Classification of pain can be according to time, namely: acute pain and Chronic

a. Acute Pain
Acute pain is pain that has been present for less than 3 months
Acute pain occurs due to acute tissue damage. Acute pain is pain that arises suddenly and not
last long. Usually characterized by symptoms of increased respiration, heart rate and
increased blood pressure. acute (0–4 days)

b. Subacute Pain

Subacute pain is a subset of acute pain: It is pain that has been present for at
least 6 weeks but less than 3 months. subacute (5–14 days),

c. Chronic Pain
Chronic pain is pain that has been present for more than 3 months
Whereas chronic pain is pain that arises slowly, it continues though the lesion
has healed. Some use the time limit of 3 months as pain chronic. Postacute more
than 14 days?

Based on location, pain is divided into several classifications such as:

- Peripheral pain consisting of pain on the surface, deep and divert (not at the source of
the pain).

- Central pain, namely pain that occurs due to stimulation of the central nervous system
and brain stem

- Phsycogenic pain, namely pain that occurs due to psychological factors

- Radiating pain, which is pain that occurs and extends to the surrounding tissue.

- Panthom pain, which is pain in parts of the body that no longer exist, such as due to
amputation.

Based on source :
*Nociceptive: represents the normal response to noxious insult or injury of tissues such as
skin, muscles, visceral organs, joints, tendons, or bones.
Examples include:
- Somatic: musculoskeletal (joint pain, myofascial pain), cutaneous; often well
localized
- Visceral: hollow organs and smooth muscle; usually referred
*Neuropathic: pain initiated or caused by a primary lesion or disease in the somatosensory
nervous system.
Sensory abnormalities range from deficits perceived as numbness to hypersensitivity
(hyperalgesia or allodynia), and to paresthesias such as tingling.
Examples include, but are not limited to, diabetic neuropathy, postherpetic neuralgia, spinal
cord injury pain, phantom limb (post-amputation) pain, and post-stroke central pain.

*Inflammatory: a result of activation and sensitization of the nociceptive pain pathway by a

variety of mediators released at a site of tissue inflammation.
The mediators that have been implicated as key players are proinflammatory cytokines such
IL-1-alpha, IL-1-beta, IL-6 and TNF-alpha, chemokines, reactive oxygen species, vasoactive
amines, lipids, ATP, acid, and other factors released by infiltrating leukocytes, vascular
endothelial cells, or tissue resident mast cells
Examples include appendicitis, rheumatoid arthritis, inflammatory bowel disease, and herpes
zoster.

Anterior Cruciate Ligaments (ACL)

The anterior cruciate ligament is the main stabilizer of the knee joint. It attaches to both shins
(shin) and femur (femur). This ligament prevents the femur from gliding abnormally on the
tibia during activities such as running, spinning and managing stairs or tilting.
The ACL runs diagonally in the middle of the knee, prevents the tibia from sliding in front of
the thigh, and provides stability to the spine of the knee.
Posterior cruciate ligament (PCL)
is the ligament inside the knee joint,. PCL - similar to anterior cruciate ligament (ACL) -
connects the femur (femur) with the shin (tibia). PCL is located right in the middle of the
knee joint and is opposite the Anterior Cruciate Ligament (ACL), so that it forms the letter
"X". Both of these ligaments function to balance the joints and prevent abnormalities in the
position of the knee.
Medial Collateral Ligament (MCL)
is located inside, from your knee. Ligaments function to connect bones and provide stability
and strength to the joints.The MCL connects the upper part of the tibia, or shin bone, to the
bottom of the femur, or femur.
Lateral Collateral Ligament (LCL)
is the main supporting ligament on the outside side of the knee. Ligaments provide stability
to the joints when the knee is pushed out.
The meniscus
is a fibrocartilage pad that is attached to the medial (inner side) and lateral (outer side) tibial
plateu.
-This meniscus serves to widen and deepen the contact surface between the femur and the
tibia, this causes a reduction in stress or pressure on the articular cartilage.
- The meniscus will distribute the burden received by the knee joint.
- Meniscus also functions to maintain joint stability and lubrication function to produce joint
fluid.
Knee fluid or bursa.
This knee fluid-filled sac works as a pressure reducer that lubricates the tissue that forms the
knee so that it can reduce friction between the muscles and tendons around the joint. The
location of this exchange itself is there at the tip of the shin and above the kneecap.

