Knee Flashcards
1
Q
Well known site for ACL impingement in the knee
A
Intercondylar fossa
2
Q
Trochlear groove is higher on the (lateral/medial side)
A
Lateral side = increases lateral stability
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)
4
Q
Normal sulcus angle
A
Normal = 132°-144°
5
Q
Congruency angle
- interpretation of + vs - numbers
A
If lateral of central line = + number
If medial of central line = - number
6
Q
Congruency angle
- Norms
A
- 6° (medial tilt)
7
Q
What patellar congruency angle is associated with lateral patellar subluxation
A
+16° (lateral tilt)
8
Q
Normal angle of the knee (valgus vs varus)
A
180°-185° = normal (slight valgus
9
Q
What medial angle classifies as genu valgum?
A
> 185° (knock-knees)
10
Q
What medial angle classifies as genu varum?
A
<175° (bow legs)
11
Q
T/F: menisci reduces stress on the articular cartilage and underlying subchondral bone?
A
True, also disperses forces and increases congruency
12
Q
During closed chain activities the menisci can take up to what % of force?
A
70% of load on the knee
13
Q
Red zone of the mensici
A
Outer 1/3rd, receives vascularization from capsular arteries
14
Q
Red-white zone of the menisci
A
Middle 1/3rd, poor vascularity
15
Q
White zone of the menisci
A
Inner 1/3rd, poor vascularity
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
17
Q
How does the menisci connect to the patella
A
Via patellomeniscal ligaments (thickenings of the anterior capsule)
18
Q
The lateral meniscus is posteriorly connected to what structures?
A
Popliteus tendon, PCL, meniscofemoral ligament (connects to medial condyle of femur)
19
Q
Anterior horn of lateral meniscus shares a common insertion site on the tibia with what structure?
A
ACL
20
Q
Medial meniscus is attached posteriorly to what structure?
A
semimembranosus tendon
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
22
Q
Which knee menisci (lateral vs medial) is less mobile? And why?
A
Medial meniscus d/t attachment to the MCL (deep portion)
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
24
Q
What part of the meniscus are innervated with pain receptors and jt mechanoreceptors?
A
Horns and outer 1/3rd (peripheral vascularized portions)
25
The central portion of the menisci is (neural/aneural)
Aneural
26
T/F: loss of the menisci does not affect stability of the knee
False, it decreases jt stability
27
Fabella
Sesamoid bone in posterior/lateral knee, present in 15-30% of population
28
Is the LCL (intra/extracapsular)?
Extracapsular
29
What is the optimal knee flexion degree to test LCL?
25° knee flexion = post structures are on slack
30
What excessive motions does the LCL resist?
Varus stress and tibia ER (@60-90° flexion)
31
What is the optimal knee flexion degree to test MCL?
25° knee flexion = post structures are on slack
32
Posterior oblique ligament (POL)
Resistance to the valgus loads when the knee is fully extended
Reinforces posteromedial aspect of the knee
33
What does the POL attach to?
Semimembranosis tendon sheath AND oblique popliteal ligament
34
The MCL deep and superficial layers are separated by what structure?
Bursa
35
Primary function of the superficial MCL
Restrain valgus stress, lat tibial rotation, and medial tibial rotation
36
Lysis of which knee ligaments in combo result in greater valgus laxity?
MCL and PCL
37
T/F: The MCL assists the ACL in resisted anterior translation of the tibia
True, So when MCL is damaged = greater stress on ACL
38
Can the MCL heal from injuries?
Yes, it is well vascularized
39
Layers of the knee capsule
External fibrous layer and internal synovial layer
40
The VMO courses with what structure to a patellar insertion?
Medial patellofemoral ligament (MPL)
Which is just an extension from the capsule
41
T/F: ITB supports the anterior/lateral patella as the lateral patellofemoral ligament
True
42
Oblique popliteal ligament is an expansion of what structures?
