Knee Articular Cartilage Dysfunction - Lecture 4

Question 1

What muscle being weak is linked to knee OA? What is the reason for this?

Answer 1

Quads

With activities like stair accent / decent / squatting if the quad isnt doing its job (eccentrically activating) its going to cause more compression between the tibia and the femur
* so the hamstrings will fire and crush the two bones together because the quads arent contracting eccentrically slowing it down?

Question 2

In knee OA which side of the tibial platea (and femoral condyle) is more deformed?

Answer 2

Medial side is typically mroe deformed

Question 3

Why is muscle weakness linked to knee OA?

Answer 3

Because they stop moving

Question 4

w/ knee OA there is laxity. Where is it?

Answer 4

Medial compartment laxity
* Think medial meniscus / MCL (remember this side is more deformed as well)

Question 5

What special test would we run to look at MCL laxity?

Answer 5

Valgus testing (stresses this ligament)

Question 6

What happens more w/ knee OA valgus or varus?

Answer 6

Valgus

Remember those medial components are lax so this makes sense

Question 7

What happens to ROM w/ knee OA?

Answer 7

Decreases

Question 8

What is a big thing (other than pain / decreased ROM) a pt w/ knee OA will report? (key factor). What two things go along w/ it?

Answer 8

Knee instability

Buckling / shifting go along w/ it
* NOTE: this buckling could be due to quad weakness not letting them get into that full extension on heel strike

Question 9

Whats harder for an OA pt, stair decent or asscent? Why?

Answer 9

Decent harder

Because the quads have to be more eccentrically active

Question 10

KNOW: Weight loss is good for knee OA (makes sense less weight pushing into the knee)

Question 11

When would we use an assistive device for knee OA?

Answer 11

In the very early acute phase to alleivate pain

Question 12

In acute knee OA what kind of ROM training should we do?

Answer 12

Pain reduced ROM (not pushing far into that pain)

Question 13

Should we do weight bearing w/ knee OA when there is pain? Why?

Answer 13

Yes

Because by moving the joint were lubricating it

Question 14

When would you do Quad sets / Hamstring sets for knee OA? Why?

Answer 14

Veyr very early acute phase

Very rare to do after week one

We want to have them upright and moving

Question 15

patient is 3 weeks into physical therapy for knee OA. Are quad sets / glute sets a good idea for this pt?

Answer 15

No! Dont use them after week one

Question 16

**Why should most knee OA exercises be done in an upright position? **

Answer 16

Because this is how the joint is meant to be loaded. Almost everything passed week 1 should be upright

Question 17

Does OA do well w/ traction / distraction? Why?

Answer 17

Yes

Because it is intracapsular - so pulling those articulating bones apart (off of that inflammed cartilage) feels great because were reducing that friction

Question 18

What grades of traction/distraction do we use for acute knee OA?

Answer 18

Grade 1 and 2

because this is pain dominant at this phase we dont want to push into the other 2 because the other 2 are stiff dominant

Question 19

What is the point of traction/distraction for knee OA pts? (other than just making them feel better [intracapsular likes this])

Answer 19

To wake up the joint and remind it can move
* Calms the nociceptors down

Question 20

Whats the difference between traction and distraction

Answer 20

Traction = pulled exactly perpendicular
* distracted at a perpendicular angle
* T = perpendicular

Distraction = pulling in a manner thats not perpendicular to the joint surface (think lateral distraction)

NOTE: In the knee distraction = traction

Question 21

KNOW: Stationary bike is great for subacute/chronic knee OA. This is good because in the persons head they arent loading the joint (so they arent scared of pain) but they are still moving the joint which is increasing that synovial fluid making it more lubricated
* usually this is a good starting point for those OA pts - the goal is to get them on a walking program so that they are getting taht weight bearing as well as locomotion at that joint

Question 22

Are walking programs good for knee OA pts? Where?

Answer 22

Yes! loads the joint and moves the joint

Mall (because other people are around)

Question 23

KNOW: We asses balance in knee OA pts
* Romberg
* Modified CATSIB
* TUG
* and lots more

Question 24

Can pt use adaptive equipment (cane etc) w/ knee OA in the subacute / chronic phase?

Answer 24

Yes, but try and ween off of it in the clinic

Question 25

When should you do joint mobilizations (grade 1,2,3,4) w/ knee OA treatment?

