Knee - Evaluation Flashcards
Evaluation: Diagnostic Classification
During the evaluation, what are the three diagnostic classifications we use to address impairments ?
Knee - Evaluation
Evaluation: Diagnostic Classification:
- Patho-Anatomical
- Movement System
- Treatment Response
Evaluation: Personnel - Review
- (1) Examination →
- (2) ? →
- (3a) ? →
- (3b) ? →
- (4) ? →
- (5) Outcome
Knee - Evaluation
- (1) Examination →
- (2) Evaluation →
- (3a) Diagnosis →
- (3b) Prognosis →
- (4) Intevention →
- (5) Outcome
The Patient’s Story
Fill in the blanks
Knee - Evaluation
The Patient’s Story
- Positives:
- Young Age
- Healthy Lifestyle
- No Red Flags
- ↓ Comorbidities
- ↓Severity
- ↓ Irritability
- Impairments:
- Strength
- Mobility
- Coordination
- Muscle Tightness
- Pain Guarding
- Chief Complaint:
- Patient’s description of what brought them for therapy.
- Treatment:
- Two or three general types of treatment to address your selected impairments.
- Participation:
- Patient’s Goal for Therapy
The Patient’s Story - Review
Five components of the patient’s story = ?
Knee - Evaluation
The Patient’s Story:
- Positives
- Impairments
- Chief Complaint
- Treatment
- Participation
Patellofemoral Pain Syndrome
Annual prevalence is higher for _ ? _ , and _ ? _ .
Knee - Evaluation
Patellofemoral Pain Syndrome:
- Annual Prevalence
- 22.7% / Year
- Higher for Adolescents (29%) & Athletes (45%).
- Mechanism of Injury:
- Compression
- Quads/ITB are too Tight/Active
- Unstable Tracking
- Ligamentous Laxity, ↓ Neuromuscular Control
- Chondritis/Chondromalacia:
Inflammation and Pain of Joint Surface
Articular Cartilage Breakdown & Softening
- Plica:
Pinching and Pain of Vestigial Synovial Fold
Medial Most Common
Patellofemoral Pain Syndrome
Two common mechanisms of injury = ?
Knee - Evaluation
Patellofemoral Pain Syndrome:
- Mechanism of Injury:
(1) Compression = Quads/ITB are too Tight/Active.
- Excessive compression comes about from too much loading through the extensor mechanism.
- We see too much quad loading in cases where the muscles are adaptively shortened or are overly active secondary to spasm or functional demands.
(2) Unstable Tracking = Ligamentous Laxity / ↓ Neuromuscular Control
- In conditions of laxity or poor control, we see an unbalanced lateral pull secondary to IT-band tightness, vastus lateralis dominance, and Q-angulation that starts to glide and tilt the patella laterally, rubbing it asymmetrically against the lateral condyle, or in its most profound state, subluxing or dislocating the patella laterally.
Patellofemoral Pain Syndrome
Chondritis / Chondromalacia = ?
Knee - Evaluation
Patellofemoral Pain Syndrome:
(1) Chondritis: Inflammation and Pain of Joint Surface.
(2) Chondromalacia: Articular Cartilage Breakdown & Softening / An affliction of the hyaline cartilage coating of the articular surfaces of the bone.
Notes:
- These issues tend to be more lateral, secondary to the valgus alignment of the knee.
Patellofemoral Pain Syndrome
- What is Plica = ?
- Most often, occurs laterally or medially ?
Knee - Evaluation
Plica:
- Pinching and pain of vestigial synovial fold
- Medial Most Common
Notes:
Plica = A band of thick, fibrotic tissue that extends from the synovial capsule of a joint.
- Like your cheek finding its way between your teeth when you munch.
What am I = ?
- Male, 28 y/o
- Anterior knee pain worsened by running and squatting.
- Localized pain around the patella.
- (+) Clarke’s grind test
- (-) Femoral neural tension.
Knee - Evaluation
What Am I = Patellofemoral Pain Syndrome
- Male, 28 y/o
- Anterior knee pain worsened by running and squatting.
- Localized pain around the patella.
- (+) Clarke’s grind test
- (-) Femoral neural tension.
What am I = ?
- Female, 38 y/o
- Anterior knee pain during stair climbing.
- Pain centered on the front of the knee.
- ↓ knee flexion ROM
- (+) Patellar tilt test
Knee - Evaluation
What Am I = Patellofemoral Pain Syndrome
- Female, 38 y/o
- Anterior knee pain during stair climbing.
- Pain centered on the front of the knee.
- ↓ knee flexion ROM
- (+) Patellar tilt test
What am I = ?
- Male, 42 y/o
- Anterior knee pain aggravated by jumping sports.
- Reports pain pehind the patella.
- (+) Lateral pull test
- (-) for hyper joint play.
