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MM I > Chronic Knee > Flashcards

Chronic Knee Flashcards

1
Q

What condition is NON-inflammatory arthritis in the knee ?

A

OA

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2
Q

What are 4 types of inflammatory arthritis in the knee?

A
  1. RA
  2. Systemic lupus erythematosus (SLE)
  3. Gout
  4. Psoriatic arthritis

appears read and warm, unlike with non-inflammatory (OA)

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3
Q

T or F: OA can occur in any/all of the 3 compartments:
- Medial
- Lateral
- Patellofemoral

A

True.

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4
Q

What are 8 risk factors for OA?

A
  1. > 50 yo
  2. Female
  3. Higher BMI
  4. Previous knee injury or malalignment
  5. Joint laxity
  6. Occupation/recreational use of knee
  7. Family hx of arthritis
  8. Presence of Heberden’s nodes on fingers
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5
Q

What are sxs of knee OA?

A
  1. Usage-related pn (often worse end of day), pn relieved by rest
  2. “Giving way” of knee(s)
  3. Mild morning/inactivity stiffness
  4. Impaired function
  5. More persistent rest and night pn may occur in advanced OA
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6
Q

According to Zhang 2010, you can correctly diagnose 99% of knee OA pts when ALL 6 criteria are met:

A
  1. Persistent knee pn
  2. Morning stiffness
  3. Reduced function
  4. Crepitus in knee
  5. Restricted knee mobility
  6. Bony enlargement of knee
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7
Q

What is the GOLD standard for OA imaging?

A

Plain radiography (WBing, semi-flexed PA view, plus lateral and merchant views)

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8
Q

What are 4 classic radiographic findings for knee OA?

A
  1. Focal jt space narrowing
  2. Osteophytes
  3. Subchondral bone sclerosis
  4. Subchondral cysts
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9
Q

What are tests/measures you would consider performing with a patient with known/suspected knee OA?

A
  1. Pt-reported outcomes: LEFS, WOMAC, KOOS
  2. Static posture (genu varum: med compartment OA, genu valgum: lat compartment OA)
  3. Gait analysis (OA characteristics: slower speed, dec stride length, dec knee flex, varus thrust)
  4. Joint effusion: Ballotable patella sign
  5. Knee ROM: loss of AROM & PROM
  6. Muscle strength & endurance: (MMT, functional tests: STS, curb ascent, stair climbing)
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10
Q

What does the OARSI (OA Research Society International) recommend for interventions for knee OA?

A

“Structured land-based exercise programs, dietary weight management in combination w/ exercise, and mind-body exercise (Tai Chi and yoga) were considered by the panel to be effective and safe for all pts w/ knee OA, regardless of comorbidity”

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11
Q

T or F: Research has shown that for knee OA…

Both aerobic exercise and home-based strengthening are effective in reducing pain and disability

Land-based therapeutic exercise was shown to reduce pain and inc function

A

True.

True.

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12
Q

What are surgical interventions for knee OA?

A
  • High tibial osteotomy
  • Total joint replacement: uni, bi, tri compartmental
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13
Q

What is osteochondritis dissecans (OCD)?

A

Focal, idiopathic alteration of subchondral bone with risk for instability and disruption of adjacent articular cartilage that may result in premature OA.

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14
Q

What is the most common location for osteochondritis dissecans?

A

Medial femoral condyle (lateral surface)

Can also occur on lat femoral condyle and patella (less common tho)

Rare: tibial plateau

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15
Q

Osteochondritis dissecans is more common during ___ years and 4x higher in __(sex)__

A

Teen

Males

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16
Q

What are potential etiologies for osteochondritis dissecans?

A

Microtrauma: repetitive squatting (baseball catchers)

Trauma: impact injury (causing bone bruise leading to cartilage death) –> 60% report being involved in sporting activities

Genetic: ACAN gene assoc w/ familial OCD

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17
Q

What are 3 sxs of osteochondritis dissecans?

A
  1. knee jt pn w/ WBing
  2. swelling (variable)
  3. “locking” of knee
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18
Q

Where may a pt with suspected osteochondritis dissecans have pain with palpation?

