Anatomy, Pathology & Treatment of the Knee Joint

Knee Anatomy

The knee joint actually comprises of two joints. The tibiofemoral joint is the connection between the tibia (lower leg) and femur (upper leg). The other joint is the connection between the kneecap and the femur known as the patellofemoral joint.

The knee joint is known as a synovial joint meaning that the bones are not in direct contact due to the presence a synovial fluid filled joint capsule. Synovial joints allow greater mobility compared with other joints such as fibrous and cartilaginous joints. Unfortunately, this feature is also the reason why synovial joints are more prone to injury and wear and tear.

Within the knee joint there are two types of cartilage, articular and fibrocartilage. Articular cartilage is very smooth and coats the end of the bones allowing them to glide past one another with minimal friction during movement. Fibrocartilage is the second type and is what the meniscus is made of within the knee. The meniscus are two semi-circular rings of cartilage that act as shock absorbers during weight bearing activities.

The knee is stabilised by both muscles and ligaments. The main ligaments that stabilise the knee are;

• Anterior cruciate ligament
• Posterior cruciate ligament
• Lateral collateral ligament
• Medial collateral ligament
  

There are many muscles that stabilise the knee. The first that spring to mind are usually the quadriceps (front) and the hamstring (back) muscles however the understanding that muscles in the lower leg towards the ankle and muscles in the upper leg towards the hip also have a role in stabilising the knee is crucial when trying to improve stability of the knee through rehabilitation.

The knee is known as a hinge joint meaning that its main movement is bending (flexion) and straightening (extension). The normal range of movement of the knee joint is 140 degrees. There is also the ability for the knee to rotate in and out (internal and external rotation) when the knee is bent however this is not its primary movement.

Common Pathology of the knee

Osteoarthritis

Osteoarthritis is a general term used to describe any degree of wear and tear within a joint. The cartilage within the joint can become less efficient over time and therefore less able to take stress that is being placed on it.

People often get concerned about a ‘diagnosis of osteoarthritis’ however most adults have some degree of wear and tear in their joints without there being any associated symptoms. In almost all situations physiotherapy will be the first line of treatment in dealing with osteoarthritis of the knee.

In most cases symptoms can be significantly improved by building the strength and stability of the knee through rehabilitation and a referral to an orthopaedic surgeon is not required.  

Meniscus tear

The two rings of fibrocartilage within the knee joint can sometimes tear through trauma, usually a twisting injury, or through normal wear and tear. The meniscus can struggle to heal due to its poor blood supply however outcomes after meniscus injuries are mostly very good.

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A ‘degenerative tear’ more often occurs in the older population and can be due to the fact that the cartilage is thinner than in the younger population. These tears are either managed with physiotherapy or with surgery known as an arthroscopy where the meniscus is debrided; a process where the surgeon smooths or trims the affected area.

Tears can occur in the younger population and is often associated with significant trauma such as a football or skiing injury. These are sometimes surgically repaired (stitched back together) which is then followed by a course of physiotherapy.

Ligament injury

Ligament injuries are almost always traumatic. They do not tend to wear with time due to the fact they are not within the actual joint and act as joint stabilisers rather than shock absorbers.

The anterior cruciate ligament (ACL) can be ruptured during certain sporting activities and mostly requires surgery where a repair is done by taking a graft of a tendon from the hamstring. An ACL repair requires a lengthy time period of physiotherapy rehabilitation (6-9 months) however a return to full function and sporting activities is expected.

The posterior cruciate ligament is very rarely injured except in extreme trauma.

The medial and lateral collateral ligaments are reasonably common but rarely require surgical repair.

They are categorised into three types of injury;

• Grade 1 - Mild injury with minimal torn fibres and no joint laxity
• Grade 2 – Moderate injury with a partial tear and moderate joint laxity
• Grade 3 – Severe injury with a complete tear and significant joint instability

Physiotherapy rehabilitation can help to resolve injuries to these collateral ligaments in almost all scenarios.

Patellar Tendinopathy

The patellar tendon is located at the front of the knee and connects the kneecap (patella) or the shin (tibia). A tendinopathy can occur when the load placed through the tendon exceeds the load capacity of that tendon.

