Knee Flashcards
Well known site for ACL impingement in the knee
Intercondylar fossa
Trochlear groove is higher on the (lateral/medial side)
Lateral side = increases lateral stability
Sulcus angle vs congruency angle
Sulcus = reflective of depth of the groove
Congruency angle = From center of sulcus to lowest portion of patellar ridge (aka deepest/most posterior point)
Normal sulcus angle
Normal = 132°-144°
Congruency angle
- interpretation of + vs - numbers
If lateral of central line = + number
If medial of central line = - number
Congruency angle
- Norms
- 6° (medial tilt)
What patellar congruency angle is associated with lateral patellar subluxation
+16° (lateral tilt)
Normal angle of the knee (valgus vs varus)
180°-185° = normal (slight valgus
What medial angle classifies as genu valgum?
> 185° (knock-knees)
What medial angle classifies as genu varum?
<175° (bow legs)
T/F: menisci reduces stress on the articular cartilage and underlying subchondral bone?
True, also disperses forces and increases congruency
During closed chain activities the menisci can take up to what % of force?
70% of load on the knee
Red zone of the mensici
Outer 1/3rd, receives vascularization from capsular arteries
Red-white zone of the menisci
Middle 1/3rd, poor vascularity
White zone of the menisci
Inner 1/3rd, poor vascularity
Area of outer menisci that is separated from the capsule?
Is it vascular or avascular?
Posterior lateral corner of lateral meniscus - separated from capsule by the popliteus tendon
AVASCULAR
How does the menisci connect to the patella
Via patellomeniscal ligaments (thickenings of the anterior capsule)
The lateral meniscus is posteriorly connected to what structures?
Popliteus tendon, PCL, meniscofemoral ligament (connects to medial condyle of femur)
Anterior horn of lateral meniscus shares a common insertion site on the tibia with what structure?
ACL
Medial meniscus is attached posteriorly to what structure?
semimembranosus tendon
The anterior horn of the medial meniscus receives fibers from (ACL/PCL) and the posterior horn receives fibers from (ACL/PCL)
Anterior = ACL
Posterior = PCL
Which knee menisci (lateral vs medial) is less mobile? And why?
Medial meniscus d/t attachment to the MCL (deep portion)
T/F: muscular contraction in the leg can cause movement of the menisci?
True, contractions of the semimembranosus and poplitus muscles can create movement due to their attachments of the medial and lateral menisci, respectively
What part of the meniscus are innervated with pain receptors and jt mechanoreceptors?
Horns and outer 1/3rd (peripheral vascularized portions)
The central portion of the menisci is (neural/aneural)
Aneural
T/F: loss of the menisci does not affect stability of the knee
False, it decreases jt stability
Fabella
Sesamoid bone in posterior/lateral knee, present in 15-30% of population
Is the LCL (intra/extracapsular)?
Extracapsular
What is the optimal knee flexion degree to test LCL?
25° knee flexion = post structures are on slack
What excessive motions does the LCL resist?
Varus stress and tibia ER (@60-90° flexion)
What is the optimal knee flexion degree to test MCL?
25° knee flexion = post structures are on slack
Posterior oblique ligament (POL)
Resistance to the valgus loads when the knee is fully extended
Reinforces posteromedial aspect of the knee
What does the POL attach to?
Semimembranosis tendon sheath AND oblique popliteal ligament
The MCL deep and superficial layers are separated by what structure?
Bursa
Primary function of the superficial MCL
Restrain valgus stress, lat tibial rotation, and medial tibial rotation
Lysis of which knee ligaments in combo result in greater valgus laxity?
MCL and PCL
T/F: The MCL assists the ACL in resisted anterior translation of the tibia
True, So when MCL is damaged = greater stress on ACL
Can the MCL heal from injuries?
Yes, it is well vascularized
Layers of the knee capsule
External fibrous layer and internal synovial layer
The VMO courses with what structure to a patellar insertion?
