non-operative management of the knee Flashcards
how do we treat both bursitis and plica?
modalities prn (reduce inflammation, steroid injection?)
activity reduction/modification (running, jumping, deep squatting)
flexibility of LQ
strengthening
biomechanics retraining
if failure to progress –> surgical excision
how do we treat both osgood schlatter’s and sinding larsen johannsen?
avoidance of tension loading activities until stable
patient education
modalities prn
flexibility (hamstrings, quads-timing?)
strength training (PREs-hamstrings)
how do we treat a traumatic and recurrent patellar dislocation?
modalities prn acute swelling
restore ROM deficits (flexion/extension, medial patellar glide)
normalize gait
muscle engagement -> strengthening (quad sets, SLR, SAQ, LAQ, squatting, step up/down, lunging)
failure to progress –> surgery
what is the intervention for PFPS when it is from overuse/overload without other impairment?
taping is best
activity modification/relative rest
what is the intervention for PFPS when it is from PFP with movement coordination deficits?
gait and movement retraining
what is the intervention for PFPS when it is from PFP with muscle performance deficits?
hip/gluteal muscle strengthening and quadriceps muscle strengthening
what is the intervention for PFPS when it is from PFP with mobility impairments?
for hypermobility: foot orthosis, taping
for hypomobility: patellar retinaculum/soft tissue mobilization, muscle strengthening (hamstrings, wuads, gastrocs, soleus, IT band)
what strengthening can we do for PFPS?
hip (early)-posterolateral chain
knee (later)- WB: restricted squats, NWB: resisted knee extension
what does patellar taping do for PFPS?
short term application (1-4 weeks)
pain reduction
patient specific
combined with exercise
what do foot orthoses do for PFPS?
pre-fabricated
short term (1-6 weeks)
excessive foot pronation
combined with exercise therapy
what does running gait retraining do for PFPS?
forefoot strike pattern
increase run cadence
reduce peak hip adduction
what is important with patient education for PFPS?
patient specific
adherence to active treatment
biomechanics education
kinesiophobia
is acupuncture used for PFPS?
it may be used in the states within scope of practice. lacking comparison to placebo or sham Rx evidence
what are some combined interventions for PFPS?
flat shoe inserts
exercise therapy
patellar taping
patellar mobilization
lower limb stretching
what can blood flow restriction therapy do for PFPS?
combined with high rep knee exercise
limit painful resisted knee extension
what should you not do with PFPS?
biofeedback- EMG, visual
bracing- compression sleeves, straps, PF knee brace
manual therapy- ineffective as stand alone treatment
biophysical agents- us, cryotherapy, iontophoresis, estim, laser
what is the treatment for chondromalacia patella?
patient education (activity avoidance, biomechanics and modifications)
flexibility (GS complex, HS, RF, TFL)
patellar mobility (medial glide, medial tipping)
muscle performance (NWB- quad set, SLR, SAQ extensions, multi-angle isometrics. WB- limited body weight, bilateral loading, single limb loading)
plyometrics and agility training (sport specific)
what are the 2 classifications of tendionopathy?
reactive tendinopathy
reactive on degenerative tendiopathy
what are the phases of progression for tendinopathy?
pain reduction and load management (isometric loading)
isotonic loading (heavy-slow resistance through con-ecc phases)
energy-storage loading (plyometric loading)
return to activity/sport
what are the interventions for tendinopathy?
patient education
prolonged isometric contractions of moderate intensity (40-70%) with tendon in shortened range throughout entirety of rehab
progressive muscle-tendon loading program
correction of kinetic chain deficits
joint/soft tissue mobilizations to adjacent areas
return to activity/sport progression
what are some indications that a patient is in phase 1: pain reduction and load management of tendinopathy?
patient experiences reactive pain. range of acceptable pain levels may vary dependent on patient tolerance and understanding of therapeutic ranges
unable to maintain current activity levels due to pain
localized tenderness at tendon
what are some activity modifications for a patient in phase 1: pain reduction and load management of tendinopathy?