This can occur in an elite level runner if they suddenly increase the intensity of their training or it can occur in an elderly person if they suddenly spend the weekend gardening after a month of rain. In both scenarios the load placed on the tendon is more that it is used to or is able to cope with and therefore the tendon can become painful or tendinopathic.

Notice that we are not using the term tendonitis here. Tendonitis implies that inflammation is present however we now understand that inflammation is not present in this condition and is the main reason why ice, anti-inflammatories and rest do not cause long term improvements.

The treatment for any tendinopathy is to improve the ability for the tendon to take load and can be done through a series of certain exercises provided by a physiotherapist.

Iliotibial band syndrome aka Runners’ Knee

The iliotibial band (ITB) is a structure that travels down the side of the leg and attaches onto the tibia.

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As you bend and straighten the knee the band moves in front and then behind the bony prominence at the outside of your knee.

The ITB can become irritated during activities such as running and hill walking and can make normal activities like walking up and down stairs or getting up off a chair very difficult.

Contributing factors for ITB irritation include over pronated feet, weak hip muscles, tight upper and lower leg muscles and weak core.

A physiotherapist will be able to assess for these factors and more to ensure you have a tailored rehabilitation plan.  

Treatment

The White House Clinic is much more than just a regular physiotherapy clinic. We have the ability to facilitate any intervention that is needed to help manage and rehabilitate any type of knee injury or issue. The information below outlines all of the services available at the clinic.

Physiotherapy assessment and treatment

We have a group of highly experienced physiotherapists who will be able to provide a thorough assessment and diagnosis of your knee issue. Following this they will be able to provide you with the most evidence-based treatment to ensure improvement and hopefully resolution of your symptoms.

In the case where further investigations or treatment is required, they have the knowledge base and contacts to make sure the appropriate onward referrals are made with minimal waiting times.

State-of-the-art gym and rehabilitation facilities

Our clinic is equipped with both a gym and a studio both filled with modern equipment enabling our physiotherapists have the facilities to provide the best rehabilitation available.

Rapid access to investigative and scanning facilities

If you require further investigation such as an x-ray or MRI scan, we have the clinical pathways to refer you quickly. Many knee issues can be assessed with an ultrasound scan which we are able to perform in house with no waiting list.

Corticosteroid injections

In certain situations, an anti-inflammatory, pain relieving injection known as a corticosteroid injection is used in the management of knee pain. We are able to provide these injections on site.

Ossur and Medi knee braces

Knee braces can be a very useful adjunct to physiotherapy treatment in the management of knee issues. Your physiotherapist will be able to guide you through the process of selecting the correct knee brace for you if this is required.

Ossur ‘Unloader’ knee braces are regarded as the best on the market. They can be used to effectively ‘off-load’ osteoarthritic changes in the knee, providing pain relief and allowing for improved function. Using one of these braces can be a great conservative way to manage your knee pain and even prevent your need for surgery.

Even if you have been told you require surgery these braces are useful to provide relief whilst you are on a waiting list for an operation.

We are the only registered ‘Ossur knee brace fitting centre’ in the region and are able to arrange next day delivery for their products, as well as knee bracing/support products from Medi.

Direct referral links to the top orthopaedic specialists in the area

We have long standing professional relationships with the top orthopaedic specialists in the area so in the scenario where an orthopaedic referral, possibly leading to surgery, is required we are able to refer swiftly and directly.

Pre-operative and Post-operative rehabilitation

We have a vast amount of experience in dealing with patients before and after knee surgery with many of the local hospitals referring a large variety of surgical cases to us.

Prior to surgery it is best practice to optimise the range of movement and strength of the knee joint which will allow for a quicker recovery after surgery

After surgery there is a surgical protocol that is followed. Our physiotherapists will be able to guide you through this protocol to ensure optimal recovery is achieved.

Summary

At the White House Clinic we are able to help you with any form of knee issue at any stage of the process to recovery.

The knee joint can be a source of pain and decreased function for many people however there is almost never a situation where you ‘just have to live with it’.

If you have any questions about your knee or any of the services that we provide then get it contact with us today and we will be happy to help.

Please refer to the ‘Hip and Knee Service’ section on our website for more information regarding the treatments covered in this article.