the lateral semilunar cartilage. The same variations
occur as with a medial cartilage tear.
• Tear of a degenerate meniscus.
• Cyst of a semilunar cartilage, usually the lateral.
• THE COMMONEST DERANGEMENT IS MEDIAL COLLATERAL
LIGAMENT INJURY FOLLOWED BY MEDIAL MENISCUS INJURY
AND ACL

8. • Physical trauma is the cause of the vast majority of
IDKs.
• The majority of acute knee injuries result from a
valgus and/or twisting strain. Most commonly, they
involve the medial joint structures and the anterior
cruciate ligament.
• The type of physical trauma causing IDK may be a
sports injury, a road traffic accident or an
occupational stress; by far the most common at the
present time is a sports injury.

9. • The most frequent cause of damage to the medial
collateral ligament is forced valgus injury to the
knee
• Lateral collateral ligament injuries are much less
common, as varus stress to the knee occurs much
less frequently than valgus stress.
• Anterior cruciate ligament injury occurs from forced
valgus stress to the fully extended knee.
• Posterior cruciate ligament injury is liable to occur
in motor car accidents caused by high velocity
trauma, with posterior dislocation of the tibia on a
flexed knee, as in a dashboard impact

10. • Meniscus tears occur when substantial
rotational stresses are applied to the flexed
knee. They are particularly common in
footballers, when the player is tackled from
the side; they are also liable to occur in other
sports such as hockey, tennis, badminton,
squash and skiing.

11. Anatomy:
MCL is composed of superficial & deep portions
superficial MCL
anatomically this is the middle layer of the Medial
compartment
proximal attachment: posterior aspect of medial femoral
condyle.
distal attachment: metaphyseal region of the tibia, upto 4-5
cm distal to the joint, lying beneath the pes anserinus

12. function:
provides primary restraint to valgus stress at the
knee providing from > 60-70% of restraining force
depending on knee flexion angle:
at 25° of flexion, the MCL provides 78% of the
support to valgus stress;
at 5° of flexion, it contributes 57% of the support
against valgus stress;

13. superficial ligament can be divided into
anterior & posterior portions;
anterior fibers of superficial portion of
ligament appear to tighten with knee flexion
of 70 to 105 deg;
posterior fibers form the posterior oblique
ligament

14. anatomically this is the third (deep) layer of the medial
compartment which in many cases will be separated
from the superficial MCL (layer II) by a bursa (which
allows sliding of the tissues during flexion)
divided into meniscofemoral and meniscotibial
ligaments
inserts directly into edge of tibial plateau & meniscus
firmly attaches to the meniscus but does not provide
significant resistance to valgus force

15. valgus stress test
clinical findings may be subtle even with complete
injury;
it is helpful to anchor the thigh on the table with the
knee and leg off the edge of the table;
opening of 5-8 mm compared to opposite knee may
indicate complete tear;
determine the point of maximal tenderness to
determine whether the tear has occurred
proximally, mid-substance, or distally;

16. instability in slight flexion:
anterior portion of the medial capsule is primary
stabilizer at 30 deg of flexion;
hence at 30 flexion, testing is specific for just MCL;
instability in extension:
posterior portion of the MCL, posterior oblique
ligament, ACL, medial portion
of posterior capsule & possibly PCL;

17. • location of tears:
- femoral tear:
- mid substance tear:
- tibial tear:
• INVESIGATIONS
- X-ray:
- MRI:

18. • Non Operative Treatment:
• optimum healing of the medial collateral ligament occurs
when the torn ends are in contact
healing potential is directly related to size of the gap
between the torn ends
healing of extra-articular ligaments is analogous to healing
of other soft tissue structures, through production and
remodeling of scar tissue
maturation of scar occurs from 6 weeks to upto one year
• although the maturing scar tissue has only about 60% of
the strengh of the normal MCL, ultimate load to failure is
unchanged (since the amount of scar tissue is larger
than original ligamentous tissue)

19. • with concomitant MCL and ACL tears, most
surgeons now recommend ACL reconstruction
after the valgus stability has returned
• the one exception might be the MCL tear
arising from the tibial insertion

20. • surgical plan depends on whether injury is proximal,
mid substance or distal
femoral avulsion:
• with femoral avulsion, it is important to remember
that reattachment anterior to its orgin may limit
knee flexion where as posterior placement may
cause ligament laxity
the knee should be held flexed at 30 deg and held
in varus when the ligament is reattached

