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OCS prep > Knee ligament CPG > Flashcards

Knee ligament CPG Flashcards

1
Q
  • The incidence of ligamentous injury from greatest to least is:
A

ACL, PCL, MCL, LCL

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2
Q
  • The most common multiligamentous injuries include:
A

o ACL and MCL

o Posterolateral corner (PLC) and either the ACL or PCL

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3
Q

What demographics have the highest incidence of ligamentous injury?

A
  • Ligamentous knee injury is substantially higher for people in the military and professional athletes; moderately higher for amateur athletes
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4
Q

What are the stats for second ACL injury following ACL reconstruction?

A

o patients under the age of 25 have a second ACL injury rate of 21%
o athletes under the age of 25 who return to sport have a second ACL injury rate of 23%
o Female athletes returning to sport are 4.5x more likely to have a second ACL injury within 24 months than female controls

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5
Q

What sports are arguably the most dangerous for ACL injury?

A
  • soccer accounts for a third of all ACL reconstructions, however football is more dangerous for males.
  • skiing carries a higher risk of injury in general, but lower volume of injury
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6
Q

What is the standard mechanism of ACL injury?

A

o Non-contact
o Acceleration or deceleration with excessive quad contraction and reduced hamstring co-contraction at or near full extension.
o Loading is higher with quadriceps force combined with knee internal rotation, a valgus load combined with knee internal rotation, or excessive valgus loads applied during weight bearing deceleration activities

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7
Q

What is/are the standard mechnism(s) for PCL injury?

A

o “dashboard/anterior tibial blow injury” (38.5%),
o fall on the flexed knee with the foot in plantar flexion (24.6%)
o a sudden violent hyperextension of the knee joint (11.9%)

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8
Q

What is the standard mechanism for PLC injury? (isolated)

A

Isolated injury to the PLC can occur from a posterolateral directed force to the proximal medial tibia with the knee at or near full extension, forcing the knee into hyperextension and varus.

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9
Q

What is the standard mechanism for PLC injury? (combined)

A

Combined PLC injuries can result from knee hyperextension, external rotation, and varus rotation; complete knee dislocation; or a flexed and externally rotated knee that receives a posteriorly directed force to the tibia

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10
Q

What does the evidence say about early vs delayed ACL reconstruction?

A
  • There is high quality evidence that shows:
    o No difference between early and delayed ACL reconstruction for multiple outcomes including knee laxity/instability and return to sport levels
    o No difference between early ACL reconstruction with structured rehabilitation and structured rehabilitation with the option for delayed ACL reconstruction at 5 year follow up with multiple outcome measures
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11
Q

Are there differences between quad tendon, hamstring tendon, or patellar tendon grafts for ligamentous stability and patient reported outcomes?

A
  • Level II evidence shows that outcomes are generally similar between graft types
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12
Q

What are the expectations following ligament injury and surgical management with regards to graft type and timing of surgery?

A

The clinical course for most patients after ligament injury and surgery is satisfactory, with no differences between graft type or timing of surgery.

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13
Q

Can people expect to return to sport following ligamentous injury and surgical management?

A

Rates of return to any sport are good, but there are substantially lower rates for return to preinjury levels or competitive sports. Physical impairments, performance-based tests, PROs, and psychological responses may influence return-to-sport rates.

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14
Q

Is there an effect of psychological factors on return to sport following ACL reconstruction?

A

yes

Other important factors include psychological responses, including fear of movement/reinjury, athletic confidence, self-efficacy, and emotions, after ACL reconstruction.

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15
Q

What two environmental (literally) conditions are associated with risk of ACL injury?

A
  • Dry weather conditions and artificial turf surface
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16
Q

What are other risk factors associated with the risk of ACL injury? (6)

A
  • Female sex
  • narrow intercondylar femoral notch size
  • lesser concavity depth of the medial tibial plateau
  • greater anterior/poste¬rior tibiofemoral joint laxity
  • prior ACL reconstruction
  • familial predisposition
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17
Q

Is the magnitude of the posterior slope of the tibia a risk factor for ACL injury?

