Knee Flashcards
Ottowa Knee Rules
- Age > 50
- Ambulate > 4 steps WB
- Knee flexion < 90 degrees
- TTP to patella
- TTP to fibular head
Functional Tests
HOP FOR DISTANCE - best for ACL
- want quads 85% strength of contalateral
Non-op ACL (Coper)
- number of giving way from injury to screen <1
- 6 m hop test 80% of non-involved LE
- knee outcome score (KOS) at least 80% of contralateral limb
- Global rating scale of perceived knee function GRS 80% of contralateral limb
ACL rehab
Only type A evidence is therex. Both open and closed chain stability exercises
B: knee brace immediate post op, NMES, supervised rehab, immediate WB post op
C: cryotherapy
Meniscal involvement
- JOINT LINE TENDERNESS- most diagnostic +22LR (ruling in) thessaly for r/o.
- delayed swelling (6-24 hrs vs. lig that swells immediately) - clicking, locking
- pain with end range knee flexion
- pain with forced hyperextension
- (+) mcmurrays
Bonus: pain, clicking/locking in jt line with thessaly at 5, 20 degres
ACL graft px
Hamstring- no resisted knee flexion x 12 weeks
Allograft- higher risk for graft failure
- faster immediate recovery, less post op pain
BTB- pain with kneeling
ACL with mensicetomy vs repair
- Meniscectomy doesnt change rehab
- REPAIR does!
- no WB >45 knee flexion x 4 weeks
- WB < 90 x 4 weeks
- 8 weeks post op, resume normal protocol
ACL with chondral repair
usually staged procedures
- debridement doesnt change rehab
- MICROFRACTURE does
- NWB 2-8 weeks
ACL with other ligament repair
MCL usually treated non-op
- if MCL is repaired- knee immobilizer in full ext x 6 weeks, WBAT
- multilig stabilization - 6-8 weeks NWB
PLC- avoid varus and tibial ER, hyperextension and resisted knee flexion x 12 weeks
0-40 degrees knee flexion
high COMPRESSIVE forces
PFPS
two theories
1. patellar malalignment
- a/p; m/l opposing forces
- a/p - patellar alta (tight quads) vs stress to patellar tendon
- tight hamstrings can lead to overactive quads during walking
m/l: tight lateral retinaculum, imbalances of quads
- joint overload
- excessive activity overloads PJ jt
- usually runners and increase in training
Exacerbated by increased loads
- sitting, stairs, squatting, running
TIGHT CALVES, TRIGGER POINTS IN QL AND GLUTE MED, WEAK QUADS/HIP ABD/ER
PFPS clincial tests
Only two with good reliability
- Squatting - assess for pain
- patellar tilt test- try to move lateral edge of patella off, if you cant, (+) retinacular tightness
Osgood Schlatter
Traction apophysitis of tibial tubercle
Sinding Larsen Johannson syndrome
traction apophysitis of distal (inferior) patellar pole
PFPS predisposing factors
- larger q angle
- shallow trochlea
- weak quads/ hip abd/er
- patellar tilt angle
- lateral retinaculum thickening
- TIGHT GASTROC/SOL!!
patellofemoral forces
relies on contact area of patella, muscle force and vector between quad and patella
- quad compression force greatest at knee ext
- patella contact smallest at knee ext (want larger area to offset pressure)
from 45-0 of open chained= high compression force
CKC- 0-45 least amount of compression
OKC 50-90 degrees less compression
PCL special tests
- Posterior drawer test (99 Spec, 90 sens)
- 90 degrees knee flexion, add p/a force - Posterior sag sign (100% spec, 78.9 sens)
- with active quad contraction (100% spec, 97.6 sens)
45 degrees hip flexion, 90 degrees knee flexion
- look for a sag/sulcus of posterior shear of tibia
Posterolateral corner
- tendon of popliteus
- lateral head of gastroc
- Arcuate popliteal ligament
- LCL
Taught with ER at 90 degrees flexion
Special Tests:
Dial test
reverse pivot shift test
- take knee into 70-80 degrees knee flexion
- add axial force, apply valgus force and bring knee into extension. Assess for any clunk/relocation of the posterior subluxation.
ACL
Originates on posteromedial aspect of LATERAL femoral condyle
Attaches to anteromedial tibia
two bundles
- Anteromedial (smaller)- tested by Anterior drawer!
- tight throughout flexion- resists translation when knee is flexed!
