KNEE 1 Flashcards
Knee 1: ACL, MCL, LCL, meniscus
ACL sprains/tears are defined as
sudden/violent twist of tibiofemoral joint, which stretches/tears ACL
Grade I knee sprains
MILD: stretched ligament with micro tears. Can still WB
Grade II knee sprain
MODERATE: partial tear
mild to mod instability, knee giving out while standing/walking
Grade III knee sprain
SEVERE: complete tear, unstable
Most ACL injuries occur (with/without) contact?
WITHOUT CONTACT, mostly landing a jump. No single cause (combo of intrinsic and extrinsic factors)
ACL injury intrinsic factors
joint laxity
larger Q angle (women)
narrow intercondylar notch
ACL injury extrinsic factors
muscle strength! SPECIFICALLY HAMSTRINGS (ACL agonist to prevent anterior tibial translation)
-usually quad is stronger, so there is imbalance
ACL common demographics
female athletes
14-29 years (highly athletic)
*differences due to muscle stuff, joint laxity, narrower notch width index
ACL provides 85% of total restraining force of ____ translation of tibia
anterior
ACL strains can occur due to what 3 things?
- sudden stop/twist/pivot
- hyperextension/extreme straightening
- direct impact to outside of knee/lower leg
*usually during sudden cut/deceleration NONCONTACT
ACL is frequently injured along with what structures?
MCL and medial meniscus
There is a 100 fold increase in ACL injury in ____ players compared to general pop.
college football players
Are male or female athletes more susceptible to ACL injuries?
female
What are three contributing factors to ACL injuries? hint* sports related, gender, NWI
- sports related (football, baseball, soccer, skiing, basketball)
- female athletes
- femoral notch stenosis (NWI<0.2)
What are the common signs of ACL tears?
pain
AUDIBLE/FELT POP**
feeling knee give out
inability to continue sport
swelling, large hemarthrosis
instability
loss of knee ROM
What hurts ACL tears?
walking, stairs up or down, sport
change of direction
cutting, pivot, jump
What makes ACL tears better?
elevation
NSAIDS
muscle relaxants
ice
rest
surgical options of ACL tears
intraarticular reconstruction:
1. bone-patella-bone autografts
2. hamstring tendon grafts
3. allografts
surgical reconstruction:
1. autografts (patellar tendon, quad tendon, hamstring, medial head of gastroc)
2. allografts (donor achilles, patellar, quad, hamstring tendon)
Why would you use an allograft for ACL tear?
less invasive, quicker return to function
cons: disease, infection, weaker than autografts
Rehab of ACL depends on if they had surgery or not.
If they had surgery, take into mind that…
autographs undergo ligamentation (strong at implantation)
collagen matures for 1-2 years after surgery
transplanted graft does not ever get to normal ACL tissue level
Can you test meniscal tears through palpation?
very low validity. rely on X-rays
When does collagen mature in ACL autograft?
1-2 years after surgery (never obtains all cellular features of normal ACL tissue)
What are the stages of ligamentation? (ACL surgery)
- necrosis (1-3 weeks)
- revascularization (6-8 weeks): peripheral to central
- cellular proliferation (8+ weeks)
- collagen formation, remodeling, maturation (8+ weeks)
Phase I of ACL rehab (0-14 days)
ACUTE INFLAMMATORY PHASE
goals: maintain ROM, decrease inflammation
*basically all interventions for all the phases include meds, modalities like e-stim on quads, ultrasound, ice, myofascial release, LE flexibility of hamstrings, ITB, hip flexors, and a HEP
Phase 2 of ACL rehab (15-21 days)
Reparative Phase: progress as pain allows
gals: return ROM (FULL EXTENSION), MINIMIZE SWELLING
Phase 3 of ACL rehab (22-60)
Remodeling phase
progress when PAIN FREE ROM and NO FUNCTIONAL LIMITATIONS
goals: increase agility, progress to return to sports, address contributing factors
Phase 4 of ACL rehab (day 60-1 year)
Remodeling Phase
Progress to this phase when NO FUNCTIONAL LIMITATIONS
goals: correct contributing factors to injury, retrain muscles
MCL tears are defined as:
sudden twist of tibiofemoral joint, stretching MCL.
what is the unhappy triad?
MCL, ACL, medial meniscal tears together
What is the most common of all ligament injuries?
MCL sprain
What contributes to MCL injuries?
