Knee Complex Flashcards
Meniscal Tear
Defintion
A tear in the meniscus of the knee
Most meniscal tears occur in the vascular region & will heal on their own
Meniscus
Details
- The menisci are attached to the tibia by the coronary ligament (meniscotibial ligaments)
- Medial & lateral menisci are attached to each other by the transverse ligament
- Outer 1/3 of the meniscus is vascular. Inner 2/3 is avascular. If the outer 1/3 is torn, surgeon may attempt to suture meniscus back together as opposed to removing it
Medial meniscus = C-shaped (thicker posteriorly & anteriorly)
Lateral meniscus - O-shaped (equal thickness around)
Both menisci are thicker around the periphery & thinner on the inner margin
During flexion both meniscus move posteriorly
- D/t the LATERAL mensici having greater excursion posteriorly, it is less prone to injury (lateral = 10 cm, medial = 2cm)
Medial Meniscus is attached to: MCL, ACL, PCL, & semimembranosus
Lateral Meniscus attached to: PCL, & the tendon of the popliteus mm through capsular connections
Function of Meniscus
(6)
- Aid in lubrication & nutrition of the joint
- Act as shock absorbers
- Increase congruency of joint surfaces
- Improve weight distribution (by increasing area of contact between the condyles)
- Reduce friciton during movement
- Aid the ligaments & capsule in preventing hyperextension
Meniscal Tear: Etiology
1 + 3
MOI: Leaded shearing/ twisting forces in tibiofemoral joint
- Typically occurs in WB (compression) & hyperflexion (> 90 degrees) - deep squat
- Early flexion = anterior meniscus II Deep flexion = posterior meniscus (posterior excursion)
- Tibial ER = medial meniscus II Tibal IR = lateral meniscus
ex. LT foot planted - cutting to RT = IR femur > ER tibia = medial meniscus
Meniscal Tear: S/S
(7)
- May present with joint line tenderness
- May present with joint effusion
- May present with “locking” in the case of a displaced tear (ie bucket handle)
- May present with clicking noise w/ movement
- May report knee “gives way” - result of edema
Effusion - lots of swelling caues quads to inhibit b/c of inhibition of quads - ppl feel like knee is giving out - May have loss of ROM
- May present with “springy block” end-feel in the case of a displaced tear
Springy block = HALLMARK - will not see with other conditions
Types of Meniscal Tears
(4)
Posterior Horn
- Most common
- Caused by hyperflexion & compression (squat - deep & jump - screening test)
Transverse Tear
- More commonly found in lateral meniscus
- Associated with ACL injuries
Longitudinal Tear
- A longitudinal split across the length of the meniscus
Bucket Handle Tear
- a longitudinal tear in which the inner edge of the meniscus flips up & may get caught in the interconfylar notch
- Can cause the knee to “lock” (1/2 conditons that locks knee)
- More common with MEDIAL meniscus tear
- Associated with ACL injuries
Meniscal Tear: Special Test
(4)
- McMurry’s Test
- Apley’s Tests
- Thessaly Test
- “Bounce Home” Test
Meniscal Tear: Interventions
PT Management:
- Decrease inflammation
- Pain-free ROM
- Strengthening - all mm of leg
Within tolerable ranges
Surgical Management:
- Meniscal repair (vascular zone)
Prone to OA & developing degeneration b/c bone is exposed
- Partial or total meniscectomy
Less than 7 days to return to work
Caution: > 90 degree of flexion - 4-6 weeks
AVOID: WB flexion > 90 for 3-4 months
No pivoting / cutting sports for 3-4 months
Anterior Cruciate Ligament (ACL)
(3)
Attaches from medial tibial plateau, runs superior-posterior-lateralto the lateral femoral condyle
- BULL - Back, UP, & Lateral
Medial -> lateral, Distal - proximal
Has two bands: anteromedial band & posterolateral band
Anteromedial band is taut in FLEXION (anterior drawer)
Posterolateral band is taut in extension (Lachmans test)
Restrains anterior tibial translation, medial tibial rotation, tibial valgus/varus (secondary)
Anterior Cruciate Ligament Tear
Description & Epi
A tear in the ACL
F>M
Anterior Cruciate Ligament Tear:
Etiology
(3)
Excessive anterior translation of tibia
Contact:
- Most common contact mechanism is a valgus force to the lateral side of the knee
- Terrible Triad: injury to ACL, MCL & medial meniscus
Non-Contact:
- Pivoting or cutting movements (tibia ER or tibia IR on femur w/ planted foot)
- Rapid deceleration - strong CONCENTRIC quad contraction
- Forceful hyperextension - anterior shear & translation of tibia
Anterior Cruciate Ligament:
S/S
(7)
- May have audible “pop” or snap” noise at time of injury
- May report tearing sensation at time of injury
- Pain
Constant, throbbing, aching
Increased pain w/ mvmt or WB - ligaments are used to stabilizing - stress on sensitive structures around - May present with hemiarthrosis immediately after injury
- Joint effusion
- May report knee “giving out” or feeling of instability
2 reasons: excessive swelling causing quad inhibition & instability from having a tear - Limited ROM - swelling, pain, apprehension
Anterior Cruciate Ligament Tear:
Special Tests
(3)
- Anterior Drawer Test
- Lachman’s Test
- Pivot-Shift Test
Anterior Cruciate Ligament Tear:
Interventions
PT Management (conservative)
- Decrease pain
- Decrease swelling
- Bracing
- Crutches if necessary - ++ instability / pain
- Strengthening (CKC > OKC)
OKC were originally believed to be dangerous - thought exercises caused anterior translation - debunked
- Proprioception
- Restore ROM
Surgical Management
- ACL reconstruction
Autograft: Gracilis + Semitendinosus (hamstring) graft, Patellar tendon graft
Semi - attaches to meniscus so do not want to use that hamstring / disrupt function & also important dynamic stabilizer > more prone to re-injure ACL
Patellar - CON: issue w/ quad strength = INC risk of developing PFPS
Allograft - donor tissue
Posterior Cruciate Ligament
(3)
Attaches from lateral tibial plateau, runs superior-anterior-medial, to the medial femoral condyle
Restrains posterior tibial translation, medial tibial rotation, tibial varus/valgus (secondary)
Stronger & thicker than ACL & less likely to tear
Posterior Cruciate Ligament Tear:
Etiology
(4)
- Posterior translation of the tibia on the femur (typically knee in flexion)
- “Dash-board” injury - posterior translation
- Falling on flexed knee - tibial tuberosity hits first
- Sudden forceful hyperflexion or hyperextension
- Hyperflexion more common
Posterior Cruciate Ligament Tear:
S/S
(6)
- Pain
Constant, aching, throbbing
Increased pain w/ mvmt, especially kneeling or stairs - May present with hemarthrosis immediately after injury
- Joint effusion
- Limited ROM in acute stage
- Increase passive extension ROM
- May present with genu recurvatum on observation
** More FUNCTIONAL instability so they do NOT feel it as much & as a result they are less likely to report it
Does not cause GROSS instability like an ACL does - conservative > surgery
Posterior Cruciate Ligament Tear:
Special Tests
(3)
- Posterior Drawer Test
- Posterior Sag Sign
- Godfrey (Gravity) Test
Posterior Cruciate Ligament Tear:
Intervention
PT Management (conservative)
- Decrease pain
- Decrease swelling
- Bracing
- Strengthening
- Proprioception
- Restore ROM
Surgical Management:
- PCL Reconstruction - results of Sx are poor & rarely presented as an option
Autograft: Gracilis + semitendinosus (hamstring) graft, patellar tendon graft
Allograpfts: Achilles tendon
Medial Collateral Ligament
(3)
Broad ligament with 2 layers: superficial & deep
- The deeper layer blends with the capsule & adheres to the medial meniscus
Restrains valgus, lateral tibial rotation, anterior & posterior tibial translation (secondary)
All the fibers are taut in full extension
- Anterior fibers = most taut in flexion
- Posterior fibrs = most taut in extension
Medial Collateral Ligament Tear
Des & Etiology & S/S & Special Test & Intervention
A tear in MCL
Etiology (MOI)
- Valgus force (with or without rotation) = ER of tibia will make it more taut
S/S:
1. Pain
Constant, aching, throbbing
Increased pain w. mvmt or WB
2. Joint effusion
3. May report knee “giving out” or feeling of instability
4. Limited ROM
Special Test: Valgus Stress Test
Interventions:
PT Management (conservative)
- Decrease pain
- Decrease swelling
- Strengthening
- Proprioception
- Restore ROM
- Bracing (not in full extension d/t to MCL being taut)
Surgical Management
- Not usually performed on collateral ligaments. The MCL can heal conservatively
