1
Q
- Excessive pronation of feet = __________ tibial rotation
- Excessive supination of feet = _________ tibial rotation
A
- Excessive pronation of feet = INTERNAL tibial rotation
- Excessive supination of feet = EXTERNAL tibial rotation
2
Q
Patella Alta
- patella sits _______ than normal
- Increases contact forces causing ___________ pain and increasing risk of __________ impingement
- may result in _________ or ____________
A
- patella sits HIGHER than normal
- Increases contact forces causing ANTERIOR KNEE pain and increasing risk of FAT PAD impingement
- may result in SUBLUXATION or DISOLOCATION
3
Q
Patella Baja
- abnormally ______ patella in relation to femur
- most often results from soft tissue __________ and _________ of quadriceps muscle following surgery or trauma to knee
A
- abnormally LOW patella in relation to femur
- most often results from soft tissue CONTRACTURE and HYPOTONIA of quadriceps muscle following surgery or trauma to knee
4
Q
Role of Patella
- Keep femur from sliding ________ on tibia
- When a person decelerates, the knee is flexed and the patella should be in the ____________. If _____________ is present, then patella may not be in groove, thus increasing stress on patellar tendon
A
- Keep femur from sliding ANTERIORLY on tibia
- When a person decelerates, the knee is flexed and the patella should be in the TROCHLEAR GROOVE. If PATELLA ALTA is present, then patella may not be in groove, thus increasing stress on patellar tendon
5
Q
Squinting patella = patella is directed _______
A
Squinting patella = patella is directed MEDIALLY
6
Q
“Frog Eyed” patella = patella is directed _______
A
“Frog Eyed” patella = patella is directed LATERALLY
7
Q
Genu Varum “bow legged”
- increased compressive forces on ______ patellar facts
A
- increased compressive forces on MEDIAL patellar facts
8
Q
Genu Valgum “knock kneed”
- Excessive ________ forces
- increasing pressure on _______ facets
A
- Excessive LATERAL forces
- increasing pressure on LATERAL facets
9
Q
Q-Angle
- Relation btw ________ line of pull & _______ tendon
- If increased, then more force is placed on the _______ patellar facet, ________ patellar retinaculum, and ______ border of the femoral trachea
A
- Relation btw QUADS line of pull & PATELLAR tendon
- If increased, then more force is placed on the LATERAL patellar facet, MEDIAL patellar retinaculum, and LATERAL border of the femoral trachea
10
Q
Tubercle Sulcus Angle
- More ________ assessment of quadriceps vector (compared to Q-angle)
- Relationship btw ____________ & _______ patellar pole
If tuberosity is > ______ deg. lateral to inferior pole = predisposed to lateral patellar tracking
- Measured /c knee in ______ deg of flexion; line drawn from _________ to center of _______
A
- More ACCURATE assessment of quadriceps vector (compared to Q-angle)
- Relationship btw TIBIAL TUBEROSITY & INFERIOR patellar pole
If tuberosity is > 10 deg. lateral to inferior pole = predisposed to lateral patellar tracking - Measured /c knee in 90 deg of flexion; line drawn from TIBIAL TUBERCLE to center of PATELLA
11
Q
Q-Angle
- Measured by extending line thru center of ________ to __________ and another line from tibial tubercle thru center of __________ (intersection of these 2 lines is the Q-angle)
A
- Measured by extending line thru center of PATELLA to ASIS and another line from tibial tubercle thru center of PATELLA (intersection of these 2 lines is the Q-angle)
12
Q
What are 4 causes of an increased Q-angle?
A
- Excessive femoral anteversion
- External tibial torsion
- Genu valgum
- Subtalar hyperpronation
13
Q
Where do you align the goniometer for Q-angle?
A
Axis/fulcrum = over midpoint of patella
Stationary arm = over line from the ASIS to patella
Moving arm = over line from patella to tibial tuberosity
14
Q
Normal Q-angle:
Males = _________ deg.
Females = _________ deg.
A
Males = 10 - 13 deg. Females = 15 - 18 deg.
15
Q
Abnormal Q-Angle > _______ deg.
A
Abnormal Q-Angle > 20 deg.
16
Q
- Genu varum is associated /c ________ tibial torsion
- Genu Valgum is associated /c _______ tibial torsion
A
- Genu varum is associated /c MEDIAL tibial torsion
- Genu Valgum is associated /c LATERAL tibial torsion
17
Q
Knee Flexion ROM: Axis? Stationary arm? Moving arm? Normal?
A
Axis = lateral epicondyle of femur
Stationary arm = in line /c greater trochanter & midline of femur
Moving arm = in line /c lateral malleolus and midline of fibula
Normal = 135 - 150
18
Q
Knee Extension ROM: Axis? Stationary arm? Moving arm? Normal?
A
Axis = lateral epicondyle of femur
Stationary arm = in line /c greater trochanter & midline of femur
Moving arm = in line /c lateral malleolus and midline of fibula
Normal = 0 - 10 deg. extension
19
Q
To complete the last 15 deg. of knee extension, a ______% increase in force of the quads is required
A
To complete the last 15 deg. of knee extension, a 60% increase in force of the quads is required
20
Q
What does a quadriceps lag mean?
A
The quads are not strong enough to fully extend the knee. When performing an SLR, the knee will drop slightly (into flexion)
21
Q
Functional ROM:
______ deg. of flexion is necessary for activities such as squatting to tie a shoelace or to pull on a sock
Sitting in a chair requires ~ ____ deg. of flexion
Climbing stairs (average height) requires ~ ______ deg. of flexion
A
117 deg. of flexion is necessary for activities such as squatting to tie a shoelace or to pull on a sock
Sitting in a chair requires ~ 90 deg. of flexion
Climbing stairs (average height) requires ~ 80 deg. of flexion
22
Q
ROM:
- during EXT, the patella glides ___________ and ___________
- during FLEX, the patella glides ___________ and __________
A
- during EXT, the patella glides SUPERIORLY and LATERALLY
- during FLEX, the patella glides INFERIORLY and MEDIALLY
23
Q
What 3 structures does a medial patellar glide stress?
