Knee Flashcards
Merchant view radiograph measurements (2 angles)
Sulcus angle: measured by the lines of the highest peaks in the medial and lateral femoral condyle. Normal angle is 138° +-6°
Congruency angle (patellar tilt): patellar position in the trochlear groove. if the patella ridgeline falls medial to midpoint of sulcus angle value is negative, if the line falls lateral value is positive. normal is -6°. positive 16° maybe associated with the patellar subluxation
Knee Varus versus valgus angle measures
Genu valgum angle greater than 185°
Genu Varum angle less than 175°
Anatomical axis: 185 degrees
Vascularlization of the meniscus
Red zone: peripheral third of meniscus
Red white zone: middle third of meniscus
White zone: central third of meniscus
Posterior lateral corner of lateral meniscus separated from capsule by popliteus tendon, therefore a vascular.
Vascularlization of the meniscus
Red zone: peripheral third of meniscus
Red white zone: middle third of meniscus
White zone: central third of meniscus
Posterior lateral corner of lateral meniscus separated from capsule by popliteus tendon, therefore a vascular
NOTE: posterolateral meniscus supported by poplitues and will not heal independently.
Lateral meniscus connect Chin’s
- Transverse Ligament: to medial meniscus anteriorly
- Patellomeniscal LIgament: to patella anteriorly
- Posteriorly to popliteus muscle and PCL
- meniscofemoral ligament to medial femoral condyle (*Is taut with IR)
Medial meniscus connections
- Transverse ligament: to lateral meniscus anteriorly
- Patelomeniscal ligament: to patella anteriorly
- Posteriorly to semimembranosus muscle
- Connections to PCL and ACL and posterior and anterior horn’s respectively
Meniscus mobility
- Medial meniscus less mobile than lateral which contributes to a higher incidence of injury.
- Muscular contractions of semimembranosus in popliteus muscle can create movement in medial and lateral meniscus respectively
- -Menisci innervated by proprioceptors and nociceptors
Lateral compartment of knee (three main regions)
One: anterior region
– Supported by lateral retinaculum
Two: middle third
– Supported by iliotibial band
Three: posterior third
–supported by arcuate complex (LCL)
**Flabella w/in LCL present in 15-30% of patients
**Muscular attachments to PL complex: b.femoris and popliteus
**Minimal assist from ITB and JC to support LCL
MCL superficial and deep layer function
Superficial layer: primary function to restrain valgus stress
Deep function: meniscal support and control restraint to anterior translation
MCL and LCL most stressed in what position
25-30° knee flexion
MCL superficial and deep layer function
Superficial layer: primary function to restrain valgus stress
Deep function: meniscal support and control restraint to anterior translation
**MCL insertion distal to pes anserine
58% valgus restrain in extension (5 deg flexion)
78% valgus restrain in flexion (25 deg flexion)
**Attachment of MCL to semimembranosus and VM allows for dynamic response of ligament of muscular forces
Oblique popliteal ligament
Reinforces posterior medial knee joint capsule obliquely on a lateral to medial diagonal
Tendinius expansion of semimembranosus muscle
Posterior oblique ligament
Reinforce his posterior medial knee joint capsule obliquely on the medial to lateral diagonal
ACL bundles and function
-Larger posterolateral bundle: taut 0-20 deg flexion (i.e. Lachman’s test)
Valgus stress on ACL
Increased throughout flexion on both bands when MCL is unable to support medial side of knee
PCL bundles function
Anterior lateral bundle tight in flexion primary restrain to posterior translation from 40 to 120°
Posterior medial bundle tight in extension primary restraint to posterior translation after 120
Minimal to no restraint to posterior translation at near extension therefore reliance upon MCL and posterior capsule is increased
PCL bundles function
Anterolateral bundle (95% of substance): tight in flexion primary restrain to posterior translation from 40 to 120°
Posterior medial bundle (5% substance) tight in extension primary restraint to posterior translation after 120
- Minimal/no restraint to posterior translation at near extension: reliance on MCL and posterior capsule is increased
- clinically greatest posterior translation at 70-90 deg knee flexion due to slacking of all other supports at this angle (MCL, poplieus, JC): optimal angle to assess PCL integrity
Knee flexor to joint muscles
Primary: Hamstrings
Secondary: popliteus gastrocnemius sartorial gracillis, tensor facia latae
Muscles creating a Varus moment in knee
Semimembranosus, semitendinosis, medial head of gastrocnemius sartorial and gracilis
(other way to think of it: provide valgus restraint)
Patellafemmoral quadriceps vectors
Vastis lateralis 35°, vastus medialis
Unable to preferentially contract VMO over vastus medialis
Muscles creating a valgus moment at the knee
Biceps femoris lateral head of gastrocnemius and
popliteus
(Other way to think of it: provide varus restraint)
Degrees of knee flexion and patellofemoral contact areas
20°: inferior small
