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Clinical Interventions > knee pathology and rehabilitation > Flashcards

knee pathology and rehabilitation Flashcards

1
Q

definition: unable to get full terminal knee extension due to delayed firing of the quadriceps muscles

A

Quad Lag

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2
Q

What patient population commonly presents with quad lag? Why?

A

a. TKA

b. weakness of the quadriceps and swelling

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3
Q

What is the prime knee extensor muscle?

A

rectus femoris

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4
Q

What is the only muscle crossing the anterior axis of the knee?

A

Quadriceps femoris

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5
Q

What improves leverage of extensor force? How does it do this?

A

a. patella
b. increases the distance of the quadriceps tendon from the knee joint axis

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6
Q

The physiological advantage of the quads rapidly diminish during the last ____ degrees of EXT due to shortened length (decreased mechanical advantage)

A

15 degrees

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7
Q

What are the primary flexors of the knee?

A

Hamstrings

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8
Q

What is the prime function of the gastrocnemius?

A

Supports the posterior capsule of the knee and avoid hyperEXT (CKC support)

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9
Q

What does the popliteus do?

A

Knee FLX
supports posterior capsule
Acts to unlock the knee (Screwhome mechanism)

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10
Q

What does the pes anserine do?

A

Provides medial stability to the knee
affects ROT of the tibia in CKC

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11
Q

Normal gait cycle is about ___-___ degrees of knee FLX.

A

0-60

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12
Q

What controls the amount of knee flexion during initial contact?

A

Quadriceps

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13
Q

What normally controls the forward swinging leg during terminal swing?

A

Hamstrings

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14
Q

You need ___-___ degrees of knee FLX with stairs.

A

80-100 degrees

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15
Q

What can you see with climbing stairs with a knee pathology?

A

Hip hiking and circumduction

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16
Q

Referred pain to the anterior aspect of the knee can be from the ___ nerve roots.

A

L3

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17
Q

Referred pain to the posterior aspect of the knee can be from the ______ nerve roots.

A

S1 and S2

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18
Q

AROM of the knee is (less/more) than the PROM. Why?

A

a. less

b. due to joint distention, stiffness, pain, weakness, and reflex inhibition

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19
Q

(CKC/OKC) exercises tend to be less stressful in early management of knee pathology.

A

CKC

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20
Q

OKC exercises provides less resistance and has less discomfort at (lower/higher) velocities

A

higher velocities

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21
Q

What does an osteotomy of the tibia provide?

A
  • correcting joint deformity
  • redistributing WB forces
  • reduces pain
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22
Q

When is knee surgery indicated?

A

When conservative management cannot control pain and effusion with knee arthritis

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23
Q

definition: shaving of the patellar cartilage

A

arthroscopic chondroplasy

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24
Q

definition: scraping to the posterior of the patella w/ chondromalacia to induce inflammation/bleeding

A

Abrasion arthroplasty

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25
Q

How long can a TKA be cemented for?

A

10-15 years

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26
Q

Why would a cementless arthroplasty require longer periods of immobilization?

A

to allow bone growth

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27
Q

What muscles should you look to strengthen during the maximum-protection phase of rehab for TKA?

A

quads, hamstrings, and gastrocnemius

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28
Q

Is vigorous passive stretching appropriate during early post-operative periods?

A

NO

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29
Q

When can you start performing mobilizations to the patella after a TKA?

A

2-3 days post-op (may be difficult with staples)

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30
Q

What does WB progression depend on after TKA?

A

Type of prosthesis
Type of Fixation

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31
Q

What type of WB is almost always indicated after a TKA?

A

WB as tolerated

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32
Q

With patellectomy, there is a lot of strength lost with what motion?

A

Knee EXT

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33
Q

The peak torque of quadriceps muscles occur between ___-___% of knee FLX

A

50-70% (usually about 66)

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34
Q

Patellar compression increases with knee FLX at approx. ____ degrees when WB

A

45 degrees

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35
Q

What is the normal female Q angle?

A

17-18 degrees

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36
Q

What is the normal male Q angle?

A

13-14 degrees

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37
Q

There is usually ___ tract with a grater Q angle

A

Lateral

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38
Q

Lateral fixation of the patella is provided by what?

A

IT band, lateral retinaculum

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39
Q

Patellar function is opposed by the medial pull of what?

A

VMO

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40
Q

The ______ fixates the patella inferiorly.

A

patellar ligament

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41
Q

The ___ fixates the patella superiorly.

