4 - Chronic Knee Disorders Flashcards
How can arthritis of the knee be classified? (2)
- Degenerative
2. Destructive
What type of arthritis is classified as Degenerative? (1)
- Osteoarthritis
What types of arthritis are classified as Destructive? (3)
- Autoimmune
- Inflammatory (SLE)
- Rheumatoid Arhritis
Which form of arthritis is the most common form of knee arthritis?
Osteoarthritis (OA)
What compartments can knee OA occur in?
Any of the 3
- Medial Compartment
- Lateral Compartment
- Patellofemoral
How is the Medial Compartment of the knee defined?
- Medial Tibial Plateau
2. Medial Femoral Condyle
How is the Lateral Compartment of the knee defined?
- Lateral Tibial Plateau
2. Lateral Femoral Condyle
How is the Patellofemoral Compartment defined?
- Patella
2. Femoral Trochlear Notch
How is knee is knee OA characterized? (3)
- Progressive loss of articular cartilage,
- sclerosis of the subchrondral bone,
- and formation of osteophyted.
Knee OA pathological changes lead to: (2)
- loss of functional ability
2. and decreased quality of life
Common causes of OA: (6)
- Injury
- History of Fractures
- Meniscus tears
- Post-menisectomy
- Chronic knee instability
- Congenital Predisposition
What are common causes of OA influenced by? (2)
- age
2. and body weight
What are symptoms of knee OA? (2)
- pain
2. and stiffness
What age does knee OA often affect?
most often affects patients over 55 years
What is knee OA often associated with? (2)
- obsesity
2. and family history
In the onset of knee OA pain usually immediate or insidious?
insidious
How does knee OA pain progress? (initally to later
Initially: pain only with activity
Later: pain can occur even at rest
Patients with end-stage disease complain of:
- Pain (mild, moderate, or severe)
- Stiffness
- Limited joint range of motion
- Joint effusion
How many critieria need to be met for knee OA to establish a Dx?
three
What are the clinical diagnoses criteria for knee OA? (Altman et al)
- Age > 50 years
2. Morning Stiffness
Are the clinical diagnoses for more sensitive or specific?
Sensitivity = .95; Specificity = .69; LR+ 3.1
You can correctly diagnose __% of Knee OA patients when ___ criteria are present? (Zhang et al)
99% when ALL 6 criteria are present
What are the clinical for diagnoses for knee OA? (Zhang et al)
- Persistent knee pain
- Limited morning stiffness
- Reduced function
- Crepitus
- Restricted Motion
- Bony enlargement of the knee
What things can be analyzed during a Physical Examination of Knee OA? (5)
- Gait Analysis
- Joint Effusion
- Knee joint ROM
- Muscle Strength and Endurance
- Assess of Functional Level (ADL’s)
What is assessed during a Gait Analysis for knee OA? (2)
- Assess for restricted sagittal plane motion
2. Assess for frontal plane deformity
When assessing for frontal plane deformity during a Gait Analysis for knee OA, what do you look for? (2)
- Genu varum
2. and valgum
What tests can be done to analyze Joint Effusion for knee OA? (2)
- Fluctuation
2. Ballotable Patella Sign
What ways is Knee Joint ROM analyzed for knee OA?
- Passive
2. and Active
What tests are performed when Muscle Strength and Endurance is analyzed for knee OA? (2)
- Manual Muscle Testing
2. Functional Tests
How do you Assess of Functional Level (ADL’s) for knee OA? (2)
- KOOS
2. LEFS
What are Goal of Physical Therapy Intervention for knee OA? (3)
- Decrease Pain and Symptoms
- Improve Functional Levels
- Prolong the need for Surgical Intervention (Total Knee Arthroplasty)
Extensor Mechanism Disorders are defined as dysfunction in any of the following structures: (3)
- Patellar tendon and attachment to either patella or tibial tuberosity
- Patellar stabilizing structures (dynamic or static)
- Proximal Hip &/or Quadriceps musculature
Dysfunction leads to disruption of: (3)
- Patellar articulating surface
- Femoral trochlear surface
- Chronic joint inflammation
T/F: It is difficult to explain pain and dysfunction with extensor mechanism disorders using pathoanitomical rationale.
