hip and knee final Flashcards
0
Q
anatomically compound
A
more than 2 joint surfaces
1
Q
anatomically simple
A
2 bones, 1 capsule
2
Q
complex
A
has a meniscus
3
Q
mechanically simple
A
moves 3 axes at 90 degree angles to eachother
4
Q
unmodified ovoid
A
ball and socket
a sphere with three axes and 3 degrees of freedom
5
Q
modified ovoid
A
ellipse shape
2 axes, 2DF
(MCP)
6
Q
unmodified sellar
A
saddle, 2 axes and 2 DF
thmb
7
Q
modified sellar
A
hinge joint
1 axis
1DF
(IP, Elbow)
8
Q
synarthrosis
A
no genuine joint space no fluid (synovium) divided by tissue in between
9
Q
syndesmosis
A
has fibrous tissue between it
ankle, tib, and fib
10
Q
synchondrosis
A
has cartilage between joint surfaces
costochondral joints
11
Q
synostosis
A
bonytissue between (sutures in skull)
12
Q
diarthrosis
A
divided according to amount of movement
13
Q
sympheses
A
half joints
connective tisssue partly fills the joint
ie pubic symphesis
14
Q
synoviales
A
movable joints with all characteristics of synovial joints
- amphiarthrosis: less than 10 degrees of movement
- articulations: more than 10 degrees of movement
15
Q
amphiarthrosis
A
less than 10 degrees of movement
16
Q
articulations
A
more than ten degrees of movement
17
Q
degrees of freedom
A
the number of axes a joint moves in
18
Q
osteokinematics
A
movement of the bones
19
Q
spin
A
pure rotation around a mechanical axis
rotation of a long bone in place–internal and external rotation
20
Q
pure or cardinal swing
A
the shortest route between two points
21
Q
arcuate or impure swing
A
spin and swing
22
Q
spin
A
rotation around a stationary mechanical axis
23
Q
gliding or sliding
A
one point on moving surface comes into contact with a new points on a stationary surface
24
rolling
both surfaces move, new points on each surface come into contact with new surfaces all the time
25
gliding or translation
one surface (arc surface) slides over another surface without adding another component
26
angulation
increase or decrease in angle formed between two adjacent bones (knee)
27
movement of joint in opposite directions hurt: passive extension and active flexion
If bicep: hurts to contract and to stretch it
28
passive and active movement hurts in the same direction
it is the joint itself
29
what happens in resting position
maximallly relaxes the noncontractile structures
| we want to eliminate those when we test contractile structures
30
fabella
an extra joint some people have that is sesamoid and on the lateral femoralcondyle
31
Femoral Tibial Joint
| -joint type
1. complex joint (meniscus)
2. modified hinge joint since mostly 1df
3. dual condylar (two condyles)
largest joint in the body
32
knee joint
degrees of freedom
one: flexion and extension (x axis)
accessory second degree of freedom that occur with flexion and extension
- rotation: long axis with knee flexed: IR/ER
- angulation: abduction/adduction: need external torque (if land on foot can create valgus but it does not occur independently)
33
femoral patella joint
- joint type
- what can go wrong
sellar joint/modified plane joint
--has a little peak, convex and concave and sits in groove between femoral condyles--propriotracking: if not--patellofemoral syndrome
ultimately osteochondritis or osteomalasia patella where there is wearing away of cartilage under patella causing pain
- -patella femoral syndrome is the mal-alignment
- -chondromalasia is when it becomes soft and erodes
34
Knee
- resting position
- closed packed position
- capsular pattern
Knee
-resting position: 25-40 degrees of flexion
allows maximal laxity of the noncontractile structures
-closed packed position: full extension WITH MAXIMAL EXTERNAL ROTATION OF THE TIBIA (screw home mechanism)
-capsular pattern: limitation of FLEXION to 90 degrees more than extension 5 degrees
35
why is the capsular pattern of the knee 90 degrees of flexion > 5 degrees of extension?
