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MSK 2 > MSK Test 1 > Flashcards

MSK Test 1 Flashcards

1
Q

Fully contracted quad in full extension produces ____ patellofemoral contact forces

A

Little

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2
Q

TKA phase 2 interventions

A

Incision Mobilization (after suture removal, incision clean and dry)
Progressive passive stretches
Stationary bike or peddler
Pain- free progressive resisted exercises
Proprioceptive training
Manual therapy
Closed- kinetic chain strengthening (mini-squats)
Gait training (wean off assistive device)
Protected, progressive aerobic exercise (cycling w/o resistance, walking or swimming)

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3
Q

Patellofemoral soft tissue lesions:

A

Suprapatellar plica syndrome
IT band friction
Fat pad syndrome
MPFL injury

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4
Q

ACL Intermediate post-op phase treatments

A

Weeks 3-5
Tibiofemoral Mobilization with rotation for ROM if joint mobility limited
Progress bike and stair master duration (10 min minimum)
Begin balance and proprioceptive activities

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5
Q

Autograft Rehab implications: hamstring autograft

A

Less aggressive early on
No isolated hamstring strengthening until p/o week 8
Hamstrings and transverse plane control

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6
Q

____ associated with lower function scores (WOMAC) in knee OA

A

Limited knee motion

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7
Q

As the angle of knee flexion increases, so do compressive forces. Greatest patellafemoral compression force at ____

A

90* flexion

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8
Q

Hallmark signs of medial meniscus

A

Joint like tenderness
Positive entrapment tests (Squat, McMurry’s, Apley’s Compression)
Mild-moderate effusion
Quad inhibition

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9
Q

VMO provides more ____ patellar glide, not ____.

A

Superior patellar glide

Not medial patellar glide.

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10
Q

Closed chain…
Decreased dorsi flexion…. decreased knee ____.
Decreased plantar flexion….
decreased knee ____.

A

Decreased DF: decreased knee flexion

Decreased PF: decreased knee extension

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11
Q

Pivot shift test

A

ACL exam
Designed to produce the “giving away” phenomenon
Knee extended, tibia internally rotated
Valgus force applied to proximal tibia to “sublux” Lateral tibial plateau
Knee moved into flexion
Tibia “shifts” back into place about 30-40* flexion

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12
Q

3 zones of menisci vascularization

A

Red-red-zone: later 1/3
Red-white/pink zone: middle 1/3
White-white zone: inner 1/3

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13
Q

PCL fail at ~ ____% ________ at knee

A

~30% hyperextension

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14
Q

Collagen Type II have ______ properties

A

Elastic properties

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15
Q

Menisci enhance proprioception via ____

A

Mechanoreceptors

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16
Q

Shapes of the tibial plateaus

A

Medial: oval and long
Lateral: more circular

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17
Q

ACL late post-op phase treatments

A

Weeks 6-8
Progress exercise in intensity and duration
Begin running progression; treadmill or track with functional brace
Transfer to fitness facility if all milestones met

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18
Q

____* knee flexion needed to get on/off toilet

A

75*

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19
Q

The tibial plateaus are ___ and slope _____.

The ____ is ~50% larger. The ___ compensate for incongruency.

A

Concave
Slope posteroinferiorly
Medial plateau larger
Menisci compensate

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20
Q

Tibiofemoral joint is a ___ _____. It provides ___ degrees of freedom. ____ in sagittal plane and ____ in transverse plane. It prevents motion in the ___ plane.

A 
Double condyloid 
2 degrees of freedom 
Flex/Ext in sagittal 
Med/Lat rotation in transverse 
Motion prevented in frontal plane.
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21
Q

Patellar fracture treatment

A

Nondisplaced transverse fractures with intact extensor mechanism
Knee immobilized 6 weeks, PWB crutches
May displace and need ORIF

Displaced fractures, or disrupted extensor mechanism
May need ORIF or partial/total patellectomy

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22
Q

Well’s CPR for PE

A 
3 points: Clinical s/six of DVT 
3 points: alt diag less likely than PE
1.5 points: HR greater than 100bpm
1.5 points: immobilization/surgery in prev 4 weeks 
1.5 points: previous DVT/PE
1 point: hemoptysis
1 point: malignancy

> 6 points = high risk
2-6 = moderate risk
< 2 = low risk

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23
Q

TKA Phase 2 rehab and goals

A 
3-6 weeks
Goals:
Diminish swelling and inflammation 
Increase ROM 0-115* 
Increased weight bearing tolerance 
Muscle strength 4/5-5/5 
Return to functional activities 
Adhere to HEP
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24
Q

Complex meniscus lesions

A

Typically produced by repeated knee trauma

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25
Q

Mechanism of ACL injury

A

80% non-contact
Fixed foot with knee that undergoes Valgus/rotational loaf (cutting, pivoting)
Hyperextension load (step in pothole)

20% contact
Posteriorly directed blow to anterior femur
Blow to lateral knee when foot planted

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26
Q

Patella usually dislocates ____. More common in ____.

MOI:

A

Laterally
Adolescents- girls > boys
Twisting injury, Valgus load or direct blow

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27
Q

The ACL is on average ___ in length and ____ in diameter

A

33 mm length

11 mm diameter

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28
Q

People with inconsistent knee pain had ____ and physical function scores.
Pain may be more inconsistent in ____ and becomes ____

A

Better quad strength

Early stages of disease and becomes more consistent with increasing severity (pain at rest and at night)

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29
Q

Patellofemoral longitudinal stabilizers

A

Quad tendon

Patellar tendon

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30
Q

The MCL has ____ blood supply. Grade 1 and 2 tears ___.

