I.

DEFINITION OF TERMS
medial meniscusmade of fibrous, crescent shaped cartilage and attached
to the tibia, on the inside of the knee

lateral meniscusmade of fibrous, crescent shaped cartilage and attached

to the tibia, on the outside of the knee

articular cartilage is on the ends of all bones in any joint

Medial Collateral Ligament (tibial collateral ligament) attaches the

medial side of the femur to the medial side of the tibia and limits sideways
motion of your knee.
Lateral Collateral Ligament (fibular collateral ligament) attaches the
lateral side of the femur to the lateral side of the fibula and limits sideways
motion of your knee.
Anterior cruciate ligament attaches the tibia and the femur in the
center of your knee; its located deep inside the knee and in front of the
posterior cruciate ligament. It limits rotation and forward motion of the tibia.
Posterior cruciate ligament is the strongest ligament and attaches the
tibia and the femur; its also deep inside the knee behind the anterior cruciate
ligament. It limits the backwards motion of the knee.
Patellar ligament attaches the kneecap to the tibia
Menisci- Rims of fibrocartilage situated on the articular surface of the tibial
plateau
fibular Collateral Lig.- connect lateral femur to the fibula. Unique because
it leaves a space where you can see the popiteal lig. Prevents adduction of the
leg.
Tibial Collateral Lig.- Medial femur to the tibia. Attaches to medial
meniscus. Prevents abduction of the leg.
Collateral Ligaments prevent- medial and lateral glides.
Cruciate Ligaments prevent- Anterior and posterior slides.
Unhappy triad.-Planted foot and lateral strike to the knee can cause the TCL
to break which in turn can damage the medial meniscus and the ACL.

A meniscus tear is a common knee injury. The meniscus is a rubbery, C-shaped disc
that cushions your knee. Each knee has two menisci (plural of meniscus)-one at the
outer edge of the knee and one at the inner edge. The menisci keep your knee
steady by balancing your weight across the knee. A torn meniscus can prevent your
knee from working right. A meniscus tear is usually caused by twisting or turning
quickly, often with the foot planted while the knee is bent. Meniscus tears can occur
when you lift something heavy or play sports. As you get older, your meniscus gets
worn. This can make it tear more easily.
II. EPIDEMIOLOGY
Frequency
United States

Although the exact incidence and prevalence of meniscal injury are unknown, it is
a fairly common sports-related injury among adults. Although less common than in
adults, knee meniscal injuries do occur in individuals who are skeletally immature.
Meniscal injuries are rare in children younger than 10 years with morphologically
normal menisci
Mortality/Morbidity
Meniscal injuries usually are associated with pain that results in gait deviation and
loss of time from work and/or sport.
Race
A correlation of race and meniscal injuries is not known to exist.
Sex
Meniscal injuries are more common in males, which may be a reflection of males
being more involved in aggressive sporting and manual activities that predispose
to rotational injuries of the knee.
Age
Meniscal injuries are common in young males who are involved in sporting or
manual activities. A second peak of incidence is observed in elderly persons older
than 55 years; this incidence is secondary to a degenerate meniscus being
susceptible to injuries with minor trauma. Meniscal injuries are rare in children
younger than 10 years with morphologically normal menisci.

III. ANATOMY, PHYSIOLOGY AND KINESIOLOGY

The menisci are C-shaped wedges of fibrocartilage located between
the tibial plateau and femoral condyles. The menisci contain 70% type I
collagen. The larger semilunar medial meniscus is attached more firmly than
the loosely fixed, more circular lateral meniscus. The anterior and posterior
horns of both menisci are secured to the tibial plateaus. Anteriorly, the
transverse ligament connects the 2 menisci; posteriorly, the meniscofemoral
ligament helps stabilize the posterior horn of the lateral meniscus to the
femoral condyle. The coronary ligaments connect the peripheral meniscal
rim loosely to the tibia. Although the lateral collateral ligament (LCL) passes
in close proximity, the lateral meniscus has no attachment to this structure

Menisci are half moon shape piece of cartilage

Acts as lubrication, nutrition, shock absorption, prevent of cartilage
wear to increase congruency
80% collagen, 10% protein,10% glycoxaminoglycans
Wedge shape

o -central- thin
o -peripheral- thick
Avascular especially on the inner 2/3
Nerve ending: Meniscotibial ligament/coronary ligament (suture the
menisci)

