Knee - Evaluation Flashcards by Benjamin Kozak

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

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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

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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

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The Patient’s Story - Review

Five components of the patient’s story = ?

Knee - Evaluation

The Patient’s Story:

Positives
Impairments
Chief Complaint
Treatment
Participation

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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

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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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

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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

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Patellar Tendinopathy

Common MOI = ?

Knee - Evaluation

Patellar Tendinopathy:

- Mechanism of Injury = Rapid Increase in Knee Extension.

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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

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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

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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

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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.

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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.

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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.

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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

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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

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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

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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.

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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

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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

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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.

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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