Knee Region Flashcards

Functional Anatomy of the Knee Region

• Brief review of functional anatomy (see FAB notes).
• Common clinical disorders of the knee and potential treatment options.

Objectives

• Identify and describe the functional anatomy of the knee (see FAB notes for more detailed information).
• Describe considerations associated with examination of the knee.
• Describe common clinical presentations including pathology, diagnosis, and treatment options.

Functional Anatomy

• Two (three) joints:
  • Tibiofemoral joint (TFJ).
  • Patellofemoral joint (PFJ).
  • (Superior tibiofibular joint).

Tibiofemoral Joint (TFJ)

• Articulation between the tibia and femur.
• Primary weight-bearing synovial joint; modified hinge joint.
• Motions:
  • Flexion/extension.
  • Medial/lateral rotation.
  • Abduction/adduction (passive motion).

Patellofemoral Joint (PFJ)

• Articulation between the patella and femur; modified plane joint.
• The patella improves leverage of the quadriceps muscles.
• Implicated during loaded flexion, such as climbing stairs or walking up/down hills.
• Clinically important to differentiate from TFJ.

Superior Tibiofibular Joint

• Articulation between the tibia and fibula; plane joint.
• Not a common cause of knee pain but should not be neglected.

Muscles of the Knee

• Flexors:
  • Hamstrings.
  • Gastrocnemius.
  • Gracilis.
  • Sartorius.
• Extensors:
  • Quadriceps.
• Medial Rotators:
  • Semitendinosus, semimembranosus (medial hamstrings).
  • Gracilis.
  • Sartorius.
  • Popliteus.
• Lateral Rotators:
  • Biceps femoris (lateral hamstring).
  • Popliteus.

Ligaments of the Knee

• Anterior cruciate ligament
• Posterior cruciate ligament
• Tibial collateral ligament
• Fibular collateral ligament
• Patellar tendon
• Popliteal tendon
• Transverse ligament
• Medial meniscus
• Lateral meniscus

Bursae of the Knee

• Suprapatellar bursa
• Subcutaneous prepatellar bursa
• Subcutaneous infrapatellar bursa
• Deep intrapatellar bursa
• Subsartorial (pes anserinus) bursa
• Semimembranosus bursa

Screw Home Mechanism

• Physiological locking mechanism in the tibiofemoral joint between 30° of flexion and full extension (0°) – most prominent around last 5° of extension.
• Medial rotation of the femur on the tibia (closed chain).
• Lateral rotation of the tibia on the femur (open chain).
• Combination of ligament, joint, and muscle mechanics.
• Essential for:
  • Stability of the joint.
  • Reduction in friction.
  • Improved muscle efficiency.
  • Improved gait efficiency.
• Clinically needed to ensure full extension AND rotation.

Acute Knee Pain: Differential Diagnosis

• Medial meniscus tear
• Patellar tendon rupture
• Fracture of the tibial plateau
• MCL sprain
• Quadriceps tendon rupture
• Fracture of the patella
• ACL sprain (rupture)
• Acute patellofemoral contusion
• Avulsion fracture of the tibial spine
• Lateral meniscus tear
• LCL sprain
• Osteochondritis dissecans (adolescents)
• Articular cartilage injury
• Bursal haematoma/bursitis
• Complex regional pain syndrome type 1 (post injury)
• PCL sprain
• Acute fat pad impingement
• Quadriceps muscle rupture
• Patella dislocation
• Avulsion of biceps femoris tendon
• Superior tibiofibular joint injury

