Soft tissue injury of the knee Taiz University , faculty of medicine and health sciences By Dr : Baha'a Abdulhameed

1. SOFT TISSUE INJURY OF THE
KNEE
Done by : baha’a abdulhameed
group D
2015

2. INTRODUCTION
Soft tissue injuries of the knee are some of the most
common and clinically challenging musculoskeletal
disorders in patients presenting to the ED.
soft tissue structures that stabilize and cushion the
knee joint including
ligaments
muscles
tendons
menisci

3. SPRAIN VS STRAIN
Definitions of sprains and strains
Sprains:
characterized by the stretching or tearing of non-
contractile structures, such as the investing ligaments
or of the joint capsule itself.
strain :
characterized by stretching or severing along the
course of muscles or tendons.
*Both collateral ligament and cruciate ligament
sprains, as well as muscular strains, are
relatively common.

4. GRADES OF SPRAINS AND STRAINS
Grade I sprain
Stretching but no tearing of the ligament, local tenderness,
minimal edema, no gross instability with stress testing, firm end
point
Grade II sprain
Partial tears of the ligaments, moderate local tenderness, mild
instability with stress testing (but firm end point), moderately
incapacitating
Grade III sprain
- Complete tear, discomfort with manipulation but less than
expected for degree of injury, variable amount of edema
(ranging from negligible to grossly conspicuous), clear
instability with stress testing (expressing a mushy end point),
severe disability

5. knee ligaments

6. Of the all ligaments there are 4 ligaments which are
commonly injured , they can be classified as following
:
1-intra-articular
-anterior cruciate ligament ACL
-posterior cruciate ligament PCL
2-extra-articular
-medial (tibial ) collateral ligament MCL
-lateral (fibular) collateral ligament LCL

8. ANTERIOR CRUCIATE LIGAMENT
The anterior cruciate ligament (ACL) , it resists the anterior translation
of the tibia relative to the
femur.
- it originates on the anterior intercondylar area of the tibia and passes
upward backward and laterally to be inserts to posteromedial aspect of
the lateral condyle of the femur
- ACL includes two functional bundles:
1- anteromedial bundle, which tightens in flexion,
2-posterolateral bundle, which tightens in extension
-ACL prevents posterior displacement of the femur on the tibia -with
the knee joint flexed the ACL prevents the tibia from being pulled
anterior -tight in hyperextension of the knee.

9. MECHANISM OF INJURY

10. The posterior cruciate ligament (PCL) resists against
posterior translation of tibia over femur .
It originates on the posterior intercondylar area of the tibia
and passes upward forward and medially and insert to the
anterolateral aspect of the medial femoral
condyle
-The PCL also is made up of two functional bundles. 1-
anterior meniscofemoral 2-
posterior meniscofemoral ligament originate from the
posterior horn of the lateral meniscus and contribute to the
function of the PCL.
- PCL prevent anterior displacement of femur on tibia -
with the knee joint flexed the PCL prevent the tibia from
being pulled posteriorly - tight in hyperflexion

13. CLINICAL PICTURE

14. Complete tearpartial tear
a complete tear the
patient may have little or no pain,
a partial
tear the knee is painful.
Swelling is less with complete tearSwelling also is worse with
partial tears
Abnormal movement of a complete
tear is often painless or
prevented by spasm
attempted movement is always
painful

15. DIAGNOSIS
A- CLINICALLY ,by physical examination
ACL examination

16. A- lockman test
*position of the patient :
supine
*position of the examiner:
- he or she stand on the side of affected
limb
-the proximal hand attaches to the patient
femur and stabilizes it.
- the distal hand attaches to proximal part
of the tibia position it in 20 of flexion and
push it forward .
- not forget to examine the other limb for
comparison .
*results:
positive test indicated by noticing
abnormal ant displacement of the tibia
forward .

