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RADHIKA CHINTAMANI
CONTENTS
*Anatomy
*Arthro- and Oteokinematics
*Functions
*Common conditions in knee joint
*Assessment
*
KNEE JOINT
*Menisci
*Fibro cartilaginous disk
*Thick peripherally and
thin centrally
*Wedge shape in cross section
*Medial meniscus is C-shaped
*Lateral meniscus is 4/5 th of a circle , covers
more surface of small lat.tibial plateu
*Medial condyle more prone for compressive loads
*
*Congruence
*Reduce friction
*Wt bearing forces distribution
*Shock absorber
*Menisci nutrition & innervations
•During I year of life ----- entire
•Wt bear ----- only outer 25% -33%
•>50 year age
only periphery
Central ----synovial fluid
Wt bearing Muscle contraction
femur rotation on fixed
tibia
Immobilization
Only periphery
-inflammation
-Repair
-remodelling
Vascular:
oHorns ,peripheral vascular
area---free nerve endings
3 different mechano receptors
ruffini - ----stretch
pacinian --- compression
galgi -----pressure
Loss of mechanoreceptors
Loss of proprioception
Innervation
*Meniscal attachments
*Horns attach firmly to tibia below
*Transverse ligament
*Patello- meniscal ligament
*Coronary ligament
Semi membrinosus via
capsular connections
Popliteal muscle tendon
A & P horns of medial
meniscus
Attach to ACL@PCL resp.
Posteriorly lateral meniscus
attach to PCL
MCL
*Joint capsule
*Attachments
*The A-M& A-L portion of the capsule called M&L
patello femoral retinaculae----- extensor
retinaculam
*It is innervated by nauci , mechanoreceptors
(muscle stabilization)
*Synovial layer
Structures intra capsular and extra synovial
ACL , PCL , popliteus muscle tendon(PL) , semi
membrinosus and gastrocnemious medial head(PM)
PATELLAR PLICA: synovial folds
In ng order frequency of location
inferior(infra patellar plica)
superior(supra patellar plica)
medial(medio patellar plica)
Joint Kinetics
Movement Axis Arthrokinematics
Flexion Femoral epicondyle Roll posteriorly and
glide anteriorly
Extension Femoral epicondyle Rolls anteriorly and
glide posteriorly
In weight bearing phase
In non-weight bearing phase
Movement Axis Arthrokinematics
Flexion Tibial epicondyle Rolls anteriorly
Glide posteriorly
Extension Tibial epicondyle Rolls posteriorly
Glide anteriorly
Osteokinematics
Knee Flexion
Normal: 130-140 degrees
Normal gait: 60-70 degrees
Ascending stairs: 80 degrees
Knee extension
Normal: 0
Genu recurvatum: >5 degree
Knee rotations (maximum at
90degree of knee flexion)
LR: 0-20 degrees
MR: 0-15 degrees
Valgus / varus:
Full extension: 8
At 20degree of knee flexion:
13 degree
Calliet R. Knee Pain and Disability. 1992: ed.3:1-70
Patellofemoral Joint
Patellofemoral Joint
KNEE POSITION PATELLO-FEMORAL CONTACT
Extension Inferior pole
At 100-200 of knee flexion Inferior margin of medial &lateral facets of
patella
As range progress Inferior to more superior
By 900of knee flexion Except ODD FACET all portions
experience some contact
>900 Odd facet begins with medial femoral
condyle first time
At full knee flexion Lodged in inter condylar groove
Contact is only lateral& odd facet
Calliet R. Knee Pain and Disability. 1992: ed.3:1-70
PATELLO FEMORAL JOINT STRESSES
*Stress(F/A) can be influenced by force
&contact areas (large and small )
*P-F jt force is influenced by
oThe Q’ceps forces and knee angle
oVertical position of patella
At full knee extension –minimal
compressive forces
Knee flexion - joint
compressions
*>900 contact area decreases –stress increases on
lateral &odd face
Vertical position of patella (Insall –salvati
index)
*Patellar alta --------- more joint compression
*Patellar baja--------- less joint compression
oFrom 0-900 although joint compressive forces
increases the patellar contact area also increases
accordingly
*ASYMMETRY OF P-F
STABILIZATION
Assess by Q-ANGLE :
•Measurement :
•Normal :100-150 in full
extension or slight flexion
Q angle lateral force compression
forces enough lateral force
subluxation
W>M : - wider pelvis
 Increased femoral anteversion
Relative knee valgus angle
*Q angle of 200 or >200 is
abnormal(leads to pain)
*Imbalance between VL and VM muscles
*Presence of tight IT band
*Genu valgum
*Ante version
*Lateral tibial torsion
*Laxity of medial retinaculum
*Excessive tension and adaptive shortening of
lateral retinaculum
*WB vs NWB exercises with P-F
joint pain
 In NWB &WB due to more Q’cep force against MA resistance ----
- increase compression-----increase pain
 Studies recommended
--- avoid deep flexion while doing WB extension exercises
--- avoid the final 300 of extension during NWB knee extension
exercises
*
static : providing stability and strength to
support the weight of the body.
dynamic: Flexibility, strength, and stability are
needed for standing and for motions like
walking, running, crouching, jumping, and
turning.
*Lateral rotation of tibia with extension
During last 300 of knee extension(300-00)
shorter lateral tibial plateu /femoral condyle first
complete its rolling and gliding movts before the longer
medial articular surface do it
Most evident in final 50 of extension
Also known as locking or screw home mechanism
Screw home mechanism
Common conditions seen in Knee
jointCondition Structures
affecting
Mechanisms
1. Ligament
Injury
ACL Sudden landing on unstable knee,
twist and turn in unstable flexed knee
PCL Sudden posterior blow
MCL Accidental Injury experienced during,
lateral rotation of tibia with foot on
ground usually in extension
LCL Same as above but with Medial
rotation of tibia in extension
2. Meniscal
injury
Medial If cutting and grinding in foot on ground
in laterally rotated position, may lead to
meniscal tear.
