Knee Interventions Flashcards
Patellofemoral Pain Interventions
- Taping
- Bracing
- Surgical
- Strengthening
Patellofemoral Pain classifications
- Overuse/Overload without other impairment
- PFP with movement coordination deficits
- PFP with muscle performance deficits
- PFP with mobility impairments
describe taping for PFP
- minimal long-term effects
- neuromuscular and proprioceptive effect likely; biomechical correction unlikely
- loose taping vs corrective taping → similar effects in pain management
- biomechanical theory → improved patellar tracking/alignment leads to redistributed patellofemoral stress
- imaging studies have not supported repositioning of patellar with taping
describe bracing for PFP
- certain braces (e.g Protronics) may be effective in pain reduction
- exact mechanisms unclear (similar to taping)
describe a surgical approach for PFP
- Lateral Release, debridement
- early concentration on ROM, inflammation management, coordination/activation exercises
- progression to w/b exercises, muscle performance exercise
- progress to exercise based on activity limitations (progressing appropriately until remodeling phase)
describe the subtype: PFP overuse/overload without other impairments
- pain primarily due to overuse/overload
- pt presents with a history suggesting an increase in magnitude and/or frequency of PFJ loading at rate that surpasses the ability of his/her PFJ tissues to recover
describe the subtype: PFP muscle performance deficits
- may respond favorably to hip and knee resistance exercises.
- pt presents with LE muscle performance deficits in the hip and quads
describe the subtype: PFP with movement coordination deficits
- may respond favorably to gait retraining and movement re-education interventions leading to improvements in LE kinematics and pain
- assess dynamic knee valgus during movement
- pt presents with excessive or poorly controlled knee valgus during dyanamic task, but not necessarily due to weakness of LE muscles
describe the subtype: PFP with mobility impairments
- may have impairments related to either hyper/hypomobile structures
- pt presents with higher than normal foot mobility and/or flexibility deficits of 1 or more of the following structures:
- hamstrings
- quads
- gastroc
- soleus
- lateral retinaculum
- ITB
Intervention strategies for PFP Overuse/overload without other impairment
- taping (B)
- activity modification/relative rest (F)
intervention strategies for PFP with movement coordination deficits
- gait and movement retraining (C)
intervention strategies for PFP with muscle performance deficits
- hip/gluteal muscle strengthening (A)
- quad strengthening (A)
Intervention strategies for PFP with mobility impairments
- Hypermobility
- foot orthosis (A)
- taping (B)
- Hypomobility
- patellar retinaculum/soft tissue mobilization (F)
- muscle stretching (F)
- hamstrings
- quads
- gastroc
- soleus
- ITB
surgical options for articular deficits at the knee
- arthroscopic lavage and debridement
- microfracture
- grafts/chondrocyte implantation
arthroscopic lavage and debridement PT implications
- full extension ROM by week 1
- full flexion ROM by week 3
- progress loading as tolerated once motion functional and inflammatory/pain permits
microfracture PT implications
- full extension (active assisted) ROM by ~week 1
- full flexion (active assisted) ROM by ~week 3
- progress w/b over ~week 6-12
- avoid loading at lesion site until ~6-12 weeks
grafts/chondrocyte implantation PT implications
- Early PROM and active assisted ROM
- should restore:
- full extension by end of ~week 1
- flexion by ~week 6
- avoid loading lesion site intially with AA ROM
- CKC exercises once full WBAT
- Full WB ~6 weeks
- Progressive loading ~6-12 weeks
- avoid loading lesion site initially
osteoarthropathy intervention suggestions
- Pt edu → focus on pt empowerment/progression to independence and activity modification
- Manual therapy
- sustained hold
- +/- oscillation mobs
- LE strengthening/endurance exercise (hip and knee)
- Diet/weight loss
- Walking/gait training
- Pain control modalities +/-
Management of Arthrofibrosis
- exercise, MT
- based on stage of progression
- Acute stage → self management, ROM/mobility exercises, stretches, pain/inflammation control interventions, muscles performance as tolerated (adjacent joints and hip)
- Chronic stage → aggressive joint mobs, stretching, strengthening, static stretching devices (crep)
surgical managment of Arthrofibrosis
- MUA
- Arthroscopic capsular release
conservative management of meniscus lesions
