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MSK II > Knee > Flashcards

Knee Flashcards

1
Q

When do you conservatively manage a meniscal injury?

A
  1. Able to weight bear
  2. Pain on McMurray’s only at full flexion (px + clunking later in range means it may be too far gone for conservative mgmt)
  3. Minimal injury/peripheral meniscal tear
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2
Q

What are the aims of conservative management?

A
  1. Increase ROM
  2. Address pain/swelling
  3. Strengthen (co-contraction between Q+H)
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3
Q

When’s it likely to refer to surgery for meniscal injury?

A
  1. Severe twisting injury
  2. Locking of joint
  3. Clunk+pain on McMurrays
  4. Not responding to 3 weeks of conservative management

Surgery = suturing, stitching, or cutting away torn part of meniscus

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4
Q

Describe the grades of ligament injury

A

Grade 1: pain, no swelling or laxity
Grade 2: pain, swelling+some laxity
Grade 3: +/- pain, swelling, gross laxity, sensation of instability

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5
Q

What is the ‘Unhappy Triad’?

A

ACL+MCL+meniscus

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6
Q

Valgus stress test sensitivity?

A

56-96% - so could be good to rule OUT a MCL problem

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7
Q

Management of collateral lig injuries?

A

Clinical healing occurs after several weeks, but microscopic remodeling can take 1+ years

Early mobilization very important!

  • improves longitudinal alignment of collagen
  • increases load bearing ability of the tissue
  • increases concentration of collagen
  • reduces laxity and increases tensile strength!

AIMS of conservative treatment:

  1. control swelling/pain
  2. provide control of movement (brace/tape)
  3. Restore ROM+strength
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8
Q

Based on grade of lig injury, how soon can someone expect to get back to sport?

A

Grade 1 - 2 weeks
Grade 2 - 4 weeks
Grade 3 - 6 weeks

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9
Q

What are risk factors for ACL injury?

A
  1. Fam hx
  2. Prev ACL injury
  3. Bony geometry? (ie. shallow intercondylar notch?)
  4. Poor neuromm motor patters
  5. Increase AP laxity
  6. Environmental factors (eg. cleats, synthetic floors)
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10
Q 
There are different theories that describe the MOI for ACL injuries. Describe them:
LIgament dominance theory
Quads dominance theory
Trunk dominance theory
Leg dominance theory
A

Ligament dominance theory:
- injury d/t anything that strains lig past its ability to withstand; hip IR, knee valgus, hip add

Quads dominance theory:
- too much quad strength; in 20-30º of flexion if quads are too strong, turn on too early, or hams too late - hyperextension - ACL injury risk

Trunk dominance theory:
- an inability to control the trunk in 3D space; trunk motion and proprioception predicts risk of future knee lig injury

Leg dominance theory:
- side-side asymmetries in mm recruitment/strength/flexibility

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11
Q

What are acute symptoms of ACL injury?

A

Audible pop/snap
Effusion*
Pain
Instability

*with ACL injury - its highly vascularized - so immediate swelling - PERIARTICULAR; pt adopts 20-30º flexion to accomodate for swelling

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12
Q

Describe brush/swipe test

A
  • brush UP on medial side; brush DOWN on lateral side
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13
Q

Anterior drawer + Lachmans’ general idea of sensitivity?

A

Anterior drawer - 22-95%
Lachmans* - 80-99%

*tested in 20-30º of flexion

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14
Q

How do you decide whether surgery is needed for ACL injury?

A
  1. Age
  2. Level of function needed
  3. Associated injury
  4. Degree of instability

Surgery should be delayed 3 weeks - if you operate too early when there’s still swelling/inflammation in the joint - then more likely to fibrose and lose ROM

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15
Q

What are teh different types of grafts for ACL?

A

Autograft - patella (mid 1/3), hamstring (semitendinosis/gracilis)
Synthetic - LARS (ligament augmentation+reconstruction system)

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16
Q

What is the difference in outcomes between conservative and surgical management of ACL injury?
- Forbell et al (2010) study

A

RCT in Sweden found:

  • early or delayed surgery gives same outcomes
  • in a post hoc analysis - rehab alone did better in the short term (3 months) compared to rehab+early surgery and rehab+delayed surgery; everyone had same level of outcomes at 2 year time point
  • but this only measured FUNCTION
17
Q

Whats the difference between patella vs hams autograft?

