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MSPT I > Knee-Final Lecture: Exam 2 > Flashcards

Knee-Final Lecture: Exam 2 Flashcards

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1
Q

Knee Jt. Sx

What do you NEED to keep in mind??

*AVOID overstressing what was done!

A

Tx Principles

  • Avoid?
  • Emphasize?
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2
Q

Tissue stress/Jt. Stress

  1. Symptom Mod. & Tissue Protection
  2. Movement Control
  3. Functional Optimization
A
  • Symptom Mod. & Tissue Protection
    • ​LOAD IT CAREFULLY!
    • Ex. in UPPER pt of maintenance, LOWER pt of hypertrophy
  • Movement Control
    • ​LOAD IT THOROUGHLY
    • Ex. in the hypertrophy zone, AVOIDING injury
  • Fxnl Optimization
    • ​LOAD IT IN CONTEXT
    • Ex. in NEW hypertrophy zone, AVOIDING injury
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3
Q

When in doubt….

W/ Knee Sx

A
  • Get Op report
    • Repair vs. Reconstruction
      • ​tells you about Tissue Quality
    • YOU CAN ALWAYS MOBILIZE THE PATELLA
    • ​Get a good Isolated Quad Contraction!!!
      • ​Quad sets—–hundreds!!!
      • Stim the hell out of the Quad
      • Extension to 0o
        • GET THEM TO ZERO!!!
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4
Q

Gen. Knee Sx

Phase 1: Symptom Mod. & Tissue Protection

A

Ranked (MOST important FIRST)

  1. Protect the Sx
    1. ​Sx & Tissue specific cond’s
  2. Regain EXTENSION
  3. Restore Quadriceps Contraction
  4. Regain FLEXION
    1. ​emphasize ability to transition from FLEX to EXT.
  5. DEC effusion/Inflammation
  6. Prevent atrophy of other mm’s
  7. Normalize Gait
    1. ​*Actually MORE important than FLEX.
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5
Q

Tissue Protection Phase

GOALS:

A
  • Restore ROM w/out over-stressing sx tissues
  • Prevent mm atrophy and contractures
  • Modify gait patterns to improve overall fxn
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6
Q

Tissue Protection Phase

Causes of Concern

*Not making progress + Immediate Referral

A
  1. Concerning ROM Limits:
    1. ​Not achieving 0o by 4 wks
    2. Not achieving 90o by 4 wks
  2. IMMEDIATE REFERRAL OUT:
    1. ​10o FLEX contracture @ 6wks
      1. *compared to anatomic 0o
    2. Not achieving 90o by 12wks
    3. Consistent motion loss
    4. Symptomatic instability
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7
Q

Post-OP Brace & AD Use—Lig. Sx

Post-OP Orthosis

A
  • Brace locked in EXT ~1 week
  • Brace UNLOCKED after week 1 for ambulation and PT
    • ​**IF quad lag has been resolved
  • Discharge brace when pt has:
    • ​FULL passive hyperEXT (0o) AND @ least 90o of FLEX
    • FULL Active EXTENSION
    • “NORMAL” pain-free gait pattern
    • Usually around 4-6wks
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8
Q

Post-OP Brace & AD Use—-Lig Sx

AD Use

A
  • WBAT w/ crutches for first 4 wks
  • SAME CRITERIA AS DISCHARGING BRACE
  • Begin weaning to 1 crutch and THEN discharge crutches when:
    • ​1. pt exhibits non-antalgic gait pattern
      1. Reaches FULL EXT @ Heel Strike
      1. Pt. does NOT display any INC in swelling
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9
Q

Restoring Quadriceps Function

SO IMPORTANT!!!!

