Knee

Question 1

What movement does the ACL mostly resist?

Answer 1

Anterior tibial translation

Question 2

What are the two main bundles of the ACL and where does each bundle get the most taut?

Which tests isolate each bundle for damage?

Answer 2

anteromedial-gets more taut with knee flexion (anterior drawer test)

posterolateral-taut in full extension (Lachman test)

Question 3

Is the anterior drawer test more specific or sensitive?

Is the Lachman test more specific or sensitive?

Is the Pivot Shift test more sensitive or specific?

Answer 3

Ant Drawer test is moderately specific and sensitive but is more specific (58%) than sensitive (49%)

Lachman is the most sensitive test for ACL tear (85%) but is actually more specific (94%)

Pivot shift test has terrible sensitivity but is very specific (95%)

Question 4

What risk factors are associated with increased chance of ACL tears?

Answer 4

-turf and dry weather
-females
-prior ACL reconstruction
-anatomical deficiencies

Question 5

What subjective and objective exam findings mostly are associated with ACL tear?

Answer 5

-a non-contact accel/decel MOI with a valgus load
-pt felt a pop in their knee
-swelling within 12 hours of injury
-positive Lachman
-positive pivot shift

Question 6

What movement does the PCL mostly resist?

How is it most commonly injured?

Answer 6

posterior tibial movements, especially between 30-90 degrees

with hyperflexion or severe hyperextension and is also associated with dashboard injury (external posteriorly directed force to proximal tibia)

Question 7

What structure is often injured alongside the posterolateral articular corner?

Answer 7

PCL

Question 8

What ligaments and structures help make up the posterolateral corner?

Answer 8

arcuate lig., LCL, popliteus tendon, lateral head of gastrocnemius, and biceps femoris tendon

Question 9

How can you use the posterior drawer test to detect an isolated injury of the posterolateral corner?

Answer 9

if you have a positive posterior drawer test at 30 degrees but is negative at 90 degrees it may be due to an isolated injury to the posterolateral corner

Question 10

If during the Dial Test you get a positive finding at 30 degrees but not at 90 degrees what diagnosis should be ruled up?

What if it is positive at both 30 and 90 degrees?

What if it is positive only at 90 degrees?

Answer 10

If (+) at 30 but not 90=posterolateral corner injury

both 30 and 90 are (+)= PCL w/ PL corner but PCL more so

only (+) at 90=PCL isolated injury

Question 11

How do the two portions of the MCL run anatomically and what is each bundles main function?

Answer 11

superficial bundles runs from posterior aspect of the medial condyle and attaches to the pes anserine-it’s main duty is be the primary restraint of valgus forces

deep portion attaches to the meniscus from the tibia and the femur and primary function is support meniscus and help reduce anterior tibial translation

Question 12

True or False: The MCL and LCL are intracapsular ligaments?

Answer 12

False, the MCL is intracapsular but the LCL is extracapsular

Question 13

What does the LCL attach to and what does it restrain?

Answer 13

arises from the lateral condyle and attaches to the fibular head

restrains Varus forces and also helps to resist lateral rotation of tibia

Question 14

What is the ideal knee flexion angle to test varus and valgus stress tests on the knee?

Answer 14

30 degrees to limit how much the ACL and PCL can help resist the movements

Question 15

Does pain make the varus and valgus stress test more specific/sensitive than laxity?

Answer 15

No, laxity makes the tests much more sensitive and specific

Question 16

What is the job of the oblique popliteal ligament and the posterior oblique ligament?

Answer 16

Reinforce the posterior medial knee joint capsule

Question 17

What are the two branches of the arcuate ligament and what does this ligament do?

Answer 17

medial branch-attaches to OPL

lateral branch-attaches to fibular head

ligaments provides support to the posterior lateral knee capsule

Question 18

What are the Ottawa Knee Rules?

Answer 18

Following an acute knee injury, if any one of these 5 factors if present, imaging should be performed

-age over 55
-cannot bend pass 90 degrees
-cannot bear weight immediately or in the ER
-fibular head tenderness
-patellar tenderness without any other TTP

Question 19

The IKDC 2000 and Knee Injury and osteoarthritis outcome scores are measurements of what?

Answer 19

Function, both go from 0-100 with the higher score = better function

Question 20

According to the ACL injury CPG, what interventions following an ACL reconstruction received an A level recommendation?