2 types of menisci:
1. medial meniscusmade of fibrous, crescent shaped cartilage and
attached to the tibia, on the inside of the knee
2. lateral meniscusmade of fibrous, crescent shaped cartilage and
attached to the tibia, on the outside of the knee
MEDIAL MENISCUS
LATERAL MENISCUS
SHAPE
C shaped
O shaped
THICKNESS
10mm
12-13 mm
MOVEMENT
Less mobile
More mobile
RISK OF INJURY Increase
Less/
ATTACHMENT
Patella via patellar ligament
Patella
Intercondylar eminence
Tibial condyle
Transverse ligament
UNIQUE
- medial meniscus
-PCL
ATTACHMENT
ACL}
unhappy triad
of
MCL
ODonoghue
(cause by valgus force
to a flexed, externally
rotated knee)
MUSCLE
Gastrocnemius
Popliteus
Bone Structure
Bone tissuee (osseous tissue) differs greatly from other tissues in the body.
Bone is hard and many of its functions depend on that characteristic
hardness. Later discussions in this chapter will show that bone is also
dynamic in that its shape adjusts to accommodate stresses. This section will
examine the gross anatomy of bone first and then move on to its histology.
Functions of Bones
Support. Bones provide a framework that supports the body and cradles its
soft organs act as pillars to support the body trunk when we stand, and the rib
cage supports the thoracic wall.
Protection. The fused bones of the skull protect the brain. The vertebrae
surround the spinal cord, and the rib cage helps protect the vital organs of the
thorax.
Movement. Skeletal muscles, which attach to bones by tendons, use bones
as levers to move the body and its parts.
Mineral and growth factor storage. Bone is a reservoir for minerals, most
importantly calcium and phosphate. The stored minerals are released into the
bloodstream in their ionic form as needed for distribution to all parts of the
body.

 Triglyceride (fat) storage. Fat, a source of energy for the body, is stored in
bone cavities.
Hormone production. Bones produce osteocalcin, a hormone which not only
helps regulate bone formation, but also protects against obesity, glucose
intolerance, and diabetes mellitus.
Our knee is the most complicated and largest joint in our body. Its also the
most vulnerable because it bears enormous weight and pressure loads while
providing flexible movement. When we walk, our knees support 1.5 times our
body weight; climbing stairs is about 3-4 times our body weight and squatting
about 8 times.
The knee joint is a synovial joint which connects the femur, our thigh bone and
longest bone in the body, to the tibia, our shinbone and second longest bone.
There are two joints in the kneethe tibiofemoral joint, which joins the tibia to the
femur and the patellofemoral joint which joins the kneecap to the femur. These two
joints work together to form a modified hinge joint that allows the knee to bend
and straighten, but also to rotate slightly and from side to side.
Knee
The knee is a complex pivotal hinge joint that connects the bones in the upper and
lower leg, comprised of muscle, ligaments, tendons, and the meeting of four
bones: the femur, tibia, fibula, and patella. It is the largest joint in the body.
The knee is part of a chain that includes the pelvis, hip, and upper leg above, and
the lower leg, ankle and foot below. All of these work together and depend on each
other for function and movement.
The knee joint bears most of the weight of the body. When were sitting, the tibia
and femur barely touch; standing they lock together to form a stable unit. Lets
look at a normal knee joint to understand how the parts (anatomy) work together
(function) and how knee problems can occur.

The knee is the meeting point of the femur (thigh bone) in the upper leg and the
tibia (shinbone) in the lower leg. The fibula (calf bone), the other bone in the
lower leg, is connected to the joint but is not directly affected by the hinge joint
action. Another bone, the patella (kneecap), is at the center of the knee.
Two concave pads of cartilage (strong, flexible tissue) called menisci minimize the
friction created at the meeting of the ends of the tibia and femur.
Anterior if facing the knee, this is the front of the knee
Posterior if facing the knee, this is the back of the knee, also used to describe
the back of the kneecap, that is the side of the kneecap that is next to the femur
Medial the side of the knee that is closest to the other knee, if you put your
knees together, the medial side of each knee would touch
Lateral the side of the knee that is farthest from the other knee (opposite of the
medial side)

Structures often have their anatomical reference as part of their name, such as the
medial meniscus or anterior cruciate ligament. The medial meniscus would refer to
the meniscus on the inside of the knee, the anterior crucial ligament would be on
the anterior side (front) of the knee.
The main parts of the knee joint are bones, ligaments, tendons, cartilages and a
joint capsule, all of which are made of collagen. Collagen is a fibrous tissue present
throughout our body. As we age, collagen breaks down.
The adult skeleton is mainly made of bone and a little cartilage in places. Bone and
cartilage are both connective tissues, with specialized cells called chondrocytes
embedded in a gel-like matrix of collagen and elastin fibers. Cartilage can be
hyaline, fibrocartilage and elastic and differ based on the proportions of collagen
and elastin. Cartilage is a stiff but flexible tissue that is good with weight bearing
which is why it is found in our joints. Cartilage has almost no blood vessels and is
very bad at repairing itself. Bone is full of blood vessels and is very good at self
repair. It is the high water content that makes cartilage flexible.