A
- Lateral retinaculum
- Lateral capsule
- IT band
24
Q
What 3 structures does a lateral patellar glide stress?
A
- Medial retinaculum
- VMO
- Medial capsule
25
What position are patellar glides performed in?
supine /c bolster placed under knee so that it is flexed to 30 deg.
26
Medial Patellar Glides
- Patella should glide _______ quadrants (1/2 its width medially)
- Movement < ______ quadrant is hypomobile, which indicates a tight ________ retinaculum or ______
- Movement > _____ quadrants is hypermobile, which indicates ______ of the lateral restraints
- Patella should glide 1-2 quadrants (1/2 its width medially)
- Movement < 1 quadrant is hypomobile, which indicates a tight LATERAL retinaculum or IT BAND
- Movement > 2 quadrants is hypermobile, which indicates LAXITY of the lateral restraints
27
Lateral Patellar Glides
- Normal = _________ quadrants of glide
- movement < ______ is hypomobile, indicating tight ________ restraints
- movement > _______ is hypermobile, indicating laxity of _______ restraints; predisposed to ________/_________
- Normal = 1/2 - 2 quadrants of glide
- movement < 1/2 is hypomobile, indicating tight MEDIAL restraints
- movement > 2 is hypermobile, indicating laxity of MEDIAL restraints; predisposed to SUBLUX/DISLOCATION
28
What is the patient position for performing patellar tilts?
Supine /c knee extended; femoral condyles parallel to the table
29
Positive Test result for Patellar Tilt
- Normal = lateral border raises/lifts _____ & ______ deg.
- More than _____ deg. = hypermobile lateral tilt ---> predisposes to _______ knee pain, especially after long periods of ________ ("theater knee")
- Less than _____ deg. = hypomobile --> tight ______ restraints; often in conjunction /c _________ medial glide
- Normal = lateral border raises/lifts 0 & 15 deg.
- More than 15 deg. = hypermobile lateral tilt ---> predisposes to ANTERIOR knee pain, especially after long periods of SITTING ("theater knee")
- Less than 0 deg. = hypomobile --> tight LATERAL restraints; often in conjunction /c HYPOMOBILE medial glide
30
Swelling
- _________ test for swelling when examining the knee
- /c swelling, knee assumes its resting position of ________ deg. of flexion, which allows the synovial cavity the maximum capacity for holding _________
- What tests are used for swelling?
- ALWAYS test for swelling when examining the knee
- /c swelling, knee assumes its resting position of 15 - 25 deg. of flexion, which allows the synovial cavity the maximum capacity for holding FLUID
- What tests are used for swelling? BRUSH, STROKE, BULGE, PATELLAR TAP TEST
31
Intracapsular Joint effusion may indicate
- torn _____
- ________ tear
- torn __________
- _________ of patella
- fractured ____________
- ___________ fracture
* fluid most likely _________ b/c of bleeding from these structures (hemarthrosis)
- torn ACL
- MENISCAL tear
- torn CAPSULE
- DISLOCATION of patella
- fractured TIBIAL PLATEAU
- OSTEOCHONDRAL fracture
* fluid most likely DARK RED b/c of bleeding from these structures (hemarthrosis)
32
Extracapsular Edema
- often caused by inflammation of the __________ surrounding the joint
- possibly indicating inflamed ________ or __________
- often caused by inflammation of the SOFT TISSUES surrounding the joint
- possibly indicating inflamed BURSAE or CONTUSION
33
TKA Rehab Considerations
- Major ________ of patients
- Related to the development of ___________ (ex. DVT)
- Potential mechanism for __________________ (AMI of quads)
- Alters ________ availability in muscle and can cause ________ damage
- Related to ______, ________, _________ strength, and ________ performance
- ___% at 3 years have felt swelling in the knee in last 30 days
- Major COMPLAINT of patients
- Related to the development of COMPLICATIONS (ex. DVT)
- Potential mechanism for ARTHROGENIC MUSCLE INHIBITION (AMI of quads)
- Alters ENERGY availability in muscle and can cause MECHANICAL damage
- Related to PAIN, ROM, QUAD strength, and FUNCTIONAL performance
- 26% at 3 years have felt swelling in the knee in last 30 days
34
Volumetric Edema Measurement
| - not __________ given wound healing and burden
- not REALSTIC given wound healing and burden
35
Circumferential Edema Measurement
- Questions regarding ________ and ________
- Can be confounded d/t muscle _______ and ____________
- Questions regarding RELIABILITY and VALIDITY
| - Can be confounded d/t muscle ATROPHY and BANDAGING
36
Ultrasound Edema Measurement
| - Questions regarding _________ and __________ error
- Questions regarding RELIABILITY and OPERATOR error
37
Bioelectrical Impedance
- high ________ (ICC > 0.80)
- Good ______________ (SEM = 2%)
- Limitations = not ______ specific and ______
- high RELIABILTY (ICC > 0.80)
- Good RESPONSIVENESS (SEM = 2%)
- Limitations = not JOINT specific and COST
38
True or False: applying a compression bandage after TKA did not result in any clinical improvement in limb circumference ROM or pain
True
39
What is the biggest source of eliminating edema?
Motion
40
Edema Management:
- Use of frequent AROM/PROM --> 1 min of ankle pumps can increase blood flow for up to _______ minutes
- Use of manual lymph drainage massage should be performed ________ at home by patient. It is effective at _______ control. Unknown if it is effective at __________ reduction.
- Use of frequent AROM/PROM --> 1 min of ankle pumps can increase blood flow for up to 30 minutes
- Use of manual lymph drainage massage should be performed DAILY at home by patient. It is effective at PAIN control. Unknown if it is effective at SWELLING reduction.
