Knee Flashcards
Why do such huge forces travel through the knee?
- Largest joint in the body between the 2 longest levers
What type of movement is required for the knee to function osteokinematically?
- Rotation around 2 axis
- Slides in both direction
- Rocking
What is the main type of stability across the knee joint?
Ligamentous
What is the close packed position of the knee?
Maximal extension with ER
What is the loose packed position of the knee?
25 degrees flexion.
What is the capsular pattern of the knee?
- More limited flexion than extension
How is the medial meniscus shaped?
- Shaped like a C
- Thicker posteriorly
How is the lateral meniscus shaped?
- O shaped
- Uniform thickness
How are both menisci shaped in cross-section?
- Wedge shaped
What are the 3 roles of the mensici of the knee?
- Shock absorption
- Joint nutrition
- Guide motion
How well are the menisci innervated?
poorly
What type of effusion occurs with meniscal injury?
- Clear/ synovial effusion
Which meniscus is more frequently injured?
- Medial meniscus
What are the 3 zones of the meniscus?
- Interior: White
- Middle: White/Red or Pink
- Peripheral: Red
Which joint has the thickest articular cartilage in the body?
Patellofemoral joint
What are the 2 functions of the patella?
- Increase moment arm of quads
- Protects articular cartilage
Which part of the patella is usually affect first by pathology? Why?
- Odd facet affected due to its contact with the femur during the greatest angles of knee flexion
What are the plica?
- Remnants from when the knee joint had many components
Which plica causes the most problems? How does it present?
- Medial plica causes problems
- Painful to palpation at medial condyle
- Can be palpated
- Pops or snaps
- Hurts most in flexion
How are plica impairments treated?
- Address inflammation
- Correct biomechanical faults
Can the plica be stretched?
- No
How are plica and patellar pathology differentiated?
Palpation
How much GRF does the superior tib-fib joint bear?
Up to 10 %
What type of superior tib-fib impairment can lead to knee pain?
Hypomobility
What is the pittsburgh knee rule?
-Blunt trauma or fall AND - Inability to take 4 steps immediately and in clinic OR - < 12 yo OR - > 50 yo
What is the ottawa knee rule?
Any of the following:
- Age > 55
- Tenderness at fibular head or patella
- Inability to flex knee > 90 due to pain
- Inability to take 4 steps immediately and in clinic
How sensitive and specific is the Pittsburgh knee rule?
Sn: 100
Sp: 70
How sensitive and specific is the Ottawa Knee Rule?
Sp: 92
Sp: 50
Are the ottawa and pittsburgh knee rules more specific or sensitive? Why?
More sensitive; don’t want to miss any fractures/
What is injured in a varus or valgus force at the knee?
- Collateral ligaments
- Some possible cruciate ligament damage
What is injured in an anterior or posterior force at the knee?
- Cruciate ligaments
- Some possible secondary collateral damage
What is injured in a noncontact hyperextension or deceleration of the knee?
- ACL
- Possible menisci damage
What is injured in a rotary force of the knee?
- Menisci
What does a pop in the knee typically indicate in an injury?
ACL tear
What are 4 key questions during the history taking portion of the exam for a knee injury?
- Has it been injured before?
- What functional limitations do you have?
- Pain?
- Does the knee lock or “give way”?
What is implicated by a knee locking?
- Internal derangement or menisci injury
What is meant by a lock?
- A blocked ROM of flexion or extension that can be shaken out
What is meant by the knee giving way?
Quad inhibition due to a SHARP pain
- Feels like a dis- and re-location
What can be implicated by a “giving way”?
- Menisci
- ACL
- Patellofemoral pain
- Plica
- Arthritis
How can the giving way of the knee be further investigated during the subjective portion?
During what phase of gait does it occur?
What are 4 common subjective scales of the knee?
- Cincinnati knee score
- Lysholm score
- Knee outcome survey
- Lower extremity functional score
What does the cincinnati knee score assess?
- General/ everyday activities
What does the lysholm score assess?
- Ligamentous/ meniscus injury
What does the knee outcome survey assess?
- General/ funcitonal limitaitons
What does the lower extremity funcitonal scale assess?
