1
Q
General Intervention Goals- Acute
A
- decrease inflammation (RICE)
- patient education
- maintain ROM –> minimize stiffness
- minimize muscle atrophy
- prevent deformity and protect joint
- CV training when possible
- fall prevention
- body mechanics to minimize stress
2
Q
Why is swelling in the knee particularly an issue?
A
Quads become very sensitive to the effects
3
Q
General Intervention Goals- Subacute/Chronic
A
- Decrease effects of stiffness from inactivity
- Decrease pain from mechanical stress
- Increase ROM
- Increase mobility of soft tissue (skin needs to stretch!)
- increase strength and endurance
- include functional training
- include balance/proprioception
- CV training
- Monitor signs of inflammation closely (swelling, redness, warmth, pain)
- Weight bearing/gait training as needed
4
Q
General Intervention Goals- Surgical Intervention Early Considerations
A
- scar healing
- decrease inflammation
- weight bearing status
- manage pain
- increase ROM –> not necessarily trying to gain, but more so moving through ROM
- maintain muscle function
5
Q
General Intervention Precautions
A
- Overuse
- Increasing ROM when muscle strength is not adequate to control motion
- Strong muscle contractions may increase joint symptoms (compression)
- Weight-Bearing status
- condition of joint surfaces
- joint stability
- medications
- general medical conditions
6
Q
Dr Hall wants you to review the textbook
A
shocking
7
Q
MCL Lesion Etiology
A
football, soccer, baseball, skiing, MVA
8
Q
LCL lesion etiology
A
baseball, skiing, miscellaneous
9
Q
MOI MCL
A
contact to lateral/ posterolateral knee or non contact with foot planted
10
Q
MOI LCL
A
contact medial knee
11
Q
Symptoms of Grade I MCL/LCL Sprain
A
- history
- pain with valgus/varus stress
- palpation over ligament
- possible local swelling
- joint is stable
- AROM may be painful
12
Q
Symptoms of Grade II MCL/LCL Sprain
A
- history
- local swelling and some effusion
- pain with valgus/varus stress
- ROM limited
- Laxity at 30 degrees
- palpable defect
13
Q
Symptoms of Grade III MCL/LCL Sprain
A
- full thickness tear
- greater amounts of grade II findings
14
Q
Why might there not be a ton of swelling with MCL/LCL sprain?
A
there is not a ton of blood flow in this area
15
Q
See Conservative Management- Ligament Lesions Table
A
16
Q
Can you do sidelying SLR for LCL injury?
A
No
It creates a varus force
17
Q
What is the most commonly injured ligament in the knee?
A
ACL
18
Q
Etiology of noncontact ACL lesion
A
forceful hyperextension or lateral rotation force when foot is planted
19
Q
Etiology of contact ACL lesion
A
valgus force to the knee
20
Q
Symptoms of ACL lesion
A
- history
- acute, tense effusion
- Lachman’s Test
- Anterior Drawer, Levers Tests
- Posterior knee pain (acute)
- Posterior and lateral knee pain (chronic)
21
Q
What is the terrible triad?
A
- MCL
- ACL
- Medical meniscus
22
Q
Etiology of PCL ligament lesion
A
Most commonly injured by a forceful blow to the anterior tibia while the knee is flexed
23
Q
Are males or females more likely to injure the ACL?
A
Females are 3 times more likely to injure ACL in non contact situations
24
Q
What are the 4 risk factor categories theorized to be the reason females are more likely to injure ACL?