Medial patellofemoral ligament (MPL)
Which is just an extension from the capsule
T/F: ITB supports the anterior/lateral patella as the lateral patellofemoral ligament
True
Oblique popliteal ligament is an expansion of what structures?
Expansion of the semimembranosus tendon and its lateral extension
Posterior knee
3 Primary stabilizers of the posterolateral corner
1) LCL
2) Popliteofibular ligament (PFL)
3) Popliteus tendon
What artery supplies vascularization to the ACL and PCL
Genicular artery
What nerve supplies innervation the the ACL and PCL
Branches of the tibial nerve
3 mechanoreceptors that are found in the ACL/PCL
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)
ACL attaches to what structures?
Lateral femoral condyle (medial side) to just anteromedial to intercondylar eminence on the tibia
In addition to resisting anterior translation of the tibia, the ACL is responsible for limiting (ER/IR) of the tibia
IR
Non-contact injuries to the ACL are often what mechanism?
Deceleration in slight flexion, coupled with IR/ER tibial rotation
PCL is divided into 2 bundles. Which one is the main one (95%)
Anterolateral
T/F: In the case of multi-ligament compromise (MCL and post capsule), an isolated PCL reconstruction is good enough to restore stability
False
What degrees of knee flexion is the PCL the most taut in?
30-90° knee flexion
When the PCL and surrounding structures are compromised, you will see increased (ER/IR) tibial torsion?
ER
Are open kinetic chain (OKC) knee extension exercises contraindicated in post-ACL rehab?
Not anymore, no significant difference in anterior tibial laxity
What part of the patella is in contact with the femur at: full extension
Inferior pole
What part of the patella is in contact with the femur at: 20° flexion
Med/lateral facets
What part of the patella is in contact with the femur at: 90° flexion
Superior 1/3rd
What part of the patella is in contact with the femur at: >90° flexion
Contact shifts INF/LAT (loading odd and lateral facets)
What side of the patella is the odd facet on?
Medial
The (lateral/medial) facet of the patella bears the greatest load up to 70° of knee flexion
Medial
In flexion angles >90°, what other structure contacts the femoral groove dissipating forces?
Quadriceps tendon
Q-angle norms for men and women
Men: 10-15°
Women: 15-20°
Consequences of Q-angles >20°?
Increased lateral patellar forces and displacement
What range during OKC exercises (such as LAQ) should you optimize to reduce patellofemoral joint stress?
30-90° flexion
Cancer screening questions
Rapid/unexplained weight changes, fever, night pain, acute/insidious onset of pain, unexplained jt aching and malaise
Short-form 36 (SF-36)
36-item patient-reported questionnaire that covers eight health domains
High correlations noted with knee OA population
Sickness impact profile
Behaviorally-based measure of health status
Immediate jt swelling (<2hrs) can indicate?
Internal jt trauma, hemarthrosis, patellofemoral dislocation
Delayed jt swelling (2-12hrs) can indicate?
Intraarticular ligament involvement
Jt swelling with onset >12-24hrs post-injury can indicate?
Synovial fluid response (often capsular/ligamentous strain or meniscal involvement)
Ottawa Knee Rules
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
Is the ottawa knee rule cluster sensitive?
Yes, 100% sensitive to ruling OUT fx’s
Age range the Ottawa knee rules are applicable?
13-49
Knee questionnaire(s) for: OA and TKA
1) WOMAC
2) KOOS
Knee questionnaire(s) for: patellar tendinopathy
1) Victorian Institute of Sport Assessment Questionnaire, Patellar Tendon (VISA-P)
Knee questionnaire(s) for: Ligament
1) International Knee Documentation Committee (IKDC) questionnaire
2) Lysholm knee score (can be lig & meniscus)
Neither are good
Knee questionnaire(s) for: ACL repair
1) ACL-RSI
GOOD
Knee questionnaire(s) for: Non-specific knee conditions
1) Cincinnati Knee Rating System
2) Knee Outcome Survey (KOS)
Is there a correlation between muscular inhibition and large knee effusion?
