Week 6 Flashcards
1
Q
What are the joints that the knee is composed of?
A
- Tibiofemoral
- Patellofemoral
- Superior tibiofibular
2
Q
__ is an extracapsular joint
A
Superior tibiofibular is an extracapsular joint
3
Q
What kind of joint is the knee considered to be?
A
• Double condyloid
4
Q
What does the double condyloid joint of the knee do?
A
Prevents motion in frontal plane
5
Q
How many degrees of freedom does the knee have? and in what planes does it move?
A
- 2 degrees of freedom
- Flex/Ext in sagittal plane
- Med/Lat rotation in transverse plane
6
Q
What are the characteristics of the tibiofemoral joint as a femoral articular surface joint?
A
- Large AP convexity
- Small curvature posterior
- Medial condyle
7
Q
What are the characteristics of the medial condyle?
A
- Longer than lateral
* Extends further distally for angled femur
8
Q
Both the medial and lateral tibial plateau are __ and slope ____
A
Both the medial and lateral tibial plateau are concave and slope posteroinferiorly
9
Q
The articular cartilage of the ____ tibial plateau is 3x thicker than the ___
A
The articular cartilage of the medial tibial plateau is 3x thicker than the lateral
10
Q
___ plateau is more circular than the ____
A
Lateral plateau is more circular than the medial
11
Q
Any incongruency between the femur and he tibia, is accommodated for by the ____
A
Any incongruency between the femur and he tibia, is accommodated for by the menisci
12
Q
What are the functions of the menisci?
A
- Increase stability by deepening tibial plateau
- Decreases friction by 20%
- Increases contact area by 70%
- Enhances proprioception via mechanoreceptorsn
- Attenuates forces
13
Q
What are the characteristics of the medial meniscus?
A
- C shaped
- Firm attachment to deep layers of MCL
- Thick posteriorly
14
Q
What are the characteristics of the lateral meniscus?
A
- O shaped
- Loose attachment to lateral capsule
- Uniform thickness
15
Q
Both the medial and lateral meniscus are thicker on ___, and thinner along the ____
A
Both the medial and lateral meniscus are thicker on periphery, and thinner along the inner margin
16
Q
Shock absorption capability reduced by 20% with complete ____
A
Shock absorption capability reduced by 20% with complete menisectomy
17
Q
What vascularizes the meniscus?
A
In adults, vascularized by capillaries from joint capsule and synovial membranes
18
Q
When does the meniscus cease to be well vascularized? And what happens after?
A
Recedes to periphery by age 11
19
Q
What region of the meniscus is the most vascularized and can be healed on its own?
A
The lateral 1/3
20
Q
What region of the meniscus is the least vascularized?
A
The middle 1/3
21
Q
What do the ligaments of the knee control/resist?
A
- Hyperextension
- Varus/valgus
- AP displacement of tibia on femur
- Med/lat rotation of tibia on femur
- Combination of AP & rotation motions
22
Q
What movement does the MCL prevent?
A
Prevents abduction (valgus stress)
23
Q
What movement does the LCL prevent?
A
Prevents adduction (varus stress)
24
Q
Which ligament has deep and superficial layers and where does this ligament attach?
A
- MCL.
- Attaches 7-10cm below joint line
25
What does the MCL assist with?
Assists in prevention of anterior tibial translation
26
Which ligament attaches to the joint capsule and the meniscus on its side?
MCL. LCL does not attach to the joint capsule or menisci
27
When are the anterior fibers of the MCL taut?
Anterior fibers taut in midrange
28
When are the posterior fibers of the MCL taut?
Posterior fibers taut in full flexion
29
What does the LCL assist with?
Assists with IR and ER restraint
30
What ligament has greater laxity and why?
LCL has greater laxity than the MCL, because it has no attachment to the capsule or menisci
31
When is the LCL tight?
Tight in knee extension
32
When is the LCL loose?
Loosens as knee flexes
33
Which ligament has a better healing potential?
Neither, they are both well vascularized and will heal well
34
What is the LCL shaped like?
Pencil-like band of tissue
35
From where to where does the ACL run?
Anterior aspect of tibial to posterior aspect of lateral femoral condyle
36
What are the 3 bundles of the ACL?
