w2 PE of overuse/ chrnic knee conditins Flashcards
1
Q
common caused of knee pain
A
patellofemoral pain
* Patellar tendinopathy
2
Q
less common anterior knee pain causes
A
- Fat pad impingement
- Sinding-Larsen– Johansson lesion in
adolescents - Osgood–Schlatter lesion in adolescents
3
Q
not to be missed for anterior knee pain causes
A
- Referred pain from the hip
- Osteochondritis dessicans
- Slipped capital femoral epiphysis
- Perthes’ disease
- Tumour (especially in the young)
4
Q
Patellofemoral Pain definition
A
all peripatellar or retropatellar pain in the absence of other pathologies”
5
Q
Patellofemoral Pain symptoms
A
- Patellofemoral joint pain (PFJP)
- Patellofemoral Pain Syndrome (PFPS)
- Anterior/retropatellar pain
- Chondromalacia patellae
- Refers to state of the patellar articular
cartilage
6
Q
extrincic factors to PF P
A
Increased or unaccustomed PFJ load
* Body mass, surfaces, footwear, volume of work, increase in amount of knee flexion required for task, eccentric work
7
Q
intrinsic factors contributing to PF P
A
Relate to patella alignment in femoral trochlea (patella tracking)
* Increased femoral internal rotation
* Increased hip adduction
* Increased knee valgus/external tibial rotation
* Poor trunk and pelvic control
* Pronated foot type
* Increased knee flexion
Local factors:
* Patella position
(Draper 2009; Lankhorst 2013)
* Quadriceps
8
Q
local fcator PF P - quads
A
- Reduced peak knee extension torque
- Quadriceps atrophy
- Reduced quadriceps flexibility
- Delayed VMO onset compared to VL
- Activation imbalance causing laterally directed patellar and altered contact forces.
- Reduced hamstring flexibility
9
Q
local factors PF P - Patella Position
A
Lateral displacement – closer to lateral femoral trochlea groove
Lateral tilt – high medial border
Posterior tilt – Inferior pole moves posteriorly
Patella alta – high riding patella
10
Q
how to test that an increase Q angle is structural
A
Imaging: MRI, radiography
11
Q
how to test that an increase Q angle is from decreased strength
A
MMT
Hand-Held Dynamometry
EMG Biofeedback
12
Q
how to test that an increase Q angle is from Decreased ROM:
A
ROM Ax via inclinometer/goniometer
FABER test, Figure 4 test
13
Q
how to test that an increase Q angle is from altered movement patterns
A
Biomechanical/Functional/Gait
/Proprioception Ax
14
Q
knee special questions
A
- May report giving way (inhibition vs true instability), crepitus, swelling, locking (pseudo) and clicking.
15
Q
Physical Examination of PF P
A
Observation
* may have swelling present locally or intracapsular, quadriceps wasting (inhibition),
patella alta, patella baja, patella tilting
* Consider remote intrinsic risk factors
Palpation
* tenderness medial or lateral facets of patella,
medial or lateral retinaculum.
ROM
* often full ROM, but can be painful with flexion
and muscle contraction in extension.
Accessory Movements
* PF jt. glide restriction (can be any direction)
16
Q
Physical Examination of PFP functional assessment
A
- Assess reported tasks that
cause pain - Squat, lunge, step down,
running, jumping. - McConnell’s Resisted
Extension in NWB or
squat/lunge in FWB - Exclude other pathology
17
Q
Patella Tendinopathy
A
- Overuse condition causing degeneration and local pathology to patella tendon.
- First referred to as “jumpers knee”
- Patella Tendinopathy = umbrella
term for degenerative condition of
patella tendon unit.
18
Q
Patella Tendinopathy
Risk factors
A
- Higher body mass index
- Higher waist-to-hip ratio
- Leg length difference
- Lower arch height of foot
- Reduced quadriceps &
hamstring flexibility - Strength - conflicting
Also - Age
- playing at national level
- Males
- Playing volleyball
- Position played
19
Q
Patella Tendinopathy MOI
A
- Repetitive mechanical loading of patella tendon
- Insidious/gradual onset
- Linked to sudden spike in load rather than high
chronic workload.
