MSK knee Flashcards
what are the 3 joints of the knee?
tibiofemoral
patellofemoral
tibiofemoral
what is the primary WB joint of the knee?
tibfem
guides flex/ex and IR/ER
what is the primary WB structure in the frontal plane?
medial condyle
describe the medial condyle in the sagittal plane?
longer by 1/2 inch
drives screw home
what is the pathway of patella tracking?
begins slightly proximal to the femoral sulcus
lateral contact guides the patellar to full contact at 30 deg
tracking forms a subtle C pattern lat/med/lat
what does patellar tracking depend on?
bony architecture of femoral sulcus/patellar
extensibility of surrounding CT
quadriceps activation
what are the mvmts of the patellofemoral joint?
superior (ext)/inferior (flex) glide
medial/lateral glide
medial/lateral tilt
medial/lateral rotation
describe the tib fib joint
NWB, 3mm of mvmt
post to tibia
fibular nerve wraps around its head
describe ACL
dynamic stabilizer of the knee
load is highest in ext
two bundles - postlat - ext, antmed - flex
anterior tib translation resisted by ACL
describe the innervation and vascularization of ACL
tibial nerve
middle genicular artery
describe PCL
dynam stabilizer
20% bigger than ACL
loaf highest in flexion
resists post tib translation
two bundles - antlat(thicker) - flex, postmed - ext
ER stabilizer
less commonly injured
originates on med fem condyle
describe MCL
limits valgus
bolstered by pes an and semimem
describe the superficial MCL
primary valgus stabilizer
taut at end ranges
semimem and post oblique lig
describe the deep MCL
stab valgus and may help with ant translation
taut in ext
meniscofemoral and meniscotibial ligs
describe LCL
resist varus
near to popliteus
bolstered by anterolateral lig - poor man’s ACL
bolstered by IT band
describe the posterior knee
durable post capsule and obl popliteal lig resists hyperext
has a release valve for synovial fluid
has rotational instability after ACL/PCL injury
what is in the posterior lateral corner?
LCL
popliteus
arcuate lig
biceps femoris
describe the menisci
stability, cushion, nutrition, proprioception to knee
attaches to: quads, semimem, bifem, capsule, MCL
which men moves more?
lateral
where is vascularity the worst in the menisci?
the MIDDLE
outside 10-30% is well vascularized
what are the roles of the other parts of the LE?
trunk - stability
hip - force generation - big butt muscles
knee - force modulation - cannot work alone
ankle/foot - force transmission - react to ground
what are the muscles that cross the knee?
IT band
quads
hams
gastroc
gracilis
sartorius
add mag
all long muscles
poor stability
great force generation
describe the posterior innervation of the knee
sciatic nerve - sacral plexus
common fibular
superficial fibular - lat leg
deep fibular - ant leg and dorsum of foot
tibial nerve - post leg and plantar of foot
sural nerve - sensory only
describe the anterior innervation of the knee
femoral - lumbar plexus - ant thigh
anterior cutaneous - prox sen
saphenous - dist sen
obturator - lumbar plex - med thigh
lateral cutaneous - lumbar plex - sen of lat thigh
what muscle should you work out if you have anterior meniscus problems?
quads
what are some outcome measures for the knee?
international specific documentation committee - ACL
knee-injury and OA outcome score
lower extremity function scale
what should you observe in the frontal view?
WB
genu varus/valgus
skin appearance
redness/swelling/discharge
quads atrophy
what should you observe in a side view?
