KNEE: Lectures 1 and 2

Question 1

Pt Scenario

First contact practitioner

if OPEN INJURY

Answer 1

OBSERVE:

Active bleeding? Bone protruding?

Question 2

First contact practitioner

if Fx:

Answer 2

OBSERVE:

WB w/out an AD?

Question 3

First contact practitioner

if Knee Dislocation

Tibiofemoral vs.

Patellofemoral vs.

Muscular avulsions vs.

Vascular issues

Answer 3

• Tib/Fib
  
  • ​Is varus/valgus alignment similar to uninjured side?
• Patellofemoral
  
  • ​is patella centered in knee joint?
• Muscular avulsions
  
  • ​is there a loss of contour @ insertion site? Muscle retraction?
• Vascular issues
  
  • ​is the foot or lower limb cyanotic?

Question 4

First contact practitioner

if Knee Jt Infection/Septic Joint

Answer 4

OBSERVE:

is the joint swollen and red?

Question 5

First contact practitioner

Open Injury

Answer 5

PALPATE:

NOTHING IF OPEN!!

Question 6

First contact practitioner

Fx:

Answer 6

PALPATE:

Fibular head, Patella

Question 7

First contact practitioner

Knee Dislocation

Tib/fib vs.

Patellofemoral vs.

Muscular avulsions vs.

Vascular issues

Answer 7

PALPATE:

• Contour of the limb:
  
  • ​Tib/Fib
    
    • ​are injured knee mm’s more/less active vs. uninjured?
  • Patellofemoral
    
    • ​Is patella tender on medial side?
  • Muscular avulsions
    
    • ​Is there a loss of contour near muscular insertion?
  • Vascular issues
    
    • ​are distal pulses intact?

Question 8

First contact practitioner

Knee jt Infection/Septic Joint

Answer 8

PALPATE:

• Joint swelling
  
  • ​intra-articular vs. extra-articular
  • **Sweep Test**

Question 9

First Contact Practitioner

Stop the Party, Call ED ….

Answer 9

• OPEN INJURY
• Neurvascular injury
  
  • ​diminished or absent pulses
  • absent sensation
• Obvious Fx OR
• (+) Ottawa Knee/Ankle Rules
  
  • ​HIGH index of suspicion Fx
• Gross misalignment of limb
  
  • ​Disloc. w/out reduction
  • DO NOT try to reduce UNLESS transit time to ED is prohibitively long

Question 10

First contact practitioner

Continue Exam; Refer out when finished:

Answer 10

• Tib/Fib OR Patellofemoral Dislocation
  
  • ​NO (or min.) neurovascular issues
  • Normal alignment
    
    • spont. reduction
  • Muscle avulsions

*NOTE: presentation is not emergent, BUT should be assessed by other providers to ensure medical stability

Question 11

Knee Rules for det. Need for Radiography

Ottawa Knee Rules

Answer 11

• Age 55+
• Isolated tenderness of patella

OR

• Tenderness over fibular head
• Unable to flex knee past 90deg
• Unable to bear wt. immed. OR in ED for 4 steps

***HIGHLY SENSITIVE BUT NOT VERY SPECIFIC***

*REMEMBER SnNout and SPpin

Question 12

Knee Rules for det. Need for Radiography

Pittsburgh Knee Rules

Answer 12

• Blunt trauma OR a fall as MOI + one of following:
  
  • Age under 12
  • Age over 50
  • Unable to bear wt. in ED for 4 steps

Question 13

JAMA and the Ottawa Knee Rules

Answer 13

• DEC in need of radiography w/out missed fx’s
• HIGHLY sensitive, reliable, very acceptable

Question 14

Rehab after Prolonged Immob. (Fx)

Sx modulation and Impairment Resolution:

what do you want to focus on?

Answer 14

• resolve effusion/edema
• improve mm activation/DEC atrophy
  
  • normalize painful mm contracts.
• Restore limtd motion, DEC jt stiff.
• Restore normal mvmt patterns

Question 15

Neurovascular Assessment of Knee Joint

Circulatory Issues: 2

Answer 15

1. Vascular Injury
2. DVT

Question 16

Neurovascular assessment of Knee

Circulatory Issues:

Vascular Injury

Answer 16

• Arterial injury interrupts blood to distal tissues
• Arteries are susceptible @ jts AND when making sharp turns around bony prominences ​

Question 17

POST. KNEE JT DISLOCATION

Impacts what?

Answer 17

• POST knee jt dislocation
  
  • impacts Popliteal Artery
    
    • ​check Post. Tib pulse

Question 18

POSTEROLATERAL KNEE JT INJURY

Impacts what?

Answer 18

• Posterolateral knee jt injury
  
  • impacts supply to Ant. Tibial Artery
  • Check Dorsalis Pedis Pulse

Question 19

DVT

what is it and what can it do ?

Answer 19

• Clotting/blocking of a distal vein
  
  • can dislodge and move thru circulatory system to Central Aspects —– heart & lungs

Question 20

DVT

More common when and why?