Not been validated
Grading of effusion - Sturgill
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
Can Effusion grading and pain scale responses be used for progression/regression of exercise programs?
Yes, when used together
T/F: assessing bony end-feels have evidence to be a predictor of pathology
False, no evidence. However, still used commonly for tx decisions
T/F: MMT - identifying differences in grading of less than a full grade has poor reliability
True AND poor sensitivity of the scale above grade 3 (fair)
Gold standard for assessment quadriceps strength?
Electrodynamometer testing
HHD is good but not as good
Amount of movement present during ligamentous stress testing (in mms):
· Grade 1+
· Grade 2+
· Grade 3+
1+ = 3-5mm
2+ = 5-10mm
3+ = >10mm
When would it be appropriate to do ligament testing on the involved side first?
If there are concerns that prior knowledge of the testing procedures will affect the pt’s ability to relax
Are the knee valgus stress tests (0°, 30°) more specific or sensitive?
Which test position is better?
Sensitive (best @30° flexion)
When should the ACL be assessed for damage in MCL injuries? hint: think valgus testing degrees
@0° testing = if >5mm laxity (also suspect PCL)
@30° testing = if >10mm laxity
Most specific test for evaluation of the: MCL
Valgus testing at 30°
Most specific test for evaluation of the: LCL
Varus testing at 30°
Most specific test for evaluation of the: PCL
Posterior sag and quadriceps activation test (shows ant translation)
ALL including post drawer are great SN/SP
Most specific test for evaluation of the: ACL
Lachman test
Most specific test for evaluation of the: posterolateral corner
Prone ER test >10° vs opposite side
aka Dial test
Most specific test(s) for evaluation of the: Meniscus
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%
Most specific test for evaluation of the: Patellofemoral
Pain during resisted isometric quad contraction AND squatting
If posterior drawer test is + at 30° and normal at 90°, you should suspect what?
Posterolateral corner issues
Best test = dial test
T/F: The pivot shift test is sensitive and specific for ACL tears in both clinical and under anesthesia situations?
False, poor sensitivity in clinic but GREAT (= w/ lachmans) under anesthesia
Arthrometer threshold for ACL tears
3mm difference from uninvolved side = ACL tear
GREAT SN/SP
Cluster of special tests for PLC (posterolateral corner) compromise
1) Posterolateral drawer test
2) Dial test
3) Reverse pivot shift
4) ER recurvatum test
When performing the posterolateral drawer test => excessive amount of laxity AND sublux posteriorly.. suspect what?
PCL injury
If dial test is + at both 30° AND 90° flexion, suspect what?
PCL injury
Is an ortho referral indicated for an unresolved acute meniscal locking episode?
Yes, non-emergent
Best clinical tests/indicators for patellofemoral pain syndrome (PFP)
Pain w/ squatting, stairs, and prolonged sitting
Cluster: 80% Probability of PFP symptoms improving with foot orthotic (pre-fab)
1) >25 y/o
2) Height <5’ 4”
3) Pain at worst >5/10
4) Mid-foot width change (≥11mm, NWB -> WB)
Sage sign
hypermobility of patellar glide (med/lat)
Apprehension test
Patellar hypermobility + apprehension
What is the gold standard for return-to-sport functional testing with PFP?
There is none!
Most commonly used is 1-legged hops
(scoring 80-85% of opposite side = normal)
Should you let your patient do a practice run of the the 1-legged hop tests?
Yes!
Performance of which 1- legged hop tests are the strongest predictor of self-reported knee function (IKDC 2000)
1) Cross over for distance
2) 6 meter hop test
1-legged hop test for RTS (Noyes et al)
1) SL for distance
2) Crossover for distance
3) Triple hop for distance
4) 6 meter timed hop
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 %?
