MSPT I > KNEE: Lectures 1 and 2 > Flashcards

KNEE: Lectures 1 and 2 Flashcards

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1
Q

Pt Scenario

First contact practitioner

if OPEN INJURY

A

OBSERVE:

Active bleeding? Bone protruding?

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2
Q

First contact practitioner

if Fx:

A

OBSERVE:

WB w/out an AD?

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3
Q

First contact practitioner

if Knee Dislocation

Tibiofemoral vs.

Patellofemoral vs.

Muscular avulsions vs.

Vascular issues

A
  • 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?
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4
Q

First contact practitioner

if Knee Jt Infection/Septic Joint

A

OBSERVE:

is the joint swollen and red?

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5
Q

First contact practitioner

Open Injury

A

PALPATE:

NOTHING IF OPEN!!

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6
Q

First contact practitioner

Fx:

A

PALPATE:

Fibular head, Patella

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7
Q

First contact practitioner

Knee Dislocation

Tib/fib vs.

Patellofemoral vs.

Muscular avulsions vs.

Vascular issues

A

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?
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8
Q

First contact practitioner

Knee jt Infection/Septic Joint

A

PALPATE:

  • Joint swelling
    • ​intra-articular vs. extra-articular
    • **Sweep Test**
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9
Q

First Contact Practitioner

Stop the Party, Call ED ….

A
  • 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
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10
Q

First contact practitioner

Continue Exam; Refer out when finished:

A
  • 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

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11
Q

Knee Rules for det. Need for Radiography

Ottawa Knee Rules

A
  • 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

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12
Q

Knee Rules for det. Need for Radiography

Pittsburgh Knee Rules

A
  • 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
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13
Q

JAMA and the Ottawa Knee Rules

A
  • DEC in need of radiography w/out missed fx’s
  • HIGHLY sensitive, reliable, very acceptable
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14
Q

Rehab after Prolonged Immob. (Fx)

Sx modulation and Impairment Resolution:

what do you want to focus on?

A
  • resolve effusion/edema
  • improve mm activation/DEC atrophy
    • normalize painful mm contracts.
  • Restore limtd motion, DEC jt stiff.
  • Restore normal mvmt patterns
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15
Q

Neurovascular Assessment of Knee Joint

Circulatory Issues: 2

A
  1. Vascular Injury
  2. DVT
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16
Q

Neurovascular assessment of Knee

Circulatory Issues:

Vascular Injury

A
  • Arterial injury interrupts blood to distal tissues
  • Arteries are susceptible @ jts AND when making sharp turns around bony prominences ​
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17
Q

POST. KNEE JT DISLOCATION

Impacts what?

A
  • POST knee jt dislocation
    • impacts Popliteal Artery
      • ​check Post. Tib pulse
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18
Q

POSTEROLATERAL KNEE JT INJURY

Impacts what?

A
  • Posterolateral knee jt injury
    • impacts supply to Ant. Tibial Artery
    • Check Dorsalis Pedis Pulse
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19
Q

DVT

what is it and what can it do ?

A
  • Clotting/blocking of a distal vein
    • can dislodge and move thru circulatory system to Central Aspects —– heart & lungs
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20
Q

DVT

More common when and why?

A
  • More common after Sx
    • hip, knee, leg/calf, abd, chest
      • ​Reduces bloodflow to a part of the body
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21
Q

DVT

Reasons why Sx can INC DVT risk: 3

A
    1. Tissue debris, PRO, fats may move into veins following Sx
    1. Vein walls damaged—> releases subs. that promote blood clotting
    1. Prolonged bed rest
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22
Q