Knee Joint
The knee joint is the largest and most complicated joint in the body. Basically, it
consists of two condylar joints
between the medial and lateral condyles of the femur and the corresponding
condyles of the tibia, and a gliding joint, between the patella and the patellar
surface of the femur
Strength of the Knee Joint
The strength of the knee joint depends on the strength of the ligaments that
bind the femur to the tibia
and on the tone of the muscles acting on the joint.
The most important muscle group is the quadriceps femoris; provided that this is
well-developed, it is capable of stabilizing the knee in the presence of torn
ligaments.
The classification of meniscal tears provides a description of pathoanatomy. The
types of meniscus tears include the following:

Longitudinal tears that may take the shape of a bucket handle if displaced

Radial tears

Parrot-beak or oblique flap tears

Horizontal tears

Root tears

Complex tears that combine variants of the above

Bones of the Knee
The bones give strength, stability and flexibility in the knee. Four bones make up
the knee:

Tibia commonly called the shin bone, runs from the knee
to the ankle. The top of the tibia is made of two plateaus
and a knuckle-like protuberance called the tibial
tubercle. Attached to the top of the tibia on each
side of the tibial plateau are two crescent-shaped shock-absorbing
cartilages called menisci which help stabilize
the knee.
Patellathe kneecap is a flat, triangular
bone; the patella moves when the leg
moves. Its function is to relieve friction
between the bones and muscles when the
knee is bent or straightened and to protect
the knee joint. The kneecap glides along the
bottom front surface of the femur between two
protuberances called femoral condyles. These condyles
form a groove called the patellofemoral groove.
Femurcommonly called the thigh bone; its the largest,
longest and strongest bone in the body. The
round knobs at the end of the bone are called condyles.
Fibulalong, thin bone in the lower leg on the lateral side,
and runs along side the tibia from the knee to the ankle.

Ligaments in the knee

The
flat
give

knee works similarly to a rounded surface sitting atop a

surface. The function of ligaments is to attach bones to bones and
strength and stability to the knee as the knee has very little
stability. Ligaments are strong, tough bands that are not
particularly flexible. Once stretched, they tend to stay
stretched and if stretched too far, they
snap.
Extracapsular ligament

Medial Collateral
Ligament (tibial collateral ligament)
attaches the medial side of the femur to the medial side of
the tibia and limits sideways motion of your knee.
-prevent Valgus stress
Lateral Collateral Ligament (fibular collateral ligament)
attaches the lateral side of the femur to the lateral side of the
fibula and limits sideways motion of your knee.
-prevents varus stress
-proximal attachment: lateral femoral condyle
- distal attachment: fibular head
Patellar ligament attaches the kneecap to the tibia

OPL/ oblique popliteal ligament- continuation on semimembranosus.

attach to the lateral condyle of femur and reinforce the post wall of the knee
Arcuate ligament
-proximal
attachment:
lateral condyle,
intercondylar
eminence
-distal
attachment:
fibular head
Intracapsular
ligament
Anterior
cruciate
ligament
attaches
the tibia
and the
femur in
the center
of your knee; its located deep inside the knee and in front of the
posterior cruciate ligament. It limits rotation and forward motion of the
tibia. It provides rotational (torsional) stability
Orientation: upward, backward, laterally
MOI: land on hyperextended knee and sudden deceleration.
Posterior cruciate ligament is the strongest ligament and attaches
the tibia and the femur; its also deep inside the knee behind the anterior
cruciate ligament. It limits the backwards motion of the knee.
Orientation: upward, forward, medially
MOI: land on flexed knee

***NOTE:
ACL
-prevents ANT translation of tibia
-prevents POST translation of femur
PCL
-prevents POST translation of tibia
-Prevents ANT translation of femur
Grade I Small area of increased signal within the meniscus
Grade II Linear area of increased signal that does not extend to an articulating
surface
Grade III Abnormal increased signal that reaches the surface or edge of the
meniscus (indicative of meniscal tearing)
Root tears Meniscal extrusion of at least 3 mm in the mid-coronal plane

A bucket handle meniscus tear is a very unique type of meniscus tear.

Bucket handle meniscus tears are more common in younger athletes. They can
occur in older adult athletes too, but most bucket handle meniscus tears occur in
people under 35 years old.

The pair of collateral ligaments keep the knee from moving too far side-to-side.
The cruciate ligaments crisscross each other in the center of the knee. They allow
the tibia to swing back and forth under the femur without the tibia sliding too far
forward or backward under the femur. Working together, the 4 ligaments are the
most important in structures in controlling stability of the knee. There is also a
patellar ligament that attaches the kneecap to the tibia and aids in stability. A belt
of fascia called the iliotibial band runs along the outside of the leg from the hip
down to the knee and helps limit the lateral movement of the knee.
Cruciate
Intercondylar area
Anterior/posterior
Prevents Internal Rotation

collateral
Side
Lateral/medial
Valgus/ varus
Prevent External rotation and extension

Tendons in the Knee

Tendons are elastic tissues that technically part of the muscle and connect muscles
to bones. Many of the tendons serve to stabilize the knee. There are two major
tendons in the kneethe quadriceps and patellar. The quadriceps
tendon connects the quadriceps muscles of the thigh to the kneecap and provides
the power for straightening the knee. It also helps hold the patella in the
patellofemoral groove in the femur. The patellar tendon connects the kneecap to
the shinbone (tibia)which means its really a ligament.
Skeletal Cartilages
is made of some variety of cartilage tissue
molded to fit its body location and function.

its

is, its
after

Consists primarily of water, which accounts for

resilience, that
ability to spring back to its original shape
beingcompressed.

