Knee- ACL PT Rx thru LCL Flashcards
Does the PT rx change from isolated ACL tear to consider additional tissue damage?
YES
- ACL
- MCL
- Medial meniscus
What percentage of ACL tears also have meniscal tears?
22-86%
What is a partial meniscectomy?
- no change
- take a tiny piece out NOT the whole thing, nothing changes from ACL protocol = no reconstruction to protect
What is a mensical repair?
- stitched meniscus, NEED TO PROTECT
- slower progressions due to greater protection needed for meniscal healing to occur
Why can a meniscal repair make achieving ROM more difficult and limit ACL prognosis?
- takes longer to reach ROM goals, have to protect the meniscus to allow healing, cant be as aggressive
What percentage of ACL tears also occur with a bone bruise?
80%
What is considered skeletally immature in regards to bone bruise healing with ACL/PCL and meniscal injuries?
2 weeks - 3 months
What is considered skeletally mature in regards to bone bruise healing with ACL/PCL and meniscal injuries?
1month - 1 year
What is the average time to heal a bone bruise with ACL/PCL and meniscal injuries?
3.2 months
What does a bone bruise do to ROM with an ACL/PCL or meniscal injury?
- delaying factor, leads to more difficulty reaching full ext and proper quad function bc of pain in extension due to CPP and bony approximation
Are MCL tears most often surgically repaired?
NO
How long do precautions last with MCL tears?
initial 4-6 weeks
What are precautions with MCL tears?
- only sagittal plane activity
- limit tibial ER and valgus stresses
When is there a better outcome with MCL tears along with an ACL tear?
- with 10 weeks delay for ACL surgery than 3 weeks
What percentage of ACL tears also have an articular cartilage defect?
36%
What is a debridement?
- “clean it up” fixing it and smoothing over tear
What are the precautions with debridement for an articular cartilage defect along with ACL tear?
- WBAT 3-5 days
- No delays to ACL rehab
What is Osterarticular Transport System (OATS) and AUtologous Chondrocyte Implantation (ACI) (cultured) doing for an articular cartilage defect with an ACL tear?
- most conservative guidelines
- greatest delays to ACL rehab for cartilage defects
** cartilage grown in petri dish, then put back in the body to protect
What is the benefit of a microfx for articular cartilage defect with ACL tears?
- Cause bleeding, inflammation for repair
- “fills in” articular cartilage’s spot
What are the precautions and outcomes with a microfx surgery for articular cartilage defects with ACL tears?
- NWB 2-8 weeks
- likely delay to ACL rehab
What is the progression of outcomes for articular cartilage defect interventions along with an ACL tear?
-OATS outcomes > ACI > Microfx
What is the clotting for repair of ACL inhibited by?
synovial fluid
Do many patients return to high risk activities post ACL tear without surgery?
- few return to high-risk activity without surgery due to continual instability
What percentage of ACL tears are surgically repaired?
65%
What are some arthroscopic techniques to repair an ACL tear?
- bone-patellar tendon-bone (BPTB) grafts (autograft or allograft)
- semitendinosus/ gracilis (STG) graft
What is the difference between autograft and allograft with BPTB grafts?
autograft = from self
allograft = from donor
What do they ensure with arthroscopic techniques when sx is over after ACL repairement?
full ROM under anesthesia
What is related to poor outcomes with sx for ACL tears?
preoperative weakness
What is the benefit of pre-op PT for ACL tears?
- preop progressive 5 wk program followed by 1 year post-op program
> superior pre-op and post-op function out to 2 years
Where is the incision with a BPTB autograft?
over the patellar tendon
What is removed with a BPTB autograft?
middle 1/3 of:
- bone of patella
- patellar tendon
- bone of tibial tuberosity
Why do up to 1/3 develop anterior knee pain with a BPTB autograft?
- supply to tendon is reduced due to the removal, so we have to be careful to settle down the inflammation and not create tendonistis on top of it
When is the graft strength with a BPTB autograft initially weakening?
within the 1st 4 weeks
- dig a plant up and put it somewhere else metaphor, supply is disrupted
When is the incorporation of the graft into the bone happening with a BPTB autograft?
6-8 weeks
When is dense fibrous tissue filled in with a BPTB autograft?
8-12 weeks
How is BPTB allograft different from a BPTB autograft?
- same procedure
- symptoms improve faster than graft incorporates so patient feels like they can do more than they should
When does the allograft incorporate in to the bone with a BPTB allograft?