- sports related injuries (similar to ACL)
- long term corticosteroid use (weakens ligaments)
- systemic diseases=joint laxity, like RA/lupus
What is the most common cause of MCL injury?
valgus stress/external tibial rotation
*direct blow to outside of knee
(combo of intrinsic/extrinsic factors)
occurs most commonly at femoral attachment
Partial MCL tears due to noncontact injuries are due to ____, ____, ____ motions
deceleration, cutting, pivoting
overuse injuries of MCL are found in ______(which kind of athlete/sport?)
swimmers
(whip-kick technique)
*also caused by severe knee twist in skiing/wrestling, fall twisting lower leg outward
common signs of MCL tears
-TEARING, NOT POP
-bruising of medial knee (MCL is extraarticular)
-swelling
-limp/pain with knee extension
-instability
-loss of ROM, stiffness
-medial joint line pain
What makes MCL injuries hurt more?
-extension of knee
-initial contact in gait
-stairs up or down
walking downhill
-starting run
-uneven ground=instability
-changing directions (turning contralaterally)
what makes MCL injuries feel better?
elevation
NSAIDS, muscle relaxants, pain meds
ice
rest
is the MCL well or poorly vascularized?
well vascularized!
surgery is rarely required.
In first 72 hours, the knee is ____ to prevent valgus stresses to knee in MCL tears
braced
During first 6 weeks post MCL tear, knee should be protected to avoid excess_______(what position/loading?)
valgus loading
*to allow scar tissue to form and reinforce damaged ligament
typically, a grade I or II MCL injury will heal within _____ days
11-20 days
a grade III MCL injury will take around _____to heal
6 months-1 year
*in rare cases, surgery performed
If patient has MCL surgery, first 3-4 weeks bracing is in what position?
Brace is kept on until 6 weeks post op
close to full EXTENSION
*bracing may be removed frequently for AAROM, AROM exercises
complete rehab of MCL surgery takes
6 months
Phase I of MCL injury (0-2 weeks)
Acute Inflammatory Phase
goals: maintain ROM, protect joint/ligament, decrease inflammation
Phase 2 of MCL injury (15-21 days)
Reparative Phase
progress as pain allows (protect full extension bc it stretches MCL)
-return ROM, minimize swelling
Phase 3 of MCL injury (22-60 dyas)
Remodeling Phase
-pain-free ROM
-no functional limitations
goals: increase agility, progress return to sports, address contributing factors
Phase 4 of MCL tear (2 months-1 year)
when to progress: no functional limitations
goals: correct contributing factors, retrain muscle activity
LCL sprains are defined as
sudden twist of tibiofemoral or tibiofibular joint, stretching LCL
LCL injury most commonly occurs at what attachment?
fibular attachment (75% of the time)
overstressing LCL occurs with a ____force at knee
varus (ligament failure due to excessive loading)
LCL sprain is the most/least common?
LEAST COMMON (2% of all knee injuries)
LCL controls varus loading and external rotation of tibia. LCL contact injuries are caused by _____ load to the knee
direct varus load=complete tear
Most common method of injury: direct varus force, foot pointed and knee extended
What are related injuries with LCL injuries?
common fibular nerve, posterolateral capsule damage, PCL damage
The much less common mechanism of injury to LCL is knee (add/abd), (flex/ext), (int/ext rotation of femur)
knee adduction, flexion, external rotation of femur
What are common signs of LCL injury?
-pain
-pop to knee (MCL is tearing, not pop)
-bruising to lateral knee (LCL is extraarticular)
-swelling building for several days
-instability
-loss of ROM and mod stiffness
-lateral joint line pain
what makes LCL tears hurt more?
-starting run
-walking long distances
-uneven ground: instability feeling
-changing directions (ipsilateral turn)
what makes LCL injuries feel better?
elevation
NSAIDS, muscle relaxants, pain meds
ice
rest
LCL rehab recommendations: after repair, patients are instructed to put ____ weight on their foot when standing/walking for up to 6 weeks
little to no weight for 6 WEEKS
after LCL repair, weight bearing precautions last up to ___ weeks
12 weeks (following ligament reconstruction)
After LCL surgery, knee is braced into ______ for 3-4 weeks
full extension for 3-4 weeks
*some surgeons use contin passive motion machine-pt can come out of brace to use it
at 5-6 weeks, LCL repair patient will wear ______
knee brace with hinge
protect during walking
complete LCL recovery takes how long?
