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MSPT I > Knee Lectures 3 & 4 > Flashcards

Knee Lectures 3 & 4 Flashcards

1
Q

Ligamentous Anatomy of the Knee

What is involved here???

A
  • ACL
  • PCL
  • Posteromedial Corner PMC
    • MCL-Medial Collateral Lig.–superf. and deep
    • Posterior Oblique Ligament
  • Posterolateral Corner PLC
    • ​Lateral (Fibular) Collateral Lig.– LCL
    • Popliteal Tendon
    • Popliteofibular ligament
    • Acruate Ligament
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2
Q

Posteromedial Corner of Knee

A

see pics

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3
Q

Posterolateral Corner of Knee

A

see pics

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4
Q

Ligament Function

Rotation–NWB (*Fixed Femur)

Medial vs. Lateral Tibial Rotation

A
  • Medial Tibial Rotation
    • ​ACL-2ndary
    • PCL-2ndary
  • Lateral Tibial Rotation
    • ​PLC-Primary
    • MCL-Primary
    • PCL- Primary in 90deg FLEX
    • LCL-2ndary
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5
Q

Ligament Function

Sagittal and Frontal Planes

A
  • Anterior Translation
    • ​ACL- Primary
    • Meniscus, Capsule, Collaterals
  • Posterior Translation
    • ​PCL-Primary
  • Varus
    • ​LCL-Primary
    • Cruciates
  • Valgus
    • ​MCL-Primary
    • Cruciates
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6
Q

Anterior Cruciate Ligament

ACL

what is it?

A
  • Primary Stabilizer
    • ​ANT Tibial translation
    • POST Femoral translation
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7
Q

ACL in Extension

does what?

A

PL Bundle taut

restricts motion

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8
Q

ACL in Flexion

does what ?

A

AM Bundle taut

restricts motion

*Anterior Drawer Test here**

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9
Q

ACL @ ~20-30o Flex.

does what ?

A

BOTH ACL & PCL contribute equally to LIMIT Ant. Tib. Translation

*Lachman Test here**

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10
Q

The ACL is a Secondary Stabilizer for: 4 things

A
  1. HyperEXTENSION
  2. Varus + Valgus forces
  3. Medial Tibial rotation
  4. Lateral Femoral rotation
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11
Q

ACL

Has ANT. attachment w/ _____________

A

has ANT. attachment w/ ANT. horn of MED. meniscus

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12
Q

Saving the ________ drastically reduces risk of OA

A

Meniscus

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13
Q

ACL Tears

Some stats….

A
  • 200,000 tears/year in US
    • 100,000 reconstructions
  • 0-13% pts w/ isolated ACL inj. dev. OA w/ 10-15yrs
    • drastic INC in OA rates w/ meniscectomy
      • _​_bc changing of articulation
  • 41-50% pts who receive ACL reconstruction sx still dev. OA by 14yrs Post-OP
    • ​inj’d knee 4x MORE LIKELY to dev. OA vs. contralat. 10yrs latera
  • Approx. 80% all ACL tears are from NON-contact inj’s

​***NOTE: do NOT need reconstruction Sx to avoid OA

***NOTE: ACL inj. does NOT mean you will get OA!!

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14
Q

NON-Contact ACL Mech’s of Injury (MOI)

A
  • Cutting combined w/ Deceleration
  • Landing from jum in or near full EXT.
  • Pivoting w/ knee near full EXT.
    • ​MED. rotation of tibia (LAT. rot. of femur)==ACL wraps around PCL
    • LAT. rotation of tibia (MED. rotation of femur)==ACL stretched over lateral femoral condyle
  • HyperEXT.
  • Dynamic Valgus
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15
Q

STUDY: Biomechanical Measures of NMSK Control and Valgus Loading of the Knee Predict ACL Injury Risk in Female Athletes