21. Discussion
lateral collateral ligament is primary restraint to varus
angulation
LCL also acts to resist internal rotation forces
cutting of LCL in combination with either anterior or
PCL results in large increase in varus opening

22. testing with extension:
LCL resists approximately 55 % of applied load at full extension
cruciate ligaments (primarily ACL) resist approx 25% of moment at
full extension
significant instability in full extension indicates complete LCL tear as
well as a tear of either the ACL or PCL ligament
note that LCL instability in extension which occurs with peroneal
palsy is a knee dislocation until proven otherwise

23. role of LCL increases with joint flexion, as posterolateral structures
become lax
with joint flexion,resistance by ACL decreases, but large forces are
found in PCL at 90 degrees of flexion
LCL is primary restraint to varus stress at 5* & 25*Flexion
lateral capsular structure provide secondary support
iliotibial band & popliteus muscles have dynamic stabilizing role

24. allograft reconstruction:
With chronic posterolateral injury, Achilles tendon allograft
may be indicated
Main goal is to create a checkrein to external rotation
At the level of Gerdy's tubercle, a bone tunnel is created in
the posterolateral tibia, just medial to the fibular head
Attachment of the IT band to the intermuscular septum
may have to be freed for optimal exposure

25. Allograft bone plug (9 mm graft and tendon) is contoured
to fit the tunnel, and is secured with an interference screw
Tendinous portion of the graft is then secured in the region
of the popliteus insertion with a bone anchor
Anchor site should not allow more than 3 mm of motion
with knee flexion and extension
With this technique, the strong stability provided by the
allograft may help compensate for disruption of the arcuate
complex

26. • The ACL is a broad ligament joining the anterior
tibial plateau to the posterior intercondylor notch.
• The tibial attachment is to a facet, in front of &
lateral to anterior tibial spine.
• Femoral attachment is high on the posterior aspect
of the lateral wall of the intercondylar notch.
• It is composed of multiple non-parellel fibres which
though not anatomically separate, act as three
distinct bundles i.e. anteromedial, posterolateral &
intermediate.

27. The biomechanical function of the ACL is complex for
it provides both mechanical stability & proprioceptive
feedback to the knee.
In its stabilising role it has four main functions;
1.Restrains anterior translation of tibia.
2.Prevents hyperextention of knee.
3.Acts as a secondary stabiliser to valgus stress,
reinforcing medial collateral ligament.

28. contd….
4.Controls rotation of tibia on
the femur in femoral
extention of 0-30 degrees.
The final role is the main
clinical function of ACL.

29. This critical function in the range of 0-30* is important for
movements such as side-stepping & pivotting.

30. • T he ligament is surrounded by synovium,thus making it
extra synovial.
• Blood supply
• primarily from the middle genicular Artery which
pierces the posterior capsule & enters the intercondylar
notch near femoral attachment.
• Additional supply comes from retropatellar pad of fat
via the inferior medial & lateral geniculate arteries.
• NERVE SUPPLY: Posterior articular nerve

31. • Rupture of ACL causes significant short term &
long term disability.
• With each episode of instability there is
subluxation of tibia on the femur, causing
stretching of the enveloping ligaments &
abnormal shear stress on the menisci & on the
articular cartilage.
• Delay in the diagnosis & treatment gives rise to
increased intrarticular damage as well as the
stretching of secondary capsular ligaments.

32. The long term outlook for an ACL deficient knee is
for the development of significant osteoarthrosis.
CAUSES OF ACL RUPTURE
1.Most common cause of ACL rupture is traumatic
force applied to the knee in a twisting moment.
This can occur with direct or indirect force.
2.Patients with narrow intercondylar notch are
more prone to rupture their ACL.

33. 3. Patients with genu recurvatum tend to be more
likely to rupture their ACL & are more difficult to
treat.
4.Patients with generalised ligamentous disorder.
5.Familial predisposition has been found to play a
role in some patients especially those who
sustain bilateral ACL tears.

34. • Begins with a non contact deceleration, jumping or cutting
action.
• Other mechanisms of injury include external forces applied
to the knee.
• The patient often describes the knee as having been
hyperextended or popping out of the joint & then reducing.
A pop is being frequently heard or felt. The patient usually
has fallen to the ground & is not immediately able to get
up. Resumption of activity is not possible & walking is often
difficult. Within a few hours knee swells & aspiration of
joint reveals haemarthosis. In this scenario ,the likelihood
of ACL injury is greater than 70%.

