Week 7 Flashcards
1
Q
What is anterior knee pain/ patellofemoral pain?
A
Pain around or behind the patella, which is
aggravated by at least one activity that loads the patellofemoral joint during weight bearing on a flexed knee (eg. squatting, stair ambulation, hopping/jumping)
2
Q
Vastus medialis obliquus (VMO) atrophy is representative of ___
A
Vastus medialis obliquus (VMO) atrophy is representative of quad weakness, hence why it is not the cause of abnormal patellar tracking
3
Q
What direction of glide does the VMO move the patella?
A
Superior glide
4
Q
What are the painful structures in the knee?
A
Anterior synovial tissues, retinaculum, fat pad, and capsule
5
Q
What are the non- painful structures in the knee?
A
Patellar articular cartilage
6
Q
Patella femoral pain is a ____ problem
A
Patella femoral pain is a soft tissue problem
7
Q
There is a direct relationship between severity of pain and severity of neural damage within the ____
A
There is a direct relationship between severity of pain and severity of neural damage within the lateral retinaculum
8
Q
What are the 3 subgroups within the patellofemoral pain population?
A
- Strong
- Weak and tight
- Weak and pronated
9
Q
What are the subgroups of patellar compression syndromes?
A
- Excessive lateral pressure syndrome (ELPS)
* Global patellar pressure syndrome (GPPS)
10
Q
What are the presentations of an excessive lateral pressure syndrome (ELPS)?
A
- Tight lateral retinaculum
- Tight IT band
- Tight TFL
11
Q
What are the presentations of a global patellar pressure syndrome (GPPS)?
A
- Tight gastroc, quads and hamstrings
12
Q
What are the presentations of patients with patellar instability?
A
- Lax ligaments
- Ellas danlos: inability to control the patella
- Shallow trochlear groove
13
Q
What are the presentations of a biomechanical dysfunction of the knee?
A
Significant genu valgus and femoral IR (so the femur is the problem, not the patella)
14
Q
____ strengthening is effective in reducing the intensity of pain and improving functional capabilities in patients with patella femoral pain syndrome (PFPS)
A
Hip muscle strengthening is effective in reducing the intensity of pain and improving functional capabilities in patients with patella femoral pain syndrome (PFPS)
15
Q
____ is a shock absorber tat controls the extensor mechanism of the knee
A
The quads is a shock absorber tat controls the extensor mechanism of the knee
16
Q
What are the things that drive patellar hypomobility?
A
- Lateral retinaculum
- Patella alta
- General hypomobility
17
Q
How do we deal with a patellar hypomobility caused by the lateral retinaculum?
A
Lateral border lift with medial glide
18
Q
How do we deal with a patellar hypomobility caused by the patella alta?
A
Stretch quadriceps
19
Q
How do we deal with a patellar hypomobility caused by the general hypomobility?
A
- Patellar mobilizations at 0 and 30 degrees
- Low load, long duration stretching
20
Q
What are the things that drive patellar hypermobility?
A
- General soft tissue laxity
- Bony stability (shallow trochlear groove)
- Lateral instability
- Patella alta
- Biomechanical
21
Q
How do we deal with a patellar hypermobility caused by general soft tissue laxity and bony stability?
A
Use a brace
22
Q
How do we deal with a patellar hypermobility caused by lateral instability?
A
Assess and treat ITB and TFL
23
Q
How do we deal with a patellar hypermobility caused by patella alta?
A
Test and stretch quads
24
Q
How do we deal with a patellar hypermobility caused by biomechanical problems?
A
Address NM deficits
25
What does a problem with the gastroc length lead to in the LE from a flexibility stand point?
- Reduced DF
| - Excessive subtalar pronation and tibial IR
26
What does a problem with the quad length lead to in the LE from a flexibility stand point?
Increased patellofemoral pressures
27
Do orthoses(comfort thingies you put in your shoe) work for patients with PFP?
Fora subgroup of people. And usually over the counter ones work
28
What subgroup of people do orthoses work for?
* Greater midfoot mobility
* Reduced ankle dorsiflexion
* Immediate pain reduction with orthoses as seen with SL squat
29
What type of knee fracture account for about 72% of knee fractures?
- Patella 40%
| - Tibial Plateau 32%
30
What are the two clinical prediction rules to rule out a knee fracture?
- Ottawa Knee Rule
| - Pittsburgh Knee Rule
31
What are the conditions that if present will indicate that a radiograph should be done in the ottawa knee rule?
```
• Age 55 or older
• Isolated tenderness of patella
• Tenderness over fibular head
• Unable to flex knee > 90
degrees
• Unable to weight bear
immediately, or in the emergency room for 4 steps
```
32
What are the conditions that if present will indicate that a radiograph should be done in the pittsburgh knee rule?
