Common knee injuries

OSTEOARTHRITIS
  OA has been acknowledged as the most common cause of
disability in the United States. Thirty-three percent of
persons aged 63–94 years are affected by OA of the knee,
which often limits the ability to rise from a chair, stand
comfortably, walk, and use stairs.
 Osteoarthritis (OA) is a chronic inflammatory joint disorder
in which there’s progressive softening & destruction of the
articular cartilage , accompanied by new growth of cartilage
OSTEOARTHRITIS and bone at the joint margins (osteophytes) and capsular
fibrosis leading to bone exposure & severe pain .
 Recognized risk factors include physically demanding
occupations, particularly jobs that involve kneeling or
squatting, certain sports, older age, female sex, evidence of
OA in other joints, obesity, and previous injury or surgery of
the knee.
 The patient experiences pain which starts insidiously and increase
slowly over time aggravated by exertion and relieved by rest.
 The clinical findings of OA at the knee include swelling, which can
vary from minimal to severe, depending on the clinical stage and
severity. The joint can also be warm to touch, although that again
depends on the stage and severity. Usually, the patient reports pain
with weight-bearing activities and, at times, pain at rest. The loss of
motion, if present, is typically in a capsular pattern. Muscle
weakness is probably the longest documented and best established
correlate of functional limitation in individuals with OA, particularly
with knee OA
 In advance stage there is deformity ,swelling, muscle wasting and
loss of mobility .
 It can be primary or secondary :
 Usually it’s Primary and idiopathic and affecting both knee joints.
 Secondary causes might be trauma , localized or metabolic diseases ,
mechanical factors , Bone Dysplasia.

 Puett and Griffin reviewed 15 controlled trials of conservative
intervention for hip and knee OA from 1966 through 1993 and
concluded that exercise reduces pain and improves function in
patients with OA of the knee, but that the optimal exercise regimen
has yet to be determined. In addition to strengthening exercises,
fitness walking and aerobic exercise have both been reported to
result in functional improvement in patients with OA of the knee.
However, unweighted treadmill walking has not been shown to
decrease pain associated with OA of the knee.
 MANAGEMENT
 It includes anti-inflammatory drugs, rest, weight loss, aids,
and physical therapy
 Ice for pain and spasm relief
 heat applications (hot moist packs or diathermy).
 Hydrotherapy and Mobilization techniques
 patients should be taught to avoid contracture.
 Stretching of the tight hamstrings & tight gastroenemius
muscles
 Exercises to strengthen the quadriceps
 Biofeedback for strengthening the vastus medialis
 Full-weight-bearing strengthening exercises in subacute and
chronic phases and avoided in the acute phase
 Unloading and weight-bearing in water should be used as
closed kinetic chain exercises in the more acute phases
 In the morning, active flexion and extension exercises
should be done before weight-bearing activities.
 Walking should be encouraged for daily activities but not
forced.
 Deep knee bends, sitting in low chairs, and remaining in the
same position for prolonged periods should be avoided.
 Other conservative interventions for OA of the knee include
cortisone injections, patient education, weight loss, and thermal
modalities.
 The use of shoes with a well cushioned sole is recommended, as are
frequent rest periods during the day. Wedged insoles with an angle
of 5–10 degrees on a frontal section have been shown to be helpful
for OA of the medial compartment knee OA.The patient is
instructed in principles of joint protection, and advised to seek
alternatives to prolonged standing, kneeling, and squatting.
 Fractures
 Any of the bones in or around the knee can be fractured.
The most commonly broken bone in the joint is the patella
or kneecap.
 High impact trauma, such as a fall or car accident, causes
most knee fractures.
 People with underlying osteoporosis may fracture their
knees just by stepping the wrong way or tripping
 The patella acts as a shield for your knee joint, it is
vulnerable to fracture if you fall directly onto your knee or
hit it against the dashboard in a vehicle collision. A
patellar fracture is a serious injury that can make it
difficult or even impossible to straighten your knee or
walk.
 Some simple patellar fractures can be treated by
wearing a cast or splint until the bone heals. In most
patellar fractures, however, the pieces of bone move
out of place when the injury occurs. For these more
complicated fractures, surgery is needed to restore
and stabilize the kneecap and allow for the return of
function.

