Knee pain and mobility impairments CPG Flashcards
How often are knee injuries meniscal injuries?
- a lot. 2nd most common knee injury
What is an additional concern for structural damage following an ACL tear?
- meniscal injury. Occurs in conjunction w/ ACL tear ~22-86% of the time.
What are the general demographics/types of traumatic meniscal tears?
- occurs w/ younger populations
- more often longitudinal or radial tears
What are the general demographics/types of degenerative meniscal tears?
- occurs w/ older populations
- more often horizontal, flap or complex tears, meniscal maceration or destruction
What is the general prevalence of articular cartilage lesions?
- based on knee arthroscopy, 60-70%
Is articular cartilage damage usually due to a contact or non-contact mechanism? Is it traumatic?
- unclear. Traumatic, non-contact thought to be between 32-58%, so non-contact mechanisms aren’t uncommon
- yeah…usually traumatic with a known MOI, I’d guess
Where are cartilage lesions most often found in the knee?
- medial femoral condyle
- patella
What other injuries are most likely to occur in conjunction w/ an articular cartilage lesion?
- ACL tear or medial meniscal tear
- more specifically, 2nd ACL injury or partial meniscectomy
Meniscal injuries account for ~ what proportion of all knee injuries?
- ~25%
Is there a gender association with meniscal tears?
- sort of. May be more likely in girls than boys that are in high school sports
Are older or younger individuals more likely to have a meniscal tear? What are the age cutoffs?
- Older folks have a higher rate of meniscal injury
- 2x increased rate between 35-55yo
- 3x increased rate at 55yo and older
- above numbers are one study, so take it with a grain of salt
Is there an association between age and lateral vs medial meniscal injury?
- lateral is more often in younger patients
- medial is more likely in older patients
Is there an association between age and having a meniscectomy vs a repair?
What are the age cutoffs?
- yes
- those over 45yo are more likely to have a meniscectomy
- those under 35 are more likely to have a meniscal repair
What is the prevalence of meniscal lesion in athletes?
- between 17%-59%, with some of those being asymptomatic
Should meniscal injury be managed surgically?
- there’s probably a range.
- However, outcomes are generally similar for those who get surgery compared to those who manage it non-operatively
- Non-surgical management is associated with similar to better outcomes in knee strength and perceived knee function in the short-term and intermediate time frames when compared to APM
Will people with meniscal injury have normal knee function after management (whether surgical or non-surgical)?
- outcomes are generally satisfactory, but pts will generally report lower knee function compared to the general population
What is the expected course in the short and long term following APM?
- poor proprioception, strength, and self-reported outcomes are expected for the first 6 months
- most impairments/limitations resolve within 2 years.
- however even out 4 years, will still report slightly lower knee function and QoL compared to healthy controls
Are there predictors for return to sport rates?
- yes
- demographics (age and eliteness of athlete), meniscal tear location, physical impairements, and functional levels from functional testing are assocaited
- lateral tears return faster than medial tears
- elite/competitive athletes return faster than recreational ones
Is there an advantage to meniscal repair vs APM in younger patients?
- looks like it. younger patients who have a repair have similar to better reported function and activity levels than those with APM
What are the expectations for return to sport for athletes following APM?
- Elite and competitive athletes, as well as athletes under 30yo typically return to sport w/in 2 months after APM
- Athletes over 30yo are likely to return w/in 3 months after APM
What has better outcomes; Osteochondral autograft transplantation (OAT) or autologous chondrocyte implantation (ACI)?
- athletes who undergo OAT have generally higher function and return to activity compared to both ACI and microfracture
T or F;
There are higher rates of failure/complication in ACI compared to other procedures
- T
After an ACI, can a pt expect to be able to return to sport?
- yes, but rate of return after ACI is often a bit delayed
What pts are more appropriate for microfracture procedures?
- those with smaller articular cartilage lesions, and lower demand sports
- those returning to higher demand sports have higher rates of failure
What are risk factors for acute meniscal injury?
- cutting and pivoting sports
What are some risk factors for both future medial and lateral meniscal injury?
- increased age
- delayed ACL reconstruction
What are risk factors for medial meniscal tears?
- female sex
- older age
- higher BMI
- lower physical activity
- delayed ACL reconstruction
What are risk factors for failure with articular cartilage repair surgeries?