35.  Examination
ANTERIOR DRAWER TEST
With the knee flexed to 90*, verification of relaxation of
hamstrings is confirmed. With foot stabilised & in neutral
rotation, a firm but gentle grip on the proximal tibia is achieved.

36. • An anterior force is applied to the proximal tibia with a
gentle to & fro motion to assess for increased translation
compared to contralateral knee. 5mm is the upper limit of
anterior tibial displacement normally.

37. • Drawer sign is minimal in isolated ACL rupture.
Abnormal displacement >5mm is permitted by loss
of restraint by ACL & more so when associated with
insufficiency of medial CL or capsular ligament.
• When an intact PCL is rendered very taut by forcible
internal rotation of tibia, it stabilises the knee to the
extent that the anterior drawer sign is negated.
• If internal rotation of tibia does not lessen the
anterior drawer sign, the PCL is also insufficient.

38. • Especially when the ligamentous Insufficiency is confined to
the ACL,the anterior drawer sign is unreliable.
• With knee flexed to 90 degrees for classical anterior sign,
medial meniscus being attached to tibia, abuts against
acutely convexed surface of medial femoral condyle & has
“door stopper” effect preventing or hindering anterior
translation of tibia.
• With knee extended, relationship is changed.
• Comparatively flat weight bearing surface of femur does
not obstruct forward motion of tibia when anterior stress
is applied.

39. • One hand secures and
stabilises the distal femur
while the other hand
grasps the proximal tibia.
• A gentle anterior translation
force is applied to the
proximal tibia.

40. • Examiner assesses for a
firm/solid or soft
endpoint.
• Stabilisation of right knee
during an examination
under anaesthesia.

41. • Application of anterior tibial translation force with
significant ant. translation of the tibia on the femur in an
ACL deficient knee.
• When veiwed from side,
a silhoutte of the inferior
pole of patella,
patellar tendon &
proximal tibia shows slight
concavity.
• Disruption of ACL &
anterior translation of tibia
obliterates the patellar
tendon slope.

42. • Patient rotated 20* from supine towards the unaffected
side. With slight distal traction on the leg,a valgus &
internal rotation force is applied to the extended knee.

43. • With maintainance of force noted
above,the knee is flexed past 30*

44. • Pivot shift in an ACL deficient knee,in the
initial stages of knee flexion,the tibia will be
anterolaterally subluxed on the distal femur
with application of valgus & internal
rotation at the knee.

45. • With further flexion of knee(past 30*) the illiotibial
band goes from an extendor to flexor of knee &
tibial anterolateral subluxation reduces back in
place.

46. • Isolated tear produces only small
subluxation, greater subluxation occurs when lateral
capsular complex or semimembranosus corner also
is deficient.
• DISADVANTAGES:
• Severe valgus instability may make this test difficult
to do because of lack of medial support.
FLEXION ROTATION DRAWER TEST
Combines anterior drawer & pivot shift test.
Mild degree of valgus stress & anterior pressure on
upper calf are applied to elicit the positive test.

48. • Plain roen.often are normal, however,a tibial
eminence fracture indicates an avulsion of the tibial
attachment of ACL.MRI is the most helpful.

49. 1.PRIMARY SIGNS:
Nonvisualisation
Disruption of the substance of ACL by increased abnormal signal
intensity
Abrupt angulation
Wavy appearance
Abnormal ACL axis.
2.SECONDARY SIGNS:
Segonds fracture
osteochondral fracture
Anterior translation of tibia
Pivot shift
Bone bruises.

51. LEFT-Normal ACL in axial plane;
RIGHT: Non-visualisation as primary sign of ACL tear with
ill-defined edema & haemorhage in the usual location of
the ACL in the I/C NOTCH.

52. ACL tear with non-linearity
of ligament; mild angulated
ACL
segonds fracture in a
patient with ACL tear.

53. • Anterior translation
of tibia as a
secondary sign of ACL
tear.
• Tangential line to the
posterior margin of
tibia passes through
the posterior horn of
lateral Meniscus
(uncovered meniscal
sign).
• In normal knee, this
line passes posterior
to the meniscus.