 Stable fracture. This type of fracture is

nondisplaced. The pieces of bone may remain in
contact with each other or be separated by just a
millimeter or two. In a stable fracture, the bones
usually stay in place during healing.
 Fractures

Displaced fracture. In a displaced fracture, the broken ends of

the bone are separated and do not line up correctly. The
normally smooth joint surface may also be disrupted. This type
of fracture often requires surgery to put the pieces of bone
back together.
 Comminuted fracture. In this type of fracture, the bone
shatters into three or more pieces. Depending on the specific
pattern of the fracture, a comminuted fracture may be either
stable or unstable.
 Open fracture. In an open fracture, the bone
breaks in such a way that bone fragments
stick out through the skin or a wound
penetrates down to the bone. An open
fracture often involves damage to the
surrounding soft tissues and may take a
longer time to heal.
 Open fractures are particularly serious
because, once the skin is broken, there is a
higher risk for infection in both the wound
and the bone. Immediate treatment is
required to prevent infection.
 PATELLAR TENDINITIS/(JUMPER'S KNEE)
 Repetitive jumping in sports such as volleyball and basketball
cause inflammatory changes of the patellar or quadriceps tendon.
 Pain is associated with swelling and joint tenderness.
 Pain may be described as burning pain with use or after
prolonged sitting with the knee flexed.
 Objective Findings
Point tenderness occurs on the posterior aspect of the inferior pole
of the patella, especially if the patella is pushed distally.
Some swelling may be noticed around the patella in acute cases;
quadriceps wasting is apparent in long-standing cases.
Pain is reproduced on resisting active knee flexion with possible
pain on passive knee flexion.
Crepitus may be present on passive movement of the patellar
tendon.
 The traditional approach designed to reduce inflammation, which
includes rest, anti-inflammatory medication, cryotherapy, and
ultrasound.
 Another approach would be to use deep friction massage
 to exacerbate the acute inflammation, so that the healing process is
no longer “stuck” in the inflammatory response phase and can
move on to the fibroblastic repair phase.
 It has been recommended that deep transverse frictions be applied
to the inferior pole of the patella for 5 to 7 minutes every other day
for approximately 1 week
 over the tendinous fibers of the suprapatellar tendon for 20 minutes
(10 to 20 sessions) to produce a good result
 the eccentric function of the quadriceps has been emphasized. The
basis of a knee program is to use activities that place maximal
stress on the tendon to increase its tensile stress by performing
variations of quick mini-squats. Eccentric squats, called drop
squats, are performed with the patient moving slowly from
standing to a squat position and return.
Deep friction to the suprapatellar
tendon.
Deep friction to the infrapatellar tendon.
Deep friction to the quadriceps
expansion
 Popliteal and Semimembranosus Tendinitis
 It follows overuse injuries, usually from long-
distance running.
 Hyperpronation of the foot result in either popliteal
or bicipital tendinitis at the knee secondary to
overuse.
 Resisted flexion and medial rotation hurt at the
lateral or posterolateral aspect of the knee
 Pain occurs on the lateral aspect of the knee on
weight bearing with the knee flexed to 15 to 20°.
There may be pain on sitting cross-legged..
 With the knee in the "figure-four" position, the LCL
and popliteal tendon are stretched and can be
palpated.
 joint tenderness at its insertion on the lateral surface
of the femoral condyle.
 Tendinitis of the semimembranosus mimic a meniscal
injury because of its proximity to the joint line. Long-
distance runners are prone to tendinitis of the insertion
of the semimembranosus on the posterior medial
capsule of the knee
 The semimembranosus functions synergistically with
the popliteus to prevent excessive external rotation of
the tibia.
 hyper pronating problems of the foot can stress the
insertion of the semimembranosus.
 Treatment consists of rest, ice for the first 72 hours,
ultrasound, and flexibility and strengthening exercises.
 Proper training techniques and appropriate shoes
should also be addressed.
Bursitis