Medial Meniscus Tear

• Problem
  • MOI: Shear stress with the knee in flexion with rotation.
  • Medial meniscus attaches to the medial joint capsule/MCL limiting its mobility, leading to increased risk of injury.
  • Incidence: 6 per 1000 people (Shiraev et al., 2012).
  • Up to 4x greater incidence in males (Shiraev et al., 2012).
  • Continuum of meniscal injury from young patients with pristine cartilage to older patients with asymptomatic cartilage damage to acute injury.
• Signs & Symptoms
  • MOI – twisting with planted foot.
  • Pain (variable).
  • Swelling (variable).
  • Restricted ROM.
  • Catching, clicking.
  • Joint line tenderness.
  • Pain on hyperflexion (e.g., squat).
• Diagnosis
  • Clinical reasoning.
  • McMurray’s Test.
  • Joint line tenderness.
  • Apley’s test.
  • Thessaly’s test.
• Management
  • Phase 1 (0-1 week):
    • Goal: Control swelling, maintain knee extension, knee flexion to 100°+, 4/5 quadriceps strength, 4+/5 hamstring strength.
    • Physiotherapy: Cryotherapy, electrotherapy, compression, manual therapy, gait re-education, patient education.
    • Exercise: Gentle ROM (extension and flexion), quadriceps/VMO setting, supported (bilateral) calf raises, hip abduction and extension, hamstring pulleys/rubbers, gait re-education drills, light exercise bike.
  • Phase 2 (1-2 weeks):
    • Goal: Eliminate swelling, full ROM, 4+/5 quadriceps strength, 5/5 hamstring strength.
    • Physiotherapy: Cryotherapy, electrotherapy, compression, manual therapy, gait re-education, exercise modification and supervision.
    • Exercise: ROM drills, quadriceps/VMO setting, mini-squats and lunges, leg press (double, then single-leg), step-ups, bridges (double, then single-leg), hip abduction and extension with rubber tubing, single-leg calf raises, gait re-education drills, balance and proprioceptive drills (single-leg).
  • Phase 3 (2-3 weeks):
    • Goal: Full ROM, full strength, full squat, dynamic proprioceptive training, return to running and restricted sport-specific drills.
    • Physiotherapy: Manual therapy, exercise/activity modification and supervision.
    • Exercise: As above - increase difficulty, repetitions and weight where appropriate, jump and land drills, agility drills, functional/sport-related activity, progress to FWB and normal gait pattern, swimming (light kick), exercise bike, walking, running.
  • Phase 4 (3-5 weeks):
    • Goal: Full strength, ROM, and endurance of affected limb, return to sport-specific drills and restricted training and match play.
    • Physiotherapy: As above.
    • Exercise: High-level sport-specific strengthening as required, swimming, road bike, sport-specific exercises (progressively sequenced). Return to sport-specific drills, restricted training and match play.
• Evidence
  • Exercise program vs. arthroscopic partial meniscectomy and exercise:
    • N = 351 (meniscal injury with OA).
    • 6-month follow-up: No significant difference between groups; 30% of exercise group had surgery.
    • 12-month follow-up: No significant difference between groups (Katz et al., 2013).
  • 12-week exercise program vs. arthroscopic partial meniscectomy:
    • N = 140 (meniscal injury, no OA).
    • 3-month follow-up: Exercise group was stronger.
    • 2-year follow-up: No significant difference between groups (Kise et al., 2016).
  • Arthroscopic partial meniscectomy vs. placebo surgery:
    • N = 146 (meniscal injury with no OA).
    • 2-year follow-up: Real surgery was no better than placebo surgery (Sihvonen et al., 2017).

Anterior Cruciate Ligament Injury (ACL)

