Knee Flashcards
What is the largest joint in the body?
Tibiofemoral joint
Which tibial plateau has a greater surface area? Which is thicker? Why?
Medial has a greater surface area and is 3x thicker
WBing!!
Pittsburgh knee rules:
MOI = fall, blunt trauma
Either one of the following:
Age: <12, >50 years old
Inabilty to take 4 WB steps
Ottawa knee rules
Radiographs appropriate if 1 of the following is present:
Age >55 years
Isolated patellar tenderness
Tenderness of the fibular head
Inability to flex the knee to 90
Inability to WB immediately post injury
3 outcome measure for the knee
KOOS
WOMAC
LEFS
This special test is known as the “grandfather” of meniscus tests
McMurray test
Identify three special tests for meniscal pathology:
McMurray test
Apley’s compression/distraction
Thessaly’s test
If there’s swelling at the knee, can you test for an ACL pathology?
Probably won’t. Either test on the field right away, or after swelling has gone down.
Identify two main ACL special tests:
Anterior drawer
Lachman’s
The Noble Compression Test is used to assess what?
ITB syndrome.
Careful: no established psychometrics
Term: Describes a spectrum of knee conditions in which loss of motion is a major finding.
Arthrofibrosis
Three interventions for arthofibrosis:
ROM exercises
Joint mobilizations
Manipulation under anesthesia (MUA)
VARUS/VALGUS deformity is common with OA at the knee.
Varus
Grade 1 and 2 ligamentous sprain conservative management:
5 things
- PRICE
- Decreased WB
- Short term mobilization
- Strengthening and proprioception
- Gradual return to activity
What is the most studied musculoskeletal pathology?
ACL pathology
4 intrinsic factors for ACL injury:
- Narrow intercondylar notch
- Weak ACL
- Generalized laxity
- LE malignment
4 extrinsic factors for injury:
- Quad and hamstring imbalances
- Limb symmetry
- Altered neuromuscular control
- Playing surface
5 MOIs for ACL injury:
- Sudden deceleration of foot
- Quad-hamstring strength imbalance
- Valgus force
- Twisting with fixed distal segment
- Extreme hyperflexion or hyperextension
What structures are included in the unhappy triad?
MCL+ACL+Medial meniscus
6 Key exam findings for ACL pathology:
- Significant effusion
- Feeling of “giving way”
- Pain with WB/altered gait
- Loss of quad function
- Decreased A/PROM
- (+) ant drawer, lachman’s
5 things to “pre-hab” the ACL before surgery
- Decrease pain, edema w/ modalities
- Hamstring strengthening
- Re-engage quads as much as possible
- Increase ROM
- Gait training with AD if needed
What are the implications of a hamstring graft?
Delayed knee flexion post-op
5 general steps for ACL rehab:
- Know graft type
- Initial mangement
- Strengthening
- Perturbation training
- Visual re-training
Phase 1 of ACL rehab timeframe
0-4 weeks
Phase 2 ACL rehab timeframe
5-12 weeks
Phase 3 ACL rehab timeframe
12 weeks-1 year
Phase 1 ACL rehab
5
- Pain management
- Education
- HEP (quad activation focus)
- WBAT
- ROM
Phase 2 ACL rehab
3
Neuromuscular retraining
approaching full ROM
CKC progressions
Phase 3 ACL rehab
4
- Return to function
- Caution: 3-4 mo. Pt will want to do more, but graft is at it’s weakest point!
- CKC and OKC
- WB -> walk -> run
Criteria needed to run post ACLR:
7
- Pain <2/10
- Knee flexion A/PROM 95% of uninvolved
- Full active knee extension
- Joint effusion resolved
- Quad/HS isometric strength = 70% uninvolved
- Single leg hop tests = 70% uninvolved
- Single leg squat/step up without knee valgus increase
Need ALL to return to run
5 return to sport tests for ACL rehab:
- Single leg hop
- Single leg vertical jump
- Triple hop
- Cross-over hop
- Vail sports test
Limb symmetry index
Affected limb value/unaffected limb value x 100 = LSI
The Vail Sports Test consists of these 4 components:
- Single leg squat for 3 minutes
- Lateral bounding for 90 seconds
- Forward jogging for 2 minutes
- Backward jogging for 2 minutes
Poor ____ strength symmetry is correlated with ris kof reinjury to ACL.
Quadriceps
3 main takeaways for return to sports after an ACL tear:
- Symmetry and strength
- Both limbs need to be trained
- Return to sports criteria completed (objective tests MUST be performed)
T/F PCL tears can be caused by micro or macro trauma.
False! Only macrotrauma due to strength.
ISOLATED/COMBINED injuries are more common in PCL.
Combined
3 signs of PCL tear
- Pain in posterior aspect of knee
- Pain worse with kneeling
- Minimal pain with extension, worse past 90 deg of flexion.
PCL rehab before/without surgery
4 items
- Quad strengthening - main point
- Control pain, edema
- Increase ROM
- Gait training if needed
2 MOIs for PCL tear:
- Blow to tibial tubercle
- Contact or non-contact hyperextionsion injury
4 guidelines for post PCL reconstruction
- Brace
- Assistive device
- Early closed chain and isometric quads
- NO resisted hamstring exercises
How long do you wait to do resisted hamstring exercises post PCL reconstruction?