Answer 20

• More common after Sx
  
  • hip, knee, leg/calf, abd, chest
    
    • ​Reduces bloodflow to a part of the body

Question 21

DVT

Reasons why Sx can INC DVT risk: 3

Answer 21

• 1. Tissue debris, PRO, fats may move into veins following Sx
• 2. Vein walls damaged—> releases subs. that promote blood clotting
• 3. Prolonged bed rest

Question 22

Arterial Assessment

Dorsalis Pedis Pulse

Check if POSTEROLATERAL KNEE JOINT INJURY bc Ant. Tib. Artery

Answer 22

Top of foot, lateral to EHL tendon

distal to Navicular

Question 23

Arterial Assessment

Post. Tib. Pulse

Check if POST. knee jt dislocation bc impacts Popliteal Artery

Answer 23

Post to medial malleolus

Question 24

Well’s Clinical Prediction Rule for DVT

Answer 24

• Probability of DVT:
  
  • 3pts==HIGH RISK 75%
  • 1 to 2pts== MOD. RISK 17%
  • <1 pt==LOW risk 3%

Question 25

Circulatory Status for DVT: ## Footnote **risk INCs w/ AGE, esp. after 60** **Lifestyle factors?**

Answer 25

* Sitting or inactive for long time * Long plane or car trips * Extra wt. * BC pills or patches * Smoking

Question 26

S/S of DVT **NOTE: 1/2 of all DVT cause NO sx's** **Some you will see....**

Answer 26

* **Swelling** in one or both legs * **Pain or tenderness** in one or both legs * MAY only occur during walking or standing * **Warmth** in the skin of affected leg * **Red or discolored skin** in affected leg * **Visible surf. veins** * Leg **fatigue**

Question 27

Neuro Screening ## Footnote **Common Peroneal Nerve** **Motor vs. Sensory Function**

Answer 27

* MOTOR: * **Ankle DF** * **Great toe EXT** * **Toe EXT** * SENSORY * **1st web space----DEEP BRANCH** * **Dorsal surf. toes 3-4----SUPERFICIAL BRANCH**

Question 28

NEURO SCREENING ## Footnote **Tibial Nerve** **Motor vs. Sensory Function**

Answer 28

* MOTOR: * **PF** * **Toe FLEX** * **little bit of Inversion** * SENSORY: * **Plantar aspect of calcaneous** * **Plantar aspect 5th toe**

Question 29

LE Peripheral Nerve Map

Answer 29

see pics

Question 30

Expected Gait Devs in Acutely Injured Knee 2

Answer 30

1. Noticeable limp 2. Flexed Knee Gait

Question 31

Gait Devs in Acutely Injured Knee ## Footnote **Noticeable Limp** **Why?**

Answer 31

* avoiding WB on injured limb * Short **stance time** on **injured limb** * Short **step length** for **uninjured limb**

Question 32

Gait Devs. for Acutely Injured Knee ## Footnote **Flexed Knee Gait** **Why and theories?**

Answer 32

* avoids TKE * avoids eccentric knee flex. * **Theories:** * **​**Quad-avoidance gait vs. Optimal length-tension for quads * **Co-contract of quads/HS to LIMIT MOTION**

Question 33

Knee Joint Swelling: ## Footnote **Joint Effusion**

Answer 33

* Fluid contained **W/IN a body cavity** * Knee jt==Largest Synovial Cavity in body * **intra-art injury==intra-art swelling** * **extra-art injury LIKELY WONT CAUSE INTRA-ART. SWELLING**

Question 34

KNEE JOINT SWELLING ## Footnote **Joint Edema**

Answer 34

GEN term for swelling \*can likely move edema thru tissue

Question 35

Effusion Assessment **Stroke Test, Sweep Test**

Answer 35

UP medially DOWN laterally

Question 36

Interventions/Sx Modulation ## Footnote **Effusion Control**

Answer 36

**RICE** * Rel. Rest * avoid excess. WB * use AD * Ice * 20 on 20 off * Compress * knee sleeve, ACE * **mm pumps----QUAD SETS!!!** * Elevate * Knee ABOVE heart

Question 37

Assess & Tx of Limtd ROM and Pain Gen. structures ## Footnote **Sx Modulation** **Knee EXT Measurements**

Answer 37

1. Resting knee EXT 2. Knee EXT w/ Quad Set 3. Knee EXT during SLR

Question 38

Knee EXT ROM Considerations ## Footnote **Resting Knee EXT** **True PROM**

Answer 38

* Rest pos or Loose-pack pos. * **20-30deg of FLEX** * Check and see if indiv. can rest w/ their limb on table and **no post. support** * Can indiv. rest their limb w/ **heel supported and nothing under knee?** * **Where is discomfort felt???** * **​**POST * **capsule vs. HS tendons vs. gastroc** * ANT * **"pinching"**

Question 39

Knee EXT ROM Considerations ## Footnote **Knee EXT w/ Quad Set** **AROM**

Answer 39

* does quad visibly contract? * does contraction produce **sup. patellar glide?** * does **glute max. co-contract?** * **​**typ see "reduction" in EXT when asked to contract quad * knee stays same place, greater troch rises bc glute contracts * does this cause **pain?** * **​**ANT * patellar tendon vs. quad tendon vs. quad mm * RETROPATELLAR * POST.