Answer 20

therapeutic exercise with early weight progressive weight bearing, concentric and eccentric strengthening 2-3x a week for 6-10 months

NMES for 6-8 weeks post-op

Question 21

According to the ACL injury CPG, what interventions following an ACL reconstruction received a B level recommendation?

Answer 21

Immediate mobilization

immediate bracing

cryotherapy to reduce pain

supervised rehab exercises

Question 22

According to the ACL injury CPG, what interventions following an ACL reconstruction received a C level recommendation?

Answer 22

continuous PROM machine

early weight bearing as tolerated

Question 23

Is functional knee bracing post-operatively recommended following ACL reconstruction?

Answer 23

It’s complicated, for post-op there is D level evidence but is there was no surgery and the ACL is just strained there is then C level evidence supporting bracing, for all other ligaments though there is F level evidence

Question 24

What muscle group works alongside the ACL resisting anterior tibial translation?

Answer 24

Hamstrings

Question 25

What is the rate of second ACL injury following an ACL tear? Of those with second injury what percentage is ipsilateral sided injury?

Answer 25

23% second injury rate with 50/50 split on contra or ipsilateral side

Question 26

True or False: Hop testing is an outcome measure for risk of re-injury?

Answer 26

False, hop testing predicts return to sport and PLoF, not re-injury risk

Question 27

What is the best indicator for risk of re-injury following an ACL reconstruction?

Answer 27

Time, 9 months is best for return to sport and those who return prior to 9 months are at a 9x risk of re-injury

Question 28

For ACL injury prevention, what makes a good injury prevention program?

Answer 28

a dynamic warm up that takes over 20 minutes to be performed multiple times a week and have multiple exercises focused on trunk strength, BLE strength, and plyometrics. balance has not be found to be helpful to work on as it relates to injury prevention of the ACL

Question 29

What criteria qualifies a patient who suffered an ACL injury to be screened on whether they can qualify as a coper or not? What is the Coper screen criteria?

Answer 29

-injury must be an isolated ACL injury/tear -no painful AROM and no joint effusion -max voluntary isometric contraction must be at least 70% of the contralateral side Coper Criteria -no more than one episode of the knee giving away -80% symmetry in the 6m hop test -80% on knee outcome survey ADL outcome measure -60% on global rating of knee function \]\

Question 30

Which meniscus section is injured more frequently? Which meniscus section is bigger and more mobile? What muscle attaches to the medial meniscus and MCL?

Answer 30

Medial lateral Semimembranosous

Question 31

What percentage of the population that has osteoarthritis also has a degenerative mensical tear?

Answer 31

~91%

Question 32

What patient reported criteria helps diagnose a torn meniscus? What are the components of the meniscal pathology scale?

Answer 32

-knee pain with a history of a twisting MOI -episodes of knee catching or locking -delayed swelling (6-24 hours after injury) -meniscal pathology scale greater than 3 findings Meniscal pathology scale -history of catching or locking -pain with forced hyperextension -pain with max knee flexion -joint line tenderness -pain with McMurray's

Question 33

Should surgery be recommended for degenerative meniscal tears?

Answer 33

No, and those who do have surgery have worse outcomes in the short and intermediate terms compared to those who did conservative care

Question 34

What patients typically due well with meniscus repair surgeries?

Answer 34

Younger athletes

Question 35

What is the typical return to sport timeline for meniscectomy patients?

Answer 35

2 months if they are young, 3 months if older than 30

Question 36

According to the meniscal injury CPG, what interventions received a B level recommendation for non-operative meniscal injury rehabilitation?

Answer 36

supervised progressive ROM and strength training

Question 37

According to the meniscal injury CPG, what interventions received a B level recommendation for post-op meniscal injury rehabilitation?

Answer 37

-early progressive ROM -in clinic supervised rehab with HEP -NMES

Question 38

According to the meniscal injury CPG, what interventions received a C level recommendation for meniscus repair rehabilitation?

Answer 38

-early progressive weight bearing -early progressive return to PLoF

Question 39

How is the modified stroke test performed and how is it scored?

Answer 39

-pt is in supine w/ knee extended -starting at the medial joint line PT stroke the knee upward 2-3 times to move swelling to suprapatellar pouch -then PT strokes down on lateral thigh toward joint line -look for a wave of fluid on the medial knee graded on 0-3+ scale 0=no wave of fluid trace=small wave of fluid 1+=large bulge with downstroke 2+=effusion returns with out lateral thigh stroke 3+=up stroke does not work

Question 40

How can you differentiate a meniscal tear from an articular cartilage lesion?

