1. THE PAINFUL KNEE
About The Author
Dr Manoj R. kandoi is the founder president of “Institute of Arthritis Care & Prevention”
an NGO involved in the field of patient education regarding arthritis. Besides providing
literature to patient & conducting symposiums, the institute is also engaged in creating
patients “Self Help Group” at every district level. The institute also conducts a certificate
course for healthcare professionals & provide fellowship to experts in the field of arthritis.
The author has many publications to his credit in various journals. He has also written a
book “ The Basics Of Arthritis” for healthcare professionals.
The author can be contacted at:
Dr manoj R. kandoi
C-202/203 Navare Arcade
Shiv Mandir Road, Opposite Dena Bank
Shiv mandir Road, Opposite Dena bank
Shivaji Chawk, Ambarnath(E) Dist: Thane Pin:421501
State: Maharashtra Ph: (0251)2602404 Country: India
Membership Application forms of the IACR for patients & healthcare professionals
can be obtained from.
Institute of Arthritis Care & Prevention
C/o Ashirwad Hospital
Almas mension, SVP Road, New Colony,
Ambarnath(W) Pin:421501 Dist: Thane
State: Maharashtra Country: India
Ph: (0251) 2681457 Fax: (0251)2680020
Mobile ;9822031683
Email: drkandoi@yahoo.co.in
CONTENT
1 Common causes of knee pain
2 History Taking
3 Physical examination
4 Common causes of anterior knee pain, treatment protocol
5 Chronic knee swelling
6 Cystic swelling around knee joint
7 Deformities around knee joint
8 Clicking of knee joint
9 Medial joint line pain
10 Lateral joint line pain
11 Tuberculosis of knee
2. 12 Internal derangement of knee
13 Osgood schlatter disease
14 Loose bodies in knee joint
15 Chondromalacia patellae
16 Recurrent dislocation of patella
17 Fractures of patella: Classification
18 Uncommon causes of knee pain
19 Locking of knee joint
20 Causes of Haemarthrosis
21 Stiffness in the joint
22 Clinical presentation of meniscus tear
23 Clinical presentation of GCT.
24 Tumors around knee joint
25 Important Terminologies Related To Sports Injuries
26 Arthroscopy of Knee Joint
27 Osteochondritis Dessicans..
28 Radiology of knee joint
Introduction: Knee joint is the major weight-bearing joint of the body, with certain peculiar
characteristics:
1. It is a compound synovial joint (comprising of ‘saddle type’ patellofemoral joint & ‘Hinge
type’ femorotibial joint).
2. Since it is a superficial joint it is more prone to injuries
3. The stability of the joint is mainly provided by soft tissue, not bones. The soft tissue includes
cruciate ligaments, collateral ligaments, capsule & quadriceps muscle.
4. The joint has a large synovial space & many bursa around it, which could get involved in
pathological processes.
5. Besides flexion & extension, slight rotational & sideward movements are possible in knee.
6. Menisci, the intra-articular structure are common source of symptoms.
7. The knee joint is normally in 7 valgus (F>M)
3. 3.1 COMMON CAUSES OF KNEE PAIN:
A. Traumatic: The injury sustained is dependent upon mechanism of injury.
Index 3.1:
Mechanism of injury Type of injury
Hyperextension Anterior cruciate tear (ACL tear)
Varus LCL & ACL tear
Valgus MCL & ACL tear
Torsion Meniscal tear
[LCL: Lateral collateral ligament, MCL: Medial collateral ligament]
Other injuries include fracture of patella, tibial condyle, femoral condyle & posterior cruciate
ligament tear.
B. Inflammatory: Synovitis, bursitis, tendonitis.
C. Vascular disorders: Osteonecrosis, sickle cell crisis, haemophilia
D. Degenerative: Osteoarthritis, meniscal degeneration.
E. Neoplastic: Primary or metastatic bone & soft tissue tumours around the knee.
F. Referred pain: From hip or spinal lesion.
3.2 HISTORY TAKING IN KNEE PROBLEMS.
1 Age (Various disease in various age groups) :
Index 3.2: Age Wise Distribution:
Age Common Clinical Conditions
0-12 Discoid lateral meniscus
12-18 - Osteochondritis dissecans
- Early episodes of recurrent dislocation of patella
- Osgood schlatter’s disease
18-30 - Meniscal tears
- Chondromalacia patellae
- Recurrent dislocation of patella
30-40 - Rheumatoid arthritis
> 40 - Rheumatoid arthritis
- Osteoarthritis
- Degenerative meniscus lesions
2 Sex: Certain diseases like recurrent dislocation of patella, chondromalacia patellae & fat pad
injuries are more common in females
4. 3 Swelling
4 Injury: The degree of violence, nature & direction of injury should be inquired. One should
inquire whether the patient was able to finish his task after injury, whether he was able to bear
weight, whether there was bruising or swelling after injury.
5 Giving Away: Giving away on twisting movements or walking on uneven surfaces may suggest
cruciates or meniscal injury.
6 Locking: Locking only occurs in varying degree of flexion in cases of meniscus lesion, loose
bodies & dislocating patella. The dislocating patella is associated with deformity. Locking due
to torn meniscus occurs in last 10 to 40 of extension & unlocking is usually associated with a
click.
7 Pain: The site, type of pain, exacerbation & relieving factors etc should be inquired.
Index 3.3: Common presenting symptoms & possible etiology:
Symptoms Possible Etiologies
Swelling synovitis, tendinitis or bursitis
Clicking or crackling sound Meniscal tear, chondromalacia patellae
Locking of joint Meniscal tear, chondromalacia patellae
Giving away or buckling ACL tear, patellofemoral disorder
Audible pop at the time of injury ACL/ PCL injury, meniscal tear
3.3 PHYSICAL EXAMINATION
Physical examination of the patient is done with both lower limbs exposed from the front, sides &
back.
A. Inspection:
a. Shape
b. Alignment of the knee: Tibia vara or valgus malalignment, genu recurvatum
c. Gait
d. Wasting of thigh muscles
e. Presence of swelling
B. Palpation:
1. Knee Joint Swelling: It may occur due to following:
A. Increased synovial effusion in the joint which may be due to
a. Synovial fluid
b. Pus
c. Blood
B. Inflamed synovial tissue
C. Hypertrophied synovium e.g. in chronic conditions such as RA, tuberculosis etc.
Types of knee joint swelling:
1 Small: It is usually associated with bulging on both sides of patellar ligament.
2 Medium: Besides bulging on both sides of patellar ligament there is obliteration of the hollows at
medial & lateral parapatellar ridges.
3 Large: besides above mentioned finding there is distension of suprapatellar pouch
4 Localised swelling: These will be dealt with later.
Features of synovial hypertrophy Vis – à - Vis synovial effusion:
1 Usually felt at the suprapatellar pouch
2 Fluctuation test is negative
3 Boggy feeling on palpation
4 Presence of local warmth in synovial hypertrophy which may or may not be present in effusions.
Clinical Tests For Synovial Effusion:
5. These Tests Include:
a. Patellar tap test
b. Fluid displacement test
c. Fluctuation test
a. Patellar Tap Test: From 15 cm above the patella, any excess
fluid out of the suprapatellar pouch is driven back into the joint
by sliding down firmly with index finger & thumb. Tip of the
thumb & three fingers of the examiner’s free hand are placed
squarely on the patella & a quick “Jerk” is given downwards. A
click can be heard as patella strikes on the femoral condyle &
“bounces” back.
The test is negative in small & tense swelling (i.e. when
effusion is either too less or too much)
b. Fluid Displacement Test: This test is useful in small effusions.