Expansion of the semimembranosus tendon and its lateral extension
Posterior knee
43
3 Primary stabilizers of the posterolateral corner
1) LCL
2) Popliteofibular ligament (PFL)
3) Popliteus tendon
44
What artery supplies vascularization to the ACL and PCL
Genicular artery
45
What nerve supplies innervation the the ACL and PCL
Branches of the tibial nerve
46
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)
47
ACL attaches to what structures?
Lateral femoral condyle (medial side) to just anteromedial to intercondylar eminence on the tibia
48
In addition to resisting anterior translation of the tibia, the ACL is responsible for limiting (ER/IR) of the tibia
IR
49
Non-contact injuries to the ACL are often what mechanism?
Deceleration in slight flexion, coupled with IR/ER tibial rotation
50
PCL is divided into 2 bundles. Which one is the main one (95%)
Anterolateral
51
T/F: In the case of multi-ligament compromise (MCL and post capsule), an isolated PCL reconstruction is good enough to restore stability
False
52
What degrees of knee flexion is the PCL the most taut in?
30-90° knee flexion
53
When the PCL and surrounding structures are compromised, you will see increased (ER/IR) tibial torsion?
ER
54
Are open kinetic chain (OKC) knee extension exercises contraindicated in post-ACL rehab?
Not anymore, no significant difference in anterior tibial laxity
55
What part of the patella is in contact with the femur at: full extension
Inferior pole
56
What part of the patella is in contact with the femur at: 20° flexion
Med/lateral facets
57
What part of the patella is in contact with the femur at: 90° flexion
Superior 1/3rd
58
What part of the patella is in contact with the femur at: >90° flexion
Contact shifts INF/LAT (loading odd and lateral facets)
59
What side of the patella is the odd facet on?
Medial
60
The (lateral/medial) facet of the patella bears the greatest load up to 70° of knee flexion
Medial
61
In flexion angles >90°, what other structure contacts the femoral groove dissipating forces?
Quadriceps tendon
62
Q-angle norms for men and women
Men: 10-15°
Women: 15-20°
63
Consequences of Q-angles >20°?
Increased lateral patellar forces and displacement
64
What range during OKC exercises (such as LAQ) should you optimize to reduce patellofemoral joint stress?
30-90° flexion
65
Cancer screening questions
Rapid/unexplained weight changes, fever, night pain, acute/insidious onset of pain, unexplained jt aching and malaise
66
Short-form 36 (SF-36)
36-item patient-reported questionnaire that covers eight health domains
High correlations noted with knee OA population
67
Sickness impact profile
Behaviorally-based measure of health status
68
Immediate jt swelling (<2hrs) can indicate?
Internal jt trauma, hemarthrosis, patellofemoral dislocation
69
Delayed jt swelling (2-12hrs) can indicate?
Intraarticular ligament involvement
70
Jt swelling with onset >12-24hrs post-injury can indicate?
Synovial fluid response (often capsular/ligamentous strain or meniscal involvement)
71
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
72
Is the ottawa knee rule cluster sensitive?
Yes, 100% sensitive to ruling OUT fx's
73
Age range the Ottawa knee rules are applicable?
13-49
74
Knee questionnaire(s) for: OA and TKA
1) WOMAC
2) KOOS
75
Knee questionnaire(s) for: patellar tendinopathy
1) Victorian Institute of Sport Assessment Questionnaire, Patellar Tendon (VISA-P)
76
Knee questionnaire(s) for: Ligament
1) International Knee Documentation Committee (IKDC) questionnaire
2) Lysholm knee score (can be lig & meniscus)
Neither are good
77
Knee questionnaire(s) for: ACL repair
1) ACL-RSI
GOOD
78
Knee questionnaire(s) for: Non-specific knee conditions
1) Cincinnati Knee Rating System
2) Knee Outcome Survey (KOS)
79
Is there a correlation between muscular inhibition and large knee effusion?
Not been validated
80
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
81
Can Effusion grading and pain scale responses be used for progression/regression of exercise programs?
