We're gonna talk about the knees.
Knees are an interesting joint,
part of the lower extremity
and difficult to manipulate because you don't
have lots of tools in your armamentarium.
What you do have is a lot of
patients who have problems.
So understanding the bomechanics,
understanding the history
and witnessing and predicting what's gonna
happen to the knee, is often all you can do.
So we're gonna talk about the knee itself- what makes
it up and what we can do and where we can focus
So starting with the anatomy,
the knee is an interesting joint.
it's basically the femur with two
grooves with the patella in between
with a whole bunch of articulations held
together by ligaments, bursa and muscles.
When you look at the
articulatons, it's a hinge joint.
You have the tibiofemoral articulation, patellofemoral
articulation, and the tibiofibular articulation.
And the tibia and the fibula
are interesting bones.
Fibula is the flat one anteriorly
and the tibia is the lateral bone
that we used to say was only
for muscular attachment,
we're not sure fully what the tibia's role is, what
we do know it does help wth some of the motion,
some of the gliding of
the knee and it's important.
We're gonna talk a lot about the
menisci - the medial and lateral menisci
Those are the shock
absorbers of the knee.
Those are the pads that displace the
energy so that when you're walking,
your pain is not gonna be pinched,
your pressure is not gonna be focused -
it's gonna be splayed, displaced and allow you
to use your whole knee and your whole foot area.
And we'll discuss the bursa.
The bursa are the little pockets that have
synovial fluids in it that will swell with overuse
and give you a sense of what's going on.
So take a look at the picture here again, assess
the innonimate, use your own body as a model.
and work on understanding the
bones, the muscles and the ligaments
that are going to explain where
you're going to have problems.
Again the bones are easy, we have the femur
superiorly, we have the tibia which is a flat bone
and the patella which is a sesamoid
bone - it's a bone with no ligament
and the fibula which comes down
on the lateral aspect of the leg.
The muscles and fascia are there,
the quadriceps are the ones you're
we're going to be focusing on the most,
the ones that are going to extend the knee, and the
quadriceps vastus, medials, lateralis and intermedius.
as well as the rectus femoris.
So the muscle and fascia are important.
you have the flexors and
extensors, you have the quadriceps
and hamstrings in the
back causing the flexion.
And then we'll talk
about the ligaments:
the anterior cruciate and posterior cruciate
ligaments that keep the knees stable,
and the medial collateral and lateral
collateral that also keep the knee in place.
So that's the four ligaments we'll
talk about that are often injured
and need to be paid attention
to and often tested for.
In terms of the joints within the articular
capsule, you have the tibiofemoral joint
and the patellofemoral joint that are
going to help with the hinge motion
and you have the superior fibulotibular
joint in the knee as well.
It is a modified hinge joint,
there's flexion and extenson of the knee,
when there is instability, you're gonna have more
motion to the sides which we try and restrict.
There's some rotation possible as
you noticed when you go side to side,
and as you do get some rotation of the knee, and
you're gonna have more rotation when it's flexed,
which is also any more
likely to injure the knee
because of the access of the
muscles and the loss of protection.
The menisci again, allow for stability of the
joint, they're deep in the tibial plateau,
they give you a subtance that will displace
energy and force when you're walking,
they will allow for smoothness of
functioning by decreasing friction,
and increases the contact area
for the femur and absorb shock.
We talked about the medial and lateral
menisci, we also know how much vascularity
it has in each portion, separating into the anterior,
middle and posterior portions of the menisci,
and the more blood supply you have, the more
likely the menisci can heal on their own.
If you don't have much blood supply, and you do
injure it - it's going to be a tough injury,
and it's not gonna be something that's
gonna heal quickly or easier on its own
and often surgical
intervention is suggested.
If you do remove the menisci
because of injury or trauma,
it doesn't stop you from
having normal function,
but it does limit the amount of
time you can have normal function
and increases the likelihood or
possibility of having swelling
or other abnormalities
occur from use of the knees
It will also lead to an increased wear
and tear on the articular surfaces,
and increase the risk of developing
degenerative joint disease later on in life.