* Anteromedial
* Posterolateral
* Intermediate
37
When is the anteromedial bundle of the ACL lax and taut?
- Lax in extension
| - Taut in flexion
38
What is the anteromedial bundle of the ACL responsible for?
Responsible for anterior- posterior control
39
When is the posterolateral bundle of the ACL lax and taut?
- Lax in flexion
| - Taut in extension
40
What does the posterolateral bundle of the ACL help control?
Rotatory stability
41
What is the function of the ACL?
* Prevent anterior tibial translation
| * Checks hyperextension
42
With assistance from the hamstrings, the ACL works with __ to stabilize against valgus
With assistance from the hamstrings, the ACL works with the *MCL* to stabilize against valgus
43
___ is one of the most strongest ligament in the body
*PCL* is one of the most strongest ligament in the body
44
What is the function of the PCL?
Prevents posterior translation of tibia on femur
45
PCL is the the primary restraint to ____ and minor restraint to ____
PCL is the the primary restraint to *posterior displacement* and minor restraint to *varus/valgus*
46
What is the tibiofemoral angle with genu valgum?
TF angle <165 deg
47
Genu valgum increases the ____ compressive forces of the knee
Genu valgum increases the *lateral* compressive forces of the knee
48
What is the tibiofemoral angle with genu varum?
• TF angle >180 deg
49
Genu varum increases the ____ compressive forces of the knee
Genu varum increases the *medial* compressive forces of the knee
50
What is the Q angle?
Angle formed by line drawn from ASIS to mid-patella, and line from mid-patella to tibial
tuberosity
51
What is the normal Q angle in males?
10-14 deg
52
What is the normal Q angle in females?
15-17 deg
53
What is the normal knee flexion ROM?
130-140 deg
54
What is the normal knee extension ROM?
5-10 deg.
55
True or false
Hyperextension of the knee is normal
True
56
What is genu recurvatum?
Excessive hyperextension. Beyond 10 deg
57
What happens to AROM of the ankle in a closed chain?
* Decreased DF: decreased knee flexion
| * Decreased PF: decreased knee extension
58
How much knee flexion is required for normal gait?
60- 70
59
How much knee flexion is required to get on and off the toilet?
75
60
How much knee flexion is required for stair climbing?
70- 80
61
How much knee flexion is required to sit and rise from a chair?
90
62
How much knee flexion is required to get in and out the bath?
90
63
How much knee flexion is required for advanced function?
115
64
ROM in internal and external rotation influenced by amount of ____
ROM in internal and external rotation influenced by amount of *flexion*
65
In what position is knee rotation restricted and what causes the restriction?
Full extension, rotation is restricted by interlocking of femoral and tibial condyles
66
What is the range of ER in 90 deg of flexion?
0- 45 deg
67
What is the range of IR in 90 deg of flexion?
0- 30 deg
68
Tibial on femoral extension is an example of what type of arthrokinematic motion?
Concave on convex, so they move in the same direction
69
Femoral on tibial extension is an example of what type of arthrokinematic motion?
Convex on concave, so they move in opposite direction
70
Where is the screw home mechanism of the knee?
During the last 5 deg of extension
71
What happens during the last 5 deg of knee extension?
* Lateral femoral condyle shorter
* Medial tibial condyle continues to move on femur (that’s why it is larger)
* Lateral rotation of tibia on femur (IR of femur)
72
The screw home mechanism/ rotation is augmented by the ___ and ___
* Tension on ACL
| * Lateral pull of quadriceps
73
Flexion requires ___
Flexion requires *unlocking*
74
What does the femur do in CKC to unlocking required for knee flexion?
• Femur must laterally rotate on tibia (CKC)
75
What does the tibia do in OKC to unlocking required for knee flexion?
• Tibia must medially rotate (OKC)
76
What does the popliteus do in OKC to unlocking required for knee flexion?
• OKC: moves tibia medial (IR)
77
What does the popliteus do in CKC to unlocking required for knee flexion?
• CKC: moves femur lateral (ER)
78
The patellofemoral joint is the articulation of the ___ and ____
The patellofemoral joint is the articulation of the *patella and the femur*
79
What kind of bone is the patella?
Sesamoid
80
The posterior surface of the patella is covered with ____
The posterior surface of the patella is covered with *thick hyaline cartilage*
81
Where does the patella slide?