Question 40

Quad Lag ## Footnote **Lag Sign**

Answer 40

* indic's mm is **not capable of holding end range pos.** * **​**ability of mm to maintain pos. **lags behind** total ROM * NO ext. resist----BW only

Question 41

**Quad Lag** **Max EXT-EXT during SLR\*\*\*\*\***

Answer 41

* quads not able to **maint. full knee EXT** when there is no support to Tibia * **Formula:** * **​**MAX EXT - EXT during SLR

Question 42

Quad Lag ## Footnote **If present, what does this mean?**

Answer 42

CONSIDERABLE mm weakness! **MMT \>3/5** * **individual likely not strong enough to achieve ACTIVE TKE in gait** * **​**Hyperextension thrust vs. Flexed knee gait

Question 43

Quad Lag ## Footnote **What do you want to do to address this?**

Answer 43

* Restore mm activation towards End Range * SUP patellar mobs * **Quad Sets\*\*\*** * **​**can be combo'd w/ SUP patellar glide to facilitate quad contraction * SAQ's * TKE ex's * **prone vs. standing vs. DF'd**

Question 44

Quad Lag ## Footnote **Isometrics** **Muscle Setting Ex's**

Answer 44

* LOW-MOD intensity iso. ex ----- little to no resist. * **practicing mm activation** * No appreciable inc in strenght----MAY slow atrophy * **INC recruitment of mm** * ADD. uses * **relaxation, circulation, reduce pain/spasm**

Question 45

Active/Passive Knee Flex. ## Footnote **Limitations in Knee FLEX freq. targeted w/ HEEL SLIDES** **To INC FLEX**

Answer 45

* Active Heel Slide * **use HS to achieve MAX FLEX.** * Active Assited Heel Slide * **hand or belt to apply overpressure @ end range** * Passive Heel Slides * **fully use hand/belt** ## Footnote **​**

Question 46

Interventions in **Sx Modulation Phase** **Painful MTU's**

Answer 46

LOAD CAREFULLY!!! * 2-3/10 pain * soft tissue mobs * GENTLE stretching of mm's * LOW grade Iso's * mult. angles

Question 47

Interventions in **Sx Modulation Phase** ## Footnote **Limited _ROM_**

Answer 47

* Patellar mobs (as necessary) ----- CAN ALWAYS MOBILIZE PATELLA!!! * AROM (if pain free OR min. pain) * AAROM (if pain free) * PROM (if pain free) * Cyclic ROM (flex/ext)---\> helps w/ ROM + Effusion * **stationary cycling w/out resist.** * **Injured ligament....** * **​**restore ROM w/out INC pain or **overstressing ligament**

Question 48

Add. Interventions for TKE ## Footnote **when Acute or Symptomatic**

Answer 48

Question 49

Classification of Knee Related Sx's in Motor Control Phase ## Footnote **Stiff Knee**

Answer 49

* Limtd ROM * Painful or Uncomfortable ROM * MM Length restrictions

Question 50

Classification of Knee Related Sx's in Motor Control Phase ## Footnote **Unstable Knee**

Answer 50

* Ligamentous instability * Meniscal Issues * Poor Neuromuscular control * Pain related instability

Question 51

Classification of Knee Related Sx's in Motor Control Phase ## Footnote **Weak "Knee"**

Answer 51

* Limtd Strength of a **Muscle relevant to knee jt function** * Pain-related weakenss

Question 52

**Simplified Tx Approach!!!**

Answer 52

If its **contributing to Activity Limitations or Participation Restrictions AND...** * **​**if its **Limited** * **​Mobilize it!** * if its **Tight** * **​Stretch it!** * if its **Weak** * **​Strengthen it!** * if it **Moves Funny** * **​Retrain it!** * if its **Involved** * **​Load it thoroughly** * **If its Injured\*\*** * **​Do all of this CAREFULLY!**

Question 53

Joint Mobilization to Improve **Knee Flexion** ## Footnote **Patellofemoral Joint** **What happens as knee flexes?**

Answer 53

* patella glides **INFERIORLY** * lateral facet and odd facet **contact femur** * ​**greater _compression_** **laterally----esp w/ effusion** * **bc high lat. wall of trochlea**

Question 54

Joint Mobilization to Improve Knee Flexion ## Footnote **Patellofemoral Joint** **Intervention:**

Answer 54

* Medial and Inf glides **IN FLEX** * Medial **tilt** mobs in **Resting\*\*\*\*** * when patello moves the most!

Question 55

Joint Mobilization to Improve Knee Flexion ## Footnote **Tibiofemoral Joint** **What happens as Knee Flexes?**

Answer 55

* Tibia glides POSTERIORLY * MIN. tibial rotation * MAYBE some post. pinching or impinge.