84%
Minimum amount of time to delay RTS post ACLR
9 months
Are SEBT and Y-balance tests reliable?
Yes, and appropriate for those not attempting to return to level 1 sports
Functional tests for elderly and those with knee OA to identify fall risk
1) Timed stair-climbing test
2) 6’ walk test
3) TUG
4) 5x STS
Is patellar taping indicated in PFP or OA?
Grade B evidence for PFP
OA evidence is mixed
Goal of using tape as an intervention to manage knee pain
Short term pain management so a person can return to an exercise program
KT tape = rigid tape
Evidence for bracing in knee pain
Very low quality, mixed
Can help if nothing else is working
Use of unloading brace
For unicompartmental degenerative jt disease, transfers forces to healthier compartment
Does NOT help with obese individuals
Evidence for use of unloading brace
Can provide significant pain relief, functional improvement, and improved exercise tolerance
Does NOT help with obese individuals
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
True, strongly recommended
Recommendations for use of functional brace s/p ACLR
Okay in short term especially where quad activation and strength are lacking, mixed reviews overall with trending towards less bracing
Recommendation for bracing in PCL injuries
Usefulness unclear, post-op brace typically discontinued by wk 4
Recommendation for bracing in MCL injuries
Suggested to provide stability in early stages of grade 2-3 sprains, typically braces are locked in 30-90° (avoid full ext)
T/F: Using braces in ACL deficient and ACLR skiiers can be detrimental to outcomes
False, it’s show to reduce risk of reinjury by 6.4 and 3.9 times respectively
When performing knee jt mobs for ROM improvements, how can you increase stress on jt capsule?
Move to end-ranges
During “bag hangs” to gain knee extension does ankle position matter?
Yes, ankle should be slightly PF or neutral
If DF is present, gastroc may prevent full knee ext
Drop-out cast
Used in stubborn cases of extension ROM loss, especially for post-op
Optimal static stretch program for length gains paramaters
30” hold x 3-4 reps
T/F: NMES in combo with quad strengthening is beneficial in gaining strength faster than exercise alone
True, when use of NMES is at least 4 wks
NMES parameters for quad re-education
Russian
Burst-modulated
Pulse duration: 400µs, 75pps, 2” ramp
10 contractions for 10” with REST for 50”
Contraindications for NMES
Pacemaker, PVD, neoplasm or infection, skin integrity issues, unable to provide feedback
Precautions for NMES
Uncontrolled HTN, excessive adipose tissue, pregnancy (location dependent), severe osteoporosis, impaired sensation
Typically the use of NMES in quad strengthening/re-education is discontinued when what metrics are met?
Quad force output of involved leg is ≥80% of the uninvolved leg
How to dose NMES without a HHD
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
Best knee position for NMES of quads
Knee flexed (seated)
Although knee extension is better vs no NMES
T/F: isolated eccentric exercise program (i.e. of quad) is better vs concentric and isometric in overall strengthening
False, It doesn’t appear to be superior over other loading programs
T/F: When performing a loading program, isometrics should be used long-term
False, more suitable for short-term use when pain relief is warranted
Considerations for use of eccentric training program to treat patellar tendinopathy
Use decline board, refrain from sport activity, bilat eccentrics = unilat
Insufficient evidence to support eccentric only programs
Goal of blood flow restriction (BFR) training
Promote hypertrophy with sub-max resistance
Blood Flow Restriction (BFR) training vs:
- High load training program
- Low load training program
High load: no superior outcomes or hypertrophy
Low load: Superior results for hypertrophy and function
What is the preferred amount (%) of arterial occlusion for BFR training
80%
BFR parameters
- Occlusion
- Intensity
- Reps
- Rest
Occlusion: 60-80% (80 preferred)
Intensity: 15-30% 1-RM
Reps: 30-15-15-15
Rest: 30” between sets
Suggested hamstring-to-quadriceps ratio prior to RTS:
- Males
- Females
Males >66%
Females >75%
Indications of an overaggressive rehab approach
Persistent or increasing pain, inflammation, swelling, worsening ROM defiicts
Screening guidelines for ACL injury (to determine who would benefit from perturbation training)
- 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
Pre-reqs for screening for potential copers (ACL non-surgical)
- Isolated tear of ACL
- Full pain-free ROM
- No effusion
- Quad MVIC ≥70% good side
- Must tolerate hopping (pain-free) once MVIC is met
“True copers”
Non-surgical ACL tears who were screened, went through a combo program including perturbation training, AND returned to L1-2 sport for 1 hr
Complications of bone-patellar tendon-bone autografts
Increased incidence of anterior knee pain, minimal increased risk of patellar fx
Complications of hamstring autografts
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
T/F: Allografts heal slower vs autografts
True
Allografts tend to have (higher/lower) failure rates vs autografts?
