Knee Flashcards
medial collateral ligament
-resists valgus stress
- gr II, III typically involve meniscus
lateral collateral ligament
- resists varus stress
- stronger than MCL
- taut from 0-30 degrees
ACL
- restraint for anterior translation of tibia on femur
-attachments with ant-medial horn of meniscus - anterior-media bundle: most taut in flexion
- posterior-lateral bundle: most taut in extension
PCL
- anterior lateral bundle: most taught in flexion
- posterior medial bundle: most taut in extension
- main restraint of posterior tibial translation or anterior femoral translation
- also limits femoral external rotation or tibial internal rotation
collateral ligament injury s/sx
- varus/valgus trauma
- varus/valgus stress testing will be positive (MCL may be associated with ACL and meniscal symptoms)
- swelling, ecchymosis
- joint effusion if meniscal involved
- tenderness to palpation of ligament
- difficulty with pivoting and cutting
MCL exam
- valgus stress test
- knee flexed to 20-30, + if laxity or pain, SN of .86
LCL exam
- varus stress test, + is presence of laxity or pain
ACL s/sx
- severe pain with joint effusion
- popping, giving way, buckling
- continued effusion
- quad inhibition
- limited ROM
- flexed knee gait
- 80% non-contact injury
- contact- 20%
ACL exam
- gold standard is lachmans
— thought to test more of posterior bundle - anterior drawer test
— thought to test more anterior bundle - pivot shift test
— highly specific
PCL s/sx
- posterior knee pain
- not as much effusion
- flexion beyond 90 may increase pain
- difficulty squatting, descending stairs, running
- not as much problem with quad inhibition
- sag sign (100 SP), + posterior drawer, reduced palpation of tibial plateau step up
MOI
- hyperflexion
- fall on flexed knee with foot in plantarflexion
- step in pot hole
- dashboard injury
PCL s/sx
- posterior knee pain
- not as much effusion
- flexion beyond 90 may increase pain
- difficulty squatting, descending stairs, running
- not as much problem with quad inhibition
- sag sign (100 SP), + posterior drawer, reduced palpation of tibial plateau step up
MOI
- hyperflexion
- fall on flexed knee with foot in plantarflexion
- step in pot hole
- dashboard injury
Knee pain and mobility impairments CPG recommended physical performance measure
LVL C- single legged hop tests, that can identify patient’s baseline status relative to pain, function, side to side asymmetries, test return to sport
Knee pain and mobility impairments CPG recommended physical impairment measures
Level B- meniscus
- modified stroke test
- knee AROM
- max isometric quad strength
- forced hyper extension
- knee PROM
- McMurray’s
- joint-line tenderness
Level D- articular cartilage
- modified stroke test
- knee AROM
- max quad strength
- joint line tenderness
Knee pain and mobility impairments CPG recommendation for progressive knee motion
Level B: early progressive active and passive knee motion following surgery for both meniscus and articular cartilage
Knee pain and mobility impairments CPG recommendation for progressive weightbearing
Level C: meniscus, early progressive weightbearing
Level B: stepwise progression of weightbearing to full bearing by 6-8 weeks after MACI for articular cartilage lesion
Knee pain and mobility impairments CPG recommendation for progressive return to activity
Level C: may utilize progressive return to activity following meniscal repair
Level E: may need to delay return to activity depending on type of articular cartilage surgery
diagnosis of patellafemoral pain
- presence of retropatellar or peripatelllar pain (LVL A)
- reproduction of pain with squatting, stairs, prolonged sitting, or other functional activities that load the PFJ in a flexed position (LVL A)
- exclusion of all other conditions (LVL B)
PFP categories
- overuse/overload without other impairment
- muscle performance deficits
- movement coordination deficits
- mobility impairments
Overuse/overload without other impairment PFP
- pain primarily due to overuse/overload
- patient presents with history suggesting an increase in magnitude or frequency of PFJ loading at a rate that surpasses the ability of his tissues to recover
muscle performance deficits PFP
- may respond favorably to hip and knee resistance exercises
- patient presents with lower extremity muscle performance deficits in hip and quad
Movement coordination deficits PFP
- may respond favorably to gait training and movement re-education interventions leading to improvements in kinematics and pain
- patient presents with with excessive or poorly controlled knee valgus during a dynamic task, but not due to weakness
Mobility impairments PFP
- hypermobile or hypomobile structures
- higher than normal foot mobility or flexibility deficits of 1 or more of the following (hamstrings, quad, GS complex, lateral retinaculum, ITB
Meniscus hx and MOI
- twisting injury
- pain worse with movement, better with rest
- may complain of locking
- joint line tenderness
- acute effusion (within 2 hours)
- acute: sudden onset in people <40
- chronic: no specific MOI in people >50
good prognosis for meniscus
- age <35
- peripheral damage
- longitudinal tear
- short tear
- acute injury
- stable knee