Hewett et al., AJSM. 2005

A
  • Female ado’s 4-6x greater chance of tearing ACL vs. males
  • 205 female ado. soccer, basketball, volleyball players screened for NMSK control + Jt. loads during jump-landing tasks
  • 9 ACL tears reported

*NOTE: more males WITH ACL tears

*NOTE: females have a GREATER RATE

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16
Q

Valgus Loading & ACL Injury

A
  • Looking @ Abnormal Frontal and Transverse Plane Mech’s
    • ​Knee motion AND knee loading during landing task are predictors of ACL injury.

see pics

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17
Q

“Dynamic Valgus”

Multi-planar motion consisting of…

*remember there is a rotational component to this as well*

A

*Femoral ADDuction

*Knee ABDuction

*Ankle Eversion

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18
Q

Abnormal Frontal & Transverse Plane Mech’s

A

ACL-injured athlete had 2.5x GREATER Knee ABD moment and 20% HIGHER GRF

Stance time was 16% SHORTER

****Ext. moment HIGHER on injured side

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19
Q

Results and Discussion

Predicting ACL injury status:

Knee ABD moments

A
  • Knee ABD moments have Sn of 78% and Sp of 73% predicting ACL injury status
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20
Q

Results and Discussion

Predictors of ACL injury:

Sagittal plane knee and hip Flex.

A

Sag. plane knee and hip FLEX====NOT predictors of injury

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21
Q

Results and Discussion

ACL injury predictors:

MM co-contraction quads + hams

A
  • MM co-contraction of Quads+HS
    • ​proposed to DEC dynamic valgus and guard against excess. ANT TRANSLATION
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22
Q

ACL Injury Assessmen

Lachman’s Test

Explain…

*NOTE: Tests POSTEROLATERAL BUNDLE better vs. Ant Drawer

A
  • Pt. SUPINE w/ Knee flexed to 30o (IMPORTANT!!!)
  • Stabilize anteroLAT. DIST. femur (stabilize w/ OUTSIDE hand
  • Mobilize w/ INSIDE hand —-translate TIBIA ANT. w/ OPP HAND (INSIDE HAND)
  • (+) Test= Ant. translation of tibia BEYOND femur with “mushy” OR “soft” end-feel

*NOTE: Tests POSTEROLATERAL BUNDLE better vs. Ant Drawer

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23
Q

ACL Injury ASSESS.

Anterior Drawer Test

Explain…

**NOTE: Tests ANTEROMEDIAL BUNDLE

A

* Pt SUPINE w/ knee flexed to 90o

  • Tibia in neut. rot.
  • Thumbs IN jt. line​
    • fem. condyles ~1cm POST to AM Tibial plateau @ 90deg
  • Translate tibia ANT—mildly forceful
  • (+) Test= INCd ANT translation and soft end-feel

**NOTE: Tests ANTEROMEDIAL BUNDLE

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24
Q

Clinical Exam of the ACL

A
  • Sensitivity
    • ​TRUE POSITIVE rate
    • people who who are (+)–what proportion actually TEST (+)
  • Specificity
    • ​TRUE NEG. rate
    • people who are (-)–what proportion actually TEST (-)
  • PPV
    • ​how likely it is pt. HAS disease AFTER test POSITIVE
  • NPV (depends on PREVALENCE)
    • ​how likely it is pt. DOES NOT HAVE disease if tested NEGATIVE
  • + LR
    • ​likelihood that pt w/ POSITIVE TEST DOES have problem?
      • ​LR+ rules disease IN (over 10=better)
  • -LR
    • ​likelihood my pt w/ NEG. TEST DOES NOT have prob?
      • ​LR- (very LOW (
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25
Q

SnNOUT

vs.