A
  • Pain + Effusion—> adversely affect quad function
    • ​=====quad inhibition
  • Quad activation failure===EXT. mech. disrupted
    • ​quad tendon OR patellar tendon autografts
  • Poor quad function ==> patellofemoral arthrofibrosis (stiff & sticky)
  • GOOD quad function requires adequate patellar mobility******
  • Restoration of quad function correlates w/ ADL fxn in EARLY STAGES OF RECOVERY
  • Quantity and Quality of exercise KEY to maint. and improving quad function
    • 50 quad sets every hour you are awake!!!
      • LOAD THEM!!!
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10
Q

Restoring Quad Function

NMES Parameters

A
  • 2500 Hz,
    • 75 bursts/sec
  • 10 contractions
  • 10” ON/50” OFF
  • Stim. produces full, sustained quad contract. w/ evidence of superior patellar glide
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11
Q

Therapeutic Ex. in Tissue Protection & Symptom Mod. Phase

Strength Training

A
  • NWB Quad Strengthening
    • ​quad sets, SAQ, LAQ
  • ​WB Quad Strengthening
    • TKE
    • Step up/downs
    • Squats
      • use shorter ROM & GET FULL EXT***
    • Leg Press
      • shorter ROM & get FULL EXT. ***
  • NMES
  • Hips/Core/HS’s
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12
Q

Therapeutic Ex. in Tissue Protection & Symptom Modulation Phase

Functional Training

A
  • GAIT TRAINING
    • sequencing w/ AD—teach them
    • 3-way Wt. Shifting
    • Step and Holds—-Neuro
  • Cycling for ROM
    • Arc of motion to stretch
    • 100-110o needed for full revolutions****
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13
Q

WB Strengthening???

A

Good, but not by itself!!!

  • More “functional” BUT does NOT isolate the quad
    • ​we NEED to get FULL EXT****
  • Gen. safer for EARLY REHAB
    • ​Reduce Ant. Shear Force—-after ACL
    • INC tibiofemoral compression
    • INC co-contraction of HS’s
  • incorporates entire kinetic chain
  • Element of proprioception
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14
Q

General Knee Sx Guidelines: Phase 2–Motor Control

in a nutshell…

A

Protect the Sx, INC load

**Sx and Tissue Specific Cond’s

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15
Q

Gen. Knee Sx Guidelines: Phase 2–Motor Control

A
  • Protect the Sx, INC load
    • ​Sx & Tissue specific cond’s—-follow them!!!
  • Maintain ROM
  • Rehab LE mm’s
    • ​lengthen+strengthen
    • QUADS IS MOST IMPORTANT
    • Hip/HS’s/Core
  • Prevent recurrence of inflammation
  • Condition CV system
    • ​walking, bike
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16
Q

Therapeutic Ex in Motor Control Phase

Strengthening vs. Functional Training

A

Strength vs. Functional Training

see pics

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17
Q

Gen. Knee Sx Guidelines: Phase 3–Functional Optimization

PROTECT THE Sx

A
  • Protect the Sx
  • CV conditioning
  • Injury Prevention Tech’s while introduce:
    • ​running
    • agility training
  • Optimize LE mm performance
    • ​Sport specific
      • lengthen and strengthen
    • QUADS IS MOST IMPORTANT***
  • Prevent recurrence of inflammation
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18
Q

Criterion-based Rehab

Time and progression

A
  • Time is a surrogate for healing
    • Time after sx for graft healing
  • Assess isolated strength, motor control, power dev.
    • ​see if ready for next activity!!!
  • Diff’s in force development and force absorption persist after sx and are indep. of time after sx
  • MUST det. appropriate fxnl milestones to progress pts w/in PT

****What do you have to do to be ready for XYZ???****

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19
Q

EX. Criterion-based Rehab

A

“When can I run?”

A: When you are 12* (just ex.) weeks post-OP AND you can demo: a, b, c

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20
Q

Progression after Sx

what does this look like?

A
  • Irritability is progressing in the right direction:
    • ​Inflamm==controlled
    • Swelling==stable + NOT inc’ing w/ INC loading
    • Pain==well controlled
  • Impairments are progressively improving
    • ​ROM
    • Strength
    • Flexibility
  • Pt. demo’s mastery of lower lvl activities
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21
Q

Progress to Straight Running

A

EXAMPLES:

  • MD Clearance—- usually indicated in protocol
  • Fast walking TM 15mins
  • Quad strength >80% vs. uninvolved
    • ​EVIDENCE-BASED!!!
    • ​Biodex
    • 1-RM Knee Ext– 90-45deg
  • 10 S/L Squats to 45deg in sagittal plane
  • 30 step and holds
  • >90% Composite Score on Y-Balance test
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22
Q

