Chapter 7 Knee and Thigh

The knee is a modified, hinged weight-bearing joint dependent on several structures for stability:

• medial and lateral collateral ligaments to prevent lateral (sideways) shearing movements

• anterior and posterior cruciate ligaments to prevent anterior (forward) and posterior (backwards) displacement during movement

• menisci (two wedge-shaped cartilages) form mechanical spacers to cushion forces, guide movements and add to overall stability.

The patella, while improving the biomechanical efficiency of the quadriceps and protecting the femoral condyles, can often be a source of knee pain.

The knee is frequently injured during sporting activity, especially contact sports, due to several factors:

• heavy weight-bearing demands on the knee during sporting activities

• mechanical disadvantages at extremes of performance, e.g. a relatively weak medial collateral ligament and its attachment to the medial meniscus

• extremes of force as seen in tackling that can lead to severe injuries such as anterior cruciate ligament ruptures.

Correct taping and treatment for knee problems allow the athlete to continue sports participation with minimal risk of sustaining further injury. Taped support assists stability to the injured structure, enhances end-range proprioceptive feedback, and promotes healing by allowing dynamic function.

1. Anterior knee.

Behind the knee on the lateral side, the rounded tendon of biceps femoris (12) can be felt easily, with the broad, strap-like iliotibial tract (17) in front of it, with a furrow between them. On the medial side, two tendons can be felt: the narrow rounded semitendinosus (14) just behind the broader semimembranosus (5). At the front, the patellar ligament (13) keeps the patella (7) at a constant distance from the tibial tuberosity (9), while at the side the adjacent margin of the femoral condyle and tibial plateau can be palpated.

2. Medial knee.

3. Lateral knee.

MUSCLES

1. Quadriceps: rectus femoris

2. Quadriceps: vastus medialis

3. Quadriceps: vastus lateralis

4. Gastrocnemius

5. Semimembranosus

6. Adductor magnus

BONES

7. Patella

8. Margin of lateral condyle of femur

9. Tibial tuberosity

10. Margin of tibial plateau

11. Head of fibula

TENDONS AND LIGAMENTS

12. Biceps femoris

13. Patellar tendon/ligament

14. Semitendinosus

15. Medial collateral ligament

16. Lateral collateral ligament

FASCIA

17. Iliotibial tract

HOLLOWS

18. Popliteal fossa

NERVES

19. Common peroneal

MEDIAL ASPECT OF THE FLEXED KNEE: BONES AND MUSCLES

1. Medial femoral condyle

2. Medial tibial condyle

3. Medial meniscus

4. Sartorius

5. Gracilis

6. Adductor magnus

7. Semimembranosus

8. Semitendinosus

9. Medial collateral ligament

10. Vastus medialis

11. Rectus femoris

LATERAL ASPECT OF THE FLEXED KNEE: BONES AND SOFT TISSUES

1. Lateral femoral condyle

2. Lateral meniscus

3. Lateral tibial condyle

4. Head of fibula

5. Lateral collateral ligament

6. Rectus femoris

7. Vastus lateralis

8. Iliotibial tract

9. Biceps femoris

10. Common peroneal nerve

ANATOMICAL AREA: KNEE AND THIGH

TAPING FOR MEDIAL COLLATERAL LIGAMENT KNEE SPRAIN

Purpose

• supports the medial collateral ligament (MCL) by tightening the medial aspect of the joint line

• prevents the last 15 ° of knee extension and external rotation of the tibia under the femur

• allows almost full flexion and functional extension of the knee

Indications for use

• MCL sprains: 1st and 2nd degree

• post immobilization of 3rd-degree MCL sprains

• for medial meniscus injuries: emphasize spiral strips which cause internal rotation of the tibia

MATERIALS

Razor

Skin toughener spray/adhesive spray

Underwrap

7.5 cm (3 in) and 10 cm (4 in) elastic adhesive bandage

5 cm (2 in) and 3.8 cm (1½ in) non-elastic tape

15.2 cm (6 in) elastic wrap

Skin lubricant

Heel and lace pads

NOTES:

• Ensure that the correct diagnosis has been made. If in doubt, refer!

• Always assess which knee and which side of that knee was injured (the athlete may have sustained spraining on the medial aspect and bruising on the lateral aspect of the same knee).

• During exercise, increased blood circulation causes swelling of thigh muscles. Ensure that circumferential strips are affixed with only light tension, avoiding constriction and possible cramping of thigh and calf muscles.

• Avoid taping over the patella, as this can cause compression, pain and subsequent problems.

For additional details regarding an injury example see T.E.S.T.S. chart, p. 144.

Positioning

Standing upright. Place a roll of tape under the heel of the foot of the injured knee, so that the knee is slightly flexed. The foot is turned inwards to medially rotate the tibia under the femur (releasing the tension from the MCL). Eighty percent of the body weight should be supported by the uninjured side.

TIP:

For stability, have the athlete lean against a wall or couch (plinth) for support.

Procedure

1. Make sure the area to be taped is clean and relatively hair free; shave if necessary.

2. Check skin for cuts, blisters or areas of irritation before spraying with skin toughener or spray adhesive.

3. Place lubricated pads over the hamstring tendons.

4. Spray midthigh and midcalf with skin toughener or adhesive spray.

5. Apply underwrap from midthigh to midcalf.

6. Apply 2 circumferential anchors of 10 cm elastic adhesive bandage, using only slight tension, to the midthigh and midcalf regions, covering the skin well beyond the edge of the underwrap.

