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Ortho 1 > Lectures knee, ankle and foot > Flashcards

Lectures knee, ankle and foot Flashcards

1
Q

Are the cruciate ligament of the knee inside the synovium

A

cruciate ligaments are extrasynovial

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2
Q

what is the angle of inclination of the hip?

A

120-125 deg

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3
Q

What is the normal valgus of the knee?

A

190 deg or about 7 deg depending on how you measure it

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4
Q

what is the angle of torsion at hip?

A

15 degrees

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5
Q

coxa valga

A

-predisposes pt. to Genu Varus

resulting in increased compression of the medial knee compartment and possible stretch laterally

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6
Q

Coxa Vara

A

predisposes pt to genu valgus

  • resulting in increased compression laterally and more tensile forces medially
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7
Q

anteversion can cause…

A

increased anteversion can cause increased internal rotation at the femur

-this may result in squinting patellae

toe in

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8
Q

retroversion can cause

A

increased external rotation of the femur

-this may result in frog-eyed patellae

toe out

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9
Q

Plicae

A

remnants of underdeveloped synovium. can get trapped or irritated by femoral movement (plica syndrome)

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10
Q

Lateral compartment of the knee

anterior 1/3

A

lateral extension of quadriceps tendon

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11
Q

Lateral compartment of the knee

middle 1/3

A

IT Band

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12
Q

Lateral compartment of the knee

Posterior 1/3

A

Arcuate complex: Fabella, fabellofibular ligt., fibular collateral ligt., popliteus tendon

Dynamic reinforcement from biceps femoris, popliteus and lateral head of gastrocnemius

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13
Q

LCL

A

primary restraint limiting lateral gapping (varus force)

25 deg really stressing LCL

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14
Q

Medial compartment of the knee

anterior 1/3

A

deep capsule, medial retinaculum

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15
Q

Medial compartment of the knee

Middle 1/3

A

MCL, Vastus medialis, semimembranosus

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16
Q

Medial compartment of the knee

posterior 1/3

A

Post oblique ligt., semimembranosus

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17
Q

MCL

A

is the primary restraint against valgus force

25 deg really stressing

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18
Q

difference in menisci

medial vs lateral

A

lateral is oval and medial meniscus is C-shaped

-wedge shaped in side view
both are attached by coronary ligts., to deep capsule

outer 1/3 is vascularized and inner 2/3 avascular

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19
Q

what is the function of menisci

A
  • Aid in lubrication and nutrition
  • Act as shock abdorbers
  • Improve joint congruency
  • Improve weight distribution
  • reduce friction during movt.
  • help prevent hyperextension
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20
Q

Medial Meniscus

A
  • Attached anteriorly by the meniscopatellar ligt. to quadriceps femoris
  • **Less mobile , more prone to injury
  • Attached posteriorly to the semimembranosus
  • Depending on extension or flexion, medial meniscus is pulled anteriorly or posteriorly
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21
Q

Lateral Meniscus

A
  • More mobile, less prone to injury
  • Has attachments to menoscopatellar ligt. anteriorly
  • Posteriorly attached to popliteus tendon
  • Lat. meniscus also moves with active extension and flexion
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22
Q

Cruciate ligaments

A
  • Cross the center of the tibiofemoral joint

- stabilize the knee in several planes

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23
Q

Anterior Cruciate ligament

A

Courses Superiorly, laterally and posteriorly from tibia to femur (SLP)

limits anterior tibial translation and hyperextension

-maximally tensed at full knee extension

assists with resisting varus and valgus fores

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24
Q

Posterior Cruciate ligament

A

Twice as strong and thicker than ACL

  • Sourses superior, anteriorly, and medially from tibia to femur (SAM)
  • Prevents post. tibial translation
  • Helps collateral ligts. resist varus and valgus force
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25
Q

Where is the tibial nerve likely entrapped?

A

-Fibrous arch in Soleus

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26
Q

Where is the common Peroneal entrapped?

A

-Head or neck of fibula

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27
Q

Where id the infrapatellar br of Saphenous N entrapped?

A

Pes anserine insertion of sartorius

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28
Q

What movement load the patellar the most and provoke pain in PFJ?