Yes, when used together
82
T/F: assessing bony end-feels have evidence to be a predictor of pathology
False, no evidence. However, still used commonly for tx decisions
83
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)
84
Gold standard for assessment quadriceps strength?
Electrodynamometer testing
HHD is good but not as good
85
Amount of movement present during ligamentous stress testing (in mms):
· Grade 1+
· Grade 2+
· Grade 3+
1+ = 3-5mm
2+ = 5-10mm
3+ = >10mm
86
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
87
Are the knee valgus stress tests (0°, 30°) more specific or sensitive?
Which test position is better?
Sensitive (best @30° flexion)
88
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
89
Most specific test for evaluation of the: MCL
Valgus testing at 30°
90
Most specific test for evaluation of the: LCL
Varus testing at 30°
91
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
92
Most specific test for evaluation of the: ACL
Lachman test
93
Most specific test for evaluation of the: posterolateral corner
Prone ER test >10° vs opposite side
aka Dial test
94
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%
95
Most specific test for evaluation of the: Patellofemoral
Pain during resisted isometric quad contraction AND squatting
96
If posterior drawer test is + at 30° and normal at 90°, you should suspect what?
Posterolateral corner issues
Best test = dial test
97
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
98
Arthrometer threshold for ACL tears
3mm difference from uninvolved side = ACL tear
GREAT SN/SP
99
Cluster of special tests for PLC (posterolateral corner) compromise
1) Posterolateral drawer test
2) Dial test
3) Reverse pivot shift
4) ER recurvatum test
100
When performing the posterolateral drawer test => excessive amount of laxity AND sublux posteriorly.. suspect what?
PCL injury
101
If dial test is + at both 30° AND 90° flexion, suspect what?
PCL injury
102
Is an ortho referral indicated for an unresolved acute meniscal locking episode?
Yes, non-emergent
103
Best clinical tests/indicators for patellofemoral pain syndrome (PFP)
Pain w/ squatting, stairs, and prolonged sitting
104
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)
105
Sage sign
hypermobility of patellar glide (med/lat)
106
Apprehension test
Patellar hypermobility + apprehension
107
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)
108
Should you let your patient do a practice run of the the 1-legged hop tests?
Yes!
109
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
110
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
111
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%
112
Minimum amount of time to delay RTS post ACLR
9 months
113
Are SEBT and Y-balance tests reliable?
Yes, and appropriate for those not attempting to return to level 1 sports
114
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
115
Is patellar taping indicated in PFP or OA?
Grade B evidence for PFP
OA evidence is mixed
116
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
117
Evidence for bracing in knee pain
Very low quality, mixed
Can help if nothing else is working
118
Use of unloading brace
For unicompartmental degenerative jt disease, transfers forces to healthier compartment
Does NOT help with obese individuals
119
Evidence for use of unloading brace
Can provide significant pain relief, functional improvement, and improved exercise tolerance
Does NOT help with obese individuals
120
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
121
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
122
Recommendation for bracing in PCL injuries
Usefulness unclear, post-op brace typically discontinued by wk 4
123
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)
124
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
125
When performing knee jt mobs for ROM improvements, how can you increase stress on jt capsule?
Move to end-ranges
126
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
127
Drop-out cast
Used in stubborn cases of extension ROM loss, especially for post-op
128
Optimal static stretch program for length gains paramaters
30" hold x 3-4 reps
129
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
130
NMES parameters for quad re-education
Russian
Burst-modulated
Pulse duration: 400µs, 75pps, 2" ramp
10 contractions for 10" with REST for 50"
131
Contraindications for NMES
Pacemaker, PVD, neoplasm or infection, skin integrity issues, unable to provide feedback
132
Precautions for NMES
Uncontrolled HTN, excessive adipose tissue, pregnancy (location dependent), severe osteoporosis, impaired sensation
133
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
134
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
135
Best knee position for NMES of quads
Knee flexed (seated)
Although knee extension is better vs no NMES
136
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
137
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
138
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
139
Goal of blood flow restriction (BFR) training
Promote hypertrophy with sub-max resistance
140
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
141
What is the preferred amount (%) of arterial occlusion for BFR training
80%
142
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
143
Suggested hamstring-to-quadriceps ratio prior to RTS:
- Males
- Females
Males >66%
Females >75%
144
Indications of an overaggressive rehab approach
Persistent or increasing pain, inflammation, swelling, worsening ROM defiicts
145
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
146
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
147
"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
148
Complications of bone-patellar tendon-bone autografts
Increased incidence of anterior knee pain, minimal increased risk of patellar fx
149
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
150
T/F: Allografts heal slower vs autografts
True
151
Allografts tend to have (higher/lower) failure rates vs autografts?