Attached to the joint capsule so it has a blood supply & can heal on its own
Lateral Collateral Ligament
(3)
Round-cord like ligament running from the lateral eipcondyle of femur to the fibular head
Restains varus, lateral tibial rotation, anterior & posterior tibial translation (secondary)
Taut in extension and loosens at > 30 degrees of flexion
Easily palpable in figure-4 position - feel into the joint space > band-like structure
Lateral Collateral Ligament Tear
Des & Etiology & S/S & Special Test & Intervention
A tear in the LCL
Etiology (MOI)
- Varus force (with or without rotation)
S/S:
1. Pain
Constant, aching, throbbing
Increased pain w/ mvmt or WB
2. Joint effusion
3. May report knee “giving out” or a feeling of instability
4. Limited ROM
Special Test;
- Varus Stress Test
Intervention:
PT Management (conservative)
- Decrease pain
- Decrease swelling
- Strengthening
- Restore ROM
- Proprioception
- Bracing
Surgical Management:
- Not usually performed on collateral ligaments
Knee OA:
Etiology (RF)
Mod & Non-Mod
Non-Modifiable
- Age
- Gender (F>M)
- Heredity
- Congenital Malformations
Unicompartmental - valgus / varus positions
Modifiable
- Obesity - HIGH RF - specifc to knee - WB joint
1 lb loss = DEC 4 lb force on knee (GRF)
- High impact activities - INC risk of developing passive structues
- Muscles weakness - more reliance on passive structures
- Trauma
- Decreased proprioception
- Joint mechanics (may or may not be able to modify)
Landing from a jump in valgus = HABITAL = hard to modify
Knee OA: S/S
- Insidious onset (months-years)
- Morning stiffness (< 30 mins)
Immobile > “gelling period” - starts to loosen up as thye walk / move it out - Pain w/ activity
Worse w/ WB, squatting, stairs, static postures, rising after prolonged sitting, excessive activity (walking), fall in barometric pressure - Joint line tenderness
- Decreased ROM
- Decreased strength
- Decreased function (d/t pain, weakness, & ROM limitations)
- Bony enlargements - friction = laying down more bone
- Crepitus
- May present with mm atrophy (d/t disuse)
- May present with swelling (no erythema)
- May present with warm knee
- May report feeling instability - joint space narrowing = INC laxity of ligaments - not as taut so do not restrict mvmt
- May present with genu varum or genu valgum (may have had it before - more prone for developing OA
Knee OA: Interventions
PT Management:
- Muscle strengthening - hip strengthening helps as well
- Low impact exercise - swiming, cycling, elliptical - can be analgesic & help w/ wt management
- Decrease swelling
- Decrease pain
- Increase ROM (CPM post-op) - passive FLEX/EXT
- Improve function
- Assistive device for ambulation if needed - cane = unload limb & more pressure through arm/cane
- Bracing if needed (unloader) - push condyle to help even out forces
- Weight loss
surgical Management
- Aspiration - decrease fluid in joint
- Injections
Hylauronic acid supplements (ie Synvisc) - component of synovial fluid (viscosupplementation)
Corticosteriods
- Arthroscopic Debridement - smooth & remove osteophytes (may be temporary affect if not modifying RF)
- Proximal Tibial Osteotomy
Closing Wedge Varus Correction - remove a piece of bone
Opening Wedge Valgus correction - put in a piece to even it out
- Partial (hemi) Knee Replacement - unicompartment OA
- Total Knee Arthroplasty
90 degrees required by 6 weeks or MUA may be required
Put under anesthetic - quickly flex knee to break up scar tissue (aggressive manipulation)
EXPECTED: At least 110 FLEXION - need it to FUNCTION (ie stairs& FULL EXT for gait
Patellofemoral Pain Syndrome (PFPS)
Description (3)
- Diffuse pain around the knee cap, seemingly as a result of abnormal patellar tracking causing increased contact pressure on the posterior surface of the patella against the femur
- Most common cause of chronic knee pain
- Diagnosis is made clinically, based on Hx & physical examination
Condromalacia Patellae
Description
A condition which creates similar signs & symptoms as PFPS with noted degeneration of the patellar articular cartilage behind the knee
- No sensation of articular cartilahe on posterior aspect of patella - likely a different tissue source causing pain (ie fat pad or synovial tissue)