- General
- TKR
- THR
What 7 factors are assessed in the observation portion of a knee exam?
- Alignment
- Leg lengths
- Equal weight bearing (shoes on and off)
- Atrophy/ hypertrophy
- Swelling, scars, redness, hair loss
- Gait deviations
What 3 alignments are assessed at the knee?
- Varus/ valgus
- Toe in/ out
- Patellar position (standing/ sitting)
What angle is measured by varus/ valgus alignment, and what is implicated by an unusual finding?
- Q angle
- Hyperextension
What is being assessed during toe in/ toe out alignment, and what is implied by an unusual finding?
- Tibial torsion
- Hip anteverison
What are 5 unusual patellar positions?
- Alta/ baja
- Gliding/ shifting
- Tilt/ “Squinting”
- Rotation
- A/P displacement
What is 7 things are palpated during a knee exam?
- Temperature
- Swelling
- Tenderness of:
- Bony prominences
- Joint line
- Muscle insertions
- Ligaments
- Fat pads
What is normal AROM flexion of the knee?
0 - 135
What is normal AROM extension of the knee?
0 - 15
What is normal AROM IR and ER of the knee at 90 degrees?
IR: 0 - 30
ER: 0 - 40
What active patellar motion is assessed during motion testing?
Patellar excursion
What specific movements are testing during motion testing of the knee if necessary?
- Repetitive motions
- Sustained end-range positions
- Combined movements
What is PROM of knee flexion? Endfeel?
0 - 140, soft
What is PROM of knee extension? Endfeel?
0 - 15, firm
What is PROM of knee IR and ER? Endfeel?
IR: 0 - 35, Firm
ER: 0 - 45. firm
How is passive motion of the patella assessed at the knee?
- Knee extended 0 degrees
- Glide laterally and medially
- Shouldn’t go past midline
What muscles that cross the knee are tested for flexbility?
- Hamstrings
- Rectus femoris
- ITB
- Gastroc
What resisted motions are assessed during a knee exam? Which should only be done if the patient complaints indicate their testing?
- Flex/ extension
- Ankle plantar flexion and dorsiflexion
- IR and ER performed if necessary
What types of resisted motions of the knee are performed when necessary besides simple planar motions?
- Repetitive motions
- Combined movements
Describe a 10 step functional test progression of the knee from benign to aggressive.
- Walking
- Ascending/ descending stairs
- Squatting
- Squatting with bounce at ER
- Running straight
- Running straight with a quick stop
- Vertical jump
- Figure 8/ carioca running (keep feet pointed forward)
- Jumping with full squat
- Cuts, twists, pivots
What are 4 measurable functional tests of the knee?
- Single hop for distance
- Triple hop for distance
- Crossover triple hop for distance
- Timed 6 minute hop
What is chondromalacia patellae
- A premature softening/ degeneration of the cartilage under the patella
What is the 4 stage process of chondromalacia patellae? What is the symptom associated with each stage?
I: Cartilage softening with blebs (blisters)
- Pain after activity
II: Fissures in cartilage
- Pain during activity, but does not prevent the activity
III: Fibrillation (crabmeat) (strains of fibrous stringy material)
- Pain prevents activity
IV Full cartilage defects
- Pain constant on compressoin
What is the only way for chondromalacia patellae to be assessed? Is this a reliable way to judge stage?
- Visualization
- Poor correlation between findings and symptoms
What is the cause of retropatellar pain syndrome?
- Overuse by poor lower extremity alignment, microtrauma, or direct trauma to the patella
What 2 activities typically provoke retropatellar pain? What are the 2 other factors that diagnose retropatellar pain?
- After prolonged sitting
- Descending or ascending stairs
- Little efussion or ROM deficit
- Crepitis
What type of exercises can be performed with retropatellar pain syndrome?
- Pain free
- Low intensity, high repetition
- Isometrics
- Flexibility
What is used for immediate pain relief of retropatellar pain symptoms?
- Ice
- NSAIDs
What 3 methods can be used to help correct malalignment causing retropatellar pain?
- Orthotics
- Patellar brace
- Hip stability strengthening
What adjunctive agent can be used with retropatellar pain syndrome?
