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OCS prep > Knee ligamentous issues > Flashcards

Knee ligamentous issues Flashcards

1
Q

Which are considered stronger, the cruciate ligaments or the collateral ligaments?

A
  • cruciate
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2
Q

Are the cruciate ligaments intra/extra capsular and/or synivoal?

A
  • they are intracapsular and extra-synovial
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3
Q

What structures is the MCL connected to?

A
  • medial meniscus and the joint capsule
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4
Q

T or F;

The MCL has a poor blood supply, healing slowly.

A
  • F

Has a rich blood supply, healing relatively well

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5
Q

The LCL connects to which structure?

A
  • joins with the biceps femoris muscle to form a conjoined tendon, attaching into the proximal fibular head
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6
Q

Which ligament is the most commonly injured?

A
  • ACL
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7
Q

The ACL becomes taut during ____ and is responsible for the which accessory motion?

A
  • taut during flexion

- responsible for the glide after the knee rolls

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8
Q

The anteromedial bundle (AMB) of the ACL prevents _______ translation in ______, and the posteromedial bundle of the ACL prevents _______ translation in ________

A

o Anteromedial band (AMB) prevents anterior translation in flexion
o Posteromedial band (PMB) prevents posterior translation in extension

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9
Q

Which ligament resists hyperextension of the knee?

A
  • ACL
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10
Q

The ACL acts as a secondary restraint against which motions?

A
  • varus and valgus
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11
Q

ACL is more likely a ______ injury, compared to teh PCL which is more likely a _______ injury

A
  • ACL more likely non-contact

- PCL more likely contact

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12
Q

The PCL becomes taut during ______ and is responsible for which accessory motion?

A
  • becomes taut in extension; as femoral condyles roll forward, becomes taut and then causes a glide
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13
Q

MCL primarily restricts which motion(s)?

A
  • valgus and lateral rotation
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14
Q

The MCL is most taut in which position?

A
  • full extension
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15
Q

In full extension, the MCL accounts for ___% of the restraining force against valgus. At 25* of flexion, the MCL accounts for ____% of the restraining force agianst valgus.

A
  • 57%

- 78%

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16
Q

What is a weird paradox about the MCL?

A
  • the MCL is most taut in full extension, however is more responsible for stabilizing valgus load in slight flexion. May be taking on greater loading when slightly lax.
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17
Q

LCL primarily restricts which motion(s)?

A
  • varus

- also limits external and internal rotation

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18
Q

The greatest strain on the LCL occurs in which position and with which force?

A
  • full extension with tibial external rotation
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19
Q

What ligament helps limit anterior and internal rotation forces in an ACL deficient knee?

A
  • LCL
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20
Q

Which ligament is the least often injured?

A
  • LCL
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21
Q

T or F:

The knee is the most commonly injured joint

A
  • T
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22
Q

Which ligaments are most often injured?

A
  • ACL has highest rate, followed by MCL
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23
Q

Ligamentous injury is more likely in what demographic?

A
  • younger female athletes (14-18 yo)

- more often in athletics in general

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24
Q

Some studies have shown as high as a ___:___ ratio for ______ (gender) for ligamentous knee injury

A

10:1, female to male ratio

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25
Q

ACL injuries typically occur in what situations?

A
  • knee in slight flexion with tibial rotation in a WB position
  • pivoting, landing, changing direction
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26
Q

What is the unhappy triad?

A
  • ACL, MCL, medial meniscal injury
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27
Q

A dashboard injury describes what ligamentous injury?

A
  • PCL
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28
Q

Hemarthrosis and immediate joint effusion are hallmark signs of what knee injury?

A
  • more common with ACL and PCL injury
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29
Q

Describe execution of the DIAL test and interpretation.

A
  • Prone w/ knees at 90* flx
  • Both feet up, ER both tibias at 90* and 30*
  • Looking for significant asymmetries in laxity
  • If symmetrical in 90* but asymmetrical in 30*, likely that the PCL is intact, but the posterolateral corner may be deficient
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30
Q

What tests are appropriate to assess anterior/posterior stability?

