The Knee Joint

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The Knee Joint

• By Aggie Brockie, Krystal Gantner, Angie Gauer,
  Krista Gooding, Laura Marchwinski, Tracy Mueller,
  Matt Schlueter, Jenn Summers

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• Bones
• Muscles
• Ligaments and Tendons
• Blood Supply
• Innervations
• Injuries
• Treatments

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Bones

• The knee joint is made up of four bones
• Femur- consists of medial and lateral condyle
  which articulate with the tibia creating a hinge
  joint
• Tibia- also has a medial and lateral condyle with
  a intercondylar eminence
• Fibula- runs parallel to the tibia
• Patella- runs over the end of the femur as the
  knee bends creating a plane joint

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Muscles

• There are many muscles associated with the knee
  joint that can be classified by their actions
• Flexor
• Extensors
• Medial Rotators
• Lateral Rotators

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Flexors

• Sartorius
• Gracilis
• Biceps Femoris
• Semitendinosis
• Semimembranosis
• Gastrocnemius
• Plantaris
• Poplitelus

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Extensors

• Gluteus Maximus
• Quadriceps Femoris
• Rectus Femoris
• Vastus Lateralis
• Vastus Medialis
• Vastus Intermedialis

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Medial and Lateral Rotators

• Medial
• Sartorius
• Semitendinosis
• Semimembranosis
• Lateral
• Biceps Femoris
• Poplitelus

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Ligaments and Tendons

• There are 2 main ligaments that help to stabilize
  the knee joint
• Posterior cruciate ligament (PCL) prevents the
  femur from sliding forward on the tibia
• Anterior cruciate ligament (ACL) prevents the
  femur from sliding backwards on the tibia
• Oblique popliteal ligament- stabilizes the
  posterior aspect of the knee

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Ligaments and Tendons

• Tibial Colateral Ligament- connects the medial
  condyle of the tibia to the medial condyle of the
  femur
• Fibular Colateral Ligament- free from the capsule
  of the knee joint and is unlikely to be injured
• Patella Tendon- attaches the quadriceps femoris
  muscles to the tibia

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Arteries

• Femoral Artery-
• Main artery of the lower limb
• Descends into the femoral triangle on iliopsoas
  and pectineus (lateral to femoral vein)
• Continuation of the external iliac artery
• Enters the adductor canal deep to the sartorius
  and exits at the adductor hiatus

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Arteries

• The femoral artery divides anteriorly and
  posteriorly
• The femoral artery divides anteriorly to form the
  descending genicular artery
• The descending genicular artery divides into an
  articular branch and a saphenous branch
• The femoral artery then divides posteriorly into
  the popliteal artery
• The popliteal artery divides into the superior
  medial genicular artery, medial superior
  genicular artery, lateral superior genicular
  artery, middle genicular artery,medial inferior
  genicular artery, and lateral inferior genicular
  artery
• The popliteal artery also divides into the tibial
  artery, peroneal artery, and the posterior.

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Arteries

• Deep Femoral Artery-
• - Main artery to the thigh
• - Largest branch of the femoral
• - Arises from the lateral aspect of the femoral
  artery in the femoral triangle
• - Supplies the anterior and medial compartments
  of the thigh
• - Supplies the posterior compartment by
  perforating arteries
• - Gives off the medial and lateral circumflex
  femoral arteries

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Arteries

• The lateral femoral circumflex artery branches
  off the deep femoral artery
• Ascending branch- passes above the greater
  trochanter of the femur
• Transverse branch- passes below and lateral to
  the greater trochanter
• Descending branch- follows the nerve to the
  vastus lateralis into the muscle and descends
  into the knee

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Arteries

• Medial femoral circumflex artery- branches off
  the deep femoral
• Passes between the pectineus and the iliopoas
  artery
• Ascending branch- appears in the gluteal region
  above the quadratus femoris
• Transverse branch- appears in back of the thigh
  between the adductor magnus and quadratus femoris

