Knee Flashcards
functional anatomy review
- largest joint in the body
- interposed between 2 longest levers
- requires freedom to rotate around 2 axes, slide in 2 directions
- ligamentous, not bony stability
capsular pattern- greater limitation in flexion than extension
close packed
max extension with ER
“screw home”
loose packed
25 deg flexion
menisci aid in
- shock absorption
- joint nutrition
- guide motion
medial meniscus
C shaped
thicker posteriorly
lateral meniscus
O shaped
same thickness
less frequently injured (less attached)
menisci
- no (poor) innervation
- injury often results in clear (synovial, not bloody) effusion
3 zones:
- interior= white
- middle= white/red
- peripheral= red
patellofemoral joint
-thickest articular cartilage in the body
patella:
- increases moment arm of quads
- protects femoral articular cartilage
- odd facet often affected first-contact at greater angles of knee flexion
plica
can cause clinical problems
=a reminant from then the knee capsule used to have several components now has 1 large continuous capsule
Typically medial side (medial to patella) pt will pt to femoral condyle medial to patella with pain on palpation and with flexion
Can actually strum the plica and that will cause pain.
Evolutionary thing not developmental- ppl are either born with it or not
Will act like patella pathology, should be able to differentiate though
proximal tib-fib joint
can weight bear up to 10% ground reaction force
-hypomobility can lead to knee pain
pittsburgh knee rule
sn=100; sp=70
- blunt trauma or fall and
- inability to take 4 steps immediately and in clinic or
- age 50
ottawa knee rule
sn=92; sp=50
- age>55
- tenderness at fib head or patella
- inability to flex knee >90 bc of pain not ROM
- inability to take 4 steps immediately and in clinic
Mechanism of Injury
Planar forces:
- varus/valgus= collaterals (2* cruciates)
- ant/post= cruciates (2* collaterals)
- noncontact hyperextension or deceleration= ACL +/- meniscii
Rotary forces involve the menisci
was there a pop?? (prob ACL snap)
patient exam- history
- has the knee been injured before?
- functional limitations?
- pain now? (where? type? rating now? at worst? 24 hour pattern? what makes better/worse?
- locking or giving way?
Have ROM, suddenly blocked from going into further flexion/extension
Could have periods of block and then in another position unlocks
Indicates flap of meniscus that flaps into and out of the joint space: sometimes in place sometimes out
“giving way” :weak quad strength? Or sublux/relux??
common subjective knee scales
cincinnati knee score: general/pt’s usual activities
Lysholm score: ligs/meniscus injury
knee outcome survey: general/functional limitations
LEFS: general/TKR/ THR
patient exam
- systems review
- OBSERVATION:
- PALPATION:
- MOTION TESTING
- functional testing
- special tests
OBSERVATION:
Alignment:
- varus/valgus- Q angle- hyperextension
- toe in/out- tibial torsion- hip anteversion
- patellar position (standing/sitting): alta/baja; glide (shift); tilt “squinting”; rotation; A/P
- leg lengths
- equal WBing (with/without shoes)
- atrophy/hypertrophy
- swelling, scars, redness, hair loss
- gait deviations
palpation
- temp
- swelling (ballotment)
- tenderness of bony prominences, joint line, muscle insertions, ligs, fat pad
motion testing
Active:(sitting or supine): flexion, ext, ER, IR, patellar excursion
- repetitive motions (if necessary)
- sustained end range positions (if necessary)
- combined movements (if necc)
Passive: sitting/supine
- flex, ext, IR, ER
- patellar med/lat glide with knee at 0; should not extend past 1/2 patella width
- flexibility: hams, rectus femoris, ITB, gastroc
Resisted: sit/supine
- flex, ext, IR, ER, ankle PF/ DF
- repetitive motions
- combined movements
functional testing
(benign to aggressive)
- walking (did this during observation)
- ascending/descending stairs
- squatting –> w/ bounce at end range
- running straight
- running straight then quick stop
- vertical jump
- figure 8, carioca running
- jumping with full squat
- hard cuts, twists, pivots
- single hop for distance
- triple hop for distance
- crossover triple hop for distance
- timed 6 meter hop
side to side comparisons of 80-85% considered normal
chondromalacia patellae
=premature softening/degeneration of cartilage under patella
I: cartilage softening with blebs (blisters)
-pain after activity
II: fissures appear in cartilage
-pain during activity- does not prevent activity
III: fibrillation (crab meat)
-pain prevents activity
IV: full cartilage defects
-pain constant on compression
*note can only diagnose by visualization- poor correlation of visual findings to symptoms
retropatellar pain syndrome
- pain after prolonged sitting
- pain on descending > ascending stairs
- crepitus
- little effusion or ROM deficit
Causes:
-overuse by poor LE alignment, micro trauma, direct trauma to patella
Treatment:
- exercise intensity ^ w/o symptoms ^
- low intensity, high rep
- isometrics
- pain relief (NSAIDS, ice, etc)
- McConnell taping
- correct malalignment (orthotics, brace, hip stability strengthening
- flexibility
plica
- physical agents to decrease pain and swelling
- friction massage
- flexibility
- if conservative treatment fails- surgery
ligament sprains
conservative if partial
surgery of complete ACL? or PCL
- protect healing ligament from excessive stress (crutches, brace, activity mod)
- pain relief/ swelling reduction
- strengthening (open/closed chain)
- neuromuscular re-ed
- proprioception training
- ROM/flexibility
- functional re-training (sports specific) when full painfree ROM
meniscal tears
partial menisectomy
meniscal repair-protocol by surgeon
partial menisectomy
- pain/swelling reduction
- strengthening-return to full function in 3 weeks
meniscal repair- protocol by surgeon
- depend on location/orientation of tear and repair
- protective WB with crutches: NWB weeks 1-2, PWB weeks 3-4
- avoid flexion >90 for 6 weeks
- strengthening: isometrics, straight plane, diagonals (transverse plane motions)
tendonitis (patellar, hamstring)
- RICE
- US/IFC/friction massage
- flexibility
- posture/alignment correction (orthotics, hip stability)
- activity mod
- patellar strap
ITB syndrome
- overuse
- pain during activity and on compression over lateral femoral condyle
conservative treatment:
- pain/swelling reduction
- correct alignment/biomechanical faults (stretching, orthotics, strengthening)
Osgood-Schlatter’s disease
- tibial tuberal apophysitis
- adolescents involved in sports
symptoms:
- localized pain with activity, resisted knee extension
- can have an enlarged tubercle when chronic
treatment:
- stop aggravating activity
- RICE
- flexibility
- symptoms will disappear when growth plate closes
- surgery rarely indicated
OA tx for acute stage
- pain relief- jt mobs
- correct biomechnical faults: orthotics, braces, stretching/ flexibility/ROM, wt reduction
- lower 1/4 strengthening: joint pain should not last >2 hrs after exercise
- endurance: walking, water aerobics, bike
- activity mod: joint protection
Refer to arthritis foundations for programs and info
basic knee exercises
quad/ham/glut sets: excellent post op (regain quad activation)
short arc quads: open chain with quad board
straight leg raise: 4 part
squats, wall slides, leg press
- uni/bilateral
- 1/2, 1/4, with or w/o ball
step downs: control frontal plane motion
lunges:
- matrix
- with reach, catch ball
extensor lag
=inability to perform SLR while maintaining terminal knee extension ?quad weakness ?hamstring tightness ?joint ROM loss -capsular restriction -meniscal blocking -joint swelling