genu recurvatum - hyperextension
knee flexion contracture
posterior swelling/baker’s cyst
ottawa vs pittsburgh knee rules
ottawa:
55+
tender head of fibula
tender patella
inability to flex to 90 deg
inability to amb 4 steps
pitts:
less than 12, over 50
inability to amb 4 steps
tibiofemoral joint posterior glide
for flexion
like post drawer
tibiofemoral joint anterior glide
for extension
like anterior drawer
valgus stress test at 30 deg knee flexion
supine with knee over edge flexed to 30
grab ankle and pull outward
stab knee with other hand
+ pain at MCL or increased mvmt
testing for MCL disruption
varus stress test
supine with knee over edge flexed to 30
grab ankle and push inward
stab knee with other hand
+ pain at LCL or increased mvmt
testing for LCL disruption
patellofemoral joint play testing
superior glide - for extension
inferior glide - for flexion
medial glide/tilt
lateral glide/tilt
mcmurray’s test
supine
heel points to side of men being tested
start in max flexion and extend, keeping rotation
+ thud or click, isolated recreation of pain
testing for posterior horn of meniscus
ege’s test
for med men - toes out and squat
for lat men - toes in and squat
have them squat a couple times
+ pain or click in corresponding joint line
testing for posterior horn of meniscus
steinmann sign I
supine
using varied degrees of hip flexion
IR and ER w/o flexion/extension
+ joint line pain
testing for midsubstance meniscus
thessaly test
standing on test knee with it flexed to 5-20
rotate body to IR/ER the knee 3 times
+ discomfort or sense of catching in joint line
testing for midsubstance meniscus
apley’s test
prone on table
with client’s knee flexed to 90 deg
compress and rotate tibia
+ worsening pain
testing for midsubstance meniscus
steinmann II
supine on table
jab “eyeballs of knee” and push out
do this at varying angles of knee flexion
+ joint line pain under thumbs during extension
testing for anterior horn of meniscus
bounce-home test
supine on table
basically drop knee into your hand (extension)
+ mechanical block that limits full knee ext, pain at end range
testing for meniscus end feel
anterior drawer test
sit on foot
pull tib to you
+ increased anterior excursion relative to other
testing for ACL tear
drop lachman’s test
stabilize leg with table
20 deg flexion
pull up on tibia and stab knee
+ increased anterior excursion relative to other
testing for ACL tear
posterior drawer test
supine
sit on foot
thumbs in joint line
push tib backwards
+ increased post tib excursion
testing for PCL tear
posterior sag sign (godfrey’s test)
supine with hip and knee flexed to 90 deg
supports leg in air at ankle and watch
+ sagging with gravity
PCL tear
pain with squatting
perform normal squat
+ pain or reproduction of pain during
testing for patellofemoral pain syndrome
pain with stair climbing
climb stairs in normal way
+ pain or reproduction of pain during
testing for patellofemoral pain syndrome
eccentric step down test
standing on small step
uninvolved leg steps down
+ provocation of pain
testing for patellofemoral pain syndrome
patellar tilt test
knee extended
lifts lateral border of pat anterior out of groove and med border posterior into groove
+ subluxing laterally
testing for PF instability
lateral pull test
full knee extension
isometric quad contraction
+ patella tracking more laterally than superiorly
testing for PF instability
clarke’s sign (patellar grind test)
supine knee in slight flexion
glide patella inferiorly as client contracts quads
+ reproduction of pain
testing for PF compression
resisted knee extension test
seated with feet off ground
client extends knee while clinician resists extension
+ reproduction of pain
testing for PFPS, PF compression
mediopatellar plica test
supine
pushes patella medially with thumb
+ pain or click
testing for plica compression
straight leg raise
testing for sciatic nerve
femoral nerve tension in side lying test
symptomatic side facing ceiling
client flexes bottom leg, holding it at knee
slumps upper body with neck flexion
stab pelvis and flexes top knee to 90 deg
keep leg at point of discomfort
+ pain, symptoms different than other side, symptoms affected by distant component
testing for femoral nerve
cross friction
supination motion
meniscopatellar are diagonal
meniscotibial are straighter
patellofemoral mobilization
superior - extension
inferior - inferior
medial glide/tilt - improves tracking
tibiofemoral extension mobilization
prerotate femur into IR
push down on femur to make tibia go forward
push femur posterior and medial
tibiofemoral flexion mobilzation
prerotate tibia into IR
put knee into max flexion
push backward on tibia
tibiofibular posterior mobilzation
pt supine
push fibula post/med
tibiofibular anterior mob
pt prone
push fibula ant/lat
what is the annual prevalence of patellofemoral pain syndrome?
22.7%/year
ados: 29%
athletes: 45%
MOI for PFPS
compression: quads/ITB are too tight or too active
unstable tracking: lig laxity, decres NM control
plica involvement of PFPS
pinching and pain of vestigial synovial fold
medial is most common
like biting your cheek
pain pattern for PFPS
localized to anterior knee
risk factors for PFPS
<50
running/jumping sports
wo>men
observation for PFPS
poor patellar tracking
exam for PFPS
pain with squatting and stairs
hyper/hypo joint play
decres flexion ROM
+ patellar tilt, lateral pull, clark’s grind, resisted extension
- femoral neural testing
patient ed for PFPS
act reduction
ice switch to forefoot running
OTC foot orthosis if overly pronated
manual therapy for PFPS
mobs: patella if hypo
STM: quad and ITB
taping
ther ex for PFPS
quad and ITB stretching if hypo
glute max, med, quad, peroneal strength
posterior depression PNF
squat/stair motor programming
BFR
angle reproduction
femoral nerve glides
MOI for patellar tendinopathy
rapid increase in knee extension
pain pattern for patellar tendinopathy
localized to proximal patellar ligament
risk factors for patellar tendinopathy
35-50
repetitive mvmts
heavy body mass
observation for patellar tendinopathy
swelling
exam for patellar tendinopathy
pain with palpation/contraction
can palpate tissue changes
+stair climbing, jumping, resisted knee extension
- patellofemoral testing
pt ed for patellar tendinopathy
act reduction
ice
orthotics - patellar tendon strap
manual therapy for patellar tendinopathy
mobs: patella if hypo
STM: cross friction - 1 direction, 2 min light, 2 min heavy
MRF: IASTM, bend/pin and stretch
ther ex for patellar tendinopathy
quad and ITB stretching
glute max and calf strengthening
for the tendon:
decline slant board - do not exceed 5/10 pain
isos - 4-5 sets of 45 sec hold
eccentric training - 2 sets of 15 with 2RIR
energy storage - rapid eccen
energy release - rapid concen
femoral nerve glides
what is tibial tubercle apophysitis?