20
Q
Patella Tendinopathy Aggravating factors:
A
- Jumping/Power based movement
- Running
- Change direction
- Decelerating
- Stairs (Can be up and/or down)
- Prolonged sitting
21
Q
Patella Tendinopathy Eases factors
A
- Often movement
- Unloading (e.g tape or bracing)
22
Q
Patella Tendinopathy physical exam obs, palp, ROM, FUNCTION testing
A
Observation
* May have localised swelling/thickening inferior to patella
* Consider local and remote intrinsic risk factors
Palpation
* Tenderness on palpation of patella tendon, inferior pole of patella, tibial tuberosity
* Often associated thickening of tendon
* May have crepitus if paratendonitis present
ROM
* Often full range, may experience “pulling” at EOR flexion.
Functional Testing
* Decline squat (30 deg) (Cook et al., 2000)
* May reproduce pain on lunge, hop, jump and/or eccentric loading.
- MMT/ joint ROM
23
Q
Hoffa’s Fat Pad Impingement def
A
- Infrapatellar fat pad impinged between patella and femoral condyle
- Very pain sensitive structure of knee
- Most commonly seen as acute injury in direct blow or with repeated or uncontrolled extension.
- Insidious onset condition less common exacerbated by extension manoeuvres and
often loaded.
24
Q
Hoffa’s Fat Pad Impingement obs palp rom functional tests other tests
A
Observation
* May have localised swelling/puffiness in area inferior to patella Palpation
* Tenderness on palpation of hoffa’s fat pad
(medial and/or lateral)
ROM
* Often full range, may have pain with quadriceps contraction at EOR extension (good to add passive overpressure and repeat this).
Functional Testing
* May reproduce pain on squat, or loaded extension and/or hyperextension
Other Tests:
* Will need to assess proximal and distal segments if believed to be influencing factor.
25
Adolescent Knee Pain
Osgood Schlatter’s Disease
* Osteochondritis at growth plate of tibial tuberosity
* Caused by rapid growth of long bones (growth spurt) in combination with repeated contraction of quadriceps muscle.
* Usually associated with repeated forced knee extension (e.g. running and jumping sports).
* Pain on palpation of tibial tuberosity
* Some association with sub-talar pronation and decreased quads muscle length .
26
Adolescent Knee Pain
Sinding Larsen-Johansson Syndrome
* Similar condition to Osgood Schlatter’s
* Affects inferior pole of patella at proximal attachment of patellar tendon
* May have slight swelling and “lump” under patella
* Pain on palpation of inferior pole of patella
* Pain with activity, especially when straightening the leg against force or following an extended period of vigorous exercise
27
Osteochondritis dessicans
10-15 yo
* Articular cartilage fragment
* Unstable...loose body
* Trauma/Ischaemia/hereditary
* Sx: Vague ache
swelling, locking/giving way
28
Slipped capital femoral epiphysis
* 10-15 yo, boys > girls, obese
* antalgic gait, out-toeing, limb shortening
29
Perthes’ disease
* 2-12yo, boys
* AVN of femoral head
* vague ache groin, thigh or knee
* Hip IR/ER reproduces symptoms
30
common causes of lateral knee pain
* Iliotibial band friction syndrome
* Lateral meniscus abnormality
* Degenerative change/ wear
31
less comoon lateral knee pain causes
* Patellofemoral syndrome
* Osteoarthritis of the lateral compartment of
the knee
* Excessive lateral pressure syndrome
* Biceps femoris tendinopathy
32
not to be missed lateral knee pain
* Common peroneal nerve injury
* Slipped capital femoral epiphysis
* Perthes’ disease
33
common medial knee pain
* Medial meniscus
* Minor tear
* Degenerative change
* Cyst
* Osteoarthritis of the medial compartment of
the knee
34
less common medial knee pain causes
Pes anserinus
* Tendinopathy
* Bursitis
* Medial collateral ligament
35
not to be missed medial knee pain
* Tumour (in the young)
* Slipped capital femoral epiphysis
* Referred pain from the hip
* Perthes’ disease
36
posterior knee pain common causes
* Baker’s cyst
* Knee joint effusion
* Referred pain
* Lumbar spine
37
posterior knee pain less common causes
* Popliteus tendinopathy
* Gastrocnemius tendinopathy
38
posterior knee pain not to be missed causes
* Deep venous thrombosis
* Claudication
* Posterior cruciate ligament sprain
39
Iliotibial Band Friction Syndrome def
* Overuse injury presenting as lateral knee pain
* Richly innervated fat pad may be source
of pain as its compressed under the band
40
Iliotibial Band Friction Syndrome aggrevating factors
* Repeated knee flexion at 15-30 degrees
* Running
* Cycling
41
Iliotibial Band Friction Syndrome MOI
* Insidious onset
* Often related to cycling or running
* May be related to sudden change in session load (duration or intensity)
* May be related to involvement of downhill activity or cambered courses.
