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MSPT I > Knee-Final Lecture: Exam 2 > Flashcards

Knee-Final Lecture: Exam 2 Flashcards

1
Q

Knee Jt. Sx

What do you NEED to keep in mind??

*AVOID overstressing what was done!

A

Tx Principles

  • Avoid?
  • Emphasize?
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2
Q

Tissue stress/Jt. Stress

  1. Symptom Mod. & Tissue Protection
  2. Movement Control
  3. Functional Optimization
A
  • Symptom Mod. & Tissue Protection
    • ​LOAD IT CAREFULLY!
    • Ex. in UPPER pt of maintenance, LOWER pt of hypertrophy
  • Movement Control
    • ​LOAD IT THOROUGHLY
    • Ex. in the hypertrophy zone, AVOIDING injury
  • Fxnl Optimization
    • ​LOAD IT IN CONTEXT
    • Ex. in NEW hypertrophy zone, AVOIDING injury
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3
Q

When in doubt….

W/ Knee Sx

A
  • Get Op report
    • Repair vs. Reconstruction
      • ​tells you about Tissue Quality
    • YOU CAN ALWAYS MOBILIZE THE PATELLA
    • ​Get a good Isolated Quad Contraction!!!
      • ​Quad sets—–hundreds!!!
      • Stim the hell out of the Quad
      • Extension to 0o
        • GET THEM TO ZERO!!!
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4
Q

Gen. Knee Sx

Phase 1: Symptom Mod. & Tissue Protection

A

Ranked (MOST important FIRST)

  1. Protect the Sx
    1. ​Sx & Tissue specific cond’s
  2. Regain EXTENSION
  3. Restore Quadriceps Contraction
  4. Regain FLEXION
    1. ​emphasize ability to transition from FLEX to EXT.
  5. DEC effusion/Inflammation
  6. Prevent atrophy of other mm’s
  7. Normalize Gait
    1. ​*Actually MORE important than FLEX.
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5
Q

Tissue Protection Phase

GOALS:

A
  • Restore ROM w/out over-stressing sx tissues
  • Prevent mm atrophy and contractures
  • Modify gait patterns to improve overall fxn
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6
Q

Tissue Protection Phase

Causes of Concern

*Not making progress + Immediate Referral

A
  1. Concerning ROM Limits:
    1. ​Not achieving 0o by 4 wks
    2. Not achieving 90o by 4 wks
  2. IMMEDIATE REFERRAL OUT:
    1. ​10o FLEX contracture @ 6wks
      1. *compared to anatomic 0o
    2. Not achieving 90o by 12wks
    3. Consistent motion loss
    4. Symptomatic instability
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7
Q

Post-OP Brace & AD Use—Lig. Sx

Post-OP Orthosis

A
  • Brace locked in EXT ~1 week
  • Brace UNLOCKED after week 1 for ambulation and PT
    • ​**IF quad lag has been resolved
  • Discharge brace when pt has:
    • ​FULL passive hyperEXT (0o) AND @ least 90o of FLEX
    • FULL Active EXTENSION
    • “NORMAL” pain-free gait pattern
    • Usually around 4-6wks
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8
Q

Post-OP Brace & AD Use—-Lig Sx

AD Use

A
  • WBAT w/ crutches for first 4 wks
  • SAME CRITERIA AS DISCHARGING BRACE
  • Begin weaning to 1 crutch and THEN discharge crutches when:
    • ​1. pt exhibits non-antalgic gait pattern
      1. Reaches FULL EXT @ Heel Strike
      1. Pt. does NOT display any INC in swelling
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9
Q

Restoring Quadriceps Function

SO IMPORTANT!!!!

