Knee

Question 1

Meniscus Zones

Answer 1

Red-Red: Outer 1/3 (will heal well)
Red-White: Middle 1/3 (some vascularity, sometimes will heal but often won’t)
White-White: Inner 1/3 (potential to heal is very low)

Question 2

Meniscus Pathophysiology

Answer 2

1. Usually twisting
2. Pain with movement, better with rest
3. May have locking (bucket handle)
4. Joint line tenderness (hallmark)
5. Acute Effusion (usually within 2 hours)

Question 3

Meniscus Issues Based on Age

Answer 3

Acute is usually sudden onset and in people less than 40. Chronic usually no specific mechanism and in people >50.

Question 4

How common are meniscus lesions?

Answer 4

Almost as common as RTC tears. How old you are is about the percentage likelihood of having a RTC tear (20% in 20’s, 30% in 30’s).

Question 5

Types of meniscal tears?

Answer 5

1. Longitudinal
2. Bucket handle
3. Radial (cut along width)
4. Root tear (at the root)
5. Oblique/Flap (looks like a little penis coming off the middle)
6. Horizontal (horizontal tear)

Question 6

When will meniscal tears heal?

Answer 6

If less than 35 years old and on the periphery there is likelihood that it will heal.

Question 7

Factors for good vs bad prognosis with meniscus tears?

Answer 7

Good:
- Age <35
- Longitudinal tear
- Peripheral tear
- Short tear
- Acute injury with bloody effusion
- Stable knee

Poor:
- Older patient
- Central damage
- Complete tear
- Bucket handle tear
- Chronic injury
- Unstable knee

Question 8

Most sensitive test for meniscus tear

Answer 8

Joint line tenderness

Question 9

McMurray’s and Thessaly’s Tests

Answer 9

They have decent specificity but poor sensitivity.

Question 10

Exercises to be careful with following meniscal repair?

Answer 10

If medial meniscus repair the semimembranosus attaches to this so be careful with isolated hamstring strengthening.

Question 11

Articular cartilage damage grades?

Answer 11

1: Nearly normal (superficial lesions. Soft indentation and/or superficial fissures/cracks)
2: Abnormal (extends down <50% of cartilage depth)
3: Severely abnormal (extends down >50% into calcified layer and down do but not through subchondral bone)
4: Into subchondral bone

Question 12

How is articular cartilage managed surgically?

Answer 12

Palliative -> Reparative -> Resorative

1. Debridement and levage
   - Removes particle of cartilage and cleans
   - Cochrane Review: Probably doesn’t do much for pain/function
2. Micro fracture
   - Poke holes through tide mark (bottom layer of cartilage that is somewhat calcified)
   - Hyaline cartilage is replaced with fribrocartilage though (fibrocartilage is less resilient)
   - WB has to be controlled
   - Advocated as 1st line of intervention
   - Decent short term data but less optimal medium/long-term
   - LIkely not appropriate for athlete
3. Autologous chondrocyte implantation
   - 2 step process
   - 1st surgery you go in and harvest chondocytes and grow them in a Petrie dish
   - Then you go back in and implant then and put a periosteal flap over it
   - Mixed reviews on outcomes
4. Osteochondral Autograft Transplantation System (OATS)
   - Harvest a bone plug from NWB surface (femoral notch) and then implant into defect
   - Not great outcomes

Question 13

Rehab after cartilage procedure

Answer 13

Usually very slow rehab. Have to go slow. Need large amounts of passive motion (CPM up to 8-10 hours each day) to smooth out the surface

Question 14

How to see if knee valgus is related to pain?

Answer 14

Have them exaggerate their valgus, it should make their pain worse. Then have them correct the valgus, they should feel better.

Question 15

Ways to reduce knee valgus?

Answer 15

Check the sagittal plane. Anterior pelvic tilt will IR the hips. When running try to have them “run taller” this will require less knee flexion and decrease the valgus.

Question 16

How to accurately measure knee valgus during running?

Answer 16

There is a lot of variability with it and in order to get an accurate measure you usually need to take an average of about 8 strides.

Question 17

Risk factors for Osgoods-Schlatters?

Answer 17

1. Male
2. Age: Male 12-15, Female 8-12
3. Sudden skeletal growth
4. Repetitive jumping/sprinting

Question 18

What can Osgood-Schlatter lead to?

Answer 18

In severe cases can lead to partial/full avulsion of tibial tubercle.

Question 19

Functional strength testing with patellar tendinopathy?

Answer 19

1. Check thigh circumference
2. 15 one legged step downs without letting foot touch
3. Single leg calf raises (jumping athlete should be able to do 40)
4. Decline squat to 30 degrees on slant board