reduced loading, modified volume of activity, and avoidance of tendon in compressive positions including end-range stretching
patient education: expected recovery progression, cognitive behavioral therapy is indicated
what is the prolonged isometric contractions exercises that patients in phase 1: pain reduction and load management of tendinopathy can perform?
perform with tendon in shortened/non-compressed position
prescription: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing form 40%-70% maximal voluntary contraction, 1-2 minute rest periods between contractions. daily
what is the criteria to progress patients to phase 2 of treatment for tendinopathy?
can complete isotonic loading with minimal reactive pain (<3/10 pain and or no increase in baseline pain lasting longer than 24 hours)
decreased pain with ADLs
what are some indications that a patient is in phase 2: isotonic loading progression of tendinopathy?
strength deficits of the involved muscle-tendon unit
history of painful loading
what is the heavy, slow resistance exercises (HSR) for phase 2 of tendinopathy?
prescription: 3-4 sets of concentric-eccentric exercise starting at 15 repetitions and progressing to 6 repetitions, performed every other day.
initially, complete exercise in modified ROM to avoid compression of tendon then progress into full ROM as strength and pain levels allow
what is the stretching exercises (HSR) for phase 2 of tendinopathy?
performed to address ROM deficits, should not create reactive pain > 24 hours
what is the prolonged isometric contractions for phase 2 of tendinopathy?
perform with tendon in shortened/non-compressed/mid-range position
prescription: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing from 40% to 70% maximal voluntary contraction. 1-2 minute rest periods between contractions. daily
what is the cognitive behavioral therapy/graded exposure for phase 2 of tendinopathy?
only indicated for cases of chronic pain or central sensitization
what is the criteria to progress patients to phase 3 of treatment for tendinopathy?
able to complete 3-4 sets of 6 repetitions throughout full ROM with minimal pain and no increase in pain lasting greater than 24 hours (patients should be at about 7/10 on borg rate of perceived exertion scale for strengthening purposes)
no pain with ADLS
what are some indications that a patient is in phase 3: energy storage loading progression (plyometrics) of tendinopathy?
symmetrical strength bilaterally (recommended strength tests: 10 RM, manual muscle testing, and/or isokinetic testing)
tolerates introduction of energy storage exercises with minimal pain
what is the sport or activity-specific movements for phase 3 tendinopathy?
progressing volume then intensity
prescription: every third day, progressing to a volume required by the sport/activity
what is the heavy, slow resistance for phase 3 tendinopathy?
prescription: 3-4 sets of concentric-eccentric exercise starting at 15 repetitions and progressing to 6 repetitions, performed every other day
initially complete exercise in modified ROM to avoid compression of tendon then progress into full ROM as strength and pain levels allow
what is the prolonged isometric contractions for phase 3 of tendinopathy?
perform with tendon in shortened/non-compressed/mid-range position. this is done as needed at this phase for pain management
prescription: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing from 40% to 70% maximal voluntary contraction. 1-2 minute rest periods between contractions. daily
what is the criteria to progress patients to phase 4 of treatment for tendinopathy?
ability to complete energy storage exercises with minimal pain and at a volume that would replicate the demands of the sport/activity
what is the proper warmup routine for phase 4 of tendinopathy?
gentle, dynamic movement relevant for the sport or activity
what is the sport or activity specific drills for phase 4 of tendinopathy?
reintegration into competition (no greater than every 3 days initially)
what is the heavy, slow resistance for phase 4 of tendinopathy?
prescription: 3-4 sets of concentric-eccentric exercise starting at 15 repetitions and progressing to 6 repetitions, performed at least 2x per week
initially, complete exercise in modified ROM to avoid compression of tendon then progress into full ROM as strength and pain levels allow
what is the prolonged isometric contractions for phase 4 of tendinopathy?
perform with tendon in shortened/non-compress/mid-range position. this is done as needed at this phase for pain management
prescription: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing from 40% to 70% maximal voluntary contraction. 1-2 minute rest periods between contractions. daily
what is the criteria for discharge of a patient with tendinopathy?