A

squatting- 7 times body weight
going down stairs- 3.5 body weight
going up stairs- 2.5
walking- 0.3

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29
Q

superior Tibiofubular joint

A
  • Plane synovial joint
  • Movement occurs here in conjunction with motion at the ankle

-in 10% of population the knee joint capsule is cont. with tibiofemoral joint capsule

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30
Q

what is resting position of tibiofemoral joint

A

25 deg of flexion

  • where we do joint mob and accessory mobility
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31
Q

what is the closed pack position of tibiofemoral joint?

A

Fullextension, lateral rotation of the tibia (screw home)

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32
Q

capsular pattern of the knee?

A

flexion greater than.. extension

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33
Q

tibiofemoral ROM
IR?
ER?

A

(@90 deg knee flexion)
IR = 30deg
ER = 40 deg

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34
Q

Patella in squat

A

Patella contacts the femur @ 20 deg. glides into trochlear groove first @ 90 deg.
- 90-135 deg, Patella rotates on vertical axis
>135 patella slips into intercondylar notch, rotates and shift laterally.
- —engages odd facet with medial condyle
—–Clinically appears as gentle “c” open laterally

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35
Q

Patella alta

A

Patella is high or patellar tendon is long. Means that there is a larger arc ROM where the patella is not very crongruent w/ the femr which puts patient at risk for sublaxation

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36
Q

Joint reaction force in squat

A

-Patellofemoral JRF is 2.5-3 times bodyweight at 90 deg flexion : Max JRF

from 90*120 deg forces either level off of decrease

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37
Q

PRE if no soreness is present

A

If no soreness is present from previous day’s exercise, progress exercise by 1 variable (amt of weight, or number of reps ) per session

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38
Q

PRE if soreness is present but goes away with warm up

A

if soreness is present from previous day’s exercise but recedes with warm up stay at same level

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39
Q

PRE if soreness is present but does not go away with warm up

A

Does not recede with warm- up, decrease exercise to the level prior to progression. consider taking the day off if soreness is still preseny with the reduced level of exercise.

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40
Q

ACL rehab

people who want to qualify for Copers

A
  1. No knee effusion
  2. Ability to hop on injured leg w/o pain
  3. Full knee ROM
  4. > /= 70% involved vs. uninvolved quadriceps strength ratio
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41
Q

Copers

A
  1. no more than 1 episode of giving way since injury
  2. > 80% on Noyes Hop test
  3. > /= 60% on Global rating of knee function test
  4. knee outcomes survey ADLs >/= 80%
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42
Q

Post surgical PCL

A

Slower healing than ACL

  • Limit flexion beyond 90 deg for 2-4 weeks
  • Post shear forces greatest in open chain resisted knee extension between 100-40 deg
  • Peak strain 85-95 deg
  • knee extension safe between 60-0 deg
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43
Q

Collateral ligaments post surgical rehab

A

-Immobilization in WB 30 deg flexed for 2-6 wks
-avoid varus or valgus stress depending on the ligament damaged 6-8 wks
Avoid excessive tibial rotation 6-8 wks
-Progressive resisted exercises performed with tibial IR for MCL sprains
-PRE’s done with tibial ER for LCL sprains

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44
Q

Meniscal Injury non-op rehab

A

Control swelling

  • restore passive knee ROM
  • minimize quad weakness with open chain PRE
  • Avoid squatting , pivoting cutting and running
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45
Q

Post-op meniscal repair rehab

A
  • MD’s try to save as much as possible
  • Knee immobilizer used to decrease swelling through decreased WB
  • Menisectomy rehab time 2-6 wks
  • Repair - slow WB progressively increased over 8 weeks
  • —0-4 weeks- no squatting >45 deg
  • —4-8 weeks - no load knee flexion >90 deg
  • Open chain quad strengthening. no cutting or pivoting activity
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46
Q

hyaluronic acid injections

A
  • lubricates joint
  • decreases swelling and inflammation
  • Usually a series of weekly injections over 3-5 weeks
  • most relief usually occurs 2-3 months later
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47
Q

articular cartilage rehab

A

Knee ROM to be minimized during early
Research shows 6 mons to 1 year for cartilage to maximally heal and no longer cause pain
-WB limited for first 3-4 weeks

