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Sports and Exercise Medicine iBSc > Knee > Flashcards

Knee Flashcards

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1
Q

Pes anserinus

A

Refers to conjoined tendons of 3 muscles that insert onto the anteromedial surface of proximal tibia

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2
Q

Pes anserinus muscles

A

Sartorius
Gracilis
Semitendinosus
–> Graft for ACL

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3
Q

Lateral structures of knee- layer 1

A

Iliotibial tract

Biceps femoris

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4
Q

Lateral structures of knee- between layers 1 and 2

A

Common peroneal nerve

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5
Q

Lateral structures of knee- layer 2

A

Patellar retinaculum

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6
Q

Lateral structures of knee- layer 3- superficial

A

LCL
Fabellofibular ligament
ALL

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7
Q

Lateral structures of knee- between layer 3 superficial and deep

A

Lateral geniculate atery

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8
Q

Lateral structures of knee- layer 3 deep

A 
Arcuate ligament
Coronary ligament
Popliteus tendon
Popliteofibular ligament
Capsule
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9
Q

Medial structures of knee- layer 1

A

Sartorius and fascia (patellar retinaculum)

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10
Q

Medial structures of knee- between layer 1 and 2

A

Gracilis, semitendinosus, and saphenous nerve

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11
Q

Medial structures of knee- layer 2

A

Semimembranosus
Superficial MCL
MPFL
Posterior oblique ligament

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12
Q

Medial structures of knee- layer 3

A

Deep MCL
Capsule
Coronary ligament

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13
Q

MCL originates

A

Posterior to medial epicondyle

Inserts 1cm long and 6cm long tibial aspect

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14
Q

ACL rupture more likely to have…. injury

A

Lateral meniscus

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15
Q

Traumatic knee injuries

A 
Anterior cruciate ligament tear
Posterior cruciate ligament injury
Chondral fracture
Patellar dislocation
Meniscal tear
Intraarticular fracture
Tear in deep portion of joint capsule
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16
Q

Atraumatic knee injuries

A 
Pigmented villonodular synovitis
Hemangioma
Hemophilia
Sickle cell anaemia
Charcot arthropathy
Pharmacologic coagulopathy
Thrombocytopenia
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17
Q

Pain

A

VAS
Constant/related to activity?
Anterior/stair climbing/prolonged sitting=patellofemoral?
PFP
Twisting rotating-meniscal?
Pain they are currently experiencing, then pain at time of injury and how it has changed

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18
Q

Pain on anterior/stair climbing/prolonged sitting

A

Patellofemoral

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19
Q

Pain on twisting rotating

A

Meniscal

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20
Q

Instability on pivoting, twisting or cutting

A

ACL

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21
Q

Linear instability- stairs/level groung

A

Quad weakness

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22
Q

Instability side to side

A

PLC

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23
Q

Meniscus bucket handle

A

Goes into the notch in the middle/loose body

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24
Q

Mechanical symptoms- locked, clicking, snappis

A

Meniscus

Could be flipped meniscus

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25
Q

Loose body?

A

From condylar fracture

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26
Q

Other relevant Qs for knee pain

A

Treatment received on pitch-side, to date
Benefits of previous treatment
Athletic hx, past level of play, hours/week, skill level, potential and athletic goals
PMHx/review of symptoms
Occupational hx
What happened at time of injury
What do you do for job

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27
Q

Knee pain- Anterior

A 
Patellofemoral syndrome
Hypertrophic fat pad syndrome
Patellar instability
Quadriceps tendonitis
Patellar tendonitis
Arthritis
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28
Q

Knee pain- Medial

A 
Mensicus tear
MCL injury
Pes anserinus bursitis
Medial plica syndrome
Hypertrophic fat pad syndrome
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29
Q

Knee pain- Lateral

A

Meniscus tear
Biceps tendonitis
Hypertrophic fat pad syndrome
Iliotibial band syndrome

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30
Q

Knee pain- diffuse

A 
OA
Inflammatory arthritis
Infection
Acute trauma with resultant hemoarthrosis
PVNS
Neoplastic
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31
Q

Common causes acute knee pain

A 
Medial meniscus tear
MCL sprain
ACL sprain (rupture)
Lateral meniscus tear
Articular cartilage injury
PCL sprain
Patellar dislocation
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32
Q

Sequence of exam

A

Inspection
Palpation
ROM + strength
Patella- tilt, apprehension, translation, crepitus, J-sign, Q-angle
Meniscal tests- McMurray’s, Apley’s, Thessaly’s
Ligamentous stability- ant drawer, Lachman’s, pivot shift, posterior drawer, quad active, varus/valgus, dial test, ext rot recurvatum
Gait
Joint above + below
N/V

