Knee Flashcards
What is the return to sport criteria after a hamstring injury?
Full strength without pain:
- tested in prone at 90 deg and 15 deg
- max effort with 4 consecutive efforts
- less than 5% bilateral deficit in eccentric hamstrings
Full ROM without pain
Replication of sport specific movements @ near max speed
- use incremental sprint testing for athletes
allograft ACL reinjury rate
The data point to a very high (>30%) early reinjury or contralateral injury rate seen with the use of allografts.
pros/cons to allografts, artificial graft
-efficient but some issues:
-incorporate less completely and more slowly than autografts
-require sterilization and are expensive.
-Recent studies do not support their use in younger patients, especially in young females
-artificial graft: Short-term results were encouraging, but after one year, issues began, and they all failed over time. Any graft must be biologic if the long-term health of the joint is to be preserved.
biceps femoris
long head- ischial tuberosity
short head- linea aspera/latreal supracondylar line
–> fibular head. tendon split by LCL
long head: tibial nerve
short head: common peroneal nerve
L5-S2
semitendinosus
ischial tuberosity-> medial tibia
tibial nerve L5-S2
semimembranosus
ischial tuberosity->posterior medial tibial condyle, attachment forms oblique popliteal ligament
tibial nerve L5-S2
gastroc
lateral head: lateral femoral condyle
medial head: popliteal surface of femur superior to medial condyle
-> calcaneous via tendon
tibial nerve S1-2
soleus
posterior fibula, soleal line/middle 1/3 of medial border of tibia, tendinous arch –> posterior surface of calcaneus
tibial nerve S1-2
plantaris
inferior end of lateral supracondylar line/oblique popliteal ligament –> calcaneus via tendon
tibial nerve S1-2
popliteus
lateral femoral condyle & lateral meniscus -> posterior surface of tibia/superior to soleal line
tibial nerve L4-S1
sartorius
ASIS/superior part of notch inferior to it–> superior part of medial tibia
femoral nerve L2-3
rectus femoris
AIIS and ilium superior to acetab-> via quad tendon, indirectly via patellar ligament to tibial tuberosity
femoral nerve L2-4
vastus lateralis
greater trochanter & lateral lip of linea aspera–>via quad tendon; also into tibia/patella via lateral patellar retinaculum
femoral nerve L2-4
vastus medialis
intertrochanteric line & medial lip of linea aspera-> quad tendon
femoral nerve L2-4
vastus intermedius
anterior/lateral surface of femur shaft-> via quad tendon
femoral nerve L2-4
knee tibial nerve innervations
L5-S2:
biceps femoris long head
semitendinosus
semimembranosus
S1-2:
gastroc
soleus
plantaris
L4-S1
popliteus
Ottawa Knee Rules
Age >55
Fibular head TTP
isolated tenderness of patella
unable to flex knee to 90
unable to bear weight immediately or in ER
high SN
Pittsburgh Knee Rules
Blunt trauma or fall of MOI
PLUS either of following:
-age >50 or <12
-unable to walk 4 WB steps in ER
high SN
Knee OA Clinical presentation
Knee pain + at least 3/6 of following:
-age >50
-AM stiffness <30 min
-crepitus on active motion
-bony tenderness
-no palpable warmth
-bony enlargement
meniscus CPR - CLinical composite score to accurately detect
-history of catching/locking
-joint line tenderness
-pain with forced hyperext (modified bounce home test)
-pain with maximal passive knee flexion
-pain/click with mcmurray
Low SN
High SP: 3+ .9; 5=.99
CPG for meniscus - risk factors level of evidence
- age, greater time from injury, participated in high level sports or had laxity after ACL injury
-cartilage- age/presence of meniscal tear considered in odds of chondral lesion
^^both evidence C
meniscus CPG - level of evidence for interventions
Progressive WB - D
Progressive Knee motion (following surgery); early return to activity: C
return to activity with chondral lesion- E (delay return)
supervised rehab: D, conflicting evidence
ther ex, NMES: B
ACL clinical presentation
contact or non contact
excess dynamic valgus, anterior tibial translation, posterior femoral translation, or hyperextension
audible pop
feeling of instability, immediate swelling
ACL special testing
Anterior drawer - SP 86-100 (low SN)
Active lachman - SN 99, SP 100
Lachman - SN 80-99, SP 91-100
ACL CPG - outcome
B:
KOOS, UKDC, lysholm scale. tegner or marx for activity level
ACL RTS after injury for psych assessment
ACL CPG interventions level of evidence
CPM, early WB: C (implement early WB)
knee bracing:
-C for functional bracing
D - pt preferences?