McConnel taping.
What are 3 treatments for plica?
- Physical agents to reduce pain and swelling
- Friction massage
- Flexibility exercises
What type of ligament sprains indicate conservative treatment?
- Partial sprains
What treatment can be provided to protect the healing ligament from excessive stress?
- Crutches
- Braces
- Activity modification
What 7 methods are used for treatments of ligament sprains?
- Protect healing ligament
- Pain relief/ swelling reduction
- Strengthening (open/closed chain)
- Neuromuscular re-education
- Proprioceptive training
- ROM/ flexibility
- Functional retraining when full painfree ROM is accomplished
What is the 2 step treatment of a partial menisectomy? When can the patient return to full function?
- Pain/ swelling reduction
- Strengthening - return to full function in 3 weeks
What is the 4 step treatment for a patient who is post-op meniscal repear?
- Protected weight bearing with crutches
- Pain/ swelling reduction
- Avoid flexion past 90 degrees for 6 weaks
- Strengthening
How long is a patient on crutches following a mensical repair who for the NWB phase, and PWB phase?
NWB: 1 -2 weeks
PWB: 3 - 4 weeks
What is the 3 step strengthening progression following meniscal repair?
- Isometrics
- Straight plane
- Diagonals (transverse plane motions)
What is the 5 step process for tendonitis of the patella and hamstring?
- RICE
- US/ IFC/ Friction massage
- Flexibility
- Posture/ alignment correction
- Activity modificaiton
What is RICE?
- Rest
- Ice
- Compression
- Elevation
What are the 2 methods of posture/ alignment correction following tendonitis?
- Orthotics
- Hip stability
What can be used in a patellar tendonitis specifically?
A patellar strap
What is ITB syndrome?
- Overuse injury
- Pain during activity and on compression of lateral femoral condyle
What the treatment for ITB syndrome?
- Pain/ swelling reduction
- Stretching
- Orthotics
- Strengthening
- Rollers
What is Osgood-Schlatter’s “Disease”?
- Tibial tubercle apophysitis
What patients typically develop Osgood-Schlatter’s “Disease”?
- Adolescents involved in sports
What are the 2 symptoms of Osgood-Schlatter’s “Disease”?
- Localized pain with activity, especially resisted knee extension
What are the 3 treatments typically applied for Osgood-Schlatter’s “Disease”?
- Activity modification
- RICE
- Flexibility
When will Osgood-Schlatter’s “Disease” activities cease?
- When the growth plate closes
When is surgery indicated for Osgood-Schlatter’s “Disease”?
Almost never.
What are the 4 general treatments of OA treatment?
- Pain relief
- Correcting biomechanical faults
- Strengthening the lower quarter
- Endurance
- Activity modification
What is typically used to reduce pain in OA of the knee?
Lower quarter joint mobilizations
How are biomechanical faults of the knee typically corrected?
- Orthotics or braces
- Stretching/ flexibility/ ROM
- Weight reduction
How do you know if you have too aggressively exercised a patient knee OA for strengthening?
- Joint pain lasting more than 2 hours after exercise.
What are 3 endurance activities for a patient with OA of the knee?
- Walking
- Water aerobics
- Bike
What are 6 basic exercises for the knee?
- Quad/ ham/ glute sets
- Short-arc quads
- Straight leg raise - 4 part
- Squats, wall slides, leg press
- Step-downs - controlled frontal plane motion
- Lunges
What exercises are particularly good following surgery?
`- Quad/ ham/ glute sets
What can be used to make short arc quads easier?
- Quad board
What are some variations for squats, wall slides, and leg presses?
- Uni/bilateral
- 1/2 way, 1/4 way
- Use of an exercise ball
How can a lunge with advanced?
- Matrix
- With reach
- Catch a ball
What is knee extensor lag?
- Inability to perform SLR while maintaining terminal knee extension
What are 3 causes of extensor lag?
- Quad weakness
- Hamstring tightness
- Joint ROM loss
What are 3 possible causes of joint ROM loss causing extensor lag?
- Capsular restriction
- Meniscal blocking
- Joint swelling