The suprapatellar pouch is evacuated as described above &
medial side of the joint is emptied into the other side of the knee
by stroking any excess fluid. Now the distended lateral side is
pressurized & refilling of the hollow of emptied medial side is
observed.
c. Fluctuation Test: It is useful in large effusion. In this test
thumb & index finger of one hand is placed on both sides of the
ligamentum patellae at infrapatellar fossae. Pushing the fluid by
the thumb & index finger of the opposite hand placed in
suprapatellar pouch region one can elicit cross fluctuation.
Swelling Around Knee Joint
Generalized swelling Localised swelling
e.g. bursa ,meniscal cyst,
exostosis
Confined to limits Extending beyond the
Of synovial cavity limit of the joint
& suprapallellar pouch
Major Tumor Infections
Trauma - Cellulitis
e.g. fracture - Muscle abscess
- Infection of tibia,
femur or joint
Synovial Hemarthrosis Pyarthrosis Synovial Space occupying
Effusion thickening lesion in joint
e.g. - RA
- TB
2. Popliteal fullness: It is commonly felt in baker’s cyst.
3. Tenderness: Joint line tenderness exacerbated by tibial rotation
(stein Mann test) is suggestive of meniscal tear.
6. Tenderness is looked for in the following manner
a. First joint line is palpated by flexing the knee & looking for hollows at both sides of patellar
ligament which lie over the joint line.
b. Look for tenderness at joint line which is common in meniscal tear, collateral ligament & fat
pad injuries.
c. Look for tenderness at both proximal & distal attachment of collateral ligaments
d. Palpate for tenderness at tibial tubercle
e. Flex the knee fully & palpate for tenderness over femoral condyles
Index 3.4
Site of tenderness Possible Etiologies
Joint line tenderness - Osteoarthritis
- Meniscal, ligament & fat pad injuries
Tenderness over point - Collateral ligament injury
Of attachment of ligament
Tibial Tubercle - Posttraumatic avulsion
- Osgood schlatter’s disease
Femoral Condyle - Osteochondritis dessicans
4. Patellofemoral compression test: Patella is pressed against femoral condyle with knee slightly
flexed & side-to-side movement of patella done. Tenderness is suggestive of chondromalacia
patellae.
5. Palpable osteophyte (osteoarthritic knee).
6. Local warmth
C. Range of motion:
1. Restriction of range of motion may be due to variety of causes
2. Look for presence of patellofemoral crepitus during motion.
Range of movement:
Extension: Full extension is considered as 0 with preferably
both knees examined at the same time. Any loss of extension
(extension lag) or any block in extension (springy block e.g.
bucket handle meniscus or rigid block as in fixed flexion
deformity) is noted as “ The knee lock X of extension”.
Hyperextension (extension beyond 0) is noted by lifting the
leg while pressing on the patella; preferably compared to the
other side. Hyperextension may be seen in:
Patella Alta
Chondromalacia patellae
Ehlers-Danlos syndrome
Recurrent patellar dislocation
Sometimes ligament injuries.
7. Passive extension may be tested by prone hanging test. Here patient lies down in prone position with
lower limbs below the knee hanging beyond the edge of
examination table. The knee is allowed to extend fully
passively & heel height distance of 2 limbs measured. It
gives a good estimate of knee FFD deformities.
Flexion: Flexion is measured with goniometer from 0 of
extension. Normal range of motion is 0 -135. Loss of
flexion may be due to arthritis or synovial effusion.
D. McMurry test: Here with the knee in full flexion, the tibia is rotated internally & externally
while the knee is brought slowly into extension, meniscal tear is associated with an audible click
during the menoveure. For medial meniscus tear knee is externally rotated & abducted whereas
for lateral meniscus knee is internally rotated & adducted. The more posterior is the tear, in more
flexed position of the knee sign will become positive.
E. Apley’s grinding test: With the patient in prone position & knee flexed to 90 compression is
applied along the long axis of the tibia while rotating it on the femur akin to grinding movement.
Pain on external rotation suggests medial meniscus tear while on internal rotation it indicates
lateral meniscus tear.
F. Ligament stability:
1. Varus & valgus stability: This is best demonstrated by applying a medial or lateral knee
stress with knee flexed to 15. Anything more than a jog of motion is suggestive of MCL or
LCL injury.
Testing For Medial Collateral Ligament Injury
Test in extension
If positive If negative
MCL +ACL Injury
Test in 30 flexion
+ ve - ve
Only medial collateral No ligament tear
Ligament injury
2. Anterior & posterior cruciate ligament:
8. Tests For Ligament Injury:
Lachman Test: With the knee flexed to 30 femur is held firmly with one hand
while an anteriorly directed force is applied to the posterior surface of the tibia
with other hand. The degree of anterior excursion as well as end point is noted.
False Positive Test: Uncommonly a bucket handle tear of a meniscus may alter the end point with a
normal anterior cruciate ligament giving a false positive result.
False Negative Test: It may occur if a bucket handle tear of a meniscus is displaced preventing
anterior tibial excursion or altering the end point.
Anterior Drawar Test: With the patient’s knee flexed to 90, the examiner sits on patient’s foot &
applies anterior displacement force on the proximal tibia. Minimum excursion & a firm end point
should be noted in a negative test.
Posterior Drawar Test: It is similar to anterior drawar test but here a posterior displacement force is
applied on the proximal tibia. It is positive mainly in chronic instability.
Posterolateral Instability Test: It is similar to posterior drawar test, in addition to posterior force an
external rotation force is applied to the proximal tibia. Increased external rotation & drop back of
tibia is noted if laxity is present.
External Rotation Recurvatum Test: Hold the large toe & gradually bring the knee from 10 of
flexion to extension. If positive, the knee goes into external rotation & recurvatum. The positive test
indicates posterolateral capsular, lateral collateral ligament & posterior cruciate ligament damage.
Index 3.5
Ligament Injury Symptomatic Instability
- Only medial or lateral collateral ligament laxity Minimal symptoms
- Only cruciate injury Moderate instability
- Cruciate with collateral ligament injury Severe instability
Pivot Shift Test: Foot is held in mild internal rotation & a valgus force is applied
to the proximal tibia as the knee is brought from a flexed position of 45 to
extension. Positive test is present when a transient anterior subluxation of tibia on
the femur is noted with internal rotation. It is suggestive of anterior cruciate
injury. False negative test may be seen in following circumstances:
Holding the leg externally rotated
Failure to apply valgus force
9. Holding leg maximally internally rotated
Medial ligament injury
Reverse Pivot Shift Test: Foot is externally rotated, knee is moved from a flexed to an extended
position, minimal valgus force is required. As the knee is brought into extension a jump will be
noted. This indicates posteriorly tibia suddenly moving into reduced position in the femur. It is
indicative of posterolateral instability (i.e. damage to PCL, LCL & biceps)
Apley’s Distraction Test: With the patient in prone position in 90 of knee flexion; stabilize his
thigh with your knee. A traction force is applied along the long axis of tibia while rotating the leg
internally & externally. Pain indicates ligament instability.
Apprehension Test: With patient in supine position, patella is displaced laterally. Sudden tightness
of the quadriceps tendon & an apprehension look on the patient’s face is suggestive of a chronic
tendency towards frequent patella dislocation.
Dreyer’s Test: While in the supine position, the patient is instructed to raise his leg without bending
the knee. If he is unable to do so, the quadriceps tendon is stabilized just above the knee & patient is
instructed to raise his leg again, if he is able to raise his leg the second time, a fracture of patella
should be suspected.
G. Muscle strength: Quadriceps & hamstring muscle strength must be noted. Thigh circumference
should be measured on both side at a fixed point from the pole of patella.