So the patella is the largest
sesamoid bone in the body,
it floats in the quadriceps tendon, and the quadriceps
are the four muscles that will extend the knee,
the patella will slide vertically along
the ridges of the femoral condyles,
and it does have an articulation,
so it's a fulcrum and it helps with motion,
it helps with stabilty and it gives you the
strength to move the leg harder and stronger.
It does also have other motions in the patella -it
moves side to side, and give you some freedom.
The ligaments, there are four
ligaments holding the knee together -
the anterior cruciate ligament which will
prevent anterior displacement of the tibia
and prevents hyperextension of the knee.
Occasionally, you'll see people who
will extend greater than 180 degrees,
there's some ligamentous laxity
on occasion, and that can occur
but the anterior cruciate ligament
keeps it strong, keeps it stable,
and prevents overextension
and stabilizes the knee.
The posterior cruciate ligament will prevent
posterior displacement of the tibia,
and hyperflexion of the knee.
The medial collateral are the deep fibers
that are attached to the medial meniscus,
and keep the knee stabilized
and the lateral collateral does
not attach to the lateral meniscus
but it attaches to the fibula so
it does bring the fibula into motion
Why are we talking about ligaments and
muscles in osteopathic medicine lecture?
because people will complain of
pain, people have trouble functioning
and it's important to know when to
use flexion, when to use extension
and how you use knee motion to both affect one
joint above the hip and one joint below the ankle,
So those are important concepts.
Bursa are the little pockets with synovial fluid,
they have serous membranes that will secrete
a lubricating fluid that eases motion.
they're found in locations where
you have fricton and motion.
They swell up with more use,
they shrink up with less use
and allows the structures
of the knee to move freely
and it's also a warning sign when you
overuse a joint or misuse a joint.
If you have an unstable or a deviated
knee, the bursa in that area will swell up.
You will also have increased bony
deposition in areas of greater friction,
Wolff's law - pressure is gonna increase
bony formation, is affected by the bursa,
The bursa gives you a little bit of leeway in that
you're not always having the bone on bone friction
causing bony growth, you're having some
bursa some fluid, some area of separation.
When you walk, the bursa will
also affect limitations of motion,
and it's important to know what's possible
when you're walking, you need to be
able to move from 0 to 60 to 70 degrees,
when you're climbing stairs, you need to be able to get
to 80 degrees of motion of the knee to get upstairs,
when you're going downstairs,
you need to get to 90 degrees of motion,
stting down you want to be able to
flex the knee a little bit past 90,
so 90 to 95 is usually gonna be comfortable
stting on a chair or on a couch,
In order to tie your shoe, you need to be
able to flex it to a 100 or 110 degrees,
that's why a lot of people will
lose the ability to tie a shoe
before they lose the ability to walk up
and downstars, or have trouble sitting,
and lifting objects often takes
greater flexion - up to a 120 degrees.
So you're gonna lose your ability
to lift objects comfortably
and you need to be off
balanced lifting objects
using other muscles and pulling skeleton in
other ways in order to stabilize yourself
using a wider gait, using your arms and starting
to develop dfferent centers of gravity.
So even though this is the knee
that's having the limitation,
it affects the functioning
of the whole body.
In assesssing the knee, you always look at the
tibia and femur in relaton to each other.
So tibial dysfunctions are actually
pretty common - tough to treat
and people usually dont think
of it as an osteopathic issue,
they think of it as orthopedic
issue and a bony issue.
The dysfunctions that we treat osteopathically are
typically distal tibia and distal fibula, not the proximal
A tibial dysfunction can be when you have the tibia
ABducted or ADducted or it goes anterior or posterior
Again the tibial dysfunctions we can
treat are going to be the distal ones.
And it's usually accessed by
sliding the tibia laterally,
pushing it away from the body
or medially and anteriorly.
Typically, I push it more laterally
and treat the tibia that way.
In terms of the fibular dysfunction, you can
have an anterior or posterior fibular head
and as the distal fibular
head close to the ankle
and it's usually asessed by sliding
the fibula anteriorly or posteriorly.