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48
Q

Patellofemoral dysfunction

A
  • Quadriceps weakness is one of the culprits
  • Gluteus medius/maximus weakness
  • Hip ER weakness
  • Valgus stress at knee from frontal plane instability
  • Loss of midtarsal joint stability (pronation) at the foot can lead to this as well
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49
Q

Tendinosis microcospic finding

A
  • Collagen disorientation
  • disorganization and fiber separation
  • increase in mucoid ground substance
  • increase of cells and vascular spaces with or w/o new vessels and focal cell death or calcification
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50
Q

tendinitis microscopic findings

A
  • Degenerative changes as above with added evidence of tears, including increased fibroblasts, bleeding and scar tissue
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51
Q

Total hip replacement contras

A

no Flexion >80or 90 deg
no Adduction past neutral: use abduction pillow
no IR

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52
Q

Isometric ex for THA

A

Quad set, SLR <80, gluteal set, ankle pumps, Hip ABD, Thomas test in bed

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53
Q

Common problems after THA

A
  • Trendelenburg gait
  • flexion contractures
  • uneven stride length
  • excess knee flexion at terminal stance
  • excess hip flexion/lumbar flexion at mid to late stance
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54
Q

WB status for THA

A
  • cemented: WB as tolerated w/ walker for at least 6 weeks

- Cementless: toe touch WB with walker for 6-8 weeks up to 12

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55
Q

WB status for TKA

A
  • cemented: WB with walker from 1 day post op

- Hybrid: touch down WB with walker first 6 weeks

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56
Q

which graft is better?

A

Patellar tendon graft seems to tolerate accelerated rehab safely

  • Some say hamstring graft allows more laxity but they have tolerated accelerated rehab well also
  • allograft- typically for multiple ligament repairs or revisions
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57
Q

meniscal repair WB status

A
  • Limit WB but ok with knee braced in extension
  • Limit flexion to 45 deg for first 4 weeks
  • loaded knee flexion limited to 90 deg from 4-8 weeks post op
  • For ACL and meniscal repar
58
Q

MCL injury

Grade 1

A

microtrauma with no elongation

  • tender ligament
  • normal valgus laxity 0-5mm
59
Q

MCL injury

Grade 2

A
  • Elongated but intact

- increased valgus laxity 510 mm but firm end feel

60
Q

MCL injury

Grade 3

A
  • complete disruption
  • Increased valgus laxity with soft end feel
  • > 10mm
61
Q

gout

A

great toe extension limited and painful

62
Q

Hammer toe

A

MTP ext
PIP flex
DIP ext

63
Q

Claw toe

A

MTP ext
PIP flex
DIP flex

64
Q

mallet toe

A

DIP flex

65
Q

Total ankle replacement post -op management

A
  • Ankle immobilized for 3-6 wks
  • non-WB 3-6 wks
  • Start partial WB –> full WB after clearance from MD
  • elevate foot
66
Q

how much ankle ROM is needed for normal gait?

A

Pt. needs 10 deg DF and 25 deg PF

67
Q

arthrodesis of ankle and foot post -op

A

-immobilized 6-12 weeks post op
-NON WB for 4-8 weeks
- Full weight bearing w/o immobilizer usually by 12-16 weeks post-op
-AROM of associated joints
-orthodics to accomodate fused joints
-

68
Q

overuse syndromes result from

A
  • Faulty alignment
  • muscle imbalances
  • fatigue
  • changes in exercise or routine
  • training errors
  • poor footwear
69
Q

Maximum protection phase Achilles tendon repair

A
  • 6-8 wks if immobilization
  • non-WB for 2 wks
  • ankle in slight PF for 3-4 wks
  • neutral for 3-4 wks
  • elevation and edma control
  • after 2 wks partial WB allowed
  • muscle setting inversion and eversion -> 3-4 wks isometric DF and PF
70
Q

Mod protection phase Achilles tendon repair

A
  • 6weeks post op
  • closed chain strengthening -seated heel raises
  • add open chian resisted ankle ROM
  • progress to standing stretch for gastroc
71
Q

minimum protection phase Achilles tendon repair

A

-10-16 weeks closed chain double -leg heel raise–> single leg heel raises

18-20 weeks–> heel drops and raises over the edge
progress to jogging and jumping
5-6 mos return to high level activity
-strength and endurance should be 90-95% of uninvolved extremity

72
Q

peroneal tendon sublaxation post op care max protection phase

A
  • Soft tissue mob around wound after sutures removed
  • joint mobilizations
  • AROM after 10-21 days post-op
  • least stressful motions are PF and eversion (PROM in early phase)
73
Q

peroneal tendon sublaxation post op care

mod to min protection phase

A
  • WB
  • balance and gait training
  • strength training
  • plyometrics
  • functional activities
74
Q

What happens when someone has a forefoot varus deformity?