• Problem
  • MOI: Slight knee flexion with quads activation, valgus collapse, and internal rotation of femur relative to fixed tibia – “cutting maneuver”.
  • Less common MOI: Hyperextension – femur moves posteriorly.
  • Commonly injured knee ligament.
  • 52 per 100,000 in Australia (Janssen et al., 2012).
  • 15-25 years commonly injured.
  • Males > females.
  • 70% non-contact injury.
  • Highest incidence (descending order): Skiing, AFL, Rugby, Netball, Soccer.
  • Three grades of ligament injury.
• Signs & Symptoms
  • Feeling pop or snap at time of injury.
  • Severe pain at time of injury (inability to continue play).
  • ± current pain (depending on stage).
  • 1° complaint giving way/instability.
  • Swelling++/Heamarthrosis.
  • Loss of ROM.
  • Weakness/inability to maximal contract.
• Diagnosis
  • Special tests:
    • Lachman’s test.
    • Anterior Drawer Test.
    • Pivot shift test.
  • MRI, X-ray (sulcus sign).
  • Outcome measures:
    • Strength ratio (between legs/between quads/hamstrings).
    • RTS.
    • ACL QoL Questionnaire.
    • LLTQ, SF-36.
• Treatment (not a one size fits all)
  • Phase 1 (Acute phase) goals:
    • Control pain and swelling, Restore pain free ROM, Improve flexibility, Normalize gait mechanics (WBAT w crutches), Establish good quadriceps activation.
  • Phase 2 (Sub-acute/strengthening phase) goals:
    • Avoid patella femoral pain, Maintain ROM and flexibility, Restore muscle strength, Improve neuromuscular control.
  • Phase 3 (Limited return to activity phase) goals:
    • Avoid patella femoral pain, Maintain ROM and flexibility, Progress with single leg strengthening to maximize strength, Progress dynamic proprioception exercises to maximize neuromuscular control, Initiate plyometrics* and light jogging*.
  • Phase 4 (Return to activity/sport phase) goals:
    • Maintain adequate ROM, flexibility and strength, Continue progressive/dynamic strengthening, proprioceptive, plyometric and agility training, Achieve adequate strength to return to sport (pending physician’s clearance).
• Evidence
  • Conservative vs. Surgery 6 – 16 months follow-up
    • n = 12 conservative vs. n = 21 operative.
    • Operative group scored better for ligamentous stability.
    • Conservative group had > muscle strength (knee ext & flx, ankle plantarflexors).
  • Conservative vs. Surgery 11 year follow-up
    • n = 109 (60 surgery, 49 conservative) Isolated ACL rupture – same rehab program.
    • 11 years after ACL rupture, surgery group had better stability but more Knee OA (>Grade II), no difference in physical activity level (both groups decreased physical activity level) (Karanikas et al., 2005). (Kessler et al., 2008)

Patella Dislocation

• Problem & Signs & Symptoms
  • 5.8-7.0 /100,000 people.
  • 29/100,000 10-17 year olds.
  • Females > males.
  • Younger > older.
  • Signs and Symptoms
    • Traumatic MOI – twisting, jumping.
    • Severe pain++ and immediate swelling++.
    • Deformity (can relocate with extension).
    • “Popping out”.
    • Differential diagnosis – ACL rupture (MOI S&S).
    • Weakness/reluctance to use quads (Brukner & Khan, 2017) p763.
• Diagnosis
  • Clinical:
    • Ottawa knee rules.
    • Patella apprehension test.
    • Pain on palpation of the medial border.
    • Pain during compression.
  • Imaging:
    • X-ray (bony deformities).
    • CT or MRI (bony and soft tissue).
    • MPFL (ruptured).
• Management
  • Phase 1(0-2 weeks)
    • Goal of Phase:
      • Control of Swelling
      • Maintain knee extension
      • Isometric quadriceps strength
    • Physiotherapy treatment:
      • Extension splint (removal dependent on surgeon/physician)
      • Cryotherapy
      • Electrotherapy
      • PFJ taping
      • Manual therapy
    • Exercise program
      • Quadriceps drills (supine)
      • Bilateral calf raises
      • Foot and ankle
      • Hip abduction
      • ROM drills
  • Phase 2 (2-6 weeks)
    • Goal of Phase:
      • No swelling
      • Full extension
      • Flexion to 100°
      • 4+/5 quadriceps strength
      • 5/5 hamstring strength
    • Physiotherapy treatment:
      • Cryotherapy
      • Electrotherapy
      • Compression
      • Manual therapy
      • Gait re-education
      • Exercise modification
    • Exercise program
      • Quadriceps/VMO setting
      • Mini-squats and lunges
      • Bridges (double, then single-leg)
      • Hip abduction and extension with rubber tubing
      • Single-leg calf raises
      • Gait re-education drills
      • Balance and proprioceptive drills (single-leg)
  • Phase 3 (6-8 weeks)
    • Goal of Phase:
      • Full ROM
      • Full strength and power
      • Return to jogging, running, and agility
      • Return to restricted sport-specific drills
    • Physiotherapy treatment:
      • Manual therapy
      • Exercise/activity modification and supervision
    • Exercise program
      • As above increase difficulty, repetitions, and weight, where appropriate
      • Single-leg squats
      • Single-leg press
      • Jump and land drills
      • Agility drills
      • Functional/sport-related activity
      • Progress to FWB
      • Walking
      • Exercise bike
      • Straight-line jogging
      • Swimming (light kick)
  • Phase 4 (8-12 weeks)
    • Goal of Phase:
      • Return to sport
    • Physiotherapy treatment:
      • As above
    • Exercise program
      • Road bike
      • Straight-line running
      • Progressing to sport-specific running and agility (progressively sequenced) (e.g. running forwards, sideways, backwards, sprinting, jumping, hopping, changing directions, kicking)
      • Progressive return to sport (e.g. restricted training, unrestricted training, match play, competitive match play)

