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Samantha Calvet

The Knee
Muscles:
Name
Rectus Femoris

Vastus Lateralis
Vastus
Intermedius
Vastus Medialis

Origin

Insertion

Anterior Inferior Iliac


Spine

Lateral lip of linea


aspera.
Upper 2/3 of the
anterior surface of
the femur
Medial lip of the
linea aspera and the
internal condyloid
ridge

Sartorius

Anterior Superior
Iliac Spine

Gracilis

Inferior border of
pubic body near
symphisis

Flexion of hip
Extension of
knee
Quadriceps
tendon to base
of patella and
onto tibial
tuberosity via
the patellar
ligament

Pes Anserine

Semitendinosus
Semimembrano
sus
Biceps Femoris
(Long Head)
Biceps Femoris
(short head)

Gastrocnemius

Plantaris

Ischial Tuberosity

Distal linear aspera


& lateral
supracondylar ridge
of femur
Lat. & Med. Condyle
of Femur

Lat. Fem Condyle

Action

Posterior medial
condyle of tibia

Head of fibula
and lateral
condyle of tibia

Comments
25-33%
stronger
than
hamstrings

Extension of
knee
Extension of
knee

Flexes Knee
Flexes abducts
and laterally
rotates hip
Flexes knee
Adducts at hip
Flexes knee
Extends hip
Flexes knee
Extends hip
Flexes knee
and laterally
rotates hip

Calcaneus via
Achilles Tendon

Flexes knee
and plantar
flexes foot

Dorsum of
calcaneus

Flexes leg
Plantarflexes

Makes up
triceps
Surae +
Soleus

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Popliteus

Lat. Condyle of
Femur

Post. Tibia
above soleal
line

foot
Flexes and
rotates leg
medially

Unlocks
knee

Special Tests
Lachman Test ACL
Stabilize distal femur and translate proximal tibia forward on
femur
+ Pain/Laxity
Anterior Drawer Test ACL
Supine with foot stabilized on table, knee flexed to 90 degrees
with hamstrings relaxed. Translate proximal tibia anterior on the
femur. (Rotate foot IR/ER 30 degrees Rotary instability)
+Pain/laxity
Posterior Drawer Test PCL
Supine with foot stabilized on table, knee flexed to 90 degrees
with hamstrings relaxed. Translate proximal tibia posterior on the
femur
+Pain/laxity
Sag (Godfrey) Test PCL
Supine 90/90, support LE. Compare the level of tibial
tuberosities.
+Posterior displacement of tibial tuberosity is greater in
the involved leg
Varus Test LCL
Supine; knee in full extension and then repeat at 30 degrees of
flexion. Apply varus stress to joint line of the knee.
+Pain/excessive gaping
Valgus Test MCL
Supine; knee in full extension and then repeat at 30 degrees of
flexion. Apply valgus stress to joint line of the knee.
+Pain/excessive gaping
Apley Test Mensicus
Prone; knee flexed to 90, grasp foot and apply downward
pressure whilst rotating tibia internally and externally
+Pain, popping, snapping, locking, crepitus

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McMurray Test Meniscus
Supine; with one hand on the side of patella and other hand at
proximal tibia. Varus stress and then return to maximal flexion
and extend knee with ER or the tibia and valgus stress
+Pain, Snapping, Clicking. Flexion posterior horn of
meniscus, extension anterior meniscus.
Thessaly Test Meniscal Tear
Standing on involved LE with the knee flexed at 5 degrees. Hold
clients arms and ask the mto rotate internally then externally 3x
and repeat at 20 degrees of knee flexion
+Locking or Catching
KKU Test Meniscal Tear
Supine, palpate knee joint line and grasp ankle. Apply axial
compression to knee while rotating tibia at different degrees of
knee flexion.
+Pain, Locking or Catching
Duck walking Test Meniscal Tear
Squatting; simulate a duck walk.
+Pain, Locking or Catching
Patella Apprehension Test Subluxing Patella
Supine or seated, 30 degree knee flexion, quad relaxed. Push
ptatella laterally
+Feels patella about to dislocate and contracts quads
Noble Test ITB irritation
Supine, start at 90/90. Apply pressure over lateral femoral
condyle while extending knee
+Pain, clicking at lateral femoral condyle
Ober Test Tight ITB
Side lying with involved hip up. Extend hip and allow LE to drop
into adduction
+LE fails to adduct past anatomical neutral
Plica Signs and Symptoms
Injury results from direct trama or a significant increase in unaccustomed
activity (presense of medial plica is more common than lateral plica)
The infrapatellar fat pad just posterior to patellar tendon is an insertion point
for synovial folds of tissue known as plica
o An anatomical variant that may be irritated or inflamed with injuries or
overuse of the knee
o Plica syndrome
Medial plica most commonly injured

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o
o
o
o

Poor formation during embryonic development


Occurs in about 25-50% of knees
Rest, anti-inflammatory, isometric exercises
Pain over medial femoral condyle
Clicking snapping or giving way
Full ROM, pain at end range of flexion
MRI is only non-invasive procedure that shows plica

Chondromalacia Signs and Symptoms


Softening of patella articular cartiglate secondary to poor biomechanical
alignment, tracking and/or weak hip ER
o Anterior knee pain
o Pain with stairs
o VMO atrophy, weak hip ER
o Incrase knee valgus or higher Q angle
o Confirmed via MRI

