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MSK II - EXAM 3 KNEEEEEEE > Knee- ACL thru PT Rx > Flashcards

Knee- ACL thru PT Rx Flashcards

1
Q

What is the ACL?

A

Anterior Cruciate Ligament

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2
Q

Where does the ACL attach?

A
  • centrally and anteriorly on the tibial plateau
  • lateral aspect on the intercondylar fossa
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3
Q

Where does the ACL run?

A

superior, posterior and laterally

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4
Q

What excessive tibial motions does the ACL limit?

A
  • limits anterior tibial translation
  • IR of tibia
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5
Q

What is the ACL the primary restrain for?

A

excessive anterior tibial glide secondary restraint to tibial IR

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6
Q

What percentage of knee injuries are due to the ACL?

A

20%

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7
Q

What population are ACL injuries most often happening in?

A

younger and active biological females

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8
Q

What are non-modifiable risk factors for a non-contact ACL injury?

A
  • biological sex (female)
  • bony morphology
  • congenital joint hypermobility
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9
Q

What biological sex is more prone to non-contact ACL injury?

A
  • female tears> males
  • 2 weeks following start of menstrual period
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10
Q

What bony morphologies are more prone to an ACL injury?

A
  • narrow intercondylar femoral notch
  • posterior tibial slope and hyperext both correlated with non-contact ACL injuries
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11
Q

What are some modifiable risk factors for the primary ACL injury?

A
  • high shoe-surface interaction/friction
  • High BMI
  • Bracing - inconsistent benefit
  • muscle strength
  • altered loading patterns
  • impaired trunk proprioception and kinesthesia
  • greater activation of visual-motor strategy
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12
Q

Why can kinds of muscle strength issues be a modifiable risk factor for ACL injury?

A
  • lower overall with ACL tears
  • Ham to quad ratio strength
    > lower in females vs. males
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13
Q

Why are the hamstrings important to the ACL?

A

BALANCE
- if hamstrings not as strong, quads pull the tibia forward and dont have the hamstrings to pull backwards

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14
Q

Why is impaired LE control a risk factor for ACL injury?

A
  • increased dynamic knee valgus and hip adduction
  • earlier and nearly 2x faster with impaired LE control (falling into it sooner, moving through it faster = excess stress)
  • very good ability to visually identify high knee valgus angles with vertical drop jump test
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15
Q

Why is decreased knee flexion a risk factor for ACL injury??

A

larger GRF or harder landings so cant absorb landings

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16
Q

What can indicate poor control in landing with ACL?

A
  • significant valgus movement
  • knee medial to foot
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17
Q

What can indicate reduced control with the ACL?

A
  • some valgus movement
  • knee NOT entirely medial to foot
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18
Q

What shows GOOD control with the ACL upon landings?

A
  • no valgus movement
  • knee vertical with toes
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19
Q

Why can impaired trunk proprioception and kinesthesia be a risk factor for ACL injury?

A
  • greater trunk lean toward support limb
  • greater trunk rotation toward support limb
    = less ability to counterbalance, more stress
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20
Q

What is a visual-motor strategy and why can be be a risk factor for ACL injury if used instead of sensory-motor strategy?

A
  • using eyes to control movement instead of sensory or proprioceptive feedback = sports difficult to use vision
  • take away visual for intervention to force proprioception use
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21
Q

What are risk factors for a secondary ACL injury?

A
  • like primary ACL injury plus excessive femoral IR moment
  • WORK ON ERs
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22
Q

What muscle group needs addressed MORE for a secondary ACL injury?

A

ER! Most prone to injury with weakness!!!

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23
Q

What is the etiology of a second ACL injury?

A
  • non contact: 50-70%
  • contact: 30%
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24
Q

What are functional questionnaires for the ACL?

A
  • IKDC (international Knee Documentation Committee)
  • KOS (knee outcome Survery)
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25
Q

What are symptoms of an ACL sprain?

A

consistent with any sprain plus:
- effusion, popping, and giving way following trauma
- WBing activities limited with likely giving way

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26
Q

What are signs of an ACL sprain found in ROM?

A

Consistent with any sprain plus:
- ROM: limited and painful, particularly into hyperext and IR (directions the ACL limits!)

