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OCS > Knee > Flashcards

Knee Flashcards

1
Q

Medial Collateral Ligament Function

A
  • resists valgus force
  • resists knee extension
  • resists extremes of axial rotation, especially knee external rotation.
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2
Q

Common MOI for MCL

A
  • valgus producing force with foot planted

- severe hyperextension of the knee

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3
Q

Lateral Collateral Ligament Function

A
  • resists varus
  • resists knee extension
  • resists extremes of axial rotation
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4
Q

Common MOI for LCL

A
  • varus producing force with foot planted

- severe hyperextension of the knee

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5
Q

Posterior Capsule Function

A
  • resists knee extension
  • oblique popliteal ligament resists knee ER
  • posterior lateral capsule resists varus
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6
Q

Common MOI for posterior capsule

A

-hyperextension OR combined hyperextension with knee ER of knee

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7
Q

ACL function

A
  • resist extension

- resists extremes of varus, valgus, and axial rotation

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8
Q

Common MOI for ACL

A
  • large valgus producing force with foot firmly planted
  • large axial rotational torque applied to the knee with foot firmly planted
  • any combo of valgus force with axial rotation, especially with strong quadricep contraction with the knee in full or near full extension
  • severe hyperextension of the knee
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9
Q

Function of PCL

A
  • resist knee flexion

- resists extremes of varus, valgus, and axial rotation

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10
Q

Common MOI for PCL

A
  • falling on a fully flexed knee with ankle plantar flexed so tibia hits ground first.
  • forceful posterior translation of the tibia
  • large axial rotation or valgus-varus applied torque to the knee with foot firmly planted
  • severe hyperextension of the knee causing a large gapping of posterior joint
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11
Q

ACL incidence of re-tear

A
  • 8% tear ipsilatarel ACL

- 7% tear contralateral ACL

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12
Q

When do non-contact ACL injuries happen

A
  • happen during deceleration and acceleration motions with excessive quadriceps contraction, and reduced hamstring contraction at or near full extension
  • risk increases when combined with knee internal rotation, or excessive valgus load during weight bearing deceleration activities.
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13
Q

Common ways of PCL injury

A
  • dashboard (posterior force to tibia) 38.5%
  • fall on flexed knee with foot plantarflexed 24.6%
  • sudden hyperextension of knee 11.9%
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14
Q

ACL incidence of re-tear

A
  • 8% to ipsilateral ACL
  • 7% to contralateral ACL
  • Higher in pts <25 years of age
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15
Q

When do non contact ACL injuries happen

A

During deceleration and acceleration motions with excessive quadriceps contraction and reduced hamstring contraction at or near full extension.

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16
Q

Likelihood of returning to sport post ACLR

A
  • 81% return to some level of sport
  • 65% return to preinjury level of sport
  • 55% return to competitive level of sport
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17
Q

Risk factors for developing ACL tear

A
  • dry weather conditions and artificial turf
  • female
  • narrow intercondylar femoral notch
  • lesser concavity depth of the medial tibial plateau
  • Greater anterior/posterior tibiofemoral joint laxity
  • prior ACLr
  • familial predisposition
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18
Q

Diagnosis of ACL tear can be made with reasonable certainty with the following criteria…

A
  • MOI consistent with a deceleration and acceleration motions with non contact valgus load at or near full extension. -
  • hearing or feeling a “pop” at time of injury
  • hemarthrosis 0-12 hours after injury
  • hx of giving way
  • (+) lachman test
  • (+) pivot shift test
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19
Q

Diagnosis of PCL tear can be made with reasonable certainty with the following criteria…

A
  • posterior directed forece on the proximal tibia, a fall on a flexed knee with plantarflexed foot, or a sudden violent hyperextension of the knee joint
  • localized posterior knee pain with kneeling or deceleration
  • (+) posterior drawer test at 90 degrees
  • posterior sag of proximal tibia
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20
Q

Diagnosis of MCL tear can be made with reasonable certainty with the following criteria…

A
  • trauma buy a force applied to the lateral knee or LE
  • rotational trauma
  • medial knee pain with valgus stress test
  • increased separation between femur and tibia with valgus stress test
  • TTP over MCL
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21
Q

