Knee Flashcards
Ottawa XR Rules (1 of 5) to rule out fracture, if all negative then XR not required.
Age >= 55 TTP patella only; TTP fibular head; AROM less than 90 Unable to WB
Common ACL MOI(s)? ACL special tests?
Tibia IR on an ER femur (CKC)
Femur ER on an IR tibia (CKC)
Tibia anteriorly translates on femur (Hyperextension)
Valgus/IR load with increased quad, dec. H/S
1) Lachman’s (rule in/out), 2) Pivot-shift
Common PCL MOI(s)? PCL Special Tests?
Dashboard or blunt trauma to tibia
Fall on Flexed knee
Violent hyperextension
1)Post. Drawer (rule in/out), 2)Post. Sag (next best)
Common MCL MOI(s)? MCL Special Tests?
Valgus force (Lateral blow with foot fixed)
Valgus test at 30 degrees (pain and/or laxity)
Common Post. Lat. corner MOI(s)? Special Tests?
Hyperextension + ER/Varus
Complete Dislocation
Flexed/ER knee with A/P trauma
Posterolateral drawer
Dial test (Prone ER at 30 and 90 degrees of flexion) *if + at 30 PLC involved, if + at both consider PCL
Reverse pivot-shift
Recurvatum + ER
Common LCL MOI(s)? LCL Special tests?
Varus stress (medial blow to the knee)
Varus stress test at 30 degrees (pain and/or laxity)
Common Meniscus MOI(s)? Special tests?
Deep flexion injury (too much compression)
Hyperextension
Rotation on planted leg
Meniscal Pathology Composite Score (3+/5) Thessaly Test (SL standing while pivoting IR/ER)
What is the Meniscal Pathology Composite Score (3+/5)?
Combines 5 tests H/O Locking/catching TTP at joint line pain with hyperextension pain with end range PROM flexion pain/click with McMurray
*Consider ACL involvement if 3/5 positive
Limb Symmetry Index for functional tests
Ideally better than 85% (Best of 2 trials with 2 practice attempts)
Ligament response to injury
ACL/PCL intracapsular (immediate swelling with injury) Menisci extracapsular (delayed swelling)
*Grade 3 MCL rupture can swell immediately due to capsular attachment
Soreness Rules for progression
No Soreness - modify 1 variable
Soreness diminished by warm-up - same level
Soreness remains after warm-up - decrease to prior level or consider taking the day off if still not resolved
Grading knee effusion
Trace (small wave on medial side with down stroke)
1+ (large bulge on medial side with down stroke)
2+ (effusion spontaneously returns to medial side after upstroke)
3+ (so much effusion it can’t be moved out of medial knee)
Surgical Precautions for knee
ACL with PTB consider likely patellar tendinitis
ACL with H/S graft (no resisted H/S 8-12 weeks)
Meniscal repair (No WB flexion beyond 45 degrees, 1 month)
Mircrofracture (NWB 2-4 weeks)
MCL (avoid valgus stress 4-6 weeks)
Post. Lat. corner avoid hyperextension, ER and varus stress 6-8 weeks, No resisted H/S 12 weeeks
Running progression
requires 80% strength of uninvolved, trace or less effusion
Candidates for UKA
Intact ACL
near normal weight (BMI
Posterior Oblique Ligament
Posteromedial stabilizer which works with semimembranosus to resist valgus force near full extension
Arcuate ligament complex
Posterolateral stabilizer of the knee (resists ER/hyperextension)
Posterolateral corner is made up of:
Arcuate ligament, LCL, popliteal tendon, lateral gastroc
Knee outcome measures and MCID
KOOS (WOMAC+) 100 is the best possible score, MDC ranges based on section
LEFS
MCID and MDC are both 9
KOS
MCID 7 and MDC 8.87
PF joint during flexion/extension
Inferior facet (0-20 deg) medial/lateral facets (20 deg) Middle facet (45 deg) superior facet (90 deg) odd/lateral facets (beyond 90 deg)
PF radiography
Merchant (sunrise view at 45 deg) allows to see the sulcus angle (in the trochlear groove) and congruency angle between the patella and trochlea.
Ligament dominance vs. trunk dominance vs. quad dominance vs. leg dominance
Ligament dominance is due to poor use of the posterior chain (mainly the glutes) leads to excess IR/valgus. Train Technique.
Quad dominance is due to poor H/S recruitment which causes dec. opposition to anterior tibial translation. Presents with landing on extended knees. Train H/S and glute strengthening.
Leg dominance relates to females landing more frequently on single leg when tearing ACL, strength asymmetry compared to non-favored leg. Train leg symmetry.
Trunk/Core dominance relates to inability to control the trunk in space due to being “top heavy” and weak core.
Train core and perturbation.
Best tests in isolation for meniscus lesion
Medial is TTP at joint line, Lateral is Thesaly at 5 degrees
Knee OA predictors (3/4)
Knee pain/crepitus during AROM
Morning stiffness 38 or Bony enlargement
PFPS causes
Muscle imbalances (Hams. tightness causes quads to work harder to extend the knee and increases compressive force) also caused by weakness in ABDuctors, quad atrophy and tightness of triceps surae
Patella Alta
OKC knee extension 0-40 degrees (increased compression on joint)
Compression from tight ITB/Lateral retinaculum decreases medial glide
Hypermobility/Instability with tibial torsion, anteversion, foot pronation (MOI usually valgus stress with ER)
Limb length
PFPS tests
Squat with pain (negative test rules out PFPS) Patella tilt (try to lift lateral border of patella, + indicates tight retinaculum)
Apophysitis conditions
Osgood-Schlater’s (tibial tuberosity)
SLJ syndrome (Distal patellar pole)
Treating PFPS
Optimize eccentric control vs. hypertrophy
Strengthen Hip ABD
Long stride lunge without step (better than step lunge)
Straps during squatting alter timing to delay VL contraction
SIJ manip with PFJ mobilization (grade B evidence)
MTSS Risk factors
Female Excessive pronation Increased Hip IR/ER BMI > 20 small calf girth Previous MTSS
MTSS DDx and treatment
MTSS is exercise induced leg pain with TTP 2/3 posteromedial tibial border. Best results with bony recovery (rest). Educated on use of shock absorbing shoe and increase strength/endurance of soleus. Stretching is not effective.
Exertional compartment syndrome demonstrates no TTP but anterolateral tightness/pain/neurologic symptoms related to exercise
Tibial stress Fx (TTP anterior/proximal 1/3 tibia)
Nerve entrapment
