Study Notes for Knee Anatomy and Management

Definition: A modified hinge joint that connects two long bones (levers).
Stability: Considered the least stable joint in the lower extremity when the foot contacts the ground surface (closed kinetic chain).

Definition: Angle measured from the Anterior Superior Iliac Spine (ASIS) to the center of the patella (extend the line), then from the tibial tuberosity to the center of the patella (extend the line).
Normal Ranges:
- Males: Normal angle is < 10 degrees.
- Females: Normal angle is > 10 degrees.
- Unstable angles: 20 degrees.

Cumulative biomechanical micro or macro trauma to the cartilage leading to tracking problems of the patella in the trochlear groove of the femur.

Symptoms:
- Knee pain, especially with sustained knee flexion.
- Retro-patellar crepitus.
- Decreased joint space observed on X-ray.
- Abnormal patellar position/tracking.

Knee Pain Symptoms:
- Pain or increased pain on the medial side of the knee going up steps or hills; exercise to strengthen Vastus Lateralis (related to Medial Patellar Tracking Syndrome / Patellar Femoral Arthralgia = PFA or PFS).
- Pain or increased pain on the lateral side of the knee going down steps or hills; exercise to strengthen Vastus Medialis (VMO) to mitigate Excessive Lateral Patellar Syndrome (ELPS).
Exercise Considerations:
- Medial weakness exercises should occur in the last 15-20° of knee extension.
- Lateral weakness exercises should exclude the last 15-20° of knee extension.
- Taping and straps across the patellar tendon may be beneficial.

Hydration: Increase H2O consumption.
Supplementation:
- Glucosamine sulfate: 500 mg per 50 lbs of body weight.
- Methylsulfonylmethane (MSM).
- Consider Cho-Pat support/patellar brace.
- Use orthotics if biomechanically indicated.
- Adjust spine, knee, and lower extremity if necessary.

Jumper’s Knee (Patellar Tendonitis):
- Occurs at the attachment of the patellar tendon to the patella or tibial tuberosity.
Other Diagnoses:
- Patella alta or baja.
- Osgood Schlatter disease affecting the tibial apophysis.
- Bursitis with localized swelling: Common forms include:
- Suprapatellar bursitis.
- Prepatellar bursitis.
- Infrapatellar bursitis.
- Pes anserinus bursitis.

Includes collateral, cruciate, and meniscus damage, typically associated with twisting motions and having the foot fixed.

Progressive Knee Exercises Post-Injury:
- Emphasize reduced load for various motions.
- Incorporate all directions of movement (extension, flexion, abduction).
- Include step exercises (both up and down).
Proprioception Training:
- Incorporate balance and increase difficulty, beginning with support.

Functionality: The tibia must accomplish up to 20° of relative external rotation from internal rotation to achieve closed-pack/full knee extension.
Mid-foot Stance Considerations:
- During mid-foot stance, the tibia internally rotates, with hyper-pronation creating excessive internal rotation.
- This requires excessive internal rotation of the femur concerning the hip joint to achieve full extension of the knee.

Standard procedures include a soft 'bounce home' test and assessing the popliteus muscle's strength, which may indicate a potential posterior tibia issue simulating meniscus involvement or inability to fully extend the knee.

Check Procedure:
- Patient Positioning (P.P.): Supine, knee and hip flexed at 90°.
- Doctor Support (D.S.): Support the patient's leg with the inferior leg and/or inferior hand. The superior hand should be on the lateral and medial joint line or both sides of the tibial tuberosity.
Motion Checking:
- Assess both internal and external rotation motion for any decreases.
- Evaluate movement from medial to lateral sides based on the tibial tuberosity's position.

Procedure:
- Patient Position: Supine, knee and hip flexed at 90°.
- Doctor's Support: Stabilize the patient's leg above the ankle. The SCP (Specific Contact Point): Lateral aspect of the anterior margin of the tibia, 1" distal to the tibial tuberosity.
- Contact Point: Ball of the hand or palmar MCP joint.
- Line of Correction (L.O.C.): Take the joint to tension, rotating the top hand from lateral to medial, extending the elbows. This breaks adhesions on the medial side, increases internal rotation, and assists with an externally rotated tibia. Then, recheck RMT.

Procedure:
- Doctor's Support: On the opposite side of the involved knee with a similar setup. The SCP is medial aspect; L.O.C. follows a similar pattern by taking the joint to tension while rotating from medial to lateral.
- The aim is to assist with restoring external rotation and address an internally rotated tibia.

Patient Position: Supine with the flexed leg, foot on the table.
Specific Contact Points: Posterior proximal tibia and fibula. Contact Point: Interlocking fingers with hands on the posterior region.
L.O.C.: Take the joint to tension from posterior to anterior, applying gentle impulse in the P-A vector.

Procedure:
- Patient Position: Supine, involved leg flexed and elevated.
- Contact Points: Posterior proximal and anterior distal tibia; stabilized using the elbow.
- The motion follows an anterior to posterior push to facilitate flexion while maintaining a 90° hip angle without pulling with the hands.

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Procedure:
- Patient Position: Prone with involved leg flexed, foot elevated.
- Stabilization: Anterior distal tibia is stabilized with the shoulder.
- Contact Points: Posterior proximal tibia/fibula, using interlocked fingers. Take the joint to tension, and impulse posterior to anterior.

Defined: Tibial plateaus refer to the check for the motion of the tibial plateaus on the femoral condyles, resembling the top of a heart. Important to identify areas of restricted motion or catches, which may help reset the joint and surrounding muscles.
Technique: Check for medial and lateral tibial plateau movement with impulse in the direction of restriction, stabilizing the patient's slightly flexed leg with the doctor’s knees.

Medial Tibial Plateau Correction: Move from medial to lateral while bending the inside elbow to 90° and impulsing M-L.
Lateral Tibial Plateau Correction: Move from lateral to medial, ensuring the elbow is bent at 90°, emphasizing the impulse direction from lateral to medial.