Hip and Knee Flashcards
1
Q
Which muscles are often shortened in the lower extremity?
A
- iliopsoas
- rectus femoris
- hamstrings
- TFL
- adductors
- erector spinae
- gastroc/soleus
2
Q
What muscles are often lengthened and weak in the lower extremity?
A
- glut med and max
- hamstrings
- multifidus
- transverse abdominus
- internal oblique
- anterior/posterior tib
3
Q
What muscles are tight in a flat-back posture?
A
tight hams that tilt the pelvis back
4
Q
What muscles are tight in a lordotic posture?
A
tight hip flexors
5
Q
Which fibers of the glut med are prone to weakness? What actions do those fibers do?
A
- posterior fibers of glut med are often week
- these fibers do more extension and external rotation
6
Q
How do you isolate the posterior fibers of glut med in an exercise?
A
put pt in sidelying, point toes to ceiling, and abduct leg
7
Q
What do the anterior fibers of glut med do?
A
flexion and internal rotation (like TFL)
8
Q
T/F: Internal rotation of the stance limb helps drive the contralateral limb forward.
A
true
9
Q
Why would we strengthen glut med when dealing with ACL injuries?
A
- ACL can be due to valgus collapse, which can be due to weak ERs of the hip
- so strengthen post. glut med, since it does ER
10
Q
What does the Thomas test look for?
A
tight iliopsoas
- laying supine with one knee at chest and leg in question hanging off table, looking to see if thigh is up in air
Also tests for tight TFL, rectus femoris, and sartorius
11
Q
If the Thomas test shows that the leg is in abduction when laying in air, what muscle is tight?
A
TFL
12
Q
If Thomas test shows external rotation, what muscle is tight?
A
sartorius
13
Q
T/F: The more hip flexion you use in a clamshell exercise, the more glut med you use.
A
false, more hip flexion = less glut med activity
14
Q
What’s the easiest way to start a clamshell exercise?
A
Start in supine with legs bent, and abduct legs with theraband around them. Then lift butt into bridge and hold abducted leg position
15
Q
What’s the highest intensity exercise that activates the glut med for a clamshell?
A
side-lying abduction
16
Q
What are some common exercises for glut med? (list five)
A
- clams
- side-lying abduction
- single limb squat/wall slide
- lateral band walk
- lunges diagonal, sideways, forward
17
Q
What is hip adduction syndrome? What populations see this syndrome?
A
hip adduction with or without internal rotation
- may be associated with piriformis syndrome
- female athletes and CP often have this
18
Q
What can cause hip adduction syndrome?
A
pelvic width, muscle imbalance, poor training
19
Q
How will a patient present if they have tight R adductor syndrome?
A
the pelvis may be dropped to the right, with the right femur internally rotated and abducted
20
Q
What hip extensor is a tri-planar muscle? Describe each movement in each plane.
A
glut max
- superior fibers = abductor and IR
- inferior fibers = adductor and ER
- also does hip extension
21
Q
Abduction and internal rotation are done by what fibers in glut max?
A
superior fibers
22
Q
Is the bridge exercise appropriate for end-stage glut max strengthening? If not, what should we use instead?
A
not appropriate for end range, not enough MVC with that exercise
- move to single leg wall slides, single leg mini squat, single limb deadlift
23
Q
What muscle stabilizes the hip during knee extension?
A
glut max
24
Q
How is glut max important during gait?
A
controls hip flexion in stance and then decelerates hip flexion during swing
25
What is often the cause of a trochanteric bursitis?
muscle imbalance
- TFL gets tight, inhibits glut max
- this muscle imbalance rubs the bursa over trochanter wrong
26
What do our interventions focus on after a THA?
- normalizing ROM
- working within WB restrictions
- improving neuromuscular control as well as core
- strengthening and endurance training
27
What are some indications that your patient may have OA?
- limited IR to 15 degrees!! (and limitations in one other motion also)
- stiffness of joints goes away in morning after around 60 minutes
- pain with increased WB activities, usually around anterior and lateral hip, can move into thigh/knee
- older than 50 yo
- no history of traumatic fall
28
When someone comes to prehab, what do we do with them?
- teach them how to use their device
- strength and aerobic training
- transfer training and home prep
29
Which has better outcomes, the total hip arthroplasty or the hemi?
total, a lot of hemis have to go back and end up getting the total later
30
What's the main complication in a total hip?
loosening of prosthetic components
31
With what kind of THA can you begin weight bearing sooner?
cement one, quick adhesion
32
What is the protocol for a hip ORIF?
non-WB for 1-2 wks, followed by partial WBAT
33
In what instances is an ORIF or OREF used? (internal or external fixators)
multiple breaks, often car accidents
34
What PT can we do with someone that has an internal/external fixator?
work on things proximal and distal to the injury
35
What is replaced in a total hip vs. hemi hip?
```
total = ball and acetabulum replaced
hemi = just ball replaced
```
36
With a posterior approach for THA, what are the precautions?
post. THA = no hip flexion past 90, no IR, no adduction past neutral
37
For these post. THA patients, what is important to remember, as far as ADLs, so that the pt abides by the precautions?
