11 The knee

Biomechanics of the extensor mechanism

The patella is the largest sesamoid bone in the body. It is attached above to the quadriceps ten- don,
below to the patellar tendon, and medially and laterally to the patellar retinacula. The breadth of the
pelvis and close proximity of the knee creates a valgus angulation to the femur. Coupled with this,
the direction of pull of the quadriceps is along the shaft of the femur and that of the patellar tendon
is almost vertical (Fig. 11.1). The difference between the two lines of pull is known as the Q angle
and is an important determinant of knee health. Normal values for the Q angle are in the region of
15-20°,

and knees with an angle greater or less than this can be considered malaligned.

As the knee flexes and extends, the patella should travel in line with the long axis of the femur.
However, the horizontal force vector created as a result of the Q angle tends to pull the patella
laterally, a movement which is resisted by the horizontal pull of the lower fibres of vastus media- lis.
These lower fibres can be considered as a functionally separate muscle, the vastus medialis oblique
(VMO) (Speakman and Weisberg, 1977). The quadriceps as a whole have been shown to undergo
reflex inhibition as the knee swells (de Andrade et al., 1965; Stokes and Young, 1984). However, the
VMO can be inhibited by as little as 10 ml effusion while the vastus lateralis and rectus femoris
require as much as 60 ml (Arno, 1990). Minimal effusion occurs frequently with minor trauma and
may go unnoticed by the athlete. However, this will be enough to weaken the VMO and alter the
biomechanics of the patella.

in full extension the patella does not contact the femur, but lies in a lateral position. As flexion
progresses, the patella should move medially. If it moves laterally it will butt against the prominent
lateral femoral condyle, and the lateral edge of the patellar groove of the femur. As flexion
progresses different areas of the patella's undersurface are compressed on to the femur. At 20°
flexion the inferior pole of the patella is compressed and by 45° the middle section is affected. At 90°
flexion, compression has moved to the superior aspect of the knee. In a full squatting position, with
the knee reaching 135° flexion, only the medial and lateral areas of the patella are compressed (Fig.
11.2). Compression tests of the patella to examine its posterior surface must therefore be performed
with the knee flexed to different angles.

Patello-femoral loads may be as high as three or four times body weight as the knee flexes in
walking, and nine times body weight when de- scending stairs (Cox, 1990). While the posterior
surface of the patella is compressed, the anterior aspect receives a tensile force when seen in the
sagittal plane (Fig. 11.3b). The effect of the Q angle is to create both horizontal and vertical force
vectors which tend to compress the lateral aspect of the patella but submit the medial aspect to
tensile stress (Fig. 11.3a). Clearly, alterations in the Q angle will change the pattern of stress
experienced by the patellar cartilage.Knee angles in the stance phase of walking or running will be
altered by foot and hip mechanics through the closed kinetic chain. Excessive foot pronation and hip
internal rotation and adduction (causing a 'knock knee' posture) have been linked to anterior knee
pain (see below).
Anterior knee pain

Pathology

Anterior knee pain is variously called chondromala- cia patellae and patella malalignment
syndrome.It

(a) The Q angle causes the lateral edge of the patellar cartilage to be compressed, while the medial
aspect is subjected to tensile stress

(b) The posterior surface of the patella is compressed. Fo, quadriceps pull; Fp, patellar tendon. From
Cox (1990), with permission.

is a condition affecting the posterior surface of the patella sometimes attributed to cartilage damage
and on occasion incorrectly seen as a direct precur- sor to osteoarthritis. Since hyaline cartilage is
aneural, changes in the patellar cartilage surface itself would not result in anterior knee pain. Fur-
thermore, at arthroscopy cartilage changes are often seen in patients who have no anterior knee
pain. If cartilage degeneration does occur with this

condition, it is to the ground substance and colla- gen at deep levels on the lateral edge of the
patella. This results in a blistering of the cartilage as it separates from the underlying bone, but the
cartil- surface itself is still smooth (Gruber, 1979). In osteoarthritis (see pp. 39-40) the initial changes
age occur to the cartilage surface of the odd facet (medial) and are followed by fibrillation. The
retinacula supporting the patella may be a major source of pain (Fulkerson, 1982), as may be the
subchondral bone of the odd facet (Hertling and Kessler, 1990). As we have seen, the odd facet is
only occasionally compressed in a full squatting position, and so its sub-chondral bone is less dense
and weaker. Lateral movement of the loaded patella could pull the odd facet into rapid contactwith
the patellar surface of the femur, causing pain

The complex mechanical relations of the patella make biomechanical assessment of the lower limb a
necessity in the treatment of anterior knee pain, and static and dynamic posture should be analysed.

Muscle strength imbalances

Flexibility and strength of the knee tissues and muscles will often reveal asymmetry. The relation-
ship between the hamstrings and quadriceps (HQ ratio) is particularly important and may require
isokinetic assessment of peak torque values. In cases where genu' recurvatum is present, streng-
thening the hamstrings may be necessary in at- tempting to correct the knee hyperextension. In
addition to knee musculature, hip strength is parti- cularly important. The hip abductors and lateral
rotators warrant special attention, as weakness here has been associated with this condition
(Beckman, Craig and Lehman, 1989). It is common for young athletes to allow the knee to adduct
and medially rotate when descending stairs. This may be due to weakness in the hip abductors,
particularly the gluteus medius, causing the ilio tibial band to overwork and tighten, pulling on the
lateral retina- culum. Manual muscle testing of the gluteus medius in a side-lying position will often
reveal weakness in the affected leg, and tightness in the ITB should be evaluated. Weakness in the
VMO will allow the patella to drift laterally as the quadriceps contract. Streng- thening has
traditionally been achieved by the use of short-range quadriceps exercises and straight leg raising
exercises. However, these are both open chain movements and, as the knee is in closed chain
motion during the stance phase of gait, closed chain actions are more likely to carry over into
functional activities.
Closed chain VMO strengthening may be carried out by performing limited range squats or lunges
moving the knee from 20-30° flexion to full exten- sion. Step downs from a single stair are useful as
they can retrain correct knee motion. The patient should be instructed to keep the knee over the
centre of the foot (avoiding adduction and medial rotation) throughout the movement.

Flexsibility

lexibility should be evaluated against accepted norms and against the contralateral limb. Normal
values of flexibility are highly subjective, but com-parisons with other athletes of a similar stature
whoare performing similar sports will give some gui-dance.Tightness in the quadriceps will increase
com- pression of the patello-femoral joint, while tight hamstrings (which tend to flex the knee
passively) will place a demand on the quadriceps during knee extension. Quadriceps flexibility may
be assessed by passively flexing the knee in a prone-lying position and flexing the knee and
extending the hip in a side-lying position to test the rectus femoris. In the same position the ITB may
be evaluated using the Ober manoeuvre. This is performed by adopt- ing a side-lying position with
the affected limb uppermost. The unaffected limb is flexed and the knee held by the patient to
stabilize the pelvis. The therapist flexes the knee of the affected limb and then passively abducts and
then extends the hip, to pull the knee behind the plane of the body. While maintaining knee and hip
extension, the knee is passively pushed into adduction. Full movement occurs when the hip adducts
far enough to allow the knee to touch the couch. Minimal ITB tight- ness is said to be present if the
knee is unable to touch the couch but will adduct into the horizontal position. If the horizontal
position cannot be reached, the tightness is moderate (Gose and Schweizer, 1989).

Hamstring flexibility may be assessed by actively extending the knee with the hip flexed to 90° in the
sitting or lying position (see p. 69). Failure to extend the knee fully while maintaining 90° hip flexion
constitutes inflexibility. The hip flexors are tested using the Thomas test. The patient lies supine with
the popliteal area of the knee over the couch end. The unaffected limb is flexed and the knee
gripped and pulled in towards the chest (Fig. 11.4a). Normal stretch of the hip flexors will allow the
lower leg to remain in contact with the couch as the flexed limb contacts the patient's chest, but
tightness is indicated if the lower leg starts to lift (Fig. 11.4b). Differentiation between the ilio-psoas
and rectus femoris can be made by assessing the difference made to the movement by further
flexing the knee of the lower leg. If the rectus is tight, the knee will not flex fully The Thomas test.

