Ligament, joint injury, Post-Op, and Lifespan considerations Flashcards
What is the anatomy of a ligament?
Similar to tendons
- collagen fibers in longitudinal bundles
- 70% water
- 70-80% dry weight is type I collagen
- 5% elastin
Intra vs extraarticular
What is included in the epiligament layer of a ligament?
- hypocellular (fibroblasts)
- hypovascular
- mechanoreceptors
What are some properties of ligaments?
- resists tensile forces
- connects bones (structural)
- guides joints
- limits joint excursion
- viscoelastic properties
What happens with rapid vs constant force through ligaments?
Rapid:
- increase in stiffness
Constant:
- exhibits creep
Are ligaments inert tissue?
Yes
- but have proprioceptive roles due to including mechanoreceptors and estrogen receptors
How do mechanoreceptors help ligaments?
- reflex arc: in synergy with muscles
- active and passive stability
- functional joint stability (mechanical and sensory characteristics)
How do sprains occur in ligaments?
Usually high force tension or trauma
- contact = external force
- non-contact = deceleration or rapid direction change
What is the amount of tensile strain a ligament can withstand?
4% = collagen disruption and sub-failure
8% = total failure
What are the risk factors for a ligament sprain?
- recurrent microtraumas
- genetic disposition
- inhibition/alteration of reflex arc in associated muscles
- age
- hormones
- disuse
What are the 4 stages of healing for ligaments?
1) Hemorrhagic: hematoma in gap
2) Inflammatory: clearing necrotic tissue, neovascularization, granulation tissue and recruiting cells
3) Proliferation
4) Remodeling
What happens during the proliferation phase of ligament healing?
1st week:
- fibroblasts arrive last and begin collagen and protein production
2nd week:
- original clot more organized
- capillary buds, collagen content high but disorganized
What happens during the remodeling phase of ligament healing?
- gradual decrease cells and matrix becomes dense/organized
- normalize water content & type I: III ratio (want type I = stronger)
How is the strength of a ligament after 5 weeks, 6 months, and 1 year of healing?
5 weeks: some tensile strength
6 months: 50% strength
1 year: 80% strength
NEVER reaches full strength
How does intraarticular healing differ from extraarticular healing in a ligament?
Intraarticular:
- EX: ACL of knee
- Less likely to heal w/o surgery
- Does not follow typical healing phases due to being incased in the synovium
Extraarticular:
- EX: MCL of knee
- in epiligament lay so HIGHLY vascular and cellular w/ sensory/proprioceptive nerves
- follows normal phase of healing for ligaments
- greater likelihood of healing w/o surgery
Why does a ligament not heal as well while incased in the synovium?
- blood dissipates into synovium
- hematoma is prevented
- limits the amount of growth factors and cytokines needed to mediate inflammation and healing
don’t really heal on their own
What are some clinical signs of a ligament injury?
- history of trauma
- point tenderness
- joint effusion & ecchymosis (severe cases)
- positive stress tests (joint gapping)
- imaging
What is the tissue damage, clinical signs, and implications of a grade I ligament injury?
Tissue Damage:
- fiber stretching or tearing
Clinical signs:
- point tenderness
- mild swelling/ecchymosis
- joint stiffness (some)
- no abnormal motion
Implications:
- minimal function loss
- early return to training w/ some protection
What is the tissue damage, clinical signs, and implications of a grade II ligament injury?
Tissue Damage:
- some tearing or separation of fiber’s
Clinical signs:
- tenderness
- joint effusion/hemarthrosis
- stiffness
- laxity & abnormal motion
- moderate loss of function
Implications:
- tendency to reoccur
- modified immobilization
- longer term instability w/ arthritis risk
What is the tissue damage, clinical signs, and implications of a grade III ligament injury?
Tissue Damage:
- total rupture
Clinical signs:
- initial severe pain then minimal-none
- profuse swelling and ecchymosis
- marked laxity & abnormal motion
- moderate loss of function
Implications:
- needs prolonged protection
- surgery
- persistent functional instability
- traumatic arthritis
How do you manage a ligament injury in the protective phase?
- control pain and swelling using PRICEMEM
- relative rest vs complete immobilization
- submax isometrics
- pain-free ROM (PROM, AROM, AAROM)
How do you manage a ligament injury in the controlled motion phase?
- restore ROM
- address kinetic chain
- progression of strengthening
- stabilization and proprioception (static and supported)
How do you manage a ligament injury in the remodeling phase?