42
Iliotibial Band Friction Syndrome obs palp rom special tests and other tests
--Observation
May have localised swelling
--Palpation
Tenderness on lateral femoral epicondyle
Crepitus may be felt
--Range of Motion
Pain reproduced with repeated knee flexion/extension
--Special Tests
Ober’s test (tightness ITB) + passive flexion
--Other Tests
Will need to assess proximal and distal segments if believed to be influencing factor.
43
Degenerative Meniscal Lesions
as a result of long term loading and resultant stress.
* Generally have a complex pattern and predominantly affect posterior horn and midbody.
* Often horizontal in nature
* Associated with articular cartilage changes
- medial or lateral pain
44
Degenerative Meniscal Lesions pt history, obs, palp, rom
--Patient History:
Older. Worsening knee pain often accompanied by mechanical symptoms (i.e. clicking, catching, locking, giving way).
Insidious onset
-- Observation
May present with joint effusion, often absent
-- Palpation
Tenderness locally to medial +/- lateral tibiofemoral joint line
-- Range of Motion
Often full, however common to have pain and restriction at end ranges of flexion and
extension (worse with OP).
Larger tears with have mechanical catch through range.
May have associated click with movement
45
Knee Osteoarthritis
* major cause of pain and locomotor disability
worldwide.
* present clinically in widespread variation and
stages.
* Affects medial (more so) and lateral TFJ and PFJ
* Mechanical degenerative condition of articular
components of tibiofemoral and patellofemoral joints.
46
Clinical Presentation of OA risk factors
* Age: older age
* Gender: Females esp from middle age
* Race
* Hereditary
* Obesity
* Previous knee injury esp ACL and meniscal (affects younger age group)
* Knee malalignment
* varus = med knee OA
* valgus = lateral knee OA
47
Clinical Presentation of OA pt interview/ report
* Gradual insidious onset
* Morning stiffness or stiff after rest/activity
* Swelling post activity
* Worsening function
* Worsening knee pain often accompanied by mechanical symptoms (i.e. clicking, catching, locking, giving way).
48
Diagnose osteoarthritis clinically without investigations if a person:
* Is 45 or over and
* Has activity related joint pain and
* Has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes
49
common acute injuries
* ACL sprain (rupture)
* PCL sprain
* MCL sprain
* Medial meniscus tear
* Lateral meniscus tear
* Patellar dislocation
50
less common acute injuries
* LCL sprain
* Superior tibiofibular joint injury
* Patellar tendon rupture
* Quadriceps tendon rupture
51
not to be missed acute injuries
* Fracture of the tibial plateau
* Avulsion fracture of tibial spine
* Osteochondritis dissecans (in adolescents)
* Complex regional pain syndrome type 1 (post
injury)
* Quadriceps muscle rupture
52
Important Special Questions when diagnoising acute injuries as MOI
* Mechanism of injury (MOI) – must tease out eg jumping twisting
* Swelling - immediate vs delayed onset
The 3 conditions that will cause a large immediate effusion are:
1) ACL rupture
2) Fracture
3) Patella Dislocation
* Giving way – true instability vs quads inhibition
* Locking – true vs. pseudo locking
* Noises – presence of ?