- don't let them sit in low chairs where knees will get above hips (too much HF)
- no donning/doffing socks
- no bending to pick something up
- no pivoting or turn/twisting on affected leg
- don't lie on that side (put pillow there)
38
With a posterior approach to THA, what muscle may be damaged/cut through?
glut max incised, piriformis and ERs may be weak
| - can lead to post. dislocations since all muscles posteriorly are weak
39
With an anterior approach to THA, what muscles may be retracted and thus painful after surgery?
TFL, sartorius, rectus femorus are retracted, so may be sore/weak
- this can lead to anterior dislocations since all these anterior muscles are weak
40
What are the precautions for anterior approach to THA? How do they differ from posterior approach?
ant. approach = no hip flexion above 90, no adduction, no ER past neutral
- post. approach = avoiding IR
41
What muscle does the anteriolateral approach to THA cut through?
glut med
- allows for decreased risk of dislocations but glut med needs to recover
- may result in leg length discrepancy
42
What muscles will be weak following a lateral approach for a THA?
TFL, and all glutes
43
Why do we need to take a femoral nerve block into consideration?
this makes walking difficult following the surgery, even 1-4 days out
- so it may not be a strength issue, they may just still be nerve blocked
44
What are some early interventions for hip surgery?
isometrics (muscles sets), gait training, transfers, ROM restrictions, and PATIENT EDUCATION ON PRECAUTIONS
45
Avoiding prone laying and end-range extension during gait should be kept in mind for what approach to THA?
anterior/anteriolateral approach
46
What muscles will be weak with a posteriolateral approach?
piriformis and ERs, as well as abduction weakness
47
General hip strength decreases by what percent after the first year post-op hip surgery?
18%: work on strengthening extension, IR/ER, and abduction
48
What test is able to predict ambulation ability post THA? What does it indicate?
TUG test
- pts with 10s or less TUG before operation are more likely to ambulate w/o assistive device at 6 mo post THA
- pts with a longer TUG time will likely still be using assistive device for walking at 6mo out
YAY for prehab!
49
What does PFP usually look like? What aggravates symptoms?
- pain around, behind, or below patella
| - pain increases with prolonged sitting, squatting, stairs, or repetitive weight-bearing over flexed knee
50
What could be going wrong at the hip that may explain PFP?
weak hip abductors and/or hip ERs
| - need to strengthen glut med and glut max
51
T/F: There is strong evidence for isolated quad strengthening to relieve PFP symptoms.
true: don't forget about the knee!
| - do hip and knee strengthening
52
With what knee motion do we have increased force on the patella? Why is this important to note when thinking of exercise programs for our patients?
increased knee flexion (60-90) = increased force on patella
| - this means increased KF like in squats may be very painful for patients with PFP: just do mini squat and lunges
53
What degrees of KF/KE ROM should you stay in for both OKC and CKC exercises for your patients with PFP to avoid excess pain?
open chain: stay away from 45 - 0 degrees KF; maintain work at 90-45 degrees
closed chain: stay away from 60-90 degrees KF; maintain 0-60 degree squats, lunges, etc
54
What muscle group do you work on strengthening for PCL repairs?
quad strength
55
What is extensor lag and why is it so important that we approach that in therapy?
- extensor lag = the last 12-20 deg. KE are the most difficult to get actively for the patient
- but we need these last degrees for transfers, so we really need to strengthen that quad at that end range
56
During a quad strengthening exercise, how do we make sure that we emphasize quad activation when doing straight leg raise instead of the rectus femoris, as is often the case?
have your patient set their quad FIRST, then proceed into straight leg raise
57
What are two exercises that may help strengthen VMO (not in isolation but in conjunction with rest of quads)?
lateral step up and lunges
58
What exercises are really good at activating the hamstrings?
unilateral bridges and quadruped arm/leg left
59
What is the exercise protocol for reps/sets for eccentric exercise?
3 sets of 15 reps, but base it on your pt's tolerance
60
T/F: PCL is a double-bundle ligament.
true
61
What is the difference between an allograft and an autograft?
```
autograft = tissue from their own body
allograft = tissue from cadaver
```
62
What knee motion do you need to initially limit in PCL repair?
Knee flexion
- gradually increase the range of motion to terminal knee extension to maybe 60 degrees KF after several weeks
- want to emphasize quad control instead
63
T/F: Weight bearing is more restrictive for ACL than for PCL
false, PCL has more weight bearing restrictions for longer
64
What activites should a PCL rehab pt avoid?
avoid
- running downhill
- resisted ham curls
- squats with excessive trunk flexion
65
When the pt with a PCL repair is in supine, what do we need to remember to do?
put pillow under knee to prevent posterior tibial sag
66
What exercises do we avoid early on in any rehab?
exercises with lots of shear and compressive force, so OKC exercises
- need to wait until later in rehab for that kind of strengthening
67
To decide when a brace for PCL should come off, what are you looking for?
any instability, good ROM, good ham/quad control
68
When should PCL repairs have full ROM by?