SpPIN

A
  • w/ high Sensitivity, a Negative test rules OUT
    • ​NEG. result on highly Sensitive test==useful
  • w/ high Specificity, a Positive test rules IN
    • ​POS. result on highly Specific test==useful
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26
Q

LR Interpretation

A

see pics

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27
Q

PCL

A

see pics

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28
Q

Posterior Cruciate Ligament

PCL

Anterior-Lat bundle vs. Posterior-Med bundle

A

PRIMARY “knee stabilizer”

​​120-150% ACL CSA

  • Anterior-Lat. bundle
    • ​​MOST TAUT IN FLEX
  • Posterior-Med. bundle
    • ​MOST TAUT IN EXTENSION
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29
Q

PCL

PRIMARY Restraint of:

A
  • POST Tibial translation OR
  • ANT Femoral translation
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30
Q

PCL

SECONDARY role in LIMITING:

A
  • Femoral ER
  • Tibial IR
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31
Q

PCL MOI

4

A
    1. HYPERFLEX
    1. Fall on Flexed Knee w/ foot in PF
      * ​(**Fall on flexed knee w/ foot in DF==shattered patella)
    1. HYPEREXT mech’s
      * stepping in pot hole
    1. Blow to ANT. Tibia—Dashboard
      * ​*classic PCL—MVA
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32
Q

PCL Injury

Differential Dx

A
  • Patellofemoral pain w/ chronic PCL tears
  • Need to R/O Posterior Lateral complex involve.
  • False + ACL testing
  • Consider chondral lesions when MVA trauma involved
  • Meniscal tears @ POST horns
33
Q

PCL Injury Assess.

Posterior Drawer Test

Explain…

A
  • Pt is SUPINE —- knee flexed to 90o
  • Assess tibial plateau
  • Thumbs on ANT jt line—-apply POST force
  • (+) Test= EXCESS. POST translation and/or soft end-feel
    • *90% Sn—-10% FN’s
    • *90% Sp—-10% FP’s
34
Q

PCL Injury Assess.

Post. Sag Sign/Godfrey’s

A
  • STATIC TEST
    • ​pts knees supported and flexed to 90o
  • (+) Test= ANT. aspect of tibia appears to SAG
    • *100% Sp
    • 79% Sn–21% FN’s
35
Q

PCL Injury Assess.

Quad Activation Test

A
  • Pt lies SUPINE
  • w/ PCL Tear—–tibia sags posteriorly
  • While sitting on pt’s foot—-instruct pt to perform ISOMETRIC Quads contraction
    • “tell them to kick you off of their foot”
  • (+) Test= Relocation of tibia
    • ​Sn= .54, 46% FN’s
    • Sp= .97, 3% FP’s
36
Q

Healing Potential of PCL

A
  • healing possible 1 yr after injury W/ PROTECTION
    • ​67-75% demo’d continuity on MRI @ 1 yr
    • tended to have Firm end-pt w/ residual laxity
    • **Greater INITIAL laxity/COMBO’d injuries===LESS healing
  • ***Adequate protection of post translation of tibia (or ant. translation of Femur) during rehab ====optimizes healing
    • not well tested
37
Q

Makes up Posteromedial Corner

PMC

A
  • MCL
    • superf
    • deep
  • Post. Oblique Ligament
38
Q

makes up Posterolateral Corner

PLC

A
  • Lateral (Fibular) Collateral Ligament: LCL
  • Popliteal Tendon
  • Popliteofibular Ligament
  • Acruate ligament
39
Q

The MCL

Deep vs. Superficial

A
  • DEEP Layer​
    • ​fibers that blend w/ medial meniscus
  • SUPERFICIAL Layer
    • ​more vascularized and FIRST to be injured
40
Q

MCL

primarily RESISTS….

also resists….

A

primarily resists Valgus stress

  • ALSO resists…..
    • LAT Tibial rotation
    • MED Femoral rotation
41
Q

MCL

Primarily responsible for controlling:

and what does it do WITH the LCL?