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• The blood supply of the knee joint is done so
  primarily through the descending and genicular
  branches from the femoral, popliteal, and lateral
  femoral circumflex artery, the circumflex fibular
  artery, and the recurrent branches from the
  anterior tibial artery in the leg.
• These vessels anatomize around the joint

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Veins

• Great Saphenous Vein-
• Begins along the medial side of the dorsum of the
  foot
• Passes in front medial malleolus
• Anatomizes with the small saphenous vein
• Ascends the medial side of the leg and then
  posterior to the knee
• Ascends along the medial thight to the saphenous
  hiatus in the fascia lata
• Empties into the femoral vein

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Veins

• Small Saphenous Vein-
• Runs behind the lateral malleolus
• Ascends along the lateral border of the calcaneal
  tendon
• Pierces the deep fascia
• Empties into the popliteal vein
• Accompanied by the sural nerve

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Major Nerves of the Knee

• The knee joint is innervated by branches from the
  obturator, femoral, tibial, and common peroneal
  nerves (Drake, 538).
• Other nerves associated with the knee joint
  include the saphenous nerve, the infrapatellar
  branch of the saphenous nerve, the sural nerve,
  the medial sural cutaneous nerve and lateral
  sural cutaneous nerve, the superficial peroneal
  nerve, as well as, the deep peroneal nerve.

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Obturator Nerve

• Arises from the anterior rami of the nerves L2 to
  L4.
• In the area of the obturator canal, the obturator
  nerve divides into anterior and posterior
  branches.
• Throughout their course through the medial
  compartment, these two branches supply cutaneous
  innervation to the medial aspect of the upper
  part of the leg and articular branches to the
  knee joint (Drake, 494).

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Femoral Nerve

• Arises from the anterior rami of nerves L2 to L4.
• Cutaneous branches of the femoral nerve include
  medial and intermediate cutaneous nerves, as
  well, as the saphenous nerve.
• Articular branches of the femoral nerve supply
  the hip and knee joints (Drake, 494).

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Saphenous Nerve

• Is a branch off of the femoral nerve.
• It supplies the skin on the medial side of the
  knee, leg, and foot (Drake, 530).
• The saphenous nerve also gives rise to the
  infrapatellar branch, which pierces the sartorius
  muscle.

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Tibial Nerve

• The nerve associated with the posterior
  compartment of the leg is the tibial nerve, a
  major branch of the sciatic nerve that descends
  into the posterior compartment from the popliteal
  fossa.
• The popliteal fossa is a diamond-shaped space
  behind the knee joint formed between muscles in
  the posterior compartments of the thigh and leg
  (Drake, 541).
• It also gives rise to the medial sural nerve,
  which is a cutaneous nerve that supplies the
  middle of the back of the leg.

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Common Peroneal Nerve

• This nerve originates proximal to the popliteal
  fossa.
• It continues to the lateral side of the leg where
  it swings around the neck of the fibula and
  enters the lateral compartment of the leg (Drake,
  542).
• It gives rise to the superficial and deep
  peroneal nerves.
• It also gives rise to the lateral sural nerve,
  which is a cutaneous nerve that supplies the
  lateral part of the back of the leg.

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Sural Nerve

• The lateral and medial sural nerves usually
  combine to form the sural nerve, which is the
  cutaneous nerve of the back of the leg.

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Knee Injuries

• Sprains and Strains
• Tendonitis
• Patellar Dislocation
• Osgood-Schlatter
• ACL Injuries
• Arthritis

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Sprains and Strains

• A sprain means you've stretched or torn a
  ligament.
• A strain means you've partially or completely
  torn a muscle or tendon. With knee strains, you
  may feel symptoms similar to a sprain and may see
  bruises around the injured area.

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Tendonitis

• Patellar tendonitis is the condition that arises
  when the tendon and the tissues that surround the
  patella, become inflamed and irritated. This is
  usually due to overuse, especially from jumping
  activities. This is the reason patellar
  tendonitis is often called "jumper's knee."
• Patellar tendonitis usually causes pain directly
  over the patellar tendon.

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Tendonitis (cont.)