Lateral If cutting and grinding in foot on ground
in medially rotated position, may lead to
meniscal tear.
3. Arthritis Tibio-
femoral
Age related changes, post-menopausal,
obesity.
Patello-
femoral
Age related changes, post-menopausal,
obesity.
Assessment
History:
*Reason for his entrance in clinic
*How was the injury?
*Stiffness or pain since??
*Particular movement or task inducing
or aggravating pain?
*Difficulty in ADL’s?
Ottawa Knee Rule
diagram
Cook C. Orthopedic Manual Therapy-An evidence based approach; 2007: pg-14-16
Title, Author,
Year
Aim Methodology Conclusion
Implementation
of the Ottawa
rule for the use
of radiography
in acute knee
injuries- A
clinical Trial
Stiell IG, Wells
GA, Hoag RH,
Sivilotti ML,
Cacciotti TF,
Verbeek PR, et
al.
December 1997
To assess
impact on
clinical
practice of
implementin
g the
Ottawa knee
rule.
3907 adults with
acute knee
injuries during 12
months period
before and after
the intervention.
Main outcome
measures were:
referral for knee
radiography,
accuracy and
reliability of the
rule, mean time
in emergency
department
Reduction of 26.4%
in the proportion of
patients referred for
knee X-ray
compared to control
group. (p<0.001*).
Both group by
group and group by
time were
significant.
Thus
implementation of
this rule led to
decrease in use of
knee radiography.
Parameter ACL PCL
Onset Traumatic. Traumatic
Precipitating
factor
Active movement
(flexion)
Active movement
(extension )
Quality of pain Deep Deep
Relieving factor Rest, medications Rest, medications
Site of pain Avulsion: tibial
tuberosity and mid-
substance tear: intra-
articular.
Usually mid-substance tear
is seen: intra-articular
Temporal
variations
NS NS
Pain History
Parameter MCL LCL
Onset Traumatic Traumatic
Precipitating factor Active movement
(extension, flexion and
maximum pain in
lateral rotation of tibia)
Active movement
(extension, flexion and
maximum pain in
medial rotation of
tibia)
Quality of pain Deep Deep
Relieving factor Rest, medications Rest, medications
Site of pain medial aspect of the
knee joint.
Lateral aspect of knee
joint
Temporal
variations
NS NS
Parameter Medial meniscus Lateral meniscus
Onset Traumatic Traumatic
Precipitating factor Weight bearing,
walking, closed kinetic
movements
Weight bearing,
walking, closed kinetic
movements
Quality of pain Deep Deep
Relieving factor Rest, medications Rest, medications
Site of pain Medial knee joint line Lateral knee joint line
Temporal
variations
NS NS
Parameter Arthritis Pain of muscular
origin
Onset Insidious in onset,
gradual increase.
Sudden/Traumatic,
gradual increase.
Precipitating factor PFA: stair climbing up
TFA: Climbing down
Weight bearing,
walking, closed kinetic
movements
Contraction of muscle
Eccentric painful more
than concentric
Quality of pain Deep Tear: deep and dull
Spasm: Dull
Relieving factor Rest, medications Rest, medications
Site of pain Area affected Muscle affected
Temporal
variations
NS NS
Cook C. Orthopedic Manual Therapy-An evidence based approach; 2007: pg-25-26
Parameter Onset
ACL Develops within an hour or two post injury.
PCL Develops within an hour or two post injury.
MCL Develops within an hour or two post injury.
LCL Develops within an hour or two post injury.
Arthritis Present only on exertion of WB activities.
Muscular origin May be present at the site of the impact.
Swelling
Calbach W, Hutchens M. Evaluation of patients presenting with knee pain: Part II.
Differential Diagnosis: 2003; 68 (5): 917-922
Cyriax palpation:
1. Joint line
2. Patella
3. Patellar tendon
4. Tibial tuberosity
5. MCL
6. LCL
7. Gastrocnemius: Medial and Lateral head
8. Hamstring
9. Quadriceps: the bulk
10. Meniscii, ACL and PCL can not be palpated
On Palpation
Palpation of swelling
Large Medium Small
Palpation form 10
cm above patella
Dancing patella test Phase I: Proximal
and lateral
Phase II: Back to
medial
(Fluid displacement
test)
Resisted Isometric done post-surgery or even after immediate
injury. Otherwise Manual muscle testing can be used to
assess the strength of the muscle.
Muscle strength testing
ISOKINETIC DEVICE
A novel device used to determine the strength of knee joint
within each range of knee motion also targeting every
individual muscle.
A Novel Device NORDBOARD
*The tool is invented by Dr. Tony Shield.
*Uses: assess eccentric hamstring strength, risk of hamstring
injury in athletes and bilateral limb strength assymetry.
Title , Author
Year
Aim Procedure Results
A novel device using
the Nordic Hamstring
Exercise to assess
Eccentric knee flexor
strength: a reliability
and retrospective
injury study.
Opar D, Piathowski
T, Williams M, Shield
A
2013
To assess the
reliability of
the hamstring
nord board
while
measuring
eccentric
hamstring
strength.
30
recreationally
active males
without a
history of HSI
completed the
Nordic
hamstring
exercise on
the device.
High to
moderate
reliability(IC
C=0.83 to
0.90)
Isokinetic Dynamometer
*
Title , Author
Year
Aim Procedure Results
Isokinetic
dynamometer
in anterior
cruciate
ligament
injury and
reconstruction
Yong-Hao P,
Bryant A,
Steele J,
Newton R,
Wrigley T.
2008
To determine
the
usefulness of
isokinetic
dynamomete
r to isolate
and qunatify
the muscular
deficits
present
within ACL
deficient or
reconstructe
d knees.
Considered 6 studies
with ACLR patients
having isokinetic
angular velocity in
common. Few studies
having peak quadriceps
torque and hamstring
torque, and some
considering peak quads
torque alone.