A
  • conflicting evidence
18
Q

Are there biomechanical or neuromuscular risk factors associated with non-contact ACL injury?

A
  • no evidence to support their existence at this time
19
Q

What are the CPG diagnostic criteria for ACL sprain diagnosis? (6)

A

o Mechanism of injury consisting of deceleration and acceleration motions with noncontact valgus load at or near full knee extension
o Hearing or feeling a “pop” at time of injury
o Hemarthrosis within 0 to 12 hours following injury
o History of giving way
o Positive Lachman test with “soft” end feel or increased anterior tibial translation (sensitivity, 85%; 95% CI: 83%, 87% and specificity, 94%; 95% CI: 92%, 95%)
o Positive pivot shift test (sensitivity, 24%; 95% CI: 21%, 27% and specificity, 98%; 95% CI: 96%, 99%)

20
Q

What are expected movement coordination impairment measures following ACL sprain that can assist diagnosis? (3)

A
  • 6-meter single-limb timed hop test result that is less than 80% of the uninvolved limb
    • Maximum voluntary isometric quadriceps strength index that is less than 80% using the burst superimposition technique
    • Reported history of giving-way episodes with 2 or more activities of daily living (ADLs)
21
Q

What are the CPG diagnostic criteria for PCL sprain diagnosis? (4)

A

o Posterior-directed force on the proximal tibia (dashboard/ anterior tibial blow injury), a fall on the flexed knee, or a sudden violent hyperextension of the knee joint
o Localized posterior knee pain with kneeling or decelerating
o Positive posterior drawer test at 90° with a nondiscrete end feel or an increased posterior tibial translation (sensitivity, 90%; 95% CI not available and specificity, 99%; 95% CI not available)
o Posterior sag (subluxation) of the proximal tibia posteriorly relative to the anterior aspect of the femoral condyles (sen¬sitivity, 79%; 95% CI: 57%, 91% and specificity, 100%; 95% CI: 85%, 100%)

22
Q

What are the CPG diagnostic criteria for MCL sprain diagnosis? (5)

A

o Trauma by a force applied to the lateral aspect of the lower extremity
o Rotational trauma
o Medial knee pain with valgus stress test performed at 30° of knee flexion (sensitivity, 78%; 95% CI: 64%, 92% and specificity, 67%; 95% CI: 57%, 76%)
o Increased separation between the femur and tibia (laxity) with a valgus stress test performed at 30° of knee flexion (sensitivity, 91%; 95% CI: 81%, 100% and specificity, 49%; 95% CI: 39%, 59%)
o Tenderness over the MCL and its attachments reproduces familiar pain

23
Q

What are the CPG diagnostic criteria for LCL sprain diagnosis? (5)

A

o Varus trauma
o Localized swelling over the LCL
o Tenderness over the LCL and its attachments reproduces familiar pain
o Lateral knee pain with varus stress test performed at 0° and 30° of knee flexion
o Increased separation between the femur and tibia (laxity) with varus stress test applied at 0° and 30° of knee flexion

24
Q

What are the key clinical findings indicative of knee instability as a clinical diagnosis? (11)

A

o Symptom onset linked to precipitating trauma
o Deceleration, cutting, or valgus motion associated with injury
o “Pop” heard or felt at time of injury
o Hemarthrosis within 0 to 12 hours following injury
o Knee effusion present
o Sense of knee instability reported
o Excessive tibiofemoral laxity with (cruciate/collateral) ligament integrity tests
o Pain/symptoms with (cruciate/collateral) ligament integrity tests
o Lower-limb strength and coordination deficits
o Impaired single-leg proprioception/balance
o Abnormal compensatory strategies observed during deceleration or cutting movements

25
Q

What outcome measures are most appropriate for use to measure knee symptoms and function in the context of ligamentous injury?

A
  • IKDC 2000
  • KOOS
  • also “may” use Lysholm scale
26
Q

What outcome measures are more appropriate for use to measure/track efficacy of intervention for impairment/activity/participation with knee ligamentous injury?

