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Clinical Medicine II > Knee Ligament Injury ACLR > Flashcards

Knee Ligament Injury ACLR Flashcards

1
Q

What range is peak torque on the quadriceps

A
  • 50-70 degrees of knee flexion
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2
Q

What position of the knee requires the most contractile force

A
  • terminal knee extension due to shortened quad muscle & decreased mechanical advantage of the patella
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3
Q

Immediate impairments following initial ligament injury

A
  • swelling for several hrs unless blood vessels are torn
  • pain when injuries ligament is stressed
  • instability if complete tear
  • redistricted motion & quad inhibition if there is effusion
  • impaired WBing & need for AD
  • concern for concomitant injuries
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4
Q

MCL injury

A
  • isolated injury with high valgus load
  • grade I, II, III classification
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5
Q

LCL injury

A
  • infrequent injury
  • usually traumatic varus moment at the knee that loads the ligament
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6
Q

PCL injury

A
  • “dashboard injury”
  • caused by a forceful trauma to the anterior tibia while the knee is flexed
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7
Q

MOI of ACL tear contact versus non-contact

A
  • Contact: blow to the lateral side of the knee resulting in large valgus moment
  • Non-contact: rotational mechanism in which the tibia is rotated on the planted foot with forceful hyperextension of the knee
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8
Q

Risk factors for ACL tear

A
  • high friction b/w the shoe & the surface
  • narrow femoral notch, Increased BMI, increased joint laxity
  • early & late follicular phases of menstruation in women
  • dynamic valgus
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9
Q

Indications for surgery for ACL tear

A
  • disabling instability
  • frequent knee buckling
  • high risk of re-injury
  • rule of 3rds (1/3 compensate & return to physical activities, 1/3 compensate but must give up activities, & 1/3 can’t compensate
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10
Q

Contraindications for surgery for ACL tear

A
  • inactive lifestyles
  • advanced arthritis in the knee
  • poor compliance
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11
Q

Patient selection for ACL to heal and stabilize the knee

A
  • non-high athlete
  • age >25
  • acute proximal one bundle ACL rupture
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12
Q

Potential copers for ACL tear

A
  • demonstrate sufficient dynamic knee stability
  • ability to compensate following injury
  • good potential to return to pre injury high level activities following a 1-year non-operative treatment
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13
Q

Potential non-copers for ACL tear

A
  • poor potential to return to pre injury activities following non-operative treatment
  • poor dynamic knee stability
  • advised to consider surgical management
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14
Q

Pre-screening to determine if someone might be a coper for ACL tear

A
  • no concomitant knee injuries
  • zero to trace knee effusion, full knee ROM, & normal gait
  • greater then 70% isometric quad strength
  • no pain with hopping up & down
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15
Q

Criteria to be classified as a potential coper for ACL tear

A
  • one or non giving way episode with ADLs
  • single-legged 6 meter timed hop score greater than or equal to 80%
  • KOS-ADLS score greater than or equal to 80%
  • GRS score greater than or equal to 60%
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16
Q

Bracing non-operative ACL deficient knee

A
  • for the ACL deficient knee every effort is made to prevent a giving way or shifting episode in order to avoid any further damage to the articular surfaces
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17
Q

Allograft for ACL reconstruction

A
  • donor tissue
  • used if an autograph is not available/previously failed
  • greater risk of failure
  • decreased graft strength
  • potential disease transmission
  • longer rehab times compared to autograph
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18
Q

Autograft for ACL reconstruction

A
  • patients own tissue
  • requires two surgical procedures
  • damages & weakens healthy tissue at donor site
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19
Q

Gold standard for ACL reconstruction

A
  • patellar tendon
  • uses the central 1/3 of tendon bone plugs
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20
Q

Advantages of using the patellar tendon for ACL reconstruction

A
  • high strength & stiffness
  • secure bone to bone fixation (6-8 wks)
  • permits accelerated rehab
  • safe return to pre-injury levels
21
Q

Disadvantages of using the patellar tendon for ACL reconstruction

A

-anterior knee pain at harvest site
- pain with kneeling
- long term quad weakness
- potential patellar fracture or rupture

22
Q

Advantages of using hamstring for ACL reconstruction

A
  • high tensile strength & stiffness
  • no disturbance of epiphyseal plate in immature patients
  • generally no problem with kneeling
  • no pain at anterior knee
23
Q

Disadvantages of using hamstring for ACL reconstruction

A
  • tendon to bone devices are not as reliable as bone
  • longer healing times
  • hamstring muscle strain in early rehab
  • knee flexor muscle weakness
  • increased anterior knee translation
24
Q

