Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

MSPT I > KNEE: Lectures 1 and 2 > Flashcards

KNEE: Lectures 1 and 2 Flashcards

1
Q

Pt Scenario

First contact practitioner

if OPEN INJURY

A

OBSERVE:

Active bleeding? Bone protruding?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

First contact practitioner

if Fx:

A

OBSERVE:

WB w/out an AD?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

First contact practitioner

if Knee Dislocation

Tibiofemoral vs.

Patellofemoral vs.

Muscular avulsions vs.

Vascular issues

A
  • Tib/Fib
    • ​Is varus/valgus alignment similar to uninjured side?
  • Patellofemoral
    • ​is patella centered in knee joint?
  • Muscular avulsions
    • ​is there a loss of contour @ insertion site? Muscle retraction?
  • Vascular issues
    • ​is the foot or lower limb cyanotic?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

First contact practitioner

if Knee Jt Infection/Septic Joint

A

OBSERVE:

is the joint swollen and red?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

First contact practitioner

Open Injury

A

PALPATE:

NOTHING IF OPEN!!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

First contact practitioner

Fx:

A

PALPATE:

Fibular head, Patella

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

First contact practitioner

Knee Dislocation

Tib/fib vs.

Patellofemoral vs.

Muscular avulsions vs.

Vascular issues

A

PALPATE:

  • Contour of the limb:
    • ​Tib/Fib
      • ​are injured knee mm’s more/less active vs. uninjured?
    • Patellofemoral
      • ​Is patella tender on medial side?
    • Muscular avulsions
      • ​Is there a loss of contour near muscular insertion?
    • Vascular issues
      • ​are distal pulses intact?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

First contact practitioner

Knee jt Infection/Septic Joint

A

PALPATE:

  • Joint swelling
    • ​intra-articular vs. extra-articular
    • **Sweep Test**
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

First Contact Practitioner

Stop the Party, Call ED ….

A
  • OPEN INJURY
  • Neurvascular injury
    • ​diminished or absent pulses
    • absent sensation
  • Obvious Fx OR
  • (+) Ottawa Knee/Ankle Rules
    • ​HIGH index of suspicion Fx
  • Gross misalignment of limb
    • ​Disloc. w/out reduction
    • DO NOT try to reduce UNLESS transit time to ED is prohibitively long
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

First contact practitioner

Continue Exam; Refer out when finished:

A
  • Tib/Fib OR Patellofemoral Dislocation
    • ​NO (or min.) neurovascular issues
    • Normal alignment
      • spont. reduction
    • Muscle avulsions

*NOTE: presentation is not emergent, BUT should be assessed by other providers to ensure medical stability

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Knee Rules for det. Need for Radiography

Ottawa Knee Rules

A
  • Age 55+
  • Isolated tenderness of patella

OR

  • Tenderness over fibular head
  • Unable to flex knee past 90deg
  • Unable to bear wt. immed. OR in ED for 4 steps

***HIGHLY SENSITIVE BUT NOT VERY SPECIFIC***

*REMEMBER SnNout and SPpin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Knee Rules for det. Need for Radiography

Pittsburgh Knee Rules

A
  • Blunt trauma OR a fall as MOI + one of following:
    • Age under 12
    • Age over 50
    • Unable to bear wt. in ED for 4 steps
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

JAMA and the Ottawa Knee Rules

A
  • DEC in need of radiography w/out missed fx’s
  • HIGHLY sensitive, reliable, very acceptable
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Rehab after Prolonged Immob. (Fx)

Sx modulation and Impairment Resolution:

what do you want to focus on?

A
  • resolve effusion/edema
  • improve mm activation/DEC atrophy
    • normalize painful mm contracts.
  • Restore limtd motion, DEC jt stiff.
  • Restore normal mvmt patterns
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Neurovascular Assessment of Knee Joint

Circulatory Issues: 2

A
  1. Vascular Injury
  2. DVT
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Neurovascular assessment of Knee

Circulatory Issues:

Vascular Injury

A
  • Arterial injury interrupts blood to distal tissues
  • Arteries are susceptible @ jts AND when making sharp turns around bony prominences ​
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

POST. KNEE JT DISLOCATION

Impacts what?

A
  • POST knee jt dislocation
    • impacts Popliteal Artery
      • ​check Post. Tib pulse
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

POSTEROLATERAL KNEE JT INJURY

Impacts what?

A
  • Posterolateral knee jt injury
    • impacts supply to Ant. Tibial Artery
    • Check Dorsalis Pedis Pulse
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

DVT

what is it and what can it do ?

A
  • Clotting/blocking of a distal vein
    • can dislodge and move thru circulatory system to Central Aspects —– heart & lungs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

DVT

More common when and why?