A

Femoral condyles at different degrees of knee flex

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19
Q

For a pt w/ osteochondritis dissecans, what would indicate that you can proceed with PT interventions? And what would those interventions consist of?

A

If the OCD fragment is stable.

  1. Protected WBing
  2. Activity mod for 3 mo
  3. Impairment-focused interventions: ROM, strengthening, balance
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20
Q

If a pt has osteochondritis dissecans and the fragment is unstable or free-floating in the knee joint, is PT appropriate?

A

No, they would be referred for surgery:
- Microfracture technique
- Osteochondral graft (mosaicplasty)
- Autologous cartilage implantation (ACI)

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21
Q

What are 2 passive structures that provide laterally directed forces on the patella?

A
  1. IT band
  2. Lateral retinacula
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22
Q

What are 3 passive structures that provide medially directed forces on the patella?

A
  1. medial retinacula
  2. medial patellofemoral lig (MPFL)
  3. raised lateral wall of trochlear groove
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23
Q

What are 4 dynamic structures that act on the patella?

A
  1. Vastus medialis
  2. Vastus intermedius
  3. Vastus lateralis
  4. Rectus femoriss
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24
Q

Why have clinicians transitioned away from trying to “isolate” the VMO?

A

The VMO does NOT have distinct and separate innervation since the femoral N has large motor units that innervate across all 4 heads of the quads….therefore, you cannot “isolate” the VMO!

(Smith 2009)

25
Q

Identify risk factors for patellofemoral pain syndrome (anterior knee pain)

A
  1. Active women
  2. Dec quad iso strength
  3. Quad atrophy
  4. Inc dynamic valgus angulation (more evidence to support “DYNAMIC” Q-angle in dev of ant knee pain than static Q-angle
  5. Dec prominence of lat wall of trochlear groove
  6. Abnormal length of patellar tendon
  7. Psychological factors: anxiety, depression, pain catastrophizing
26
Q

T or F: Static Q-angle is NOT a predictive factor in the dev of PFPS

A

True.

(Pappas 2012)

27
Q

What is the difference between patella alta and patella baja?

A

Patella alta: patellar tendon length >1.2x patella height

Patella baja: patellar tendon length <0.8x patella height

Both alta and baja change the normal pattern of articular cartilage compression during flex/ext

28
Q

What 4 things indicate a poorer prognosis for PFPS?

A
  1. Higher # of pn sites
  2. Longer pn duration
  3. Lower self-efficacy, higher emotional distress
  4. Worse SKPA score at baseline
29
Q

What are 3 sxs of PFPS/ant knee pn?

A
  1. general complaints of ant knee pn
  2. +/- crepitus w/ movement of PFJ
  3. Sxs inc w/ stairs, squatting, and/or prolonged sitting (“theater sign”)
30
Q

What should you include in your examination of a pt with suspected PFPS/ant knee pain?

A
  1. Pt-reported outcome tools: LEFS, AKPS (Anterior Knee Pain Scale), KOOS-PF
  2. Obs standing posture
  3. Obs gait
  4. Assess jt effusion: ballotment test
  5. Obs patellar mvmt during knee AROM
  6. Muscle strength testing: hip, knee, ankle
  7. Muscle length testing: mm crossing hip and knee
  8. Assess patellar position & mobility (poor reliability)
  9. Palpation: patella borders, retinaculum, patellar facets
  10. Special tests: apprehension, McConnell’s tilt
  11. Mvmt assessment (Obs for “dynamic” Q-angle): Ecc step test (15 cm height), DL/SL squat, drop jump test
31
Q

What are 3 special tests for PFPS?

A
  1. Apprehension
  2. McConnell’s
  3. Tilt
32
Q

Describe how to perform McConnell’s test for PFPS and what a + test is

A

How:
- Pt sitting
- PT performs iso knee ext at 30, 60, 90, 120 deg
- If pn, repeat w/ medial patellar glide (ask if it changes pn…if no more pn = candidate for patellar taping)

+ test: pn relieved w/ medial glide

33
Q

How does a Patellofemoral Pain Classification influence POC?

