MSK Test 1 Flashcards
1
Q
Fully contracted quad in full extension produces ____ patellofemoral contact forces
A
Little
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)
3
Q
Patellofemoral soft tissue lesions:
A
Suprapatellar plica syndrome
IT band friction
Fat pad syndrome
MPFL injury
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
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
6
Q
____ associated with lower function scores (WOMAC) in knee OA
A
Limited knee motion
7
Q
As the angle of knee flexion increases, so do compressive forces. Greatest patellafemoral compression force at ____
A
90* flexion
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
9
Q
VMO provides more ____ patellar glide, not ____.
A
Superior patellar glide
Not medial patellar glide.
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
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
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
13
Q
PCL fail at ~ ____% ________ at knee
A
~30% hyperextension
14
Q
Collagen Type II have ______ properties
A
Elastic properties
15
Q
Menisci enhance proprioception via ____
A
Mechanoreceptors
16
Q
Shapes of the tibial plateaus
A
Medial: oval and long
Lateral: more circular
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
18
Q
____* knee flexion needed to get on/off toilet
A
75*
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
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.
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
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
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
24
Q
Complex meniscus lesions
A
Typically produced by repeated knee trauma
25
Mechanism of ACL injury
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
26
Patella usually dislocates ____. More common in ____.
| MOI:
Laterally
Adolescents- girls > boys
Twisting injury, Valgus load or direct blow
27
The ACL is on average ___ in length and ____ in diameter
33 mm length
| 11 mm diameter
28
People with inconsistent knee pain had ____ and physical function scores.
Pain may be more inconsistent in ____ and becomes ____
Better quad strength
Early stages of disease and becomes more consistent with increasing severity (pain at rest and at night)
29
Patellofemoral longitudinal stabilizers
Quad tendon
| Patellar tendon
30
The MCL has ____ blood supply. Grade 1 and 2 tears ___.
Good blood supply
| Heals well when injured
31
Excessive knee hypertension is beyond ___* and called _____
Beyond 10*
| Genu recurvatum
32
Rehab MCL and LCL sprain Phase 2
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
33
The MCL attaches to ___ and ____.
It attaches ___ below joint line.
Assists in prevention of _____ tibial translation.
Joint capsule and medial meniscus.
7-10 cm below joint line
Anterior
34
Post-op ACL considerations
Initial graft strength
Graft type
Healing and maturation of graft
35
ACL late post-op Phase milestones
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
36
Femoral condylar fracture
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
37
Segund fracture
Bony avulsion of lateral tibial plateau
Site of LCL attachment
Pathognomonic with ACL disruption
Radiograph with lateral capsule sign
38
Menisci are ____-shaped ___.
Wedge shaped
| Fibrocartilage
39
The PCL is one of the strongest ligaments of the body. It is ____ and ____ than the ACL.
Shorter and less oblique
40
ITB syndrome
Aggravated by activity (running)
TTP femoral epicondyle
Noble’s test
Ober’s test
41
(ARC) American College of Rheumatology OA criteria clinical classification
```
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...
42
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 __%
6x more likely
Reduces rate of OA development, or improved the long-term symptomatic outcome
Preinjury level 63%
Return to sport 44%
43
Genu valgum aka __
Tibiofemoral angle: _____
Increased ______ ______ forces.
Knock knees
<165*
Increased lateral compressive forces
44
LCL injury
Varus stress trauma
Varus stress test ~30* knee flexion
Less common injury
45
Modifiable pre-treatment factors influencing outcome
```
Obesity
Joint mobility
Lower limb alignment
Knee instability
Psycho-social factors
```
46
Early post-op Phase ACL Milestones
```
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%
```
47
The MCL prevents ____, or ____ stress.
Abduction
| Valgus stress
48
Salter-Harris Classification of Epiphyseal Complex Fractures
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
49
ACL the ____ bundle is more taught in knee flexion
Anterior-medial
50
Meniscus exam tests
McMurray’s
JLT
Thessaly 20*
51
Knee dislocation
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
```
52
Coper defined as
Resume previous activity for > 1 year
No episodes of giving way
No ACL surgery required
53
Anterior Drawer Test
```
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
54
Higher BMD (bone mineral density) resulted in _____ incidence of knee OA.