A
  • More common after Sx
    • hip, knee, leg/calf, abd, chest
      • ​Reduces bloodflow to a part of the body
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

DVT

Reasons why Sx can INC DVT risk: 3

A
    1. Tissue debris, PRO, fats may move into veins following Sx
    1. Vein walls damaged—> releases subs. that promote blood clotting
    1. Prolonged bed rest
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Arterial Assessment

Dorsalis Pedis Pulse

Check if POSTEROLATERAL KNEE JOINT INJURY bc Ant. Tib. Artery

A

Top of foot, lateral to EHL tendon

distal to Navicular

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Arterial Assessment

Post. Tib. Pulse

Check if POST. knee jt dislocation bc impacts Popliteal Artery

A

Post to medial malleolus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Well’s Clinical Prediction Rule for DVT

A
  • Probability of DVT:
    • 3pts==HIGH RISK 75%
    • 1 to 2pts== MOD. RISK 17%
    • <1 pt==LOW risk 3%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Circulatory Status for DVT:

risk INCs w/ AGE, esp. after 60

Lifestyle factors?

A
  • Sitting or inactive for long time
  • Long plane or car trips
  • Extra wt.
  • BC pills or patches
  • Smoking
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

S/S of DVT

NOTE: 1/2 of all DVT cause NO sx’s

Some you will see….

A
  • Swelling in one or both legs
  • Pain or tenderness in one or both legs
    • MAY only occur during walking or standing
  • Warmth in the skin of affected leg
  • Red or discolored skin in affected leg
  • Visible surf. veins
  • Leg fatigue
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Neuro Screening

Common Peroneal Nerve

Motor vs. Sensory Function

A
  • MOTOR:
    • Ankle DF
    • Great toe EXT
    • Toe EXT
  • SENSORY
    • 1st web space—-DEEP BRANCH
    • Dorsal surf. toes 3-4—-SUPERFICIAL BRANCH
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

NEURO SCREENING

Tibial Nerve

Motor vs. Sensory Function

A
  • MOTOR:
    • PF
    • Toe FLEX
    • little bit of Inversion
  • SENSORY:
    • Plantar aspect of calcaneous
    • Plantar aspect 5th toe
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

LE Peripheral Nerve Map

A

see pics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Expected Gait Devs in Acutely Injured Knee

2

A
  1. Noticeable limp
  2. Flexed Knee Gait
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Gait Devs in Acutely Injured Knee

Noticeable Limp

Why?

A
  • avoiding WB on injured limb
  • Short stance time on injured limb
  • Short step length for uninjured limb
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Gait Devs. for Acutely Injured Knee

Flexed Knee Gait

Why and theories?

A
  • avoids TKE
  • avoids eccentric knee flex.
  • Theories:
    • ​Quad-avoidance gait vs. Optimal length-tension for quads
    • Co-contract of quads/HS to LIMIT MOTION
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Knee Joint Swelling:

Joint Effusion

A
  • Fluid contained W/IN a body cavity
  • Knee jt==Largest Synovial Cavity in body
    • intra-art injury==intra-art swelling
    • extra-art injury LIKELY WONT CAUSE INTRA-ART. SWELLING
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

KNEE JOINT SWELLING

Joint Edema

A

GEN term for swelling

*can likely move edema thru tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Effusion Assessment

Stroke Test, Sweep Test

A

UP medially

DOWN laterally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Interventions/Sx Modulation

Effusion Control

A

RICE

  • Rel. Rest
    • avoid excess. WB
    • use AD
  • Ice
    • 20 on 20 off
  • Compress
    • knee sleeve, ACE
      • mm pumps—-QUAD SETS!!!
  • Elevate
    • Knee ABOVE heart
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Assess & Tx of Limtd ROM and Pain Gen. structures

Sx Modulation

Knee EXT Measurements

A
  1. Resting knee EXT
  2. Knee EXT w/ Quad Set
  3. Knee EXT during SLR
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Knee EXT ROM Considerations

Resting Knee EXT

True PROM

A
  • Rest pos or Loose-pack pos.
    • 20-30deg of FLEX
  • Check and see if indiv. can rest w/ their limb on table and no post. support
  • Can indiv. rest their limb w/ heel supported and nothing under knee?
  • Where is discomfort felt???
    • ​POST
      • capsule vs. HS tendons vs. gastroc
    • ANT
      • “pinching”
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Knee EXT ROM Considerations

Knee EXT w/ Quad Set

AROM

A
  • does quad visibly contract?
  • does contraction produce sup. patellar glide?
  • does glute max. co-contract?
    • ​typ see “reduction” in EXT when asked to contract quad
    • knee stays same place, greater troch rises bc glute contracts
  • does this cause pain?
    • ​ANT
      • patellar tendon vs. quad tendon vs. quad mm
    • RETROPATELLAR
    • POST.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Quad Lag

Lag Sign

A
  • indic’s mm is not capable of holding end range pos.
    • ​ability of mm to maintain pos. lags behind total ROM
    • NO ext. resist—-BW only
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Quad Lag

Max EXT-EXT during SLR*****

A
  • quads not able to maint. full knee EXT when there is no support to Tibia
  • Formula:
    • ​MAX EXT - EXT during SLR
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Quad Lag

If present, what does this mean?