A

Good blood supply

Heals well when injured

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31
Q

Excessive knee hypertension is beyond ___* and called _____

A

Beyond 10*

Genu recurvatum

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32
Q

Rehab MCL and LCL sprain Phase 2

A

Weeks 2-3
Goals: FWB w/o crutches or brace, but may take longer with grade II-III injuries

Treatments: continue to progress ROM
Increase duration of time and resistance with stationary bike
Progress to more aggressive strengthening exercises as tolerated (squats, lunges, step-ups, knee extension/hamstring curls)
Initiate balance/proprioception activities, as tolerated

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33
Q

The MCL attaches to ___ and ____.
It attaches ___ below joint line.
Assists in prevention of _____ tibial translation.

A

Joint capsule and medial meniscus.
7-10 cm below joint line
Anterior

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34
Q

Post-op ACL considerations

A

Initial graft strength
Graft type
Healing and maturation of graft

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35
Q

ACL late post-op Phase milestones

A

Week 6-8
Quad strength greater than 80% of uninvolved side
Normal gait pattern
Full knee ROM (compared to uninvolved side)
Knee effusion of trace or less

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36
Q

Femoral condylar fracture

A

Supracondylar, intercondylar, or condylar
MOI: axial loading with Valgus or varus stress
Unable to weight bear
Pain over distal femur
Hemarthrosis
Conservative or ORIF depends on stability
Prognosis moderate for femoral condylar fractures, 14% recover full quad strength, 20% have residual knee stiffness 1 year after injury

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37
Q

Segund fracture

A

Bony avulsion of lateral tibial plateau
Site of LCL attachment
Pathognomonic with ACL disruption
Radiograph with lateral capsule sign

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38
Q

Menisci are ____-shaped ___.

A

Wedge shaped

Fibrocartilage

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39
Q

The PCL is one of the strongest ligaments of the body. It is ____ and ____ than the ACL.

A

Shorter and less oblique

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40
Q

ITB syndrome

A

Aggravated by activity (running)
TTP femoral epicondyle
Noble’s test
Ober’s test

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41
Q

(ARC) American College of Rheumatology OA criteria clinical classification

A 
Knee pain + 3 of 6...
Age > 50
Morning stiffness < 30 min 
Crepitus
Tenderness 
Bony enlargement 
No palpable warmth

95% SN
69% SP

Or 1 of those 3 along with radiographic proof…

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42
Q

Females are ___ likely to tear their ipsilateral ACL within 24 mo after surgery
There is no clear evidence that ACL reconstruction reduces _____ or ____
Return to sport rates:
Pre-injury level of participation ___%
Return to competitive sports __%

A

6x more likely
Reduces rate of OA development, or improved the long-term symptomatic outcome
Preinjury level 63%
Return to sport 44%

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43
Q

Genu valgum aka __
Tibiofemoral angle: _____
Increased ______ ______ forces.

A

Knock knees
<165*
Increased lateral compressive forces

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44
Q

LCL injury

A

Varus stress trauma
Varus stress test ~30* knee flexion
Less common injury

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45
Q

Modifiable pre-treatment factors influencing outcome

A 
Obesity 
Joint mobility 
Lower limb alignment 
Knee instability 
Psycho-social factors
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46
Q

Early post-op Phase ACL Milestones

A 
Week 2 
Knee flexion greater than 110* 
Walking without crutches 
Use of stair climber/cycle without difficulty 
Walking w/ full knee extension 
Reciprocal stair climbing 
SLR w/o knee extension lag
Knee outcome survey ADL greater than 65%
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47
Q

The MCL prevents ____, or ____ stress.

A

Abduction

Valgus stress

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48
Q

Salter-Harris Classification of Epiphyseal Complex Fractures

A

Type 1: fracture through physis
Type 2: fracture partway through physis extending to metaphysis
Type 3: fracture partway to physis extending down into epiphysis
Type 4: fracture through metaphysis, physis and epiphysis (can lead to angularion deformities when healing)
Type 5: crush injury to physis

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49
Q

ACL the ____ bundle is more taught in knee flexion

A

Anterior-medial

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50
Q

Meniscus exam tests

A

McMurray’s
JLT
Thessaly 20*

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51
Q

Knee dislocation

A

True limb-threatening
Described based on displacement of tibia on femur
Must common is anterior
Posterior with direct trauma
Popliteal Artery and Nerve
May be fractures of tibial spine or top of fibula
Disrupts cruciate/collateral ligaments

Neurovascular bundle injuries:
10% with normal pulse
Peroneal nerve
Dorsum sensory, DF 
Post tibial nerve 
Plantar sensory, PF
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52
Q

Coper defined as

A

Resume previous activity for > 1 year
No episodes of giving way
No ACL surgery required

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53
Q

Anterior Drawer Test

A 
ACL exam
Supine w knee flexed to 90* 
Tibia in neutral rotation 
Thumbs placed in joint line 
Femoral condyles should be ~1cm Posterior to tibial plateau at 90*
Translate tibia anteriorly

+ = increased Anterior translation and soft end-feel

Thought to test more of anterior bundle

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54
Q

Higher BMD (bone mineral density) resulted in _____ incidence of knee OA.

