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T OCS > Knee > Flashcards

Knee Flashcards

1
Q

Ottowa Knee Rules

A
  1. Age > 50
  2. Ambulate > 4 steps WB
  3. Knee flexion < 90 degrees
  4. TTP to patella
  5. TTP to fibular head
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2
Q

Functional Tests

A

HOP FOR DISTANCE - best for ACL

- want quads 85% strength of contalateral

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3
Q

Non-op ACL (Coper)

A
  1. number of giving way from injury to screen <1
  2. 6 m hop test 80% of non-involved LE
  3. knee outcome score (KOS) at least 80% of contralateral limb
  4. Global rating scale of perceived knee function GRS 80% of contralateral limb
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4
Q

ACL rehab

A

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

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5
Q

Meniscal involvement

A
  1. JOINT LINE TENDERNESS- most diagnostic +22LR (ruling in) thessaly for r/o.
    - delayed swelling (6-24 hrs vs. lig that swells immediately)
  2. clicking, locking
  3. pain with end range knee flexion
  4. pain with forced hyperextension
  5. (+) mcmurrays

Bonus: pain, clicking/locking in jt line with thessaly at 5, 20 degres

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6
Q

ACL graft px

A

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

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7
Q

ACL with mensicetomy vs repair

A
  1. Meniscectomy doesnt change rehab
  2. REPAIR does!
    - no WB >45 knee flexion x 4 weeks
    - WB < 90 x 4 weeks
    - 8 weeks post op, resume normal protocol
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8
Q

ACL with chondral repair

A

usually staged procedures

  • debridement doesnt change rehab
  • MICROFRACTURE does
    • NWB 2-8 weeks
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9
Q

ACL with other ligament repair

A

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

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10
Q

0-40 degrees knee flexion

A

high COMPRESSIVE forces

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11
Q

PFPS

A

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

  1. 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

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12
Q

PFPS clincial tests

A

Only two with good reliability

  1. Squatting - assess for pain
  2. patellar tilt test- try to move lateral edge of patella off, if you cant, (+) retinacular tightness
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13
Q

Osgood Schlatter

A

Traction apophysitis of tibial tubercle

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14
Q

Sinding Larsen Johannson syndrome

A

traction apophysitis of distal (inferior) patellar pole

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15
Q

PFPS predisposing factors

A
  1. larger q angle
  2. shallow trochlea
  3. weak quads/ hip abd/er
  4. patellar tilt angle
  5. lateral retinaculum thickening
  6. TIGHT GASTROC/SOL!!
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16
Q

patellofemoral forces

A

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

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17
Q

PCL special tests

A
  1. Posterior drawer test (99 Spec, 90 sens)
    - 90 degrees knee flexion, add p/a force
  2. 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
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18
Q

Posterolateral corner

A
  1. tendon of popliteus
  2. lateral head of gastroc
  3. Arcuate popliteal ligament
  4. 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.

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19
Q

ACL

A

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

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20
Q

MCL

A

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
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21
Q

PCL

A

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)
22
Q

PCL vs PLC injury

A

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

23
Q

Soreness rules with therex

A
  • soreness of the knee joint itself, NOT the muscles
24
Q

Tendon healing rate

A

tendinitis 3-7 weeks

Laceration of tendon 5 weeks- 6 months

25
Q

Muscle healing rate

A

Gr 1: 0-4 days
Gr 2: 4 days - 3 months
Gr 3: 3 weeks- 6 months

26
Q

Ligament healing rate

A

Gr 1: 1 week
Gr 2: 4 days - 3 months
Gr 3: 6 weeks - 6 months

27
Q

Bone healing rate

A

6 weeks - 3 months

28
Q

Ligament GRAFT healing rate

A

2 months - 2 years

29
Q

Articular cartilage repair healing rate

A

2 months - 2 years

30
Q

ACL revision surgery

A
  • 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)
31
Q

6 measures for determining successful outcome s/p ACL

A
  1. No swelling
  2. quad strength 90% contralateral
  3. absence of giving way episodes
  4. participation in 1-2 seasons of sport activity
  5. KOS 80%
  6. Global rating scale 80%
32
Q

PCL Post op Rehab

A

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!

33
Q

PLC Rehab

A
  • 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
34
Q

PLC MOI

A

blow to anteromedial tibia in a posterolateral direction

- Varus, hyperextension, ER trauma

35
Q

MCL/LCL post op px

A
  • PROTECT SITE- in a brace locked at 30 degrees for 2-6 weeks
  • early ROM good
  • quad strength
36
Q

Meniscus non op

A
  • 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
37
Q

Menisectomy post op rehab

A
  • no precautions, standard knee scope progression with symptom management
38
Q

Meniscus REPAIR post op rehab

A
  • 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
39
Q

Meniscus REPAIR post op rehab

A
  • 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
40
Q

Microfracture sx

A

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
41
Q

MACI procedure

A

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
42
Q

OATS procedure

A
  • bone plugs covered with hyaline cartilage from NWB part of femoral condyle
  • used for cartilage damage < 2cm
43
Q

Anteromedial rotary instability

A

Posteromedial corner restrains AMRI
- clipping injury in football

Slocum test (anterior drawer with tibial ER- which should tension posteromedial corner)

44
Q

Anterolateral Rotary Instability

A

IR and varus MOI

test with tibial IR ( pivot shift test)
Jerk test- Hughston

45
Q

ACL surgical errors

A

femoral tunnel too anterior = loss of flexion

Tibial tunner too anterior = loss of ext

46
Q

Stroke test with grading

A

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

47
Q

LCL op

A

operate within 3 weeks to prevent retraction and tissue necrosis

48
Q

Best to rule IN PCL tear

A

Posterior drawer - abnormal > 6mm, LR 90

49
Q

Best to rule in ACL

A

Lachmanns LR 10.2

50
Q

Best to rule in/out medial meniscus

A

Joint line tenderness with palpation

51
Q

best to rule in out lat meniscus

A

Rule in: joint line tenderness with palpation

rule out: Thessaly at 5 degrees

T OCS (16 decks)

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