H. Examination of patella:
1 Patellar Alignment: It is tested by asking the patient to stand with the feet together with
inner borders of feet parallel to each other & pointing toward the examiner.
a. Infacing (squinting) patellae: Here the patellae are angled toward each other with
sometimes-associated patellofemoral pain. It is commonly seen in increased femoral anti-
version with compensatory increased external tibial rotation.
Intoeing
b. Outfacing Patellae: These are seen in patients with habitual dislocation/ subluxation of
patella as with knee fully extended ,the patellae sublux outwards.
2 Q-Angle: It is the angle between a line from the anterior superior iliac spine to the center of
patella and line from center of patella to the tibial tubercle. It is a measurement of overall
patellar alignment. It is normally between 14 to 17 (F> M). The foot & hip should be in
neutral position while recording. The biomechanics of patellofemoral joint are affected by
the length of patellar tendon and Q angle. An increased Q angle increases the risk of patellar
subluxation, Q angle is increased in genu valgum, external tibial torsion, increased femoral
anteversion, laterally placed tibial tuberosity, tight lateral retinaculum.
10. 3 Tubercle-Sulcus Angle: Patient sits on the end of examination table with the knees flexed to
90. In this position normally patellae are well seated in the trochlear sulcus of the distal
femur. One line is drawn from the center of the patella perpendicular to the floor, other line is
drawn from center of patella to center of tibial tubercle. The angle sustained should be
between 5 to 8 (F>M). Increase in angle is suggestive of lateral displacement of tibial
tubercle.
4 Patellar Height: Patellar alta is the term used for high riding patella whereas patella baja
(patella infra) is a low riding patella. Patella alta may be seen acutely in patellar tendon
rupture. Patellar baja may result due to trauma or surgery.
Clinically this is tested with the patient sitting at the edge of the table with knee flexed to 90.
In a normal patient, the patellae should face directly forward in this position. In high riding
patellae, patellae faces upward towards the ceiling, patellae baja is detected by clinically
correlating height of both patellae.
5. Perkin’s Sign: Patella is displaced on one side (medial or lateral); palpate for presence of
peripheral tenderness. It is positive in chondromalacia.
6. Fouchet’s Sign: Also known as patellar grind test.
7. Clarke’s Sign: Patient lies in supine position with knee extended, examiner pushes the
patella by his hand in a downward direction & patient is asked to contract the quadriceps.
Chondromalacia is associated with retro patellar pain.
I. EXAMINATION IN PRONE POSITION: It includes examination for presence of any
swelling in popliteal fossa, any bursa at muscle attachment or any tenderness due to trauma.
J. SPECIAL TESTS:
1 Test For Osteochondritis Dessicans: It can be vaguely tested by looking for local
tenderness on the surface of the femoral condyle with knee flexed.
2 Wilson Test: This test is useful for osteochondritis of medial femoral condyle. Here the knee
is flexed to 90, internally rotated & then it is gradually extended. When the raw area comes
into contact, patient will complain of pain which gets relieved with external rotation of knee.
K. OTHER EXAMINATION: This include examination of:
Ipsilateral hip
Contralateral knee
Neurovascular structures of the limb.
3.4 COMMON CAUSES OF ANTERIOR KNEE PAIN:
1. Patellofemoral overload
2. Misuse of knee
3. ‘Jump’ Knee
4. Patellofemoral malaligament
5. ? Bipartite patella
6. Patellar cyst or tumours
7. Plica syndrome
8. Prepatellar bursitis
9. Osteochondritis dissecans
10. Discoid meniscus
11. Torn meniscus
12. Fat pad syndrome
13. Sinding-Larsen-Johansson syndrome
11. 14. Post surgical neuroma
15. Pes Anserinus bursitis
16. Referred /radiating pain from hip, spine
Index 3.6 Difference Between Arthritis & Arthralgia
Arthritis Arthralgia
1. Both subjective & objective - Only subjective complaints
Signs are present - No objective signs present
2. Signs of inflammation such - No signs of inflammation
as pain, edema, tenderness
present
3. It may be due to local or - It is a sign of generalized disease.
Systemic disease
Flowchart 3.1:
Anterior knee pain
History /Examination (change in activity levels,
Swelling, increase in quadriceps angle, crepitus)
Objective findings
Chondromalacia Prepatellar bursitis Patellar tenderness Anterior joint line
& tenderness
Patellar tracking patellar tendinitis X-rays
disorder
Treat accordingly
Yes Stress fracture Negative Meniscal No other
Tumour, infection signs +ve meniscal
Quadriceps programme Activity signs
Improvement modification
Arthroscopy
Continue & No improvement Observe
Improvement No improvement observe
Bone scans
Continue program Patellar realignment
& modify activity stress fracture
Splint, modify activity
3.5 CHRONICALLY SWOLLEN KNEE
Painful knee
1. Traumatic
a. Torn Meniscus
b. Ligament laxity
c. Traumatic Synovitis
2. Recurrent Dislocation of Patella
3. Chronic Arthritis:
a. Chronic Septic Arthritis
b. Tuberculosis arthritis
c. Reactive Arthritis & other seronegative spondyloarthropathy
d. Rheumatoid arthritis
e. Osteoarthritis
12. f. Haemophilic Joint
4. Loose Bodies in Knee joint
Painless Knee:
1 Charcot’s joint.
2 Syphilis
Flowchart 3.2:
Chronic Knee Swelling
Cold Other Findings Hot
(Patellofemoral malalignment,
snapping tendon, IDK knee)
X-Rays Aspirate
Normal Bony degeneration Inflammatory Septic Sympathetic
- OA (Infective)
- Loose Bodies
Aspiration Synovial biopsy Aspirations
Treat Underlying pathology Antibiotics
- Treat Underlying Arthrotomy
condition
Improvement improvement - SOS synoviectomy Treat underlying cause
+ve - ve
Physical Therapy Diagnostic Arthroscopy
3.6 CYSTIC SWELLINGS AROUND KNEE
Anteriorly:
a. Suprapatellar Bursa: Superior extension of
synovium beneath the quadriceps tendon
b. Prepatellar Bursa (Housemaid’s Knee): It lies
beneath the skin in front of patella
c. Intrapatellar Bursa (Clergyman’s Knee): Lies in
between the ligamentum patellae & anterior
surface of tibia. It may be superficial or deep.
Laterally:
a. Biceps Bursa: Lies between biceps tendon &
fibular collateral ligament.
b. Posterolateral Bursa:
I. Between popliteus tendon & fibular collateral ligament
II. Between popliteus tendon & lateral condyle of femur
Medially:
a. Bursa between medial head of gastrocnemius & capsule of the joint
b. Cyst of medial meniscus
13. c. Pes anserinus bursa
Posteriorly:
a. Morant Baker’s cyst: It is a midline herniation of the synovial cavity of the knee secondary to
persistent effusion in the knee.
b. Semimembranosus Bursa (Commonest): It lies postero-medially between the medial head of
gastrocnemius & the musculotendinous mass of semimembranosus
c. Popliteal aneurysm must be differentiated from morant baker’s cyst.
Morrant Baker’s Cyst: It is a popliteal cyst which was first
described by Adam in the year 1840 & later by baker in 1877.
Site: The distended bursa may arise between.
1 Hamstring & collateral ligaments
2 Hamstring & tibial condyles
3 Each head of gastrocnemius
Etiology:
1 Herniation of synovial membrane through posterior part of
capsule
OR
2 Escape of fluid via the normal communication of either semimembranosus or medial
gastrocnemius bursa with knee.