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33
Q

Medial meniscus looks like

A

Big C

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34
Q

Lateral meniscus looks like

A

Smaller C

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35
Q

Which tears are more common

A

Medial Tears

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36
Q

In ACL, rupture more likely to be

A

Lateral

Has popliteal hiatus where it isn’t attached to the capsule

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37
Q

How do fibres run in meniscus- tears

A

Either have longitudinal tear that runs around the periphery

OR a horizontal cleavage tear along the fibres

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38
Q

Degenerative tears in older patients

A

Posterior horn of medial meniscus

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39
Q

Zones of meniscus- Red zone

A

Outer 1/3rd
Vascularized
Try to repair as increased chance of healing

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40
Q

Zones of meniscus- Red white zone

A

Middle third

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41
Q

Zones of meniscus- white zone

A

Inner third
Avascular
Will not heal
Need debridement

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42
Q

Symptoms meniscal injuries

A

Pain
Locking/clicking
Delayed or intermittent swelling

43
Q

What is locking

A

When have knee slightly flexed and cannot fully extend it

44
Q

Meniscal injuries O/E

A

Joint line tenderness
Effusion
McMurray’s

45
Q

Meniscal injuries age

A

14-55 years

46
Q

Meniscal injuries Investigations

A

Radiographs

MRI

47
Q

Double PCL sign

A

Bucket handle tear (vertical tear which may displace into the notch)
Fluid where meniscus should be

48
Q

Meniscal injuries management

A

Degenerative tears (non-operative) but partial meniscectomy or arthroscopic meniscal repair in general

49
Q

Arthroscopy for meniscal injury

A

Majority of people who have meniscal tear reported on MRI will probably have to have an arthroscopy if between 15 and 50
Most of the time will try + fix a tear to try and reserve as much cushioning as possible- so even if its supposedly inoperable, can try and arrest the progression of the tear and making it worse

50
Q

Meniscal injury non-operative management

A

<5mm stable peripheral tear
Stable vertical longitudinal tears (peripheral)
Infrequent and minimal mechanical symptoms
Associated ligamentous instabilities
Medically unfit

51
Q

Meniscal injuries after 50

A

People have degenerative tears after 50

Pain won’t go away as its arthritis causing pain- meniscus is collateral damage

52
Q

Articular cartilage lesions

A

Large proportion associated with structural abnormality- patella realignment/osteotomies
Usually follows trauma
Give rise to loose bodies, painful + accelerate OA
Incidental finding/accompanies another injury
Meniscal insufficiency

53
Q

Articular cartilage lesions- symptoms

A

Joint line tenderness/localized pain
Effusion
Catching sensation

54
Q

Articular cartilage defect- Grade 0

A

Intact cartilage

55
Q

Articular cartilage defect- Grade I

A

Chondral softening or blistering with an intact surface

56
Q

Articular cartilage defect- Grade II

A

Shallow superficial ulceration, fibrillation, or fissuring involving less than 50% of the depth of the articular surfacce

57
Q

Articular cartilage defect- Grade III

A

Deep ulceration, fibrillation, fissuring, or a chondral flap involving 50% or more of the depth of the articular cartilage without exposure of subchondral bone

58
Q

Articular cartilage defect- Grade IV

A

Full-thickness chondral wear with exposure of subchondral bone

59
Q

Pathway of treatment

A

Microfracture –> OATS –> ACI

Synthetic patch also available (blood clot fills the gap)

60
Q

Articular cartilage imaging

A

MRI with gadolinium

Often done when you have done repair and want to see how it’s gone

61
Q

Articular cartilage treatment

A

Surgery better for grade 3 or 4 lesions

Avoid surgery in obesity, inflammatory conditions and degenerative change

62
Q

Articular cartilage- Microfracture

A

Better if <2cm2 and <35
If grade 4 + it’s down to bone, and less than 2cm2, will do microfracture
Punch holes in subchondral bone, makes bone bleed, clot fills defect, defect surrounded by solid wall of cartilage around it, so it contains the defect, then becomes fibrocartilage

63
Q

Articular cartilage- OATS

A

better in lesions <2cm2 and patient older/lower demand
Good for small lesions
Use dau grafts- take from inside knee or pre-prepared- and plug it into affected area

64
Q

Articular cartilage- ACI

A

Chondrocyte cells into defect + cover with patch

Better in larger lesions, bigger than 2cm2

65
Q

What is better in larger lesions

A

Osteochondral allograft

ACI

66
Q

Osteochondral allograft

A

Bone graft from cadaver- like ACI but from cadaver rather than own person

67
Q

Patellofemoral joint defects

A

Have poorer results with any technique

ACI preferred

68
Q

Osteochondral defects

A

Better treated non-op in pts with open growth plates

69
Q

What techniques perform best

A

OATS
ACI
Osteochondral allograft

70
Q

Microfracture recovery

A

Immediate post-op ROM on CPM instituted
TWB’ing for 6-8 weeks
RTS after 4-9 months depending on size of defect + type of sport