41
Reflexes & Cutaneous Distribution
- Check patellar (_______) and medial hamstring (_______) reflexes for difference btw the 2 sides
- true knee pain tends to be __________ to the knee, but may also be referred to hip or ankle
- pain may be referred to knee from ______ spine, ______, and _______
- Check patellar (L3 - L4) and medial hamstring (L5 - S1) reflexes for difference btw the 2 sides
- true knee pain tends to be LOCALIZED to the knee, but may also be referred to hip or ankle
- pain may be referred to knee from LUMBAR spine, HIP, and ANKLE
42
What muscle has this referral pattern...
| Lateral aspect of thigh
Tensor fasciae latae
43
What muscle has this referral pattern...
| Over course of muscle (anterior thigh)
Sartorius
44
What muscle has this referral pattern...
| Anterior thigh, patella, lateral thigh, and knee (vastus lateralis)
Quadriceps
45
What muscle has this referral pattern...
| Superior anterolateral thigh, anterior thigh, proximal to patella and sometimes down anteromedial leg
Adductor longus & brevis
46
What muscle has this referral pattern...
| Medial thigh from groin to adductor tubercle
Adductor magnus
47
```
What muscle has this referral pattern...
Medial thigh (primarily the midportion)
```
Gracilis
48
What muscle has this referral pattern...
| Ischial tuberosity, posterior thigh, and posteromedial calf
Semimembranosus & Semitendinosus
49
What muscle has this referral pattern...
| Posterior knee up posterior thigh
Biceps femoris
50
What muscle has this referral pattern...
| Posterior knee
Popliteus
51
What muscle has this referral pattern...
| Posterior knee, posterolateral calf, and posteromedial calf to foot instep
Gastrocnemius
52
What muscle has this referral pattern...
| Posterior knee and calf
Plantaris
53
If sensation is impaired here — medial side of knee, may extend down medial side of leg to medial malleolus — what nerve is affected?
Saphenous nerve
54
Bauer's CPR for Acute Knee Fracture
- Severe ___________ tenderness
- Severe localized _________ and _________
- Flexion less than ______ degrees
- Inability to _____________
- Severe JOINT LINE tenderness
- Severe localized SWELLING and EFFUSION
- Flexion less than 90 degrees
- Inability to WEIGHT BEAR
55
Ottawa Knee Rules
- Age > _____
- Tenderness at ___________
- Isolated tenderness at ___________
- Inability to flex to ______ degrees
- Inability to __________ immediately or in ER/at evaluation
- Age > 55
- Tenderness at FIBULAR HEAD
- Isolated tenderness at PATELLA
- Inability to flex to 90 degrees
- Inability to WEIGHT BEAR immediately or in ER/at evaluation
56
Pittsburgh Knee Rules
- _________ trauma or _______ as mechanics of injury ... PLUS
- Age less than ______ or over ______
- Inability to weight bear ______ steps in emergency room
- BLUNT trauma or FALL as mechanics of injury ... PLUS
- Age less than 12 or over 50
- Inability to weight bear 4 steps in emergency room
57
Valgus MOI:
- What structures are under tensile stress (4)?
- What structures are under compressive stress (1)?
```
Tensile = MCL, medial joint capsule, pes anserine, medial meniscus
Compressive = lateral meniscus
```
58
Varus MOI:
- What structures are under tensile stress (4)?
- What structures are under compressive stress (1)?
```
Tensile = LCL, lateral joint capsule, IT band, biceps femoris
Compressive = medial meniscus
```
59
Anterior tibial Displacement MOI:
- What structures are under tensile stress (6)?
- What structures are under compressive stress (2)?
```
Tensile = ACL, IT band, LCL, MCL, medial and lateral joint lines
Compressive = posterior portion of medial and lateral menisci
```
60
Posterior Tibial Displacement MOI:
- What structures are under tensile stress (4)?
- What structures are under compressive stress (2)?
```
Tensile = PCL, popliteus, medial and lateral joint capsules
Compressive = anterior portion of medial and lateral menisci
```
61
Internal Tibial Rotation MOI:
- What structures are under tensile stress (5)?
- What structures are under compressive stress (2)?
```
Tensile = ACL, anterolateral joint capsule, posteromedial joint capsule, posterolateral joint capsule, LCL
Compressive = medial meniscus (anterior horn) & lateral meniscus (posterior horn)
```
62
External Tibial Rotation MOI:
- What structures are under tensile stress (5)?
- What structures are under compressive stress (2)?
```
Tensile = Posterolateral joint capsule, MCL, LCL, ACL, PCL
Compressive = lateral meniscus (anterior horn) & medial meniscus (posterior horn)
```
63
Hyperextension MOI:
- What structures are under tensile stress (3)?
- What structures are under compressive stress (2)?
```
Tensile = ACL, posterior joint capsule, PCL
Compressive = anterior portion of medial and lateral meniscii
```
64
Hyperflexion MOI:
- What structures are under tensile stress (2)?
- What structures are under compressive stress (2)?
```
Tensile = ACL, PCL
Compressive = posterior portion of medial and lateral meniscii
```
65
What are 4 uniplanar knee sprains?
1. MCL sprain
2. LCL sprain
3. ACL sprain
4. PCL sprain
66
What is the MOI of an MCL sprain?
- Valgus force to knee
| - ER of tibia
67
What special test is (+) /c an MCL sprain?
(+) Valgus stress test @ 25 deg. of knee flexion
68
MCL injury:
- pain is near _________ joint line
- May present /c __________ gait depending on acuity of injury
- Both _______________ may be limited d/t pain
- May have ___________ tenderness along joint line
- Possible to have __________ deficits depending upon pain as well
- H/o "pop" should suggest associated ___________ or _________ injury
- Swelling at _________ aspect of knee
- acute injury
- pain is near MEDIAL joint line
- May present /c ANTALGIC gait depending on acuity of injury
- Both FLEXION/EXTENSION may be limited d/t pain
- May have PALPABLE tenderness along joint line
- Possible to have STRENGTH deficits depending upon pain as well
- H/o "pop" should suggest associated MENISCUS or ACL injury
- Swelling at MEDIAL aspect of knee
- acute injury
69
Grade I MCL Tear
| - Palpable ___________ over MCL; _________ laxity
- Palpable TENDERNESS over MCL; NO laxity
70
Grade II MCL Tear
| - ________ laxity /c ________ end feel; Palpable ___________ over MCL
- SOME laxity /c SOFT end feel; Palpable TENDERNESS over MCL
71
Grade III MCL Tear
| - ___________ laxity /c _______ end point
- SIGNIFICANT laxity /c NO end point
72
What are 4 Differential Dx for MCL sprain?