Types:
1 Cyst In Children: Here the intra-articular pathology is rare with no communication of cyst with
the joint capsule. Recurrence rate is very low & postoperative immobilization is not required.
2 Cyst In Adults: Intra-articular pathology is seen in 50% of cases with cyst usually communicating
with capsule, because of intracapsular extension recurrence is common & postoperative
immobilization is required.
3 Giant Cyst: It is a huge popliteal cyst seen in rheumatoid arthritis. It is excised in 2 stages:
Cyst excision in first stage followed by synoviectomy later.
Clinical Features In Adults:
Usually in middle aged patients
Pain on walking along with tenderness
Swelling situally usually near the midline of popliteal fossa
Cystic in nature
Fluctuation +ve.
Knee movements are usually painful & restricted with synovial effusion + ve.
X-Rays may show degeneration or inflammatory arthritic changes.
Differential Diagnosis of Popliteal Mass:
1 Synovial cysts
2 Baker’s cyst
3 Arterial or venous aneuysms (Expansile pulsatile swelling)
14. 4 Thrombophlebitis
5 Cysts of artery
6 Pigmented villonodular synovitis
7 Synovial haemangioma
8 Rhabdomyosarcoma
Treatment:
1 The cyst in children tends to disappear by 7 years of age & hence excision should be avoided by
this age.
2 Aspiration followed by crepe bandage
3 If it fails, complete excision of bursa by a transverse incision & closure of the capsular orifice by
a. Scarrification of edges & suturing
b. By using tendon graft from gastrocnemius
4 Treatment of associated joint pathology if any e.g. rheumatoid or osteoarthritis
Prepatellar Bursa :-
It is a superficial bursa present between skin and patella containing minimal fluid. It usually
does not communicate with the knee joint.
Pathophysiology :-
This synoviumlined structure separates the patella from the patellar tendon and skin. Its main
function is to reduce friction and allow maximal range of motion. Inflammation of bursa is
known as prepatellar bursitis.
Incidence :-
Bursitis is mere common in males and can occur at any age. In pediatric age group and
immunocomposed host it is likely to be infective.
Clinical presentation :-
- Knee pain
- swelling or redness of the knee.
- inability to kneel on the affected side.
- difficulty in walking.
- history suggestive of possible etiology such as excessive kneeling, history of trauma or
repetitive motion.
Physical findings :-
- Tenderness and erythema over the patella.
- fluctuant swelling over the lower pole of patella.
- reduced knee motion due to pain at terminal range.
Etiology :- It includes :
- direct trauma.
- repetitive overuse (i.e. kneeling)
- infective process (should be differentiated from septic arthritis where joint motion is
extremely painful and restricted and where popliteal fossa fullness and tenderness can be
felt).
- crystalline arthropathy.
- inflammatory rheumatic diseases.
- occupational predisposition : especially in homemaker (housemaid knee), plumber, coal
miner etc.
Differential Diagnosis :-
Must be differentiated from other causes of anterior knee pain, cellulites and connective tissue
disorders.
Investigations :-
These include X-rays (to rule out other pathologies) and aspiration of fluid for biochemistry and
microbiological analysis. Rarely MRI may be required in difficult cases. Aspirated fluid may
show presence of pus cells, bacteria and crystals of crystalline arthropathies.
Treatment :-
Prepatellar Bursitis
15. Conservative treatment (rest, ice, NSAID, avoidance of
kneeling, use of knee pads)
Successful Failure
Continue Aspirate
Non infective Septic
Steroid injection incision and Drainage
Responsive Unresponsive
Continue conservative Surgical Excision of bursa.
3.7 DEFORMITIES AROUND KNEE JOINT:
A. Genu Valgum (Knock-Knee) & Genu Varum (Bow-Leg): Normally the children are born with
a varus tibia-femoral angle which decreases with age. By 18-24 months of age, the knee becomes
straight. At the age of 3-5 years, valgus angulation becomes more pronounced from then to the
attainment of maturity there is a valgus normal angulation of knee around 5- 10.
In genu valgus the knee is angled inwards, the tibia being abducted in relation to the femur. The
two malleoli are away from each other, the distance between the two is indicator of severity of
genu valgus.
In genu varum the knee & leg are bowed inwards with & femoral condyles away from each
other. The deformity can be measured by measuring the distance between two medial femoral
condyles.
Genu Varum: It is lateral angulation of knee with medial deviation of long axis of femur & tibia
Classification:
A. Depending upon bone involvement
Tibial
Femoral
Combined
B. Depending upon number of knee involved
Unilateral
16. Bilateral
Types
Unilateral Bilateral
a. Traumatic (Affecting growth epiphysis)
b. Infective (E.g. osteomyelitis)
c. Neoplastic
d. Growth abnormalities Physiological Pathological
(Should get corrected by
4 years)
Common Uncommon
Congenital Bilateral trauma,
Developmental Neoplastic or
Metabolic Infective involvement
Endocrine
Degenerative
Inflammatory
Occupational
Idiopathic
Paget’s Disease
Blount’s Disease
Associated Deformities:
1 Intoeing of both feet
2 Internal rotation (torsion) of distal tibia
3 Patella faces outward during stance phase
4 Associated laxity of lateral structures of knee
5 Contracture of medial structures of knee
Examination In Genu vara:
1 Degree of varus & tibial torsion should be especially measured & recorded
Both ankles of child are held together & the distance between the knee is measured
2 Knee motion & ligamentous instability should also be assessed.
3 Plum line Test: A line drawn from ASIS through the center of patella passes normally through
medial malleoulus. In genu varum medial malleoulus is medial to the line.
Differential Diagnosis of Genu Varum:
1 Bow Leg: This is deformity at leg with an inward concavity of tibia, the knee joint is not
deformed. It can be detected by dropping a plumb line from the midinguinal paint. Unlike in
genu varum where the knee lies outside to the joint, the knee of bow leg lies at the center of the
line.
Causes of Bow Leg:
a. Physiological of infancy
b. Idiopathic
c. Posttraumatic
d. Congenital
e. Syphilitic tibia
f. Paget’s disease
g. Pseudoarthritis of tibia
h. Osteogenesis imperfecta
i. Dyschondroplasia
17. 2. Anteversion of femoral neck may lead to apparent genu varum.
Genu Valgum (Knock Knee):
Definition: Outward deviation of longitudinal axis of both tibia & femur with apex at knee directed
medially is known as genu valgum.
Classification:
Types
Physiological Pathological
Unilateral Bilateral
Etiology:
Unilateral Deformities:
1 Traumatic
2 Neoplastic
3 Infective lesions
Bilateral Deformities:
1 Congenital
2 Idiopathic (commonest)
3 Endocrine disorders (e.g. thyroid
disorders)
4 Rickets
5 Epiphyseal dysphasia
6 Inflammatory disorders (e.g. RA)
7 Paralytic disorders
8 Degenerative disease.
Concomitant Deformities
1 Lateral rotation of lower end of femur & upper end of tibia by pull of biceps & tensor fascia lata.
2 Medial rotation of lower end of tibia
3 Lateral dislocation of patella
4 Shortening of lateral structures & elongation of medial structures of knee
5 The gait pattern is marked by circumduction
6 Pronated flat foot may be present.
Clinical Examination:
1 The extent of valgus deformity is noted by measuring the intermalleolar distance with both knee
touching each other & patella facing upward (>10 cm is abnormal)
2 Tibial torsion, should be looked for.
3 Ligament laxity if any is noted
4 Range of motion is tested
5 If deformity lies in the lower end of femur, it will disappear with flexion of knee whereas it will
persist in upper tibial pathology.