Higher
T/F: Double bundle technique provides better outcomes vs single bundle
False, no evidence that it’s better. It can provide better static stability but no correlation to better outcomes
“Calm knee”
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
Post-op ACLR:
OCK vs CKC exercises
Use both, they have similar levels of ACL strain
IN FACT, walking has more ACL strain vs both OCK and CKC!!
What 2 factors/deficits post ACLR are associated with decreased post-op function?
Residual quad weakness AND loss of ext ROM
T/F: Use of NMES in combo w/ exercise is better vs exercise alone in ACLR rehab?
True
ACLR w/ meniscus repair:
- protocol deviation
Weight bearing knee flexion > 45°contraindicated for 4wks
ACLR w/ cartilage damage and/or repair:
- protocol deviation
Restricted weight bearing for 3-4wks
ACLR w/ MCL sprain:
- protocol deviation
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
ACLR w/ PCL sprain:
- protocol deviation
Follow PCL rehab
ACLR revision leads to (less/more) rigid graft fixation
Less
ACLR revision rehab is (slower/quicker) vs initial ACLR
Slower, everything is delayed. PWB w/ crutches for 2wks, avoid unstable environments for 4wks
Tests/measures to determine if an ACLR is “successful”
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
Is HS weakness post ACLR a concern?
Not usually, it’s not predictive of function and strength typically returns to normal within 2 yrs, even with HS allograft.
Returning to L1 sports after ACLR results in how much more likelihood to re-injure the ACL?
Chance of injury of contralateral ACL?
4x
5x for contralat
What is one of the biggest barriers to RTS in post-op ACLR patients?
Fear of retear
T/F: If individuals scored low on the IKDC 2000, they were 4x more likely to fail the return to activity batter of tests?
True
If surgery for ACL tear in skeletal immature individuals is delayed, what other negative events can happen?
High risk for meniscus tear, lead to early OA, progressive jt instability
Cluster of 4 clinical signs in skeletal immature individuals that would indicate the need for earlier surgical intervention
1) ≥14 y/o
2) Partial tear >1/2 thickness
3) Tear of posterolateral bundle
4) Pivot shift grade B/II or greater
Can “ACL injury prevention” programs actually lower risk of injury?
Yes, they are effective (up to 50-67% in one study)
ACL injury prevention plans should include:
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
Most common MOI for isolated PCL tear
Athletic injuries
Typical RTS after a grade I or II PCL sprain
4wks
Is early quad or HS strengthening crucial in PCL sprains?
Quad, HS pulls tibia post
Is there a correlation between PCL laxity (residual) and functional deficits or pain?
NOPE!
Do grade III PCL tears require immobilization?
Often immobilized in full ext for 2-4wks (to reduce post sublux from HS)
Grade III PCL strain rehab should avoid what initially?
Knee flexion >70° and isolated HS exercises
Emphasis on concerns that early activity can lead to increased laxity and graft strain
How long s/p PCL repair should you wait to do HS strengthening (resisted knee flexion)
4 months
Can you do LAQ or knee ext s/p PCL injury?