(a) Normal stretch. The lower leg remains on the couch as the upper hip is flexed to the chest.

(b) Hip flexor tightness causes the lower leg to lift off the couch.

(c) Rectus femoris tightness prevents the lower knee from flexing fully. From Saunders (1989),
with permission.

Satisfactory scores of knee flexion to 80° have been quoted for industrial workers, and if the lower
hip flexes 10° or more off the table, and/or the lower knee does not flex to at least 70, tightness is
present (Saunders, 1989). If the lower leg drifts into abduction the ITB may be tight, and should be
tested by pressing the leg into adduction. This position mimics the Ober manoeuvre.

A tight gastrocnemius will affect the sub-talar joint and can increase pronation, a condition which in
turn will affect the patello-femoral joint. The gastrocnemius is assessed using a forward lunging
position against the wall whilst mainting full knee extension.
Foot biomechanics

During normal running gait (pp. 152-154) the sub-taloid joint (STJ) is slightly supinated at heel strike.
As the foot moves into ground contact, the joint pronates, pulling the lower limb into internal
rotation and unlocking the knee. As the gait cycle progresses, the STJ moves into supination, ex-
ternally rotating the leg as the knee extends (locks) to push the body forward. This biomechanical
action combines mobility and shock absorbtion (STJ pronation and knee flexion) with rigidity and
power transmission (STJ supination and knee ex- tension), and shows the intricate link between foot
and knee function.

If STJ pronation is excessive or prolonged, ex- ternal rotation of the lower limb will be delayed. At
the beginning of the stance phase, STJ pronation should have finished. But, if it continues, the tibia
will remain externally rotated and prevent the knee from locking. The leg must compensate to
prevent excessive strain on its structures, and so the femur rotates instead of the tibia, and the knee
is able to lock once more. As the femur rotates internally in this manner, the patella is forced to
track laterally.

In certain circumstances the patella can cope with this extra stress, but if additional malalign- ment
factors exist, they are compounded. Antever- sion of the femur (internal rotation), VMO weak- ness,
and tightness of the lateral retinaculum may all increase the lateral patellar tracking causing
symptoms (Tiberio, 1987). For anterior knee pain to be treated effectively
therefore, a biomechanical

assessment of the lower limb is mandatory. If hyperpronation is present, it must be corrected. This
will involve assessment of sports footwear, patient education and orthotic prescription.

Patella position

Quantifying the position of the patella is important because, as described above, excessive pressure
on the odd facet may result if the patella position is at fault. McConnell (1986) described four
different patellar position faults which could be assessed with the patient in the supine position with
the quadriceps relaxed. By using the patellar poles as landmarks and comparing their position with
the planes of the femur any malalignment becomes evident. In addition, accessory patellar
movements can be assessed with particular emphasis on medial and lateral gliding. Patellar glide
occurs when the patella moves from a neutral position. The distance from the centre of the patella
to the medial and lateral femoral condyles is assessed (Fig. 11.5a). Tightness in the lateral
retinaculum, a frequent occurrence in anterior knee pain sufferers, will cause lateraliza tion of the
patella. Patellar tilt evaluates the position of the medial and lateral facets of the patella,with patello-
femoral pain patients frequently showing a more prominent medial facet (Fig. 11.5b). Patellar
rotation occurs when the inferior pole of the patella deviates from a neutral position. In- ternal
rotation is a change to the medial side position (Fig. 11.5c). The anterior-posterior relates to the
position of the inferior pole as the quadriceps contract. During this movement, the inferior pole
should remain inferior and not tilt above the plane of the superior pole (Fig. 11.5d). Arno (1990)
attempted to quantify the patellar position with a description of the A angle. This relates patellar
orientation to that of the tibial tubercle. The poles of the patella are palpated and a line is drawn
bisecting the patella. Another line is drawn from the tibial tubercle to the apex of theinferior pole of
the patella and the angle of intersec-tion forms the A angle (Fig. 11.5e). The sameauthor argued that
an A angle greater than 35°constituted malalignment when the Q angle re-mained constant. DiVeta
and Vogelbach (1992)showed A angle measurement to be reliable, withaverage values of 12.3° for
normals and 23.2° forpatients with patellofemoral dysfunction.Pain relief may often be provided by
temporarilycorrecting any underlying fault in patella positionthrough strapping. Excessive lateral tilt
is cor-rected by passively medially tilting the patella andapplying adhesive taping from the midpoint
of thepatella to the medial aspect of the knee. Decreasedmedial glide is corrected with a similar
tapingmethod, but this time extending from the lateralborder of the patella to the medial knee. If
theinferior pole of the patella lies posterior to thesuperior pole, taping is applied to the upper half
ofthe patella to compress it. Patella rotations are corrected by placing the patella in a neutral posi-
tion.

Surgery

Before surgery is considered, conservative management must be attempted. Indeed, Insall (1979)
stated that surgery was only indicated when continuous pain limited normal activities for at least
sixmonths and the condition had not responded to management. The comple differentconsondition
has led to a number of e of theapproaches. carried out Release of tight lateral retinaculum is
performed through a small incision or arthroscopy to divide the retinaculum from the lower fibres of
the vastus lateralis. Patellar debridement/shaving has been o remove degenerate articular cartilage
on the patella undersurface. Small areas of cartilage may be removed en bloc or larger areas shaved.
Realignment procedures involve structural transfer to reduce or alter compression forces on the
patella. The Maquet operation elevates the tibial tubercle to reduce patella reaction forces and the
Hauser manoeuvre uses distal and medial transfer to reduce the valgus vector acting on the patello-
femoral joint. Realignment of the attach- ment of the vastus medialis aims to increase the
mechanical advantage of the VMO.

Patellar fracture

Patellar fractures in sport occur most frequently in adolescent athletes, usually as a result of
jumping. Fracture may occur at the pole of the patella, or as transverse, vertical, or comminuted
injuries. Stress fracture at the distal third of the patella has been reported after sprinting (Jerosch,
Castro and Jantea, 1989). Conservative treatment, consisting of immobilizing the limb in a cast for
two to three weeks, is sufficient in 50-60% of cases (Exler, 1991). Surgical treatment involves internal
fixation of the patellar fragments, and hemipatellectomy or total patellectomy in the case of
comminuted injuries, combined with immobilization in a cast. Following immobilization, mobility
exercises and quadriceps strengthening are started. Streng-thening begins with straight leg raising.
An extension lag is common in these patients. The leg is locked from a long sitting position and, as it
is raised, the tibia falls 2-3 cm as the patient is unable to maintain locking. Re-education of the knee
locking mechanism may be achieved in a side-lying (gravity eliminated) position. This is followed by
knee bracing with a rolled towel under the knee, the patient being instructed to 'push down' on the
towel with the back of the knee and at the same time to lift the heel from the couch surface. Short
range movements over a knee block using a weight bag is the next progression. When 60-90° knee
flexion is achieved, light weight training on universal machine with a relaxation stop, or isokinetic
training, is used before closed chain activities.

Patellar dislocation

Patellar dislocation may occur traumatically with any athlete, but is more frequently seen in children
between the ages of 8-15 years and middle-aged women who are overweight and have poor
muscular development of the quadriceps. Biomechanically, the individual is more susceptible to this
condition if they demonstrate genu valgum, excessive femoral anteversion or external rotation of
the tibia, and if the VMO is weak. The injury usually occurs when the knee is externally rotated and
straightened at the same time, such as when the athlete turns to the left while pushing off from the
right foot. In this position the tibial attachment of the quadriceps moves laterally in relation to the
femur, increasing the lateral force component as the muscle group contracts. The patella almost
always dislocates laterally and is accompanied by a ripping sensation and excruciating pain, causing
the knee to give way. As the knee straightens, the patella may reduce spontaneously with an audible
click. Swelling is rapid due to the haemarthrosis, causing the skin to become taught and shiny.
Bruising forms over the medial retinaculum, and the athlete is normally completely disabled by pain
and quadriceps spasm. Initial treatment is to immobilize the knee com- pletely and apply the RICE
protocol. Aspiration may be required if pain is intense, but swelling usually abates with non-invasive
management. Quadriceps re-education plays an important part in the rehabilitation process, with
VMO strengthening being particularly important. The medial retinaculum must be allowed to heal
fully, and it is a mistake to allow these athletes to mobilize unprotected too soon. Only when 90°
knee flexion isachieved and the patient is able to perform atstraight leg lift with 30-50% of the
power of the The knee 175 uninjured leg are they ready to walk without support.