6 If a plumb line is drawn from ASIS to center of patella, the medial malleolus will lie outside the
line, normally the line passes through medial malleolus.
Indications For Treatment In Genu Vara/ Genu Valga:
1 Presence of bowleg or knock-knee outside the age range (i.e. bowleg beyond age 3 & knock-knee
beyond age 7)
2 If it is unilateral
3 The intercondylar or intermalleolar distance of more than 2 inches
4 If the intercondylar or intermalleolar distance is rapidly progressing by more than ½ inch within
6 months.
18. 5 Associated symptoms like pain or limp or sign of rickets or Blount’s disease or other disease
syndromes.
Treatment:
Treatment Protocol
< 6 years of age > 6 years of age
Observation
Before attainment of maturity After maturity
- Stapling of epiphyseal Corrective Osteotomy
Convex side of deformity
- Epiphyseodesis: excision & fusion
of epiphyses on convex side of
deformity
Genu Recurvatum: It involves hyperextension at the knee joint.
It may be:
1. Congenital
2. Acquired :
a. Polio
b. Charcot’s joint
c. Ligament Laxity (Marfan’s syndrome)
d. Mal-united Fracture
e. Epiphyseal growth defects
Treatment:
Supportive Brace
Corrective Osteotomy
3.8 CLICKING OF KNEE JOINT:
1. Snapping of iliotibial band across a bony spur
2. Snapping of medial hamstring.
3. Loose bodies in the joint
4. Meniscal tear
5. Patellofemoral malalignment
3.9 MEDIAL JOINT LINE PAIN:
Commonest causes are:
1. Patellofemoral malalignment
2. Medial compartmental OA
3. Meniscal tear/degeneration
4. Medial collateral ligament tear.
3.10 LATERAL JOINT LINE PAIN:
1. Loose body
2. Meniscal cyst
3. Torn lateral meniscus usually associated with anterolateral rotatory instability.
4. Iliotibial band syndrome caused due to friction with lateral femoral condyle
5. Lateral compartment DJD (Rare secondary to long standing valgus malalignment at knee or
due to avascular necrosis).
19. 3.11 TUBERCULOSIS OF THE KNEE
The knee joint is the third commonest site for osteoarticular tuberculosis & forms approximately
10% all skeletal TB.
Pathology:
2 Types
Osseous Tuberculosis Synovial tuberculosis
(Start in femoral or (starts in synovium)
tibial condyle or rarely
patella)
Tuberculous Granulation tissue formation
Erosion of articular cartilage, cruciate ligament, periarticular
tissues, capsules & ligament
Articular Fibrous ankylosis Triple deformity: flexion
cartilage fraying due to filling up of of joint with posterior
of joint by granulation subluxation, lateral
tissue subluxation & lateral
rotation, abduction of tibia
Prognosis:
It depends upon stage of disease
Stage of synovitis stage of early stage of advanced
treatment arthritis: treatment arthritis: treatment
Excellent ROM Good ROM Arthrodesis in functional
good prognosis
fair prognosis position
20. Clinical Features:
Symptoms: Gradual onset
Younger age group usually 10-25 yrs
Pain & swelling
In later stages stiffness & deformity
Signs:
A. Swelling: due to
a. Synovial hypertophy
b. Synovial effusion
B Muscle atrophy: usually due to disease
C. Regional lymphadenopathy
D. Deformity:
a. Flexion
I. Due to synovial effusion
II. Muscle spasm.
b. Triple displacement due to ligament laxity.
E. Cold abscesses & sinus formation.
F. Movements: Earlier restriction is due to muscle spasm, later restriction is due to secondary
arthritis.
Radiographic Changes: Typical radiographic changes as noted in osteoarticular TB can be
observed.
Differential Diagnosis: Other Mono-Articular affections must be differentiated e.g.
- Rheumatic arthritis (in children)
- Chronic traumatic synovitis as in Internal Derangement of knee
Rheumatoid arthritis
Subacute pyogenic arthritis
Haemoarthrosis
Dysenteric arthritis
Villonodular synovitis
Synovial chondromatosis
Synovioma
Haematoma.
Treatment:
Aim: To achieve, whenever possible, a painless mobile joint
Methods:
Methods
Conservative Surgical
- Medication
- Splintage
- Physiotherapy
21. Diagnostic Curative
Arthroscopic/ open - Synoviectomy
Synovial Biopsy - Joint
Synovial Aspiration debridement
- Arthrodesis
Treatment plan for TB Knee:
T.B. knee
Stage I & II Stage 3 & 4
Traction + AKT Traction + AKT
Mobilization
Reasonable Reasonable
joint possible joint not
Possible
Pop immobilization surgical
arthrodesis
Fibrous Ankylosis
Individual Techniques:
A. Synoviectomy: it can be done by 2 methods
a. Open synoviectomy
b. Arthroscopic synoviectomy
Indications:
a. Plain synoviectomy in stage I knee TB.
b. Synoviectomy & joint debridement in stage 2 knee TB.
B. Joint debridement: Done in stage 2 knee TB whereby pus is drained, synovium tissue excised,
cavities curetted.
C. Arthrodesis: Done in functional position of 5-10 of flexion & neutral rotation in stage 3 arthritis
not responding to conservative treatment.
Methods used:
1. Charnley's compression arthrodesis
2. Intramedullary nail from femur to tibia.
3. Ilizarov apparatus.
4. Internal fixation using plates or steinmann crossed pins.
3.12 INTERNAL DERANGEMENT OF KNEE JOINT (I.D.K)
The term internal derangement originally coined by William Hey (1784) is loosely used to describe
the abnormalities in the knee functions due to any cause, but mostly traumatic.
These include the following:
Articular Proper Lesion:
1. Bony Lesion
a. Sliced fracture of articular cartilage.
b. Epiphyseal fracture
22. c. Condylar fracture
- Tibial
- Femoral
d. Tibial spine fracture or avulsion
e. Bony loose bodies
f. Chondromalacia patellae
g. Osteochondritis dessicans
h. Chondrocalcinosis
i. Osgood schlatter’s disease
j. Pellegrini steida’s disease
k. Sinding -Larsen- Johansson’s disease
l. Traction osteochondritis of lower pole of patella
m. Recurrent subluxation / dislocation of patella
Soft Tissue Lesion:
a. Meniscal Lesions: tear, cyst, discoid meniscus
b. Cruciate tear or avulsion: ACL or PCL injuries
c. Synovial folds entrapment
d. Nipping of intrapatellar pad of fat; hoffa's
disease
e. Loose bodies: fibrous loose bodies
- Cartilaginous loose bodies
- Synovial chondrocalcinosis
Walls Of The Joint:
Lesions of the capsule with its reinforcing ligaments
Avulsion or rupture of
Collateral ligament
Oblique ligament
Quadriceps expansion
Accurate ligaments.
Quadriceps Apparatus Lesions:
Quadriceps tendon rupture
Fracture of patella
Avulsion or rupture of ligamentum patella
Avulsion/ fracture of tibial tuberosity
Clinical Presentation Of IDK: These include
1. History of trauma (usually twisting or rotational)
2. Immediate pain
3. Swelling
4. Slight flexion of knee
5. Inability or disability in bearing weight
6. History of locking or giving away (instability)
7. Other associated features of etiological condition.
Investigations in suspected IDK:
a. Arthroscopy
b. Arthrography: It is gradually being displaced by arthroscopy
c. Examination under anesthesia: It is specially useful in tense swellings & painful muscle
spasms.
d. Provocative Exercises: Specially useful in doubtful meniscal lesions. It is aimed at stressing
the menisci by applying torsional stress to the weight-bearing knee. In damaged meniscus,
the exercise is followed by localized pain, swelling & sometimes locking.