Muscle Spasms
Commonly, muscle spasms are normal responses to muscle overexertion, pain, or fatigue,
dehydration, and electrolyte abnormalities. A muscle spasm is a sudden, involuntary
contraction of one or more muscles. A spasm results from an abnormally sustained muscle
contraction and is often painful. Muscle cells require enough water, glucose, sodium,
potassium, calcium, and magnesium to allow the proteins within them to develop an
organized contraction. Abnormal supply of these elements can cause the muscle to
become irritable and develop spasm. Atherosclerosis or narrowing of the arteries
(peripheral artery disease) may also lead to muscle spasm and cramps, again
because an inadequate blood supply and nutrients are delivered to the muscle.
Peripheral artery disease can decrease the flow of blood to the legs, causing pain in
the legs with activity. There may also be associated muscle cramps. Dystonias are
movement disorders where groups of muscles forcefully contract and cause twisting.
Uncontrolled repetitive movements and the inability to maintain normal posture may
be the result of this type of muscle spasm and cramping.
Various muscles may develop spasms, including the small intrinsic hand muscles of a
musician to the larger “charley horse” calf muscles of a runner. Muscle spasms may involve
the skeletal muscles of the limbs and spine, responsible for locomotion and upright
posture, or the smooth muscles lining the hollow, tubular internal organs of our body, such
as the muscles lining the colon or bladder. Skeletal and smooth muscles have different
embryological origins, functions, innervations, and physiologies. The spasm may occur if
the muscle has been overstretched or if it has been held in the same position for a
prolonged period of time. In effect, the muscle cell runs out of energy and fluid and
becomes hyperexcitable, resulting in a forceful contraction. This spasm may involve part of
a muscle, the whole muscle, or even adjacent muscles. For the purposes of this discussion,
the focus will be on skeletal muscle spasms. Smooth muscles that are within the walls of
hollow organs (like the colon) can go into spasm, causing significant pain. Often this pain is
colicky, meaning that it comes and goes. Examples include the pain associated with
menstrual cramps, diarrhea, gallbladder pain, and passing a kidney stone.

Muscle stiffness
Muscles stiffness can also be accompanied by pain, cramping, and discomfort. A
common cause of muscle stiffness is exercise or hard physical labor of some kind.
Often, stiffness can occur when someone starts a new exercise routine or program
or has increased the intensity and duration of their routine. When this happens, the
muscles are required to work harder, and this causes microscopic damage to the
muscle fibers, resulting in stiffness or soreness. The most common cause of muscle
stiffness is a sprain or strain, which can affect both the muscles and ligaments. A
strain is when the muscle fibers are stretched or torn. Strains are particularly
common in the legs and lower back. A sprain is when the ligaments have been
stretched, twisted, or torn. The ligaments are the bands of tissue around the joints
that connect the bones together.

Type I collagen
is the most abundant collagen, and is expressed in virtually all connective tissues. It
is an interstitial matrix component and the major structural protein of bone, skin,
tendon, ligament, sclera, cornea, blood vessels, as well as an important component
of other tissues. Of these tissues, bone and skin are the organs with the most
prominent functional role for type I collagen. Type I collagen comprises
approximately 95% of the entire collagen content of bone and about 80% of the total
proteins present in bone [1], thereby representing the tissue with, by far, the largest
amount of type I collagen. Heterotrimers of two α1(I) and one α2(I) chains are the
dominant isoform of type I collagen. Homotrimers of three α1(I) chains are found in
fetal tissues,19tumors20–25 and some fibrotic lesions.26–28 The homotrimeric
isoform is more resistant to cleavage by collagenases, which might explain its
accumulation and functional role in tumors and fibrotic lesions.25,29 However, this isoform
becomes prevalent in other tissues only in extremely rare disorders associated
with COL1A2deficiency.3

Type I collagen Function

Minimize fine lines and wrinkles and improves skin elasticity and hydration. Not only does it
help rebuild your muscles, eyes, bones, and spine, it’s also good for strengthening your nails
and helping you grow stronger, thicker hair. Supports muscle recovery, supplement with
both marine and bovine collagen.Type 1 collagen is most abundant in Marine Collagen.