- Posterolateral (larger)- tested by lachmann
- primary restraint in full extension!- until about 20 degrees of flexion
No strain on ACL from 0-120 knee flexion ROM
- strain at last 30degrees of terminal knee ext
ACL graft WEAKEST at 12 weeks- want to do any open chained strengthening before that
MCL
primary restraint to valgus force
- resists valgus force in ext ~ 57%
- ~25 degrees of knee flexion, adds 78% of valgus restraint
- to avoid stressing it with ACL recovery, IR tibia with knee flexion or saggital plane movements
PCL
originates on lateral aspect of medial femoral condyle– > spine of tibial tubercle posteriorly
Anterolateral bundle (larger 95%) - tight in FLEXION (b/w 30-90 degrees)
Posteromedial bundle (smaller 5%) - tight in EXTENSION (b/w 40-120 degrees)
PCL vs PLC injury
Dial test:
prone tibial ER at 30 degrees and 90 degrees
- if ER > 10 vs contralateral tibia at 30 degrees, suspect PLC injury
- check tibial ER at 90 degrees- PCL is a secondary restraint to ER. If no change, think only PLC injury. If ER is even more at 90 degrees vs contralateral, think both PCL and PLC injury
- if no increase in tibial ER at 30, but > 10 degrees at 90, think PCL without PLC involvement
Soreness rules with therex
- soreness of the knee joint itself, NOT the muscles
Tendon healing rate
tendinitis 3-7 weeks
Laceration of tendon 5 weeks- 6 months
Muscle healing rate
Gr 1: 0-4 days
Gr 2: 4 days - 3 months
Gr 3: 3 weeks- 6 months
Ligament healing rate
Gr 1: 1 week
Gr 2: 4 days - 3 months
Gr 3: 6 weeks - 6 months
Bone healing rate
6 weeks - 3 months
Ligament GRAFT healing rate
2 months - 2 years
Articular cartilage repair healing rate
2 months - 2 years
ACL revision surgery
- more conservative, less rigid graft fixations used
- first 2 weeks: PWB with AC and brace
- WB exercises usually held till 4 weeks
- jumping delayed ( need to protect the graft for a longer time)
- delay in return to sport ( also due to poorer fixation)
6 measures for determining successful outcome s/p ACL
- No swelling
- quad strength 90% contralateral
- absence of giving way episodes
- participation in 1-2 seasons of sport activity
- KOS 80%
- Global rating scale 80%
PCL Post op Rehab
Slow progression of ROM, especially Flexion!!
- avoid flexion > 90 degrees for 2-4 weeks (graft tensioned bw 70-90)
- No active hamstring exercises for 8 weeks
- no resisted hamstring exercises for 3-4 months
Knee ext forces on PCL greatest at midrange (100-40, peak at 85- 95)
- less between 60-0, perform knee ext in this range!
PLC Rehab
- use split achilles tendon graft
- NWB, knee immobilizer x 6 weeks to not stress/stretch graft
- 90 degrees flexion by week 2, full ROM by 6 weeks
- no isolated hamstring exercises x 4 months
PLC MOI
blow to anteromedial tibia in a posterolateral direction
- Varus, hyperextension, ER trauma
MCL/LCL post op px
- PROTECT SITE- in a brace locked at 30 degrees for 2-6 weeks
- early ROM good
- quad strength
Meniscus non op
- works if tear is small and to peripheral 1/3 (red zone) where it is highly vascular
- focus on NON WB therex
- avoid - squatting/pivoting/cutting to minimize stress to the area
Menisectomy post op rehab
- no precautions, standard knee scope progression with symptom management
Meniscus REPAIR post op rehab
- CONTROLLED WB AND ROM IS KEY
- protect site- protected WB x 8 weeks (MD specific)
- some WBAT locked in ext, some begin x 2 weeks, progressing to full by 4 weeks
Meniscus REPAIR post op rehab
- CONTROLLED WB AND ROM IS KEY
- protect site- protected WB x 8 weeks (MD specific)
- some WBAT locked in ext, some begin x 2 weeks, progressing to full by 4 weeks
- WB exercises with > 45 degrees of depth avoided
- loaded knee flexion > 90 degrees avoided for 8 weeks
- QUAD STRENGTH IN OPEN CHAIN in short term
Microfracture sx
stimulates healing through small drills of bone (fibrocartilage substitute for hyaline cartilage damage)
- indicated for cartilage damage < 2 cm
- quicker than plug procedures, but still usually NWB 4 weeks, FWB by 8 weeks
MACI procedure
cartilage plug up to 10 cm
- two step process, harvested from knee, chondrocytes grown in a lab, implanted - grows similar to type 2 hyaline cartilage
- can be used if microfracture and OATS have failed
OATS procedure
- bone plugs covered with hyaline cartilage from NWB part of femoral condyle
- used for cartilage damage < 2cm
Anteromedial rotary instability
Posteromedial corner restrains AMRI
- clipping injury in football
Slocum test (anterior drawer with tibial ER- which should tension posteromedial corner)
Anterolateral Rotary Instability
IR and varus MOI
test with tibial IR ( pivot shift test)
Jerk test- Hughston
ACL surgical errors
femoral tunnel too anterior = loss of flexion
Tibial tunner too anterior = loss of ext
Stroke test with grading
Tests joint effusion
3+ - so much edema that you cant move medial swelling with upstroke
2+ you push edema medially with upstroke, but dont need to downstroke laterally, edema returns spontaneously
1+ you push edema proximally, downstroke brings edema back
Trace- you push edema proximally, small return medially with lateral stroke
zero- no edema produced on downstroke
LCL op
operate within 3 weeks to prevent retraction and tissue necrosis
Best to rule IN PCL tear
Posterior drawer - abnormal > 6mm, LR 90
Best to rule in ACL
Lachmanns LR 10.2
Best to rule in/out medial meniscus
Joint line tenderness with palpation
best to rule in out lat meniscus
Rule in: joint line tenderness with palpation
rule out: Thessaly at 5 degrees