54. • Conservative or non-operative Rx
• Surgical Rx
• Indications of non-operative Rx
 isolated ACL tears ; likely to be succesfull in patients with partial tears
& no instability symptoms.
 complete tears & no symptoms of knee instability during low demand
sports who are willing to give up high demand sports
 Who do light manual work or live sedentary habits
 Whose growth plates are still open(children)

55. NON-OPERATIVE RX:- consists of
Progressive physical therapy & rehabilitation can
restore the knee to a condition close to its
preinjury state.
Educate the patient how to prevent knee
instability.
This may be supplemented with the use of
hinged knee brace.

56. INDICATIONS
• Patients with knee instability, pain, swelling or giving way
should consider surgical reconstruction of the knee.
• In some cases reconstruction is necessary because of
damage to menisci or articular cartilage of the knee.
• Progressive premature degenerative changes in patients
with unstable knee may also be an indication.

57. • CHOICE of RX mainly depends on assesment of
three patient factors:
• AGE: The child ,the adolescent, the young adult,
the middle aged & the elderly represent different
surgical problems.
• FUNCTIONAL DISABILITY:
• It may vary from undiagnosed asymptomatic
rupture to a patient whose knee gives way on daily
basis.

58. FUNCTIONAL REQUIREMENTS:
Vary from sedentary patients with low activity
requirements, through those patients with an
active social sporting life or physically
demanding work, to the elite athelete whose
fame & fortune depends upon a highly
functional knee.
Rupture of ACL in the child or elderly is very
rare & are usually Rx conservatively.
Rupture in the adolescent is not uncommon &
presents its own problems because of skeletal
immaturity. Most isometric reconstructions
place the growth plate at risk.

59. Reconstruction may be delayed up to skeletal
maturity. However, in elite adolescent athelete
with an acute rupture it is possible to repair
the ligament early & to supplement this with
semitendinosus & gracilis reconstruction. This
is possible by performing surgery within the
epiphysis.
Vast majority of patients fall in to young adult
& middle aged persons. Males are more
frequently seen than females though this
pattern is reversed in skiers where a
disproportionate no. of female skiers are
injured.

60. • Before any surgical Rx, patient is sent to physical
therapy.
• Resolution of inflammation & return of full motion
reduce the incidence of postoperative stiffness
• It usually takes 2 to 3 weeks from the time of
injury to achieve full range of motion.
• It is also recommended that some ligament
injuries be braced & allowed to heal prior to ACL
surgery.

61. • Repair of ACL either isolated or with augmentation.
• Reconstruction with either autograft, allograft or
syntheticsp
• Primary repair of the ACL is no longer
recommended because repaired ACL have generally
been shown to fall overtime.
• The torn ACL is generally replaced by a substitute
graft made of tendon.The grafts commonly used:
PATELLAR TENDON AUTOGRAFT;HAMSTRING TENDON;QUADRICEPS TENDON

64. ANATOMY
• Intra-articular but extrasynovial, static stabiliser of knee:
• composed of two major parts:Large anterior part that
forms the bulk of the ligament & a smaller portion that
runs obliquely to the back of tibia.
• PCL is attached proximally to the posterior part of the
latral surface of the medial condyle.The tibial attachment
is to a depression behind & below the intra-articular
portion of tibia with a slip usually blending with the
posterior horn of the latral meniscus.

68. • Progressive tightening of the PCL occurs during internal
rotation of tibia with the knee in either flexion or full
extension.
• Also in full extension the PCL allows only minimal
abduction or adduction widening of the knee despite
complete removal of accessory supports;the extensor
retinaculum, capsular ligaments, collateral ligaments &
posterior capsule.
• This fact emphasis the importance of the PCL as the
basic stabiliser of the knee, while the ACL & collateral
ligaments augment its stabilising effect.

69.  provides restraint against hyperextension,
 against posterior displacement of tibia in flexed
knee,
 internal rotation of the tibia &
 valgus/varus angulation-particularly in extended
knee.

70. • ACUTE TEAR: Requires much more force than to tear ACL.
• Following ways:
• 1.Severe rotational injury; an external rotation-valgus injury or an
internal rotation-varus injury produces tear of PCL assoc. with
disruption of MCL or LCL.The PCL is interupted at its midportion or
at its femoral attachment.
• 2.Hyperextension injury: Tibial attachment is avulsed usually
• 3.Direct trauma to upper tibia while the knee is flexed-Dashboard
injury.
• 4.Complete dislocation of knee.