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27
Q

What is the anterior drawer special test for the ACL?

A
  • anterior drawer (+)
  • stabilize foot with 90° knee flx in supine HL; glide tibia ant
  • LR+= 1.6-8.3 and increases to 19 if effusion, popping, and giving way after trauma
  • LR- = .1-.78
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28
Q

What is Lachman’s special test for the ACL?

A
  • sens > spec
  • in supine, stabilize femur @ 15° flx; glide tibia ant
  • possible false negatives due to blocking of anterior glide :
    • severe swelling tightens capsule
    • Hamstring guarding
    • meniscal tear
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29
Q

What is the pivot shift test for the ACL?

A
  • in supine, hold tibial IR with valgus stress from 90° flx to full ext slowly
    high spec
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30
Q

What should we know about the special tests for ACL?

A

others possibly positive for additional tissue damage, i.e. meniscus, MCL, etc.

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31
Q

What leads to muscle inhibition?

A
  • pain
  • swelling
  • laxity
  • disuse
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32
Q

What is a sign of ACL sprain in MMT/Muscle activity?

A

inhibition of quads due to:
- pain
- effusion (joint swelling)
- joint laxity or giving away
- muscle weakness/incoordination

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33
Q

Where can effusion (swelling) be found with ACL sprains?

A
  • involved knee inhibition (42%)
  • uninvolved knee inhibition (21-33%)
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34
Q

Is the amount of swelling always correlated with the amount of muscle inhibition?

A

NO

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35
Q

What can the arthrogenic muscle inhibition of quads with an ACL injury lead to?

A
  • atrophy and more inhibition / weakness - deficits common out to 2 and 4 years post op and even in both LEs
36
Q

What is the inhibition of quads determined by?

A
  • observation, palpation and muscle testing
37
Q

What is the “local muscle” of the knee?

A

vastus medialis

38
Q

What should we know about return to LOWER RISK activity with an ACL tear?

A
  • MOST can return to lower risk activity without surgery and with good outcomes
39
Q

What are the 3 primary and early goals with an ACL tear?

A
  1. full to nearly full ROM, esp ext
  2. minimal to no swelling
  3. quads activation/ endurance/ coordination
40
Q

How can we achieve full to nearly full ROM, esp ext with an ACL tear?

A
  • immediate mobilization for ROM, pain, and minimizing immobilization effects (mod support)
41
Q

When should we IDEALLY have full extension with an ACL injury?

A

no later than 4 weeks

42
Q

What does the gain of full ext in the expected time frame predict?

A

extension at 12 weeks

43
Q

How does achieving full extension post ACL injury contribute to a lower risk of OA?

A
  • if ext not re-gained in 12 weeks = increased risk of knee age related joint changes
  • joints healthiest when they can move through their full ranges, maintains the cartilage integrity with good stresses, which DECREASES THE RISK OF OA
44
Q

Can you contract the quads fully without full knee ext?

A

NO

45
Q

When is quad activation best?

A

with FULL EXTENSION

46
Q

What test can measure good quad activity post ACL injury?

A
  • SLR without extension lag
47
Q

Quad set should be what percentage of the uninvolved side? Why is this misleading?

A
  • ≥ 90% uninvolved side
  • BUT uninvolved side could also be inhibited
48
Q

What should we know about early WBing with ACL injury?

A
  • without detrimental effects if symmetrical
  • leads to better outcomes
49
Q

What is there WEAK support for with ACL injury?

A
  • cryotherapy
  • continuous passive motion (CPM) devices
50
Q

When should manual therapy be initiated with ACL injury?

A

post op

51
Q

What should we use for muscle activation/coordination/strength with ACL injury?

A
  • Neuromuscular Electrical Stimulation (NMES)
  • significant increase in quad strength
  • NO significant changes with function
  • isometrics at varying angles based upon symptoms and commorbidities
52
Q

When should the usage of NMES be discontinued?

A
  • once quad index in ≥80% of uninvolved side
53
Q

When is NMES even BETTER?

A

when done with a quad set, makes active intervention instead of passive; also MORE comfortable

54
Q

What assumptions HAVE to be made about MET for ACL injury?