Accuracy on
comparison
with self-
reported
athletic
performance
was moderate
to best
(r<0.70)
Glide Normal Abnormal
AP 1-5mm 5-7mm grade 1 injury
7-10mm grade 2
>10mm grade 3
Medial- Lateral 0.5-1mm 1mm Grade 1injury
1-2mm Grade 2
>2mm grade 3
Compression-
Distraction
2-5mm
Accessory movements
ACL Reduced flexion due to pain.
Extension reduced if quadriceps tendon is also affected.
PCL Reduced extension due to pain.
MCL Reduced both flexion and extension due to pain.
LCL Reduced both flexion and extension due to pain.
Arthritis In chronic stage: Reduced movements in both WB and
NWB status.
In acute stage: reduced in WB status.
Muscular
origin
Tear: Reduced both positive and negative muscle work
Spasm: only positive work is reduced
Range of Motion
ACL NWB (unstable) flexion affected, Walking impaired,
WB impaired.
PCL NWB (unstable) extension affected, Walking and
weight bearing impaired.
MCL NWB (unstable) flexion-extension affected, Walking
and weight bearing impaired
LCL NWB (unstable) flexion-extension affected, Walking
and weight bearing impaired
Arthritis Walking for too long, constant standing, squatting,
sitting with crossed legs, stair climbing.
Muscular
origin
Any movement leading to eccentric contraction of the
affected muscle.
Functional Disability
Functional Testing
Starting
position
Action Functional test
Standing Walking backward
Running forward (20
degrees of knee
flexion)
6-8mts: Functional
3-6mts: functionally fair
1-3mts: functionally poor
0mts: nonfunctional
Standing Squat: 20-30degrees
Jump, lifting body off
floor
5-6reps: functional
3-4reps: functionally fair
1-2reps: functionally poor
0reps: nonfunctional
Palmar M, Epler M. Clinical Assessment Procedures in Physical Therapy.
Philadelphia, J.B. Lippincott, 1990. pp 275-276.
ACL Lever sign, Heel height test
PCL Dial test
MCL Swain test, Slocum antero-medial
rotatory instability test
LCL Slocum antero-lateral rotatory
instability test
Meniscal involvement Ege’s test
Arthritis Duck walk test
Patellofemoral disorders Vastus medialis co-ordination test
Special test
Lever Sign Test
The lever sign is one of the diagnostic test to assess partial as
well as complete anterior cruciate ligament tears and even for
acute injuries.
A: Intact ACL
B: Ruptured ACL
*
Title, Author,
Year
Aim Procedure Results
The “Lever
sign” a new
clinical test for
the diagnosis of
anterior cruciate
ligament
rupture.
Jarbo K,
Hartigan D,
Scott K, Patel K
and Chhabra A.
2017
To assess the
sensitivity and
specificity of
the lever sign
for diagnosis
of acute ACL
injuries
Out of 102 patients
54 were posted for
operation cases and
48 were non-
operative cases.
Test was performed
on both groups. For
non-operated cases
in OPD and
operative cases
before SX
intervention on GA.
MRI results were
compared.
The accuracy
was similar
between
patient under
anesthesia and
awake. The
study showed
high sensitivity
and specificity
values.
Heel height test
The examiner grasps the great toe and lifts the foot vertically
while stabilizing the distal thigh to avoid knee elevation and
rotation. An assistant measures the distance between the heel and
the examination or surgical table. Side to side difference was
calculated.
Title, Author,
Year
Aim Methodology Conclusion
Heel height test: A
novel tool for the
detection of
combined anterior
cruciate ligament
and fibular
collateral ligament
tear
Cinque M, Geeslin
A, Chahla J,
Moatshe G,
Laprade R,
Dephillipo N. et al
2017
To determine
the clinical
utility of
heel height
SSD
assessment
in
ACL+LCL
ligament
injury
2 groups; A:
isolated ACL
tears, B:
ACL+FCL
tears.
(158 patients)
High sensitivity and
excellent specificity
for diagnosis of
ACL+FCL tears
compared with
sensitivity and
specifictiy of MRI
detection.
Dial test
Compare it with the
contralateral limb, different
degrees of rotation at 30 as
well as 90 degrees of knee
flexion. Check at both the
degree of knee flexion. The
ACL ruptured leg rotates
more compared to intact
leg.
Title, Author,
Year
Aim Methodology Conclusion
Evaluation of
reliability of dial
test for postero-
lateral rotatory
instability: a
cadaveric study
using an isotonic
rotation machine
Bae JH, Choi IC,
Suh SW, Lim HC,
Bae TS, Nha KW,
et al.
2008
To evaluate
reliability of
dial test by
assessing
correlation
between the
severity of
posterolateral
corner injury
and the amount
of external
rotation of the
tibia
41 paired
cadaveric legs. 2
Groups;
A: Posterolateral
corner +PCL
B: isolated PCL.
External rotation
angle were
measured with a
6-Nm rotational
torque
Valuable
method for
diagnosing
PCL and
posterolateral
structures
The knee is flexed to 90 degree and tibia is fully
externally rotated. The test is considered positive if
patient complains of pain in medial side of knee
joint.
*
Title , Author
Year
Aim Procedure Results
Medial
Collateral
Ligament
Injuries of the
Knee: An
evolution of
surgical
reconstruction-
A pilot study
Lonergan K,
Taylor D.
2002
To discuss
initial
evaluation
and the pre-
operative
assesement
8 patients with non-
operative treatment
with isolated MCL
injuries were assessed
for rotatory instability
test with Swain test.
Excellent
accuracy was
found with the
test.
*
Title ,
Author
Year
Aim Procedure Results
Anterolater
al rotatory
instability
of the
knee: an
analysis of
the Ellison
procedure
Hanks G,
Joyner D,
Kalenak A
1981
To identify wheather
the solcum
anterolateral test was
accurate in
identifying the
anterolateral
instability due to
MCL alone or in
combination with
ACL injuries
Out of 30 patients who had
injured their knee during
athletic activities were
conservatively managed
before OT. After a follow-up
of 9 months 28 patients
returned to the clinic with
knee giving away. Physical
examination of solcum ALRI
test against MRI was done
and patients were operated for
the same using Ellison
procedure.
