Knee Treatments

Question 1

Patellar Tendinitis

Answer 1

Resolves with rest or modification of activity; adjust mm imbalances; patella strap may be helpful (it decreases the work load on tendon)

Question 2

Fat Pad Syndrome; “Hoffa’s”

Answer 2

RICE
Modalities ???
Motor control exercises to limit and slow hyperextension

Question 3

Knee Bursitis

Answer 3

Remove the irritation with activity modification
Acute: Ice, NSAIDs
Sub-acute: Isometrics, gentle ROM, improve muscle imbalances, protect area from further irritation

Question 4

ITB Friction Syndrome

Answer 4

Improve LE Mechanics:
Hip - decrease TFL activity and improve glute med activity, improve glute max activity to assist with ITB stability; Foot - correct foot mechanics with stability and/or orthoses

Modify activity
Soft tissue mobilization to loosen ITB adhesions
Flexibility

Question 5

Baker’s Cyst

Answer 5

Typically conservative; NSAIDs, ice, decreased WB’ing status
PT Intervention: ROM, pain, strength…
Excision rarely indicated; occasionally aspirated (frequent in athletics)
**TREAT the underlying cause!

Question 6

Tibial Plateau Stress Fracture

Answer 6

Reduction in activity and in some cases casting; external bone stimulator
Chronic = intramuscular nailing of fracture

Question 7

PFPS

Answer 7

Improve posterolateral hip muscles activation; bracing and taping may be beneficial; combination of orthotics and therapeutic exercise; feedback interventions during running; multimodal approach seems to be best; physical agents not helpful; no long term gains seen

Question 8

PFJ Instability

Answer 8

First time or infrequent dislocators usually do well with conservative tx; chronic: usually require surgical intervention; Similar to PFPS (foot and hip interventions); patella bracing with lateral buttress (no adequate evidence to support or refute the use of bracing)

Question 9

ACL Non surgical Treatment

Answer 9

Restore joint mobility
Increase strength around the knee
Quads and hamstrings: HS help promote dynamic posterior pull of the tibia supporting ACL deficiency
Bracing (sports/activities) to prevent anterior translation of the tibia
Treatment success more for sedentary individuals
“Copers” - higher level function without ACL via stabilization or bracing

Question 10

ACL Reconstruction

Answer 10

*

Question 11

PCL Non Operative

Answer 11

Brace immobilization x2-4 weeks
Focus on ROM, quad activation and limiting HS overactivity initially progressing to closed chain strengthening, proprioception, and quad strength
*slower progression compared to ACL because more unstable

Question 12

PCL Postoperative

Answer 12

Weeks 1-3: NWB, crutches, long leg brace locked in full extension
Weeks 4-6: NWB c crutches until end of Post Op wk 6. Brace unlocked and progressive ROM begins
Weeks 7-10: Progressive WB c crutches at ~25% bw per week (full bw WB by week 10)
Weeks 11-24: Progressive ROM and strength training, avoiding resisted HS exercises
Weeks 25-52: Cont. strength and agility training; return to sports or heavy labor when strength ROM and proprioceptive skills are symmetric to the uninjured LE

Question 13

Grade I/II MCL (non operative)

Answer 13

Rest/Ice, hinged brace, early ROM - strength/proprioception, early WB’ing, Avg. return to football 20 days (grade II), 74% return to pre injury activity level at 3 mo

Question 14

Grade III MCL

Answer 14

Controversial; most treated non operatively same as I/II

Question 15

Collateral Ligament

Answer 15

Managed conservatively; studies indicate no significant benefit from surgically management; Imperative to limit varus forces (LCL) or valgus forces (MCL) and rotational forces within 6-8 weeks post injury; Restore ROM and improve dynamic stability to take stress off collaterals

Question 16

Non-Surgical management of meniscal injury

Answer 16

Leave alone, conservative care of impairments and functional limitations (control swelling, restore ROM and progressive stability)

Question 17

Surgical options for Meniscal injury

Answer 17

Meniscus repair, partial meniscetomy, allograft transplantation

Question 18

Partial Menisectomy Treatment

Answer 18

Little to no protection
Moderate last 3-4 weeks
Muscle setting, SLR, active ROM
WBAT
Full WB and 90 degrees flexion typically achieved by 10 days
Initiate closed chain exercise a few days post op
Caution* Pts can go too quickly, closely monitor signs

Question 19

Meniscal Repair/Transplantation

Answer 19

Dependent on type/location of repair/transplant (Physician directed)
Generally:
Restricted WBing 2-4 weeks
Long leg brace x^ wks (typically immobilized in extension progressively allowing flex)
Flexion ROM restricted to 80 week 1, 120 week 4, 135 week 6
OC exercises progressive to CC exercises
Biking wk 7, straight running month 4, cutting month 5, return to sport month 5

Question 20

Non Operative treatment of PLC injury

Answer 20

Phase 1: Edema mgmt; QS activation, ROM Return
Phase 2: Gait mechanics, increase strength - QS, HS, GS, Popliteus, Hip, Lumbopelvic
Phase 3: NMC, control of varus and tibial ER at increased angles of knee flexion
Phase 4: Sport specific training

Question 21

Post Op PLC Injury

Answer 21

NWB x6 wks, immobilizer locked out for 1-2 weeks
ROM: 0-90 in 2 weeks, full in 6 weeks
Full body squats permitted by 12 weeks
until 4 months NO:
CKC therex at greater than 70 degree knee flexion
Tibial ER
Resisted or repetitive HS in knee flexion

Question 22

Treatment options for Chondral defects

Answer 22

Conservative/Palliative (debridement/lavage)
Reparative (Subchondral drilling, microfracture)
Restorative (Osteochondral grafting “OATS”, Autologous Chondrocyte Implantation “ACI”)

Question 23

Chondromalacia/OA

Answer 23

Muscle imbalances, hip strength, flexibilit, alignment issues, possible surgical, aerobics, lose wt, *EXERCISE reduces pain and improves function but no significant different between types (aerobic vs strengthening, or high vs low impact); manual therapy

Question 24

PT Knee OA management

Answer 24

Education: Wt loss, activity modification, Exercise - incorporate multiple muscles, Manual Therapy, Bracing (medial unloader/Valgus), Heel wedge (lateral heel wedge to unload medial knee compartment), Aquatic therapy, modalities (?)

Question 25

Medical management of Knee OA

Answer 25

Medication: NSAIDs Cox II inhibitors, injections, TKA

Question 26

Patellar Tendinopathy/Tendinosis

Answer 26

Activity modification and eccentric loading to the tendon; single limb squat on a decline board, systematic review shows efficacy but mechanisms unknown

Question 27

Management of Saphenous nerve injury

Answer 27

RICE, possibly surgical release of fascial bands

Question 28

Medical Plica

Answer 28

Conservative treatment typically successful
Ensure pt’s activity level was appropriate
Implement stretching program for mm of LE: Quads, Gastrocs, HS
Instruct in knee extension exercises, especially Terminal knee extension