1. Medial meniscal tear
2. Medial knee contusion
3. Patellar instability; subluxation/dislocation
4. Fracture of distal femoral physis
73
What is the common population for MCL injuries?
- soccer players (struck on instep while passing ball)
- skiers (non contact valgus rotation injury)
- swimmers (overuse in breaststroke)
74
Treatment of Grade I MCL sprain
- ________ (avoid at lateral knee, can cause perineal nerve injury)
- __________ as tolerated (WBAT)
- __________ exercises; achievement of _______ AROM as tolerated
- Strengthening; ___________ chain as tolerated
- progression toward ________, __________, and __________ related drills
- May return to sport in as little as ______ days to ______ weeks
- ICING (avoid at lateral knee, can cause perineal nerve injury)
- WEIGHT BEARING as tolerated (WBAT)
- AROM exercises; achievement of FULL AROM as tolerated
- Strengthening; OPEN/CLOSED chain as tolerated
- progression toward AGILITY, PROPRIOCEPTION, and SPORT related drills
- May return to sport in as little as 10 days to 2 weeks
75
Treatment of Grade II MCL sprain
- WBAT /c long leg brace (locked in extension for ______ weeks)
- AROM exercises started ___________
- _______ strengthening; _______ started immediately (once quad lag has resolved)
- ____________ and __________ drills begin once full ROM and functional strength are achieved
- return to play in ________ days
- WBAT /c long leg brace (locked in extension for 1-2 weeks)
- AROM exercises started IMMEDIATELY
- QUAD strengthening; SLR started immediately (once quad lag has resolved)
- PROPRIOCEPTION and AGILITY drills begin once full ROM and functional strength are achieved
- return to play in 21 - 28 days (3-4 weeks)
76
Treatment of Grade III MCL sprain
- Long leg brace (locked in extension _______ weeks)
- Immediate ROM per discretion of _________
- Weight bearing determined by degree of _________
- Strengthening of ________ / ________ immediately
- ________ chain exercises as tolerated / depending on WBing status
- Proprioception/agility/drills/brace as ___________ per return to full functional strength
- return to play like greater than ______ days
- may consider ____________ intervention if fail conservative management
- Long leg brace (locked in extension 3 - 6 weeks)
- Immediate ROM per discretion of ORTHOPOD
- Weight bearing determined by degree of LAXITY
- Strengthening of QUADS / SLR immediately
- CLOSED chain exercises as tolerated / depending on WBing status
- Proprioception/agility/drills/brace as TOLERATED per return to full functional strength
- return to play like greater than 28 days (4 weeks)
- may consider SURGICAL intervention if fail conservative management
77
What is the MOI of an LCL sprain?
- contact/noncontact varus stress to partially flexed knee in IR of tibia
- IR of tibia
78
What special test is (+) for an LCL sprain?
(+) varus stress test, especially at 30 deg.
79
LCL sprain characteristics:
- ________ common ligamentous injury of knee; ______ in isolation
- Both ___________ may be limited d/t pain
- May have palpable ___________ along joint line
- Possible to have _________ deficits depending upon pain as well
- ________ is most likely associated sport
- LCL is _______-articular: mild to moderate swelling is associated
- LEAST common ligamentous injury of knee; RARE in isolation
- Both FLEXION/EXTENSION may be limited d/t pain
- May have palpable TENDERNESS along joint line
- Possible to have STRENGTH deficits depending upon pain as well
- WRESTLING is most likely associated sport
- LCL is EXTRA-articular: mild to moderate swelling is associated
80
Grade I LCL Sprain
| - Palpable ___________ over LCL; ________ laxity
- Palpable TENDERNESS over LCL; NO laxity
81
Grade II LCL Sprain
| - _________ laxity /c ________ end feel; palpable ___________ over LCL
- SOME laxity /c SOFT end feel; palpable TENDERNESS over LCL
82
Grade III LCL Sprain
| - ___________ laxity /c _________ end point
- SIGNIFICANT laxity /c NO end point
83
What are 8 differential Dx for LCL Sprain?
1. Proximal fibula avulsion fx
2. Biceps femoris strain
3. ITB strain
4. Popliteus strain/tear
5. Associated ACL/PCL injury
6. Lateral meniscus tear
7. Tibial plateau fracture
8. Peroneal nerve injury
84
Treatment of Grade I LCL Sprain
- No ____________ necessary but may utilize hinged flexion brace limiting flexion to _______ degrees
- return to play (_____ weeks)
- ________/ROM
- progress /c _________ strength as tolerated
- Proprioception/agility as gain ______ functional strength
- No IMMOBILIZATION necessary but may utilize hinged flexion brace limiting flexion to 45 - 60 degrees
- return to play (1-2 weeks)
- ISOMETRICS/ROM
- progress /c FUNCTIONAL strength as tolerated
- Proprioception/agility as gain FULL functional strength
85
Treatment of Grade II LCL sprain
- Limited short term use of immobilizer (____ week or less) followed by _______ brace
- Return to play ______ weeks
- Limited short term use of immobilizer (1 week or less) followed by HINGED brace
- Return to play 4 -6 weeks
86
Treatment of Grade III LCL sprain
- Short term use of immobilizer (followed by _______ Brace)
- Same progression as other sprains
- Return to play ______ weeks
- Short term use of immobilizer (followed by HINGED Brace)
- Same progression as other sprains
- Return to play 6 -8 weeks
87
What is the MOI of an ACL sprain?
