1. Age > 50 2. Ambulate > 4 steps WB 3. Knee flexion < 90 degrees 4. TTP to patella 5. TTP to fibular head

1. number of giving way from injury to screen <1 2. 6 m hop test 80% of non-involved LE 3. knee outcome score (KOS) at least 80% of contralateral limb 4. Global rating scale of perceived knee function GRS 80% of contralateral limb

1. JOINT LINE TENDERNESS- most diagnostic +22LR (ruling in) thessaly for r/o. - delayed swelling (6-24 hrs vs. lig that swells immediately) 2. clicking, locking 3. pain with end range knee flexion 4. pain with forced hyperextension 5. (+) mcmurrays Bonus: pain, clicking/locking in jt line with thessaly at 5, 20 degres

two theories 1. patellar malalignment - a/p; m/l opposing forces - a/p - patellar alta (tight quads) vs stress to patellar tendon - tight hamstrings can lead to overactive quads during walking m/l: tight lateral retinaculum, imbalances of quads 2. joint overload - excessive activity overloads PJ jt - usually runners and increase in training Exacerbated by increased loads - sitting, stairs, squatting, running TIGHT CALVES, TRIGGER POINTS IN QL AND GLUTE MED, WEAK QUADS/HIP ABD/ER

Only two with good reliability 1. Squatting - assess for pain 2. patellar tilt test- try to move lateral edge of patella off, if you cant, (+) retinacular tightness

1. Posterior drawer test (99 Spec, 90 sens) - 90 degrees knee flexion, add p/a force 2. Posterior sag sign (100% spec, 78.9 sens) - with active quad contraction (100% spec, 97.6 sens) 45 degrees hip flexion, 90 degrees knee flexion - look for a sag/sulcus of posterior shear of tibia

Originates on posteromedial aspect of LATERAL femoral condyle Attaches to anteromedial tibia two bundles - Anteromedial (smaller)- tested by Anterior drawer! - tight throughout flexion- resists translation when knee is flexed! - Posterolateral (larger)- tested by lachmann - primary restraint in full extension!- until about 20 degrees of flexion No strain on ACL from 0-120 knee flexion ROM - strain at last 30degrees of terminal knee ext ACL graft WEAKEST at 12 weeks- want to do any open chained strengthening before that

primary restraint to valgus force - resists valgus force in ext ~ 57% - ~25 degrees of knee flexion, adds 78% of valgus restraint - to avoid stressing it with ACL recovery, IR tibia with knee flexion or saggital plane movements

Knee Flashcards by Travis Ng

Ottowa Knee Rules

Age > 50
Ambulate > 4 steps WB
Knee flexion < 90 degrees
TTP to patella
TTP to fibular head

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Functional Tests

HOP FOR DISTANCE - best for ACL

- want quads 85% strength of contalateral

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Non-op ACL (Coper)

number of giving way from injury to screen <1
6 m hop test 80% of non-involved LE
knee outcome score (KOS) at least 80% of contralateral limb
Global rating scale of perceived knee function GRS 80% of contralateral limb

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ACL rehab

Only type A evidence is therex. Both open and closed chain stability exercises

B: knee brace immediate post op, NMES, supervised rehab, immediate WB post op

C: cryotherapy

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Meniscal involvement

JOINT LINE TENDERNESS- most diagnostic +22LR (ruling in) thessaly for r/o.
- delayed swelling (6-24 hrs vs. lig that swells immediately)
clicking, locking
pain with end range knee flexion
pain with forced hyperextension
(+) mcmurrays

Bonus: pain, clicking/locking in jt line with thessaly at 5, 20 degres

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ACL graft px

Hamstring- no resisted knee flexion x 12 weeks
Allograft- higher risk for graft failure
- faster immediate recovery, less post op pain
BTB- pain with kneeling

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ACL with mensicetomy vs repair

Meniscectomy doesnt change rehab
REPAIR does!
- no WB >45 knee flexion x 4 weeks
- WB < 90 x 4 weeks
- 8 weeks post op, resume normal protocol

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ACL with chondral repair

usually staged procedures

debridement doesnt change rehab
MICROFRACTURE does
- NWB 2-8 weeks

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ACL with other ligament repair

MCL usually treated non-op

if MCL is repaired- knee immobilizer in full ext x 6 weeks, WBAT
multilig stabilization - 6-8 weeks NWB