45°: middle (both med and lat sides)medium
90°: superior 1/3 large
135° medial and lateral greater on lateral side and on odd facet
Percent of adult knees with plica and locations
30% have medial plica (can be painful)
-infrapatellar are most common plica though rarely painful
Functional activities enforces through patellofemoral joint
Walking: 50% body weight
Running: five times bodyweight
Rising from chair: 6.7 times bodyweight
Q – angle definition and norms
Represents Structural relationship between quadriceps muscle in the patella (ASIS to patellar midpoint)
Men 10 to 15°
women 15 to 20°
Angles greater than 20° considered abnormal
Ottawa rules for knee
1: age greater than 55
2: isolated tenderness of the patella
3: tenderness at the fibular head
4: inability to flex knee to 90°
5: inability to bear weight both immediately and in the emergency room ( four steps limping is okay)
Best positions to avoid Patellafemmoral compressive forces
-Avoid terminal < 30° knee extension during non-weight-bearing exercise (due to decreased contact)
–>SLR has decreased patellar force than with quad activation with increased knee flexion BUT decreased patellar stability so if unstable train at greater degrees knee flexion
-Avoid 90° flexion or greater in weight-bearing activity
(Due to decreased contact force and increased quad activation)
Immediate joint swelling versus delayed joint swelling
- -Immediate swelling indicates internal trauma and hemiarthrosis
- -Delayed onset of hours or days indicate synovial fluid response, often to joint surface strain (patellar dislocation, MCL injury)
Knee stress testing grading scale
Grade 1+ equals 3 mm to 5 mm
Grade 2+ equals 5 mm to 10 mm
Grade 3+ equals greater than 10 mm
Differential diagnosis slipped capital femoral epiphysis and legg calve perthes syndrome
SCFE – overweight or very tall and thin prepubescent male 7-18 yo; reproduce knee pain with FABER; loss of hip IR and excessive ER
LCPD 5 to 18-year-old; associated with (+) knee exam of swelling, gradual onset pain and locking
Collateral ligament integrity tests
Performed at zero and 20 to 30° knee flexion
Valgus stress test at full extension determines possible or probable involvement of MCL along with secondary restraints
– Grade 2+ PCL may be involved ACL usually involve
– Grade 3+ ACL probably involved
Varus stress test at full extension determines possible involvement of LCL ACL and PCL
Varus sensitivity .25
Valgus sensitivity .86-.96
Specificity unknown
ACL tests
- Anterior drawer – tests anteromedial bundle
– ACL rupture if excursion is greater than 6 mm with soft or and feel
– Increased excursion with tibial IR may indicate compromise of lateral capsule/PCL
– increased excursion with external rotation May indicate MCL, posterior capsule, or posterior oblique ligament involvement
-Sensitivity 76%/ specificity 86% - Lachman test-posterolateral (larger) bundle: gold standard
– Sensitivity 96% specificity 100%
Pivot shift: guarding often an issue
- sensitivity 24% specificity 98%
PCL tests
Posterior drawer –
– If increased laxity with tibial ER indicates possible posterior lateral corner injury
– Sensitivity 89% specificity 92%
Posterior sag sign – performed at 45° hip flexion 90° knee flexion
– Sensitivity to 78% specificity 100%
–Activate Quads in this position: reduction is 97.6% sensitive and 100% specific for PCL rupture
Meniscus tests
Unlikely to be confirmed with clinical examination unless patient experiences an acute locking episode
McMurray test – attempt to elicit locking or clicking complaints
– Sensitivity 58.5% and 16%
– Specificity 93.4% and 98%
Aptly test –pain with distraction indicates ligamentous injury, pain with compression indicates meniscal injury
– Medial meniscus 81%
– Lateral meniscus 90%
Joint line tenderness low sensitivity and specificity
Combination of all three tests sensitivity 78.8% specificity 79.3%
Meniscus tests
Unlikely to be confirmed with clinical examination unless patient experiences an acute locking episode
McMurray test – attempt to elicit locking or clicking complaints (IR tibia for lateral men, ER for medial men)
– Sensitivity 58.5% and 16% (LOW)
– Specificity 93.4% and 98%
Aptly test –pain with distraction indicates ligamentous injury, pain with compression indicates meniscal injury
– Medial meniscus 81%
– Lateral meniscus 90%
Joint line tenderness low sensitivity and specificity
Combination of all three tests sensitivity 78.8% specificity 79.3%
Meniscal pathology composite score
one: history of catching or locking
two: joint line tenderness
three: pain with forced hyperextension
Four: pain with maximal passive flexion
Five: pain or an audible click with McMurray
5/5= 92.3% +PV Specificity: 99%
4/5 specificity 96%
Ankle position during seated passive knee extension
Plantarflexion is ideal to decrease the gastrocnemius moment arm
Patellofemoral tests
- pain with MMT through quadriceps ROM
- Step down test – says visual analog scale and range of motion
- But tell him ability – normal between 25 and 50% of the teller with, greater movement suggest laxity (Sage sign)WHAT?!
