Knee & Ankle Flashcards
1
Q
Explain what it means when we say the knee is part of a kinetic chain.
A
- affected by actions and/or transmits forces
- occurring at the foot, ankle, and lower leg
- from the hip, pelvis and spine
2
Q
Why is the knee one of the most traumatized joints in sports?
A
- due to the stresses that are regularly applied
- in ADL, activity, mobility
- due to forces = vulnerable
- exposed joint in sport, lack of medial and lateral stability
3
Q
Identify structures of stability and support in the knee:
A
- ligamentous, joint capsule, meniscus, bursa (structural, inert)
- muscles surrounding the knee (functional)
4
Q
Explain what it means when we say the ankle is part of a kinetic chain.
A
- relationships joint to joint
- functions to transmit ground reaction and rotational forces
- movement at the ankle joint may be dictated by the foot
- contact with the ground may impact lower leg mechanics
5
Q
Identify structures of stability and support in the ankle:
A
- muscles (contractile) structures from lower leg to toes
- ligaments, bones (inert) structures with respect to alignment and positioning
6
Q
Knee joint = _____ joint
A
tibiofemoral
7
Q
What type of joint is the knee? What structures are involved?
A
- hinge joint
- articulation of femur and tibia
8
Q
Movements at the knee:
A
- flexion-extension
- tibial rotation (with a modified pivotal joint, int. /ext. rotation)
9
Q
Screw home rotation:
A
- tibial internal rotation with flexion
- tibial external rotation with extension
10
Q
Discuss kinetic chain and rotation at the knee.
A
- functionally (gait, squat, motor skills & sports skills)
- affect of rotation to joints above and below (consider quadriceps distal attachment)
- MMT - hamstrings
11
Q
Position based observations of ROM:
A
- sitting knee flexion
- prone knee flexion
- standing knee flexion
- kneeling knee flexion
- knee rotation (medial, lateral with foot)
12
Q
Patella: _____ bone in tendon, ____ aspect of joint.
A
- sesamoid
- anterior
13
Q
Functions of the patella:
A
- covers and protects anterior surface of joint
- distributes compressive forces on the femur by increasing contact area
- aids in knee flexikon/extension
14
Q
How does the patella aid in flexion and extension?
A
- translates during flex/extension
- increases leverage tendon can exert on femur
- lengthens lever arm of quadriceps muscle
- protects the patellar tendon against friction
15
Q
Observe patellar movement _____ and _____.
A
- actively
- passively
16
Q
Direction of movements in patella:
A
- superiorly/inferiorly
- medially/laterally
17
Q
Patellar movement is influenced by ____ ____:
A
- extensor mechanism
- muscles, retinaculum, bones shape & design
- alignment with angles of pull or forces
18
Q
2 types of injury to patella:
A
- acute (fracture, tendonitis, infection etc.)
- chronic - more common (PFPS)
19
Q
PFPS =
A
patellofemoral pain syndrome
20
Q
Knee joint capsule provides ____ ____ and is supported by ______.
A
- joint stability
- ligaments
21
Q
Capsular injury results in _____ _____:
A
- capsular swelling
- intra-capsular swelling
- extra-capsular swelling
22
Q
Capsular injury is referred to as a _____.
A
sprain
23
Q
Capsular injury creates a _____ of ….
A
- pattern of restriction of ROM
- flexion more restricted than extension
24
Q
Medial & lateral menisci of knee joint: 2 ____ ____ held to ____ _____ by _____ _____.
A
- articular disks
- tibial condyles
- coronary ligaments
25
Medial and lateral menisci have limited _____ ____.
healing capacity
26
Function of medial and lateral menisci:
- improve joint stability
- increase shock absorption
- distribute weight over larger surface area to deal with contact forces
27
How do bursa at the knee joint function to increase ROM?
works with muscles & tendons to decrease tissue stress on bone, on tendons
28
Anterior bursa at knee joint:
- suprapatellar
- prepatellar (subcutaneous)
- infrapatellar (superficial & deep)
- pretibial
29
Lateral bursa at knee joint:
- lateral gastrocnemius
- fibular
- fibulopopliteal
- subpopliteal
30
Medial bursa at knee joint:
- medial gastrocnemius
- pes anserine
- semimembranosa
31
IOS =
indications for assessment
32
IOS for bursa at knee joint:
- pain presents with movement (ROM)
| - pain with compression
33
Attachments and orientation of fibres for MCL and LCL:
- both cross joint line, bone to bone
| - extracapsular (except MCL blends with the medial meniscus)
34
How do MCL and LCL add to joint stability?