6 months to 1 year
Phase I of LCL injury (day 0-2 weeks) is called
acute inflammatory phase
-initial injury
-goals: maintain ROM, protect, decrease inflammation
What are interventions for all ligament injuries?
▪ Medications: Antiinflammatories/muscle relaxants
▪ Modalities: E-stim for quadriceps contraction, ultrasound, ice after activity ▪ Myofascial release to global muscles as needed
▪ LE flexibility: Hamstrings, ITB, and hip flexors
▪ HEP: ROM exercises, lower extremity flexibility, hip strengthening, RICE
Phase 2 of LCL injury (day 15-21) is called:
Reparative phase
Progress to phase 2 as pain allows
goals: restore normal ROM, minimize swelling
interventions: walking program as needed
Phase 3 of LCL injury is (day 22-60)
REMODELING PHASE
when to progress: when ROM is PAIN FREE, no functional limits
goals: increase agility, progress to return to sports, address contributing factors
Phase 4 of LCL injury is known as (day 60-1 year)
Remodeling phase
when to progress to this phase: no functional limits
goals: correct contributing factors, retrain muscles
Meniscal injury is defined as
tear/degeneration of semilunar, fibrous cartilage in knee joint
Meniscal injury is diagnosed by palpation or arthroscopically/MRI?
arthroscopically (gold standard) or MRI
can be medial, lateral meniscus, or both
for degenerative meniscal tears, what is a risk factor?
age (60% of people older than 65 have degenerative tears)
young, active, athletic people are more susceptible to _____ meniscal tears
acute, traumatic
true or false: meniscal tears result from minor or major trauma to knee OR from degeneration
TRUE
trauma: young
degeneration: old
degenerative tears can be age related or result from repetitive _________
squatting/kneeling
medial meniscus is more commonly injured than lateral (true or false)
true! bc of its attachment to the joint capsule, it is less mobile than the lateral meniscus
meniscal tears are often associated with ____tears
ACL (think unhappy triad)
bucket handle tears are _____
vertical tear with displacement of inner margin
most often associated with ACL tear
more common in medial meniscus
radial tears are most often found in ____aspect of ____meniscus
found in medial aspect of LATERAL MENISCUS
can be associated with ACL tear
commonly from TRAUMA, often in young, active individuals
horizontal meniscal tears are (traumatic/degenerative)?
degenerative: found in older people with OA
*think older people with OA are tired and need to be horizontal (lie down)
longitudinal tears involve _____of meniscus
posterior portion of meniscus
typically associated with ACL tear
Flap tear is a displaced flap secondary result from _____, ____, ____ tear
radial
bucket handle
horizontal
what is the mot common type of meniscal tear?
LONGITUDINAL TEAR
*posterior part of meniscus, typically associated with ACL tear
oblique tears are a ____ tear running obliquely from inner edge of meniscus out into body of meniscus
FULL THICKNESS TEAR
degeneration of meniscus is always pathological (true or false)
false: degenerative tears occur as natural part of aging (collagen fibers break down)
how do traumatic meniscal tears happen?
compressive force coupled with rotation while knee is flexed
*most from NONCONTACT (landing from jump, pivoting, decelerating, cutting)
degenerative tears are found in what age group?
older than 65
nontraumatic from repetitive activities or history of trauma like ACL tear or knee surgery
4 contributing factors to meniscal tears
age (degenerative tears)
weight
previous surgical history
previous knee trauma
do meniscal injuries have a referral pattern?
no
common signs of meniscal tears
clicking, popping, locking, giving way, catching
pain with WB
joint line tenderness/pain
swelling, decreased, painful ROM
any position of non weight bearing will make meniscal injuries feel better or worse?
better (only easing activity)
meniscal repairs are recommended for who?
active young people (younger than 50) OR older athletic people
meniscal repairs are recommended for tears to the inside or outside edges of mensicus?
outer edges (vascular region)
partial meniscetomy is recommended for tears in the _____ region of meniscus
avascular region/complex tears that cant be repaired
surgical options for meniscus repairs
arthroscopy: partial meniscectomy or meniscal repair
meniscal transplantation
Goals for meniscal tear rehab include LE strength and ROM exercises with _____ (open or closed chain?)
limited weight bearing (open chain like heel slides, quad sets, straight leg raises, stationary bike, hip abduction)
what else is involved with meniscal rehab?
limit high compressive shear forces (control excess WB)
modalities to decrease pain/inflammation
stretching and soft tissue mob for hams, quads, calf to improve knee ROM
gait train with assistive device
patellar mob