- Rotation of the knee while the foot is planted
- Blow that drives the tibia anterior on the femur or the femur posterior on the tibia
- Hyperextension
88
ACL Characteristics
- pain or ______ under the patella (deep)
- Rapid joint __________
- no pain reported during _________
- positive ___________ and ____________ patella tests (for effusion)
- pain or POP under the patella (deep)
- Rapid joint EFFUSION
- no pain reported during PALPATION
- positive SWEEP and BALLOTABLE patella tests (for effusion)
89
Predisposing Factors to ACL Injury — Extrinsic Factors
- _______ specific body motions
- Muscle __________
- Muscle _____________
- Athletic skill coordination (i.e. __________)
- ___________ interface
- __________ of foot
- Weakness of ______________
- ________ pelvic tilt
- ________ hips
- _________ cycle
- SPORT specific body motions
- Muscle STRENGTH
- Muscle COORDINATION
- Athletic skill coordination (i.e. LANDING)
- SHOE-SURFACE interface
- HYPERPRONATION of foot
- Weakness of TIBIALIS POSTERIOR
- ANTERIOR pelvic tilt
- ANTEVERTED hips
- MENSTRUAL cycle
90
Predisposing Factors to ACL Injury — Intrinsic Factors
- Joint ________
- Limb ___________
- ________ intercondylar notch
- Genu ____________
- Joint LAXITY
- Limb ALIGNMENT
- SMALL intercondylar notch
- Genu RECURTATUM
91
ACL Sprain Characteristics
- Will often have immediate ________
- Patient will likely report that it feels like it _________ or _______
- May report feeling or hearing a "_____"
- _____ of ACL tears also involve a meniscus tear (d/t rotational component)
- May be unable to ___________
- _______/ altered gait pattern
- AROM/PROM: pain /c _____________
- Pain intensified /c tibial _____________ rotation
- MMT: pain and/or limitations /c ________________; _________ weakness or guarding
- Difficulty /c __________ d/t ACL stump
- Will often have immediate EFFUSION
- Patient will likely report that it feels like it LOCKS UP or GIVES
- May report feeling or hearing a "POP"
- 1/2 of ACL tears also involve a meniscus tear (d/t rotational component)
- May be unable to BEAR WEIGHT
- ANTALGIC/ altered gait pattern
- AROM/PROM: pain /c MOST ALL DIRECTIONS
- Pain intensified /c tibial EXTERNAL/INTERNAL rotation
- MMT: pain and/or limitations /c FLEXION/EXTENSION; HANSTRING weakness or guarding
- Difficulty /c EXTENSION d/t ACL stump
92
What percent of ACL tears involve meniscal injuries?
50%
93
What are 6 Differential Dx for ACL sprain?
1. PCL
2. Meniscus
3. Hamstring strain
4. Gastroc strain
5. Osteochondral fx
6. Patellar dislocation
94
What are 3 special test for ACL sprain?
1. Anterior drawer
2. Lachmans
3. Prone Lachman
95
What is the main complaint /c ACL rupture?
Instability
96
What are the criteria for a coper (non-operative) ACL treatment?
- older than 35 y.o.
- has no or minimal anterior tibial subluxation
- has no additional intra-articular injury
- not highly active
97
What are the criteria for a non-coper (operative) ACL treatment?
- younger than 25 years
- Has a marked anterior tibial subluxation
- Has additional intra-articular damage
- is heavily active
98
ACL Sprain: Treatment
- return to sport (post-surgical) = _________ months
- Autograft from __________ or __________ tendon
- Allograft (cadaver): use of ________ materials, usually considered 2nd option for failure of _________/__________ tendon graft
- return to sport (post-surgical) = 6 - 12 months
- Autograft from PATELLAR or HAMSTRING tendon
- Allograft (cadaver): use of SYNTHETIC materials, usually considered 2nd option for failure of HAMSTRING/PATELLAR tendon graft
99
ACL Bone-Patellar Tendon-Bone Graft
- Affects patellofemoral joint; increased incidence of ____________ pain
- _________ mechanism dysfunction
- Small risk of patellar ___________ d/t bone plugs
- believed to have stronger fixation d/t bone plugs that can incorporate into the femoral and tibial tunnels by _______ weeks after surgery
- Affects patellofemoral joint; increased incidence of ANTERIOR KNEE pain
- EXTENSOR mechanism dysfunction
- Small risk of patellar FRACTURE d/t bone plugs
- believed to have stronger fixation d/t bone plugs that can incorporate into the femoral and tibial tunnels by 6-8 weeks after surgery
100
ACL Hamstring Autograft (Semitendinous or Gracilis)
- concern for loss of post-op _________ strength
- Increased number of __________ strains early post-op
- concern for loss of post-op HAMSTRING strength
| - Increased number of HAMSTRING strains early post-op
101
ACL Quadriceps Tendon Autografts
- affects patellofemoral joint; increased incidence of ___________ pain
- __________ mechanism dysfunction
- affects patellofemoral joint; increased incidence of ANTERIOR pain
- EXTENSOR mechanism dysfunction
102
ACL Allograft Materials
- ________ graft
- Less _______
- no difference found btw allograft and autograft ___________ BUT the allograft group had a failure rate ____x greater than that in the autograft group, with all failures occurring within the first year after reconstruction
- CADAVAR graft
- Less PAIN
- no difference found btw allograft and autograft RECONSTRUCTIONS BUT the allograft group had a failure rate 15X greater than that in the autograft group, with all failures occurring within the first year after reconstruction
103
ACLR Considerations — Sports environment is...
- _________ focus of attention
- focus on ______ outcome, not ________ mechanics
- Rapid, __________, changing
- ________________
- EXTERNAL focus of attention
- focus on TASK outcome, not MOVEMENT mechanics
- Rapid, RESPONSIVE, changing
- REACTIONARY
104
ACLR Considerations — Clinic environment is...