Type I collagen is synthesized as a procollagen precursor, which consists of an N-

terminal propeptide, central collagen domain and C-terminal propeptide. Procollagen chains
are cotranslationally translocated into the lumen of rough endoplasmic reticulum (ER).
After post-translational modification and folding in the ER, procollagen molecules are
transported through Golgi and secreted from the cell. N- and C-propeptide cleavage
produces a 300 nm-long collagen triple helix bounded by short terminal peptides
(telopeptides). These mature collagen molecules are then assembled into fibers, often
together with a smaller fraction of molecules of type III, V and XI collagens.
Type I collagen synthesis follows translation in the endoplasmic reticulum of the pro-
collagen alpha-1 (COL1α1) and alpha-2 (COL1α2) chains
Sign

Type I collagen
synthesis and
assembly. Nascent
chains translated from
type I collagen alpha 1
and alpha 2 gene
(COLIA1 and COLIA2)
mRNA in the
endoplasmic reticulum
undergo hydroxylation
and glycosylation and
interact with molecular
chaperones that
promote
conformational folding
and winding of the
triple helix. Following
secretion the amino
terminal propeptides
(PINP) and carboxy terminal propeptides (PICP) are cleaved. PINP and PICP have
the potential to act as autocrine and paracrine feedback modulators of type I
collagen expression. Fully processed collagen molecules form fibrils that are
stabilized by crosslinks between collagen trimers.
Type II collagen
is the basis for articular cartilage and hyaline cartilage, formed by homotrimers of collagen, type
II, alpha 1 chains.It makes up 50% of all protein in cartilage and 85–90% of collagen of articular
cartilage. Type II collagen does form fibrils. This fibrillar network of collagen allows cartilage to
entrap the proteoglycan aggregate as well as provide tensile strength to the tissue. Oral
administration of native type II collagen induces oral tolerance to pathological immune responses
and may be useful in arthritis
Type 2 Collagen Function
Makes up a majority of the protein molecules in your cartilage, the connective
tissue that protects your bones at the joints, in your spinal disks, and your
eyes, making it a potent way to support joint health. One of the best sources
is Organic Bone Broth Protein.
Type II collagen
is synthesized as a procollagen molecule with noncollagenous amino and carboxy extension
peptides, by articular chondrocytes which represent the only living elements within hyaline
cartilage.
Cartilage is a flexible connective tissue that differs from bone in several ways. For
one, the primary cell types are chondrocytes as opposed to osteocytes.
Chondrocytes are first chondroblast cells that produce the collagen extracellular
matrix (ECM) and then get caught in the matrix. They lie in spaces called lacunae
with up to eight chondrocytes located in each. Chondrocytes rely on diffusion to
obtain nutrients as, unlike bone, cartilage is avascular, meaning there are no vessels
to carry blood to cartilage tissue. This lack of blood supply causes cartilage to heal
very slowly compared with bone.

Repair

Once damaged, cartilage has limited repair capabilities because chondrocytes are
bound in lacunae and cannot migrate to damaged areas. Also, because cartilage
does not have a blood supply, the deposition of new matrix is slow.

Damaged hyaline cartilage is usually replaced by fibrocartilage scar tissue. Over the
last few years, surgeons and scientists have elaborated a series of cartilage repair
procedures that help to postpone the need for joint replacement.

These include marrow stimulation techniques, including surgeries, stem cell

injections, and grafting of cartilage into damaged areas.

However, due to the extremely slow growth of cartilage and its avascular properties,
regeneration and growth of cartilage post-injury is still very slow.
Tendon Structure

STRUKTUR TENDON

The tension structure of the tendon is the collagen fibrils. These fibrils are dense, strong and
flexible. The nature of collagen fibers will be resistant to the pull and push between bones
and muscles. If it is reviewed further, it can still be obtained the basic molecules making up
collagen fibrils, which are several tropokolagen that unite to form microfibrils, and collagen
microfibrils combined to form collagen subfibrils, then the combined subfibrils will form
collagen fibrils.
Furthermore, collagen collagen fibers will be joined and collected strands of protective layers
in a single unit called collagen fibers.
Then a combination of several collagen fibers and arranged by endotendon layer will form a
Primary Collagen Fiber Bundle (Sub-fasicle).
Primary collagen fibers will be joined and processed by the endotendon layer (the layer that
serves to protect and stabilize the tendon) to form a Secondary Collagen Fiber Bundle
(fasicle).