71. • History of severe trauma is elicited.
• Degree of both immediate pain & inability to bear weight
on the injured knee is highly variable.
• These are more pronounced when capsule is intact &
haemarthrosis is confined within the joint.
• They may be minimal when the posterior capsule is
disrupted & blood escapes from the joint.

72. • Objective findings are:
• tenderness in the popliteal fossa;
• swelling in allmost all cases.
• Posterior drawer sign in allmost 60% of cases.

73. • With knee flexed to approx. 90*, verification of complete
relaxation of hamstrings is confirmed by palpation .

74. • With foot in neutral
rotation & stabilised, a firm
but gentle posterior
translation force is applied
to proximal tibia.
• Initial starting point for a
posterior drawer test(foot
in NR, knee flexed to 90*)

75. • Application of posterior
translation force results
in posterior subluxation
of tibia on the femur in
a patient with PCL
deficient knee.

76. TIBIAL BACK DROP TEST
In this test, the examiner compares the prominence of the proximal tibia
to the femoral condyles with the knee flexed to 80*.
In a PCL deficient knee, the knee will be posteriorly subluxed due to
gravity.

78. TIBIAL BACK DROP TEST IN A
PCL DEFICIENT LEFT KNEE

79. • It is performed with
the knee flexed to
80deg & in neutral
rotation.Its starting
point is in effect the
tibial drop back test.

80. • From its initial relaxed
position, the patient is
asked, to contract
Quadriceps muscle
(straighten out his leg
without extending his
knee) while examiner
applies counter
pressure against the
ankle.

81. Quadriceps pulls anteriorly through the
tibial tubercle to reduce any posterior
translation in the knee.

83. ROENGENOGRAPHIC FINDINGS:
• Plain radiographs usually normal.
• Stress radiography assists in the diagnosis of PCL
injuries.
• Increased posterior translation of 8mm or more
in stress roeng.is indication of complete rupture.
• A contrast arthogram may reveal evidence of
ligament disruption.
• Arthroscopic evaluation should be done to assess
the damage to both the cruciates & to define
additional lesions.

84. • MRI studies are more reliable for diagnosis of
PCL tears than ACL tears.

85. • NON-OPERATIVE TREATMENT:
The quoted criteria for non-operative RX include:
• (1).A posterior drawer test of < 10mm with the tibia in
neutral rotation(posterior drawer excursion decreases
with internal rotation of tibia on femur).
• (2). < 5* of abnormal rotatory laxity(specifically,
abnormal external rotation of the tibia with the knee
flexed 30*,indicating posterolateral instability).
• (3).No significant valgus-varus abnormal laxity.

86. OPERATIVE TREATMENT
• Reconstruction is usually delayed for 1 to 2 weeks
after injury to allow painful intra-articular reaction
to subside & to allow the patient to regain full
motion and some strength.
• Clinically, isolated acute PCL disruptions are
repaired if the ligament is avulsed with a fragment
of bone.
• Knee is examined arthroscopically before any open
surgical procedure.

89. • Various grafts used are :
(1).Patellar tendon graft.
(2).Bone-patellar tendon-bone graft.
(3).Tendo-achillis bone graft.
(4).Illiotibial band.
(5).Medial head of gastrocnemius tendon.
(6).Hamstring tendon.
(7).Lateral meniscus.

91. • Loss of motion is the most common complication aside from from usual postoperative
complication.
• Flexion loss is more common than extension loss.
• Failure to obtain objective stability is another common complication.
• Failure of reconstruction may be the result of untreated associated ligamentous injuries
such as the posterolateral corner, which allow excessive forces to be applied to the graft.

92. • Neurological complications(injuries) can result
from excessive tourniquet time & manifest as
neuropraxia.
• Vascular complicatons include
laceration, thrombosis,& intimal injury to the
popliteal artery.Viewing the tip of reamer & guide
pin at all times can prevent this injury.
• Osteonecrosis of medial femoral condyle has
been reported-cause thought to be local trauma
to the subchondral bone from both soft tissue
dissection & drilling.