Progressing to Low-Lvl Agility Training

*moving out of Sagittal Plane

A
  • MD clearance
  • Quad Strength >or= to 85%
    • ​1-RM on Knee Ext./Biodex
  • 10 S/L squats to 60deg
    • *w/ > or = 75% ext. wt.
  • Tolerate 1-2mi TM running
  • 100% Composite Score on Y-Balance Test
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23
Q

Progressing to Jumping

*2 feet

A
  • MD Clearance
  • Quad strength > or = to 90%
    • ​1RM Knee Ext/Biodex
  • 10 S/L squats
    • w/ >or= 85% ext. wt vs uninvolved
  • No compensation patterns displayed w/ agility training @ or near 100% speed.
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24
Q

Progress to Hopping, Sprinting, Cutting

*usually starts 50-75% effort

A
  • MD Clearance
  • 10 S/L squats w/ > or = to 90% ext. wt vs. uninvolved
  • NO compensation patterns or medial collapse w/ jumps
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25
Returning to Sport **When are they "Ready?"** **ASK:**"Is this person so **_unsafe_** that they cannot return to sport?"
* MD clearance * Tolerating **sprinting, agility drills, jumping, hopping @ 100% effort WITHOUT:** * **​**Compensation strategies * giving-way episodes * INCd pain * NEW S/S inflammation * INCd effusion * **FIRST** return to **practice** and **contact** * **​THEN** return to **games**
26
Medial CORNER injury ====
BIGGER injury vs. just MCL
27
Lig. Sx. ## Footnote **Repair vs. Reconstruction**
* **Repair** * **​**uses **sutures** and **ligament is re-attached** * **​YOU MUST BE WAY MORE CAREFUL AS TO NOT FUCK UP THE REPAIR!!!!** * **SEE PICS** * **Reconstruction---**move earlier, takes longer to heal * **​**uses **grafts and screws INTO BONE.** * **​anything into bone is MUCH stronger!!!**
28
ACL Reconstruction
* **Primary Goal:** * **​**restore **stability + Knee kinematics** to PREVENT **future degen. changes** * 40-90% pts undergoing ALC-R have **radiographic evidence** of knee OA 7-12yrs AFTER Sx * Anatomically performed * **Graft failure ranges 0-27%** * **​**based on **activity lvl after Sx** * \*\*\***Returning to prev. lvl of sport NOT guarenteed\*\*\*\***
29
ACL-Reconstruction see pics in notability Slide 16
* **Single bundle procedure**----reconstruct **AnteroMed bundle** * **"Anatomic" double bundle procedure**---reconstructs **BOTH bundles** into Anatomic Position * Graft passed thru tunnels _drilled_ into tibia and femur * Drilled====strong!!! \*\*\*NOTE: **single bundle procedure==NO spinning/rotation protection==meniscus + cartilage damage**
30
Ligament Graft Healing \***gets WEAKER _before_** **STRONGER**
* Initially----**graft is Avascular (no blood supply)** * **​**6-8wks: graft will show signs of **avascular necrosis** * **​**weaker BEFORE stronger!!! * 8-12wks: **revascularization begins;** _mesenchymal cells_ **invade graft** * 16wks: vascularization **complete;** mesenchymal cells AND proliferation AND form **collagen** * Collagen changes from **fragments** to **dense longitudinally oriented fibers** * \*\*\*\*Graft strength DECs **during pd of necrosis** and then it INCs **as it remodels and matures** * **​DOES NOT REACH ORIG. STRENGTH OF NATIVE ACL**
31
Autografts vs. Allografts
Auto===self Allo==cadaver OR donor
32
Autografts
* FASTER **incorporation and healing** * **​bc its YOURS!!!** * Better outcomes in **young, active pts** * **Donor-site morbidity?** * **Risk of Fx?** **\*NOTE:** commonly use **semitendinosis (inserts @ PES) -----**Semitendinosis is a MEDIAL STABILIZER to knee----protects against **valgus----**now you do not have that extra stabilizer----bad for **soccer players**