The combination of several secondary collagen fiber bundles and worked by endotendon
layers (layers that serve to protect and stabilize tendons) form a Tertiary Collagen Fiber
Bundle.

Now this collection of tertiary collagen fibers bundles together with the epitendon layer (the
outer layer of the tendon) will form the perfect tendon structure.
TENDON FUNCTION
The main function of the tendon is to help the occurrence of movements that are easy, free,
effective, and efficient. When the movement occurs, the tendon will also adjust changes in
bone position with the muscles so that the movement is perfect. Tendon function is closely
related to contraction (shortening) and relaxation (lengthening) of the muscles. When a
muscle contracts, the tendon transmits energy from the contraction to the bones and joints, as
well as when the muscles relax, the tendon also adjusts to its condition.
Ligament Structure
It is described as a dense band of collagen connective tissue. The structure of the ligament
consists of a protein called collagen. This collagen protein is long, flexible, and shaped like a
thread or fiber.
Ligament Function
1. Determine the range of motion
So as such, can prevent joint dislocation. Ligaments can also help prevent hyperextension of
bones or joints. So in short, the ligament serves to stabilize the joints and guide them during
the movement.
2. Protection of bones and joints
Ligaments can provide protection against bones and joints from fractures, because when
there is tension in the joints, ligaments can change shape under constant load.
3. Proprioseptive
Another function of the ligament is to maintain one's posture with a proprioceptive system.
An example is when a knee joint is bent, it will stimulate proprioceptive nerves to make
muscle contractions at the same time, thus making people aware of the position of the knee
and leg.

Knee Xray
1. Know your knee anatomy

See the the anatomical landmarks on the diagrams below.

From wikiradiography.net

Remember that the knees of younger children will look different, as the patella forms,
and the ossification centres form.
 From thesebonesofmine.wordpress.com

2. Look for an effusion

There are two fat pads in the knee

 the suprapatellar fat pad

 the prefemoral fat pad

Make sure they are next to each other. Soft tissue density in between the two fat pads
indicates an effusion – this is only reliably seen on the lateral view (see images below).

It is sometimes helpful to rotate the PACS view so you are looking at the knee in the
horizontal plane, in the same way the image is taken. Your eyes are much more adept
at picking up an effusion or even a fat/fluid level (lipohaemarthrosis) that way.

Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 29039

 Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 32559

3. Look at the main bones

Check for fractures in the fibular head, femur and tibia.

4. Check the tibio-femoral alignment

Draw a line along the margin of the lateral femoral condyle. The tibia should be within
0.5 cm of this line, otherwise it suggests a tibial plateau fracture.

Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 29039

5. Looks at the tibial plateaus

These most commonly happen on the lateral tibial plateau.

Check for a tibial plateau avulsion from the lateral edge (Segond fracture)

From orthopaedicsone.com

Tibial plateau fractures in children are exceedingly rare and require a marked degree of
axial force. They are more likely to get a Salter-Harris V.

6. Look at the intercondylar eminence

A fracture here is most common in adolescents following hyperextension of the knee. It’s
an avulsion fracture at the tibial attachment of the ACL.
 Case courtesy of Gerry Gardner, Radiopaedia.org, rID: 13915

7. Look for patellar tendon disruption

The patellar tendon goes from the inferior pole of the patella to the tibial tuberosity. Its
length should be the same as the patellar length +/- 20%. If it’s too long then think of a
patellar tendon rupture. This is the Insall-Salvatti ratio and should ideally me measure
with the knee flexed at 30 degrees.