- Apprehension test – excessive movement and patient expression of concern
- Patellar tilt test – flexion to 20° attempts to flip lateral edge of the patella upward, if unable to do so indicates type lateral retinaculum
Drop-out casts
Used in cases of recalcitrant knee extension limitations
Loose-pack position of knee
20 to 30° flexion
Quadriceps strength deficit % that indicates use of NMES
15-20%
Benefits of eccentric muscle training
Effect greater changes and neural activation and increase muscle hypertrophy
Improve volitional concentric contraction
Decrease symptoms of tendinitis
Jumpers knee eccentric exercise dosage and benefits
Three repetitions, two times per day, seven days per week for 12 weeks
More beneficial than concentric exercises
Use of a decline board if there is discomfort
Should refrain from sport activity during rehabilitation
Bilateral eccentric training may be as effective as unilateral training
Patellar taping application medial versus lateral
Apply in one direction and assess. if greater than 50% symptom reduction is not achieved in tape in alternate direction
ACL Coper criteria and screen
criteria: patient must meet ALL criteria to be considered
Isolated ACL tear, full pain-free range of motion, NO joint effusion, MVIC quadriceps 70% of uninvolved LE, single leg hopping on involved leg with out pain
* administered within two months of injury
*If 5/5 met, then trial 10 tx PT; patients must then meet all criteria to be D/C’d w/o referral back to surgeon
Screen:
- Episodes of getting way since initial injury: <1
- Hop test:greater than 80% timed
- KOS ADL: greater than 80%
- Global rating score: greater than 60%
If positive administer perturbation activities
Unloading brace function and application
Treatment of pain relief for unicompartmental degenerative joint disease in tibiofemoral joint
Minimal to no pain relief and an obese patient patients
No evidence to support the sloughing reversal of degenerative process with the use of these unloading braces
ACL bracing
No conclusive evidence demonstrates effectiveness of bracing in preventing injuries
Decrease in rx of braces s/p reconstruction, no evidence.
Use of brace 1 to 2 years post operatively correlated with significant decrease in quadriceps strength compared to bracing for three months.
Increased function where your brace in patients with 80% quadriceps strength
Unclear whether brace wearing is cause or effect to quadriceps strength
Notchplasty
Surgical technique were bone his resected from intercondylar notch using a motorized a abrader which allows for increased base in joint
ACL repair
Presurgical considerations prior to ACL reconstruction
Full knee extension and resolution of inflammatory process minimize the risk of limited postsurgical knee range of motion
Two most important measures to improve during ACL rehabilitation
Quadriceps strength and full knee extension
Inability to achieve these is strongly correlated with decreased postoperative function
Hamstring strength appears to recover without focused intervention even when this muscle group is used the source of the graft
Rationale for open chain quadricep exercises status post ACL reconstruction
Wayberry (WB) exercises were not sufficient to restore quadriceps strength.
ACL strain appears to be the highest 30° with knee extension
PROM 0-120 deg = no strain on ACL
Graft strongest day of implant, decreases in strength consistently (healing doesn’t become a factor until 4-6 wks s/p; graft weakest 12 weeks post op
Management of ACL reconstruction and coexisting pathology
Meniscal repair: no WB flexion past 45 deg 0-4 weeks post op
Chondral damage – weight-bearing cannot be restricted long enough to allow full healing of articular surfaces without compromising ACL health, restrict WB 0-4 weeks, may benefit from bracing afterward
memisectomy: no changes needed
MCL injury – ACL reconstruction provide stable environment for healing even great three MCL sprain, therefore MCL is typically not surgical repaired, place LE in IR to decrease stress on MCL
PCL – rehabilitation is focused on PCL guidelines because of risk of PCL graft failure risk
Indications of complex regional pain syndrome and
Failure to progress, complains of instability, decreased function, increased pain/ swelling, disproportionate pain to injury
ACL reconstruction revision surgery
That is often less rigid after construction revision then typically soon
Revision surgeries are often staged
Where activities and exercise must be slow down protect already compromised graft
PWB 2 weeks, still gait trainig to encourage full knee extension; defer FWB in uncontrolled environment until 4 weeks s/p
Management of ACL tear in skeletally immature population
Initially managed conservatively allowing growth plates to close
Decision to return to sport is often based on risk-benefit analysis
If surgery is indicated there are surgical options that are designed to avoid damage to epiphyseal plate
Female athletes and risk for ACL injury and prevention of if
Females are 4-8 times more likely to tear ACL than males
Injuries are out the noncontact as result of a cutting rotary motion
reasons are inward collapse of knee, muscular weakness, straight knee when landing, excessive quadriceps activation eccentric activity, joint laxity, narrow femmoral notch and hormonal influences
Exercise regimens implemented to help prevent ACL injuries have shown a decease risk for ACL injuries by 88-74%
PCL nonsurgical management
We’re coming because often has partial tears in injuries to the PCL higher rate of feeling when compared to ACL
quadricep strength and return to function
Early medial compartment to generation can be associated with media meniscus and/or PLC involvement
decreased meniscal force and increased TF force due to altered arthrokinematics
increased PF force (esp with OKC exercises)
Surgical management of PCL tear
Often indicated with continent and injuries of meniscus capsule or other ligaments
Single bundle Achilles tendon all allograft
High percentage of patients with continued laxity after surgery. some evidence suggests decrease laxity with double bundle procedure
Double bundle patellar tendon and semi tendinosis allograft
Rehabilitation initially slow progression especially inflection