A

toes don’t touch the ground b/c of the way forefoot is fixed what will often happen is the midfoot excessively pronate to bring toes down to the ground. that deformity will cause excessive pronation which will eventually stress a number of muscles like Post tib, peroneus longus, tibial nerve

75
Q

deep peroneal nerve

A

commonly injured in anterior compartment
may be caused by trauma, tight show laces, ganglion or pes cavus
-usually will see “ foot drop”
-loss of sensation, small triangle between toes 1 and 2

76
Q

superficial peroneal nerve

A
  • May occur with lateral ankle sprain
  • entrapment near head of fibula or above lateral malleolus
  • high lesion - loss of eversion and stability
  • sensory loss- lateral leg and dorsum of foot
77
Q

Tibial nerve

A
  • typically injured in popliteal area (trauma)
  • usually unable to plantar flex foot or invert foot, unable to flex, abduct or adduct toes

sensory loss at sole of foot, lateral heel , plantar surface of toes

78
Q

medial plantar nerve

A
  • Pt. may report pain or aching in arch or heel
  • altered sensation in sole of foot behind hallux
  • associated with hindfoot valgus
  • also known as jogger’s foot
79
Q

sural nerve

A

-compression at the exit from the deep fa… 1/2 way down gastroc

  • bordering Achilles tendon
  • along lateral foot and ankle
80
Q

movement coordination faults of the knee

A

Tibiofemoral rotation

knee hyperextension

81
Q

movement coordination fault of the ankle

A

insufficient DF

excessive pronation

82
Q

IR movement tests

A 
squat
SLS
hip flexor length test
prone knee flexion
Prone hip extension
83
Q

knee hyperextension movement test

A 
Gait
Thomas test
Quad MMT
step up and down
dorsiflexion wall lunge test
84
Q

excessive pronation movement test

A

Stance
SLS
squat
standing arch/hip rotation test

85
Q

Insufficient DF movement test

A

Gait
squat
DF lunge test
joint accessory mobility

86
Q

4 ways to evaluate movements

A
  • Gait
  • Step down
  • Squat
  • Jump Landing
87
Q

Initial contact ROM

A

Ankle - neutral PF moment
Knee 5 deg of flexion Ext moment
Hip- 20 deg of flexion. flexion moment

88
Q

Initial contact deviations

Flat foot & short stride

A
  • helps patient avoid heel rocker
  • limits muscle activity

Cause: ant tib weakness, glute max weakness, limited hip ROM, poor balance

89
Q

Loading Response ROM

A

*foot rocker
ANkle- neutral, PF moment (DF eccentrics)
knee- 15 deg of flexion, flexion moment (quad ecc)
Hip- 20 deg of flexion, flexion moment glute max, hamstring (eccentric)

90
Q

Loading response deviations

Lack of knee excursion in loading

A

Penalty: loss of active shock absorption. inc stress on passive structures

causes of deviation: hip weakness, quad weakness

91
Q

Loading response deviations

Extended Trunk in Loading

A

Penalty: increased use of quadriceps

Causes of deviations: hip extensor weakness, poor motor control

92
Q

Terminal Stance (heel off) ROM

A

Ankle: 10 deg of DF. inc DF moment. ( PF ecc)
Knee: 5deg of flexion
Hip: 20 deg of extension

93
Q

terminal stance deviations

Reduced DF

A
  • Less than 10 deg
  • early heel rise
  • tow walker

Penalty: overuse of plantarflexors lead to Achilles tendinopathy, plantar fasciitis