Blunt trauma or a fall as mechanism of injury plus either of the following:
• Age
• Older than 50 years or
• Younger than 12 years
• Inability to walk 4 weight-bearing steps in the emergency department
33
What is the type 1 Salter- Harris classification of epiphyseal complex fracture?
Fracture through the physis (widened physis)
34
What is the type 2 Salter- Harris classification of epiphyseal complex fracture?
Fracture partway through the physis extending up into metaphysis
35
What is the type 3 Salter- Harris classification of epiphyseal complex fracture?
Fracture partway through the physis extending down into the epiphysis
36
What is the type 4 Salter- Harris classification of epiphyseal complex fracture?
Fracture through the metaphysis, physis, and epiphysis can lead to angulation deformities when healing
37
What is the type 5 Salter- Harris classification of epiphyseal complex fracture?
Crush injury to the physis
38
What are the goals of fracture management?
* Restore the patient to optimal functional state
* Prevent fracture and soft-tissue complications
* Get the fracture to heal, and in a position which will produce optimal functional recovery
* Rehabilitate the patient as early as possible
39
Getting a fracture to heal has been improved by the use of ____ as a way to stabilize fractures and allow earlier movement, increase likelihood of a positive outcome and improved rehab process
Getting a fracture to heal has been improved by the use of *open reduction internal fixation (ORIF)* as a way to stabilize fractures and allow earlier movement, increase likelihood of a positive outcome and improved rehab process
40
What is the PT fracture care?
Movement and muscle contraction around fracture dependent upon stability
41
What are the things that the PT should always consult the physician regarding?
* Stability of fracture
* Precautions
* Motions allowed
42
During rehab in the immobilization stage, what are the ways that the PT can minimize the effects of immobilization?
```
• Patient education!
• Maintain cardiovascular fitness
• Upper body ergometer
• Maintain uninvolved joints and extremities
• Provide means of safe mobility
• Prevent respiratory complications and
decubiti
```
43
How often does a PT see the patient during the immobilization stage?
May only see patient one time
44
What are the things to assess for in the mobilization stage of rehab?
* Impairments in body function/structure
* Activity limitations
* Participation limitations
45
What are possible interventions for the mobilization stage of rehab?
* Patient education
* Manual therapy
* Therapeutic exercise
* Aerobic, strengthening, stretching
* NM reeducation/Proprioception
* Function!!!
46
What are the possible mechanisms for a distal femur fracture?
MVA or fall
47
What are the types of distal femur fractures found?
* Condylar (intraarticular)
* Intercondylar
* Supracondylar
48
What is usually the mechanism of injury for a femoral condylar fracture?
Axial loading with valgus or varus stress
49
What are the presentations of a femoral condylar fracture?
Unable to WB
• Pain over distal femur
• Hemarthrosis
50
What is the most common type of patella fracture?
Transverse
51
What are the mechanism of injury for a patella fracture?
- Direct blow to patella
- Knee hyperflexion
- Contraction of the quadriceps muscle.
52
What are the presentations of a patella fracture?
- Pain
- Swelling
- Crepitus
- Pain extending the knee
53
____, and ____fractures result in an inability to SLR
*Displaced, transverse* fractures result in an inability to SLR
54
___ view on an x- ray is the best to see a patella fracture
*Sunrise* view on an x- ray is the best to see a patella fracture
55
____ is common and is part of the development seen in a patella fracture
*Bipartite patella* is common and is part of the development seen in a patella fracture
56
What is the management/ treatment option for a nondisplaced transverse fractures with intact
extensor mechanism?
* Knee immobilizer 6 weeks, PWB crutches
| * May displace and need ORIF
57
What is the management/ treatment option for a displaced fractures, or disrupted extensor
mechanism?
• May need ORIF or partial or total patellectomy
58
The patella usually dislocates ___
The patella usually dislocates *laterally*
59
In what population is a patella dislocation more common?
Adolescent girls
60
What is the MOI of a patella dislocation?
Twisting injury, valgus load or a direct blow
61
A patella dislocation may have a ____ fracture
A patella dislocation may have a *osteochondral* fracture
62
What are the management options of a patella dislocation?
* Knee immobilizer
* Knee extensor muscle training
* PWB with crutches
* Bracing
* RICE
* McConnell taping
* E-stimulation for activation of quad
63
What are the parameters for bracing a dislocated patella/
• Set at 0 degrees initially with
ambulation
• Lateral buttress pad
64
What is the goal for using McConnell taping for a patella dislocation?