capsular pattern is not related to the contractile structures it is related to the noncontractile strucutres---has nothing to do with contractures
36
arthrokinematics of the knee:
when is it stable
when is it flexible
mechanically designed for stability in extension: if someone has instability of the knee they buckle. screw hoem mechanism is a lock
flexible in flexion
femoral neck over hangs the shaft 170-175 degrees--this creates physiological valgus--angulation from pelvis to the knee is greater in women so the angulation of the knee is also greater
femur angled off 5-10 degrees from the vertical--a degree of valgus is built into the knee
37
retroversion of the knee
tibial condyle inclined posteriorly
--the top of the tibia plateau is not vertical
retroversion of the tibial plateau because it is inclined posteriorly (5-6 degrees inclined posteriorly)
38
retroflexion of the knee
tibia bent to be concave posterioly
--there is a bowing effect, a gapping arc on the posterior aspect of the tibia
--this creates a space for the hamstring and gastrocnemius belly when the knee is in flexion
39
femoral condyles
what are their shape
where are they longer and shorter
biconcave-pulley shaped
medial and lateral aspect of the convexity
anterior and posterior aspect of the convexity
longer in the anterior posterior than in the medial lateral
40
medial femoral condyle
juts out more and is more narrow
it is longer distally and allows the knee to be horizontal because of the angle of inclination on the femur
41
lateral femoral condyle
is more directly in line with the shaft than with the medial femoral condyle, secondary to the obliquity of the shaft of the femur
42
which femoral condyle has more stresses?
WB stresses evenly distributed between the medial and lateral condyles in bilateral stance
43
tibial condyles
curved to the femur
--reciprocally curved to the femur with blunt eminence running A/P, intercondylar tubercles
44
medial tibial condyle surface
BICONCAVE
45
LATERAL TIBIAL CONDYLE SURFACE
Concave in frontal plane
Convex in saggital plane
46
difference in TIBIA articular surface: medial and lateral condyle
medial condyle articular surface is 50% larger and articular cartilage is 3x thicker
TIBIA MEDIAL CONDYLE 2x larger articular surface
medial tibial condyle cartilage is 3X thicker
47
axial rotation of the tibia - how it works
modified intercondylar tubercles of the tibia act as a pivot (fulcrum) to allow for rotation
tibia lodges in the intercondylar notch of the femur for ER/IR and to rotate in screw home mechanism
when we go into screw home mechanism in full extension we lock out the knee and do not have IR/ER, need to unlock the knee and bring it into flexion for active IR/ER to allow the little tubercle to sit in the groove and rotate
48
OKC: tibia rotate on femur
WE TREAT IN OPEN CHAIN
when go into extension the tibia ER on the femur
49
CKC: femur on tibia
we do not do manual therapy here, only exercise
when go into extension the femur internally rotates on the tibia
to squat
50
describe the roll/glide movement of femur on tibia
how big are the condyles
flexion and extension motions
which is used when
---femoral condyle is 2X as long as the tibial condyles
extension--> flexion
femoral condyles begin to roll (posterior) without gliding then slide anterior [needed at the end of the motion]
CKC: femur roll then glide on tibia
OKC: tibia roll then glide on femur
--flexion-->extension
femoral condyles roll anterior and then glide posterior
---PCL pulls posteriorly
in initial stage of rolling, the lateral condyle is 20 degrees and medial condyle is 15 degrees, since we only need 25 degrees of knee flexion in gait we do not even need the glide for ambulation
51
what makes the knee modified hinge joint
axis is not fixed but moves through ROM
in roll and glide the contact points change and the axis changes
this is why the knee joint replacement is polyaxial
52
Rotation in the knee
what happens at each condyle
what does femoral condyle contact in neutral position
ER rotation of the tibia on the femur: lateral femoral condyle moves forward over the lateral tibial condyle, medial femoral condyle moves backwards (ie tibia moves ER, femur moves IR)
in neutral position for axial rotation with knee flexed, posterior femoral condyles are in contact with the mid part of the tibial condyles
53
Superior Tibio-fibula joint
type
motion
plane synovial joint
| ankle joint PF/DF causes upward and downward rotation of fibula on mortis
54
knee joint capsule
patella, tibia, femur: complex joint
55
knee fascial connections
these help maintain knee stability and serve as secondary supports
ITB
bicep femoris
extensor retinaculum
coronary ligaments
patellomensical fibers
patellotibial fibers
vastus medialis and lateralis link muscle to capsule
patellofemoral ligaments connect patella to femur
56
role of ITB at knee
ITB for stability runs around the lateral aspect of the capsule
it is NOT position dependent and maintains a certain tension throughout
ITB is secondary reinforcement for the MCL because of its angulation and where it is located
57
where do the ACL and PCL attach to the tibial plateau
to meniscus?
is it inside the capsule?