Question 56

Joint Mobilization to Improve Knee Flexion ## Footnote **Tibiofemoral Joint** **Intervention:**

Answer 56

* Jt distraction in **Sitting** * POST glides **IN FLEX** * **​**If **Post. Impinge.** * **​Ant/Rotational glide**

Question 57

Joint Mobilization to Improve **Knee EXT** ## Footnote **Patellofemoral Joint** **What happens as knee EXTs**

Answer 57

* patella glides **SUPERIORLY** * **FULL EXT== min. contact w/ walls of trochlea** * **​**GREATER compression LAT.----bc tilt of patella

Question 58

Joint Mobilization to improve Knee EXT ## Footnote **Intervention:**

Answer 58

* Medial + Superior glides in FLEX * Medial tilt mobs in RESTING

Question 59

Joint Mobilization to improve KNEE EXTENSION ## Footnote **Tibiofemoral Joint** **What happens here when knee EXTs?**

Answer 59

* Tibia glides ANTERIORLY * Tibia must **Externally rotate to engage _Screw Home Mechanism_**

Question 60

Jt. Mobs to improve KNEE EXT ## Footnote **Tibiofemoral Joint** **Intervention:**

Answer 60

* Jt. distraction in SUPINE * ANT glides in EXT * **If missing TKE-----MAY need to bias Tibial ER**

Question 61

Proximal Tib/Fib Jt Mobs ## Footnote **When performed ?**

Answer 61

* PAIN in **Distal Anterolateral Knee Jt OR specifically @ Fibular head** * **​**mostly ANT/POST glide req'd for norm. ankle motion * **impacted w/ injury to biceps femoris**

Question 62

Assess. and Intervention of Muscle Performanc in Motor Control Phase ## Footnote **GOLD STANDARD for measuring QUADS Strength in clinical studies**

Answer 62

Electromechanical Dynamometry **Isokinetic Machine** **\*HIGHLY reliable** **\*expensive**

Question 63

Assess. and Intervention of Muscle Performanc in Motor Control Phase ## Footnote **1-RM** **Leg Extension** **Can use SL leg press if needed**

Answer 63

* Procedure: * alternating limbs * fully ext. knee * HOLD 2s * return under control * **Failure det'd by 3 unsuccessful attempts @ a single weight** * **MAX wt. lifted recorded for ea. limb**

Question 64

Leg Press 1-RM ## Footnote **Standard Leg Press S/L**

Answer 64

* Knee @ 90 * Hip ~90 * Compensation avoided: * gastroc-soleus min'd * OPP limb suspended

Question 65

Leg EXT 1-RM **Standard Leg EXT Machine**

Answer 65

* knee @ 90 * hip @ ~90 * **2 ranges tested:** * **​90-0** * **90-45**

Question 66

Remember.... W/ BIG mm's

Answer 66

**Functional Tests!!!** **L.EXT** **L.Press** **HHD's**

Question 67

Functional Strength Testing: Ex's

Answer 67

* Sit to Stand/Chair Rise test * Forward Step Down Test * Lateral Step Down test * S/L Squat test

Question 68

More Functional Tests Ex's

Answer 68

* 30s Chair Rise * 5x S2S test * SL 30s vs 5x ea leg * Forward step down----endurance

Question 69

Assessment and Intervention of Muscle Performance in Motor Control Phase Also consider... **MM's that control Femur**

Answer 69

* glute max * glute med * ER's * iliopsoas * sartorius

Question 70

Assessment and Intervention of Muscle Performance in Motor Control Phase Also consider... **MM's that control Tibia**

Answer 70

* Gastroc/Soleus * Peroneals * Post. Tib * Ant. Tib

Question 71

**MOST important** aspect in **Knee Function**

Answer 71

Strengthening Quads!!! during **Motor Control Phase**

Question 72

Quads Isometric Matrix

Answer 72

ADD IN PICTURE!!! SLIDE 32 IN FIRST KNEE LECTURE!!!!

Question 73

Sit to Stand ## Footnote **Anterior View**

Answer 73

trunk moves vertically pelvis stays lvl Knees stable in frontal plane (**slight hip ABD encouraged)** foot should NOT over-pronate

Question 74

Sit to Stand ## Footnote **Lateral View**

Answer 74

no L/S flexion pelvis + hips move trunk into Flex. motion comes from knees CoP should NOT shift into ball of foot

Question 75

What should you remember w/ sit to stands as an intervention?

Answer 75

YOU CAN MAKE THE DISTANCE LOWER OR HIGHER!!! Mini 30deg squats or Full 90deg squats **or anywhere in b/w!!!**

Question 76

Advanced WB ex. Sit to Stand **Preferential squatting**

Answer 76

Key points: * surgical leg BEHIND good leg * shift wt. onto **sx limb** * load thru **heel** * avoid excess. trunk flex

Question 77

Perturbation Training in Knee Jt Stability ## Footnote **What is it?**

Answer 77

* Progressive, purposeful **manipulation of support surfs.** to promote **active stabilization and NMSK control of knee**

Question 78

Perturbation Training in Knee Jt Stability ## Footnote **Studies in ACL deficiency and Post-Op ACL** **\*good clinical and biomech. results\***

Answer 78

* Knee jt. mechs resemble uninjured indiv's after completing ~10 sessions of perturbations * **Reduction of wear & tear** * **​**normal knee jt loading * normal knee jt flex/ext excursion during gait * reduction in knee Ext/Flex co-contraction * Improved confidence/reduced mvmt-related fear * SOME improves in clinical measures * ex. hop tests

Question 79

Perturbation Training in Knee Jt Stability SOME bennies for **OA, not consistent**

