Knee Flashcards
What movement does the ACL mostly resist?
Anterior tibial translation
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?
anteromedial-gets more taut with knee flexion (anterior drawer test)
posterolateral-taut in full extension (Lachman test)
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?
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%)
What risk factors are associated with increased chance of ACL tears?
-turf and dry weather
-females
-prior ACL reconstruction
-anatomical deficiencies
What subjective and objective exam findings mostly are associated with ACL tear?
-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
What movement does the PCL mostly resist?
How is it most commonly injured?
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)
What structure is often injured alongside the posterolateral articular corner?
PCL
What ligaments and structures help make up the posterolateral corner?
arcuate lig., LCL, popliteus tendon, lateral head of gastrocnemius, and biceps femoris tendon
How can you use the posterior drawer test to detect an isolated injury of the posterolateral corner?
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
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?
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
How do the two portions of the MCL run anatomically and what is each bundles main function?
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
True or False: The MCL and LCL are intracapsular ligaments?
False, the MCL is intracapsular but the LCL is extracapsular
What does the LCL attach to and what does it restrain?
arises from the lateral condyle and attaches to the fibular head
restrains Varus forces and also helps to resist lateral rotation of tibia
What is the ideal knee flexion angle to test varus and valgus stress tests on the knee?
30 degrees to limit how much the ACL and PCL can help resist the movements
Does pain make the varus and valgus stress test more specific/sensitive than laxity?
No, laxity makes the tests much more sensitive and specific
What is the job of the oblique popliteal ligament and the posterior oblique ligament?
Reinforce the posterior medial knee joint capsule
What are the two branches of the arcuate ligament and what does this ligament do?
medial branch-attaches to OPL
lateral branch-attaches to fibular head
ligaments provides support to the posterior lateral knee capsule
What are the Ottawa Knee Rules?
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
The IKDC 2000 and Knee Injury and osteoarthritis outcome scores are measurements of what?
Function, both go from 0-100 with the higher score = better function
According to the ACL injury CPG, what interventions following an ACL reconstruction received an A level recommendation?
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
According to the ACL injury CPG, what interventions following an ACL reconstruction received a B level recommendation?
Immediate mobilization
immediate bracing
cryotherapy to reduce pain
supervised rehab exercises
According to the ACL injury CPG, what interventions following an ACL reconstruction received a C level recommendation?
continuous PROM machine
early weight bearing as tolerated
Is functional knee bracing post-operatively recommended following ACL reconstruction?
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
What muscle group works alongside the ACL resisting anterior tibial translation?
Hamstrings
What is the rate of second ACL injury following an ACL tear? Of those with second injury what percentage is ipsilateral sided injury?
23% second injury rate with 50/50 split on contra or ipsilateral side
True or False: Hop testing is an outcome measure for risk of re-injury?
False, hop testing predicts return to sport and PLoF, not re-injury risk
What is the best indicator for risk of re-injury following an ACL reconstruction?
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
For ACL injury prevention, what makes a good injury prevention program?
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
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?
-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 ]\
Which meniscus section is injured more frequently?
Which meniscus section is bigger and more mobile?
What muscle attaches to the medial meniscus and MCL?
Medial
lateral
Semimembranosous
What percentage of the population that has osteoarthritis also has a degenerative mensical tear?
~91%
What patient reported criteria helps diagnose a torn meniscus?
What are the components of the meniscal pathology scale?
-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
Should surgery be recommended for degenerative meniscal tears?
No, and those who do have surgery have worse outcomes in the short and intermediate terms compared to those who did conservative care
What patients typically due well with meniscus repair surgeries?
Younger athletes
What is the typical return to sport timeline for meniscectomy patients?
2 months if they are young, 3 months if older than 30
According to the meniscal injury CPG, what interventions received a B level recommendation for non-operative meniscal injury rehabilitation?
supervised progressive ROM and strength training
According to the meniscal injury CPG, what interventions received a B level recommendation for post-op meniscal injury rehabilitation?
-early progressive ROM
-in clinic supervised rehab with HEP
-NMES
According to the meniscal injury CPG, what interventions received a C level recommendation for meniscus repair rehabilitation?
-early progressive weight bearing
-early progressive return to PLoF
How is the modified stroke test performed and how is it scored?
-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
How can you differentiate a meniscal tear from an articular cartilage lesion?
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
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?
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
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?
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
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?
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
What are the typical red flags that lead to surgery as it related to articular cartilage injuries?
-females
-older
-increased BMI
-low symptom duration
-previous surgeries
-low self reported function
What is the most specific test for diagnosing patellar femoral pain syndrome?
What is the most sensitive?
Eccentric step down test (82% specific)
Moderate to high sensitivity is given with reproduction of pain with squatting, kneeling, and stair navigation
What populations are most linked with the overuse/overload without other impairment classification for PF pain?
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.
What indications would suggest a patient with PF pain be classified in the PF pain w/ movement coordination deficits?
a dynamic valgus on lateral step down test is noted and frontal plane valgus of over 10 degrees during a single leg squat
How is the lateral step down test performed and scored?