Aetiology

Tightness of the ITB can occur in a number of patient groups. The tall, lanky teenager who has
recently undergone the adolescent growth spurt may experience pain if soft tissue elongation lags
behind long bone development. Tightness in adole- scent females is a frequent cause of anterior
knee pain. The second major group of sufferers are adult athletes, particularly distance runners. A
number of factors can contribute to problems within this group. Running on cambered roads and
using shoes worn on their lateral edge will increase varus knee angulation and may overstretch a
tight ITB. Rapid increases in speed or hill work can place excessive stress on the structure. In
addition, imba- lances of muscle strength and flexibility around the knee and hip may lead to the
gradual onset of symptoms. flexes to 30° and back, the ITB will pass over the lateral femoral condyle
and may cause friction and pain which builds in intensity. Flexibility tests, particularly the Ober
manoeuvre and Thomas test (p. 172) often reveal pain and a lack of flexibility. Management

The initial inflammation responds to anti- inflammatory modalities, but the underlying cause must
be addressed. Modifications include altera- tions of running surface and footwear, and changes to
training intensity, frequency, duration and con- tent. Where limited-range motion is identified,
stretching procedures are called for. Hip flexor and extensor flexibility is regained by using exercises
previously described, and the ITB itself is stretched using an adaptation of the Ober manoeuvre.

The ITB insertion at the knee is first heated with hot packs or diathermy. The pelvis is stabilized by
the patient flexing and holding the lower knee. The affected upper leg is initially abducted and ex-
tended at the hip and flexed at the knee. From this position, hip extension is maintained and the leg
is pushed downwards into adduction, and held for 30-60 seconds, with the stretch being repeated
four or five times. As adduction commences, the patient's pelvis will tend to tilt, and an assistant
should press down on the rim of the ilium to stabilize the pelvis and increase the stretch. Between
treatment sessions the patient should attempt this procedure at home. The weight of the leg may be
used to press it into adduction, and a weight bag on the knee will assist this. In addition, training
partners or family members can be taught to help. Weakness in the hip abductors may allow the
pelvis to tilt or 'dip' during the stance phase of walking or running. This often gives the impres- sion
of a mild trendelenberg gait, and may be habitual following lower limb injury. Gait re- education and
abductor strengthening are called for. The abductors may be strengthened from an open chain or
more functional closed chain starting position. Open chain strengthening is performed using a
weight bag in a side-lying hip abduction exercise. Closed chain strengthening is carried out with the
athlete standing on the affected leg, and keeping it locked. The unaffected leg is flexed a the knee.
From this position the pelvis is allowed to at drop towards the unsupported side and pulled back to
the horizontal position by hip abductor action

Collateral ligament injuries

The medial collateral ligament (MCL) is a broad flat band about 8 or 9 cm in length. It travels
downwards and forwards from the medial epicon- dyle of the femur to the medial condyle and
upper medial shaft of the tibia. The ligament has both deep and superficial fibres, with the deep
fibres attaching to the medial meniscus, and the super- ficial fibres extending below the level of the
tibial tuberosity. The superficial fibres have anterior, middle and posterior portions.

When the knee is in full extension, it is in close pack formation. The medial femoral condyle is
pushed backwards, and the medial epicondyle lifts away from the tibial plateaux, tightening the
poste- rior part of the MCL. As the knee is flexed, the posterior part of the ligament relaxes, but the
anterior and middle parts remain tight. By 80-90° flexion, the middle of the ligament is still tight, but
the anterior and posterior portions are lax. In this way, the strong middle section of the ligament
remains tight for most of the range of movement. The changing distribution of tension strain in the
ligament means that the section which is affected Hip abductor strengthening. (a) Athlete stands on
affected leg. (b) Allowing the opposite hip to drop and then pulling it up works the abductors of the
weight-bearing limb. through injury will depend on the knee angle when the injury occurred, so an
accurate history is extremely helpful.

The lateral collateral ligament (LCL) is a round cord about 5 cm long, which stands clear of the joint
capsule. It travels from the lateral epicondyle of the femur to the lateral surface of the head of the
fibula. The ligament splits the tendon of biceps femoris, and is separated from the joint capsule by
the popliteus muscle, and the lateral genicular vessels and nerve (Palastanga, Field and Soames,
1989). The lower end of the lateral ligament is pulled backwards in extension and forwards in flexion
of the knee.

Damage to the MCL can result from excessive valgus angulation of the knee coupled with external
rotation, while LCL damage is normally through varus strains coupled with internal rotation. MCL
damage usually leads to pain over the medial epicondyle of the femur, the middle third of the joint
line, or the tibial insertion of the ligament. With LCL damage, pain is normally over the head of the
fibula or lateral femoral epicondyle. The integrity of the ligaments is tested by applying a varus and
valgus stress to the knee flexed to 30°. It is ineffective to the same test with the knee locked, as this
is the close pack position, and nearly 50% of medial and lateral stability is provided by the cruciate
ligaments and joint capsule. The easiest way to perform the varus/ valgus test is with the patient's
hip abducted, the thigh supported on the couch and the lower leg over the couch side. First and
second degree injuries are generally treated conservatively. Third degree injuries (com- plete
rupture) have been treated surgically, but some authors argue that stability of the knee is not
improved to a greater extent than with non- operative intervention (Keene, 1990). First degree
injuries are generally treated partial or full weight bearing with the ligament supported by strapping.
Second and third degree injuries are managed non-weight bearing. Initially, the aim is pain relief,
swelling reduc- tion and the start of mobile scar formation. Isome- tric quadriceps drill is begun and
modalities used to reduce pain and swelling. At night a knee brace may be used to protect the
ligament. By the third or fourth day after injury (sometimes earlier with a first degree and later with
a third degree injury) gentle mobility exercises are begun either in a side-lying starting position or in
the pool. Gentle transverse frictions are used to encourage mobile scar formation. The sweep should
be quite broad and a large section of the ligament treated. Free, or light resisted exercises are begun
to the knee, hip and calf musculature within the pain-free range. Isokinetics may be used, with the
aim of restoring the HQ ratio to that of the uninjured limb.

When 90° of pain free movement is obtained (usually 10-14 days after injury with a grade three
sprain) the rehabilitation programme can be pro- gressed further to include more vigorous activities,
and increased mobility and strength training. An exercise cycle or light jogging may be used, and
swimming (not breast stroke) started. Weight training is progressed to use leg machines, and some
power training is added. Towards the end of this period, depending on pain levels, shallow jumping,
bench stepping, circle running and zig- zagging in the gym are used to gradually introduce rotation,
shear, and valgus stress to the knee. In addition to improving strength and power, these exercises
build confidence and provide an assess- ment of knee stability.

Cruciate ligaments

The cruciate ligaments are strong rounded cords within the knee joint capsule, but outside its
synovial cavity. The ligament fibres are 90% colla- gen and 10% elastic tissue, arranged in two types
of fasciculi. The first group travel directly between the femur and tibia as would be expected, but the
second set spiral around the length of the ligament. This structure enables the ligament to increase
its resistance to tension when loaded. Under light loads only a few of the fasciculi are under tension,
but as the load increases, the spiral fibres unwind bringing more fasciculi into play and effectively
increasing the ligament strength. The anterior cruciate ligament (ACL) is attached from the tibia,
anterior to the tibial spine. Here, it blends with the anterior horn of the lateral menis- cus and passes
beneath the transverse ligament. Its direction is posterior, lateral and proximal to attach to the
posterior part of the medial surface of the lateral femoral condyle. As it travels from the tibia to the
femur, the ligament twists in a medial spiral. The posterolateral part of the ACL is taut in extension
and the anteromedial portion is lax. In flexion, all of the fibres except the anteriomedial portion are
lax. The posterior cruciate ligament (PCL) arises from the posterior intercondylar area of the tibia
and travels anteriorly, medially and proximally, passing medial to the ACL to insert into the anterior
portion of the lateral surface of the medial femoral condyle. The majority of the PCL fibres are taut
in flexion, with only the posterior portion being lax, and in extension the posterior fibres are tight
but the rest of the ligament is lax. The ACL provides 86% of the resistance to anterior displacement
and 30% to medial displace- ment, while the PCL provides 94% of the restraint to posterior
displacement and 36% to lateral stresses (Palastanga, Field and Soames, 1989).