A

Quadriceps tendon

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42
Q

Where in the knee ROM does the apex of the patella have contact?

A

20 degrees

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43
Q

Where in the knee ROM does the central portion of the patella have contact?

A

45 degrees

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44
Q

Where in the knee ROM does the base of the patella have contact?

A

90 degrees

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45
Q

Where in the knee ROM does the odd facet of the patella have contact?

A

135 degrees

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46
Q

There is no release of synovial fluid until ____ degrees or more of knee FLX.

A

135 + degrees

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47
Q

definition: Imbalance in the biomechanics of the PF joint causing breakdown or degeneration in the articular cartilage

A

patellofemoral dysfunction (patellofemoral pain syndrome)

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48
Q

What is the most common type of knee pathology? What population does it affect more?

A

a. patellofemoral dysfunction
b. females and/or those with larger Q angles

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49
Q

What are possible causes of patellofemoral dysfunction?

A
  • Larger Q-angle
  • Poor VMO control
  • Strength
  • Recruitment
  • Tight lateral retinaculum
  • Patella position (tilt, rotation)
  • Increased femoral anteversion
  • Patella alta or baja (Salvati’s technique: patella tendon - length/patella length should equal 1.00)
  • Hamstring and extensor mechanism/tightness
  • ITB tightness
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50
Q

What are symptoms of patellofemoral pain?

A
  • Anterior knee pain
  • Crepitus (grating sensation, may or may not be painful)
  • Giving way sensation which is NOT reflective of a locking mechanism but reflexive inhibition of quads
  • INSIDIOUS onset of sx
  • Usually BILATERAL
  • Increased pain with stairs, greater descending
  • Pain may be increased following sitting (positive theater sign)
  • Possibly increased swelling
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51
Q

definition: A type of PFD with softening and fissuring of the undersurface of the patella

A

chondromalacia patella

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52
Q

What facet of the patella is most commonly affected with chondromalacia patella?

A

Medial facet

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53
Q

chondomalacia patella may be asymptomatic until _____ increases

A

pressure

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54
Q

What are the s/s of synovitis due to patellofemoral dysfunction?

A
  • pain in retropatellar region and possibly peripatellar or medial patellar region
  • Condition is worse with squatting, stairs (descending)
  • May present with crepitus
  • Usually MINIMAL swelling
  • Might find lateral tracking patella, tilted, rotated, patella alta, or baja
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55
Q

What is the treatment of PFD?

A
  • decrease effusion
  • increase flexibility of tight structures
  • possibly orthotics (control of foot PRON and abnormal motion)
  • strengthening
  • surgery (patellar shaving, patellar chondroplasty, patellar realignment, patellectomy) – RARE
    train hip ER/posterolateral hip
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56
Q

(concentric/eccentric) control has been shown to play an important role in PF function

A

eccentric control

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57
Q

What is another name for patellar tendonitis?

A

jumper’s knee

58
Q

What are the s/s of patellar tendonitis?

A
  • Tenderness to palpation of patella tendon
  • c/o soreness with jumping and squatting activities
  • Usually MINIMAL swelling if present
  • Pain with resistance
59
Q

Where does the ACL attach?

A

Attaches medially to anterior intercondylar region of tibia and to posteromedial aspect of the lateral femoral condyle

60
Q

What are the two bundles of the ACL? What motion causes them to be more taut?

A

smaller anteromedial (taut in FLX)

posterolateral (taut in EXT)

61
Q

What motions cause the ACL to become taut?

A

knee EXT and IR

62
Q

What are the functions of the ACL?

A
  • Restraint to anterior translation of tibia on femur (85%)
  • Assists in restraint of ER of tibia with knee flexed and with valgus stress
  • Assists in limiting varus stresses and hyperextension of the knee
63
Q

What is the most common cause of ACL injuries?

A

Non-contact injuries from sudden deceleration or a cutting maneuver

64
Q

ACL injuries from contact are commonly from a combination of ___ and ___ forces applied to the knee w/ the foot firmly placed on the ground.

A

Valgus and ER forces

*excessive IR forces or a combination of IR and hyperEXT can also cause damage to the ACL

65
Q

What is the typical presentation of an ACL injury?

A
  • Athlete usually feels or hears a pop at time of injury
  • Followed by swelling within one hour
  • Acute hemarthrosis within 12 hours
66
Q

What tests are most reliable for ACL injury Dx? What is the issue with these tests?