Arterial Assessment

Dorsalis Pedis Pulse

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

A

Top of foot, lateral to EHL tendon

distal to Navicular

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23
Q

Arterial Assessment

Post. Tib. Pulse

Check if POST. knee jt dislocation bc impacts Popliteal Artery

A

Post to medial malleolus

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24
Q

Well’s Clinical Prediction Rule for DVT

A
  • Probability of DVT:
    • 3pts==HIGH RISK 75%
    • 1 to 2pts== MOD. RISK 17%
    • <1 pt==LOW risk 3%
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25
Circulatory Status for DVT: ## Footnote **risk INCs w/ AGE, esp. after 60** **Lifestyle factors?**
* Sitting or inactive for long time * Long plane or car trips * Extra wt. * BC pills or patches * Smoking
26
S/S of DVT **NOTE: 1/2 of all DVT cause NO sx's** **Some you will see....**
* **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**
27
Neuro Screening ## Footnote **Common Peroneal Nerve** **Motor vs. Sensory Function**
* MOTOR: * **Ankle DF** * **Great toe EXT** * **Toe EXT** * SENSORY * **1st web space----DEEP BRANCH** * **Dorsal surf. toes 3-4----SUPERFICIAL BRANCH**
28
NEURO SCREENING ## Footnote **Tibial Nerve** **Motor vs. Sensory Function**
* MOTOR: * **PF** * **Toe FLEX** * **little bit of Inversion** * SENSORY: * **Plantar aspect of calcaneous** * **Plantar aspect 5th toe**
29
LE Peripheral Nerve Map
see pics
30
Expected Gait Devs in Acutely Injured Knee 2
1. Noticeable limp 2. Flexed Knee Gait
31
Gait Devs in Acutely Injured Knee ## Footnote **Noticeable Limp** **Why?**
* avoiding WB on injured limb * Short **stance time** on **injured limb** * Short **step length** for **uninjured limb**
32
Gait Devs. for Acutely Injured Knee ## Footnote **Flexed Knee Gait** **Why and theories?**
* avoids TKE * avoids eccentric knee flex. * **Theories:** * **​**Quad-avoidance gait vs. Optimal length-tension for quads * **Co-contract of quads/HS to LIMIT MOTION**
33
Knee Joint Swelling: ## Footnote **Joint Effusion**
* 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**
34
KNEE JOINT SWELLING ## Footnote **Joint Edema**
GEN term for swelling \*can likely move edema thru tissue
35
Effusion Assessment **Stroke Test, Sweep Test**
UP medially DOWN laterally
36
Interventions/Sx Modulation ## Footnote **Effusion Control**
**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
37
Assess & Tx of Limtd ROM and Pain Gen. structures ## Footnote **Sx Modulation** **Knee EXT Measurements**
1. Resting knee EXT 2. Knee EXT w/ Quad Set 3. Knee EXT during SLR
38
Knee EXT ROM Considerations ## Footnote **Resting Knee EXT** **True PROM**
* 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"**
39
Knee EXT ROM Considerations ## Footnote **Knee EXT w/ Quad Set** **AROM**
* 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.
40
Quad Lag ## Footnote **Lag Sign**
* 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
41
**Quad Lag** **Max EXT-EXT during SLR\*\*\*\*\***
* quads not able to **maint. full knee EXT** when there is no support to Tibia * **Formula:** * **​**MAX EXT - EXT during SLR
42
Quad Lag ## Footnote **If present, what does this mean?**
CONSIDERABLE mm weakness! **MMT \>3/5** * **individual likely not strong enough to achieve ACTIVE TKE in gait** * **​**Hyperextension thrust vs. Flexed knee gait
43
Quad Lag ## Footnote **What do you want to do to address this?**
* 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**
44
Quad Lag ## Footnote **Isometrics** **Muscle Setting Ex's**
* 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**
45
Active/Passive Knee Flex. ## Footnote **Limitations in Knee FLEX freq. targeted w/ HEEL SLIDES** **To INC FLEX**
* 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 **​**
46
Interventions in **Sx Modulation Phase** **Painful MTU's**
LOAD CAREFULLY!!! * 2-3/10 pain * soft tissue mobs * GENTLE stretching of mm's * LOW grade Iso's * mult. angles
47
Interventions in **Sx Modulation Phase** ## Footnote **Limited _ROM_**
* 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**
48
Add. Interventions for TKE ## Footnote **when Acute or Symptomatic**
49
Classification of Knee Related Sx's in Motor Control Phase ## Footnote **Stiff Knee**
* Limtd ROM * Painful or Uncomfortable ROM * MM Length restrictions
50
Classification of Knee Related Sx's in Motor Control Phase ## Footnote **Unstable Knee**
* Ligamentous instability * Meniscal Issues * Poor Neuromuscular control * Pain related instability
51
Classification of Knee Related Sx's in Motor Control Phase ## Footnote **Weak "Knee"**
* Limtd Strength of a **Muscle relevant to knee jt function** * Pain-related weakenss
52
**Simplified Tx Approach!!!**
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!**
53
Joint Mobilization to Improve **Knee Flexion** ## Footnote **Patellofemoral Joint** **What happens as knee flexes?**
* patella glides **INFERIORLY** * lateral facet and odd facet **contact femur** * ​**greater _compression_** **laterally----esp w/ effusion** * **bc high lat. wall of trochlea**
54
Joint Mobilization to Improve Knee Flexion ## Footnote **Patellofemoral Joint** **Intervention:**