- fibres are tight throughout ROM
| - taut in position of extension
35
MCL function:
- protects against an abducting force that puts the knee into a valgus position
- supports medial knee joint
- functions to protect against rotational forces to the knee
36
LCL function:
- protect against an adducting force that puts the knee into a varus position
- supports lateral knee joint
37
Attachments and orientation of fibres for ACL and PCL:
- bone to bone
| - intra-capsular
38
MCL =
medial collateral ligament
39
LCL =
lateral collateral ligament
40
ACL =
anterior cruciate ligament
41
PCL =
posterior cruciate ligament
42
ACL function:
protect against anterior translation of tibia relative to the femur
43
PCL function:
protect against posterior translation of the tibia relative to the femur
44
Ligaments are _____ restraints to _____ and _____ forces at the knee.
- secondary
- valgus
- varus
45
Ligaments stabilize joint in _____ ____.
excessive ROM
46
ACL works with the _____.
hamstrings m.
47
PCL works with the _____.
quadriceps m.
48
Ankle joint consists of _____ and _____.
- talocrural
| - talocalcaneal
49
Talocrural joint articulation:
- tibia
- fibular
- talus
50
Talocrural joint motion:
hinge joint with plantarflexion & dorsiflexion ROM
51
Subtalar joint (talocalcaneal joint) articulation:
- talus
| - calcaneus
52
Subtalar joint (talocalcaneal joint) motion:
gliding joint with eversion and inversion ROM
53
Ankle joint stability = _____ and _____.
- structural
| - functional
54
How does the bony shape of the ankle affect stability of the joint?
malleoli & talus = joint mortise
55
Ligamentous support of ankle joint:
- medial: deltoid is strong band
- lateral: 3 key ligaments
- superior: syndesmotic, distal tib-fib ligament assists as joint stabilizer
56
3 key ligaments on lateral ankle:
- ATFL
- PTFL
- CFL
57
ATFL =
anterior talofibular ligament
58
PTFL =
posterior talofibular ligament
59
CFL =
calcaneofibular ligament
60
4 parts that add to ankle joint stability:
- bony shape
- ligamentous support
- joint capsule support
- muscular support
61
ROM of ankle joint:
- plantar flexion, dorsiflexion
| - inversion, eversion
62
Toes (MTP joints) ROM:
- flexion
- extension
- adduction
- abduction
63
4 evertors:
- peroneus brevis
- peroneus longus
- peroneus tertius
- extensor digitorum longus
64
3 invertors:
- Tom Dick & Harry
- post tibial
- flex digit longus
- flex hall longus
65
Capsular injury of the ankle joint results in _____ swelling that _____ ____.
- capsular
| - decreases ROM
66
Medial ligaments of the ankle:
deltoid ligament
67
2 syndesmotic ligaments of ankle:
- distal ant. tibio-fibular lig
| - distal post. tibio-fibular lig
68
Key to IOS at ankle:
- MOI
| - position of injury with the orientation of ligaments
69
Injury to a bursa in the ankle can result in _____. We should consider _____.
- bursitis
| - MOI
70
Foot and toe bursae:
- metatarsal bursa
- metatarsophalangeal bursa
- calcaneal bursa
71
Ankle bursae:
- retrocalcaneal bursa
- subcutaneous calcaneal bursa
- subcutaneous bursa of medial malleolus
72
When asking additional questions for knee and ankle, questions determining ____ is critical.
MOI
73
Acute or chronic injury depends on:
- MOI and DOI
- forces delivered
- angles of stress
74
"Give way" sensation is associated with...
ligaments
75
Locking or clicking is associated with...
meniscus
76
Pops, snaps, cracks are associated with..
ligament
77
Clicking and grating are associated with...
patellar
78
What to look for with bruising and swelling:
- occur rapidly or immediately?