3.13 OSGOOD SCHLATTER DISEASE:
23. It is a painful disabling swelling about the tibial tubercle occurring in adolescents.
Etiology
Repeated trauma
Friction
Children about the rapid growth period of puberty
particularly boys are predisposed
It may be bilateral
Pathology:
Partial separation or failure of fusion of tubercle- epiphysis
With the main epiphysis may occur due to trauma
Obliteration of blood supply
Aseptic necrosis
Typical pathological changes of osteochondritis can be seen
Clinical Picture: Patient presents with pain, tenderness and soft tissue swelling without
inflammatory signs at tibial tubercle, kneeling is painful. Active extension of knee against resistance
is painful. The symptoms usually subside at 15 yrs of age when the apophysis fuses to the main bone.
X-Rays Findings: The tibial tubercle consists of multiple fragmented appearing areas of ossification
that are dense in contrast to underlying osteoporotic area in the main bone. The soft tissue anterior to
the tubercle are swollen.
D/D: In complete avulsion of the tubercle, the ossification center is displaced upward.
Treatment:
Conservative: Ice packs
NSAIDS
Ultrasonic therapy
Pop cylindrical cast immobilization
Surgical:
Surgical Options
Local steroid Multiple drill Bone peg
injection holes technique inserted thro the
tubercle
Surgical excision of persisting
Fragment (must be avoided to prevent
Premature epiphyseal plate closure)
Treatment Protocol:
Pain in tibial tubercle area with focal tenderness in adolescent
X-rays –AP & lateral projections
To rule out other bony lesion (e.g. osteosarcoma,
soft tissue lesion, tuberosity avulsion)
OSGOOD SCHLATTER DISEASE
24. Mild enlargement Moderate enlargement Marked enlargement
Few symptoms Moderate symptoms severe symptoms
Reassurance; resume Restriction of activities, Restrict activities, knee
normal activities knee immobiliser cast, NSAIDS immobiliser cast ,
NSAIDS, USG therapy
Symptoms persist
Local wycort injection
Symptoms resolves
Resume normal
activities
Symptoms persist
Surgery
3.14 LOOSE BODIES IN THE KNEE JOINT:
Loose bodies are common presentations in the joints especially the knee joint.
Types:
Fibrous loose bodies
Cartilaginous loose bodies
Bony/ osseous loose bodies
Etiology:
A. Non Traumatic
1. Osteoarthritis with detached osteophytes
2. Osteochondritis dessicans
3. Synovial chondromatosis
4. Tuberculous arthritis
5. Rheumatoid arthritis
6. Haemophilia
B. Traumatic:
1. Organised hoemarthrosis
2. Organised, snapped synovial fringes
3. Loose fragments of intraarticular fracture
4. Avulsion of articular cartilage
5. Foreign bodies
6. portions of menisci
Clinical Presentations:
Locking in the joint which may get corrected automatically & is followed by synovial
effusion
Some times loose body can be felt in the joint.
X-rays: Most loose bodies are radio opaque & can be detected by plain x-rays, fibrous loose bodies
require arthroscopic diagnosis.
Treatment:
Treatment
Surgical removal
Open surgical Removal Arthroscopic surgical removal
25. Complications: It left unattended, can lead to damage to the articular surfaces.
3.15 CHONDROMALACIA PATELLA:
It is characterized by blistering, fibrillation & cystic change in patellar cartilage mainly involving
medial facet. It is caused by patellofemoral malalignment which may be due to weak vastus medialis,
increase ‘Q’ angle, foot abnormalities, genu valgus etc.
Clinical Features: Anterior knee pain exacerbated on descending down the staircase or while sitting
for a prolonged period (as in cinema hall). Features of chronic synovitis & patellofemoral
malalignment are present. On grinding the patella on femur while flexing the knee pain is produced,
tenderness can also be felt clinically on undersurface of patella.
Stages:
1 Swelling and softening of the cartilage
2 Fissuring within the softened areas.
3 Fasciculation of articular cartilage almost to the level of subchondral bone
4 Destruction of cartilage with subchondral
bone exposed
X-ray Findings: It is better seen in slightly or
overexposed lateral x-ray. Axillary radiograph
helps in determining facet involvement.
Commonly medial facet involved.
Treatment: Rest, activity modification,
physical therapy, realignment of maltracking of
patella using orthotics & arthroscopic shaving of
undersurface of patella.
3.16 RECURRENT DISLOCATION OF PATELLA:
This condition usually occurs following an acute traumatic dislocation of patella which has not
healed properly after an initial injury. The dislocation occurs usually to the lateral side & must be
differentiated from habitual dislocation of patella in which dislocation occurs in each flexion &
extension movements of the knee.
The predisposing factors include:
A. Bony Defects
1. Patella alta
2. Genu valgum
3. Hypoplastic lateral condyle of the femur
4. Femoral anterversion
5. Hypoplastic patella
6. Genu recurvatum
B. Soft Tissue abnormalities
1. Tight lateral retinaculum
2. Lax medial retinaculum
3. Abnormal insertion of vastus medialis
4. Lateral insertion of patellar tendon
5. Atrophy of vastus medialis
6. Hypertrophy of vastus lateralis
7. Generalised joint laxity
Treatment: The results of conservative
treatment is poor, surgery being the treatment of
choice.
3.17 FRACTURES OF PATELLA:
CLASSIFICATION
26. 3.18 UNCOMMON CAUSES OF KNEE PAIN:
A. Bipartite patella: It is a common Incidental x-ray finding. If the superolateral fragment is
mobile it can give rise to pain & tenderness at the junction of two fragments. If pain is
severe, excision of extra fragment is done for getting therapeutic relief.
B. Excessive lateral pressure syndrome: Caused due to tightness of lateral retinaculum,
patient presents with pain on superolateral aspect of patella & retropatellar tenderness.
Arthroscopy shows a normal patella. Pain relief is best obtained by lateral retinacular
release done either arthroscopically or by open release.
C. Fat Pad Syndrome: Retro patellar tendon pain & tenderness may be caused by fat pad
getting caught in tibia-femoral joint. Relief is obtained by rest, NSAIDS & heat therapy.
D. Ilio-Tibial Tract Syndrome: Due to repeated rubbing of ilio-tibial tract on the lateral
femoral condyle, synovium deep to ilio-tibial tract gets inflamed & is painful. Treatment
consists of rest, NSAIDS or steroid injection.
E. Patellar tendinitis: Commonly found in sport players, the tendon may get partially torn or
inflamed at its insertion to patella (Jumpers knee). Treatment comprise of rest, NSAIDS / or
steroid injection.
Sports Related Leg Problems:
A. Shin splint: It is characterized by pain along the medial distal third of tibial shaft caused
due to overuse of tibials anterior or posterior muscle unit. Patient presents with aching
pain after running with tenderness along the involved muscle unit. Treatment comprise of
rest, NSAIDS & contrast baths. Prevention involves warm up, conditioning & stretching
program, avoidance of hard surfaces & SOS orthotic devises to prevent foot from
hyperpronation.
B. Stress Fracture: It mainly involves proximal posteromedial tibia & distal fibula.
C. Exertional Syndrome (Chronic compartment syndrome): It is caused by a transient rise
in compartmental pressure involving anterior or lateral muscular compartment of the leg
as a result of exercise. Patient presents with increasing pain in the anterior or lateral
aspect of the leg with different levels of exercises. Numbness & paraesthesia in the foot
may be present. Diagnosis is confirmed by recording compartmental pressure in excess of
30 mm Hg or a relative increase in pressure by at least 20 mm Hg after exercise.