Trying to pull the patella to the medial aspect, to tray to help the joint capsule to minimize problems
65
What is the prognosis after a patellofemoral dislocation?
* 30-50% have long-term instability or pain
* With rapid management, 70% of patients will have a painless, stable knee
* Of the remaining 30%:
* 50% have reasonable function
* 50% have chronically unstable and painful knee
66
Where is the tibial eminence?
The area between the medial and lateral tibial plateau
67
In what population is a tibial eminence fracture most common?
Most common 8-14 years old
68
What is the MOI of a tibial eminence fracture?
Direct blow to proximal tibia with knee flexed or hyperextension with varus or valgus stress
69
What are the management options for a tibial eminence fracture?
```
• Nonoperative treatment for nondisplaced
• Immobilization for 4-6
weeks.
• ORIF for displaced fractures
• Physical therapy
```
70
In what population is a tibial tubercle fracture most common?
Common in adolescents and in females.
71
What is the MOI of a tibial tubercle fracture?
Sports involving jumping
72
What are the management options for a tibial tubercle fracture?
* Nonoperative treatment for nondisplaced with immobilization for 4-6 weeks
* ORIF for displaced fractures
73
Where is the tibial tubercle?
Where the patella tendon inserts into the anterior aspect of the knee
74
What is the prognosis of a tibial tubercle fracture?
Good, but they may have lingering quad weakness
75
What is the management for a tibial plateau fracture?
* Non-displaced immobilized 4-6 wks
* ORIF for displaced fractures > 3mm
* May need bone grafting
76
What is the management goal of a tibial plateau fracture?
Stable, aligned, mobile knee to minimize risk of OA
77
What is the prognosis for a tibial plateau fracture dependent on?
Whether or not the fracture extends into the joint space and the articular cartilage is involved
78
What is the prognosis for a tibial plateau fracture when fracture extends into the joint space and the articular cartilage is involved?
There is a greater likelihood of having a long term issues in function, and 1/5 will have some type of residual loss of motion or stiffness
79
What is a segund fracture?
Bony avulsion of the lateral tibial plateau
80
Where is the site of the segund fracture?
Site of attachment of LCL
81
___ dislocations are true lim theatening, because of the loss of vascular supply
*Knee* dislocations are true lim theatening, because of the loss of vascular supply
82
A knee dislocation is described based on displacement of ___ on ___
A knee dislocation is described based on displacement of *tibia
on femur*
83
Where is a knee dislocation most common?
Most common is anterior
84
There can be a ___ knee dislocation with direct trauma
There can be a *posterior* knee dislocation with direct trauma
85
What are the possible neurovascular bundle injury seen in a knee dislocation?
* 10% with normal pulse
* Peroneal nerve
* dorsum sensory, dorsiflex
* Post tibial nerve
* plantar sensory, plantarflex
86
What needs to occur for a knee to be dislocated?
Disruption of cruciate/collateral ligaments
87
What are the management options for a knee dislocation?
* Knee immobilizer
* Long rehab to return function
* May have instability
* Most need reconstruction
88
What are the complications of knee dislocation?
* Quadriceps muscle atrophy
* Joint stiffness
* Arthritis (if intra-articular)
* Other injuries, often missed until PT starts!
* Shock
* Fat emboli (femoral shaft fx)
* Avascular necrosis (condylar)
* Quad tendon ruptures
* Patellar instability (patellar fx)
* Damage to popliteal fossa structures
89
What are some red flag conditions related to the knee?
- DVT
- Peripheral arterial occlusive
disease
- Compartment Syndrome
- Septic Arthritis
- Cellulits
90
What are the key historical findings of a peripheral arterial occlusive disease?
- Age >60
- Type II DM
- Ischemic Heart Disease history
- Smoking history
- Sedentary
- Intermittent claudication
91
What are the key physical exam findings for a peripheral arterial occlusive disease?
* Increased capillary refill time (>2 seconds)
* Decreased LE arterial pulses
* Prolonged venous refilling times (>20 seconds)
* ABI <0.90
92
What are the key historical findings of a compartment syndrome?
- History of blunt trauma
- Crush injury
- Recent casting
- Unaccustomed exercise
93
What are the key physical exam findings for a compartment syndrome?
- Severe, persistent leg pain
- Paresthesia
- Pulselessness
94
What are the key historical findings of Septic Arthritis?
History of recent infection, surgery, or injection
95
What are the key physical exam findings for Septic Arthritis?
- Constant aching or throbbing
- Joint swelling
- Warmth
- Fever
- Chills,
- Malaise
- Weakness
96
What are the key historical findings of Cellulits?
History of recent skin ulceration or abrasion, venous insufficiency, CHF, cirrhosis
97
What are the key physical exam findings for Cellulits?