A

2.3x greater incidence

May be related to obesity
But not associated w/ progression of OA

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55
Q

ACL return to sport testing must ensure

A

Adequate strength, power, endurance, dynamic control, psychological readiness

Best to fatigue them first- bc that’s when injury usually occurs as form slips

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56
Q

The LCL ____ to capsule and menisci

It is tight in ___, and loosens ____

A

Does not attach
Tight in knee extension
Loosens as knee flexes

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57
Q

Shock absorption reduced by ___% with complete menisectomy

Average load per unit area after a complete menisectomy ___ on femur, and ___ on tibial condyle

A

20%
2x on femur
6-7x on tibial condyle

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58
Q

TKA phase I interventions

A

PROM-CPM as indicated per physician
Ankle pumps (decrease DVT risk)
Bed mobility and transfers usu initiated
Heel slides (supine or sitting) to increase knee flexion
Muscle setting exercises (quad sets)
Gravity-assisted knee extension in supine
Gentle stretches (Hammies, calf, ITB)
Pain modulation modalities
Compression to control swelling
Gait training
Manual therapy

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59
Q

The LCL prevents ____, or ____ stress.

A

Adduction

Varus stress

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60
Q

Autograft Rehab implications : BPTB

A 
BPTB autograft:
Higher incidence of PFP
Persistent quad weakness 
Injury to extensor mechanism 
Avoid early heavy eccentrics 
Modify to minimize PF compression forces
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61
Q

Closed packed position at knee

A

Extension and external rotation

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62
Q

Patellofemoral pain is a ___ problem.

A

Soft tissue

Why not diag purely by X-ray/imaging

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63
Q

TKA phase 3 rehab goals

A

6 weeks and beyond
Goals:
Progress ROM 0-115* as able- to functional range for patient
Enhance strength and endurance and motor control of involved limb
Increase cardiovascular fitness
Develop maintenance program and educate patient on importance of adherence, including methods of joint protection

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64
Q

Tibial tubercle fractures

A 
Common in adolescents and females 
MOI: sports involving jumping 
Nonoperative for nondisplaced
Immobilized for 4-6 weeks 
Prognosis good
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65
Q

Restoring ROM ACL

A 
Walk slides > assisted heel slides 
LLLD heel prop > prone hangs 
Frequent extension mobes > aggressive 
Functional carryover is vital 
Address effusion
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66
Q

The ____ collateral ligament is a “pencil-like” band of tissue that has greater laxity than the ____ collateral ligament

A

LCL has greater laxity than MCL

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67
Q

Patellofemoral forces:
Foot strike, knee flexed 10-15* = ___ % body weight.
60* knee flexion = ____ body weight
130* knee flexion = ___ body weight

A

50%

  1. 3x
  2. 8x
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68
Q

ACL post-op follow-up functional testing

A 
4 mo, 5 mo, 6 mo, 1 year post-op
Maintaining gains in strength (90-100%) 
Hop test 90% or greater 
KOS-sports 90% or greater
Return to sport criteria
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69
Q

Genu varum aka __
Tibiofemoral angle: _____
Increased ______ ______ forces.

A

Bow-leg
>180*
Increased medial compressive forces

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70
Q

Meniscus history/mechanism of injury

A 
Twisting injury
Pain worse with movement, better with rest 
May complain of “locking” 
Joint line of tenderness 
Acute effusion (w/in 2 hrs) 
Acute: sudden onset in people <40 y/o 
Chronic: no specific MOI >50 y/o
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71
Q

Tibial plateau fractures management

A

Non-displaced immobilized 4-6 weeks

ORIF for displaced > 3mm
May need bone grafting

Goal: stable, aligned, mobile knee to minimize risk of OA

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72
Q

Longitudinal Meniscus Lesion

A

Typical of 3rd decade
Most frequent menus so injury
29% of all medial lesions
33% of all lateral lesions

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73
Q

Primary role of ACL

A

To resist anterior translation translation of tibia on femur
Sagittal plane
Also posterior translation of femur on tibia

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74
Q

Medial patella pica

A

Palpable
Pain occurs with motion
Painful crepitus

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75
Q

Patellofemoral: Overuse syndromes

A

Osgood-Schlatter

Singing-Larsen-Johnson

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76
Q

Knee exam: constant aching or throbbing, joint swelling, warmth, fever, chills, maladies, weakness

History of recent infection, surgery or injection

A

Red flag : septic arthritis

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77
Q

Horizontal meniscus lesions

A

Degenerative lesions involving meniscus intramural portion

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78
Q

Signs and symptoms ACL injury

A 
Severe pain with joint effusion 
Popping, giving away, buckling 
Continued effusion, recurrent episodes of giving away with ADLs
Quad inhibition 
Limited ROM 
Flexed knee gait
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79
Q

What factors contribute to increased risk of ACL injury in females?

A 
Increased Q angle 
Wide pelvis
Increase flexibility 
Less developed thigh musculature 
Increased tibial external rotation 
Smaller ACL
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80
Q

PCL runs from _____ and passes ____ to _____

A

Posterior tibia intercondylar eminence
Passes superiorly but almost anteriorly to
Lateral side of medial femoral condyle

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81
Q

Knee exam: severe persistent leg pain, paresthesia, pulselessness

History: blunt trauma, crush injury, recent casting, unaccustomed exercise

A

Red flag: compartment syndrome

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82
Q

Grade II ligament sprain

A

Pain with stress testing

Instability but with firm end feel

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83
Q

Ligaments are dense in type ___ ___ arranged in _____.