Hyaline Cartilages- look like frosted

glass when freshly exposed, provide
support
with flexibility and resilience. They are the most
abundant skeletal cartilages.

Articular cartilages, which cover the ends of most bones

atmovable joints

Costal cartilages, which connect the ribs to the

sternum(breastbone)

Respiratory cartilages, which form the skeleton of the

larynx (voicebox) and reinforce other respiratory passageways
Nasal cartilages, which support the external nose
Elastic Cartilages

Elastic cartilages resemble hyaline cartilages

they contain more stretchy elastic fibers and so are better
able to stand up to repeated bending. They are found in only two skeletal
locations
ear and the epiglottis (the flap that bends to cover the opening of the larynx
each time we swallow).

Fibrocartilages
-Highly compressible with great tensile strength, fibrocartilages
consist of roughly parallel rows of chondrocytes alternating with thick
collagen fibers Fibrocartilages occur
Cartilage
The ends of bones that touch other bonesa jointare covered with articular
cartilage. Its gets its name articular because when bones move against each
other they are said to articulate. Articular cartilage is a white, smooth, fibrous
connective tissue that covers the ends of bones and protects the bones as the joint
moves. It also allows the bones to move more freely against each other. The
articular cartilages of the knee cover the ends of the femur, the top of the tibia and
the back of the patella. In the middle of the knee are
meniscidisc shaped cushions that act as shock
absorbers.

medial meniscusmade of fibrous, crescent

shaped cartilage and attached to the tibia, on
the inside of the knee
lateral meniscusmade of fibrous, crescent
shaped cartilage and attached to the tibia, on
the outside of the knee

articular cartilage is on the

ends of all bones in any jointin
the knee joint it covers the ends
of the femur and tibia and the
back of the patella. The articular
cartilage is kept slippery by
synovial fluid (which looks like
egg white) made by the synovial
membrane (joint lining). Since the
cartilage is smooth and slippery,
the bones move against each
other easily and without pain

Muscles Around the Knee

The muscles in the leg keep the knee

stable, well aligned and movingthe
quadriceps (thigh) and hamstrings.
There are two main muscle groups
the quadriceps and hamstrings.
The quadriceps are a collection of 4
muscles on the front of the thigh and
are responsible for straightening the knee by bringing a bent knee to a straight
position. The hamstrings is a group of 3 muscles on the back of the thigh and
control the knee moving from a straight position to a bent position.
The Joint Capsule
The capsule is a thick, fibrous structure that wraps around the knee joint. Inside
the capsule is the synovial membrane which is lined by the synovium, a soft tissue
that secretes synovial fluid when it gets inflamed and provides lubrication for the
knee.
Bursae
There are up to 13 bursa of various sizes in and around the knee. These fluid filled
sacs cushion the joint and reduce friction between muscles, bones, tendons and
ligaments. There are bursa located underneath the tendons and ligaments on both
the lateral and medial sides of the knee. The prepatellar bursa is one of the most
significant bursa and is located on the front of the knee just under the skin. It
protects the kneecap. In addition to bursae, there is a infra patellar fat pad that
helps cushion the kneecap.

Plica
Plica- are folds in the synovium. Plicae rarely cause problems but sometimes they
can get caught between the femur and kneecap and cause pain.
-remount of synovial fluid septa or extra synovium
1. Supratellar plica
2. Mediopatellar plica
3. Infrapatellar plica
Blood supply
The blood supply to the menisci is limited to their peripheries. The medial and
lateral geniculate arteries anastomose into a parameniscal capillary plexus
supplying the synovial and capsular tissues of the knee joint. The vascular
penetration through this capsular attachment is limited to 10-25% of the peripheral
widths of the medial and lateral meniscal rims. In 1990, Renstrom and Johnson
reported a 20% decrease in the vascular supply by age 40 years, which may be
attributed to weight bearing over time.
The presence of a vascular supply to the menisci is an essential component in the
potential for repair. The blood supply must be able to support the inflammatory
response normally seen in wound healing. Arnoczky, in 1982, proposed a
classification system that categorizes lesions in relation to the meniscal vascular
supply

An injury resulting in lesions within the blood-rich periphery is called a redred tear. Both sides of the tear are in tissue with a functional blood supply, a
situation that promotes healing.
A tear encompassing the peripheral rim and central portion is called a redwhite tear. In this situation, one end of the lesion is in tissue with good blood
supply, while the opposite end is in the avascular section.
A white-white tear is a lesion located exclusively in the avascular central
portion; the prognosis for healing in such a tear is unfavorable.