Higher
152
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
153
"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
154
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!!
155
What 2 factors/deficits post ACLR are associated with decreased post-op function?
Residual quad weakness AND loss of ext ROM
156
T/F: Use of NMES in combo w/ exercise is better vs exercise alone in ACLR rehab?
True
157
ACLR w/ meniscus repair:
- protocol deviation
Weight bearing knee flexion > 45° contraindicated for 4wks
158
ACLR w/ cartilage damage and/or repair:
- protocol deviation
Restricted weight bearing for 3-4wks
159
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
160
ACLR w/ PCL sprain:
- protocol deviation
Follow PCL rehab
161
ACLR revision leads to (less/more) rigid graft fixation
Less
162
ACLR revision rehab is (slower/quicker) vs initial ACLR
Slower, everything is delayed. PWB w/ crutches for 2wks, avoid unstable environments for 4wks
163
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
164
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.
165
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
166
What is one of the biggest barriers to RTS in post-op ACLR patients?
Fear of retear
167
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
168
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
169
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
170
Can "ACL injury prevention" programs actually lower risk of injury?
Yes, they are effective (up to 50-67% in one study)
171
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
172
Most common MOI for isolated PCL tear
Athletic injuries
173
Typical RTS after a grade I or II PCL sprain
4wks
174
Is early quad or HS strengthening crucial in PCL sprains?
Quad, HS pulls tibia post
175
Is there a correlation between PCL laxity (residual) and functional deficits or pain?
NOPE!
176
Do grade III PCL tears require immobilization?
Often immobilized in full ext for 2-4wks (to reduce post sublux from HS)
177
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
178
How long s/p PCL repair should you wait to do HS strengthening (resisted knee flexion)
4 months
179
Can you do LAQ or knee ext s/p PCL injury?
Yes but in limited range (60°-0°
180
Reconstruction of PCL is typically what type of graft?
Achilles tendon allograft
181
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
182
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
183
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
184
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
185
MCL injuries: surgery vs non-surgical
Same outcome
186
LCL injuries: surgery vs non-surgical
Mixed results for outcomes
187
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
188
Bracing/immobilization post-MCL or LCL repair
Locked at 30° flexion for 2-6wks during ambulation
189
Use of bracing in non-surgical management of MCL or LCL sprains
Mixed effectiveness
190
Meniscus tear: surgery vs non-surgical managment
Equal, no difference especially in middle aged and older
191
2 most important components to rehab meniscal repair
1) Controlled weight bearing
2) ROM
192
What to avoid in meniscus repair cases:
WB activities with >45° knee flexion, loaded knee flexion >90° (for 8wks)
193
Meniscus repair: OKC vs CKC strengthening
OKC better initially
194
T/F: injury to the meniscus has been associated with progressive OA
True, especially with menisectomies
195
Indications for meniscus transplant
Previous meniscectomy and STILL have pain
196
Meniscus transplant contraindications
Varus/valgus malalignments, advanced OA, instability, arthrofibrosis, significant muscle atrophy, obesity
197
Is there WB restrictions post-meniscal transplant?
Yes, typically limited from 3-6wks
Early WB may increase risk of transplant failure
198
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
199
Meniscal transplantation is good for (long/short) term benefits
Short-term
200
Is exercise (strongly/moderately/weakly) supported by research for knee OA?