8-12 weeks
When is there dense fibrous tissue with a allograft?
GREATER THAN 12 weeks
What is the difference in rehab for allografts vs autografts with BPTB repairs?
- allografts have a delayed timeline and longer rehab
What are advantages of a BPTB allograft?
- pre-pubescent population
- avoids anterior knee pain associated with autograft
What are advantages of a STG graft (semitendinosus with/wo gracilis)?
- prepubescent youth to avoid epiphyseal plate complications
- avoids anterior knee pain
When can PURE strengthening for hamstrings start with a STG graft?
- at 6-8 weeks
When should heavy strengthening of the hamstrings be delayed to with a STG graft?
12 weeks
What is the prognosis for post op with ACL repairs at 18-24 months?
- muscle weakness and impaired neuromuscular control remain
- all grafts and bone show continued healing on imaging
What is common out to 2 years ( and 4 years) post op with ACL repairs?
- inhibition, atrophy and weakness common out to 2 years and 4 years and even in both LEs
What is the prognosis of BPTB grafts at 40 months? (percentages)
- 45% resumed pre-injury level
- 29% returned to competitive sport
LOW #s
What is the failure rate of ACL repairs?
up to 30%
When do 75% of the 2nd tears of the ACL occur?
- between 18-24 months
How can we reduce injury rate after ACL reapirs?
waiting at least 9 months to return to play
When is prognosis of ACL repairs WORSE?
- with meniscal or articular cartilage involvement or ext lag
Which has a lower rate of radiological OA between STG vs. BPTB grafts?
stg graft - lower rate of radiological OA
What are there NO differences between STG and BPTB grafts with?
- clinical outcomes, laxity, return to play, ROM, quad size, PF crepitations
- postoperative graft failure
What tibial glides are limited by the PCL?
- excessive posterior glide and IR
Which is thicker and stronger the PCL or the ACL?
PCL
Where does the PCL attach?
- centrally and posterior on the tibial plateau
- anteriorly on the medial aspect of the intercondylar fossa
Where does the PCL run?
- superior and anterior
What is the prevalence of PCL injury?
least injured knee lig
What is the etiology of PCL injuries?
hyperflexion primarily but also hyperextension
What are S&S of PCL tears?
- consistent with any lig injury plus:
- ROM limited and painful, least in ER
- Positive PCL special tests
What are special tests for the PCL?
- quads active
- post drawer
- post sag
What is the PT rx for PCL?
- ligament rx plus emphasis on limiting posterior tibial gliding
What is the MCL?
a flat broad ligament with two bands
Where does the MCL run?
from medial condyles of femur and tibia
What excessive motions are limited by the MCL?
valgus and ER stresses
What does the anterior band of the MCL limit?
flexion
What does the posterior band of the MCL limit?
hyperextension
What does the MCL attach to?
- medial meniscus
- posterior capsule
- adjacent muscle/tendon units
What is the prevalence of MCL injuries?
MOST injured knee ligament
What is the etiology of MCL injuries?
excessive valgus and/or ER stress
What are S&S of a MCL injury?
consistent with lig injury plus;
- ROM impaired and painful, least with IR
- positive MCL and possibly medial meniscus special tests
- palpation: TTP
What are special tests for MCL injury?
- valgus stress at 0 and 30 degrees
> more extended postion tests other structures like cruciates and capsules
What is the PT rx for MCL injuries?
- early protection with valgus and ER stress
Will MOST people with MCL tears need surgery?
NO - ligament is extraarticular and can scar/heal on blended capsule
What is the LCL?
lateral collateral ligament: a round cordlike ligament
Where does the LCL attach?
to the lateral condyle of the femur to the fibular head
Does the LCL attach to the menisci?
NO
What does the LCL limit?
excessive varus and ER stresses
What is the prevalence of LCL injuries?
strong, seldom injured
What is the etiology of LCL injuries?
excessive varus and/or ER stress and hyperextension
What are S&S of LCL injury?
consistent with ligament injury plus:
- ROM limited and painful, particularly ext and ER
- positive LCL special tests
- Palpation: TTP
What is a special test for the LCL?
- varus stress at 0 and 30 degrees
What is the PT rx for the LCL?
ligament rx plus emphasis on:
- early protection with varus and ER stress
Does the LCL need surgery to be repaired?
- may need surgery because ligament remains distant from the capsule even through it is extraarticular
What should the MET for all sprains include?
- combo of supervised and HEP better tha either alone
- combo of open/closed chain exercises
- coordination training