Patella Fracture

• Problem
  • Fractures of the distal femur, proximal tibia and patella make up 6.7% of all LL fractures.
    • 47% proximal tibia.
    • 32% distal femur.
    • 21% Patella.
  • Cause (e.g. fall, RTA).
  • Patella – direct blow.
  • Tibial plateau – compression.
  • Stress fracture (Vun et al., 2013).
• Diagnosis
  • Clinical diagnosis:
    • Instant PAIN+.
    • Swelling++/Heamarthrosis.
    • Quads weakness, or inability to extend leg.
    • Pain++ on palpation, depending on fracture type might be able to feel gap.
    • OWATTA KNEE RULES.
  • X-Ray:
    • Confirmation.
    • Referral Orthopaedic Specialist.
  • Outcomes: Knee Society Clinical Rating Scale (KSCRS), WOMAC, KOOS, LLTQ, SF-36.
• Ottawa Knee Rules
  • Sensitivity 98.5%.
  • Specificity 48.6%.
  • A knee x-ray series is only required for knee injury patients with any of these findings:
    1. age 55 or older.
    2. isolated tenderness of patella (no bone tenderness of knee other than patella).
    3. tenderness of head of fibula.
    4. inability to flex to 90°.
    5. inability to bear weight both immediately and in the emergency department for 4 steps (unable to transfer weight twice onto each lower limb regardless of limping).
• Treatment
  • Non-displaced (retains normal form and position):
    • Brace Knee Immobilizer (full extension) 4 – 6 weeks.
    • Period of NWB (7 days) than WBAT.
    • Physiotherapy:
      • ROM.
      • Strengthening.
      • Restore normal function.
  • Displaced:
    • ORIF (4 – 6 weeks immobilizer brace).
    • Physiotherapy:
      • Same as above.
• Evidence
  • Percutaneous vs. Open surgery 2 year follow-up.
    • n = 53 patients (displaced patella fracture).
    • Percutaneous repair was associated with shorter surgical time, less pain, better mobility angle (flexion > extension), better KSCRS at 4 and 8 weeks follow up.
    • Knee society clinical rating scale was greater in the percutaneous group at 12 and 24 months (Luna-Pizarro et al., 2006).