ACL and PCL attach distally to the tibial plateau
this distal attachment is extra-capsulaer--and as they come inside they become intracapsular
they are located in the middle of the knee joint within the capsule
MCL attaches to the medial meniscus
LCL DOES NOT ATTACH TO A MENISCUS
58
Bursa
name 6
fluid filled sac that can get inflamed (hot and swollen when inflamed)
```
suprapatella bursa
prepatellar bursa
infrapatella bursa
deep infrapatella bursa
gastracnemius bursa
popliteus bursa
```
59
plica
residual from embryonic development when synovial membrane developed in the knee
it had component parts from three sections that merged and the plica is the seam that merges the sections of the synovium
this seam is palpable in certain parts of the knee
one is easy that feels like a guitar string, if you strum it when it is irritated it is very uncomfortable
60
the 3 knee compartments
1. SUPERIOR COMPARTMENT: suprapatellar bursa: Superior part of the plica
2. INFRAPATELLA PLICA-infrapatellar fold-inferior part of the plica and is an empty space (bound by anterior intercondylar fossa of tibia, ligamentum patella anteriorly, and inferior aspect of patella surface of femur)
- --infrapatella fatpad is filled with adipose tissue; infrapatella pad (Hoffa's Pad) contains synovium. if this gets inflamed there is a significant amount of fluid that can be held since it is an empty space with a fat pad, and if extend your knee fluid gets pushed forward by the gastroc. if flex knee stretch quad and fluid gets pushed backwards
- --edema in knee: extend knee and fluid moves anterior and flex knee and fluid moves to popliteal fossa in posterior knee
3. mediopatella plica: CAN PALPATE IT
61
suprapatella bursa
quadricep femoris bursa
locate up under the quadricep (can communicate with the knee capsule)
62
prepatella bursa
under skin fold in front of patella
63
infrapatella bursa
under skin anterior to the ligamentum patella/quadriceps tendon
64
is the quadriceps tendon a tendon
even though it is btwn two bones it is a tendon
it is thought of as an attachment of muscle to bone it is a tendon and has tensile ability
it technically goes bone to bone and that would make it a ligament (ligaments are not designed to give, they are designd for support)
65
deep infrapatella bursa
under the tendon/ligament anterior to the tibia
66
gastrocnemius bursa
under lateral head of the gastroc
inflamed more than the popliteus bursa
gastroc bursitis (gold ball sized lump in the popliteal fossa)
67
popliteal bursa
under the popliteus
under popliteal tendon in LATERAL femoral condyle
popliteal and gastroc can be hard to differentiate since both are in the same area
68
lateral meniscus
horns are close together just shy of a full circle--rounder and smaller mensicus
69
medial meniscus
half moon shape
larger meniscus
thicker periphery than the center to help with congruency to fill the void of the femoral condyle convexity
70
what shape are the menisci
semilunar catilage
71
purpose of the menisci, are they vascular
1. increase radius of curvature of tibial condyles (tibial condyle is smaller than femoral condyle)
2. distribute WB surfaces
3. decrease friction
shock absorbers
AVASCULAR STRUCTURES: in the inner 2/3
only the outer 1/3 is vascular on the periphery because it is bathed by synovium that provides nutrition
72
3 surfaces of menisci
superior surface: concave and articulates with femoral condyles
peripheral surface: thickening that is adherent to capsule
inferior surface: almost flat, almost plane-rests on edge of medial and lateral tibial condyles
73
force on the menici
menisci transmits:
50% of the forces in extension
85% of the forces in flexion
IF REMOVE THE MENISCUS INCREASES LOAD: 2X ON THE FEMUR AND 6-7X ON THE TIBIA--major issue for the bone
-if tear mensici this force goes to the cartilage
74
Name the meniscal attachments
| 4
1. intercondylar tubercles of the tibia attach to both mensici
2. coronary ligaments attached round the periphery to the tibia by vertical coronary ligaments (meniscotibial ligaments) composed of fibers of joint capsule
3. patellomeniscal ligaments: or patellotibial ligaments attach both mensici to patella--anterior capsule thickening
4. transverse ligaments: attach menisci anterior horns--runs between them and connects medial and lateral menisci together
75
ligaments that attach to LATERAL MENISCUS
PCL
popliteus muscle via coronary ligaments
posterior meniscofemoral ligaments which attach to femoral condyles
CONNECTIONS ARE LOOSE AND GIVE A FAIR AMOUNT OF MOBILITY ON THE LATERAL TIBIAL CONDYLE
76
ligaments that attach to medial meniscus
```
MCL
Semimembranosus
ACL
FIRMLY ATTACHED, LESS MOVABLE,
*******************TORN MORE FREQUENTLY
```
77
unhappy triad
```
triad of odanehu
medial meniscus
MCL
ACL
need reconstructive surgery
```
78
how does the Q angle affect the _____ part of the knee
if the Q angle (quadriceps angle) of the knee changes and the knee goes from valgus to varus
it loses 5 degrees of the angle
and increases compression of the medial knee about 50%
bow legged people have major problems at the medial part of the knee
the Q angle is needed to take pressure off the medial part of the knee
79
movement of the meniscus
flexion and extension
Menisci move POSTERIORLY in FLEXION (pushed by femur)
mensici move ANTERIORLY in EXTENSION
80
menisci move in flexion
!