A

Dense in type 1 collagen arranged in near parallel.

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84
Q

Phase 1 rehab following MCL and LCL sprains

A

RICE, consider immobilization and crutches if there is excessive pain with movement and FWB
For grade II/III avoid stressing injured tissues for 3-4 weeks

Try to achieve full extension and 90* flexion quickly
Ideally unlock brace to allow 0-90* ASAP to avoid negative effects of prolonged immobilization

Isometrics and then isotonics- quad sets, SLR for hip, standing
Stationary bike

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85
Q

ACL post-op Intermediate Phase milestones

A

Weeks 3-5
Knee flexion ROM to within 10* of uninvolved side
Quad strength greater than 60% of uninvolved side

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86
Q

Can lose ___% of mechanical strength by 6-9 weeks of immobilization

A

50%

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87
Q

Interventions for alignment (I.e. knee braces, shoe orthodics) for knee OA..

A

Inconclusive
Moderate quality evidence for orthodics/insoles
Low cost, may be worth trying to see if helps a specific patient

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88
Q

Pre-op considerations for ACL

A 
Pain
Effusion 
ROM 
Muscle function 
Extension lag
Gait
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89
Q

PCL signs and symptoms

A

Posterior knee pain
Not as much effusion as ACL
Flexion beyond 90* may increase pain (open chain)
Difficulty descending stairs, squatting, running
Not as much problem with quad inhibition
+ sag sign
+ posterior drawer
Reduced palpation of tibial plateau step- off

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90
Q

Coper tests (ACL)

A

Hop test +/= 80%
Knee outcome survey +/= 80%
Global knee function +/= 60%
Episodes of giving away = 1 episode

Test after ~10 episodes PT
> 60 days
< 6 months

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91
Q

___* knee flexion needed to climb stairs

A

70-80*

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92
Q

Copers have ___ quad control, preferential activation of ___.

A

Reduced (but not poor) quad control

Preferential VL and medial hamstring activation

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93
Q

Progression of changes in bone structure…

A 
Subchondral bone (sclerosis/hardening; cyst formation)
Osteophyte formation 
Bone marrow lesions 
Osteonecrosis and bone attrition 
Joint deformity
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94
Q

Knee flexion requires unlocking.
Closed chain; ___ must laterally rotate on ___. Popliteus moves ____.
Open chain; ___ must medially rotate. Popliteus moves __.

A

Closed: femur laterally rotates on tibia
Popliteus moves femur lateral (ER)

Open: tibia medially rotates
Popliteus moves tibia medial (IR)

95
Q

The articular cartilage is ___x thicker on the ____ plateau

A

3x thicker on medial plateau

96
Q

Altered properties during healing

A

Heals with scar tissue
Scar tissue predominantly Type III collagen, has less tensile strength
Collagen more randomly oriented and more hydrogen cross-link bonds
Scar tissue will contract, possibly reducing joint motion

97
Q

Bone knee OA pain

A

Sub-chondral bone: thinning of cartilage; vascular congestion
Periostitis from osteophyte formation
Bone marrow lesions found in 77% of people with knee pain

98
Q

Risk factors for knee OA

A

Age (risk increases with age)
Sec: 70/30 Female/Male
Obesity
Previous knee injuries: ACL and/or meniscus significant increased risk
Knee alignment (varum…medial; valgum…lateral; chicken-egg if cause or result unknown)
Leg length discrepancy

99
Q

Meniscus “good prognosis”

A 
<35 y/o
Peripheral damage 
Longitudinal tear
Short tear 
Acute injury (bloody effusion) 
Stable knee
100
Q

3 main subgroups within patellofemoral pain population

A

Strong
Weak and tighter
Weak and pronated

101
Q

Pittsburgh knee rule

A

Blunt trauma or fall as mechanism AND either…
Age 50+
Age under 12
Inability to walk 4 weight bearing steps in ER

102
Q

The ___ facet will bear the most force in the patellofemoral joint

A

Medial

103
Q

Copers vs non copers:
___% return to activity
___% reduced activity scores
Self- reports ____

A

82%
21%
“Good function”

104
Q

Screw home mechanism last 5*

A

During last 5* of extension
Lateral femoral condyle shorter
Medial tibial condyle continues to move on femur (why it’s larger)
Lateral rotation of tibia on femur (IR of femur)

Augmented by tension on ACL
Lateral pull of quads

105
Q

Normal knee flexion

A

130-140*

106
Q

Menisci are vascularized until age 11. In adults, vascularized by ___ from ____ and ____.

A

Capillaries

Joint capsule and synovial membranes

107
Q

One of the most common orthopedic problems in ER, but only ___% knee injuries have fractures

A

Knee fractures

6%

108
Q

Flexibility contribution to patellofemoral pain

A

Gastrocnemius: reduces DF, excessive subtalar pronation and tibial IR
Quadriceps: increased patellofemoral pressure
Hamstring and ITB: mixed research results

109
Q

Patellar articular cartilage _____ with regard to pain.

A

No pain caused by patellar articular cartilage- even with grade 2 and 3 chondromalacia.

110
Q

Coper kinematics

A

Joint stability
Fewer episodes of knee giving way
Normal knee ROM and forces during functional activities

111
Q

MCL and LCL are both tested at ___* and ___* ___

A

0* and 30* flexion

112
Q

Ligament bone Insertion (_____ fibers) transition from ___ to _____ and eventually bone.