Knee - Evaluation
What Am I = Patellofemoral Pain Syndrome
- Male, 42 y/o
- Anterior knee pain aggravated by jumping sports.
- Reports pain pehind the patella.
- (+) Lateral pull test
- (-) for hyper joint play.
What am I = ?
- Male, 48 y/o
- Anterior knee pain exacerbated by prolonged sitting and standing.
- Pain around & behind the patella.
- (+) Patellar tilt test
- (-) Clarke’s grind test.
Knee - Evaluation
What Am I = Patellofemoral Pain Syndrome
- Male, 48 y/o
- Anterior knee pain exacerbated by prolonged sitting and standing.
- Pain around & behind the patella.
- (+) Patellar tilt test
- (-) Clarke’s grind test.
Patellofemoral pain syndrome can result in = ?
think classifications
Knee - Evaluation
Patellofemoral Pain Syndrome - Classifications:
(-) Retropatellar Pain: Retropatellar pain refers to pain behind the kneecap or patella.
- It is often associated with conditions such as patellofemoral pain syndrome, patellar tendonitis, or chondromalacia patellae.
(-) Extensor Mechanism Dysfunction: The extensor mechanism of the knee involves the quadriceps muscle, the patella (kneecap), the patellar tendon, and the tibial tuberosity.
- Dysfunction of this mechanism can occur due to various factors such as muscle weakness, patellar malalignment, or injury to any component of the extensor mechanism, leading to issues with knee extension and stability.
(-) Chondromalacia: Also known as chondromalacia patellae, is a condition characterized by softening or degeneration of the cartilage on the underside of the patella (kneecap).
- This can result in pain, especially with activities that involve bending the knee.
(-) Plica Syndrome: Plica syndrome occurs when the synovial plica, which is a fold in the synovial membrane of the knee, becomes irritated or inflamed.
- If the plica becomes inflamed due to overuse, injury, or repetitive movements, it can cause pain, swelling, and sometimes “catching” or “clicking” sensations within the knee joint.
Patellofemoral Pain Syndrome
What should manual therapy for patellofemoral pain syndrome include = ?
Knee - Evaluation
Patellofemoral Pain Syndrome - Manual Therapy:
- Patient Education:
- Activity Reduction
- Ice
- Switch to forefoot running
- OTC foot orthosis (If overly Pronated)
- Joint Mobilization
- Patella mobs (if Hypo)
- STM/MFR:
- Quad Muscles
- ITB
- Taping
Patellofemoral Pain Syndrome
What should the therapeutic exercise for patellofemoral pain syndrome include = ?
Knee - Evaluation
Patellofemoral Pain Syndrome - Therapeutic Exercise:
- Motor:
- Quad Stretching, if hypomobile
- ITB Stretching, if hypomobile
- Glute Max Strength
- Glute Med Strength
- Quad Strength
- Peroneal Strength
- Posterior Depression PNF
- Squat/Stair Motor Programming
- Blood Flow Restriction
- Sensory:
- Angle Reproduction
- Neurodynamics:
- Femoral Nerve Glides
Patellar Tendinopathy
Common MOI = ?
Knee - Evaluation
Patellar Tendinopathy:
- Mechanism of Injury = Rapid Increase in Knee Extension.
Patellar Tendinopathy
Describe the inner tendon’s three Phases = ?
Knee - Evaluation
Patellar Tendinopathy - Inner Tendon’s Three Phases:
(1) Reactive:
- 20’s
- Inflammatory
- ↑ Proteoglycans
(2) Disrepair:
- 30’s
- Separation & III Collagen
- Neural Ingrowth
(2) Degenerative:
- 40’s+
- Breakdown
- Cell Death
Patellar Tendinopathy
What is meant by “Focus on the Donut, Not the hole!” = ?
2 Things
Knee - Evaluation
Patellar Tendinopathy:
- Outer Remains Metabolically Active
- “Focus on the Donut, Not the hole!”
- Increase tendon thickness on the outside
- Improve capacity to manage load
What am I = ?
- Male, 40 y/o
- Localized pain & swelling in/around the knee, especially during and after running or climbing stairs.
- Pt. reports pain around the top of patellar ligament.
- Pain w/ resisted knee extension elicits pain.
- (+) Stair Climbing, Jumping
Knee - Evaluation
What am I = Patellar Tendinopathy
- Male, 40 y/o
- Localized pain & swelling in/around the knee, especially during and after running or climbing stairs.
- Pt. reports pain around the top of patellar ligament.
- Pain w/ resisted knee extension elicits pain.
- (+) Stair Climbing, Jumping
What am I = ?
- Female, 45 y/o
- Persistent, sharp pain just below the kneecap aggravated w/ squatting.
- Pain at the proximal aspect of the patellar tendon.
- Swelling evident upon observation.
- Tenderness along the patellar tendon.