Repair of lesions in the red zone has yielded good results, according to Stone.
Reports describe techniques for manufacturing a vascular access channel from the
peripheral vasculature to improve the chance that tissue in the central region will
repair itself.
Biomechanics
The menisci follow the motion of the femoral condyle during knee flexion and
extension. Shrive et al presented a model of normal meniscal function.During
extension, the femoral condyles exert a compressive force displacing the menisci
anteroposteriorly. As the knee moves into flexion, the condyles roll backward onto
the tibial plateau. The menisci deform mediolaterally, maintaining joint congruity
and maximal contact area. As the knee flexes, the femur externally rotates on the
tibia, and the medial meniscus is pulled forward. Studies by Shrive, Fukubayashi,
Walker, and Kurosawa state that the menisci directly influence the transmission of

forces, distribution of load, amount of contact force, and pressure distribution

patterns.

Kinesiology
The Quadriceps Mechanism is made up of the patella (kneecap), patellar
tendon, and the quadriceps muscles (thigh) on the front of the upper leg. The
patella fits into the patellofemoral groove on the front of the femur and acts like a
fulcrum to give the leg its power. The patella slides up an down the groove as the
knee bends. When the quadriceps muscles contract they cause the knee to
straighten. When they relax, the knee bends.
Tibiofemoral shaft angle
Normal angle is 6, reference point is on the mid. point of patella
Q angle
Normal angle in Male 13 in female 18
It is the measurement of the alignment of quadriceps muscle (rectus femoris)
and patellar tendon
Intersecting line: ASIS to mid patella and Tibial tubercle to mid patella.
Chondromalacia patella
Patella alta (camel back sign)
Chondromalacia patella
Sublaxed patella
Increase femoral anteversion
Lateral tibial torsion
Genu valgum
THE LEVER SYSTEM
Bones, ligaments, and muscles are the structures that form levers in the
body to create human movement. In simple terms, a joint (where two or more
bones join together) forms the axis (or fulcrum), and the muscles crossing the joint
apply the force to move a weight or resistance. Levers are typically labeled as first
class, second class, or third class. All three types are found in the body, but most
levers in the human body are third class.

a. First-class lever has the axis (fulcrum) located

between the weight (resistance) and the force. Firstclass levers in the human body are rare. One
example is the joint between the head and the first
vertebra (the atlantooccipital joint). The weight
(resistance) is the head, the axis is the joint, and the
muscular action (force) come from any of the
posterior muscles attaching to the skull, such as the
trapezius.

b. Second-class lever, the weight (resistance)

is located between the axis (fulcrum) and the
force. In the human body, an example of a
second-class lever is found in the lower leg when
someone stands on tiptoes. The axis is formed by
the metatarsophalangeal joints, the resistance is
the weight of the body, and the force is applied
to
the
calcaneus
bone
(heel)
by
the
gastrocnemius and soleus muscles through the Achilles tendon.

c. Third-class lever, the most common in the

human body, force is applied between the
resistance (weight) and the axis (fulcrum). There
are numerous third-class levers in the human
body; one example can be illustrated in the
elbow joint .The joint is the axis (fulcrum). The
resistance (weight) is the forearm, wrist, and
hand. The force is the biceps muscle when the
elbow is flexed.

IV. ETIOLOGY
Sudden meniscus tears often happen during sports. Players may squat and twist
the knee, causing a tear. Direct contact, like a tackle, is sometimes involved.
Older people are more likely to have degenerative meniscus tears. Cartilage
weakens and wears thin over time. Aged, worn tissue is more prone to tears. Just
an awkward twist when getting up from a chair may be enough to cause a tear, if
the menisci have weakened with age.

V. PATHOPHYSIOLOGY

Force on knee jt.


Increasing force concentration on cartilage

Damage to meniscus

Tear produce rough suface

Abnormal loading pattern

Meniscal tear
The force distribution is across the knee joint, increasing force concentration on the
cartilage and other joint structures
Damage to the meniscus due to rotational forces directed to a flexed knee (as may
occur with twisting sports) is the usual underlying mechanism of injury. A valgus
force applied to a flexed knee with the foot planted and the femur rotated
externally can result in a lateral meniscus tear. A varus force applied to the flexed
knee when the foot is planted and the femur rotated internally result in a tear of
the medial meniscus.
Tears produce rough surfaces inside the knee, which cause catching, locking,
buckling, pain, or a combination of these symptoms. Abnormal loading patterns
and rough surfaces inside the knee, especially when coupled with return to sports,
significantly increase the risk of developing arthritis if not already present
VI. CLINICAL SIGNS AND SYMPTOMS
Most meniscal injuries can be diagnosed by obtaining a detailed history. Important
points to address include the following:

Mechanism of injury (eg, twisting, squatting, changes in position)

Pain (commonly intermittent and usually localized to the joint line)

Mechanical complaints (eg, clicking, catching, locking, pinching, or a

sensation of giving way)

Swelling (usually delayed, sometimes absent; degenerative tears often

manifest with recurrent effusions)
Physical findings that are significant in the examination of a patient with a possible
meniscus injury include the following:

Joint line tenderness (77-86% of patients with a meniscal tear)

Effusion (~50% of patients presenting with a meniscal tear)

Impaired range of motion A mechanical block to motion or frank locking can

occur with displaced tears; restricted motion commonly results from pain or
swelling

Swelling: One of the most common symptoms is local swelling. There are
two types of swelling. One is caused by the knee producing too much synovial
fluid and the other is caused by bleeding into the joint (hemarthrosis). Swelling
within the first hour of an injury is usually from bleeding. Swelling from 2-24
hours is more likely to be from the joint producing large amounts of synovial
fluid trying to lubricate an abnormality inside the knee. The best home
treatment for swelling is R.I.C.E. therapy. Chronic swelling can distend the
knee, prohibit full range of motion and the muscles can atrophy from non-use.
Also, if the cause of the swelling is blood, the blood can be destructive to the
joint.