A

Lachman test
Pivot Shift test

–> can produce false negatives due to swelling, muscle guarding, and pain

67
Q

When does ACL rehab start?

A

IMMEDIATELY following surgery (in recovery room)

68
Q

When are patients with ACL injuries allowed to start WB?

A

day after surgery (WBAT) –> crutches

69
Q

What type of ROM is encouraged immediately post-op?

A

PROM (full EXT)

70
Q

A person with an ACL injury will be in a knee immobilizer after surgery until when?

A

Until adequate quadriceps contraction

–> will then be put into a ROM brace

71
Q

When are patellar mobilizations started after an ACL surgery?

A

First week

72
Q

Quad strengthening starts during the first week of ACL post-op but only with (CKC/OKC) exercises

73
Q

OKC exercises with heavy resistance are held off until weeks __-__ after an ACL repair

74
Q

What is the most important consideration for the first 2+ months after an ACL surgery?

A

Graft protection

75
Q

When are grafts the weakest after ACL repairs?

A

first 4-8 weeks

76
Q

Isokinetic testing is deferred from ACL repair rehab until week ____.

77
Q

Active Total Knee EXT w/ heavy resistance should be avoided for __-__ weeks after an ACL repair.

78
Q

A patellar tendon graft after an ACL repair has ____% the strength of the original ACL at the time of implantation. What causes a decrease in strength of the graft over time?

A

168%

3 months: 53%
6 months: 52%
1 year: 81%

–> necrosis of the graft and subsequent revascularization

79
Q

Where does the PCL connect?

A

Arises from the posterior intercondylar region of the tibia and attaches to the lateral aspect of the medial femoral condyle

80
Q

What are the bundles of the PCL? When are they taut?

A

posterolateral (taut with EXT)
anteromedial (taut with FLX)

81
Q

What are the functions of the PCL?

A
  • limit posterior translation of tibia on femur
  • Some control of varus and valgus stresses at knee
  • Minimal rotational control
82
Q

What ligament is referred to as the “key stabilizer” of the knee?

83
Q

PCL deficient knees tend to have greater ___ forces and ___ compartment compression.

A

greater PF forces

Medial compartment compression

84
Q

What are the typical causes of a PCL injury?

A

anteromedial force to a flexed knee “dashboard injury”

Posterior force to the anterior/proximal aspect of tibia

slide tackling

85
Q

PCL injury rehab mimics ACL rehab EXCEPT the_______ are avoided acutely and ___ are pushed early.

A

Hamstrings avoided acutely

Quads pushed early

86
Q

What is stronger… autograft or allograft?

87
Q

What causes an increased morbidity (patellar tendonitis, exc)… autograft or allograft?

88
Q

Allografts can be rejected due to what?

A

AIDS and HIV

89
Q

Why are allografts not as strong?

A

Need to be sterilized and preserved

90
Q

What is another name for the MCL?

A

tibial collateral ligament

91
Q

What are the bundles of the MCL?

A

Superficial and deep

92
Q

What are the attachment sites of the MCL?

A

Proximal attachment: medial femoral condyle, just distal to the adductor tubercle

Distal attachment: medial margin of the tibia, deep to pes ans

93
Q

The ____ portion of the MCL is firmly attached to the medial meniscus and blends with the medial joint capsule

94
Q

When is the MCL taut?

A

Full EXT w/ ER

95
Q

Avoid ___ and ___ AROM/PROM with an MCL tear.

A

Full EXT and ER

96
Q

What are the functions of the MCL?

A
  • Resists valgus stress at the knee
  • assists in resisting rotation and anterior-posterior excursion at the knee
97
Q

What is the common cause of a MCL injury?

A

a valgus force, with knee in full extension (or < 90° flexion)

98
Q

What is the unhappy triad?

A

MCL, ACL, and Medial meniscus

99
Q

(true/false) Surgical intervention for MCL injuries are rare.

100
Q

What motion should you avoid during acute rehab of a MCL injury?

A

full knee FLX

101
Q

What is another name of the LCL?

A

fibular collateral ligament

102
Q

What are the attachment sites of the LCL?

A

From the lateral femoral epicondyle to the head of the fibula
Superior attachment is fused with lateral capsule

103
Q

What portions of the LCL do not attach to the capsule?

A

Middle and distal portions

104
Q

What are the functions of the LCL?

A
  • Resists varus stress at the knee
  • assists in controlling ER of tibia
105
Q

What ligament of the knee is injured less frequently? Why?

A

LCL because of its location and the rarity of varus forces.