Answer 40

Meniscus ears will occur with a twisting MOI and there will be delayed swelling whereas articular cartilage injuries have an insidious onset most frequently and swelling is intermittent

Question 41

What does microfracture surgery for an articular cartilage injury consist of? What population is it mostly used for and what is the major risk of this surgery?

Answer 41

when holes are drilled in the cartilage to increase bleeding and healing used for younger patients with low load and small lesions increased failure rate if returning to high level of activity

Question 42

What does Antilogous Chondrocyte Implantation surgery for an articular cartilage injury consist of? What population is it mostly used for and what is the major risk of this surgery?

Answer 42

a 2 stage surgery where chondrocytes are harvested and then put back into joint after 2 weeks good for those who want to return to activity even under high loads timeline is long and failure rate is high

Question 43

What does osteochondral autograph transplant (OAT) surgery for an articular cartilage injury consist of? What population is it mostly used for and what is the major risk of this surgery?

Answer 43

cartilage from non-weight bearing areas are put in where old lesion was best for higher level of demand such as with athletes, this method also has high rate of function and return to sport as well as decreased pain compared to ACL or microfracture

Question 44

What are the typical red flags that lead to surgery as it related to articular cartilage injuries?

Answer 44

-females -older -increased BMI -low symptom duration -previous surgeries -low self reported function

Question 45

What is the most specific test for diagnosing patellar femoral pain syndrome? What is the most sensitive?

Answer 45

Eccentric step down test (82% specific) Moderate to high sensitivity is given with reproduction of pain with squatting, kneeling, and stair navigation

Question 46

What populations are most linked with the overuse/overload without other impairment classification for PF pain?

Answer 46

linked with training load factors military and recreational runners who both increase load without proper recovery So if a patient presents with PF pain and a history of increase load magnitude or frequency and has reproduction of anterior knee pain with eccentric step down test with no impairments leading to other classifications would fit this classification.

Question 47

What indications would suggest a patient with PF pain be classified in the PF pain w/ movement coordination deficits?

Answer 47

a dynamic valgus on lateral step down test is noted and frontal plane valgus of over 10 degrees during a single leg squat

Question 48

How is the lateral step down test performed and scored?

Answer 48

Patient is on a 20cm step and steps down laterally 5 criteria to score, one point each except if examiner notices any of the following -arm strategy (removes arms from side) -trunk alignment/leaning -pelvic plane-tilt -tibial tuberosity is medial to 2ndtoe (two points given if medial to medial foot border) -steady stance, if stance foot moves it is one point positive test is 2+ points

Question 49

True or false: Dynamic valgus is a sign of hip weakness

Answer 49

False, valgus does not equal weakness it only indicates poor movement coordination

Question 50

What indications would suggest a patient with PF pain be classified in the PF pain with muscle performance deficits?

Answer 50

-based on hip and knee strength deficits in isometrics -normal for there to be a 10% difference from dominant side to non-dominant

Question 51

For isometric muscle testing, what are the cut off scores for men and women for the following muscle groups?

Answer 51

Hip Abductors: Men-37% of BW Women-30% of BW Hip ERs: Men 13% Women 17% Hip Ext: Me-28% Women 30% Knee extensors: men 44% women 37%

Question 52

How can you measure hypermobility as it relates to PF pain with mobility impairments classification?

Answer 52

measure mid-foot with in NWB and then again in WB movements; if there is a difference of over 11 degrees that means he is a =hypermobile

Question 53

What factors would lead an examiner to place a patient in the PF pain with hypomobility impairments classification?

Answer 53

-positive patellar tilt test for tightness of lateral patella -decreased LE muscle length -decreased hip IR or ER

Question 54

According to the Patellofemoral Pain CPG, what recommendations have been made for interventions for the overload/overuse classification and what level of evidence do these interventions have?

Answer 54

B level evidence for patellar taping using the Tailored McConnel method with the combination of exercise F level evidence for activity modification and rest

Question 55

According to the Patellofemoral Pain CPG, what recommendations have been made for interventions for the movement coordination classification and what level of evidence do these interventions have?

Answer 55

B level evidence AGAINST adding visual biofeedback C level evidence for gait and movement retraining

Question 56

According to the Patellofemoral Pain CPG, what recommendations have been made for interventions for the Muscle Performance classification and what level of evidence do these interventions have?

Answer 56

A level evidence for hip and knee targeted exercise

Question 57

According to the Patellofemoral Pain CPG, what recommendations have been made for interventions for the mobility impairments (hypo/hypermobility) classification and what level of evidence do these interventions have?

