Nonsurgical Knee Disorders Flashcards
1
Q
Differential dx - referral from lumbar spine, hip, or ankle
A
medial knee = L3
2
Q
Differential dx - local musculoskeletal
A
strains, sprains, ligament, tendon, meniscus, bursitis, tendonitis, nerve, joint, bone
3
Q
Differential dx - systemic disease
A
thyroid tumors pyrogenic arthritis hemophilic arthritis inflammatory disease (RA, gout, reiters)
4
Q
Differential dx - vascular system
A
arterial - intermittent claudication
venous - DVT
compartment syndrome
5
Q
External tibial torsion
A
patella position compared to foot position
tibia has rotated so the distal tibia is lateral rotated compared to the proximal tibia
6
Q
External tibial torsion
Mechanism
Can lead to
A
Congenital
Can lead to OA or patellafemoral pain/foot issues
7
Q
If you see patient foot turning out but their knee cap is straight..
A
they likely have external tibial torsion - could be internal but is way less common
8
Q
Miserable Mal-alignment syndrome
A
Femoral anteversion Genu valgum VMO dysplasia Lateral tibial torsion Forefoor pronation
9
Q
Patella alta - cause
A
can be congenital but more likely cause is tear of patellar tendon
10
Q
Patella baja - cause
A
can be congenital but more likely cause is scarring/shortening in tendon secondary to surgery or tear of quad tendon
11
Q
Camel sign
A
2 bumps when looking laterally
One is tibial tub and one is patella
Secondary to patella alta
12
Q
Squinting patella
A
Patellas look at each other
Cause femoral anteversion
Weakness in post glut med and possible TFL tightness
13
Q
TAKE HOME
A
almost all structural deviations can cause patella femoral pain
14
Q
Articular disorders of the knee
A
RA Gout Hemophilic arthritis Pyogenic arthritis OA
15
Q
OA site of disease
A
medial joint tends to be more impacted
16
Q
RA site of disease
A
Kind of all over the place
17
Q
CPPD (pseudogout) site of disease
A
?
18
Q
RA - etiology
A
Chronic inflammatory disease
Can involve cardiovascular and pulmonary systems
19
Q
RA - epidemiology
A
peak onset 30-40 yo
20
Q
RA - pathology
A
Infiltration of immune cells into synovial fluid and destruction of capsule - massive inflammation and articular cartialge destruction and synovial hyperplasia
Usually in both joints
21
Q
RA - Clinical presentation
A
In acute = hot and swollen
In chronic = joint deterioration with deformity, ROM limitations, gait abnormalities
22
Q
RA treatment - Acute
A
Refer to physician for medical care
23
Q
RA tx - Subacute
A
AROM, PROM, mobilization, stretching, strengthening
24
Q
RA tx - chronic
A
Supportive devices, assistive devices, strengthening
25
Gout/Pseudogout - epidemiology
M-F 3:1
| Usually age 40+
26
Gout Clinical presentation
swollen, hot knee, painful - refer to physician
27
Gout Clinical presentation post acute phase
ROM, infrequently seen by PT
28
Gout pathology
Elevated serum uric acid and deposition of urate crystals in joints soft tissues and kidneys
29
Pseudogout pathology
deposit of calcium psyrophosphate crystals
| very often located in patellafemoral joint
30
Reactive arthritis - Reiters syndrome - Etiology
from microbial pathogen away from site
31
Reiters syndrome - Pathology
usually caused by VD or dysentery - triate of urethritis, conjunctivitis, and arthritis, common in HIV patients
32
Reiters syndrome - Epidemiology
Males, 30s, hx of infection
33
Reiters syndrome - clinical presentation
```
Swollen knee
Inflammatory synovitis
Erosion of insertion of ligaments and tendons
Edema of synovium
Often skin lesions
Hard to dx
```
34
Hemophilic Arthritis
knee most common joint
35
Hemophilic arthritis etiology
blood in joint leads to cartilage degeneration
36
Hemophilic arthritis - clinical presentation
swelling, warmth, motion limitations, pain
37
Hemophilic arthritis - treatment
medical emergency secondary to joint destruction - clotting factor given
Immobilization followed by cautious mobilization
38
Pyogenic Arthritis - Etiology
Bacterial infiltration primarily from gonococcal infections, lyme disease, TB, styphilis, knee most common
39
Pyogenic arthritis - pathology
microabcesses from in synovial membrane and break open into joint
Medical emergency
Total destruction of joint w/in 2-3 wks
40
Pyogenic arthritis - clinical presentation
