Knee 3: ARJC- PFPS (Test 3) Flashcards
in the year prior to TKA over 50% of non-inpatient costs were associated with what
injections
PT
Orthotics
Prescriptions (about 30% of this is HA injections alone)
how much of a cost reduction would occur for knee patients if CPG treatments alone were used
cost associated with OA would be decreased by 45%
shows over utilization of ineffective interventions and less efficient use of visits
effectiveness of NSAIDs for ARJC
strong support
better than Tylenol
includes topical application
effectiveness of tylenol
stong support
NSAIDs better
effectiveness of narcotics for ARJC
adverse effects and not effective
effectiveness of injections for ARJC
cortisone = inconclusive; maybe short term relief
hyaluronic acid (synvisc) = claims to mimic synovial fluid; strong evidence against
platlet rich plasma = may help
effectiveness of arthroscopy for ARJC
strong recommendation against in nearly all patients
no clinically important benefits vs placebo in regards to pain, function, or quality of life
prognosis for ARJC for patients with TKA + PT vs PT alone for 12 months
greater pain relief/function with TKA, but higher risk of adverse events
non-surgical Rx delayed TKA
timing of TKA influences outcome (dont wait to long; may affect other parts of the body)
MD Rx for ARJC
partial knee arthroplasty
total knee arthroplasty
-more common
-mini-procedure
-increasing in prevalence
MD Rx prior to TKA
pre op PT reduced cost by $1215
-assistive device
-recovery plan
-expectations
better quality of life with 8 weeks of exercise 5x/week prior to sx
3x/week for 4-8 weeks increased strength and function for those with severe OA
3 week program accelerated functional recovery after a TKA
what does a TKA involve
incise capsule
collaterals remain and possibly the PCL
ACL always removed
forceps hold back adj structures
dislocate knee
add prosthetic
close capsule
full range ensured under anesthesia
importance of early rehab within 24 hours after a TKA compared to 48-72 hours after
earlier decreases mean hospital stay and number of sessions
greater progress with ROM/strength
faster autonomy and normal gait and balance with TKA
early and intense rehab variables to consider
higher intensity
spread visits over a longer duration
single leg training
higher level of functional exercises
results in better quad activity out to a year
ROM goals for PT after a TKA
0 degrees extension - 1-2 weeks
110 degrees flexion - 6 weeks
120 degrees overall
other names for patello-femoral pain syndrome
PFPS
anterior knee pain
retripatellar pain syndrome
describe the ground reaction forces associated with the patello-femoral joint for: walking, 30 deg flexion, stair climbing, squatting, and peak
walking = 50% BW
30 deg flex = BW
stair climbing = 3x BW
squatting = > 7x BW
peak = at 90 deg
forces are even greater with those who have patellofemoral pain syndrome
prevalence of PFPS
37% of military recruits
70-90% recurrent and persistent
risk factors for PFPS
military recruits
dynamic NOT static excessive pronation
females > males
-larger Q angle
-differing hip strength/coordination
patellar and femoral bone shape
etiology/pathomechanics of PFPS
trauma is rare
idiopathic is the largest % of pts
describe the idiopathic etiology of PFPS with the theory of malalignment or maltracking
patella glides and tilts more laterally relative to the femur
involves decreased surface area contact between the patella and femur due to:
-patellar and femoral bone shape
-femoral IR and add
-quad weakness/incoordination/atrophy
-unclear contribution from excessive pronation and tibial IR
changes that take place with PFPS
overload of patellar subchondral bone, especially the lateral facet
tissue ischemia
loss of tissue homeostasis
neural ingrowth increase in substance P nerve fibers that transmit more pain
structures involved with PFPS
subchondral bone of patella
infrapatellar fat pad
-behind patellar tendon/in front of capsule
-inflamed with excessive tibial IR and patellar hypermobility
-can refer to groin
bursae (superficial and deep)
-between skin and patellar tendon
-between patellar tendon and tibia
quad and patellar tendons
synovium