- female sex
- older age
- higher BMI
- longer symptom duration
- previous procedures/surgeries
- lower self-report knee function
What outcome measures are appropriate for use with meniscal and cartilage lesions?
- for knee specific issues should use:
- IKDC 2000
- KOOS
- may use the Lysholm as well with some caveats
- for activity/participation level
- may use Tegner scale or Marx activity rating scale
- SF-36 and EQ-5D can be used for health measures
- KQoL-26 may be used for knee quality of life
Should clinicians use physical performance measures for pts w/ knee meniscus or articular cartilage issues?
- technically no. Hop tests, etc, “may” be used.
- If you’re looking to quantify asymmetry, or pain/disability/lack of function with improvement with specific tasks, then they’re ok to do, they just have weak evidence for support
What are the general diagnostic criteria for the clinical diagnosis of an articular cartilage lesion? How certain is it?
- Low level of certainty
o Acute trauma with hemarthrosis (0-2 hours) (associated with osteochondral fracture)
o Insidious onset aggravated by repetitive impact
o Intermittent pain and swelling
o History of “catching” or “locking”
o Joint-line tenderness
What factors compose the Meniscal Pathology Composite Score? How many are recommended to have present to classify someone with meniscal pathology?
- hx of catching or locking
- pain with forced hyperextension
- pain with maximum passive knee flexion
- joint line tenderness
- pain or audible click with McMurray’s
- greater than 3 are recommended
What are the currently recommended criteria for dx of meniscal pathology?
- knee pain
- hx of catching or locking
- twisting knee MOI
- delayed onset of effusion
- meniscal pathology composite score of greater than 3 positive findings
Is the presence of jointline tenderness more specific/sensitive for the medial or lateral meniscus?
- jointline tenderness is more sensitive for medial meniscal pathology
- however it’s more specific for lateral meniscal pathology
What are the best practice recommendations for activity limitation self-report measures per the CPG for meniscal tears?
- KOOS and IKDC 2000
What are the best practice recommendations for physical performance measures for meniscal tears?
(early rehab timeframe)
- 30 sec chair stand test
- stair-climb test
- TUG
- 6MWT
(return to sport)
- single leg hop tests
What are the best practice recommendations for physical impairment measures for meniscal tears?
- modified stroke test for effusion assessment
- assessment of knee AROM
- maximum voluntary isometric or isokinetic quad strength testing
- forced hyperextension
- maximum passive knee flexion
- McMurray’s
- joint line tenderness
What are the best practice recommendations for activity limitation self-report measures per the CPG for articular cartilage lesions?
- KOOS and IKDC 2000
What are the best practice recommendations for physical performance measures for cartilage lesions?
(early rehab timeframe)
- 30 sec chair stand test
- stair-climb test
- TUG
- 6MWT
(return to sport)
- single leg hop tests
What are the best practice recommendations for physical impairment measures for cartilage lesions?
- modified stroke test for effusion assessment
- assessment of knee AROM
- maximum voluntary isometric or isokinetic quad strength testing
- joint line tenderness
Is progressive early ROM recommended for meniscal or articular cartilage surgery?
- in short yes; has a “may” recommendation
Is progressive weightbearing recommended for meniscal or articular cartilage surgery?
- yes following meniscal repair, with weak evidence support
- yes following just matrix-supported autologous cartilage implantation (MACI) surgery, with moderate support. No other surgical types noted.
Is progressive return to activity recommended for meniscal or articular cartilage surgery?
- yes following meniscal repair with moderate evidence
- “may need to delay” return to activity with articular cartilage surgery, but really not enough research to support specific recommendations
Is supervised rehabilitation recommended for meniscal or articular cartilage surgery? What would it consist of?
- yes, but only APM is mentioned.
- recommends that exercise happen in clinic, as well as for HEP with education to support independence
Is therex recommended for meniscal or articular cartilage surgery? What would it consist of?
- yes for both
(should consist of)
- progressive ROM
- progressive strengthening of HIP and KNEE
- NM re-ed
Is NMES recommended for meniscal or articular cartilage surgery? What are the expected outcomes?
- yes, but just for meniscal procedures
- to improve quad strength, functional performance, and knee function