A
  • Pain + Effusion—> adversely affect quad function
    • ​=====quad inhibition
  • Quad activation failure===EXT. mech. disrupted
    • ​quad tendon OR patellar tendon autografts
  • Poor quad function ==> patellofemoral arthrofibrosis (stiff & sticky)
  • GOOD quad function requires adequate patellar mobility******
  • Restoration of quad function correlates w/ ADL fxn in EARLY STAGES OF RECOVERY
  • Quantity and Quality of exercise KEY to maint. and improving quad function
    • 50 quad sets every hour you are awake!!!
      • LOAD THEM!!!
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10
Q

Restoring Quad Function

NMES Parameters

A
  • 2500 Hz,
    • 75 bursts/sec
  • 10 contractions
  • 10” ON/50” OFF
  • Stim. produces full, sustained quad contract. w/ evidence of superior patellar glide
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11
Q

Therapeutic Ex. in Tissue Protection & Symptom Mod. Phase

Strength Training

A
  • NWB Quad Strengthening
    • ​quad sets, SAQ, LAQ
  • ​WB Quad Strengthening
    • TKE
    • Step up/downs
    • Squats
      • use shorter ROM & GET FULL EXT***
    • Leg Press
      • shorter ROM & get FULL EXT. ***
  • NMES
  • Hips/Core/HS’s
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12
Q

Therapeutic Ex. in Tissue Protection & Symptom Modulation Phase

Functional Training

A
  • GAIT TRAINING
    • sequencing w/ AD—teach them
    • 3-way Wt. Shifting
    • Step and Holds—-Neuro
  • Cycling for ROM
    • Arc of motion to stretch
    • 100-110o needed for full revolutions****
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13
Q

WB Strengthening???

A

Good, but not by itself!!!

  • More “functional” BUT does NOT isolate the quad
    • ​we NEED to get FULL EXT****
  • Gen. safer for EARLY REHAB
    • ​Reduce Ant. Shear Force—-after ACL
    • INC tibiofemoral compression
    • INC co-contraction of HS’s
  • incorporates entire kinetic chain
  • Element of proprioception
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14
Q

General Knee Sx Guidelines: Phase 2–Motor Control

in a nutshell…

A

Protect the Sx, INC load

**Sx and Tissue Specific Cond’s

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15
Q

Gen. Knee Sx Guidelines: Phase 2–Motor Control

A
  • Protect the Sx, INC load
    • ​Sx & Tissue specific cond’s—-follow them!!!
  • Maintain ROM
  • Rehab LE mm’s
    • ​lengthen+strengthen
    • QUADS IS MOST IMPORTANT
    • Hip/HS’s/Core
  • Prevent recurrence of inflammation
  • Condition CV system
    • ​walking, bike
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16
Q

Therapeutic Ex in Motor Control Phase

Strengthening vs. Functional Training

A

Strength vs. Functional Training

see pics

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17
Q

Gen. Knee Sx Guidelines: Phase 3–Functional Optimization

PROTECT THE Sx

A
  • Protect the Sx
  • CV conditioning
  • Injury Prevention Tech’s while introduce:
    • ​running
    • agility training
  • Optimize LE mm performance
    • ​Sport specific
      • lengthen and strengthen
    • QUADS IS MOST IMPORTANT***
  • Prevent recurrence of inflammation
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18
Q

Criterion-based Rehab

Time and progression

A
  • Time is a surrogate for healing
    • Time after sx for graft healing
  • Assess isolated strength, motor control, power dev.
    • ​see if ready for next activity!!!
  • Diff’s in force development and force absorption persist after sx and are indep. of time after sx
  • MUST det. appropriate fxnl milestones to progress pts w/in PT

****What do you have to do to be ready for XYZ???****

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19
Q

EX. Criterion-based Rehab

A

“When can I run?”

A: When you are 12* (just ex.) weeks post-OP AND you can demo: a, b, c

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20
Q

Progression after Sx

what does this look like?

A
  • Irritability is progressing in the right direction:
    • ​Inflamm==controlled
    • Swelling==stable + NOT inc’ing w/ INC loading
    • Pain==well controlled
  • Impairments are progressively improving
    • ​ROM
    • Strength
    • Flexibility
  • Pt. demo’s mastery of lower lvl activities
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21
Q

Progress to Straight Running

A

EXAMPLES:

  • MD Clearance—- usually indicated in protocol
  • Fast walking TM 15mins
  • Quad strength >80% vs. uninvolved
    • ​EVIDENCE-BASED!!!
    • ​Biodex
    • 1-RM Knee Ext– 90-45deg
  • 10 S/L Squats to 45deg in sagittal plane
  • 30 step and holds
  • >90% Composite Score on Y-Balance test
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22
Q

