Exam 3 - Knee Flashcards
what is the functional ROM of kee flexion during the swing phase
60 degrees
what is the functional ROM of knee extension during heel off
10 degrees
t/f
if the knee does not reach full extension, then the ankle may become hypermobile
true
how does the hip compensate if the knee does not fully extend or hyper extend
the hip will not compensate because it needs to IR when the knee ER at heel off
how many degrees of knee flexion is need when descending stairs
90 degrees flexion
may need p to 120 degrees flexion
how many degrees of flexion is needed with sit to stand from a toilet/low chair
105 degrees flexion
what is the goal of knee flexion with TKA
~120 degrees
if a patient reports pain or limited with a deep squat, what femoral glide needs improvement
posterior glide
what are the arthrokinematics of the knee when kneeling and deep squatting
femoral ER and posterior glide
slight abduction and lateral glide
what is a sprain
stretching or tearing of lig that may lead to some laxity and dysfunction
what is functional joint instability
able to offset laxity through neuromuscular function
what is mechanical joint instability
unable to offset laxity
likely requires surgery
describe a grade 1 sprain
mild S&S
activity can continue
fibers are stretched, but not torn
minimal to no change during lig special tests
describe a grade 2 sprain
moderate S&S
activity stops
fibers are stretched and torn = increased laxity
soft/late end feel during lig special tests
describe a grade 3 sprain
severe S&S
activity stops
fibers torn completely with possible avulsion
significant increase with laxity with empty end feels during lig tests
describe ligaments and capsules
dense connective tissue
type 1 collagen - resists tension
low elastin - better joint stabilization
fibrocytes
more multi-directional fibers than tendons
ends of ligs are hypervascular and hyperneural
describe the healing phases of sprains
initial tensile strength @ 3-5 weeks
dense connective tissue @ 12 weeks
normal strength @ 10-12 months
what is the Rx following sprains
POLICED
external support/AD
position lig in shortened position to heal to avoid laxity
MET for tissue proliferation/integrity/stabilization
what are the attachments of the ACL
attaches centrally and anteriorly on tibial plateau
runs superior, posterior, laterally
attaches to lateral aspect of the intercondylar fossa
what motions does the ACL primarily resist
excessive anterior tibial glide
secondary restraint to tibial IR
what is the prevalence of ACL injuries
20% of all knee injuries
mostly in young, active females
what are the non-modifiable risk factors for non-contact ACL injury
female
2 weeks following start of period
boy morphology
congenital joint hypermobility
what are the modifiable risk factors for non-contact ACL injury
high shoe-surface interaction/friction
high BMI
inconsistent benefit of preventative bracing
greater muscle imbalances in females vs males
lower strength with ACL tears
low ham:quad
altered loading patterns
impaired trunk proprioception and kinesthesia
greater activation of visual-motor strategy
what altered loading patterns could lead to an ACL injury
impaired LE control
- increased dynamic knee valgus and hip add
earlier and 2x faster with impaired LC control
decreased knee FLX with larger ground reaction forces/harder landing
what would be considered poor LE control that could lead to an ACL injury
significant valgus movement
knee medial to foot
what would be considered reduced LE control that could lead to ACL injury
some valgus movement
knee not entirely medial to foot
what would be considered good LE control
no valgus movement
knee vertical with toes
what are examples of impaired trunk proprioception and kinesthesia that could lead to ACL injury
greater trunk lean toward support limb
greater trunk rotation toward support limb
what is the etiology of non contact ACL injury
50-70% of cases
deceleration-rotation - femur ERs on tibia which is relative IR of the tibia in CKC
hyperextension
what are the symptoms of ACL injury
effusion, popping, and giving way following trauma
WBing activities limited with likely giving way
what ROM would you expect with an ACL injury
limited and painful - particularly into hyperext and IR
what special tests would be positive with ACL injury