A
  • Primarily responsible:
    • ​controlling excessive Valgus Forces
      • ​MAINLY ANT. FIBERS
  • WITH LCL:
    • ​2* responsibility in preventing excess Femoral IR/Tibial ER
42
Q

MCL

Differential Dx

A
  • Med. meniscus tear
  • ACL/PCL
  • Epiphyseal plate injury
  • Patella dislocation
43
Q

MCL Eval

A
  • Palpation
  • Valgus Stress Test
    • ​1. Knee flexed @ 20-30o
      • ​now 78% valgus load absorbed by MCL
      • apply valgus stress
      • +Test= laxity/pain
      • Sn=86%
    • 2. Repeat @ 0o
      • ​now 57% valgus load absorbed by MCL
      • If laxity here====multiple lig. injury
44
Q

MCL Eval

Valgus Stress @ 0o

If lot of lax===mult. lig. injury

A

see pics

45
Q

Healing Potential of MCL

A
  • When combined w/ ACL Injury…
    • ​SUPERFICIAL MCL—–responded well to bracing
    • SUPERF & DEEP MCL—-often req. Sx
  • Tibial sided injury—–not heal as well
  • ***Functional rehab important!!!
    • ​AVOID Valgus stress
      • ​work on OPP side—-pulls them into varus
46
Q

Lateral Collateral Lig

LCL

info..

A
  • NOT attached to capsule OR meniscus
  • Separated from meniscus by Popliteus tendon
47
Q

LCL

PRIMARILY resists…..

ALSO resists….

A
  • PRIMARILY resists: Varus stress
  • ALSO resists:
    • ​LAT Tibial rotation
    • MED Femoral rotation
48
Q

LCL

Diff Dx

A
  • ACL/PCL
  • PLC
  • Lat. meniscus
  • ITB
  • Biceps Fem
  • Popliteus
49
Q

LCL Eval

A
  • Palpation of jt. line
  • Varus Stress Test
    • ​1. Knee flexed to 20-300 (always start here)
      • ​now 55% Varus load absorbed by LCL
      • apply Varus stress
      • (+) Test= laxity/pain
    • 2. Repeat @ 00
      • ​69% varus load absorbed by LCL
      • looking @ mult. lig. injury if more laxity/pain
50
Q

Posterolateral Corner

PLC

STATIC Structures:

A
  • LCL
  • POST horn lateral meniscus
  • PL capsule
51
Q

Posterolateral Corner

PLC

DYNAMIC Structures

A
  • ITB
  • Popliteus
  • Biceps Fem
52
Q

PLC Injuries

A
  • Posterolateral directed force TO ANTEROMEDIAL Tibia
  • Knee HYPEREXT.
  • SEVERE Tibial ER w/ knee in low FLEX angles
  • VARUS forces to Flexed Knee
  • Atraumatic may present as chronic laxity W/OUT PCL component
    • ​ER of lat. tibial plateau occurs around still intact PCL
53
Q

W/ the PCL

what is important????

A

ROTATION

54
Q

PCL Injury Eval

Dial Test

PLC===Rotation Important!!!

A
  • Pt is Prone w/ knees FLEXED to 30o and 90o
  • MAXIMALLY ER lower leg
  • (+) Test= 15o diff. compared to uninvolved leg
  • Isolated PLC Injury:
    • ​GREATER diff @ 30o but NOT @ 90o
  • Combined PCL/PLC Injury:
    • ​Diff @ 30o AND 90o
55
Q

Pre-OP and NON-OP Tx of Ligament Tears

Remember….Even though it is torn, you MAY NOT NEED Sx

A

!!!!!!!!!!!!!!

56
Q

PREHAB!!!