* Stairs – up/down
53
Anterior Cruciate Ligament
* Origin: medial aspect of anterior intercondylar area of tibia.
* Insertion: posteromedial aspect of the lateral femoral condyle.
* 2 bands
* Anteromedial - taut in flexion and through ROM
* Posterolateral - taut in extension
54
Functional Roles of ACL
1º role
* resist anterior translation of tibia on femur
* Contributes most at 30º flexion
2º role
* resist internal tibial rotation
* resist abd/add in full extension
55
ACL injuries
* 60-80% of ACL injuries from noncontact situations (Brukner 2016)
* Cutting/side-stepping
manoeuvre
* One-leg landing
* Functional/dynamic valgus
56
ACL – MOI
Non-contact (most common)
- Deceleration
- Landing from a jump
- Pivot (torsion/twist)
- Hyperextension
* Contact
- Direct trauma to knee
57
ACL- pt interview
* Experience of a “popping sensation”.
* Intense high level pain initially then subsides
* Giving way sensation “my knee dislocated”
* Immediate gross effusion
58
Physical Examination of ACL obs, palp, rom, clinical tests
Observation
* Grossly swollen knee Brush swipe test (presence of intracapsular effusion)
Palpation
* May often be tender lateral joint line from bony contusion.
ROM
* May only lack end ranges of extension and flexion
Clinical Orthopaedic Tests
* Lachman’s test
59
ACL injuries – risk factors
Higher in females (2.4 -9.7 x higher) proposed that:
* Smaller ACL cross sectional area
* Smaller and different shaped intercondylar notch
* Greater Q angle
* Greater ligament laxity (Brukner 2016)
* Knee hyperextension
* Assymmetry of AP/PA tib-fem laxity
* Quadriceps dominance
60
Posterior Cruciate Ligament
Origin: anterolateral aspect of the medial femoral condyle
* Insertion: posterior aspect of tibial plateau
* 2 bands
* Anterolateral (taut in mid flexion)
* Posterolateral (taut in extension and full flex (>100º)
* Proposed synergistic role
61
Functional Roles of PCL
1º role
* Resist posterior translation of the tibia on the femur
* Contributes most at 90º
2º role
* Resist tibial external rotation (90-120º)
* Increasing evidence of restraint to internal
rotation also.
62
PCL- MOI
Non-contact:
* Hyperextension
Contact (Direct Trauma):
* Sports (tackle or collision)
* MVA (dashboard knee)
* Fall onto bent knee.
63
PCL- pt interview
Acute:
* Vague presentation
* May have mild effusion
* Posterior knee pain and/or pain with kneeling
Sub Acute:
* Poorly localised knee pain
* Pain deceleration or with inclines
* Pain with full stride running
* Patellofemoral symptoms from increased anterior femoral translation
64
Physical Examination of PCL obs palp rom special test
Observation
* May have mild to moderate effusion, depends on capsule integrity
Palpation
* Often non specific
ROM
* Vague posterior pain in mid-late flexion ROM and EOR extension.
Special Tests (NB: end feel and laxity)
* Posterior drawer test
* Posterior sag test
65
Medial Collateral Ligament
* Origin: medial aspect of medial epicondyle
* Insertion: medial aspect of proximal tibia (posterior to pes anserine insertion)
* Taut in extension, and end range flexion
66
Functional Roles of MCL
1º role
* Prevents valgus strain/knee abduction
* Limits extension and internal tibial rotation
2º role
* Resist anterior tibial translation
67
MCL MOI
* Contact
-Direct valgus force to lateral aspect of knee
- High energy collisions (multi-ligamentous injury)
* Non contact
- Valgus stress + tibial external rotation e.g. side
step, COD unstable surface, landing from jump.