anterior drawer test
lachman’s test
pivot shift
what factors could result in a false positive when testing ACL
sever swelling that tightens capsule
hamstring guarding
meniscal tear
what leads to muscle inhibition
swelling/inflammation
disuse
weakness
laxity
pain
why would the quads be inhibited with ACL injury
pain
effusion/joint swelling
joint laxity or giving away
mm weakness/incoordination
not due to denervation
t/f
amount of joint swelling is always correlated with the amount of mm inhibition
false
the amount of swelling is not always correlated with amount of muscle inhibition
atherogenic muscle inhibition of quads leads to
atrophy and more inhibition/weakness - deficits common out 2-4 years post op and even in both LE
how do you determine inhibition of quads
observation, palpation, m testing
what are eh 3 primary and early goals of PT with ACL injury
full to near full ROM, especially ext
minimal to no swelling
quads activation/endurance/coordination
how should PT treat to improve ROM after ACL injury
immediate mobilization for ROM and pain
full ext no later tan 4 weeks
what do you look for with quad activation after ACL injury
SLR without extension lag
quad set >/= 90% of uninvolved side
what is the PT rx following ACL injury
early Wbing
POLICED
functional bracing
MT
MET
what is the benefit of using neuromuscular electrical stimulation (NMES) following ACL injury
significant increase in quad strength
no significant change with function
isometrics @ varying angles based upon symptoms and comorbidities
discontinue once quad indez is >/= 80% of uninvolved side
why is there a greater load with NWBing activities following an ACL injury than WB activities
NWB: asymmetrical mm activation, only quads activated
WB: quads, hamstrings, etc are activated = more support for the joint
when is the load the greatest at the knee
50 degrees of full extension with NWB and WB
when is load increased/decreased with WB activities such as squatting, lunging, and leg press
increased with knees past toes
decreased with forward trunk lean
why is walking considered to have as much load as NWB activities
repetitive terminal knee extension
what is the prevalence of meniscal injuries
2nd most common knee injury
medial > lateral meniscus
posterior > anterior drawer
what is the prevalence of degenerative meniscal injuries
older, >60 years
male > female
work related kneeling/stairs
what is the function of the meniscus
stability
deepen joint surface
describe the outer 1/3 of the meniscus vs the inner 1/3 of the meniscus
outer: 80% of type 1 collagen
inner: 60% type 2 collagen, 40% type 1 collagen
describe how the meniscus attaches
nearly circular
wedge-shaped fibrocartilage disc on the tibial plateau
attaches to tibia via horizontal coronary ligaments
what symptoms would you expect with meniscus injury
joint pain with possible referral to shin
acute injury with WB sports
chronic with older individual with or without prior injury
limited and painful motion
WB limitation with catching or locking
what would you expect to observe with meniscal injury
possible swelling
potential asymmetrical and antalgic gait
what would you expect to find in the scan of a meniscal tear/injury
ROM: limited and painful motion
RST: potentially weak and painful quads
ST: possibly painful with compression
what special tests would be used if you suspect a meniscal tear/injury
mcmurrays
ege’s
thessaly’s - lateral meniscus only
apley’s - compression
what is the PT Rx for a meniscal tear
POLICED
AD to avoid limping
JM
MET
what is the focus of MET for a meniscal tear
meniscal integrity and stabilization
NMES
what is the effect of surgery vs PT with degenerative meniscal tears
PT equally effective as surgery for improved pain
less anxiety and depression vs surgery
describe baker’s cyst
excessive swelling in popliteal space
mostly due to particular changes
fluid-filled cyst due to persistent inflammation and/or subsequent weakening of capsule
what condition does baker’s cyst commonly mimic
meniscal tear
what are the S&S of baker’s cyst
asymptomatic until significant effusion
ROM: limited and painful FLX/EXT
RST: painful into flx
palpation: popliteal protrusion just medial to medial gastroc head
what is the precaution for PT with baker’s cyst, why
forceful activity such as a deep squat or heavy resistance training