A

Autografts - in general no immune reaction

  • patella can be good if subject needs hams (eg. sprinter)
  • but patella graft can leave subject with knee pain
  • hams graft better for knee pain but the donor site needs to be treated/rehabbed
18
Q

What is LARS and what are its proposed benefits

A

LARS is an industrial strength polyester fibre - artificual ACL
Benefits:
- don’t have to deal with donor site problems
- (perceived) improvement in knee stability?
- early return to impact loading activities*
- minimal synovitis
- low current rupture rate

*pts 10x likely to rupture in 1st year and 3x more likely after that

19
Q

Describe the conservative management for ACL injury

A

PREHAB:
- swelling+pain, ROM, strength

POST-OP REHAB:

  • depending on where graft is from, address patella/hamstring
  • day 1 - WBAT (crutches) - must keep knee extended to prevent fibrosis
  • brace until quad control improves
  • progression of strengthening
20
Q

Describe the 4-phase rehab progression 0-12 months

A

Phase 1: 0-2 weeks
- swelling/ROM/strength

Phase 2 (2-12 weeks):
- Full ROM/functional activities/balance
Phase 3 (3-6 months)
- jogging+sport specific drills
Phase 4 (6mons-12mons)
- RTS
21
Q

How can the diagnosis of PCL injury be made?

A 
MOI (hyperflexion or direct blow - dashboard injury)
Area of pain (post/posterolateral knee)
Instability
Swelling/bruising in the calf
Clinical tests + (post sag/post drawer)
MRI/Arthoscopy
22
Q

Patellofemoral dislocation risk factors (name 5)

A
  1. Femoral anteversion
  2. Genu valgum
  3. Subtalar pronation
  4. Increased Q angle
  5. Shallow femoral groove
  6. Patella alta
  7. Lateral tightness + medial weakness
  8. Lig laxity
  9. Prev dislocation
23
Q

Patellar dislocation physical exam

A

Obs - swelling/gross deformity

Tests - patellar apprehension test

24
Q

Patellar dislocation management

A

Conservative:

  • immobilze in cast/brace/splint (3-7 weeks)
  • address contributing factors
  • strengthening (VMO)/coordination
25
Q

Diagnosis of OA? (based on ACR guidelines)

A
  • osteophytes
  • knee pain
    AND 1 of 3:
  • age > 50
  • stiffness
  • crepitus

91% sensitive, 86% specific

26
Q

Knee OA management -exercise

A
  • reduces pain
  • improves function, QoL, medication use
  • doesn’t alter disease progression
27
Q

Surgical options for knee OA?

A

Arthroscopy
High tibial osteotomy
Knee joint replacement*

*TKR delayed as long as possible since it has a plastic component that wears away - will need replacing

28
Q

What do you do in post op TKR physiotherapy

A
  • gentle exercises the same day (knee slides/quad setting/ankle pumps)
  • teach ambulation (NWB or PWB)
  • hydrotherapy
  • motor control
  • gait retraining
29
Q

What is the pathophysiology of ITBS?

A

Repetitive flexion causing distal ITB to flick anteriorly/posteriorly over the lateral epicondyle of femur
- subsequent inflammation

Possible MRI findings - ST injury around the ITB?; osseous edema, subchondral lateral condyle erosion, bursal irritation?

30
Q

Management of ITBS?

A

Acute phase:

  • address pain/inflammation
  • modify activity
  • treat the impairment (STW, stretching)
  • strengthening hip ABs, biomechanical factors
31
Q

What are the potential sources of pain in PFPS?

A
  • damage to subchondral bone
  • synovial irritation
  • retinaculum
32
Q

What factors contribute to developing PFPS?

A
  • mm tightness
  • mm imbalance
  • increased load
  • biomechanics (eg Q angle)
33
Q

Physical Exam for PFPS

A

Obs: effusion, alignment, pronation, Q angle
IMT: px with knee extension
Functional: step down - less pain with medial glide to patella
PAM - PFJ
Length tests - quads, hams, ITB

34
Q

Management of PFPS

A 
NSAIDS
Taping (McConnell)
Footwear
Strengthening
Stretching
35
Q

Fat pad irritation diagnosis + management?

A

Obs: swelling medially or laterally of patellar tendon?
Palp: look for pain here
Fxnal test - px with walking backwards
AROM - extension = px
PROM - worse with pushing inf pole down; better with pushing superior pole up

Management - taping to lift the patella inf pole; strengthning + motor control

MSK II (7 decks)

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