- Pain
- Skin swelling
- Warmth,
- Advancing irregular erythema
- Fever
- Chills
- Malaise
- Weakness
98
What are the medical screening questions for the knee?
1. Have you recently had a fever?
2. Have you recently taken antibiotics or medicine for an infection?
3. Have you recently had surgery?
4. Have you recently had an injection to your joint?
5. Have you recently had a cut or open wound?
6. Have you been diagnosed as having an immunosuppressive disorder?
7. Do you have a history of heart trouble?
99
Where is septic arthritis found?
Intra-articular joint
100
What are the medical screening questions for the knee contd?
8. Have you ever been diagnosed as having poor circulation in your legs?
9. Do you have a history of cancer?
10. Have you recently had a long car, plane, or bus ride?
11. Have you recently been bed-ridden for any reason?
12. Do you have hip, thigh, groin, or calf pain that increases with movement or exercise?
13. Have you recently begun a vigorous physical exercise or training program?
14. Have you recently sustained a blow to your shin or other trauma to your legs?
101
What are some potential causes of anterior knee pain?
- Patellar Issues
| - Tibial Aphophysitis
102
What are the patella issues that can cause anterior knee pain?
* Subluxation/ Dislocation
* PFPS
* Patellar Tendonitis
* Articular Cartilage
* Osteoarthritis
103
What are the characterisitcs of Tibial Aphophysitis?
```
• Osgood-Schlatter’s Disease
• Adolescent, more common
in athletes, slightly more common in males
• Enlarged tibial tubercle
• Painful, activity limiting
• Radiographic separation of
patellar ligament insertion
```
104
What is the medical management involved with Tibial Aphophysitis?
There really isn't one, just find the activity or limits of pain for patient and keep them there
105
What are the causes of posterior knee pain?
1. Hamstring Tendon Insertions
| 2. Popliteus Muscle
106
What are the presentations of Hamstring Tendon Insertions that causes posterior knee pain?
```
• Pain with active/resisted
knee flexion
• Weakness
• Tenderness to palpation
• Pain with acceleration/
deceleration motions
```
107
What are the presentations of the Popliteus Muscle that causes posterior knee pain?
• Pain with running (downhill)
• Prone: knee flex & tibial IR = pain
• Often occurs as an injury in
extension, can mimic mild ACL/posterior capsule sprain
108
How would we manage a hamstring tendon insertion pain?
- Progressive exercise program
- Light stretching
- Ice and anti inflammatory medications
109
What are the causes of lateral knee pain?
- LCL injury
- IT band syndrome
- Lateral meniscus
110
An LCL injury is seen with ___ trauma
An LCL injury is seen with *a varus stress* trauma
111
What test do we use to identify a potential ligamentous damage to the LCL?
Varus stress test - 30° knee flexion
112
Why isn't an LCL injury common?
Because it takes a blow to the medial side of the knee to impact the LCL
113
What are the ways the lateral meniscus can be injured?
- Contact
| - Turning with the foot planted
114
What are the things the patient will complain of with a lateral meniscus injury?
- Sudden pain
| - Pain with foot planted
115
In what area is it common for the lateral meniscus to be injured?
The posterior lateral horn of the lateral meniscus
116
IT band syndrome is aggravated by...?
IT band syndrome is aggravated by *activity (running)*
117
What are the test that can be done to test for an IT band syndrome?
* Noble’s Test
| * Ober’s Test
118
How is the ober's test done?
- Put patient in side lying
- Get them to relax, then lower the leg, with the knee flexed and hip at neutral to slightly extended position
- Assess for decreased mobility
119
How is the noble's compression test done?
Compress the lateral ITB as the patient flexes and extends the knee and see if it mimics symptoms
120
What are the causes of medial knee pain?
- Medial Patella Plica syndrome
- MCL injury
- Medial meniscus
- Pes anserine bursitis
121
What is a medial patella plica?
A redundancy of the joint capsule
122
What are the presentations of a medial patella plica syndrome?
* Palpable
* Pain occurs with motion
* Painful crepitus
123
What causes a MCL injury?
- Valgus stress trauma
- Lateral blow to the knee
- Body turning on a planted leg
124
If you have an MCL tear, there is a possibility of having a ____ tear, because they are so close to one another
If you have an MCL tear, there is a possibility of having a *medial meniscus* tear, because they are so close to one another
125
What are the hallmark signs of a medial meniscus injury/ tear?
```
• Joint like tenderness (superior and inferior to the joint line and posterior aspect)
• Positive entrapment tests
(Squat, McMurry’s, Apley’s Compression)
• Mild-mod effusion
• Quad Inhibition
```
126
Where is the most common are for patients to have discomfort with a medial meniscus injury?