Graft is most tension between 70-90° of flexion
Limited resistance of knee flexion (hamstrings) for four months
Minimal P Cialis year from 60° to 0 nonweightbearing knee extension
Bottom Line: SLOW knee flexion and ROM gains
- knee flexion to 60 at 2 weeks
- knee flexion to 110 at weeks 3-5
- full knee ROM at 16 weeks
- Tension at graft greatest at 70-90 degrees flexion so train knee extension at 60-0deg flexion (greater deg found to have posterior shear force with OKC knee extension)
- NO resisted knee flexion until 8 weeks (due to post shear of hamstrings)
Considerations with collateral ligament rehabilitation
Injured ligaments should be protected from stress during initial 6-8 weeks of healing
Internal rotation of the tibia will decrease MCL stress extra rotation of tibia decrease LCL stress
Normalizing quadriceps strength in facilitating dynamic stabilization are the focus
Grade 3 strain space repair can be braced or immobilize and 30° flexion during wb first 2-6 weeks
MCL often treated conservatively; surgery vs conservative tx = results
–NOTE: MCL injury in children, suspect epiphyseal injury vs MCL due to fairly of bone vs ligament
LCL: mixed nonop results
Arthritis definition
Degeneration of articular cartilage, inflammation of the synovium, and changes in the underlying subchondral bone to the point where patients are typically debilitated by pain and resultant loss in function
Meniscal injury rehab considerations
Nonoperative treatment:
–if injury is localized to the peripheral third
– Primary focus controlling swelling worse during passive range of motion and minimizing quadrate step strength losses with nonweightbearing activity
– Patient education to avoid squatting pivoting cutting and running to minimize stress
Decision to remove/repair based on meniscus tear location (peripheral 1/3 repair esp in younger patients)
-Meniscectomy – recovery time to six weeks
-Repair – WB slowly progressed for 8 weeks, if stable fixation and good vascularization then gait with knee locked in extension allowed WBAT for 4-6 weeks; week 1-4: no WB flexion past 45 deg
4-8 wks: no WB flexion past 90
recovery time 6 to 9 months
Sport activities: 4 months after longitudinal repair, 6-9 months after radial and central 1-3 repair
Meniscal transplant:
–recovery time 6 to 9 months
– age under 40, high activity level, minimal osteoarthritis, not a candidate for TKA
-Limit WB 3-6 weeks s/p; FWB achieved 6-9 weeks s/p
Quadriceps strength and knee arthritis
Reported to be the strongest single predictor of functional limitations in patients with knee arthritis
Preoperative quadriceps strength is predictive of functional ability one year after TKA
hyaluronic acid injections
Found to lubricate join and decrease swelling and inflammation by inhibiting induction inactivity of degenerative enzymes in proinflammatory signals
Oral Chondroprotective agents
Current recommendation for a glucosamine sulfate and chondroitin can be used but discontinued after six months of no benefit has occurred
Osteotomy procedure in knee for arthritis
Medial compartment – high tibial osteotomy it
Lateral compartment– Femoral osteotomy
When performed in patients less than 60 years old may delay need for TKA up to 10 years but failure rate as high as 25%
after osteotomy treat like Fx: no FWB for 4 weeks; no ankle cuff/resistance distal to osteotomy site; full ROM immediately okay NMES (full extension but no external fixator as with ACL)
Benefits of UKA
Quicker rehabilitation
Maintenance of normal joint kinematics due to cruciate ligament sparing
Better proprioception
Bone preservation
Improve functional abilities compared to TKA
Survivorship rate ranging from 94 to 97% over 10 years
UKA selection criteria
Maximum of 10° Varus or 5° valgus Flexion contracture less than 10° Intact ACL Absence of the telephone moral symptoms BMI below 32 age <60
Quadriceps weakness and the elderly population
Correlated with higher risk of falls and a slide toward morbidity
Quadriceps strength after TKA
60% acute decline
Decreased functional abilities with tug test and stairclimbing test
Can be due to activation failure or muscle atrophy
early electrical stimulation
TK a prosthesis failure rates
Increases 1% per year from about 10% at 10 years to about 20% at 20 years
Risk factors for Patellafemmoral joint dysfunction
Decrease quadriceps flexibility, hypermobile patella, altered VMO response time, and diminished quadriceps explosive strength
Patellofemoral joint syndrome surgical options
Synovectomy, lateral retinaculum release, realignment procedures both proximal and distal to proximal
NMES for patients with subluxation of patella
Patellar taping and knee flexion angle of 70 to 90° to decrease risk of patellar subluxation
avoid terminal knee extension
Tibial stress reaction after patellofemoral joint realignment procedure
Sounds like pop or snap resulting in pain it tibial tubercle. patients recover quickly
Osgood-Schlatter disease
Children ages 10 to 15 years
Present bilaterally 25% of the time
Incidents as high as 20% and athletes 5% of nonathletes
Treatment: rest ice and stretching strengthening of quadriceps hamstrings and Iliotibial band NSAIDs and time
Self-limiting condition should be allowed to continue all activity to toleration
Bipartite Patella
Generally is asymptomatic, inadvertent find on xray
Become symptomatic as a result of the trauma to patella, creating instability
Requires surgical intervention
Sinding Larson Johansson syndrome
Ages 10 to 12 years
Inferior pole of the talent
Treatment similar to OSD
Jumpers knee
Presentation similar to SLJ however location of pain is deep within tendon fibers
Tell her fitness most often it just opened all of the Tele
ICRS cartilage injury classification grading levels
Grade 0– normal Cartlidge without notable deficits
Grade 4 – severe abnormal full thickness osteochondral injury
Most common localization of Cartlidge lesions in knee
Medial femoral condyle and the patellar articular surface
The four operated methods for articular Cartlidge lesions
Arthroscopic lavage and debridement, microfracture, autologous chondrocyte implantation (ACI), osteochondral transplantation (OATS)
Outcomes of articular Cartlidge surgery
Methodological quality of articular cartilage repair studies is generally low.