Treatment involves rest, orthotics, stretching exercises. In non responsive cases
fasciotomy (decompressions) of the compartment may be required.
Common causes of leg pain:
In children:
Osteitis or other infection
Neoplasm
Adolescent:
Neoplasm (osteod osteoma, osteoblastoma, osteosarcoma)
Young Adults:
Stress fracture
Infection (brodie’s abscess)
Anterior compartment syndrome
Shin splints
Adults:
PID & LCS
Vascular deficiency
Paget’s disease
Syphilis
Neoplasm
Foot disorders
Ruptured plantaris tendon
27. Thrombophlebitis & DVT
3.19 LOCKING OF KNEE JOINT:
It is described as inability to complete the last few degrees of extension due to soft tissue or bony
block.
Locking of the knee
Springy block Rigid block
Meniscal tear - Loose bodies
- Fixed flexion deformity
3.20 CAUSES OF HEMARTHROSIS:
1. Trauma:
Injury with or without fracture
Iatrogenic
2. Tumors:
Pigmented villonodular synovitis
Haemangioma
Secondary metastasis
3. Bleeding disorder:
Haemophilia type A, B & C
Certain drugs such as thrombolytic therapy
4. Connective tissue disorders:
Pseudoxanthoma elasticum
Pigmented villonodular synovitis
5. Miscellaneous:
Scurvy
Acute septic arthritis
Charcot’s joint
Goucher’s disease
AV fistula or ruptured aneurysm
Haemoglobinopathies (i.e. sickle cell disease)
Clinical Presentation of Haemophilic Knee:
Family history
Previous such episodes
Patient pale, history of bleeding from other sides will be available
History of prolonged bleeding after any cut.
Patient have swollen, warm knee with flexion deformity
Advanced cases may have varus/ valgus deformity & sometimes ankylosis
No lymphadenopathy noted.
3.21 STIFFNESS IN THE JOINT:
Limitation of movements can be
a. In all directions - Due to arthritis
b. Not in all directions - Due to synovitis &/or spasm of muscle
28. c. Fixed movement in - Due to fixed deformity
one or more directions
Index 3.7 Types of joint stiffness:
Extraarticular Intraarticular
1 Biological factors like scar adhesion No obvious scar adhesion, sinus
Sinus or contracted tissue can be seen or contracted tissue can be seen.
2 Joint line tenderness is usually absent Present
3 Whatever range of motion possible is Possible movements are usually
usually painless painful
4 X-Rays are usually normal Joint space is reduced, joint
margins fluffy,osteoporosis is
usually present. Evidence of
Underlying pathology may be
present.
5 Extraarticular release improves the Extraarticular release usually not
the movements dramatically helpful
6 Manipulation under anesthesia does not It may help.
Improve range
Knee joint stiffness
Clinical examination
Mechanical block No evident mechanical block
Flexion Extension pain absent pain causing ROM
contracture contracture
Exercises
Exercises
Non-inflammatory inflammatory
? internal derangement
Effective Ineffective
- Medication
Continue serial casting Arthroscopy - physical therapy
Effective Not effective
Physical therapy
Resume Arthrolysis if no relief
Exercises including
Release of
Posterior capsule Recent onset Long duration
& hamstrings
Manipulation Quadricepsplasty
No relief
29. Effective
Exercise
3.22 CLINICAL PRESENTATION OF MENISCUS TEAR:
Patient usually presents with history of rotational injury in weight bearing & partially flexed knee.
There is history of immediate pain, mild swelling & inability to extend the knee immediately. Full
passive ROM is possible, terminal active flexion is painful. McMurry test or Apley’s grinding test is
positive. Maximum tenderness is noted in the joint line approximately at the middle of medial
compartment.
3.23 CLINICAL PRESENTATION OF GCT AROUND KNEE:
It may involve upper end of tibia or lowest end of femur in 3rd decade. It is an eccentric, tender
swelling which may yield on pressure (egg shell crackling) with knee joint motion preserved for long
time. Diagnosis is confirmed radiologically & by biopsy.
3.24 COMMON TUMOR/ TUMOR LIKE LESIONS:
A. Benign tumor-like lesion involving joints:
1 Pigmented villonodular synovitis
2 Synovial osteochondromatosis
3 Chondroma: It is an isolated cartilaginous mass mainly involving knee
4 Osteoid osteoma
5 Lipoma may involve joint capsule or synovium
6 Hemangiomas are characterized by recurrent episodes of hemarthrosis mainly involving knee
joints of children & young adults.
B. Malignant Tumors:
1 Synovial sarcoma
2 Synovial osteochondrosarcoma
3 Metastatic carcinoma (commonly from lung or breast cancer)
4 Lymphoma/ myeloma
5 Leukemic infiltration
6 Contiguous spread of adjacent bone sarcoma
3.25 IMPORTANT TERMINOLOGIES RELATED TO SPORTS INJURIES
Swimmer’s Knee: Knee pain occurring due to medial collateral ligament stress caused due to valgus
stress placed on the knee while swimming the breast stroke
Jumper’s Knee: patellar tendinitis occurring due to repetitive stresses in high jumpers & volleyball
or basketball player results in pain at the inferior pole of patella at its attachment to the patellar
tendon known as jumpers knee
Runners Knee (Patellofemoral Syndrome): Pain occurring in runners due to compression of nerve
fibers in the subchondral bone of the patella or from a synovitis
Sinding Larsen – Johansson Disease: It is caused by persistent traction at the cartilaginous junction
of patella & patellar ligament at inferior patellar pole leading to anterior knee pain with activity in
adolescent boys.
Clinically one can feel tenderness at inferior pole of patella with x-rays sometimes showing varying
amount of calcification or ossification at the junction. There is sclerosis, decalcification &
fragmentation of inferior pole of patella
D/D: It includes
1 Pediatric patella avulsion fracture
2 Patellar stress fracture
3 Bipartite patella
4 Osgood schlatter’s disease
5 Jumpers knee (which is a degeneration of patellar tendon).
30. Treatment: It includes rest, ice therapy, USG therapy, NSAIDS, quadriceps strengthening exercises,
SOS immobilisation
Pellegrini - Steida’s Disease: It is caused by incomplete rupture of the medial collateral ligament at
its femoral attachment followed by calcification. It results in localised pain & tenderness in the
region.
3.26 ARTHROSCOPY OF KNEE JOINT:
Arthroscopy refers to visualization of interior of a joint. “Endoscopy” means to see within referring
to a body cavity
Common Sites Where Commonly Arthroscopy Is Done:
Knee
Ankle
Shoulder
Hip Joint
Instrument (The Arthroscope): It consists of a trocar
through which a telescope is inserted into the joint. At
the external end the telescope terminates in an eyepiece;
at the internal end in an electrical light bulb, back of
which is the lens. The trocar is equipped with two stop-
cocks for distension & irrigation of the joint.
Arthroscope Obliquity: This depends upon angle of
the end of the optical tube of the arthroscopic to the
tube. This angle is normally 25-30 & it alters the field
of view by that many degrees from the axis of the optical tube.
Functions Of An Arthroscope:
1 Sweeping: Side to side or up & down movement to see objects or anatomic areas.
2 Pistoning: Moving the tip of the arthroscope closer to an object to magnify it & decrease the
field of vision, or moving away from an object to decrease the magnification but increase the
field of vision.
3 Rotation: Turning the arthroscope about a 360 are because the tip of arthroscope is usually
angled, this rotation increases the field of view due to the obliquity of the tip cut.
