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MSK 1 > Ligament, joint injury, Post-Op, and Lifespan considerations > Flashcards

Ligament, joint injury, Post-Op, and Lifespan considerations Flashcards

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1
Q

What is the anatomy of a ligament?

A

Similar to tendons
- collagen fibers in longitudinal bundles
- 70% water
- 70-80% dry weight is type I collagen
- 5% elastin

Intra vs extraarticular

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2
Q

What is included in the epiligament layer of a ligament?

A
  • hypocellular (fibroblasts)
  • hypovascular
  • mechanoreceptors
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3
Q

What are some properties of ligaments?

A
  • resists tensile forces
  • connects bones (structural)
  • guides joints
  • limits joint excursion
  • viscoelastic properties
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4
Q

What happens with rapid vs constant force through ligaments?

A

Rapid:
- increase in stiffness

Constant:
- exhibits creep

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5
Q

Are ligaments inert tissue?

A

Yes
- but have proprioceptive roles due to including mechanoreceptors and estrogen receptors

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6
Q

How do mechanoreceptors help ligaments?

A
  • reflex arc: in synergy with muscles
  • active and passive stability
  • functional joint stability (mechanical and sensory characteristics)
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7
Q

How do sprains occur in ligaments?

A

Usually high force tension or trauma
- contact = external force
- non-contact = deceleration or rapid direction change

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8
Q

What is the amount of tensile strain a ligament can withstand?

A

4% = collagen disruption and sub-failure
8% = total failure

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9
Q

What are the risk factors for a ligament sprain?

A
  • recurrent microtraumas
  • genetic disposition
  • inhibition/alteration of reflex arc in associated muscles
  • age
  • hormones
  • disuse
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10
Q

What are the 4 stages of healing for ligaments?

A

1) Hemorrhagic: hematoma in gap
2) Inflammatory: clearing necrotic tissue, neovascularization, granulation tissue and recruiting cells
3) Proliferation
4) Remodeling

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11
Q

What happens during the proliferation phase of ligament healing?

A

1st week:
- fibroblasts arrive last and begin collagen and protein production

2nd week:
- original clot more organized
- capillary buds, collagen content high but disorganized

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12
Q

What happens during the remodeling phase of ligament healing?

A
  • gradual decrease cells and matrix becomes dense/organized
  • normalize water content & type I: III ratio (want type I = stronger)
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13
Q

How is the strength of a ligament after 5 weeks, 6 months, and 1 year of healing?

A

5 weeks: some tensile strength
6 months: 50% strength
1 year: 80% strength

NEVER reaches full strength

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14
Q

How does intraarticular healing differ from extraarticular healing in a ligament?

A

Intraarticular:
- EX: ACL of knee
- Less likely to heal w/o surgery
- Does not follow typical healing phases due to being incased in the synovium

Extraarticular:
- EX: MCL of knee
- in epiligament lay so HIGHLY vascular and cellular w/ sensory/proprioceptive nerves
- follows normal phase of healing for ligaments
- greater likelihood of healing w/o surgery

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15
Q

Why does a ligament not heal as well while incased in the synovium?

A
  • blood dissipates into synovium
  • hematoma is prevented
  • limits the amount of growth factors and cytokines needed to mediate inflammation and healing

don’t really heal on their own

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16
Q

What are some clinical signs of a ligament injury?

A
  • history of trauma
  • point tenderness
  • joint effusion & ecchymosis (severe cases)
  • positive stress tests (joint gapping)
  • imaging
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17
Q

What is the tissue damage, clinical signs, and implications of a grade I ligament injury?

A

Tissue Damage:
- fiber stretching or tearing

Clinical signs:
- point tenderness
- mild swelling/ecchymosis
- joint stiffness (some)
- no abnormal motion

Implications:
- minimal function loss
- early return to training w/ some protection

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18
Q

What is the tissue damage, clinical signs, and implications of a grade II ligament injury?

A

Tissue Damage:
- some tearing or separation of fiber’s

Clinical signs:
- tenderness
- joint effusion/hemarthrosis
- stiffness
- laxity & abnormal motion
- moderate loss of function

Implications:
- tendency to reoccur
- modified immobilization
- longer term instability w/ arthritis risk

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19
Q

What is the tissue damage, clinical signs, and implications of a grade III ligament injury?

A

Tissue Damage:
- total rupture

Clinical signs:
- initial severe pain then minimal-none
- profuse swelling and ecchymosis
- marked laxity & abnormal motion
- moderate loss of function

Implications:
- needs prolonged protection
- surgery
- persistent functional instability
- traumatic arthritis

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20
Q

How do you manage a ligament injury in the protective phase?