painful, red, hot, may weep pus if open wound, pain, swelling, loss of function
41
Pyogenic arthritis - treatment
confirmed by aspiration and blood work, joint aspiration, rest (little to no movement), antibiotics
42
OA etiology
Usually in medial compartment or patella
| Wear and tear due to age, post trauma
43
OA epidemiology
older adults or post trauma
44
OA pathology
wearing away hyaling cartilage to subchondral bone with lost of joint height and boney changes
45
OA diagnostic radiographic findings
Dec joint space, asymmetrically
Sclerosis subchondral bone
Osteophyte formation at joint margins
Subchondral cyst formation
46
OA clinical presentation (10)
```
Osteophytes limit motion
Joint deformity occurs
Medial compartment more common (genu varus)
Altered mechanics
Activity inc pain, dec with rest
Pt complains of initial stiffness with movement initiation
Mild inflammation
Muscle atrophy
C/o instability
Joint line tenderness
```
47
OA tx - medical
weight loss
NSAIDs
Hyaluronic acid injections
Glucosinamine/choidroiten sulfate
48
OA tx - surgical
arthroscopy
tibial osteotomy
total joint replacement
49
OA complications post TKA
DVT - some studies have placed occurrence at 70%
Infections (2.5%)
Dislocations or improper alignment
Neurovascular
50
OA PT post surgery
```
AROM PROM, must achieve 90 degrees flexion before d/c
Continuous passive motion machines
Pain control
Protected WB with gait
Strengthening
Functional mobility
```
51
PT for OA
Compression for swelling
Minimize forces around knee with assistive devices
Strengthening
Mobilization
Bracing and heel wedges
Transition to ex program w/o stressing knee
52
Meniscal injuries - Incomplete
Partial through the body of the meniscus
53
Meniscal injuries - Complete
across the entire body
54
Meniscal injuries - Horizontal
most often chronic degenerative type of tear
55
Meniscal injuries - Vertical
traumatic, more common (bucket handle)
56
Meniscal injuries - Radial
central part of the meniscus
57
Meniscal injuries - Flap
progression of degenerative changes
58
Etiology of meniscal tears
cause primarily in a cutting motion during sport, quick rotation or degeneration
59
Meniscal tear - most likely to occur
in 30 degrees of flexion
| often associated with ACL and MCL injury if caused by trauma
60
Meniscal tear - pathology
symptomatic when torn portion is mobile and moves into abnormal position
Poor blood supply except for outer edge of meniscus leads to poor healing
61
Meniscal tear - clinical presentation
```
Locking - unable to extend
Instability
Pain, sharp with ache
May click or snap
Swelling not suddenly
```
62
Meniscal tear - special tests
```
joint line palpation
valgus/varus stress tests
Apley's compression and distraction
McMurray
Arthrogram
MRI
```
63
Meniscal tears - non surgical treatment
goal is to protect articular cartilage
Progressive strengthening of lower quadrant
NSAIDs
64
Meniscal tears - surgical treatment
Menisectomy
| Meniscus repair - protective phase is longer with repair
65
Ligamentous injuries
```
WB injuries with stress
Inability to WB after injury
Immediate swelling
May hear pop or feel tear
May have associated injuries of other ligaments, meniscus, or capsule
```
66
ACL etiology
contact and noncontact
hyperextension (femur pushed post) OR flexed/abducted/valgus/ER
(tibia ant with abd/ER force)
67
ACL epidemiology
More frequent in females
68
ACL clinical presentation
often audible pop, swelling, knee flexion secondary to protection from hams
69
ACL special tests
Lachmans, ant drawer, pivot shift
70
ACL treatment
surgical repair may not be needed - each patient is different
71
Post surgical rehab for ACL
```
swelling reduction
ROM
quad activation/hamstring strengthening
normalize gait
proprioception/balance
functional activities
```
72
KT 1000/2000 tests
machine to assess tibial translation and how functional one can be with ACL injury
73
PCL etiology
posterior tibial translation
most often MVA with tibia into dashboard
Falling onto flexed knee
Hyperextension with force through tibia
74
Epidemiology of PCL
much rarer than ACL
75
Clinical presentation PCL
Acute hemarthrosis, no pop or snap; pain
76
Special tests PCL
post drawer, post sag, reverse lachmans
77
PCL - surgical
using infra or supra patellar tendon graft