Locking. Locking is when something is keeping the knee from fully

straightening out. This is usually a loose body in the knee. The loose body can
be as small as a grain of sand or as big as a quarter. The best treatment is
removal of the loose body by arthroscopy. Another type of locking is when the
knee hurts so bad that you just wont use it. The best treatment here is rest
and maybe some ice; swelling is not usually present.

Giving Way. If your kneecap slips out of is groove for an instant, it causes
your thigh muscles to loose control causing the feeling of instabilitythat is,
you dont feel like your knee is stable, wont support your weightand you
usually try to grab hold of something for support. Giving way can also be
caused by weak leg muscles or an old ligament injury.

Snaps, Crackles and Pops. Noises coming from your knee without pain
are likely nothing to worry about. Sometimes the noise is caused by loose
bodies that just float around and are not causing pain or injury to the knee.
However, If you have pain, swelling or loss of knee function, you should see
an orthopedist. The most common causechondromalacia patellais caused
by an injury. Another common cause is a dislocating kneecapthat is, a
kneecap that keeps slipping out of its groove. Pops without trauma (injury) are
not worrisome, pops with trauma can mean ligament tears. Crackling, grinding
or grating (crepitus) means there is a roughness to the bone surfaces and
likely from degenerative disease or wear-and-tear arthritis (osteoarthritis).

Pain and Tenderness. Where and how bad the pain is will help find the
underlying cause. It also helps to know what caused it and what makes it hurt.
Pain that gets worse with activity is often tendinitis or stress fractures. Pain
and tenderness accompanied by swelling can be more serious such as a tear
or sprain. Some pain can be caused by muscles spasms associated with
trauma.

With a minor tear, you may have slight pain and swelling. This usually goes away
in 2 or 3 weeks.
A moderate tear can cause pain at the side or center of your knee. Swelling slowly
gets worse over 2 or 3 days. This may make your knee feel stiff and limit how you
can bend your knee, but walking is usually possible. You might feel a sharp pain
when you twist your knee or squat. These symptoms may go away in 1 or 2 weeks

but can come back if you twist or overuse your knee. The pain may come and go
for years if the tear isn't treated.
In severe tears, pieces of the torn meniscus can move into the joint space. This can
make your knee catch, pop, or lock. You may not be able to straighten it. Your knee
may feel "wobbly" or give way without warning. It may swell and become stiff right
after the injury or within 2 or 3 days.
VII. DIAGNOSTIC TOOL/ PROCEDURES/TEST
1. X-ray
-in early stages, it shows bone demineralization and soft tissue
swelling; later, loss of cartilage and narrowing of joint spaces: and finally,
cartilage and bone destruction and erosion, subluxations, and deformities.
2. MRI
-An MRI uses a magnetic field to take multiple images of your knee. It
will be able to take pictures of cartilage and ligaments to determine if
theres a meniscus tear.
3. Ultrasound
-ultrasound uses sound waves to take images inside the body. This will
determine if you have any loose cartilage that may be getting caught in your
knee.
4. Arthroscopy
-If your doctor is unable to determine the cause of your knee pain from
these techniques, they may suggest arthroscopy to study your knee. If you
require surgery, your doctor will also most likely use an arthroscope. With
arthroscopy, a small incision, or cut, is made near the knee. The arthroscope
is a thin and flexible fiberoptic device that can be inserted through the
incision. It has a small light and camera, and surgical instruments can be
moved through the arthroscope or through additional incisions in your knee.
After an arthroscopy, either for surgery or examination, people can often go
home the same day.
In the hands of a competent arthroscopist, arthroscopy is considered the
best tool for meniscal tear diagnosis, with sensitivity, specificity, and
accuracy approaching 100%.
Arthroscopy is therapeutic and diagnostic and thus offers the advantage of
immediate treatment of most disorders
5. One of the main tests for meniscus tears is the McMurray test. Your doctor
will bend your knee, then straighten and rotate it. This puts tension on a torn
meniscus. If you have a meniscus tear, this movement will cause a clicking
sound. Your knee will click each time your doctor does the test.
6. Arthrography Once the standard imaging study for meniscal tears but now
largely supplanted by magnetic resonance imaging (MRI)
7. Steinmann test Asymmetric pain with external (medial meniscus) or
internal (lateral meniscus) rotation
8. Apley test Pain at the medial or lateral joint