A
  • control pain and swelling using PRICEMEM
  • relative rest vs complete immobilization
  • submax isometrics
  • pain-free ROM (PROM, AROM, AAROM)
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21
Q

How do you manage a ligament injury in the controlled motion phase?

A
  • restore ROM
  • address kinetic chain
  • progression of strengthening
  • stabilization and proprioception (static and supported)
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22
Q

How do you manage a ligament injury in the remodeling phase?

A
  • more advanced stabilization & proprioception (dynamic, complex, and unsupported)
  • restoration of agility, power, speed, for return to sport/occupation
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23
Q

What are the 9 structures that are involved in joint stability?

A
  • ligaments**
  • muscles
  • tendons
  • synovial fluid
  • joint nerve supply
  • meniscus
  • labrum
  • capsule
  • bony architecture
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24
Q

What are the three zones of joint movement?

A
  • neutral zone: little to no resistance to movement
  • elastic zone: first barrier to motion encountered
  • plastic zone: permanent deformation may lead to injury
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25
What are normal barriers to movement?
- articular shape (bone and cartilage) - restraining ligament tension - capsular tension - muscle length - synovial fluid
26
What are some reasons for hypomobility?
- internal derangement (loose body) - arthrosis - ankylosis - myofascial length - effusion, hemarthrosis - capsular
27
What are some ways a joint can be hypermobile?
- generalized, multi-joint - localized - instability
28
What are some ways to manage hypomobility?
- manual therapy to address underlying impairments - exercise to promote normal movement (increase range, regain strength, re-educate movement patterns) - medial intervention: surgical release, debridement, repair
29
What is the difference between laxity, hypermobility, and flexibility?
Laxity: - more than normal motion present but NOT a problem if asymptomatic Hypermobility: - laxity + symptoms associated w/ inability to control joint during motion Flexibility: - function of contractile tissue length/resistance - refers to muscle length when a restriction is present
30
What scale is used to assess hypermobility?
Beighton scale - greater than a 4 in adults is positive for generalized hypermobility
31
What is included in the Beighton scale?
- elbow, knee hyperextension >10 degrees - thumb touches volar forearm - 5th finger extension >90 - bend over w/ palms on floor *get a point for each side*
32
What is localized hypermobility?
Response to neighboring hypermobility - after injury or immobilization - after surgical fusion or arthrodesis - neighboring joints become more mobile
33
What is instability?
Too much movement w/ NO control - loss of joint congruency in response to loading - increased ROM w/o adequate neuromotor control - interfere w/ function - altered kinematics and physiological motion
34
What are the 4 components of joint stability?
- joint integrity: articular surfaces, congruity - muscle: static stability & dynamic stability - passive restraints: ligament, capsule, skin - motor control: activation, magnitude, timing
35
What is the MOI and some clinical signs of functional stability?
MOI: congenital, attenuation of forces (microtrauma), degenerative, traumatic event, systemic disease Signs: - early morning stiffness - feeling of "giving way" up to dislocation - feeling unstable may not be chief complaint - reduced force production across joint - altered quality of motion - apprehension & avoidance - excessive joint motion
36
How do you manage hypermobility in a joint?
Generalized: - not a lot we can do - neuromuscular control, supportive orthotics Localized: - supportive orthotics prn - treat neighboring hypomobilities - exercise for muscular stability (isos, weight bearing, co-contraction) - exercise for increased strength - retrain movement patterns Medical intervention: - surgical stabilization, fusion
37
What are some of the most common indications for surgical management of MSK conditions?
- knee replacement - ACL surgery - hip replacement - shoulder replacement - arthroscopy - joint fusion
38
What are some common post-op complications?
- infection - DVT - PE - poor wound healing - scarring and adhesions - prolonged immobilization
39
What are some risk factors for infection and what is the PTs role in the management?
Risk Factors: - coincident infection/colonization - steroid use - obesity - smoking - extremes of age, poor nutritional status PT Role: - monitor surgical site - educate patient and practice infection control - report signs of infection to pt, care-giver, surgeon
40
What are some risk factors for DVT and what is the PTs role in the management?
Risk Factors: - bed rest, immobility, distance travel - CHF - major trauma - past DVTs - obesity PT ROle: - recognize signs and symptoms and refer out fast - prevention of immobility: mobilization, exercise to promote circulation - monitor anti-coagulant times
41
What are some risk factors for poor wound healing and what is the PTs role in the management?
