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Clinical Medicine II > Knee Ligament Injury ACLR > Flashcards

Knee Ligament Injury ACLR Flashcards

1
Q

What range is peak torque on the quadriceps

A
  • 50-70 degrees of knee flexion
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2
Q

What position of the knee requires the most contractile force

A
  • terminal knee extension due to shortened quad muscle & decreased mechanical advantage of the patella
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3
Q

Immediate impairments following initial ligament injury

A
  • swelling for several hrs unless blood vessels are torn
  • pain when injuries ligament is stressed
  • instability if complete tear
  • redistricted motion & quad inhibition if there is effusion
  • impaired WBing & need for AD
  • concern for concomitant injuries
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4
Q

MCL injury

A
  • isolated injury with high valgus load
  • grade I, II, III classification
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5
Q

LCL injury

A
  • infrequent injury
  • usually traumatic varus moment at the knee that loads the ligament
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6
Q

PCL injury

A
  • “dashboard injury”
  • caused by a forceful trauma to the anterior tibia while the knee is flexed
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7
Q

MOI of ACL tear contact versus non-contact

A
  • Contact: blow to the lateral side of the knee resulting in large valgus moment
  • Non-contact: rotational mechanism in which the tibia is rotated on the planted foot with forceful hyperextension of the knee
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8
Q

Risk factors for ACL tear

A
  • high friction b/w the shoe & the surface
  • narrow femoral notch, Increased BMI, increased joint laxity
  • early & late follicular phases of menstruation in women
  • dynamic valgus
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9
Q

Indications for surgery for ACL tear

A
  • disabling instability
  • frequent knee buckling
  • high risk of re-injury
  • rule of 3rds (1/3 compensate & return to physical activities, 1/3 compensate but must give up activities, & 1/3 can’t compensate
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10
Q

Contraindications for surgery for ACL tear

A
  • inactive lifestyles
  • advanced arthritis in the knee
  • poor compliance
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11
Q

Patient selection for ACL to heal and stabilize the knee

A
  • non-high athlete
  • age >25
  • acute proximal one bundle ACL rupture
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12
Q

Potential copers for ACL tear

A
  • demonstrate sufficient dynamic knee stability
  • ability to compensate following injury
  • good potential to return to pre injury high level activities following a 1-year non-operative treatment
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13
Q

Potential non-copers for ACL tear

A
  • poor potential to return to pre injury activities following non-operative treatment
  • poor dynamic knee stability
  • advised to consider surgical management
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14
Q

Pre-screening to determine if someone might be a coper for ACL tear

A
  • no concomitant knee injuries
  • zero to trace knee effusion, full knee ROM, & normal gait
  • greater then 70% isometric quad strength
  • no pain with hopping up & down
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15
Q

Criteria to be classified as a potential coper for ACL tear

A
  • one or non giving way episode with ADLs
  • single-legged 6 meter timed hop score greater than or equal to 80%
  • KOS-ADLS score greater than or equal to 80%
  • GRS score greater than or equal to 60%
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16
Q

Bracing non-operative ACL deficient knee

A
  • for the ACL deficient knee every effort is made to prevent a giving way or shifting episode in order to avoid any further damage to the articular surfaces
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17
Q

Allograft for ACL reconstruction

A
  • donor tissue
  • used if an autograph is not available/previously failed
  • greater risk of failure
  • decreased graft strength
  • potential disease transmission
  • longer rehab times compared to autograph
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18
Q

Autograft for ACL reconstruction

A
  • patients own tissue
  • requires two surgical procedures
  • damages & weakens healthy tissue at donor site
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19
Q

Gold standard for ACL reconstruction

A
  • patellar tendon
  • uses the central 1/3 of tendon bone plugs
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20
Q

Advantages of using the patellar tendon for ACL reconstruction

A
  • high strength & stiffness
  • secure bone to bone fixation (6-8 wks)
  • permits accelerated rehab
  • safe return to pre-injury levels
21
Q

Disadvantages of using the patellar tendon for ACL reconstruction

A

-anterior knee pain at harvest site
- pain with kneeling
- long term quad weakness
- potential patellar fracture or rupture

22
Q

Advantages of using hamstring for ACL reconstruction

A
  • high tensile strength & stiffness
  • no disturbance of epiphyseal plate in immature patients
  • generally no problem with kneeling
  • no pain at anterior knee
23
Q

Disadvantages of using hamstring for ACL reconstruction

A
  • tendon to bone devices are not as reliable as bone
  • longer healing times
  • hamstring muscle strain in early rehab
  • knee flexor muscle weakness
  • increased anterior knee translation
24
Q

Precautions for patellar tendon autograft ACL reconstruction

A
  • be aware of patellofemoral forces & possible irritation
  • treat patellofemoral pain as it arises
  • alter knee flexion angle b/w 45-60 degrees for MVIC assessment & NMES treatments
25
Q

Precautions for hamstring autograft ACL reconstruction

A
  • no resisted hamstring strengthening until wk 12
  • may start AROM as early as wk 4-6
26
Q

Precautions for an ACLR with meniscal repair

A
  • no WBing flexion beyond 45 degrees for 4 wks
  • WBing in full extension is allowed
  • multi-angle quad isometrics can substitute for WBing exercises
27
Q

Precautions for an ACLR with MCL tear

A
  • restrict motion to sagittal plane until wks 4-6
  • consider brace for patients with severe pain during exercise
28
Q

Non-repaired MCL ROM restrictions

A
  • Grade I = no ROM restrictions
  • Grade II = 0-90 degrees in wk 1, 0-110 degrees in wk 2
  • Grade III = 0-30 degree in wk 1, 0-90 degrees in wk 2, 0-110 degrees in wk 3
29
Q

