Chronic Knee Flashcards
What condition is NON-inflammatory arthritis in the knee ?
OA
What are 4 types of inflammatory arthritis in the knee?
- RA
- Systemic lupus erythematosus (SLE)
- Gout
- Psoriatic arthritis
appears read and warm, unlike with non-inflammatory (OA)
T or F: OA can occur in any/all of the 3 compartments:
- Medial
- Lateral
- Patellofemoral
True.
What are 8 risk factors for OA?
- > 50 yo
- Female
- Higher BMI
- Previous knee injury or malalignment
- Joint laxity
- Occupation/recreational use of knee
- Family hx of arthritis
- Presence of Heberden’s nodes on fingers
What are sxs of knee OA?
- Usage-related pn (often worse end of day), pn relieved by rest
- “Giving way” of knee(s)
- Mild morning/inactivity stiffness
- Impaired function
- More persistent rest and night pn may occur in advanced OA
According to Zhang 2010, you can correctly diagnose 99% of knee OA pts when ALL 6 criteria are met:
- Persistent knee pn
- Morning stiffness
- Reduced function
- Crepitus in knee
- Restricted knee mobility
- Bony enlargement of knee
What is the GOLD standard for OA imaging?
Plain radiography (WBing, semi-flexed PA view, plus lateral and merchant views)
What are 4 classic radiographic findings for knee OA?
- Focal jt space narrowing
- Osteophytes
- Subchondral bone sclerosis
- Subchondral cysts
What are tests/measures you would consider performing with a patient with known/suspected knee OA?
- Pt-reported outcomes: LEFS, WOMAC, KOOS
- Static posture (genu varum: med compartment OA, genu valgum: lat compartment OA)
- Gait analysis (OA characteristics: slower speed, dec stride length, dec knee flex, varus thrust)
- Joint effusion: Ballotable patella sign
- Knee ROM: loss of AROM & PROM
- Muscle strength & endurance: (MMT, functional tests: STS, curb ascent, stair climbing)
What does the OARSI (OA Research Society International) recommend for interventions for knee OA?
“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”
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
True.
True.
What are surgical interventions for knee OA?
- High tibial osteotomy
- Total joint replacement: uni, bi, tri compartmental
What is osteochondritis dissecans (OCD)?
Focal, idiopathic alteration of subchondral bone with risk for instability and disruption of adjacent articular cartilage that may result in premature OA.
What is the most common location for osteochondritis dissecans?
Medial femoral condyle (lateral surface)
Can also occur on lat femoral condyle and patella (less common tho)
Rare: tibial plateau
Osteochondritis dissecans is more common during ___ years and 4x higher in __(sex)__
Teen
Males
What are potential etiologies for osteochondritis dissecans?
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
What are 3 sxs of osteochondritis dissecans?
- knee jt pn w/ WBing
- swelling (variable)
- “locking” of knee
Where may a pt with suspected osteochondritis dissecans have pain with palpation?
Femoral condyles at different degrees of knee flex
For a pt w/ osteochondritis dissecans, what would indicate that you can proceed with PT interventions? And what would those interventions consist of?
If the OCD fragment is stable.
- Protected WBing
- Activity mod for 3 mo
- Impairment-focused interventions: ROM, strengthening, balance
If a pt has osteochondritis dissecans and the fragment is unstable or free-floating in the knee joint, is PT appropriate?
No, they would be referred for surgery:
- Microfracture technique
- Osteochondral graft (mosaicplasty)
- Autologous cartilage implantation (ACI)
What are 2 passive structures that provide laterally directed forces on the patella?
- IT band
- Lateral retinacula
What are 3 passive structures that provide medially directed forces on the patella?
- medial retinacula
- medial patellofemoral lig (MPFL)
- raised lateral wall of trochlear groove
What are 4 dynamic structures that act on the patella?
- Vastus medialis
- Vastus intermedius
- Vastus lateralis
- Rectus femoriss
Why have clinicians transitioned away from trying to “isolate” the VMO?
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)
Identify risk factors for patellofemoral pain syndrome (anterior knee pain)
- Active women
- Dec quad iso strength
- Quad atrophy
- Inc dynamic valgus angulation (more evidence to support “DYNAMIC” Q-angle in dev of ant knee pain than static Q-angle
- Dec prominence of lat wall of trochlear groove
- Abnormal length of patellar tendon
- Psychological factors: anxiety, depression, pain catastrophizing
T or F: Static Q-angle is NOT a predictive factor in the dev of PFPS
True.
(Pappas 2012)
What is the difference between patella alta and patella baja?
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
What 4 things indicate a poorer prognosis for PFPS?
- Higher # of pn sites
- Longer pn duration
- Lower self-efficacy, higher emotional distress
- Worse SKPA score at baseline
What are 3 sxs of PFPS/ant knee pn?
- general complaints of ant knee pn
- +/- crepitus w/ movement of PFJ
- Sxs inc w/ stairs, squatting, and/or prolonged sitting (“theater sign”)
What should you include in your examination of a pt with suspected PFPS/ant knee pain?
- Pt-reported outcome tools: LEFS, AKPS (Anterior Knee Pain Scale), KOOS-PF
- Obs standing posture
- Obs gait
- Assess jt effusion: ballotment test
- Obs patellar mvmt during knee AROM
- Muscle strength testing: hip, knee, ankle
- Muscle length testing: mm crossing hip and knee
- Assess patellar position & mobility (poor reliability)
- Palpation: patella borders, retinaculum, patellar facets
- Special tests: apprehension, McConnell’s tilt
- Mvmt assessment (Obs for “dynamic” Q-angle): Ecc step test (15 cm height), DL/SL squat, drop jump test
What are 3 special tests for PFPS?
