Knee and ankle Flashcards
Tibiofemoral Joint
- biaxial, modified hinge joint
- menisci and ligaments provide cushion and stability
Tibiofemoral joint distal and proximal end
convex portion at distal end of femur
concave portion at proximal end of tibia
Patellofemoral joint
knee flexion: patella slides caudually
knee extension: patella slides superiorly
Dynamic stability of the knees comes from
- cruciate and collateral ligaments
- neuromusclar system to coordinate motor control of surrounding muscle groups
- nervous system to modulate muscle stiffness & provide proprioceptive feedback
Stability of knee during gait is controlled by:
Quadriceps
Hamstrings
Soleus
Gastrocnemius
How many degrees does the knee go through during gait?
60 degrees
Common source of referred pain to the knee:
- common peroneal nerve (L2-4)
- saphenous nerve (L2-4)
- L3 refers to anterior aspect
- S1-S2 refers to posterior aspect
Possible nonoperative causes of knee joint hypomobility
Osteoarthritis or Degenerative Joint Disease
Rheumatoid arthritis
Postimmobilization
Edema
Knee Treatment Options :Goals: control pain and protect the joint
Patient education Functional adaption PROM AAROM AROM Grade I or II tractions or glides Isometric “setting” exercises
Hemi/Partial/ Unicompartmental Knee Arthroplasty Disadvantages of TKA
Less predictable pain relief
Potential need for more surgery
Hemi/Partial/ Unicompartmental Knee Arthroplasty Advantages of TKA
Quicker recovery
Less pain after surgery
Less blood loss
Pt report it “feels more natural”
ACL injuries
Noncontact
Contact valgus force to knee
PCL injuries
Forceful blow to the anterior tibia while the knee is flexed
MCL injuries
Valgus force across medial joint line of knee
LCL injuries
Varus force across the knee
ACL reconstruction: patellar tendon autograft
- middle third of patellar tendon of patient along w/bone from shin and kneecape
- “gold standard”
- lower rate of graft failure compared to hamstring graft
- for high demand athlete
- not recommended for people who kneel
ACL reconstruction: patellar tendon autograft disadvantages
- post-op pain behind kneecap
- pain with kneeling
- somewhat increased risk of post op stiffness
ACL reconstruction: hamstring tendon autograft
- inner side of the semitendiosus tendon
- some surgeons also use gracilis
- 2-strand or 4-strand tendon graft is created
Hamstring tendon advantageous to patellar autograft due to:
fewer problems with anterior knee pain or kneecap post op
less post-op stiffness
smaller incision
faster recovery
ACL reconstruciton: hamstring tendon autograft disadvantages:
- no one plugs so function limited by strength & type of fixation
- susceptible to graft stretching causing joint laxity
- possible decreased hamstring strength post-op
- not recommended for hypermobile patients
- contraindicated for patients w/MCL laxity/injury
- loss of stability
ACL reconstruction: quadriceps tendon autograft
- middle third of quadriceps tendon and bone plug from upper end of kneecap
- used for patients with failed ACL reconstructions
- generates larger graft for taller and heavier patients
ACL reconstruction: quadriceps tendon autograft disadvantages:
fixation is not as solid as patellar tendon graft due to only having one bone plug
high association with post-op anterior knee pain
low risk of patella fracture
incision is not cosmetically appealing
ACL reconstruction: allograft
- graft taken from cadavers (patellar & achilles tendon)
- used to repair failed ACL reconstruction
Advantages of ACL reconstruction with allograft
- eliminate pain to patient at donor site for autograft
- decreased surgery time
- smaller incisions
Disadvantages of ACL reconstruction with allograft
- risk of infection including HIV and Hep C
- possible death from bacterial infection from allograft
- susceptible to graft stretching with causes joint laxity
- higher failure rate (23-34.4%) compared to autograft (5-10%) for young athletes returning to high demand sports
Patellofemoral Dysfuntion: causes of pain
Plica syndrome Fat pad syndrome Tendinitis IT band friction syndrome Prepatellar bursitis Patellar pressure syndrome OCD lesions Traumatic patellar chondromalacia Patellofemoral OA Apophysitis Trauma
Patellofemoral Treatment options:
Patient education HEP Increase flexibility of restricting tissues Patellar mobilization Patellar tipping Patellar taping VMO strengthening Quad sets
Patellofemoral surgery
Alter alignment of patellofemoral joint
Correct imbalances
Decrease abnormal Q-angle
Debride or repair articular surfaces
Patellofemoral surgery procedures:
Lateral retinacular release
Proximal realignment of extensor mechanism
Distal realignment of extensor mechanism
Meniscal tears
Can cause acute locking of the knee or chronic intermittent locking
Pain along the joint line
Increased swelling
Some quad atrophy possible
Joints of ankle and foot
-tibiofibular joints
Ankle (talocrural) joint
Subtalar (talocalcaneal) joint
Talonavicular joint
Transverse tarsal joint
Remaining intertarsal and tarsometatarsal joints
Metatarsophalangeal and interphalangeal joints of the toes
Tibiofibular joints include:
- superior tibiofibular joint characteristics
- inferior tibiofibular joint characeristics
- accessory motions
Muscle control of the ankle and foot during gait
Ankle dorsiflexors Ankle plantarflexors Ankle evertors Ankle inverters Intrinsic muscles
Referred pain in foot and ankle
- L4
- L5
- S1
Major nerves subject to pressure and trauma
Common peroneal nerve
Posterior tibial nerve
Plantar and calcaneal nerves
Possible nonoperative causes of foot and ankle hypomobility
Rheumatoid arthritis
Degenerative Joint Disease or Osteoarthritis
Postimmobilization
Gout
Foot and Ankle Common Deformities
- Hallux valgus
- Hallux rigidus
- Claw toe (hyperflexed)
- Dorsal dislocation of the proximal phalanges on the metatarsal heads
Ankle supination
varus
Ankle pronation
valgus
Foot and Ankle treatment options
Patient education
Joint Mobilization
Soft Tissue Mobilization
Balance Training
TKA focuses on:
normalizing gait
strengthening muscles
independent transfer
increasing proprieception
Hemi/Partial/ Unicompartmental Knee Arthroplasty
Progress more quickly than TKA
Less gait deviations noted
Less post-op pain, less swelling, and easier rehabilitation
Goals for rehab of ACL reconstruction
decreasing knee swelling
mobility of patella to prevent anterior knee pain problems
regaining full ROM
strengthening quadriceps and hamstring muscles
Increase proprioception (typically takes 4-6 months)
What can patient return to sports after ACL reconstruction?
no pain or swelling, full knee ROM, and muscle strength, endurance and functional use of LE have fully returned
ACL reconstruction: patellar tendon autograft precautions
- no kneeling
- scar massage
ACL reconstruction: hamstring tendon autograft precautions
-no active hamstring contraction for 4-6 weeks
ACL reconstruction: allograft precautions:
some surgeons order NWB for 4-6 weeks
Achille’s Repair
No PROM/AROM x 6 weeks
TAA
- NWB
- ROM restrictions