Slocum test
proved to be as
significant as MRI
with accuracy of
about 70%.
Also, Ellison
procedure
significantly
reduced the giving
away of knee, and
was as efficient
compared to other
procedures.
Slocum AMRI/ALRI test
Ege’s test (WB McMurray’s test)
It is nothing but
McMurray’s test but in
weight bearing
position.
*
Title , Author
Year
Aim Procedure Results
A new weight
bearing
meniscal test
and a
comparison
with
McMurray’s
test and joint
line tenderness
Akeseki D,
Pinar H.
2004
To describe
a new
weight
bearing
McMurray’
s test
(Ege’s test)
and to
compare its
dignostic
value with
McMurray’
s test and
joint line
tenderness
127 patients among
which 90 had medial,
28 had lateral and 9 had
both meniscal tears.
Better
accuracy
(71%)
sensitivity
(67%)and
specificity
(81%) rates
were found
with the new
test.
*
Title , Author
Year
Aim Procedure Results
Diagnostic accuracy of
the Thessaly test,
standardised clinical
history and other clinical
examination tests
(Apley’s, McMurray’s
and joint line tenderness)
for meniscal tears in
comparison with
magnetic resonance
imaging diagnosis
Blyth M, Anthony I,
Downie P, MacLean A,
Norrie J, Powell A. et al
2015
To determine
diagnostic
accuracy of
the Thessaly
test and to
determine if
Thessaly test
alone or in
combination
with other
tests can
obviate the
need of
investigation
by MRI
367 subjects
were recruited in
2 groups. A: 292:
with knee
pathology and B:
75: without knee
pathology as
control.
Thessaly test
had sensitivity
of 0.66 and
specificity of
0.55 and
diagnostic
accuracy of
54%. Hence it
was moderately
accurate in
diagnosing Knee
pathology on
comparison with
MRI.
Thessaly test
Bounce home test
Duck walk test
*
Title , Author
Year
Aim Methodology Conclusion
What is the
diagnostic
accuracy of the
duck walk test
in detecting
meniscal tears
Van der A,
Noorduyn J,
Scholtes V,
Mutsaerts E.
2017
To
determine
the
sensitivity
and
specificity
of the duck
walk test in
diagnosing
medial
meniscal
tear.
136 subjects with
knee injury who
had MRI before
(24%) or after
(76%) physical
examination and
had duck walk
test performed.
The calculated
sensitivity was 71%,
with low specificity
39% and no
significant scores
between medial and
lateral tears in
diagnosing the
specific site of tear.
Vastus medialis co-ordination test
*
Title , Author
Year
Aim Methodology Conclusion
Diagnostic
value of five
clinical tests in
patellofemoral
pain syndrome
JoNijs,
BartVan, Velde
2005
Examining
the validity
of five
clinical
patellofemo
ral tests
used in
dignosis of
patellofemo
ral pain
syndrome.
45 subjects were
divided into
either PFPS or
the non-PFPS
group. The five
tests were Vastus
medialis
cordination test,
Patellar
apprehension test,
Waldron’s test,
Clarke’s test and
eccentric step
test.
The postive
likelihood of Vastus
medialis
coordination test and
patellar apprehension
test was 2.36 and rest
were below 2. but
these data question
the validity of the
tests as negative
threshold value
exceeded 0.5
THANK YOU
1. Susan, Standring. Gray’s Anatomy: The anatomical basis of clinical
practice. In: Elsevier Churchill Livingstone publication; Edinburgh New
York; 2005(39): 1367-85
2. Calliet R. Knee Pain and Disability. 1992: ed.3:1-70
3. Stiell IG, Wells GA, Hoag RH, Sivilotti ML, Cacciotti TF, Verbeek PR, et
al. Implementation of the Ottawa rule for the use of radiography in acute
knee injuries- A clinical Trial; 1997:
4. Cook C. Orthopedic Manual Therapy-An evidence based approach; 2007:
pg-25-26
5. Calbach W, Hutchens M. Evaluation of patients presenting with knee pain:
Part II. Differential Diagnosis: 2003; 68 (5): 917-922
6. Cyriax J, Cyriax P. Cyriax’s Illustrated Manual of Orthopedic
Medicine;1983: ed. 2: 93-110
7. Opar D, Piathowski T, Williams M, Shield A. A novel device using the
Nordic Hamstring Exercise to assess Eccentric knee flexor strength: a
reliability and retrospective injury study; 2013:
8. Rezaei M, Ebrahimi I, Gharamaleki B, Pirali M, Mortaza N, Malmir K.
et al. Isokinnetic dynamometer of knee extensors and flexors in Iranian
healthy males and females; 2014
9. Yong-Hao P, Bryant A, Steele J, Newton R, Wrigley T. Isokinnetic
dynamometer in anterior cruciate ligament injury and reconstruction;
2008: 37(4): 330-340
10.Palmar M, Epler M. Clinical Assessment Procedures inn Physical
Therapy. Philadelphia, J.B. Lippincott, 1990. pp 275-276
11.Jarbo K, Hartigan D, Scott K, Patel K and Chhabra A. The “Lever sign”
a new clinical test for the diagnosis of anterior cruciate ligament rupture;
2017
12.Cinque M, Geeslin A, Chahla J, Moatshe G, Laprade R, Dephillipo N. et
al. Heel height test: A novel tool for the detection of combined anterior
cruciate ligament and fibular collateral ligament tear; 2017
13.Bae JH, Choi IC, Suh SW, Lim HC, Bae TS, Nha KW, et al. Evaluation
of reliability of dial test for postero-lateral rotatory instability: a
cadaveric study using an isotonic rotation machine; 2008:
14. Lonergan K, Taylor D. Medial Collateral Ligament Injuries of the
Knee: An evolution of surgical reconstruction- A pilot study; 2002.