Answer 79

* Pts w/ OA more **heterogenous than pts after ACL injury**

Question 80

Meniscal Tears ## Footnote **Longitudinal** **(Buckethandle)**

Answer 80

* springy end feel * IMMEDIATE REPAIR * easy to screw up * **meniscus flips over into joint**

Question 81

Meniscal Tears ## Footnote **Oblique**

Answer 81

* typ. older pts * does OK w/ repair

Question 82

Meniscal Tears ## Footnote **Radial or Transverse**

Answer 82

see pics

Question 83

Meniscal Tears **Horizontal**

Answer 83

* when you bear wt. w/ this tear-----\> **pushes edges closer together**

Question 84

Meniscal Tears ## Footnote **Complex Degenerative**

Answer 84

* does well w/ OR w/out Sx * Older pts---degenerative * you want to DEC mech. sx's

Question 85

Meniscal Injuries **MOI**

Answer 85

* Cutting/Pivoting * **sudden direction change w/ foot fixed ground** * HYPERFLEXION * HIGH impact compression * MCL or ACL Mechs.

Question 86

Meniscal injuries **MOI** **MCl or ACL Mechs.....why?**

Answer 86

* MCL * **deeper fibers connect to MCL** * ACL * **connects to Ant. Horn or Med. Meniscus** ## Footnote **​**

Question 87

Meniscal Injuries ## Footnote **S/S**

Answer 87

* **Twist/tearing sensation** @ time of injury * **Severe pain ON injury----Effusion 6-24 hrs POST-injury** * Giving way on injury * **Later, intermittent pain, effusion** * **CATCHING OR LOCKING** * Jt. line tenderness * Limtd ROM **w/ premature end feel** * **​**IF piece of meniscus IN joint * Repro. of sx's w/ **deep squatting or HYPERFLEX** pain * **\*\*Quad inhibition\*\***

Question 88

Meniscal Special Tests: ## Footnote **5 "Cluster" Dx Tests** **REVIEW YOUR LAB NOTES!!!!** **YOU GOT THIS SHIT!!!**

Answer 88

* 1. Joint line palpation * be sure to go BEHIND KNEE!!! * 2. McMurray * Axial loading * can combine IR, ER, ABD, ADD * 3. FLEX overpressure * 4. EXT overpressure * 5. Hx of **Catching or Locking**

Question 89

Clinical Composite Score for Meniscal Patho. **\*\*accurately detects meniscal patho.**

Answer 89

* Studied 635 knees **w/ 5 Dx (cluster tests) tests** eval'd presence of meniscal lesions * 1. Hx catching/locking * 2. Jt line tenderness * 3. Pain w/ forced HYPEREXTENSION * 4. Pain w/ MAX passive Knee FLEXION * 5. **Pain or Audible click w/ McMurray**

Question 90

Mensical Special Tests ## Footnote **Thessaly Test**

Answer 90

see pics ## Footnote **The "Dancing" one**

Question 91

Meniscal Special Tests ## Footnote **Apley's Compression** **Apley's Distraction**

Answer 91

Exactly what it sounds like.....the Med/Lat rotate Tibia

Question 92

NON-OP Tx of Meniscus Tears ## Footnote **What did MeTEOR Study find?**

Answer 92

* Often, **acute tears are _operatively addressed_** * **DMT's (degen meniscus tears) MAY be amenable to non-op care** * **​**lg, multi-center study of OP vs. NON-OP for DMT vs. OA (**MeTEOR Study)** * 6m after **randomization,** 30% NON-OP groud had sx * **94% of OP group had Sx** **\*\*\*\*REMEMBER WE WANT TO TRY AND _AVOID_ GEN. ANASTHESIA \*\*\*\***

Question 93

Sx vs. PT for Meniscal Tear w/ OA The New England Journal of Medicine BIG DEAL TO BE PUBLISHED BY THEM!!!

Answer 93

* **NOTE:** * **​equivalent outcomes in WOMAC scores AND KOOS Pain Scores b/w the 2 methods!!!**

Question 94

Summary of PT Regimen **Sx vs. PT for Meniscal Tear and OA** **New England Journal of Medicine**

Answer 94

**PHASE I**

Question 95

Summary of PT Regimen ## Footnote **Sx vs. PT for Meniscal Tear and OA** **New England Journal of Medicine**

Answer 95

**PHASE II** & **PHASE III**

Question 96

Knee--Meniscal Injuries **Partial Menisectomy** When?

Answer 96

* IF meniscal tear disrupts **mechanics of the knee AND pt is not a good candidate for meniscal repair** * **\*\*\*\*DEBRIDEMENT\*\*\*** * **​**remove as little as poss. * down to a **stable rim**

Question 97

Rehab Following Arthroscopic Debridement (**Menisectomy)** ## Footnote **\*NOTE: these are EASIER to rehab** **3 things we focus on:**

Answer 97

1. Muscle Strengthening and Joint Mobility 2. Ambulation 3. Return to Activity

Question 98

Rehab Following Arthroscopic Debridement (Menisectomy) \*NOTE: these are EASIER to rehab **Muscle strengthening and joint mobility**

Answer 98

* Isometrics, AROM, **PF mobs IMMEDIATELY** * Soft tissue manip. of **portal scars when healed** * Progress to PREs **when tolerated** * consider **NMES**