- Apprehension
- McConnell’s
- Tilt
Describe how to perform McConnell’s test for PFPS and what a + test is
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
How does a Patellofemoral Pain Classification influence POC?
It drives intervention plan!
What are the 4 Patellofemoral Pain Classifications? And what would indicate you classifying someone under each classification w/ a fair level of certainty?
- Overuse/overload w/o other impairment
- Inc in mag/freq of PFJ loading at
rate that surpasses ability of PFJ
tissues to recover
- Inc in mag/freq of PFJ loading at
- Muscle performance deficits
- LE muscle performance deficits in
hip & quads
- LE muscle performance deficits in
- Movement coordination deficits
- excessive/poorly controlled knee
valgus during dynamic task (not
necessarily due to weakness)
- excessive/poorly controlled knee
- Mobility impairments
- Higher than norm foot mobility
and/or flexibility deficits of 1 or
more of: HS, Quads, gastroc, sol,
lat retinaculum, IT band
- Higher than norm foot mobility
What are interventions to address the 4 Patellofemoral Pain Classifications?
- Overuse/overload w/o other impairment
- Muscle performance deficits
- Movement coordination deficits
- Mobility impairments
- Overuse/overload w/o other impairment: taping, activity mod
- Muscle performance deficits: hip and quad strengthening
- Movement coordination deficits: gait and mvmt retraining
- Mobility impairments: foot orthoses or taping, muscle stretching
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
True.
In early stages of tx, there may be a preference to hip-targeted exercises over knee-targeted exercises
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
True.
T or F: according to the PFPS CPG, clinicians should NOT use patellofemoral knee orthoses (including braces, sleeves, and straps) for tx of PFPS
True
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)
True.
T or F: according to the PFPS CPG, clinicians should NOT use dry needling for tx of of pts w/ PFPS
True.
T or F: according to the PFPS CPG, clinicians should NOT use manual therapy (lumbar, knee, patellofemoral manip/mob) in ISOLATION for PFPS
True.
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.
True.
What is the etiology of PLICA SYNDROME?
- 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
What are sxs of PLICA SYNDROME?
- Pain/discomfort over sup & med aspects of patella
- “Clicking” or “snapping” sensation w/ knee mvmt
What are intervention options for pts w/ PLICA SYNDROME?
- Exercise (address muscle length and/or strength impairments
- Iontophoresis w/ dexamethasone (corticosteroid) to dec plical inflammation
- Activity mod as needed
T or F: the term “tendinopathy” encompasses a spectrum of tendon changes…such as the terms: “tendin-itis” and “tendin-osis”
True.
Tendinitis = ACUTE inflammatory condition
Tendinosis = CHRONIC degenerative condition
Compare a normal tendon with an ‘altered’ tendon?
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)
What kinds of sports is patellar tendinopathy common?
Sports that involve a lot of jumping!
- Basketball
- Volleyball
- High/long jumpers
What are risk factors for patellar tendinopathy based of off consistent themes across risk studies?
- High load jumping sports (basketball, volleyball etc)
- Sudden inc in training vol
- Dec ecc quad mm performance
- Dec quad/HS flexibility
- Inc foot pronation vel
- Fluoroquinolone (antibiotic) use
- Genetics
What are things that a pt could describe or you could ask about their hx that would align w/ patellar tendinopathy?
- Recent change in training: surface, load, volume
- Insidious onset of tendon pain, esp at INFRAPATELLAR POLE
What are tests/measures appropriate for a pt with suspected patellar tendinopathy?
- Self-reported outcome tool: VISA-P (Victorian Institute of Sport Assessment Patellar –> specific to patellar tendinopathy)
- Obs/posture: foot type, quad mm symmetry, patellar tendon thickness, LE movement pattern (SL squat)
- Mobility impairment: assess ROM, muscle length
- Muscle performance impairment: assess hip, knee, ankle strength
- Palpation: inf patellar pole (high SEN 97.5% and mod SPEC 70%
- 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)
- SL decline squat test (+: pn w/
What are intervention options for pts w/ patellar tendinopathy?
- Resisted exercise
- Quad/HS stretching
- Orthotics (anecdotal)
What are resisted exercise options for a pt w/ patellar tendinopathy?
- Quad ecc exercise (Alfredson protocol: 3x15, 2x/day, 7 days/wk, 12 wks = pnful tendon training)
- Heavy slow resistance (HSR): standing squat or seated leg press w/ high load (60-85% 1RM)
- High load Iso exercises: 70-80% MVC at 60 deg knee flex for 5x45 sec holds
What are common features of successful ecc training for patellar tendinopathy (and other tendonopathies)?
- Decline squat
- Painful training: pt should have up to 4/10 pain w/ exercise (if no pain, inc load!!)
- Athletes should take time away from sport
Why prescribe ecc training? (3 reasons)
- Inc Type I collagen
- Inc tendon stiffness
- Dec tendon neovascularity
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. 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
What are 2 examples of PHYSES (growth plate) DISORDERS?
- Osgood-Schlatter disease
- Sinding-Larsen-Johansson disease (SLJ)
Compare the following 2 PHYSES (growth plate) DISORDERS:
- Osgood-Schlatter disease
- Sinding-Larsen-Johansson disease (SLJ)
- 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
- Repetitive stress –> avulsion
- 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
- Similar to OSD but occurs at