Causes of Knee Pain – Chronic/idiopathic

• OA
• PFP
• Patellar tendinopathy
• Iliotibial band friction syndrome
• Fat pad impingement
• Sinding-Larsen-Johansson lesion (in adolescents)
• Osgood schlatter disease (in adolescents)
• Synovial plica
• Pre-patellar bursitis
• Quadriceps tendinopathy
• Infrapatellar bursitis
• Tenoperiostitis of upper tibia
• Referred pain from the hip
• Osteochondritis dissicans
• Slipped capital femoral epiphysis
• Perthes’ disease
• Tumour (especially in the young)
• Stress fracture of patella

Osteoarthritis (OA)

• Problem
  • Significant problem (older population) – 1.4 million Australians (2009).
  • Two types:
    • Primary – idiopathic, gradual deterioration, affects many joints (older age).
    • Secondary – following injury, localised to one joint (younger age).
• Diagnosis
  • Clinical diagnosis (Think age, main symptoms: pain, stiffness, limited movement of the affected joint).
  • X-ray (Kellgren & Lawrence OA Grades).
  • Outcomes: WOMAC, KOOS, LLTQ, 6MWT, TUG, STS.
• Treatment
  • 12 Non-pharmacological therapies – advice and education, self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening, water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal.
  • 8 Pharmacological modalities (NSAID, topical NSAID, intra-articular injections).
  • 5 Surgical modalities (arthroscopy, partial joint replacement, total joint replacement) (Zhang et al., 2008).
• Evidence
  • RCT exercise vs. no exercise
    • Both groups received the same treatment except exercise.
    • Exercise group had > improvement in pain, disability, walking, stair climbing, and sit up speed at all time points (1, 3, 12 months) (Deyle et al., 2005).
  • Physiotherapy program vs. home exercise program
    • 2 Groups – supervised exercises with manual therapy vs. home exercise program over 4 weeks.
    • Both groups improved.
    • Supervised group had significantly greater improvements on 6MWT and WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) (Nejati et al., 2015).

PatelloFemoral Pain (PFP)

• Problem
  • 23% of the general population.
  • 29% in adolescents.
  • Females > Males.
  • 6-13% in military.
  • Risk factors:
    • Quadriceps weakness (military recruits).
    • Greater hip abductor strength (adolescents).
  • Not a Risk Factor age, height, weight, BMI, body fat, Q-angle (Neal et al., 2019).
• Signs and Symptoms
  • Clinical presentation (think age):
    • Anterior knee pain: Peripatellar pain, hard to describe.
    • Pain on loaded or prolonged flexion (running,stairs, sitting).
    • Weak medial and tight lateral.
    • Poor patellar tracking (observation).
    • Weak/poor control of hip muscles/altered hip and/or foot biomechanics.
    • Crepitus (severe cases).
    • Giving way due to weak quads.
  • No scans in early stages (may scan if not improving).
  • Outcomes: VAS, Anterior Knee Pain Scale (AKPS) (Valid and Reliable, Crossley et al., Arch. Phys. Med. Rehabil. 2004 85(5) p815), GROC, Functional outcomes (ROM, strength, running).
• Diagnosis
  • Clinical tests:
    • Palpation (might be hard to feel).
    • Compression (caudal/cephalad/medial/lateral).
    • Pain/Crepitus.
    • VMO coordination test.
    • Eccentric step test (Nijs et al., 2006).
  • Quick test: Pick a provocative test (steps) have the patient complete (establish pain) this and then apply a medial glide to the patella and repeat. If pain decreases during the task it is a positive test and indicator for further treatment.
• Treatment
  • Guidelines for non-operative treatment – Individualised exercise dependant on P/E findings.
  • Hip Glutes Intrinsic Foot Hip retraining Hip Tape Correct deficit Othoses (Brukner & Khan, 2017) p784/5.
• Evidence
  • RCT arthroscopy + exercise vs. exercise alone (9 month follow-up) (Kettunen et al., 2007).
    • Both groups treated with 8 week exercise program.
    • No difference between groups at follow-up (Kujala Score and VAS).
    • Arthroscopy cost exceeded exercise group by €901/patient.
  • 179 participants (18-40 years)
    • Six weeks intervention
    • Physio
    • Joint mobs
    • Taping
    • Quadriceps retraining
    • Education Collins et al.