Case courtesy of Dr Wael Nemattalla, Radiopaedia.org, rID: 10329

8. Look for a patellar fracture

Bipartite patellas are common. It is a congenital condition that occurs when the patella is
made of two bones instead of a single bone. Normally the two bones would fuse
together as the child grows but in bipartite patella they remain as two separate bones.
The edges appear well corticated as compared to in a fracture. See an example below.

Case courtesy of Radiopaedia.org, rID: 11236

Most patella fractures are transverse, but they can be vertical.

Consider a skyline view. This gives a clearer view of the patella in cases of clinically
suspected patella fracture where the AP and laterals look ok. It gives a good view of the
space between the patella and the femur. See a normal skyline view below.
 From wikiradiography.com

9. Remember the fabella…

This is a normal variant and not a floating fracture! It’s normal sesamoid bone that lies in
the posterior knee.

Describes criteria for knee trauma patients

The knee joins with the femur bone above it and with
tibia bone underneath. Smaller bones are located
on the lateral side of the tibia (fibula) and kneecap (patella) are
other bones that make up the knee joint. There are two joints in the joint
namely the tibiofemoral knee, which joins the tibia to the femur and joint
patellofemoral that joins the patella with the femur bone. Second
joints work together so that the knee can be flexed and extended, and rotated
in the external and internal direction.
The main parts of the knee joint are bones, ligaments, tendons,
cartilage, and joint capsules, all of which are made of collagen.
Collagen is fibrous tissue that exists throughout the body. On
old age, collagen function decreases and prone to damage.
Knee Forming Bones The knee joint is formed from three bones, namely the femur, tibia
bone, fibula bone, and patellar bone.
Patellar bone
Is the largest sesamoid bone in the human body with triangular and flat shapes. On the front
surfaceor anterior coarse patellar bone while surface deep or dorsal has more joint surface
large and smaller medial facies.
Soft tissue around the knee joint
• Meniscus Meniscus is soft tissue. Meniscus is wedge-shaped fibrocartilage structure and is
located on between femoral condyle and tibial plateau. Medial Meniscus the "U" shape
covers 60% of the medial compartment while lateral medicals tend to be in the "C" shape
with a shorter distance that covers 80% of the sides lateral. The meniscus tissue mainly
contains water and collagen fiber type I. The meniscus functions are: • distribution of
loading; • shock absorbers (shock absorber); • facilitate rotational movements; and • as a
stabilizer by absorbing each pressure and forward it to the joint.

• Bursa
Bursa is a liquid-filled bag that makes it easy friction and movement, thin-walled, and
limited by synovial membrane.
There are several exchanges that are found in the knee joint include: • popliteus exchange; •
supra patellar exchange; • infra patellaris exchange; • subcutaneous subcutaneous exchanges;
and • sub patellar exchange.

• Ligaments of the knee joint Ligaments have a fairly flexible nature and tissue strong enough
that serves as a barrier to movement and joint stability.

There are several knee joint ligaments, namely:

1) Anterior cruciate ligament
Walking from the front of the anterior intercondyloidea fossa to
the lateral surface of the femoral condyle
function to hold hyperextension and hold
tibia shifting forward.
2) Posterior cruciate ligament
Running from the lateral facies of the medial condylus
femoris heading to the tibial intercondylodea fossa
serves to hold the tibia shifting towards
back.
3) lateral collateral ligament
Walk from the lateral epicondylus to the capitulum
fibula which serves to hold the movement of varus or
outside side.
4) Medial collateral ligament
Walk from the medial epicondylus to
tibial medial surface (tibia medial epicondylus)
which serves to hold the valgus or
side in the highlight. However, simultaneously
collateral ligament functions hold
tibia shift forward at 90 ° knee.
5) Patellar ligament
Which is a continuation of the M. Quadriceps tendon
Femoris that travel from patella to tuberosity
tibia.
9
6) Lateral and medial retinacullum patella
This ligament is lateral to the tendon
M. Quadricep Femoris and walk towards tibia,
where these ligaments are attached to
tibial tuberosity.
7) Ligament popliteum articuatum
Located in the femoral lateral condylus tightly
his relationship with M. Popliteum.
8) Ligamentum popliteum oblicum
Walk from the lateral femoral condylus later
descending across towards the fascia popliteum
serves to prevent knee hyperextension.