Thigh & Knee Flashcards
Norms for sulcus angle of femoral condyles
132 to 144 degrees
Patellar tilt angle norms
medial tilt to 6 degrees is normal
> 16 degrees lateral associated w/ lateral patellar subluxation
Tibiofemoral joint angle norms and genu varum/valgum indicators
180-185 is normal position for tibiofemoral joint
>185 genu valgum
<175 genu varum
Revised Lysholm Knee Score use and ranges for score
used for post-op ligament surgery
-8 items for symptoms and function
95-100= excellent
84-94= good
65-83= fair
<65= poor
MDC is 10 points
Tegner Activity level scale
0-10 score participation and function
0= sick leave/disability
10= sport participation at national elite level
MDC is 1 point for meniscal and ACL injuries
KOOS intended populations
ACL Reconstruction
meniscectomy
tibial osteotomy
posttraumatic OA
post-op TKA
reliable within OA and TKA populations
-validated on post TKA patients in PT
-has a floor effect, may be more difficult to track progress for lower functioning patients
IKDC-subjective form(SF) use
good internal consistency, test-retest reliability, content and structural validity, no floor/ceiling effects
-useful for all types of knee injuries
MCID is
11.5 for maximal sensitivity to change
20.5 for maximal specificity to change
Cincinnati Knee Rating System use
reliable, valid, response to change over time for ACLR
MDC subsets
2.45 for pain
2.86 swelling
2.82 partial giving way
2.30 full giving way
Knee Outcome Survey(KOS)
2 separate scales
ADL and sports activity scale
MDC 8.7 points
MCID is 7.1% greater than previous examination
valid, reliable, response for assessing functional limitations of various knee pathologies
LEFS
valid for LE conditions
-knee ligamentous strains
-non specific knee sprain/strain
-meniscal injury
-hip or knee OA
-ankle sprain/fracture
-hip or knee arthroplasty
MDC
9 points for LE condition or TKA
10 points hip and knee OA
8 points anterior knee pain
Patient Specific Functional Scale
pt identifies top 3 activities they ar having difficulty with
MDC for knee conditions
3 points for 1 activity
2 points for average score of 3 activities
Pain scales
VAS(visual analog)
VRS(verbal rating)
NRS(numeric rating)
ALL are responsive to changes
MCID of VAS = 10mm on 100mm scale for post-op patients
Cluster for meniscus injury
History
-reports of catching/locking
Exam
-tibiofemoral joint line tnederness
-pain w/ forced hyperextension
-pain w/ maximal knee passive flexion
-mcmurry test: pain or audible click
5/5 present = 92.3% chance of meniscal tear
3/5 present= 75% chance
Meniscal Pathology composite score findings
-subjective knee locking/catching
-tibiofemoral joint line tenderness w/ palpation
-pain w/ forced knee hyperEXT
-pain w/ maximal passive knee FLX
-pain or audible click w/ McMurray test
5/5 PPV
100% for acute patients(<6 weeks)
89% for chronic (>6 weeks)
3/5PPV
75% and 76% respectively
other concurrent pathology decreases impact of this
PFPS subjective reports of pain
-squatting 93.7%
-stairs 91.2%
-running 90.8%
-sitting 80.2%
PFPS clinical tests
pain w/ squatting
hypomobility w/ patellar tilt test
these are the ojnly 2 w/ specific diagnostic qualities
What is a “sage sign”
GREATER displacement than 25-50% of patellar width
-knee in full extension
-indicative of patellar hypermobility
-consistent w/ excessive joint laxity or history of patella sublux/dislocations
Norm values for single hop test (cm)
Male College
192+-20
Female College
149+-17
Male High School
181+-20
Female High School
129+-18
Norm values for 6 meter timed hop (sec)
Male College
1.74+-0.21
Female College
2.13+-0.20
Male High School
1.91+-0.23
Female High School
2.25+-0.24
Norm values triple hop(cm)
Male College
632+-72
Female College
470+-53
Male High School
583+-72
Female High School
428+-54
Norm values crossover hop(cm)
Male College
575+-75
Female College
406+-54
Male High School
522+-77
Female High School
375+-60
Bracing recs for ACLR
no evidence for long term outcomes