~8 weeks post op
3 exam signs for MCL/LCL pathology:
- Pain with A/PROM testing
- (+) varus / valgus testing
- Possible pain with WBing
3 potential complications of knee dislocation:
- Structures that cross the knee at risk
- Popliteal artery rupture or contusion
- Common fibular nerve stretch
Conservative management of a knee dislocation:
2 items
- Long cast in slight flexion
- Knee rehab
Functional test for ruling out meniscus tear:
Squat
Total menisectomy leads to….
Early degenerative changes
Menisectomy management guidelines:
5 items
- Control pain and edema
- Increase ROM
- NM strengthening
- Gait training
- Proprioception
Goals of the menisectomy subacute phase:
3 items
- Increase to pre-op ROM
- Normal gait
- Increase strength
5 exercises for menisectomy acute phase:
- Bike
- Isometrics
- SLR
- Knee ext and flex (pain free arc)
- Hamstring and calf stretches
2 exercises for menisectomy subacute phase:
- Squats
- lunges (pref reverse)
Don’t forget to address these structures in menisectomy rehab!!
Hip and ankle (Above and below)
T/F PFPS patients will likely have a mal-tracking patella
False. They could, but not necessarily
2 factors that could predispose someone to a lateral tracking patella
- Increased Q-angle
- Lateral tibial torsion
Most important interventions for PFPS:
3 items
- Quad strengthening
- Hip ER/ABD training
- Neuromotor re-training
When managing PFPS what other 2 structures should be looked at?
Hip and ankle
What does McConnell taping address?
Lateral glide of the patella
MOI for patellar dislocation
Abduction/external rotation injury
Management of a patellar dislocation
3 items
- Closed reduction
- Immobilization in long leg cast in extension
- Recurrent dislocations - lateral release, repair VMO and joint capsule.
Two causes of patellar tendinopathy:
- Overuse
- Overload (increase in intensity)
4 signs of patellar tendinopathy:
- Inflammation
- Decreased open chain AROM extension
- Resisted static contraction of quads is painful
- Squat painful
Name each stage of patellar tendinopathy rehab:
- Load
- Move
- Bounce
- Hop and bound
Adipose tissue is HIGHLY/MINIMALLY innervated at the knee
Highly
What sex is ITBS more predominant in?
Males
2 MOI for superficial and deep infrapatellar knee bursitis
- Kneeling
- Direct trauma
Identify:
Pain and swelling on palpation of the prepatellar bursa
Prepatellar bursitis
“housemaid’s knee”
Identify:
Medial knee pain just distal to joint line
Tibia may externally rotate compared with uninvolved side
Superficial pes anserinus bursitis
5 components of knee bursitis treatment:
- Removal of the irritation
- Stretching adaptively shortened structures
- Joint mobilizations as needed to correct alignment
- Anti-inflammatory meds
- Cryotherapy
3 potential causes of Hoffa’s syndrome:
- Impingement between femoral condyles and tibial plateau during knee extension
- Direct trauma or overuse causing irritation
- Posterior tilt of the inferior pole of the patella
Diagnostic test for Hoffa’s
Bounce test: pain elicited with passive knee hyperextension
2 treatment approaches for Hoffa’s
- Active approach: Shift load away from anterior knee; modify WB
- Passive approach: rest, ice, NSAIDs, local corticosteroid injection to fat pad
Red flag associated with direct blow to muscle, usually the quads.
Myositis ossificans
Identify:
Condition where bone tissue forms within the muscle
Myositis Ossificans
Define:
Genu Varum
Knees >6 cm apart with malleoli together
Define:
Genu Valgum
Malleoli >10 cm apart with knees together
Normal developmental course of knee position
- Birth to 18 months - increased varus
- 18 months to 3-4 years - develop genu valgus
- By age 8-10 - corrected to normal adult alignment
Define:
Genu Recurvatum
> 5 degrees hyperextension at the knee
3 underlying diseases that may cause Genu recurvatum
- RA
- Polio
- Charcot’s disease
Identify:
Joints without pain sense or proprioception
Charcot’s disease
Internal tibial torsion is NORMAL/ABNORMAL in infants
Normal
Excessive INTERNAL/EXTERNAL torsion can lead to patellar tracking problems.
External
Identify:
Compression, fragmentation, or separation of a small fragment of bone
Osteochondritis
Osteochondritis commonly occurs in what demographic?
Childhood or adolescence
3 types of Osteochondritis:
- Crushing - compressive
- Splitting - osteochondritis dessicans
- Pulling - traction apophysitis
Osteochondritis dessicans (splitting) often occurs at which locations?
2 Items
- Talus
- Femoral condyle
Management of Osgood-Schlatter’s disease
5 items
- Rest
- Decreased WB
- Quad stretching (if tight)
- Possible casting 2-4 weeks
- Usually resolves on own
3 S/Sx of osteochondritis dissecans:
- Initially intermittent aching and swelling
- Episodic catching or locking
- Atalgic gait
What condition does osteochondritis dissecans present similarly to?
Meniscus lesion
Identify:
Poor mineralization problem occuring in kids
Rickets
Identify:
Adults rickets
Osteomalacia
3 S/Sx of rickets:
- Bone pain
- Muscle cramping
- Impaired growth
Management of rickets
2 items
- Medical disease management
- Osteotomy to straighten tibia
Identify:
Structurally weak bone commonly occuring in skull, pelvis, and tibia
Paget’s disease
4 S/Sx of Paget’s disease
- Increased skill size
- Bowing of LEs
- Increased kyphosis
- Fractures occur more easily
Management of Paget’s disease
Meds similar to those with osteoporosis
