knee pathologies Flashcards
what is the MOI of patellar dislocations?
traumatic or autraumatic
what generally is seen in the case of a traumatic patellar dislocation?
high level of pain c/o hearing a sound rotation of knee on a fixed foot direct trauma knee flexed and varus stress
what generally is seen in the case of a atraumatic patellar dislocation?
-hyperlaxity of genu recurvatum leading HE of the knee
patella altra
increased Q angle
previous Hx of dislocations
on which side is the paterlla generally dislocated on?
lateral side
what is the pain site for patellar dislocations?
severe pain around the patella
if dislocation is not reduced, where is the patella generally located w/ flexed knee?
on the outside
is there presence of swelling w/ patellar dislocations?
yes, immediate, especially if traumatic
how is ROM in patellar dislocation?
aprehension w/ knee flexion and extension or w/ lateral patellar glide
how is RISOM w/ patellar dislocation?
ms inhibition, pain w/ quad contraction
how is palpation of patellar dislocation?
apprehension
pain on the medial border of the patella and medial PF ligament
what special tests can be used to detect patellar dislocation?
moving patellar apprehension test
when can the moving patellar apprehension test be performed?
once reduces, not immediately post injury
what tests/methods are use to diagnose patellar dislocations?
xray, CT, MRI which are used to R/O #
what may lead to recurrence of patellar dislocations?
patella alta
shallow groove
torn ligament
how is patellar dislocation treated?
conservative Rx for > 3 months
extension splint for ~2 weeks
increase in quad str
improvement of proprioception
what is the PFPS?
pain in the anterior knee
who is most likely to be affected by PFPS?
women
teens
what is the etiology of PFPS?
multifactorial
what are predicitors for poorer outcomes w/ PFPS?
Longer duration of Sx prior to Rx
overall poorer function
worse pain
are specific tests used to diagnose PFPS?
no, most test have low accuracy for PFPS
What are the criteria for diagnosis of PFPS?
The presence of retropatellar or peripatellar pain
AND
Reproduction of retropartellar or peripatellar pain w/ squatting, stair climbing, prolonged sitting, other functional activities loading the PFJ in a flexed position
AND
Exclusion of all other conditions that may cause AKP including tibiofemoral pathologies
how are PFP classified
in 4 sub categories 1. overuse/overload w/o other impairments 2. ms performance deficit 3. mvmt coordination deficit 4.mobility impairments
when are overload/overuse PFPS observed?
When pt present w/ Hx of increase load magnitude or frequency
when are muscle performance deficit PFPS observed?
When pt presents w/ decrease strength in hip ms or quadriceps
when are coordination derficits in PFPS observed?
-pt is asked to perform SL squat and dynamic knee valgus can be observed and isnt related to a decrease in strength
how to differentiate knee valgus due to decrease in strenght vs coordination?
MMT testing: test hip abd/ER and no weakness but still see dynamic knee valgus then it a motor control issue
when can mobility impairement for PFPS be observed?
pt presents w/ increased foot mobility and/or decreased flexibility in one of the following muscles; gastroc, soleus, lateral retinaculum, ITB
why will hypermobility of the foot lead to PFPS?
due to overpronation of the foot
why will hypomobility of the foot lead to PFPS?
decreased flexibility of the muscles in the involved area
what are the most important risk factors for pt w/ PFPS?
- physically active
- weak quad esp in military populations
- quad athrophy?
- dynamic knee valgus
what factors can be associated w/ the development of PFP?
age body mass height BMI static Q angle in NWB and WB
what factors may lead to abnormal patellar tracking and hence PFPS?
Abnormal alignment of LE
Stiffness, tightness of structures around the patella
Weakness of structures around the patella and in the LE kinetic chain
what are possible anatomical factors which may lead to PFPS?
Femoral anteversion (hip section) Knee valgus Tibia ER or tibial tubercle laterally positioned Patella alta Shallow groove (lower lateral groove)
what dynamic factors leading to possible PFPS can be Rx w/ physio
-increase dynamic knee valgus by increase add/IR of the hip and abd/ER of the knee during WB
what may cause the increased dynamic knee valgus in the knee?
weak hip extension, abd, ER
decreased hip ER rom
LE motor control deficits
foot hyperpronation
what is FPPA?