A

CONSIDERABLE mm weakness!

MMT >3/5

  • individual likely not strong enough to achieve ACTIVE TKE in gait
    • ​Hyperextension thrust vs. Flexed knee gait
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Quad Lag

What do you want to do to address this?

A
  • Restore mm activation towards End Range
    • SUP patellar mobs
    • Quad Sets***
      • ​can be combo’d w/ SUP patellar glide to facilitate quad contraction
    • SAQ’s
    • TKE ex’s
      • prone vs. standing vs. DF’d
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Quad Lag

Isometrics

Muscle Setting Ex’s

A
  • LOW-MOD intensity iso. ex —– little to no resist.
    • practicing mm activation
  • No appreciable inc in strenght—-MAY slow atrophy
    • INC recruitment of mm
  • ADD. uses
    • relaxation, circulation, reduce pain/spasm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Active/Passive Knee Flex.

Limitations in Knee FLEX freq. targeted w/ HEEL SLIDES

To INC FLEX

A
  • Active Heel Slide
    • use HS to achieve MAX FLEX.
  • Active Assited Heel Slide
    • hand or belt to apply overpressure @ end range
  • Passive Heel Slides
    • fully use hand/belt

​

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Interventions in Sx Modulation Phase

Painful MTU’s

A

LOAD CAREFULLY!!!

  • 2-3/10 pain
  • soft tissue mobs
  • GENTLE stretching of mm’s
  • LOW grade Iso’s
    • mult. angles
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Interventions in Sx Modulation Phase

Limited ROM

A
  • Patellar mobs (as necessary) —– CAN ALWAYS MOBILIZE PATELLA!!!
  • AROM (if pain free OR min. pain)
    • AAROM (if pain free)
    • PROM (if pain free)
  • Cyclic ROM (flex/ext)—> helps w/ ROM + Effusion
    • stationary cycling w/out resist.
  • Injured ligament….
    • ​restore ROM w/out INC pain or overstressing ligament
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Add. Interventions for TKE

when Acute or Symptomatic

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Classification of Knee Related Sx’s in Motor Control Phase

Stiff Knee

A
  • Limtd ROM
  • Painful or Uncomfortable ROM
  • MM Length restrictions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Classification of Knee Related Sx’s in Motor Control Phase

Unstable Knee

A
  • Ligamentous instability
  • Meniscal Issues
  • Poor Neuromuscular control
  • Pain related instability
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Classification of Knee Related Sx’s in Motor Control Phase

Weak “Knee”

A
  • Limtd Strength of a Muscle relevant to knee jt function
  • Pain-related weakenss
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Simplified Tx Approach!!!

A

If its contributing to Activity Limitations or Participation Restrictions AND…

  • ​if its Limited
    • ​Mobilize it!
  • if its Tight
    • ​Stretch it!
  • if its Weak
    • ​Strengthen it!
  • if it Moves Funny
    • ​Retrain it!
  • if its Involved
    • ​Load it thoroughly
  • If its Injured**
    • ​Do all of this CAREFULLY!
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Joint Mobilization to Improve Knee Flexion

Patellofemoral Joint

What happens as knee flexes?

A
  • patella glides INFERIORLY
  • lateral facet and odd facet contact femur
    • ​greater compression laterally—-esp w/ effusion
    • bc high lat. wall of trochlea
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Joint Mobilization to Improve Knee Flexion

Patellofemoral Joint

Intervention:

A
  • Medial and Inf glides IN FLEX
  • Medial tilt mobs in Resting****
    • when patello moves the most!
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Joint Mobilization to Improve Knee Flexion

Tibiofemoral Joint

What happens as Knee Flexes?

A
  • Tibia glides POSTERIORLY
    • MIN. tibial rotation
    • MAYBE some post. pinching or impinge.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Joint Mobilization to Improve Knee Flexion

Tibiofemoral Joint

Intervention:

A
  • Jt distraction in Sitting
  • POST glides IN FLEX
  • ​If Post. Impinge.
    • ​Ant/Rotational glide
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Joint Mobilization to Improve Knee EXT

Patellofemoral Joint

What happens as knee EXTs

A
  • patella glides SUPERIORLY
  • FULL EXT== min. contact w/ walls of trochlea
    • ​GREATER compression LAT.—-bc tilt of patella
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Joint Mobilization to improve Knee EXT

Intervention:

A
  • Medial + Superior glides in FLEX
  • Medial tilt mobs in RESTING
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Joint Mobilization to improve KNEE EXTENSION

Tibiofemoral Joint

What happens here when knee EXTs?