Overall good to excellent improvement with no clear best Surgical technique
Risk factors for articular Cartlidge legions associated with ACL tears
Age greater than 30 years
ACL index injury greater than five years ago
Diagnosis of meniscal tear can be made with a fair level of certainty when the following clinical findings are found (9 findings)
– Twisting injury
– Tearing sensation a time of injury
– Delayed effusion 6 to 24 hours post injury
– History of catching your locking
– Pain with forced hyperextension
– Pain with maximum flexion
– Pain or audible click with McMurray’s maneuver
– Joint line tenderness
– Discomfort or sense of walking or catching in the over either the medial or lateral joint line during the Thessaly test at 5 or 29 degrees flex
Diagnosis of articular cartilage defect can be made with a low level of certainty on the following clinical findings are present (5 findings)
– Acute trauma with hemathrosis 0–2 hours
– Insidious onset aggravated by repetitive impact
– Intermittent pain and swelling
– History of catching or locking
– Drain line tenderness
MRI versus clinical examination for articular cartilage lesion
Clinical examination is frequently inconclusive due to non-specific nature of symptoms
MRI sensitivity 83.2%, specificity 94.3% for chondral lesions
MRI versus clinical examination form meniscal injury
Examination by will train clinician may be as accurate as MRI in regards to diagnosing of meniscus injury
Minimum detectable change KOS
8.87
Single leg hop tests mean distance and MDC
Single hop test – mean distance: 208.08 cm, MDC: 8.09%
Triple hop test – mean distance: 67 670 cm, MDC: 10%
Crossover hop test – mean distance: 640 cm, MDC: 12.25%
6 m hop test – mean time: 1.85 seconds, MDC 12.96%
Six minute walk test, tide, stair measure test MDC for total knee and total hip arthroplasty’s
Six minute walk test: 6.31 m
Tag: 2.49 seconds
Stare measure: 5.49 seconds
Modified stroke test grading system
Zero – no wave with downward stroke
Trace – small wave of fluid on the medial side
1+: large bulge of fluid on the medial side
2+: fusion completely fills medial knee sulcus and returns to be outside without downward stroke
3+: inability to move the fusion out of the medial aspect of the knee
The joint line tenderness palpation sensitivity and specificity for medial and lateral meniscus tear
Sensitivity: medial – 83% lateral – 68%
Specificity: medial – 76% lateral – 97%
McMurray and Thessaly test’s test specificity and sensitivity for medial lateral meniscus tear
McMurray
– Sensitivity 55%: medial meniscus – 50% lateral meniscus – 21%
- Specificity 77%: medial meniscus-77% lateral meniscus – 94%
Thessaly test 5° knee flexion
– Sensitivity: medial 41%-66%, lateral 16%-81%
– Specificity media meniscus 68% to 86%, lateral 89-91%
Thessaly test 20° knee flexion
– Sensitivity: medial 59%-89%, lateral 67%-92%
– Specificity media meniscus 83% to 97%, lateral 95-96%
Mezcal path ologies composite score (5 findings)
specificity and sensitivity
Findings:
– History of mechanical catching or locking reported by patient
– Joint line tenderness
– Pain with forced knee hyperextension
– Pain with maximum passive knee flexion
– Pain or audible click with McMurray maneuver
5 positive findings – specificity: 99.0% sensitivity: 11.2%
1 positive finding - sensitivity: 76.6%, specificity: 43.1%
Use of CPM following debridement with microfracture
85% of patients to use CPM had satisfactory outcome in lesion grade, where as 15% of those who did not have satisfactory outcome
Accelerated rehabilitation for isolated meniscal repair
This includes a meal weight-bearing as tolerated really mobile vision with emphasis on prevention of fusion and return to sports one range of motion was achieved along with demonstration of 75% strength Index and completion of functional running program
90% of accelerated group had successful repair versus 88% of standard group
Recommendation level for progressive knee motion in meniscal and articular Cartilage lesions
C: clinicians me utilize early progressive need mobilization following the menus am and articular cartilage surgery
Recommendation level for progressive weight-bearing in meniscal and articular cartilage lesions
D: there are conflicting opinions regarding the best use of progressive weight-bearing patients with meniscal repairs or chondral lesions
Recommendation level for progressive return to activity with meniscal and articular Cartlidge lesions
Meniscus – C: clinicians me lies early progressive return to activity following Nieman it’s cool repair surgery
Articular Cartlidge – E: conditions may need to delay return to activity depending on the type of articular cartilage surgery.