71
Q

OATS

A

NWB’ing for 3 weeks
Full ROM immediately
4/12 RTS

72
Q

ACL Injury

A

Non-contact pivoting injury

Often associated with lateral meniscus injury

73
Q

ACL- symptoms

A

Pop
Pain deep in knee
Immediate swelling

74
Q

ACL- O/E

A

Effusion
Quadricep avoidance gait (don’t fully extend knee)
Lachman’s test (positive anterior draw), pivot shift sound –> reocn required

75
Q

ACL- Ix

A

Radiograph

MRI

76
Q

ACL- Mx

A

Bone, PT, bone (graft)

Reduced laxity in graft, bone on bone healing

77
Q

ACL- hamstring graft

A

Jumping sports athletes- RTP delayed by 6 months
Closed chain exercises emphasised early in rehab as open chain stretches the graft
Running delayed 3-4 months and sports delayed 6-9 months

78
Q

PCL injury

A

Hyperflexion of the knee with plantar-flexed foot, dashboard injury

79
Q

PCL Sx

A

Posterior knee pain

Instability

80
Q

PCL O/E

A

Posterior sag
Posterior draw
Quadriceps active test

81
Q

PCL Ix

A

Radiographs

MRI

82
Q

PCL Mx- first 6 weeks

A
  • PWB’ing, hamstring and gastrocnemius stretching and quadriceps strengthening
  • Avoid hamstrings active engagement
  • Use of PCL that provides dynamic anterior drawer
83
Q

PCL Mx- 6-12 weeks

A

Increase strength + ROM

84
Q

PCL Mx- 13-18 weeks

A

Running and sports specific exercise

RTS 4-6 months when quad strength equal to contralateral side

85
Q

MCL Injury

A

Excessive valgus stress e.g. skiing, rugby, football

40% of knee ligament injuries (most common ligamentous injury)

86
Q

MCL Sx

A

Pop

Medial joint line pain

87
Q

MCL O/E

A

Tenderness
Effusion
Valgus stress

88
Q

MCL Ix

A

Radiographs

MRI

89
Q

MCL Mx- Grade 1

A

NSAIDs
Rest
Therapy (RTP 1 week)

90
Q

MCL Mx- Grade 2

A 
Bracing
NSAIDs
Rest
Therapy (RTP 2-4 weeks)
Grade 1 + 2 will heal- good blood supply
91
Q

MCL Mx- Grade 3

A

operative

Repair or reconstruction

92
Q

ACL + MCL rupture

A

6 weeks in ROM brace before think of reconstructing ACL

93
Q

Posterolateral corner injury

A

LCL
Popliteus tendon
Popliteofibular ligament

94
Q

Posterolateral corner injury Sx

A

Instability when knee is in full extension
Dial test- discriminates between posterolateral, PCL rupture or both? 30 degrees = posterolateral corner, 90 degrees = PCL

95
Q

Posterolateral corner injury Ix

A

Radiographs

MRI

96
Q

Posterolateral corner injury Mx

A

Knee immobilization in full extension for 4 weeks then rehab OR PLC repair (grade 2+)

97
Q

Patella instability

A
  • Increased TTTG (tibial tuberosity and trochlear groove sulcus – J sign)
  • RF: “miserable malalignment syndrome” - increased Q angle (femoral anteversion, genu valgum, external tibial torsion / pronated feet)
  • Non-contact twisting injury with knee extended and foot externally rotated
98
Q

Patella tendinopathy

A

Jumping athletes- repetitive forceful eccentric contraction of extensor mechanism

99
Q

Patella tendinopathy Sx

A

Insidious onset of anterior knee pain at inferior border of patella- pain after or during activity

100
Q

Patella tendinopathy O/E

A

Swelling over tendon
Tenderness inf border of patella
Basset’s sign (tenderness to palpation at distal pole of patella in full extension but none in flexion)

101
Q

Patella tendinopathy Ix

A

Radiographs
US
MRI

102
Q

Patella tendinopathy Mx

A

Eccentric exercise programme and stretching of quadriceps and hamstrings
US therapy
Chopat’s strap or taping
NO cortisone injections- risk of rupture

103
Q

Patella dislocation

A

Increase VMO
Reconstruct MPFL
Reduce TT

Sports and Exercise Medicine iBSc (13 decks)

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