Of the two ligaments the ACL is far more commonly injured in sport. The athlete has usually
participated in either a running/jumping activity or skiing. The history is usually of a non-contact
movement such as rapid deceleration, a 'cutting' action in football, or a twisting fall. The
combination is frequently one of rotation and abduction, a similar action to that which causes MCL
or medial meniscus damage, and the three injuries often coalesce to form an 'unhappy triad'.
Swelling is usually immediate as a result of haemarthrosis, and instability may be noticed at this
stage. A tense effusion is apparent within 24 hours of injury. The classic anterior drawer test is often
negative early on, due to hamstring muscle spasm and effusion. The high strain rates encoun- tered
in sports cause the majority of injuries to occur to the ligament substance rather than the osseous
junction and so X-ray is usually unrevealing Diagnosis relies heavily on clinical history and tests for
instability, the latter being the subject of some debate. The two most common tests are the anterior
drawer test and modifications on this, and the pivot shift. The classic anterior drawer test (Fig. 11.7)
in- volves flexing the patient's knee to 90° and stabilizing the foot with the examiner's body weight.
The proximal tibia is pulled anteriorly and the amount of movement compared with the 'normal'
value of the uninjured leg. Various grades of movement may be assessed, grade one being up to 5
mm of anterior glide, grade two 5-10 mm and grade three over 30 mm. The test can however give
false negatives if haemarthrosis prevents the knee being flexed to 90°. Movement can also be
limited by protective hamstring spasm or if the posterior horn of the medial meniscus wedges
against the medial femoral condyle. The Lachman test, a modification of the anterior drawer test,
has been shown to be highly reliable (Donaldson, Warren and Wickiewicz, 1985). The test is
performed with the patient lying supine. The examiner holds the patient's knee in 20° flexion,
minimizing the effect of hamstring spasm and reducing the likelihood of meniscal wedging. One
hand stabilizes the femur and the other applies an anterior shearing force to the proximal tibia,
avoid- ing medial rotation (Fig. 11.8). If anterior transla- tion of the tibia is felt, the test is positive.
The movement is compared with that of the uninjured knee, both for range and end feel, an ACL
tear giving a characteristically soft end feel. The same grading system is used as with the
anterior drawer test. Another frequently used test is the pivot shift, and its adaptations. These work
on the basis that the ACL-deficient knee will allow the lateral tibial plateau to sublux anteriorly. By
applying forces to enforce this and then moving the knee, the tibia can be made to reduce rapidly,
causing a 'thud'. The pivot shift test starts with the affected leg in full extension. The examiner
grasps the ankle of this leg with his or her distal hand and the outside of the ipsilateral knee with his
or her proximal hand. The ankle and tibia are forced into maximum internal rotation, subluxing the
lateral tibial pla- teau anteriorly. The knee is slowly flexed as the proximal hand applies a valgus
stress. If the test is positive, tension in the ITB will reduce the tibia, causing a sudden backward
'shift'. The major disadvantage with this test is that the patient must be relaxed throughout the
manoeuvre, a situation which often is not possible because of pain. Donaldson, Warren and
Wickiewicz, (1985) tested more than 100 ACL-deficient knees preoperatively and found the pivot
shift test to be positive in only 35% of cases. The same examination carried out under anaesthesia
(with the muscles completely relaxed) gave 98% positive results. This test is reversed in the jerk test
(Table 11.1), while the flexion rotation drawer (FRD) test elim The knee 179 inates the need for a
valgus force by using gravity to sublux the tibia. A reliability of 62% has been reported for the FRD,
rising to 89% with the anaesthetized patient (Jensen, 1990). The Slocum test uses a side lying
position to perform a pivot shift and is particularly suitable for heavier patients. Since the ACL has
two functionally separate portions (see above), depending on the knee angle at the time of injury,
only one portion may be damaged, thus resulting in a partial ligament tear. If the anteroinedial band
is damaged but the poste- rolateral portion is intact, the Lachman test may be negative, but the
anterior drawer test positive. This is because the anteromedial portion is tightened as the knee
flexes, and so will be tighter (and there- fore instability will be more apparent) with the 90° knee
angle of the anterior drawer. Similarly, if the posterolateral band is disrupted (the more usual
situation) the anterior drawer may be negative but the Lachman positive, as this portion of the liga-
ment becomes tighter as the knee approaches extension. Partial tears usually remain intact and
show good long-term results. However Noyes et al. (1989) argued that progression to complete
deficiency, although unlikely in knees which have sustained
Management

First and second degree injuries may be immobi- lized initially and then subjected to intense rehabi-
litation to re-strengthen the supporting knee musculature. A derotation brace may be used to
protect the knee until muscle strength is sufficient. Third degree injuries with marked instability may
be treated surgically, although some authors argue that rehabilitation alone is the better solution
(Garrick and Webb, 1990). Surgery involves repair and reconstruction, most authors agreeing that
the latter is more appropriate. Reconstruction tech- niques may be extracapsular, intracapsular, or a
combination of the two . Extracapsular reconstruction has been described using the MacIntosh
procedure (Wilson, Lewis and Scranton, 1990). A 10 x 1 cm strip of the ITB is passed beneath the
fibular collateral ligament, under the lateral attachment of the gastrocnemius and then looped back
on itself. The knee is flexed to 60° and the leg externally rotated before the ITB is pulled tight and
secured with sutures. Alternatively, a graft may be cut from the middle third of the patellar tendon,
to include both non- articular patellar and tibial tubercle bone. This has the advantage that it leaves
other structures around the knee intact. Tunnels are then drilled in the tibia and femur travelling
through the attachments of the ACL. The graft is passed through the bone tunnel and attached to the
lateral aspect of the lateral femoral condyle and the tibial tubercle. The graft is secured with
cancellous screws and sutures. This procedure gives a very strong graft, but may have the
complication of patellar pain following surgery. Flexion contraction of 5° or more may be present in
almost one quarter of these patients (Sachs et al., 1989), and patello-femoral irritability can result.
Where contracture is a likelihood, reha- bilitation should place a greater emphasis on main- taining
full knee extension. A similar technique has been described by Wilson, Lewis and Scranton (1990)
using the semi-tendinosus tendon instead of the patellar tendon, to avoid patellar complications.
Several structures may be used for grafts, and Noyes, Butler and Grood (1984) showed the patel- lar
tendon graft to have a strength of 168% of the ACL, while the semi-tendinosus had only 70%,
gracilus 49% and the quadriceps/patellar retinacu- lum only 21%. Synthetic tissues, such as polyte-
trafluoroethylene (PTFE), are now used more frequently, and mobility may be attained more rapidly
following surgery using these materials. However, synthetics are generally only used where intra-
articular reconstructions have failed. Bovine substances have been used, but problems have been
caused by reactive synovitis following these operations. Allogenic tendon grafts from cadavers and
amputation specimens have been used to good effect in patients suffering chronic ACL insuf- ficiency
(Shino et al., 1986). Rehabilitation will depend very much on the Rehabilitation will depend very
much on the particular procedure which has been performed. The problem is that immobilization is
thought to be desirable for healing of the graft, but early mobility is required to avoid cartilage
degenera- tion, soft tissue contracture and muscle atrophy. The solution is to mobilize the patient
early, pro- viding the movement used does not overly stress the graft. The range of motion possible
without placing undue tension on the graft must be estab- lished, and a protective brace may be
used to limit undesirable movements. Sandberg, Nilsson and Westlin (1987) showed the time
needed to return to sport to be five weeks shorter and range of motion significantly better following
the use of a hinged cast allowing knee flexion from 20-70°. Noyes, Mangine and Barber (1987)
mobilized patients on the second day after surgery and found no adverse effects on the ligament
reconstruction. The use of a leg extension regime using a sitting position has been criticized
(Palmitier et al., 1991). Contraction of the quadriceps from this open chain position places
considerable anterior shear on the knee and may stretch the ACL. Closed chain motions, such as the
squat or leg press movement, reduce the shear. With these actions, a more functional co-
contraction is used, with the hamstr- ing contraction used primarily for hip extension now
counteracting some of the shear created by the quadriceps.