- (+) Response to resisted knee extension.
- Negative findings on (-) patellofemoral testing.
Knee - Evaluation
What am I = Patellar Tendinopathy
- Female, 45 y/o
- Persistent, sharp pain just below the kneecap aggravated w/ squatting.
- Pain at the proximal aspect of the patellar tendon.
- Swelling evident upon observation.
- Tenderness along the patellar tendon.
- (+) Response to resisted knee extension.
- Negative findings on (-) patellofemoral testing.
What am I = ?
- Female, 37 y/o
- Pt. resports dull ache and stiffness in the front of the knee, particularly after sitting or standing for a long period of time.
- Pain near the insertion of the patellar tendon.
- Pain elicited upon palpation and contraction of the tendon.
- Noticeable swelling around the patellar tendon.
- (-) Negative patellofemoral testing.
Knee - Evaluation
What am I = Patellar Tendinopathy
- Female, 37 y/o
- Pt. resports dull ache and stiffness in the front of the knee, particularly after sitting or standing for a long period of time.
- Pain near the insertion of the patellar tendon.
- Pain elicited upon palpation and contraction of the tendon.
- Noticeable swelling around the patellar tendon.
- (-) Negative patellofemoral testing.
What am I = ?
- Female, 48 y/o
- Pt. reports persistent pain and tenderness just below the kneecap, worsened w/ activity.
- Pain at proximal patellar tendon.
- Swelling observed around the patellar region.
- (+) Stair climbing
- (+) Resisted knee extension
- (-) Patellofemoral testing.
Knee - Evaluation
What am I = Patellar Tendinopathy
- Female, 48 y/o
- Pt. reports persistent pain and tenderness just below the kneecap, worsened w/ activity.
- Pain at proximal patellar tendon.
- Swelling observed around the patellar region.
- (+) Stair climbing
- (+) Resisted knee extension
- (-) Patellofemoral testing.
Patellar Tendinopathy
What should manual therapy for patellar tendinopathy include = ?
Knee - Evaluation
Patellar Tendinopathy - Manual Therapy:
- Patient Education:
- Activity Reduction
- Ice (If Inflammatory)
- Orthotics - Patellar Tendon Strap
- Joint Mobilization
- Patella - If Hypo
- STM/MFR:
(a) Cross-friction Massage
- 1 Direction
- 2 min light, 2 min heavy
(b) Quadriceps
- Instrument Assisted
- Bend/Pin & Stretch
Patellar Tendinopathy
What should the therapeutic exercise for patellar tendinopathy include = ?
Knee - Evaluation
Patellar Tendinopathy - Therapeutic Exercise:
- Motor:
- Stretch = Quad & ITB stretching
- Strengthen = Glute Max & Calf strengthening
- Tendon:
- Pain should not exceed 5/10
- Decline Slant Board
(I) Isometrics
- If pain reducing, 4-5 sets of 45 sec. hold
(II) Eccentric Training
- 2 x 15, w/ 2RiR
- > 24 Hour Rest
(III) Energy Storage
- Rapid Eccentrics
(IV) Energy Release
- Rapid Concentrics
- Neurodynamics:
- Femoral Nerve Glides
Tibial Tubercle Apophysitis
Three pathologies & areas effect:
- Thrower’s (Little Leaguer’s) Elbow = ?
- Osgood-Schlatter Disease = ?
- Sever Disease = ?
Knee - Evaluation
Tibial Tubercle Apophysitis:
- Similar Pathology:
(I) Thrower’s (Little Leaguer’s) Elbow = Medial Epicondyle
(II) Osgood-Schlatter Disease = Tibia
(II) Sever Disease = Calcaneus
- Mechanism of Injury:
- Rapid bone growth without muscle lengthening.
- Excessive Force
- - Too High/Repetitive
- - Poorly Controlled
“Apophysitis” : is the medical term used to indicate inflammation and stress injury where a muscle and its tendon attaches to the area on a bone where growth occurs in a child or adolescent, an area called the “growth plate
Tibial Tubercle Apophysitis
Apophysis is ? x weaker than surrounding bone/tendon.
Knee - Evaluation
Tibial Tubercle Apophysitis - Apophysis:
- Site of bone growth, not connected to joint line.
- 2-5 x weaker than surrounding bone/tendon.
Tibial Tubercle Apophysitis
MOI’s include = ?
Knee - Evaluation
Tibial Tubercle Apophysitis -Mechanism of Injury:
(1) Rapid bone growth without muscle lengthening.
(2) Excessive Force
- Too High/Repetitive
- Poorly Controlled
What am I = ?