A

Sharpey’s fibers

Collagen to calcified cartilage

113
Q

NMES TKA rehab

A

Start 2 days post-op
Electrodes: distal vastus medialus and proximal vastus Lateralis
Leg secured by Velcro at 60*
Intensity set to maximum tolerance
(Active movement contractions with NMES not passive)

Parameters:
Biphasic 50Hz
Pulse duration 250s 
15s on/45s off 
15 reps (2x day) for 3 weeks, then 15 reps (1x day) for 3 weeks
114
Q

Most ligaments are packaged into _____, which may be more tense than others at ___.

A

Bundles

Different joint angles

115
Q

___ ACL injuries in US annually

___% surgically repaired

A

200,000

90%

116
Q

Oblique meniscus tears (flap)

A

Generally in region between 1/3 back and 1/3 medium

117
Q

Lateral meniscus is ___-shaped.
It is _____ and thicker on _____, thinner along ___.
It has ___ attachment to ____.

A

O-shaped
Uniform thickness
Thicker on periphery, thinner along inner margin

118
Q

____* knee flexion needed for gait

A

60-70*

119
Q

____* knee flexion needed to get in/out of bath and up/down from chair

A

90*

120
Q

Dislocation of patella, may have ____ fracture.

A

Osteochondral fracture

121
Q

Meniscus tears, like rotator cuff tears, tend to increase ___% with every __..

A

10% for every decade

ie, 20% of 20 y/o have tear, 40% of 40 y/o…etc

122
Q

The PCL prevents _____ translation of tibia on femur. It is the primary restraint to ____ displacement.

A

Posterior

Posterior

123
Q

Tibial eminence fractures management

A

Nonoperative for non-displaced
Immobilization 4-6 weeks

ORIF for displaced fractures

124
Q

MCL exam

A

Palpation: May be difficult to differentiate from meniscus bc of anatomical proximity

Valgus stress test:
Knee flexed to 20-30*
Valgus stress introduced
+ test is presence of laxity and/or pain

Sn = .86

125
Q

Initial post-op goals : ACL

A 
Quickly restore full passive extension 
Restore patellar mobility 
Control post-op inflammation 
Gently and slowly increase flexion ROM
Establish and increase volitional quad strength
Restore normal gait pattern
126
Q

Sag sign

A

PCL exam
Static test
Patient knees supported and flexed to 90*
+ = anterior aspect of tibia appears to sag
100% Sp

127
Q

Generic risk factors for OA

A

Genetics 40-65% (OA in general, but particularly in hip, hand and knee)

BMD: bone mineral density
Higher BMD = 2.3x greater incidence of knee OA

Occupation (lots of squatting, kneeling, combined with heavy lifting)

Physical activity

128
Q

Patellar hypomobility

A

Laterally: lateral retinaculum
Lateral border lift with medial glide
Patella Alta: stretch quads
General hypomobility: patellar mobilizations at 0 and 30 degrees

129
Q

OCD: osteochondritis dessicans

A

Adults or children
Etiology poorly understood
Result of acute trauma or repetitive stress
May or may not be visible on plain film
Symptoms include: mild knee effusion, pain, worse with activity
Absence of + special tests

130
Q

Patellofemoral joint stability

A

Lateral wall of femoral groove
ITB
Transverse stabilizers: med/lat retinaculum, VMO/VL, MPFL
Longitudinal stabilizers: quad tendon and patellar tendon

131
Q

Patellofemoral transverse stabilizers

A

Medial/Lateral retinaculum
VMO/VL
MPFL

132
Q

Ottawa knee rule

A 
Radiographs if any present:
Age 55+
Isolated tenderness of patella 
Tenderness over fibular head
Unable to flex knee >90*
Unable to weight beat immediately, or 4 steps in ER
133
Q

3 bundles of ACL

A

Anteromedial
Posterolateral
Intermediate

134
Q

Popliteus Posterior knee pain

A

Pain with running (downhill)
Prone: knee flexion and tibial IR = pain
Often occurs as an injury in extension
Can mimic mild ACL/posterior capsule sprain

135
Q

Allografts ACL

A

Was acute pain
Greater decrease in structural properties
Slow rate of biological incorporation
Better for revisions

Rehab may need to be less aggressive compared to autograft - little known about graft ability to withstand load/strain during healing and maturation

136
Q

Causes of lateral knee pain

A

LCL injury

ITB Syndrome

137
Q

Pes Anserine Bursitis

A

Hamstring issue
Tenderness to palpation
Pain with activity
Nocturnal pain

138
Q

Open packed knee position

A

25* flexion

139
Q

Posterior drawer test

A

PCL exam
Supine knee flexed to 90*
Assess tibial plateau- should rest appx 1cm anterior to femoral condyle
Thumbs in anterior joint line, apply posterior force
+ = excessive posterior translation and/or soft end feel

140
Q

2 patellar compression syndromes

A

ELPS: excessive lateral pressure syndrome
GPPS: global patellar pressure syndrome

141
Q

Tibial Aphophystis

A

Osgood-Schlatter’s disease
Adolescent, more common in athletes, slightly more common in males
Enlarged tibial tubercle
Painful,activity limiting
Radiographic separation of patellar ligament Insertion
Anterior knee pain

142
Q

Phase 4 MCL/LCL sprain Rehab

A

6+ weeks
Goals: eliminate brace completely, except with athletes (can use 3-4 mo)
Stop brace with gait if able to walk normally with FWB
Normalize strength and gait

Treatments: progress to sports specific ad prior functional activities. Move to agility and unilateral activities, if haven’t already

143
Q

PCL the ___ bundle is more taught in knee flexion

A

Anterior-Lateral bundle

144
Q

Angle formed by line drawn from ASIS to mid-patella, and line from mid-patella to tibial tuberosity.