avoid excess stress on the cyst
what is the prognosis of baker’s cyst
difficult to manage in active individuals
a ruptured baker’s cyst can mimic what other condition
gastroc tear
what is the MD rx for baker’s cyst
aspiration or surgical repair
what is the incidence/prevalence of ARJC at the knee
most commonly of medial femoral condyle and patella articular surface
seen with 60-80% of sopes
greatest prevalence in elite level sports
similar prevalence in non-elite athletic and non-athletic population
what are risk factors for ARJC at the knee
increased age
previous joint injury, especially mensicus
increased BMI
occupation
quad weakness
what are the symptoms of ARJC at the knee
gradual and unknown onset of pain that is worse in WBing
severity associated with bone edema with subarticular bone attrition and synovitis
can become nociplastic pain
pain relieved in NWB
stiffness <30 mins after prolonged positions
limited and painful motion
what would you expect to observe with ARJC
antalgic/asymmetrical gate
possible genu varum
why is genu varum common with ARJC at the knee
medial aspect of the tibial tuberosity is most affected
what ROM would you expect to find with ARJC at the knee
PROM just as limited as AROM with firm end feels
pain with closed packed position of the knee
capsular pattern of restriction of flx > ext
what would you expect to find with combined motions with ARJC at the knee
consistent block
what would you expect to find with stress test with ARJC at the knee
distraction - possibly relieving
compression - likely painful
what would you find with accessory motion at the knee with ARJC
hypomobility
what would special tests would be positive with ARJC at the knee
(+) meniscal tests
impaired walking distance and gait velocity with 6 MWT and TUG test
what would you expect to find with RST at the knee with ARJC
inhibited quads and hip abductors
what would you expect to find with palpation with ARJC at the knee
joint line tenderness
what is the prognosis of orthotics/braces with ARJC at the knee
lateral heel wedges not recommended
unloader knee brace could be helpful
how should JM be used with ARJC at the knee
as needed with exercise to aide in making exercises more beneficial
what should be the prescription of PT for a patient with ARJC at the knee (# of visits in what amount of time)
12 PT sessions over a year is better than 12 sessions over 9 weeks
what medications are most useful with ARJC a the knee
NSAIDS, tylenol
narcotics and injections have adverse effects or research is inconclusive
what is the prognosis of arthroscopy or “cleaning” out the joint with ARJC at the knee
strong recommendation against all patients with ARJC
no clinical important benefits
when is a joint replacement necessary for a patient
when the joint begins to affect other parts of the body or mental health
what do you teach the patient during prehab prior to TKA
AD training
planning for recovery (HEP)
expectation management
stair climbing is _x body weight force on knee
3x body weight
squatting is _x body weight force on knee
7x body weight
why is the peak force of the knee at 90 degrees
closed packed position in PF joint
what are the risk factors for patella femoral syndrome
military recruits
dynamic not static excessive pronation
females
patellar and femoral bone shape
why do females have a higher risk factor for developing PFPS
larger Q angle
differing hip strength and coordination
what is the etiology or pathomechanics of PFPS
mainly idiopathic
theory of PF malalignment/maltracking
describe the PF malalignment/maltracking with PFPS
patella glides and tilts more laterally relative to femur
involves decreased surface area contact between patella and femur
explain the pathomechanics of PFPS
overload of patellar subchondral bone, especially lateral facet
tissue ischemia
loss of tissue homeostasis
neural ingrowth increase in substance pain nerve fibers that ransmit more pain
what structures are involved with PFPS
subchondral bone of patella
infrapatellar fat pad
bursae
quad and patella tendons
synovium
med and lat retinaculum
what are the symptoms of PFPS
often gradual onset
primarily anteromedial knee pain
pain increased with stairs, sitting, squatting, kneeling, prolonged sitting
what would you expect to observe with PFPS
increased Q angle