15. Hanks G, Joyner D, Kalenak A. Anterolateral rotatory instability of
the knee: an analysis of the Ellison procedure;1981.
16. Akeseki D, Pinar H. A new weight bearing meniscal test and a
comparison with McMurray’s test and joint line tenderness; 2004.
17. Blyth M, Anthony I, Downie P, MacLean A, Norrie J, Powell A. et
al. Diagnostic accuracy of the Thessaly test, standardised clinical
history and other clinical examination tests (Apley’s, McMurray’s
and joint line tenderness) for meniscal tears in comparison with
magnetic resonance imaging diagnosis;2015
18. Van der A, Noorduyn J, Scholtes V, Mutsaerts E. What is the
diagnostic accuracy of the duck walk test in detecting meniscal
tears;2017
19. JoNijs, BartVan, Velde. Diagnostic value of five clinical tests in
patellofemoral pain syndrome. 2005;5:109-115

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Knee joint anatomy, biomechanics, pathomechanics and assessment

  • 4. *Menisci *Fibro cartilaginous disk *Thick peripherally and thin centrally *Wedge shape in cross section *Medial meniscus is C-shaped *Lateral meniscus is 4/5 th of a circle , covers more surface of small lat.tibial plateu *Medial condyle more prone for compressive loads
  • 5. * *Congruence *Reduce friction *Wt bearing forces distribution *Shock absorber
  • 6. *Menisci nutrition & innervations •During I year of life ----- entire •Wt bear ----- only outer 25% -33% •>50 year age only periphery Central ----synovial fluid Wt bearing Muscle contraction femur rotation on fixed tibia Immobilization Only periphery -inflammation -Repair -remodelling Vascular: oHorns ,peripheral vascular area---free nerve endings 3 different mechano receptors ruffini - ----stretch pacinian --- compression galgi -----pressure Loss of mechanoreceptors Loss of proprioception Innervation
  • 7. *Meniscal attachments *Horns attach firmly to tibia below *Transverse ligament *Patello- meniscal ligament *Coronary ligament Semi membrinosus via capsular connections Popliteal muscle tendon A & P horns of medial meniscus Attach to ACL@PCL resp. Posteriorly lateral meniscus attach to PCL MCL
  • 8. *Joint capsule *Attachments *The A-M& A-L portion of the capsule called M&L patello femoral retinaculae----- extensor retinaculam *It is innervated by nauci , mechanoreceptors (muscle stabilization)
  • 9. *Synovial layer Structures intra capsular and extra synovial ACL , PCL , popliteus muscle tendon(PL) , semi membrinosus and gastrocnemious medial head(PM) PATELLAR PLICA: synovial folds In ng order frequency of location inferior(infra patellar plica) superior(supra patellar plica) medial(medio patellar plica)
  • 10. Joint Kinetics Movement Axis Arthrokinematics Flexion Femoral epicondyle Roll posteriorly and glide anteriorly Extension Femoral epicondyle Rolls anteriorly and glide posteriorly In weight bearing phase In non-weight bearing phase Movement Axis Arthrokinematics Flexion Tibial epicondyle Rolls anteriorly Glide posteriorly Extension Tibial epicondyle Rolls posteriorly Glide anteriorly
  • 11. Osteokinematics Knee Flexion Normal: 130-140 degrees Normal gait: 60-70 degrees Ascending stairs: 80 degrees Knee extension Normal: 0 Genu recurvatum: >5 degree Knee rotations (maximum at 90degree of knee flexion) LR: 0-20 degrees MR: 0-15 degrees Valgus / varus: Full extension: 8 At 20degree of knee flexion: 13 degree Calliet R. Knee Pain and Disability. 1992: ed.3:1-70
  • 13. Patellofemoral Joint KNEE POSITION PATELLO-FEMORAL CONTACT Extension Inferior pole At 100-200 of knee flexion Inferior margin of medial &lateral facets of patella As range progress Inferior to more superior By 900of knee flexion Except ODD FACET all portions experience some contact >900 Odd facet begins with medial femoral condyle first time At full knee flexion Lodged in inter condylar groove Contact is only lateral& odd facet Calliet R. Knee Pain and Disability. 1992: ed.3:1-70
  • 14. PATELLO FEMORAL JOINT STRESSES *Stress(F/A) can be influenced by force &contact areas (large and small ) *P-F jt force is influenced by oThe Q’ceps forces and knee angle oVertical position of patella At full knee extension –minimal compressive forces Knee flexion - joint compressions
  • 15. *>900 contact area decreases –stress increases on lateral &odd face Vertical position of patella (Insall –salvati index) *Patellar alta --------- more joint compression *Patellar baja--------- less joint compression oFrom 0-900 although joint compressive forces increases the patellar contact area also increases accordingly
  • 16. *ASYMMETRY OF P-F STABILIZATION Assess by Q-ANGLE : •Measurement : •Normal :100-150 in full extension or slight flexion
  • 17. Q angle lateral force compression forces enough lateral force subluxation W>M : - wider pelvis  Increased femoral anteversion Relative knee valgus angle
  • 18. *Q angle of 200 or >200 is abnormal(leads to pain) *Imbalance between VL and VM muscles *Presence of tight IT band *Genu valgum *Ante version *Lateral tibial torsion *Laxity of medial retinaculum *Excessive tension and adaptive shortening of lateral retinaculum
  • 19. *WB vs NWB exercises with P-F joint pain  In NWB &WB due to more Q’cep force against MA resistance ---- - increase compression-----increase pain  Studies recommended --- avoid deep flexion while doing WB extension exercises --- avoid the final 300 of extension during NWB knee extension exercises
  • 20. * static : providing stability and strength to support the weight of the body. dynamic: Flexibility, strength, and stability are needed for standing and for motions like walking, running, crouching, jumping, and turning.