Frontal plane projections; 2d surrogate for a 3d measure of hip add, IR, knee ABD, ER
FPPA is the angle b/w which two lines
ASIS to midpoint of TF joint and midpoint of TF joint to midpoint of ankle mortise
when measuring FPPA changes from what to what are assessed?
change in FPPA from start position to the point of peak knee flexion
what is considered as dynamic valgus w/ a change in FPPA
more than 10 degrees in the positive direction
what is considered as dynamic varus w/ a change in FPPA
more than 10 degrees in the negative direction
what happens if there is less than 10 degree change in FPPA in either directions (+/-)
no change
what muscles stiffness may be associated w/ PFPS?
rectus femoris
ITB
hamstring
calf
what stiff muscle will lead to an excessive superior force on the patella esp w/ knee flexion
rectus femoris
what stiff ms will cause excess lateral force on the partella and can ER the tibia
ITB
what stiff ms will cause knee flexion and thus increase the pressure at the PF joint?
hamstring and calf
what happens in the event of a tight calf?
decreased DF in the midstance leading to increased foot pronation and thus to compensate increase in knee valgus and will pull the patella laterally
what happens if the lateral retinaculum of the knee is tight?
pulls the patella laterally and wiull change the tracking of the patella and cause changes in force where they shouldnt be present
what is the MOI for PFPS?
AKP w/ activity associated w/ increased load that the PF joint
what is the pain site for PFPS?
Ant knee pain, retropatellar and peripatellar pain
what is the pain type associated w/ PFPS
may c/o catching sensation but usually poorly defined pain quality
what is the pain pattern associated w/ PFPS?
activities causing an increase in load at the PF joint, especially w/ flexed knee position will lead to increase pain
what are general observations associated w/. PFPS?
quad Athrophy foot hyperpronation FH anteversion knee valgus patellar position; lateral shift or patella Alta
what functional tests may be performed to assess for PFPS
SL squat, step downs, or lateral stepdowns and FPPA can be assessed andf look for signs of hyperpronation
full squat to assess for pain in flexion and at EOR
trendelenberg to detect glute med weakness to assess for tension on ITB
how is the knee ROM in PFPS?
Generally not an issue, if tight anterior structures, knee flexion may be limited
how is hip ROM w/ PFPS?
decrease hip ER is possible
how is PROM of the patella?
glides will be Ax for stiffness
medial glide might be decreased due to increased stiffness of ITB or lateral retinaculum
inferior glide might be decrease due to stiffness of rectus femoris
how is RISOM w/ PFPS?
weakness of hip extensors hip abductors hip ER knee extensors hipSIT
how is palpation w/ PFPS?
Assess for pain around the patella
what can be observed w/ flexibility Ax in PFPS
Stiffness Ax hamstring 90-90 or SLR gastroc and soleus w/ DF in wb w/ knee straight or bent rectus fem w/ modified thomas test ITB w/ ober's or modified thomas test
what are special tests that can be performed top assess for PFPS?
Patellar tilt test where the lateral aspect of the patella can not go beyond the horizontal
what is suggested CPG for overuse or overload PFPS?
Eccentric step down test
what are the suggested CPGs for muscle performance deficits in PFPS?
hipSIT and MMT of thigh ms
what are the suggested CPGs for mvmt coordination deficits in PFPS?
dynamic valgus on lateral step down test
frontal plane valgus in SL squat
what is the suggested CPG for hypomobility in PFPS?
patellar tilt test
flexibility test: HS, gastroc, soleus, ITB, quads
ROM: hip IR/ER
what is the suggested CPG for hypermobility in PFPS?
foot mobility test
foot posture index
what are some self reported outcome measures
VAS or NPRS for pain
validated questionaires s/a anterior knee pain scale, PF pain and OA subscale of knee injuries and OA outcome scores
ENG and pierrynosku questionnaire
what is the goal of Rx for PFPS?
decrease compression on PF joint during daily activities
how can compression on the PF joint be decreased?
decrease in jt rxn force
decrease in pain, irritation and inflammation
center the patella w/in the trochlea
is PFPS a self limiting condition
no
education about what is essential in PFPS?
load management BW management importance of adherence to active Rx evidence regarding Rx options kinesiophobia education to improve compliance and adherence
what may be used for pain management in cases of PFPS?
- Reduction and removal of aggravating factors/activities
- taping for ST correction of patella position and decrease in PF stress
- foot orthosis in cases of hyperpronation
- biophysical agents
what are the CPGs associated w/ foot orthosis in the case of PFPS?
- Prescribed in pts w/ greater than normal pronation allowing for ST reduction in pain
- prescribed w/ exercise program
- NSAIDS
which biophysical agents should not be used to reduce pain in pts w/ PFPS?