Patella slides within trochlear groove
82
What is the structure of the medial facet of the patella?
Flat to slightly convex
83
What is the structure of the lateral facet of the patella?
Longer than medial
84
What is the structure of the odd facet of the patella?
Medial angle
85
When do we have the 1st consistent patellofemoral contact?
Between 10-20o flexion
86
By ___ deg of flexion all aspects of facets, with the exception of the ____ facet of the patella have made contact with the femur
By *90* deg of flexion all aspects of facets with the exception of the *odd* facet of the patella have made contact with the femur
87
When does the odd facet make contact with the femur?
At 135 deg contact is on odd and lateral facets
88
As the angle of knee flexion increases, so do ____ forces
As the angle of knee flexion increases, so do *compressive* forces
89
Greatest patellofemoral compression force at ___
Greatest patellofemoral compression force at *90 deg flexion*
90
As Q-angle increases, so will ____, due to the pull of the quads
As Q-angle increases, so will *lateral vector*, due to the pull of the quads
91
Fully contracted quad in full extension produces ___ patellofemoral contact force
Fully contracted quad in full extension produces *little* patellofemoral contact force
92
Which facet bears the most force?
Medial facet will bear most force
93
What are the transverse stabilizers of the patella?
* Med/lat retinaculum
* Vastus lateralis (VMO/VL)
* Medial patellofemoral ligament
94
What are the longitudinal stabilizers of the patella?
* Quad tendon
| * Patellar tendon
95
What do the medial patellofemoral ligament of the patella do?
Prevents the patella from translating laterally
96
What are the other structures that help the patella stabilize?
* ITB
| * Lateral wall of femoral groove
97
What is the meniscus comprised of?
Comprised of wedge-shaped fibrocartilage
98
Which meniscus is more mobile?
Lateral meniscus
99
What do the menisci serve to do?
Distribute stresses or forces across the knee during weight bearing and provide appropriate shock absorption
100
What is the typical mechanism of injury for the meniscus?
Twisting injury
101
When is pain worse and when is it better with a meniscus injury?
Pain worse with movement, better with rest
102
What is something that a patient with a meniscus injury might complain of?
May complain of “locking” sensation
103
What type of tear do patients typically have when they complain of a locking sensation with a meniscal injury
Bucket- handle tear
104
What are hallmark signs of a meniscus pathophysiology?
- Joint line tenderness
| - Acute effusion (within 2 hours)
105
In what population do we see an acute sudden onset of a meniscus pathophysiology?
Younger than 40 years old
106
In what population do we see a chronic non specific mode of injury(MOI) of a meniscus pathophysiology?
Older than 50
107
What are the characteristics for a good prognosis of healing of a meniscal pathophysiology?
- Age <35
- Peripheral damage
- Longitudinal tear
- Short tear
- Acute injury (bloody effusion)
- Stable knee
108
What are the characteristics for a poor prognosis of healing of a meniscal pathophysiology?
- Older patient
- Central damage
- Complete tear
- Bucket handle tear
- Chronic injury
- Unstable knee
109
What are the hallmark signs to be looking for in the objective exam as it relates to a meniscal examination?
- Joint line tenderness: good sensitivity
- 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
110
What are the surgical management options for a meniscus pathophysiology?
- Debridement/menisectomy
- Repair
- Transplant
111
What are the indications for a meniscus repair?
* Traumatic lesion within vascular zone
* Intact peripheral circumferential fiber
* Minimal damage to meniscal body
* Longer than 8mm
112
Is there a significant difference between surgery then PT or just PT for meniscal injuries?
No there isn't
113
What are the principles for meniscus rehab?
```
• Understand surgical procedure well
• Repair vs. debridement
• Semimembranosus insertion on
medial meniscus, so no hamstring therex
• WB precautions
• Timeline of repair
• Control effusion
• Do NOT push ROM
• Restore normal gait
• Restore strength and proprioception
```
114
What are the main zones in articular cartilage?
- Zone 1: Tangental zone
- Zone 2: Transitional zone
- Zone 3: Radial zone
- Zone 4: Calcified cartilage
115
What type of cartilage is articular cartilage?