- location
- any changes since DOI
- what kind of swelling (intra/extra capsule)
79
An important additional question to ask is regarding their ability to ____ ____ after injury. This includes...
- weight-bear
- walk? continue activity?
- ADL
- consider functional limitations
80
What components of past medical history are important for the knee and ankle?
- PMHx of joints above and/or below
| - frequent joint instability episodes
81
In activity history, it is important to find...
- history of instability in activity
- relevant findings to activity (changes to ...)
- linking to MOI (forces or stress to structures)
82
With personal history, we should consider the affect of ____ on the ankle and knee, including...
- age
- growth spurts (young)
- load with time (age)
83
Why is it important to consider anthropometrics in personal history for ankle and knee injuries?
changes to weight = loads to structures
84
Why is male/female important?
- Q-angles
| - pelvic posture
85
Personal history: know _____ limb relationship to CC.
dominant
86
Personal history: know _____ and _____ relationship to CC.
- occupation
| - ADL
87
Flag type questions for differential diagnosis of CC;
- progressive or severe neurological deficits in the LE
| - young patients with swelling
88
Local observations for knee and ankle:
- swelling, red, bruising (inflammation)
| - asymmetries or malalignment (bony landmarks, muscle girth, deformity)
89
Global observations for knee and ankle:
- overall LE alignment and position
| - function of LE, signs of altered function
90
How to assess overall LE alignment and position:
trunk & pelvis to the arches of foot
91
How to assess function of LE:
- gait: unremarkable or remarkable
| - able to walk on toes, walk on heels, sit/squat
92
Components of gait:
- equal weight
- stride length
- heel-toe walking
- limp
- toe in/out
- abnormal gait
93
Patella baja:
low patella
94
Patella alta:
high patella
95
Notable observation at the knee: observe ____ positioning.
patella
96
Patella can be displaced how?
- high or low
| - medial or lateral
97
What can we do for patellar positioning?
taping
98
Patella moves with the _____, and the angle of pull can be affected by the position of the _____.
- quadriceps
| - foot
99
PFS =
patellofemoral syndrome
100
PFS is commonly described as:
pain to patellar area
101
Cause of PFS:
TBD
102
MOI and IOS of PFS:
- subluxation
- dislocation
- chondromalacia
- tendonitis/tendonopathy
- sprain to retinaculum, to medial patellar ligament
- contusion
- fracture (avulsion)
103
Intra-capsular knee joint swelling:
inside of knee joint effusion --> structures
104
Extra-capsular knee joint swelling:
outside of knee joint --> structures
105
Additional global observations of LE relative to the knee and ankle:
- hyper-extension
- genu varum
- genu valgum
106
Genu varum:
bow leggedness
107
Genu valgum:
knock knee
108
Global observations of ankle:
- over pronation (eversion)
- pronation
- neutral
- supination
- over supination (inversion)
109
Normal arch means what kind of foot alignment?
normal alignment
110
High arched print means what kind of foot alignment?
- supinator
| - rolls to outside/lateral
111
Flatfoot print means what kind of foot alignment?
- pronator
| - rolls to inside/medial
112
MMT for bicep femoris:
- prone, knee flexed
- externally rotate foot
- pull down on ankle as they try and flex knee
113
MMT for semimembranosus/semitendinosis:
- prone, knee flexed
- internally rotate foot
- pull down on ankle as they try and flex knee
114
MMT for gastrocnemius:
- prone, knee extended
- stabilize distal leg
- resist movement at bottom of foot as they plantar flex
115
MMT for soleus:
- prone, knee flexed 90 degrees
| - resist movement at bottom of foot as they plantar flex
116
MMT for tib posterior:
- sit over the table legs over
- plantar flex, invert
- pushed out and up
117
MMT for tib. anterior:
- dorsi flex, inversion
| - pressure on medial part down and out
118
MMT for ext. digitorum from ext. dig. hallicus:
big toes vs other toes pulling up
119
Special tests at the knee:
patellar apprehension
120
Special tests at the ankle:
- kleiger test
| - anterior drawer
121
When doing the patellar apprehension test, apply _____ pressure to _____.