Progressing to Low-Lvl Agility Training

*moving out of Sagittal Plane

A
  • MD clearance
  • Quad Strength >or= to 85%
    • ​1-RM on Knee Ext./Biodex
  • 10 S/L squats to 60deg
    • *w/ > or = 75% ext. wt.
  • Tolerate 1-2mi TM running
  • 100% Composite Score on Y-Balance Test
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23
Q

Progressing to Jumping

*2 feet

A
  • MD Clearance
  • Quad strength > or = to 90%
    • ​1RM Knee Ext/Biodex
  • 10 S/L squats
    • w/ >or= 85% ext. wt vs uninvolved
  • No compensation patterns displayed w/ agility training @ or near 100% speed.
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24
Q

Progress to Hopping, Sprinting, Cutting

*usually starts 50-75% effort

A
  • MD Clearance
  • 10 S/L squats w/ > or = to 90% ext. wt vs. uninvolved
  • NO compensation patterns or medial collapse w/ jumps
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25
Q

Returning to Sport

When are they “Ready?”

ASK:“Is this person so unsafe that they cannot return to sport?”

A
  • MD clearance
  • Tolerating sprinting, agility drills, jumping, hopping @ 100% effort WITHOUT:
    • ​Compensation strategies
    • giving-way episodes
    • INCd pain
    • NEW S/S inflammation
    • INCd effusion
  • FIRST return to practice and contact
    • ​THEN return to games
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26
Q

Medial CORNER injury ====

A

BIGGER injury vs. just MCL

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27
Q

Lig. Sx.

Repair vs. Reconstruction

A
  • Repair
    • ​uses sutures and ligament is re-attached
      • ​YOU MUST BE WAY MORE CAREFUL AS TO NOT FUCK UP THE REPAIR!!!!
      • SEE PICS
  • Reconstruction—move earlier, takes longer to heal
    • ​uses grafts and screws INTO BONE.
      • ​anything into bone is MUCH stronger!!!
28
Q

ACL Reconstruction

A
  • Primary Goal:
    • ​restore stability + Knee kinematics to PREVENT future degen. changes
  • 40-90% pts undergoing ALC-R have radiographic evidence of knee OA 7-12yrs AFTER Sx
  • Anatomically performed
  • Graft failure ranges 0-27%
    • ​based on activity lvl after Sx
  • ***Returning to prev. lvl of sport NOT guarenteed****
29
Q

ACL-Reconstruction

see pics in notability

Slide 16

A
  • Single bundle procedure—-reconstruct AnteroMed bundle
  • “Anatomic” double bundle procedure—reconstructs BOTH bundles into Anatomic Position
  • Graft passed thru tunnels drilled into tibia and femur
    • Drilled====strong!!!

***NOTE: single bundle procedure==NO spinning/rotation protection==meniscus + cartilage damage

30
Q

Ligament Graft Healing

*gets WEAKER before STRONGER

A
  • Initially—-graft is Avascular (no blood supply)
    • ​6-8wks: graft will show signs of avascular necrosis
      • ​weaker BEFORE stronger!!!
    • 8-12wks: revascularization begins; mesenchymal cells invade graft
    • 16wks: vascularization complete; mesenchymal cells AND proliferation AND form collagen
      • Collagen changes from fragments to dense longitudinally oriented fibers
  • ****Graft strength DECs during pd of necrosis and then it INCs as it remodels and matures
    • ​DOES NOT REACH ORIG. STRENGTH OF NATIVE ACL
31
Q

Autografts vs. Allografts

A

Auto===self

Allo==cadaver OR donor

32
Q

Autografts

A
  • FASTER incorporation and healing
    • ​bc its YOURS!!!
  • Better outcomes in young, active pts
  • Donor-site morbidity?
  • Risk of Fx?