68
MCL pt interview
Acute traumatic event
* Reports twisting/valgus motion
* Sharp localised pain to medial aspect of knee
* Localised swelling if isolated injury (extracapsular)
* Feeling of instability (floppy with lateral movement)
69
Physical Examination of MCL obs, palp, rom, special tests
Observation
* Localised swelling to medial aspect of knee joint
Palpation
* Specific tenderness at MFC attachment and along ligament to tibial insertion
ROM
* Often pain at terminal extension, pain with flexion >100deg.
Special tests (performed at 0° flexion and 30° flexion).
* Valgus Stress Test (Laxity)
* Valgus Stress Test (Pain)
70
Menisci attachment and function
Attachments
* Meniscal horns anchor menisci to tibial plateau anteriorly and posteriorly
* Medial meniscus is attached around its margin
of joint capsule and MCL.
* Lateral meniscus attaches to popliteus not
capsule.
* Transverse ligaments interconnect anterior
menisci.
Function
* Deepen tibial plateaus increase congruency load bearing surface area shock absorb
* good blo
71
Menisci MOI
Typically a twisting/shearing motion in weight bearing
72
Menisci Common Subjective Hx/ pt interview
* Often localised joint line pain, may present vague intracapsular knee pain.
may feel clicking
instability
locking
73
Physical Examination of Menisci. obs palp rom special tests
Observation
* Presence of intracapsular effusion
Palpation
* Palpable tenderness of joint line: Sensitivity
ROM
* Pain and often restriction at end range extension and flexion. Commonly pain
through flexion range from >90 degrees.
Special Tests
* McMurray’s test
74
The Unhappy Triad
* Multi-ligamentous injury – ACL,MCL
and Medial Meniscus
* +/- bony pathology – tibial plateau
fracture
75
Acute Injuries to the PFJ
* Patella dislocation
* Patella fracture
* Rupture of the quadriceps tendon
* Rupture of the patella tendon
76
Patella Dislocation MOI
Traumatic (Indirect)
- powerful quads contraction against internally rotated femur e.g. twisting on planted foot, and jumping.
* Traumatic (Direct)
- direct blow to medial aspect of patella e.g fall or collision
* Atraumatic
- ligamentous laxity (hypermobility syndromes
- bony abnormalities (genu valgus, external tibial torsion)
77
Patellar Dislocation pt interveiw
Kneecap giving way “knee cap
popped out of place”
* May report previous
episode/history of instability
78
Patella Dislocation Physical Examination
Palpable tenderness of medial border of patella and lateral trochlea (crash sites)
* Palpable tenderness of medial retinaculum and MPFL
* Large haemarthrosis
79
Patella Fracture MOI
* Direct Blow
* Collision/Tackle
* Fall onto anterior knee
* Forceful contraction of
quadriceps
* Retinaculum & vasti
disruption
80
pattella # pt interview
Event of trauma
* Often high reported pain level
* Large effusion/bruising
* Great difficulty/inability to extend knee
81
Lateral Collateral Ligament function
1º role
* restraint varus strain/knee adduction mostly in ext.
2º role
* external rotation tibia
* anterior and posterior translation (large)
82
LCL MOI
* Direct blow to the medial aspect tibia in a fully extended knee, with the force directed in a
posterolateral direction.
* Hyperextension injury (often noncontact)
* Anterior rotatory dislocations
* Posterior rotatory dislocation
83
Physical Examination of PLC and LCL obs palp rom special tests
Observation
* May have localised swelling and/or bruising.
Palpation
* Diffuse tenderness over the posterolateral aspect and lateral joint line, and localised pain at the fibular head.
Range of motion
* Will often have increased hyperextension +/- increased ER
Special Tests
* Varus Stress test:
84
Proximal Tibiofibular Joint biomechanics
* Torsional stress applied from the ankle
* Dissipation of lateral tibial bending.
* Ankle dorsiflexion = ER at proximal TFJ.
85
Proximal Tibiofibular Joint MOI
--Acute dislocations
* Large injury often from direct
trauma. Uncommon.
--Joint sprains
* Often from weight bearing
torsion motion.
* Can be in conjunction with
inferior tibiofibular joint injury.
86
Proximal Tibiofibular Joint assessment
Increased laxity on anteroposterior glide