Posterior- medial aspect of the knee
127
What are the presentations of pes anserine bursitis?
* Hamstring Issue
* Tenderness to palpation
* Pain with activity
* Nocturnal Pain
128
In what population is Osteochondritis Dessicans (OCD) most common?
Occur in adults or in children
129
Osteochondritis Dessicans (OCD) is a result of ___
Osteochondritis Dessicans (OCD) is a result of *acute trauma or repetitive stress, or avascularization*
130
What are the symptoms of Osteochondritis Dessicans (OCD)?
- Mild knee effusion
- Pain
- Worse with activity
- Absence of positive special tests
131
What does Osteochondritis Dessicans (OCD) result in?
Flaking away or breaking down of the sub- chondral bone
132
____ is an early indicator of gout
*Big toe* is an early indicator of gout
133
A crystal- induced inflammatory arthropathy is thought of as ____
A crystal- induced inflammatory arthropathy is thought of as *pseudo- gout*
134
What are the presentations of a crystal- induced inflammatory arthropathy?
* Warm, red, swollen joint
* Exquisitely painful
* Sudden onset
* Chronic with intervals between attacks
135
What are the presentations of a neoplastic disease?
Persistent knee pain that exists without positive special tests, or is not reproducible through movement testing, especially in adolescents
136
A knee infection can range from ___ to ___ knee
A knee infection can range from *mild warm to swollen* knee
137
____ is a more serious infection that is seated in the distal aspect of the tibia
*Osteomyelitis* is a more serious infection that is seated in the distal aspect of the tibia
138
Ligaments are made up of ____, arranged in near parallel
Ligaments are made up of *dense type 1 collagen* arranged in near parallel
139
The elastic properties of the ligaments is due to ____
The elastic properties of the ligaments is due to *the type 1 collagen*
140
What does the elastic properties of the ligaments allow it to do?
• When load is applied, body
will deform in proportion to the load.
• When load is removed, body
will assume its original shape.
141
What does the viscous property of the ligament allow it to do?
* Resistance to flow of fluid
| * Ability to dampen forces
142
What are the characteristics of the biological material of the ligament?
• Not perfectly viscous or elastic
• Constantly undergo metabolic and structural changes
• Mechanical properties vary, depending on conditions such as temperature, injury,
disease, aging
143
The scar tissue formed by ligaments is a type __ collagen, hence it has less tensile strength
The scar tissue formed by ligaments is a *type 3 collagen*, hence it has less tensile strength
144
Moderate stress during the healing of a ligament induces ______
Moderate stress during the healing of a ligament induces *organization of collagen in more parallel arrangement in direction of applied forces*
145
Mechanical stress during healing of a ligament induces biochemical changes that result in ____
Mechanical stress during healing of a ligament induces biochemical changes that result in *more covalent cross link formation*
146
Mechanical stress during healing of a ligament ____ contraction of scars
Mechanical stress during healing of a ligament *minimizes* contraction of scars
147
Movement of joint during early phases of healing of a ligament appears to be ____
Movement of joint during early phases of healing of a ligament appears to be *sufficient stress*
148
What are the responses to immobilization in the ligament?
• Atrophy of ligament: Catabolic state predominates
• Get reduction in intracellular matrix and inferior ligament material production
• Can have resorption of bony insertion sites
• Adaptive shortening of structures
• Changes can begin to occur in just a few weeks of
immobilization
149
How long does it take to lose 50% of mechanical strength in a ligament due to immobilization?
• Can loose 50% of mechanical strength by 6-9 weeks of immobilization
150
What is the overall effect of immobilization to a ligament?
Overall effect is reduced tensile strength
151
True or false
Changes occur to uninjured structures when you mobilize a ligament for too long
True
Changes occur even in uninjured structures
152
During the recovery after immobilization of a ligament, ___ sites seem to recover 1st
During the recovery after immobilization of a ligament, *bone insertions* sites seem to recover 1st
153
Ligament injuries in the ___ of the ligament take longer to heal. Why?
Ligament injuries in the *middle* of the ligament take longer to heal. Because they have poor blood supply
154
Aging of ligaments results in____
Aging of ligaments results in *the inability to withstand peak loading*
155
In children, _____ sites are weaker and less developed so failure of ligaments in children usually occur here.
In children, *bony insertion* sites are weaker and less developed so failure of ligaments in children usually occur here.