Risk Factors: - smoking - infection - diabetes - age - nutrition - immune function PT Role: - encourage proper nutrition - behavior modification - infection control
42
What are some risk factors for scars and adhesions and what is the PTs role in the management?
Risk Factors: - prolonged immobilization PT Role: - early mobilization as safe, passive mobility - scar mobilization
43
What are some detrimental effects of immobilization?
Prolonged immobilization will degrade tissues and make it more susceptible to injury - cartilage degen - ligament degen - decrease in bone mineral density - weakness and atrophy of muscle
44
How is a post-operative exam different from a normal PT exam?
Diagnosis is already known, mainly focusing on: - establishing a baseline - fully examine the kinetic chain - identify impairments in need of intervention
45
What is the number 1 mistake that PTs make when prescribing exercise to geriatric patients?
NOT overloading this population
46
What is the mode, frequency, duration, and intensity for aerobic training in the geriatric population?
M: walk, bike, jog, treadmill F: 3-7x/wk D: 30-40 minutes I: Use target HR (60-80%), RPE, talk test, NPRS, BP
47
What is the mode, frequency, duration, and intensity for balance training in the geriatric population?
M: SLS, eyes open vs closed, side stepping, tandem walking F: 1-7x/wk D: 10-15 minutes broken up I: progressively challenging them
48
What is the mode, frequency, duration, and intensity for gait training in the geriatric population?
M: walk, march, jog, skip F: 5-7x/wk D: incorporate into ADLs/aerobic training I: increase difficulty via speed, surfaces, demand, directions
49
What is the mode, frequency, duration, and intensity for flexibility training in the geriatric population?
M: static stretch w/ gravivty, body position F: 2-7x/wk D: 30 secs that add up to 60 seconds I: slight stretch sensation w/ mild discomfort
50
What is the mode, frequency, duration, and intensity for muscle/strength training in the geriatric population?
M: elastic bands, weights, machines, medicine balls F: 3x/wk D: 20-30 minutes (on average) I: increase w/ 60-100% 1RM but NOT to 1RM (more advanced pts can push closer to 1RM)
51
Why are children not just little adults?
- they are constantly changing - still have not grown into their bodies fully
52
What happens during the adolescent growth spurt and what age does that normally occur?
Trunk grows faster than extremities - bone normally grows faster than muscle (takes about 3 months to catch up) - bone demineralization occurs prior to growth spurt
53
What is the epiphysial plate?
growth plate
54
What is the diaphysis?
- the shaft of a childs bone - primary ossification center
55
What is the epiphysis?
- the ends of the bone - secondary ossification center
56
What is the metaphysis?
- between the epi- & diaphysis - part of the growth plate
57
What is the apophysis?
- secondary ossification center - growth plate attachment of a muscle
58
What is an overuse injury?
- repetitive submaximal loading of the muscular system - stress injuries - rest is not adequate to allow for structural adaptation
59
What are some common injury sites for overuse injuries?
- muscle-tendon junction - bone - articular cartilage - physis stress injury - bursa
60
What are some characteristics of adolescent tissues that make then susceptible to overuse injuries?
Growth cartilage: less resistant to tensile, shear, and compressive forces Bone: decrease BMD and strength Rapid changes in limb length/body mass: creates a longer lever arm that requires greater demand to move
61
What are some other risk factors for overuse injuries?
- previous injury - history of amenorrhea - high training volume - poor fitting equipment - overscheduling competitive events - sport specific training (don't get exposed to different stresses)
62
What are some prevention strategies with moderate evidence?
- limits on participation (per wk, year, event) & scheduled rest - closely monitored training - pre-season conditioning - pre-practice neuromuscular training (warm up)
63
What are some suggestions for training young children?
- make exercise FUN - higher reps w/ lower weight - teach proper technique - keep it simple
64
What is the evidence for manual therapy in those under 18?
- not definitive - have to weigh out the risk vs reward
65
What are some indications for manual therapy in children?
- improve joint mobility - improve neurophysiology to gain better response to exercise - address pain and stiffness
66
What are some things to consider for manual therapy in those under 18?
- skeletal maturity - muscular/ligament support - size of patient - systemic problems
67
Should cervial manipulations be performed in those under 1 month old?
NO; increased risk of stroke due to: - skeletal immaturity - immature ligament support - immature musculature to support head/neck
68
What are some symptoms of stroke in children and infants?
Infants: - seizures Children: - headaches - trouble moving - paralysis on one side - slurred speech - loss of vision - confusion
69
What are some absolute contraindications for manual therapy in children?
- malignancy - tuberculosis - osteomyelitis - osteoporosis - ligament rupture - Flu

MSK 1 (4 decks)

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