Precautions for patellar tendon autograft ACL reconstruction

A
  • be aware of patellofemoral forces & possible irritation
  • treat patellofemoral pain as it arises
  • alter knee flexion angle b/w 45-60 degrees for MVIC assessment & NMES treatments
25
Precautions for hamstring autograft ACL reconstruction
- no resisted hamstring strengthening until wk 12 - may start AROM as early as wk 4-6
26
Precautions for an ACLR with meniscal repair
- no WBing flexion beyond 45 degrees for 4 wks - WBing in full extension is allowed - multi-angle quad isometrics can substitute for WBing exercises
27
Precautions for an ACLR with MCL tear
- restrict motion to sagittal plane until wks 4-6 - consider brace for patients with severe pain during exercise
28
Non-repaired MCL ROM restrictions
- Grade I = no ROM restrictions - Grade II = 0-90 degrees in wk 1, 0-110 degrees in wk 2 - Grade III = 0-30 degree in wk 1, 0-90 degrees in wk 2, 0-110 degrees in wk 3
29
Ligamentization
- graft is its weakest at 6-8 wks post-op - by 30 wks a graft will have tissue characteristics of a ligament
30
Open and closed chain exercise considerations for ACL repair
- Open chain: limit knee ROM to only 90-45 degrees for non-weight bearing exercises early on; progress to knee ROM from 90-10 degrees by wk 12 - Close chain: wall slides & step ups in pain free ranges typically 0-60 degrees
31
ACL loading/force in NWB and WBing exercises
- loading b/w 10-50 degree is greater in NWB knee extension exercises - seated knee extension exercises b/w 10-50 degrees of knee flexion ROM with or without resistance produces greater ACL loading compared to WB exercises
32
ACLR rehab goals
- full knee extension ROM - absent or minimal effusion - no knee extension lag with leg raise - quad strength deficit should be minimized (15-40%)
33
What sets the stage for successful rehab for ACLR post-op care
- achieving symmetrical full knee extension - decreasing effusion - quads activation
33
What sets the stage for successful rehab for ACLR post-op care
- achieving symmetrical full knee extension - decreasing effusion - quads activation
34
Patient presentation in max protect phase for ACLR
- pain - hemarthrosis - decreased ROM - diminished quad activation - crutch ambulation - bracing if prescribed
35
Patient presentation in mod protect phase for ACLR
- pain & joint effusion are controlled - full knee ROM - 3+ or 4/5 muscle strength - developing neuromuscular control - independent ambulation
36
Patient presentation in min protect phase for ACLR
- no joint pain, instability, or swelling - full ROM - 75% function of non-involved LE - symmetrical gait - unrestricted ADL - possible brace/sleeve
37
Interventions for max protect phase post ACLR
- PRICE - gait training - PROM/AAROM - patellar mobs - muscle setting/isometrics - assisted SLR - ankle pumps - Wks 2-4: progress to FWB, SLRs in four planes, low load PRE hamstrings and knee extension (90-40 degrees), trunk/pelvis stabilization, & aerobic conditioning
38
Interventions for mod protect phase post ACLR
- multiple angle isometrics - close chain strength/stretch of LE - endurance training - proprioceptive training in SLS - trunk stabilization/band walks - Wks 7-10: advance strength/endurance/flexibility, progress proprioceptive training, & initiate walk/jog program
39
Interventions for min protect phase post ACLR
- LE stretching - advance PRE - advanced close chain exercises - introduce plyometrics - introduce more advanced plyometric drills - advance proprioceptive training - progress agility drills - simulated work/sport specific training - transition to full speed jogging/sprints/running/cutting
40
Soreness rules during rehab
- Sore during warm-up that continues = 2 days off & drop 1 level - Sore during warm-up that goes away = stay at level that led to soreness - Sore during warm-up that goes away but redevelops during session = 2 days off & drop 1 level - Sore the day after lifting (not muscle soreness) = 1 day off & don't advance program to next level - No soreness = advance 1 level per week or as instructed by healthcare professional
41
Return to running progression
- Level 1: 0.1 mi walk/0.1 mi jog repeat 10x = jog straights/walk curves for 2 mi - Level 2: 0.1 mi walk/0.2 mi jog repeat for 2 mi = jog straights & 1 curve every other lap - Level 3: 0.1 mi walk/0.3 jog repeat for 2 mi = jog straights & 1 curve every lap - Level 4: 0.1 mi walk/0.4 mi jog repeat for 2 mi = jog 1.75 lap/walk curve - Level 5: 2 mi jog - Level 6: increase to 2.5 mi - Level 7: increase to 3.0 mi - Level 8: 0.25 mi jog/0.25 mi run
42
Minimum criteria post ACLR to begin return to sport progression
- min 12 wks post-op - 90% or greater on quad index - 90% or greater on all hop tests - 90% or greater on KOS-ADL - 90% or greater on global rating score of knee function - follow up testing at 4 mo, 5 mo, 6 mo, & 1 year post
43
Criteria for post ACLR discharge
- isokinetic & functional hop test 90% or greater limb symmetry - acceptable quality movement assessment - lack of apprehension with sport specific movements - flexibility to accepted levels of sort performance - independence with gym program for maintenance & progression of therapeutic exercise program at discharge
44
PCL injury
- not commonly injured - accompanied by damage to other structures to the knee - High velocity = dashboard injury - Low velocity = hyper flexion athletic injury with a plantar flexed foot
45
Post-op management for PCL reconstruction
- immobilization in a hinged range limiting protective brace locked in full extension - 24/7 for first 4-8 wks post-op to avoid posterior tibial migration as a result of gravity - can be removed for therapy but follow MD guidelines - slower weight bearing progression than with ACL repair
46
Criteria for ambulation w/o crutches after PCLR
- minimal to no pain or joint effusion - full active knee extension with a SLR - passive & active knee flexion from 0-90 degrees - quad strength about 70% or 4/5 MMT grade - no hair deviations
47
General precautions for post-op PCLR
- avoid exercises that place excessive posterior shear forces & cause posterior displacement of the tibia - limit the number of reps of knee flexion to minimize potential abrasion to the pCL graft

Clinical Medicine II (21 decks)

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