US phonophoresis iontophoresis estim laser
which biophysical agents should be used to reduce pain in pts w/ PFPS?
US IF TENS ice IFC
what other factors may need to be adressed to manage pain in PFPS?
MS Stretching as needed
stretching of stiff retinaculum if needed
ms strengthening of hip E, ABD, ER in WB, of knee E/F in wb and NWB
what are the CPGs suggested for ms strengthing in the case of ms strengthening rehab?
exercise program should combine hip targetted str exercises and knee targetted STR exercises
target hip ms in the posterolateral chain
knee exercises for F/E in NWB also
how to treat for gait and mvmt retraining in the case of PFPS?
- work on aligment of the LE in WB exercises
- reduce FPPA
- gait and running retraining
what is the purpose of knee orthosis in pts w/ PFPS?
Maintain medial glide C shaped lateral buttress decrease lateral patellar displacement increase contact surface area decrease PFK stress increase proprioception of the knee
should knee orthosis be used for PFPS?
based on CPGs no
should combined interventions be used for PFPS?
YES
superior outcomes compared to no Rx
exercises is generally always combined w/ other interventions
what are the Rx recommendations based on overuse/overload stage of PFPS?
- Taping
* Activity modifications/relative rest
what are the Rx recommendations based on Ms performance deficit stage of PFPS?
- Hip and glute ms str
* Quad str
what are the Rx recommendations based on coordination deficit stage of PFPS?
gait and mvmt retraining
what are the Rx recommendations based on hypomobility deficit stage of PFPS?
Patellar retinaculum/ST mobilizations
Ms stretching: HS, gastroc, soleus, quad, ITB
Hip ER vs IR ROM exercises
what are the Rx recommendations based on hypermobility deficit stage of PFPS?
Foot orthosis
Taping
Short foot ms str/extrinsic ms str
can surgery be used as Rx for PFPS?
- not recommended due to poor surgical outvcomes
- done only if consevrative Rx has failed multiple times
what surgical procedures are generally done in the case of PFPS if Sx is done?
chondroplasty or lateral retinaculum release
what is baker’s cyst generally associated w/?
intra-articular pathology where a mass of synovial fluid accumulates
what is the baker’s cyst generally connected w/?
knee joint capsule and SM or medial head of gastroc bursae
what can baker’s cyst minic?
DVT due to increase leg warmt, leg girth and pain
what pain pattern is associated w/ baker’s cyst?
pain EOR knee flexion
how is palpation of baker’s cyst?
swollen and tender mass on posterior knee
what is the MOI for MCL sprains in the knee?
valgus stress on partially flexed knee; can occur w/ contact or non contact injuries
or
rotation on a fixed foot
where is the pain in a MCL sprain?
medial knee pain over MCL
what is the pain pattern for an MCL sprain?
pain w/ valgus
pain w/ side to side cutting action
instability if grade 2+
what is a grade 1 sprain?
no or minimal swelling, firm EF, reproduction of pain, localized POP
what is a grade 2 sprain?
swelling, normal EF, gaping, reproduction of symptoms. POP
what is a grade 3 sprain?
swelling, lig stress test; soft EF, gapping, possible reproduction of symptoms, POP
how to control pain and swelling w/ conservative Rx for MCL sprain?
crutches initially for NWB/PWB/WB pain freee rom STR in painfree rom proprioception NM training functional activities and exercises hinged knee brace in severe injuries for 2-4 weeks
optimal MCL healing generally takes how long to heal?
4-6 weeks but can extend to 3 months
which b/w MCL or LCL sprain is more common in the knee?
MCL more than LCL
what is the MOI of an LCL sprain in the knee
varus stress
ER of flexed knee over a fixed foot
where is the pain site in LCL sprain in the knee?
over the LCL
what is the pain pattern associated w/ LCL sprain of the knee?
pain w/ varus stress
unstable if over grade 2
what is the most common ligament sprain and most serious
ACL sprain
what is known as the common triad?