Strongly
Most research suggests a combo of LE strengthening and aerobic exercises
201
What is the single strongest predictor of functional limitations in those with knee OA?
Quad weakness
202
Patients with (lateral/medial) knee OA benefited more from addition of hip strengthening?
Medial knee OA
203
Is balance/proprioceptive training suggested in tx of knee OA?
Yes when incorporated w/ strength and aerobic program
204
Aquatic PT, yoga, Tai Chi benefits for knee OA
May be helpful
205
Does behavioral change techniques have shown to have (good/limited) effectiveness to promote adherence to HEP?
Limited
206
Evidence for use in tx of knee OA: cryotherapy
Insufficient
207
Evidence for use in tx of knee OA: Low-level laser therapy
Positive findings, but unknown parameters
208
Evidence for use in tx of knee OA: US
May have short-term relief, no extra benefit with phonophoresis
209
Evidence for use in tx of knee OA: manual therapy
Positive when COMBINED with exercise
210
Glucocorticod injection vs manual therapy & exercise
Manual therapy + exercise is BETTER
211
Evidence for use in tx of knee OA: mobilization with movement
NOT supported to improve ROM
212
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
213
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
214
Evidence for use in tx of knee OA: jt lubrication injections (hyaluronic acid)
Can be used as adjunct tx for OA
215
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
216
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
217
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
218
Use of osteotomy vs UKA
Osteotomy: higher level
UKA: quick rehab
Same outcomes
219
High tibial osteotomy vs femoral osteotomy
High tib: medial compartment OA
Femoral: lateral compartment OA
220
Rehab of UKA vs TKA
Same but UKA pt's will typically hit milestones quicker
221
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
222
Weight bearing restrictions for cemented vs non-cemented TKA
Cemented: FWB
Non-cemented: progressive WB over 6 wks
223
Evidence for use of CPM post-TKA
Not supported
224
Are patellar mobs supported as post-TKA tx?
Yes, should be started early
225
Are tibiofemoral jt mobs indicated post-TKA?
Unclear
226
In PCL-sacrificing surgical techniques (TKA) what jt mob should be avoided?
Posterior glides, can compromise engaged cam
227
Best preventative measure against arthrofibrosis and stiffness post-TKA
Early supervised PT
228
Is kneeling safe to perform post-TKA
Yes, towards end of rehab
229
Are balance and proprioceptive training important for post-TKA?
Yes, because decreased quad strength = higher risk for falls post-TKA
230
4 primary phases of tissue healing?
1) Proliferation
2) Transition
3) Remodeling
4) Maturation
231
Does articular cartilage repair cause regrowth of hyaline cartilage?
Not for debridement, chondroplasty or microfractures
They stimulate fibrocartilage replacement
232
WB precautions for post-op chondroplasty vs microfracture
Chondroplasty: limited for 3-5days
Microfracture: NWB 2-4wks, FWB by 8wks
233
OATS
Osteochondral autograft transplantation (OATS) - bone plugs covered with hyaline cartilage from NWB surface in knee
234
ACI
Autologous chondrocyte implantation (ACI) - harvesting articular cartilage that is grown in lab, then put back in knee
235
"Kissing lesions" in regards to articular cartilage lesions
Bipolar (femoral and tibial) lesions
236
T/F: ACI is okay to do with kissing lesions?
False
237
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
238
T/F: Are quad deficits common long-term post-articular cartilage repairs
True (can persist up to 5-7yrs)
239
Evidence for BFR following articular cartilage procedures
Emerging evidence for positive results
240
Evidence for anti-gravity treadmills following articular cartilage procedures
Emerging evidence indicates use
241
Which group is shown to have higher success rates to return to PLOF:
- Microfracture
- OATs
- ACI
OATS
242
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.