PFP vs. Patellar Tendinopathy

• PFP
  • Onset: Running, steps/stairs, hills, any weight-bearing activities involving knee flexion.
  • Pain: Non-specific or vague; may be medial, lateral or infrapatellar; aggravated by activities that load the PFJ.
  • Tenderness: Usually medial or lateral facets of patella but may be tender in infrapatellar region; may have no pain on palpation due to areas of patella being inaccessible.
  • Swelling: May have small effusion, swelling, suprapatellar or infrapatellar.
  • Clicks/clunks: occasional.
  • Crepitus: Occasionally under patella.
  • Giving way: Rarely, due to quadriceps weakness/inhibition or subluxation.
  • Knee range of motion: May be decreased in severe cases but usually normal.
  • Quadriceps contraction in extension: Can be painful, often normal.
  • PFJ movement: May be restricted in any direction. Commonly restricted medial glide due to tight lateral structures.
  • Functional testing: Squats, stairs may aggravate. PFJ taping should decrease pain.
• Patellar Tendinopathy
  • Onset: Activities involving jumping and/or changing direction.
  • Pain: At the inferior pole of patella, aggravated by energy storage loads such as jumping.
  • Tenderness: Localised to inferior pole of patella; this tenderness can exist in jumping athletes without patellar tendinopathy.
  • Swelling: Tendon may be increased in thickness; no joint swelling.
  • Clicks/clunks: No.
  • Crepitus: No.
  • Giving way: Rarely, due to quadriceps weakness/inhibition.
  • Knee range of motion: Normal.
  • Quadriceps contraction in extension: Often painful.
  • PFJ movement: Normal PFJ biomechanics.
  • Functional testing: Decline squats aggravate pain; PFJ taping has less effect.

Patellar and Quadriceps Tendinopathy (Jumper’s Knee)

• Patellar tendon > quads tendon.
• High prevalence in jumping sports (basketball, volleyball).
• Younger population (<40 years old).
• Localized pain on the inferior pole of the patellar.
• Pain during loading of the tendon (jumping, running, decline squat).
• VISA - P Diagnosis is clinical.
  • Pt history and site of symptoms (specific).
  • Pain on palpation.
  • Pain during loading.
  • Thickening on palpation.
• Imaging is not very reliable and should be used to confirm diagnosis if patient not progressing.
• 4 Stage process
  • Stage 1 Isometrics.
  • Stage 2 Isotonics.
  • Stage 3 Energy storage.
  • Stage 4 Energy storage and release.

Brukner and Khan (2017) Clinical Sports Medicine p50

• Acute Management
  • Isometrics (70% 1RM 5 x 45 seconds) v Isotonic (4 x 8 reps 8RM) (Rio et al., 2015) (Holden et al., 2019).
• Management
  • Heavy slow resistance training vs. corticosteroid injection vs. eccentric declined squat training.
    • N = 39 - 12 weeks of treatment.
    • All groups improved from 0 – 12 weeks.
    • CSI group had greater pain and poorer outcomes at 6 month follow up.
    • HSR had better patient satisfaction at follow-up.
  • Take home message: HSR better than ECC for patellar tendinopathy in terms of patient satisfaction but both groups improved (Kongsgaard et al., 2009).

ITB Friction Syndrome

• Overuse condition – rubbing of the ITB over the lateral femoral epicondyle.
• ITB switches from extensor 0-20° to flexor 20-90°.
• Predominantly thought to be bursa but now consider it a fat pad impingement.
• Marathon runners.
• Military personal 1-12%.
• Cyclists – ITBFS accounts for up to 25% of overuse injuries (Brukner & Khan, 2017), p810.
• Signs and Symptoms
  • Pain over the lateral aspect of the knee.
  • Exacerbated by sporting activities (running or cycling).
  • Tenderness 2-3 cm above lateral joint line.
  • Crepitus & local swelling.
  • Repeated flexion/extension ↑ knee pain.
  • Positive Ober’s test – pain – pulling – burning.
  • Muscle shortening – glutes/TFL.
  • Weakness of hip abductors.
  • ? Look for internal rotation of the tibia.
• Treatment
  • Focus should be on the entire kinetic chain.
  • Foot alignment – orthotics – intrinsic control.
  • Hip biomechanics and strength/neuromuscular control.
  • Oral NSAIDs in early stages.
  • Electrotherapy – Cryotherapy/shock wave.
  • Soft-tissue therapy – proximal ITB.
  • Stretching of the ITB is limited (due to anatomy).
  • Stretching of glutes and TFL.
  • Hip and knee strengthening.