- Female, 14 y/o
- Pt. reports persistent discomfort & swelling below the knee, during and after participation in sports
- Pain over tibial tubercle
- Palpation reveals tenderness and swelling at the tibial tubercle
- (+) Resisted leg extension
- (-) Patellofemoral testing
Knee - Evaluation
What am I = Tibial Tubercle Apophysitis
- Female, 14 y/o
- Pt. reports persistent discomfort & swelling below the knee, during and after participation in sports
- Pain over tibial tubercle
- Palpation reveals tenderness and swelling at the tibial tubercle
- (+) For activities such as running, jumping, and resisted leg extension
- (-) Patellofemoral testing
What am I = ?
- Male, 10 y/o
- Sharp pain & swelling at the front of the knee
- Pain over tibial tubercle
- Palpation elicits pain and tenderness
- (+) Stair climbing
- (-) Patellar ligament palpation.
Knee - Evaluation
What am I = Tibial Tubercle Apophysitis
- Male, 10 y/o
- Sharp pain & swelling at the front of the knee
- Pain over tibial tubercle
- Palpation elicits pain and tenderness
- (+) Stair climbing
- (-) Patellar ligament palpation.
What am I = ?
- Male, 13 y/o
- Dull, aching pain below the kneecap
- Focal swelling evident upon observation.
- Pain w/ palpation and swelling at the tibial tubercle.
- (+) Squatting & resisted leg extension
- (-) Patellofemoral testing
Knee - Evaluation
What am I = Tibial Tubercle Apophysitis
- Male, 13 y/o
- Dull, aching pain below the kneecap
- Focal swelling evident upon observation.
- Pain w/ palpation and swelling at the tibial tubercle.
- (+) Squatting & resisted leg extension
- (-) Patellofemoral testing
What am I = ?
- Male, 12 y/o
- Localized pain & tenderness over the tibial tubercle
- Pain exacerbated by activities like running and jumping
- Swelling observed around the tibial tubercle
- (+) response to stair climbing, squatting, and resisted leg extension
- (-) Patellofemoral testing
- (-) Patellar ligament palpation
Knee - Evaluation
What am I = Tibial Tubercle Apophysitis
- Male, 12 y/o
- Localized pain & tenderness over the tibial tubercle
- Pain exacerbated by activities like running and jumping
- Swelling observed around the tibial tubercle
- (+) response to stair climbing, squatting, and resisted leg extension
- (-) Patellofemoral testing
- (-) Patellar ligament palpation
Tibial Tubercle Apophysitis
What should manual therapy for tibial tubercle apophysitis include = ?
Knee - Evaluation
Tibial Tubercle Apophysitis - Manual Therapy:
- Patient Education:
- Activity Reduction = “Strategic Rest”
- Ice
- STM/MFR:
(I) Quadriceps
- Instrument Assisted
- Bend/Pin & Stretch
- Petrissage
Petrissage: A massage technique that involves applying deep pressure to the muscles, using the palmar surface of the hand, fingers, and thumbs
Tibial Tubercle Apophysitis
What should the therapeutic exercise for tibial tubercle apophysitis include = ?
Knee - Evaluation
Tibial Tubercle Apophysitis - Therapeutic Exercise:
- Motor:
(I) Stretch = Quad & ITB Stretching
(II) Strengthen = Glute
(III) Spot-treat Poor Functional Mechanics:
- Stairs
- Squat
- Lunge
- Deadlift
- Sports
Meniscus Injury
MOI’s include = ?
Knee - Evaluation
Meniscus - Mechanism of Injury:
- Excessive Rotation
- Closed Chain > Open Chain
Meniscus Injury
True or False:
- The majority of cases get better with conservative care.
Knee - Evaluation
True
- Majority of cases get better with conservative care, and in potentially operative cases, PT performs as well as surgery.
What am I = ?
- Female, 25 y/o
- Rports pain & swelling around the knee
- Pain is worse after rugby practice
- Lateral & medial knee pain.
- Knee exhibits guarded movements & stiffness upon examination.
- (+) McMurray’s
- (+) Thessaly’s
- (+) Apley’s
Knee - Evaluation
What am I = Meniscus Injury
- Female, 25 y/o
- Rports pain & swelling around the knee joint, worse after rugby practice
- Lateral & medial knee pain.
- Knee exhibits guarded movements & stiffness upon examination.
- (+) McMurray’s Test (Posterior)
- (+) Thessaly’s Test (Mid-Substance)
- (+) Apley’s Test (Mid-Substance)
What am I = ?
- Female, 28 y/o
- Pt. reports vague lateral knee pain that’s worse w/ activity, and “giving out”
- Swelling observed at the joint line
- Knee appears guarded w/ examination
- (+) Thessaly’s
- (+) Apley’s
Knee - Evaluation
What am I = Meniscus - Midsubstance
- Female, 28 y/o
- Pt. reports vague lateral knee pain that’s worse w/ activity, and “giving out”
- Swelling observed at the joint line
- Knee appears guarded w/ examination
- (+) Thessaly’s
- (+) Apley’s
What am I = ?