Ligamentization

A
  • graft is its weakest at 6-8 wks post-op
  • by 30 wks a graft will have tissue characteristics of a ligament
30
Q

Open and closed chain exercise considerations for ACL repair

A
  • Open chain: limit knee ROM to only 90-45 degrees for non-weight bearing exercises early on; progress to knee ROM from 90-10 degrees by wk 12
  • Close chain: wall slides & step ups in pain free ranges typically 0-60 degrees
31
Q

ACL loading/force in NWB and WBing exercises

A
  • loading b/w 10-50 degree is greater in NWB knee extension exercises
  • seated knee extension exercises b/w 10-50 degrees of knee flexion ROM with or without resistance produces greater ACL loading compared to WB exercises
32
Q

ACLR rehab goals

A
  • full knee extension ROM
  • absent or minimal effusion
  • no knee extension lag with leg raise
  • quad strength deficit should be minimized (15-40%)
33
Q

What sets the stage for successful rehab for ACLR post-op care

A
  • achieving symmetrical full knee extension
  • decreasing effusion
  • quads activation
33
Q

What sets the stage for successful rehab for ACLR post-op care

A
  • achieving symmetrical full knee extension
  • decreasing effusion
  • quads activation
34
Q

Patient presentation in max protect phase for ACLR

A
  • pain
  • hemarthrosis
  • decreased ROM
  • diminished quad activation
  • crutch ambulation
  • bracing if prescribed
35
Q

Patient presentation in mod protect phase for ACLR

A
  • pain & joint effusion are controlled
  • full knee ROM
  • 3+ or 4/5 muscle strength
  • developing neuromuscular control
  • independent ambulation
36
Q

Patient presentation in min protect phase for ACLR

A
  • no joint pain, instability, or swelling
  • full ROM
  • 75% function of non-involved LE
  • symmetrical gait
  • unrestricted ADL
  • possible brace/sleeve
37
Q

Interventions for max protect phase post ACLR

A
  • PRICE
  • gait training
  • PROM/AAROM
  • patellar mobs
  • muscle setting/isometrics
  • assisted SLR
  • ankle pumps
  • Wks 2-4: progress to FWB, SLRs in four planes, low load PRE hamstrings and knee extension (90-40 degrees), trunk/pelvis stabilization, & aerobic conditioning
38
Q

Interventions for mod protect phase post ACLR

A
  • multiple angle isometrics
  • close chain strength/stretch of LE
  • endurance training
  • proprioceptive training in SLS
  • trunk stabilization/band walks
  • Wks 7-10: advance strength/endurance/flexibility, progress proprioceptive training, & initiate walk/jog program
39
Q

Interventions for min protect phase post ACLR

A
  • LE stretching
  • advance PRE
  • advanced close chain exercises
  • introduce plyometrics
  • introduce more advanced plyometric drills
  • advance proprioceptive training
  • progress agility drills
  • simulated work/sport specific training
  • transition to full speed jogging/sprints/running/cutting
40
Q

Soreness rules during rehab

A
  • Sore during warm-up that continues = 2 days off & drop 1 level
  • Sore during warm-up that goes away = stay at level that led to soreness
  • Sore during warm-up that goes away but redevelops during session = 2 days off & drop 1 level
  • Sore the day after lifting (not muscle soreness) = 1 day off & don’t advance program to next level
  • No soreness = advance 1 level per week or as instructed by healthcare professional
41
Q

Return to running progression

A
  • Level 1: 0.1 mi walk/0.1 mi jog repeat 10x = jog straights/walk curves for 2 mi
  • Level 2: 0.1 mi walk/0.2 mi jog repeat for 2 mi = jog straights & 1 curve every other lap
  • Level 3: 0.1 mi walk/0.3 jog repeat for 2 mi = jog straights & 1 curve every lap
  • Level 4: 0.1 mi walk/0.4 mi jog repeat for 2 mi = jog 1.75 lap/walk curve
  • Level 5: 2 mi jog
  • Level 6: increase to 2.5 mi
  • Level 7: increase to 3.0 mi
  • Level 8: 0.25 mi jog/0.25 mi run
42
Q

Minimum criteria post ACLR to begin return to sport progression

A
  • min 12 wks post-op
  • 90% or greater on quad index
  • 90% or greater on all hop tests
  • 90% or greater on KOS-ADL
  • 90% or greater on global rating score of knee function
  • follow up testing at 4 mo, 5 mo, 6 mo, & 1 year post
43
Q

Criteria for post ACLR discharge

A
  • isokinetic & functional hop test 90% or greater limb symmetry
  • acceptable quality movement assessment
  • lack of apprehension with sport specific movements
  • flexibility to accepted levels of sort performance
  • independence with gym program for maintenance & progression of therapeutic exercise program at discharge
44
Q

PCL injury

A
  • not commonly injured
  • accompanied by damage to other structures to the knee
  • High velocity = dashboard injury
  • Low velocity = hyper flexion athletic injury with a plantar flexed foot
45
Q

Post-op management for PCL reconstruction

A
  • immobilization in a hinged range limiting protective brace locked in full extension
  • 24/7 for first 4-8 wks post-op to avoid posterior tibial migration as a result of gravity
  • can be removed for therapy but follow MD guidelines
  • slower weight bearing progression than with ACL repair
46
Q

Criteria for ambulation w/o crutches after PCLR

A
  • minimal to no pain or joint effusion
  • full active knee extension with a SLR
  • passive & active knee flexion from 0-90 degrees
  • quad strength about 70% or 4/5 MMT grade
  • no hair deviations
47
Q

General precautions for post-op PCLR

A
  • avoid exercises that place excessive posterior shear forces & cause posterior displacement of the tibia
  • limit the number of reps of knee flexion to minimize potential abrasion to the pCL graft

Clinical Medicine II (21 decks)

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