• Patellar tendonitis can also happen to people who
  have problems with the way their hips, legs,
  knees, or feet are aligned. This alignment
  problem can result from having wide hips, being
  knock-kneed, or having feet with arches that
  collapse when you walk or run, a condition called
  over-pronation.
• Also, some patients develop patellar tendonitis
  after sustaining an acute injury to the tendon,
  and not allowing adequate healing. This type of
  traumatic patellar tendonitis is much less common
  than overuse syndromes.

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Patellar TendonitisTreatment

• Rest (most important)
• Anti-inflammatory medications
• Stretching the quads, hamstring, and calf muscles
  prior to activity. This will also prevent a
  recurrence of the problem.
• Ice treatments
• Support straps, knee braces, or custom orthotics

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Patellar Dislocation

• Patellar dislocation happens when the patella is
  knocked off to the side of the knee joint, by
  twisting or some kind of impact. Sometimes it
  will go back to its normal position by itself,
  but usually it will need to be put back into
  place by a doctor.
• Symptoms include swelling and a lot of pain at
  the front of your knee. There will usually be an
  abnormal bulge on the side of your knee, and you
  may be unable to walk.

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Patellar Dislocation (cont.)

• Patellar subluxation or dislocation may occur
  during childhood but is more frequently seen in
  adolescence
• It occurs equally in males and females and often
  occurs from high level sports.

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Patellar Dislocation (cont.)

• Most often the medial patellofemoral ligament
  fails off of its femoral attachment, but in some
  cases it fails off of the patellar attachment.
• Dislocation is usually attributed the quadriceps
  muscle, specifically the vastus medialis obliquus
  (or VMO). This muscle pulls the kneecap towards
  the middle of the knee joint, maintaining its
  position in the joint. If this muscle is not as
  well developed as other muscles around the knee,
  or if its muscle fibers are not adequately
  oriented to control the kneecap, then patellar
  subluxation may result.
• As the knee is extended, however, the patella may
  subluxate or dislocate if static and dynamic
  restraints are deficient

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Patellar Dislocation/ Subluxation Treatment

• May need a surgical procedure known as a lateral
  release
• Physical therapy with emphasis on quadriceps
  strengthening
• Braces
• Taping of the knee
• Better footwear

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Osgood-Schlatter

• Osgood-Schlatter disease is a painful disorder
  caused by repetitive stress on the front end of
  the tibia where the patellar tendon connects to
  the bone. It happens most frequently in young
  athletes between the ages of 10 to 15 years.
  Symptoms include a bump below the knee joint
  that's painful to the touch and is also painful
  with activity.
• It causes swelling, pain and tenderness just
  below the knee, over the tibia.

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• During activities that involve a lot of running,
  jumping and bending, the pull of the quadriceps
  can place tension on the patellar tendon. The
  patellar tendon may begin to pull away from the
  raised area on the tibia where it attaches
  (tibial tuberosity), resulting in pain and
  swelling.

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Osgood-Schlatter (cont.)

• Pain, swelling and tenderness at the tibial
  tuberosity on the tibia, just below the kneecap
• Knee pain that worsens with activity, especially
  running and jumping, and improves with rest.
• Tightness of the surrounding muscles, especially
  the quadriceps.

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Osgood-Schlatter Disease

• Surgery is rare
• Can manage pain without formal treatment
• The main treatment is REST
• Also you can use RICE
• Rest, Ice, Compress, Elevate

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Osgood-Schlatter Disease ctd.

• Ice after participating an any physical
  activities
• NSAIDS may be of help by reducing the swelling
• Beware though, some NSAIDS are not approved for
  children which are the more common sufferers of
  the disease
• Wearing a pad or brace to protect the knee during
  activity

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Osgood-Schlatter Disease ctd.

• Wear a strap across the patellar tendon to help
  relieve stress where it inserts
• Switch activities to swimming or cycling
• But most of all, rest and stretch the quads

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ACL Injuries

• Most ACL injuries happen during sports and
  fitness activities. The ligament may tear when
  you slow down suddenly to change direction or
  pivot with your foot firmly planted, twisting or
  overextending your knee.