site of bone growth
not connected to joint line
2-5x weaker than surrounding bone/tendon
MOI of TTA
rapid bone growth w/o muscle lengthening
excessive force - too high, repetitive, poorly controlled
pain pattern for TTA
localized to tibial tub
risk factors for TTA
8-15
boys > girls
repetitive knee extension
heavy body mass
observation for TTA
focal (localized) swelling
exam for TTA
pain with palpation
+ stair climbing, squatting, running, jumping, resisted leg extension
- patellofemoral testing, patellar ligament palpation
pt ed for TTA
act reduction
strategic rest
ice
manual therapy for TTA
STM/MFR: quads - IASTM, bend and stretch, petrissage
ther ex for TTA
quad and ITB stretching
glute strengthening
spot treat poor functional mechanics
MOI for meniscus injury
excessive rotation
closed chain»_space;> open chain
neurovascular supply of meniscus
primarily in outer 1/3 and ant/post horns
conservative vs surgical recovery in meniscus
majority get better with conservative
in potentially operative cases PT performs as well as surgery
pain pattern for meniscus injury
vague, medial or lateral
risk factors for meniscus injury
women > men
work: kneeling, bending, stairs
soccer or rugby
observation for meniscus injury
swelling at joint line
guarded or stiff knee
leg give out
exam for meniscus injury
pain to palpation and functional motion
+ mcmurray, ege, thessaly, apley, steinmann I and II, bounce home
pt ed for meniscus injury
act reduction
avoid closed chain rotation
ice
manual therapy for meniscus injury
mobs: meniscofemoral, meniscotibial
STM: crossfriction - 2 min light and 2 min heavy
ther ex for meniscus injury
progressive ROM and WB
rotational motor control
- open to closed chain
- ham/gastroc
quad and hams strength
angle reproduction and reflex reactivation
- turning
- stairs, squatting, jumping
- sport specific
MOI for ACL
non contact is most common (70%)
rapid decel in low flexion
minimal help form hams at (0-15 deg)
primary prevention for ACL
52-88% decreased injury rate
programs decrease severity
start in preseason
use as warm up
recommendation for ACL prevention
all 12-25 yo athletes in ACL risky sports should participate
secondary prevention for ACL
24-30% have a second rupture
50% need meniscus surgery
increased OA up to 50%
increase daily activity
maintain healthy BMI
4x retear in pivot sports
re-tear rate decreased for 9 months
ACL specific programs
harmoknee
knakontroll
labella
olsen
petersen
general rec for ACL prevention
core, hip and knee decreases risk
- knee only will not decrease risk
best practice is strength and plyometrics
factors: duration, frequency, compliance
ACL prehab literature
increase quad activity at 3 months
increase single leg hop and 3 months
9% increase return to sport
improved functional scores at 3 months and 2 years
pt ed in ACL prehab
functional expectation
OA risk expectation
return to sport
post-surgical expectations
benchmarks to begin ACL prehab
full ROM
minimal pain
limited to no effusion
able to hop on one leg for plyos
sample protocol for ACL prehab
3-6 weeks
leg press
leg curl machine
leg extension machine
step ups - anterior and lateral
balance drills
perturbations
pain pattern for ACL
deep, diffuse pain
risk factors for ACL
15-40
pivot sports
wo > men
decreased ACL size
increased laxity
decreased motor control
increased peak reaction force
fatigue
generalized laxity
dynamic valgus/foot pronation
poor hamstring activation
tibial slope
turf conditions: increased if artificial and dry
observation for ACL
heard an audible pop
immediate swelling
difficulty walking
exam for ACL
pain with most mvmts
decreased ROM
+ anterior drawer, lachman’s
- PCL
pt ed for ACL
act mod
crutches
ice
orthotics - hinged knee
manual therapy for ACL
mobs: patellofemoral (3-4), tibiofemoral
STM: ITB, quad, calves, hams
ther ex for ACL
prehab beneficial
early mobility and WB
early ice and bracing
strength and motor control
- start with closed chain
- open chain after 4 weeks
- e stim
test battery
no CPM or functional brace
PROTOCOL IN WEEKS:
preop
post op - 1
early rehab - 2-4
progressive control - 5-10
advanced activity - 10-16
RTS - 16+
MOI for PCL
high energy trauma: MVA, fall on flexed knee
PCL pain pattern
deep, diffuse pain