  • 21. *Lateral rotation of tibia with extension During last 300 of knee extension(300-00) shorter lateral tibial plateu /femoral condyle first complete its rolling and gliding movts before the longer medial articular surface do it Most evident in final 50 of extension Also known as locking or screw home mechanism Screw home mechanism
  • 22. Common conditions seen in Knee jointCondition Structures affecting Mechanisms 1. Ligament Injury ACL Sudden landing on unstable knee, twist and turn in unstable flexed knee PCL Sudden posterior blow MCL Accidental Injury experienced during, lateral rotation of tibia with foot on ground usually in extension LCL Same as above but with Medial rotation of tibia in extension
  • 23. 2. Meniscal injury Medial If cutting and grinding in foot on ground in laterally rotated position, may lead to meniscal tear. Lateral If cutting and grinding in foot on ground in medially rotated position, may lead to meniscal tear. 3. Arthritis Tibio- femoral Age related changes, post-menopausal, obesity. Patello- femoral Age related changes, post-menopausal, obesity.
  • 24. Assessment History: *Reason for his entrance in clinic *How was the injury? *Stiffness or pain since?? *Particular movement or task inducing or aggravating pain? *Difficulty in ADL’s?
  • 25. Ottawa Knee Rule diagram Cook C. Orthopedic Manual Therapy-An evidence based approach; 2007: pg-14-16
  • 26. Title, Author, Year Aim Methodology Conclusion Implementation of the Ottawa rule for the use of radiography in acute knee injuries- A clinical Trial Stiell IG, Wells GA, Hoag RH, Sivilotti ML, Cacciotti TF, Verbeek PR, et al. December 1997 To assess impact on clinical practice of implementin g the Ottawa knee rule. 3907 adults with acute knee injuries during 12 months period before and after the intervention. Main outcome measures were: referral for knee radiography, accuracy and reliability of the rule, mean time in emergency department Reduction of 26.4% in the proportion of patients referred for knee X-ray compared to control group. (p<0.001*). Both group by group and group by time were significant. Thus implementation of this rule led to decrease in use of knee radiography.
  • 27. Parameter ACL PCL Onset Traumatic. Traumatic Precipitating factor Active movement (flexion) Active movement (extension ) Quality of pain Deep Deep Relieving factor Rest, medications Rest, medications Site of pain Avulsion: tibial tuberosity and mid- substance tear: intra- articular. Usually mid-substance tear is seen: intra-articular Temporal variations NS NS Pain History
  • 28. Parameter MCL LCL Onset Traumatic Traumatic Precipitating factor Active movement (extension, flexion and maximum pain in lateral rotation of tibia) Active movement (extension, flexion and maximum pain in medial rotation of tibia) Quality of pain Deep Deep Relieving factor Rest, medications Rest, medications Site of pain medial aspect of the knee joint. Lateral aspect of knee joint Temporal variations NS NS
  • 29. Parameter Medial meniscus Lateral meniscus Onset Traumatic Traumatic Precipitating factor Weight bearing, walking, closed kinetic movements Weight bearing, walking, closed kinetic movements Quality of pain Deep Deep Relieving factor Rest, medications Rest, medications Site of pain Medial knee joint line Lateral knee joint line Temporal variations NS NS
  • 30. Parameter Arthritis Pain of muscular origin Onset Insidious in onset, gradual increase. Sudden/Traumatic, gradual increase. Precipitating factor PFA: stair climbing up TFA: Climbing down Weight bearing, walking, closed kinetic movements Contraction of muscle Eccentric painful more than concentric Quality of pain Deep Tear: deep and dull Spasm: Dull Relieving factor Rest, medications Rest, medications Site of pain Area affected Muscle affected Temporal variations NS NS
  • 31. Cook C. Orthopedic Manual Therapy-An evidence based approach; 2007: pg-25-26
  • 32. Parameter Onset ACL Develops within an hour or two post injury. PCL Develops within an hour or two post injury. MCL Develops within an hour or two post injury. LCL Develops within an hour or two post injury. Arthritis Present only on exertion of WB activities. Muscular origin May be present at the site of the impact. Swelling Calbach W, Hutchens M. Evaluation of patients presenting with knee pain: Part II. Differential Diagnosis: 2003; 68 (5): 917-922
  • 33. Cyriax palpation: 1. Joint line 2. Patella 3. Patellar tendon 4. Tibial tuberosity 5. MCL 6. LCL 7. Gastrocnemius: Medial and Lateral head 8. Hamstring 9. Quadriceps: the bulk 10. Meniscii, ACL and PCL can not be palpated On Palpation
  • 34. Palpation of swelling Large Medium Small Palpation form 10 cm above patella Dancing patella test Phase I: Proximal and lateral Phase II: Back to medial (Fluid displacement test)
  • 35. Resisted Isometric done post-surgery or even after immediate injury. Otherwise Manual muscle testing can be used to assess the strength of the muscle. Muscle strength testing ISOKINETIC DEVICE A novel device used to determine the strength of knee joint within each range of knee motion also targeting every individual muscle.