*NOTE: commonly use semitendinosis (inserts @ PES) —–Semitendinosis is a MEDIAL STABILIZER to knee—-protects against valgus—-now you do not have that extra stabilizer—-bad for soccer players

33
Q

Allografts

A
  • Higher cost
  • Predictable graft size
  • Availability****
  • Better for revisions
  • Re-injury rate?
    • HIGHER
  • ****They don’t hurt enough!!!
    • ​bc of this—–pt wants to do MORE TOO early
34
Q

GOLD STANDARD ACL PROCEDURE

A

Bone-Patellar Tendon-Bone Autograft

BPTB

35
Q

Bone-Patellar Tendon-Bone Autograft

BPTB

*Gold-Standard*

6-8wks to heal

A
  • GOLD STANDARD ****
  • Provides rigid bone to bone fixation which allows accelerated rehab to attain full ROM and Strength
    • ​Boney plugs==heal approx. 6-8wks
    • 30% pts complain donor-site moribidity
  • ***Central 1/3 of tendon is 186% as strong as native ACL****
  • Patellar Fx
    • ​NO aggressive strengthening for 6-8wks
    • AVOID high eccentric loading for 12-16wks
  • Patellar Tendon Rupture
    • ​Persistent extensor lag w/ SLR @ 4wks post-op
    • Inability to perform SLR 1-2wks post-op
36
Q

Hamstring Tendon Autograft (self)

*Falling out of favor***

*8-12wks to heal

A
  • USUALLY semitendinosis/gracilis graft
    • ​Semitendinosis== 70% strong as native ACL
    • Gracilis== 49% strong as native ACL
  • Fixation NOT AS STRONG as BPTB
  • Potentially LESS quad atrophy
  • LESS donor-site morbidity
    • ​able to kneel
    • BUT now you’ve disrupted HS’s== implications in injury prevent.
  • **soft tissue-to-bone heals approx 8-12wks
37
Q

Quad Tendon-Bone Autograft vs.

Quad Tendon Soft Tissue Autograft

A
  • Stability similar (OR superior to) BPTP graft BUT w/ less kneeling pain
    • ​Quads activation is poorer than other autografts
    • Harvest site pain w/ contraction
    • few long term studies
  • Need to target rec fem while stretching and strengthening
38
Q

Allografts

from cadaver or donor

usually what??

A
  • USUALLY bone-patellar tendon-bone, Achilles, Tib. Ant.
  • Mixed results for:
    • failure rates
    • laxity
    • ROM outcomes
    • Can allow for FASTER REHAB bc DECd pain
39
Q

Post-OP ACL Rehab

CKC ex’s vs. OKC ex’s

A
  • Generally, CKC ex’s cause LESS STRAIN vs. OKC
  • 44 Subj’s randomized into CKC ex only vs. CKC and OKC ex’s following reconstruction w/ BPTB graft
    • ​OKC ex’s initiated @ 6wks post-OP and in range of 90-40degs and progressed to 90-110degs by 12 wks post-OP
40
Q

Post-Op Rehab

Generally, CKC ex’s cause LESS STRAIN vs. OKC

44 Subj’s randomized into CKC ex only vs. CKC and OKC ex’s following reconstruction w/ BPTB graft

​OKC ex’s initiated @ 6wks post-OP and in range of 90-40degs and progressed to 90-110degs by 12 wks post-OP

A
  • Results:
    • NO sig. diff in ant. knee laxity @ 6mos
    • Sig. INC in quads torque in CKC/OKC group
    • Sig. HIGHER # pts returned to pre-injury lvl in CKC/OKC group and did so 2 mos EARLIER than CKC group
  • Conclusion:
    • Incorporate OKC ex’s WITH CKC’s in the protected ranges following ACL-Reconstruction
41
Q

Acceptable OKC Quad Strengthening:

A
  • Isometrics @ 90o and 60o
  • Long Arc Quads
    • ​Weeks 0-12: 90-60degs
    • Weeks 12-16: 90-45degs
    • Weeks 16+: 90-0degs
  • Short Arc Quads
    • ​0-10degs does NOT put excess strain on ACL
    • 0-30degs may NOT be approp. after ACL-R
42
Q

Quad Strengthening

Patella

A
  • GREATER axial strain on patella in GREATER DEGREES OF FLEX.
43
Q

Risk Factors for Recurrent ACL-R

A
  • Graft failure or contralat. ACL tears exceed 20% in young athletes returning to competitive sports
  • Risk factors for recurrent ACL-R
    • tech. failure in tunnel placement** or **graft position
    • Contralat. ACL tear rates 6-9%
    • Higher rates w/ younger pop. + allograft use
      • ​bc returning to sport===higher risk
44
Q

Return to Sports w/ ACL-R

Where are we now?