- Male, 30 y/o
- Knee pain, particularly on the lateral side
- Pain worse w/ kneeling at work and participating in soccer matches.
- Vague, predominantly lateral knee pain
- Swelling observed at the joint line
- (+) McMurray’s
- (+) Steinmann I & II
- (+) Bounce Home tests.
Knee - Evaluation
What am = Meniscus Injury
- Male, 30 y/o
- Knee pain, particularly on the lateral side
- Pain worse w/ kneeling at work and participating in soccer matches.
- Vague, predominantly lateral knee pain
- Swelling observed at the joint line
- (+) McMurray’s
- McMurray’s - Posterior
- Steinmann I = Mid-Substance
- Steinmann II = Anterior
- Bounce Home tests = End feel
What am I = ?
- Female, 29 y/o
- Pt. reports persistent medial knee pain
- Pt. reports occasional giving out of the leg.
- Pain worsened by kneeling and bending at work
- (+) McMurray’s
- (+) Ege’s
- (+) Apley’s
Knee - Evaluation
What am I = Meniscus Injury
- Female, 29 y/o
- Pt. reports persistent medial knee pain
- Pt. reports occasional giving out of the leg.
- Pain worsened by kneeling and bending at work
- (+) McMurray’s Test (Posterior Horn)
- (+) Ege’s Test (Posterior Horn)
- (+) Apley’s Test (Mid-Substance)
Meniscus
What should manual therapy for a meniscus injury include = ?
Knee - Evaluation
Meniscus Injury - Manual Therapy:
- Patient Education:
(I) Activity Reduction
- Avoid Closed-Chain Rotation
(II) Ice - If Inflammatory
- Joint Mobilization:
(I) Meniscofemoral I-IV
(II) Meniscotibial I-IV
- STM/MFR:
(I) Cross-friction Massage
- Menisotibial Ligaments
- Patellomeniscal Ligament
- 1 Direction
- 2 min light, 2 min heavy
Meniscus
What should the therapeutic exercise for a meniscus injury include = ?
Knee - Evaluation
Meniscus Injury - Therapeutic Exercise:
- Motor
(I) Progressive
- ROM
- Weight-bearing
(II) Rotational Motor Control
- Open → Closed Chain
- Lumbar
- Hip
- Hamstrings/Gastroc
- Peroneals/Intrinsics
(III) Quad Strength
(IV) Hamstring Strength
- Sensory:
(I) Angle Reproduction and Reflex Reactivation
- Turning (Car Entrance/Exit)
- Stairs/Squatting/Jumping
- Sport-Specific
ACL Injury
MOI = ?
Knee - Evaluation
ACL Injury - Mechanism of Injury:
- Non-contact is Most Common (70+%)
- Rapid Deceleration in Low Flexion Angle (0-30°)
- Tibial Ant Shear > Valgus + Tibial IR
- Minimal Help from Hamstrings at (0-15°)
ACL Prevention
“Primary Prevention”, Patient education includes = ?
Knee - Evaluation
Primary Prevention:
- Supportive Evidence
- 52-88% ↓ Injury Rate
- Programs Decrease Severity
- Patient Education
- Start in Preseason
- Use As a Warm-up (Esp. Women < 18)
- Recommendation:
- All 12-25 year-old athletes in ACL-risky sports should undertake.
- ACL Prevention Protocols
“Secondary Prevention”, Patient education includes = ?
Knee - Evaluation
Secondary Prevention
- Supportive Evidence:
- 24-30% - 2nd ACL Rupture
- 50% - Meniscus Surgery
- Increased OA up to 50%
- Patient Education:
- Increasing Daily Activity
- Maintaining Healthy BMI
- 4x Re-tear in Pivot Sports
- Re-tear Rate ↓ for 9-months
ACL Prehabilitation
Benchmarks to Begin Prehab include = ?
Knee - Evaluation
Initiation:
- Benchmarks to Begin:
- Full RoM
- Minimal Pain
- Limited-to-No Effusion
- If Incorporating Plyo = Able to SL Hop
- May Take Up To 2 Months
Post-surgical ACL Rehabilitation
Manual Therapy during post-surgical ACL rehabilitation includes:
- Patient Education = ?
- Joint Mobs = ?
- STM/MFR = ?
Knee - Evaluation
Manual Therapy:
- Patient Education:
- Activity Modification
- Crutch Use
- Ice
- Orthotics (adjustable hinged knee brace)
- Joint Mobilization:
- Patellofemoral (III-IV)
- Tibiofemoral (I-IV)
- STM/MFR:
(I) ITB
(II) Leg Muscles
- Quads
- Hamstrings
- Calf
Post-surgical ACL Rehabilitation
What can expect to find in your Examination = ?