81
menisci move in extension
!
82
menisci move in external rotation
lateral mensicus is pulled anteriorly
medial meniscus is pulled posteriorly
83
lateral mensicus in external rotation
anterior
84
medial mensicus in external rotation
posterior
85
tibia external rotation: menisci movement
lateral menisci pull anterior
medial menisci pull posterior
this is due to the position of the femoral condyle to the tibial plateu
they attach to the TIBIA and not to the femur
they are fixed on the bottom and the femur give them a push
INJURED WHEN THE MENISCI DO NOT FOLLOW THE FEMUR (compression with sudden twist)
86
lateral mensicus compared to medial meniscus movement in extension/flexion
LATERAL mensicus goes 2X as far as medial meniscus
87
what causes mensical tears
menisci injured during movement if fail to follow femoral condyles
injured part fails to follow normal movements and become wedged between femoral and tibial condyles (ie unlocked flexion with rotation)
so if ER tibia the lateral meniscus should go anterior and medial meniscus is moved posteriorly
88
patella
what shape
how many facets
how does it help the quads
where does it move and how far
triangle shape from anterior view
7 facets around the outside (some say 5): superior, inferior, medial, lateral, odd (odd is the vertical ridge on the top)
patella enhances the efficiency of the quadriceps muscle extension: INCREASE MECHANICAL ADVANTAGE 25%
patella moves superiorly in extension and inferiorly in flexion
in flexion the patella moves 2x its length
89
in flexion the patella moves ___ its length
what needs to happen for patella to move
what can prevent it
2x
the infrapatellar fat pad moves out of the way to prevent effusion of the inferior fold
patella can only move if the soft tissue around it has enough length, the quad need to give enough leeway for the patella to move
bursa need to move out of the way to go from flexion to extension --- articularis genu muscle comes off the vastus medialis and its job is to move the suprapatellar bursa out of the way when we extend the knee so that you do not pinch it
if there is inflammation adhesions can hold the patella in a fixed spot and then it is impossible to move the patella
90
role of articularis genu
bursa need to move out of the way to go from flexion to extension --- articularis genu muscle comes off the vastus medialis and its job is to move the suprapatellar bursa out of the way when we extend the knee so that you do not pinch it
91
what prevents patellar dislocation
lip on the femur
92
INSALL AND SALVATI RATIO
ratio of
patella: length of tendon
--------------the ratio varies in gender, in females longer
this ratio is important. if it is not equal the patella can be displaced
patella alta: the tendon is 20% longer than patella size (it is longer inferiorly)
patella baja: patella inferiorly displaced when the tendon is 20% shorter than the patella size (it is shorter inferiorly)
93
Patella displacements: 4
alta: patella displaced superiorly
baja: patella displaced inferiorly
squinting: patella displaced medially
bull frog eyes: patella displaced laterally*****
94
Patella movement on the Tibia in IR/ER
ER: femur is medial to tibia, this pulls the PATELLA medially
IR: femur is lateral to patella when the tibia IR, therefore the PATELLA moves laterally
95
Transverse Ligament
links the two anterior horns of the menisci
| attached to the patella by strands of the infrapatella fat pad
96
MCL
1. its direction
2. where it attaches
3. what it supports
4. what it is strengthened by
5. how it helps the knee
6. does it attach to a mensicus
1. runs INFERIOR and ANTERIOR
2. medial femoral condyle--> posterior to pes anserine on tibia
3. helps support the ACL
4. pes anserine strengthens (semimem, semiten, gracilis)
5. takes stresses on medial knee: takes 57% of valgus stress at 5 degrees of flexion, 78% of the force at 25 degrees of flexion--bad to tear the MCL
6. anterior fibers are seperate from capsule, posterior fibers blend with medial meniscus!!!