A

Q angle
Males 10-14*
Females 15-17*

145
Q

Normal knee extension

A

5-10*

146
Q

The Anterior MCL fibers are taut in ____ and Posterior fibers taut in ____

A

Anterior fibers taut midrange

Posterior fibers taut in full extension

147
Q

Prognosis patellar dislocation

A

30-50% long-term instability or pain
With rapid management, 70% will have a stable, painless knee
Of the remaining 30% : half have reasonable function and half fave chronically unstable and painful knee

148
Q

ACL originates at ____ and resists ___

A

Posterior medial aspect of lateral femoral condyle
Medial/lateral rotation
Anterior translation of tibia on femur

149
Q

Tibial eminence fractures

A

Most common in 8-14 y/o

MOI: direct blue to proximal tibia with knee flexed or hyperextension with varus or Valgus stress

150
Q

Patellar issues

A 
Subluxation/dislocation 
PFPS 
Patellar tendonitis 
Articular cartilage 
OA
151
Q

Immediate ACL post-op Phase

A 
Regain knee extension ROM
Patellar mobility 
Control swelling 
Improve quad activation 
Normalize gait
152
Q

Grade III ligament sprain

A

Complete tear
+ instability, no firm end-feel
May be Lars’s pain due to complete ligament ruptur

153
Q

ACL attaches from ___ to ____.

A

Anterior aspect of tibia to posterior aspect of lateral femoral condyle

154
Q

Tibiofemoral ligaments control/resist…

A 
Hyperextension
Varus/Valgus 
AP displacement of tibia on femur 
Med/lat rotation of tibia on femur
Combo of AP and rotation motions
155
Q

Patellar fracture with closed reduction, similar to other fractures, limit knee flexion for ____.
ORIF can do ___ and ____ post-op. Will need ____ because may be PWB ____.

A

4-6 weeks

AROM and sub-max isometrics post-op
Gait training, may be PWB 6-8 weeks

156
Q

Signs and symptoms of collateral ligament injury

A

Varus or Valgus trauma is typical
Varus or Valgus stress test +
MCL May be associated with ACL and meniscal symptoms
Swelling, ecchymosis
Joint effusion if meniscal involvement
Tenderness to palpation of ligament, attachments and intrasubstance

Difficulty with pivoting, cutting, etc
“I can run in a straight line but my knee feels like it’s going to fall apart if I run quickly”

157
Q

Meniscus “poor prognosis”

A 
Older patient 
Central damage
Complete tear
Bucket-handle tear
Chronic injury 
Unstable knee
158
Q

Distal femur fracture

A

4%
Mechanisms: MVA or fall
Types: condylar (intraarticar), intercondylar, supracondylar

159
Q

Canadian probability for acute DVT

A 
1 point each:
Active cancer 
Paralysis or immobilization of LE 
Surgery <4 weeks, bedridden >3 days
Thigh + calf swelling on affected side
Tenderness along deep venous system 
Affected calf >3 cm larger than other calf 
Pitting edema 
Collateral superficial veins

-2 points if alt diag is as likely or greater

3 or more = high probability
1-2 = intermediate probability
0 = low probability

160
Q

Unhappy triad

A

ACL, MCL, Medial meniscus

161
Q

Knee rotation is influenced by amount of __.

A

Flexion

162
Q

Articular cartilage exam (knee)

A 
History 
Thorough palpating 
Malalignments
Painful crepitus
Mechanical symptoms 
Quad atrophy 
Sensitivity to weather changes 
Pain and effusion after use
Deep, dull ache
163
Q

Menisci decrease friction by ___% and increases contact by ___%.
Menisci transmit ___% of imposed load at knee.

A

20%
70% - this is key as it disperses pressure
50-60%

164
Q

Patellofemoral pain is typically of ___ origin, not _____

A

Soft tissue origin

Not articular cartilage

165
Q

____ acts as a shock absorber and controls extensor mechanism

A

Quads

166
Q

Knee flexion at 90*
ER normal range….
IR normal range….

A

ER 0-45*

IR 0-30*

167
Q

ACL ___ bundle most taught in knee extension. This portion plays more of a role in ____.

A 
Posterior-lateral 
Rotational control (IR)
168
Q

Early post-op ACL treatment

A

Week 2
Step-ups in pain free range
Portal/incision Mobilization as needed
Stair master/wall squats
Progress to functional brace as swelling permits
Prone hangs if lacking full extension
Patellar mobilization i. Flexion (if limited flexion)

169
Q

TKA phase 3 interventions

A

Continue previous phases; advance as appropriate
Implement exercises specific to functional tasks
Improve cardio respiratory and muscle endurance with activities such as cycling, walking or aquatic programs

170
Q

LCL exam

A

Palpation: May be more sensitive than MCL bc ligament isn’t attached to lateral meniscus

Varus stress test:
Patient supine; knee flexed 20-30*
Intro varus stress at joint line
+ = laxity and/or pain

171
Q

Knee OA radiographic signs

A

Osteophyte formation
Joint space narrowing
Sclerotic (hardening) changes in subchondral bone

172
Q

Screw home open and closed chain

A

Open chain: tibia externally rotates on a fixed femur

Closed chain: femur internally rotates on fixed tibia

Popliteus unlocks knee (externally rotates femur on fixed tibia)

173
Q

Effects of mechanical stress during healing

A

Moderate stress induced organization of collagen in more parallel arrangement in direction of applied forces.
Induces biochemical changes that result in more covalent cross link formation
Minimizes contraction of scar
Movement of joint during early phases of healing appears to be sufficient stress.