F: acute PCL/severe MCL/PLC
immediate vs delayed motion: B (use immediate motion)
cryo: B - use immediately
supervised rehab: B
A: ther ex, NMES (6-8 wks), NMR
PCL special test
posterior sag: SP 100, SN 79
posterior drawer: SP 99, SN 51-100
quadriceps active test: SP 97-100
MCL special test
valgus stress test
SN 86-96, SP 93
MCL CPR
trauma by external force to leg
rotational trauma
pain with valgus test at 30 deg
laxity with valgus at 30 deg
LCL special test
varus stress test SP 99
PLC injury / test
MOI: hyperextension,trauma to anteromedial knee, or varus force at knee
DIAL ( SP/SN unknown)
external rotation recurvatum test: SP 99
meniscus zones
white zone- inner 2/3- no direct blood supply and no nerve ending
red zone- good blood supply, outer 1/3
knee capsule layers
-superficial= deep fascia, sartorius
-middle – superficial medial ligament
-deep :
-tibial collateral ligament (MCL)- deep & superficial components, intimate meniscal attachment, posterior femur to anterior tibia, taut in extension/lax in flexion, prevents valgus/ER
-LCL fibular collateral ligament – cord like, anterior femurposterior fibula, taut in extension/lax in flexion, limits varus/ER
laxity classification
grade I: <3-5mm
grade II: 5-10mm
Grade III: >10mm
meniscus special tests
mcmurray
appleys compression
joint line tenderness
thessaly
-greatest strain on ACL exercises
-isometric quad at 15 deg
-squatting with sport cord
-active flex/ext w/ weighted boot
-Lachman test
-squatting
least strain exercises on ACL
isometric quad from 30-90 deg
-simultaneous quad/hamstring contraction at 60-90deg
PCL- motor control focus
popliteus shares role of PCL in checking posterior translation of tibia
quads reduce strain on PCL most between 20-60 deg
gastroc greatest strain on PCL when knee flexed >40 deg
Hamstring also posterior shear
least likely collateral ligament to be damaged
LCL
MOI for PCL tear
-following flexed knee with foot in pf
-anterior blow to knee from dashboard
-sudden extreme hyperextension
popliteus- when does it act as stabilzer
when ER torque applied to knee flexed between 60-90
functions of popliteus
-tibial IR
-inhibits ER Of tibia
-femoral ER when tibia is fixed
deep peroneal nerve entrapment symptoms
N/T in web space of 1st/2nd toes
deep posterior compartment injury- would cause what symptoms
tibial nerve
N/T in plantar surface of 1/2nd toes
Osgood schlatter vs sinding larsen johnson syndrome
both anterior knee pain with bumps often present
Osgood- localized to tibial tubercle
SLJ- inferior pole of patella (proximal attachment of patellar tendon)
what range does patella most often dislocate at
0-20 deg
bony stability between patellofemoral joint is maximal between 20-60deg
PLC vs PCL tear
Posterolateral corner injury:
-Dial test: at 30 deg flexion, excess ER by 15 deg relative to other leg
*NOT excess ER at 90 deg flexion
If PCL: would see excess ER at BOTH 30 and 90 deg flexion
in PLC rehab, what motions to avoid early in rehab
hyperextension
tibial ER
ideal knee flexion angle to cycles avoid knee injuries when pedal closest to ground
25-30 deg
tennis leg
medial gastroc head rupture
what amount of gapping with valgus stress test indicates sprain/further injury
gapping >1-2mm = grade II MCL sprain & cruciate ligament injury
(at 20 deg flexion)
segond fracture
cortical avulsion fracture off lateral tibia, distal to plateau at site of mid 1/3 LCL insertion
high association with ACL injury
excess IR + varus
osgood schaltter
tibial tubercle apophysitis
sinding larsen johanssen syndrome
patellar tendon + lower part of patella
(instead of upper margin of tibia like osgood)
Which of the following surgical procedures is most likely to restore anteromedial and rotary stability of the tibiofemoral joint with the lowest risk of reinjury
Anatomic autograft reconstruction
grade III MCL injury- what ROM allowed after surgery
3 weeks = 0-110
ACL jumping- which movements indicate greater risk of reinjury
greater peak external hip flexion
Knee abduction at initial contact
shorter stance on involved side