A
  • Lachman’s (reverse Lachman’s)
  • Anterior drawer (posterior drawer)
  • Pivot shift (reverse pivot shift)
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31
Q

What type of imaging is most sensitive to rule out ligamentous involvement?

A
  • MRI

- radiographs should be first

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32
Q

T or F;

It is possible for a professional level athlete to return to competitive level performance without surgical management for an ACL tear.

A
  • T

- requires a significant focus on motor control/strength

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33
Q

What are the two primary focuses for ACL and PCL rehab?

A
  • motor control

- strength of the LE

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34
Q

What muscles provide anterior tibial shear?

A 
o	Quads through patellar tendon
o	Gastroc (proximal tendon wraps posterior tibia)
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35
Q

What muscles provide posterior tibial shear?

A 
o	Hamstrings (increases as knee flexion increases)
o	Soleus (when in closed chain)
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36
Q

What is a consideration for open-chain therex after ACL injury?

A
  • open-chain quad exercise is thought to put more anterior shear force on the tibia, especially in full extension
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37
Q

What are 4 examples of things that may put significant strain on an ACL?

A
  • isometric quad contraction at 15* flx
  • squatting
  • Lachmans
  • active flx/ext w/ weighted boot
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38
Q

What are 2 examples of exercises that may minimize ACL strain?

A
  • isometric quad contraction at 30 to 90* flx

- simultaneous quad/hamstring contraction at 60-90*

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39
Q

What muscle shares the role of the PCL?

A
  • popliteus
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40
Q

What muscle will reduce strain on the PCL between which range? (not the popliteus)

A
  • quads, between 20-60*
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41
Q

When does the gastroc place the greatest strain on the PCL?

A
  • when the knee is flexed over 40*
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42
Q

What are the 2 principles for MCL injury management?

A
  • manage pain and inflammation initially (RICE)

- progressively increase controlled stress, with less stress in full extension

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43
Q

What ROM should you be more conservative with when adding stress during MCL rehab?

A
  • less stress in full extension
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44
Q

How long can remodeling take with an MCL injury?

A
  • some studies show up to a year
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45
Q

What are the 2 principles for LCL injury management?

A
  • manage pain and inflammation initially (RICE)
  • progressively increase controlled stress, with less stress in full extension
  • same as MCL
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46
Q

What is the expected outcome for LCL/MCL injury with rehab?

A
  • usually responds well to conservative care
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47
Q

What are the flexor muscles of the knee? (8)

A 
o	Semimembranosus
o	Semitendinosus
o	Biceps femoris (long and short heads)
o	Gracilis
o	Sartorius
o	Popliteus
o	Soleus
o	Gastroc
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48
Q

What are the extensor muscles of the knee? (4)

A

o Quadratus femoris
o Vastus lateralis
o Vastus intermedius
o Vastus medialis

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49
Q

What two muscles attach to the patella via the patellar retinaculum?

A
  • vastus lateralis

- vastus medialis

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50
Q

What muscles limit anterior translation of the knee?

A

o TFL via the ITB
o Soleus (only in WB)
o Glute max (only in WB)

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51
Q

What muscles limit posterior translation of the knee?

A

o Quadriceps
o Popliteus
o Medial and lateral heads of the gastroc

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52
Q

What muscles limit valgus stress at the knee?

A

o Pes anserinus
o Semimembranosus
o Medial head of gastroc

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53
Q

What muscles limit varus stress at the knee?

A

o Biceps femoris

o Lateral head of gastrocnemius

54
Q

Define quadriceps insufficiency.

A

o Failure of voluntary activation of skeletal muscle is defined as the inability to produce all available force of a muscle despite maximal voluntary effort

55
Q

The quads are __x as strong as the hamstrings

A
  • 2x
56
Q

What ROM is the most difficult to create force with for the quads?

A

o Last 15* of extension are most difficult to create active force in open chain, due to lack of pulley through patella; quad contraction must increase in order to compensate for the decrease in the moment-arm

57
Q

What are some potential causes for quad lag? (3)

A

 Patellar tendon graft
 Prolonged immobilization of the knee
 Active insufficiency (contracture)

58
Q

What other muscles assist the quad with stability in WB knee extension?