- lateral
| - patella
122
Positive test (remarkable) for patellar apprehension test:
- painful/apprehensive (guarding)
- patellar instability/laxity
- patellar dislocation or subluxation
123
What structures are assessed with the patellar apprehension test?
- patellar ligament
- patellar retinaculum
- quads
- quad tendon
124
Knee joint positioning for patellar apprehension test:
- 0 degrees
| - no muscle tension
125
How is the patellar apprehension test a observation test?
- end lateral glide feel and description
| - observe quad muscle response
126
Anterior drawer test assesses which structures?
- inert
- ligaments: ATFL, CFL, deltoid
- capsule, bone
127
Anterior drawer test is assessing for...
- laxity
- pain
- crack, clunk
128
Ankle joint positioning for anterior drawer test:
- in degrees of PF
| - glide talus - calcaneus anteriorly
129
How is anterior drawer test a passive movement?
- note joint movement bilaterally
| - end feel description
130
With the anterior drawer test, the degree of injury is associated with...
amount of laxity
131
IOS of anterior drawer:
test is looking for ligament
132
Kleiger test is assessing which structures?
- inert ankle
- ligaments
- anterior and/or posterior tib fib ligaments
- interosseous membrane
133
Kleiger test is assessing for...
- pain (location, description)
| - laxity
134
Describe Kleiger's test:
- knee at 90 degrees
- stabilize lower leg
- dorsiflex and externally rotate at ankle joint
135
IOS of Kleiger test:
test is looking for a ligament injury and the degree of injury
136
Functional movements for knee and ankle: tests for joint position of stress:
- gait: on heels, toes
- squat- duck walk
- stairs
- activity related movement
137
Functional movement at the ankle joint includes _____ and _____.
- stability
| - mobility
138
Influences at the ankle joint of static or inert structures:
- joint (bony)
- ligaments
- joints
- capsule
- plantar fascia
- retinaculum
139
Muscular groupings in ankle:
- anterior: dorsiflexors & extensors
- posterior: plantarflexors & flexors
- lateral: everters with dorsifelxors
140
Affect/effect of ankle structures on stability and mobility:
position of stability vs positions of mobility and function
141
Compartment syndrome related to functional movement:
- movement or repetitive activity of muscles within a compartment
- pressure within builds; decrease blood flow
142
The pressure that builds and decreases blood flow with compartment syndrome affects...
- muscles
| - neurovasculature
143
2 types of compartment syndrome:
- acute compartment syndrome
| - chronic (exertional) compartment syndrome
144
Signs and symptoms of compartment syndrome:
- pain that is functionally related to movements of respective compartment
- cramping during exercise subsides when activity stops
- may affect sensation or colour of foot, visible muscle bulging
145
Main compartments of the lower leg:
- anterior compartment
- lateral compartment
- deep posterior compartment
- superficial posterior compartment
146
There can be ____ on structures of foot and toes based on _____ position.
- stress
| - functional
147
The feet and toes absorbs ____ from activity, acts as ____ ____ ____.
- forces
| - weight-bearing stress
148
Lisfranc injury:
- common in basketball players
| - metatarsals displace from tarsals = stress fracture
149
Stable position of foot:
- heel
- 1st toe
- 5th toe
150
Knee is a joint that features ______ over _____.
- movement
| - stability
151
Stability at the knee joint is affected and influenced by:
- position of LE (ie. plant position of foot, lower leg rotation, posture of the knee joint)
- contractile or dynamic structure for stability
- positions of joint laxity
152
Discuss how the position of LE affects the stability of the knee joint:
- forces directed to knee joint (angle of stress) in position found
- ligaments and meniscus provides some stability when motion tries to exceed the limits of the envelope of passive motion
153
Discuss how the contractile or dynamic structure affects the stability of the knee joint:
- joint is dependent upon muscles to provide dynamic stability
- retains stability with static structures: bony joint, ligaments, meniscus, capsule
- reinforced with muscular mechanism to support joint stability (importance of strength and neuromuscular re-training goals in a rehab plan)
154
Discuss how the positions of joint laxity affects the stability of the knee joint:
- are often positions of function
| - may be hip and ankle dependent
155
Stability and mobility at the patellar-femoral articulation is influenced by:
- patellar retinaculum
- shape of patella; depth of femoral trochlear groove
- Q-angle
- position of patella (at rest, in flexion)
- strength (VMO & quads, patellar tendon)
- IT tract flexibility
156
Objective evaluation =
palpation
157
Why evaluate by palpating?
