Knee Flashcards
MOI for patella fracture
- fall onto anterior knee
- sudden quad activation - usually as the knee is flexing
Symptoms and physical exam of patella fracture
Symptoms
- painful/inability to extend knee
- anterior knee pain
Physical examination
- palpable gap at fx site
- local tenderness
- painful MMT > AROM knee extension
- painful end range flexion ROM
- antalgic gait
What are signs of antalgic gait?
- diminished stance time
- lift off pattern/flat foot instead of toe off
- decreased knee extension during gait
______ tendon ruptures are common for < 40 y/o
patella
_______ tendon rupture common with > 40 y/o
quad
- males 4-8x more likely
MOI of quad and patellar tendon
- eccentric overload extensor trauma
- force of quad while the knee is flexing. ex: landing from a jump
quad - commonly related to regaining balance/ rapid quad contraction
patellar - jump landing common
Symptoms and physical exam of patella and quad tendon rupture
Symptoms
- anterior knee pain
Physical Exam
- absent AROM knee extension vs painful AROM knee extension
- painful knee flexion
- palpable defect
- antalgic gait vs unable to ambulate
What is Osgood Schlatter disease? Who is common to get this?
- apophysitis (calcification) of tibial tubercle
- adolescent athlete - repetitive loading of knee into flexion
- male - 10-15 y/o
- female - 8-13 y/o
Symptoms and physical exam of Osgood Schlatter
Symptoms
- anterior knee pain
- aggravated w/ activity or resisted knee extension
Physical Exam
- local TTP
- prominent tibial tubercle
- pain at end range knee flexion
- painful MMT w/ knee extension > AROM
What is the most common site of osteochondritis dissecans?
lateral aspect of medial condyle
Who is common to get osteochondritis dissecans?
- males > females
- greatest 10-20 y/o
- active individuals
- common bilateral
MOI of osteochondritis dissecans. What else occurs?
- traumatic MOI most common
- hemarthrosis - blood in the joint within 2 hours if traumatic
Symptoms of osteochondritis dissecans
Symptoms
- non-specific knee pain
- aggravated w/ activity and improves w/ rest
- stiffness/swelling w/ activities
- grinding, locking, catching
Physical Exam findings of osteochondritis dissecans
- TTP femoral condyle/medial and lateral joint lines
- antalgic gait
- knee effusion - multidirectional ROM loss
- limited/painful knee ROM (flexion/extension)
Symptoms and physical exam of meniscus lesion
Symptoms
- catching, locking, giving way at the knee
- local knee pain
Physical Exam
- pain at end range knee extension
- pain/limited flexion ROM
- painful/weak flexion and extension resistive testing
- joint line tenderness
Why should you check history of an older patient who has gradual onset of knee pain?
Knee OA incidence is high following ACL injury
Physical exam findings of ACL lesions
- weight shifted posture
- knee joint effusion
- antalgic gait
- A/PROM painful/limited all planes
- Boggy/guarded endfeel
- weak MMT and painful in all planes
Physical exam findings of PCL sprain
- limited knee extension in stance phase
- knee effusion
- limited/painful knee extension and flexion ROM
- pain w/ resistive testing of extension > 90 deg
What is one clinical correlation of ACL tears that can be looked at in the clinic?
quad-hamstring ratio
- decreased hamstring or core strength
Symptoms of PCL injury
- local posterior knee pain aggravated w/ deceleration and kneeling
- feelings of LE giving way/instability
Common MOI for MCL sprain. Who most commonly get MCL injury?
- valgus force to knee
- rotary trauma - quick directional change
younger males are most commonly injuried
MCL injury symptoms and physcial exam
Symptoms
- medial knee pain
- aggravated w/ activity, change in direction, valgus force at knee
Physical exam
- swelling/bruising and local TTP
- antalgic gait
- limited/painful A/PROM
Symptoms and physical exam of LCL sprain
Symptoms
- lateral knee pain
- aggravated w/ directional change during ambulation
Physical Exam
- local lateral knee effusion and TTP
- guarded/boggy end-feel w/ end range ROM flexion/extension
What predisposes someone to patellofemoral instability?