9. Thessaly test Pain or a locking or catching sensation at the medial or

lateral joint line
10. Similar tests, including those that elicit the Bragard, Bhler, Payr, Merke,
Childress, and Finochietto signs

VIII. DIFFERENTIAL DIAGNOSIS

Anterior Cruciate Ligament Injury are most often a result of low-velocity,

noncontact, deceleration injuries and contact injuries with a rotational
component. Contact sports also may produce injury to the ACL secondary to
twisting, valgus stress, or hyperextension all directly related to contact or
collision

ContusionsMuscle indicates a direct, blunt, compressive force to a

muscle. Contusions are one of the most common sports-related injuries. The
severity of contusions ranges from simple skin contusions to muscle and
bone contusions to internal organ contusions.

Iliotibial Band Syndrome is the most common cause of lateral knee pain
among athletes.ITBS develops as a result of inflammation of the bursa
surrounding the ITB and usually affects athletes who are involved in sports
that require continuous running or repetitive knee flexion and extension. This
condition is, therefore, most common in long-distance runners and cyclists.
ITBS may also be observed in athletes who participate in volleyball, tennis,
soccer, football, skiing, weight lifting, and aerobics

Knee Osteochondritis Dissecans is a disorder of one or more ossification

centers, characterized by sequential degeneration or aseptic necrosis and
recalcification. OCD lesions involve both bone and cartilage. These lesions
differ from acute traumatic osteochondral fractures; however, they may
manifest in a similar fashion.

Lateral Collateral Knee Ligament Injury result from a varus force across
the knee. A contact injury, such as a direct blow to the medial side of the
knee, or a noncontact injury, such as a hyperextension stress, may result in a
varus force across the knee injuring the LCL. In terms of functionality, the LCL
has often been grouped with the popliteofibular ligament and the popliteus
tendon as the posterolateral corner (PLC).

Lumbosacral Radiculopathy results from nerve root impingement and/or

inflammation that has progressed enough to cause neurologic symptoms in
the areas that are supplied by the affected nerve root(s).

Medial Collateral Knee Ligament Injury

Medial Synovial Plica Irritation are embryological structures that form

within the knee. They are normal anatomical structures found within the joint
capsule of the knee, appearing as thin, soft, and flexible structures that move
with the knee during flexion and extension. Impingement of the plicae during
motion of the knee can cause inflammation, resulting in medial knee pain.

Patellofemoral Joint Syndromes Patellofemoral joint complaints are one

of the most common musculoskeletal complaints in all age groups. Complaints
vary from anterior knee pain to peripatellar knee pain to retropatellar knee
pain.

Pes Anserine Bursitis

Posterior Cruciate Ligament Injury

Rheumatoid Arthritis An autoimmune condition that can cause arthritis

in any joint, including the knees. If untreated, rheumatoid arthritis can cause
permanent joint damage.
Plica Syndrome
Osteoarthritis is a chronic, degenerative disorder and defined as the
gradual deterioration (degeneration) of the cartilage in a joint. This
noninflammatory disorder may follow a trauma or be a complication of
malformations at birth. Osteoarthritis affects the cartilages on the ends of
the bones between joints. Healthy cartilages are smooth and prevent friction
when the joint surfaces rub each other. It has a cushioning effect in the joint
and acts as a shock absorber when there is physical movement. In
osteoarthritiscalled wear and tear arthritisthe cartilage wears off and the
surfaces of the bones become rough. Rubbing together then causes pain,
swelling, and loss of motion of the joint. Pieces of bones or cartilage can also
break off and float in the joint space.

Chondromalacia
can be caused by overuse or injury to the kneecap and is a
condition where the articular cartilage of the knee bones
softens. It is most common on the back of your kneecap
where the kneecap rubs with straightening of the knee. As
the cartilage softens, it wears away more easily during joint
movements. The cartilage can also be damaged by directly
injuring the knee. Or the cartilage may just thin with age,
which can cause catching or locking of the knee, giving way
or buckling of the knee (instability), pain or swelling.

In chondromalcacia, if the articular cartilage is worn or damaged, the bones will

probably rub against each other. This can cause pain walking down hill or down
stairs, pain after sitting for long periods, getting out of a chair or aching in the knee
area. Recovery from mild damage to the surface cartilage can take 4-6 weeks;
more severe damage can take 3-4 months

Loose Body (Joint Mouse)

Any free-floating object in the synovial fluid of the knee is known
as a loose body or joint mouse. It can be a fragment of bone,
cartilage, or meniscus. It can also be a piece of glass, metal or
any foreign object. A loose body isnt usually noticeable until it
lodges somewhere in the joint. Your symptoms can change
depending upon the exact location within your knee. A loose body
can cause catching or locking of the knee, giving way or buckling
of the knee (instability), pain or swelling. Osteochondritis

Dissecans

Osteoarthritis (Degenerative Arthritis) Caused by aging and wear and

tear of cartilage, symptoms may include knee pain, stiffness, and swelling.