106
Q

What causes an LCL injury?

A

Varus stress applied to a fully or partially flexed knee

107
Q

LCL repair is (less/more) common than an MCL repair.

A

more common

108
Q

What motions should you avoid with LCL rehab?

A

Varus stress and ABD with forces distal to the knee

109
Q

Autografts and allograft have a (poor/good) success rate.

A

poor success rate

110
Q

What are the functions of the menisci?

A
  • Increase joint congruency
  • Shock absorption
  • Stability
  • Lubrication and nutrition of joint
111
Q

What are s/s of meniscal tears?

A
  • VMO atrophy
  • Pain with or without swelling
  • “Giving way”
  • Locking & unlocking
    (+) diagnostic special tests
  • Joint effusion
  • Joint line tenderness
  • Blocking at end ranges
112
Q

What special tests are used for menisci injuries?

A

McMurray
Apley’s
Bounce Home
Anderson medial-lateral grind
Thessley

113
Q

Meniscal repair rehab is (less/more) aggressive with strengthening due to tendon and ligament attachments.

A

less aggressive

114
Q

After knee surgery the ROM of knee flx is ____ degrees and __-__ degrees of EXT.

A

80 degrees of FLX

10-15 degrees of EXT

115
Q

Describe the grading of valgus laxity when evaluating the knee.

A

Grade I: 5 mm
Grade II: up to 10 mm
Grade III: > 10 mm

116
Q

Describe the grading of varus laxity when evaluating the knee.

A

Grade I: 5mm
Grade II: 8mm
Grade III: > 8mm

117
Q

What is the OPP of the tibiofemoral joint?

A

20-30 degrees of EXT

118
Q

___ glide of the tibia assists with EXT of the knee (prone)

A

Anterior glide (EXT)

119
Q

____ glide of the tibia assists with FLX of the knee (supine)

A

Posterior glide (FLX)

120
Q

___ glide of the patella assists with FLX of the patellofemoral joint

A

caudal/inferior (FLX)

121
Q

___ glide of the patella assists with EXT of the patellofemoral joint.

A

superior/cephalic (EXT)

122
Q

(true/false) PROM is ok (and necessary) immediately following ACL repair/tear, both extension and flexion

123
Q

(true/false) Full passive extension to zero degrees is ok and encouraged after ACL repair/tear (joint is moved into full extension in surgery room)

124
Q

Active terminal knee extension with moderate to heavy wts. (last 20-30°) should be avoided for the first __-__ weeks after an ACL repair/tear

125
Q

Brace is usually at full ____ acutely following ACL reconstruction

A

EXT (closed chain)

126
Q

Avoid terminal ____ both passively and actively to avoid stretching of healing MCL

A

EXT (last ~10-20 degrees)

–> also avoid full knee FLX acutely

127
Q

If anterior horn of the menisci is involved: might need to avoid terminal knee _____ acutely and resisted knee _____

A

terminal and resisted knee EXT

128
Q

If posterior horn of the menisci is involved: avoid full knee ____

A

FLX
(and resisted knee flexion if repaired)

129
Q

Patellofemoral syndrome should acutely avoid excessive _______ to avoid compressive forces of the articular surface of the patella.

A

Resisted knee FLX

130
Q

What are the 4 stages of cartilage wear?

A
  1. minimal fraying
  2. 1/4-1/2 tear
  3. Cartilage almost worn down to the bone and significant crepitus
  4. bone on bone
131
Q

At what stage of cartilage wear is there no pain but crepitus is present? Why?

A

Stage 3

Cartilage is avascular/aneural at that stage

132
Q

What type of joint is the tibiofemoral joint?

A

modified hinge

133
Q

Avoid (FLX/EXT) if the anterior portion of the menisci is damaged

134
Q

Avoid (FLX/EXT) if the posterior portion of the menisci is damaged

135
Q

Anterior-posterior stability of the tibiofemoral joint is provided by what ligaments?

A

ACL and PCL

136
Q

Medial-lateral stability of the tibiofemoral joint is provided by what ligaments?

A

MCL and LCL

137
Q

Where is the femoral condyle longer? Why?

A

medial

contributes to locking mechanism of the knee

138
Q

What tibial plateau is larger?

139
Q

What structures does the medial meniscus attach to?

A

joint capsule (coronary ligaments)
semimembranosus
ACL
MCL

140
Q

The patella engaged in motion between __-___ degrees.

A

60-90 degrees

Clinical Interventions (25 decks)

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