94. • The menisci are C-shaped or semicircular
fibrocartilaginous structures with bony attachment
at anterior and posterior tibial plateau. The medial
meniscus is C-shaped, with a posterior horn larger
than the anterior horn in the anteroposterior
dimension.
• The capsular attachment of medial meniscus on the
tibial side is referred to as the coronary ligament. A
thickening of the capsular attachment in the
midportion spans from the tibia to femur and is
referred to as the deep medial collateral ligament.

95. • The lateral meniscus is also anchored
anteriorly and posteriorly through bony
attachments and has an almost semicircular
configuration. It covers a larger portion of the
tibial articular surface than does medial
meniscus

96. • The fibrocartilaginous structure of the meniscus
has a varied architecture of coarse collagen
bundles.
• At birth the entire meniscus is vascular.
• By age 9 months, the inner one-third has become
avascular. This decrease in vascularity continues
by age 10 years, when the meniscus closely
resembles the adult meniscus.

97. • In adults, only 10 to 25% of the lateral meniscus
and 10 to 30% of the medial meniscus is vascular.
This vascularity arises from superior and inferior
branches of the medial and lateral genicular
arteries, which form a perimeniscal capillary
plexus.
• Because of the avascular nature of the inner two-
thirds of the meniscus, cell nutrition is believed to
occur mainly through diffusion or mechanical
pumping.

98. • The classification of meniscal tears provides a
description of pathoanatomy. The types of
meniscus tears are:
• Longitudinal tears that may take the shape of a
bucket handle if displaced
• Radial tears
• Parrot-beak or oblique flap tears
• Horizontal tears and
• Complex tears that combine variants of the
above.

99. • Most meniscal injuries can be diagnosed by
obtaining a detailed history.

100. – Meniscus tears are sometimes related to trauma;but
significant trauma is not necessary.
– A sudden twist or repeated squatting can tear the
meniscus.
– Meniscus tears typically occur as a result of twisting or
change of position of the weight-bearing knee in varying
degrees of flexion or extension.

101. Pain from meniscus injuries is commonly intermittent;
usually the result of synovitis or abnormal motion of the
unstable meniscus fragment & is localized to the joint
line.
Mechanical complaints: Descriptions by patients are
often nonspecific but include reports of clicking,
catching, locking, pinching or a sensation of giving way.
Swelling usually occurs as a delayed symptom or may
not occur at all. Immediate swelling indicates a tear in
the peripheral vascular aspect.
Degenerative tears often manifest with recurrent
effusions due to synovitis.

102. Joint line tenderness
– Joint line tenderness is an accurate clinical sign.This
finding indicates injury in 77-86% of patients with
meniscus tears. Despite the high predictive value,
operative findings occasionally differ from the
preoperative assessment.
– The examiner must differentiate collateral ligament
tenderness that may extend further toward the
ligament attachment sites above and below the joint
line.

103. • Effusion
– Effusion occurs in approximately 50% of the patients
presenting with a meniscus tear.
– The presence of an effusion is suggestive of a peripheral
tear in the vascular or red zone (especially when
acute),an associated intra-articular injury, or synovitis.
• Range of motion
– A mechanical block to motion or frank locking can occur
with displaced tears.
– Restricted motion caused by pain or swelling is also
common.

104. • These techniques cause impingement by creating
compression or shearing forces on the torn
meniscus between the femoral and tibial surfaces.

105. The McMurray test:
• This maneuver usually elicits pain or a reproducible
click in the presence of a meniscal tear.
• The medial meniscus is evaluated by extending the
fully flexed knee with the foot/tibia internally
rotated while a varus stress is applied.
• The lateral meniscus is evaluated by extending the
knee from the fully flexed position, with the
foot/tibia externally rotated while a valgus stress is
applied to the knee.
• One of the examiner's hands should be palpating
the joint line during the maneuver.

107. • Differential diagonosis
• Anterior Cruciate Ligament Injury
• Medial Synovial Plica Irritation
• Contusions
• Patellofemoral Joint Syndromes
• Iliotibial Band Syndrome
• Pes Anserine Bursitis
• Knee Osteochondritis Dissecans
• Posterior Cruciate Ligament Injury
• Lateral Collateral Knee Ligament Injury
• Lumbosacral Radiculopathy
• Medial Collateral Knee Ligament Injury
• Articular cartilage pathology including arthritis
• Crystalline deposition diseases including gout and pseudogout
(chondrocalcinosis)
• Ipsilateral hip disease:Osteonecrosis of the femur or tibia

108. • Plain radiography: An AP weight-bearing view, PA
45* flexed view, lateral view and Merchant
patellar view should be obtained to rule out
degenerative joint changes (arthritis) or fractures
• Arthrography: Historically, arthrography was the
standard imaging study for meniscal tears but it
has been replaced now by MRI.
• MRI: This is the standard imaging study for
imaging meniscus pathology and all intra-articular
disorders.