33
Allografts
* Higher **cost** * **Predictable graft size** * Availability\*\*\*\* * Better for **revisions** * Re-injury rate? * HIGHER * \*\*\*\***They don't hurt enough!!!** * **​**bc of this-----**pt wants to do MORE TOO early**
34
GOLD STANDARD ACL PROCEDURE
**Bone-Patellar Tendon-Bone Autograft** **BPTB**
35
Bone-Patellar Tendon-Bone Autograft **BPTB** **\*Gold-Standard\*** **6-8wks to heal**
* GOLD STANDARD \*\*\*\* * Provides rigid **bone to bone fixation** which allows **accelerated rehab** to attain **full ROM and Strength** * **​**Boney plugs==heal approx. 6-8wks * 30% pts complain **donor-site moribidity** * \*\*\***Central 1/3 of tendon is 186% as strong as native ACL\*\*\*\*** * **Patellar Fx** * **​**NO aggressive strengthening for 6-8wks * AVOID high _eccentric_ loading for 12-16wks * **Patellar Tendon Rupture** * **​**Persistent **extensor lag** w/ SLR @ 4wks post-op * Inability to perform **SLR 1-2wks post-op**
36
Hamstring Tendon Autograft (self) **\*Falling out of favor\*\*\*** **\*8-12wks to heal**
* USUALLY **semitendinosis/gracilis graft** * **​**Semitendinosis== 70% strong as native ACL * Gracilis== 49% strong as native ACL * **Fixation NOT AS STRONG as BPTB** * Potentially LESS **quad atrophy** * LESS **donor-site morbidity** * **​**able to **kneel** * BUT now you've disrupted **HS's==** implications in injury prevent. * **\*\*soft tissue-to-bone heals approx 8-12wks**
37
Quad Tendon-Bone Autograft vs. Quad Tendon Soft Tissue Autograft
* Stability **similar (OR superior to)** BPTP graft BUT w/ **less kneeling pain** * ​Quads activation is **poorer** than other autografts * **Harvest site** **pain** w/ contraction * few long term studies * Need to target **rec fem** while **stretching** and **strengthening**
38
Allografts ## Footnote **from cadaver or donor** **usually what??**
* USUALLY **bone-patellar tendon-bone, Achilles, Tib. Ant.** * Mixed results for: * failure rates * laxity * ROM outcomes * **Can allow for FASTER REHAB bc DECd pain**
39
Post-OP ACL Rehab ## Footnote **CKC ex's vs. OKC ex's**
* Generally, **CKC ex's cause LESS STRAIN vs. OKC** * 44 Subj's randomized into CKC ex only vs. CKC and OKC ex's following **reconstruction w/ BPTB graft** * **​**OKC ex's initiated @ 6wks post-OP and in range of 90-40degs **and progressed to 90-110degs by 12 wks post-OP**
40
Post-Op Rehab ## Footnote Generally, CKC ex's cause LESS STRAIN vs. OKC 44 Subj's randomized into CKC ex only vs. CKC and OKC ex's following reconstruction w/ BPTB graft ​OKC ex's initiated @ 6wks post-OP and in range of 90-40degs and progressed to 90-110degs by 12 wks post-OP
* Results: * NO sig. diff in **ant. knee laxity @ 6mos** * Sig. INC in **quads torque in CKC/OKC group** * Sig. HIGHER # pts **returned to pre-injury lvl** in **CKC/OKC group** and did so 2 mos EARLIER than CKC group * Conclusion: * Incorporate OKC ex's WITH CKC's **in the protected ranges** following ACL-Reconstruction
41
Acceptable OKC Quad Strengthening:
* Isometrics @ **90o and 60o** * **Long Arc Quads** * **​**Weeks 0-12: 90-60degs * Weeks 12-16: 90-45degs * Weeks 16+: 90-0degs * **Short Arc Quads** * **​**0-10degs does NOT put excess strain on ACL * 0-30degs **may NOT be approp. after ACL-R**
42
Quad Strengthening ## Footnote **Patella**
* GREATER **axial strain** on patella in GREATER DEGREES OF FLEX.
43
Risk Factors for Recurrent ACL-R