4 Triangulation: using sweeping, pistoning & rotation to place an object in the direct field of
vision of the arthroscope through an adjacent portal.
Portal: Portals are small cut down incisions placed to access specific anatomic areas & avoid vital
structures.
Basics Steps Of Arthroscopy:
1 Anesthesia: Routinely spinal preferred,
but sometimes general or local
anesthesia can be used.
2 Skin incision & opening of the capsule
using stab knife
3 Insertion of trocar
4 Collection of synovial fluid
5 Irrigation of joint to achieve distension
6 Introduction of the telescope
7 Inspection of the joint in a systemic
manner.
8 Removal of specimen for pathological
examination
9 Flushing of joint & closure of the
wound
Indications for knee Aarthroscopy :-
31. 1. Injuries : ALC tear, meniscal tear, cartilage injuries.
2. Recurrent effusions.
3. Locking of joint.
4. Chronic synovitis.
5. Haemarthrosis : for evacuation of blood and diagnosis of possible etiology.
6. Knee pain of unknown cause.
Advantage of Athroscopic surgery :-
1. Very low morbidity and complication rate.
2. Can be done as an outpatient procedure or short indoor procedure.
3. Cosmetically excellent.
4. Short recovery time.
5. No disturbance of any sensory supply.
6. Associated injuries may also be treated.
7. Hard to reach regions such as posterior horn of meniscus may be visualized.
Complications of Arthroscopy:
1 Infection.
2 Vascular or nerve injury: Nerve injury is mainly due to prolonged tourniquet time.
3 Chronic persistent synovitis.
4 Haemarthrosis.
5 Persistent drainage with synovial fistula.
6 Deep venous thrombosis.
3.27 OSETOCHONDRITIS DESSICANS :-
This localized condition affects articular surface involving separation of cartilage and subchondral
bone.
Etiology :- There are various theories proposed :
1. Ischaemia
2. Trauma.
3. Abnormalities of epiphyseal ossification.
4. Metabolic factor.
5. Hereditary factor.
6. Anatomical variation.
Incidence :- More common in males ( M : F 3:1). Bilateral occurrence is around 30 percent. It
is most commonly seen in adolescents.
Clinical features :- Anterior knee pain.
Features of loose bodies in joints.
History :-
- A vague pain with history of clicking or popping.
- Swelling and stiffness may be present.
- Symptoms may be associated with activities.
- Features of locking may occur due to loose bodies.
- Long standing cases may have features of arthritis.
- Giving away may occur secondary to weakness of quadriceps mass..
Examination :-
- Synovial effusion.
- Quadriceps wasting.
- Joint line tenderness.
- Restricted range of motion.
- Palpable loose bodies.
- Positive Wilson’s test.
Investigations :- These include X-rays / MRI. Bone scans are useful in monitoring healing
process.
Differential Diagnosis :- Other causes of anterior knee pain must be ruled out.
32. 1. Osteoarthritis.
2. Chondral fracture.
3. Meniscal tear.
4. Synovial osteochondromatosis.
Grading of Lesion :-
Grade 1 : Detected on X-ray with articular surface intact.
Grade 2 : On arthroscopy articular injury seen.
Grade 3 : Lesion separates from rest of the bone.
Grade 4 : Loose fragment within joint.
Treatment :-
Severity of loose body
Grade I and II Grade III Grade IV
3 – 6 months of non operative Pinning Drilling of defect for revascularisation
trial using restricted motion screw fixation pinning
and axillary crutches. Screw fixation
excision of loose fragments
osteochondral autograft transplantation
3.28 RADIOGRAPHIC EXAMINATION OF KNEE JOINT:
It includes AP, lateral, axilla view & tunnel view in skeletally immature patient.
AP View: This view is taken with patient in supine position, knee extended & leg in neutral position.
Central beam should be directed vertically with 5 to 7 cephalic tilt.
One can visualize:
Femoral/ tibial angle
Medial & lateral compartment space
Size, position & integrity of patella
Axilla View of the knee: It profiles the patellofemoral joint, one can visualize patellar tilt, patellar
subluxation & sulcus angle.
Method: These x-rays are taken of both knees together (for comparison) in a knee flexion between
20 to 45.Any flexion more than 45 will mask patellofemoral anamolies.
Types:
Laurin Technique: The axial view taken in 20 of flexion is used to measure lateral patellofemoral
angle which gives an idea of an abnormal tilt. The angle formed by lateral patellar facet & line drawn
across most prominent aspect of anterior portion of femoral trochlea normally opens laterally.
Stress Axila View: Here knee is flexed to 35 at the end of x-rays table & a constant pressure is
exerted at the patella in an attempt to displace it laterally. The symptomatic & asymptomatic knees
are compared.
Sunrise View: The tangential view of patella is taken with the patient prone & knee flexed to 115.
The central beam is directed towards the patella with 15 cephalic tilt.
Merchant’s View: This view is taken with the knee flexed to 45 at the table’s edge with patient in
supine position. The cassette is held perpendicular to the tibia at a distance of 10cms from knee level.
The central beam is directed caudally through patella with 60 angle from vertical or 30 angle from
horizontal.
33. Method of measurement:
Step I. First sulcus angle is drawn as a zero reference line (It is the angle formed between the 2
femoral condyle & is around 141)
Step II. A line is drawn bisecting the sulcus angle
Step III. Second line is projected from the lowest point of articular ridge of patella to apex of sulcus
Step IV. Angle formed between 2 lines is measured (congruence angle). If the congruence angle is
lateral to congruence line the angle is positive, if it is medial to congruence line it is
negative. Normal angle is less than -16 (males -6 & females -10 normally)
Lateral X-rays: Patient lies flat on the affected side with the knee flexed 25-30. The central beam
is directed toward the medial aspect of knee joint with 5-7 of cephalic tilt.
It helps in detecting
a. Patellar height
b. Fabella lesions
c. Evaluation of fat density zone
Fat Density Zone: The suprapatellar pad of fat is seen as fat density zone behind the quadriceps. In
joint effusions it is displaced anteriorly.
Fabella: Seen in 10 to 20% of individuals, it is seen embedded in lateral head of gastrocnemius.
Patellar height: 2 methods of measurement:
Insall & Salvati Method: In this method ratio of length of patella & length of patellar tendon is
measured. A ratio less than 1 indicated patella alta. The length of tendon is measure on its posterior
surface from the lower pole of patella to its insertion on top of tibial tubercle. Length of patella is the
greatest diagonal length of patella measured.
Blackburne & Peel Method: It is the ratio between perpendicular distance from lower articular
margin of patella to tibial plateau (A) & the length of articular surface of patella (B)
Tunnel Radiograph of Knee: It provides an angled PA projection of knee. Patient is prone with
knee flexed at 40. The central beam is directed caudally toward the knee joint at a 40 angle from
the vertical. It gives a good profile of intercondylar notch & posterosuperior articular surfaces of
femoral condyle. It is specially useful in detecting osteochondritis dissecans.
Rosenburg View For OA Knee: This view is used to evaluate for narrowing of the cartilage space
in posteroanterior flexion weight bearing radiograph. The film has anterior margin of tibial plateau
superimposed on the posterior margin
Method: Patient stands with knees flexed at 45, weight equally distributed on both extremities,
patella touching the cassette & toes pointing straight forward. The x-ray machine is 40 inches from
the cassette & central beam is directed at inferior pole of patella with 10 caudal tilt. Narrowing of
cartilage space of more than 2 mm is indicative of major degeneration (Grade III or IV)
34. Fracture Patella Osteomyelitis lower end Total knee replacement
with tension of femur
band wiring
Unicondylar knee replacement Complete PCL tear