A
- Biomechanical risk factors
- Neuromuscular Control of the Joint
- Structure Risk Factors
- Hormonal Differences
25
Biomechanics Risk Factors
- Awkward or improper dynamic body movements
- Deceleration/Change of direction
(Decreased hip and knee flexion with cutting activities = increased risk)
26
Neuromuscular control of the joint
- influence on joint position and movement
| - weaker hip and knee strength along with altered activation patterns
27
Structural risk factors
- femoral notch size
- ACL size
- Lower extremity alignment
28
Advantages of Bone-Tendon-Bone graft for ACL repair
- high tensile strength/stiffness
- secure/reliable bone-to-bone fixation
- rapid revascularization/biological fixation (6 weeks), allowing accelerated rehabilitation
- Return to high-demand activities/preinjury status
29
Advantages of Semiteninosus-gracilis autograft for ACL repair
- high tensile strength/stiffness
- no disturbance of epiphyseal plate in skeletally immature patients
- hamstring regeneration at donor site
- flexor strength loss remediated within 2 years
30
Disadvantages of Bone-Tendon-Bone graft for ACL repair
- Anterior knee pain (site of donor graft)
- pain during kneeling
- extensor mechanism/patellofemoral dysfunction
- long-term quad weakness
- patellar fracture during graft harvest
- patellar tendon rupture (rare)
31
Disadvantages of Semiteninosus-gracilis autograft for ACL repair
- Tendon to bone fixation, not as reliable
- Longer healing time at bone-tendon interface (12 weeks)
- Hamstring muscle strain during early rehabilitation
- Short/long term flexor muscle weakness
- possible increased anterior tibial translation
32
See "ACL Reconstruction- Intervention for Accelerated Rehabilitation" Slide
Slide 15
| Kisner et al table 21.5 in current edition
33
What are ACL/PCL precautions?
- 45-0 resisted extension in OKC; 60-90 in CKC for ACL
| - Avoid OKC knee flexion for PCL
34
Exercise precautions post ACL reconstruction for resistance training
- progress exercises more gradually for reconstruction with hamstring tendon graft than bone-patellar tendon-bone graft
- progress knee flexor strengthening exercises cautiously if a hamstring tendon graft was harvested and knee extensor strengthening if a patellar tendon graft was harvested
35
Exercise precautions post ACL reconstruction- Closed Chain Training
- When squatting in an upright position, be sure that the knees do not move anterior to the toes as the hips descend because this increases shear forces on the tibia and could potentially place excess stress on the autograft
- Avoid closed-chain strengthening of the quadriceps between 60-90 degrees of flexion
36
Exercise precautions post ACL reconstruction: Open Chain Training
- During PRE to strengthen hip musculature, initially place the resistance above the knee until knee control is established
- Avoid resisted, open-chain knee extension between 45 degrees or 30 degrees to full extension
- Avoid applying resistance to the distal tibia during quadriceps strengthening
37
Criteria to return to high demand activity post ACL reconstruction
- No knee pain or joint effusion
- full active knee ROM
- quadriceps strength > 85% of contralateral side or peak torque/body mass 40% and 60% for men and 30% and 50% for women
- hamstring strength 100% of contralateral side
- No postoperative history of knee instability/giving way
- negative pivot shift test
- Knee stability measured by arthrometer: < 3 mm difference between reconstructed and uninjured side
- Proprioceptive testing: 100%
- Functional testing: >85% or >90% of contralateral side normative values
- Acceptable patient-reported score on comprehensive, quantitative knee function tool
- Acceptable confidence and motivation based on variables such as kinesiophobia or emotional preparedness for return to activities
38
General precautions post PCL reconstruction
- Avoid exercises and activities that place excessive posterior shear forces and cause posterior displacement of the tibia on the femur, thus disrupting the healing graft
- Limit number of flexion repetitions
39
Early and Intermediate Rehabilitation post PCL Reconstruction
- Begin exercise to restore knee flexion while in a seated position, allowing gravity to passively flex the knee and the hamstrings to remain essentially inactive
- During squatting exercises to increase quadriceps strength, avoid excessive trunk flexion as it causes increased activity in the hamstrings to avoid flexion past 60 to 70 degrees to limit posterior translation