* **Graft failure** or **contralat. ACL tears** exceed 20% in young athletes returning to competitive sports * Risk factors for recurrent ACL-R * **tech. failure in _tunnel placement**_ or _**graft position_** * Contralat. ACL tear rates 6-9% * **Higher rates w/ younger pop. + allograft use** * **​**bc returning to sport===higher risk
44
Return to Sports w/ ACL-R ## Footnote **Where are we now?**
* 1/3 pts return to same lvl of competitive sports 12mos after sx * \<50% pts return to sports 2-7yrs after sx * **Young active pts** are 6x MORE LIKELY to sustain 2nd ACL injury w/in 24 mos after ACLR and RTS vs healthy controls * 20% contralat; 9% ipsilat.
45
Ardern CL. BJSM. 2014 ## Footnote **Updated systematic review assessing RTS**
* 81% (of 4837 pts) return to sport * 65% return to **pre-injury lvls of sport** * 55% return to **competitive sports** * **MEN are 1.5 MORE LIKELY vs. females to return to pre-injury OR competitive lvls of sport** * **​**bc DUMBER!!!
46
Rehab Considerations for **Multiple Ligament Knee Injuries** ## Footnote **MLKI's** **Controversies in Rehab**
* Avail reports are biased, non-random., retrospective concerning rehab after sx for **MLKI** * Timing and composition of rehab has not been researched * **BEST EVIDENCE COMES FROM ACL-R** * **​GOLD STANDARD:** * **​Early** WB * **Early** ROM * **Early** Exercise
47
Controversies in Rehabilitation ## Footnote **ACL-R vs. Sx for MLKI**
* **ACL-R** * **​Lvl 1 Evidence:** better outcomes w/: * **EARLY** WB * **EARLY** ROM * **EARLY** EXERCISE * **Sx for MLKI** * **​Lvl 5 Evidence:** questionable benefit, recommends: * **DELAYED** WB * **DELAYED OR LIMTD** ROM * **DELAYED** EXERCISE
48
Criterion-Based Post-Sx Rehab Progression ## Footnote **GOALS:**
1. Return indiv. to **normal ADLs** 2. Return to work, military duty, sports acts **@ same lvl of participation as prior to injury**
49
Criterion-Based Post-Sx Rehab Progression ## Footnote **Three phases of Post-OP Rehab**
1. Tissue Protection 2. Motor Control 3. Optimization of Function
50
"As Tolerated" Approach ## Footnote **General Recommendations** **Look @ knee jt irritability table\*\*\*\***
* **Generally,** keep pain 3/10 OR LESS * Advance ROM w/out OP/stretching * **end range mobs + stretching @ \>4wks** * WBAT **w/ crutches\*\*\*\*** * Exercise **w/out INCing irritability**
51
Know the Surgery. Respect the Surgery. Know the surgeon. Respect the surgeon.
"In preparing for battle I have always found that plans are useless, but **planning is indespensable."** **-Dwight D. Eisenhower**
52
Phase 1: Tissue Protection Phase ## Footnote **Evidence Supporting ROM Recommendations**
* Early motion **is @ least equivalent to** immobilization * **MLKIs** * **​****Early sx**and**Early motion**led to**fewer ROM deficits** * **ACL** * **​**ESP in combined procedures * **may lead to tunnel widening** * PCL
53
Phase 1: Tissue Protection Phase **Practical Application of ROM Exercise**
* PROM w/in **avail. range** * ​AROM **pending tissue restricts.** * **Pain and tissue stretch** are _guidelines for intenisty of ROM_ * **Patellar mobs in NEUTRAL** * **​can ALWAYS mobilize the patella!!!** * Positioning in EXT w/ **tibial support** to avoid over-stressing repairs * Cycling for ROM * **Week 3---mod. irritability--0-90deg**
54
Phase 1: Tissue Protection Phase **Evidence Supporting WB Status**
* Controlled Gait Lab * training w/ bathroom scale to a clinically variable % of BW * \*\*\*21 of 23 pts w/ Fx **bore TOO MUCH WT** * **​3% to 163%** * **No diffs after ACL-R**
