Lectures knee, ankle and foot Flashcards
Are the cruciate ligament of the knee inside the synovium
cruciate ligaments are extrasynovial
what is the angle of inclination of the hip?
120-125 deg
What is the normal valgus of the knee?
190 deg or about 7 deg depending on how you measure it
what is the angle of torsion at hip?
15 degrees
coxa valga
-predisposes pt. to Genu Varus
resulting in increased compression of the medial knee compartment and possible stretch laterally
Coxa Vara
predisposes pt to genu valgus
- resulting in increased compression laterally and more tensile forces medially
anteversion can cause…
increased anteversion can cause increased internal rotation at the femur
-this may result in squinting patellae
toe in
retroversion can cause
increased external rotation of the femur
-this may result in frog-eyed patellae
toe out
Plicae
remnants of underdeveloped synovium. can get trapped or irritated by femoral movement (plica syndrome)
Lateral compartment of the knee
anterior 1/3
lateral extension of quadriceps tendon
Lateral compartment of the knee
middle 1/3
IT Band
Lateral compartment of the knee
Posterior 1/3
Arcuate complex: Fabella, fabellofibular ligt., fibular collateral ligt., popliteus tendon
Dynamic reinforcement from biceps femoris, popliteus and lateral head of gastrocnemius
LCL
primary restraint limiting lateral gapping (varus force)
25 deg really stressing LCL
Medial compartment of the knee
anterior 1/3
deep capsule, medial retinaculum
Medial compartment of the knee
Middle 1/3
MCL, Vastus medialis, semimembranosus
Medial compartment of the knee
posterior 1/3
Post oblique ligt., semimembranosus
MCL
is the primary restraint against valgus force
25 deg really stressing
difference in menisci
medial vs lateral
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
what is the function of menisci
- Aid in lubrication and nutrition
- Act as shock abdorbers
- Improve joint congruency
- Improve weight distribution
- reduce friction during movt.
- help prevent hyperextension
Medial Meniscus
- 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
Lateral Meniscus
- 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
Cruciate ligaments
- Cross the center of the tibiofemoral joint
- stabilize the knee in several planes
Anterior Cruciate ligament
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
Posterior Cruciate ligament
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
Where is the tibial nerve likely entrapped?
-Fibrous arch in Soleus
Where is the common Peroneal entrapped?
-Head or neck of fibula
Where id the infrapatellar br of Saphenous N entrapped?
Pes anserine insertion of sartorius
What movement load the patellar the most and provoke pain in PFJ?
squatting- 7 times body weight
going down stairs- 3.5 body weight
going up stairs- 2.5
walking- 0.3
superior Tibiofubular joint
- 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
what is resting position of tibiofemoral joint
25 deg of flexion
- where we do joint mob and accessory mobility
what is the closed pack position of tibiofemoral joint?
Fullextension, lateral rotation of the tibia (screw home)
capsular pattern of the knee?
flexion greater than.. extension
tibiofemoral ROM
IR?
ER?
(@90 deg knee flexion)
IR = 30deg
ER = 40 deg
Patella in squat
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
Patella alta
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
Joint reaction force in squat
-Patellofemoral JRF is 2.5-3 times bodyweight at 90 deg flexion : Max JRF
from 90*120 deg forces either level off of decrease
PRE if no soreness is present
If no soreness is present from previous day’s exercise, progress exercise by 1 variable (amt of weight, or number of reps ) per session
PRE if soreness is present but goes away with warm up
if soreness is present from previous day’s exercise but recedes with warm up stay at same level
PRE if soreness is present but does not go away with warm up
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.
ACL rehab
people who want to qualify for Copers
- No knee effusion
- Ability to hop on injured leg w/o pain
- Full knee ROM
- > /= 70% involved vs. uninvolved quadriceps strength ratio
Copers
- no more than 1 episode of giving way since injury
- > 80% on Noyes Hop test
- > /= 60% on Global rating of knee function test
- knee outcomes survey ADLs >/= 80%
Post surgical PCL
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
Collateral ligaments post surgical rehab
-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
Meniscal Injury non-op rehab
Control swelling
- restore passive knee ROM
- minimize quad weakness with open chain PRE
- Avoid squatting , pivoting cutting and running
Post-op meniscal repair rehab
- 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
hyaluronic acid injections
- lubricates joint
- decreases swelling and inflammation
- Usually a series of weekly injections over 3-5 weeks
- most relief usually occurs 2-3 months later
articular cartilage rehab
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
Patellofemoral dysfunction
- 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
Tendinosis microcospic finding
- 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
tendinitis microscopic findings
- Degenerative changes as above with added evidence of tears, including increased fibroblasts, bleeding and scar tissue
Total hip replacement contras
no Flexion >80or 90 deg
no Adduction past neutral: use abduction pillow
no IR
Isometric ex for THA
Quad set, SLR <80, gluteal set, ankle pumps, Hip ABD, Thomas test in bed
Common problems after THA
- Trendelenburg gait
- flexion contractures
- uneven stride length
- excess knee flexion at terminal stance
- excess hip flexion/lumbar flexion at mid to late stance
WB status for THA
- cemented: WB as tolerated w/ walker for at least 6 weeks
- Cementless: toe touch WB with walker for 6-8 weeks up to 12
WB status for TKA
- cemented: WB with walker from 1 day post op
- Hybrid: touch down WB with walker first 6 weeks
which graft is better?
