L9 Knee Conditions Flashcards
Primary Knee Conditions
PFP
Ligament injuries
PF instability
Meniscus
OA
Anterior Knee Pain can be…
PFP
Chondromalacia patellae
PF instability
Clinical Findings accompanying anterior knee pain
patellar hypo or hypermobility
biomechanical alignmnet issues
foot pronation
chondral lesions
tendon or bursae reactivity
fear/avoidance behaviors
PFP syndrome
most common cause of anterior knee pain
common in 12-19 and 50-59
more common in females
episodic, often multiple
has a slow, progressive history
Anterior knee pain patient history
superficial or retropatellar pain
aggraved with running, squatting, stairs, sitting
no clear MOI
changes in activity or mode
changes in job
prior knee injury or surgery
Kinetic chain Exam
strength of glut max, abductors, ER
foot posture
ability to activate foot core
How is PFP diagnosed?
usually a diagnosis of exclusion
no definitive single test, usually testing combined with patient history
Potential Clusters for PFPS
pain with resisted knee extension
pain with palpation of posteromedial and posterolateral patella
pain with squatting
pain with anterior step down
hypomobile patellar tilt test
Possible Causes for PFP
- Overuse/overload without other impairments/pathology
- Muscle performance/capacity deficits
- Movement coordination deficits
- Mobility Impairments
Which muscles show deficits with PFP
hip abductors
ERs
extensors
quadriceps
Myths in treatment of PFP
adjusting the pelvis will restore normal alignment
taping will help patella track properly
stretching ITB will help patella track
strengthening VMO helps patella to track
RICE will solve it
Interventions for PFP, week 0-4
Activity mods, load management
initiation of or alternative exercises
address soft tissue restrictions
taping up to 4 weeks
Foot orthoses up to 6 weeks
PFP Intervention Weeks 4-12
Foot orthoses up to 6 wks
Posterolateral hip muscle strengthening
kee, foot muscle strengthening
balance exercises
progressive loading towards functional
gait retraining
progressive/graded return to sport
PFP Intervention weeks 8-12
Plyometrics/power training
gait re-training
progressive graded return to sport/activity
education regarding management of recurrence
Pain levels and activity
0-3/10 = safe zone
4-5/10 = acceptable
6+/10 = excessive
mild pain during activity is ok as long as it settles in 24 hours
Highest loads required on patella
1 leg decline squat
Lowest load required on patella
walking
Manual therapy for PFP
talocrural joint posterior glides
patellofemoral glides
talonavicular glides
soft tissue mobs
Talocrural joint post glides
loss of ankle DF due to limited joint play/glide
may present itself during squatting, step downs
Patellofemoral glides
assess and treat relevant directions
Talonavicular glides
dorsal if there is a rigid flatfoot deformity
Soft tissue mobs for PFP
TFL
vastus lateralist
retinaculum
scar tissue
Peak muscle activation from these groups causes PFP
hip adductors
hip IR
PFPS return to running
Easier impact and quicker cadence can improve pain and knee function without significantly altering kinematics
Poor outcome for PFPS associated with
longer duration of S/S before intervention
overall lower levels of physical function
worse pain
negative psychological stresses
articular surface of patellar findings are not strongly associated with outcomes
Overall summary for PFP
keep the pt active, progressively load and address kinetic chain contributions while monitoring pain
RF for ACL Injury
Female when younger, Male when older
quad to hamstring deceleration strength ratio
landing biomechnics
higher BMI
smaller femoral notch
previous ACL injury
higher risk sports. soccer, basket, skiing
Exam of ACL Injury
Hx: patient reported a pop, shift, giving out. Unwilling to WB, feeling instable, swelling.
Observe: lack of full ext during stance phase of gait, lack of flexion during swing, effusion
ACL Controveries
Conservative vs surgical
graft types
bracing
return to sport
Nonoperative methods for ACL
less complications if meniscus is intact
better for sedentary lifestyle
requires weight control
will have continuous instability
neuromuscular reeducation
Graft Types
allograft
autograft
primary repair
BEAR procedure
allograft
from a cadaver
patellar ligament or A/P tibialis tendon
Autograft
from the patient
semitendinosus
patellar
quads tendon
Primary repair
suture and anchor back to exisiting ACL
Prehab/Pre op phase
minimize swelling
maximize strength/ROM without pain
assess and education about surgery/rehab
Surgery phase
stabilize, repair, remove
know what tissues were traumatized, repaired, and removed
Phase 1 of ACL recovery
recover from surgery
control edema and pain
protect graft
activate quads
Phase 2 of ACL recovery
force development and motor control
progressive of quad and hamstring loading
full ROM
global conditioning
Phase 3 of ACL recovery
force attenuation and plyometrics
assessing and training all 3 planes
varying loads and speeds
Phase 4 of ACL recovery
return to sport progression
sports specific drills
return to participation
play and performance
Phase 5 of ACL recovery
prevention of re-injury
long-term self management
mitigation of modifiable RF
Components of impairment based progression of ACLR rehab
early loading
early/frequent education
early/frequent testing/retesting
individualized
adherence
resources
communication with all members of team
Impairment based rehab
you can do “d” once you have been able to accomplish A, B, and C. Being able to D is an essential component of being able to do EFGH
Bracing in ACL deficient knee
C grade that clinicians may use functional knee bracing in patients without an intact ACL
Bracing in immediate post op phase
patient preferences appear to matter more than biomechanical data
Bracing during return to sport phase
patient preferences continue, but required for higher risk sports
Return to Sport post ACL
for every 1 mnth delay in RTS, the reinjury rate is decreased by 50%
RTS Testing
quad strength
single hop for distance
triple crossover hop
triple hop
6M timed hop
KOS-ADLS
global rating scale
all should be at least 90% or greater than original scoring
Improving ACLR Outcomes
protect graft in early stages
regaining knee extension AROM
psychological readiness
building strength early
completing POC
early Y balance
PCL Injury Interventions
protected weight bearing
quads rehab
PCL Prognosis
return to sport within 4 weeks
chronic PCL leads to increased contact pressure in anterior and medial compartments, early onset of degenerative changes
MCL Interventions
Grade 1 = quad sets, SLR, cyclling, closed chain exercises. RTS in 5-7 days
Grade 2/3 = immobilizer, hinged brace for walking, RTS in 4-8 weeks
Posterolateral Corner Injuries
varus and hyperextension stres
often accompanies an ACL injury
missed PLC injuries are common cause of ACL repair failure
PLC consists of
LCL, popliteus tendon and ligment
capsule, arcuate ligaments
Emergent cases of PLC injuries
vascular damage
peroneal nerve palsy (more common, 25%)
Presentation of rotary instability
tenderness and swelling in posterolateral corner
flexed knee during gait
varus thrus during gait
avoids hyperextension