Answer 25

Do it before stretching so they can get deeper into that ROM 1,2 = pain dominant = more acute OA 3,4 = stiff dominant = more chronic/subacute OA (as long as its stiff and not painful)

Question 26

For knee OA: * were strething flexors and extensors (quads / hamstrings) * We can do open and closed chain EX * We want them to eventually be pain free

Question 27

KNOW: Good Ex for knee OA = * Step up / step down / forward / backward = smaller steps w/o much flexion / extension - just keep progressing it * We can add balance into this as well * We can do wall slides / minisquats (these are functional) progress passed 90 if tollerable * can have pt pick things up off the floor = more functional - make thing they're picking up heavier and heavier

Question 28

Can pts squat passed 90 degrees?

Answer 28

Yes

Question 29

Why would weak quads cause buckling?

Answer 29

Because if they can't get to full extension in heel strike then their leg is going to buckle

Question 30

KNOW: For balance: * we can change the surface * Foot position * Vision * Dosage * Have them do something cognitive (math) - called dual tasking * Perturbations (taping pt) (anticipated vs non anticiapited) * Surroundings nonmoving and moving (closed vs open) If its to easy for a pt you can adjust a few little things --> don't abadon ship Don't memorize all this - just be able to apply some of it to challenging pts

Question 31

KNOW: We want range of motion to be available to strengthen in that range * For instance if they really dont have much range passed 90 degrees we shouldnt be strengthening at 95 degrees

Question 32

What two things done muscular wise make knee OA hurt? (cause symptoms to come on)

Answer 32

Pushing deep into flexion (stretching that already weak quad) Or using strong quad contraction (going into knee extension) - actively = due to weak quads

Question 33

Do we want the muscle to be forced to spasm?

Answer 33

No! will create fear avoidance

Question 34

If a knee OA pt walks in and their knee OA is extremely acute and really anything I'm doing to it is hurting. What is my plan of action (what should I do) - dont just say calm it down - what should I do functionally

Answer 34

Go to the surrounding joints (most likely hip) work into some hip movement I still want them to exercise - strengthen that hip and those benefits will translate to balance and other things that will benefit the pt

Question 35

ALL FOR articular cartilage repair KNOW: A surgery that can be done for articular cartilage repair is to create microfractures in the articulating cartilage --> this creates more BF to the area --> inflammatory response --> more healing (increased osteoblasts in that bone) Can also do an OSteochondral autograft trasnfer: taking some of your bone shaving it off and using it at the knee Autologous chondrocte implantation = poor mans version of stim cells basically taking some of your chondrocytes from somewhere else and putting it in knee (cartilage cells) Osteochondral allogarft transplants: bone from a donor

Question 36

Can a articular cartilage repair Wb right after surgery?

Answer 36

No! strict instructions

Question 37

What range is a articular cartilage repair going to be allowed to move in 1-2 weeks post OP?

Answer 37

0-45 degrees of extension into flexion

Question 38

How is a articular cartilage repair braced?

Answer 38

Braced into extension for 4-6 weeks (note: we can break this in therapy)

Question 39

# articular cartilage repair How long does rehab take for articular cartilage repair

Answer 39

8-12 weeks this is long because its weight bearing bone

Question 40

How long should the articular cartilage repair pt do low impact activities?

Answer 40

6 months

Question 41

when can a articular cartilage repair pt start moving into high impact activity? what about higher impact activity

Answer 41

8-12 months 12-18 months

Question 42

Unicompartment knee replace is a

Answer 42

partial knee replacement

Question 43

compare and contrast a total knee replacement and a partial knee replacement rehab time?

Answer 43

Its very similar so a total is often done

Question 44

List some indications TKA (6)

Answer 44

Pain impacting WB/Function Destruction of articular cartilage Deformity (varus or valgus) instability Motion loss Failure of conservative treatment

Question 45

Explain what a unicompartmental knee replacement is?

Answer 45

Medial or lateral joint surface replaced (medial femoral codyle + medial tibial plateau or lateral femoral condyle + lateral tibial plateau)

Question 46

What is a bicompartmental knee replacement

Answer 46

The same as a total knee replacement * femoral and tibial surfaces are replaced

Question 47

What is a tricompartmental knee replacement?