A
  • glute max

- soleus

59
Q

Asymmetrical differences in quad strength 6 months after TKA range from ~____ to ____%.

A

15-21%

60
Q

T or F;

Quad weakness is directly related to the development of knee OA

A
  • T
61
Q

T or F;

Quad weakness has not been found to have an association with decline in physical function

A
  • F
62
Q

T or F;

Decreased function and motor control of the quads results in a decrease in compressive forces inside the tibiofemoral joint.

A
  • F; increased compressive forces
63
Q

Decreased control/strength of the quads can result in damaging what other structures at the knee?

A
  • articular surfaces (development of OA; increased compressive force)
  • menisci (increased shear)
  • ligaments
  • patella (general maltracking, as well as increased compression of the PF joint when in deeper knee flexion; tension on the quad in deep flexion pulls the patella a bit away from the femur)

In general, less strength = increased reliance on passive structures for stability

64
Q

In weight bearing, the femur rotates _______ to extend (lock), and ________ to flex (unlock)

A
  • medially to extend

- laterally to flex

65
Q

Posterior shear throughout leg press/squat peaks between ___* and ___* of flexion

A
  • 83* and 105*
66
Q

Quad function in WB is reinforced by which muscles?

A
  • glute max

- soleus

67
Q

T or F;

There is no anterior shear at the knee in WB

A

T

68
Q

In weight bearing, the tibia rotates _______ to extend (lock), and ________ to flex (unlock)

A
  • laterally to extend

- medially to flex

69
Q

In open-chain, the greatest forces for the quad contraction occur when? In closed-chain?

A
  • last 15* of extension in open chain

- with increased flexion in closed chain

70
Q

Anterior shear is found between ___ and ___ during open-chain leg extension exercise, peaking between ____ and ____

A

10-40* of extension

- peaks between 10-20*

71
Q

Posterior shear is found between ___ and ___ of knee flexion

A

60-100*

72
Q

What hip musculature is important to focus on to improve knee stability?

A
  • hip abductors

- hip extensors

73
Q

What 3 functional muscles assessments were noted in the presentation for muscle impairment for knee issues?

A
  • hop tests (single leg and triple hop)
  • FMS tests for the lower extremity
  • Lower quarter Y-balance
74
Q

What % of ACL injuries are managed surgically?

A
  • 90%
75
Q

What % of surgically managed ACL injuries also had a meniscal procedure at the same time?

A
  • 90%…weird
76
Q

What biases are there to ACL reconstruction demographics?

A
  • Men are more likely to have ACL reconstruction
  • White people are more likely to have reconstruction
  • Increasingly they are outpatient procedures conducted with a nerve block, not general anesthesia
77
Q

T or F;

It has not been demonstrated that operative management of ACL injury is superior to non-operative management

A
  • T
78
Q

What are a few limitations with the research for operative vs non-operative management of ACL injury?

A
  • it’s pretty early in the literature process at this point

- there is significant crossover from the non-surgical to the surgical groups in many of the studies

79
Q

What are some basic concepts for why to operatively manage an ACL injury? (4)

A

 Restore knee stability
 Prevent meniscal damage
 Protect articular cartilage
 Avoid degenerative changes

80
Q

T or F;

Some portion of the ACL is taut throughout the entire range.

A
  • T
81
Q

What are some issues created by operative management of an ACL injury? (5)

A 
	Pain
	Effusion
	ROM limitation
	Decreased muscle function
	Impaired kinesthetic awareness
82
Q

T or F;

Most people return to their previous level of activity following ACL injury.

A
  • T
83
Q

T or F;

Most people return to their previous level of health-related quality of life after ACL injury.

A
  • F

- about a 10% reduction; so they get better, but they typically don’t make it all the way back.

84
Q

The anterior drawer test might preferentially test which portion of the ACL?

A
  • anteromedial bundle prevents anterior translation in flexion
  • posteromedial bundle prevents posterior translation in extension
85
Q

What percentage of ACL injuries are non-contact?

A
  • ~60%
86
Q

What is the common knee position in a non-contact ACL injury?

A
  • knee in, toe out

- valgus with IR

87
Q

Non-contact ACL injury has the greatest risk of occurring during _______?