97
Posterior oblique ligament
superficial bands of MCL blend with the posteromedial corner of the capsule
this adds more support
98
MCL: what stress does it take
takes stress on medial knee: takes
57% of valgus stress at 5 degrees of flexion
78% of the force at 25 degrees of flexion
--bad to tear the MCL
99
Name secondary supports on medial and lateral posterior knee
medial side: semimembranosus, semitendanosis, gracilis, popliteal complex
lateral side: biceps, ITB, arcuate complex
100
LCL
1. its direction:
2. where it attaches:
3. distinct bands:
4. forms the arcuate ligamentous complex --
3. what it does in the knee:
4. what it supports:
1. its direction: INFERIOR and POSTERIOR
2. where it attaches: outer lateral condyle-->head of fibula
3. distinct bands: anterior, medial, posterior
4. forms the arcuate ligamentous complex --additional support on the posterior lateral aspect of the knee (fibers that come off the capsule and ligement and couple with bicep femoris, ITB and popliteus)
3. what it does in the knee: controls lateral rotation: if tibia ER then it creates tension on the LCL
4. what it supports: it supports the ACL: preventing hyperextension and anterior glide!!!
101
Transverse Stability of the Knee
femoral axis = inferior + medial
force on tibia is not vertical, it is both vertical and transverse (valgus position creates wider gap medial)
this creates some valgus, wider medial space
MEDIAL FORCE: increase valgus and can fx lateral tibial condyle and rupture the MCL
102
bucket handle tear
menisci more firmly attached to the anterior and posterior horns and so if the transition is not smooth the mensici get caught in between the semicircular part can become distorted and the middle part of the mensicus is more movable than the 2 horns so
COMPRESSION and TWIST
103
anteroposterior stability of the knee
when the knee is slightly flexed the force of BW behind the axis, and NEED QUADS
if not hyperextend when walking to move behind the axis to not need the quads and not buckle the knee
if hyperextend the knee the posterior capsule taut, but if stretch it can get genu recurvatum
104
ACL
1. where it runs
2. is it in the capsule
3. how much load it takes in anterior translation when knee is extended
4. vascular supply
5. proprioception
6. what it is made of
7. nerve
8. when it is maximally taut
runs superior/posterior/lateral
starts on tibia extracapsular and goes into capsule (has an extrasynovial component throughout)
takes 87% of the load with anterior translation of the extended knee
extrasynovial and has rich vascular supply
has mechanoreceptors --so if you tear it you get partial deaffrentation of the joint because you do not know where your knee is in space and it will be easy to re-injure it
viscal elastic structure so it can adjust for load and length
supplied by posterior articular nerve
maximally taut at 70-90 degrees and 0-20 degrees
105
When is the ACL maximally Taut
PLB: Posterior Lateral Band is maximally taut at 0-20 degrees: and lax in flexion
AMB: Anterior Medial Band is maximally taut at 70-90 degrees of flexion and lax in extension
RESTING POSITION: between these at 25-40 degrees of flexion
106
PCL
1. where it runs
2. attachments
3. ratio to acl
4. amount of load it takes
5. when is it taut
6. when is flexed knee maximally displaced posteriorly
1. runs medial/anterior/superior
2. posterior rim of upper tibia-->lateral surface of medial femoral condyle
3. shorter than the ACL, PCL: ACL ratio is 3:5
4. STRONGEST STABILIZER IN THE KNEE, takes 90% of the load in the extended knee with posterior translation
5.