2.3x greater incidence
May be related to obesity
But not associated w/ progression of OA
55
ACL return to sport testing must ensure
Adequate strength, power, endurance, dynamic control, psychological readiness
Best to fatigue them first- bc that’s when injury usually occurs as form slips
56
The LCL ____ to capsule and menisci
| It is tight in ___, and loosens ____
Does not attach
Tight in knee extension
Loosens as knee flexes
57
Shock absorption reduced by ___% with complete menisectomy
| Average load per unit area after a complete menisectomy ___ on femur, and ___ on tibial condyle
20%
2x on femur
6-7x on tibial condyle
58
TKA phase I interventions
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
59
The LCL prevents ____, or ____ stress.
Adduction
| Varus stress
60
Autograft Rehab implications : BPTB
```
BPTB autograft:
Higher incidence of PFP
Persistent quad weakness
Injury to extensor mechanism
Avoid early heavy eccentrics
Modify to minimize PF compression forces
```
61
Closed packed position at knee
Extension and external rotation
62
Patellofemoral pain is a ___ problem.
Soft tissue
| Why not diag purely by X-ray/imaging
63
TKA phase 3 rehab goals
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
64
Tibial tubercle fractures
```
Common in adolescents and females
MOI: sports involving jumping
Nonoperative for nondisplaced
Immobilized for 4-6 weeks
Prognosis good
```
65
Restoring ROM ACL
```
Walk slides > assisted heel slides
LLLD heel prop > prone hangs
Frequent extension mobes > aggressive
Functional carryover is vital
Address effusion
```
66
The ____ collateral ligament is a “pencil-like” band of tissue that has greater laxity than the ____ collateral ligament
LCL has greater laxity than MCL
67
Patellofemoral forces:
Foot strike, knee flexed 10-15* = ___ % body weight.
60* knee flexion = ____ body weight
130* knee flexion = ___ body weight
50%
3. 3x
7. 8x
68
ACL post-op follow-up functional testing
```
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
```
69
Genu varum aka __
Tibiofemoral angle: _____
Increased ______ ______ forces.
Bow-leg
>180*
Increased medial compressive forces
70
Meniscus history/mechanism of injury
```
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
```
71
Tibial plateau fractures management
Non-displaced immobilized 4-6 weeks
ORIF for displaced > 3mm
May need bone grafting
Goal: stable, aligned, mobile knee to minimize risk of OA
72
Longitudinal Meniscus Lesion
Typical of 3rd decade
Most frequent menus so injury
29% of all medial lesions
33% of all lateral lesions
73
Primary role of ACL
To resist anterior translation translation of tibia on femur
Sagittal plane
Also posterior translation of femur on tibia
74
Medial patella pica
Palpable
Pain occurs with motion
Painful crepitus
75
Patellofemoral: Overuse syndromes
Osgood-Schlatter
| Singing-Larsen-Johnson
76
Knee exam: constant aching or throbbing, joint swelling, warmth, fever, chills, maladies, weakness
History of recent infection, surgery or injection
Red flag : septic arthritis
77
Horizontal meniscus lesions
Degenerative lesions involving meniscus intramural portion
78
Signs and symptoms ACL injury
```
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
```
79
What factors contribute to increased risk of ACL injury in females?
```
Increased Q angle
Wide pelvis
Increase flexibility
Less developed thigh musculature
Increased tibial external rotation
Smaller ACL
```
80
PCL runs from _____ and passes ____ to _____
Posterior tibia intercondylar eminence
Passes superiorly but almost anteriorly to
Lateral side of medial femoral condyle
81
Knee exam: severe persistent leg pain, paresthesia, pulselessness
History: blunt trauma, crush injury, recent casting, unaccustomed exercise
Red flag: compartment syndrome
82
Grade II ligament sprain
Pain with stress testing
| Instability but with firm end feel
83
Ligaments are dense in type ___ ___ arranged in _____.
Dense in type 1 collagen arranged in near parallel.