Posterior cruciate damage

The PCL is the strongest ligament in the knee (Baylis and Rzonca, 1988) and much less fre- quently
damaged in sport than the ACL. When an injury does occur it may be the result of a force directed
posteriorly onto a flexed knee, forced hyperextension, or forced flexion where the athlete falls into a
kneeling position pressing the ankle into plantarflexion (Keene, 1990). Unlike ACL injury, the athlete
with a damaged PCL can usually con- tinue playing and may notice only minimal swel- ling, but there
is marked pain on the posterior aspect of the knee. Posterior subluxation of the tibia may be seen
from the side if the knee is flexed to 90°. This may be accentuated if the patient contracts their
quadriceps against a resistance pro- vided by the examiner. The patient is asked to 'slide the foot
down the couch' (Daniel et al., 1988), as the examiner stabilizes the ankle. If not viewed from the
side, the subluxation may be missed, and the injury wrongly diagnosed as an ACL tear, the tibia
moving forwards to reduce and mimicking an anterior drawer sign.

As with ACL damage, conservative treatment involving intensive muscle strengthening is tried first.
The PCL is contained within a synovial sheath which enhances its ability to heal in contin- uity
(Fowler and Messieh, 1987). Reconstruction may be attempted, using a similar patellar tendon graft
to that described above. This time, the graft is positioned lateral to the tibial attachment of the PCL
and travels through the femur at the junction of the medial condyle and the intercondylar notch.
The knee with isolated PCL insufficiency pro- ducing unidirectional instability generally does well
conservatively, but when PCL damage is associated with additional tissue damage which results in
multidirectional instability, surgery should be con- sidered (Torg, 1989). In a study investigating the
long-term effects of non-operative management of PCL damage, Parolie and Bergfeld (1986)
assessed 25 athletes on average 6.2 years after injury. Of these 84% had returned to their previous
sport. Importantly, those who were not satisfied with their knee had less than 100% strength
compared with the undamaged knee (measured as mean torque on an isokinetic
dynamometer at varyingangular velocities), and those who were satisfied had strength values
greater than 100%. The impor tance of maintaining superior muscle strength fol- lowing PCL injuries
is therefore clear.

The menisci

The menisci are fibrocartilage structures which rest on the tibial condyles. They are crescent-shaped
when viewed from above, but triangular in cross- section. Their peripheral border is formed from
fibrous tissue and attached to the deep surface of the joint capsule. These same fibres attach the
menisci to the tibial surface forming the coronary ligaments. Anteriorly, the two menisci are joined
by the transverse ligament, a posterior transverse ligament being present in 20% of the population
(Palastanga, Field and Soames, 1989).

The medial meniscus is the larger of the two, semicircular in shape, and broader posteriorly. Its
anterior horn is attached to the front of the intercon- dylar area of the tibia in front of the ACL. The
posterior horn attaches to the posterior intercondy- lar area between the PCL and the lateral
meniscus. It has an attachment to the MCL, and the oblique popliteal ligament coming from
semimembranosus. The upper part of the meniscus is firmly attached to the MCL, the fibres here
forming the medial menisco-femoral ligament. The lower part, at- tached to the coronary ligament,
is more lax. This has important functional consequences because the medial meniscus is anchored
more firmly to the femur than to the tibia. In flexion/extension the femur is thus able to glide on the
tibia, while in rotation, the meniscus can slide over the tibial plateau (Evans, 1986). The lateral
meniscus is more circular, and has a uniform breadth. Its two horns are attached close together, the
anterior horn blending with the at- tachment of the ACL. The posterior horn attaches just anterior to
the posterior horn of the medial meniscus. The meniscus has a posterolateral groove which receives
the popliteus tendon, and a few fibres from this muscle attach to the meniscus itself. In addition, the
tendon of popliteus partially separates the lateral meniscus from the joint cap- sule, a configuration
which makes the lateral meniscus more mobile than its medial counterpart. The posterior part of the
lateral meniscus has two ligamentous attachments, the anterior and pos terior meniscofemoral
ligaments. These divide around the PCL, and in extreme flexion, as the PCL tightens, so do the
anterior and posterior meniscofemoral ligaments. The lateral meniscus is thus pulled backwards and
medially. The menisci receive blood from the inferior genicular arteries which supply the
perimeniscal plexus. Small penetrating branches from this plex- us enter the meniscus via the
coronary ligaments. Up until the age of about 11 years, the whole meniscus has a blood supply, but
in the adult only 10-25% of the periphery of the meniscus is vascu- lar. The anterior and posterior
horns are covered by vascular synovium and have a good blood supply (Amoczky and Warren, 1983).
The peri- pheral vessels are within the deeper cartilage substance, the surface receiving its main
nutrition via diffusion from the synovial fluid. A few myeli- nated and non-myelinated nerve fibres
are found in the outer third of the menisci, but no nerve endings. Because the menisci are held more
firmly centrally, they are able to alter their shape and move forwards and backwards over the tibial
pla- teau. The lateral meniscus has a greater amount of movement, and is often 'pulled away from
trouble' leaving the medial meniscus to be more commonly injured in association with the MCL and
ACL to which it has attachments. In flexion, the lateral meniscus is carried back- wards, onto the
steep posterior slope of the lateral tibial plateau, and with extension, it moves for- wards again. In
flexion/extension the medial menis- cus is held firm until the last 20° of extension when the knee
begins to rotate (screw home mechanism p. 150). As this happens, the medial meniscus is carried
backwards. In extension, the menisci are squeezed and elongated in an anteroposterior direc- tion,
and in flexion, they become wider. The menisci enlarge the tibio-femoral contact area, thus
spreading the pressure taken by the sub-chondral bone (Fig. 11.9a). It has been esti- mated that the
menisci disperse between 30% and 55% of the load across the knee (Kelley, 1990). When only a
portion of the meniscus is removed, he joint surface contact forces may increase by 350% (Seedhom
and Hargreaves, 1979). The menis- ci contribute substantially to knee stability. In the ACL deficient
knee, the anterior drawer test may be positive in only 35% of knees with an intact medial meniscus,
but in 83% when the meniscus is removed (Levy, Torzilli and Warren, 1982). The menisci limit sagittal
gliding of the femur over the tibial plateau, a movement greatly increased in patients who have
undergone menisectomy. In addition, they allow a dual movement to occur, normally only possible
in joints which are far more lax. The menisci also aid joint lubrication by spreading the synovial fluid
over the surface of the articular cartilage.

Injury
It has been estimated that meniscal injury occurs with a frequency of 61 per 100 000 individuals. The
condition is three times more prevalent in males than females, with the medial meniscus wing
injured four times as often as the lateral (Kelley, 1990)

The history of injury is usually one which com bines twisting on a semiflexed knee with the foot
fixed on the ground. The onset is sudden, and pain is felt deep within the knee, the patient often
saying they felt something go', Effusion may be extensive after injury, and haemarthrosis may result
if the injury occurs in combination with ACL or MCL damage. Tears may occur to the periphery or
body of the meniscus, running horizontally or vertically. A longitudinal tear (Bucket handle) of the
medial meniscus may allow its lateral portion to slip over the dome of the medial femoral condyle
causing blocked extension (true locking). On examination, effusion is apparent and tender- ness is
often found over the joint line, most usually medially. A capsular pattern may be noticeable (Table
2.2), and terminal extension is often blocked with a springy end feel if muscle spasm is not present.
Various tests are used to assess the problem, of which the two most common are McMurray's and
Apley's. McMurray's test requires full flexion of the knee and so is not suitable for the acute joint.
The medial joint line is palpated and, from the fully flexed position, the knee is externally rotated
and extended, as a slight varus strain is applied. If positive, a painful click is felt over the medial
meniscus. The lateral meniscus is similarly tested by extending the knee with internal rotation and a
valgus strain. In each case only the posterior por- tion of the meniscus is tested, and so a negative
McMurray's sign does not preclude meniscal dam- age, but when positive the test is clinically revea-
ling.

