The KneeErin Lyons, John Miller and Nick Wright

Learning Objectives- Understand how the complicated anatomy of the knee leads to large number

of possible injuries- Explain how the technology to diagnose and surgically fix knee has improved- Name different types of knee injuries and how they are treated.- Explore upcoming technologies that will continue to evolve the field

Anatomy Review: Bones and Cartilage● Femur● Tibia and Fibula● Patella● Meniscus

○ Medial and Lateral

Medial Meniscus Lateral Meniscus

Fibula

Femur

Tibia

Patella

Anatomy Review: Muscles● Quadriceps

○ 4 muscles: Rectus Femoris, Vastus lateralis, Vastus medialis, Vastus intermedius○ Pulls for extension of knee

● Hamstring○ Pulls for flexion of knee

● Calf○ Soleus, Gastrocnemius

Anatomy Review: Tendons and Ligaments● The “Big 4”

○ ACL○ MCL○ PCL○ LCL

● Quadricep Tendon○ Distal Portion: Patellar Tendon

● Hamstring Tendon

Knee Injury Statistics

● 6.5 million visits to US emergency departments from 1999-2008

● Knee sprains, strains or tears accounted for nearly 50% of injuries resulting in lost work time

● Washington State workers compensation system (1997-2007)

○ 25,000 knee injuries

○ Just under $500 million

Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes

- Focus: ACL tears in female athletes- ACL tears are 5 times more common in females than males playing the same high-risk sports

- Most common cause: noncontact

Methods/ Data Collection

ACL Injury Prevention- Sports Training- General Knowledge

- Strengthening muscles- Flexibility

ACL & PCL Tear● Most PCL and ACL

(cruciate ligament) tears occur when the foot is planted and a sudden force is applied the knee.

● Twisting (seen to the right)

Immediate Testing?● Trainers can immediately test for injuries

using the posterior and anterior drawer.

● Volunteers?

Other On-Field Tests

Diagnosis ● Why is the MRI (Magnetic Resonance

Imaging) the most effective screening method for ligament tears?

● MRI uses a magnet to align the nuclei of hydrogen atoms and creates a magnetic field to make the atoms resonate.

Diagnosis ACL ● Images show a normal and a

torn ACL of the knee

PCL MRI Image Before and After Injury

MCL/ LCL Tears ● Collateral Ligaments● Less common ● Usually happens from a planted

foot and contact from the side of the knee

● Stability Testing and immediate bruising are used to diagnose

Meniscus Tears● One of the more common knee injuries

● Usually the result of twisting or pivoting on the knee in a short burst.

● Can tear in many ways making treatment unique to every situation

MeniscusBucket Handle Tear:

● One of the many tears that can happen● The meniscus fragment can become

wedged within the knee● Causes the patient to lose the ability to

fully extend the leg● Arthroscopic surgery needed for most

cases of meniscal tears

Osgood-Schlatter DiseaseWhat: Tibia Tubercle is pulled by Patellar Tendon causing it to become inflamed and irritated.

Who: Common in Adolescents

What: A noticeable bump on the knee will be present. Even complete separation of the Tibia Tubercle can occur.

Osgood-Schlatter’s Treatment● Non-steroidal anti-inflammatory drugs

● Stretching, and use of knee brace

● Last effort: Surgery to reshape Tibia Tubercle

Patellar Tendonitis● Painful inflammation of the patellar tendon

● Common in athletes who jump a lot

● Overuse injury

Patellar Tendonitis Treatments● Physical therapy

● Non-steroidal anti inflammatory medication (NSAIDs)

● Knee braces

● Icing and immobilization

Arthritis● Natural erosion of cartilage

○ Meniscus

● Many causes○ Heredity, age, weight○ Repetitive injuries, atheltics○ Osteoarthritis vs Rheumatoid

Arthritis Complications● Bone spurs

● Joint deformation

● Loss of function

Arthritis Treatments● Braces

○ Unloader, Support

● Physical Therapy

● Exercise and weight loss

● Surgery- Total Knee Replacements

Total Knee Replacement Video

http://www.ohsu.edu/xd/health/services/ortho/getting-treatment/total-knee-replacement.cfm

Question: Does this injury require surgery?- Will the injury heal on its own?

- Self-Management- How has the individual’s quality of life been impacted?- Individuals with chronic knee pain may choose non-operative care over surgery

- Non-Operative Care

Immobilization- then vs now 1967- Knee braces were developed

1968- first knee brace was born in the Super Bowl by Joe Namath

He played his entire career on a torn ACL suffered during college

Types of Surgical Procedures

● Marrow Stimulation Procedures

● Autologous Chondrocyte Implantation

● Patellar Tendon Realignment Procedure

● Meniscal Disorders

● Anterior Cruciate Ligament Reconstruction

● Osteochondral Autograft/Allograft Transplantation

● Arthroplasty

ACL Reconstructive Surgery- Connection between ACL injuries and arthritis - Reconstructive Focus- Development of arthroscopy techniques

- Increased success rate of the surgery significantly- Easier to recovery and rehabilitation

Rehabilitation and Recovery● Length of disability? ● Physical therapy is necessary for knee

function to return to normal

Upcoming Technology: Regenexx - “Your Alternative to Knee Surgery”- Two main procedures:

- Stem Cell Treatments- Blood Platelet Treatments

- Can be used to treat injuries to the meniscus, cartilage, ACL or MCL ligaments or chronic knee pain

Meniscus Tear Example