anterior band: taut 80-90 degrees of flexion and lax in extension
posterior band: taut in EXTENSION and lax in 80-90 degrees of flexion
6. flexed knee maximally displaced posteriorly at 75-90 degrees of flexion because tighter in the 80-90 degree range
107
WHen is the PCL taut
anterior band: taut 80-90 degrees of flexion and lax in extension
posterior band: taut in EXTENSION and lax in 80-90 degrees of flexion
108
Mechanical Role of the Cruciates for flexion/extension
stabilize knee in anterior/posterior direction
FLEXION: PCL vertical, ACL horiozontal
they pull the femoral condyles and make them slide on tibial plateaus in direction opposite rolling
Flexion--ACL is needed to slide femoral condyles anteriorly
Extension--PCL needed to slide femoral condyles posteriorly
MCL Is secondary restraint to the ACL: (because runs inferior anterior)
109
ACL and PCL:
| in femoral roll and glide
Posterior roll, anterior glide: ACL pulls femoral condyles anteriorly
Anterior roll, posterior glide of femur: PCL pulls femoral condyles posteriorly
110
posterior knee capsule ligaments
oblique popliteal ligament: posteriormedial capsule reinforced by tendounous expansion of semimembranosus, also against valgus
arcuate popliteal ligament: posteriorlateral aspect of capsule, bicep femoris helps, arcuate also against varus
111
ROTATIONAL STABILITY
CRUCIATES AND COLLATERALS
IR: collaterals relax (MCL and LCL), cruciates taut (ACL, PCL)
ER: collaterals taut (MCL, LCL), cruciates lax (ACL, PCL)
112
knee pain scales
anterior knee pain scale
LE functional scale
GLobal rating of change form
KOOS
113
OTTAWA KNEE RULES
raises suspision send for an xray (have a lot of pain, probably a fx)
used to determien necessity for ordering pt xray
1. patient above age 55yrs
2. isolated tenderness above fibular head
3. isolated tenderness over patella
4. unable to flex knee to 90 degrees
5. unable to WB immediately and in the emergency room
114
```
angles needed to
tie shoes
sit
go down stairs
go up stairs
knee flexion in gait
```
```
tie shoes--106
sit---93
go down stairs---90
go up stairs--83
knee flexion in gait--67 (in accelerated gait)
```
115
Helfet Test
dot the patella and tibial tubercle when knee in flexion and extend leg, tibial tubercle should rotate laterally
tibial tubercle should ER as tibia ER when goes into extension in the screw home mechanism
116
Knee:
| active/passive movement testing
```
Active movement testing supine:
flexion: 135/140 degrees
extension: 10 degrees hypreextension
ER: 30/40 degrees
IR with knee flexed 15 degrees
```
```
Passive movement testing:
flexion: soft tissue end feel
extension: hard/firm end feel
ER: capsular endfeel
IR with knee flexed: capsular endfeel
```
117
analgesic
masks pain, will not get accurate reading during testing and may over treat because pain is masked
118
why resting position is used
put the noncontractile structures on slack so that we can test the contractile structures
119
muscle is strong but has pain
small tear
120
what to do if a grade of 2/6 on mobility scale
it is hypomobile
| do a 3-4 mobilization
121
what do we do if a jt is not cleared in active movement testing?
do PROM
122
if there is significant pain can we stretch?
NO
123
If mobility restriction, how do we tx??
tx restriction to get to the end range and so grade 3-4 at the end of the barrier
124
femoral triangle
base of the triangle is the INGUINAL LIGAMENT
lateral border is the sartorius
medial border is the adductor
FLOOR IS THE DEEP PART OF THE TRIANGLE AND THAT IS THE ILLIOPSOAS
125
what do instability tests test?>
ligament integrity
126
clinical prediction rule on MCL
prediction rules
1. history of force to leg or rotational trauma and
2. patient has pain and laxity with a valgus stress at 30 degrees
GOLD STANDARD: MCL on MRI
Test clinically with valgus stress tets
127
kt1000
ACL
mild displaced: 5mm
moderate displaced: 5-10mm
severe displaced: 10mm
ANOTHER TIME SHE SAID >3mm is unstable
128
what is most relaible knee test
lachman
129
laxity vs instability
subjective complaint: unstable
objective measure: laxity
130
Knee effusion prediction variables
1. self noticed knee swelling
2. positive ballotment test (=patella tap test where tap patella and fluid comes out)
2. Standard reference MRI: with intraarticular fluid within the infrapatellar, medial, or lateral compartment
131
patellafemoral dysfunction
patella doesnt track correctly in trochlear groove causing patellafemoral dysfunction which can lead to chondromalacia patella (softening, erosion of cartilage on posterior of patella-pain syndrome)