Answer 47

femoral and tibial and **patellar** surfaces are replaced

Question 48

What are the 3 kinds of TKA? When are they used? * under what age gets mboile bearing?

Answer 48

Fully constrained: used for extremely unstable joints, severe deformity. These pts after surgery will have much more limited motion and minimal rotation - don't expect your pts to ever get to that 120 degrees of knee flexion semiconstrained: - most common - some stability provided. very much a lock and key mechanism - when doing mobilizations you will here a click as you work into grades 3 and 4 (dont freak out you didnt dislocate them) * if they are under 65 they will do a mobile bearing which alows some rotation at the knee Unconstrained: used w/ pts w/ no inherent instability - used in unicompartmental knee replacements

Question 49

KNOW: lots of times w/ TKA the cruciate ligaments are removed

Question 50

What is manipulation under asthesia?

Answer 50

Knocking pt out to make sure you have the correct ROM * is pain stopping you from flexion or is it structural * often videoed to show pt that nothing is wrong w/ the knee - fear is just stopping you

Question 51

KNOW: TKA complications: * Infection * Joint instability * Wear * Component Loosening * DVT * Wound healing (smoking, alc, diabetes, hypertension) * Limited knee flexion * Patellar tracking * Extensor lag - when someone goes through a straight leg raise and the leg drops a little bit (doesnt get that full extension)

Question 52

**What is this? (test question)**

Answer 52

Extensor lag

Question 53

**What kind of modalitity helps w/ extensor lag (test question)**

Answer 53

Russian estem

Question 54

What is CPM?

Answer 54

Continuous passive motion pt just lays there and puts the leg through passive motion used early on

Question 55

Whats more important for gait - knee flexion angle or knee extension angle?

Answer 55

Extension because of that heel strike

Question 56

What is our goal for flexion and extension for TKA pts?

Answer 56

110 flexion (even though 120 is normal they typically have slightly less) 0 extension

Question 57

Question 58

Whats more likely to be injuired - medial meniscus or lateral?

Answer 58

Medial meniscus is 5x more likely to be injuired than latearl

Question 59

What ligament is the medial meniscus attached to? being attached to this ligament means what position stresses it

Answer 59

MCL valgus

Question 60

What kind of injuries cause medial meniscus injuiry?

Answer 60

femur on tibial rotation during weight bearing - think pivoting This is due to the valgus it is put through (valgus stresses MCL which is attached to medial meniscus)

Question 61

When there is a medial meniscul tear what two ligaments are like to be torn

Answer 61

most likely = MCL --> ACL (terrible triad)

Question 62

KNOW: Squatting / high force activity = put pressure on meniscus (shock absorbers)

Question 63

What is a tell tale sign its a meniscus tare (3)

Answer 63

locking / catching / sensation of giving away

Question 64

What kind of meniscus tear is this? does it need surgery? what kind of tear does it turn into

Answer 64

Longitudinal meniscular tear needs surgery turns into bucket handle tear

Question 65

What kind of meniscus tear is this? does it need surgery? what kind of tear does it turn into

Answer 65

radial tear turns into a parrot beak tear needs surgery

Question 66

What kind of meniscus tear is this? does it need surgery? what kind of tear does it turn into

Answer 66

horizontal tear may progress to a flap tear may or may not need surgery

Question 67

what muscle might be atrophyed w/ meniscual tears?

Answer 67

quad atrophy - because of pain the pt won't want to go into that full extension and close down on the meniscus

Question 68

what position has locking w meniscular tears (degrees)

Answer 68

20-45 degrees

Question 69

**Why would a meniscus pt have issues fully extending the knee**

Answer 69

because the posterior horn of the medial meniscus has attachments to medial hamstring as you go into full extension the hamstrings become more taut and pull on that posterior horn

Question 70

**If I have a medial meniscual tear (just post OP) what muscle activation do I want to avoid in the early phases? Why?**

Answer 70

Hamstring activation because it pulls on the medial horn of the meniscus (which is near that surgery site) and we don't want that direct pulling So avoid that extension because the hamstring will be pulling eccentrically | semitendinosis and membranosis attach here

Question 71

KNOW: special tests for meniscual injuries: * McMurray * Apley's Compression * Thessaly's But really the best way to know is looking for that clunking / catching / locking are also going to have tenderness over jointline KNOW: Proably won't be able to get into full flexion and will cause pain

Question 72

What is the best imaging for meniscus?