Diagnosis of LCL tear can be made with reasonable certainty with the following criteria…

A
  • varus trauma
  • localized swelling over the LCL
  • TTP over the LCL
  • lateral knee pain with varus stress test
  • increased separation between femur and tibia with varus stress test
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22
Q

Expected symmetry in single limb hop tests

A
  • 76%-90% 6 months post ACLr
  • 88%-95% 12 months post ACLr
  • 92%-99% 24 months post ACLr
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23
Q

Single leg hop tests

A
  • hop for distance
  • crossover hop for distance
  • 6 meter timed hop
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24
Q

Meniscus lesion statistics

A
  • women have greater incidence than men
  • lateral tears are more likely to occur in younger pts and medial tears are more likely in older pts.
  • increased prevalence of meniscus tears with ACL tears
  • > 45 y/o likely to have menisectomy, <35 years old likely to have meniscus repair
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25
Q

Methods of operation for articular cartilage damage

A
  • arthroscopic lavage and debridement
  • microfracture (used in younger patients)
  • autologus chondrocyte implantation (ACI)
  • osteochondral autograft transplantation (OAT)
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26
Q

Arthroscopic lavage and debridement

A
  • typically for knee OA

- clean out joint space

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27
Q

Microfracture

A
  • cartilage is cleaned up
  • small microfractures made 3-4mm apart
  • 75-80% of patient report significant pain relief
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28
Q

Autologus chondrocyte implantation

A
  • surgeon harvests some articular cartilage then isolates the chondrocytes in the lab
  • 6-8 weeks later chondrocytes are implanted over the articular cartilage defect
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29
Q

Osteochondral autograft transplantation

A
  • small chunk of bone and damage cartilage removed
  • new piece of bone and healthy cartilage is re-implanted, can be autograft or allograft
  • self reported better outcomes in athletes compared to ACI and microfractures
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30
Q

Risk factors for articular cartilage damage

A
  • athletes in cutting and pivoting sports are at increased risk
  • women, older age, increased BMI, decreased physical activity, and delayed ACLr are risk factors for medial meniscus tears.
  • women, older age, increased BMI, longer symptom duration, previous procedures and surgeries, and lower self reported knee function are associated with higher failure rates with articular cartilage repair procedures
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31
Q

Diagnosis of meniscus tear can be made with fair certainty with the following findings…

A
  • twisting injury
  • tearing sensation at time of injury
  • delayed effusion (6-24 hours post injury)
  • hx of “catching” or “locking”
  • pain with forced hyperextension
  • pain with maximum passive knee flexion
  • pain or audible click with McMurray’s test
  • joint line tenderness
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32
Q

Diagnosis of articular cartilage defect can be made with low level certainty with the following findings…

A
  • acute trauma with hemarthrosis (0-2 hours) associated with osteochondral fx.
  • insidious onset aggravated by repetitive impact
  • intermittent pain and swelling
  • hx of “catching” and “locking”
  • joint line tenderness
33
Q

Early intervention strategies for meniscus injury

A
  • progressive AROM and PROM
34
Q

Early to late rehab strategies for meniscus injury

A
  • progressive weight bearing
  • progressive return to sport
  • supervised rehab
  • ther-ex
  • NMR
35
Q

Early rehab strategies for articular cartilage damage

A
  • progressive AROM and PROM
36
Q

Early to late rehab strategies for articular cartilage damage

A
  • progressive weight bearing (reach full weight bearing by 6-8 weeks)
  • progressive return to activity (dependent on type of surgery)
  • ther ex
  • NMR
37
Q

Functional limitations with patellofemoral pain

A

-pain with squatting, sports, stairs, prolonged sitting, and walking

38
Q

Risk factors for patellofemoral pain

A
  • poor knee extension strength
  • decreased quad flexibility
  • shorter reflex response time of VMO
  • decreased vertical jump height
  • higher than normal medial patellar mobility
  • weakness in hip ABD’s, trunk extensors, and ankle plantar flexors in women
  • decreased rate of time to peal rear foot eversion and greater rear foot eversion at initial heel contact during walking.
39
Q

Psychological factors for patellofemoral pain

A
  • mental health (anxiety and depression)
  • cognitive factors (pain catastrophization)
  • behavioral factors (fear of movement)
40
Q

Who will have poorer outcomes with patellofemoral pain recovery?