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
meniscal repair WB status
- 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
MCL injury
Grade 1
microtrauma with no elongation
- tender ligament
- normal valgus laxity 0-5mm
MCL injury
Grade 2
- Elongated but intact
- increased valgus laxity 510 mm but firm end feel
MCL injury
Grade 3
- complete disruption
- Increased valgus laxity with soft end feel
- > 10mm
gout
great toe extension limited and painful
Hammer toe
MTP ext
PIP flex
DIP ext
Claw toe
MTP ext
PIP flex
DIP flex
mallet toe
DIP flex
Total ankle replacement post -op management
- Ankle immobilized for 3-6 wks
- non-WB 3-6 wks
- Start partial WB –> full WB after clearance from MD
- elevate foot
how much ankle ROM is needed for normal gait?
Pt. needs 10 deg DF and 25 deg PF
arthrodesis of ankle and foot post -op
-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
-
overuse syndromes result from
- Faulty alignment
- muscle imbalances
- fatigue
- changes in exercise or routine
- training errors
- poor footwear
Maximum protection phase Achilles tendon repair
- 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
Mod protection phase Achilles tendon repair
- 6weeks post op
- closed chain strengthening -seated heel raises
- add open chian resisted ankle ROM
- progress to standing stretch for gastroc
minimum protection phase Achilles tendon repair
-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
peroneal tendon sublaxation post op care max protection phase
- 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)
peroneal tendon sublaxation post op care
mod to min protection phase
- WB
- balance and gait training
- strength training
- plyometrics
- functional activities
What happens when someone has a forefoot varus deformity?
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
deep peroneal nerve
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
superficial peroneal nerve
- 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
Tibial nerve
- 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
medial plantar nerve
- 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
sural nerve
-compression at the exit from the deep fa… 1/2 way down gastroc
- bordering Achilles tendon
- along lateral foot and ankle
movement coordination faults of the knee
Tibiofemoral rotation
knee hyperextension
movement coordination fault of the ankle
insufficient DF
excessive pronation
IR movement tests
squat SLS hip flexor length test prone knee flexion Prone hip extension
knee hyperextension movement test
Gait Thomas test Quad MMT step up and down dorsiflexion wall lunge test
excessive pronation movement test
Stance
SLS
squat
standing arch/hip rotation test
Insufficient DF movement test
Gait
squat
DF lunge test
joint accessory mobility
4 ways to evaluate movements
- Gait
- Step down
- Squat
- Jump Landing
Initial contact ROM
Ankle - neutral PF moment
Knee 5 deg of flexion Ext moment
Hip- 20 deg of flexion. flexion moment
Initial contact deviations
Flat foot & short stride
- helps patient avoid heel rocker
- limits muscle activity
Cause: ant tib weakness, glute max weakness, limited hip ROM, poor balance
Loading Response ROM
*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)
Loading response deviations
Lack of knee excursion in loading
Penalty: loss of active shock absorption. inc stress on passive structures
causes of deviation: hip weakness, quad weakness
Loading response deviations
Extended Trunk in Loading
Penalty: increased use of quadriceps
Causes of deviations: hip extensor weakness, poor motor control
Terminal Stance (heel off) ROM
Ankle: 10 deg of DF. inc DF moment. ( PF ecc)
Knee: 5deg of flexion
Hip: 20 deg of extension
terminal stance deviations
Reduced DF
- 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
Terminal stance deviations
excessive DF
- greater than 15 deg
- Leads to excessive knee flexion
Penalty: increased quad use, Achilles strain
Causes: calf weakness, limited knee extension, limited hip extension
Terminal stance deviations
inadequate hip/knee extension
- 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
Initial swing ROM
Ankle: 5 deg PF
Knee: 60 deg of flexion
Hip: 15 deg of flexion
Initial swing HIP muscles
Flexion
- Iliacus
- Adductor longus
- Gracilis
Initial swing Knee muscles
Flexion
- gracilis
- Sartorius
- biceps femoris
Initial swing ankle muscles
Dorsiflexion
- anterior tib
- extensor digitorum longus
- extensor halluces longus
Initial swing DEviation
-Inadequate knee flexion
-less than 55 deg of flexion
Poor foot clearance
anterior tib overuse
Causes: hip flexor weakness, slow speed, limited knee flexion ROM
Increasing Quad strength progression
-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
Achilles tendon rupture immediately postoperative protocol
- posterior splint with stirrup for ankle
- NWB briefly then WB with walking boot and small heel lift
Achilles tendon rupture 2-6 weeks postoperative
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
Achilles tendon rupture 6 weeks postoperative
Patient instructed on weaning himself from the ankle foot orthosis.