-some form of bracing 4-5 months after surgery beneficial
-bracing may be helpful in low load conditions, especially for those w/ insufficient quad activation/strength
unclear if bracing causes decreased quad strength or not
those who stopped bracing at 3 months had greater quad strength and hop performance
Bracing recs for PCL injury
generally not prescribed
-if used, typically DC by post-op week 4
Bracing recs for MCL
early bracing while MCL heals from grade 2/3 injuries
-locked to avoid full knee extension <30 degrees or flexion > 90 degrees
-this diminishes stress on MCL
-soft tissue healing timeline 4-6 weeks, so no further bracing after this generally
NMES for quad strength deficits
russian type
-pulse duration 400 microseconds
-75 pulse/sec
-2 sec rap
10 x 10 sec, 50 sec rest time
used if strength is <80% of contralateral
NMES should generate AT LEAST 50% of MVIC
-this must be very strong/painful in my opinion
BFR for LE parameteres
% of 1RM: 15-30%
Reps per set: 30-15-15-15
Rest between sets: 30 sec
% arterial occlusion: 60-80%(80% preferred)
Suggested Hamstring:Quad ratio for RTS
Prior to RTS
>66% for males
>75% for females
Potential ACL copers screening requirements
Required milestones:
-isolated ACL tear(no REPAIRABLE meniscal injury or other ligament injury)
-full pain free ROM
-no knee joint effusion
-MVIC of quads 70% or greater of uninvolved side
ACL-R autograft vs allograft
allograft incorporation slower than autograft
-slower timeline needed for return to running, agility, plyos, sport
irradiation/chemical cleaning of allograft also likely contributor to increased RE-tear
-5.2x GREATER vs autograft bone-patellar tendon-bone
When is ACL graft weakest post-op?
Approx 12 weeks
-crucial to have full quad recovery for dynamic stability
Open chain or closed chain for ACL rehab?
OKC and CKC have similar levels of ACL strain
-peak of 3-5% at 10* knee flexion
normal gait is 3x greater than heavy OKC quad exercise
comprehensive rehab program of OKC and CKC is likely to improve strength and coordinated movement
Considerations for ACLR w/ meniscal repair
WB flexion > 45* avoided for 4 weeks
-avoid compression w/ movement of healing meniscus repair
Considerations for ACLR w/ chonral damage or chondroplasty to WB surface
restriction in WB for 3-4 weeks to avoid stressing the healing chondral defect
Considerations for ACLR and PCLR
follow PCL guidelines
-PCL outcomes typically worse for ACLR and PCL may stretch out, thus needs of PCLR supersede ACLR
Re-injury rates
return to level 1 sports= 4x likelihood
-young athletes 4x for ipsilateral and 5x/ for contralateral injury
6-19 years old w/ ACLR had second ACL injury rate of 27%
-females had 32% rate
Return to sport rates for ACLR and revision ACLR
83% for primary reconstruction
67% for revision
PCL injury treatment grades 1-3
1 and 2 conservatively
grade 3 may be conservative if isolated PCL or surgical if involving other structures or more laxity
-grade 3 may have extension immobilization for 2-4 weeks to reduce subluxation
-avoid knee flexion > 70 degrees and isolated hamstring work
When is peak posterior shear force on knee?
resisted knee esxtnesion between 100 and 40 degrees
-peak at 85-95*
-forces lower from 0-60
take home message is more flexion leads to greater strain generally
How to minimize stress on MCL and LCL after injury
tibia in IR decreases MCL stress
tibia in ER decreases LCL stress
this is relevant during resistance exercises
Post-op precautions after menisectomy
no precautions
-rehab guided by presence of swelling, ROM, quad strength
possible knee immobilizer to reduce stress during WB
typical recovery 2-6 weeks
post-op precautions after meniscal repair
limited WB to allow for healing
-decreased compression and shear forces
-possible knee brace locked in extension
often WB in full extension x 2 weeks followed by FWB at 4 weeks
loaded knee flexion >45* limited x 4 weeks and >90* for 8 weeks
OKC vs CKC after meniscal repair?