  • 36. A Novel Device NORDBOARD
  • 37. *The tool is invented by Dr. Tony Shield. *Uses: assess eccentric hamstring strength, risk of hamstring injury in athletes and bilateral limb strength assymetry. Title , Author Year Aim Procedure Results A novel device using the Nordic Hamstring Exercise to assess Eccentric knee flexor strength: a reliability and retrospective injury study. Opar D, Piathowski T, Williams M, Shield A 2013 To assess the reliability of the hamstring nord board while measuring eccentric hamstring strength. 30 recreationally active males without a history of HSI completed the Nordic hamstring exercise on the device. High to moderate reliability(IC C=0.83 to 0.90)
  • 39. * Title , Author Year Aim Procedure Results Isokinetic dynamometer in anterior cruciate ligament injury and reconstruction Yong-Hao P, Bryant A, Steele J, Newton R, Wrigley T. 2008 To determine the usefulness of isokinetic dynamomete r to isolate and qunatify the muscular deficits present within ACL deficient or reconstructe d knees. Considered 6 studies with ACLR patients having isokinetic angular velocity in common. Few studies having peak quadriceps torque and hamstring torque, and some considering peak quads torque alone. Accuracy on comparison with self- reported athletic performance was moderate to best (r<0.70)
  • 40. Glide Normal Abnormal AP 1-5mm 5-7mm grade 1 injury 7-10mm grade 2 >10mm grade 3 Medial- Lateral 0.5-1mm 1mm Grade 1injury 1-2mm Grade 2 >2mm grade 3 Compression- Distraction 2-5mm Accessory movements
  • 41. ACL Reduced flexion due to pain. Extension reduced if quadriceps tendon is also affected. PCL Reduced extension due to pain. MCL Reduced both flexion and extension due to pain. LCL Reduced both flexion and extension due to pain. Arthritis In chronic stage: Reduced movements in both WB and NWB status. In acute stage: reduced in WB status. Muscular origin Tear: Reduced both positive and negative muscle work Spasm: only positive work is reduced Range of Motion
  • 42. ACL NWB (unstable) flexion affected, Walking impaired, WB impaired. PCL NWB (unstable) extension affected, Walking and weight bearing impaired. MCL NWB (unstable) flexion-extension affected, Walking and weight bearing impaired LCL NWB (unstable) flexion-extension affected, Walking and weight bearing impaired Arthritis Walking for too long, constant standing, squatting, sitting with crossed legs, stair climbing. Muscular origin Any movement leading to eccentric contraction of the affected muscle. Functional Disability
  • 43. Functional Testing Starting position Action Functional test Standing Walking backward Running forward (20 degrees of knee flexion) 6-8mts: Functional 3-6mts: functionally fair 1-3mts: functionally poor 0mts: nonfunctional Standing Squat: 20-30degrees Jump, lifting body off floor 5-6reps: functional 3-4reps: functionally fair 1-2reps: functionally poor 0reps: nonfunctional Palmar M, Epler M. Clinical Assessment Procedures in Physical Therapy. Philadelphia, J.B. Lippincott, 1990. pp 275-276.
  • 44. ACL Lever sign, Heel height test PCL Dial test MCL Swain test, Slocum antero-medial rotatory instability test LCL Slocum antero-lateral rotatory instability test Meniscal involvement Ege’s test Arthritis Duck walk test Patellofemoral disorders Vastus medialis co-ordination test Special test
  • 45. Lever Sign Test The lever sign is one of the diagnostic test to assess partial as well as complete anterior cruciate ligament tears and even for acute injuries. A: Intact ACL B: Ruptured ACL
  • 46. * Title, Author, Year Aim Procedure Results The “Lever sign” a new clinical test for the diagnosis of anterior cruciate ligament rupture. Jarbo K, Hartigan D, Scott K, Patel K and Chhabra A. 2017 To assess the sensitivity and specificity of the lever sign for diagnosis of acute ACL injuries Out of 102 patients 54 were posted for operation cases and 48 were non- operative cases. Test was performed on both groups. For non-operated cases in OPD and operative cases before SX intervention on GA. MRI results were compared. The accuracy was similar between patient under anesthesia and awake. The study showed high sensitivity and specificity values.
  • 47. Heel height test The examiner grasps the great toe and lifts the foot vertically while stabilizing the distal thigh to avoid knee elevation and rotation. An assistant measures the distance between the heel and the examination or surgical table. Side to side difference was calculated.
  • 48. Title, Author, Year Aim Methodology Conclusion Heel height test: A novel tool for the detection of combined anterior cruciate ligament and fibular collateral ligament tear Cinque M, Geeslin A, Chahla J, Moatshe G, Laprade R, Dephillipo N. et al 2017 To determine the clinical utility of heel height SSD assessment in ACL+LCL ligament injury 2 groups; A: isolated ACL tears, B: ACL+FCL tears. (158 patients) High sensitivity and excellent specificity for diagnosis of ACL+FCL tears compared with sensitivity and specifictiy of MRI detection.
  • 49. Dial test Compare it with the contralateral limb, different degrees of rotation at 30 as well as 90 degrees of knee flexion. Check at both the degree of knee flexion. The ACL ruptured leg rotates more compared to intact leg.
  • 50. Title, Author, Year Aim Methodology Conclusion Evaluation of reliability of dial test for postero- lateral rotatory instability: a cadaveric study using an isotonic rotation machine Bae JH, Choi IC, Suh SW, Lim HC, Bae TS, Nha KW, et al. 2008 To evaluate reliability of dial test by assessing correlation between the severity of posterolateral corner injury and the amount of external rotation of the tibia 41 paired cadaveric legs. 2 Groups; A: Posterolateral corner +PCL B: isolated PCL. External rotation angle were measured with a 6-Nm rotational torque Valuable method for diagnosing PCL and posterolateral structures
  • 51. The knee is flexed to 90 degree and tibia is fully externally rotated. The test is considered positive if patient complains of pain in medial side of knee joint.
  • 52. * Title , Author Year Aim Procedure Results Medial Collateral Ligament Injuries of the Knee: An evolution of surgical reconstruction- A pilot study Lonergan K, Taylor D. 2002 To discuss initial evaluation and the pre- operative assesement 8 patients with non- operative treatment with isolated MCL injuries were assessed for rotatory instability test with Swain test. Excellent accuracy was found with the test.
  • 53. * Title , Author Year Aim Procedure Results Anterolater al rotatory instability of the knee: an analysis of the Ellison procedure Hanks G, Joyner D, Kalenak A 1981 To identify wheather the solcum anterolateral test was accurate in identifying the anterolateral instability due to MCL alone or in combination with ACL injuries Out of 30 patients who had injured their knee during athletic activities were conservatively managed before OT. After a follow-up of 9 months 28 patients returned to the clinic with knee giving away. Physical examination of solcum ALRI test against MRI was done and patients were operated for the same using Ellison procedure. Slocum test proved to be as significant as MRI with accuracy of about 70%. Also, Ellison procedure significantly reduced the giving away of knee, and was as efficient compared to other procedures. Slocum AMRI/ALRI test
  • 54. Ege’s test (WB McMurray’s test) It is nothing but McMurray’s test but in weight bearing position.