Hyaline cartilage
116
What is the job of articular cartilage?
To reduce the friction at the end of 2 long bones and can be a shock absorber
117
What are the characteristics of a traumatic articular cartilage pathophysiology?
* Often associated with concomitant ligament damage
| * Often missed acutely
118
What are the characteristics of a non traumatic articular cartilage pathophysiology?
* Repetitive microtrauma
* Many lesions are non-progressive and remain asymptomatic
* Grade I and II lesions are typically asymptomatic
119
What are the things to do or look for during an articular cartilage examination?
- Thorough history
- Thorough palpation (tenderness or bony)
- Malalignments
- Painful crepitus (knee making noise)
- Mechanical symptoms
- Quad atrophy
- Sensitivity to weather changes
- Pain and effusion after use
- Deep, dull ache
120
What are the mechanical symptoms we're looking for in an articular cartilage examination?
Cracking, knocking, grinding
121
What are the things to asses in the quad during an articular cartilage examination?
- Quad girth
- Quad tone
- Ability to recruit the quads
122
What are the surgical management options for an articular cartilage pathophysiology in order of most conservative?
- Debridement and lavage
- Microfracture
- Autologous Chondrocyte Implantation
- Osteochondral Grafting (OATS)
123
What is a debridement and lavage and what kind of relief symptoms does it have?
- Remove particles of cartilage and inflammatory cells
| - Short term pain relief of symptoms
124
Why don't we see a debridement and lavage anymore?
- Probably does not improve pain or ability to function compared to placebo (sham surgery)
- Probably leads to little or no difference in pain or ability to function compared to lavage
- May improve pain compared to washout
- May not lead to any difference in pain or ability to function compared to closed needle joint lavage
125
What are the characteristics of a microfracture of the articular cartilage?
- Pick holes through tidemark
- Encourage blood flow
- Replaced with fibrocartilage
- WB has to be controlled
- Long-term data
126
In what population might a microfracture be more indicated and why?
In the less active population, because there is alot of NWB with this procedure
127
What does the surgeon do during an Autologous Chondrocyte Implantation (ACI)?
- Small biopsy of autologous articular cartilage is harvested
- Cartilage is enzymatically digested in lab to release chondrocytes
- Chondrocytes cultured, and implanted at second surgery
- Periosteal flap placed as patch
128
What does the surgeon do during an Osteochondral Grafting (OATS)?
- Remove plug from NWB surface
| “Press-fit” plugs implanted into lesion
129
What are the factors to help decide the surgical intervention for an articular cartilage pathophysiology?
- The size of the tear
| - Patient's activity level
130
What are the basic rehab principles for articular cartilage lesions?
- Fully understand the surgical procedure
- Control WB status
- PROM is key
- Slow and progressive rehab
- Rarely return to sports: emphasis on ADL’s without pain
- Constant communication with MD
131
What is osteoarthritis OA?
The degeneration of cartilage and underlying bone
132
Knee OA causes significant limitations in...?
Significant limitations in ambulation, stairclimbing, getting up from a chair, carrying groceries, heavy household chores
133
What does articular cartilage function to do?
Functions to bear and distribute compressive loads and to reduce friction between joint surfaces
134
What are the types of tissue that the knee joint depend on to function properly?
* Cartilage
* Bone
* Capsule and ligaments
* Muscle and tendon
135
What are the changes that can occur in the structure of a subchondral bone?
* Sclerosis (hardening)
| * Cyst formation
136
What does sclerosis do to the bone?
A hardening that decreases the ability to withstand repetitive compressive forces
137
What are the types of changes in bone structure that may occur?
* Subchondral bone
* Osteophyte formation
* Bone marrow lesions
* Osteonecrosis and bone attrition
* Joint deformity
138
What are the generic risk factors for OA?
- Genetics
- Bone mineral density
- Occupation
- Physical activity
139
What are the characteristics of bone mineral density (BMD) as a generic OA risk factor?
* Higher BMD resulted in 2.3x greater incidence of knee OA
* Higher BMD was not associated with progression of OA in those who already had OA
* Bony attrition associated with the progression of OA might explain this finding
140
What kind of occupation is a generic OA risk factor?
Occupations requiring lots of squatting, kneeling combined with heavy lifting
141
What are the risk factors for knee OA?