78
PCL non surgical
Protected ROM (0-60 at first)
Strength
WB exercises
Avoid isolated hams during first 3-4 wks
79
MCL etiology
valgus stress (contact) - most injuries with rotational forces will damage other structures too
80
MCL clinical presentation
swelling, pain, instability, point tenderness, limited motion due to pain
81
MCL special tests
valgus stress test (0 and 30)
| Grades 1-3, Grade 1 slight sprain, grade 3 = complete tear
82
MCL treatment
usually monsurgical
bracing - long leg immobilizer 2 wks progressing to brace - lateral supports for 6 wks
Stretch/strengthen, proprio, functional
83
Quad tendon rupture etiology
overuse or trauma
more common in people over 40
tight quad is risk factor
tends to happen at 90 degrees knee flexion
84
Quad tendon rupture clinical presentation
palpable defect in suprapatellar tendon
| pain, swelling, unable to actively extend knee, decreased ability to WB
85
Quad tendon rupture treatment
operative repair
86
Quad tendon rupture post surgical rehab
gradual WB, gradual strengthening, soft tissue mob, patellar mob
87
Patella tendon rupture - etiology
usually forceful eccentric contraction
88
patella tendon rupture - epidemiology
more common in those under 40, usual underlying problem prior to rupture
89
patella tendon rupture - treatment
surgery
| prolonged rehab with flexion cautions
90
Patellofemoral pain etiology
idiopathic, multi factorial, malalignment causing abnormal compression, chondromalacia
91
Patellofemoral pain clinical presentation
inc pain with quad loading; possible palpable tenderness
92
Patellofemoral pain treatment
EMG/biofeedback, stretch/strength, posture/alignment, stress reduction, HIP STRENGTHENING, patella taping
Surgical lateral release
93
Patella subluxation/dislocation etiology
tends to sublux more frequently than dislocate, instability with giving way when cutting away from affected side
94
Patella sub/dis epidemiology
females: males
3: 2
95
Patella sub/dis clinical presentation
```
click, slide and lock felt
Vastus medialis atrophy
Vastus lateralis hypertrophy
+ apprehension test
Tenderness around patellar border and lots of swelling
```
96
Patella tendonitis etiology
overuse, repetitive jumping, running
97
Patella tendonitis pathology of tendonitis
inflammation of the tendon - acute presentation with pain, swelling warmth
98
Patella tendonitis - pathology of tendinopathy
repeated bouts of inflammation causing pain, scarring, poor circulation to tendon
99
Epidemiology of tendonitis
common age 20-40 yo
100
Clinical presentation of tendonitis
insidious onset, pain at inf patellar pole, inc with knee ext and dec with rest
101
Treatment of patella tendonitis
stretch quads, progressive quad strength, patellar mobs, tendon compression/bracing/taping, posture alignment, stress reduction
Surgical excision of necrotic fibers is rare
102
Pre patellar bursitis etiology
prolonged kneeling
| repetitive falls onto knees
103
Pre patellar bursitis clinical presentation
pain to palpation of swollen pre patellar bursa, swelling, ROM is WNL but feels tight
104
Pre patellar bursitis treatment
aspiration of excision if sever, activity modification, physical agents if needed
105
Chondromalacia patellae etiology
trauma, multiple subluxations, overuse
106
Chondromalacia patellae patholgoy
softening/flaking off of cartilage on undersurface of patella
107
Chondromalacia patellae clinical presentation
inc pain with quad loading
108
Chonromalacia patellae treatment
physical agents, stretch tight muscles, strengthen LE, posture/alignment, reduce stress to patella with tape or brace
Can do arthroscopic shaving too
109
Fat pad syndrome etiology
irritation of infrapatellar fat pad
mostly due to impingement of fat pad btw femoral condyles and patella
patient often genu recurvatum
110
Fat pad syndrome treatment
lontophoresis, corticosteroid injection, orthosis, taping of patella, treat causative factor behind the irritation
111
Distal femur fracture etiologyu
trauma with result soft tissue injury
112
Distal femur fracture treatment
usually surgical - if not will cast brace with knee ROM of 30-40 degrees NWB to TTWB
113
Distal femur fracture - surgical tx
ORIF with intermedullary rod
| WB depends PWB from 4-12 wks