Recommendation level for supervised rehabilitation and meniscal and Articular Cartlidge lesions
D: there are conflicting opinions regarding the best use of clinic-based programs for patients following meniscectomy to increase quadriceps strength and functional performance
Recommendations for therapeutic exercises in minutes going articular Cartlidge
B: clinician should consider strength training and functional exercise to increase quadriceps and hamstring strength, quadriceps endurance and functional performance following menisectomy
Recommendation level for neuromuscular reeducation stimulation for meniscal and articular cartilage lesions
B: neuromuscular electrical stimulation can be used with patients following meniscal or chondral injuries to increase quadriceps muscle strength
Incidence of meniscal tears in patients with ACL deficient knee
One year: 40%
Five year: 60%
10 years: 80%
Percent of patients with PCL injuries that have associated ligamentous injuries
95%
Most common multi ligament knee injuries
PCL with a Seattle
PLC with ACL or PCL
Possibility of ACL tears with valgus stress test
No that was laxity: 20%
That was laxity at 30° of knee flexion: 53%
Fagus laxity at 0° knee flexion: 78%
Most common mechanism of injury for noncontact ACL injuries
Acceleration and deceleration motions with excessive quadriceps contraction and reduced hamstring cocontraction at or near full knee extension
Most common mechanisms of injury for PCL
Dashboard injury: 38.5%
On flexed knee with foot plantar flexed: 24.6%
Sudden violent hyperextension: 11.9%
PLC structures and primary functions
Lateral head of the gastroc, popliteus tendon, popliteofibular ligament, LCL, arcuate ligament-fbellofibular ligament
Primary resistant to varus and external rotation forces secondary resistant to posterior translation of tibia and femur
Distribution of ACL injuries and ability to recover
One third of individuals will compensate and successfully returned unrestricted activity without surgery
One third of individuals will return to recreational activities with the bracing and lower extremity strengthening program and activity modification
One third of individuals will not be able to return to sport due to instability and will require surgical intervention
Biomechanical and biological consequences of PCL deficiency
No correlation between laxity in functional or subjective outcomes
Majority of subjects treated nonoperatively can expect to return to activity at the same or similar level
No significant differences are noted in range of motion following a PCL injury
MCL grade and nonoperative treatment
Long-term outcomes for a sleigh grade 3 sprain our poor Eli
Grade one into sprain long-term outcomes are good
PLC grade and nonoperative treatment
Good results documented for grade one and 2 injuries using nonoperative treatment
Conservative management of more severe PLC injury is Lisa poor functional outcomes
Surgical interventions of the PLC injuries are more successful than chronic
ACL injury risk factors: four categories
Environmental: increase shoe surface interaction for higher traction may increase risk of ACL injury
Anatomical: increase BMI, narrow femoral notch and increased joint laxity
Hormonal: early and late follicular phases of menstrual cycle increased risk of injury
Neuromuscular: combined loading patterns detrimental to ACL injury such as Varus or valgus extension moments especially during slight knee flexion. Strong quadriceps activation during eccentric contractions maybe a main factore in injury to ACL
Sensitivity and specificity of ACL Coper screen
Sensitivity: 44.1%
Specificity: 44.4%
Potential copers and potential noncopers can be equally consider candidates for non-operative ACL management
Diagnosis of sprain of the anterior cruciate ligament can be made with a reasonable level of certainty with these clinical findings
– MOI consisting of deceleration and acceleration motions with noncontact Valgus load at a near full knee extension
– Hearing or feeling of the pop at the time of injury
– Swelling within 0 to 2 hours phone injury
– History of giving way
– Last event range knee extension
– Positive Lachlan test with nondiscrete end feel increased anterior tibial translation
– positive pivot shift test
– 6 m singling hop test result that is less than 80% of the uninvolved Limb