MCL, medial meniscus and ACL tears
what are the MOI for ligament sprain?
accelerations/deceleration
ER of the knee on a fixed foor w/ knee flexed to 10-30 degree + in a valgus position
knee in HE
Valgus/varus stress eg ski fall
in what postion is considered to be the point of safety
hip in slight flexion, knee flexed, neutral tibial rotation, and feet in controled balance
what is considered to be the point of no return
hip in Adduction and IR
knee decreased flexion and valgus (femur more add, tibia abd)
one foot out of control, unbalanced (hyperpronated)
a pt w/ an ACL sprain will likely complain of what?
that they feel that the knee is giving way
can the pt continue playing sport immediately post injury?
large amount of swelling inhibits from returning
how is the pain site w/ ACL sprain?
widespread around the knee, pain more locaized to posterolateral joint if secondary to stretch of lateral capsule
how is the pain type for ACL sprain?
instability
how is the pain pattern for ACL sprain?
Pain w/ knee flexion and extension
Limited by swelling/hemiarthrosis
what is generally seen w/ observation post ACL sprain?
large, tense effiusion and hemarthrosis
VMO athrophy is possible
how is ROM w/ acl sprain?
limited ROM from swelling
how is RISOM post ACL sprain?
in acute cases weakness due to ms inhibition
how to best diagnose for ACL sprain?
ligament stress test optimal if performed within 1H of injury
what ligament stress tests can be done to Ax for ACL sprain?
lachman test: + if complete tear
ant. drawer test: + not painful thus based on EF and gap
lever’s sign: + for complete tear
pivot shift test: + only if intact MCL and ITB and near full knee E
in ACL sprains, what are Xrays used for?
to r/o avulsion # of the ligament and # of tibial platea
is MRI needed to confirm ACL sprain?
not always needed only if diagnosis is left unclear,
can also see bone marrow lesion over lateral femoral condyle and other injuries
how to manage ACL sprains?
conservative of surgically
Treatment to manage ACL sprain depends on what factors?
pts age; generally younger opt for surgical
degree of instability and activities performed by pt
social factors; $, time off work availible to pt
willingness to partake in rehab
any abnormalities
what is a consequence of repeated events of the knee giving way post ACL sprain?
increases the risk for OA
what can arthroscopy help assess in the case of conservative Rx?
level of instability
washout of the hemiarthosis
assess and treat other injuries
what are the aims in conservative Rx?
Decrease pain and swelling
Improve ROM and Gait
Improve strength/power/proprioception
derotation of the knee w/ braces
when is surgical process used for ACL tears
in the case of important tear size
how does ACL surgical procedure look like?
3 small incision are done around the knee
remnants of the torn ACL gets removed, tunnels drained through femur and tibia and graft is passed through and then fixed in place
what is a BTB graft?
central 1/3 of the patellar tendonj is removed w/ a small block of bone at either end of the ligament, this portion of the tendon will regrow over time
what is the downfall to a BTB graft
results in problems of the tendon s/a PFPS or patellar tendinopathy
what is the most common type of graft for ACL rupture?
hamstring tendon graft
what is an advantage of using hamstring tendon autograft for ACL repair
tendon is long and can be doubled up, and wont predispose to patellar tendiopathy
what is a challenge of hamstring tendon autograft?
More challenging to anchor in femur and tibia since no blocks of bone at each end
if there an autograft that is more beneficial than another
no it really depends on the clinical course of the rupture however in patellar tendon graft more pts experienced anterior knee pain w/ kneeling and w/ hamstring autograft more pts have decreased EOR knee flexion power
what is an allograft?
graft taken from a cadaver
what is the general timeline for ACL reconstruction?
-wait until swelling has decreased, near full ROM and normal gait
if MCL has been torn ~6 weeks post tear
what is the pre-op management of ACL tears?
- reduce pain w/ police and modalities
- full ROM
- STR and proprioception
- education about hospital protocols
- knee brace fitting
what are the post op management for ACL tears?
-WB status
CKC vs OKC
what is the WB statis in the case of meniscal repair w/ Sx?
WB only restricted at first
what is the WB statis in the case of ACL repair w/ Sx?
WBAT
what is the aim for the 2 first week post knee surgery
focus on regaining rom in extension and ensure proper quad activation
what is better suggested b/w OKC and CKC post surgery for the knee
no or minimal difference b/w both
what is the procedure post op for ACL repair?
similar to conservative Rx
depends on surgeon’s guidelines
criteria based rather than time based
what are the CPGs for ACL reconstruction rehab?
-immediate mobilization and supervised program: STR, HEP, NM ex’s
-early WBAT w/in 1st week
WB and NWB concentric and eccentric exercises w/in 4-6 weeks 2-3x/week for 6-10 months
what is the MOI of a PCL sprain?
direct blow to anterior, proximal tibia w/ knee in a flexed position
knee in full flexion
HE of the knee
what is the pain site
poorly defined pain, especially posteriorly
what can be observed w/ PCL sprain
swelling but less than w/ ACL
what special tests can be performed for PCL sprain?
brush test might be positive if sufficent effusion
posterior drawer test +
posterior sagittal test +
what treatment is used for PCL sprain?
conservative w/ comprehensive rehab and significant quad STR
what is a longitudinal meniscal tear?