Yes but in limited range (60°-0°
Reconstruction of PCL is typically what type of graft?
Achilles tendon allograft
Injuries to the posterolateral corner (PLC) is usually associated with what concomitant injury?
PCL tear
Rarely does the PLC tear without injury to the PCL
T/F: PCL repair without fixing torn PCL is associated with same outcomes as repairing both?
False, failure to restore both may be possible cause of PCL graft failure
In PCL repairs, can you delay LCL repairs?
No, LCL should be fixed within 3 wks of injury otherwise a full reconstruction may need to happen
Post-op PLC repair rehab considerations
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
MCL injuries: surgery vs non-surgical
Same outcome
LCL injuries: surgery vs non-surgical
Mixed results for outcomes
Non-surgical management of MCL or LCL sprains
Brace to prevent valgus/varus for 6-8wks, avoid rotation
FOCUS on quad strength and facilitating dynamic stabilization
Bracing/immobilization post-MCL or LCL repair
Locked at 30° flexion for 2-6wks during ambulation
Use of bracing in non-surgical management of MCL or LCL sprains
Mixed effectiveness
Meniscus tear: surgery vs non-surgical managment
Equal, no difference especially in middle aged and older
2 most important components to rehab meniscal repair
1) Controlled weight bearing
2) ROM
What to avoid in meniscus repair cases:
WB activities with >45° knee flexion, loaded knee flexion >90° (for 8wks)
Meniscus repair: OKC vs CKC strengthening
OKC better initially
T/F: injury to the meniscus has been associated with progressive OA
True, especially with menisectomies
Indications for meniscus transplant
Previous meniscectomy and STILL have pain
Meniscus transplant contraindications
Varus/valgus malalignments, advanced OA, instability, arthrofibrosis, significant muscle atrophy, obesity
Is there WB restrictions post-meniscal transplant?
Yes, typically limited from 3-6wks
Early WB may increase risk of transplant failure
Rehab of meniscal transplant:
- ROM
- Exercises
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
Meniscal transplantation is good for (long/short) term benefits
Short-term
Is exercise (strongly/moderately/weakly) supported by research for knee OA?
Strongly
Most research suggests a combo of LE strengthening and aerobic exercises
What is the single strongest predictor of functional limitations in those with knee OA?
Quad weakness
Patients with (lateral/medial) knee OA benefited more from addition of hip strengthening?
Medial knee OA
Is balance/proprioceptive training suggested in tx of knee OA?
Yes when incorporated w/ strength and aerobic program
Aquatic PT, yoga, Tai Chi benefits for knee OA
May be helpful
Does behavioral change techniques have shown to have (good/limited) effectiveness to promote adherence to HEP?
Limited
Evidence for use in tx of knee OA: cryotherapy
Insufficient
Evidence for use in tx of knee OA: Low-level laser therapy
Positive findings, but unknown parameters
Evidence for use in tx of knee OA: US
May have short-term relief, no extra benefit with phonophoresis
Evidence for use in tx of knee OA: manual therapy
Positive when COMBINED with exercise
Glucocorticod injection vs manual therapy & exercise
Manual therapy + exercise is BETTER
Evidence for use in tx of knee OA: mobilization with movement
NOT supported to improve ROM
Evidence for use in tx of knee OA: lifestyle changes for weight loss
Can be beneficial for pain and function as obesity is risk factor for knee OA
Is education in jt-sparing techniques beneficial with knee OA?
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
Evidence for use in tx of knee OA: jt lubrication injections (hyaluronic acid)
Can be used as adjunct tx for OA
Evidence for use in tx of knee OA: corticosteroids
May have short-term pain relief, no effect on function
Comparable to other injections and long-term PT
Reason for use of osteotomy procedures in knee OA?
For unilat OA, redistributes load bearing away from bad area.