6 wks
69
What exercises can we do for a PCL that's 4-6wks post-op?
- hip strengthening: standing 4way hip
- seated ankle exercises
- PROM/AAROM for KF
- aerobic activity for KF (bike)
progress to
- walking on treadmill
- CKC to 60 deg KF
70
What is the gold-standard for an autograft ACL? How quickly does this form heal?
patellar tendon bone-tendon-bone
| - will see anterior knee pain but they're 37% stronger and only 8 wks to heal
71
What's the strongest autograft for the ACL?
quadruple bundle of hamstrings, makes it 90% stronger but 12 wks to heal
72
What are some complications with allografts?
- never 100% sterile
| - different sterilization techniques at each bank, can affect tensile strength and tissue
73
T/F: Collagen has low ability to create immune response when used as a graft.
true
74
Describe the bundles in the ACL, and what they're responsible for.
1) anterior medial bundle: gives anterior stability
| 2) posterolateral: gives rotational stability close to extension
75
What can we do immediately after ACL repair with rehab?
- do patellar mobes
- monitor incision healing and knee girth from swelling
- watch for quad inhibition
76
During the beginning phases of ACL rehab, what are some things we might focus on?
- neuromuscular control training: balance
- increasing KF range of motion to 110 after 3-4 wks
- full KE with active quad and NO WEIGHT
- muscles sets ASAP
- supine SLR (remember set quad first!)
- PROM-AAROM
77
If the hamstring tendon was used as a graft for the PCL, how long should you wait to rehab it with resistance?
hold off on resisted hamstring exercise for 12 wks
78
What can inhibit the quad?
swelling
79
What part of the meniscus is avascular and thus leads to prolonged healing times, if damaged?
central zone tear
| - progress slower with rehab here
80
How do you suspect meniscal tear with your pt?
if they have a painful click with weight bearing
| - flap that's torn in meniscus is causing that
81
If your ACL athlete has soreness during a warm up that goes away but then persists later in the session, what is the protocol?
2 days off, drop down one level
82
If your ACL athlete has soreness after lifting that's not muscle soreness, what is the protocol?
one day off, don't move up a level
83
If your ACL athlete has no soreness during warmup or session, what is the protocol?
advance them up 1 level each week
84
What is the issue with a posterior horn tear in the meniscus?
called a bucket-handle tear, it anchors the meniscus so it's a more complicated repair
85
At what time do you want 120 deg KF and full knee extension with a meniscal repair?
8 wks
| - slowly increasing ROM and controlling for swelling throughout
86
What kind of exercise do we really limit with meniscus patients, more so than any other knee rehab?
weight bearing: this will be really painful since meniscus takes the load of the weight
- these pts will be on crutches for awhile
- limit CKC range!! 0-45 then 0-60 at 8wks
87
What should CKC range be with a meniscal tear?
limit to 40-45 degrees KF for first 4 wks
| then progress to 60 degrees KF by 8 wks
88
What is essential to remember with fresh TKA patients in the hospital?
PREVENT CIRCULATORY COMPLICATIONS
| - DVT is common
89
When can TKA patients begin weightbearing?
depends on fixation: cement is ofter WBAT, but biological is often NWB for 6 wks
90
T/F: You can regain neuromuscular control of the hip and knee while the knee is still mobilized.
true, somehow (READ)
91
How can the quad become inhibited with a TKA?
pain and swelling often inhibit the quad, which may delay ROM in flexion and terminal extension
92
Why is ROM so important early on in TKA rehab?
these pts are prone to flexion contractures since they can't reach terminal extension
- need to work on maintaining that ROM they do have
93
Why should we do patellar mobilizations early on with TKA?
swelling may inhibit patellar movement, so get those mobilizations going early to prevent this
94
T/F: Avoid valgus and varus stresses of knee with TKA pts.
true
95
For the inpatient TKA, what would we focus on?
- ROM, gait training, education on assistive device, isometrics, transfers
96
For the outpatient TKA, what would we focus on?
- ROM, strengthening, endurance, balance!!, gait, aerobic exercise, isometrics
97
T/F: Isometrics help with swelling.
true, they flush the system
98
What is your goal for the TKA patient as far as ROM before they leave the hospital?
75-90 deg KF
99
What is your goal for the TKA patient with ROM by the time you discharge them from PT?
115-120 deg KF
100
These patients will be experiencing a lot of pain with KF. What do you tell them with this? Do you push them through it?
they need to get gains in ROM so they need to be stretched into KF
- do it for 30s increments, tell them it will hurt but we'll be quick
- make sure you MEASURE GAINS EACH TIME
- make sure they're pain isn't sharp and shooting here, though
101
What's a good exercise while they're seated to work on KF ROM? (for TKA pt)
- sit in chair and put towel on ground, slide towel under chair with foot
- have them pull their knee into flexion with a towel