Knee Ligaments
Anterior Cruciate Ligament
Resists anterior tibial translation
Originates from posteromedial corner of medial aspect of lateral femoral
condyle in the intercondylar notch.
Runs inferiorly and medially
Attaches to the anterior intercondyloid eminence of the tibia
Two bundle components
o Anteromedial bundle (AMB) tight in flexion
o Posterolateral bundle (PLB) tight in extension
40% longer than PCL
Posterior Cruciate Ligament
Resists posterior tibial translation
Originates at posterior intercondylar area of tibia
Attaches at medial condyle of the femur
Two Bundles
o Anterolateral bundle (AL) tight in flexion and inward rotation
o Posteromedial bundle (PM) tight in extension
Medial Collateral Ligament
Resist valgus stress on the knee
Originates from medial epicondyle of the femur

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Attaches at medial condyle of tibia


Taught during extension
78% or valgus restraint

Lateral Collateral Ligament


Resist varus stress on the knee.
Originates at lateral epicondyle of the femur
Attaches at the head of the fibula
Taught when knee is in extension
69% of varus restraint
Meniscus
Fibrocartilaginous structure
Theres a lateral and medial meniscus
Concave on the top and flat on the bottom
Blood flow to meniscus is from the outside to the central meniscus. It
decreases with age and by adulthood the central meniscus becomes
avascular.
Coronary ligaments provide peripheral attachments between tibial plateau and
the perimeter of both menisci
Medial Mensiucs:
o C-Shaped
o Transmits 50% of load
o Attached to MCL which limits mobility
o Only 10-30% of border receives direct blood supply
Lateral Meniscus:
o Semicircular
o Transmits 70% of load
o Connected to femur via anterior (ligament of Humphrey) and posterior
(ligament of Wrisberg) meniscofemoral ligaments
o Only 10-25% of border receive direct blood supply
The geniculate artery which branches off the popliteal artery is what provides
the major vascularization to the meniscus

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Screw home mechanism
Knee screws home to fully extend due to the shape of medial femoral
condyle
As knee approaches full extension tibia must externally rotate
approximately 10 degrees to achieve proper alignment of tibial &
femoral condyles
During initial flexion from full extension
Knee unlocks by tibia rotating internally, to a degree, from its
externally rotated position to achieve flexion

Q Angle
ASIS Midpoint of patella Tibial Tuberosity
Q Angle is 13 18 degrees for females
Q Angle is 10 15 for males

Genu Valgum/Knock Knees


Genu Varum/Bow Leged
Genu Recurvatum

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Bakers cyst
Defect in posterior capsule that is influenced by chronic irritation or meniscus tear.
Golf ball size swelling at semimembranosus tendon or medial gastroc muscle
belly; best palpated in full knee extension
Stiff and tender with limited knee ROM
Osgood-Schlatter Disease
Tibial apophysitis that may occur from growth of femur resulting in avulsion of
proximal tibial physis; may have genetic predispotiion 8-15 male > female
Intermittent aching pain at tibial tubercule and distal patellar tendon
Enlarged tibial tuberosity
Tight quads and hamstring resulting in decreased AROM
Effusion results in knee extensor lag
Jumpers knee
Patella tendonitis secondary to traction overuse injury such as jumping, kicking,
running or microtrauma
o TTP over patella tendon insertion and pain with resisted knee extension
o Localized crepitus and swelling
o High Q angle
o Confirmed with MRI
Pes Anserine
Gracilis
Semitendinosus
Sartorius

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Research on ACL Surgery
Reading the three articles, they all state that with the continuing improvements softtissue graft fixation tends to be preferable over the bone-patellar tendon-bone graft.
The bone-patellar tendon-bone graft is taken from the central one third of the patellar
tendon. The bone-patellar tendon-bone autograft is the gold standard. However,
complications with this can include anterior knee pain, patella fracture and prolonged
effusion. The fact that this was a gold standard was surprising because the metaanalysis journal article stated that since 2001 it was statistically proven that
hamstring autografts reduce anterior knee pain. Also, the sensitivity analysis on
fixation technique weakens the evidence that BTB autografts give better stability
when using femoral fixation techniques for the hamstring tendon autograft.
Soft-tissue fixation can come from either the semitendinosus/gracilis (ST-G) or the
central quadriceps tendon. The quadrupled ST-G is a popular graft source. Some
benefits of soft-tissue fixation include possible reduced short-term postoperative pain
and effusion due to less invasive harvesting procedures. The decreased pain and
swelling allows for an expedited postoperative rehabilitation. Concerns about this
include, weakness in a prime muscle agonist to the ACL, reduced initial fixation
strength and increased laxity.
The central quadriceps free tendon is a newer autograft for ACL reconstruction.
Benefits include preserving the semitendinosus and gracilis, preventing anterior knee
pain, reducing bleeding and patellar fracture risks after bone-patellar tendon-bone
harvest. Concerns are similar to the ST-G graft in that they revolve around early
fixation strength. Patients in the central quadriceps free tendon group achieved full
extension faster than BTB group. Both ST-G and central quadriceps free tendon
groups had less effusion post operatively and the ST-G group spent less time on
crutches.
ST-G is better than BTB because harvesting is performed through smaller incision
and dysfunction of the extensor mechanism of the knee is avoided. The ST-G graft
makes it possible to double the thickness and fixing the graft with an endobutton or
retrobutton is closer to the anatomical rigidity of native ACL.
In conclusion, I believe that the new quadriceps central free tendon autograft is the
best option. The ST-G graft is preferred over the BTB graft for several reasons. It
doesnt quite make complete sense as to why you would weaken/take from the
muscle that is in essence protecting the ACL as the hamstrings also prevent anterior
tibial translation. So for that reason, taking from the quadriceps would make more

Samantha Calvet
sense.

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