open chain maltracking of patella
quad atrophy
impaired LE control
weak trunk control
describe what the patient with PFPS will demonstrate in regards to impaired LE control
proprioceptive deficits
dynamic excessive pronation
abnormal planar motions, especially in females
increased frontal and sagittal plane motions
hip ER weakness
what ROM would you expect to find with PFPS
limited and painful
flx - greater PF compression
ext - more fat pad irritation
what would you expect to find during RST with PFPS
possible pain/weakness with ext
likely inhibited quad activity
potential anti-gravity trunk and hip weakness
what would you expect to find with ST with PFPS
possible pain with PF compression
what would you expect to find during neuro test with PFPS
limited dural mobility of femoral nerve in 1/3 of patients
what special tests would you expect to be positive with PFPS
medial patella plica test
pain with knee MMT
apprehension test
what muscles would be possibly shortened with PFPS
thomas test: rectus
ober’s: TFL/ITB
SLR: hams
gastroc
explain the use of foot orthotics for PFPS
effective immediately
effective in short and mid term
no difference at a year
mechanism is unclear
what is the prognosis of STM and JM to treat PFPS
clinically important difference for pain in short term
improvements but less for function
better when used with exercise
what muscle groups are targeted with PFPS
quads, hips
what verbal cues would be appropriate for PFPS
cue to run softly and not to let your knee fall in
contract glutes and keep knee pointing straight ahead
waht is the prognosis of PFPS
80% pts that completed rehab still reported pain
74% reduced activity acter 5 years
worse with higher initial pain levels, longer duration of pain, and lower function
how can PFPS lead to OA
disuse
subchonral one is damaged = eariler ARJC
back of the patella is one of the most common areas to have ARJC
what is a lateral retinacular release
longitudinal incision of lateral retinaculum
can lead to medial instability
what is extensor mechanism realignment
repositioning of insertion site
open procedure = longer rehab with long-term extensor lag problems
what are the risk factors for patellar dislocation
preexisting patellar hypermobility
more common with shallow sulcus angle/trochlear groove and/or large positive congruence angle or laterally located patella
what is the etiology of patellar dislocation
trauma with lateral patella displacement
may be more likely with preexisting patellar hypermobility
what are the S&S of patellar dislocation
traumatic and worse case of PFPS
patellar apprehension (+)
what is the PT rx for patellar dislocation
POLICED
MET
how does taping affect the prognosis of patellar dislocation
applied after 1 week of immobilization for better outcomes than complete immobilization
what is the prognosis of patellar dislocation
up to 44% redislocation rate
higher without surgery
explain the MET for patellar dislocation
CKC exercises to OKC
quad - isometrics and isotonic
extensibility and elasticity of postlat structures (hams, ITB, gastroc)
what is ITB syndrome
tendinopathy of the distal ITB
what is the prevalence of ITB syndrome
5-14% of runners
2nd leading cause of knee P! in runners
males compromise in 50-81% of cases
what are the risk factors of ITB syndrome
running
training errors
weak hip ERs and ABDs
excessive prnation
increased hip add and IR
trunk leanin U stance
associated with GTPS and PFPS
what structures are involved with ITB syndrome
TFL/ITB
lateral femoral epicondyle
gerdy’s ubercle insertion
associated bursae and fat pad
what are the symptoms of ITB syndrome
gradual onset of lateral knee pain
worse with activities involving repetitive knee motion, grades, dynamic U stance
what are the signs of ITB syndrome
obs: impaired LE control
ROM: pain likely with hip add
RST: possible hip ER and ABD weakness, particularly in a lengthened position
Special: (+) obers
palpation: TTP over lateral femoral condyle and gerdy’s tubercle
what is the purpose of MET with ITB syndrome
tendon proliferation and stabilization
what are the progressions of MET with ITB syndrome
isometric loading from shortened
isotonic loading from shortened to neutral
isotonic loading from neutral to lengthened
isometric loading with weight bearing - CC hip abd, ER, ext
plyometrics