84
Phase 1 rehab following MCL and LCL sprains
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
85
ACL post-op Intermediate Phase milestones
Weeks 3-5
Knee flexion ROM to within 10* of uninvolved side
Quad strength greater than 60% of uninvolved side
86
Can lose ___% of mechanical strength by 6-9 weeks of immobilization
50%
87
Interventions for alignment (I.e. knee braces, shoe orthodics) for knee OA..
Inconclusive
Moderate quality evidence for orthodics/insoles
Low cost, may be worth trying to see if helps a specific patient
88
Pre-op considerations for ACL
```
Pain
Effusion
ROM
Muscle function
Extension lag
Gait
```
89
PCL signs and symptoms
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
90
Coper tests (ACL)
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
91
___* knee flexion needed to climb stairs
70-80*
92
Copers have ___ quad control, preferential activation of ___.
Reduced (but not poor) quad control
| Preferential VL and medial hamstring activation
93
Progression of changes in bone structure...
```
Subchondral bone (sclerosis/hardening; cyst formation)
Osteophyte formation
Bone marrow lesions
Osteonecrosis and bone attrition
Joint deformity
```
94
Knee flexion requires unlocking.
Closed chain; ___ must laterally rotate on ___. Popliteus moves ____.
Open chain; ___ must medially rotate. Popliteus moves __.
Closed: femur laterally rotates on tibia
Popliteus moves femur lateral (ER)
Open: tibia medially rotates
Popliteus moves tibia medial (IR)
95
The articular cartilage is ___x thicker on the ____ plateau
3x thicker on medial plateau
96
Altered properties during healing
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
Bone knee OA pain
Sub-chondral bone: thinning of cartilage; vascular congestion
Periostitis from osteophyte formation
Bone marrow lesions found in 77% of people with knee pain
98
Risk factors for knee OA
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
Meniscus “good prognosis”
```
<35 y/o
Peripheral damage
Longitudinal tear
Short tear
Acute injury (bloody effusion)
Stable knee
```
100
3 main subgroups within patellofemoral pain population
Strong
Weak and tighter
Weak and pronated
101
Pittsburgh knee rule
Blunt trauma or fall as mechanism AND either...
Age 50+
Age under 12
Inability to walk 4 weight bearing steps in ER
102
The ___ facet will bear the most force in the patellofemoral joint
Medial
103
Copers vs non copers:
___% return to activity
___% reduced activity scores
Self- reports ____
82%
21%
“Good function”
104
Screw home mechanism last 5*
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
Normal knee flexion
130-140*
106
Menisci are vascularized until age 11. In adults, vascularized by ___ from ____ and ____.
Capillaries
| Joint capsule and synovial membranes
107
One of the most common orthopedic problems in ER, but only ___% knee injuries have fractures
Knee fractures
| 6%
108
Flexibility contribution to patellofemoral pain
Gastrocnemius: reduces DF, excessive subtalar pronation and tibial IR
Quadriceps: increased patellofemoral pressure
Hamstring and ITB: mixed research results
109
Patellar articular cartilage _____ with regard to pain.
No pain caused by patellar articular cartilage- even with grade 2 and 3 chondromalacia.
110
Coper kinematics
Joint stability
Fewer episodes of knee giving way
Normal knee ROM and forces during functional activities
111
MCL and LCL are both tested at ___* and ___* ___
0* and 30* flexion
112
Ligament bone Insertion (_____ fibers) transition from ___ to _____ and eventually bone.
Sharpey’s fibers
| Collagen to calcified cartilage
113
NMES TKA rehab
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
Most ligaments are packaged into _____, which may be more tense than others at ___.
Bundles
| Different joint angles
115
___ ACL injuries in US annually
| ___% surgically repaired
200,000
| 90%
116
Oblique meniscus tears (flap)
Generally in region between 1/3 back and 1/3 medium
117
Lateral meniscus is ___-shaped.
It is _____ and thicker on _____, thinner along ___.
It has ___ attachment to ____.