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
True or false: Dynamic valgus is a sign of hip weakness
False, valgus does not equal weakness it only indicates poor movement coordination
What indications would suggest a patient with PF pain be classified in the PF pain with muscle performance deficits?
-based on hip and knee strength deficits in isometrics
-normal for there to be a 10% difference from dominant side to non-dominant
For isometric muscle testing, what are the cut off scores for men and women for the following muscle groups?
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%
How can you measure hypermobility as it relates to PF pain with mobility impairments classification?
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
What factors would lead an examiner to place a patient in the PF pain with hypomobility impairments classification?
-positive patellar tilt test for tightness of lateral patella
-decreased LE muscle length
-decreased hip IR or ER
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?
B level evidence for patellar taping using the Tailored McConnel method with the combination of exercise
F level evidence for activity modification and rest
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?
B level evidence AGAINST adding visual biofeedback
C level evidence for gait and movement retraining
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?
A level evidence for hip and knee targeted exercise
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?
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
For general patellofemoral pain what two approaches does the PF pain CPG recommend AGAINST?
A level evidence against manual therapy as a stand alone treatment
B level evidence against the use of patellar bracing
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?
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
According to the CPG for TKA’s (primary TKA following knee OA only) are continuous passive motion machines recommended post-op?
Is cryotherapy recommended?
No, there is moderate level of evidence AGAINST their use due to cost and prolonged bed rest
Yes, for pain relief immediately after surgery
According to the CPG for TKA’s (primary TKA following knee OA only) how early can strength training begin?
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
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?
False, discharge to home just as good as discharge to a SNF and the faster they are seen by OP PT the better
What is Hoffa Knee?
What causes it?
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
What is IT band friction syndrome?
what causes it?
What test can help confirm this diagnosis?
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
Where is pain normally associated with Pes Anserine bursitis?
pain at the site of the attachment of the sartorious, gracilis, and semitendinosus
common with OA patients
Where is pain normally associated with suprapatellar bursitis?
swelling and TTP above the knee cap but with bogginess
What is house maid’s knee or carpenter’s knee?
a prepatellar bursitis which is brought on by direct pressure or blow to the knee and causes pain on patella
What is clergyman’s knee?
infrapatellar bursitis that is associated with kneeling and causes pain distal to the attachment of the patellar tendon
What is Osgood Schlatter’s Disease?
what is the most common population affected?
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
What is Sinding Larsen-Johanson Syndrome?
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
What is the best test for lateral patellar instability?
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
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?
30%
60-70%
What are the best predictors for subsequent episodes of patellar dislocation?
trochlear dysplasia
skeletal immaturity
age under 18
females
patella alta
history of contralateral dislocation
What is the difference between Patellar Tendinopathy vs. patellofemoral pain?
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
Of the athletes who have tendinopathy pain, what percentage will have recurrent episodes?
What percentage will retire from their sport due to the pain?
50%
50%
What are common pain generators in the knee for patient with OA?
inflammation
synovium
bone marrow lesion
peripheral nerve hyper sensitivity
cartilage is not a pain generator
What is the Altman Criteria for diagnosis knee OA?
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
how is the Kellgren Lawrence OA classification system graded?
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)
For obese patient with OA what percentage of weight loss is recommended to start seeing improvement of symptoms?
~5%
What interventions are recommended AGAINST for knee OA?
-lateral heel wedge
-TENS
-Oral Narcotics
-PRP injection
What is the CPR criteria for whether hip mobilizations with help with knee OA symptoms?
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
What are the parameters for NMES when the trying to improve quadriceps strength?
Type: Russian
Current: Burst
Pulse Duration: 400 microseconds
pulses per second: 75
Ramp: 2 seconds
Contract:Relax Ratio-10:50seconds
What has chronic (2+ years) brace wearing post ACL reconstruction been linked to?
Decreased quadriceps strength and poorer prognosis
What is the typical time needed to heal for tendinitis?
What about tendon lacerations?
3-7 weeks
5 weeks-6 months
What is the typical time needed for grades 1-3 muscle strains to heal?
Grade 1: 0-14 days
Grade 2: 4 days to 3 months
Grade 3: 3 weeks to 6 months
What is the typical time needed for grades 1-3 ligament strains?
Grade 1: 0-5 days
Grade 2: 3 weeks to 6 months
Grade 3: 5 weeks to a year
How long does a ligament graft need to fully heal?
Bone fractures?
articular cartilage repair?
2 months up to 2 years
5 weeks to 3 months
2 months up to 2 years
How long after a meniscus repair surgery, should FWB be limited?
What ROM limitations should be in place after surgery?
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
If you wanted to rule OUT a meniscus injury, what test should yo use?
What if you wanted to rule a meniscal injury IN?
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
What are the main goals for post-op meniscus injuries for the first 6 weeks post-operatively?
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
What is the difference between Tendinitis vs Tendonosis
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.
What is the difference between the acute and chronic (or sports related pain
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.