Causes: tight gastroc, contr hip extensor weakness, limited joint moblity

94
Q

Terminal stance deviations

excessive DF

A
  • greater than 15 deg
  • Leads to excessive knee flexion

Penalty: increased quad use, Achilles strain

Causes: calf weakness, limited knee extension, limited hip extension

95
Q

Terminal stance deviations

inadequate hip/knee extension

A
  • less than 20 deg hip extension
  • greater than 5 deg knee flexion

Penalty: quad overuse, joint degeneration, lack of glute activity

Causes: hip flexor tightness, knee flexion contracture, calf weakness

96
Q

Initial swing ROM

A

Ankle: 5 deg PF
Knee: 60 deg of flexion
Hip: 15 deg of flexion

97
Q

Initial swing HIP muscles

A

Flexion

  • Iliacus
  • Adductor longus
  • Gracilis
98
Q

Initial swing Knee muscles

A

Flexion

  • gracilis
  • Sartorius
  • biceps femoris
99
Q

Initial swing ankle muscles

A

Dorsiflexion

  • anterior tib
  • extensor digitorum longus
  • extensor halluces longus
100
Q

Initial swing DEviation

-Inadequate knee flexion

A

-less than 55 deg of flexion

Poor foot clearance
anterior tib overuse

Causes: hip flexor weakness, slow speed, limited knee flexion ROM

101
Q

Increasing Quad strength progression

A

-quad set with NMES
-SLR with assistance +NMES
-SLR with quad re-set
-SLR w/o knee extension lag (@this point progress to standing activities)
-Mini wall squats
-mini squats
open chain knee extension

102
Q

Achilles tendon rupture immediately postoperative protocol

A
  • posterior splint with stirrup for ankle

- NWB briefly then WB with walking boot and small heel lift

103
Q

Achilles tendon rupture 2-6 weeks postoperative

A

Check the repair wound and soft tissue status. Ultrasound.

Use a ankle foot orthosis with brace at 20 deg PF. working down to 2 deg PF over next 3 weeks.

WB as tolerated with weaning crutch to support

104
Q

Achilles tendon rupture 6 weeks postoperative

A

Patient instructed on weaning himself from the ankle foot orthosis.

ROM exercises with resistance tubing. stationary cycle. heel raises with both legs

105
Q

Achilles tendon rupture 3 mo. postoperative

A

Unilateral heel raises added at 3 mo

106
Q

Achilles tendon rupture 6-12 mo. postoperative

A

If patient passes functional test, resume recreational activities. heel raise endurance should be 80% unaffected limb

107
Q

TKA Phase 1 Days 1-10goal

A

active quadriceps contraction. knee extension to 0 deg. knee flexion to 90 deg or greater. control of swelling, inflammation, and bleeding

108
Q

TKA Phase 2 weeks 2 -6 goal

A 
Improve ROM
Enhance muscular strength and endurance
dynamic joint stability
Diminish swelling and inflammation
Establish return to functional activities
improve general helath
109
Q

TKA Phase 3 weeks 7-12 goal

A
  • Progression of ROM (0-115 deg)
  • enhancement of strength and endurance
  • eccentric-concentric control of the limb
  • cardiovascular fitness
  • functional activity performance
110
Q

TKA Phase 4 Weeks 14-26 goal

A
  • allow selected patients to return to advanced level of function
  • maintain and improve strength and endurance of lower extremity
  • return to normal lifestyle
111
Q

THA Postoperative goals for posterior approach

A
  • Guard against dislocation of the implant
  • Gait functional strength
  • strengthen hip and knee musculature
  • Prevent bedrest hazards (DVt, embolism, pneumonia etc)
  • teach independent transfers and ambulation w/ assistive devices
  • obtain pain-free ROM w/in precaution limits
112
Q

Meniscal repair Phase 1 week 0-2 goals

A
  • full motion
  • no swelling
  • full WB
113
Q

Meniscal repair Phase 2 weeks 2-4 goals

A

improved quadriceps strength

  • normal gait
  • closed-kinetic resistance exercise
  • early phase functional training
114
Q

Meniscal repair Phase 3 week 4-8 goal

A
  • strength and functional testing at least 85% of contralateral side.
  • discharge from PT to full activity
115
Q

after meniscal repair maximum protection Weeks 1-6

A

stage 1: RICE, brace locked at 0 deg, ROM 0-90 deg.
-isometrics for quads, hamstrings, hip AB and AD. WB as tolerated. proprioception training

stage 2: PRE 1-5 pounds. limited range knee extension, toe raises, mini squats, cycling, surgical tubing exercises, flexibility exercises