“What would the pt. say?” / +’s & -‘s
Knee - Evaluation
Post-surgical ACL Rehabilitation:
- Observation:
- Heard an Audible ‘Pop’
- Immediate Swelling
- Difficulty Walking
- Examination:
- Pain w/ most movements
- ↓ ROM
- (+) Anterior Drawer
- (+) Lachman’s
- (-) PCL
PCL Injury
MOI = ?
Knee - Evaluation
PCL Injury - Mechanism of Injury:
- PCL Controls Posterior Tibial Translation
- High-energy Trauma:
- Dashboard MVA
- Fall on a Flexed Knee
- Forced Hyperextension
- Frequently Occur with Other Ligament Injuries.
True or False:
- Recovery from PCL surgical repair usually takes longer than recovering from an ACL surgical repair, and has a more strict protocol to follow?
Knee - Evaluation
True:
- Recovery from PCL surgical repair usually takes longer than recovering from an ACL surgical repair, and has a more strict protocol to follow.
What am I = ?
- Male, 28 y/o
- Feels like a deep ache in the knee
- Plays flag football regularly, and states, “It feels like my shinbone shifts back more than it should”
- (+) Posterior drawer test
- (+) Godfrey’s sag sign
Knee - Evaluation
What am I = PCL Injury
- Male, 28 y/o
- Feels like a deep ache in the knee
- Plays flag football regularly, and states, “It feels like my shinbone shifts back more than it should”
- (+) Posterior drawer test
- (+) Godfrey’s sag sign
What am I = ?
- Female, 35 y/o
- Pt. reports diffuse pain, posterior knee
- Pt. reports, “Hurts when I try to do almost anything with my knee, and seems to rotate out more than usual”
- (+) Reverse pivot-shift test
- (+) Dial test at 80 degrees
- Meniscus seems unaffected
Knee - Evaluation
What am I = PCL Injury
- Female, 35 y/o
- Pt. reports diffuse pain, posterior knee
- Pt. reports, “Hurts when I try to do almost anything with my knee, and seems to rotate out more than usual”
- (+) Reverse pivot-shift test
- (+) Dial test at 80 degrees
- Meniscus seems unaffected
What am I = ?
- Male, 22 y/o
- Deep, gnawing pain in the back of knee
- Pt. states “It feels like my shin goes back too much, and it’s really painful to move my knee at all”
- (+) Godfrey’s sag sign
Knee - Evaluation
What am I = PCL Injury
- Male, 22 y/o
- Deep, gnawing pain in the back of knee
- Pt. states “It feels like my shin goes back too much, and it’s really painful to move my knee at all”
- (+) Godfrey’s sag sign
What am I = ?
- Female, 30 y/o
- Pt., reports pain following falling on knee during soccer game
- Constant, dull ache deep in knee
- Pain w/ all knee movement
- (+) Reverse pivot-shift test
- (-) MCL
- (-) Meniscus
Knee - Evaluation
What am I = PCL Injury
- Female, 30 y/o
- Pt., reports pain following falling on knee during soccer game
- Constant, dull ache deep in knee
- Pain w/ all knee movement
- (+) Reverse pivot-shift test
- (-) MCL
- (-) Meniscus
What should the manual therapy
for a PCL Injury include = ?
Knee - Evaluation
PCL Injury - Manual Therapy:
- Patient Education:
- Recovery Expectations
- WB Status
- Ice
- Crutch Training
- Orthotics - Adjustable Hinged Knee Brace
- Joint Mobilization
- Patellofemoral Joint (III-IV)
- STM/MFR
(I) ITB
(II) Leg Muscles
- Quads
- Hamstrings
- Calf
PCL Injury
What should the therapeutic exercise for a PCL Injury include = ?
Knee - Evaluation
PCL Injury - Therapeutic Exercise:
- Non-Operative:
- 2-4 Wks Immobilization in full extension
- Followed by stabilization program & quad focus
- Operative:
- Healing can take twice as long as ACL
- Similar Protocol to ACL
- Longer Immobilization (3-6w)
- Longer Brace Time (2-4m)
Focus:
- (I) Progressive Weight Bearing
- (II) Limiting Posterior Tibial Shear
- (III) Limiting Hamstring Recruitment
- (IV) Promote Quad Activation
Collateral Injury
MOIs = ?
Knee - Evaluation
Collateral Injury - Mechanism of Injury:
- High-energy Trauma:
(I) Contact Sports
- Blow to Outside of knee = MCL
- Blow to the Inside of Knee = LCL (Least common ligament injury)
(II) Least Common Ligament Injury
- Frequently Occur with ACL/Meniscus Injury
- Deep Portion Torn First – Compromises Meniscus
What am I = ?