Infectious Arthritis

Chondromalacia Patellae Pain from irritation of the cartilage on the

underside of the kneecap; a common cause of knee pain in young people.

Gout A form of arthritis caused by buildup of uric acid crystals in a joint.

Sometimes the knees may be affected causing severe pain and swelling.

IX. MANAGEMENT
Pharmacological Management

Anti-inflammatory painkillers (nsaids)

Nonsteroidal anti-inflammatory drugs or nsaids are available both over-the-counter
and by prescription. Almost everyone with arthritis has taken or is taking one of
these drugs. Prescription doses can help curb inflammation.
Ibuprofen (Motrin, Ibuprin)
Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Celecoxib (Celebrex)
Inhibits primarily COX-2, which is considered an inducible isoenzyme; induced
during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID
GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus,
GI toxicity may be decreased. Seek lowest dose for each patient.

Analgesics
Pain control is essential to quality patient care. It ensures patient comfort,
promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics
have sedating properties that benefit patients who have sustained fractures.
Acetaminophen (Tylenol, Feverall, Aspirin-Free Anacin)
for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with
upper GI disease, or who are taking oral anticoagulants.

Narcotic analgesics
Hydrocodone and acetaminophen (Vicodin, Lortab, Norcet)
Drug combination for moderate to severe pain.

Oxycodone (Roxicodone, OxyContin, OxyIR)

Indicated for moderate to severe pain.

Antibiotics

Antibiotic therapy must be comprehensive and cover all likely pathogens in the
context of the clinical setting.

Medical/Surgical Procedures
Knee Replacement
Knee arthroscopyA camera and instruments inserted through portals in a knee.
Partial meniscectomy. In this procedure, the damaged meniscus tissue is
trimmed away.
Meniscus repair More intensive rehabilitation; one option is avoidance of weight
bearing for 4-6 weeks, with full motion encouraged; the authors prefer to allow full
weight bearing with the knee braced and locked in full extension for 6 weeks, while
encouraging full motion when the knee is not bearing weight
Close-up of partial meniscectomy Meniscus repair. Some meniscus tears can
be repaired by suturing (stitching) the torn pieces together. Whether a tear can be
successfully treated with repair depends upon the type of tear, as well as the
overall condition of the injured meniscus. Because the meniscus must heal back
together, recovery time for a repair is much longer than from a meniscectomy.
Cast Immobilization
A plaster or fiberglass cast is the most common type of fracture treatment,
because most broken bones can heal successfully once they have been
repositioned and a cast has been applied to keep the broken ends in proper
position while they heal.
Functional Cast or Brace
The cast or brace allows limited or "controlled" movement of nearby joints. This
treatment is desirable for some, but not all, fractures.
Traction
Traction is usually used to align a bone or bones by a gentle, steady pulling action.
External Fixation
In this type of operation, metal pins or screws are placed into the broken bone
above and below the fracture site. The pins or screws are connected to a metal bar
outside the skin. This device is a stabilizing frame that holds the bones in the
proper position while they heal.
In cases where the skin and other soft tissues around the fracture are badly
damaged, an external fixator may be applied until
surgery can be tolerated.

PT MANAGEMENT

TENS therapy. Transcutaneous electrical nerve stimulation, or TENS, is a physical

therapy method that uses small pulses of electricity to target areas of arthritis
pain. Electrodes are placed on the skin covering the painful joint, and low levels of
electricity are passed into the joint, temporarily relieving pain. The procedure can
be performed by a physical therapist, other medical professionals, or even using
TENS equipment at home.
Diathermy. This form of heat therapy uses ultrasound, radio or microwaves, or
electrical currents to heat the tissue inside painful joints. The heat kills damaged
cells that cause joint pain, easing your arthritis symptoms.
Massage. A massage therapist can help you to manage arthritis pain by
massaging, kneading, and rubbing muscles and joints to boost blood circulation to
the painful areas. (Poor blood circulation can contribute to joint pain.
Exercises, Stretching for joint protection and mobility.
Rest your knee, and use crutches to avoid any weight bearing on the joint. Avoid
any activities that worsen your knee pain.
Ice your knee every three to four hours for 30 minutes.
Compress or wrap the knee in an elastic bandage to reduce inflammation.
Elevate your knee to reduce swelling

References:
Marieb Human Anatomy & Physiology 9th edition
Braddoms Physical Medicine and Rehabilitation by David X. Cifu et al, 5th Edition
Clinical
Handbook of Orthopaedic Surgery by Brashear & Raney, 10th Edition
Differential Diagnosis for Physical Therapist by Goodman and Snyder
PT-OT reviewer by Pablo Santos
Physical Rehabilitation: Assessment and Treatment by O Sullivan, S& Schmitz, T.,
3rd Edition
http://www.webmd.com/fitness-exercise/tc/meniscus-tear-topic-overview#1
http://www.mayoclinic.org/diseases-conditions/torn-meniscus/diagnosistreatment/diagnosis/dxc-20262376
http://emedicine.medscape.com/