Bursitis – Pre-patellar and Infrapatellar

• Inflammation of the bursae.
• Pre-patellar bursa (most common)  housemaid’s knee.
  • Superficial anterior knee pain – kneeling.
  • Superficial swelling anterior knee.
• Infrapatellar bursa
  • Anterior knee pain – similarly to patellar tendinopathy.
• Difficult to treat.
• NSAID (oral, topical).
• Aspiration and infiltration with corticosteroid/local anaesthetic agent (Brukner & Khan, 2017), p803.

Fat Pad Impingement

• Impingement between tibia and femur.
• Trauma or physiological.
• Common and relatively unrecognised.
• Extreme pain – highly innovative.
• Pain during hyperextension of the knee.
• Straight leg raises, prolonged standing.
• Pain during quads contraction.
• Pain during PROM – knee extension.
• Quads weakness – inhibition.
• Swelling/puffiness of the anterior knee.
• Deep to patellar tendon.
• Treatment
  • Activity modification.
  • Neuromuscular control of quads.
  • Strength and endurance.
    • Quads/hamstrings.
    • Proximal muscles - hips.
    • Distal muscles – ankle and foot.
  • Therapeutic tape.
    • Unload fat pad.
    • Superior tilt of patellar.
  • Improve lower limb biomechanics - orthoses.

Osgood-Schlatter Disease

• Osteochondritis of the growth plate of the tibial tuberosity.
• Common in adolescents.
• Males > females.
• Associated with high level of physical activity during growth spurts.
• Forced knee extensions (jumping, running e.g. basketball, gymnastics).
• TOP – tibial tuberosity.
• Pain during exercise.
• Clinical reasoning.
• Thickening of the tibial tuberosity.
• Clinical diagnosis – limited need for imaging.
• Treatment
  • Activity modification
  • A reduction in activity will help reduce pain.
  • Full rest is not required.
  • Stretching
    • STT – quadriceps.
  • Correction of biomechanical causes.
  • No CSI or surgery.

References

• Brukner, P. & Khan, K. Clinical sports medicine (5th ed). McGraw Hill Education, Sydney, Australia.
• Janssen, K.W., J.W. Orchard, T.R. Driscoll, and W. van Mechelen, High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003-2004 to 2007-2008: time for an anterior cruciate ligament register by Scandinavian model? Scand J Med Sci Sports, 2012. 22(4): p. 495-501.
• Katz et al. (2013). Surgery versus physical therapy for a meniscal tear and osteoarthritis. New England Journal of Medicine, 368(18), 1675-1684. doi: 10.1056/NEJMoa1301408
• Karanikas et al., Sportverletzung-Sportschaden 2005, 19(1) p15
• Kessler et al. Knee Surg Sports Traumator Arthrosc, 2008 16, p442
• Kise et al. (2016). Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two-year follow-up. BMJ .354 :i3740
• Sihvonen et al. (2017). Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Annals of the Rheumatic Diseases Published Online First: 18 May doi: 10.1136/annrheumdis-2017-211172
• Shiraev, T., S. Anderson, and N. Hope, Meniscal tear Presentation, diagnosis and management. Australian Family Physician, 2012. 41: p. 182-187.
• Vun S.H., Aitken S.A., McQueen M.M., & Court-Brown C.M. (2013). Adult fracture patterns: Epidemiology of fractures around the knee. Orthopaedic Proceedings 95(B:SUPP