- Female, 23 y/o
- “I play soccer, I tried to make a right cut and felt a pretty bad pain on the inside of my knee”
- “Hurts when I try to move my knee to the side”
- Pt. walking w/ limp
- Pain with palpation over medial knee
- (+) valgus stress test
- (-) PCL
Knee - Evaluation
What am I = (MCL) - Collateral Injury
- Female, 23 y/o
- “I play soccer, I tried to make a right cut and felt a pretty bad pain on the inside of my knee”
- “Hurts when I try to move my knee to the side”
- Pt. walking w/ limp
- Pain with palpation over medial knee
- (+) valgus stress test
- (-) PCL
What am I = ?
- Male, 60 y/o
- “It’s a sharp pain along the inner side of my knee”
- Through observation, pt. is favoring injured leg w/ walking
- Pain w/ end ROM
- (+) Valgus stress test
Knee - Evaluation
What am I = (MCL) - Collateral Injury
- Male, 60 y/o
- “It’s a sharp pain along the inner side of my knee”
- Through observation, pt. is favoring injured leg w/ walking
- Pain w/ end ROM
- (+) Valgus stress test
What am I = ?
- Female, 21 y/o
- Localized pain along lateral knee
- Pt reports, “I play rugby and ran into another player when I tried to make a cut”
- Pt. displays limp and attributes it to pain w/ walking
- Tender to touch
- (+) Varus stress test
Knee - Evaluation
What am I = LCL - Collateral Injury
- Female, 21 y/o
- Localized pain along lateral knee
- Pt reports, “I play rugby and ran into another player when I tried to make a cut”
- Pt. displays limp and attributes it to pain w/ walking
- Tender to touch
- (+) Varus stress test
What should the manual therapy for a collateral injury include = ?
Knee - Evaluation
Collateral Injury - Manual Therapy:
- Patient Education:
- Activity Modification
- Ice
- Crutch Training
- Orthotics - Hinged Knee Brace
- Joint Mobilization:
- Patellofemoral Joint (III-IV)
- Tibiofemoral Joint (I-IV)
- STM/MFR:
(I) Cross-friction Massage:
- Directly to LCL/MCL
- 1 Direction
- 2 min light, 2 min heavy
(II) Muscles:
- Adductors
- Hamstrings
- Gastrocnemius
What should the therapeutic exercise for a collateral injury include = ?
Knee - Evaluation
Collateral Injury - Therapeutic Exercise:
- Non-surgical Treatment:
- Progressive RoM & WB
- ↑ Glute, Ham, Quad, Add
- Protocol:
Phase I (1-4 Weeks)
- Inflammation Control
- Bracing
- ROM/Stretching/Biking
- Non-WB Strengthening
- Progressive WB
Phase II (4-6 Weeks)
- Discontinue Brace
- Full WB
- WB Strengthening
- Cardiovascular Program
- Balance/Proprioception
Phase III (6-12 Weeks)
- Multi-directional Ex
- Sport Specific Training
Potential Return to Sport
- Consider around 3 month
At what joint is OA the most common ?
Knee - Evaluation
At what joint is OA the most common = The Knee
What am I = ?
- Female, 57 y/o
- Experiencing diffuse pain in both knees
- BMI = 30 & history of knee injury
- (+) antalgic gait
- Noticeable varus deformity
- ↓ ROM
- “clicking” sensation & morning stiffness
- (-) meniscus testing
Knee - Evaluation
What am I = Knee OA
- Female, 57 y/o
- Experiencing diffuse pain in both knees
- BMI = 30 & history of knee injury
- (+) antalgic gait
- Noticeable varus deformity
- ↓ ROM
- “clicking” sensation & morning stiffness
- (-) meniscus testing
What am I = ?
- Male, 48 y/o
- Diffuse knee pain, more pronounced in the left knee
- (+) Antalgic gait
- Varus deformity noted in the left knee
- Audible crepitus during joint movement
- (-) Meniscus testing
Knee - Evaluation
What am I = Knee OA
- Male, 48 y/o
- Diffuse knee pain, more pronounced in the left knee
- (+) Antalgic gait
- Varus deformity noted in the left knee
- Audible crepitus during joint movement
- (-) Meniscus testing
What am I = ?
- Male, 50 y/o
- Bilateral, diffuse knee pain
- No significant history of knee trauma
- Slight varus deformity
- Pain during closed-chain ROM assessment
- Pt. reports occasional “clicking” sensation and morning stiffness
Knee - Evaluation
What am I = Knee OA
- Male, 50 y/o
- Bilateral, diffuse knee pain
- No significant history of knee trauma
- Slight varus deformity
- Pain during closed-chain ROM assessment
- Pt. reports occasional “clicking” sensation and morning stiffness
What should the manual therapy for knee OA include = ?