174
Q

TKA rehab Red flags

A

DVT
Pulmonary embolism
Infection

175
Q

Lachmans test

A

ACL exam
Supine w/knee flexed 30*
Stabilize anterolateral distal femur
Translate tibia anteriorly w opposite hand

+ = anterior translation of tibia beyond femur with a “mushy” or “soft” end-feel

Thought to test more of posterior bundle

176
Q

The ___ assists with IR and ER restraint (tibiofemoral ligament)

A

LCL

177
Q

Persistent knee pain that exists without + special tests, or is not reproducible through movement testing.
Especially in adolescents should generate concern

A

Neoplastic disease

Osteosarcomas often occur in adolescents after a period of rapid skeletal growth

178
Q

Patellar hypermobility

A 
General soft tissue laxity: brace it 
Bony stability (shallow trochlear groove): brace it
Lateral: assess and treat ITB and TFL 
Patella Alta: year and stretch quads 
Biomechanical: address NM deficits
179
Q

Pain caused by ____ in chondromalacia

A

Anterior synovial tissues
Retinaculum
Fat pad
Capsule

180
Q

Sources of pain in knee OA

A

Synovium
Bone
Nerves

181
Q

The MCL has ____ blood supply. Grade ____ tears ____ when injured

A

Good blood supply

Grade I and II tears heal well when injured

182
Q

Medial meniscus is ___-shaped.
It is thick _____ and thicker on _____, thinner along ___.
It has ___ attachment to ____.

A

C-shaped
Thick posteriorly
Thicker on periphery, thinner along inner margin.
Firm attachment to deep layers of MCL

183
Q

Articular cartilage pathophysiology- non-traumatic

A

Repetitive microtrauma
Many lesions are non-progressive and remain asymptomatic
Grade 1 and 2 lesions are typically asymptomatic

184
Q

Knee dislocation management

A

Knee immobilizer
Long rehab to return function
May have instability
Most need reconstruction

185
Q

Patellofemoral 1st contact with patella is between ____
By ___* all aspects of facets have made contact, with exception of odd facet
At ____* contact is on odd and lateral facets

A

10-20* flexion
90*
135*

186
Q

Grade I ligament sprain

A

Pain with stress testing

No instability

187
Q

Autografts ACL

A

Faster incorporation and healing
Better outcomes in young active patients
Donor site morbidity
Risk of fracture

188
Q

Pain around or behind the patella, aggravated by at least 1 activity that loads patellofemoral joint during weight bearing on a flexed knee (ie squatting, stair ambulation, hopping/jumping)

A

Anterior knee pain

Patellofemoral pain

189
Q

Articular cartilage pathophysiology - Traumatic

A

Often assoc with concomitant ligament damage

Often missed acutely

190
Q

The screw home mechanism is used during the last ___* of knee extension.
The ____ continues to move of the femur, and the ___ rotation of ___ on ___.

A

5*
Medial tibial condyle continues to move on femur
Lateral rotation of tibia on femur (IR of femur)

191
Q

The femoral articular surface:
Large ___ convexity
Small curvature ___
The ___ condyle is longer, and extends further distally for ___.

A

AP convexity
Small curvature posterior
Medial condyle longer, extends further distally for angled femur

192
Q

Dislocation of patella management

A 
Knee immobilizer 
Knee extensor muscle training 
PWB with crutches 
Bracing: set at 0* initially with ambulation, lateral buttress pad 
RICE 
McConnell taping 
E-Stim for quad activation
193
Q

Hamstring tendon Insertion posterior knee pain

A

Pain with active/resisted knee flexion
Weakness
Tenderness to palpation
Pain with acceleration/deceleration motions

194
Q

A posterior blow to the anterior femur, or blow to lateral knee with foot planted- likely to injure …

A

ACL

195
Q

2 clinical prediction rules for the knee

A

Ottawa knee rule: rule out: Sn 97%, Sp 27%

Pittsburgh knee rule: rule out Sn 99%, Sp 60%

196
Q

More than ____ TKA in US each year

A

600,000

197
Q

TKA Rehab Phase I and goals

A 
Phase 1 rehab exercises (0-1 to 2 weeks) 
Goals:
Control post-op swelling 
Minimize pain
Knee ROM 0-90*
Muscle strength 3/5-4/5
Ambulation with or without use of assistive device 
Establish home exercise program
198
Q

Hip muscle strengthening is effective in reducing pain intensity and improving functional capabilities in patients with ____

A

PFPS: patellofemoral pain syndrome

199
Q

____ knee flexion is needed for advanced function

A

115*

200
Q

PCL ____ bundle is most taut in knee extension

A

Posterior-medial

201
Q

Patellar fracture

A

Largest sesamoid bone
Almost all intra-articular
Transverse most common 50-80%
MOI: direct blow, knee hyper flexion, contraction of quad muscle
Swelling, crepitus and pain extending the knee
Displaced, transverse fractures result in inability to SLR

202
Q

Increased capillary refill time
Decreased LE arterial pulse
Prolonged venous refilling
ABI <0.90

History: age > 60, type 2 DM, ischemic heart disease, smoking, sedentary, intermittent claudication

A

Red flag: peripheral arterial occlusive disease

203
Q

PCL originates at ___ and resists ___ and ___

A

Lateral edge of medial condyle of femur

Resists internal rotation and posterior translation of tibia on femur

204
Q

_____ is not a patellar fracture, it is congenital

A

Bipartite patella

205
Q

ACL post-op transitional phase treatment

A

Weeks 9-12
Sports specific activities
Agility exercises
Functional testing

206
Q

The PCL provides minor restraint to _____. It is ____ than ACL. It is _____ injures.