110. • Acute Phase
• Rehabilitation Program
• Physical Therapy

111. • A home physical therapy program or simple rest with activity
modification, Ice and NSAIDs is the nonoperative management of
possible meniscus tears.
• The physical therapy program goals are to minimize the effusion,
normalize gait, normalize pain-free range of motion, prevent
muscular atrophy, maintain proprioception and maintain
cardiovascular fitness. Choosing this course of treatment must
include consideration of the patient's age, activity level, duration of
symptoms, type of meniscus tear, and associated injuries such as
ligamentous pathology
• A trial of conservative treatment should be attempted in all but the
most severe cases, such as a locked knee secondary to a displaced
bucket-handle tear

112. • The main complication at this stage of treatment is
the absence of healing and failure of symptoms to
resolve.
• The natural history of a short (<1 cm), vascular,
longitudinal tear is often one of healing or
resolution of symptoms.
• Stable tears with minimal displacement,
degenerative tears, or partial-thickness tears may
become asymptomatic with nonoperative
management.

113. • Most meniscal tears do not heal without
intervention.
• If conservative treatment does not allow the patient
to resume desired activities, his or her occupation,
or a sport, surgical treatment is considered.
• Surgical treatment of symptomatic meniscal tears is
recommended because untreated tears may
increase in size and may abrade articular cartilage,
resulting in arthritis

114. Indications:-
• Symptoms persist.
• If the patient cannot risk the delay of a potentially unsuccessful period of
observation.
• In cases of a locked knee.
• Principle of meniscus surgery is to save the meniscus.
• Tears with a high probability of healing with surgical intervention are
repaired.
• Most tears are not repairable and resection must be restricted to only the
dysfunctional portions, preserving as much normal meniscus as possible.

115. • Surgical options include partial meniscectomy or meniscus
repair (and in cases of previous total or subtotal
meniscectomy, meniscus transplantation).
• Arthroscopy, a minimally invasive outpatient procedure
with lower morbidity, improved visualization, faster
rehabilitation, and better outcomes than open meniscal
surgery, is now the standard of care.

116. • Partial meniscectomy is the treatment of choice for tears in
the avascular portion of the meniscus or complex tears that
are not amenable to repair.
• Meniscus repair is recommended for tears that occur in the
vascular region (red zone or red-white zone), are longer
than 1 cm, involve greater than 50% of the meniscal
thickness, and are unstable to arthroscopic probing.

117. Human allograft meniscal transplantation
is a relatively new procedure but is being
performed increasingly frequently.
Specific indications and long-term results
have not yet been clearly established.
Meniscus transplantation requires further
investigation to assess its efficacy in
restoring normal meniscus function and
preventing arthrosis.

118. • Recovery Phase
• Rehabilitation Program
• Physical Therapy
• Physical therapy during recovery is directed
toward the same goals as those in the acute
phase.
• For partial meniscectomy, patients may return to
low-impact or nonimpact workouts such as
stationary cycling or straight-leg raising on the
first postoperative day and may advance rapidly
to preoperative activities

119. • When a meniscus repair is performed, the
rehabilitation is typically more intensive.
• Three main issues are considered in the
rehabilitation of meniscus repairs: knee
motion, weight bearing, and return to sports.
• A common protocol is avoidance of weight
bearing for 4-6 weeks, with full motion
encouraged.

120. • Complications
• Reported complication rates for arthroscopic meniscectomy
range from 0.5-1.7% and these can occur intraoperatively or
postoperatively.
• Intraoperative complications include anesthetic problems,
articular cartilage damage, vessel or nerve injury or instrument
failure.

121. • Postoperative complications include anesthetic concerns,
thrombophlebitis, hemarthrosis, infection, stiffness,
persistent pain, effusion or synovitis.
• Reported complication rates for meniscus repairs range
from 1-30%.
• The list of complications is the same as that for
meniscectomies, with a greater concern for neurovascular
injury. Additionally, failure to heal or meniscal reinjury can
occur.