 Bursae are small fluid-filled sacs that cushion the knee joints and
allow the tendons and ligaments to slide easily over the joint.
 These sacs can swell and become inflamed with overuse or
repeated pressure from kneeling. This is known as bursitis.
 Most cases of bursitis are not serious and can be treated by self-
care. However, some instances may require antibiotic treatment or
aspiration, which is a procedure that uses a needle to withdraw
excess fluid.
 The intervention for bursitis includes the removal of the irritation.
This may involve the stretching of adaptively shortened structures
or joint mobilizations to help correct alignment.
Bursitis
 Iliotibial band syndrome
 Iliotibial band syndrome is common among long-distance runners. It is
caused when the Iliotibial band, which is located on the outside of the knee,
rubs against the outside of the knee joint.
 Typically, the pain starts off as a minor irritation. It can gradually build to the
point where a runner must stop running for a period to let the Iliotibial band
heal.
 Subjectively, the patient reports pain with the repetitive motions of the knee.
There is rarely a history of trauma. Although walking on level surfaces does
not generally reproduce symptoms, especially if a stiff-legged gait is used,
climbing or descending stairs often aggravates the pain. Patients do not
usually complain of pain during sprinting, squatting, or during such stop-and-
go activities as tennis, racquetball, or squash. The progression of symptoms is
often associated with changes in training surfaces, increased mileage.The
lateral knee pain is described as diffuse and hard to localize.
 Objectively, there is localized tenderness to palpation at the lateral
femoral condyle
 The resisted tests are likely to be negative for pain. The special test
for the ITB Ober, s test, should be positive for pain, or crepitus, or
both, especially at 30 degrees of weightbearing knee flexion
 Conservative intervention for ITBFS consists of activity
modification to reduce the irritating stress (decreasing mileage,
changing the bike seat position, and changing the training surfaces),
using new running shoes, heat or ice applications, strengthening of
the hip abductors, and stretching of the ITB.
Iliotibial band
syndrome
POPLITEAL
CYST
  A popliteal cyst, better known as Baker’s cyst, is a fluid-filled
swelling that is developed at the back of the knee in the popliteal
fossa region. Ganglia which are benign cystic tumors, originate
from synovial tissue. Common areas for cyst can occur at the wrist,
POPLITEAL hand, foot, and knee.
CYST  The cyst can exercise pressure on some anatomical structures, in
most cases, the affected anatomical structure is the popliteal vein.
Which can develop into thrombophlebitis.
 There are two types of cysts:
 Primary Cyst is an expansion arising independently from the joint and
there is no knee derangement.
 Secondary Cyst is a distension of the bursa located between the
gastrocnemius and semimembranosus tendons, fluid finds its way through
the channel the normal bursa communicates with the joint. This is the most
common occurrence.
 Symptoms can include:
 vague posterior pain
 swelling and a mass in the popliteal space
 limited range of motion
 stiffness in the back of the knee sometimes increased by activity
 tightness behind the knee
 The conservative intervention for this condition normally involves treating
the articular disorder that caused the cyst to swell. The medical
management includes aspiration or surgical resection.
CHONDROMALACIA
PATELLAE
 Chondromalacia patellae is referred to as anterior knee pain due to
the physical and biomechanical changes. The articular cartilage of
the posterior surface of the patella is going though degenerative
changes which manifest as a softening, swelling, fraying, and
erosion of the hyaline cartilage underlying the patella and sclerosis
of the underlying bone.
 Chondromalacia patella is usually described as an overload injury,
caused by malalignment of the femur to the patella and the tibia.
 It consists of 4 stages:
• Grade 1 severity indicates softening of the cartilage in
the knee area.
• Grade 2 indicates a softening of the cartilage along with
abnormal surface characteristics. This usually marks the
beginning of tissue erosion.
• Grade 3 shows thinning of cartilage with active
deterioration of the tissue.
• Grade 4, the most severe grade, indicates exposure of
the bone with a significant portion of cartilage
