Knee Patterns - Non-Acute Flashcards
Knee Osteoarthritis: Definition
Deterioration of the articular cartilage and remodelling of the periarticular bone
Knee Osteoarthritis: Onset and Mechanism
Onset: Gradual, insidious
Mechanism:
•Primary – nil mechanism
•Secondary – post trauma (i.e. acute injuries) [or overweight]
Knee Osteoarthritis: Subjective Info
Subjective
•I/M deep knee pain/ache 1st with activity & stiffness after rest
•Progresses to constant & night pain (particularly if they have a flare up) & AM stiffness (
Knee Osteoarthritis: Physical/Objective Info
Physical
•Antalgic gait eg. limp
•Valgus/ varus deformity (often developed from walking with antalgic gait and muscle imbalance)
•Swelling (usually small, cold swelling but with flare up progressed to hot swelling) + TOP jt line
•ROM: F/E restricted, pain and stiffness during ROM (normal flexion = about 160, OA = 90-110; normal extension = 0 -5 deg hyp, lack hyp)
•+/- crepitus (knee grates)
•+/- stiff patella accessory movements (because not moving leg through full ROM)
Knee Osteoarthritis: Management with Good Evidence
Good evidence for: •Active exercise -range of movement -F/E -strengthening eg quadriceps -stretching/imbalance-hamstrings tight from prolonged flexion -proprioception -gait re-education - gait aid to reduce pain on WB, usually stick -contributing factors - long term poor gait eg tight hip flexors from prolonged knee flexion o-soft tissue tightness •Wt ↓ and self management education •Gait aids •Aquatic therapy (NWB exercises) •NSAIDs (oral paracetomol or topical) •Cold pack •Tai Chi
Knee Osteoarthritis: Management with Less Evidence
Would you use these forms of management or not? Why?
Less evidence for; • EPAs-US, laser • STM • Braces • Magnetic bracelets • Glucosamine • leeches!!
Yes can use.
•Even though there is not a great amount of evidence, they may still be used if it works well for patient
•But wouldn’t solely use them
Knee Osteoarthritis: Surgical Management
Later surgery (Total joint arthroplasty) may be needed •Joint replacements don’t last forever, and so if someone got one too early on, they would likely need a replacement •There are also various risks involved with the surgery •Last option
Anterior Knee Pain: Common sources
Common sources
oPatellofemoral Joint Syndrome
oPatellar tendinopathy
oPatellofemoral instability & dislocation
Anterior Knee Pain: Less common sources
• Less common sources
oFat pad impingement-fat pad behind patellar tendon
oQuadriceps tendinopathy
oBursitis (pre-patellar, infra patellar are the most common in anterior knee problem)
oStress fracture patella
oOsgood Schlatters –inflamed patellar ligament at insertion on tibial tuberosity (traction apophysitis)
oJohansson Larsen-osteochondritis (degeneration of cartilage) inferior pole patellar
oSynovial plica (fold in synovium)-medial pain
Anterior Knee Pain: Less common sources but MUST be screened for
• Less likely sources but MUST be scanned for in S/E and P/E
oOsteochondritis dissecans (sometimes in children who do a lot of activity, can form a loose body in knee from cartilage degeneration)
oSlipped Capital Femoral Epiphysis + referred pain
oPerthes disease (femoral head deteriorating and dying from insufficient blood supply, refer to knee)
oReferred pain from hip/ Lx spine
oBone tumour
– red flags –
Patello-femoral pain syndrome (PFPS): Common presentation and Aetiology
- Young women
- Nil structural or significant pathological changes
Aeitology – multi-factorial
oPatella maltracking (can cause contact with bones)
oVMO v V. Lateralis imbalance (might pull the patella laterally, causing changes around patella because of shift)
oWeakness of hip abductors (causing hip to IR which causes patella to move to a different position)
oAbnormal foot mechanics (can cause a change in the contact surface of the patella)
oITB tightness (pull patella laterally)
Patello-femoral pain syndrome (PFPS): Causes of pain
oPatellar alignment relative to femoral trochlear
oAbnormalities of articular cartilage
o↑ pressure/stress on lateral surface of patella
•Hypothesis: Excessive mechanical loading and chemical irritation of nerve endings > inflammatory cascade > peripatellar synovitis
Patello-femoral pain syndrome (PFPS): Subjective (onset, area, nature and behaviour)
Onset: •Gradual overuse or after injury (i.e. blow to knee) Area: •Vague ant/lat or ant/med pain •Often bilateral Nature: •i/m, deepish ache, +/- crepitus •Often irritable
Behaviour:
•Agg: ↑ PFJ forces (i.e. Squat, stairs, sitting)
•Ease: ↓ PFJ force (i.e. rest, tape to realign)
Patello-femoral pain syndrome (PFPS): Physical Info (Observation, Function, ROM, PFJ, RSC, MLT and Palpation)
Obs: •+/- slight swelling (can be hard to see because it is a small, contained area; pick up with patella tap/palpation) •Knee HE (more contact between patella and femur – cause of condition; or generally hyper extendable) •Foot pronation •Femoral IR/ add •↑ Q angle •Wasted VMO •Tilted patella
Functional:
•pain & poor control on squat & going ↓ stairs
ROM: usually FROM +/- pain @ EOR Flexion (when compress patella)
PFJ: pain/creps on comp/ glides
RSC: Ext may cause P (positive result - RSQ compress patella, can be negative result)
MLT: tight ITB
Palpation:
•Patella usually lateral +/- tilt.