full ROM and strength/power
pain-free high load resistance test, ensuring no pain in positions that normally compress the tendon
full training with minimal pain
what is the indication for use of isometric loading for patellar tendinopathy?
more than minimal pain with isotonic loading (>3/10)
5 repetitions, 30-60 second hold at 70% of MVIC, 3x/day, 1-2 min between each rep ( midrange knee flexion 30-60º, knee extension machine-single leg, spanish squat- bilateral 70-90º)
good prognostic sign if immediate decrease in pain on SLDS
what is the indication for use of isotonic loading for patellar tendinopathy?
minimal pain with isotonic loading (<3/10)
3-4 sets of 15RM progressing to 6RM, rest 30 sec between sets, 3-5x/week (every 2nd day using a fatiguing load)
NWB exercises 10-60º progressing toward 90º
progress to single leg loading (leg press, split squat, seated knee extension -> increase speed. walking lunges with BW or extra load. stair walking -> increase speed
what is the indication for use of energy storage for patellar tendinopathy?
adequate strength and consistent with uninvolved side (able to tolerate approx 150% of BW for jumping athletes 4 sets of 8 single leg press)
load tolerance with initial-level energy storage
what are the activities for patellar tendinopathy?
jumping (2 leg jump, hops, forward hops, split jumps)
acceleration
deceleration
cutting
what is the indication for use for return to sport for patellar tendinopathy?
load tolerance to energy storage progression that replicates demands of training
what are the activities for return to sport for patellar tendinopathy?
drills and training meeting the demands of the specific sport
return to play recommended when fill training tolerated and power deficits resolved
what can medial/ lateral knee pain be?
meniscus tear
MCL/LCL
OA (medial compartment)
what are the outcome measures for meniscal tears?
International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form
Knee Injury and Osteoarthritis Outcome Score (KOOS)
Tegner Scale
Marx Activity Rating Scale
what is progressive knee motion that can be done for meniscal tears?
early AROM/PROM after surgery
what is therapeutic exercise that can be done for meniscal tears?
progressive ROM
PRE of hip and knee
what is neuromuscular retraining that can be done for meniscal tears?
reeducation of movement, balance, coordination, kinesthetic sense, and/or posture
what is NMES that can be done for meniscal tears?
increase quad strength after injury or surgery
what are the outcome measures for ligamentous sprain/tears?
IKDC
KOOS
Lysholm Scale
Tegner Activity Scale
Marx Activity Rating Scale * ACL-RSI
when can CPM be used for a ligament sprain/tear?
may use in immediate post operative period to decrease pain after ACL reconstruction
when can early WB be used for a ligament sprain/tear?
implement early WBAT within 1 week of surgery after ACL reconstruction
when can functional knee bracing be used for a ligament sprain/tear?
may be used in pts with ACL deficiency
patient preference for use
may use for pts with acute PCL or severe MCL injury
when can mobilization for a ligament sprain/tear?
immediate mobilization after ACL reconstruction
increase ROM
decrease pain
reduce risk of adverse events
when can cryotherapy be used for a ligament sprain/tear?
immediately after surgery to reduce post-op pain
when can therapeutic exercise be used for a ligament sprain/tear?
WB and NWB concentric/eccentric exercises
4-6 weeks, 2-3x/week for 6 to 10 months to increase thigh musculature and functional performance
when can NMES be used for a ligament sprain/tear?
6-8 weeks to augment muscle strengthening exercises to increase quad strength
when is neuromuscular re-education used for a ligament sprain/tear?
done with muscle strengthening
what could posterior knee pain be?
hamstring tear/tendinopathy
baker’s cyst
ACL tear
PCL tear
gastroc strain/tear
DVT
when is eccentric loading used for hamstring strains?
to patient tolerance added to stretching, strengthening, stabilization, progressive running programs to improve RTP
when is agility and trunk stabilization used for hamstring strains?
impairment based decision making
reduce reinjury rate
when is neural mobilization used for hamstring strains?
to reduce adhesions to surrounding tissue
when are modalities used for hamstring strains?
to control pain and swelling early in the rehab process