Guiding Principles of Prehab Phase:

A
  • PREVENT gross instability/giving way
    • ​Regardless of what is torn
  • PROTECT injured structures w/ pot. to heal
    • ​MCL
    • PCL in particular*****
  • PROTECT any risk of vessel/nerve injury
  • RESTORE ROM and Quadriceps Function
57
Q

Prehab Phase

GOALS:

A
  • 0-120o ROM w/out Stiffness
    • ​MD may limit to 90o
  • PREVENT mm atrophy and contracture
    • ​*SLR w/out lag
    • *Norm patellar mobility
  • MODIFY gait patterns to improve overall function
    • ​Brace+Crutch reco’d
58
Q

Prehab Phase

Causes of Concern:

A
  • IMMEDIATE REFERRAL
    • ​S/S of nerve or vessel compromise
    • ​Instabilitythat can NOT be managed w/bracing or act. mods.
    • Suspected furthering of injury
59
Q

Collateral (MCL/LCL) Lig. Injury

S/S

A
  • Varus (LCL) or Valgus (MCL) Stress tests (+)
  • Swelling over lig. —- Ecchymosis
    • ​Jt. Effusion IF meniscal involve.
  • ***Quadriceps dysf & Inhibition (Pain Related)
  • Tenderness to palpation of lig.
    • ​Attach’s AND mid-substance
  • Difficulty w/ pivoting, cutting, etc..
    • ​“I can run in a straight line, but my knee feels like it’s going to fall apart if I turn quickly”
60
Q

ROM loss w/ ACL

A

Limited EXT > FLEX

61
Q

ACL INJURY

S/S

A
  • (+) Tests:
    • ​Lachman, Ant. Drawer, Pivot-shift
  • Popping, Giving Way, Buckling
    • ​SEVERE pain w/ jt effusion
  • Recurrent “giving way” episodes
    • ​ADLs, Sports
  • Cont’d effusion
  • QUAD INHIBITION****
    • ​43% ACLD have quad activation failure
      • ​Gen GREATER in lg. effusions
    • ​Quad strength+Time from injury NOT clinical predictors of AMI
  • LIMTD ROM
    • ​Limtd EXT>FLEX
  • Flexed Knee Gait
    • ​ADDRESS IMMEDIATELY!!!
62
Q

PCL Injury

S/S

A
  • POST. knee pain
  • Not as much effusion as ACL
  • Flex beyond 90o may INC pain (in OPEN CHAIN)
  • Diff. descending stairs, squatting, running
  • NOT AS MUCH PROBLEM W/ Quad Inhibition
  • (+) Tests:
    • ​Sag sign, POST. Drawer, REDUCED palpation of tibial plateau step off
      • ​BC tibia sagging POST.
63
Q

These Lig. injuries MORE LIKELY TO CAUSE PAIN

A

MCL

LCL

64
Q

Lig. Rehab

Symptom Modulation

A
  • Eliminate effusion
  • Restore ROM
    • ​Full HYPEREXT. NOW
    • Get past 90o FLEX quickly
      • ​ESP MCL injuries
    • Post. Tib. support for FLEX after PCL injury
  • Soft Tissue Mobs
  • Quad+HS strengthening in pain-free ROMs
    • WB OR NWB
  • Hip strengthening
    • NO ADD. for MCL injuries
      • ​puts Valgus on knee
    • NO ABD. for LCL injuries
      • ​puts Varus on knee
  • NORMALIZE GAIT!!!
65
Q

Lig. Rehab

Motor Control

(once things are calmed down)

A
  • MM strength
  • MM length
  • WHOLE BODY
    • ​hips
    • HS’s
    • CORE
  • Injury Prevention Tech’s
    • balance
    • landing patterns
    • Direction changes
66
Q

Quadriceps Neutral Angle

*Use for strengthening post-injury*

A
  • Knee Flexion range @ which tension in quadriceps does NOT create ANT or POST shear force
    • ​LESS THAN 60O produces Ant. shear (60-0o)
      • ​90-600 FLEX==Safe for ACL
    • GREATER THAN 75O produces Post. shear
      • ​0-60o FLEX==Safe for PCL
67
Q

Ligament Rehab

Functional Optimization

*Note “Functional”

returning to “Function” or “prev. activity”

A
  • Running
    • SIMPLEST form of DYNAMIC loading
  • Agility+Plyo’s
    • jump
    • hop
    • cut/pivot
  • Sport-specific
68
Q

Ligament Tear

Why should I WAIT?