17. B- PIVOT SHIFT TEST
*position of the patient:
supine
*position of examiner :
. The examiner should lift the tested leg off the
table with the knee fully extended. Place the
heel of one hand behind the fibular head of the
patient. Use the other hand to grasp the tibia,
while palpating the medial joint line. While
maintaining a valgus force and internal rotation
of the tibia throughout the test, slowly flex the
patient's knee (note: the test starts by putting
the tibia in the abnormal position!).
*results:
if there is an anterior subluxation felt during
extension the test is positive for instability

18. C-ANTERIOR DRAWER TEST
The patient lies supine on a plinth with
their hips flexed to 45degrees, his/her
knees flexed to 90degress and feet flat
on the plinth. The examiner sits on the
toes of the tested extremity to help
stabilize it. The examiner grasps the
proximal lower leg, just below the tibial
plateau or tibiofemoral joint line, and
attempts to translate the lower leg
anteriorly. The test is considered positive
if there is a lack of end feel or excessive
anterior translation relative to the
contralateral side.

19. 2- PCL examination

20. 2-POSTERIOR DRAWER TEST
The patient lies supine on a plinth with
their hips flexed to 45degrees, his/her
knees flexed to 90degress and feet flat on
the plinth. The examiner sits on the toes of
the tested extremity to help stabilize it. The
examiner grasps the proximal lower leg,
just below the tibial plateau or tibiofemoral
joint line, and attempts to translate the
lower leg posteriorly . The test is
considered positive if there is a excessive
posterior translation relative to the
contralateral side.

21. 1-POSTERIOR SAG TEST
*position of the patient :
supine
*position of the examiner:
- the examiner stand on the side of the patient
and passively bring the hip and knee to 90 of
flexion ,and compare the level of tibial
tubersiteies of both knee.
*results:
a positive test is indicated when posterior
displacement of tibal tuberosity is more in the
affected limb .

22. 2- IMAGING
* knee x ray
Although x-rays do not show meniscal tears, they
may show other causes of knee pain, such
osteoarthritis and demonstrate bone avulsion if
present .
*Magnetic resonance imaging (MRI)
This study can create better images of the soft
tissues of your knee joint, like a meniscus

25. Treatment

26. TREATMENT
A- conservative
RICE. The RICE protocol is effective for most sports-related
injuries. RICE stands for Rest, Ice, Compression, and
Elevation.
Aspiration of hemartharosis to relive pain .
Exercises and physiotherapy must start since thediagnosis
is approved to prevent adhesion .
using knee brace until pain is disappear .

27. B- SURGICAL TREATMENT
Unfortunately, the cruciate ligaments -- ACL and PCL
-- cannot be repaired.
Once they are completely torn or stretched beyond
their limits, The only option a reconstruction.
In this procedure, tendons are taken from other parts
of your leg or a cadaver to replace the torn ligament.

30. Collateral ligaments

31. Medial collateral ligamentis
flat band and attached above to the medial epicondyle
of the femur and below to the shift of the tibia it is
firmly attached to the edge of the medial meniscus -
(MCL) is the primary restraint to valgus stress.
*The MCL is the most commonly injured knee
ligament.

32. LATERAL COLLATERAL LIGAMENT
is cordlike and is attached above to the lateral
condyle of the femur and below to the head of fibula
the tendon of the popliteus muscle intervenes
between the ligament and the lateral meniscus -
(LCL) is the primary restraint to varus stress

33. MECHANISM OF INJURY
Medial collateral ligament
tears often occur as a result of a direct blow to the
outside of the knee. This pushes the knee inwards
(toward the other knee).
lateral collateral ligament
tears often occur as a result of a direct Blows to the
inside of the knee that push the knee outwards.

34. MCL LCL

35. CLINICAL PICTURE:
1-Pain at the sides of knee.
If there is an MCL injury, the pain is on the
inside of the knee; an LCL injury may cause pain
on the outside of the knee.
2-Swelling over the site of the injury
3-Instability : the feeling that your knee is giving
way.

