Knee Flashcards
Subjective: Immediate swelling
- Immediate swelling
- hemarthrosis
- Intracapsular injury(acl,pcl, capsule)
- good blood supply, therefore quick bleed and swelling
Subjective: Delayed Swelling>24 hours
- Intrasynovial or extra capsular
- menisci, collateral ligaments, patella tendon, patella subluxation
- menisci are bathed in synovial fluid- synovitis type swelling occurs over a longer period
- exception is Grace 3 mcl injuries that swell immediately due to attachment to the capsule
Subjective: Giving Way
Straight walking - Patella instability Cutting movements - Acl, Pcl, Capsule Descending stairs - quad inhibition
Ottawa knee rules for radiographs
- Age 55 or older
- isolated tenderness to patella( no other bony tenderness)
- tenderness to fibular head
- active flexion < 90 degrees
- inability to WB 4 steps immediately after injury
What is the MOI for ACL?
No contact
- acceleration/ deceleration activities; excessive quad/ diminished hamstring activation
- quad force + valgus load + knee Ir, WB, deceleration
What is the mode of injury for PCL?
- Dashboard/ anterior tibial blow injury
- fall on flexed knee with ankle in plantar flexion
- violent hyper extension
What is the mode of injury for MCL?
Valgus torque to the knee
- typically hot to lateral knee with foot on the ground
What is MOI for PLC?
Knee hyper extension + ER + varus
Complete knee dislocation
Flexed and Er knee that receives AP blow to tibia
What is CPG for ACL?
- MOI - deceleration+ acceleration motions with non contact valgus load
- hearing a “pop” at time of injury with hemarthrosis within 2 hours
- loss of end range extension
- Lachmans and pivot shift
- single leg hop less than 80% of unaffected limb
- MVIC less than 80% of uninvolved limb
What are two graft types used in ACL repair?
- Bone- patella - bone
- patella tendon pain during quad pre’s - Hamstring Graft
- no hs PRE for 12 weeks
What is the return to sport criteria for ACL repair?
- Minimum of twelve weeks and 90% or greater in most outcome measures ( quad index, KIS, hop test)
What are four common factors for female acl injuries?
- Ligament dominance
- results in valgus position upon landing - Quadriceps dominance
- increased knee flexion during landing - Leg dominance
- Bears weight mostly on 1 leg - Trunk dominance
- inability to control trunk in 3D space
Treatment strategy for ligament dominant.
Train proper landing technique
Treatment strategy for quadriceps dominant?
Strengthen posterior chain muscles
Treatment strategy for leg dominant .
Train side to side symmetry, single leg balance, single leg hopping
Treatment strategy for trunk dominance.
Core training, pertubations, TA , multifidus and pelvic stabilizers
- emphasize hip
- eccentric control is paramount
What are goals of week 1of acl rehab?
Week 1: AROM/PROM to 90, active quad contraction, superior patella glide, knee extension ROM
Treatment : wall slides, patellar mobs, gait training, nmes
What are goals of week 2 acl rehab?
Knee flexion > 110, walking without AD, full knee extension, stair climber, SLR without lag
- ckc(0-60) OKC ( 90-45)
Treatment: step ups in pain free range, stair master, wall squats, prone hangs, functional brace if decreased swelling, patellar mobs
What are goals week 3-5 acl.
Week 3-5
- knee flexion within 10 degrees of uninvolved side
- quad strength greater than 60% of uninvolved side
Treatments: balance and proprioception, progress bike, stair climber
What are goals of late post operative phase?
Week 6-8 Quadriceps strength greater than 80% Normal gait Full rom Treatments: begin running progression, transfer to fitness facility
What are goals of transitional phase?
Weeks 9-12
Maintain or greater than 80% quad strength
Hop test greater than 85%
KOS sports questionnaire greater than 70%
Treatments: sports specific exercises, agility drills, functional testing
Follow up testing for acl 4,5,6,months to 1 year.
Maintain quad at 90% or greater than uninvolved side
Hop test 90% or greater
KOS sports 90% or greater
Return to sport criteria
What is the occurrence of MCL injuries?
MCL is injured in 42% of knees with ligamentous injuries.
Males affected twice as much as females
At what degree is the MCL the primary restraint against valgus force.
25 degrees flexion, mcl provides 78% restraint
- in extension the mcl provides 57% of valgus restraining force
What are three grades of MCL injury?
Grade 1- no gapping
Grade 2 - 6-10 mm gapping
Grade 3 greater than 10 mm gapping with no endpoint
What is the CPG for meniscus tear?
- twisting, tearing at time of injury
- delayed effusion
- joint line tenderness
- Hx of catching, locking
- Pain with passive knee extension and max flexion
- (+) mcmurrays
- (+) Thessaly at 5 or 20 degrees flexion
Management of meniscus tear
Best evidence
- therex - focus on quads and hamstrings
- Estim
-
Meniscal repair repair guidelines
- Wait 8 weeks prior to initiating ROM >90
- CKC 3-4 weeks
Ruling in LCL
- joint line tenderness
- (+) Mcmurrays
- (+) Thessaly at 20 Degrees and 5 degrees
What are predisposing factors for ACL injury?
Non contact
- shoe surface interaction
- high BMI
- narrow femoral arch
- increased joint laxity
- strong quad activation during eccentrics
- valgus positioning of LE upon landing
Acl with chondral defect guideline:
- chondral debreidment
- WBAT 3-5 days post op, no modification
- microfracture procedure
- NWB crutches 2-8 weeks
Acl with MCL repair guidelines
Exercises performed in Sagittal plane 4-6 weeks
- maintain tibial IR during exercises to minimize valgus stress in mcl
Acl with posteriorlateral corner repair
Minimize ER torque and varus stress x 6 weeks
-no resisted knee flexion x 12 weeks
Soreness rules
- soreness during warmup that continues - 2 days off, drop 1 level
- soreness during warm up that goes away, stay at same level
- soreness during warmup they goes but redevelops mid session- 2 days off drop 1 level
- soreness the day after lifting- 1 day off, do not advance next level
- no soreness- advance 1 level per week
CPG for PCL
MOI: posterior force on proximal tibia
Abrasions/ ecchymosis on anterior/ proximal tibia
(+) posterior drawer, (+)posterior sag- better to rule in
(+) modified stroke sign
Loss of knee extension during ambulation
-Posteriorlateral corner injury- Pain with terminal stance and push off
Management of pcl injuries
PWB 2-4 weeks
- avoid varus, hyperextension, ER of tibia
CPR for hip mobilizations for knee OA
- Hip/ groin pain or parasthesia
- anterior thigh pain
- Pain with distraction
- knee flexion less than 122
- hip ir rom less than 17
- used hip ap/pa mobs, caudal glide, posterior glide with flex,abd, Er
PFS diagnostic tests
- Squat with pain
- patella tilt test
Symptoms of PFS
- symptoms of anterior knee pain x 1 month
- average knee pain 3/10 with 9.8” step down
- anterior knee pain/ retro patella knee pain with at least of:
- prolonged sitting, stairs, kneeling, hopping, squatting
- presence of two of the following: pain with apprehension test, patella compression, crepitation
Lateral patella pain is linked to the development of:
Knee OA
Osgood - schlatter disease
Apophysis of tibial tubercle
- young males with rapid growth spurt
- ttp along tibial tubercle, worse with jumping, squatting, kneeling
- treatment: ice massage, strengthen quads and hamstrings
