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MSK II > Knee 2 (test 3) > Flashcards

Knee 2 (test 3) Flashcards

1
Q

attachments/path of the ACL

A

attaches centrally and anteriorly on tibial plateau

runs posteriorly, superior, and lateral

attaches at lateral aspect of intercondylar fossa

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2
Q

ACL restrains what

A

excessive anterior tibial glide

secondary restraint to tibial IR

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3
Q

prevalence of ACL injury

A

20% all knee injury

younger females

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4
Q

non modifiable risk factors for ACL injury

A

female > males

2 weeks following start of period = ligament laxity

bony morphology:
-narrow intercondylar femoral notch
-post tibial slope and hyperextension both correlated with non contact ACL

congenital hypermobility

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5
Q

modifiable risk factors for ACL injury

A

high shoe-surface interaction/friction

high BMI

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6
Q

possible risk factors we can change for ACL injury

A

bracing = inconsistent benefit

muscle strength
-lower overall with ACL tears
-ham/quad ratio strength

loading pattern

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7
Q

why would hamstring quad ratio affect ACL injury

A

predicts LE control

hamstrings prevent anterior translation

lower ratio present in females vs males

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8
Q

what altered loading patterns affect the ACL

A

impaired LE control

loading patterns happen earlier and nearly 2x faster with impaired control

thus this causes decreased knee flexion with larger ground reaction forces/harder landing (land with stiff knee to offset possible knee valgus that would occur otherwise)

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9
Q

what can you see with impaired LE control

A

increased dynamic knee valgus and hip add

very easy to see with vertical drop test

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10
Q

poor control is defined by

A

significant valgus movement

knee is medial to foot

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11
Q

reduced control is defined by

A

some valgus movement

knee not entirely medial to foot

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12
Q

good control is defined by

A

no valgus

knee vertical to toes

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13
Q

what might you see with the trunk with ACL injury/modifiable risk factor

A

greater trunk lean toward support limb

greater trunk RT toward support limb

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14
Q

what does it mean that those at higher risk for ACL injury have greater activation of visual motor strategy vs sensory motor strategy

A

relying heavily on their eyes for focus

have them close their eyes and movement is poorer/less stable

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15
Q

risk factors for secondary ACL injury

A

same as primary ACL plus excessive femoral IR moment

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16
Q

% of ACL injuries that are contact vs non contact

A

non contact = 50-70%

contact = 30%

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17
Q

functional questionaires for ACL

A

international knee documentation committee (IKDC)

Knee Outcome Survey (KOS)

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18
Q

typical sprain S&S

A

empty painful endfeels (acute)
limited motion if acute, excess if not
popping
pain with distraction
joint laxity
+ special tests for ligament

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19
Q

symptoms of ACL injury

A

consistent with any ligament injury

effusion, popping, AND giving away following trauma

WBing activities with likely giving away

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20
Q

signs of ACL injury

A

consistent for ligament sprain plus

ROM is limited paingul particularly with hyper ext and IR

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21
Q

special tests for ACL

A

anterior drawer + (possible - if HS tight)

lachmans (possible false neg due to blocked anterior glide via severe swelling that tightens capsule, HS guarding, or meniscal tear)

+ pivot shift

other possibly + for additional tissue damage (i.e. meniscus, MCL, etc)

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22
Q

ACL injuries are often accompanied by arthrogenic muscle inhibition of quads due to what factors

A

pain

effusion (joint swelling)
-involved knee inhibition
-uninvolved knee inhibition
-amount of swelling not always correlated to amount of inhibition

joint laxity/giving away

muscle weakness/correlation

NOT due to denervation

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22
Q

ACL injuries are often accompanied by arthrogenic muscle inhibition of quads due to what factors