deteriorated. Bone exposure means bone-to-bone
rubbing is likely occurring in the knee.
 The main symptom of chondromalacia patellae is anterior knee pain
which is exacerbated by common daily activities that load the
patellofemoral joint, such as running, stair climbing, squatting,
kneeling or changing from a sitting to a standing position. The pain
often causes disability affecting the short term participation of daily
and physical activities. Other symptoms are tenderness on palpating
under the medial or lateral border of the patella, crepitation, minor
swelling, a weak vastus medialis muscle and a high Q-angle. This
condition can cause a deficit in quadriceps strength, therefore,
building and/or maintaining quadriceps strength is essential. A
significant number of individuals are asymptomatic, but crepitation
in flexion or extension is often present.
OSGOOD
SCHLATTER’S
DISEASE
  Osgood-Schlatter's disease is a traction apophysitis at the level of
the tibial tubercle due to repetitive strain on the secondary
ossification center of the tibial tuberosity. and inferior pole of the
patella (Sinding–Larsen–Johanssen syndrome) .The repetitive strain
is from the strong pull of the quadriceps muscle produced during
sporting activities.
OSGOOD  Osgood–Schlatter disease presents between the ages of 8 and 13
SCHLATTER’S years in females and 10 and 15 years in males, who are affected
about three times as often
DISEASE  The clinical picture consists of pain localized to the area of the
tibial tubercle. In some cases the tubercle may be swollen and
hypertrophied and there is also tightness of the quadriceps muscle.
Characteristics such as temperature or intra-articular swelling is not
relevant (rarely the tuberosity can feel warm), but swelling,
tenderness and pain of the tibial tuberosity often appears.
 Sinding–Larsen–Johanssen syndrome usually occurs prior to the
growth spurt. Fragmentation of the tibial tubercle or irregular
calcification of the inferior patellar pole may be seen on radiographs.
Pain is usually reported with use of the knee in activities such as
athletics, cycling, or resisted knee extension. The involved area is
tender and usually prominent on physical examination
 Symptoms show painful palpation of the tibial tuberosity, pain at the
tibial tuberosity that worsens with physical activity or sport,
increased pain at the tibial tuberosity with squatting, stairs or
jumping. In some cases increased bony protuberance at the tibial
tuberosity.
 The intervention for these conditions is usually symptomatic,
including short courses of anti-inflammatory medications, a focus on
hamstring flexibility, and moderate-intensity quadriceps
strengthening.
PES
ANSERINE
BURSITIS
  Pes Anserine bursitis, also known as intertendinous bursa, is an
inflammatory condition of bursa of the conjoined insertion of the
sartorius, gracilis and semitendinosus.
PES  Pes Anserine bursitis often occurs when the related muscles are
repeatedly used, by doing movements such as flexion and
ANSERINE adduction. This causes friction and also increases pressure on the
BURSITIS bursa. The bursitis can also be due to a trauma, such as a direct hit
in the Pes Anserine region. A contusion to this area results in an
increased release of synovial fluid in the lining of the bursa. The
bursa then becomes inflamed and tendered or painful and
underlying Osteoarthritis of the knee.
 The patient may experience spontaneous anteromedial knee pain on
climbing or descending stairs and tenderness at the PA as well, the
region around the bursa will be swollen or tender to touch.
 Other clinical presentations may include:
 Decreased muscle strength
 Gait deviations
 Decreased function
 Decreased ROM
 Postural dysfunction/impaired lower extremity biomechanics
 Aggravating factors include activities that require movements like
flexion and rotation. Pivoting, kicking, squatting or quick
movements from side to side, such as in the sports mentioned
above, may also cause further irritation.
 Typically, pes anserine bursitis will heal within 6-8 weeks or
sooner, depending on its severity, adequate treatment, or rest.
Typically, it is best to stop all activities that involve the knee until
the injury has fully healed, and the bursa is no longer inflamed.
 Rest, icing, Anti-inflammatory and pain-relieving medications
 The intervention for bursitis includes the removal of the irritation.
This may involve the stretching of adaptively shortened structures
or joint mobilizations to help correct alignment