Answer 57

Hypermobile A level evidence for foot orthosis for patients with greater than normal pronation and exercise (orthosis does not need to be custom) B level evidence for patellar taping (Tailor McConnell) Hypomobile F level evidence for LE stretching and mobilization of lateral patellar retinaculum

Question 58

For general patellofemoral pain what two approaches does the PF pain CPG recommend AGAINST?

Answer 58

A level evidence against manual therapy as a stand alone treatment B level evidence against the use of patellar bracing

Question 59

According to the CPG for TKA's (primary TKA following knee OA only) what pre-operative recommendation are given and what level of evidence is given for them?

Answer 59

Moderate level evidence for pre-op exercise programs for strength and mobility expert opinion level evidence for pre-op education that includes post-op program and prognosis

Question 60

According to the CPG for TKA's (primary TKA following knee OA only) are continuous passive motion machines recommended post-op? Is cryotherapy recommended?

Answer 60

No, there is moderate level of evidence AGAINST their use due to cost and prolonged bed rest Yes, for pain relief immediately after surgery

Question 61

According to the CPG for TKA's (primary TKA following knee OA only) how early can strength training begin?

Answer 61

there is moderate level evidence that high intensity strength training as early as 3 days post-op but those with muscle activation issues may need to address that first with NMES NMES has moderate level of evidence to improve quad strength and gait quality in first 3 weeks at highest tolerable level

Question 62

According to the CPG for TKA's (primary TKA following knee OA only) discharge to a SNF is recommended over home discharge and outpatient therapy should be on hold for at least 6 weeks, true or false?

Answer 62

False, discharge to home just as good as discharge to a SNF and the faster they are seen by OP PT the better

Question 63

What is Hoffa Knee? What causes it?

Answer 63

an infrapatellar fat pad injury where pain is located in front of the knee behind the patellar tendon and is associated with repetitive knee extension activities

Question 64

What is IT band friction syndrome? what causes it? What test can help confirm this diagnosis?

Answer 64

pain in the lateral knee with TTP over the lateral condyle of the femur that is very common in runners and cyclist as it is caused by repeated cycling through 20-40 degrees of flexion and comes on after an increase in activity or resistance test to confirm is the Noble Compressions test where the examiner puts pressure over lateral femoral condyle and moves knee into flexion and extension and if there is familiar paint he test is positive

Question 65

Where is pain normally associated with Pes Anserine bursitis?

Answer 65

pain at the site of the attachment of the sartorious, gracilis, and semitendinosus common with OA patients

Question 66

Where is pain normally associated with suprapatellar bursitis?

Answer 66

swelling and TTP above the knee cap but with bogginess

Question 67

What is house maid's knee or carpenter's knee?

Answer 67

a prepatellar bursitis which is brought on by direct pressure or blow to the knee and causes pain on patella

Question 68

What is clergyman's knee?

Answer 68

infrapatellar bursitis that is associated with kneeling and causes pain distal to the attachment of the patellar tendon

Question 69

What is Osgood Schlatter's Disease? what is the most common population affected?

Answer 69

a traction apophysitis of the growth plate at the tibial tubercle which causes pain and a prominent tibial tubercle due to calcification mostly affects young athletic population in sports with repetitive jumping or squatting

Question 70

What is Sinding Larsen-Johanson Syndrome?

Answer 70

a traction apophysitis of the patellar growth plate that is less common than Osgood Schlatter's pain is in lower pole of patella due to irritation of the growth plate and is normally found in growth years

Question 71

What is the best test for lateral patellar instability?

Answer 71

patellar apprehension test which is positive if there is pain or contraction of the quad as an examiner pushes a patient's patella laterally on a relaxed and extended knee

Question 72

How many patient who suffer a patellar dislocation will have another? what percentage of first time dislocations will be able to regain full control of their knee without surgery?

Answer 72

30% 60-70%

Question 73

What are the best predictors for subsequent episodes of patellar dislocation?

Answer 73

trochlear dysplasia skeletal immaturity age under 18 females patella alta history of contralateral dislocation

Question 74

What is the difference between Patellar Tendinopathy vs. patellofemoral pain?

Answer 74

The location of pain, tendinopathy will be localized to the patellar tendon or lower pole of the patella pain at rest, there should be no pain at rest with a tendinopathy where as PFJ pain can have pain at rest Males are more common to have tendinopathy while females are more likely to have PFJ pain syndrome

Question 75

Of the athletes who have tendinopathy pain, what percentage will have recurrent episodes? What percentage will retire from their sport due to the pain?