– Maximum voluntary isometric quadriceps strength Index that is less than 80% using burst superimposition technique
Diagnosis of sprain of posterior cruciate ligament can be made with reasonable level of certainty with the following clinical findings
Posterior directed force on proximal tibia, fall on flex me with foot plantar flexed, or sudden violent hyperextension of need joint
– Abrasions or Ecchymosis on anterior aspect of proximal tibia
– Localize posterior knee pain with kneeling or decelerating
– Positive posterior drawer test at 90° with non-discreet and feel or increment creased posterior tibial translation
– Positive posterior sag test
– Positive modified stroke test or Goldstein
– Lots of new extension during gate observation or range motion testing
Diagnosis of sprain of MCL made with a reasonable level of certainty with the following clinical findings
– Trauma by force applied to lateral aspect of the lower extremity
– Rotational trauma
– Pain with valgus stress performed at 30° knee flexion
– Increased separation between femur and tibia with valgus stress
– Normal knee range of motion
– Palpatory provocation of MCL reproduces familiar pain
– Positive modified stroke or both sign
Diagnosis of LCL sprain can be made with reasonable level of certainty with the following clinical findings
– Excessive there is drama
– Localize effusion over LCL
– Palpatory provocation of LCL reproduces pain
– Pain with Varus stress at zero and 30° or increased laxity
– Positive stroke or bulge sign
Lachlan test sensitivity specificity and norms
Sensitivity: 85%
Specificity: 94%
Normal = -1 to 2 mm
Nearly normal = 325 mm
Abnormal = 6 to 10 mm
severely abnormal = greater than 10 mm
Pivot shift test specificity and sensitivity
Sensitivity: 24%
Specificity: 98%
Posterior drawer test specificity sensitivity
Sensitivity 90%
Specificity 99%
Posterior SAG test specificity
Sensitivity 79% specificity 100%
Pain with valgus stress test at 30°
Laxity with valgus stress test at 30°
Pain: Sensitivity 78% specificity 67%
Laxity: sensitivity 91% specificity 49%
Varus stress test at zero and 30°
No quality studies have been performed
Ligament sprain Continuous passive motion recommendation level
C: quotations can consider using continuous passive motion in the immediate postoperative period to decrease postoperative pain
Ligament sprain early weight bearing recommendation level
C: early weight-bearing can be used for patients following ACL reconstruction without incurring detrimental effects on stability or function
Little evidence exists for MCL, PCL, multiple ligament injuries and weight-bearing. However current surgical protocols recommend limited weight-bearing in PCL, multiple ligaments and MCL reconstructions. But mcl injured can have WB immediately.
ACL deficiency knee bracing recommendation level
C: the use of functional need bracing appears to be more beneficial than not using a brace and patients with ACL deficiency.
Not great professional Scears with ACL deficiency have 6.4 times greater risk of stating subsequently injury
bracing immediately post op ACL reconstruction recommendation levels
B: the use of immediate postoperative need racing appears to be no more beneficial than not using a brace following ACL reconstruction
Use a function on the bracing after ALC reconstruction recommendation levels
D: conflicting evidence exists for the use of function on the bracing inpatients following ACL reconstruction
It appears higher-level patients (skiers) decreased risk for subsequent injury.
Need bracing for PCL injuries recommendation
Expert opinion
Non-op: bracing typically not recommended
Op: hinge brace locked in full knee extension for 2 to 4 weeks
MCL injury knee brace recommendation
Expert opinion
Non-op: Bracing for grade 2 and three raptures for 4 to 6 weeks
Op: Following surgery long hinged brace allowing 30° to 90° new motion for first three weeks
Multi ligament surgery bracing recommendation levels
Expert opinion
Knee brace locked in for extension four weeks after surgery
Recommendation level for ACL reconstruction immediate versus delayed mobilization
B: immediate mobilization is supported with the goal of decreasing pain increasing range of motion in limiting adverse changes to soft tissue structure
Recommendation level cryotherapy after ACL reconstruction
C: clinician should consider use of credit therapy to reduce. Postoperative knee pain.