156
____decreases with age and loses tensile strength
*Collagen content* decreases with age and loses tensile strength
157
___ is the primary restraint to valgus stress
*MCL* is the primary restraint to valgus stress
158
Grade __ and ___ injury to the MCL usually involves the
| meniscus
Grade *2 and 3* injury to the MCL usually involves
159
____ layer of the MCL is more vascular and first to be injured
*Superficial* layer of the MCL is more vascular and first to be injured
160
___ is the primary restraint to varus stress
*LCL* is the primary restraint to varus stress
161
In what position is the MCL most taut?
Knee extension and flexion
162
The LCL is separated from meniscus by the ____
The LCL is separated from meniscus by the *popliteus tendon*
163
Which is stronger, the LCL or the MCL?
LCL
164
When is the LCL most effective in its restraint?
0- 30 deg flexion
165
___ is the primary restraint for anterior translation of the tibia on femur or posterior translation of the femur on tibia
*ACL* is the primary restraint for anterior translation of the tibia on femur or posterior translation of the femur on tibia
166
The ACL has attachments with the ___
The ACL has attachments with the *anterior- medial horn of the meniscus*
167
In what position is the anterior- medial bundle of the ACL most taut?
Flexion
168
In what position is the posterior- lateral bundle of the ACL most taut?
Extension
169
Which of the bundles of the ACL is thought to play a greater role in rotational control?
Posterior- lateral bundle
170
In what position is the twisting of the bundles of the ACL more noted?
Flexion
171
In what position is the anterior- lateral bundle of the PCL most taut?
Flexion
172
____ bundle of the PCL is most taut in extension
*Posterior-medial* bundle of the PCL is most taut in extension
173
What does the PCL mainly restrain against?
Main restraint of posterior tibial translation or anterior femoral translation
174
What is the secondary role of the PCL?
Limiting:
• Femoral external rotation
• Tibial internal rotation
175
What does the PCL do when the knee extends?
When the knee extends the PCL slides the femoral condyles posteriorly as the femur rolls anteriorly
176
What does the ACL do as the knee flexes?
When the knee flexes the ACL slides the femoral condyles anteriorly as the femur rolls posteriorly
177
What are the things that a patient feels with an injury to the cruciate ligaments of the knee?
- Instability
- Catching
- Knee feels like its giving out
178
What are the signs and symptoms of a collateral ligament injury?
* Varus or valgus trauma is typical of MOI
* Varus or valgus stress testing will be positive
* MCL may be associated with ACL and meniscal symptoms
* Swelling, ecchymosis
* Joint effusion if meniscal involvement
* Tenderness to palpation of ligament (Attachments . and intrasubstance)
* Difficulty with pivoting, cutting, etc
179
What are the MCL examination findings for palpation?
May be difficult to differentiate from meniscus because of their anatomic
proximity
180
How is the Valgus stress test done?
* Knee flexed to 20-30°
* Valgus stress introduced
* (+) test is the presence of laxity and/or pain
* Sensitivity = .86
181
What are the LCL examination findings for palpation?
May be more sensitive than the MCL because the ligament isn’t attached to
the lateral meniscus or the capsule
182
How is the varus stress test done?
* Patient is supine; knee flexed to 20-30°
* Introduce varus stress at the joint line
* (+) test is the presence of laxity and/or pain
183
What are the signs and symptoms of an ACL injury?
* Severe pain with joint effusion
* “Popping”, “Giving way”, “Buckling”
* Continued effusion, recurrent episodes of giving way with ADLs
* Quad inhibition
* Limited range of motion
* Flexed knee gait
184
What are the non contact mechanism of injury of and ACL?
```
• Fixed foot with knee that
undergoes valgus/rotational
load (cutting, pivoting)
• Hyperextension load (step in
pot hole)
```
185
What are the contact mechanism of injury of and ACL?
• Posteriorly directed blow to
anterior femur
• Blow to the lateral knee when the foot is planted
186
What is the gold standard examination for ACL assessment?
Lachmans Test
187
How is the Lachmans Test done?
* Patient is supine with the knee flexed to 30°
* Stabilize the anterolateral distal femur
* Translate the tibia anteriorly with the opposite hand
* (+) test is anterior translation of the tibia beyond the femur with a “mushy” or “soft” end-feel
188
The Lachmans Test is thought to test more of the ___ bundle of the ACL
The Lachmans Test is thought to test more of the *posterior* bundle of the ACL
189
What would be present in a negative lachmans test?
A stopping feeling
190
What are some other test done for the ACL exam?
- Anterior drawer test
| - Pivot shift test (highly specific)
191
How is the anterior drawer test done?