- small patella, shallow groove for patella
- lateral tilt and lateral displacement toward extension (30 deg)
- patella alta/baja
- quad muscle imbalance
- generalized ligamentous laxity
There is a high occurrence for what after patellar dislocation?
condyle articular cartilage injury
Symptoms and Physical exam of patellofemoral instability
Symptoms
- giving way of LE (reflex inhibition)
- peri-patella pain
Physical Exam
- peripatellar tenderness
- hypermobility of patellofemoral
- apprehension sign
- swelling
Clinical correlations to patellofemoral pain syndrome
- quad weakness/muscle imbalance
- lateral retinaculum tightness (genuvalgum)
- increased Q angle
- hip abduction/ER weakness
- altered foot/ankle kinematics
- increased femoral angle of inclination
- increased anteversion
- limited hip extensor endurance
- subtalar pronation (IR of tibia)
History of PFPS
- athletes
- female gender
- insidious onset
Symptoms of PFPS
- anterior knee pain
- aggravated w/ sitting, stair ambulation, inclined walking, squatting
- knee crepitus
- catching of the knee (degeneration of underside of patella)
Physical Exam of PFPS
- patella alta/baja
- abnormal Q angle
- painful squat
- swelling
- painful/limited knee flexion/extension
- painful/weak knee extension
- Hip ER/Abduction weakness
- painful/hyper PF joint mobility testing
Symptoms and Physical Exam of knee OA
Symptoms
- retropatellar pain
- aggravated by w/b activities, squatting, stairs, prolonged sitting
- Crepitus
Physical Exam
- antalgic gait
- swelling and TTP joint lines
- painful/limited knee ROM
- painful/limited knee resistive testing
Arthrofibrosis history
- traumatic injury
- progressive increase in pain and knee ROM limitatins
Symptoms and physical exam of Arthrofibrosis
Symptoms
- stiffness (worse in morning)
- knee swelling
- crepitus
- diffuse knee pain
Physical Exam
- limited knee extension during stance
- limited/painful knee ROM
- firm end feel w/ PROM
- hypomobile knee and patella joint
- swelling
- weak/painful knee extension
How much hyperextension is genu recurvatum? Where is the stress placed?
> 10 degrees
- excessive stress on posterior knee structures
What does genu recurvatum predispose someone to?
- ACL injury
- compressive injury anteriomedial tibiofemoral joint
- tensile loading posterolateral joint supporters
- posterior corner capsulo-ligamentous avulsion injuries
What should be checked in a patient w/ genu recurvatum?
distal pulses for nerve or vascular compression
What is jumper’s knee?
patella tendinopathy
Symptoms and physical exam of patella tendinopathy
Symptoms
- anterior knee pain
- aggravated w/ jumping/extensor mechanism
Physical Exam
- TTP patellar tendon
- painful squat
- pain at end range flexion
- pain during knee extension MMT
In what knee position will someone w/ IT band friction likely have issues?
30 deg of knee flexion
Correlations of IT band friction syndrome
- prominent femoral epicondyle
- leg length discrepancy
history of IT band friction syndrome
- long distance runners
- downhill skiers, jumping spots, weight lifters, cycling
- insidious/progressive onset
Symptoms and physical exam of IT band friction syndrome
Symptoms
- lateral knee pain
- aggravated w/ activity/ repetitive knee flexion/extension and stairs
Physcial Exam
- local TTP
- Ober’s test
- hip ROM painful end range ADDuction
- potentially painful hip abduction MMT
When should plica syndrome be considered?
after all other diagnoses have been ruled out
Baker’s cyst physical exam
- local swelling proximal to popliteal fossa
- pain knee flexion/extension ROM
- prominence of cyst increases w/ resisted knee flexion
Superficial fibular nerve potential areas of compression
trauma posteriolateral knee, compartment syndrome
- dog hit side of knee or tackle to outside of knee
motor distribution of superficial fibular nerve
Weakness w/ eversion
- fibularis longus and brevis
Sensory distribution of superficial fibular nerve
distal 2/3 lateral leg/ankle/dorsal foot
joint line tendernes indicates what?
meniscus lesion
Thessaly test
- test to rule out meniscus lesion
- standing on 1 leg and pivot at full extension and 30 deg flexion
Dynamic test
- lateral meniscus lesion
- figure 4 position and PROM to adduction and IR of hip
Mcmurray’s test
- meniscus lesion
- Flex knee then apply ER rotation while palpating joint line and extend, then again with IR rotation
Appley’s test
- meniscus lesion
- pt in prone, flex knee to 90 and compress and rotate. Then distract and rotate
- if more pain w/ compression and distraction alleviates pain
What is the gold standard for confirming ACL tears? What position is the knee in?