- _________ focus of attention
- _________ & ___________ feedback of mechanics
- slow, __________, sustained
- ________________
- INTERNAL focus of attention
- MANUAL & VISUAL feedback of mechanics
- slow, CONTROLLED, sustained
- PRE-PLANNED
105
Early Rehab of ACL should include
- Quad sets
| - Early hip proprioception
106
Neuromuscular Effects of ACLR
- Despite surgical intervention and rehab _______% of individuals continue to have impairments and decreased function at return to sport
- _______% have reinjury within 2 years
- Prolonged _______ weaknesss (common impairment after knee joint injury, most severe immediately following injury or surgery, can persist beyond 15 - 20 years after injury)
- ACLR restores passive stability — native ACL contains _____________ that are not restored after ACLR
- Despite surgical intervention and rehab 30 - 50% of individuals continue to have impairments and decreased function at return to sport
- 20 - 30% have reinjury within 2 years
- Prolonged QUAD weaknesss (common impairment after knee joint injury, most severe immediately following injury or surgery, can persist beyond 15 - 20 years after injury)
- ACLR restores passive stability — native ACL contains MECHANORECEPTORS that are not restored after ACLR
107
Muscle performance after ACLR
- ___________ neuromuscular dysfunction
- Poor quad function alters _________ mechanics, increases _________ risk, has potential to impair ________ performance
- _________ and _______ strengthening is a fundamental component of ACLR rehab
- Quad assessment = typically quantified as maximal strength (________% LSI for RTS)
- Persistent dysfunction even /c recovery of quad strength ____________
- QUADRICEPS neuromuscular dysfunction
- Poor quad function alters MOVEMENT mechanics, increases REINJURY risk, has potential to impair SPORTS performance
- QUAD and LE strengthening is a fundamental component of ACLR rehab
- Quad assessment = typically quantified as maximal strength (85 - 90% Limb Symmetry Index for Return To Sport)
- Persistent dysfunction even /c recovery of quad strength SYMMETRY
108
Neuroplasticity associated /c ACLR
- Trauma to the ACL has been shown to modify how the nervous system processes the interactions between ________ and ____________
- The loss of previously recognized ___________ and _______ motor neuron drive to prepare the CNS function to engage appropriately may require "up-training" of other systems such as increased utilization of visual feedback to maintain the required sensory input for motor control
- Post ACL injury/rehab, knee motion requires increased activation of _______, ________, and _______ sensory areas in the brain = neuroplasticity
- Trauma to the ACL has been shown to modify how the nervous system processes the interactions between VISION and SOMATOSENSATION
- The loss of previously recognized REFLEXES and GAMMA motor neuron drive to prepare the CNS function to engage appropriately may require "up-training" of other systems such as increased utilization of visual feedback to maintain the required sensory input for motor control
- Post ACL injury/rehab, knee motion requires increased activation of MOTOR, VISUAL, and SECONDARY sensory areas in the brain = neuroplasticity
109
What is the MOI of PCL tear?
- posterior displacement of tibia on femur
- Hyperextension
- Hyperflexion
- Dashboard injury
110
PCL Tear Characteristics:
- Pain _______ knee, radiating ___________
- Posterior ________ sign
- Tenderness in ______________
- C/o pain, stiffness, and weakness
- c/o of pain /c weight placed on _________ knee
- c/o pain /c ___________ stairs or squatting
- Pain WITHIN knee, radiating POSTERIORLY
- Posterior SAG sign
- Tenderness in POPLITEAL FOSSA
- C/o pain, stiffness, and weakness
- c/o of pain /c weight placed on SEMIFLEXED knee
- c/o pain /c CLIMBING stairs or squatting
111
What are 3 (+) special tests for the PCL?
1. Posterior drawer test
2. Godfrey's sign (posterior sag)
3. External Rotation Test
112
What are 6 differential dx for PCL tear?
1. ACL tear
2. Tibia or fibular Fx
3. Collateral LIgament injury
4. Meniscal derangement
5. Posterolateral corner injury
6. Knee dislocation
113
Treatment of Grade I/II PCL Tear
- Early _______
- Aggressive __________ strengthening
- _________ weight bearing
- PCL brace may be useful for protection against ____________
- Return to play ________ weeks
- Early ROM
- Aggressive QUAD strengthening
- PARTIAL weight bearing
- PCL brace may be useful for protection against POSTERIOR SAG
- Return to play 2 - 4 weeks
114
Treatment of Grade III PCL Tear
- ______ weeks of immobilization in full extension
- Early _______
- __________ strengthening
- progressive __________ strengthening
- Progressive ________/__________ once full functional strengthening gained
- Return to play ____ months
- 2-4 weeks of immobilization in full extension
- Early ROM
- QUADRICEPS strengthening
- progressive FUNCTIONAL strengthening
- Progressive BALANCE/AGILITY once full functional strengthening gained
- Return to play 3 months
115
What is the MOI of meniscal tears?
Tibial rotation (IR or ER) combined /c flexion and varus/valgus stress
116
Pain characteristics of Meniscal Tears
- Pain along ________
- Reports "__________"
- Pain along JOINT LINE
| - Reports "GIVING OUT"
117
What is the predisposing condition for Meniscal Tears?
repetitive motion can degrade the lateral meniscus
118
ACUTE Meniscal Tears:
- No signs of ________ present
- Swelling may develop within ________ hours
- No signs of INJURY present
| - Swelling may develop within 24 - 48 hours
119
CHRONIC Meniscal Tears:
- Swelling in _____________ or along __________ is common
- ___________ gait d/t inability to terminally extend knee
- Swelling in POPLITEAL FOSSA or along JOINT LINE is common
| - ANTALGIC gait d/t inability to terminally extend knee
120
Meniscal Tear Characteristics:
- AROM = possibly _________
- PROM = pain in terminal _________ and _________
- RROM/MMT = pain or __________ reveled as torn portion passes beneath femur's articulating surface
- Suspect ___________ ligament injuries /c meniscal injuries (and vice versa)
- AROM = possibly DECREASED
- PROM = pain in terminal FLEXION and EXTENSION
- RROM/MMT = pain or LOCKING reveled as torn portion passes beneath femur's articulating surface
- Suspect UNIPLANAR ligament injuries /c meniscal injuries (and vice versa)
121
What are 3 special tests to use for Meniscal Tears?