No reduction in postoperative drainage or improvement in early new range of motion demonstrated
Recommendation level for supervised rehabilitation with ACL reconstruction
B: clinician should consider the use of exercise as part of the in clinic program, supplemented by prescribed home-based program supervised by a physical therapist
Recommendation level NMR with ACL
B: clinician should consider the use of neuromuscular education is a supplementary program to strength training in patients with me stability and movement coronation impairments
Nonoperative ACL care with perturbation activity improve successful outcomes by 4.88 times versus standard rehab
Recommendation level accelerated rehabilitation with ACL reconstruction
B: rehabilitation that emphasizes early restoration of knee extension and early weight-bearing activity appears to be safe for patients with ACL reconstruction. No evidence exists to determine the efficacy your safety of early return to sports
Recommendation letter for eccentric strengthening with ACL reconstruction
B: clinician should consider use of eccentric exercises are gone there inpatients following ACL reconstruction to increase muscle strength and functional performance. Clinician should consider the use of eccentric squat program in patients with PCL injury to increase muscle strength and functional performance
Tibial torsion
measured at malleoli; 12-18 degrees normal
Gender anatomical difference:
Females have narrower femoral groove, smaller crucial ligament CSA, greater Q-angle
Medial meniscal role in ACL deficient knee:
- If ACL inTact, medial meniscus doesn’t have significant role on AP stability
- If ACL deficient, posterior horn of medial meniscus functions as secondary restraint to AP translation by wedging b/t femur and tibia
LCL:
Extracapsular; restrains tibial ER
- -55% varus restrain in extension (5 deg flexion)
- -69% varus restrain in flexion (25 deg flexion)
Anterior knee ligaments:
Medial PF ligament and lateral PF ligament
**Note: MPFL can tear with patellar dislocation, causing patellar instability
Greatest combo of ligamentous tears for valgus instability
Lysis of MCL + PCL
MOI ACL injury:
- hyperextension injury (land with straight knee from jumping)
- Can be injured with medial (winds around PCL) or lateral (winds around lateral condyle) tibial rotation injuries
MOI PCL Injury:
- Knee hyperflexion injury or knee fixed and stuck against object (EX: fall onto knees; dashboard MVA injury)
- PCL MOST taut in knee flexion, resulting in injuries with knee flexion vs extension with ACL
Semimembranosus role on meniscus/tibia
pulls meniscus posteriorly and IRs tibia on femur during knee flexion
Knee Osteokinematics:
- Knee extension: increased valgus and tibial ER (screw home)
- Knee flexion: increased varus
- *Note: posterior shear at 85-105 knee flexion: rationale for training after PCL injury at less knee flexion and for training after ACL injury at high degree knee flexion
Knee arthrokinematics:
Closed Chain:
1. Flexion: posterior roll, anterior glide of f.condyles
2. Extension: anterior roll, posterior glide of f.condyles
Open Chain
1. flexion: posterior roll and glide of tibia on femur
2. extension: anterior roll and glide of tibia on femur
Things that increase Q angle:
Femoral anteversion, external tibial torsion, genu valgum, subtalar hyperpronation
Functional testing (return to sport)
Cluster 4 hop tests (Noyes et al): all hop tests have low sensitivity (~50%)
- times and untimed single hop for distance highly specific (95%)
- normal is 80-85% uninvolved
Muscles worked (concentric vs eccentric) in walking (uphill vs downhill)
- Walking Uphill:
- -Concentric: gastroc/hamstrings - Walking Downhill:
- -Eccentric: quads
**uphill and retro treadmill walking produce less PF joint restrictive forces than forward walking
Soreness Rules (24 hr response)
- No soreness: progress 1 variable/1 step
- Soreness dissipates with warm up: stay at same level
- Soreness remains with warmup: day off or decrease 1 level)
Healing time guidelines: ligament, bone, tendon, muscle strains, ligament sprains
- Ligament or articular cartilage: s/p 2 months -2 years
- Bone: 5 weeks–>3 months
- Tendon: -itis: 3-7 weeks; laceration: 5 wks -6 months
- Mucle Strains:
–Gr I: 14 days
–Gr 2: 4 days-3 months
–Gr 3: 3 weeks to 3-6 months - Ligament Sprains: (take 2x as long as muscles to heal, likely due to vascularity)
Gr 1: 3 days
Gr 2: 3 wks-3-6 months
Gr 3:3 weeks -6-12 months
ACL graft Pros/Cons: BPTB, hamstring, allograft
- BPTB: decreased healing time due to bone-bone interface BUT increased incidence anterior knee pain, extensor mechanism dysfunction, patellar fracture
- Hamstring: increased healing time due to soft tissue and bone interface (ex: 12 weeks vs 6-8 weeks) risk hamstring strain but no decreased hamstring strength
- Allograft: much slower healing than autograft; >failure chance and risk of disease transmission; not optimal for younger patients
TKA Types
PCL Sparing: maintains proprioception of ligament, decreased risk of subluxation/dislocation due to ligament intact; improved knee flexion and potentially increased quad activation
PCL substituting: Greater ease of surgery and deformity correction, decreased wear rate
if PCL sacrificed, DON’T mobilize TF joint due to risk of subluxing/dislocating knee
Patellar Fracture: MOI and treatment
MOI: Direct blow (fall) or indirect (jumping)
Tx: aspiration with long cast/brace 3-6 weeks; return to WBAT and gradual progress ROM (esp flexion) and strength after cast removal; Cycling and CKC exercises 6 weeks s/p, return to full ROM/strength 12 weeks
If nondisplaced: early WBAT, AAROM and isometric quads 4-6 weeks
severly comminuted: PWB 6 weeks, gradual AAROM in 3-6 weeks
ORIF: ROm at 1-2 weeks s/p
Quadricep tendon rupture MOI & TX
80% of patients >40 MOI is forced knee flexion with max quad activation
Tx: surgical with KI in full extension for 6 weeks; 6 months time for rehab
Proximal tibial fractures management
Only fracture of knee with initial NWB
- *PT secrets 4 variations of tx:
1. PROM and strength w/o WB until 6-12 weeks
2. NWB cast (long leg foot groin cast w/ 5 deg flexion) 3-6 wks then 2-4 wks NWB rehab then progress WB 9-16 wks
3. traction with passive exercise 6 weeks; NWB 12 weeks
4. cast with NWB and progressive WB 12 weeks
ROM expectations after plating: 1-122 deg
FWB ~12.6 weeks s/o