- Degenerative from repeated trauma
* Often bilateral and may be asymptomatic
what is a bucket handle meniscus tear?
traumatic tear
Medial:lateral meniscus (3:1)
Often associated w/ ACL tears and locked knee
Specify it it remains stuck in a “locked” position
More often posterior horn
what is a radial meniscus tear
Traumatic usually
Middle 1/3 of the menisucus
Lateral > medial meniscus
what is a parrot beak tear a progression of
progression of a radial meniscal tear
what is a flap meniscus tear?
a tear that is either displaced or undisplace, usually traumatic and can progress to being other types of tears
what is a horizontal cleavage tear of the mensicus
• Type of tear that can be seen by doing a cross section of the meniscus
what factors may increase risk of meniscal tears?
- age, work related kneeling and squatting for degenerative tears and climbing stair can all lead to degenerative tears
cutting and pivottinh sports
acl reconstruction due to increased knee laxity
how can meniscal tear occur from a twisting movement
rotation about a fixed foot
under valgus stress what meniscus is affected? how?
medial
hit from the side bringing knee into a valgus position
under varus stress what meniscus is affected? how?
lateral meniscus; hit knee into varus position
what are MOI of meniscal tears
twisting injury valgus varus HE of knee HF of knee
which mensicus is more commonly injured
medial more than lateral
symptoms associated to small meniscal tear
degenerative usually or after minimal trauma in elderly
delayed symptoms
symptoms associated w/ more severe meniscal tears
more pain effusion w/in 6-24H decreased EOR flexion and extension intermittent locking may unlock spontaneously often associated w/ MCL/ACL tears
where is the pain site of a meniscal tear?
along the joint line either medial or lateral depending on meniscus affected
what is the pain type for meniscal tear?
c/o catching sensation in case of flap or intermittent locking
what is the pain pattern associated w/ meniscal tear
w/ EOR knee flexion or extension
is there significant swelling w/ meniscal tears
no
what functional tests can be performed for meniscal tears
squatting pain w/ post horn tear
how is ROM w/ meniscal tear
decreased and painful in flexion and extension due to torn flap of effusion
how is palpation of a meniscal tear?
•Joint line pain on palpation knee b/w 45-90 degree flexion
what special tests can be performed for meniscal tear
brush test for effusion
McMurray test if pain or audible crick will be +
tessaly test if pain or discomfort or sens of locking
what is the best imagery technique for meniscus tears
MRI
what criterias are looked at in the meniscal pathology composite score
Hx of catching or locking pain w/ forced HE pain w/ max passive flexion joint line tenderness pain w/ audiable crick w/ McMurray's manoeuver
what is the conservative Rx suggested for meniscal tear?
option unless locking of the knee better results w/ smaller tears manage pain and swelling increase pain free ROM increase STR, proprioception, NM control return to functional activities
what are the 2 surgical repair option for meniscal tears
meniscal repair or menisectomy
what is the success rate in meniscal repairs?
higher in young populations and if in vascularized zones of the meniscus
how is meniscal repair accomplished
Use sutures or tacks to repair the damaged meniscus
Punch an arrow though the damaged part of the meniscus
• The arrow is biodegradable (after 6 months)
• Anchor the 2 torn edges together while tear heals
what is the process of a menisectomy
-straight forward
when are menisectomy generally performed
degenerative flaps, horizontal cleavage, complex meniscal tears
what is the effect of removal of the meniscus on compressive stress
16-34% loss of meniscus increases compressive stress by 350%
what happens to the knee when meniscus is removed?
loosens up and instability may lead to OA
how rapidly can pt return to activity post menisectomy
~4 weeks
what rehab is needed prior to surgery post op for meniscus
decrease pain and swelling
maintain or increase STR of quad, HS, hip abd, hip E
increase proprioception and NM control
protect for further dsamage; education
what rehab is needed post op for meniscus
~3-6 weeks for menisectomy WBAT ~3-8 months for meniscal repair prgression over a 4-6 week period, can go over 90 degree knee flexion for the first 4 weeks POLICE pain free rom w/ HEP and mobilization STR w/in availible range proprioception