True
Dye reported that during arthroscopy with NO intrarticular anesthesia: (3)
- No pain with direct probing of Grade III chondromalacia
- Intense severe pain with light touch of synovial membrane, infrapatellar fat pad
- Patellar pain with increase pressure 2deg to saline injection
Since Extensor Mechanism Disorders cause pain in front of knee - clinically referred to as ___.
Anterior Knee Pain (AKP)
What structures comprise the Extensor Mechanism? (3)
- Passive Lateral Structures
- Passive Medial Structures
- Dynamic Stabilizers
Passive Lateral Structures of the Extensor Mechanism include: (3)
- Iliotibial band
Soft Tissue Structures: - Transverse Retinacula
- Periarticular Synovium
Passive Medial Structures include: (2)
- Medial retinacula
2. Medial patellofemoral ligament
Dynamic Stabilizers are broken into what categories? (2)
- Lateral
2. Medial
Dynamic Stabilizers, Lateral and Medial are broken into what categories? (2)
- Proximal
2. Distal
Dynamic Stabilizers: Lateral, Proximal include: (3)
- Gluteus Maximus
- Gluteus Medius
- Tensor Fascia Latae
Dynamic Stabilizers: Lateral, Distal include: (1)
- Vastus Lateralis
Dynamic Stabilizers: Medial, Proximal include: (1)
- Hip Adductors
Dynamic Stabilizers: Medial, Distal include: (1)
- Vastus Medialis - Oblique Fibers (VMO)
What is the relationship of VMO to Adductor Magnus?
VMO fibers can attach to the tendinous portion of the Adductor Magnus muscle?
T/F: Use of ball between knees increases VMO increase activity.
False
Proposed Etiologies of AKP include: (5)
- An increase valgus angulation at the knee
- Reduction in proximal hip muscle strength (Gluteal group, TFL, Hip rotators)
- Increased foot pronation
- Decreased prominence of the lateral femoral condyle
- Changes in length of the patellar tendon
Increased “static” Q angle caused by: (3)
- Genu valgum
- Femorial or tibial torsion abnomalities
- Increased foot pronation
T/F: There is minimal evidence to support that an increase in static Q angle is a factor in the development of AKP
True: much more interested in “dynamic” Q angle
When is “dynamic” Q angle assessed? (3)
- Walking
- Running
- Jumping
What effects the degree of “dynamic” Q angle?
Stabilization by “proximal” hip musculature:
- Glutues Maximus
- Glutues Medius
- TFL
- Hip Rotators
What are the changes in length of the patellar tendon?
- High riding patella (patella alta)
2. Low riding patella (patella baja)
Both Patella Alta and Baja change ___.
the normal pattern of articular cartilage compression during flexion and extension
What are the specific subclassification of Extensor Mechanism Disorders leading to Anterior Knee Pain? (4)
- Patellofemoral Pain Syndrome (PFPS)
- Plica Syndrome
- Patellar Tendinopathy (tendinitis)
- Physes (Growth Plate) Disorders
What is PFPS also known as?
Chondromalacia patellae
What is the etiology of PFPS: (4)
- Trauma
- Prolonged or repeated stress on tissues as a result of abnormal lower extremity alignment
- Lack of normal articular cartilage stress (period of immobilization)
- Post Surgery Complication
What are Symptoms of PFPS: (3)
- General complaints of anterior knee pain
- Crepitation with movement of patellofemoral joint
- Symptoms increased with ascending and descending stairs, squatting, &/or prolonged sitting (“theater sign”)
What is done during a physical examination for PFPS: (12)
- Observation of standing posture
- Observation of gait OR functional movements for “dynamic” Q angle
- Observe patellar movement during active knee ROM
- Assess Active Knee ROM
- Observe and palpate Quadriceps bulk (especially VMO as patient performs Quad Set)
- Assess Joint Effusion
- Palpation of medial and lateral patellar posterior borders
- Assess medial patellar mobility
- Assess for patella Baja or Alta
- Muscle Strength Testing
- Appropriate muscle length/flexibility tests
- Eccentric Step test (from 15cm height)
During a physical examination for PFPS, when Observation of Gait OR function movements for “dynamic Q angle look for: (3)
- Genu valgum / genu varum
- Patellar position at midstance
- Foot posture during stance phase
During a physical examination for PFPS, what can be done after assessing active knee ROM?