A
  • Tibia glides ANTERIORLY
    • Tibia must Externally rotate to engage Screw Home Mechanism
60
Q

Jt. Mobs to improve KNEE EXT

Tibiofemoral Joint

Intervention:

A
  • Jt. distraction in SUPINE
  • ANT glides in EXT
  • If missing TKE—–MAY need to bias Tibial ER
61
Q

Proximal Tib/Fib Jt Mobs

When performed ?

A
  • PAIN in Distal Anterolateral Knee Jt OR specifically @ Fibular head
    • ​mostly ANT/POST glide req’d for norm. ankle motion
    • impacted w/ injury to biceps femoris
62
Q

Assess. and Intervention of Muscle Performanc in Motor Control Phase

GOLD STANDARD for measuring QUADS Strength in clinical studies

A

Electromechanical Dynamometry

Isokinetic Machine

*HIGHLY reliable

*expensive

63
Q

Assess. and Intervention of Muscle Performanc in Motor Control Phase

1-RM

Leg Extension

Can use SL leg press if needed

A
  • Procedure:
    • alternating limbs
      • fully ext. knee
      • HOLD 2s
      • return under control
    • Failure det’d by 3 unsuccessful attempts @ a single weight
    • MAX wt. lifted recorded for ea. limb
64
Q

Leg Press 1-RM

Standard Leg Press S/L

A
  • Knee @ 90
  • Hip ~90
  • Compensation avoided:
    • gastroc-soleus min’d
    • OPP limb suspended
65
Q

Leg EXT 1-RM

Standard Leg EXT Machine

A
  • knee @ 90
  • hip @ ~90
  • 2 ranges tested:
    • ​90-0
    • 90-45
66
Q

Remember….

W/ BIG mm’s

A

Functional Tests!!!

L.EXT

L.Press

HHD’s

67
Q

Functional Strength Testing:

Ex’s

A
  • Sit to Stand/Chair Rise test
  • Forward Step Down Test
  • Lateral Step Down test
  • S/L Squat test
68
Q

More Functional Tests Ex’s

A
  • 30s Chair Rise
    • 5x S2S test
    • SL 30s vs 5x ea leg
  • Forward step down—-endurance
69
Q

Assessment and Intervention of Muscle Performance in Motor Control Phase

Also consider…

MM’s that control Femur

A
  • glute max
  • glute med
  • ER’s
  • iliopsoas
  • sartorius
70
Q

Assessment and Intervention of Muscle Performance in Motor Control Phase

Also consider…

MM’s that control Tibia

A
  • Gastroc/Soleus
  • Peroneals
  • Post. Tib
  • Ant. Tib
71
Q

MOST important aspect in Knee Function

A

Strengthening Quads!!! during Motor Control Phase

72
Q

Quads Isometric Matrix

A

ADD IN PICTURE!!!

SLIDE 32 IN FIRST KNEE LECTURE!!!!

73
Q

Sit to Stand

Anterior View

A

trunk moves vertically

pelvis stays lvl

Knees stable in frontal plane (slight hip ABD encouraged)

foot should NOT over-pronate

74
Q

Sit to Stand

Lateral View

A

no L/S flexion

pelvis + hips move trunk into Flex.

motion comes from knees

CoP should NOT shift into ball of foot

75
Q

What should you remember w/ sit to stands as an intervention?

A

YOU CAN MAKE THE DISTANCE LOWER OR HIGHER!!!

Mini 30deg squats or Full 90deg squats

or anywhere in b/w!!!

76
Q

Advanced WB ex.

Sit to Stand

Preferential squatting

A

Key points:

  • surgical leg BEHIND good leg
  • shift wt. onto sx limb
  • load thru heel
  • avoid excess. trunk flex
77
Q

Perturbation Training in Knee Jt Stability

What is it?

A
  • Progressive, purposeful manipulation of support surfs. to promote active stabilization and NMSK control of knee
78
Q

Perturbation Training in Knee Jt Stability

Studies in ACL deficiency and Post-Op ACL

*good clinical and biomech. results*

A
  • Knee jt. mechs resemble uninjured indiv’s after completing ~10 sessions of perturbations
    • Reduction of wear & tear
      • ​normal knee jt loading
      • normal knee jt flex/ext excursion during gait
      • reduction in knee Ext/Flex co-contraction
  • Improved confidence/reduced mvmt-related fear
  • SOME improves in clinical measures
    • ex. hop tests
79
Q

Perturbation Training in Knee Jt Stability

SOME bennies for OA, not consistent

A
  • Pts w/ OA more heterogenous than pts after ACL injury
80
Q

Meniscal Tears

Longitudinal

(Buckethandle)

A
  • springy end feel
  • IMMEDIATE REPAIR
  • easy to screw up
  • meniscus flips over into joint
81
Q

