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Lower test 2 > Knee Articular Cartilage Dysfunction - Lecture 4 > Flashcards

Knee Articular Cartilage Dysfunction - Lecture 4 Flashcards

1
Q

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

A

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?

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2
Q

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

A

Medial side is typically mroe deformed

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3
Q

Why is muscle weakness linked to knee OA?

A

Because they stop moving

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4
Q

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

A

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

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5
Q

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

A

Valgus testing (stresses this ligament)

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6
Q

What happens more w/ knee OA valgus or varus?

A

Valgus

Remember those medial components are lax so this makes sense

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7
Q

What happens to ROM w/ knee OA?

A

Decreases

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8
Q

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?

A

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

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9
Q

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

A

Decent harder

Because the quads have to be more eccentrically active

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10
Q

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

A
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11
Q

When would we use an assistive device for knee OA?

A

In the very early acute phase to alleivate pain

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12
Q

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

A

Pain reduced ROM (not pushing far into that pain)

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13
Q

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

A

Yes

Because by moving the joint were lubricating it

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14
Q

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

A

Veyr very early acute phase

Very rare to do after week one

We want to have them upright and moving

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15
Q

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

A

No! Dont use them after week one

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16
Q

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

A

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

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17
Q

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

A

Yes

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

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18
Q

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

A

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

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19
Q

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

A

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

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20
Q

Whats the difference between traction and distraction

A

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

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21
Q

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

A
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22
Q

Are walking programs good for knee OA pts? Where?

A

Yes! loads the joint and moves the joint

Mall (because other people are around)

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23
Q

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

A
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24
Q

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

A

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

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25
Q

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

A

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)

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26
Q

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

A
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27
Q

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

A
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28
Q

Can pts squat passed 90 degrees?

A

Yes

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29
Q

Why would weak quads cause buckling?

A

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

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30
Q

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

A
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31
Q

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

A
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32
Q

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

A

Pushing deep into flexion (stretching that already weak quad)

Or using strong quad contraction (going into knee extension) - actively = due to weak quads

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33
Q

Do we want the muscle to be forced to spasm?

A

No! will create fear avoidance

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34
Q

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

A

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

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35
Q

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

A
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36
Q

Can a articular cartilage repair Wb right after surgery?

A

No! strict instructions

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37
Q

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

A

0-45 degrees of extension into flexion

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38
Q

How is a articular cartilage repair braced?

A

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

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39
Q

articular cartilage repair

How long does rehab take for articular cartilage repair

A

8-12 weeks

this is long because its weight bearing bone

40
Q

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

A

6 months

41
Q

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

what about higher impact activity

A

8-12 months

12-18 months

42
Q

Unicompartment knee replace is a

A

partial knee replacement

43
Q

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

A

Its very similar so a total is often done

44
Q

List some indications TKA (6)

A

Pain impacting WB/Function

Destruction of articular cartilage

Deformity (varus or valgus)

instability

Motion loss

Failure of conservative treatment

45
Q

Explain what a unicompartmental knee replacement is?

A

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

46
Q

What is a bicompartmental knee replacement

A

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

47
Q

What is a tricompartmental knee replacement?

A

femoral and tibial and patellar surfaces are replaced

48
Q

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

A

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

49
Q

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

A
50
Q

What is manipulation under asthesia?

A

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

51
Q

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)

A
52
Q

What is this? (test question)

A

Extensor lag

53
Q

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

A

Russian estem

54
Q

What is CPM?

A

Continuous passive motion

pt just lays there and puts the leg through passive motion

used early on

55
Q

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

A

Extension because of that heel strike

56
Q

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

A

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

0 extension

57
Q
A
58
Q

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

A

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

59
Q

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

A

MCL

valgus

60
Q

What kind of injuries cause medial meniscus injuiry?

A

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)

61
Q

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

A

most likely = MCL –> ACL (terrible triad)

62
Q

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

A
63
Q

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

A

locking / catching / sensation of giving away

64
Q

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

A

Longitudinal meniscular tear

needs surgery

turns into bucket handle tear

65
Q

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

A

radial tear

turns into a parrot beak tear

needs surgery

66
Q

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

A

horizontal tear

may progress to a flap tear

may or may not need surgery

67
Q

what muscle might be atrophyed w/ meniscual tears?

A

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

68
Q

what position has locking w meniscular tears (degrees)

A

20-45 degrees

69
Q

Why would a meniscus pt have issues fully extending the knee

A

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

70
Q

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

A

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

71
Q

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

A
72
Q

What is the best imaging for meniscus?

A

MRI

73
Q

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

A
74
Q

What do we do acutely for meniscal tears? (modality wise) 4

How long does it take ot return to activity?

A

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

75
Q

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

A
76
Q

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

A

Outside tears (perimeter tears) heal better

Because they are still vascularized

So the inside of the meniscus is avascular

77
Q

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

A
78
Q

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

A

Saphenous n

79
Q

Which nerve may be damaged w/ lateral meniscus surgery?

A

Pernoneal (fibular) n

80
Q

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?

A

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

81
Q

KNOW: Extensor lag might happen as a meniscal surgery complication

Failure w/ loading and knee flexion beyond 45 degrees might also happen

A
82
Q

meniscus pts are often braced in full extension

A
83
Q

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

A

peripheral because of the vascularization

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

84
Q

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)

A
85
Q

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

T

This machine

A

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

86
Q

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

A

Hamstring curl
Leg press

87
Q

This is a prone hamstring curl

A
88
Q

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

A

90 degrees flexopm

89
Q

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

A

Full 120

90
Q

KNOW: We can use patellar mobility for meniscus repair

A
91
Q

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

A

In a brace

92
Q

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

A
93
Q

how long do meniscus repair pts keep the brace on?

A

6-8 weeks

94
Q

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

A

60-80%

95
Q

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

A

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

96
Q

For an ACL where is your peak shear forces?

A

15-30 degrees of knee flexion

97
Q

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

A

0-60 degrees

Lower test 2 (4 decks)

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