OKC reduces stress via loading/crompression, so OKC is preferred, also in positions of less knee flexion
post-op precautions after meniscal transplant
limited WB, w/ brace in full extension for 3-6 weeks
FWB progression at 6-9 weeks
generally limited WB and no flexion >90* for 6 weeks
early PROM ok, limited to < 90*
-goal of 120* by 3-4 weeks and 135* by 5-6 weeks
quad isometrics or AAROM from 90 to 0* started immediately after surgery
Rehab differences for chondroplasty vs microfracture procedure
chondroplasty may have limited WB for 3-5 days, w/ return to full functional activities and impact activities as early as 4 weeks
microfracture procedure NWB 2-4 weeks
FWB at 8 weeks,
high impact activities at 4-6 months(small lesion)
8 months(large lesion)
PFP prevalence
25% general population
15-20% incidence in adolescents
Best diagnostic indicators of PFP(per CPG)
activities that increase PFJ compressive forces
-squatting
-stair climbing/descent
-sitting w/ flexed knee
CPG recs for foot orthoses and PFP
high quality reviews, RCTs, and moderate quality systematic reviews for prefab foor orthoses for people w/ excessive foot pronation
-short term of 6 weeks
-best combined w/ exercise program
long term use of orthoses yields no additional benefit
Osgood-Schlatter disease
traction apophysitis of patellar tendon insertion at tibial tubercle
most commonly coincides w/ growth spurt
females 8-13
males 10-15
generally a self limiting condition
-no conlusive evidence over best treatment
Sinding-Larson-Johansson syndrome
traction apophysitis at inferior pole of patella
typically in active 10-15 year olds
self limiting and also no conclusive evidence for best treatment
Best practice for patellar tendinopathy
No current gold standard
progressive tendon loading including eccentric loading is considered best practice
-non invasive(tape, brace, US, Laser) and invasive(DN, PRP) treatment options should be considered adjunct to progressive loading
Silbernagel et al Pain Monitoring model
0-2 safe zone
2-5 acceptable zone
5-10 high risk zone
pain can reach 5/10 during exercise, but must subside to baseline by next morning
baseline pain not allowed to increase week over week
Heavy Slow resistance progression
Week 1: 4 sets of 15RM
Week 2-3: 4 sets of 12RM
Week 4-5: 4 sets of 10RM
Week 6-8: 4 sets of 8RM
Week 9-12: 4 sets of 6RM
3 sec eccentric and 3 sec concentric phase
Extracorporeal shockwave therapy recs for patellar tendinopathy
no clear evidence if radial vs focused shock waves
radial = more superficial
focused = reaches deeper soft tissue
no difference between the 2 types when combined w/ eccentric training for chronic patellar tendinopathy
-suggested for recalcitrant cases when surgery is being considered
Therapeutic US recs for patellar tendinopathy
no additional benefit over eccentric exercise or placebo
Low level laser therapy recs for patellar tendinopathy
1 small study suggests that LLLT + eccentrics
was superior than LLLT or eccentrics alone
-more research needed
PRP and autologous blood injection recs for patellar tendinopathy
PRP and autologous injections provided short term pain relief and increased function
-there was no statistical difference between groups
-short term value but unclear long term value
-consider risk of invasive procedure for short term gains
Corticosteroid recs for patellar tendinopathy
oral or injectable
-risk for decreased tendon strength
-no significant improvement above eccentric or HSR training
Summary of recs for patellar tendinopathy
address risk factors
-load mgmt, weight, jumping/running mechanics, hip/knee/ankle strength and flexibility
Isometric, eccentric and HSR loading programs
-declined squat training
-pain monitoring model
-education that improvement can take 6+ months
PRP can be considered
-some short term benefit
-long term results unclear
Steroid injection and US not recommended
DN and LLLT may be considered but more research needed
Shockwave therapy positive for pain and function for those who had not responded to non-surgical mgmt,
Surgery can be considered after 6 months of unresponsive non-surgical treatment
Wells Criteria DVT
> = 2 DVT likely
<=1 DVT UNlikely
-active cancer
-recent bedridden 3 days or surgery in last 12 months
-calf swelling > 3cm compared to contralateral
-collateral superficial veins present(non varicose)
-entire leg swollen
-localized tenderness to deep venous system
+1
-pitting edema confined to symptomatic leg
-paralysis, paresis, or recent plaster immobilization
-previously documented DVT
-2
alternative diagnosis as likely or more likely
differentiate Sinding-Larsen vs Osgood-schlatters
SLJ is apophysitis at tibial tubercle
OSD would be at inferior pole of patella