Meniscal Tears

Oblique

A
  • typ. older pts
  • does OK w/ repair
82
Q

Meniscal Tears

Radial or Transverse

A

see pics

83
Q

Meniscal Tears

Horizontal

A
  • when you bear wt. w/ this tear—–> pushes edges closer together
84
Q

Meniscal Tears

Complex Degenerative

A
  • does well w/ OR w/out Sx
  • Older pts—degenerative
  • you want to DEC mech. sx’s
85
Q

Meniscal Injuries

MOI

A
  • Cutting/Pivoting
    • sudden direction change w/ foot fixed ground
  • HYPERFLEXION
  • HIGH impact compression
  • MCL or ACL Mechs.
86
Q

Meniscal injuries

MOI

MCl or ACL Mechs…..why?

A
  • MCL
    • deeper fibers connect to MCL
  • ACL
    • connects to Ant. Horn or Med. Meniscus

​

87
Q

Meniscal Injuries

S/S

A
  • Twist/tearing sensation @ time of injury
  • Severe pain ON injury—-Effusion 6-24 hrs POST-injury
  • Giving way on injury
    • Later, intermittent pain, effusion
  • CATCHING OR LOCKING
  • Jt. line tenderness
  • Limtd ROM w/ premature end feel
    • ​IF piece of meniscus IN joint
  • Repro. of sx’s w/ deep squatting or HYPERFLEX pain
  • **Quad inhibition**
88
Q

Meniscal Special Tests:

5 “Cluster” Dx Tests

REVIEW YOUR LAB NOTES!!!!

YOU GOT THIS SHIT!!!

A
    1. Joint line palpation
      * be sure to go BEHIND KNEE!!!
    1. McMurray
      * Axial loading
      • can combine IR, ER, ABD, ADD
    1. FLEX overpressure
    1. EXT overpressure
    1. Hx of Catching or Locking
89
Q

Clinical Composite Score for Meniscal Patho.

**accurately detects meniscal patho.

A
  • Studied 635 knees w/ 5 Dx (cluster tests) tests eval’d presence of meniscal lesions
      1. Hx catching/locking
      1. Jt line tenderness
      1. Pain w/ forced HYPEREXTENSION
      1. Pain w/ MAX passive Knee FLEXION
      1. Pain or Audible click w/ McMurray
90
Q

Mensical Special Tests

Thessaly Test

A

see pics

The “Dancing” one

91
Q

Meniscal Special Tests

Apley’s Compression

Apley’s Distraction

A

Exactly what it sounds like…..the Med/Lat rotate Tibia

92
Q

NON-OP Tx of Meniscus Tears

What did MeTEOR Study find?

A
  • Often, acute tears are operatively addressed
  • DMT’s (degen meniscus tears) MAY be amenable to non-op care
    • ​lg, multi-center study of OP vs. NON-OP for DMT vs. OA (MeTEOR Study)
    • 6m after randomization, 30% NON-OP groud had sx
    • 94% of OP group had Sx

****REMEMBER WE WANT TO TRY AND AVOID GEN. ANASTHESIA ****

93
Q

Sx vs. PT for Meniscal Tear w/ OA

The New England Journal of Medicine

BIG DEAL TO BE PUBLISHED BY THEM!!!

A
  • NOTE:
    • ​equivalent outcomes in WOMAC scores AND KOOS Pain Scores b/w the 2 methods!!!
94
Q

Summary of PT Regimen

Sx vs. PT for Meniscal Tear and OA

New England Journal of Medicine

A

PHASE I

95
Q

Summary of PT Regimen

Sx vs. PT for Meniscal Tear and OA

New England Journal of Medicine

A

PHASE II

&

PHASE III

96
Q

Knee–Meniscal Injuries

Partial Menisectomy

When?

A
  • IF meniscal tear disrupts mechanics of the knee AND pt is not a good candidate for meniscal repair
  • ****DEBRIDEMENT***
    • ​remove as little as poss.
      • down to a stable rim
97
Q

Rehab Following Arthroscopic Debridement (Menisectomy)

*NOTE: these are EASIER to rehab

3 things we focus on:

A
  1. Muscle Strengthening and Joint Mobility
  2. Ambulation
  3. Return to Activity
98
Q

Rehab Following Arthroscopic Debridement (Menisectomy)

*NOTE: these are EASIER to rehab

Muscle strengthening and joint mobility

A
  • Isometrics, AROM, PF mobs IMMEDIATELY
  • Soft tissue manip. of portal scars when healed
  • Progress to PREs when tolerated
  • consider NMES
99
Q

Rehab Following Arthroscopic Debridement (Menisectomy)

*NOTE: these are EASIER to rehab

Ambulation

A
  • WBAT IMMED. w/ least restrictive AD
  • progress to FWB when walking w/out limp
    • ​usually 1-2 wks
      • ​want NEGATIVE quad lag
100
Q

Rehab Following Arthroscopic Debridement (Menisectomy)

*NOTE: these are EASIER to rehab

Return to Activity

A
  • TM running if…
    • quad strength >80%
    • NO jt. pain
    • trace or less effusion
  • Lvl Surf. Running, sprints, agility if…
    • normal gait on TM
    • no reactive effusions after TM running or any progress. of activity
  • Return to full activity (usually about 6 wks) if…
    • quad strength >90%
    • HOP Tests if returning to lvl I or II sports
101
Q

Meniscal Repair

When considered?