36. diagnosis

37. A-BY PHYSICAL EXAMINATION
Valgus vs varus stress tests
*position of the patient:
supine
*position of the patient leg :
hip is abducted and knee flexed with 20 degree
*position of the examiner:
-the examiner stands on the side of the affected leg
,with one hand on the medial and lateral
(respectively for LCL,MCL) line of the knee and the
other hand on the lateral aspect of the ankle .
1- a varus force pushing toward the Medline is
applied to the ankle for testing LCL injury
2- a valgus force pushing away from Medline is
applied through the ankle for testing MCL injury

39. RESULTS OF THE TESTS
1- in MCL injury
pain and excessive gaping is positive indicator for the
injury

40. 2- in LCL injury
pain and excessive gaping is positive indicator for the
injury

41. DIAGNOSIS

42. IMAGING
1-MCL ON MRI

43. 2-LCL ON MRI

44. The menisci

45. WHAT IS KNEE MENISCI ??
they are fibrocartilagenous structures
present In the intercondylar fossa between
.femur and tibia condyles
.
- functions:
1- disperse the Wight of the body
2-stabalization of knee joint
3- reduce friction between articular surfaces
of tibia and femur condyle.
4-shock absorber

47. CAUSES OF MENISCI TEAR

48. What is a meniscus injury?
Patients describe meniscal tears in a
variety of ways.
Knowing where and how a meniscus
was torn helps the doctor determine the
best treatment.
Location :- A tear may be located in the
anterior horn, body, or posterior horn. A
posterior horn tear is the most common.
The meniscus is broken down into the
outer, middle, and inner thirds. The third
in which the tear is located will
determine the ability of the tear to heal,
since blood supply in that area is critical
to the healing process. Tears in the
outer 1/3 have the best chance of
healing.

49. Pattern -
Meniscal tears come in many
shapes. The pattern of the tear
influences the doctor's decision
on treatment. Examples of the
various patterns are:
longitudinal
bucket-handle
displaced bucket handle
parrot beak
radial
displaced flap

50. CLINICAL PICTURE
1- severe pain
2-joint locking
3-limited movement of knee joint
4-swelling
5-inablity to stand on affected limb
6-popping or clicking within knee

51. DIAGNOSIS
•A – clinically by :
1-physical examination ,including the
following tests
a- muc Murray's test
b- Thessaly's test
c- apley’s test

52. HOW TO INSURE UR DIAGNOSIS BY
EXAMINATION ??
1-muc Murray's test
* Position of the patient
supine
*position Of the examiner:
-stand on the side of the patient , the proximal
hand on knee joint and the distal one on the heel
of the same limb
- the knee should be fully flexed ,the examiner
passively rotate the tibia and extend the knee for
examining medial menisci , internal rotation and
extension of the tibia for examining the lateral
menisci
*results
a positive test indicated by hearing a crepitus
associated with pain .

53. 2-THESSALY’S TEST
*position of the patient :
stand on the affected leg
*position of the examiner:
stand in front of the patient and provide his or her
hands for stability
*principle:
- knee is flexed 5 and femur is rotate medially and
laterally for 3 times
- the same step is repeated with knee flexed 20
*results :
a positive test is indicated if there is locking of
movement .

54. 3-APLEY’S TEST
For this test, the patient is
positioned prone, with his or
her knee flexed. Compression
and external or internal
rotation may be painful,
showing that the medial or
the lateral meniscus are torn.
This test is always checked,
by performing rotation without
compression

55. B- IMAGING
* knee x ray
Although x-rays do not show meniscal tears, they
may show other causes of knee pain, such
osteoarthritis.
*Magnetic resonance imaging (MRI)
This study can create better images of the soft
tissues of your knee joint, like a meniscus.