A
  • pain >4 months
  • increased age
  • higher baseline severity of pain
  • lower patient function
41
Q

Cluster tests for PFP

A
  • presence of retropatellar or peripatellar pain
  • reproduction of pain with squatting, stair climbing, prolonged sitting, or other function activities that load PFJ in a flexed position
  • exclusion of all other conditions that may cause anterior knee pain, including tibiofemoral pathologies.
42
Q

Overuse/overload without other impairment for anterior knee pain

A
  • too much load magnitude, too much load frequency, and/or at too great a rate of increase
  • those at risk for overuse include athletes and military population
  • load magnitude: amount of PFJ loading resulting from physical activity
  • load frequency: amount of repetition of an activity
43
Q

Muscle performance deficits with regards to anterior knee pain

A
  • hip strength deficits, especially weakness with hip ABD’s, extensors, and external rotators
44
Q

Movement coordination deficits with regards to anterior knee pain

A
  • increased hip ADD, hip IR, and knee abduction during dynamic activities can increase dynamic Q angle, knee ABD, and ER.
45
Q

Mobility impairments

A
  • lack of mobility of structures surrounding the knee can potentially increase compressive forces across PFJ
46
Q

Differential dx’s for knee pain (medical)

A
  • tumors
  • dislocation
  • septic arthritis
  • arthrofibrosis
  • DVT
  • neurovascular compromise
  • fracture
  • slipped capital femoral epiphysis
47
Q

Differential dx’s for knee pain (musculoskeletal)

A
  • lumbar radiculopathy
  • peripheral N entrapment
  • hip/knee OA
  • ligamentous injuries
  • meniscal injuries
  • articular cartilage injuries
  • distal ITB syndrome
  • quad/patellar tendonopathies
  • plica syndrome
  • patellar and tibial apophysitis
  • patellar subluxation or instability
48
Q

Differential dx for anterior knee pain

A
  • PFP
  • patellar tendonopathy
  • patellar subluxation or dislocation
  • tibial apophysitis
  • patellar apophysitis
49
Q

Patellar tendonopathy

A
  • pain localized to inferior pole of patella
  • TTP over patellar tendon
  • aggravated by activities that require high rates of knee extensor loading, such as jumping or sprinting
50
Q

Patellar instability

A
  • apprehension with passively applied lateral patellar movement
51
Q

Tibial and patellar apophysitis

A
  • age and TTP over tibial tubercle and inferior pole of patella
52
Q

Classification system for PFP

A
  • overuse/overload without other impairments
  • PFP with muscle performance deficits
  • PFP with movement coordination deficits
  • PFP with mobility impairments
53
Q

Interventions for PFP

A
  • exercise (open and closed chain)
  • taping
  • foot orthoses
54
Q

Assessments and treatment used for overuse/overload PFP

A
  • eccentric step down test
  • reproduction of anterior knee pain
  • taping (B level)
  • activity modification/relative rest (level F)
55
Q

Assessments and treatment used for movement coordination deficits

A
  • dynamic valgus on lateral step down test
  • frontal plane valgus during single leg squat
  • gait and movement retraining (C level)
56
Q

Assessments and treatment used for PFP with muscle performance deficits

A
  • HipSIT (resisted clamshell mmt)
  • isometric hip muscle strength testing
  • thigh strength testing
  • hip/gluteal muscle strengthening (A level)
  • quadriceps strengthening (A level)
57
Q

Assessments and treatment used for PFP with mobility impairments

A
  • hypermobility in foot
  • hypomobility in LE muscles and hip IR and ER ROM
  • hypermobility: foot orthoses (A level), taping (B level)
  • hypomobility: patellar retinaculum/soft tissue mobs (F level), muscle stretching (F level)
58
Q

ACL biomechanics

A
  • prevents hyperextension of the knee, anterior translation
  • most commonly injured ligament ini the knee, usually non contact injury
  • acts as secondary restraint against varus/valgus force
59
Q