PLC- avoid varus and tibial ER, hyperextension and resisted knee flexion x 12 weeks

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0-40 degrees knee flexion

high COMPRESSIVE forces

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PFPS

two theories
1. patellar malalignment
- a/p; m/l opposing forces
- a/p - patellar alta (tight quads) vs stress to patellar tendon
- tight hamstrings can lead to overactive quads during walking
m/l: tight lateral retinaculum, imbalances of quads

joint overload
- excessive activity overloads PJ jt
- usually runners and increase in training

Exacerbated by increased loads
- sitting, stairs, squatting, running

TIGHT CALVES, TRIGGER POINTS IN QL AND GLUTE MED, WEAK QUADS/HIP ABD/ER

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PFPS clincial tests

Only two with good reliability

Squatting - assess for pain
patellar tilt test- try to move lateral edge of patella off, if you cant, (+) retinacular tightness

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Osgood Schlatter

Traction apophysitis of tibial tubercle

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Sinding Larsen Johannson syndrome

traction apophysitis of distal (inferior) patellar pole

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PFPS predisposing factors

larger q angle
shallow trochlea
weak quads/ hip abd/er
patellar tilt angle
lateral retinaculum thickening
TIGHT GASTROC/SOL!!

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patellofemoral forces

relies on contact area of patella, muscle force and vector between quad and patella

quad compression force greatest at knee ext
patella contact smallest at knee ext (want larger area to offset pressure)
from 45-0 of open chained= high compression force

CKC- 0-45 least amount of compression
OKC 50-90 degrees less compression

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PCL special tests

Posterior drawer test (99 Spec, 90 sens)
- 90 degrees knee flexion, add p/a force
Posterior sag sign (100% spec, 78.9 sens)
- with active quad contraction (100% spec, 97.6 sens)
45 degrees hip flexion, 90 degrees knee flexion
- look for a sag/sulcus of posterior shear of tibia

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Posterolateral corner

tendon of popliteus
lateral head of gastroc
Arcuate popliteal ligament
LCL

Taught with ER at 90 degrees flexion

Special Tests:
Dial test
reverse pivot shift test
- take knee into 70-80 degrees knee flexion
- add axial force, apply valgus force and bring knee into extension. Assess for any clunk/relocation of the posterior subluxation.

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ACL

Originates on posteromedial aspect of LATERAL femoral condyle

Attaches to anteromedial tibia

two bundles

Anteromedial (smaller)- tested by Anterior drawer!
tight throughout flexion- resists translation when knee is flexed!
Posterolateral (larger)- tested by lachmann
primary restraint in full extension!- until about 20 degrees of flexion

No strain on ACL from 0-120 knee flexion ROM
- strain at last 30degrees of terminal knee ext

ACL graft WEAKEST at 12 weeks- want to do any open chained strengthening before that

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MCL

primary restraint to valgus force

resists valgus force in ext ~ 57%
~25 degrees of knee flexion, adds 78% of valgus restraint
to avoid stressing it with ACL recovery, IR tibia with knee flexion or saggital plane movements

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PCL

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originates on lateral aspect of medial femoral condyle– > spine of tibial tubercle posteriorly

Anterolateral bundle (larger 95%)
- tight in FLEXION (b/w 30-90 degrees)

Posteromedial bundle (smaller 5%)
- tight in EXTENSION (b/w 40-120 degrees)

PCL vs PLC injury

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Dial test:
prone tibial ER at 30 degrees and 90 degrees
- if ER > 10 vs contralateral tibia at 30 degrees, suspect PLC injury
- check tibial ER at 90 degrees- PCL is a secondary restraint to ER. If no change, think only PLC injury. If ER is even more at 90 degrees vs contralateral, think both PCL and PLC injury
- if no increase in tibial ER at 30, but > 10 degrees at 90, think PCL without PLC involvement

Soreness rules with therex

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soreness of the knee joint itself, NOT the muscles