- When strengthening hip musculature, place resistance above the knee
- Postpone open-chain active knee flexion against the resistance of gravity (prone or standing) for 6-12 weeks
40
Advanced rehabilitation Post PCL Reconstruction
- Postpone resistance training for the knee flexors, such as use of a hamstring curl machine, for 5-6 months
- When performing resisted hamstring curls, use low loads
- Avoid downhill inclines during walking, jogging, or hiking
- Avoid activities that involve knee flexion combined with rapid deceleration when one or both feet are planted
- Postpone returning to vigorous functional activities for at least 9-12 months
- Possibly consider wearing a functional knee brace during high-demand activities
41
Osteoarthritis vs Rheumatoid Arthritis Age of Onset
OA: usually after 40
RA: usually begins between age 15 and 50
42
Osteoarthritis vs Rheumatoid Progression
OA: usually develops slowly over many years in response to mechanical stress
RA: May develop suddenly, within weeks or months
43
Osteoarthritis vs Rheumatoid Manifestations
OA: cartilage degradation, altered joint architecture, osteophyte formation
RA: Inflammatory synovitis and irreversible structural damage to cartilage and bone
44
Osteoarthritis vs Rheumatoid Joint involvement
OA: Affects a few joints, asymmetrically, typically DIP, PIP, 1st CMC, cervical/lumbar spine, hips, knees, 1st MTP of feet
RA: Usually affects many joints, bilateral, typically MCP and PIP of hands, wrists, elbows, shoulders, cervical spine, MTP, talonavicular, and ankle
45
Osteoarthritis vs Rheumatoid Joint Signs and Symptoms
OA: AM stiffness lasting less than 30 minutes, increased joint pain with WB'ing and strenuous activity, crepitus, loss of ROM
RA: redness, warmth, swelling, and prolonged morning stiffness, increased joint pain with activity
46
Osteoarthritis vs Rheumatoid Systemic Signs and Symptoms
OA: none
RA: general feeling of sickness and fatigue, weight loss and fever, may develop rheumatoid nodules, may have ocular, respiratory, hematological, and cardiac symptoms
47
Conservative management of RA- Plan of Care
1. educate the patient
2. relieve pain and muscle guarding and promote relaxation
3. minimize joint stiffness and sustain available motion
4. minimize muscle atrophy
5. prevent deformity and protect the joint structures
48
Precautions for RA
- Respect fatigue and increased pain
| - Do not overstress osteoporotic bone or lax ligaments
49
Contraindications of RA
- do not stretch swollen joints or apply heavy resistance exercise that causes joint stress
50
Principles of Joint Protection and Energy Conservation
- Monitor activities and stop when discomfort or fatigue begins to develop
- Use frequent but short episodes of exercise (3-5 sessions per day)
- Alternate activities to avoid fatigue
- decrease level of activities or omit provoking activities if joint pain develops and persists for more than 1 hours after activity
- Maintain a functional levels of joint ROM and muscular strength and endurance
- Balance work and rest to avoid muscular and total body fatigue
- Increase rest during flares
- Avoid deforming positions
- Avoid prolonged static positioning; change positions during the day every 20-30 minutes
- Use stronger and larger muscles and joints during activities whenever possible
- Use appropriate adaptive equipment
51
Conservative Management of OA- Plan of Care
1. Educate the patient
2. Decrease effects of stiffness --> active ROM & Joint play mobilization techniques
3. Decrease pain from mechanical stress and prevent deforming forces
4. Increase ROM
5. Improve neuromuscular control, strength, and muscle endurance
6. improve balance
7. Improve physical conditioning --> non-impact or low-impact aerobic exercise
52
Precautions of OA
- When strengthening supporting muscles, increased pain in the joint during or following resistive exercises probably means that too great a weight is being used or stress is being placed at an inappropriate part of ROM
- Analyze the joint mechanics and at what point during the range the greatest compressive forces are occurring
- Maximum resistance exercise should not be performed through that ROM
53
Microfracture Repair
- Indicated for repair of very small defects femoral condyles or patella