Answer 75

50% 50%

Question 76

What are common pain generators in the knee for patient with OA?

Answer 76

inflammation synovium bone marrow lesion peripheral nerve hyper sensitivity cartilage is not a pain generator

Question 77

What is the Altman Criteria for diagnosis knee OA?

Answer 77

patient must have knee pain and 3 of any of the following -age over 50 -less than 30 minutes of morning stiffness -crepitus -bony tenderness -bony enlargement -no warmth of synovium

Question 78

how is the Kellgren Lawrence OA classification system graded?

Answer 78

0-no OA (definite absence of changes of OA) 1-doubtful OA (doubtful joint space narrowing and possible osteophyte) 2-minimal OA (definite osteophytes and possible joint narrowing) 3-Moderate OA (osteophytes and moderate joint space narrowing) 4- Severe OA (large osteophytes and marked narrowing as well as severe sclerosis and boney deformity)

Question 79

For obese patient with OA what percentage of weight loss is recommended to start seeing improvement of symptoms?

Answer 79

~5%

Question 80

What interventions are recommended AGAINST for knee OA?

Answer 80

-lateral heel wedge -TENS -Oral Narcotics -PRP injection

Question 81

What is the CPR criteria for whether hip mobilizations with help with knee OA symptoms?

Answer 81

Need one to two of the following -hip/groin pain or parasthesia -anterior thigh pain -passive knee flexion less than 122 degrees -passive hip flexion less than 17 degrees -pain with hip distraction

Question 82

What are the parameters for NMES when the trying to improve quadriceps strength?

Answer 82

Type: Russian Current: Burst Pulse Duration: 400 microseconds pulses per second: 75 Ramp: 2 seconds Contract:Relax Ratio-10:50seconds

Question 83

What has chronic (2+ years) brace wearing post ACL reconstruction been linked to?

Answer 83

Decreased quadriceps strength and poorer prognosis

Question 84

What is the typical time needed to heal for tendinitis? What about tendon lacerations?

Answer 84

3-7 weeks 5 weeks-6 months

Question 85

What is the typical time needed for grades 1-3 muscle strains to heal?

Answer 85

Grade 1: 0-14 days Grade 2: 4 days to 3 months Grade 3: 3 weeks to 6 months

Question 86

What is the typical time needed for grades 1-3 ligament strains?

Answer 86

Grade 1: 0-5 days Grade 2: 3 weeks to 6 months Grade 3: 5 weeks to a year

Question 87

How long does a ligament graft need to fully heal? Bone fractures? articular cartilage repair?

Answer 87

2 months up to 2 years 5 weeks to 3 months 2 months up to 2 years

Question 88

How long after a meniscus repair surgery, should FWB be limited? What ROM limitations should be in place after surgery?

Answer 88

4-8 weeks depending on surgeon preference no strengthening past 45 degrees of flexion for first 4 weeks and then at 90 degrees for another 4 weeks

Question 89

If you wanted to rule OUT a meniscus injury, what test should yo use? What if you wanted to rule a meniscal injury IN?

Answer 89

Thessaly helps rule out, this is a very SENSITIVE test which allows us to rule down a diagnosis if the result is a negative McMurray's or Joint Line Tenderness are better at ruling IN due to being more SPECIFIC

Question 90

What are the main goals for post-op meniscus injuries for the first 6 weeks post-operatively?

Answer 90

standard double-upright, hinged knee brace first 6 weeks * toe-touch weight bearing with the knee in full extension - 4 weeks, with gradual progression to full weight bearing by 6 weeks postoperatively * Early range-of-motion exercise is begun immediately, including full extension * Flexion is limited to 90 degrees during the first 4 weeks * Range of motion is progressed after 4 to 6 weeks * Closed kinetic chain strengthening exercises within the flexion limits - 3 weeks

Question 91

What is the difference between Tendinitis vs Tendonosis

Answer 91

Tendinitis is an acutely inflamed swollen tendon that doesn’t have microscopic tendon damage. The underlying culprit in tendinitis is inflammation. Tendinosis, on the other hand, is a chronically damaged tendon with disorganized fibers and a hard, thickened, scarred and rubbery appearance.

Question 92

What is the difference between the acute and chronic (or sports related pain

Answer 92

Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury and is extremely painful. Without treatment, it can lead to permanent muscle damage. Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion and is reversible with rest.