knee clinical conditions pt 2 Flashcards
result from an overconstrained patella whose motion is severely restricted by surrounding soft tissues
Patellar Compression Syndromes
2 types of Patellar Compression Syndromes
Lateral patellar compression syndrome
Infrapatellar contracture syndrome
tight lateral retinaculum may be responsible for patellar tilt and excessive pressure on the lateral patellar facet, producing the excessive lateral pressure syndrome
diagnosis is confirmed clinically by a decreased medial patellar glide and evidence of a lateral patellar tilt.
The medial stabilizers play a role in the lateral pressure and the VMO frequently becomes atrophied, probably as a result of the new patellar position, the associated pain, and the resultant inflammation.
Lateral patellar compression syndrome
Characterized by a restriction of patellar movement because both the medial and lateral retinaculum are excessively tight
Decrease in knee flexion and extension → global patellar pressure syndrome
Development of this condition appears to be related to direct trauma and subsequent pathologic fibrous hyperplasia in the peripatellar tissues or secondary to prolonged immobilization after surgery
Infrapatellar contracture syndrome (IPCS)
Stages of Infrapatellar contracture syndrome (IPCS)
Prodromal stage
Active Stage
Residual stage
2-8 wks after trauma to the knee
Rehabilitation should be initiated with early patellar mobilization, stretching of the hamstrings, hip flexors, quadriceps, gastrocnemius, and ITB, with the emphasis on restoring full knee extension.
should include active ROM, multi angle isometric strengthening of the quadriceps, neuromuscular stimulation, transcutaneous electrical nerve stimulation (TENS), and NSAIDs
When performing the patella mobilizations, the glides should be held for a long duration (1–12 minutes) to enhance the remodeling of the soft tissue.
Prodromal stage
restriction of passive and active knee ROM
There are also tissue texture changes in the patella tendon
This creates a positive shelf sign: an abrupt step-off or shelf from the patellar tendon to the tibial tubercle
Patients who progress to this stage require surgery, with open intra articular and extra-articular debridement.
Immediate daily rehabilitation with continuous passive motion (CPM), full AROM, and extension splints at night
Active Stage
notable for significant patellofemoral arthrosis and a residual low-riding patella at 8 months or even years after the onset of IPCS.
The patient history typically includes complaints of knee pain and stiffness, swelling, and crepitus, and giving way may also be reported.
On physical examination, the diagnosis may be made by a 10-degree or greater loss of extension, a 25-degree or greater loss of flexion, and significantly reduced patellar mobility as demonstrated by decreased patellar glide.
Additional findings include atrophy of the quadriceps femoris, palpable patellofemoral crepitus, diffuse synovitis, and an antalgic or flexed knee gait.
Residual stage
Common cause of pain and functional disability
Since nonoperative rehabilitation and palliative care for this condition are frequently unsuccessful, many patients opt for surgical procedures designed to facilitate the repair or transplantation of autogenous cartilage tissue.
Articular Cartilage Defect
performed to reduce the inflammation and mechanical irritation within a given joint.
Debridement can include smoothing of the fibrillated articular or meniscal surfaces, shaving of motion-limiting osteophytes, and removal of inflamed synovium
Arthroscopic lavage and debridement
controlled perforation of the subchondral bone plate to permit an efflux of pluripotent marrow elements into a chondral defect
Microfracture
Chondrocyte will form the cartilage again
Osteochondral autograft transfer
Osteochondral allograft transplant
Autologous chondrocyte implantation
Post surgical rehabilitation progression
Proliferation phase
Transition phase
Remodeling phase
Maturation phase
Lasts 4-6 weeks following surgery.
Goals during this phase are: to protect the repair, decrease swelling, gradually restore PROM and weight bearing and to enhance volitional control of the quadriceps
Ice after surgery, change to heat
Proliferation phase
Typically consists of weeks 4-12 post surgery.
During this phase, the patient progresses from partial to full weight bearing while full ROM and soft tissue flexibility is achieved.
During this phase in which patients typically resume most normal activities of daily living except if he is in sports
Transition phase
Takes place from 3-6 months postoperatively
Patient typically notes improvement of symptoms and has normal ROM.
During this phase, low-to-moderate impact activities, such as bicycle riding, golfing, and recreational walking, are gradually incorporated.