Apley's grinding test involves placing the patient in a prone lying position, flexing the knee to 90"
rotating the tibia and compressing it against the femur in an attempt to elicit a popping or snapping
sensation. It is important not to force the move- ments too far, as this may further tear the already
damaged meniscus (Garrick and Webb, 1990). The intention with this test is to help differentiate
between meniscal and MCL damage at the joint line. Symptoms will be present as the knee is
compressed when the meniscus is damaged, but not if the MCL alone is injured, because this
Management If a meniscal tear is present, the choice is either non-operative management or
surgical intervention involving removal or repair of the injured menis-Non-operative management

Henning (1988) argued that meniscal tears of less than 10 mm in length, and partial thickness
injuries involving 50% or less of the vertical height of the meniscus could be treated non-operatively,
pro- vided that the ACL was undamaged. Weiss et al. (1989) reported that stable vertical longitudinal
tears in the vascular outer area of the meniscus had a good potential for healing, whereas stable
radial tears did not. They performed a repeat arthroscopy on 32 patients (on average 26
months after the first procedure), and found that 17 longitudinal tears had healed completely. Five
radial tears showed no evidence of healing and one had extended. No degenerative changes were
found in the adjacent articular cartilage of the stable lesions.

Meniscal repair

The peripheral part of the meniscus has a blood supply sufficient to support healing. Initial healing in
this region is by fibrosis with vessels from the capillary plexus and synovial fringe penetrating the
area. Fibrous healing may be complete within 10 weeks, and the scar tissue can be remodelled into
normal fibrocartilage within several months (Ham- mesfahr, 1989). The mid-portion of the meniscus
is avascular and has traditionally been thought not to heal. However, Arnoczky and Warren (1983)
demonstrated healing in canine tissue by cutting an access channel from the peripheral region to the
midpoint of the meniscus. The peripheral vessels proliferated through the channel into the lesion,
giving fibrovascular scarring throughout both areas. The peripheral tear may be sutured, and healing
improved by abrading the parameniscal synovium. Henning (1988) argued that healing may be
further enhanced by injecting an exogenous blood clot into the injury site. Results are good when
repair is limited to the vascular area of the meniscus and to vertical tears (Ryu and Dunbar, 1988).
Weight bearing or full range motion will deform the menis- ci and so pull on the scar site. For this
reason rehabilitation of the repaired meniscus is much less intense than that of a patient who has
undergone menisectomy. DeHaven et al. (1989) reported follow-up results on 80 repaired menisci
on average 4.6 years after surgery. Of these, 11% had torn again (only three at the repair zone), and
these authors recom- mended meniscal repair in view of the degenerative changes following
menisectomy.

Menisectomy

The preceding descriptions of non-operative mana- gement and meniscal repair make it apparent
that menisectomy is not the first choice in many cases of meniscal tearing. Degenerative changes
which have been described after total menisectomy include joint narrowing, ridging and flattening
(Fairbank, 1948). However, where the meniscus is grossly damaged, and the knee is unstable, a
partial or total menisectomy may be required. The minimum amount of tissue should be removed to
reduce the biomechanical impairment to the joint. been described after total menisectomy include
joint narrowing, ridging and flattening (Fairbank, 1948). However, where the meniscus is grossly
damaged, and the knee is unstable, a partial or total menisectomy may be required. The minimum
amount of tissue should be removed to reduce the biomechanical impairment to the joint. The
traditional method for menisectomy (O'Do- noghue, 1976) is with the patient supine, and the knee
flexed to 90° over the table end. For a medial menisectomy a straight incision is often used, starting
proximal to the lower pole of the patella and medial to the patellar tendon, and stretching parallel to
the tendon. The retinaculum is split and the joint washed out (lavaged) with warm saline to remove
any blood. The whole cartilage may be visible if the knee can be sprung open medially, but usually
only palpation with forceps is possible. The bony attachment of the meniscus is dissected and the
meniscus itself removed. Arthroscopic removal of all or part of the menis- cus is commonplace
nowadays. An anterolateral or anteromedial approach may be taken, depending on which
compartment of the knee the lesion is in. The knee is held in 10° flexion and the joint is gapped by
applying a valgus or varus stress. The joint is distended with fluid, to allow easier inspec- tion of the
tissue surfaces. An initial incision is made into the anterior part of the meniscus, and the incision is
then extended into the middle and posterior segments. The posterior horn is released, followed by
the anterior horn and the meniscus is removed. In cases where only part of the meniscus is
removed, the edge of the remaining tissue is trimmed. Arthroscopy, although commonplace, is not
without risk of complication. The committee on complications of arthroscopy of North America
(1985) found a 0.8% complication rate in over 100 000 procedures, while Sherman et al. (1986)
reported a complication rate of 8.2%. Neurological injury, poor wound healing, instrument breakage,
intra-articular infection, knee ligament injury, and pulmonary embolism resulting in death have all
occurred. The patient's age and the length of time that a tourniquet is used have been found to be
the most significant factors in predicting problems (Sherman et al., 1986).

The use of arthroscopy with local anaesthesia is steadily increasing (Ngo et al., 1985; Besser and
Stahl, 1986; Buckley, Hood and MacRae, 1989), and obviously removes the risk inherent in any
procedure involving a genera! anaesthetic. The skin puncture sites are injected with lignocaine or
simi- lar, and the joint is distended with saline and anaesthetic solution. Arthroscopic surgery of this
type allows the patient to be discharged signifi- cantly earlier than when general anaesthesia is used.

Jumper's knee

Jumper's knee is an anterior knee pain affecting the teno-osseous junctions of the quadriceps
tendon where it is attached to the superior pole of the patella, and the patellar tendon where it is
attached to the inferior pole of the patella and tibial tuberos- ity. It is therefore an insertional
tendonopathy resulting in derangement of the bone-tendon unit (Colosimo and Bassett, 1990).

The injury is often described as patellar or quadriceps tendinitis, although these conditions represent
an inflammation of the tendon itself, rather than isolated damage to the teno-osseous junction. In a
strict sense the conditions should be considered separately, but they are generally ac- cepted as a
single entity. However, it should be remembered that tendinitis does not necessarily mean that the
teno-osseous junction is affected, but when the tendon insertion itself is damaged, the tendon will
almost always be inflamed.jumper's knee occurs more frequently in athletes who regularly impose
rapid eccentric loading (trac- tion) on the extensor mechanism of the knee, especially on hard
surfaces. The condition affects the inferior pole of the patella in 80% of cases and is most common at
this site in athletes over 40 years of age. The insertion of the quadriceps is more commonly affected
in the over 40s, and the tibial tuberosity is the most common sight for jumper's knee in children
(David, 1989). Repetitive stress on the teno-osseous junction causes microtearing over time, and an
insidious onset of pain. The condition progresses in a series of stages. Initially, pain is experienced
only after intense activity, as a well-localized dull ache without a history of trauma. With time, pain
occurs at the onset of activity, and disappears when the athlete is warmed up, only to reappear
when the sport has finished. Eventually, pain is constant with consequent impairment of
performance, and as a final, but rare, scenario the tendon may rupture completely. Repetitive stress
causes microtearing over time, and an insidious onset of pain. The condition progresses in a series of
stages. Initially, pain is experienced only after intense activity, as a well-localized dull ache without a
history of trauma. With time, pain occurs at the onset of activity, and disappears when the athlete is
warmed up, only to reappear when the sport has finished. Eventually, pain is constant with
consequent impairment of performance, and as a final, but rare, scenario the tendon may rupture
completely.