A
  • 1/3 pts return to same lvl of competitive sports 12mos after sx
  • <50% pts return to sports 2-7yrs after sx
  • Young active pts are 6x MORE LIKELY to sustain 2nd ACL injury w/in 24 mos after ACLR and RTS vs healthy controls
    • 20% contralat; 9% ipsilat.
45
Q

Ardern CL. BJSM. 2014

Updated systematic review assessing RTS

A
  • 81% (of 4837 pts) return to sport
  • 65% return to pre-injury lvls of sport
  • 55% return to competitive sports
  • MEN are 1.5 MORE LIKELY vs. females to return to pre-injury OR competitive lvls of sport
    • ​bc DUMBER!!!
46
Q

Rehab Considerations for Multiple Ligament Knee Injuries

MLKI’s

Controversies in Rehab

A
  • Avail reports are biased, non-random., retrospective concerning rehab after sx for MLKI
  • Timing and composition of rehab has not been researched
  • BEST EVIDENCE COMES FROM ACL-R
    • ​GOLD STANDARD:
      • ​Early WB
      • Early ROM
      • Early Exercise
47
Q

Controversies in Rehabilitation

ACL-R vs. Sx for MLKI

A
  • ACL-R
    • ​Lvl 1 Evidence: better outcomes w/:
      • EARLY WB
      • EARLY ROM
      • EARLY EXERCISE
  • Sx for MLKI
    • ​Lvl 5 Evidence: questionable benefit, recommends:
      • DELAYED WB
      • DELAYED OR LIMTD ROM
      • DELAYED EXERCISE
48
Q

Criterion-Based Post-Sx Rehab Progression

GOALS:

A
  1. Return indiv. to normal ADLs
  2. Return to work, military duty, sports acts @ same lvl of participation as prior to injury
49
Q

Criterion-Based Post-Sx Rehab Progression

Three phases of Post-OP Rehab

A
  1. Tissue Protection
  2. Motor Control
  3. Optimization of Function
50
Q

“As Tolerated” Approach

General Recommendations

Look @ knee jt irritability table****

A
  • Generally, keep pain 3/10 OR LESS
  • Advance ROM w/out OP/stretching
    • end range mobs + stretching @ >4wks
  • WBAT w/ crutches****
  • Exercise w/out INCing irritability
51
Q

Know the Surgery. Respect the Surgery.

Know the surgeon. Respect the surgeon.

A

“In preparing for battle I have always found that plans are useless, but planning is indespensable.”

-Dwight D. Eisenhower

52
Q

Phase 1: Tissue Protection Phase

Evidence Supporting ROM Recommendations

A
  • Early motion is @ least equivalent to immobilization
    • MLKIs
      • ​Early sxandEarly motionled tofewer ROM deficits
    • ACL
      • ​ESP in combined procedures
      • may lead to tunnel widening
    • PCL
53
Q

Phase 1: Tissue Protection Phase

Practical Application of ROM Exercise

A
  • PROM w/in avail. range
    • ​AROM pending tissue restricts.
    • Pain and tissue stretch are guidelines for intenisty of ROM
  • Patellar mobs in NEUTRAL
    • ​can ALWAYS mobilize the patella!!!
  • Positioning in EXT w/ tibial support to avoid over-stressing repairs
  • Cycling for ROM
    • Week 3—mod. irritability–0-90deg
54
Q

Phase 1: Tissue Protection Phase

Evidence Supporting WB Status

A
  • Controlled Gait Lab
    • training w/ bathroom scale to a clinically variable % of BW
    • ***21 of 23 pts w/ Fx bore TOO MUCH WT
      • ​3% to 163%
  • No diffs after ACL-R
55
Q