- more advanced stabilization & proprioception (dynamic, complex, and unsupported)
- restoration of agility, power, speed, for return to sport/occupation
What are the 9 structures that are involved in joint stability?
- ligaments**
- muscles
- tendons
- synovial fluid
- joint nerve supply
- meniscus
- labrum
- capsule
- bony architecture
What are the three zones of joint movement?
- neutral zone: little to no resistance to movement
- elastic zone: first barrier to motion encountered
- plastic zone: permanent deformation may lead to injury
What are normal barriers to movement?
- articular shape (bone and cartilage)
- restraining ligament tension
- capsular tension
- muscle length
- synovial fluid
What are some reasons for hypomobility?
- internal derangement (loose body)
- arthrosis
- ankylosis
- myofascial length
- effusion, hemarthrosis
- capsular
What are some ways a joint can be hypermobile?
- generalized, multi-joint
- localized
- instability
What are some ways to manage hypomobility?
- manual therapy to address underlying impairments
- exercise to promote normal movement (increase range, regain strength, re-educate movement patterns)
- medial intervention: surgical release, debridement, repair
What is the difference between laxity, hypermobility, and flexibility?
Laxity:
- more than normal motion present but NOT a problem if asymptomatic
Hypermobility:
- laxity + symptoms associated w/ inability to control joint during motion
Flexibility:
- function of contractile tissue length/resistance
- refers to muscle length when a restriction is present
What scale is used to assess hypermobility?
Beighton scale
- greater than a 4 in adults is positive for generalized hypermobility
What is included in the Beighton scale?
- elbow, knee hyperextension >10 degrees
- thumb touches volar forearm
- 5th finger extension >90
- bend over w/ palms on floor
get a point for each side
What is localized hypermobility?
Response to neighboring hypermobility
- after injury or immobilization
- after surgical fusion or arthrodesis
- neighboring joints become more mobile
What is instability?
Too much movement w/ NO control
- loss of joint congruency in response to loading
- increased ROM w/o adequate neuromotor control
- interfere w/ function
- altered kinematics and physiological motion
What are the 4 components of joint stability?
- joint integrity: articular surfaces, congruity
- muscle: static stability & dynamic stability
- passive restraints: ligament, capsule, skin
- motor control: activation, magnitude, timing
What is the MOI and some clinical signs of functional stability?
MOI: congenital, attenuation of forces (microtrauma), degenerative, traumatic event, systemic disease
Signs:
- early morning stiffness
- feeling of “giving way” up to dislocation
- feeling unstable may not be chief complaint
- reduced force production across joint
- altered quality of motion
- apprehension & avoidance
- excessive joint motion
How do you manage hypermobility in a joint?
Generalized:
- not a lot we can do
- neuromuscular control, supportive orthotics
Localized:
- supportive orthotics prn
- treat neighboring hypomobilities
- exercise for muscular stability (isos, weight bearing, co-contraction)
- exercise for increased strength
- retrain movement patterns
Medical intervention:
- surgical stabilization, fusion
What are some of the most common indications for surgical management of MSK conditions?
- knee replacement
- ACL surgery
- hip replacement
- shoulder replacement
- arthroscopy
- joint fusion
What are some common post-op complications?
- infection
- DVT
- PE
- poor wound healing
- scarring and adhesions
- prolonged immobilization
What are some risk factors for infection and what is the PTs role in the management?
Risk Factors:
- coincident infection/colonization
- steroid use
- obesity
- smoking
- extremes of age, poor nutritional status
PT Role:
- monitor surgical site
- educate patient and practice infection control
- report signs of infection to pt, care-giver, surgeon
What are some risk factors for DVT and what is the PTs role in the management?
Risk Factors:
- bed rest, immobility, distance travel
- CHF
- major trauma
- past DVTs
- obesity
PT ROle:
- recognize signs and symptoms and refer out fast
- prevention of immobility: mobilization, exercise to promote circulation
- monitor anti-coagulant times
What are some risk factors for poor wound healing and what is the PTs role in the management?
Risk Factors:
- smoking
- infection
- diabetes
- age
- nutrition
- immune function
PT Role:
- encourage proper nutrition
- behavior modification
- infection control
What are some risk factors for scars and adhesions and what is the PTs role in the management?
Risk Factors:
- prolonged immobilization
PT Role:
- early mobilization as safe, passive mobility
- scar mobilization
What are some detrimental effects of immobilization?