1. McMurray's Test
2. Apley's Compression/Distraction Test
3. Thessley Test
122
Meniscus:
- Onset?
- Symptom site?
- Locking?
- Weight Bearing?
- Cutting Sports?
- Squatting?
- Kneeling?
- Jumping?
- Stairs/hills?
- Sitting?
- Onset = acute /c twisting
- Symptom site = localized medial or lateral joint line
- Locking = transient locking; unable to fully extend knee
- Weight Bearing = sharp pain & simultaneous /c loaded WB
- Cutting Sports = Pain /c loaded twisting maneuvers
- Squatting = pain at full squat; inability to "duck walk"
- Kneeling = not painful b/c meniscus is not WB
- Jumping = weight loaded w/o torque or twist tolerated
- Stairs/hills = pain often going up /c loaded knee flexion
- Sitting = no pain
123
Patellofemoral:
- Onset?
- Symptom site?
- Locking?
- Weight Bearing?
- Cutting Sports?
- Squatting?
- Kneeling?
- Jumping?
- Stairs/hills?
- Sitting?
- Onset = direct trauma; insidious, overuse, anterior
- Symptom site = diffuse, most commonly anterior
- Locking = catching w/o locking; stiffness after sitting
- Weight Bearing = pain possibly develops during WB & continues into night
- Cutting Sports = some pain possible, but not sharp and clearly related to cutting
- Squatting = pain when extensors used to rise from a squat
- Kneeling = pain from patellar compression
- Jumping = extensors heavily stressed, causing pain on descent impact
- Stairs/hills = more patellar loading & pain going down
- Sitting = stiffness & pain
124
Osteochondral Defect
- Fractures of the ________________
- 8% of knee OCDs occur on the __________ femoral condyle (other locations include lateral femoral condyle, tibial articulating surface, and patella)
- OCD occurs in _________ 3x more frequently than __________
- No specific ________ (compressive/shear forces can cause articular fractures)
- Fractures of the ARTICULAR CARTILAGE
- 8% of knee OCDs occur on the MEDIAL femoral condyle (other locations include lateral femoral condyle, tibial articulating surface, and patella)
- OCD occurs in MALES 3x more frequently than FEMALE
- No specific MOI (compressive/shear forces can cause articular fractures)
125
Pain Characteristics of Osteochondral Defect
- _________ pain _________ knee
- Sensations of _________, ___________, ________ way
- Pain increases during _____________ activities
- patient will complain of diffuse/deep knee pain (most commonly in _______ femoral condyle). Pain often been present for ________
- DIFFUSE pain WITHIN knee
- Sensations of LOCKING, CLUNKING, GIVING way
- Pain increases during WEIGHT BEARING activities
- patient will complain of diffuse/deep knee pain (most commonly in MEDIAL femoral condyle). Pain often been present for MONTHS
126
Functional Tests for Osteochondral Defect
| - Increased pain and decreased strength /c _________ chain activities
- Increased pain and decreased strength /c CLOSED chain activities
127
What special test and what imaging are used for Osteochondral Defect?
- Wilson's Test
| - MRI necessary for definitive diagnosis
128
What is the MOI of ITB friction syndrome?
repeated knee flexion/extension
129
IT Band Friction Syndrome:
- _______ onset
- Pain over ________ femoral condyle (proximal to joint line)
- Pain increased when running ______ hill
- CHRONIC onset
- Pain over LATERAL femoral condyle (proximal to joint line)
- Pain increased when running DOWN hill
130
What are 4 predisposing conditions for ITB friction syndrome?
1. Tightness of IT Band
2. Genu Varum
3. Pronated Feet
4. Leg Length Discrepancy (LLD)
131
What are 2 special tests for IT Band Friction Syndrome?
