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Knee conditions Flashcards

1
Q

What aspects are observed during a knee assessment

A

Joints above and below

Anterior view, alignment and level, e.g. varu or valgus
lateral view, flexion or hyperextension,

Gait is observed

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2
Q

what are typical ranges of movement for knee movements actively and passively

A

Active ROM
- Knee flexion 135°
- Knee extension 0°
- Internal knee rotation 10°
- External knee rotation 30°-40°

Passive ROM
- Knee flexion 150°
- Knee extension 10° (up to)
- Internal knee rotation 10°
- External knee rotation 30°-40°

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3
Q

what are possible passive ranges of movement that can be conducted at the knee

A
  • Flexion
  • Extension
  • Tibial internal rotation
  • Tibial external rotation
  • Superior patellar glide
  • Inferior patellar glide
  • Medial patellar glide
  • Lateral patellar glide
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4
Q

what are possible isometric muscle tests at the knee

A

Extension
Flexion

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5
Q

what special tests are used to measure test the ACL

A

Lachman’s test
Anterior drawer test

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6
Q

What tests are used to test the PCL

A

Posterior drawer
Sag sign

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7
Q

what is the test for the MCL/LCL

A

Valgus / varus stress test

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8
Q

What test is used for the meniscus?

A

McMurray

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9
Q

What test is used for the patellofemoral ligament

A

Apprehension

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10
Q

what test is used for the ITB

A

Ober’s test

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11
Q

How is lachman’s test carried out

A

tests for ACL injury

pt is in supine, with knee flexed to 20-30 degrees, distal femur stabilised with one hand, other hand on proximal tibia with thumb on tibial tuberosity, anterior pressure is then put onto the tibia, whilst some posterior pressure is put on the femur

a positive test is shown by a 2mm difference compared to the unaffected side or 10 mm translation suggested ACL damage

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12
Q

How is the posterior drawer test carried out?

A

Tests for damage/laxity in the posterior cruciate ligament

Foot rests on plinth, both hands wrap round tibia plateu, try and locate femur tibia step off,

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12
Q

How is the anterior drawer test carried out?

A

Tests the ACL for damage, anterior knee laxity

In supine knee is flexed to 60-90 degrees
Both hands put behind tibia and attempt to displace anteriorly, test is repeated in both 30 ext and internal rotation

positive test from increased displacement of the tibia

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13
Q

How is the posterior drawer test conducted?

A

The posterior drawer test looks at the integrity of the posterior cruciate ligament (PCL)

Patient in supine with knee flexed 60-90 degree, sitso on toes to stabilize limb, grasps proximal tibia with thimbs on tibial plateu to joint line, try to translate posteriorly

positive if lack of end feel or excessive posterior translation

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14
Q

how is the posterior sag sign carried out

A

helps identify PCL tears

pt in supine, hips to 45 and knee in 90, in this position the tibia may be dropped, if positive bring hip to 100 degree, the pt extends knee and tibia should move back to its correct position

positive, tibia creates a concave bellow the knee

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15
Q

How are the MCL and LCL stress tests conducted

A

Valgus stress test
tests integrity of the MCL

2 versions, both pt in supine lying, palpate medial joint line, move knee into valgus , then in neutral apply valgus force

positive if excessive gapping or pain, may also be extra laxity

Varus stress test
Tests LCL ligament integrity

Same as valgus but in varus direction

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16
Q

how is the mcmurray test conducted

A

determines presence of a meniscal tear

Pt lies supine with knee flexed
Proximal hand is on the knee joint line with thumb one side and fingers the other
distal hand holds sole of foot and acts to support limb
from max flexion knee is extended with internal rotation and a varus stress, its returns to max flexion and is then extended with external rotation and valgus stress

internal rotation with varus tests lateral meniscus

external rotation with valgus stress stests medial meniscus

positive finding with pain, snapping, clicking and locking

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17
Q

how is the apprehension test conducted

A

tests integrity of the patellofemoral ligament

pt in supine
press on medial patellar with knee in 30 degree flexion, quads shouldbe relax
thumbs should put lateral pressure

positive if pt attempts to straighten knee or resists

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18
Q

how is clarke’s sign conducted

A

identifies patellofemoral disorders

supine with leg relaxed and in extension, clasp patella with thumb and finger on superior, pt contracts quads,

positive if pain on contraction

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19
Q

how is the ober’s test conducted

A

tests the iliotibial band / contractors in tensor fascia latae

pt in side lying, flexion in hip and knee
extend hip slightly and abduction,
slowly lower leg down to the table,

positive if leg stays in air and does not fall to table

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20
Q

What is the epidemiology of ACL injuries

A

one of most frequently injured structures
20,000 injuries annually in the UK
most common in directional change sports
so football, basketball, skiing
women 2-4 times more likely to obtain this injury

