Practical Management of Common Knee Problems
The knee is a complex joint, a tri-compartmental, diarthrodial, synovial-type hinge joint. Two weight-bearing articulations comprise the concave condyles of the femur, which rest on the flatter tibial plateau. In the knee their congruence and stability is maintained by fibrocartilaginous structures on each side; the menisci. In the intercondylar notch are two broad collagenous structures, the cruciate ligaments which not only prevent A-P translocation but also serve to deliver some proprioceptive information back to the nervous system.
The other part of the joint, the non-weight-bearing portion, is comprised of the patella, which is a sesamoid bone formed in the quadriceps tendon that articulates in the femoral sulcus, the femoral trochlear groove and as such protects the knee from a direct blow and increases the mechanic efficiency of a knee extension. Not shown on a diagram such as this are many other important structures about the knee, particularly as one evaluates why it hurts; the capsule, the synovial lining of the capsule, the adjacent collateral ligaments, the various muscles responsible for stability and motion, and the various bursa about the knee, also the fourth joint of the knee – the fibrous fibular tibial joint – which can be important as a pain generator.
As we assess these structures and their role in the production of pain, we need to know a little bit about how that pain gets back. The knee is quite richly enervated, although selectively so. Enervated by two basic types of nerves. The darker ones here are myelinated nerves that serve to send back messages regarding pressure and traction, serving mainly to judge proprioception. The thinner nerves are either very thinly myelinated sympathetic nerves that control blood flow, or unmyelinated C fibers that serve to conduct pain back. Notice that they are distributed mainly through bone, at capsule and capsular attachments, not in cartilage of course. A little bit on the edge of the menisci and, not shown on this schematic, are the various entheses where there are quite a few type C fibers.
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