Knee

Question 1

three joints of the knee

Answer 1

• Two (three) joints:
– Tibiofemoral joint (TFJ)
– Patellofemoral joint (PFJ)
– (Superior tibiofibular joint)

Question 2

tibiofemoral joint

Answer 2

• TFJ is the articulation between the tibia and femur
– 1° Weight-bearing synovial joint
– Modified hinge joint • Flexion/extension
• Medial/lateral rotation
• Abduction/adduction (passive motion)

Question 3

patellofemoral jt

Answer 3

• PFJ
– Articulation between the patella and femur
– Modified plane joint
• The patella acts to improve the leverage of
the quadriceps muscles
─ PFJ implicated during loaded flexion of the knee,
e.g. climbing stairs, walking up/ down hills ─ ImportantclinicallytodifferentiatefromTFJ

Question 4

superior tibiofibular jt

Answer 4

• Superior tibiofibular joint
– Articulation between the tibia and fibula
– Plane joint
• Not most common cause of knee pain but shouldn’t be neglected

Question 5

muscles of the knee

Answer 5

– Flexors:
• Hamstrings
• Gastrocnemius • Gracilis
• Sartorius
– Extensors:
• Quadriceps
– Medialrotators
• Semitendinosus, semimembranosus (medial hamstrings)
• Gracilis
• Sartorius
• Popliteus
– Lateralrotators
• Biceps femoris (lateral
hamstring)
• Popliteus

Question 6

ligs of the knee

Answer 6

ACL 
PCL 
LCL 
MCL 
M meniscus
L Meniscus

Question 7

Bursae of the knee

Answer 7

suprapatellar bursa 
Deep infrapatellar bursa 
Subsartorial 
Semimemb
Subcutaneous prepatellar 
subcutaneous infraptella

Question 8

screw home mechanisms

Answer 8

• A locking mechanism occurs in the tibiofemoral joint between 20° of flexion and full extension (0°)
• Most prominent around last 5° ext • Necessary for stability
• Reduction in friction
• Improved efficiency

Question 9

locking unlocking

Answer 9

12

Question 10

PE

Answer 10

• Observation
– Walking from the waiting room
– Sitting in chair/on plinth
– Removing shoes etc.
• Patient history
• Gait analysis
– Lower limb functional task that nearly everyone does.
– Formal observation
• Baseline functional test – can you replicate the primary complaint? – e.g. Sit to stand, walking, squatting
• Active Range of Motion
– Quantity and quality (what limits motion e.g. pain, caution, can they maintain the position (severity), does the pain go away instantly (irritability))
• Passive Range of Motion
– Quantity and quality (what limits, e.g. pain, caution, some clinicians
value ‘end-feel’)
– Differentiate between active and passive system?
• Resisted tests (MMT)
– Isometric &/or Isotonic (pain vs. weak) – Functional (pain vs faulty patterns)
– Global lower limb
• Clearing tests
• Palpation
• Accessory Movements (joint play)
• Special tests (specific to pathology/clinical reasoning)
– Abundance of “special tests”
– Be cautious, potential for false positives (e.g. positive McMurray’s without relevant meniscal pathology)
• Neurological assessment and/or Neurodynamic tests

Question 11

Causes of acute knee pain

Answer 11

trauma - #'s 
- patella, femoral condyles, tibial plateau, avulsion #
Patella disclocation 
Ligament damage
Haemarthrosis 
Muscle strain/contusion 
Meniscal damage
Fat pad damage 
bursitis 
tendon rupture

Question 12

ACL problem

Answer 12

• Most commonly injury knee ligament
– 52 per 100,000 in Australia (Janssen et al. Scand J Med Sci Sports. 2012 22(4), p 495)
– Incidence rises through adolescence and early adulthood – males > females.
– Highest incidence (descending order)
• Skiing • AFL
• Rugby • Netball • Soccer

Question 13

ACL Dx

Answer 13

• Clinical diagnosis
– «»
– 1° complaint giving way/instability
– ± pain
– Swelling++/Heamarthrosis
– Special tests; Lachman’s test, Anterior Drawer Test, pivot shift test
• MRI, X-ray (sulcus sign)
• Three grades of ligament injury
http://www.youtube.com/watch?v=L51ASg2_07Q
• Outcomes: KOOS, LLTQ, SF-36, functional measures