* Increased risk with increased age
* 70/30 Female/Male
* Obesity
* Associated with increased incidence of Knee OA
* Associated with greater progression if you already have knee OA
* Knee OA + Obesity yields greater disability than Knee OA without obesity
142
What are the characteristics of pervious knee injury as a risk factor for knee OA?
* ACL and/or meniscus injury significantly increases the risk of incident knee OA
* Surgical management does not prevent the incidence of knee OA at this time
143
Genu varum leads to increased ____ compartment OA
Genu varum leads to increased *medial* compartment OA
144
Genu valgum leads to increased ____ compartment OA
Genu valgum leads to increased *lateral* compartment OA
145
True or false
People with a leg length discrepancy are 2x more likely to have knee OA
True
146
True or False
Leg length discrepancy is associated with the incidence of knee OA
False
147
What are the typical radiographic signs of knee OA?
* Osteophyte forma:on
* Joint space narrowing
* Sclerotic (hardening) changes in the subchondral bone
148
What is a grade 0 in the radiographic grading criteria for knee OA?
No radiographic findings of OA
149
What is a grade 1 in the radiographic grading criteria for knee OA?
Minute osteophytes of doubtful clinical significance
150
What is a grade 2 in the radiographic grading criteria for knee OA?
Definite osteophytes with unimpaired joint space
151
What is a grade 3 in the radiographic grading criteria for knee OA?
Definite osteophytes with moderate joint space narrowing
152
What is a grade 4 in the radiographic grading criteria for knee OA?
Definite osteophytes with severe joint space narrowing and subchondral sclerosis
153
What are the limitations of radiographic exams?
• Can have normal radiographic even though there are early signs of cartilage degeneration
• MRI can pick up early cartilage loss better than radiographs
• Standard MRI may appear normal even though there are degenerative changes within the cartilage
• Specialized enhanced MRI procedures (e.g., gadolinium) are becoming more common to recognize early changes in
cartilage
154
What are the clinical and radiographic classification of knee OA?
* Knee pain and at least 1 of the following 3:
* Age > 50
* Morning stiffness < 30 minutes
* Crepitus + Osteophytes
• 91% Sensitivity, 86% Specificity
155
What are the clinical classification of knee OA?
* Knee pain plus 3 of the following 6:
* Age > 50
* Morning stiffness < 30 minutes
* Crepitus
* Tenderness
* Bony Enlargement
* No palpable warmth
95% Sensitivity, 69% Specificity
156
What are the sources of pain in knee OA?
* Synovium
* Bone
* Nerves
157
Why isn't the cartilage a source of pain in knee OA?
It is not innervated
158
How can the synovium cause pain?
Synovitis from inflammatory cell infiltration, cartilage and bone debris
159
What may trigger synovitis?
Infrapatellar fat pad irritation may trigger synovitis
160
How may bone be a cause of pain in a knee OA?
```
• Sub-chondral bone
• Thinning of cartilage
• Vascular congestion
- Intraosseus pressure
- Bone angina
- Bone attrition
• Periostitis from osteophyte formation
• Bone marrow lesions
```
161
How may nerves be a cause of pain in a knee OA?
• Damage to joint tissues may also result in
alterations of nerve structure in tissues
• May result in neuropathic pain source
• Nerves become hypersensitive
162
Is there a direct connection for severity of knee OA and pain?
Not in all patients
163
What are the potential modifiable pre-treatment factors influencing the outcome of knee OA?
* Obesity
* Joint Mobility
* Lower Limb Alignment
* Knee Instability
* Psycho-Social Factors
164
How is obesity a risk factor for knee OA?
* Increased probability of development and/or progression of knee OA.
* Obese individuals with knee OA have greater disability than those with knee OA who are not obese.
165
How is limited knee motion associated with lower functional scores?
* Reduced flexion/extension excursion associated with lower function score.
* Reduced maximum knee flexion associated with lower function on WOMAC
166
How does alignment correlate with pain in the knee?
Neutral alignment has greater pain relief
167
What interventions are there for alignment in regards for pain and relief?
None, some may help individual patients but there is no standard one.
168
Promoting ____ during rehab may help improve overall function even if it
is difficult to overcome physical impairments.