Knee - Evaluation
Knee OA - Manual Therapy:
- Patient Education:
- Ice or Heat
- Compression
- Varus Unloading Braces
- Weight Management
- Assistive Device (Cane)
Referral for:
- Injection/Meds/Topicals
Supplements:
- Turmeric
- Ginger Extract
- Glucosamine/Chondroitin
- Vitamin D
- Joint Mobilization:
- Tibiofemoral Joint (I-II)
- Soft Tissue Massage
What should therapeutic exercise for a knee OA include = ?
Knee - Evaluation
Knee OA - Therapeutic Exercise:
- Motor:
- Functional Motor Patterns
- Glute Max Strength
- Glute Med Strength
- Foot Intrinsic Strength
- Peroneal Strength
- Sensory:
- Balance
- Proprioception
- Protocol Stage (Weeks):
- Post-operative (1-2
- Motion (3-6
- Intermediate (7-12
- Advanced Activity (13-26
What am I = ?
- Female, 23 y/o
- Deep, diffuse pain in the knee
- Pt. reported hearing an audible ‘pop’ when she planted her foot to cut at basketball practice
- Noticable swelling, and difficulty walking
- ↓ knee ROM
- (+) Anterior drawer
- (+) Lachman’s test
Knee - Evaluation
What am I = ACL Injury - (Post-surgical Rehabilitation)
- Female, 23 y/o
- Deep, diffuse pain in the knee
- Pt. reported hearing an audible ‘pop’ when she planted her foot to cut at basketball practice
- Noticable swelling, and difficulty walking
- ↓ knee ROM
- (+) Anterior drawer
- (+) Lachman’s test
What am I = ?
- Male, 18 y/o
- Pt. reports pain “deep” in the knee after pivoting around another player at soccer practice
- Additionally, they couldn’t finish practice due to immediate swelling, difficulty w/ walking, and pain
- ↑ Laxity noted
- (+) Anterior drawer
Knee - Evaluation
What am I = ACL Injury - (Post-surgical Rehabilitation)
- Male, 18 y/o
- Pt. reports pain “deep” in the knee after pivoting around another player at soccer practice
- Additionally, they couldn’t finish practice due to immediate swelling, difficulty w/ walking, and pain
- ↑ Laxity noted
- (+) Anterior drawer
What am I = ?
- Female, 30 y/o
- Deep knee pain
- During the interview, pt. reports they’ve never really been active, however, they’ve lost 100 lbs. over the past 12 months, primarily going to ZUMBA class and jogging on turf.
- Last week, they felt a ‘pop’ in the middle of their ZUMBA class and it was hard to walk after.
- Upon examination, you note ↓ knee ROM
- (+) Lachman’s
- (-) PCL test
Knee - Evaluation
What am I = ACL Injury - (Post-surgical Rehabilitation)
- Female, 30 y/o
- Deep knee pain
- During the interview, pt. reports they’ve never really been active, however, they’ve lost 100 lbs. over the past 12 months, primarily going to ZUMBA class and jogging on turf.
- Last week, they felt a ‘pop’ in the middle of their ZUMBA class and it was hard to walk after.
- Upon examination, you note ↓ knee ROM
- (+) Lachman’s
- (-) PCL test
What am I = ?
- Male, 35 y/o
- Pain throughout the entire “middle” of the knee
- Pt. reports that they actively engage in recreational basketball, soccer, and had “injured” both knees playing football in college.
- During the exam, you note ↑ laxity noted
- (+) Anterior drawer
Knee - Evaluation
What am I = ACL Injury - (Post-surgical Rehabilitation)
- Male, 35 y/o
- Pain throughout the entire “middle” of the knee
- Pt. reports that they actively engage in recreational basketball, soccer, and had “injured” both knees playing football in college.
- During the exam, you note ↑ laxity noted
- (+) Anterior drawer
What should manual therapy for post-surgical ACL rehab include = ?
Knee - Evaluation
Post-surgical ACL Rehabilitation - Manual Therapy:
- Patient Education:
- Activity Modification
- Crutch Use
- Ice
- Orthotics - Adjustable Hinged Knee Brace
- Joint Mobilization:
- Patellofemoral (III-IV)
- Tibiofemoral (I-IV)
- STM/MFR:
(I) ITB
(II) Leg Muscles
- Quads
- Hamstrings
- Calf
What should therapeutic exercise for post-surgical ACL rehab include = ?
Knee - Evaluation
Post-surgical ACL Rehabilitation - Therapeutic Exercise:
- Clinical Practice Guideline
- Prehab is beneficial
- Early mobility and WB
- Early ice and bracing
- Test Battery is Beneficial
- No CPM or Functional Brace
- Long or Guided Therapy?
Strength and Motor Control
- Start with Closed Chain
- Open Chain After 4 Wks
- Use e-Stim
- Protocol Stage (Weeks)
- Preoperative Management
- Post-operative Period (wk 1
- Early Rehabilitation (wk 2-4
- Progressive Control (wk 5-10
- Advanced Activity (wk 10-16
- Return to Activity (wk 16+