A

It drives intervention plan!

34
Q

What are the 4 Patellofemoral Pain Classifications? And what would indicate you classifying someone under each classification w/ a fair level of certainty?

A
  1. Overuse/overload w/o other impairment
    • Inc in mag/freq of PFJ loading at
      rate that surpasses ability of PFJ
      tissues to recover
  2. Muscle performance deficits
    • LE muscle performance deficits in
      hip & quads
  3. Movement coordination deficits
    • excessive/poorly controlled knee
      valgus during dynamic task (not
      necessarily due to weakness)
  4. Mobility impairments
    • Higher than norm foot mobility
      and/or flexibility deficits of 1 or
      more of: HS, Quads, gastroc, sol,
      lat retinaculum, IT band
35
Q

What are interventions to address the 4 Patellofemoral Pain Classifications?

  1. Overuse/overload w/o other impairment
  2. Muscle performance deficits
  3. Movement coordination deficits
  4. Mobility impairments
A
  1. Overuse/overload w/o other impairment: taping, activity mod
  2. Muscle performance deficits: hip and quad strengthening
  3. Movement coordination deficits: gait and mvmt retraining
  4. Mobility impairments: foot orthoses or taping, muscle stretching
36
Q

T or F: It is recommended that Hip + Knee exercises are performed to reduce pain and improve function in short/long term….compared to only knee exercises

A

True.

In early stages of tx, there may be a preference to hip-targeted exercises over knee-targeted exercises

37
Q

T or F: according to the PFPS CPG, clinicians MAY use tailored patellar taping in combo w/ exercise to assist in immediate pn reduction, and to enhance outcomes of exercise in short term

A

True.

38
Q

T or F: according to the PFPS CPG, clinicians should NOT use patellofemoral knee orthoses (including braces, sleeves, and straps) for tx of PFPS

A

True

39
Q

T or F: according to the PFPS CPG, clinicians SHOULD prescribe prefabricated foot orthoses for pts w/ greater than norm pronation, to reduce pn, but only short term (up to 6 wks)

A

True.

40
Q

T or F: according to the PFPS CPG, clinicians should NOT use dry needling for tx of of pts w/ PFPS

A

True.

41
Q

T or F: according to the PFPS CPG, clinicians should NOT use manual therapy (lumbar, knee, patellofemoral manip/mob) in ISOLATION for PFPS

A

True.

42
Q

T or F: according to the PFPS CPG, clinicians should NOT use biophysical agents, incl US, cryotherapy, phonophoresis, iontophoresis, E stim, therapeutic laser, for tx of PFP.

A

True.

43
Q

What is the etiology of PLICA SYNDROME?

A
  • irritation of embryologic synovial tissue circling the patella (the PLICA) - usu sup or med aspect of patella
  • Abnormal tracking of patella can cause inc tissue stress w/ plica becoming thicker & fibrotic
44
Q

What are sxs of PLICA SYNDROME?

A
  1. Pain/discomfort over sup & med aspects of patella
  2. “Clicking” or “snapping” sensation w/ knee mvmt
45
Q

What are intervention options for pts w/ PLICA SYNDROME?

A
  1. Exercise (address muscle length and/or strength impairments
  2. Iontophoresis w/ dexamethasone (corticosteroid) to dec plical inflammation
  3. Activity mod as needed
46
Q

T or F: the term “tendinopathy” encompasses a spectrum of tendon changes…such as the terms: “tendin-itis” and “tendin-osis”

A

True.

Tendinitis = ACUTE inflammatory condition
Tendinosis = CHRONIC degenerative condition

47
Q

Compare a normal tendon with an ‘altered’ tendon?

A

Normal:
- Highly arranged parallel collagen fibers
- Sparse cells (mostly tenocytes)

‘altered’ tendon:
- Fragmented collagen fibers & disorganized collagen bundles
- Accumulation of GAGs
- inc microvasculature assoc. w/ neoinnervation
- inc non-tendon tissue (fat, bone)

48
Q

What kinds of sports is patellar tendinopathy common?

A

Sports that involve a lot of jumping!