Lachman’s test
- knee flexed 15 degrees
What is the anterior and posterior drawer testing? What is the position of the knee
- anterior drawer - ACL integrity
- posterior drawer - PCL integrity
- knee in 90 deg flexion in hook lying and therapist sitting on feet
Pivot shift test
- ACL integrity, rotary stability
- listening for audible pop of tibia relocating onto femoral condyle due to no ACL stopping the motion
Clarke’s sign
- Patellofemoral pain syndrome
- patient in full knee extension and pressure provided to quad tendon as patient contracts
Pittsburgh Knee Decision Rule
1) Pt Hx blunt trauma or fall
2) Inability to bear weight x 4 steps
3) age < 12 or > 50
Criterion 1 or Criterion 1 + 2 or 3 - refer for imaging
Ottawa Knee Decision Rule
1) TTP head of fibula
2) inability to bear weight x 4 steps
3) age > 55
- inability to flex knee 90 deg
- isolated TTP of patella
Any observed - refer for imaging
Arthroscopic lavage and debridement
- want full extension ROM by week ____
- want full flexion ROM by week ____
full extension ROM by week 1
full flexion ROM by week 3
how long should you avoid loading of microfracture lesion?
~ 6-12 weeks
How long is the protection phase after a meniscus repair?
~ 6 weeks
What is the gold standard for ACL reconstruction?
double-bundle semitendinosus and gracilis autograft
immediate post-op ACL phase
- weeks, ROM, muscles/exercises
- week 1
- knee A/PROM 0-90 deg
- active quad contraction
early post-op phase ACL
- weeks, ROM, muscles/exercises
- week 2
- knee flexion > 110 deg, full kne extension during gait
- no extension lag w/ SLR
- stair climb and cycling
When can you start tibiofemoral mobs after ACL reconstruction?
around week 3
Intermediate post-op ACL
- weeks, ROM, muscles/exercises
- weeks 3-5
- knee flexion ROM within 10 deg of nonaffected LE
- quad strength 60% of nonaffected LE
- closed chain exercises, step up and squats
late phase-op phase ACL
- weeks, ROM, muscles/exercises
- weeks 6-8
- full knee ROM
- quad strength > 80% of nonaffected LE
- normal gait
transitional phase ACL
- weeks, ROM, muscles/exercises
- weeks 9-12
- full knee ROM
- maintain/improve quad strength
- hop test > 85% of nonaffected side (wk 12)
patella and quad tendon rupture repair first 3 weeks
protection, pain/inflammatory management
patella and quad tendon rupture repair weeks 3-6
- light loading
- ROM 0-45
- active knee flexion to 45 deg
- gait w/ AD
- hip muscle performance
patella and quad tendon rupture repair weeks 7-12
- progression of loading to full w/b
- hinge commonly locked 0-60 flexion
- progressive CKC
- knee extensor activation/coordination
patella and quad tendon rupture repair weeks 9-12
- single leg CKC exercises
- increase tensile loading - max knee extension activation
What is the TKA gold standard?
medial parapatellar (paramedian)
Medial parapatellar (paramedian) TKA Advantages and Disadvantages
Advantages
- great exposure for the surgeon
- optimal for alignment
Disadvantages
- compromises quad muscle tendon (quad weakness)
Subvastus TKA Advantages and Disadvantages
Advantages
- spares quad
- better post-op flexion
- less pain and higher pt satisfaction
- better patella tracking
- faster ADL recovery
Disadvantages
- more technically complicated
Midvastus TKA Advantages and Disadvantages
Advantages
- minimizes quad trauma
Disadvantages
- disrupts VMO
- no evidence to suggest any better outcomes than paramedian
Lateral TKA Advantages and Disadvantages
Advantages
- great exposure to structures that may be released
- allows for correction of malalignment
Disadvantages
- less medial visualization
- more technically complicated
Minimally invasive TKA Advantages and Disadvantages
Advantages
- avoids quad trauma
- avoids patellar disruption
Disadvantages
- a greater technical challenge