* Patient is supine with knee flexed to 90°
* Tibia in neutral rotation
* Thumbs should be placed in joint line
* Femoral condyles should be ~1cm posterior to the tibial plateau at 90°
* Translate the tibia anteriorly
* Positive test is increased anterior translation and a soft end-feel
192
The anterior drawer test is thought to test more of the ___ bundle of the ACL
The anterior drawer test is thought to test more of the *anterior* bundle of the ACL
193
Why would an IR or ER be added to the anterior drawer test?
To possible identify involvement of either the cruciates or parts of the joint capsule that might be torn
194
____ test is designed to reproduce the “giving way”
| phenomena
*Pivot shift test* is designed to reproduce the “giving way”
phenomena
195
How is the pivot shift test done?
* Knee extended, tibia internally rotated
* Valgus force applied to proximal tibia to “sublux” lateral tibial plateau
* Knee moved into flexion
* Tibia “shifts” back into place about 30-40° of flexion
196
What are some possible impact to other tissues during an ACL injury?
* Multiple Ligament Injury
* Meniscal Injury
* Fracture/Dislocation
* Chondral Defects
* Neurovascular Compromise
197
What are the signs and symptoms of a PCL injury?
```
• Posterior knee pain
• Not as much effusion as ACL
• Flexion beyond 90° may
increase pain (open chain)
• Difficulty descending stairs,
squatting, running
• Not as much problem with
quad inhibition
• (+) Sag Sign, (+) Posterior
Drawer, reduced palpation of tibial plateau step-off
```
198
What are the mechanism of injury of the PCL?
```
• Hyperflexion
• Fall on a flexed knee with foot in plantarflexion
• Hyperextension mechanisms
• Step in a pothole
• Blow to anterior tibia
(Dashboard)
```
199
How is the posterior drawer test done?
* Patient supine with the knee flexed to 90°
* Assess tibial plateau
* With thumbs in the anterior joint line, apply a posterior force
* Positive test is excessive posterior translation and/or a soft end feel
200
How is a sag sign test done?
* Static test where the patient’s knees are supported and flexed to 90°
* Positive test is the anterior aspect of the tibia appears to sag
* Test has 100% Specificity
201
How do you assess the tibial plateau when doing the PCL examination?
* Tibial plateau should rest approximately 1cm anterior to femoral condyle
* Can create a situation where you obtain a false negative due to posterior position of the tibial plateau
202
What population is 6x more likely to tear their ipsilateral ACL with 24 months after surgery?
Females
203
Why is surgery considered standard for and ACL repair?
* Promote knee stability
* Prevent meniscal damage
* Protect articular cartilage
* Avoid degenerative changes
204
What are the 2 forms of stability at the knee?
- Mechanical stability
| - Proprioception
205
What does mechanical stability of the knee depend on?
Bony congruency, Ligamentous stability
206
What does proprioception stability of the knee depend on?
Mechanoreceptors
207
Which form of knee stability can be restored with surgery?
Mechanical stabilty
208
What is a coper?
An individual who can dynamically stabilize an ACL deficient knee
209
What are the characteristics of a coper?
* Must resume previous activity for >1 year
* No episodes of giving way
* Do not require surgery
210
What happens when a coper can not resume activity within a year?
Then the person is considered a non coper
211
What is a non coper?
An individual who can not dynamically stabilize an ACL deficient knee
212
What are the characteristics of a non coper?
* Giving way
* Unable to resume previous level of activity
* Require surgery
213
What are the kinematics of a coper?
* Joint stability
* Fewer episodes of giving way
* “Normal” knee ROM and forces during functional activities
214
What are the kinematics of a noncoper?
• Increased joint laxity
• Reduced knee ROM
during hop testing
• Reduced knee compression and shear forces during gait
215
What are the EMG presentations of a coper?
• Reduced quad control
• Preferential activation of
VL and medial hamstring
216
What are the EMG presentations of a non coper?
* Poor quad control
| * Increased quad activity during knee flexion
217
What are the activity differences of a coper vs a non coper?
NONE, they both present with:
* Return to activity: 82%
* Reduced activity scores: 21%
* Self-reports: “good function”
218
When should a patient be tested for whether or not they are a coper or non coper?
* After approximately 10 sessions of PT
* >60 days
* <6 months
219
What is an adapter?
An individual who can't necessarily go back to their former activities, but are still able to perform some other activity
220
What are the things to consider before going into ACL surgery, that might suggest you don't yet?
```
Pain
Effusion
Range of motion
Muscle function
Extension lag
Gait
How “angry” is it?
```
221
What ROM measurements are vital to have before going into ACL surgery?
- Full knee extension ROM
| - At least 120 deg flexion
222
What are the post op consideration for an ACL surgery?
- Initial graft strength
- Graft type
- Healing and maturation of graft
223
What are the pros of an ACL surgery that used an autograft?