  1. Basketball
  2. Volleyball
  3. High/long jumpers
49
Q

What are risk factors for patellar tendinopathy based of off consistent themes across risk studies?

A
  1. High load jumping sports (basketball, volleyball etc)
  2. Sudden inc in training vol
  3. Dec ecc quad mm performance
  4. Dec quad/HS flexibility
  5. Inc foot pronation vel
  6. Fluoroquinolone (antibiotic) use
  7. Genetics
50
Q

What are things that a pt could describe or you could ask about their hx that would align w/ patellar tendinopathy?

A
  1. Recent change in training: surface, load, volume
  2. Insidious onset of tendon pain, esp at INFRAPATELLAR POLE
51
Q

What are tests/measures appropriate for a pt with suspected patellar tendinopathy?

A
  1. Self-reported outcome tool: VISA-P (Victorian Institute of Sport Assessment Patellar –> specific to patellar tendinopathy)
  2. Obs/posture: foot type, quad mm symmetry, patellar tendon thickness, LE movement pattern (SL squat)
  3. Mobility impairment: assess ROM, muscle length
  4. Muscle performance impairment: assess hip, knee, ankle strength
  5. Palpation: inf patellar pole (high SEN 97.5% and mod SPEC 70%
  6. Special tests:
    • SL decline squat test (+: pn w/
      squatting) = MOST discriminative
      of 5 tests (step up, DL squat,
      decline DL squat, decline SL
      squat, decline SL jump)
    • Royal London Hospital Test:
      palpate prox tendon w/ knee ext
      and flex (+: pn reduced/absent in
      knee flex)
52
Q

What are intervention options for pts w/ patellar tendinopathy?

A
  1. Resisted exercise
  2. Quad/HS stretching
  3. Orthotics (anecdotal)
53
Q

What are resisted exercise options for a pt w/ patellar tendinopathy?

A
  1. Quad ecc exercise (Alfredson protocol: 3x15, 2x/day, 7 days/wk, 12 wks = pnful tendon training)
  2. Heavy slow resistance (HSR): standing squat or seated leg press w/ high load (60-85% 1RM)
  3. High load Iso exercises: 70-80% MVC at 60 deg knee flex for 5x45 sec holds
54
Q

What are common features of successful ecc training for patellar tendinopathy (and other tendonopathies)?

A
  1. Decline squat
  2. Painful training: pt should have up to 4/10 pain w/ exercise (if no pain, inc load!!)
  3. Athletes should take time away from sport
55
Q

Why prescribe ecc training? (3 reasons)

A
  1. Inc Type I collagen
  2. Inc tendon stiffness
  3. Dec tendon neovascularity
56
Q

If a pt w/ patellar tendinopathy is looking for short-term pn relief and they are in the middle of a season, which exercise would be more effective:

A. Isometric exercises
B. Heavy slow resistance or Ecc exercises

A

A. Isometrics! (appear to be more effective during competitive seasons for short-term pain relief

HSR or ecc = more suitable for long-term pain reduction & improvement in knee function

57
Q

What are 2 examples of PHYSES (growth plate) DISORDERS?

A
  1. Osgood-Schlatter disease
  2. Sinding-Larsen-Johansson disease (SLJ)
58
Q

Compare the following 2 PHYSES (growth plate) DISORDERS:

  1. Osgood-Schlatter disease
  2. Sinding-Larsen-Johansson disease (SLJ)
A
  1. Osgood-Schlatter disease
    Etiology:
    • Repetitive stress –> avulsion
      injury where patellar tendon
      inserts into tibial tubercle
      secondary ossification center
    • Onset: early adolescence
    • 5x > adolescence in sports
    • 2-3x > males
      Sxs:
    • Pn at attachment site of tendon
      to tibial tubercle exacerbated by:
      running, jumping, kneeling
    • Pn w/ prolonged sitting w/ knees
      flex
  2. Sinding-Larsen-Johansson disease (SLJ)
    • Similar to OSD but occurs at
      JUNCTION of patellar tendon and
      distal pole of patella
    • Intervention: protection,
      stretching quads, icing

MM I (9 decks)

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