ROM exercises with resistance tubing. stationary cycle. heel raises with both legs
Achilles tendon rupture 3 mo. postoperative
Unilateral heel raises added at 3 mo
Achilles tendon rupture 6-12 mo. postoperative
If patient passes functional test, resume recreational activities. heel raise endurance should be 80% unaffected limb
TKA Phase 1 Days 1-10goal
active quadriceps contraction. knee extension to 0 deg. knee flexion to 90 deg or greater. control of swelling, inflammation, and bleeding
TKA Phase 2 weeks 2 -6 goal
Improve ROM Enhance muscular strength and endurance dynamic joint stability Diminish swelling and inflammation Establish return to functional activities improve general helath
TKA Phase 3 weeks 7-12 goal
- Progression of ROM (0-115 deg)
- enhancement of strength and endurance
- eccentric-concentric control of the limb
- cardiovascular fitness
- functional activity performance
TKA Phase 4 Weeks 14-26 goal
- allow selected patients to return to advanced level of function
- maintain and improve strength and endurance of lower extremity
- return to normal lifestyle
THA Postoperative goals for posterior approach
- 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
Meniscal repair Phase 1 week 0-2 goals
- full motion
- no swelling
- full WB
Meniscal repair Phase 2 weeks 2-4 goals
improved quadriceps strength
- normal gait
- closed-kinetic resistance exercise
- early phase functional training
Meniscal repair Phase 3 week 4-8 goal
- strength and functional testing at least 85% of contralateral side.
- discharge from PT to full activity
after meniscal repair maximum protection Weeks 1-6
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
After meniscal repair mod protection Weeks 6-10. Goals
Goals: increase strength, power, endurance. normalize ROM prepare patients for advanced exercises
after meniscal repai min protection Weeks 11-15. Goals
increase power and endurance. emphazise return to skill activities. prepare for return to full unrestricted activities
continue all exercises. initiate running
ACL reconstruction Phase 1 Weeks 0-2 goals
- 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
ACL reconstruction Phase 2 weeks 2-4 goals
- 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.
ACL reconstruction Phase 3 Week 6- 4 mo. goal
- 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,
ACL reconstruction Phase 4 : Month 4 goals
return to restricted activities
ex: continue flexibility and strengthening programs
ACL reconstruction reconstruction Phase 5: return to sport. goals
- 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
what joints make up the hindfoot?
- inferior tib-fib
- talocrural
- subtalar
what joint make up forefoot?
- tarsometatarsal
- intermetatarsal
- metatarsophalangeal
- interphalangeal
tibio fibular joint
- fibrous syndesmosis
- - mm of spread can occur here with DF. a superior glide of fibula with DF
open pack for tibio fibular joint
plantar flexion
closed pack for tibiofibular joint
max DF
Capsular pattern for tiobiofibular joint
Pain on stress
talocrural joint
-uniaxial, modified hinge, synovial joint
-talus is wider ant than post
-
what does a loss of talocrural DF cause in the joints around it?
laxity in the midfoot and forefoot, more pronation in the midfoot
talocrural ROM
DF deg
PF deg
talocrural open pack
deg PF mid way between max inversion and eversion
talocrural Close pack
full DF
talocrural capsular pattern
Plantar flexion, then DF
subtalar joint axis
- axis inclines 42 deg up and 16 deg medially
subtalar joint
- motion is restricted by the different facets
- resulting in triplanar motion around 1 axis
- primarily supination and pronation
- these motions DO NOT occur independently
NWB supination…
calcaneus and foot move around talus
-calcaneal add, inversion an dPF
NWB pronation
calcaneus and foot move around talus
-calcaneal abd, eversion, DF
WB supination
- calcaneal inversion
- talar abd
- tal df
- tibiofibular lateral rotation
WB pronation
- calcaneal eversion
- talar adduction
- talar PF
- tibiofibular medial rotation
what happened if the hind foot is very everted and never inverts?
- 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
talocalcaneonavicular joint
- 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