A
  • competition
88
Q

What is the “most clinically” accurate test for ACL laxity?

A
  • Lachman test
89
Q

What are the 3 primary tests for ACL laxity?

A
  • Lachman test
  • Pivot shift
  • Anterior drawer
90
Q

When is the pivot shift more appropriate for use?

A
  • under anesthesia; won’t work if pt is guarding

- used to determine integrity of repair

91
Q

What is a third test for ACL injury? Is it more sensitive or specific?

A
  • Loss of extension test

- more specific than sensitive

92
Q

What is the gold standard for ACL tear detection?

A
  • MRI
93
Q

What is a Segond fx? What is it indicative of?

A
  • avulsion fx of the lateral tibial plateau
  • traditionally though of as occurring in conjunction w/ ACL tear. May actually just be an avulsion of the anterior longitudinal ligament instead
94
Q

What are the kinematic differences between ACL copers vs non-copers?

A
  • copers: stable joints with fewer episodes of giving way, and fairly normal ROM and forces during functional activities/gait
  • non-copers: increased joint laxity, reduced knee ROM during hop tests, reduced knee compression and shear forces during gait
95
Q

What are the EMG characteristics of an ACL coper?

A

 Poor quad control

 Preferentially utilized a vastus lateralis and medial HS activation pattern during a cutting drill

96
Q

What are the EMG characteristics of an ACL non-coper?

A

 Poor quad control
 Increased quad activity during knee flexion activities
 Increased co-contraction strategies (stiffening strategy)

97
Q

What are the functional differences between ACL copers and non-copers?

A
  • copers generally demonstrate increased functional scores and hop tests
  • non-copers are reluctant to participate and demonstrate fear avoidant behaviors
98
Q

What differences exist between ACL copers and non-copers with activity?

A
  • not really much. ~82% return to activity in both groups; fairly similar between groups for activity and self-report
99
Q

The U of Delaware found what 4 criteria to ID potential ACL copers?

A

 No episodes of giving way
 Over 80% 6m timed hop test
 Over 80% KOS ADL subscale
 Over 60% Global Rating of Knee Function

100
Q

About what percentage of people can be identified as true ACL copers?

A
  • ~40% on initial screen

- however, 70% of non-copers were actually copers at one year follow up after being ID’d as non-copers

101
Q

When is the typical timeframe to assess ACL coper vs non-coper?

A
  • ~10 sessions of treatment
  • at least 60 days, but before 6 months, usually. Really they just need to be at a place where hop testing is appropriate.
102
Q

T or F;

It doesn’t make a difference if you do OKC vs CKC or both for ACL rehab.

A
  • F

- current evidence indicates to do both. OKC may significantly improve quad function

103
Q

T or F;

ACL rehab should include perturbation training

A
  • T
104
Q

With an ACL coper rehab program, when should they expect to resume prior level of activities?

A
  • within 6 months to one year….I would argue closer to a year.
105
Q

What type of performance would you want to see with an ACL repair pt prior to being ok with them on a leg extension or curl machine?

A
  • tolerating cuff weights of 12-15 reps with 10#
106
Q

What are general ROM considerations for early ACL rehab for open chain therex?

A
  • limit knee extension from 90-60* initially when working knee extensor strengthening
  • limit knee flexion (HS curls) from 0-90* to avoid active insufficiency or hamstring cramping. Also don’t do it if it was a HS graft.
107
Q

What is an appropriate timeframe to expect independent ambulation with minimal deviations following ACL repair?

A
  • 2-4 weeks
108
Q

What is an appropriate timeframe to expect 110* flexion after ACL repair?

A
  • 2-4 weeks
109
Q

What is an appropriate timeframe to expect 125* flexion after ACL repair

A
  • 6-8 weeks
110
Q

What is the timeframe goal to achieve 60% quad strength after ACL repair?

A
  • 4 weeks
111
Q

What is the timeframe goal to achieve 80% quad strength after ACL repair?

A
  • 8-10 weeks
112
Q

When can a pt with an ACL repair expect to start running on a treadmill? What criteria should they hit first?