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21
Q

what is the mechanism of injury for ACL injuries

A

80% of injuries are non-contact
often occur when:
quickly changing direction, landing from jump and have sudden deceleration before changing direction

dynamic lower extremity valgus = most common cause of injury
= hip adduction with medial rotation, knee valgus lateral rotation and partial flexion with ankle eversion

can also be due to varus internal rotation
hyperextension

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22
Q

what are the grades of acl rupture and how frequent are they

A

15% of acl injuries are partial ruptures
85% are complete ruptures

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23
Q

what is the prevalence of associated injuries for ACL injuries

A

ACL occurs as an isolated injury in 25% of cases

60% with meniscal injury
30% with articular cartilage damage
30% with other collateral ligaments
>50% with anterolateral ligament
? 10% with posterolateral corner

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24
What are the symptoms of an ACL injury?
In the early stages pain and swelling later stage main concern of ACL injury is functional instability
25
what is functional instability in terms of ACL injuries
Giving way or apprehension of giving way, during activities involving rotation Experienced mainly by participants of jumping, pivoting and directional change sports Pivot shift phenomenon relocates and clunks back and forward subluxation and relocation of femur and tibia normally done by surgeons under aneasthetic
26
How are ACL injuries diagnosed
History 60% of patients report audible pop immediate pain in many cases Significant swelling within first 2 hours 85% of cases have acute haemarthrosis due to the tear Manual testing Anterior drawer test lachman test Imaging MRI X-rays rule out bony injuries
27
what are medical treatment options for ACL injuries
Conservative management 3+ months rehab many dont cope as they dont cope are worse by the time they have surgery so have worse outcomes post surgery some elite athletes can cope without an ACL Surgical ACL reconstruction surgery 6 months+ rehab
28
which acl injured patients are more likely to need surgery
pts at high risk of giving way ○ Ppts of pivoting and cutting (change direction) sports ○ Very physically-demanding jobs § E.g. firefighters ○ Combined ligament injuries Pts with repairable meniscal tears ○ Improved meniscus healing when combined with ACLR
29
what are the stages of surgical ACL reconstruction
Graft harvest 2 common choices Bone-patellar tendon-bone (BPTB) graft 8-11 mm wide graft taken from central third of patella tendon Quadrupled hamstring graft Semitendinosus and gracilis tendons folded in half and combined More flexibility with hamstrings So often preferred to have BPTB Sutures passed through bone plugs Tibial and femoral tunnel drilling Passage of graft through holes Graft fixated with screws
30
what is the process of ligamentisation
Over several months/ years tendon loses tendon properties becoming a ligament animal studies have shown the process is necrosis, revascularisation, cellular proliferation, remodelling
31
what occurs in the early stages of ACL rehabilitation
1-2 weeks aim to control pain and swelling maintain patella mobility protect graft (brace and crutches) Gait re-education Begin regaining ROM - hyperextension (early, full hyperextension reduces incidence of anterior knee pain and other post-op) Lifted ankle on supine ankles off bed in prone early balance exs, early quads and hamstring strengthening
32
what occurs in the intermediate stage of ACL rehab
3-12 weeks quad strengthening exercies recommend open chain with closed chain quad exercises balance training aerobic fitness Controlling dlev - Single leg squat, theraband pull to valgus, resist valgus toe taps, flex knee bring opposite leg back or lateral dynamic step up hamstring strengthening protect ACL e.g. hamstring curls with exs ball, -> single leg
33
what are the componenets of late stage ACL rehab
jogging - running running sideways and backwards changing directions plyo + sport specific drills activities with impact should be introduced slowly and built gradually as majority of ACL injuries have articular cartilage trauma
34
what is the epidemiology of meniscal injuries
often seen in athletes 15% of cases are sport injuries most common in men (men are more likely to get bucket handle lesions) women more likely to have peripheral datachment as more of an elderly injury from minor trauma mean age of injury is 28-40
35
what are risk factors for meniscal injuries
playing sports osteoarthritis (can lead to spontaneous meniscal tear) torn or completley ruptured sport older age overweight intensive training reduced muscle strength varus or valgus deformities
36
what are the types of meniscal tears
traumatic meniscal tear degenerative meniscal tear meniscal rupture
37
what is the mechanims of injury for meniscal tears
most common mechanism of injury is twisting injury on a semi-flexed limb through weight bearing knee can be associated with other ligament injuries at the knee
38
what are the symptoms of a traumatic meniscal lesion
○ Produced by instability of torn fragment ○ Locking of knee (in bucket handle tears) ○ Responsible for knee clicking and popping § Torn part moves under femoral condyle ○ Medial or lateral knee pain (depends on compartment affected) § Caused by abnormal increase in tension in capsule
39
what are the symptoms for a degenerative meniscus