Remodeling phase
begins in a range of 4-6 months and can last up to 15-18 months post surgery
The duration of this phase varies based on lesion size and location, and the specific surgical procedure performed
Can do more impact exercises: running, jumping
Maturation phase
most common cause of disability in the United States
“wear and tear”, “degenerative”
Muscle weakness is probably the longest documented and best established correlate of functional limitation in individuals with knee OA
Tibiofemoral Osteoarthritis
Pain is the first symptom
Swelling
Warm to touch
Pain with weight-bearing activities and, at times, pain at rest
Loss of motion
Clinical findings of Tibiofemoral OA
Obese
Previous history of trauma to the knee: avascular necrosis, knee injury, ligament tear
Does a lot of activity that involves the knee: carrying, lifting loads
No cure to degeneration
Risk factors of Tibiofemoral OA
Decreasing weight
Exercise to strengthen quadriceps
Aerobic exercises
For elderly: best exercise is swimming (there’s less weight but you can strengthen the joints)
Conservative treatment for Tibiofemoral OA
Softening of the cartilage on the posterior aspect of the patella
Occur in fewer than 20% of persons who present with anterior knee pain
Most common in the 12–35-year-old age group, predominance in females
Chondromalacia Patella
Two types of Chondromalacia Patella
- surface degeneration of the patella that is age dependent and most often asymptomatic
- basal degeneration results from trauma and abnormal tracking of the patella and is symptomatic
intact joint surface that is spongy
softening is reversible
a blister or raised portion of the articular surface is seen
Grade 1. Closed disease
fissures that may or may not be obvious initially
Grade 2. Open disease
Severe exuberant fibrillation or crabmeat appearance.
Grade 3
fibrillation is full-thickness and the erosive changes extend down to bone, which may be exposed
This is, in effect, OA and its extent depends on the size of the lesion.
Grade 4
Sudden deceleration, an abrupt change of direction, and a fixed foot
knee popping or giving out as the tibia subluxes anteriorly
+ anterior drawer’s test
+ hemaarthrosis
ACL Tear
Incidence of ACL tear
F > M
Femoral Notch as risk of ACL tear
narrow intercondylar increase the potential for ACL ruptures
Joint laxity as risk of ACL tear
greater in women than in men
estrogen, estradiol, and relaxin as risk of ACL tear
increased ACL injury in females
ACL size as risk for ACL tear
women have smaller ACL size than men, increases risk of tear
Muscular strength and muscular activation patterns as risk for ACL tear
women significantly have less muscle strength in quads and hamstrings compared to men
Anatomic alignment and structural differences as risk for ACL tear
differences in pelvic width and tibiofemoral angle
magnitude of the quadriceps femoris angle (Q-angle)
width of the femoral notch
most common cause of mechanical symptoms in the knee
occur when the patient attempts to turn, twist, or change direction when weight-bearing
can also occur from contact to the lateral or medial aspect of the knee while the lower extremity is planted
history of swelling, popping, or clicking, and pain along the joint line.
Meniscal Tears
medial meniscus, ACL, & MCL. Injury to 3 ligaments
Unhappy triad of o’donoghue
most common type of meniscus tear
Bucket handle
anterior pain
clicking, catching, locking, or pseudo locking of the knee
may even mimic acute internal derangement of the knee.
Plica Syndrome
stretching of the quadriceps, hamstrings, and gastrocnemius
sometric strengthening, cryotherapy, ultrasound, patellar bracing, antiinflammatory medication,
conservative intervention for plica syndrome
overuse conditions that are frequently associated with eccentric overloading during deceleration activities (e.g., repeated jumping and landing, downhill running)
Patellar Tendinitis (Jumper’s knee)
5-minute warm-up period consisting of a series of three to five static stretches held for 15–30 seconds each is performed
Treated with modalities (if there is pain), lessen the activity of the patient, then strengthening exercises
Next, the patient, from a standing position, flexes the knees, abruptly drops to a squatting position, and then recoils to the standing position
strengthening program of eccentric exercise for chronic patellar tendinitis
repetitive stress injury that results from friction of the ITB as it slides over the prominent lateral femoral condyle at approximately 30 degrees of knee flexion
most common overuse syndrome of the knee, being particularly common in long-distance runners (20–40 miles/week)
localized tenderness to palpation at the lateral femoral condyle or Gerdy’s tubercle
(+) Ober’s test
Iliotibial Band Friction Syndrome
activity modification to reduce the irritating stress (decreasing mileage, changing the bike seat position, and changing the training surfaces)
using new running shoes
heat or ice applications
strengthening of the hip abductors
stretching of the ITB
Conservative intervention for Iliotibial Band Friction Syndrome
bursa in the medial aspect of the knee
Pes anserine bursitis
tendons inserted in pes anserine bursitis
semitendinosus, gracilis, sartorius
carpet layer’s knee, housemaid’s knee
Prepatellar bursa
clergyman’s knee (those who kneel like for prayer)
Infrapatellar bursa
Anti-inflammatory medicines
Applying heat, ultrasound
TENS for pain and to strengthen the quadriceps
Treatment for pes anserine bursitis
Apophysitis of the tibial tubercle
avulsion of the tibial tubercle
Osgood–Schlatter disease
Apophysitis of the inferior pole of the patella that occurs in skeletally immature individuals
Sinding–Larsen–Johanssen syndrome