A
  • Tegner scale

- Marx Activity Rating Scale

27
Q

What outcome measures are most appropriate for use to measure/track efficacy of intervention for psychological factors with knee ligamentous injury?

A
  • ACL-RSI

- “may” use

28
Q

What two hop tests are associated with a cut-off to predict prognosis or specific intervention? What is the cut-off?

A
  • Single-leg hop for distance at 88% or greater predicts normal knee function at 1 year; when conducted 6 months after ACL reconstruction, can predict normal knee function at one year as well
  • 6m timed hop test for athletes that demosntrated less than 88% cutoff may benefit from isolated strengthening to improve outcomes
29
Q

Are single leg hop tests predictive of success, preoperatively?

A
  • no
30
Q

What are the recommended impairment level things that should be measure through course of care for a knee ligamentous sprain? (5)

A
  • knee joint laxity
  • thigh muscle strength
  • lower limb movement coordination
  • knee effusion
  • knee joint ROM
31
Q

What clinical tests are most appropriate for dx of ACL sprain?

A
  • Lachmans, anterior drawer, pivot shift

- all have good properties; arguably Lachmans and anterior drawer are better

32
Q

What clinical test is the most sensitive for PCL tear? Most specific?

A
  • sensitive: posterior sag sign

- specific: quad active test

33
Q

Is preoperative quad strength associated with outcomes post-ACL surgery?

A
  • kind of.
  • quad strength deficits are associated with self-reported impaired knee function at 6 months and 2 years
  • higher pre-op quad strength index along with younger age and male sex is associated with higher quad strength 6 months post-op
  • the cutoff of 70.2% quad strength index preop is associated with moderate probability of having 85% quad strength index at 6 months postop
34
Q

What are the recommendations for using a CPM following ACL reconstruction?

A
  • weak evidence

- it can be used in the immediate post-op phase to help control pain…oddly…not improve ROM

35
Q

What are the recommendations for early weight bearing following ACL reconstruction?

A
  • weak evidence
  • fairly standard at this point though
  • may implement WBAT within 1 week post-op
36
Q

What are the recommendations for use of knee bracing for ligamentous injury and post-op?

A
  • Grade F evidence for MCL, LCL, PCL, etc. You can use it, there’s just no research looking at those
  • For post-op ACL, there is moderate evidence that use of a brace is no more beneficial than not using one.
  • some evidence of a statistical difference in joint laxity for those that wear braces, but not clinically different. No real difference in ROM, strength, function, etc
37
Q

What are the recommendations for use of cryotherapy for ACL reconstruction?

A
  • it should be used in the immediate post-op phase to control pain
  • no evidence that it has effects in other variables such as ROM, effusion, etc
38
Q

What are the recommendations for immediate vs delayed mobilization post-op ACL reconstruction?

A
  • moderate evidence supporting immediate (w/in 1 week) mobilization to improve:
  • ROM
  • pain
  • risk of adverse responses; e.g., loss of knee extension
39
Q

What are the recommendations for supervised rehabilitation for post-op ACL reconstruction?

A
  • it should be done.

- Should consist of exercise, HEP progression/supervision, and education to ensure independent performance

40
Q

What are the recommendations for therapeutic exercise for post-op ACL reconstruction?

A
  • It should be done with the goal of increasing thigh muscle strength
  • Should consist of WB and non-WB eccentric and concentric exercise
  • Should start w/in 4-6 weeks post-op, conducted 2-3x/week for 6-10 months
41
Q

What are the recommendations for NMES use for post-op ACL reconstruction?

A
  • Strong evidence that it should be used in the first 6-8 weeks to augment quad strengthening exercise
  • enhances short term outcomes
  • can be used longer per some studies
  • most studies are worded using the NMES with exercise as opposed to just the NMES alone
42
Q

What are the recommendations for NM re-education for post-op ACL reconstruction?

A
  • Strong evidence that it should be used WITH strength training to improve knee stability and movement coordination impairments
  • really no explanation of what exactly NM re-ed consists of though…

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