On examination, quadriceps wasting is apparent in long-standing cases, and pain occurs to resisted
extension with slight soreness to full passive flex- ion. Some swelling may be noticed around the
patellar tendon in acute cases, with fluctuance present if the condition is severe. A non-capsular
pattern is found. Palpation is performed with the knee in full extension to relax the patellar tendon.
Palpation to the lower pole of the patella is best performed by pressing with the flat of the hand
onto the upper surface of the patella to tilt it. This brings the lower pole into prominence and
enables the practitioner to reach the part of the teno-osseous junction which lies on the under-
surface of the angular lower pole.

Radiographic changes are usually apparent if symptoms have been present for more than 6 months
(Colosimo and Bassett, 1990). An elonga- tion of the involved pole of the patella may be seen with
calcification of the affected tendon matrix. Bone scan has indicated increased blood pooling and
concentration of radioactive tracer in the inflamed area (Kahn and Wilson, 1987).
Both intrinsic and extrinsic factors have been implicated as possible causes. Intrinsic factors in- clude
biomechanical alterations in the extensor mechanism, such as hypermobility, altered Q angle and
genu valgum or genu recurvatum. Changes in the HQ ratio and hamstring flexibility may also have
part to play and should be examined. Extrinsic factors include frequency and intensity of training,
training surface and footwear. Feretti (1986) showed a correlation between jumper's knee and both
hardness of playing surface and training frequency. Thirty seven percent of players (matched for
sport, playing position and training type) using cement surfaces in his study suffered from the
condition, compared with only 5% of those using softer surfaces. In addition, the per- centage of
players affected by the condition esca- lated as the number of training sessions per week increased.
As with any overuse syndrome, part of the management of the condition involves avoidance or
modification of training. Athletes should be en- couraged to warm up adequately, and practise
flexibility exercises to both the quadriceps and hamstrings. Strength must be developed sym-
metrically, and footwear should incorporate shock- absorbing materials. In the early stages of the
condition these modifi- cations combined with ice application when pain is acute are usually
sufficient. Later, transverse fric- tional massage is the treatment of choice. Frictions to the teno-
osseous junctions attaching to the patel- la are only effective if the patella is tilted and pressure from
the therapist's finger is directed at a 45° angle to the long axis of the femur rather than straight
down.

In chronic conditions, where scar tissue has formed at the teno-osseous junctions, limitation in
flexion may be apparent. Flexibility exercises will increase the range of movement, but more by
stretching the quadriceps than the scar tissue. Where this is the case, soft tissue manipulation may
be required in an attempt to rupture the adherent scarring. If this procedure fails to produce a com-
plete result surgery may be required. Various procedures have been described, some of which
attempt to alter underlying malalignment and others to excise abnormal tissue.

Sinding-Larsen-Johansson disease

In this condition the secondary ossification centre on the lower border of the patella is affected in
adolescents. The epiphysis is tractioned, leading to inflammation and eventual fragmentation.
Avascu- lar necrosis is not usually present, but a temporary osteoporosis has been described
(Traverso, Baldari and Catalani, 1990) during the adolescent growth spurt. This may weaken the
inferior pole of the patella making avulsion more likely.

Sinding-Larsen-Johansson disease can easily be confused with chondromalacia on first inspection as

it causes pain in the lower pole of the patella, especially when kneeling. However, on closer exa-
mination the differences are soon apparent, and X-ray confirms the bony change. The condition may
exist with Osgood-Schlatter's syndrome (Tra- verso, Baldari and Catalani, 1990), and the conser-
vative management of the two syndromes is largely the same, involving the use of pain
relieving/anti- inflammatory modalities, and training modifica- tion. Surgical removal of the lower
pole of the patella has been recommended in persistent cases (Williams and Sperryn, 1976).

Osgood-Schlatter's syndrome
This condition affects adolescents, especially males. Most often the patient is an active sportsper-
son who has recently undergone the adolescent growth spurt. With Osgood-Schlatter's syndrome
traction is applied to the tibial tubercle, eventually causing the apophysis of the tubercle to separate
from the proximal end of the tibia. Initially, frag- mentation appears, but with time the fragments
coalesce and further ossification leads to an increase in bone. This gives the characteristic prominent
tibial 'bump' often noticeable when the knee sil- houette is compared with that of the unaffected
side.

The infrapatellar tendon shows increased vascu- larization and, particularly where radiographic
changes are not apparent, soft tissue swelling and infrapatellar fat pad involvement is noted. Pain is
highly localized to the tibial tubercle and exacer- bated by activities such as running, jumping and
descending stairs. The condition may coalesce with patellar malalignment faults, such as patella
infera and patella alta. Patellar tendon avulsion can occur following this condition, and Levi and
Coleman (1976) reported 26% of those seen with this type of fracture to have had in bone. This gives
the characteristic prominent tibial 'bump' often noticeable when the knee sil- houette is compared
with that of the unaffected side.

Initial management is by limiting activity. Pain relief and reduction of inflammation may be ob-
tained using electrotherapy modalities alone or iontophoresis with an anti-inflammatory medica-
tion and local anaesthetic (Antich and Brewster, 1985). Injection of the tibial tubercle with hydro-
cortisone has been described (Grass, 1978). The use of an infra-patellar strap to reduce the pull of
the quadriceps onto the tibial tubercle has been used with some success (Levine and Kashyap, 1981).

Assessment of the lower limb musculature often reveals hypertrophy and inflexibility of the quadri-
ceps. When passive knee flexion is tested, intense pain precludes the use of quadriceps stretching.
However, when pain has subsided, flexibility of this muscle group must be regained. If prolonged
rest has given rise to muscle atrophy, strengthening exercises are indicated. Ice packs may be used
to limit pain or inflammation following activity.

Synovial plica -

The synovial plica is a remnant of the septum which separates the knee into three chambers until
the fourth intrauterine month. The plica, placed supra-medially, may be present in some 20-60% of
knees (Amatuzzi, Fazzi and Varella, 1990), but does not necessarily cause symptoms. In a series of
3250 knee disorders, Koshino and Okamoto (1985) found only 32 patients to have the complaint
(1%). The structure separates the knee joint into two reservoirs, one above the patella and the other
constituting the joint cavity proper. The normal plica is a thin, pink, flexible structure, but when
inflamed it becomes thick, fibrosed and swollen, losing its elasticity and interfering with patello-
femoral tracking.

These tissue changes are often initiated by trau- ma that results in synovitis, and is more common in
athletes. Pain is usually intermittent and increases with activity. Discomfort is experienced when de-
scending stairs and may mimic anterior knee pain. However, pain of plical origin normally subsides
immediately when the knee is extended. In addi- tion, the 'morning sign' may be present. This is a
popping sensation which occurs as the knee is extended, particularly on rising, but disappears
throughout the day. The popping may be accom- panied by giving way, and is caused by the thick-
ened plica passing over the medial femoral condyle. As the day progresses, joint effusion pushes the
plica away from the condyle. This sign may be reproduced with some patients by extending the knee
from 90° flexion while internally rotating the tibia and pushing the patella medially. The pop is
usually experienced at between 45° and 60° flexion. Conservative treatment has been found to be
effective in 60% of cases (Amatuzzi, Fazzi and Varella, 1990) and aims to reduce the compression
over the anterior compartment of the knee, by using stretching exercises. The length of the
hamstrings, quadriceps and gastocnemius muscles should be assessed, and these muscles stretched
if noticeable shortening is found. Where conservative treatment fails, and symptoms limit sport or
daily living, surgery may be warranted. Koshino and Okamoto (1985) reported pain and symptom
relief in 90% of knees treated surgically by plical resec- tion, but did not quote figures for long-
term follow up.