55
Phase 1: Tissue Protection Phase ## Footnote **Evidence Supporting WB Status:**
* controlled gait lab * NO diffs after ACL-R * PWB/TTWB gen. not supported * **No data on NWB in MLKIs** * **​**may be surgeon preference
56
Phase 1: Tissue Protection Phase ## Footnote **_Practical_ Application of WB**
* NWB vs. WBAT w/ crutches WITH brace **locked in EXT** * **​**does NOT mean FWB is promoted * consider S/S of **inflamm & irritability** * adjust as necessary * **Crutch Use== MIN. of 3wks** * **Brace Use== MIN of 6wks**
57
Tissue Specific Protections: PCL ## Footnote **OFTEN reconstructed OR repaired** **PCL Injury, Reconstruction or Repair**
* WBAT w/ **brace and crutches** * Restricted ROM----**AVOID HYPEREXTENSION!** * ​GOAL: anatomic 0 (neutral) EARLY---maint. for 4-8wks * GOAL: 90degs **w/out excess. post. tibial sublux** * AVOID POST. TIBIAL GLIDES FOR FLEXION! * **Therapeutic Ex---Care for HS TEs** * **​**AVOID NWB, non-resisted ex. for 8wks * \*ADD resistance @ 12wks
58
Tissue Specific Precautions: Lateral Corner ## Footnote **PLC Injury, Reconstruction, Repair**
* WBAT w/ **brace AND crutches** * Restricted ROM: * **GOAL:** anatomic 0 (neutral) EARLY, **avoid HYPEREXTENSION** * **GOAL:** 90degs w/out excess. **post. tibial subluxation** * **No VARUS force, tibial rotation, and post. tibial glides \*\*\*\*\*\***
59
PLC Reconstruction
* after **acute injuries**-----repair typ. done **w/in 3 wks to avoid tissue retraction, tissue necrosis** * **Chronic PLC injuries---** MORE diff. to repair due to **excess. scarring** * **​**therefore, **reconstruction performed** * LCL reconstructions---**usually use semitendinosis autografts**
60
Tissue Specific Precautions: ## Footnote **Medial Corner**
Medial Corner Injury, Reconstruction, Repair * WBAT w/ brace and crutches * Restricted ROM: * **GOAL:** anatomic 0 (neutral) EARLY, **may avoid hyperEXT completely bc capsular involve.** * **GOAL:** 90deg w/out **excessive valgus forces/tibial ER** * **TherEX** * **​**care for HS TE's if possible * **avoid valgus forces** * **watch semimembranosus**
61
Tissue Specific Protections: HS Considerations **Active Posterior Drawer**
* if contraction of HS's causes **visible post. dislocation or sublux. or tibia====\> insuff. healing of PCL or PLC** * **​refer back to surgeon** * If this causes sig. pain after HS repair===\> incomp. healing
62
Tissue Specific Protections: HS Considerations **Non-resisted HS Ex.**
* 8 wks post-sx * heel slides * Prone HS curls * standing HS curls * prone glute press
63
Tissue Specific Restrictions: ## Footnote **Meniscus Repair**
1. Meniscus BODY repair has **equivocal outcomes w/ EARLY WB and motion compared to DELAYED WB and motion\*\*\*\*\*** 2. Meniscus **ROOT** repairs are HIGHLY STRESSED IN WB---leading to greater risk of failure
64
Tissue Specific Restrictions ## Footnote **Cartilage Sx**
* current concepts based on combo of basic science data, sx tech's current. avail., empirical info., limtd # clinical studies * Rehab reporting scores LOWER than their surgical equivalent
65
Tissue Specific Restrictions: ## Footnote **Peroneal N. Injuries**
* 10.8% of MLKIs * reasonably common * consider HOW injury is affecting **function**
66
Tissue Specific Restrictions: ## Footnote **Tibial Artery Injuries**
* 3.3% of MLKIs * rel. UNcommon * Consider **extent of repair and intervention** * **​PREVENT over-stressing** * **monitor S/S of _compromised circulation_**

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