57. TREATMENT
Conservative Treatment
RICE. The RICE protocol is effective for most sports-
related injuries. RICE stands for Rest, Ice, Compression,
and Elevation.
If the joint is not locked, it is reasonable to hope that the
tear is peripheral and can therefore heal spontaneously.
After an acute episode, the joint is held straight in a
plaster backslab for 3–4 weeks; the patient uses crutches
and quadriceps exercises are encouraged .

58. by arthroscopy :
Meniscectomy
In this procedure, the damaged meniscal tissue is
trimmed away.
Meniscus repair. Some meniscal tears can be
repaired by suturing (stitching) the torn pieces
together
SURGICAL TREATMENT

60. RUPTURE OF QUADRICEPS TENDON
The four quadriceps muscles
meet just above the kneecap
(patella) to form the quadriceps
tendon. Tendons attach
muscles to bones. The
quadriceps tendon attaches the
quadriceps muscles to the
patella. The patella is attached
to the shinbone (tibia) by its
tendon, the patellar tendon.
Working together, the
quadriceps muscles, quadriceps
tendon and patellar tendon
straighten the knee.

61. QUADRICEPS TENDON TEARS
Quadriceps tendon tears more common in people more
40 year , can be either partial or complete.
Partial tears. Many tears do not completely disrupt the
soft tissue. This is similar to a rope stretched so far that
some of the fibers are torn, but the rope is still in one
piece.
Complete tears. A complete tear will split the soft tissue
into two pieces.
When the quadriceps tendon completely tears, the muscle
is no longer anchored to the kneecap. Without this
attachment, the knee cannot straighten when the
quadriceps muscles contract.

62. Cause
Injury
A quadriceps tear often occurs when there is a heavy
load on the leg with the foot planted and the knee
partially bent. Think of an awkward landing from a
jump while playing basketball. The force of the
landing is too much for the tendon and it tears.
Tears can also be caused by falls, direct force to the
front of the knee, and lacerations (cuts).
Tendon Weakness
A weakened quadriceps tendon is more likely to tear.

63. CLINICAL PICTURE
1-The typical injury is followed by tearing pain and
giving way of the knee.
3-There is bruising and local tenderness;
3-Active knee extension is either impossible
(suggesting a complete rupture) or weak (partial
rupture)

64. BY EXAMINATION
SOMETIMES A GAP CAN BE FELT PROXIMAL TO
THE PATELLA.

65. DIAGNOSIS
X-rays.
The kneecap moves out of place when the
quadriceps tendon tears. This is often very obvious
on a "sideways" X-ray view of the knee. Complete
tears can often be identified with these X-rays
alone.
MRI
diagnosis can be confirmed by MRI.

67. DIAGNOSIS

68. TREATMENT
Partial tears
Non-operative treatment with plaster cylinder is
applied for 6 weeks, followed by physiotherapy that
concentrates on restoring knee.
Complete tears
Early operation is needed, End-to-end suturing can
be reinforced by turning down a partial-thickness
triangular flap of quadriceps tendon proximal to the
repair (Scuderi).

70. RUPTURE OF PATELLAR LIGAMENT
This is an uncommon injury; it is usually seen in
young athletes and the tear is almost always at the
proximal or distal attachment of the ligament.

71. CLINICAL PICTURE
* The patient gives a history of :
1-sudden pain on forced extension of
the knee
2- bruising
3-swelling
4- tenderness at the lower edge of the
patella or more distally.

72. DIAGNOSIS
X-rays
may show a high-riding patella (patella alta ) .

73. MRI
.

74. TREATMENT
Partial tears : can be treated by applying a plaster cylinder.
Complete tears : need operative repair or reattachment to
bone, and keep the knee in extension position and use knee
immobilizer for 4-6 weeks Immobilization in full extension
may precipitate stiffness – after all, it is a joint injury – and it
may be better to support the knee in a hinged brace with
limits to the amount of flexion permitted. This range can be
gradually increased after 6 weeks.