O-shaped
Uniform thickness
Thicker on periphery, thinner along inner margin
118
____* knee flexion needed for gait
60-70*
119
____* knee flexion needed to get in/out of bath and up/down from chair
90*
120
Dislocation of patella, may have ____ fracture.
Osteochondral fracture
121
Meniscus tears, like rotator cuff tears, tend to increase ___% with every __..
10% for every decade
| ie, 20% of 20 y/o have tear, 40% of 40 y/o...etc
122
The PCL prevents _____ translation of tibia on femur. It is the primary restraint to ____ displacement.
Posterior
| Posterior
123
Tibial eminence fractures management
Nonoperative for non-displaced
Immobilization 4-6 weeks
ORIF for displaced fractures
124
MCL exam
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
Initial post-op goals : ACL
```
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
Sag sign
PCL exam
Static test
Patient knees supported and flexed to 90*
+ = anterior aspect of tibia appears to sag
100% Sp
127
Generic risk factors for OA
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
Patellar hypomobility
Laterally: lateral retinaculum
Lateral border lift with medial glide
Patella Alta: stretch quads
General hypomobility: patellar mobilizations at 0 and 30 degrees
129
OCD: osteochondritis dessicans
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
Patellofemoral joint stability
Lateral wall of femoral groove
ITB
Transverse stabilizers: med/lat retinaculum, VMO/VL, MPFL
Longitudinal stabilizers: quad tendon and patellar tendon
131
Patellofemoral transverse stabilizers
Medial/Lateral retinaculum
VMO/VL
MPFL
132
Ottawa knee rule
```
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
3 bundles of ACL
Anteromedial
Posterolateral
Intermediate
134
Popliteus Posterior knee pain
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
Allografts ACL
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
Causes of lateral knee pain
LCL injury
| ITB Syndrome
137
Pes Anserine Bursitis
Hamstring issue
Tenderness to palpation
Pain with activity
Nocturnal pain
138
Open packed knee position
25* flexion
139
Posterior drawer test
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
2 patellar compression syndromes
ELPS: excessive lateral pressure syndrome
GPPS: global patellar pressure syndrome
141
Tibial Aphophystis
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
Phase 4 MCL/LCL sprain Rehab
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
PCL the ___ bundle is more taught in knee flexion
Anterior-Lateral bundle
144
Angle formed by line drawn from ASIS to mid-patella, and line from mid-patella to tibial tuberosity.
Q angle
Males 10-14*
Females 15-17*
145
Normal knee extension
5-10*
146
The Anterior MCL fibers are taut in ____ and Posterior fibers taut in ____
Anterior fibers taut midrange
| Posterior fibers taut in full extension
147
Prognosis patellar dislocation
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
ACL originates at ____ and resists ___
Posterior medial aspect of lateral femoral condyle
Medial/lateral rotation
Anterior translation of tibia on femur
149
Tibial eminence fractures
Most common in 8-14 y/o
| MOI: direct blue to proximal tibia with knee flexed or hyperextension with varus or Valgus stress
150
Patellar issues
```
Subluxation/dislocation
PFPS
Patellar tendonitis
Articular cartilage
OA
```
151
Immediate ACL post-op Phase
```
Regain knee extension ROM
Patellar mobility
Control swelling
Improve quad activation
Normalize gait
```
152
Grade III ligament sprain
Complete tear
+ instability, no firm end-feel
May be Lars’s pain due to complete ligament ruptur
153
ACL attaches from ___ to ____.
Anterior aspect of tibia to posterior aspect of lateral femoral condyle
154
Tibiofemoral ligaments control/resist...
```
Hyperextension
Varus/Valgus
AP displacement of tibia on femur
Med/lat rotation of tibia on femur
Combo of AP and rotation motions
```
155
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 ____.
4-6 weeks
AROM and sub-max isometrics post-op
Gait training, may be PWB 6-8 weeks
156
Signs and symptoms of collateral ligament injury
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
Meniscus “poor prognosis”
```
Older patient
Central damage
Complete tear
Bucket-handle tear
Chronic injury
Unstable knee
```
158
Distal femur fracture
4%
Mechanisms: MVA or fall
Types: condylar (intraarticar), intercondylar, supracondylar
159
Canadian probability for acute DVT
```
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
Unhappy triad
ACL, MCL, Medial meniscus
161
Knee rotation is influenced by amount of __.