if necessary Passive ROM
During a physical examination for PFPS, what can be done for Muscle strength testing? (3)
- Partial or full squat
- Vastus medialis coordination test
- Hip extensors, abductors, external and internal rotators
During a physical examination for PFPS, what can be done for Appropriate muscle length/flexibility tests? (3)
- Ober’s test
- Hamstrings (90/90)
- Calf muscle
During a physical examination for PFPS, what are you assessing and observing in a Eccentric Step test (from 15cm height)? (2)
- Assess pain and symptoms
2. Observation of “dynamic” Q angle
Cook C, et al reported the strongest PFPS Dx test was pain encountered with
resisted quadriceps contraction of knee
PFPS test findings were more diagnostic with 2 of 3 following:
- pain with quad contraction
- pain with squatting
- pain with palpation
What is the Etology of PLICA syndrome?
Irritation of embrologic synovial tissue circling the patella (the PLICA)
Where on the patella is PLICA experiences?
Usually the superior and medial aspect of patella
What can cause increased tissue stress with the plica becoming thicker and fibrotic?
abnormal tracking of the patella
What are symptoms of plica syndrome?
Pain and discomfort over the superior and medial aspect of the patella
How is it best to assess plica syndrome?
palpation performed with the patient sitting (superior and medial aspect of patella)
In what way is PLICA syndrome managed?
Conservatively, hopefully not surgery as usually not successful.
What is Patellar Tendinopathy (tendinitis)?
inflammation of the distal pole of the patella and the patellar tendon
What can Patellar Tendinopathy also cause?
inflammation of infrapatellar fat pad
What is Patellar Tendinopathy caused by?
Chronic repetitive tendon overloading which results in weakening of tendon.
What are contributing factors/etiology of Patellar Tendinopathy?
Associated quadriceps weakness, lack of hamstring and gastrocnemius flexibility, as well as patella alta
What sports ususally case Patellar Tendinopathy?
Usually caused by repetitive jumping sports:
- Volleyball
- Basketball
T/F: Chronic patellar tendinopathy shows absent or minimal inflammation as underlying pathology at this point is degenerative.
True
Chronic patellar tendinopathy degenerative changes include: (2)
- loss of longitudinal collagen fibers
2. as well as fiber disorganization in tendon
What are symptoms of patellar tendinopathy?
- Pain with palapation of tendon, especially inferior pole of patella
- Infrapatellar fat pad effusion/swelling
- Extremely painful at start of and after resting at end of activity
What are the two types of Physes (Growth Plate) Disorders?
- Osgood-Schlatter Disease
2. Sinding-Larsen-Johansson Disease
What is the etiology of Osgood-Schlatter Disease?
Repetitive stress leads to an avulsion injury where the patellar tendon inserts into tibial tubercle secondary ossification center.
When is onset of Osgood-Schlatter disease?
during early adolescence at secondary ossification site which is weak link to repetitive quadriceps contraction.
Occurance of Osgood-Schlatter disease is 5 X’s greater in
adolescents active in sports
Osgood-Schlatter disease occurs 2 to 3 X’s more frequently in
males than females
What are symptoms of Osgood-Schlatter disease
- Pain at attachment site of tendon to tibial tubercle exacerbated by running, jumping and kneeling activities
- Pain can also occur after prolonged sitting with knees flexed.
What is the difference between Osgood-Schlatter disease and Sinding-Larsen-Johansson disease?
SLJ occurs at the junction of the patellar tendon and DISTAL POLE of patella