○ Same as in traumatic ○ May also be problems with patella or cartilage ○ Symptoms frequently worsened by flexing and loading at knee § e.g. squatting and kneeling □ These are poorly tolerated
40
what are the different types of ruptures
Radial rupture Oblique rupture Longitudinal rupture Bucket handle Horizontal rupture Complex rupture
41
how are meniscal tears classified
tear length tear depth tear pattern
42
what diagnostic procedures are used for diagnosing ACL tears
MRI athroscopy CT scan
43
what is the main medical treatment used for meniscal injuries
conservative treatment is often used however is normally unsuccessful for young adults probability of healing is also low in degenerative tears operative treatments include: arthroscopy repair and partial reconstruction meniscal allograft transplantation can also be used
44
what are the focusses of physiotherapy in meniscal tear conservative management
focusses on quad strengthening will use strengthening exercises for quads and hamstrings flexibility exercises can also be important joint mobilizations also key
45
what is the acute management for meniscal tear
RICE cryotherapy
46
what is the epidemiology of MCL injuries
athletes ligament injuries account for 40% of all knee injuries and MCL are the most common
47
what is the mechanims of injury for MCL injuries
turning, cutting or twisting direct blows to the knee
48
what is the key anatomy for MCL injuries
one 4 ligaments which stabilizes the knee spans entire medial side of knee from medial aspects of extensor mechanism to posterior aspect of the knee controls for excessive movements at the joint
49
what is the pathophysiology for MCL injuries
Impact on outside of knee, lower thigh or upper legs when foot is unable to move MCL goes under stress due to impact and combined flexion/valgus/ external rotation leads to fibre tears
50
what conditions will have similar symptoms to MCL tears
Medial meniscal tear or injury ACL tear Tib plateau # patellar subluxation/ dislocation medial knee contusion paediatric femoral fracture damage to posteromedial corner structures
51
what are the overall principles for treating MCL injuries
controlling oedema initiating medial quads working to restore ROM as early as possible
52
how is rehab conducted for MCL injuries in the first 2 weeks
ice as needed and tolerated crutches for pain whilst early weight bearing is encouraged maintenance of flex/ ext 0-90 static bike use encouraged
53
what rehab is used MCL injures in the second phase
ROM exs are key pt should progress to 20 mins biking hamstring curls, leg press, step ups
54
what kind pf rehab is from week 5 for MCL injuries
FWB on injured knee discontinued brace when mobilising / weaning Full ROM continue cold therapy for swelling
55
what is the rehab for the final therapy stage of MCL recovery
discontinue brace cold therapy exs are sport specific increased exs intensity
56
what is typical medical treatment for MCL injuries
grade I and II treatment is normally conservative Grade III is usually unsuccessful conservatively
57
what is the epidemiology for patella tendinopathy
young athletes 15-30 yrs more likely in men sports with repetitive loading such as basketball, volleyball, athletic jumping events over 40% prevalence in volleyball and basketball players only 0.1% in general population
58
what are risk factors for patella tendinopathy
gender, weight and BMI more risk at age 30 onwards tight quads and poor core stability
59
what is the key anatomy for mcl injuries
quads inferior to pole of patella through quad tendon patellar ligament connects bottom of patella to tibial tuberosity does not have own nerve supply but adjacent tendon nerve ending are present
60
what is the process of patella tendinopathy
3 stages: * Reactive tendinopathy ○ Non-inflammatory proliferative response to acute tensile or compressive overload ○ Increased protein production * Tendon disrepair ○ Tendon healing is continually attempted following previous stage ○ Greater matrix breakdown ○ Increased no. of cells in matrix ○ Increased vascularity and neuronal ingrowth may occur * Degenerative tendinopathy ○ Areas of cell death occur due to apoptosis, tenocyte exhaustion ○ Large areas of disordered matrix ○ Changes hard to reverse at this stage ○ Mainly seen in elder populations
61
what are the main symptoms of patella tendinopathy
localized pain to the inferior pole of the patella pain rarely present when resting may have pain from long periods of sitting, squatting or stairs loading activities load pain some have warm up phenomenon (increased pain day after activities)
62
what are conditions for differential diagnosis with patella tendinopathy
infrapatellar bursitis fat pad impingement patellofemoral pain plica injuries osgood-schlatter syndrome
63
what advice should be provided and what is the focus for patella tendinopathy rehab
advice on selective rest focus on early return to activities
64
what are the stages of patella tendinopathy managemetn
Stage 1: isometric loading Stage 2: Isotonic Loading Stage 3: Energy-Storage Loading Stage 4: Return to sport (as always based on pain level before move to next stage)
65
what advice can be given for pain management of patella tendinopathy
patellar strap and tape can be used nsaids have a risk of impeding healing corticosteroid injections can decrease pain
66
what are some knee muscle length tests
rectus femoris can be measured with Ely's test hamstrings can be measured with 90-90 stright leg raise Back saver sit and reach test
67
what are some knee functional tests
one leg stand with hands on hips one leg STS one leg hop along line

MSK (10 decks)

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