Flexion
162
Articular cartilage exam (knee)
```
History
Thorough palpating
Malalignments
Painful crepitus
Mechanical symptoms
Quad atrophy
Sensitivity to weather changes
Pain and effusion after use
Deep, dull ache
```
163
Menisci decrease friction by ___% and increases contact by ___%.
Menisci transmit ___% of imposed load at knee.
20%
70% - this is key as it disperses pressure
50-60%
164
Patellofemoral pain is typically of ___ origin, not _____
Soft tissue origin
| Not articular cartilage
165
____ acts as a shock absorber and controls extensor mechanism
Quads
166
Knee flexion at 90*
ER normal range....
IR normal range....
ER 0-45*
| IR 0-30*
167
ACL ___ bundle most taught in knee extension. This portion plays more of a role in ____.
```
Posterior-lateral
Rotational control (IR)
```
168
Early post-op ACL treatment
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
TKA phase 3 interventions
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
LCL exam
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
Knee OA radiographic signs
Osteophyte formation
Joint space narrowing
Sclerotic (hardening) changes in subchondral bone
172
Screw home open and closed chain
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
Effects of mechanical stress during healing
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
TKA rehab Red flags
DVT
Pulmonary embolism
Infection
175
Lachmans test
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
The ___ assists with IR and ER restraint (tibiofemoral ligament)
LCL
177
Persistent knee pain that exists without + special tests, or is not reproducible through movement testing.
Especially in adolescents should generate concern
Neoplastic disease
Osteosarcomas often occur in adolescents after a period of rapid skeletal growth
178
Patellar hypermobility
```
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
Pain caused by ____ in chondromalacia
Anterior synovial tissues
Retinaculum
Fat pad
Capsule
180
Sources of pain in knee OA
Synovium
Bone
Nerves
181
The MCL has ____ blood supply. Grade ____ tears ____ when injured
Good blood supply
| Grade I and II tears heal well when injured
182
Medial meniscus is ___-shaped.
It is thick _____ and thicker on _____, thinner along ___.
It has ___ attachment to ____.
C-shaped
Thick posteriorly
Thicker on periphery, thinner along inner margin.
Firm attachment to deep layers of MCL
183
Articular cartilage pathophysiology- non-traumatic
Repetitive microtrauma
Many lesions are non-progressive and remain asymptomatic
Grade 1 and 2 lesions are typically asymptomatic
184
Knee dislocation management
Knee immobilizer
Long rehab to return function
May have instability
Most need reconstruction
185
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
10-20* flexion
90*
135*
186
Grade I ligament sprain
Pain with stress testing
| No instability
187
Autografts ACL
Faster incorporation and healing
Better outcomes in young active patients
Donor site morbidity
Risk of fracture
188
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)
Anterior knee pain
| Patellofemoral pain
189
Articular cartilage pathophysiology - Traumatic
Often assoc with concomitant ligament damage
| Often missed acutely
190
The screw home mechanism is used during the last ___* of knee extension.
The ____ continues to move of the femur, and the ___ rotation of ___ on ___.
5*
Medial tibial condyle continues to move on femur
Lateral rotation of tibia on femur (IR of femur)
191
The femoral articular surface:
Large ___ convexity
Small curvature ___
The ___ condyle is longer, and extends further distally for ___.
AP convexity
Small curvature posterior
Medial condyle longer, extends further distally for angled femur
192
Dislocation of patella management
```
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
Hamstring tendon Insertion posterior knee pain
Pain with active/resisted knee flexion
Weakness
Tenderness to palpation
Pain with acceleration/deceleration motions
194
A posterior blow to the anterior femur, or blow to lateral knee with foot planted- likely to injure ...