Prolonged immobilization will degrade tissues and make it more susceptible to injury
- cartilage degen
- ligament degen
- decrease in bone mineral density
- weakness and atrophy of muscle
How is a post-operative exam different from a normal PT exam?
Diagnosis is already known, mainly focusing on:
- establishing a baseline
- fully examine the kinetic chain
- identify impairments in need of intervention
What is the number 1 mistake that PTs make when prescribing exercise to geriatric patients?
NOT overloading this population
What is the mode, frequency, duration, and intensity for aerobic training in the geriatric population?
M: walk, bike, jog, treadmill
F: 3-7x/wk
D: 30-40 minutes
I: Use target HR (60-80%), RPE, talk test, NPRS, BP
What is the mode, frequency, duration, and intensity for balance training in the geriatric population?
M: SLS, eyes open vs closed, side stepping, tandem walking
F: 1-7x/wk
D: 10-15 minutes broken up
I: progressively challenging them
What is the mode, frequency, duration, and intensity for gait training in the geriatric population?
M: walk, march, jog, skip
F: 5-7x/wk
D: incorporate into ADLs/aerobic training
I: increase difficulty via speed, surfaces, demand, directions
What is the mode, frequency, duration, and intensity for flexibility training in the geriatric population?
M: static stretch w/ gravivty, body position
F: 2-7x/wk
D: 30 secs that add up to 60 seconds
I: slight stretch sensation w/ mild discomfort
What is the mode, frequency, duration, and intensity for muscle/strength training in the geriatric population?
M: elastic bands, weights, machines, medicine balls
F: 3x/wk
D: 20-30 minutes (on average)
I: increase w/ 60-100% 1RM but NOT to 1RM (more advanced pts can push closer to 1RM)
Why are children not just little adults?
- they are constantly changing
- still have not grown into their bodies fully
What happens during the adolescent growth spurt and what age does that normally occur?
Trunk grows faster than extremities
- bone normally grows faster than muscle (takes about 3 months to catch up)
- bone demineralization occurs prior to growth spurt
What is the epiphysial plate?
growth plate
What is the diaphysis?
- the shaft of a childs bone
- primary ossification center
What is the epiphysis?
- the ends of the bone
- secondary ossification center
What is the metaphysis?
- between the epi- & diaphysis
- part of the growth plate
What is the apophysis?
- secondary ossification center
- growth plate attachment of a muscle
What is an overuse injury?
- repetitive submaximal loading of the muscular system
- stress injuries
- rest is not adequate to allow for structural adaptation
What are some common injury sites for overuse injuries?
- muscle-tendon junction
- bone
- articular cartilage
- physis stress injury
- bursa
What are some characteristics of adolescent tissues that make then susceptible to overuse injuries?
Growth cartilage: less resistant to tensile, shear, and compressive forces
Bone: decrease BMD and strength
Rapid changes in limb length/body mass: creates a longer lever arm that requires greater demand to move
What are some other risk factors for overuse injuries?
- previous injury
- history of amenorrhea
- high training volume
- poor fitting equipment
- overscheduling competitive events
- sport specific training (don’t get exposed to different stresses)
What are some prevention strategies with moderate evidence?
- limits on participation (per wk, year, event) & scheduled rest
- closely monitored training
- pre-season conditioning
- pre-practice neuromuscular training (warm up)
What are some suggestions for training young children?
- make exercise FUN
- higher reps w/ lower weight
- teach proper technique
- keep it simple
What is the evidence for manual therapy in those under 18?
- not definitive
- have to weigh out the risk vs reward
What are some indications for manual therapy in children?
- improve joint mobility
- improve neurophysiology to gain better response to exercise
- address pain and stiffness
What are some things to consider for manual therapy in those under 18?
- skeletal maturity
- muscular/ligament support
- size of patient
- systemic problems
Should cervial manipulations be performed in those under 1 month old?
NO; increased risk of stroke due to:
- skeletal immaturity
- immature ligament support
- immature musculature to support head/neck
What are some symptoms of stroke in children and infants?
Infants:
- seizures
Children:
- headaches
- trouble moving
- paralysis on one side
- slurred speech
- loss of vision
- confusion
What are some absolute contraindications for manual therapy in children?
- malignancy
- tuberculosis
- osteomyelitis
- osteoporosis
- ligament rupture
- Flu