Tendon healing rate

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tendinitis 3-7 weeks

Laceration of tendon 5 weeks- 6 months

Muscle healing rate

Gr 1: 0-4 days Gr 2: 4 days - 3 months Gr 3: 3 weeks- 6 months

Ligament healing rate

Gr 1: 1 week Gr 2: 4 days - 3 months Gr 3: 6 weeks - 6 months

Bone healing rate

6 weeks - 3 months

Ligament GRAFT healing rate

2 months - 2 years

Articular cartilage repair healing rate

2 months - 2 years

ACL revision surgery

- more conservative, less rigid graft fixations used - first 2 weeks: PWB with AC and brace - WB exercises usually held till 4 weeks - jumping delayed ( need to protect the graft for a longer time) - delay in return to sport ( also due to poorer fixation)

6 measures for determining successful outcome s/p ACL

1. No swelling 2. quad strength 90% contralateral 3. absence of giving way episodes 4. participation in 1-2 seasons of sport activity 5. KOS 80% 6. Global rating scale 80%

PCL Post op Rehab

Slow progression of ROM, especially Flexion!! - avoid flexion > 90 degrees for 2-4 weeks (graft tensioned bw 70-90) - No active hamstring exercises for 8 weeks - no resisted hamstring exercises for 3-4 months Knee ext forces on PCL greatest at midrange (100-40, peak at 85- 95) - less between 60-0, perform knee ext in this range!

PLC Rehab

- use split achilles tendon graft - NWB, knee immobilizer x 6 weeks to not stress/stretch graft - 90 degrees flexion by week 2, full ROM by 6 weeks - no isolated hamstring exercises x 4 months

PLC MOI

blow to anteromedial tibia in a posterolateral direction | - Varus, hyperextension, ER trauma

MCL/LCL post op px

- PROTECT SITE- in a brace locked at 30 degrees for 2-6 weeks - early ROM good - quad strength

Meniscus non op

- works if tear is small and to peripheral 1/3 (red zone) where it is highly vascular - focus on NON WB therex - avoid - squatting/pivoting/cutting to minimize stress to the area

Menisectomy post op rehab

- no precautions, standard knee scope progression with symptom management

Meniscus REPAIR post op rehab

- CONTROLLED WB AND ROM IS KEY - protect site- protected WB x 8 weeks (MD specific) - some WBAT locked in ext, some begin x 2 weeks, progressing to full by 4 weeks

Meniscus REPAIR post op rehab

- CONTROLLED WB AND ROM IS KEY - protect site- protected WB x 8 weeks (MD specific) - some WBAT locked in ext, some begin x 2 weeks, progressing to full by 4 weeks - WB exercises with > 45 degrees of depth avoided - loaded knee flexion > 90 degrees avoided for 8 weeks - QUAD STRENGTH IN OPEN CHAIN in short term

Microfracture sx

stimulates healing through small drills of bone (fibrocartilage substitute for hyaline cartilage damage) - indicated for cartilage damage < 2 cm - quicker than plug procedures, but still usually NWB 4 weeks, FWB by 8 weeks

MACI procedure

cartilage plug up to 10 cm - two step process, harvested from knee, chondrocytes grown in a lab, implanted - grows similar to type 2 hyaline cartilage - can be used if microfracture and OATS have failed

OATS procedure

- bone plugs covered with hyaline cartilage from NWB part of femoral condyle - used for cartilage damage < 2cm

Anteromedial rotary instability

Posteromedial corner restrains AMRI - clipping injury in football Slocum test (anterior drawer with tibial ER- which should tension posteromedial corner)

Anterolateral Rotary Instability

IR and varus MOI test with tibial IR ( pivot shift test) Jerk test- Hughston

ACL surgical errors

femoral tunnel too anterior = loss of flexion | Tibial tunner too anterior = loss of ext

Stroke test with grading

Tests joint effusion 3+ - so much edema that you cant move medial swelling with upstroke 2+ you push edema medially with upstroke, but dont need to downstroke laterally, edema returns spontaneously 1+ you push edema proximally, downstroke brings edema back Trace- you push edema proximally, small return medially with lateral stroke zero- no edema produced on downstroke

LCL op

operate within 3 weeks to prevent retraction and tissue necrosis

Best to rule IN PCL tear

Posterior drawer - abnormal > 6mm, LR 90

Best to rule in ACL

Lachmanns LR 10.2

Best to rule in/out medial meniscus

Joint line tenderness with palpation

best to rule in out lat meniscus

Rule in: joint line tenderness with palpation | rule out: Thessaly at 5 degrees

Knee Flashcards

(51 cards)