poor prognosis for meniscus
- older patient
- central damage
- complete tear
- bucket handle tear
- chronic injury
- unstable knee
meniscus hallmark findings
- joint line tenderness: good SN
- effusion: mild to mod over 1-2 days
- positive entrapment test: mcMurray’s, apley’s, squat
- quad inhibition: atrophy over first week or two following injury
microfractures for articular cartilage
- encourage blood flow
- replaced with fibrocartilage (not the same as hyaline cartilage)
- WB is controlled
- not great for active people
- good short term outcomes
ACI (autologous chondrocyte implantation
- small biopsy of autologous cartilage is harvested
- cartilage is enzymatically digested in lab to release chondrocytes
- chondrocytes cultured and implanted in second surgery
Osteochondral autograft transplantation system
- full thickness defects
- remove plug from NWB surface
- “press-fit” plugs implanted into lesion
- need CPM if mosiac is done to smooth out surface
outcome measures for PFP
Lvl A:
- AKPS
- KOOS
- visual analog scale
- EPQ
exercise for PFP
LVL A
- hip and knee targeted exercises
- hip before knee in early stages
paterllar taping for PFP
LVL B
- may use taping with exercise to reduce pain and enhance outcomes in short term
Bracing for PFP
LVL B
- should not use orthoses for PFP
foot orthoses for PFP
LVL A
- for patients with greater than normal pronation to reduce pain but only for short term
- should be combined with exercise
- no evidence on custom versus prefabricated
biofeedback for PHP
LVL B
- should not use EMG based feedback for quad
LVL B
- should not use visual biofeedback for lower extremity alignment
running gait retraining PFP
LVL C
- forefoot strike pattern
- cueing to increase running cadence
- cueing to reduce peak hip adduction while running
BFR + high rep knee exercise PFP
LVL F
- may use for those with limiting painful resisted knee extension
needling PFP
LVL A
- should not use TPDN
LVL C
- may use acupuncture
manual therapy PFP
LVL A
- should not use manual therapy alone
biophysical agents PFP
LVL B
- should not use biophysical agents (ultrasound, cryotherapy, phono/ionto, estim, laser)
patient education PFP
LVL F
- may educate on load management, body weight, adherence to active treatments
combined interventions PFP
LVL A
- should combine physical therapy interventions
Anteromedial rotary instability test
- slocum test (PMC)
anterolateral rotary instability tests
-jerk test of hughston
- losee test
- side-lying test of slocum
- flexion rotation drawer test
posterolateral rotary instability tests
- dial test at 30 and 90 (prone external rotation test)
- reverse pivot shift test
- posterolateral drawer test
- external rotation recurvartum test
- posterolateral external rotation test
J sign
for patellar tracking
ottowa knee rules
- 55 years or older
- isolated tenderness of patella
- tenderness at head of fibula
- inability to flex 90 degrees
- inability to bear weight both immediately and in ED for 4 steps (unable to transfer weight twice onto each lower limb
CPM
knee ligament sprain
LVL C
- may use cpm immediately postop to decrease pain for ACL
early weightbearing
knee ligament sprain
LVL C
- may implement early weightbearing within 1 week for ACL
knee bracing
knee ligament sprain
LVL C
- may use functional knee bracing for ACL deficiency
LVL D
- should document patient preference in decision to use knee bracing following ACL reconstruction
LVL F
- may use appropriate knee bracing for acute PCL, severe MCL, or PLC injuries
immediate versus delayed mobilization
knee ligament sprain
LVL B
- should use mobilization within 1 week after ACL reconstruction to increase joint ROM, reduce joint pain, reduce risk of adverse responses of surrounding soft tissue structures
cryotherapy
knee ligament sprain
LVL B
- should use cryotherapy immediately following ACLR to reduce postop knee pain
supervised rehab
knee ligament sprain
LVL B
- should use exercises and proved and supervises HEP
therapeutic exercises
knee ligament sprain
LVL A
- WB and NWB concentric and eccentric should be implemented within 4-6 weeks, 2-3 times per week for 6-10 months
NMES
knee ligament sprain
LVL A
- should be used for 6-8 weeks following ACLR to augment muscle strength to enhance short term functional outcomes
neuro re-ed
knee ligament sprain
LVL A
- should be incorporated with muscle strengthening exercises in patients with knee stability and movement coordination impairments
risk factors for osgood schlatters
- male gender
- male: 12-15
- female: 8-12
- sudden skeletal growth
- repetitive activities like jumping and sprinting
osgood schlatters presentation
- anterior knee pain with or without swelling which can be bilateral or unilateral
- starts as dull ache over tibial tubercle
- insidious
- improves with rest and subsides minutes to hours after stopping activity
- worse with running, jumping, knee trauma, kneeling, squatting
- enlarged prominence
- poor flexibility of quad and hamstrings
treatment of osgood schlatters
- may last for 2 years until apophysis fuses
- relative rest, activity modification
- ice and NSAIDS for pain relief
- can use knee pad to protect tibial tubercle
- quad and hamstring stretching and strengthening