PCL biomechanics

A
  • often injured with contact injury

- limits posterior translation of the tibia

60
Q

MCL biomechanics

A
  • primary restraint against valgus and lateral rotation forces
  • most taut in full extension
61
Q

LCL biomechanics

A
  • primary varus restraint
  • limits internal tibial rotation
  • greatest strain on LCL occurs in full extension and tibial ER
  • in an ACL deficient knee, it is a secondary restraint to anterior and internal rotation forces
  • least often injured ligament in the knee
62
Q

Muscles that provide anterior tibial shear

A
  • quadriceps
  • gastrocnemius
  • Limit with ACL tears initially
63
Q

Muscles that provide posterior tibial shear

A
  • hamstrings (greater force as knee flexion increases)
  • soleus (only when planted on the ground)
  • Limit with PCL tears initially
64
Q

Open vs close chained exercises

A
  • Open chain: quads thought to put greater anterior shear forces on tibia (especially in full extension)
  • most stress going through ACL with last 15 degrees of knee extension
    Close chain: co-contraction of hamstring and quads is thought to provide more stability to the knee joint and less stress to ACL/PCL
65
Q

Greatest strain through ACL with specific exercises

A
  • isometric quad contraction at 15 degrees knee flexion
  • squatting with sport cord
  • active flexion-extension with 45N weight boot
  • lachman’s test
  • squatting
66
Q

Least strain through ACL with specific exercises

A
  • isometric quad contraction from 30-90 degrees

- simultaneous quad and hamstring contraction 60-90 degrees

67
Q

PCL motor control

A
  • agonists: popliteus mm helps limit posterior translation of the tibia. Quads reduce the strain on the PCL between 20-60 degrees.
  • antagonists: gastrocnemius puts the most strain on the PCL when knee is flexed >40 degrees. Hamstring provides significant posterior shear.
68
Q

Exercise/management of meniscus tear

A
  • limit excessive end range knee flexion
  • minimize tibial rotation
  • regular force on the meniscus is important for healing
  • 6 week return to activity program, minimum
69
Q

Biomechanics of ITB

A
  • ITB is a passive lateral stabilizer pf the knee though has very little movement
  • knee flexed: ITB is posterior to lateral femoral condyle
  • knee extended: ITB is anterior to lateral femoral condyle
  • has a minor attachment to the patella
70
Q

Lateral knee pain etiology

A
  • most common running injury 1.6-12%
  • comprises 15% of all knee injuries in cyclists
  • thought to be caused by excessive load on the band over the knee
  • ITB alternates from flexor to extensor at about 20 degrees of flexion.
71
Q

Management of lateral knee pain

A
  • treat inflammation during acute phase
  • stretching ITB and related structures
  • strengthening of hip ABDs
  • manual therapy to soft tissue structures
  • improve motor control
  • rest and activity modification
72
Q

Primary purpose of meniscus

A
  • load transmission at the knee
  • shock absorption
  • joint stability
  • joint nutrition
  • joint lubrication
  • joint proprioception
  • absorbs 50-70% of compressive forces in the knee
  • only the outer 10-30% is vascularized
73
Q

Lateral meniscus

A
  • 4/5ths of a circle
  • larger than medial meniscus
  • more mobile than medial meniscus (10 mm movement)
  • muscle attachments: popliteus, which aides in stability
  • less commonly injured compared to medial meniscus
74
Q

Medial meniscus

A
  • C-shaped
  • smaller than lateral meniscus
  • less mobile (2 mm of movement)
  • muscle attachment: semimembranosus, which aides in stability
  • Broader posterior than anterior
  • Absorbs greater and more frequent forces than lateral side
  • More attachments to the joint capsule, which limits translation and movement
75
Q

Ottawa knee rule

A
  • age 55 or older
  • isolated tenderness of the patella
  • tenderness of the head of the fibula
  • cannot flex to 90 degrees
  • unable to weight bear both immediately and in the ER
  • used only for injuries <7 days
76
Q

Why do ACLr?

A
  • restore knee stability
  • prevent meniscal damage
  • protect articular cartilage
  • avoid degenerative changes
77
Q

Anterior-medial bundle of ACL

A

most taught in flexion

78
Q

Posterior-lateral bundle of ACL

A

most taught in extension

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