A

arthrogenic muscle inhibition

(NOT NO PAIN NO GAIN)

55
Q

What can we gradually progress to with MET for ACL injury?

A

intense resistive training without inducing pain

56
Q

What types of exercise should we emphasize with ACL injury?

A

both concentric and eccentric training

57
Q

What are the general exercise guidelines for initial ACL loading with NON WB vs WBing activities?

A
  • generally greater load on ACL with NON-WB due to working the quads, nothing opposing the anterior translation of the tibia! WB quads have the HS to counteract the glide of the tibia
  • NON-wbing activities less of a concern than in the past
58
Q

When are there the greatest loads with NON-Wbing and WBing activities?

A

within 50˚ of full extension with both

59
Q

What should we know about general exercise guidelines with squatting, lunging, and leg press with initial ACL loading?

A

Load is…
- increased with knee beyond toes
- decreased with forward trunk lean

60
Q

What are general exercise guidelines for ACL loading when walking?

A
  • as much load as non-wbing knee ext due to repetitive terminal knee ext (need terminal knee ext to walk)
  • several times greater than other WBing activities
61
Q

What are Spaddy’s take home points with MET for ACL?

A
  • Open kinetic chain and closed kinetic chain activities early and often, especially if they are walking and using correct trunk and LE control
  • carefully and progressively work toward end range ext
62
Q

Why should we emphasize hamstring strength and coordination?

A
  • Hams > 66% of quad activity in males
  • Hams > 75% of quad activity in females
  • predicts LE control
63
Q

Does normal strength equal proper neuromuscular control of LE?

A

NO ≠

64
Q

What can we do with trunk proprioception and kinesthesia to help with neuromuscular training?

A

minimize lean and twist

65
Q

What can we do to improve LE control using neuromuscular control?

A
  • minimize excessive frontal and transverse plane motion
  • promote sagittal plane knee and trunk flexion
  • decrease GRF with softer landings
  • Progressive speed and difficulty
  • emphasize balance
66
Q

How often and how long must we do MET for ACL injury?

A

at least 2-3x a week for 6-10 months

67
Q

What should we do regarding each LE?

A
  • work each LE individually as well as bilaterally for cross education
    = less deficit compared to only exercising involved knee
68
Q

What should we know about blood flow restriction for ACL injury?

A
  • similar strength and hypertrophy as high intensity training
  • good alternative if high intensity training cant be done otherwise
69
Q

What is another PT rx for ACL injury to improve movement?

A

motor learning for improved movement patterns

70
Q

What is the internal focus at the start with ACL injury?

A

on movement itself

71
Q

What is the learning pace at the start?

A

slower

72
Q

What is the carryover at the start?

A

Less

73
Q

What resources are available for other factors at the start?

A

less (think too much)

74
Q

How much psychological and psysiological stress is there at the start?

A

MORE

75
Q

What kind of feedback is needed at the start?

A

More, simple

76
Q

What is the focus with progressing?

A

on effect of movement
- ex: act like you’re sitting in a chair
- familiar

77
Q

What is the learning pace with progressions?

A

Faster due to familiarity

78
Q

How much carryover is there with progression?

A

MORE

79
Q

What resources are available for other factors with progress?

A

More due to familiarity in premotor cortex

80
Q

How much psychological and physiological stress is there with progression?

A

Less

81
Q

How much feedback does the patient need with progress?

A

Less, but some may benefit from more detail if requested; simple

82
Q

What are the benefits of motor learning with external focus for ACL PT rx?

A
  • improved balance (central pressures)
  • higher vertical jump
  • more force production
  • greater knee flexion
  • softer landing (decreased GRF)
  • improved coordination
83
Q

What should we know about functional bracing for ACL injury?

A
  • more beneficial than NOT with ACL deficiency
  • conflicting support with ACL reconstruction
84
Q

What can further motor learning with observation added to practice do to help with PT rx of ACL injury?

A
  • with others by competition, motivation, responsibility
  • post and real-time feedback including in slow motion
85
Q

What should we know about plyometrics for ACL PT rx?

A
  • vertical drop jump = similar loading to NON-wbing ext
  • increased loading with rate of deceleration

MSK II - EXAM 3 KNEEEEEEE (6 decks)

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