Promoting *self-efficacy* during rehab may help improve overall function even if it
is difficult to overcome physical impairments.
169
What is adherence to HEP and physical activity recommendations associated with?
* Reduced pain (WOMAC-pain)
| * Better Function (WOMAC-physical function)
170
How do we encourage adherence in our patients?
* Periodic communication
* Periodic face-to-face rechecks
* Use of exercise diaries
* Use of booster sessions
* Engaged family
171
What are the indications for total knee arthroplasty (TKA)?
* OA
* Inflamed synovium (RA)
* Post-traumatic arthritis
172
What is the protocol for TKA now?
* Admitted morning of surgery
* Mobilize day of surgery or POD 1
* Usually WBAT
* Length of stay (LOS) < 5days
173
What happens to quad strength and activation post TKA?
Strength reduces by 60% and activation by 20%
174
What is the role of pre-op education for a TKA?
• Inconsistent outcomes, but the studies have generally reported decreased post-op pain, medication use, LOS, and fear/anxiety
175
What is the role of pre-op exercise for a TKA?
* Inconclusive studies
| * Improvement with pre-op function but not in post-op recovery, decrease of LOS or complications
176
When does phase 1 of TKA rehab exercise start?
0- 1/2 weeks
177
What are the goals of phase 1 of TKA rehab exercise?
* Control postoperative swelling
* Minimize pain
* Knee ROM 0-90°
* Muscle strength 3/5-4/5
* Ambulation with or without use of an assistive device
* Establish home exercise program
178
What are the interventions utilized in phase 1 of TKA rehab?
* Passive range of motion (PROM)-CPM as indicated per physician
* Ankle pumps to decrease risk of DVT
* Bed mobility and transfers usually initiated
* Heel slides in supine or sitting to increase knee flexion
* Muscle setting exercises (Quad sets)
* Gravity-assisted knee extension in supine
* NMES
* Gentle stretches for the hamstrings, calf, and iliotibial band
* Pain modulation modalities
* Compression to control effusion
* Gait training
* Manual Therapy
179
When should an NMES treatment start post TKA?
Started Day 2 Post-op
180
Where is the electrodes placed for NMES treatment for TKA rehab?
Electrodes placed over distal vastus medialis and proximal vastus lateralis
181
Where should the leg be during NMES treatment for TKA rehab?
Leg secured by Velcro at 60˚ knee flexion
182
What should the intensity of the NMES unit be set to for TKA rehab?
Intensity set to maximum tolerance
183
What are the parameters for NMES treatment for TKA rehab?
* Biphasic, 50Hz current
* Pulse duration: 250s
* 15 second on-time, 45 second off-time
* 15 repetitions (2x/day) for 3 weeks, then
* 15 repetitions (1x/day) for 3 weeks
184
When is phase 2 of TKA rehab exercise?
3-6 weeks
185
What are the goals for phase 2 rehab exercise?
* Diminish swelling and inflammation
* Increase ROM 0-115° or more
* Increased weight bearing tolerance
* Muscle strength 4/5-5/5
* Return to functional activities
* Adhere to home exercise program
186
What are the interventions utilized in phase 2 of TKA rehab?
* Incision mobilization after suture removal, when incision is 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, such as cycling without resistance, walking, or swimming
187
When is phase 2 of TKA rehab exercise?
6 weeks and beyond
188
What are the goals for phase 3 rehab exercise?
* Progress ROM 0-115° as able, to a functional range for the patient
* Enhance strength and endurance and motor control of the involved limb
* Increase cardiovascular fitness
* Develop a maintenance program and educate patient on the importance of adherence, including methods of joint protection
189
What are the interventions utilized in phase 3 of TKA rehab?
* Continue interventions of previous phases; advance as appropriate
* Implement exercises specific to functional tasks
* Improve cardiorespiratory and muscle endurance with activities such as bicycling, walking, or aquatic programs
190
What are the red flags to look for in a TKA rehab?
* DVT
* Pulmonary Embolism
* Infection
191
What are the characteristics of an infection as it relates to a TKA?
* Persistent fever (higher than 100°F orally)
* Shaking chills
* Increasing redness, tenderness, or swelling of the knee wound
* Drainage from the knee wound
* Increasing knee pain with both activity and rest