Can delay TKA for up to 10 yrs
Considerations for rehab post-osteotomy
Limited WB for 4 wks
NO resistance put DISTAL to fx site - can cause fracture to not heal properly
Full ROM okay immediately
Use of osteotomy vs UKA
Osteotomy: higher level
UKA: quick rehab
Same outcomes
High tibial osteotomy vs femoral osteotomy
High tib: medial compartment OA
Femoral: lateral compartment OA
Rehab of UKA vs TKA
Same but UKA pt’s will typically hit milestones quicker
Which of the following are associated with worse outcomes post-TKA surgery:
-> depression, high BMI, DM2
Depression and high BMI
Diabetes is NOT known to have bad outcomes
Weight bearing restrictions for cemented vs non-cemented TKA
Cemented: FWB
Non-cemented: progressive WB over 6 wks
Evidence for use of CPM post-TKA
Not supported
Are patellar mobs supported as post-TKA tx?
Yes, should be started early
Are tibiofemoral jt mobs indicated post-TKA?
Unclear
In PCL-sacrificing surgical techniques (TKA) what jt mob should be avoided?
Posterior glides, can compromise engaged cam
Best preventative measure against arthrofibrosis and stiffness post-TKA
Early supervised PT
Is kneeling safe to perform post-TKA
Yes, towards end of rehab
Are balance and proprioceptive training important for post-TKA?
Yes, because decreased quad strength = higher risk for falls post-TKA
4 primary phases of tissue healing?
1) Proliferation
2) Transition
3) Remodeling
4) Maturation
Does articular cartilage repair cause regrowth of hyaline cartilage?
Not for debridement, chondroplasty or microfractures
They stimulate fibrocartilage replacement
WB precautions for post-op chondroplasty vs microfracture
Chondroplasty: limited for 3-5days
Microfracture: NWB 2-4wks, FWB by 8wks
OATS
Osteochondral autograft transplantation (OATS) - bone plugs covered with hyaline cartilage from NWB surface in knee
ACI
Autologous chondrocyte implantation (ACI) - harvesting articular cartilage that is grown in lab, then put back in knee
“Kissing lesions” in regards to articular cartilage lesions
Bipolar (femoral and tibial) lesions
T/F: ACI is okay to do with kissing lesions?
False
T/F: Effusion can be a sign of excessive stress on the knee jt post-OATs or ACI procedure
True, effusion must be monitored at ALL stages
T/F: Are quad deficits common long-term post-articular cartilage repairs
True (can persist up to 5-7yrs)
Evidence for BFR following articular cartilage procedures
Emerging evidence for positive results
Evidence for anti-gravity treadmills following articular cartilage procedures
Emerging evidence indicates use
Which group is shown to have higher success rates to return to PLOF:
- Microfracture
- OATs
- ACI
OATS
Best indicator of PFP?
Pain with squatting, stair climbing, and sitting with a flexed knee
No gold standard for diagnosis. Best is above activities that provoke pain.
PFP is a diagnosis of (exclusion/inclusion)
Exclusion, no gold standard for diagnosis
Do psychosocial factors play a role in PFP?
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)
Risk factors for PFP
Female, limited quad flexibility, patella hypermobility, decreased quad strength (isometric/isokinetic and explosives)
Does q-angle, BMI, and age play a role in predicting future PFP?
No
4 sub-categories of PFP
1) Overuse/overload (w/o other impairments)
2) Muscle performance deficits
3) Movement coordination deficits
4) Mobility impairments
Still at level of expert opinion
T/F: Hip weakness is a universal finding amongst published papers regarding PFP
False, only in some
Use of BFR in rehab of PFP
Can be helpful when high intensity training is limited by pain
Should taping, bracing, orthoses, and NMES be used in PFP?
Can be in COMBO with well-designed exercise program
T/F: Foot orthoses can be helpful in treating PFP?
Can help with short-term pain relief
Custom orthoses vs prefab for use in PFP?