- specific structures relative to IOS
| - to confirm or dispute your IOS
158
How to palpate:
- palpate with client in position that is effective
- palpate bilaterally for comparisons
- palpate to assess for pain
- palpate to assess status of structure
159
Why palpate the joint line (medially and laterally)?
- tibial condyles
- femoral condyles, epicondyles
- meniscus deep
160
Why palpate the patella for movement or joint play?
- move medially, laterally, superiorly, inferiorly
| - note pain, apprehension, mobility
161
Why palpate the muscles?
- deformity
- pain
- spasm
- swelling
- soft tissue
162
What to palpate for bone (fracture)?
- palpate tibia and fibula
- malleoli
- palpate and compression of tibia and fibula (compression of bones above or below site of concern)
- palpate the ankle and foot
163
When palpating for bone (fracture), we are assessing for...
- pain
- tenderness
- instability
- crepitus
- deformity
- localized
164
When palpating the ankle and foot, consider ____ ___ ____ as a guideline for referral to physician (____).
- Ottawa Ankle Rules
| - x-ray
165
Ottawa Ankle Rules: ankle x ray:
- bone tenderness at posterior tip of lateral malleolus
- bone tenderness at posterior tip of medial malleolus
- inability to weight bear
166
Ottawa Ankle Rules: foot x ray:
- bone tenderness at base of 5th metatarsal
- bone tenderness at navicular
- inability to weight bear
167
What 3 ankle ligaments should we palpate?
- anterior tibiofibular ligament
- anterior talofibular ligament
- calcaneofibular ligament
168
What structures to assess:
- bone
- joint
- ligament
- muscular
- nerve
- meniscus
- bursa
- capsule
169
Types of possible injuries:
- sprain
- strain, tendonitis
- bursitis
- fracture, bone stress fracture
- compartment syndrome
- plantar fascitis
170
Grade 1 achilles tendon strain:
- stretching
| - minor tear
171
Grade 2 achilles tendon strain:
partial tear
172
Grade 3 achilles tendon strain:
ruptured
173
What needs to be monitored throughout treatment sessions?
alignment of foot, knee and hip
174
During rehab, we should prevent _____ and ensure ____ ____.
- re-injury
- optimal recovery
- reducing chance of injury producing loads being applied (protective equipment, bracing, taping)
175
Why do we have to monitor strength during rehabilitation?
- prevent muscle atrophy
- decrease quadriceps inhibition and increase ability
- strength in all ROMs for the ankle joint
176
In rehab, we have to move from ____ _____ and emphasize _____ slowly move to ____ and _____ movements. Ex. ...
- static postures
- alignments
- motion
- ballistic
- squat, lunge, forward motion, lateral motion, change of direction, ballistic activity (plyometrics)
177
Rehab: ROM is generally ____ due to injury. Early mobilization can...
- lost
| - reduce the histological changes that ligamentous tissue encounter (ie decrease collagen-cross linkage)
178
When looking at ROM in rehab, ____ motion to patient _____ is critical.
- controlled
| - tolerance
179
Pitfalls in ROM acquisition during rehab:
- joint capsule or ligament contractures (structures shortening)
- muscular resistance due to pain
180
With ROM in rehabilitation, we must determine ____ of limitations and manage accordingly.
cauase
181
Joint mobilization techniques at the knee:
must re-establish accessory motions of tibiofemoral, tibiofibular and patellofemoral joints to ensure appropriate physiological motion
182
Joint mobilization techniques at the ankle:
must re-establish accessory motions of joints in ankle and in foot and toes.
183
When strengthening in rehab, consider using ....
open vs closed kinetic chain exercises
184
Open vs closed kinetic chain exercises:
- positions of stability
- re-education to movement and technique
- must be aware of potential joint stresses at varying degrees of motion during strengthening
- seen as progressions in movement (start with CKC, progress with OKC)