A
  • considered when lesion is in area of good vascularization
    • ​IF tear w/in 3mm of periphery
      • vascular
    • IF 3-5mm from periphery
      • gray zone
    • IF >5mm from periphery
      • avascular
102
Q

Indications and Contraindications for Meniscus Repair

NOTE: ACL + Meniscus together===> MORE blood supply ===> better healing

A

see table

103
Q

Superior Vertical divergent suture

Inferior vertical divergent suture

A

see pics

104
Q

Radial Meniscus Tear Repair

A

see pics

105
Q

Repair for Flap Tears

A

see pics

106
Q

Meniscal Repair of Avascular, Central Region

*Becoming MORE COMMON

*Want to preserve meniscus when possible!!!

A
  • Mods. of Sx tech’s to enhance healing in this area used:
    • ​Fibrin clot
    • Rasping of synovial fringe
    • Creating vascular access channels
107
Q

Meniscal Repair of Avascular, Central Region

Older Pts 40+

What did this study show?

A

30 repairs in pts 40+

26 pts asymptomatic; had NO further Sx after mean of 34 mos

see pics for Rehab program + Conclusions

108
Q

Meniscal Repair of Avascular, Central Region

Younger pts <20yo

what did this study find?

A
  • 71 knees of indiv’s <19yo
  • 75% had NO sx’s and showed no signs of clinical failure @ follow-up (18-51 mos)

see pics for Rehab Program followed:

109
Q

Meniscus Root Repair

**NOTE: where meniscus is most firmly attached

usually protected 4-6wks

*like trying to carry a bucket w/out other side of handle attached ****

A
  • HOOP STRESS!!!
    • disrupting root can cause meniscal extrusion in WB
    • AFTER repair—WB can sig. stress repair
      • shown in Biomech. studies not clinical studies
  • HS’s attach to medial meniscus****
    • ​contraction causes post. glide
110
Q

Meniscal Repair and Transplantation

A
  • preserve meniscal tissue at all costs
  • Goal of Rehab:
    • ​prevent excess WB and compression that has pot. to disrupt graft or transplant
  • protocols based on type of meniscal lesion, concomitant proc’s, stage of degen.
    • ​Peripheral tears progressed quicker vs. central tears****
  • SPECIFIC ROM & Heckman et al strongly recommend patellar mobs in ALL directions!!!
    • ​can always mobilize patella!!!
111
Q

Explain Cartilage Cyclic Loading

A
  • Cartilage is like a sponge
    • ​Load ON==
      • ​push BAD stuff OUT
    • UNLOAD==
      • ​GOOD stuff comes IN
112
Q

Articular Cartilage

Explain…

A
  • SELF-lubricating
  • Load Applied=== Fluid RELEASED
  • Load Released===Fluid ABSORBED
  • Lack of intermittent loading REDUCES lubrication process
113
Q

Articular Cartilage Respone to Loads

in Knee

when REDUCED LOADING

A
  • Reduced Nutrition
    • ​== degen changes
  • Reduced Lubrication
    • ​== INCs friction b/w jt surfs
    • == degen changes
  • LOW coeff. of friction
114
Q

Articular Cartilage Response to Loads

in Knee

when EXCESSIVE LOADING

A
  • *Actually has ability to bear VERY LG LOADS
  • Damage to collagen fiber network
  • Proteoglycan wash out
  • Loses ability to respond to compressive AND shear forces
115
Q

Articular Cart. Response to Loads

in Knee

when IMPACT LOADING

A
  • Occurs when loads applied @ FAST RATE
  • Cart. becomes stiffer
  • now unable to deform and redistribute loads fast enough
116
Q

The Knee–Art. Cart. Response to Immobilization

A

see pics for REVIEW

117
Q

Physical Stress Theory

A

Tissue Stress= Load/Area of Load Application

  • Too MUCH or Too LITTLE stress may be harmful to bio. tissue
  • Window of Adequate Stress that maintains health of biologic tissue
118
Q

Joint Stress/Tissue Stress== Force/Area of Force Application

A
  • FORCE components
    • ​current or prev. injury
    • Magnitude of Load
      • body mass
      • activity surface
      • foot wear
      • AD (grad. use)
    • Muscle and motor strength
  • Area of Force Application components
    • ​Loading rate
    • Joint mobility
    • Joint alignment
119
Q