  • 55. * Title , Author Year Aim Procedure Results A new weight bearing meniscal test and a comparison with McMurray’s test and joint line tenderness Akeseki D, Pinar H. 2004 To describe a new weight bearing McMurray’ s test (Ege’s test) and to compare its dignostic value with McMurray’ s test and joint line tenderness 127 patients among which 90 had medial, 28 had lateral and 9 had both meniscal tears. Better accuracy (71%) sensitivity (67%)and specificity (81%) rates were found with the new test.
  • 56. * Title , Author Year Aim Procedure Results Diagnostic accuracy of the Thessaly test, standardised clinical history and other clinical examination tests (Apley’s, McMurray’s and joint line tenderness) for meniscal tears in comparison with magnetic resonance imaging diagnosis Blyth M, Anthony I, Downie P, MacLean A, Norrie J, Powell A. et al 2015 To determine diagnostic accuracy of the Thessaly test and to determine if Thessaly test alone or in combination with other tests can obviate the need of investigation by MRI 367 subjects were recruited in 2 groups. A: 292: with knee pathology and B: 75: without knee pathology as control. Thessaly test had sensitivity of 0.66 and specificity of 0.55 and diagnostic accuracy of 54%. Hence it was moderately accurate in diagnosing Knee pathology on comparison with MRI. Thessaly test
  • 59. * Title , Author Year Aim Methodology Conclusion What is the diagnostic accuracy of the duck walk test in detecting meniscal tears Van der A, Noorduyn J, Scholtes V, Mutsaerts E. 2017 To determine the sensitivity and specificity of the duck walk test in diagnosing medial meniscal tear. 136 subjects with knee injury who had MRI before (24%) or after (76%) physical examination and had duck walk test performed. The calculated sensitivity was 71%, with low specificity 39% and no significant scores between medial and lateral tears in diagnosing the specific site of tear.
  • 61. * Title , Author Year Aim Methodology Conclusion Diagnostic value of five clinical tests in patellofemoral pain syndrome JoNijs, BartVan, Velde 2005 Examining the validity of five clinical patellofemo ral tests used in dignosis of patellofemo ral pain syndrome. 45 subjects were divided into either PFPS or the non-PFPS group. The five tests were Vastus medialis cordination test, Patellar apprehension test, Waldron’s test, Clarke’s test and eccentric step test. The postive likelihood of Vastus medialis coordination test and patellar apprehension test was 2.36 and rest were below 2. but these data question the validity of the tests as negative threshold value exceeded 0.5
  • 63. 1. Susan, Standring. Gray’s Anatomy: The anatomical basis of clinical practice. In: Elsevier Churchill Livingstone publication; Edinburgh New York; 2005(39): 1367-85 2. Calliet R. Knee Pain and Disability. 1992: ed.3:1-70 3. Stiell IG, Wells GA, Hoag RH, Sivilotti ML, Cacciotti TF, Verbeek PR, et al. Implementation of the Ottawa rule for the use of radiography in acute knee injuries- A clinical Trial; 1997: 4. Cook C. Orthopedic Manual Therapy-An evidence based approach; 2007: pg-25-26 5. Calbach W, Hutchens M. Evaluation of patients presenting with knee pain: Part II. Differential Diagnosis: 2003; 68 (5): 917-922 6. Cyriax J, Cyriax P. Cyriax’s Illustrated Manual of Orthopedic Medicine;1983: ed. 2: 93-110 7. Opar D, Piathowski T, Williams M, Shield A. A novel device using the Nordic Hamstring Exercise to assess Eccentric knee flexor strength: a reliability and retrospective injury study; 2013:
  • 64. 8. Rezaei M, Ebrahimi I, Gharamaleki B, Pirali M, Mortaza N, Malmir K. et al. Isokinnetic dynamometer of knee extensors and flexors in Iranian healthy males and females; 2014 9. Yong-Hao P, Bryant A, Steele J, Newton R, Wrigley T. Isokinnetic dynamometer in anterior cruciate ligament injury and reconstruction; 2008: 37(4): 330-340 10.Palmar M, Epler M. Clinical Assessment Procedures inn Physical Therapy. Philadelphia, J.B. Lippincott, 1990. pp 275-276 11.Jarbo K, Hartigan D, Scott K, Patel K and Chhabra A. The “Lever sign” a new clinical test for the diagnosis of anterior cruciate ligament rupture; 2017 12.Cinque M, Geeslin A, Chahla J, Moatshe G, Laprade R, Dephillipo N. et al. Heel height test: A novel tool for the detection of combined anterior cruciate ligament and fibular collateral ligament tear; 2017 13.Bae JH, Choi IC, Suh SW, Lim HC, Bae TS, Nha KW, et al. Evaluation of reliability of dial test for postero-lateral rotatory instability: a cadaveric study using an isotonic rotation machine; 2008:
  • 65. 14. Lonergan K, Taylor D. Medial Collateral Ligament Injuries of the Knee: An evolution of surgical reconstruction- A pilot study; 2002. 15. Hanks G, Joyner D, Kalenak A. Anterolateral rotatory instability of the knee: an analysis of the Ellison procedure;1981. 16. Akeseki D, Pinar H. A new weight bearing meniscal test and a comparison with McMurray’s test and joint line tenderness; 2004. 17. Blyth M, Anthony I, Downie P, MacLean A, Norrie J, Powell A. et al. Diagnostic accuracy of the Thessaly test, standardised clinical history and other clinical examination tests (Apley’s, McMurray’s and joint line tenderness) for meniscal tears in comparison with magnetic resonance imaging diagnosis;2015 18. Van der A, Noorduyn J, Scholtes V, Mutsaerts E. What is the diagnostic accuracy of the duck walk test in detecting meniscal tears;2017 19. JoNijs, BartVan, Velde. Diagnostic value of five clinical tests in patellofemoral pain syndrome. 2005;5:109-115