No evidence that custom is better than prefab
Hoffa disease
Infrapatellar fat pad irritation
Fat pad irritation
Common in hyperextension or repeated knee extension activities (i.e. gymnasts), aka Hoffa Disease (infrapatellar fat pad)
Symptoms of moderate to severe PFOA (patellofemoral OA)
Swelling, genu valgus, pain w/ patellar compression, decreased quad strength
Bipartite patella
Patella is made of two bones instead of a single bone
Generally asymptomatic unless trauma causes instability
Osgood-Schlatter disease
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
Tx for Osgood-Schlatter disease
Non-surgical and often self-limiting
Rest, ice, stretching of ant/lat hip, strength of hip/knee, NSAIDs
Indication for surgical approach with Osgood-Schlatter disease
If non-conservative measures fail, success of tx is good to excellent in 93% of patients
Sinding-Larsen-Johansson Syndrome
Pain and swelling by inferior pole of patella (traction apophysitis)
Common in active females 10-15 y/o
Tx similar to OSD
Early sports specialization of younger (male/female) athletes can lead to 4x greater likelihood of OSD and SLJ syndrome
Female
Fulkersons osteotomy
Moving tibial tuberosity medial
Used for chronic lateral patella subluxations (failed conservative tx)
Goal of post-op tx for lateral retinacular release
Scar tissue avoidance (do patellar glides!!)
Considerations for post-op extensor mechanism surgical realignment
AVOID Valgus positioning, high frequency of quad shut down => use NMES but NOT on VMO
Tibial stress reaction (post-extensor mechanism surgical realignment)
- What is it
- Tx considerations
Aggravation at tibial tubercle, may have “POP” or “SNAP”
Symptom management for a couple days then return to full activity
Patellar tendinopathy
Focal pain at inferior pole of patella and load-dependent (usually no pain @rest)
Common in younger males, volleyball and basketball players
Possible US findings when looking at patellar tendinopathy
Hypoechoic areas (dark areas), tendon thickening, and neovascularity
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?
An issue with non-contractile tissues
Are there evidence based risk factors for development of patellar tendinopathy
No solid ones
Best practice for rehab of patellar tendinopathy
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
T/F: There is some evidence for supplementing eccentric training (patellar tendinopathy) with stretching and core stab
True
Crucial education for dealing with patellar tendinopathy
Slow progress, sometimes 6+ months
Evidence for use in rehab of patellar tendinopathy: Taping/strapping
Short-term benefit to assist with loading program (during and 2hrs after activity)
Tape: decreased pain DURING & AFTER
Strap: decreased pain AFTER
Evidence for use in rehab of patellar tendinopathy: Extracorporeal shockwave therapy
Seemingly safe and promising, mixed evidence
However, no better vs surgery
Evidence for use in rehab of patellar tendinopathy: US
Not recommended
Evidence for use in rehab of patellar tendinopathy: LLL
limited research, not used as stand-alone tx
Evidence for use in rehab of patellar tendinopathy: Dry needling
Do not use
Evidence for use in rehab of patellar tendinopathy: PRP and autologous blood injections
Mixed, PRP may be more appropriate
Evidence for use in rehab of patellar tendinopathy: corticosteroids
NOT advised!
Pain monitoring model “safe zone”
0-5/10 VAS pain
Used in achilles and patellar tendon rehab
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°)
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
Soreness rules (action):
Soreness during warm-up that continues
2 days off, drop down 1 step
Soreness rules (action):
Soreness during warm-up that goes away
Stay at step that led to soreness
Soreness rules (action):
Soreness during warm-up that goes away but redevelops during session
2 days off, drop down 1 step
Soreness rules (action):
Soreness the day after lifting (not muscle soreness)
1 day off, do not advance program yet
Soreness rules (action):
No soreness
Advance 1 step/wk or as instructed by healthcare provider
T/F: quadriceps index is overestimated with 1-RM testing compared to electrodynamometry
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