Osteoarthritis

OA

A
  • Degen of Art. Cart.
  • 80% indiv’s 65+
  • Females>Males
    • 70% vs. 30%
  • Risk Factors:
    • age, gender
    • occup/rec. activity
    • obesity***
    • LE malalign.
    • QUAD WEAKNESS
    • Prev. structural damage to knee****
120
Q

OA Self-Report Symptoms

A
  • ***Typ. stiffness in morning that resolves w/in 30 mins**** CARDINAL SIGN
  • Pain w/ prolonged sitting bc no cart. nutrition
  • creak/crack/crunch (crepitus)
  • Occ. pain @ night
  • diff’s on stairs
    • bc poor eccentric control
121
Q

OA S/S

A
  • Pain w/ WB
  • Loss of Jt Mobility====CAPSULAR PATTERN
    • ​Flex > Ext ***************
  • poss. effusion
  • Quad weakness and/or inhibition
    • ​remember quad strength super important in obstructive lung diseases too!!!!!!
  • Osteophyte formation
122
Q

Altman’s Criteria for OA

Clinical

A

6 Criteria

  • Age >50yrs
  • Stiffness >30mins
  • Crepitus
  • Bony tenderness
  • Bony enlargement
  • No palpable warmth
123
Q

Altman’s Criteria

Clinical and Laboratory

A

Knee Pain and @ least 5 out of 9 criteria

  • Age >50yrs
  • Stiffness >30mins
  • Crepitus
  • Bony tenderness
  • Bony enlargement
  • No palpable warmth
  • Erythrocyte Sedimentation Rate <40
  • Rheumatoid Factor <1:40
  • Synovial Fluid signs of OA
124
Q

Altman’s Criteria

Clinical and Radiographic

A

Knee Pain and @ least 1 of 3 Criteria

  • Age >50yrs
  • Stiffness >30mins
  • Crepitus
  • Osteophytes
125
Q

OA

A

Look @ picture specifically @:

Osteophyte formation

Sclerotic (hardening) subchondral (below cart.) bone

Narrowing of jt. space (loss of art. cartilage)

126
Q

OA

Basic Tx Approach

A

Alter Joint Stress by Minimizing Loads and Maximizing Area of Load Application

Joint/Tissue Stress==Load/Area of Load Application

  • mm strength and jt. mobility
  • Wt Control: diet+exercise
  • AD’s
  • proper foot wear+orthotics
  • modif. of act. surfs
  • minimize impact loading
127
Q

Osteochondral Lesions

A
  • separation of fragment of art. cart. from the underlying subchondral bone from the epiphysis
    • ​Cart. pulls off of bone==> delaminates
      • ​*NOTE: different from OCD which is seperation of the ACTUAL BONE FRAGMENT from the subchondral region
  • Result from:
    • prolonged, repetitive loading OR traumatic, high impact loading​
      • typ shearing injury to WB area of bone
      • seperation of cartilage in the Weakest zone
        • ​*tidemark area*
128
Q

Risk Factors Assoc’d w/ Articular Cart. Lesions

A
  • pt age
    • INC age==INC likelihood (bc degen.)
  • Presence of meniscal tear
  • ACL Injuries (following are presented w/ cum. loading w/ shearing forces:
    • ​2-5yrs after ACL w/out repair, odds were 2.2x higher of having subsequent art. cart. injury vs. in first year
    • after 5 yrs odds inc’d to 5.9x
    • Retrospective study showed prevalence of art. cart. lesions w/ ACL injury to be 19%
    • Large study of pts undergoing arthroscopy 60% were found to have chondral lesions
  • Clinical exam may be inconclusive w/ pts presenting w/ non-specific complaints of jt pain or swelling
129
Q

Traumatic Osteochondral (OC) lesions

Lateral Patellofemoral Dislocation

A
  • OC lesion occurs on relocation
  • Med border of patella compresses against lat. fem. condyle as it is reduced by quads. contraction
  • Combo of compression + shear cause OC fx of either the lat. fem. condyle OR med. inf. patellar surf.
130
Q

Traumatic OC Lesions

ACL Rupture

A
  • During displace. of femur, ant tibial spine may contact med. fem. condylar surf. ==== causes lesion
  • Lat. fem. condyle can also be injured by forceful compression + shear that occurs when femur and post-lat. tibia collide during relocation of a “giving way” episode
131
Q

Osteochondritis Dessicans (OCD)

A
  • Defect in subchondral region w/ partial OR complete separation of bone fragment
  • Overlying art. cart. may remain intact
  • Prognosis depends on age and WB surf. affected AND the condyle
132
Q