Question 99

Rehab Following Arthroscopic Debridement (Menisectomy) \*NOTE: these are EASIER to rehab **Ambulation**

Answer 99

* WBAT IMMED. **w/ least restrictive AD** * progress to FWB when **walking w/out limp** * **​usually 1-2 wks** * **​want NEGATIVE quad lag**

Question 100

Rehab Following Arthroscopic Debridement (Menisectomy) \*NOTE: these are EASIER to rehab **Return to Activity**

Answer 100

* TM running if... * **quad strength \>80%** * **NO jt. pain** * **trace or less effusion** * Lvl Surf. Running, sprints, agility if... * **normal gait on TM** * **no _reactive effusions_ after TM running or any progress. of activity** * Return to full activity (usually about 6 wks) if... * **quad strength \>90%** * **HOP Tests if returning to lvl I or II sports**

Question 101

Meniscal **Repair** ## Footnote **When considered?**

Answer 101

* considered when lesion is in **area of good vascularization** * **​**IF tear w/in 3mm of periphery * **vascular** * IF 3-5mm from periphery * **gray zone** * IF \>5mm from periphery * **avascular**

Question 102

Indications and Contraindications for Meniscus Repair **NOTE: ACL + Meniscus** **_together_===\> MORE blood supply ===\> better healing**

Answer 102

see table

Question 103

Superior Vertical divergent suture Inferior vertical divergent suture

Answer 103

see pics

Question 104

Radial Meniscus Tear Repair

Answer 104

see pics

Question 105

Repair for Flap Tears

Answer 105

see pics

Question 106

Meniscal Repair of **Avascular, Central Region** **\*Becoming MORE COMMON** **\*Want to _preserve meniscus when possible!!!_**

Answer 106

* Mods. of Sx tech's to **enhance healing in this area used:** * **​**Fibrin clot * Rasping of synovial fringe * Creating **vascular access channels**

Question 107

Meniscal Repair of **Avascular, Central Region** ## Footnote **Older Pts 40+** **What did this study show?**

Answer 107

30 repairs in pts 40+ 26 pts asymptomatic; **had NO further Sx after mean of 34 mos** **see pics for Rehab program + Conclusions**

Question 108

Meniscal Repair of **Avascular, Central Region** ## Footnote **Younger pts \<20yo** **what did this study find?**

Answer 108

* 71 knees of indiv's \<19yo * 75% had NO sx's and showed **no signs of clinical failure @ follow-up (18-51 mos)** **see pics for Rehab Program followed:**

Question 109

Meniscus Root Repair **\*\*NOTE: where meniscus is** **_most firmly attached_** **usually protected 4-6wks** **\*like trying to carry a bucket w/out other side of handle attached \*\*\*\***

Answer 109

* HOOP STRESS!!! * disrupting root can cause **meniscal extrusion in WB** * AFTER repair---WB can sig. stress repair * **shown in Biomech. studies not clinical studies** * **HS's attach to medial meniscus\*\*\*\*** * **​**contraction causes **post. glide**

Question 110

Meniscal Repair and **Transplantation**

Answer 110

* **preserve meniscal tissue _at all costs_** * **Goal of Rehab:** * **​**prevent excess WB and compression that has pot. to disrupt graft or transplant * protocols based on **type of meniscal lesion, concomitant proc's, stage of degen.** * **​**Peripheral tears progressed quicker vs. central tears\*\*\*\* * **SPECIFIC ROM & Heckman et al strongly recommend** **_patellar mobs in ALL directions!!!_** * **_​can always mobilize patella!!!_**

Question 111

Explain Cartilage **Cyclic Loading**

Answer 111

* Cartilage is like a **sponge** * **​****Load ON==** * **​push BAD stuff OUT** * **UNLOAD==** * **​GOOD stuff comes IN**

Question 112

Articular Cartilage Explain...

Answer 112

* SELF-lubricating * **Load Applied=== Fluid RELEASED** * **Load Released===Fluid ABSORBED** * **_Lack of intermittent loading REDUCES lubrication process_**

Question 113

Articular Cartilage Respone to Loads **in Knee** **when REDUCED LOADING**

Answer 113

* **Reduced Nutrition** * **​==** degen changes * **Reduced Lubrication** * **​**== INCs friction b/w jt surfs * == degen changes * **LOW coeff. of friction**

Question 114

Articular Cartilage Response to Loads **in Knee** **when EXCESSIVE LOADING**

Answer 114

* \*Actually has ability to bear VERY LG LOADS * Damage to **collagen fiber network** * **Proteoglycan** wash out * Loses ability to respond to **compressive AND shear forces**

Question 115

Articular Cart. Response to Loads in Knee **when IMPACT LOADING**

Answer 115

* Occurs when loads applied **@ FAST RATE** * Cart. becomes **stiffer** * now **unable to deform and redistribute loads fast enough**

Question 116

The Knee--Art. Cart. Response to **Immobilization**

Answer 116

see pics for REVIEW

Question 117

Physical Stress Theory

Answer 117

**Tissue Stress= Load/Area of Load Application** * Too MUCH or Too LITTLE **stress** may be **harmful to bio. tissue** * **Window of Adequate Stress** that maintains health of biologic tissue