1. Nobel's compression test
| 2. Ober's Test
132
Popliteus Tendinitis
- _________ onset
- Pain in ______________ radiating to ___________ attachment of LCL
- Pain /c running _____ hill
- MOI = __________
- Predisposing condition = _________________
- Swelling along _________ joint line
- Palpation in ___________ postion; __________ to anterior LCL
- RROM = pain during resisted ________ from _________ (unscrewing of tibia from femur)
- CHRONIC onset
- Pain in POPLITEAL FOSSA radiating to ANTERIOR attachment of LCL
- Pain /c running DOWN hill
- MOI = OVERUSE
- Predisposing condition = HYPERPRONATION
- Swelling along LATERAL joint line
- Palpation in FIGURE 4 postion; CREPITUS to anterior LCL
- RROM = pain during resisted FLEXION from FULL EXTENSION (unscrewing of tibia from femur)
133
Arthritis
- > _____ different MSK disorders
- 40 million people have some type of arthritis (_____ or 26 million are females)
- Rheumatoid arthritis (RA) is ____% of US population (3-4 million are people aged _______; _______% is females)
- Juvenile Idiopathic Arthritis in > 300,000 children in US under _____ y.o. (70 - 80%)
- Osteoarthritis in ______% of 75 y.o. (75% in women)
- Annual cost to US economy > ______ billion (meds, physician visits, OT/PT, hospitalizations, surgeries)
- > 80 different MSK disorders
- 40 million people have some type of arthritis (2/3 or 26 million are females)
- Rheumatoid arthritis (RA) is 1% of US population (3-4 million are people aged 20 - 65; 75 - 80% is females)
- Juvenile Idiopathic Arthritis in > 300,000 children in US under 16 y.o. (70 - 80%)
- Osteoarthritis in 70 - 80% of 75 y.o. (75% in women)
- Annual cost to US economy > 80 billion (meds, physician visits, OT/PT, hospitalizations, surgeries)
134
Genetic Influences of Inflammatory Arthritis
- (+) family history in _______%
- Human leukocyte antigen (HLA) association (+ HLA DR4 in severe disease in ______ and _____)
- (+) family history in 20 - 30%
| - Human leukocyte antigen (HLA) association (+ HLA DR4 in severe disease in RA and JIA)
135
Current Theories of Disease of Inflammatory Arthritis
"Trigger" starts the inflammatory cascade
- ______ > __________
- Damaged ______ proteins
Inflammatory Cascade
- prolongs and increases the ________
- Causes _______ of joints and __________ of organs
- Systemic signs = ________, _________, and weight ______
"Trigger" starts the inflammatory cascade
- VIRAL > BACTERIAL
- Damaged COLLAGEN proteins
Inflammatory Cascade
- prolongs and increases the INFLAMMATION
- Causes EROSION of joints and INFLAMMATION of organs
- Systemic signs = FEVER, FATIGUE, and weight LOSS
136
Rheumatoid Arthritis
- Onset = subacute to chronic (_______ to _______)
- Severity is variable = moderate ______, ________, and pain
- Formation of ________ at joint margins (develops during the first ______ months from onset)
- Joint deterioration takes _______ to _____
- Systemic symptoms/complications in > _____%
- Onset = subacute to chronic (WEEKS to MONTHS)
- Severity is variable = moderate SWELLING, STIFFNESS, and pain
- Formation of EROSIONS at joint margins (develops during the first 3 - 12 months from onset)
- Joint deterioration takes MONTHS to YEARS
- Systemic symptoms/complications in > 25%
137
General Features of Osteoarthritis
- Develops very _______
- Minimal __________ or __________
- Does not produce _____________ manifestations
- Gradual deterioration of __________
- __________ form slowly, over years
- Develops very SLOWLY
- Minimal INFLAMMATION or SWELLING
- Does not produce SYSTEMIC manifestations
- Gradual deterioration of CARTILAGE
- OSTEOPHYTES form slowly, over years
138
What are 4 PRIMARY risk factors of OA?
1. Female
2. Caucasian
3. Obesity (2x risk for overweight Female)
4. Genetics
139
What are 4 SECONDARY risk factors of OA?
1. Mechanical forces: scoliosis, congenital, deformity
2. Metabolic, endocrine disorders
3. Prior trauma
4. Prior RA and JIA or other inflammatory processes
140
Genetics and OA
- Women ______X more risk
- Influence of multiple genetic factors (especially in ________ OA)
Cartilage defects
- Cartilage = _____________ + ____________________
- Collagen gene defects cause __________ OA (ex. mutations in gene for type II procollagen)
- Women 10X more risk
- Influence of multiple genetic factors (especially in HAND OA)
Cartilage defects
- Cartilage = COLLAGEN + MUCOPOLYSACCHARIDES
- Collagen gene defects cause PREMATURE OA (ex. mutations in gene for type II procollagen)
141
Differences btw OA and RA and JIA
- Characteristics age of onset (OA = _____ y.o.; RA = _____ y.o.; JIA = _____ y.o.)
- Features of arthritis: ________ and _________
- Risk of __________ differs
- Pathologic ___________ differences are distinct
- ____________ appearance distinct
- Risks and types of _____________
- Characteristics age of onset (OA = after 40 y.o.; RA = after 18 y.o.; JIA = less than 16 y.o.)
- Features of arthritis: DISTRIBUTION and SUBTYPES
- Risk of COMPLICATIONS differs
- Pathologic MICROSCOPIC differences are distinct
- RADIOGRAPHIC appearance distinct
- Risks and types of COMPLICATIONS
142
Osteoarthritis:
- Onset after _____ y.o.
- Gender = ________ > __________
- Onset after 40 y.o.
| - Gender = Female > male
143
Rheumatoid Arthritis
- Onset after ______ y.o.
- Gender = ___________ > _________
- Onset after 18 y.o.
| - Gender = Female > male
144
Juvenile Idiopathic Arthritis
- Onset less than ______ y.o.
- Gender ________ > ________
- Onset less than 16 y.o.
| - Gender female > male
145
Osteoarthritis Symptoms
- _____ pain in a few locations
- morning stiffness less than ________
- swelling _________
- no ______ problems (no rash, fevers, systemic signs; pain causes ________; ___________ cause pain)
- JOINT pain in a few locations
- morning stiffness less than 1/2 HOUR
- swelling MILD
- no SYSTEMIC problems (no rash, fevers, systemic signs; pain causes SYMPTOMS; OSTEOPHYTES cause pain)
146
JIA/RA Symptoms
- Often _________ joint involvement and pain
- morning stiffness greater than __________
- swelling _______ to _________
- ________ illness (fevers, weight loss, muscle atrophy, internal organ problems — eyes, skin rash, lungs, heart, nodes)
- Often WIDESPREAD joint involvement and pain
- morning stiffness greater than 1-2 HOURS
- swelling MILD to MODERATE
- SYSTEMIC illness (fevers, weight loss, muscle atrophy, internal organ problems — eyes, skin rash, lungs, heart, nodes)
147
OA
- some common areas
- OA may occur only after ________ or _________
- What 5 joints are typically involved?
- some common areas
- OA may occur only after INJURY or INFLAMMATION
- (1) HANDS, (2) KNEES, (3) HIPS, (4) ENTIRE SPINE, (5) FEET
148
JIA/RA
- almost ______ joint
- What 9 joints are involved?
- What 2 joints are spared?
- almost ANY joint
- (1) HANDS, (2) KNEES, (3) HIPS, (4) TMJ, (5) CERVICAL SPINE, (6) FEET, (7) ANKLES, (8) SHOULDERS, (9) ELBOWS
- (1) DIP, (2) MID-LOWER SPINE
MSK 1
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