Phase 1: Tissue Protection Phase

Evidence Supporting WB Status:

A
  • controlled gait lab
  • NO diffs after ACL-R
  • PWB/TTWB gen. not supported
  • No data on NWB in MLKIs
    • ​may be surgeon preference
56
Q

Phase 1: Tissue Protection Phase

Practical Application of WB

A
  • NWB vs. WBAT w/ crutches WITH brace locked in EXT
    • ​does NOT mean FWB is promoted
    • consider S/S of inflamm & irritability
    • adjust as necessary
  • Crutch Use== MIN. of 3wks
  • Brace Use== MIN of 6wks
57
Q

Tissue Specific Protections: PCL

OFTEN reconstructed OR repaired

PCL Injury, Reconstruction or Repair

A
  • WBAT w/ brace and crutches
  • Restricted ROM—-AVOID HYPEREXTENSION!
    • ​GOAL: anatomic 0 (neutral) EARLY—maint. for 4-8wks
    • GOAL: 90degs w/out excess. post. tibial sublux
    • AVOID POST. TIBIAL GLIDES FOR FLEXION!
  • Therapeutic Ex—Care for HS TEs
    • ​AVOID NWB, non-resisted ex. for 8wks
    • *ADD resistance @ 12wks
58
Q

Tissue Specific Precautions: Lateral Corner

PLC Injury, Reconstruction, Repair

A
  • WBAT w/ brace AND crutches
  • Restricted ROM:
    • GOAL: anatomic 0 (neutral) EARLY, avoid HYPEREXTENSION
    • GOAL: 90degs w/out excess. post. tibial subluxation
    • No VARUS force, tibial rotation, and post. tibial glides ******
59
Q

PLC Reconstruction

A
  • after acute injuries—–repair typ. done w/in 3 wks to avoid tissue retraction, tissue necrosis
  • Chronic PLC injuries— MORE diff. to repair due to excess. scarring
    • ​therefore, reconstruction performed
  • LCL reconstructions—usually use semitendinosis autografts
60
Q

Tissue Specific Precautions:

Medial Corner

A

Medial Corner Injury, Reconstruction, Repair

  • WBAT w/ brace and crutches
  • Restricted ROM:
    • GOAL: anatomic 0 (neutral) EARLY, may avoid hyperEXT completely bc capsular involve.
    • GOAL: 90deg w/out excessive valgus forces/tibial ER
  • TherEX
    • ​care for HS TE’s if possible
    • avoid valgus forces
    • watch semimembranosus
61
Q

Tissue Specific Protections:

HS Considerations

Active Posterior Drawer

A
  • if contraction of HS’s causes visible post. dislocation or sublux. or tibia====> insuff. healing of PCL or PLC
    • ​refer back to surgeon
  • If this causes sig. pain after HS repair===> incomp. healing
62
Q

Tissue Specific Protections:

HS Considerations

Non-resisted HS Ex.

A
  • 8 wks post-sx
    • heel slides
    • Prone HS curls
    • standing HS curls
    • prone glute press
63
Q

Tissue Specific Restrictions:

Meniscus Repair

A
  1. Meniscus BODY repair has equivocal outcomes w/ EARLY WB and motion compared to DELAYED WB and motion*****
  2. Meniscus ROOT repairs are HIGHLY STRESSED IN WB—leading to greater risk of failure
64
Q

Tissue Specific Restrictions

Cartilage Sx

A
  • current concepts based on combo of basic science data, sx tech’s current. avail., empirical info., limtd # clinical studies
  • Rehab reporting scores LOWER than their surgical equivalent
65
Q

Tissue Specific Restrictions:

Peroneal N. Injuries

A
  • 10.8% of MLKIs
  • reasonably common
  • consider HOW injury is affecting function
66
Q

Tissue Specific Restrictions:

Tibial Artery Injuries

A
  • 3.3% of MLKIs
  • rel. UNcommon
  • Consider extent of repair and intervention
    • ​PREVENT over-stressing
    • monitor S/S of compromised circulation

MSPT I (10 decks)

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