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ACL Injuries (cont.)
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ACL Injuries (cont.)

• At the time of an ACL injury, signs and symptoms
  may include
• A loud "pop" sound
• Severe pain
• Knee swelling within four to 12 hours
• A feeling of instability with weight bearing
• The pain and swelling usually subside after two
  to four weeks, but your knee may still feel
  unstable. It may "give way" during twisting or
  pivoting movements, or feel like it wants to slip
  backwards

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ACL Treatments

• Surgery is almost certain
• Involves total reconstruction of the ligament
• Surgeons use a portion of the patellar tendon to
  recreate the ACL
• Most surgeons will perform the surgery
  athroscopically

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ACT (cont.)

• After surgery physical therapy starts as soon as
  possible
• Many times therapist break down the rehab into
  phases with short term goals
• Stretching is used to try to regain range of
  motion (passive and active)
• Each phase is a little more difficult so that the
  ACL can build up resistance

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ACL (cont.)

• Stretches and exercises include Heel raises,
  Mini squats, Hip abduction, adduction, and
  extension
• Exercises take place in and out of brace
• Progression is seen by performing slide boards,
  light leg press, grid touching, rubber bands, and
  much more
• Electrical stimulation may be an option for
  therapy such as a bio-feedback machine

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ACL (cont.)

• Therapy usually takes half a year
• Can fully participate in previous activities
  around seven months
• The more the patient exercises at home the better
  he or shes progress will be
• Bracing for the effected knee is a must,
  especially after surgery
• The braces limit and protect your range of motion
  and smaller braces help when you return to
  physical activities

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Arthritis

• Arthritis literally means "joint inflammation".
  Arthritis refers to a group of more than 100
  rheumatic diseases and other conditions that can
  cause pain, stiffness and swelling in the joints.
  

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Osteoarthritis

• Osteoarthritis, also known as degenerative joint
  disease, results from the wear and tear of life.
  The pressure of gravity causes physical damage to
  the joints and surrounding tissues, leading to
• pain
• tenderness
• swelling
• decreased function

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Arthritis
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Rheumatoid Arthritis

• Rheumatoid arthritis is an autoimmune disease
  that occurs when the body's own immune system
  mistakenly attacks the synovium (cell lining
  inside the joint). This chronic, potentially
  disabling disease causes
• joint pain
• stiffness
• swelling
• loss of joint function

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Arthritis (cont.)
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Patellar Arthritis Treatment

• Early stages
• Losing weight, switching from running to swimming
  or cycling, minimize activities that aggravate
  the condition
• Exercises can help increase range of motion and
  flexibility along with strengthening the leg
  muscles
• Using a cane, wearing energy absorbed
  shoes/inserts, or wearing a brace
• Heat/ice, water exercises, and elastic bandages
• Anti-inflammatory meds
• Hyaluronate therapy
• Gold salt injections

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Arthritis Treatment Contd

• Surgical Treatment
• Arthroscopic surgery
• An osteotomy
• Total/partial knee arthroplasty
• Cartilage grafting
• Fact Michael Jordan
• struggled with patellar
• arthritis throughout his basket-
• ball career!!!

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Total Knee Replacement

• Physical therapy will take place 48 hours or less
  after the surgery is completed
• Braces or knee immobilizers are used for
  stretching to sleeping
• Sometimes patients use a continuous passive
  motion machine, otherwise known as CPM
• This helps move the knee passively when the
  patient is relaxing

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Total Knee Replacement ctd.

• Like an ACL patient, total knee replacement
  patients need to stretch and perform exercises so
  that they can increase their use of the affected
  knee
• Walkers or crutches will be used at first
• Patients will learn how to walk up and down
  stairs
• Ice is used for swelling of all injuries

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Total Knee Replacement ctd.

• The physical therapist will increase the patients
  range of motion through passive and active
  stretching
• Electrical stimulation may be used such as
  bio-feedback
• Usually back to full speed after 4-6 months after
  surgery
• Medication will be necessary for the pain

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