Question 118

Joint Stress/Tissue Stress== **Force/Area of Force Application**

Answer 118

* **FORCE components** * **​**current or prev. injury * Magnitude of Load * **body mass** * **activity surface** * **foot wear** * **AD (grad. use)** * Muscle and motor strength * **Area of Force Application components** * **​**Loading rate * Joint mobility * Joint alignment

Question 119

Osteoarthritis OA

Answer 119

* **Degen of Art. Cart.** * 80% indiv's 65+ * Females\>Males * 70% vs. 30% * Risk Factors: * age, gender * occup/rec. activity * obesity\*\*\* * LE malalign. * **QUAD WEAKNESS** * Prev. structural damage to knee\*\*\*\*

Question 120

OA **Self-Report Symptoms**

Answer 120

* \*\*\***Typ. stiffness in morning that resolves w/in 30 mins\*\*\*\*** CARDINAL SIGN * Pain w/ prolonged sitting **bc no cart. nutrition** * creak/crack/crunch (crepitus) * **Occ. pain @ night** * diff's on stairs * **bc poor** **_eccentric control_**

Question 121

OA **S/S**

Answer 121

* Pain w/ WB * **Loss of Jt Mobility====CAPSULAR PATTERN** * **​Flex \> Ext \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*** * poss. effusion * **Quad weakness and/or inhibition** * **​remember quad strength super important in obstructive lung diseases too!!!!!!** * Osteophyte formation

Question 122

Altman's Criteria for OA ## Footnote **Clinical**

Answer 122

6 Criteria * Age \>50yrs * Stiffness \>30mins * Crepitus * Bony tenderness * Bony enlargement * No palpable warmth

Question 123

Altman's Criteria **Clinical and Laboratory**

Answer 123

**Knee Pain and _@ least 5 out of 9 criteria_** * Age \>50yrs * Stiffness \>30mins * Crepitus * Bony tenderness * Bony enlargement * **No palpable warmth** * Erythrocyte Sedimentation Rate \<40 * Rheumatoid Factor \<1:40 * Synovial Fluid signs of OA

Question 124

Altman's Criteria ## Footnote **Clinical and Radiographic**

Answer 124

**Knee Pain and _@ least 1 of 3 Criteria_** * Age \>50yrs * Stiffness \>30mins * Crepitus * Osteophytes

Question 125

OA

Answer 125

Look @ picture specifically @: **Osteophyte formation** **Sclerotic (hardening) subchondral (below cart.) bone** **Narrowing of jt. space (loss of art. cartilage)**

Question 126

OA ## Footnote **Basic Tx Approach**

Answer 126

Alter **Joint Stress** by **Minimizing Loads** and **Maximizing Area of Load Application** **Joint/Tissue Stress==Load/Area of Load Application** * **mm strength and jt. mobility** * **Wt Control: diet+exercise** * **AD's** * **proper foot wear+orthotics** * **modif. of act. surfs** * **minimize impact loading**

Question 127

Osteochondral Lesions

Answer 127

* separation of **fragment of art. cart. from the underlying subchondral bone from the epiphysis** * **​**Cart. pulls off of bone==\> **delaminates** * ​\*NOTE: **different from OCD which is seperation of the ACTUAL BONE FRAGMENT from the subchondral region** * Result from: * **prolonged, repetitive loading** OR **traumatic, high impact loading****​** * typ **shearing injury** to WB area of bone * seperation of cartilage in the **Weakest zone** * **​\*tidemark area\***

Question 128

Risk Factors Assoc'd w/ **Articular Cart. Lesions**

Answer 128

* pt age * INC age==INC likelihood (**bc degen.)** * Presence of **meniscal tear** * ACL Injuries (following are presented w/ **cum. loading w/ shearing forces:** * **​**2-5yrs after ACL w/out repair, **odds were 2.2x higher of having subsequent art. cart. injury vs. in first year** * after 5 yrs odds inc'd to 5.9x * Retrospective study showed prevalence of art. cart. lesions w/ ACL injury to be 19% * Large study of pts undergoing **arthroscopy** 60% were found to have **chondral lesions** * Clinical exam may be **inconclusive w/ pts presenting w/ non-specific complaints of jt pain or swelling**

Question 129

Traumatic Osteochondral (OC) lesions **Lateral Patellofemoral Dislocation**

Answer 129

* OC lesion occurs on **relocation** * **Med border of patella** compresses against **lat. fem. condyle** as it is reduced by **quads. contraction** * Combo of **compression + shear** cause OC fx of either the **lat. fem. condyle OR med. inf. patellar surf.**

Question 130

Traumatic OC Lesions ## Footnote **ACL Rupture**

Answer 130

* During displace. of femur, **ant tibial spine** may contact **med. fem. condylar surf. ==== causes lesion** * **Lat. fem. condyle** can also be injured by forceful **compression + shear** that occurs when **femur and post-lat. tibia** collide during **relocation of a "giving way" episode**

Question 131

Osteochondritis Dessicans (OCD)

Answer 131

* Defect in **subchondral region** w/ partial OR complete separation of bone fragment * **Overlying art. cart.** may remain **intact** * **Prognosis** depends on **age and WB** **surf.** affected AND the **condyle**