Answer 72

MRI

Question 73

red arrow is the tare * look how its lifted up = tare

Question 74

What do we do acutely for meniscal tears? (modality wise) 4 How long does it take ot return to activity?

Answer 74

Ice Compression Elevation Trying to get rid of swelling also limit activity (calming it down) * limit excessive end range knee flexion (think squatting all the way down to tie shoes) --> just for acute --> were going to get back into doing this after acute phase * Minimize tibial rotation (dont do that pivoting that proably tore it) * However, force is necessary for healing so we will need to put force on it in a necessary manner 6 weeks to return to activity minimum

Question 75

KNOW: For a chonic mensical tear we want to focus on muscle stability and decrese stress on meniscus

Question 76

**Which part of the meniscus heals better the outside or the inside? Why**

Answer 76

Outside tears (perimeter tears) heal better Because they are still vascularized So the inside of the meniscus is avascular

Question 77

KNOW: partial menisectomy is the #1 choice for meniscus tears

Question 78

Which nerve could potentially get damaged w/ a medial meniscus surgery?

Answer 78

Saphenous n

Question 79

Which nerve may be damaged w/ lateral meniscus surgery?

Answer 79

Pernoneal (fibular) n

Question 80

pt comes in w/ signicant swelling at the knee after meniscus surgery. their injury was 2 weeks ago. They barely have any knee extension. Is this due to muscle atrophy? Why or why not?

Answer 80

It is not beucase the quads wouldnt have had time to atrophy yet It is more likely due to that swelling making it hard for them to extend / making the muscle painful

Question 81

KNOW: Extensor lag might happen as a meniscal surgery complication Failure w/ loading and knee flexion beyond 45 degrees might also happen

Question 82

meniscus pts are often braced in full extension

Question 83

**What kind of a tare in the meniscus has better healing capaibilities. central zone repair or peripheral zone repair**

Answer 83

peripheral because of the vascularization KNOW: Any clicking sensation heard during meniscus tare rehab (post OP) should be a call to the surgen

Question 84

KNOW: avoid repeitive, high joint compression and shearing forces w/ acute meniscus repair pts **avoid prolonged squattting in full flexion** * NOTE: you can do that full knee flexion on a bike - but the loading in the flexion is the issue - so thats why you wouldnt want them doing that squatting *** But in that first month ISH avoid that full knee flexion w/ loading (like in the squat)** * Also avoid lunges (in that deep flexion w/ loading)

Question 85

**A medial meniscus pt is doing a leg press machine. Which part of that movement may be the issue? why?** T | This machine

Answer 85

The eccentric lowering is the issue because the hamstrings are eccentically activated and pulling on the medial horn of the meniscus (which is something we dont want to do right after surgery) so avoid the leg press in the first 8 weeks also avoid hamstring curls in first 8 weeks

Question 86

Which 2 exercise movements would we want to avoid in the first few weeks (8 weeks) after meniscular repair?

Answer 86

Hamstring curl Leg press

Question 87

This is a prone hamstring curl

Question 88

After 2 weeks of meniscus repair what is our goal for AROM?

Answer 88

90 degrees flexopm

Question 89

1 month post meniscus repair how much knee flexoin should we have?

Answer 89

Full 120

Question 90

KNOW: We can use patellar mobility for meniscus repair

Question 91

Would you rather have menisucs pt do straight leg raises w/ an extensor lag or correct done but in a brace?

Answer 91

In a brace

Question 92

For most knee pathologies our goal is to have: * Full knee extension * quad activiation * No extensor lag

Question 93

how long do meniscus repair pts keep the brace on?

Answer 93

6-8 weeks

Question 94

When someone progresses to the subacute phase of meniscus knee repair they have * No pain * No effusion * Full active knee ROM * LE strength is _ compaired to contralateral

Answer 94

60-80%

Question 95

when does the pt become a chronic meniscus repair (time frame)

Answer 95

4-9months is typically when they enter this phase Note: were no longer seeing these pts very often - we set them up with a personal trainer

Question 96

For an ACL where is your peak shear forces?

Answer 96

15-30 degrees of knee flexion

Question 97

what is the degree range for maximum anterior shear forces in knee flexion?

Answer 97

0-60 degrees