A

Minor restraint to varus/Valgus
Shorter and less oblique than ACL
PCL is rarely injured

207
Q

Initial post-op ROM goals

A

1-2 weeks: full passive extension
2-3 weeks: 100* flexion
3-4 weeks: full active extension
4-6 weeks: full flexion

Lack of extension = TROUBLE
Cyclops lesion
Poor graft placement
Restricted scar mobility

208
Q

____ needs to be focus of ACL Rehab

A

Neuromuscular control

209
Q

MCL injury

A

Valgus stress trauma
Valgus stress test 30* flexion
Tenderness to palpation

210
Q

Patella slides within ___

It has 3 facets…

A

Trochlear groove

1) medial - flat to slightly convex
2) lateral- longer than medial
3) odd- medial angle

211
Q

ACL post-op transitional phase milestones

A

Weeks 9-12
Maintain for gaining quad strength
Hop tests greater than 85% of uninvolved side at 12 weeks
KOS- sports questionnaire greater than 70%

212
Q

Articular cartilage is type ___

A

type 2 collagen

213
Q

Meniscus rehab principles

A 
Know exactly what procedure (as restrictions/protocols different) 
Control effusion 
Do NOT push ROM
Restore normal gait 
Restore strength and proprioception
214
Q

Fractures…%

Patella, tibial plateau, fibular head

A

40% patella
32% tibial plateau
9% fibular head

215
Q

___ weeks is the weakest point of ACL graft post op

A

8-12 weeks

216
Q

Knee OA and TKA annual costs in US

A

OA $60 billion

TKA $11 billion

217
Q

In full extension of the knee, rotated restriction by __.

A

Interlocking of femoral and tibial condyles

218
Q

Causes medial knee pain

A

Medial patella pica
Medial meniscus
MCL
Pes anserine bursitis

219
Q

Knee exam: pain, skin swelling, warmth, advancing irregular erythema, fever, chills, malaise, weakness

History: recent skin ulceration, abrasion, venous insufficiency, CHF, cirrhosis

A

Red flag: cellulitis

220
Q

Tibial plateau fracture prognosis

A

Moderate
14% recover full quad strength
20% residual knee stiffness at 1 year

221
Q

Synovium knee OA pain

A

Synovitis from inflammatory cell infiltration, cartilage, and bone debris
Infrapatellar fat pad irritation may trigger synovitis

222
Q

Complications of knee dislocation

A 
Quad muscle atrophy 
Joint stiffness 
Arthritis (if intra-articular)
Fat emboli (femoral shaft fracture)
Avascular necrosis (condylar)
Quad tendon rupture 
Patellar instability (patellar fracture) 
Damage to popliteal fossa structures
223
Q

Hallmark objective findings: meniscus

A

Joint line tenderness: good Sn
Effusion: mild-moderate over 1-2 days
Positive entrapment test: McMurray’s, Apley’s, Squat
Quad inhibition: atrophy over first week or two following injury

224
Q

Causes of posterior knee pain

A

Hamstring tendon Insertion

Popliteus muscle

225
Q

PCL mechanism of injury

A 
Hyperflexion
Fall on flexed knee with foot in plantarflexion 
Hyoerextension mechanisms
Step in pothole 
Blow to anterior tibia (dashboard)
226
Q

Radial meniscus lesions

A

Usually originate from free side to periphery

227
Q

____% of all adult Americans have knee OA

A

19-37%

228
Q

The ACL prevents ____, checks ____, and works with MCL to ____.

A

Anterior tibial translation
Hyperextension
Stabilize against Valgus (w/ assistance from hamstrings)

229
Q

Decreased VMO activity is ____ cause of abnormal patellar tracking. VMO ____ be preferentially activated. VMO atrophy is representative of ____.

A

Decreased VMO activity NOT cause of abnormal patellar tracking
VMO canNOT be preferentially activated.
VMO atrophy representative of quad weakness

230
Q

Phase 3 rehab MCL and LCL sprain

A

3-4 weeks
Goals: discontinue crutches if still being used; stop brace with gait if able to walk FWB normally
WNL ROM

Treatments: progress strengthening activities, maintain endurance, advance balance and proprioception activities
Initiate running when tolerated

231
Q

Direct relationship between severity of pain and severity of ____ within _____.
(Chondromalacia)

A

Neural damage within lateral retinaculum

232
Q

Bucket-handle meniscus lesion

A

A complete longitudinal can become a bucket-handle lesion

Frequent in medial meniscus

233
Q

Ankle/Foot contributions to patellofemoral pain

A 
Orthoses not beneficial to all 
Subgroup: 
Greater midfoot mobility 
Reduced ankle DF 
Immediate pain reduction with orthoses as seen with S.L. squat

MSK 2 (2 decks)

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