- Faster incorporation and healing
| - Better outcomes in young, active patients
224
What are the characteristics of an ACL surgery that used an allograft?
- Less acute pain (not necessarily good)
- Greater decrease in structural properties
- Slow rate of biological incorporation
- Better for revisions
225
What are the cons of an ACL surgery that used an autograft?
- Donor site morbidity
| - Risk of fracture
226
What are the implications of a bone patellar tendon bone (BPTB) autograft?
```
Higher incidence of PFP
• Persistent quad weakness
• Injury to extensor mechanism
• Avoid early heavy eccentrics
• Modify squats to minimize PF
compression forces
```
227
What are the implications of a hamstring autograft?
```
• Less aggressive early on
• No isolated hamstring
strengthening until 8 weeks post op
• Hamstrings and transverse
plane control
```
228
How should the rehab implications following an allograft surgery to the ACL?
- Rehab following allograft reconstruction may need to be
less aggressive compared to autograft rehab
- Little is known about graft’s ability to withstand loads and
strain during healing and maturation
229
What happens when you 1st replace the ACL with a tendon from another part of the body?
- The tendon first starts to get weaker and is at its weakest point somewhere in week 8-12.
- After that, there is re-vascularization and the tendon comes back to life as a ligament. Wont achieve full capacity until a couple of years post op
230
What are the initial post op goals of the ACL?
- Quickly restore full passive extension
- Restore patellar mobility
- Control post-op inflammation
- Gently and slowly increase flexion ROM
- Establish and increase volitional quad strength
- Restore normal gait pattern
231
What does it mean to quickly restore full passive extension to the knee and how will that be done post ACL op?
- Reduce effusion
| - Alter WB status
232
How long post ACL op do we want to achieve PROM and AROM knee extension?
PROM: minimum 2 wks
AROM: 2- 3 weeks
233
What are the initial post ACL op ROM goals?
1-2 weeks: full passive extension
2-3 weeks: 100 degrees flexion
3-4 weeks: full active extension
4-6 weeks: full flexion
234
What does lack of extension post ACL op mean?
Cyclops Lesion
Poor graft placement
Restricted scar mobility
235
What are the ways to restore ROM post op ACL?
- Wall slides > assisted heel slides
- Low- low long duration (LLLD) heel prop > prone hangs
- Frequent extension mobes > aggressive
- Functional carryover is vital
- Address effusion!!!
236
Why are wall slides better than assisted heel slides to restore ROM post ACL op?
- Being in supine with leg elevated, allows effusion to drain out
- Passive intervention
237
What is the problem with a prone hang to restore ROM post ACL op?
- Not comfy
| - Hamstrings will guard (esp with a hamstring autograft)
238
___ combined with exercise may be more effective in improving quadriceps strength than exercise alone
*NMES* combined with exercise may be more effective in improving quadriceps strength than exercise alone
239
Should we be doing OKC or CKC strengthening exercises?
Both, as long as tey are modified
240
What range is the safe range for exercise post ACL op in OKC?
60- 90 deg
241
What is the 1st phase for neuromuscular training post ACL op?
- Usually a 2 legged task or a unidirectional single leg task
242
What is the goal of the 1st phase for neuromuscular training post ACL op?
Master basic component technique; control out of plane motions of extremities and trunk
243
What is the 2nd phase for neuromuscular training post ACL op?
Double to single leg transition, decreasing stability of support surface; narrowing base of support
244
What is the goal of the 2nd phase for neuromuscular training post ACL op?
Integrate additional component of task without compromise of technique
245
What is the 3rd phase for neuromuscular training post ACL op?
Introduction of 2nd perturbation to the patient's neuromuscular system
246
What is the goal of the 3rd phase for neuromuscular training post ACL op?
Patient is able to avoid loss of balance or form under perturbed conditions
247
What is the 4th phase for neuromuscular training post ACL op?
Multidirectional tasks that demand explosive movements and quick repetition; unstable surfaces and destabilizing perturbations
248
What is the goal of the 4th phase for neuromuscular training post ACL op?
Quick, explosive precise moments with rapid response to perturbations and without feedback from the PT
249
Should we be using a Criterion-Based vs. Timeline for a post ACL op rehab?
Both
Respect timeline
Emphasize criterion
250
What are the things to test for in the return to sport test for post ACL op?
Must ensure adequate strength,
| power, endurance, dynamic control, psychological readiness
251
What are the progressions test that we do in the return to sport test for post ACL op?
- YBT, FMS (if they pass the 2, progress to next test)
- Hop testing (3% difference between limbs)
- Tuck jump assessment
- Landing error scoring system
- Agility drills
- Fatigue protocol
- Kinesiophobia measures