•Tender under surface of patella; crepitus
Patello-femoral pain syndrome (PFPS): Management
PFPS: Management
•↓ pain and inflammation
-EPAs
•Stretch tight lateral structures (eg. ITB) - DTF, Myofascial release, stretches
•Strengthen VMO- Exercise program, EMG biofeedback
•Patella mobilisation techniques
- Correct contributing factors) -Orthotics, Training programme, Strengthen hip ER/ abductors
- Patellar taping – tape medially
- Strengthen hips (glut med and min so don’t go into IR)
Patellar Tendinopathy (PT): Presentation and Pathology
- “Jumpers knee”
- Symptoms just inferior to the patella
- Tendon degeneration rather than inflammation (tendonitis if inflammatory)
•Pathology:
–tendons have lost their typical structure of tightly bundled parallel collagen fibres
–↑ground substance
–Collagen fibres disorganised and discontinuous
Patellar Tendinopathy: Symptoms/Subjective Info (Onset, Area and Behaviour)
Onset: •Gradual overuse, common in jumping sports Area: •Inferior pole of the patella •Superficial (as patella tendon is a superficial structure) Behaviour: •Agg: Jumping, hopping, bounding •Ease: Rest, ice
Patellar Tendinopathy: Signs/Physical Info (ROM, RSC, PFJ, Palpation and Function)
Knee ROM: Usually normal
RSC: Q/S weakness in severe cases; may cause pain reproduction
Palpation:
•TOP attachment to inferior pole of patella.
•Thickening also common.
PFJ: Normal, taping has less effect
Functional: Decline squats ↑pain
Patellar Tendinopathy: Mx
- Local treatment i.e. ice/ EPA’s, TF
- Address contributing factors - Quads/ HS tightness, LL biomechanics (such as foot position), PFJ (may not glide enough superiorly, stretch tendon), Core stability
- ‘strengthening’ of PT à progressive eccentric exs
•Eccentric treatment program- decline board, some level of discomfort, work up to 3 sets of 15 reps daily, modify sports activities
Patellar Dislocation: Presentation
- Lateral»_space; medial
- 5 % associated with osteochondral #
- Congenital – e.g. Downs syndrome
- Habitual – occurs each time knee is flexed
- Traumatic
- Recurrent > Patellar instability – may lead to damage to lateral femoral condyle and PFJ
•Medial retinacular injury
Patellar Dislocation: Onset and Mechanism
Onset: Sudden, severe pain
Mechanism: •Jumping/twisting – knee gives way •+/- audible pop •Often reduces spontaneously •Immediate, gross effusion
Patellar Dislocation: Signs/Physical Info
Signs:
•Haemarthrosis (blood around patella)
•RSC: Q/S ↑pain
•Lateral apprehension test +ve (if you push in direction than dislocated in, they will spasm)
Patellar Dislocation: Mx (Conservative and Surgical)
Conservative – 4 weeks extension splint and quads rehab +++
Surgical
•Lateral release (release structures on lateral side to stop patella being pulled laterally)
•VMO advancement or transfer of patellar tendon [limited evidence for efficacy]
Bursitis: Definition and Presentation
- Inflammation of the bursa
- Due to repetitive friction (from surrounding structures)
- Soft fluctuant swelling (extra-capsular)
- Locally painful-eg over knee cap or behind quadriceps tendon (suprapatellar bursa) or behind patellar tendon (infrapatellar bursa)
- Inflammatory presentation i.e. constant pain, night pain, hot/ red/ swollen/ tender
- Rx: rest form aggravating activity, ice, elevation, medication, prevention
Lateral Knee Pain -
ITB Friction Syndrome: Onset and Mechanism
Onset: gradual
Mechanism: Unclear
-? Friction between posterior edge of ITB & lateral femoral condyle
-Repetitive compression of sub-ITB structures (from repetitive activities like running)
-Bursitis
ITB Friction Syndrome: Signs/Physical Info
Signs:
•Weak knee F & E
•↓ braking forces
•Weak hip abductors (worse eccentrically) & hip F
•TOP lateral femoral epicondyle (2-3cm ↑ jt line)
•+/- tight & TrP in ITB, TFL, glutes
•Biomechanical & foot posture contributors
ITB Friction Syndrome: Symptoms/Subjective Info
Symptoms:
•Ache over lateral knee
•Agg: running (worse with longer distances, ↓ hill or cambered/slope surface)
•Ease: rest
ITB Friction Syndrome: Rx/Prescription
- Activity modification
- Symptom relief – EPAS, analgesics
- STR
- ITB stretch
- Correct biomechanical contributing factors