Question 132

OCD

Answer 132

OCD w/

Question 133

OCD ## Footnote **Presentation, Signs, Symptoms**

Answer 133

* COMMON older children/young adult MALES * no hx traumatic event * accumulative trauma/stress mech. * phys. active adolescent OR * rel. sedentary, overweight * non-local knee pain WORSE w/ jumping/WB * intermitt. effusion w/ pain * catching/locking/giving way IF **loose body present** * Laxity test NORMAL * affected **fem. condyle tender** * forcible compression on affected side==Crepitus

Question 134

OCD ## Footnote **Tx**

Answer 134

* Rel good healing pot. IF **physeal plates NOT YET CLOSED + lesion stable** * **​improved if art. cart. over lesion INTACT** * WB restricted 6-8wks * some evidence for casting \<12yo * PT works on **strength + ROM** DURING pd of NWB * sx follows pts for 6mos before return to high impact act. * **IF UNSTABLE LESION OR CLOSED PHYSEAL PLATES====Sx Repair** * **​== fragmental separation** * **PT Role==**Recognize when present and refer out

Question 135

Art. Cart. Repair Procedures ## Footnote **More for Osteochondral defects:**

Answer 135

* Abrasion arthroplasty * Micro-Fx * **promotes blood supply + bone healing** * Mosaicplasty (OATS) * Autologous (from self) Chondrocyte (cartilage cells) Transplantation w/ Periosteal Graft * Re-align. proc's

Question 136

Basic Science and Sx Tx Options for **Articular Cartilage Injuries of the KNEE**

Answer 136

written by physicians for PT's

Question 137

Abrasion Arthroplasty ## Footnote **to joint OR jt. surf.** **one small portion**

Answer 137

* subchondral bone abraded to **create bleeding in lesion site** * **Fibrin clot** forms in lesion * **Fibrin clot** facilitates **mesenchymal cells** to form **fibrocart.** in the defect * Mesenchymal Cells: * stem cells found in **bone marrow** that are important for **making and repairing skeletal tissues: cartilage, bone, and fat found IN bone marrow**

Question 138

Micro-Fx Procedure ## Footnote **Abrasion Arthroplasty ON STEROIDS!!!!**

Answer 138

* Sm. holes punctured in **subchondral bone** * **Stem cells** from **bone marrow** migrate into lesion site * **Stem cells** become **chondrocyte-producing cells** that eventually **synthesize fibro-cart.** in the lesion site \*NOTE: athletes + older adults PRIOR to **TKA** will use.

Question 139

Mosaicplasty (OATS) Procedure **Osteochondral Autograph Transplant Sx**

Answer 139

* **Hyaline cart. grafts** w/ underlying **subchondral bone** harvested from NWB site * Grafts **press-fitted** into lesion site * SMALLER lesions get **Autologous (from self) grafts** * LARGER lesions get **Allografts (from cadaver)**

Question 140

NOTE: **Fibrocartilage vs. Hyaline Cartilage**

Answer 140

Fibrocartilage is **WEAKER** Hyaline Cartilage is **STRONGER**

Question 141

Autologous Chondrocyte Transplantation w/ Periosteal Graft **\*graft==something put over top of something else (think skin grafts w/ burns)**

Answer 141

* Autologous (self) chondrocytes (cart. cells) from **biopsy** (taken from YOU) grown in culture * Cultured chondrocytes injected INTO lesion site * **Periosteal graft** fixed OVER lesion site * **to keep them in there\*\*\*** * Stims formation of more **hyaline-like (STRONGER) cartilage** in lesion

Question 142

Autologous Chondrocyte Transplantation w/ Periosteal Graft ## Footnote **\*graft==something put over top of something else (think skin grafts w/ burns)**

Answer 142

Another Pic of procedure

Question 143

KNEE Re-alignment Procedures **Tibial Osteotomy (tomy==cutting)**

Answer 143

* Closing Wedge * Opening Wedge * Mechanical Axis shifted AWAY from **affected compartment** * **​**totally re-align joint * arthrokinematics changed

Question 144

Cartilage Repari Proced's ## Footnote **Post-OP Rehab**

Answer 144

* Pd of **NWB/PWB 6wks** * **​aquatics + de-weighing devices for _progressive WB_** * **Controlled** Jt. Mob. Acts. * **EARLY MOTION GOOD** * Motion combining **compression + shear NOT GOOD** * ​EX. loading jt thru range * **DO use passive, AAROM, NWB AROM** * **Intermittent loading \> static loading** * **​**loading should be **compressive w/out shear** * **Resistance Ex.** * **​**brief, intermittent **isometrics** holding only **few secs/rep** \> sustained iso's * iso's avoids **compression combined w/ shear** * IF resistance ex's w/ **motion**--- use **arcs of motion that do NOT engage lesion** * **​**MOST lesions engaged b/w **20-70deg knee flex.** * NMES to INC quad strength

Question 145

Current Concepts for Rehab and Return to Sport after Knee Art. Cart. Repair in Athlete

Answer 145

Tables 1 & 2

Question 146

Current Concepts for Rehab and Return to Sport after Knee Art. Cart. Repair in Athlete

Answer 146

Table 3