gold standard dx: xray to see if good alignment and if worn down
MRI to see cartilage pathology in chondromalacia patella
132
Knee pain:
anterior
posterior
anterior: L2-L3
posterior: hip S1, S2, L3--on lateral butt so pt says butt pain (over medius)
disorders of the knee rarely refer pain posteriorly, usually it is anterior /medial/lateral pain
bursitis: posterior pain is usually bakers cyst--gastroc or popliteal bursitis
pt presentation of gold ball large localized effusion that looks like a golf ball in the popliteal fossa - it is firm and feel a fluid encapsulated area--creates posterior discomfort
133
OA of the knee: American College of Rheumatology Criteria
knee pain and > 3 of the following:
1. age above 50
2. morning stiffness less than 30 minutes
3. crepitus with active motion
4. bony tenderness (when palpate along bones of joint)
5. bony enlargement
6. no palpable warmth
- ---not systemic or inflammatory, degenerative joint disease is not inflammatory. rheumatoid arthritis is inflammatory
gold standard for djd is xray (classic to have osteophyte on xray)
134
patella tracking
should be center in anterior trochlear groove of femur in 30 degrees knee flexion
lateral overhang acceptable in extension
135
factors that increase patella alignment
1. increased Q angle
2. tight lateral structures
3. tight gastrocnemius/hamstrings
4. excessive pronation
5. patella
6. alta
7. vastus medialis oblique insufficiency (train with adductiona nd extension with resistance)
136
patella glide
medial and lateral glide of patella mobility
glide it
see what happens when they contract quads
137
patella tilt
Y axis
lateral tilt: lateral border lower
medial tilt: medial border lower (closer to bone)
138
rotation
relationship of inferior and superior pole around the z axis
lateral rotation: inferior pole lateral
medial rotation: inferior pole goes medial
139
anteroposterior patella
X axis
relationship of inferior and superior pole to rotate around the x axis
observe this from side of the patient
inferior pole is tilted posteriorly it irritates the fatpad in infrapatellar fold --hurts to squat and hyperextend
140
treatment of patellafemoral pain
put patella into position to be able to train the muscles appropriately with the knee taped
stretch tight lateral structures
patient self stretch
passive position with tape
141
training the VMO
sitting:
standing stance: pt stand and does mini lunge as pt bring WB force onto the leg it incorporates the vmo
shallow knee bends: mini squats concentrate on keeping knee to second toe and use VMO
steps: eccentrically going down while maintain knee control
gait: analyze gait
sport specific activity: ie ski, run, soccor
142
training patellofemoral: VMO
1. never treat through pain
2. progression-load, endurance, increase step size 4-->6', increase speed
3. train eccentrically (eccentric mini squats, lunges, step downs.) and concentrically (sitting and gait)
143
weaning McConell
1. wear tape everyday 2 wks
2. remove tape at night
3. wean off tape when VMO is coming in first on biofeedback when step downs for one minute
4. tape every 2nd day and then every 3rd day
5. wear tape for sports activities
144
ankle stability for
1. provide base of support for body
2. adapt to postural positions
3. avoid excessive muscle activity or extra energy expenditure
4. act as rigid lever for effective push off during gait
145
ankle mobility for
dampen rotation imposed by proximal jts
2. be flexible to absorbe shock of WB when foot hits ground
3. allow foot to conform to terrains
146
ankle foot functions
1. terminal part of kinetic chain
2. dissipate forces
compression-HS to midstance
shear: in gait transitions
rotation: tib/fib
tension: ligament/tendon/muscles
147
ankle joint
do not distract it, want it to be stable
axis is oblique, not in cardinal planes
--DF, PF, Ad/abduction, Inversion/eversion
PF/DF: x axis
DF (is extension at toes)
Inversion/eversion: z axis
inversion: plantar foot moves to midline
(talar tilt)
abduction/adduction: Y axis
distal foot away from midline = abduction
pronation/supination: oblique axis, motion at subtalar joint
varus/valgus
148
supination
NON WB
PF, inversion, adduction
WB:
Tibia ER
calcaneal inversion, abduction, DF
149
PRONATION
NON WB
DF, eversion, abduction
WB:
tibia IR
calcaneal eversion, abduction, PF
150
varus/valgus
valgus = calcaneal valgus = INCREASE medial angle of joint
varus = calcaneal valgus = decrease medial angle of joint