NOTE:

Re-check the athlete’s position.

7. Place a strip of 7.5 cm elastic adhesive bandage starting from the posteromedial aspect of the distal anchor, spiralling around the lateral side of the tibia, anteriorly. Cross medially below the patella with moderate tension and pull proximally with strong tension over the medial joint line to the proximal anchor.

NOTE:

This strip helps to medially rotate the tibia as well as approximate the medial joint.

TIP:

The last 7.5 cm of the strip must be applied directly to the anchor strip and must not be applied under tension. (The tape end will peel back if tension has not been released.)

8. Place the second strip of 7.5 cm elastic adhesive bandage also starting at the posteromedial aspect of the distal anchor, this time heading anteriorly on the medial side. Pull proximately with strong tension over the medial joint line to the proximal anchor anteriorly, releasing the tension only when adhering the end of the strip.

NOTE:

These two strips form an X directly on the medial joint line over the site of the medial collateral ligament.

9a Begin the lateral X with a strip of 7.5 cm elastic adhesive bandage from the posteromedial aspect, winding behind the tibia (reinforcing internal rotation of the tibia) with some tension upwards on the lateral aspect of the knee above the patella to the proximal anchor anteriorly.

9b Place the next strip of 7.5 cm elastic adhesive bandage from the anterolateral aspect of the distal anchor, pulling proximally with some tension over the lateral joint line, to the proximal anchor.

NOTE:

These last two strips form an X directly on the lateral joint line, with less tension. The ends interlock with the medial X over the anchors, reinforcing stability.

10. With the knee still flexed, apply a vertical strip of 7.5 cm elastic adhesive bandage from the centre of the posterior of the distal anchor to the centre of the proximal anchor to prevent hyperextension.

11. Apply an X of 7.5 cm elastic adhesive bandage (fully stretched) on the posterior knee.

12. Re-anchor the tape proximally and distally.

NOTE:

This completed butterfly must be tight enough to limit the last 10–15 ° of knee extension.

13. Apply an oblique vertical strip of 5 cm non-elastic tape from the posteromedial aspect of the distal anchor to the anteromedial aspect of the proximal anchor.

TIP:

Fold the edges of the tape back on themselves to reinforce its strength, making the portion crossing the ligament virtually untearable.

TIP:

When applying this strip, hold the distal end firmly against the distal anchor while pressing the knee into extreme varus and pull up with maximal force.

NOTE:

The athlete will need to hold on to the taper’s shoulder or a nearby wall for stability at this stage.

NOTE:

The knee must remain relaxed while the athlete’s weight is borne mainly on the uninjured leg.

14. Apply a second vertical strip of non-elastic tape, this time from the anterior aspect of the distal anchor to the posteromedial aspect of the proximal anchor using the same principles as outlined in step 12.

NOTE:

The X formed by these two strips must lie on the medial line over the site of the MCL.

15. Repeat the non-elastic tape X, overlapping slightly anteriorly to the first tape.

16. Using light tension, re-anchor the tape job with two circumferential strips of 10 cm elastic adhesive bandage over the midthigh and midcalf anchors.

17. Cover the end of the elastic tape with two short strips of non-elastic tape to keep the elastic tape securely in place.

18. Test the degree of restriction.

a. Extension must be limited by 10 °.

b. There must be no medial laxity.

c. There must be no pain on medial stress testing, external rotation of the tibia under the femur or extension.

19. Wrap the entire tape job with an elastic wrap prior to allowing the athlete to resume activity. This gives the tape the time and heat necessary to set.

20. Tape the elastic wrap in place with non-elastic tape.

NOTES:

• For acute sprains, leave elastic wrap on for at least the first 48 hours.

• For back-to-sport taping, leave the elastic wrap on for 15 minutes and then remove for full activity.

ANATOMICAL AREA: KNEE AND THIGH

INJURY: KNEE SPRAIN MEDIAL COLLATERAL LIGAMENT

TERMINOLOGY

• medial collateral ligament sprain: 1st–3rd degree of severity (see Sprains chart, p. 36)

• internal collateral ligament sprain: 1st–3rd degree of severity

• pulled knee

ETIOLOGY

• excessive inward pressure forcing the knee medially into valgus (inwardly bent ‘knock-kneed’ position). Example: a football player tackled at the knees from the left side may sustain a medial sprain of the left knee and potentially a lateral sprain of the right knee

• sudden impact forcing body laterally on a fixed foot

• often associated with other injured structures (medial meniscus, medial collateral ligament and anterior cruciate ligament: ‘the unhappy triad’)

SYMPTOMS

• local pain and tenderness on the medial side (inside) of the knee

• swelling, possible bruising

• active movement testing: medial pain on end-range extension

• resistance testing (neutral position): no pain on moderate resistance

• stress testing:

a. 1st- and 2nd-degree sprain: medial pain with or without instability when tested at 30 ° knee flexion

b. 3rd degree of severity: complete ligament rupture ‘opens up’ at 30 °, can be less pain than with 2nd degree

c. instability at 0 ° extension is indicative of a severe injury with posterior capsule involvement

TREATMENT

Early

• R.I.C.E.S.

• Taping: MCL sprain, p. 136 (plus elastic wrap for first 48 hours)

• therapeutic modalities

Later

• continued therapy including:

NOTE:

Surgery may be indicated for 3rd-degree sprain.

a. therapeutic modalities

b. transverse friction massage

c. mobilizations if stiff following immobilization

d. flexibility exercises for quadriceps, hamstrings and gastrocnemii

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