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OCS - Current Concepts of Ortho PT > Knee > Flashcards

Knee Flashcards

1
Q

Well known site for ACL impingement in the knee

A

Intercondylar fossa

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2
Q

Trochlear groove is higher on the (lateral/medial side)

A

Lateral side = increases lateral stability

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3
Q

Sulcus angle vs congruency angle

A

Sulcus = reflective of depth of the groove

Congruency angle = From center of sulcus to lowest portion of patellar ridge (aka deepest/most posterior point)

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4
Q

Normal sulcus angle

A

Normal = 132°-144°

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5
Q

Congruency angle
- interpretation of + vs - numbers

A

If lateral of central line = + number

If medial of central line = - number

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6
Q

Congruency angle
- Norms

A
  • 6° (medial tilt)
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7
Q

What patellar congruency angle is associated with lateral patellar subluxation

A

+16° (lateral tilt)

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8
Q

Normal angle of the knee (valgus vs varus)

A

180°-185° = normal (slight valgus

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9
Q

What medial angle classifies as genu valgum?

A

> 185° (knock-knees)

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10
Q

What medial angle classifies as genu varum?

A

<175° (bow legs)

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11
Q

T/F: menisci reduces stress on the articular cartilage and underlying subchondral bone?

A

True, also disperses forces and increases congruency

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12
Q

During closed chain activities the menisci can take up to what % of force?

A

70% of load on the knee

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13
Q

Red zone of the mensici

A

Outer 1/3rd, receives vascularization from capsular arteries

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14
Q

Red-white zone of the menisci

A

Middle 1/3rd, poor vascularity

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15
Q

White zone of the menisci

A

Inner 1/3rd, poor vascularity

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16
Q

Area of outer menisci that is separated from the capsule?

Is it vascular or avascular?

A

Posterior lateral corner of lateral meniscus - separated from capsule by the popliteus tendon

AVASCULAR

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17
Q

How does the menisci connect to the patella

A

Via patellomeniscal ligaments (thickenings of the anterior capsule)

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18
Q

The lateral meniscus is posteriorly connected to what structures?

A

Popliteus tendon, PCL, meniscofemoral ligament (connects to medial condyle of femur)

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19
Q

Anterior horn of lateral meniscus shares a common insertion site on the tibia with what structure?

A

ACL

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20
Q

Medial meniscus is attached posteriorly to what structure?

A

semimembranosus tendon

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21
Q

The anterior horn of the medial meniscus receives fibers from (ACL/PCL) and the posterior horn receives fibers from (ACL/PCL)

A

Anterior = ACL

Posterior = PCL

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22
Q

Which knee menisci (lateral vs medial) is less mobile? And why?

A

Medial meniscus d/t attachment to the MCL (deep portion)

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23
Q

T/F: muscular contraction in the leg can cause movement of the menisci?

A

True, contractions of the semimembranosus and poplitus muscles can create movement due to their attachments of the medial and lateral menisci, respectively

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24
Q

What part of the meniscus are innervated with pain receptors and jt mechanoreceptors?

A

Horns and outer 1/3rd (peripheral vascularized portions)

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25
Q

The central portion of the menisci is (neural/aneural)

A

Aneural

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26
Q

T/F: loss of the menisci does not affect stability of the knee

A

False, it decreases jt stability

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27
Q

Fabella

A

Sesamoid bone in posterior/lateral knee, present in 15-30% of population

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28
Q

Is the LCL (intra/extracapsular)?

A

Extracapsular

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29
Q

What is the optimal knee flexion degree to test LCL?

A

25° knee flexion = post structures are on slack

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30
Q

What excessive motions does the LCL resist?

A

Varus stress and tibia ER (@60-90° flexion)

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31
Q

What is the optimal knee flexion degree to test MCL?

A

25° knee flexion = post structures are on slack

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32
Q

Posterior oblique ligament (POL)

A

Resistance to the valgus loads when the knee is fully extended

Reinforces posteromedial aspect of the knee

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33
Q

What does the POL attach to?

A

Semimembranosis tendon sheath AND oblique popliteal ligament

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34
Q

The MCL deep and superficial layers are separated by what structure?

A

Bursa

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35
Q

Primary function of the superficial MCL

A

Restrain valgus stress, lat tibial rotation, and medial tibial rotation

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36
Q

Lysis of which knee ligaments in combo result in greater valgus laxity?

A

MCL and PCL

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37
Q

T/F: The MCL assists the ACL in resisted anterior translation of the tibia

A

True, So when MCL is damaged = greater stress on ACL

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38
Q

Can the MCL heal from injuries?

A

Yes, it is well vascularized

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39
Q

Layers of the knee capsule

A

External fibrous layer and internal synovial layer

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40
Q

The VMO courses with what structure to a patellar insertion?

A

Medial patellofemoral ligament (MPL)

Which is just an extension from the capsule

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41
Q

T/F: ITB supports the anterior/lateral patella as the lateral patellofemoral ligament

A

True

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42
Q

Oblique popliteal ligament is an expansion of what structures?