- Procedure designed to stimulate a bone marrow based repair response leading to ingrowth of fibrocartilage to repair the defect
54
Osteochondral Autograft Transplantation/Mosaicplasty
- Indicated for focal lesions of the chondral or subchondral tissue of weight-bearing surfaces
- Procedure involves transplantation of intact articular cartilage along with some underlying bone
55
Autologous Chondrocyte Implantation
- Indicated for full thickness chondral and osteochondral defects
- procedure involves the harvesting of chondrocytes from healthy articular cartilage and then implantation of cultures chondrocytes from healthy articular cartilage and then implantation of cultured chondrocytes into the knee
56
Osteochondral allograft transplantation
- Indicated for defects larger than 4 cm
| - procedure involves the implantation of intact articular cartilage from a cadaveric donor
57
See box 21.2 for special considerations after articular cartilage repair
Slides 28 and 29
58
Patellofemoral Dysfunction Pathologies
- Patellofemoral instability
- Patellofemoral pain with malalignment or biomechanics dysfunction
- Patellofemoral pain without malalignment
59
Patellofemoral instability causes
- Q angle
- dysplastic trochlea
- patella alta
- tight lateral retinaculum
- inadequate medial stabilizers
60
Patellofemoral pain with malalignment or biomechanics dysfunction
- abnormal patellar tracking
| - causes: increased Q-angle (femoral ante version, external tibial rotation, genu valgum, foot pronation)
61
Patellofemoral pain without malalignment
- Soft tissue lesions (plica syndrome, fat pad syndrome, tendinitis, ITB friction syndrome, pre patellar bursitis, tight medial/lateral retinaculum)
- Osteochondritis dissecans of the patella or femoral trochlea
- Traumatic patellar chondromalacia
- Patellofemoral OA
- apophysitis
- symptomatic bipartite patella
- trauma
62
Etiology of patellofemoral dysfunction
- Trauma
- mechanical overload
- faulty patellar tracking due to soft tissue length and strength imbalances or bony structural defects
- ligament laxity/joint instability
- hormonal factors in adolescence
63
Symptoms of patellofemoral dysfunction
- Pain and/or poor control going up/down stairs
- Pain with prolonged sitting with knee bent ("Movie Goer's Sign)
- Pain with running and jumping
- Deep seated ache
- Associated symptoms: stiffness, catching/locking, effusion, giving way
64
Acute Management of Patellofemoral Dysfunction
- Rest
- Gentle motion
- Isometrics in pain free positions
- Decrease Inflammation
* * Pain and effusion inhibits quad function so it is critical to control as soon as possible
65
Subacute management of Patellofemoral Dysfunction
- Increase flexibility of lateral fascia and ITB
- Increase flexibility of other tight structures
- Train and strengthen VMO in non-WB'ing
- Modify biomechanics stress
- Educate patient (overuse)
66
Management of Chronic Patellofemoral Dysfunction
- Continue to improve flexibility
- Progress resistance in painfree ROM
- Progress to more aggressive functional control activities (step height, depth of lunges, etc)
- Begin activity specific drills
67
Soft Tissue and Osseus Procedures for Patellar Instability
- Medial patellofemoral ligament repair or reconstruction
- medial retinaculum imbrication
- lateral retinacular release
- imbrication and medicalization of the VMO
- Distal realignment of the extensor mechanism
- Trochleoplasty for trochlear dysplasia
68
Articular Cartilage Procedures for Patellofemoral Dysfunction
- Arthroscopic debridement
- Repair of patellofemoral articular cartilage lesions
- Abrasion arthroplasty/chrondroplasty of the posterior surface of the patella
69
Procedures for End-Stage Patellofemoral Arthritis
- TKA or replacement arthroplasty of the posterior surface of the patella
- Patellectomy (salvage procedure)
70
Maximum protection phase (weeks 1-4) MPFL repair goals
- control postoperative swelling
- minimize pain
- knee ROM 0-90 degrees at end of week 4
- 3/5 muscle strength
- ambulate full weight bearing on operated side without assistive device but in locked brace
- establish home exercise program
71
Moderate Protection Phase (weeks 4-8) of MPFL repair Goals
- Control swelling
- knee ROM 0-120 degrees at end of week 6
- 0-135 degrees at end of week 8
- 4/5 to 5/5 strength
- improve neuromuscular control
- normalize the gift pattern
- adherence to home program
72
Minimum protection phase (weeks 8-12) of MPFL repair goals
- functional knee ROM