A

PREHAB!!!

****“Better IN, Better OUT”*****

  1. ROM
    1. ​Pre-OP ROM predicts Post-OP ROM
  2. MM Function
    1. ​Pre-OP Quad Strength==>SIG. predictor ofknee function after Sx
    2. NMES
69
Q

Neuromuscular Adaptations to Injury

A
  • Instability==HALLMARK Sx after ACL injury
  • Now inability to compensate
  • Can result in INCd injury
    • ​Now poorer outcomes after ACLR
    • Now INCd risk of OA
  • Altered function
    • ​1. Balance
      • ​altered control of frontal plane Center of Pressure (CoP)
      1. Gait
        * Co-contraction of FLEXORS and EXTENSORS
        * Truncated knee motion
        * Altered loading
70
Q

Potential Copers & Non-Copers

Fitzgerald et al. developed decision-making scheme for returning to high lvl phys. act. following ACL tear and NON-OP Tx

Screening Exam?

A
  • Screening Exam:
    • ​Single, Triple, Cross-over, Timed 6m hop test (see pic)
      • ​80% or higher vs. uninvolved leg
    • Global rating of knee function
      • 60% or higher
    • Knee Outcome Survey ADL Scale
      • 80% or higher
    • Report the # of knee giving-way episodes from time of injury to time of testing
      • ​NO MORE than one event of tibiofemoral buckling or sublux.
71
Q

Differential Responses to Injury

A
  • Gross co-contraction==crude method of stabilization
    • _​_INCs compressive forces
    • INCs degen.
72
Q

Fitzgerald et. al.

Decision-making scheme for returning pts to high-lvl act. w/ NON-OP Tx after ACL Rupture

A
  • 93% pts w/ unilat. ACL ruptures
  • 28 met criteria + attempted NON-OP Tx
  • 22 (79%) able to return pre-injury lvls of act. W/OUT recurring episodes of “giving-way” or extending the knee injury

*****PERTURBATION TRAINING******

73
Q

Return to sport for ACL====

A

9mos or longer

74
Q

Copers vs. Non-Copers

A
  • Patients who are considered copers are individuals who are able to perform functional activities despite an ACL rupture.
  • Non-copers are patients who are unable to perform functional activities and have repetitive episodes of the knee “giving-way” (also known as instability).
    • These non-copers are less likely candidates for non-operative treatment.
75
Q

Perturbation Training

Explain associatin w/ ACL Rupture

A
  • TEN SESSIONS USED:
    • Improves return to sport after injury w/out reconstruction
    • DECs co-contraction and resolves gait asymmetries
      • ​Pre-operatively in potential copers
        • can perform functional acts despite ACL rupture
      • Post-operatively in non-copers
        • unable to perform functional acts—more “giving-way”—-less likely candidates for non-op Tx
76
Q

Clinical Course of Care involving Perturbation Training

A

see pics

77
Q

Pair matched comparison of Return to Pivoting Sports @ 1 year in ACL injured pts after NON-OP vs. OP Tx course

69 matched pairs, 1 yr after injury OR Sx

OP vs. Non-OP

A

Among non-OP treated pts, those participating in Lvl II sports were MORE LIKELY to return to sport than those participating in Lvl I sports

78
Q

Tx for Acute ACL tear:

5 yr outcome of randomised trial

RCT of EARLY ACLR and OPTIONAL Delayed ACLR

A
  • NO statistically significant differences in:
    • ​Pt reported outcomes
    • Radiographic OA
    • Act. lvl

VERY INTERESTING!!!!!!!!!!!!

79
Q
A

MSPT I (10 decks)

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