A

Expansion of the semimembranosus tendon and its lateral extension

Posterior knee

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43
Q

3 Primary stabilizers of the posterolateral corner

A

1) LCL
2) Popliteofibular ligament (PFL)
3) Popliteus tendon

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44
Q

What artery supplies vascularization to the ACL and PCL

A

Genicular artery

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45
Q

What nerve supplies innervation the the ACL and PCL

A

Branches of the tibial nerve

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46
Q

3 mechanoreceptors that are found in the ACL/PCL

A

1) Ruffini corpuscles (skin stretching, movement, and finger position)

2) Pacinian corpuscles (vibrations and detect fine textures)

3) Golgi tendon organs (management of muscle tension)

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47
Q

ACL attaches to what structures?

A

Lateral femoral condyle (medial side) to just anteromedial to intercondylar eminence on the tibia

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48
Q

In addition to resisting anterior translation of the tibia, the ACL is responsible for limiting (ER/IR) of the tibia

A

IR

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49
Q

Non-contact injuries to the ACL are often what mechanism?

A

Deceleration in slight flexion, coupled with IR/ER tibial rotation

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50
Q

PCL is divided into 2 bundles. Which one is the main one (95%)

A

Anterolateral

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51
Q

T/F: In the case of multi-ligament compromise (MCL and post capsule), an isolated PCL reconstruction is good enough to restore stability

A

False

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52
Q

What degrees of knee flexion is the PCL the most taut in?

A

30-90° knee flexion

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53
Q

When the PCL and surrounding structures are compromised, you will see increased (ER/IR) tibial torsion?

A

ER

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54
Q

Are open kinetic chain (OKC) knee extension exercises contraindicated in post-ACL rehab?

A

Not anymore, no significant difference in anterior tibial laxity

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55
Q

What part of the patella is in contact with the femur at: full extension

A

Inferior pole

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56
Q

What part of the patella is in contact with the femur at: 20° flexion

A

Med/lateral facets

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57
Q

What part of the patella is in contact with the femur at: 90° flexion

A

Superior 1/3rd

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58
Q

What part of the patella is in contact with the femur at: >90° flexion

A

Contact shifts INF/LAT (loading odd and lateral facets)

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59
Q

What side of the patella is the odd facet on?

A

Medial

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60
Q

The (lateral/medial) facet of the patella bears the greatest load up to 70° of knee flexion

A

Medial

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61
Q

In flexion angles >90°, what other structure contacts the femoral groove dissipating forces?

A

Quadriceps tendon

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62
Q

Q-angle norms for men and women

A

Men: 10-15°
Women: 15-20°

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63
Q

Consequences of Q-angles >20°?

A

Increased lateral patellar forces and displacement

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64
Q

What range during OKC exercises (such as LAQ) should you optimize to reduce patellofemoral joint stress?

A

30-90° flexion

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65
Q

Cancer screening questions

A

Rapid/unexplained weight changes, fever, night pain, acute/insidious onset of pain, unexplained jt aching and malaise

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66
Q

Short-form 36 (SF-36)

A

36-item patient-reported questionnaire that covers eight health domains

High correlations noted with knee OA population

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67
Q

Sickness impact profile

A

Behaviorally-based measure of health status

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68
Q

Immediate jt swelling (<2hrs) can indicate?

A

Internal jt trauma, hemarthrosis, patellofemoral dislocation

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69
Q

Delayed jt swelling (2-12hrs) can indicate?

A

Intraarticular ligament involvement

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70
Q

Jt swelling with onset >12-24hrs post-injury can indicate?

A

Synovial fluid response (often capsular/ligamentous strain or meniscal involvement)

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71
Q

Ottawa Knee Rules

A

1) >55 y/o
2) Isolated TTP of patella
3) TTP of fibular head
4) Can’t flex knee >90°
5) Unable to bear weight both immediately and in ED (4 steps, limping is okay)

Radiographs are indicated if at least 1 of these factors are present

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72
Q

Is the ottawa knee rule cluster sensitive?

A

Yes, 100% sensitive to ruling OUT fx’s

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73
Q

Age range the Ottawa knee rules are applicable?

A

13-49

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74
Q

Knee questionnaire(s) for: OA and TKA

A

1) WOMAC
2) KOOS

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75
Q

Knee questionnaire(s) for: patellar tendinopathy

A

1) Victorian Institute of Sport Assessment Questionnaire, Patellar Tendon (VISA-P)

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76
Q

Knee questionnaire(s) for: Ligament

A

1) International Knee Documentation Committee (IKDC) questionnaire
2) Lysholm knee score (can be lig & meniscus)

Neither are good

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77
Q

Knee questionnaire(s) for: ACL repair

A

1) ACL-RSI

GOOD

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78
Q

Knee questionnaire(s) for: Non-specific knee conditions

A

1) Cincinnati Knee Rating System
2) Knee Outcome Survey (KOS)

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79
Q

Is there a correlation between muscular inhibition and large knee effusion?

A

Not been validated

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80
Q

Grading of effusion - Sturgill

A

0 = none
Trace = MMSL small amount back
1+ = Milk out, sweep sends it back
2+ = Milk out, returns immediately w/o sweep
3+ = Cannot milk swelling out

MMSL = milk medially, sweep laterally

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81
Q

Can Effusion grading and pain scale responses be used for progression/regression of exercise programs?

A

Yes, when used together

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82
Q

T/F: assessing bony end-feels have evidence to be a predictor of pathology

A

False, no evidence. However, still used commonly for tx decisions

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83
Q

T/F: MMT - identifying differences in grading of less than a full grade has poor reliability

A

True AND poor sensitivity of the scale above grade 3 (fair)

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84
Q

Gold standard for assessment quadriceps strength?

A

Electrodynamometer testing

HHD is good but not as good

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85
Q

Amount of movement present during ligamentous stress testing (in mms):
· Grade 1+
· Grade 2+
· Grade 3+

A

1+ = 3-5mm
2+ = 5-10mm
3+ = >10mm

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86
Q

When would it be appropriate to do ligament testing on the involved side first?

A

If there are concerns that prior knowledge of the testing procedures will affect the pt’s ability to relax

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87
Q

Are the knee valgus stress tests (0°, 30°) more specific or sensitive?
Which test position is better?

A

Sensitive (best @30° flexion)

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88
Q

When should the ACL be assessed for damage in MCL injuries? hint: think valgus testing degrees

A

@0° testing = if >5mm laxity (also suspect PCL)

@30° testing = if >10mm laxity

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89
Q

Most specific test for evaluation of the: MCL

A

Valgus testing at 30°

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90
Q

Most specific test for evaluation of the: LCL

A

Varus testing at 30°

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91
Q

Most specific test for evaluation of the: PCL

A

Posterior sag and quadriceps activation test (shows ant translation)

ALL including post drawer are great SN/SP

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92
Q

Most specific test for evaluation of the: ACL

A

Lachman test

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93
Q

Most specific test for evaluation of the: posterolateral corner

A

Prone ER test >10° vs opposite side

aka Dial test

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94
Q

Most specific test(s) for evaluation of the: Meniscus

A

Meniscal Pathology Composite Score

Hx
1) Catch/click

Exam
2) Jt line TTP
3) Pain w/ forces hyperextension
4) Pain w/ max knee PROM flex
5) McMurray (pain or click)

If 5/5 are + = 92.3% chance of meniscal tear
3/5 are + = 75%

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95
Q

Most specific test for evaluation of the: Patellofemoral

A

Pain during resisted isometric quad contraction AND squatting

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96
Q

If posterior drawer test is + at 30° and normal at 90°, you should suspect what?

A

Posterolateral corner issues

Best test = dial test

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97
Q

T/F: The pivot shift test is sensitive and specific for ACL tears in both clinical and under anesthesia situations?

A

False, poor sensitivity in clinic but GREAT (= w/ lachmans) under anesthesia

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98
Q

Arthrometer threshold for ACL tears

A

3mm difference from uninvolved side = ACL tear

GREAT SN/SP

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99
Q

Cluster of special tests for PLC (posterolateral corner) compromise

A

1) Posterolateral drawer test
2) Dial test
3) Reverse pivot shift
4) ER recurvatum test

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100
Q

When performing the posterolateral drawer test => excessive amount of laxity AND sublux posteriorly.. suspect what?

A

PCL injury

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101
Q

If dial test is + at both 30° AND 90° flexion, suspect what?

A

PCL injury

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102
Q

Is an ortho referral indicated for an unresolved acute meniscal locking episode?

A

Yes, non-emergent

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103
Q

Best clinical tests/indicators for patellofemoral pain syndrome (PFP)

A

Pain w/ squatting, stairs, and prolonged sitting

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104
Q

Cluster: 80% Probability of PFP symptoms improving with foot orthotic (pre-fab)

A

1) >25 y/o
2) Height <5’ 4”
3) Pain at worst >5/10
4) Mid-foot width change (≥11mm, NWB -> WB)

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105
Q

Sage sign

A

hypermobility of patellar glide (med/lat)

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106
Q

Apprehension test

A

Patellar hypermobility + apprehension

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107
Q

What is the gold standard for return-to-sport functional testing with PFP?

A

There is none!

Most commonly used is 1-legged hops
(scoring 80-85% of opposite side = normal)

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108
Q

Should you let your patient do a practice run of the the 1-legged hop tests?

A

Yes!

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109
Q

Performance of which 1- legged hop tests are the strongest predictor of self-reported knee function (IKDC 2000)

A

1) Cross over for distance
2) 6 meter hop test

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110
Q

1-legged hop test for RTS (Noyes et al)

A

1) SL for distance
2) Crossover for distance
3) Triple hop for distance
4) 6 meter timed hop

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111
Q

Those with ACLR are 4x more likely for re-injury over 2 yr span. If you pass the RTS criteria (>90% hop tests, >90% quad strength, KOS-ADLs, global rating, IKDC 200 score), the risk of re-injury reduces by what %?

A

84%

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112
Q

Minimum amount of time to delay RTS post ACLR

A

9 months

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113
Q

Are SEBT and Y-balance tests reliable?

A

Yes, and appropriate for those not attempting to return to level 1 sports

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114
Q

Functional tests for elderly and those with knee OA to identify fall risk

A

1) Timed stair-climbing test
2) 6’ walk test
3) TUG
4) 5x STS

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115
Q

Is patellar taping indicated in PFP or OA?

A

Grade B evidence for PFP

OA evidence is mixed

116
Q

Goal of using tape as an intervention to manage knee pain

A

Short term pain management so a person can return to an exercise program

KT tape = rigid tape

117
Q

Evidence for bracing in knee pain

A

Very low quality, mixed

Can help if nothing else is working

118
Q

Use of unloading brace

A

For unicompartmental degenerative jt disease, transfers forces to healthier compartment

Does NOT help with obese individuals

119
Q

Evidence for use of unloading brace

A

Can provide significant pain relief, functional improvement, and improved exercise tolerance

Does NOT help with obese individuals

120
Q

T/F: American college of rheumatology/arthritis suggest tibiofemoral braces for knee OA where there are large impacts on ambulation, jt stability, or pain that warrant use of an AD

A

True, strongly recommended

121
Q

Recommendations for use of functional brace s/p ACLR

A

Okay in short term especially where quad activation and strength are lacking, mixed reviews overall with trending towards less bracing

122
Q

Recommendation for bracing in PCL injuries

A

Usefulness unclear, post-op brace typically discontinued by wk 4

123
Q

Recommendation for bracing in MCL injuries

A

Suggested to provide stability in early stages of grade 2-3 sprains, typically braces are locked in 30-90° (avoid full ext)

124
Q

T/F: Using braces in ACL deficient and ACLR skiiers can be detrimental to outcomes

A

False, it’s show to reduce risk of reinjury by 6.4 and 3.9 times respectively

125
Q

When performing knee jt mobs for ROM improvements, how can you increase stress on jt capsule?

A

Move to end-ranges

126
Q

During “bag hangs” to gain knee extension does ankle position matter?

A

Yes, ankle should be slightly PF or neutral

If DF is present, gastroc may prevent full knee ext

127
Q

Drop-out cast

A

Used in stubborn cases of extension ROM loss, especially for post-op

128
Q

Optimal static stretch program for length gains paramaters

A

30” hold x 3-4 reps

129
Q

T/F: NMES in combo with quad strengthening is beneficial in gaining strength faster than exercise alone

A

True, when use of NMES is at least 4 wks

130
Q

NMES parameters for quad re-education

A

Russian
Burst-modulated
Pulse duration: 400µs, 75pps, 2” ramp

10 contractions for 10” with REST for 50”

131
Q

Contraindications for NMES

A

Pacemaker, PVD, neoplasm or infection, skin integrity issues, unable to provide feedback

132
Q

Precautions for NMES

A

Uncontrolled HTN, excessive adipose tissue, pregnancy (location dependent), severe osteoporosis, impaired sensation

133
Q

Typically the use of NMES in quad strengthening/re-education is discontinued when what metrics are met?

A

Quad force output of involved leg is ≥80% of the uninvolved leg

134
Q

How to dose NMES without a HHD

A

1) Find 1-RM on knee extension machine
2) NMES should be able to do 1/2 of 1-RM (i.e. 1-RM = 100#, NMES should be able to move 50#)
3) Raise the resistance to anything >50% for tx

135
Q

Best knee position for NMES of quads

A

Knee flexed (seated)

Although knee extension is better vs no NMES

136
Q

T/F: isolated eccentric exercise program (i.e. of quad) is better vs concentric and isometric in overall strengthening

A

False, It doesn’t appear to be superior over other loading programs

137
Q

T/F: When performing a loading program, isometrics should be used long-term

A

False, more suitable for short-term use when pain relief is warranted

138
Q

Considerations for use of eccentric training program to treat patellar tendinopathy

A

Use decline board, refrain from sport activity, bilat eccentrics = unilat

Insufficient evidence to support eccentric only programs

139
Q

Goal of blood flow restriction (BFR) training

A

Promote hypertrophy with sub-max resistance

140
Q

Blood Flow Restriction (BFR) training vs:
- High load training program
- Low load training program

A

High load: no superior outcomes or hypertrophy

Low load: Superior results for hypertrophy and function

141
Q

What is the preferred amount (%) of arterial occlusion for BFR training

A

80%

142
Q

BFR parameters
- Occlusion
- Intensity
- Reps
- Rest

A

Occlusion: 60-80% (80 preferred)
Intensity: 15-30% 1-RM
Reps: 30-15-15-15
Rest: 30” between sets

143
Q

Suggested hamstring-to-quadriceps ratio prior to RTS:
- Males
- Females

A

Males >66%
Females >75%

144
Q

Indications of an overaggressive rehab approach

A

Persistent or increasing pain, inflammation, swelling, worsening ROM defiicts

145
Q

Screening guidelines for ACL injury (to determine who would benefit from perturbation training)

A
  • NO knee effusion
  • Can hop without pain
  • Full ROM
  • ≥70% involved/uninvolved quad ratio

Tests:
- Noys hop: ≥80%
- KOS (ADL specific): ≥80% grade
- Global rating: ≥60%
- Episodes of giving way: no more than 1

146
Q

Pre-reqs for screening for potential copers (ACL non-surgical)

A
  • Isolated tear of ACL
  • Full pain-free ROM
  • No effusion
  • Quad MVIC ≥70% good side
  • Must tolerate hopping (pain-free) once MVIC is met
147
Q

“True copers”

A

Non-surgical ACL tears who were screened, went through a combo program including perturbation training, AND returned to L1-2 sport for 1 hr

148
Q

Complications of bone-patellar tendon-bone autografts

A

Increased incidence of anterior knee pain, minimal increased risk of patellar fx

149
Q

Complications of hamstring autografts

A

Adhesions in graft site that may pop and cause issues if full ext is not gained early on, ALSO increased risk of HS strains during rehab

150
Q

T/F: Allografts heal slower vs autografts

A

True

151
Q

Allografts tend to have (higher/lower) failure rates vs autografts?

A

Higher

152
Q

T/F: Double bundle technique provides better outcomes vs single bundle

A

False, no evidence that it’s better. It can provide better static stability but no correlation to better outcomes

153
Q

“Calm knee”

A

Post-ACL tear knee that has no evidence of inflammation = associated with few post-op complications

Mixed reviews on if it’s better vs acute repair of ACL

154
Q

Post-op ACLR:
OCK vs CKC exercises

A

Use both, they have similar levels of ACL strain

IN FACT, walking has more ACL strain vs both OCK and CKC!!

155
Q

What 2 factors/deficits post ACLR are associated with decreased post-op function?

A

Residual quad weakness AND loss of ext ROM

156
Q

T/F: Use of NMES in combo w/ exercise is better vs exercise alone in ACLR rehab?

A

True

157
Q

ACLR w/ meniscus repair:
- protocol deviation

A

Weight bearing knee flexion > 45°contraindicated for 4wks

158
Q

ACLR w/ cartilage damage and/or repair:
- protocol deviation

A

Restricted weight bearing for 3-4wks

159
Q

ACLR w/ MCL sprain:
- protocol deviation

A

No deviation, MCL sprain in the presence of ACL tear is often treated non-surgically

Can IR the leg during weight bearing to lessen forces on MCL

160
Q

ACLR w/ PCL sprain:
- protocol deviation

A

Follow PCL rehab

161
Q

ACLR revision leads to (less/more) rigid graft fixation

A

Less

162
Q

ACLR revision rehab is (slower/quicker) vs initial ACLR

A

Slower, everything is delayed. PWB w/ crutches for 2wks, avoid unstable environments for 4wks

163
Q

Tests/measures to determine if an ACLR is “successful”

A

1) Less than mild effusion
2) >90% quad and HS strength
3) No giving way
4) Participation in 1-2 seasons of sports
5) Patient reported outcomes

164
Q

Is HS weakness post ACLR a concern?

A

Not usually, it’s not predictive of function and strength typically returns to normal within 2 yrs, even with HS allograft.

165
Q

Returning to L1 sports after ACLR results in how much more likelihood to re-injure the ACL?

Chance of injury of contralateral ACL?

A

4x

5x for contralat

166
Q

What is one of the biggest barriers to RTS in post-op ACLR patients?

A

Fear of retear

167
Q

T/F: If individuals scored low on the IKDC 2000, they were 4x more likely to fail the return to activity batter of tests?

A

True

168
Q

If surgery for ACL tear in skeletal immature individuals is delayed, what other negative events can happen?

A

High risk for meniscus tear, lead to early OA, progressive jt instability

169
Q

Cluster of 4 clinical signs in skeletal immature individuals that would indicate the need for earlier surgical intervention

A

1) ≥14 y/o
2) Partial tear >1/2 thickness
3) Tear of posterolateral bundle
4) Pivot shift grade B/II or greater

170
Q

Can “ACL injury prevention” programs actually lower risk of injury?

A

Yes, they are effective (up to 50-67% in one study)

171
Q

ACL injury prevention plans should include:

A

1) Multiplaner movements
2) Unilat and bilat activities
3) Reaction & unanticipated movements
4) Correct foot positioning and muscle coordination during cutting and dynamic activities
5) Consider implications of playing surface/fatigue/bracing

172
Q

Most common MOI for isolated PCL tear

A

Athletic injuries

173
Q

Typical RTS after a grade I or II PCL sprain

A

4wks

174
Q

Is early quad or HS strengthening crucial in PCL sprains?

A

Quad, HS pulls tibia post

175
Q

Is there a correlation between PCL laxity (residual) and functional deficits or pain?

A

NOPE!

176
Q

Do grade III PCL tears require immobilization?

A

Often immobilized in full ext for 2-4wks (to reduce post sublux from HS)

177
Q

Grade III PCL strain rehab should avoid what initially?

A

Knee flexion >70° and isolated HS exercises

Emphasis on concerns that early activity can lead to increased laxity and graft strain

178
Q

How long s/p PCL repair should you wait to do HS strengthening (resisted knee flexion)

A

4 months

179
Q

Can you do LAQ or knee ext s/p PCL injury?

A

Yes but in limited range (60°-0°

180
Q

Reconstruction of PCL is typically what type of graft?

A

Achilles tendon allograft

181
Q

Injuries to the posterolateral corner (PLC) is usually associated with what concomitant injury?

A

PCL tear

Rarely does the PLC tear without injury to the PCL

182
Q

T/F: PCL repair without fixing torn PCL is associated with same outcomes as repairing both?

A

False, failure to restore both may be possible cause of PCL graft failure

183
Q

In PCL repairs, can you delay LCL repairs?

A

No, LCL should be fixed within 3 wks of injury otherwise a full reconstruction may need to happen

184
Q

Post-op PLC repair rehab considerations

A

NWB in immobilizer for 6wks, 90° flexion by wk 2, full ROM by wk 6, WB exercises should not go >70° flexion, no isolated HS strengthening (until 4 months)

DON’T: cross legs, toe-out, pivoting

185
Q

MCL injuries: surgery vs non-surgical

A

Same outcome

186
Q

LCL injuries: surgery vs non-surgical

A

Mixed results for outcomes

187
Q

Non-surgical management of MCL or LCL sprains

A

Brace to prevent valgus/varus for 6-8wks, avoid rotation

FOCUS on quad strength and facilitating dynamic stabilization

188
Q

Bracing/immobilization post-MCL or LCL repair

A

Locked at 30° flexion for 2-6wks during ambulation

189
Q

Use of bracing in non-surgical management of MCL or LCL sprains

A

Mixed effectiveness

190
Q

Meniscus tear: surgery vs non-surgical managment

A

Equal, no difference especially in middle aged and older

191
Q

2 most important components to rehab meniscal repair

A

1) Controlled weight bearing
2) ROM

192
Q

What to avoid in meniscus repair cases:

A

WB activities with >45° knee flexion, loaded knee flexion >90° (for 8wks)

193
Q

Meniscus repair: OKC vs CKC strengthening

A

OKC better initially

194
Q

T/F: injury to the meniscus has been associated with progressive OA

A

True, especially with menisectomies

195
Q

Indications for meniscus transplant

A

Previous meniscectomy and STILL have pain

196
Q

Meniscus transplant contraindications

A

Varus/valgus malalignments, advanced OA, instability, arthrofibrosis, significant muscle atrophy, obesity

197
Q

Is there WB restrictions post-meniscal transplant?

A

Yes, typically limited from 3-6wks

Early WB may increase risk of transplant failure

198
Q

Rehab of meniscal transplant:
- ROM
- Exercises

A

Early PROM = good up to 90° flexion

Flexion AROM Avoided initially!!

Exercises: quad sets, SLR, AAROM knee ext 90-0°

OKC exercises started at wk 5-6

199
Q

Meniscal transplantation is good for (long/short) term benefits

A

Short-term

200
Q

Is exercise (strongly/moderately/weakly) supported by research for knee OA?

A

Strongly

Most research suggests a combo of LE strengthening and aerobic exercises

201
Q

What is the single strongest predictor of functional limitations in those with knee OA?

A

Quad weakness

202
Q

Patients with (lateral/medial) knee OA benefited more from addition of hip strengthening?

A

Medial knee OA

203
Q

Is balance/proprioceptive training suggested in tx of knee OA?

A

Yes when incorporated w/ strength and aerobic program

204
Q

Aquatic PT, yoga, Tai Chi benefits for knee OA

A

May be helpful

205
Q

Does behavioral change techniques have shown to have (good/limited) effectiveness to promote adherence to HEP?

A

Limited

206
Q

Evidence for use in tx of knee OA: cryotherapy

A

Insufficient

207
Q

Evidence for use in tx of knee OA: Low-level laser therapy

A

Positive findings, but unknown parameters

208
Q

Evidence for use in tx of knee OA: US

A

May have short-term relief, no extra benefit with phonophoresis

209
Q

Evidence for use in tx of knee OA: manual therapy

A

Positive when COMBINED with exercise

210
Q

Glucocorticod injection vs manual therapy & exercise

A

Manual therapy + exercise is BETTER

211
Q

Evidence for use in tx of knee OA: mobilization with movement

A

NOT supported to improve ROM

212
Q

Evidence for use in tx of knee OA: lifestyle changes for weight loss

A

Can be beneficial for pain and function as obesity is risk factor for knee OA

213
Q

Is education in jt-sparing techniques beneficial with knee OA?

A

Yes, for the non-surgical population

Need to be aware of compression and shear forces on the jt

Can minimize prolonged standing, use AD, cushioned standing mats etc

214
Q

Evidence for use in tx of knee OA: jt lubrication injections (hyaluronic acid)

A

Can be used as adjunct tx for OA

215
Q

Evidence for use in tx of knee OA: corticosteroids

A

May have short-term pain relief, no effect on function

Comparable to other injections and long-term PT

216
Q

Reason for use of osteotomy procedures in knee OA?

A

For unilat OA, redistributes load bearing away from bad area.

Can delay TKA for up to 10 yrs

217
Q

Considerations for rehab post-osteotomy

A

Limited WB for 4 wks

NO resistance put DISTAL to fx site - can cause fracture to not heal properly

Full ROM okay immediately

218
Q

Use of osteotomy vs UKA

A

Osteotomy: higher level
UKA: quick rehab

Same outcomes

219
Q

High tibial osteotomy vs femoral osteotomy

A

High tib: medial compartment OA

Femoral: lateral compartment OA

220
Q

Rehab of UKA vs TKA

A

Same but UKA pt’s will typically hit milestones quicker

221
Q

Which of the following are associated with worse outcomes post-TKA surgery:
-> depression, high BMI, DM2

A

Depression and high BMI

Diabetes is NOT known to have bad outcomes

222
Q

Weight bearing restrictions for cemented vs non-cemented TKA

A

Cemented: FWB
Non-cemented: progressive WB over 6 wks

223
Q

Evidence for use of CPM post-TKA

A

Not supported

224
Q

Are patellar mobs supported as post-TKA tx?

A

Yes, should be started early

225
Q

Are tibiofemoral jt mobs indicated post-TKA?

A

Unclear

226
Q

In PCL-sacrificing surgical techniques (TKA) what jt mob should be avoided?

A

Posterior glides, can compromise engaged cam

227
Q

Best preventative measure against arthrofibrosis and stiffness post-TKA

A

Early supervised PT

228
Q

Is kneeling safe to perform post-TKA

A

Yes, towards end of rehab

229
Q

Are balance and proprioceptive training important for post-TKA?

A

Yes, because decreased quad strength = higher risk for falls post-TKA

230
Q

4 primary phases of tissue healing?

A

1) Proliferation
2) Transition
3) Remodeling
4) Maturation

231
Q

Does articular cartilage repair cause regrowth of hyaline cartilage?

A

Not for debridement, chondroplasty or microfractures

They stimulate fibrocartilage replacement

232
Q

WB precautions for post-op chondroplasty vs microfracture

A

Chondroplasty: limited for 3-5days

Microfracture: NWB 2-4wks, FWB by 8wks

233
Q

OATS

A

Osteochondral autograft transplantation (OATS) - bone plugs covered with hyaline cartilage from NWB surface in knee

234
Q

ACI

A

Autologous chondrocyte implantation (ACI) - harvesting articular cartilage that is grown in lab, then put back in knee

235
Q

“Kissing lesions” in regards to articular cartilage lesions

A

Bipolar (femoral and tibial) lesions

236
Q

T/F: ACI is okay to do with kissing lesions?

A

False

237
Q

T/F: Effusion can be a sign of excessive stress on the knee jt post-OATs or ACI procedure

A

True, effusion must be monitored at ALL stages

238
Q

T/F: Are quad deficits common long-term post-articular cartilage repairs

A

True (can persist up to 5-7yrs)

239
Q

Evidence for BFR following articular cartilage procedures

A

Emerging evidence for positive results

240
Q

Evidence for anti-gravity treadmills following articular cartilage procedures

A

Emerging evidence indicates use

241
Q

Which group is shown to have higher success rates to return to PLOF:
- Microfracture
- OATs
- ACI

A

OATS

242
Q

Best indicator of PFP?

A

Pain with squatting, stair climbing, and sitting with a flexed knee

No gold standard for diagnosis. Best is above activities that provoke pain.

243
Q

PFP is a diagnosis of (exclusion/inclusion)

A

Exclusion, no gold standard for diagnosis

244
Q

Do psychosocial factors play a role in PFP?

A

Yes.
Anxiety, depression, catastrophizing, and pain-related fear may be elevated in those with PFP. Also may have altered pain processing and sensitization (Decreased PPT)

245
Q

Risk factors for PFP

A

Female, limited quad flexibility, patella hypermobility, decreased quad strength (isometric/isokinetic and explosives)

246
Q

Does q-angle, BMI, and age play a role in predicting future PFP?

A

No

247
Q

4 sub-categories of PFP

A

1) Overuse/overload (w/o other impairments)
2) Muscle performance deficits
3) Movement coordination deficits
4) Mobility impairments

Still at level of expert opinion

248
Q

T/F: Hip weakness is a universal finding amongst published papers regarding PFP

A

False, only in some

249
Q

Use of BFR in rehab of PFP

A

Can be helpful when high intensity training is limited by pain

250
Q

Should taping, bracing, orthoses, and NMES be used in PFP?

A

Can be in COMBO with well-designed exercise program

251
Q

T/F: Foot orthoses can be helpful in treating PFP?

A

Can help with short-term pain relief

252
Q

Custom orthoses vs prefab for use in PFP?

A

No evidence that custom is better than prefab

253
Q

Hoffa disease

A

Infrapatellar fat pad irritation

254
Q

Fat pad irritation

A

Common in hyperextension or repeated knee extension activities (i.e. gymnasts), aka Hoffa Disease (infrapatellar fat pad)

255
Q

Symptoms of moderate to severe PFOA (patellofemoral OA)

A

Swelling, genu valgus, pain w/ patellar compression, decreased quad strength

256
Q

Bipartite patella

A

Patella is made of two bones instead of a single bone

Generally asymptomatic unless trauma causes instability

257
Q

Osgood-Schlatter disease

A

Pain and swelling by tibial tubercle (traction apophysitis), tends to be aligned with growth spurts

Females: 8-13 y/o
Males: 10-15 y/o

258
Q

Tx for Osgood-Schlatter disease

A

Non-surgical and often self-limiting

Rest, ice, stretching of ant/lat hip, strength of hip/knee, NSAIDs

259
Q

Indication for surgical approach with Osgood-Schlatter disease

A

If non-conservative measures fail, success of tx is good to excellent in 93% of patients

260
Q

Sinding-Larsen-Johansson Syndrome

A

Pain and swelling by inferior pole of patella (traction apophysitis)

Common in active females 10-15 y/o

Tx similar to OSD

261
Q

Early sports specialization of younger (male/female) athletes can lead to 4x greater likelihood of OSD and SLJ syndrome

A

Female

262
Q

Fulkersons osteotomy

A

Moving tibial tuberosity medial

Used for chronic lateral patella subluxations (failed conservative tx)

263
Q

Goal of post-op tx for lateral retinacular release

A

Scar tissue avoidance (do patellar glides!!)

264
Q

Considerations for post-op extensor mechanism surgical realignment

A

AVOID Valgus positioning, high frequency of quad shut down => use NMES but NOT on VMO

265
Q

Tibial stress reaction (post-extensor mechanism surgical realignment)
- What is it
- Tx considerations

A

Aggravation at tibial tubercle, may have “POP” or “SNAP”

Symptom management for a couple days then return to full activity

266
Q

Patellar tendinopathy

A

Focal pain at inferior pole of patella and load-dependent (usually no pain @rest)

Common in younger males, volleyball and basketball players

267
Q

Possible US findings when looking at patellar tendinopathy

A

Hypoechoic areas (dark areas), tendon thickening, and neovascularity

268
Q

When looking at possible patellar tendinopathy, if there is pain at rest, pain that is NOT load dependent, and in the peripatellar region - think what?

A

An issue with non-contractile tissues

269
Q

Are there evidence based risk factors for development of patellar tendinopathy

A

No solid ones

270
Q

Best practice for rehab of patellar tendinopathy

A

Progressive tendon loading (including eccentric training)
- also include jumping mechanics
- Eccentric declined squat training and heavy slow resistance training

NO gold standard program

Can use adjunct tx’s: taping, bracing, sockwave therapy, pulsed US, LLL, PRP injections or autologous blood injections

271
Q

T/F: There is some evidence for supplementing eccentric training (patellar tendinopathy) with stretching and core stab

A

True

272
Q

Crucial education for dealing with patellar tendinopathy

A

Slow progress, sometimes 6+ months

273
Q

Evidence for use in rehab of patellar tendinopathy: Taping/strapping

A

Short-term benefit to assist with loading program (during and 2hrs after activity)

Tape: decreased pain DURING & AFTER

Strap: decreased pain AFTER

274
Q

Evidence for use in rehab of patellar tendinopathy: Extracorporeal shockwave therapy

A

Seemingly safe and promising, mixed evidence

However, no better vs surgery

275
Q

Evidence for use in rehab of patellar tendinopathy: US

A

Not recommended

276
Q

Evidence for use in rehab of patellar tendinopathy: LLL

A

limited research, not used as stand-alone tx

277
Q

Evidence for use in rehab of patellar tendinopathy: Dry needling

A

Do not use

278
Q

Evidence for use in rehab of patellar tendinopathy: PRP and autologous blood injections

A

Mixed, PRP may be more appropriate

279
Q

Evidence for use in rehab of patellar tendinopathy: corticosteroids

A

NOT advised!

280
Q

Pain monitoring model “safe zone”

A

0-5/10 VAS pain

Used in achilles and patellar tendon rehab

281
Q

Pt comes in with suspected fresh ACL tear and poor (63% quadriceps index on MIC), what intervention is most appropriate:
- Bilat leg press (0-45°)
- Bilat knee ext (90-45°)
- Sit-to-stands
- Unilat knee ext (45-90°)

A

Unilat knee ext (45-90°) because a weak quad needs to be heavily prioritized, need for OKC

Decreases the potential for compensation or potential quad avoidance

282
Q

Soreness rules (action):

Soreness during warm-up that continues

A

2 days off, drop down 1 step

283
Q

Soreness rules (action):

Soreness during warm-up that goes away

A

Stay at step that led to soreness

284
Q

Soreness rules (action):

Soreness during warm-up that goes away but redevelops during session

A

2 days off, drop down 1 step

285
Q

Soreness rules (action):

Soreness the day after lifting (not muscle soreness)

A

1 day off, do not advance program yet

286
Q

Soreness rules (action):

No soreness

A

Advance 1 step/wk or as instructed by healthcare provider

287
Q

T/F: quadriceps index is overestimated with 1-RM testing compared to electrodynamometry

A

True

Return to running criteria is typically set at 80% quad strength, and knee extension 1-RM is overestimated by 8%, it is recommended that you acheive 90% quad index prior to attempting a return to running program

OCS - Current Concepts of Ortho PT (12 decks)

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