ACL
195
2 clinical prediction rules for the knee
Ottawa knee rule: rule out: Sn 97%, Sp 27%
| Pittsburgh knee rule: rule out Sn 99%, Sp 60%
196
More than ____ TKA in US each year
600,000
197
TKA Rehab Phase I and goals
```
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
Hip muscle strengthening is effective in reducing pain intensity and improving functional capabilities in patients with ____
PFPS: patellofemoral pain syndrome
199
____ knee flexion is needed for advanced function
115*
200
PCL ____ bundle is most taut in knee extension
Posterior-medial
201
Patellar fracture
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
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
Red flag: peripheral arterial occlusive disease
203
PCL originates at ___ and resists ___ and ___
Lateral edge of medial condyle of femur
| Resists internal rotation and posterior translation of tibia on femur
204
_____ is not a patellar fracture, it is congenital
Bipartite patella
205
ACL post-op transitional phase treatment
Weeks 9-12
Sports specific activities
Agility exercises
Functional testing
206
The PCL provides minor restraint to _____. It is ____ than ACL. It is _____ injures.
Minor restraint to varus/Valgus
Shorter and less oblique than ACL
PCL is rarely injured
207
Initial post-op ROM goals
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
____ needs to be focus of ACL Rehab
Neuromuscular control
209
MCL injury
Valgus stress trauma
Valgus stress test 30* flexion
Tenderness to palpation
210
Patella slides within ___
| It has 3 facets...
Trochlear groove
1) medial - flat to slightly convex
2) lateral- longer than medial
3) odd- medial angle
211
ACL post-op transitional phase milestones
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
Articular cartilage is type ___
type 2 collagen
213
Meniscus rehab principles
```
Know exactly what procedure (as restrictions/protocols different)
Control effusion
Do NOT push ROM
Restore normal gait
Restore strength and proprioception
```
214
Fractures...%
| Patella, tibial plateau, fibular head
40% patella
32% tibial plateau
9% fibular head
215
___ weeks is the weakest point of ACL graft post op
8-12 weeks
216
Knee OA and TKA annual costs in US
OA $60 billion
| TKA $11 billion
217
In full extension of the knee, rotated restriction by __.
Interlocking of femoral and tibial condyles
218
Causes medial knee pain
Medial patella pica
Medial meniscus
MCL
Pes anserine bursitis
219
Knee exam: pain, skin swelling, warmth, advancing irregular erythema, fever, chills, malaise, weakness
History: recent skin ulceration, abrasion, venous insufficiency, CHF, cirrhosis
Red flag: cellulitis
220
Tibial plateau fracture prognosis
Moderate
14% recover full quad strength
20% residual knee stiffness at 1 year
221
Synovium knee OA pain
Synovitis from inflammatory cell infiltration, cartilage, and bone debris
Infrapatellar fat pad irritation may trigger synovitis
222
Complications of knee dislocation
```
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
Hallmark objective findings: meniscus
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
Causes of posterior knee pain
Hamstring tendon Insertion
| Popliteus muscle
225
PCL mechanism of injury
```
Hyperflexion
Fall on flexed knee with foot in plantarflexion
Hyoerextension mechanisms
Step in pothole
Blow to anterior tibia (dashboard)
```
226
Radial meniscus lesions
Usually originate from free side to periphery
227
____% of all adult Americans have knee OA
19-37%
228
The ACL prevents ____, checks ____, and works with MCL to ____.
Anterior tibial translation
Hyperextension
Stabilize against Valgus (w/ assistance from hamstrings)
229
Decreased VMO activity is ____ cause of abnormal patellar tracking. VMO ____ be preferentially activated. VMO atrophy is representative of ____.
Decreased VMO activity NOT cause of abnormal patellar tracking
VMO canNOT be preferentially activated.
VMO atrophy representative of quad weakness
230
Phase 3 rehab MCL and LCL sprain
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
Direct relationship between severity of pain and severity of ____ within _____.
(Chondromalacia)
Neural damage within lateral retinaculum
232
Bucket-handle meniscus lesion
A complete longitudinal can become a bucket-handle lesion
| Frequent in medial meniscus
233
Ankle/Foot contributions to patellofemoral pain
```
Orthoses not beneficial to all
Subgroup:
Greater midfoot mobility
Reduced ankle DF
Immediate pain reduction with orthoses as seen with S.L. squat
```