A
  • ~8 weeks
  • normal gait while walking
  • at least 70% quad strength
  • minimal pain and effusion
113
Q

What are the criteria to start agility training following ACL repair?

A

 Track or road running for 1-2 miles without pain, swelling, instability
 80% quad strength at least
 Start at no >50% speed, then progress to 75%, then 100%
 No pain, swelling, instability

114
Q

T or F;

There is increased risk of meniscal damage if the ACL is not repaired.

A
  • T-ish

- one study has shown increased rates of meniscal tear without repair vs with repair

115
Q

T or F;

Rates of knee OA are higher in pts that have surgical ACL repair vs those with non-operative management.

A
  • F
116
Q

Define posterolateral instability

A

Posterior rotational subluxation of the lateral tibial plateau in relation to the femoral condyle, with the tibia rotating externally in relation to the knee axis

117
Q

What is the posterolateral ligamentous complex also known as?

A
  • arcuate ligamentous complex
118
Q

What does the posterolateral ligamentous complex consist of? (9)

A

 LCL
 Arcuate ligament
 Popliteofibular ligament
 Posterior third of the lateral capsule
 Fabellofibular ligament
 Tendoaponeurotic unit formed by the popliteus muscle (not always included)
 Biceps femoris tendon (not always included)
 Popliteal meniscal ligament (not always included)
 Lateral gastroc (not always included)

119
Q

Why should you test for MCL integrity (valgus stress) at 30* of knee flexion?

A
  • it places the ACL and PCL on slack
120
Q

What are the signs and symptoms of a collateral ligament injury? (6)

A
  • MOI: varus or valgus trauma
  • varus or valgus stress testing will be positive
  • swelling/ecchymosis
  • TTP of the ligament
  • difficulty with pivoting/cutting
  • joint effusion may be present if there is meniscal involvement
121
Q

Is palpation of the LCL or MCL likely more sensitive when screening for a collateral ligament injury? Why?

A
  • LCL palpation is likely more sensitive, as the LCL isn’t connected to the joint capsule or meniscus
122
Q

Describe execution of the varus stress test

A
  • pt in supine
  • knee in extension and flexed 20-30*
  • introduce varus stress at the joint line
  • positive test is laxity and/or pain
123
Q

What are the signs and symptoms of a PCL injury? (6)

A

o Posterior knee pain
o Less effusion than ACL injury
o Flexion beyond 90* may increase pain (open-chain)
o Difficulty descending stairs, squatting, running
o Not as much of a problem with quad inhibition
o + sag sign, + posterior drawer, reduced palpation of tibial plateau step off

124
Q

What are the potential mechanisms of injury for a PCL injury? (4)

A

o Hyperflexion
- Fall on a flexed knee with foot in plantarflexion
o Hyperextension mechanisms; step in a pot hole
o Blow to anterior tibia

125
Q

What are some general symptom/sign differences between ACL and PCL injury?

A
  • ACL injury will likely have greater joint effusion, as well as greater quad inhibition than PCL injury
126
Q

Describe execution of the posterior drawer test

A

 Patient is supine with knee flexed to 90*
 Assess tibial plateau
• Tibial plateau should rest ~1cm anterior to femoral condyle
• Easy to create a situation where a fals negative is obtained
 Thumbs on joint line, apply a posterior force
 Positive test is excessive posterior translation and/or a soft end feel

127
Q

What is the general standard test for PCL injury?

A
  • posterior drawer
128
Q

What should the starting position for the posterior drawer test be for the tibia?

A
  • tibial plateau should rest ~1 cm anterior to the femoral condyles; easy to create a false negative
129
Q

Posterolateral instability most often occurs in conjunction with injury to what other knee structures?

A
  • ACL or PCL

- Less common with something like an LCL

130
Q

Posterolateral corner injury is most often associated with damage to the ______ nerve

A
  • peroneal
131
Q

What is a common mechanism of injury for a posterolateral corner injury that occurs with contact?

A
  • usually a direct blow to the anteromedial aspect of the lower leg
132
Q

What grades of posterolateral corner injuries often have good results with conservative management?

A
  • Grades I and II; higher typically require surgical management

OCS prep (25 decks)

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