114
Distal femur fracture - classified orthopedic trauma association
Type A
Type B
Type C
```
A = extraarticular
B = unicondylar
C = bicondylar
```
115
Proximal tibial fracture etiology
Often associated with othe rknee trauma, may be missed initially
116
Proximal tibial fracture treatment
```
nonoperative = casting for 3 to 6 weeks
operative = depending on severity, NWB 12 weeks
```
117
Patella fracture etiology
usually occur with direct blow to patella (MVA to dashboard) - avulsion can occur
118
Patella fracture treatment
surgery = required for displaced more than 3mm
| Non surgical = knee immobilizer WBAT
119
Patella fracture PT treatment when healed
progressive ROM, strength function
120
Patella fracture classification by ortho trauma association
Type A
Type B
Type C
```
A = extraarticular with apex avulsion
B = partial articular with preserved extensor mechanism
C = articular with disruption of extensor mechanism
```
121
Proximal fibula fracture
usually occur with proximal or distal tibia fracture
| Less common
122
Osgood Schlatter's disease AKA tibial apophysitis - etiology
overuse injury in young athletes
123
Osgood Schlatter's disease AKA tibial apophysitis - pathology
osteochondrosis of tibial tub
124
Osgood Schlatter's disease AKA tibial apophysitis - Clinical presentation
tenderness to palpation at tibial tuberosity; inc with quad loading
125
Osgood Schlatter's disease AKA tibial apophysitis - treatment
physical agents, stretch/strength, posture/alignment, stress reduction
126
Osteochondritis Dissecans - etiology
separation of cartialge and subchondral bone
Pieve becomes necrotic, loose body in joint space
Cause is unknown but htought to relate to poor vascular suply
Most commonly medial condyle
127
Osteochondritis Dissecans - epidemiology
adolescent, young adult
128
Osteochondritis Dissecans - Clinical presentation
deep pain in knee, quadriceps atrophy, may have tenderness to palpation, feelings of instability and intermittent locking
129
Osteochondritis Dissecans - special tests
rediography
130
Osteochondritis Dissecans - treatment
operative excision or fixation may be needed
131
IT band friction syndrome etiology
overuse, common in runner and cyclists
132
IT band friction syndrome - pathology
irritation of ITB at lateral femoral condyle
133
IT band friction syndrome - Clinical presentation
localized tenderness over lateral femoral condyle
134
IT band friction syndrome - Treatment
physical agents, deep friction, stretch/strength, posture/alignment, orthotics, stress reduction, hydrocortisone injection, surgical release
135
IT band friction syndrome - special tests
noble stress test, obers
136
Bakers cyst etiology
herniated synovial linign
137
Bakers cyst clinical presentation
observable and palpable lump in popliteal fossa, presents as a mass
Might mimic intermittent claudication s/s, could rupture, knee flexion contracture is common
138
Bakers cyst treatment
drained or surgical excision if nuisance
Hams and gastroc stretching
Hams strengthening
139
Pes Anserine Bursitis - etiology
```
overuse injury (tendinopathy)
may also have tendinitis
```
140
Pes Anserine Bursitis - Clinical pres
localized tenderness to pes, insidious onset
141
Pes Anserine Bursitis - diff dx
hams tendinopathy, tibial stress fx, DJD, peudogout, meniscus
142
Pes Anserine Bursitis - special test
resisted contraction of mm inserting into area
Sartorius
Semitend
Gracilis
143
Pes Anserine Bursitis - Treatment
physical agents, stretch/strength (medial hams) posture/alignment stress reduction
144
Popliteus tendonitis etiology
overuse injury (runners, banked surfaces or downhill)
145
Popliteus tendonitis clinical pres
localized tenderness at femoral insertion
146
Popliteus tendonitis treatment
physical agents, transverse friction massage, stretch/strength, posture/alignment, stres reduction
147
Plica syndrome etiology
embryological synovial tissue, chronic irritation, diagnosis is often one of exclusion
148
Plica syndrome clinical pres
symptoms present more commonly in medial aspect of knee
| pseudo locking, pain, aches at rest
149
Plica syndrome treatment
physical agents, hamstring stretches, quad strengthening, limit repetitive motion that irritates plica initially