116
Q

After meniscal repair mod protection Weeks 6-10. Goals

A

Goals: increase strength, power, endurance. normalize ROM prepare patients for advanced exercises

117
Q

after meniscal repai min protection Weeks 11-15. Goals

A

increase power and endurance. emphazise return to skill activities. prepare for return to full unrestricted activities

continue all exercises. initiate running

118
Q

ACL reconstruction Phase 1 Weeks 0-2 goals

A
  • Protect graft fixation
  • minimize effects of immobilization
  • control inflammation
  • no CPM
  • achieve full extension, 90 deg of knee flexion
  • educate patient about rehab progress
    ex: heel slide, patellar mob, SLR
119
Q

ACL reconstruction Phase 2 weeks 2-4 goals

A
  • restore normal gait
  • restore full ROM
  • protect graft fization
  • improve strength, endurance, and proprioception to prepare for functional activities

ex: mini-squat, stationary bike, closed-chain ext, toe raises etc.

120
Q

ACL reconstruction Phase 3 Week 6- 4 mo. goal

A
  • improve confidence in the knee
  • avoid overstressing graft fixation
  • protect the patellofemoral joint
  • progress strength, power, and proprioception to prepare for functional activities

ex: cont flexibility ex, clodes-kinetic chain strengthening,

121
Q

ACL reconstruction Phase 4 : Month 4 goals

A

return to restricted activities

ex: continue flexibility and strengthening programs

122
Q

ACL reconstruction reconstruction Phase 5: return to sport. goals

A
  • Safe return to athletics
  • maintenance of strength, endurance, and proprioception
  • patient education concerning any possible limitations

ex: gradual return to sport, maintenance program for strength and endurance
agility and sport-specific drills

123
Q

what joints make up the hindfoot?

A
  • inferior tib-fib
  • talocrural
  • subtalar
124
Q

what joint make up forefoot?

A
  • tarsometatarsal
  • intermetatarsal
  • metatarsophalangeal
  • interphalangeal
125
Q

tibio fibular joint

A
  • fibrous syndesmosis

- - mm of spread can occur here with DF. a superior glide of fibula with DF

126
Q

open pack for tibio fibular joint

A

plantar flexion

127
Q

closed pack for tibiofibular joint

A

max DF

128
Q

Capsular pattern for tiobiofibular joint

A

Pain on stress

129
Q

talocrural joint

A

-uniaxial, modified hinge, synovial joint
-talus is wider ant than post
-

130
Q

what does a loss of talocrural DF cause in the joints around it?

A

laxity in the midfoot and forefoot, more pronation in the midfoot

131
Q

talocrural ROM

A

DF deg

PF deg

132
Q

talocrural open pack

A

deg PF mid way between max inversion and eversion

133
Q

talocrural Close pack

A

full DF

134
Q

talocrural capsular pattern

A

Plantar flexion, then DF

135
Q

subtalar joint axis

A
  • axis inclines 42 deg up and 16 deg medially
136
Q

subtalar joint

A
  • motion is restricted by the different facets
  • resulting in triplanar motion around 1 axis
  • primarily supination and pronation
  • these motions DO NOT occur independently
137
Q

NWB supination…

A

calcaneus and foot move around talus

-calcaneal add, inversion an dPF

138
Q

NWB pronation

A

calcaneus and foot move around talus

-calcaneal abd, eversion, DF

139
Q

WB supination

A
  • calcaneal inversion
  • talar abd
  • tal df
  • tibiofibular lateral rotation
140
Q

WB pronation

A
  • calcaneal eversion
  • talar adduction
  • talar PF
  • tibiofibular medial rotation
141
Q

what happened if the hind foot is very everted and never inverts?

A
  • excessive pronation. foot is always too soft
  • this stresses the post tib, plantar fascia, tibial nerve, peroneus longus
  • deeper heel cup helps control a calcaneal eversion
142
Q

talocalcaneonavicular joint

A
  • formed by the large convex head of tehtalus-received by concavity on navicular
  • talus acts as a ball bearing B/w the mortise and the calcaneus and navicular

Ortho 1 (8 decks)

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