Tendinitis

Tendinitis around the knee occurs most commonly within the patellar tendon (jumper's knee, see
above) the semi-membranosus, and the popliteus. Semi-membranosus tendinitis gives a persistent
ache over the posteromedial aspect of the knee. It occurs as the semi-membranosus tendon slides
over the medial corner of the medial femoral condyle, and is distinct from semi-membranosus
bursitis which affects the area of the medial tibial condyle. Pain may occur within the tendon
substance itself, or over the teno-osseous junction, when an inser- tional tendinitis is present.
Increased tracer uptake has been noted on bone scan with this latter condition (Ray, Clancy and
Lemon, 1988). Popliteus tendinitis is related to increased prona- tion of the STJ and excessive
internal rotation of the tibia (Brody, 1980). The increased internal rotation causes traction on the
popliteus attach- ment to the lateral femoral condyle. The popliteus acts with the PCL to prevent
forward displacement of the femur on the flexed tibia, and so will be overworked with downhill
running (Baylis and Rzonca, 1988). On examination, tenderness is rev- ealed over the popliteus, just
anterior to the fibular collateral ligament. The patient is examined in a supine position, with the
injured knee in the 'figure of four' position, that is affected hip flexed, ab- ducted and externally
rotated, knee bent to 90° and foot placed on the knee of the contralateral leg. The condition is
differentiated from ITB friction syn- drome by testing resisted tibial internal rotation with the knee
flexed, and palpating the popliteus as internal rotation is resisted in extension (Allen and Ray, 1989).

Treatment for tendinitis involves rest, anti- inflammatory modalities, and training modifica- tion. The
flexibility of the knee musculature and the biomechanics of the lower limb should be assessed and
corrected as necessary.

Bursitis

The knee joint has on average 14 bursae (see Table 11.2) in areas where friction is likely to occur,
between muscle, tendon, bone and skin. Any of these can become inflamed and give pain when
compressed through muscle contraction or direct palpation. Those most commonly injured in sport
include the pre-patellar, pes anserine, and semi- membranosus. rthe pre-patellar bursa is usually
injured by falling onto the anterior aspect of the knee, or by prolonged kneeling (housemaid's knee).
Hae- morrhage into the bursa can cause an inflammatory reaction and increased fluid volume.
Enlargement is noticeable and the margins of the mass are welldefined, differentiating the condition
from general knee effusion or subcutaneous haematoma. Knee flexion may be limited, the bursa
being compressed as the skin covering the patella tightens.

Septic bursitis may result from secondary infec tion if the skin over the bursa is broken by laceration
or puncture wound. If the condition becomes chronic, the bursa may collapse and the folded walls of
the thickened bursa sac appear as small hardened masses on the anterior aspect of the knee. In
these cases, erythema and exquisite ten- derness is usually present. Minor cases normally respond
to rest and ice, but more marked swelling requires aspiration. Aspiration is carried out under sterile
conditions, and a compression bandage applied. Semi-membranosus bursitis gives rise to pain and
swelling over the lower posteromedial aspect of the knee. Pain may be made worse by hamstring or
gastrocnemius contraction against resistance, and in activities involving intense action of these
muscles, such as sprinting and bounding. Pes anserine bursitis gives pain and swelling over the
metaphyseal area of the tibia, sometimes re- ferred to the medial joint line (Baylis and Rzonca,
1988). The bursa may be injured by direct trauma (hitting the knee on a hurdle) or by overuse of the
pes anserine tendons. Minor cases normally respond to rest and ice, but more marked swelling
requires aspiration. Aspiration is carried out under sterile conditions, and a compression bandage
applied.Semi-membranosus bursitis gives rise to pain and swelling over the lower posteromedial
aspect of the knee. Pain may be made worse by hamstring or gastrocnemius contraction against
resistance, and in activities involving intense action of these muscles, such as sprinting and
bounding.Pes anserine bursitis gives pain and swelling over the metaphyseal area of the tibia,
sometimes re- ferred to the medial joint line (Baylis and Rzonca, 1988). The bursa may be injured by
direct trauma (hitting the knee on a hurdle) or by overuse of the pes anserine tendons. With both of
the latter causes of bursitis, rest and anti-inflammatory modalities are required. Biomechanical
assessment of the lower limb and analysis of the athlete's training regime are called for where there
is no history of injury. One condition often referred to as 'bursitis' is a Baker's cyst. This is actually a
posterior herniation of the synovial membrane into the bursa lying between semi-membranosus and
the medial head of gastrocnemius. The mass bulges into the popliteal space, and occurs particularly
in rheumatoid ar- thritis. The posterior knee ligaments weaken and fail to support the joint capsule,
allowing the herniation to occur. The cyst can be palpated over

Fat pads

Fat pads consist of fat cells (adipose tissue) packed closely together and separated from other
tissues by fibrous septa. They have an abundant blood supply, and are well innervated. Most
significant to the knee is the infrapatellar fat pad, lying beneath the patellar tendon, and in front of
the femoral condyles. The fat pad is intracapsular but extrasy- novial, and a piece of synovial
membrane (ligamen- tum mucosum) passes from the pad to the intracon- dylar notch of the femur.
When the knee is fully flexed, the infrapatellar fat pad fills the anterior aspect of the intercondylar
notch. As the knee extends, the fat pad covers the trochlear surface of the femur within the patellar
groove (Hertling and Kessler, 1990).
The usual pathology of the infrapatellar fat pad is an enlargement causing increased pressure with
resultant pain. Direct trauma can cause haemorrh- age and local oedema, and swelling may also
occur as a result of pre-menstrual water retention. Space occupying lesions, such as osteochondrotic
frag- ments, may also cause enlargement, and Smillie (1974) described a case where a displaced
bucket handle tear of the medial meniscus was forced into the infrapatellar fat pad of the knee.

Enlargement and entrapment of the patellar fat pad has been described by Finsterbush, Frankl and
Mann (1989). The entrapped pad was shown to be in various stages of tissue degeneration, including
fat necrosis and replacement of the fatty tissue with fibrinoid material. Complete fibrosis was later
seen. Silver and Campbell (1985) described persis- tent inflammation of the knee fat pads as a cause
of delayed recovery in dancers with knee injuries. Surgical removal of the pad resulted in restoration
of full range motion at the knee. Tsirbas, Paterson and Keene (1990) described excision of the fat
pad tip to relieve patello-femoral pain. Patients pres- ented with a history of pain inferomedial, and
sometimes inferolateral, to the patella. On exami- nation, impingement pain occurred deep to the
inferior pole of the patella at 20° flexion with resisted quadriceps contraction

Knee rehabilitation

Exercise begins in a non-weight-bearing starting position and progresses to partial and full weight-
bearing movements. Straight leg raising progresses to limited range movements with short lever
arms. The quadriceps, hamstrings, hip abductors, hip adductors and knee rotators are all worked.
Free exercise progresses to resisted exercise using rubber bands, sand bags and weights.

The progression to partial and then full weight- bearing from non-weight-bearing changes the
movement from an open to a closed kinetic chain action. Rotation and shearing stresses are imposed
upon the knee, and these forces increase as the speed and range of motion increases, and also as
combined movements are used. Sagittal plane movements (flexion/extension) are progressively
combined with horizontal plane (rotation/ translation) and frontal plane (abduction/ adduction)
actions. Examples of progressions for free exercises performed in full weight-bearing are listed
below.

Walk on the spot

Walk forwards/backwards

Side step

Circle walk
Single leg dips, gradually increasing range of mo-

tion

Lunge onto affected leg, gradually increasing range of motion

Single leg squat, gradually increasing range of motion Dip and cross legs forwards and backwards
Jogging on the spot

Jogging forwards/backwards

Side step

Circle run

Figure of eight run Carioca

Running on camber

Running up/down slope

Double leg standing on balance board Single leg standing on balance board Bench stepping

Bench rib walking Step down from bench

Step over bench

Side step over bench

Lunge from floor to balance board Walk over series of balance boards (in parallel bars) Squat while
standing on balance board

Bench support alternate leg thrust Bench support jump over (both legs) Bench support jump over
(single leg)

Jumping forwards/backwards

Side jumps

Ski-training machine

jump and twist Increase depth of above

Hopping as above

Hop and hold position for 2 seconds Plyometric progressions

The exercise progressions dictate the level of training that the athlete should be allowed to use in his
or her own sport. For example, no athlete should be allowed to run on turf until he or she is able to
hop and twist without pain, as this move- ment may occur in an uncontrolled training situa- tion. The
final decision of competitive fitness will depend on the athlete's performance with advanced stage
rehabilitation exercises, and the assessment of skills by his or her coach (see p. 69).