medial and lateral retinaculum (help hold patella and tendon in position)
symptoms of PFPS
gradual onset
usually anterior medial knee pain (inhibition of VM)
pain increased with stairs, squatting, or kneeling or prolonged sitting
observation of those with PFPS
increased Q angle
open chain maltracking of patella
quad atrophy
impaired LE control
explain how impaired LE control may contribute to PFPS
proprioceptive deficits
dynamic excessive pronation
concerns related to dynamic excessive pronation
possibly leads to IR
may contribute to greater genu valgus
possible contributions from impaired DF because of DF is limited then more EV may occur
what might you observe related to impaired LE control associated with PFPS
abnormal planar motions (females especially)
frontal and sagittal plane: increased hip add
-glut med or max incoordination
-hip ext and abd weakness
transverse
-hip ER weakness/incoordination
-mixed conclusions with contributions from rotational impairments
how is poor control defined related to PFPS during a squat
significant valgus movement
knee medial to foot
how is reduced control defined related to PFPS during a squat
some valgus movement
knee NOT entirely medial to foot
how is good control defined related to PFPS during a squat
no valgus movement
knee vertical to toes
what might you observe with PFPS in other parts of the body
trunk weakness including excessive trunk lean
possible contributions form L4-S1 regional interdependence
ROM findings for those with PFPS
limited and painful especially at end ranges
FLX = greater PF compression
EXT = more fat pad irritation
resisted/MMT for PFPS
possibly pain with ext MMT and weakness
likely inhibited quad activity (especially VM)
potential anti gravity trunk and hip weakness
stress test findings for PFPS
possible pain with PF compression
possible neuro findings for PFPS
limited dural mobility of femoral nerve in 1/3 of patients
accessory motion testing for PFPS
usually excessive lateral motion and limited medial motion
all glides could be hypermobile
special tests for PFPS
medial patella plica test
pain with knee ext MMT
hoffa’s sign
apprehension test
special tests for M length associated with PFPS
thomas for rectus
ober’s for TFL/IT band
SLR for hamstrings
gastroc
palpation findings for PFPS
peri patellar TTP
position of patella
-patella alta
-patella balta
-WNL = inferior pole aligned with joint space at 90
PT Rx for PFPS
POLICED
taping
Knee orthotics
foot orthotics
STM and JM
MET
verbal and visual feedback
effectiveness of taping for PFPS
patellar taping most often medial or inferior to unload fatpad
improves posiitoning for better contact
good for pain, kinematics, and function
less efective with patients who have higher bMI or smaller Q angle
provides proprioceptive benefits
can also tape arch for excessive pronation
effectiveness of knee orthotics/different types
neoprene sleeve with hole
-increases surface contact between patella and femur (30-40%) without changing alignment/tracking
-can help with function
-proprioceptive benefits
J-lat brace
none interfere with muscle activity
effectiveness of foot orthotics for PFPS
effective immediately
effective in short and mid term
no difference at a year
what would cueing a pt to “run softly” do
changes landing pattern from rearfoot to non rearfoot strike pattern
improves pain and function
also cue “dont let your knee fall in”
how/why to cue to “contract glutes and keep knee pointed straight”
can use a visual of hip angle with mirror
improved pain and function
also helped hip mechanics
prognosis for PFPS
80% of those who did rehab still had pain
74% had reduced PA in 5 year follow up
can lead to OA
what is a lateral retinacular release
arthroscopic
longitudinal incision of lateral retinaculum
should be used in rare instances
prognosis of lateral retinacular release and when to use
use only with 10% of cases unsuccessful with PT with hyperpressure of lateral facet without instability
can lead to medial instability if additional tissue is cut or used on the wrong pt
what is an extensor mechanism realignment
repositioning of the insertion site
open procedure
long rehab
extensor lag issues