Question 14

ACL Rx

Answer 14

• Phase1(Acutephase)goals
• Control pain and swelling, Restore pain free ROM, Improve flexibility, Normalize gait mechanics (WBAT w crutches), Establish good quadriceps activation
• Phase2(Sub-acute/strengtheningphase)goals
• Avoid patella femoral pain, Maintain ROM and flexibility, Restore muscle strength,
Improve neuromuscular control
• Phase3(Limitedreturntoactivityphase)goals
• Avoid patella femoral pain, Maintain ROM and flexibility, Progress with single leg strengthening to maximize strength, Progress dynamic proprioception exercises to maximize neuromuscular control, Initiate plyometrics* and light jogging*
• Phase4(Returntoactivity/sportphase)goals
• Maintain adequate ROM, flexibility and strength, Continue progressive/dynamic strengthening, proprioceptive, plyometric and agility training, Achieve adequate strength to return to sport (pending physician’s clearance)

Question 15

ACL evidence

Answer 15

• Conservative vs. Surgery 6 – 16 months follow-up (Karanikas et al., Sportverletzung-Sportschaden 2005, 19(1) p15).
• n = 12 conservative vs. n = 21 operative
• Operative group scored better for ligamentous stability
• Conservative group had > muscle strength (knee ext & flx, ankle plantarflexors)
• Conservative vs. Surgery 11 year follow-up (Kessler et al. Knee Surg Sports Traumator Arthrosc, 2008 16, p442)
• n = 109 (60 surgery, 49 conservative) Isolated ACL rupture – same rehab program
• 11 years after ACL rupture, surgery group had better stability but more Knee OA (>Grade II), no difference in physical activity level (both groups decreased physical activity level)

Question 16

Patella # - problem

Answer 16

• Fracturesofthedistalfemur,proximaltibiaandpatella make up 6.7% of all LL fractures
• 47%proximaltibia
• 32%distalfemur
(Vun et al. http://www.bjjprocs.boneandjoint.org.uk/content/95-B/SUPP_12/10)
• Cause (e.g. fall, RTA)
• Patella–directblow
• Tibialplateau–compression
• 21%Patella

Question 17

patella # dx

Answer 17

• Clinical diagnosis
– Instant PAIN+
– Swelling++/Heamarthrosis
– Quads weakness, or inability to extend leg
– Pain++ on palpation, depending on fracture type might be able to feel gap
– OWATTA KNEE RULES
• X-Ray – Confirmation
– Referral Orthopaedic Specialist
• Outcomes:KneeSocietyClinicalRatingScale(KSCRS)
<>, WOMAC, KOOS, LLTQ, SF-36

Question 18

OTTAWA knee rules

Answer 18

age 55 or older
isolated tenderness to patella 
tenderness of head of fibula
inability to flx 90 degrees
Inability to WB both immediately and in ED for 4 steps

Question 19

Patella # Rx

Answer 19

• Non-displaced (retains normal form and position) – Brace Knee Immobilizer (full extension) 4 – 6 weeks
– Period of NWB (7 days) than WBAT
– Physiotherapy • ROM
• Strengthening
• Restore normal function
• Displaced
– ORIF (4 – 6 weeks immobilizer brace)
– Physiotherapy
• Same as above

Question 20

Patella # evidence

Answer 20

• Percutaneous vs. Open surgery 2 year follow-up (Luna-Pizarro et al. Journal of Orthopaedic 2006 20(8), P529)
• n = 53 patients (displaced patella fracture)
• Percutaneous repair was associated with shorter surgical time, less pain, better mobility angle (flexion > extension), better KSCRS at 4 and 8 weeks follow up.
• Knee society clinical rating scale was greater in the percutaneous group at 12 and 24 months

Question 21

Chronic/idiopathic causes of knee pain

Answer 21

OA
patella tendinopathy
ITB syndrome 
PFPS 
Chrondromalacia patellae
Hypermobility
knee deformity - genu varum/valgum
Osteochondritis desicans
Osgood schlatter disease

Question 22

OA - problem

Answer 22

• Significant problem (older population)
– 1.4 million Australians (2009)
• Two types (Felson et al. 2000, Annals of Internal Medicine, 133 (8) p635)
– Primary – idiopathic, gradual deterioration, affects many joints (older age) – Secondary – following injury, localised to one joint (younger age)

Question 23

OA Dx

Answer 23

• Clinical diagnosis (Think age, main symptoms: pain, stiffness, limited movement of the affected joint)
• X-ray (Kellgren & Lawrence OA Grades)
• Outcomes: WOMAC, KOOS, LLTQ, 6MWT, TUG,
STS