A

pain

effusion (joint swelling)
-involved knee inhibition
-uninvolved knee inhibition
-amount of swelling not always correlated to amount of inhibition

joint laxity/giving away

muscle weakness/correlation

NOT due to denervation

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23
Q

what does arthrogenic muscle inhibition mean

A

it starts at the joint/because of a joint issue

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24
Q

muscle inhibition of quads with ACL injury leads to

A

atrophy/more inhibition/weakness; deficits common 2-4 years after injury

determined by observation, palpation, and muscle testing

need to take seriously and communicate importance of staying on top of exercises to pt

can also affect other side/knee as well

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25
Q

PT Rx/prognosis for ACL injury if they are not returning to high risk activities

A

most can return to low risk activity without sx with good outcomes

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26
Q

3 primary/early goals for ACL injury

A

full/near full ROM (especially ext)

minimal to no swelling

quad activation/endurance/coordination

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27
Q

how to ensure ACL pts obtain full ROM

A

immediate mobilization in PT for ROM, pain, and minimizing immobilization effects

full ext should be obtained no later than 4 weeks (wont happen with everyone, especially if other structures like meniscus are involved)
-predicts ext at 12 weeks and lower risk of OA

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28
Q

what may indicate quad activation/endurance with ACL injury

A

SLR without extension lag (bend in leg)

quad set > 90% of uninvolved side (could be misleading if uninvolved side is also experiencing inhibition)

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29
Q

PT Rx for ACL strain

A

early WBing as symmetrical as possible w/o detrimental effects

POLICED

functional bracing (comes later); more beneficial with ACL deficiency, conflicting support with ACL reconstruction

weak support for continuous passive motion devices

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30
Q

why is bracing inconsistently supported for injury

A

little accessory movements/translations can still occur within brace

for ACL, outside of hyperext, brace wont prevent any other motions that could also cause pain

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31
Q

MT for ACL

A

initiate post op

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32
Q

describe purpose of neuromuscular electrical stimulaiton for MET for ACL

A

neuromusclular electrical stimulation (NMES) for activation/coordination/strength:

significant increase in quad strength ‘no significant

changes with function

isometrics at varying angles based upon symptoms

discontinue once quad index > 80% uninvolved side

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33
Q

general MET parameters for ACL

A

assumptions must be made about arthrogenic muscle inhibition

intense resistive training without inducing pain must be performed eventually

emphasize both concentric and eccentric training

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34
Q

non WBing vs WBing activities guidelines for ACL

A

load is generally greater with non WBing activities than WBing because open chain/non WBIng only activates quads but WBing will generally activate HS and other muscle groups as well to counteract the force of the quads and provide more symmetrical muscle activation across the joint

non WBing or OKC activities are less of a concern than in the past

greatest loads are found within 50 degrees of full ext with both WBing and non WBing (so i.e. you can do a knee ext from 90 to 45 only or with closed chain you dont want the pt to squat with knees over toes)

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35
Q

how does the stress on the ACL change with squatting, lunging, and leg press

A

increases with knees beyond toes

decreased with fwd trunk lean

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36
Q

walking guidelines/general exercise guidelines with ACL injury

A

with walking there is as much load as non WBing knee ext due to repetitive terminal knee ext

this is several times greater than other WBing activities

this means that both OC and CC knee activities early and often is OKAY…especially if they are walking and using correct trunk and LE control

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37
Q

goals for hamstring strength and coordination emphasis of ACL Rx

A

males: hams > 66% of quad activity

females: jams > 75% of quad activity in females

this value could be skewed if there is quad inhibition present

38
Q

neuromusclular training that should be present in an ACL Rx

A

normal strength does not equal proper neuromusclular or LE control

trunk proprioception and kinesthesia to minimize lean and twist

39
Q

components of LE proprioception and kinesthesia that should be incoorporated with neuromuscular training for ACL Rx

A

minimize frontal and transverse plane motion

promote sagittal plane knee and trunk flexion

decrease GRF with softer landing

progressive speed and difficulty

emphasis on jump landing and balance

40
Q

timing for MET Rx for ACL

A

needs to be at least 2-3x/week for 6-10 months

bilateral, for cross edu = less deficit compared to only exercising involved knee

41
Q

effectiveness of blood flow restriction

A

no better than intensive exercise

can increase growth hormone but can also decrease myostatin which would limit cell growth (cancels out)

42
Q

importance of motor learning for ACL MET

A

important to improve movement patterns

use language they can understand and help cue proper movement

43
Q

examples of motor learning with a external focus

A

improved balance/coordination

higher vertical jump

more force production

greater knee flexion

softer landing

44
Q

how could you improve motor learning by adding observation to practice

A

competition with others (motivation/responsibility)

real time feedback/post exercise feedback

45
Q

plyometrics for ACL

A

increased loading with rate of deceleration (need to control descent with good movement patterns)

vertical jump similar loading to NWB ext on ACL (with proper movement patterns)

46
Q

what % of ACL tears include meniscal tears

A

22-86%

47
Q

how can meniscal involvement with ACL tear affect recovery

A

if a partial meniscectomy there is no change

if there is a meniscal repair performed = slower progressions due to greater protection required for meniscus healing

may slow achievement of full ROM due to decreased WBing required for said protection

48
Q

how many ACL injuries have bone bruises involved

A

80% have bone bruise

49
Q

what is the general timeline for recovery with ACL tears involving a bone bruise

A

if skeletally immature (young) healing = 2 weeks to 3 months

skeletally mature healing = 1 month to 1 year

average is 3.2 months

overall bone bruise is a delaying factor that leads to more difficulty reaching full ext and proper quad function (inhibition)

50
Q

what happens if there is a MCL tear with ACL

A

MCL tears generally are not surgically repaired

if ACL is torn then often surgeons will wait 10 weeks for MCL to heal before repairing ACL (better outcomes vs earlier sx)

51
Q

precuations if there is MCL injury/involvement

A

only sagittal plane activity for 4-6 weeks

limit tibial ER and valgus stresses

52
Q

what % of ACL injuries involve articular cartilage defect

A

36%

53
Q

what are the treatment options if there is articular cartilage involvemetn

A

debridement (abrasion) = WBAT for 3-5 days and no delays to ACL rehab

osteoarticular transport system (OATS) and autologous chondrocyte implantation (ACI) (cultured) = most conservative guidelines and greatest delays

microfx of bone underneath to stimulate bleeding = NWB for 2-8 weeks; delay to ACL rehab

** dont need to know specifics; just know if articular cartilage is repaired then it will delay ACL timeline

54
Q

order of effectiveness of 3 articular cartilage repair options

A

OATS > ACI > Microfx

55
Q

why is ACL hard to heal/often surgically fixed

A

clotting repair is inhibited by synovial fluid

few return to high risk activity without sx due to continual instability

56
Q

what % ACLs are surgically repaired

A

65%

57
Q

what are the 3 arthroscopic techniques for ACL reconstruction

A

bone patellar tendon bone (BPTB) grafts- have both autograft and allogract

semitendinosus/gracilis (SGT) graft

58
Q

what is allograft vs autograft

A

allograft = cadaver

autograft = from pt

59
Q

how does pre op weakness affect outcomes of ACL sx

A

the stronger you start the better you are likely to come out

60
Q

describe a BPTB autograft

A

incision over opposite patellar tendon

remove middle 1/3 of: bone of patella, patellar tendon, and bone of tibial tuberosity

61
Q

what is a complication that may occur with BPTB autograft

A

up to 1/3 develop anterior knee pain

62
Q

graft strength timeline

A

initial weakining within 1st 4 weeks

incorporation of graft into bone at 6-8 weeks

dense fibrous tissue at 8-12 weeks

63
Q

symptom difference with BPTB allograft

A

symptoms improve faster than the graft incoorporates into the body

pt may feel like they can due more since they didn’t have the extra trauma of an autograft but it actually takes longer for the donor graft to incorporate into the body than if it was their own tissue

64
Q

graft strength for allograft

A

incorporation if graft into bone at 8-12 weeks

dense fibrous tissue at 8-12 weeks

delayed timeline and longer rehab

65
Q

why might one choose an allograft vs auto

A

if pediatric pt = dont want to interrupt growth plate

if pt has already had multiple ACL repairs and no longer has viable tissue to donate

can avoid anterior knee pain from graft being taken

66
Q

advantages of STG graft

A

prepubescent youth to avoid growth plate complications

avoids anterior knee pain

67
Q

Rx if STG graft is performed

A

may start pure strengthening of hamstrings at 6-8 weeks

delay heavy strengthening with hams for 12 weeks

68
Q

prognosis for ACL recovery

A

18-24 months post op

muscle weakness and impaired neuromuscular control remain

all grafts and bone show continued healing on imaging

inhibition, atrophy, and weakness are common out to 2 years and 4 years post op (even in both LEs)

69
Q

prognosis for BPTB grafts at 40 months

A

45% resumed pre injury level

29% returned to competitive sport

70
Q

failure rate for ACL

A

up to 30%

75% of 2nd tears occur between 18 and 24 months

reduced injury rate by waiting at least 9 months to return to play

*worse if meniscal or articular cartilage involvement or ext lag

71
Q

describe PCL

A

thicker/stronger

attaches central/posterior on tibial plateau

runs superior/anterior

attaches anteriorly on medial aspect of intercondylar fossa

72
Q

PCL primarily restrains what

A

excessive posterior tibial glide and IR

73
Q

least injured knee ligament

A

PCL

74
Q

etiology of PCL sprain

A

hyperflexion primarily but also some with hyperext

75
Q

S&S of PCL injury

A

consistent with any ligament injury

limited and painful ROM (least pain in ER)

+ PCL special tests

76
Q

special tests for PCL

A

quads active

post drawer

post sag

reverse pivot shift

77
Q

PT RX for PCL

A

ligament Rx plus emphasis on limiting posterior tibial gliding

78
Q

describe MCL

A

flat broad ligament with 2 bands

runs from medial condyles of femur and tibial

79
Q

restraint of MCL

A

anterior band = limits flexion

posterior band = limits hyperext

80
Q

MCL attaches to

A

medial meniscus

posterior capsule

adj muscle and tendon units

SO if you have a pt with MCL sprain you need to check other surrounding structures

81
Q

most injured knee lig

A

MCL

82
Q

etiology of MCL sprain

A

excessive valgus and or ER stress and or hyper ext

83
Q

S&S of MCL sprain

A

general ligament S&S plus

impaired ROM least limits with IR

+ MCL special tests adn possibly medial meniscus special tests

TTP

84
Q

special tests for MCL

A

valgus stress at 0 and 30 degrees

more extended position tests other structures like cruciates and capsules

85
Q

Rx for MCL

A

ligament RX plus

early protection with valgus and ER stress and end ranges of flx/ext

most wont need sx bc ligament is extraacrticualr and can scar/heal on blended capsule

86
Q

describe the LCL

A

round cordlike ligemetn

attaches to lateral condyle of femur and fibular head

no attachment to menisci

primary restraint to excessive varus and ER stresses

87
Q

prevalence of LCL injury

A

string ligament so rarely injured

88
Q

etiology of LCL injury

A

excessive varus and or ER stress and hyperext

89
Q

S&S of LCL injury

A

consistent woth ligament injury plus

ROM limited and painful especially in ext and ER

+ LCL special tests

TTP

90
Q

special tests for LCL

A

varus in 0 and 30

91
Q

PT Rx for LCL injury

A

like ligament Rx plus

early protection with varus and ER stress

may need sx because ligament remains from the capsule even though its extraarticular

92
Q

MET for all sprains

A

combo of supervised and HEP better than either alone

combo of open and closed chain exercises

coordination training

MSK II (18 decks)

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