OCD

A

OCD w/

133
Q

OCD

Presentation, Signs, Symptoms

A
  • COMMON older children/young adult MALES
  • no hx traumatic event
  • accumulative trauma/stress mech.
  • phys. active adolescent OR
  • rel. sedentary, overweight
  • non-local knee pain WORSE w/ jumping/WB
  • intermitt. effusion w/ pain
  • catching/locking/giving way IF loose body present
  • Laxity test NORMAL
  • affected fem. condyle tender
  • forcible compression on affected side==Crepitus
134
Q

OCD

Tx

A
  • Rel good healing pot. IF physeal plates NOT YET CLOSED + lesion stable
    • ​improved if art. cart. over lesion INTACT
  • WB restricted 6-8wks
    • some evidence for casting <12yo
  • PT works on strength + ROM DURING pd of NWB
  • sx follows pts for 6mos before return to high impact act.
  • IF UNSTABLE LESION OR CLOSED PHYSEAL PLATES====Sx Repair
    • ​== fragmental separation
  • PT Role==Recognize when present and refer out
135
Q

Art. Cart. Repair Procedures

More for Osteochondral defects:

A
  • Abrasion arthroplasty
  • Micro-Fx
    • promotes blood supply + bone healing
  • Mosaicplasty (OATS)
  • Autologous (from self) Chondrocyte (cartilage cells) Transplantation w/ Periosteal Graft
  • Re-align. proc’s
136
Q

Basic Science and Sx Tx Options for Articular Cartilage Injuries of the KNEE

A

written by physicians for PT’s

137
Q

Abrasion Arthroplasty

to joint OR jt. surf.

one small portion

A
  • subchondral bone abraded to create bleeding in lesion site
  • Fibrin clot forms in lesion
  • Fibrin clot facilitates mesenchymal cells to form fibrocart. in the defect
    • Mesenchymal Cells:
      • stem cells found in bone marrow that are important for making and repairing skeletal tissues: cartilage, bone, and fat found IN bone marrow
138
Q

Micro-Fx Procedure

Abrasion Arthroplasty ON STEROIDS!!!!

A
  • Sm. holes punctured in subchondral bone
  • Stem cells from bone marrow migrate into lesion site
  • Stem cells become chondrocyte-producing cells that eventually synthesize fibro-cart. in the lesion site

*NOTE: athletes + older adults PRIOR to TKA will use.

139
Q

Mosaicplasty (OATS) Procedure

Osteochondral Autograph Transplant Sx

A
  • Hyaline cart. grafts w/ underlying subchondral bone harvested from NWB site
  • Grafts press-fitted into lesion site
  • SMALLER lesions get Autologous (from self) grafts
  • LARGER lesions get Allografts (from cadaver)
140
Q

NOTE: Fibrocartilage vs. Hyaline Cartilage

A

Fibrocartilage is WEAKER

Hyaline Cartilage is STRONGER

141
Q

Autologous Chondrocyte Transplantation w/ Periosteal Graft

*graft==something put over top of something else (think skin grafts w/ burns)

A
  • Autologous (self) chondrocytes (cart. cells) from biopsy (taken from YOU) grown in culture
  • Cultured chondrocytes injected INTO lesion site
  • Periosteal graft fixed OVER lesion site
    • to keep them in there***
  • Stims formation of more hyaline-like (STRONGER) cartilage in lesion
142
Q

Autologous Chondrocyte Transplantation w/ Periosteal Graft

*graft==something put over top of something else (think skin grafts w/ burns)

A

Another Pic of procedure

143
Q

KNEE

Re-alignment Procedures

Tibial Osteotomy (tomy==cutting)

A
  • Closing Wedge
  • Opening Wedge
  • Mechanical Axis shifted AWAY from affected compartment
    • ​totally re-align joint
    • arthrokinematics changed
144
Q

Cartilage Repari Proced’s

Post-OP Rehab

A
  • Pd of NWB/PWB 6wks
    • ​aquatics + de-weighing devices for progressive WB
  • Controlled Jt. Mob. Acts.
    • EARLY MOTION GOOD
    • Motion combining compression + shear NOT GOOD
      • ​EX. loading jt thru range
    • DO use passive, AAROM, NWB AROM
  • Intermittent loading > static loading
    • ​loading should be compressive w/out shear
  • Resistance Ex.
    • ​brief, intermittent isometrics holding only few secs/rep > sustained iso’s
      • iso’s avoids compression combined w/ shear
    • IF resistance ex’s w/ motion— use arcs of motion that do NOT engage lesion
      • ​MOST lesions engaged b/w 20-70deg knee flex.
    • NMES to INC quad strength
145
Q

Current Concepts for Rehab and Return to Sport after Knee Art. Cart. Repair in Athlete

A

Tables 1 & 2

146
Q

Current Concepts for Rehab and Return to Sport after Knee Art. Cart. Repair in Athlete

A

Table 3

MSPT I (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions