Lateral Knee Pain

Unhappy Triad

 

I am now into physiotherapy again, awaiting another appointment with a different consultant from Orthopedics for a second opinion... or perhaps not...???

 

For physiotherapy regarding issues relating to my whole leg, eg. foot, knee and groin area, we determined that I should start at my foot. This seemed a good idea because that was where the initial problem started. 

 

ACL Laxity

 

I mentioned to my nhs physiotherapist that I had been told that this might still be a torn ACL. Nobody had mentioned an ACL problem before. He held my knee and tested it physically whilst I was lying on my back. He said that there was some ACL laxity, but 'nowhere near enough to go under the knife'.

 

The MRI report on my knee in 2012 said that the ACL and PCL were intact. Other MRIs have not highlighted any problems, but, as I look at the scans, it does appear to me that the ACL might be damaged. 

 

 

http://radiopaedia.org/articles/anterior-cruciate-ligament-tear

(Dr Yuranga Weerakkody and Dr Frank Gaillard et al.)

O'Donoghue's unhappy triad or terrible triad often occurs in contact sports, such as basketball, football, or rugby, when there is a lateral force applied to the knee while the foot is fixated on the ground. This produces the "pivot shift" mechanism.

The O'Donoghue unhappy triad comprises three types of soft tissue injury that frequently tend to occur simultaneously in knee injuries. O'Donoghue described the injuries as:

• anterior cruciate ligament (ACL) tear

• medial collateral ligament (MCL) tear/sprain

• medial meniscal tear (lateral compartment bone bruise)

The triad has subsequently been revisited, with arthoscopic findings in patients with both ACL and MCL injuries, where lateral meniscal injury is more common than medial meniscal injury 2. Mechanistically this makes sense, as during pivot shift, the lateral tibiofemoral compartment is compressed, causing failure of the lateral meniscus.

 

 

http://www.wheelessonline.com/ortho/anatomy_of_acl

(On website)

Functional Role:    

- ACL is the predominant restraint to anterior tibial displacement;    

- ligament accepts 75 % of anterior force at full extension & approx 85 % at 30 and 90 degrees of flexion;            

- deep MCL is a major secondary restraint to anterior translation;    

- role in gait: (gait menu and role of knee in locomotion)           

- ACL is taut in full knee extension, and tends to externally rotate tibia;            

- tension in ACL is least at 40 to 50 deg of knee flexion;            

- as knee moves from flexion to extension, shorter, more highly curved lateral condyle exhausts its articular surface & is checked by ACL;            

- larger and less curved medial condyle continues its forward roll and skids backward, assisted by tightening of PCL;            

- towards full extension there is lateral rotation of tibia & joint is "screwed home;"            

- consequences of ACL deficient knee                   

- absence of the normal internal rotation of the femur during the terminal swing phase 

 

 

 

 

 

https://en.wikipedia.org/wiki/Biceps_femoris_muscle

 

 

http://www.ncbi.nlm.nih.gov/pubmed/9240975

The fibular collateral ligament-biceps femoris bursa. An anatomic study.

(1997)

The anatomy of the fibular collateral ligament-biceps femoris bursa is described. The bursa is located lateral to the distal quarter of the fibular collateral ligament and forms an inverted "J" shape around the anterior and anteromedial portions of the ligament. Its most distal margin is just proximal to the fibular head where the fibular collateral ligament inserts, and its more proximal aspect is at the superior edge of the anterior arm of the long head of the biceps femoris muscle. We found this structure in all 50 knees dissected; there was a constant anatomic location of the fibular collateral ligament-biceps femoris bursa in all specimens. Measurement of the anatomic dimensions of the bursa revealed a mean width of 8.4 mm and a mean height of 18 mm. Knowing the prevalence, shape, size, and anatomic location of this bursa may aid the clinician in the differential diagnosis of lateral knee pain.

 

 

http://radiopaedia.org/articles/segond-fracture

 

 

http://kinetichealth.ca/resolving-hamstring-injuries/

(Website)

Biceps femoris

Numerous studies have shown that the biceps femoris is the most common site of hamstring injury (myotendinous junction). The biceps femoris has both a long and a short head. The long head originates in the lower pelvis (ischial tuberosity, common tendon of semitendinosis, and lower part of sacrotuberous ligament). It is easy to understand how low back pain can be also be referred from the hamstring with direct fascial attachments that run from the long head of the biceps femoris directly into the sacrotuberous ligament.

The short head originates on the outside and of the leg (posterolateral femur). Both heads insert just below the knee on the lateral side (head of fibula and lateral condyle of tibia).