243
PFP is a diagnosis of (exclusion/inclusion)
Exclusion, no gold standard for diagnosis
244
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)
245
Risk factors for PFP
Female, limited quad flexibility, patella hypermobility, decreased quad strength (isometric/isokinetic and explosives)
246
Does q-angle, BMI, and age play a role in predicting future PFP?
No
247
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
248
T/F: Hip weakness is a universal finding amongst published papers regarding PFP
False, only in some
249
Use of BFR in rehab of PFP
Can be helpful when high intensity training is limited by pain
250
Should taping, bracing, orthoses, and NMES be used in PFP?
Can be in COMBO with well-designed exercise program
251
T/F: Foot orthoses can be helpful in treating PFP?
Can help with short-term pain relief
252
Custom orthoses vs prefab for use in PFP?
No evidence that custom is better than prefab
253
Hoffa disease
Infrapatellar fat pad irritation
254
Fat pad irritation
Common in hyperextension or repeated knee extension activities (i.e. gymnasts), aka Hoffa Disease (infrapatellar fat pad)
255
Symptoms of moderate to severe PFOA (patellofemoral OA)
Swelling, genu valgus, pain w/ patellar compression, decreased quad strength
256
Bipartite patella
Patella is made of two bones instead of a single bone
Generally asymptomatic unless trauma causes instability
257
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
258
Tx for Osgood-Schlatter disease
Non-surgical and often self-limiting
Rest, ice, stretching of ant/lat hip, strength of hip/knee, NSAIDs
259
Indication for surgical approach with Osgood-Schlatter disease
If non-conservative measures fail, success of tx is good to excellent in 93% of patients
260
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
261
Early sports specialization of younger (male/female) athletes can lead to 4x greater likelihood of OSD and SLJ syndrome
Female
262
Fulkersons osteotomy
Moving tibial tuberosity medial
Used for chronic lateral patella subluxations (failed conservative tx)
263
Goal of post-op tx for lateral retinacular release
Scar tissue avoidance (do patellar glides!!)
264
Considerations for post-op extensor mechanism surgical realignment
AVOID Valgus positioning, high frequency of quad shut down => use NMES but NOT on VMO
265
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
266
Patellar tendinopathy
Focal pain at inferior pole of patella and load-dependent (usually no pain @rest)
Common in younger males, volleyball and basketball players
267
Possible US findings when looking at patellar tendinopathy
Hypoechoic areas (dark areas), tendon thickening, and neovascularity
268
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
269
Are there evidence based risk factors for development of patellar tendinopathy
No solid ones
270
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
271
T/F: There is some evidence for supplementing eccentric training (patellar tendinopathy) with stretching and core stab
True
272
Crucial education for dealing with patellar tendinopathy
Slow progress, sometimes 6+ months
273
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
274
Evidence for use in rehab of patellar tendinopathy: Extracorporeal shockwave therapy
Seemingly safe and promising, mixed evidence
However, no better vs surgery
275
Evidence for use in rehab of patellar tendinopathy: US
Not recommended
276
Evidence for use in rehab of patellar tendinopathy: LLL
limited research, not used as stand-alone tx
277
Evidence for use in rehab of patellar tendinopathy: Dry needling
Do not use
278
Evidence for use in rehab of patellar tendinopathy: PRP and autologous blood injections
Mixed, PRP may be more appropriate
279
Evidence for use in rehab of patellar tendinopathy: corticosteroids
NOT advised!
280
Pain monitoring model "safe zone"
0-5/10 VAS pain
Used in achilles and patellar tendon rehab
281
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
282
Soreness rules (action):
Soreness during warm-up that continues
2 days off, drop down 1 step
283
Soreness rules (action):
Soreness during warm-up that goes away
Stay at step that led to soreness
284
Soreness rules (action):
Soreness during warm-up that goes away but redevelops during session
2 days off, drop down 1 step
285
Soreness rules (action):
Soreness the day after lifting (not muscle soreness)
1 day off, do not advance program yet
286
Soreness rules (action):
No soreness
Advance 1 step/wk or as instructed by healthcare provider
287
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