- 75% muscle strength compared to non operated LE
- gradual return to ADL and IADL
- educate patient on resuming activity slowly, monitoring signs and symptoms
- develop maintenance program, and educate the patient on importance of adherence
73
Maximum protection phase (weeks 1-4) MPFL repair interventions
- compression wrap to control effusion
- pain modulation modalities
- gait training with crutches in locked brace, WBAT
- ankle pumps
- knee AAROM --> AROM in range limiting brace
- superior and inferior patellar mobs (grade I and II)
- setting exercises: quads, hamstrings, and glutes
- Four-position SLR in locked brace for hip strength
- flexibility program for hamstring, calf, ITB
74
Moderate Protection Phase (weeks 4-8) of MPFL repair interventions
- LE flexibility program
- continues open-chain and closed-chain strengthening
- limited-range PRE
- proprioceptive training
- stabilization and balance exercises
- gait training
- low intensity stationary cycling in range-limiting brace for aerobic conditioning
75
Minimum protection phase (weeks 8-12) of MPFL repair interventions
- continue stretching for LE flexibility
- progress PRE for strengthening
- Advanced closed-chain exercises
- Aerobic conditioning program: swimming, cycling, walking
- walk-jog progression at week 10
- Agility drills by week 10-12
- Implement drills specific to occupation or sport
- Consider bracing for high-demand activity/occupation
- Task specific training: simulated functional tasks based on signs and symptoms
76
What is the most common mechanical cause of knee symptoms?
Meniscus lesion
77
Common activities that may cause a meniscus lesion
football, soccer, basketball
78
is a meniscus lesion more common in males or females?
Males (2.5:1) ages 31-40
| Females variable
79
Is the medial or lateral meniscus more susceptible to tears?
Medial
80
Medial meniscus tear MOI
fixed foot with medial femoral rotation
| pivoting, getting out of car, clipping injury
81
Is the medial or lateral meniscus more susceptible to compression injuries?
lateral meniscus
82
Symptoms of Meniscus lesion
- feel something give in the joint; sickening, deep pain
- pain with full extension
- history of locking
- difficulty bearing weight when acute
- + McMurray test
- + Apply compression test
- Joint line tenderness
- Possible joint swelling
- Possible quads atrophy
83
Healing potential of meniscus lesion
- tears in the peripheral zone have rich vascular supply and respond well to surgical repair
- newer thinking suggests that surgery for a tear into the less well vascularized central third is appropriate for young (under 40-50) or physically active individuals
84
3 Types of Mensical Surgeries
- Partial Menisectomy
- Meniscal Repair
- Mensical Transplantation
85
Partial Menisectomy
used to manage complex, fragmented tears and historically for tears in the relatively avascular central portion of the meniscus
86
Mensical Repair
Repair highly vascularized peripheral zone tears and increasingly advocated for central zone tears in young and physically active older persons
87
Meniscal Transplantation
Emerging option using human allograft tissue in situation where a total meniscectomy has been previously done
88
Partial Menisectomy general considerations
- no immobilization
- control pain and edema first few post-op days
- WBAT
- Activity progression depends on patients presenting signs and symptoms
89
Partial meniscectomy moderate protection phase
Approx 3-4 weeks
| exercise and WB'ing should be painfree
90
partial meniscectomy minimum protection/return to function
advanced activities such as plyometrics, maximum effort isokinetic and simulated high-demand activities can be initiated as early as 4-6 weeks with emphasis on quality of movement
91
Proposed Effects of Patellar Taping
- Stress relaxation effect on tight lateral structures
- Enhanced VMO recruitment
- Effect on articular cartilage
- Correction of poor patellar tracking
92
Goals of PF Taping
- control aberrant patellar motion leading to decreased inflammation, edema, pain
- Increase lower limb mechanics
- Never train through pain
93
Asterisk Sign
- Step down
- Bilateral squat
- 1 leg squat
- 1 leg stand
- 1 leg stand with hip MR and LR
94
Patellar Orientation
- Glide Component
- Tilt Component
- Rotation component
- Anteriorposterior tilt component
95
When applying PF tape, which deviation should you tape first?
the greatest deviation