Question 24

OA Rx

Answer 24

• Treatment (Zhang et al., 2008)
• 12 Non-pharmacological therapies
– advice and education, self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening, water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal
• 8 Pharmacological modalities (NSAID, topical NSAID, intra- articular injections)
• 5 Surgical modalities (arthroscopy, partial joint replacement, total joint replacement)

Question 25

OA evidence

Answer 25

• RCT exercise vs. no exercise (Nejati et al., 2015) • Both groups received the same treatment except exercise • Exercise group had > improvement in pain, disability, walking, stair climbing, and sit up speed at all time points (1, 3, 12 months). • Physiotherapyprogramvs.homeexerciseprogram (Deyle et al. 2005 Physical Therapy 85 (12), p1301) • 2 Groups – supervised exercises with manual therapy vs. home exercise program over 4 weeks • Both groups improved • Supervised group had significantly greater improvements on 6MWT and WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index)

Question 26

PFPS: problem

Answer 26

• Most frequently diagnosed condition in patients <50 years with knee complaints (adolescent population) (Lankhorst et al., JOSPT 2012 42(2), P81) • Females > Males (Lankhorst et al., 2012) • Incidence of 25 – 43% in sports medicine and during military training (Devereaux et al., 1984: Thijs et al., 2007)

Question 27

PFPS Dx

Answer 27

• Clinical presentation (think age) – Anterior knee pain: Peripatellar pain ,hard to describe – Pain on loaded or prolonged flexion (running,stairs,sitting) – Weak medial and tight lateral – Poor patellar tracking (q-angle) –Weak hip muscles /altered hip and/ or foot biomechanics – Crepitus(severe cases) – Giving way due to weak quads • no scans in early stages (may scan if not improving) • Outcomes: VAS, Anterior Knee Pain Scale (AKPS) (Valid and Reliable, Crossley et al., Arch. Phys. Med. Rehabil. 2004 85(5) p815) , GROC, Functional outcomes (ROM, strength, running)

Question 28

PFPS evidence

Answer 28

• RCT arthroscopy + exercise vs. exercise alone (9 month follow-up) (Kettunen et al., BMC Medicine 2007 5, article #38) • Both groups treated with 8 week exercise program • No difference between groups at follow-up (Kujala Score and VAS) • Arthroscopy cost exceeded exercise group by €901/patient • Collins et al., Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. BJSM 2009 43(3), p169

Question 29

PFP

Answer 29

• Gradual onset of retropatellar or peripatellar pain PFP • Aggravated by tasks that increase patellofemoral joint (PFJ) loading – Such as jumping, running, squatting, stairs, prolonged sitting • Justtoclarify,itISNOT – Chondromallacia patella – Patellar tendinopathy – Osgood Shclatters – Sinding Larsen-Johansson’s disease – Bursitis – Plural of neuromas – Intra-articular pathology – Plica syndrome – And other rarely occurring pathologies of knee...

Question 30

PFP differentiation

Answer 30

• Themostcommon alternative diagnosis you need to differentiate is – Patellar tendinopathy • The S&S will vary ever so slightly...

Question 31

PFP contributing factors

Answer 31

``` • Extrinsic factors – Excessivetrainingload, altered training surface, incorrect footwear • Intrinsic factors – Gender? – Local • knee – Proximal • Hip, thigh, pelvis, trunk – Distal • Footandlowerleg ```

Question 32

Intrinsic risk factors of PFP

Answer 32

– Proven association with (Lankhorst, 2012) – Larger Q angle (quads angle) • But measuring protocol needs clarification – Sulcus sign/angle – Patella tilt angle • Which direction?? – Lower knee peak extension torque – ê hip abd strength as a %BW – ê hip ER strength • Prospectively (why is this important?) – Limited quads flexibility – Limited gastroc flexibility – Knee extensor weakness – ê knee extension peak torques –éknee valgus moment at initial contact • NOT a risk – Genu varum and valgum

Question 33

PFP Rx

Answer 33

• Therearearangeof interventions that have been demonstrated to be effective in PFP Rx – Proximal – hip abductors and ER strength – Distal – orthoses – Local – taping, PF mobs, vasti retraining • Multimodal PT approach is considered gold standard Rx option with strongest evidence – Patallataping – Vasti retraining – Glutealstrength • AbductorandERstrength – Patella mobs – Stretches • Orthoses....

Question 34

PFP Rx success

Answer 34

• Generallyhighwithconservativetreatmentinthe short term but longer term is more questionable – > 7 years, 30% of non-recovery patients had persistent symptoms • Manyindividualshaveunfavourableoutcomeat3 months (55%) and 12 months (40%) – How do we address the ‘subgroups’ and ensure our treatment becomes more targeted and effective.