risk factors for PCL
18-44
contact sports
observation for PCL
post tibial translation
knee ER
exam for PCL
pain with most mvmts
+ post drawer, godfrey
- ACL, MCL, LCL, meniscus
pt ed for PCL
recovery expetations
WB status
ice
crutches
orthotics
manual therapy for PCL
mobs: patellofemoral (3-4)
STM: ITB, quad, hams, calf
ther ex for PCL
NON-OP
2-4 weeks immob in full extension
stabilization program and quad focus
OP
similar to ACL, but twice as long
longer immob and brace time
focus on:
progressive WB
limiting post tibial shear
limiting hamstring recruitment
promote quad activation
MOI of collateral
high energy trauma: contact sports
MCL - blow to outside
LCL - blow to inside
pain pattern for collateral
localized to med/lat joint line
risk factors for collateral
20-23 and 55-65
contact sports
skiing
observation for collateral
antalgic gait
exam for collateral
pain with palpation and end ROM
+ valugs/varus stress test (10mm or 5-15 deg)
- ACL, PCL, meniscus
pt ed for collateral
act mod
ice
crutches
orthotics
manual therapy for collateral
mobs: patellofemoral and tibiofemoral
STM: crossfriction
MFR: adductors, hams, gastroc
ther ex for collateral
NON SURGICAL
progressive ROM and WB
glute, ham, quad, add
SURGICAL PROTOCOL
phase 1
- inflam control
- bracing
- ROM/stretching/biking
- non WB strengthening
- progressive WB
phase II
- discontinue bracing
- full WB
- WB strenghtening
- cardio program
- balance/proprio
phase III
- multi directional
- sport specific
potential RTS
- consider around month 3
impact of OA
10-13% of people over 60 have symptoms
most common joint to have OA
pain pattern for OA
diffuse knee pain
risk factors for OA
> 45
increased BMI
prior knee trauma
genetic susceptibility
wo > men
observation for OA
antalgic gait
varus deformity
bony enlargent
exam for OA
pain with closed chain ROM
decreased ROM with click/catch
morning stiffness
+ crepitus
- meniscus testing
pt ed for OA
ice or heat
compression
varus unloading braces
weight management
ADs
referral for injections/meds
supplements
manual therapy for OA
mobs: tibiofemoral
STM
ther ex for OA
functional motor patterns
glute, foot and peroneal strength
balance and proprioception
post surgical protocol if TKA
what are muscle relaxant medications?
NM blockers for PNS
spasmolytics for CNS
- flexeril
who benefits from muscle relaxants?
pts with muscle spasm due to overexertion
pts with spasticity
what are anti-inflam mediactions?
opioids
- oxycodone, vicodin (dr. house)
NSAIDS
- meloxicam
who benefits from anti inflams?
pts experiencing pain/inflam
what are neuropathic medications?
antidepressants
anticonvulsants
- neurontin
who benefits from neuropathic meds?
pts with neuropathic conditions
what is a corticosteroid injection?
anesthetic and corticosteroid into area of inflam
who benefits from corticosteroid?
with inflam
- patellar tendinopathy
- OA
what is hyaluronic acid injection?
injection into arthritic joints
lubricate joint surfaces
used to be rooster comb
who benefits from hyaluronic acid?
OA
what is prolotherapy?
hypertonic dextrose into poorly healing area
reactivates inflam response
who benefits from prolo?
recurrent dysfunction
- OA
- patellar tendinopathy
- partial ACL tear
what is platelet rich plasma?
can be leuk rich (proinflam) or poor (anti inflam)
who benefits from PRP?
mild to mod CT injury
OA - leuk poor
tendinopathy - leuk rich
what is stem cell injection?
injected into tendon, lig, arthritic joints
reduce apoptosis, modulate inflam, increase angiogenesis and cellular proliferation
who benefits from stem cell injection?
mod to severe CT injury
what is meniscus repair?
suturing and fixation of injured area
for adequate vascularity
what is meniscectomy?
removal and debridement of injured area
inadequate vascularity
what is microfracture?
debridement of joint followed by puncture of underlying bone
allows bone marrow to being stem cells to stim new bone
for those with chondral defects
what is acl reconstruction?
removal of injured acl and replacement with graft
common grafts: patellar lig, semitendinosis, donor
what is a total knee arthroplasty?
surgical removal of distal femur and proximal tibia
implants on shafts
patella might be resurfaced (82%)
cruciates may or may not be spared