- address impairments per ICF model
- pt edu
- pain management
- guarding
- joint mobility
- muscle performance: hip, knee (especially rotational stability)
post-op management of meniscetomy
- early concentration on ROM (guarding), inflammation management, coordination/activation exercise
- quicker (as tolerated after acute healing phase) progression to:
- w/b exercise (tissue loading, coordination, etc)
- strengthening exercises (LE)
- Progress to exercises based on activity limitiations
- progressing appropriately until remodeling phase
post-op management of meniscus repair (6 weeks)
- greater protection phase (~6 weeks)
- gradual increase in w/b and ROM
- address inflammation
- hip strengthening/endurance
- Gait (AD as needed)
- limit compressive loading on posterior menisci
- limit flexion ROM accordingly
- limit resisted knee flexion
- coordination/activation exercises
post-op management of meniscus repair (6-10 weeks)
- gradually increase loading on involved tissues
- aerobic equipment, etc
- address ROM
post-op management of meniscus repair (>10 weeks)
- progress to exercise based on acitivty limitations
- progressing appropriately until remodeling phase
primary goal of conservative and surgical management of ACL tears
return functional stability to the knee
Surgical management of ACL tears
- debridement
- repair (rare; scaffold placed)
- reconstruction
- tissue → bone-patellar, tendon-bone, hamstring tendon, or synthetic
- origin → allograft vs. autograft
gold standard for ACL lesion surgical management
- double-bundle semitendinosus and gracilis autograft common
- improved rotation stability
- decreased likelihood of revision, development of knee OA, damage to the meniscus
- improved function, satisfaction, and QOL as per pt self-report
post-op phases for ACL reconstruction (via Adams)
- Immediate post-op phase (week 1)
- Early post-op phase (week 2)
- Intermediate post-op phase (weeks 3-5)
- Late post-op phase (weeks 6-8)
- Transitional phase (weeks 9-12)
- Follow-up testing (4, 5, 6, 12 months)
immediate post-op phase
week 1
- Knee A/PROM 0-90 degrees
- active quad contraction (superior displacement of patella)
ACLR early post-op phase
week 2
- knee flexion >110 degrees
- ambulation w/o crutch
- full knee extension w/ambulation
- knee outcome survey (ADL subscale) >65%
- no extension lag with SLR
- reciprocal stair climbing
- cycling
ACLR intermediate post-op phase
weeks 3-5
- knee flexion ROM within 10 degree of non-affected LE
- quad strength >60% of non-affected LE
ACLR late post-op phase
weeks 6-8
- full knee ROM
- quad strength >80% of non-affected LE
- normal gait
- knee effusion trace or less
ACLR transitional phase
weeks 9-12
- maintaining/improving quad strength
- hop test >85% of non-affected side (week 12)
- KOS (sports subscale) >70%
prognositic factors for conservative management of ACLR
- age
- gender
- occupation
- sports participation level
- radiographic findings
- KT-1000 arthrometric measurement
- knee function scores
- presence of additional knee injuries
patellar tendinopathy management
- address impairments ID on exam
- Eccentrics
- facilitating tendon remodeling
- improved collagen fiber alignment
- common exercise: squats on declined slant board
tendon rupture repair <3 weeks
protection, pain/inflammatory management
tendon rupture repair 3-6 weeks
light loading (resisted - free cycle)
- bracing (motion limited with hinge brace)
- motion commonly limited by surgeon (0-~45), progressive increase during this period
- active knee flexion
- within limited range, common 45 degrees
- gait with AD
- minimal w/b exercises
- modalities PRN
- hip muscle performances
tendon rupture repair 7-12 weeks
progression of loading
- progress to full w/b:
- hinge locked 0-60 commonly
- knee extensor activation/coordination (sub-max)
- progress CKC exercises
tendon rupture repair 9-12 weeks
- single leg CKC exercises
- increase tensile loading
- max activation, knee extension exercises, etc.
patellar fracture: non-surgical management in acute phase
- WBAT with AD and locked hinge brace initially
- coordination/activation exercises for knee, muscle performance of hip
- stretching/mobility/modified CKC exercises at ~3-4 weeks
- patellofemoral mobs
patellar fracture: non-surgical management 6-12 weeks
- pain-free ranges (motion limitations)
- progress w/b exercises
Joint mobilizations at the knee
- Tibiofemoral Joint
- Posterior glide (M/L comparment)
- Anterior glide (M//L compartment)
- Traction
- Patellofemoral Joint
- medial glide
- lateral glide
- caudal glide