* Medial and Inf glides **IN FLEX** * Medial **tilt** mobs in **Resting\*\*\*\*** * when patello moves the most!
55
Joint Mobilization to Improve Knee Flexion ## Footnote **Tibiofemoral Joint** **What happens as Knee Flexes?**
* Tibia glides POSTERIORLY * MIN. tibial rotation * MAYBE some post. pinching or impinge.
56
Joint Mobilization to Improve Knee Flexion ## Footnote **Tibiofemoral Joint** **Intervention:**
* Jt distraction in **Sitting** * POST glides **IN FLEX** * **​**If **Post. Impinge.** * **​Ant/Rotational glide**
57
Joint Mobilization to Improve **Knee EXT** ## Footnote **Patellofemoral Joint** **What happens as knee EXTs**
* patella glides **SUPERIORLY** * **FULL EXT== min. contact w/ walls of trochlea** * **​**GREATER compression LAT.----bc tilt of patella
58
Joint Mobilization to improve Knee EXT ## Footnote **Intervention:**
* Medial + Superior glides in FLEX * Medial tilt mobs in RESTING
59
Joint Mobilization to improve KNEE EXTENSION ## Footnote **Tibiofemoral Joint** **What happens here when knee EXTs?**
* Tibia glides ANTERIORLY * Tibia must **Externally rotate to engage _Screw Home Mechanism_**
60
Jt. Mobs to improve KNEE EXT ## Footnote **Tibiofemoral Joint** **Intervention:**
* Jt. distraction in SUPINE * ANT glides in EXT * **If missing TKE-----MAY need to bias Tibial ER**
61
Proximal Tib/Fib Jt Mobs ## Footnote **When performed ?**
* 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**
62
Assess. and Intervention of Muscle Performanc in Motor Control Phase ## Footnote **GOLD STANDARD for measuring QUADS Strength in clinical studies**
Electromechanical Dynamometry **Isokinetic Machine** **\*HIGHLY reliable** **\*expensive**
63
Assess. and Intervention of Muscle Performanc in Motor Control Phase ## Footnote **1-RM** **Leg Extension** **Can use SL leg press if needed**
* 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**
64
Leg Press 1-RM ## Footnote **Standard Leg Press S/L**
* Knee @ 90 * Hip ~90 * Compensation avoided: * gastroc-soleus min'd * OPP limb suspended
65
Leg EXT 1-RM **Standard Leg EXT Machine**
* knee @ 90 * hip @ ~90 * **2 ranges tested:** * **​90-0** * **90-45**
66
Remember.... W/ BIG mm's
**Functional Tests!!!** **L.EXT** **L.Press** **HHD's**
67
Functional Strength Testing: Ex's
* Sit to Stand/Chair Rise test * Forward Step Down Test * Lateral Step Down test * S/L Squat test
68
More Functional Tests Ex's
* 30s Chair Rise * 5x S2S test * SL 30s vs 5x ea leg * Forward step down----endurance
69
Assessment and Intervention of Muscle Performance in Motor Control Phase Also consider... **MM's that control Femur**
* glute max * glute med * ER's * iliopsoas * sartorius
70
Assessment and Intervention of Muscle Performance in Motor Control Phase Also consider... **MM's that control Tibia**
* Gastroc/Soleus * Peroneals * Post. Tib * Ant. Tib
71
**MOST important** aspect in **Knee Function**
Strengthening Quads!!! during **Motor Control Phase**
72
Quads Isometric Matrix
ADD IN PICTURE!!! SLIDE 32 IN FIRST KNEE LECTURE!!!!
73
Sit to Stand ## Footnote **Anterior View**
trunk moves vertically pelvis stays lvl Knees stable in frontal plane (**slight hip ABD encouraged)** foot should NOT over-pronate
74
Sit to Stand ## Footnote **Lateral View**
no L/S flexion pelvis + hips move trunk into Flex. motion comes from knees CoP should NOT shift into ball of foot
75
What should you remember w/ sit to stands as an intervention?
YOU CAN MAKE THE DISTANCE LOWER OR HIGHER!!! Mini 30deg squats or Full 90deg squats **or anywhere in b/w!!!**
76
Advanced WB ex. Sit to Stand **Preferential squatting**
Key points: * surgical leg BEHIND good leg * shift wt. onto **sx limb** * load thru **heel** * avoid excess. trunk flex
77
Perturbation Training in Knee Jt Stability ## Footnote **What is it?**
* Progressive, purposeful **manipulation of support surfs.** to promote **active stabilization and NMSK control of knee**
78
Perturbation Training in Knee Jt Stability ## Footnote **Studies in ACL deficiency and Post-Op ACL** **\*good clinical and biomech. results\***
* 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
79
Perturbation Training in Knee Jt Stability SOME bennies for **OA, not consistent**
* Pts w/ OA more **heterogenous than pts after ACL injury**
80
Meniscal Tears ## Footnote **Longitudinal** **(Buckethandle)**
* springy end feel * IMMEDIATE REPAIR * easy to screw up * **meniscus flips over into joint**
81
Meniscal Tears ## Footnote **Oblique**
* typ. older pts * does OK w/ repair
82
Meniscal Tears ## Footnote **Radial or Transverse**
see pics
83
Meniscal Tears **Horizontal**
* when you bear wt. w/ this tear-----\> **pushes edges closer together**
84
Meniscal Tears ## Footnote **Complex Degenerative**
* does well w/ OR w/out Sx * Older pts---degenerative * you want to DEC mech. sx's
85
Meniscal Injuries **MOI**
* Cutting/Pivoting * **sudden direction change w/ foot fixed ground** * HYPERFLEXION * HIGH impact compression * MCL or ACL Mechs.
86
Meniscal injuries **MOI** **MCl or ACL Mechs.....why?**
* MCL * **deeper fibers connect to MCL** * ACL * **connects to Ant. Horn or Med. Meniscus** ## Footnote **​**
87
Meniscal Injuries ## Footnote **S/S**
* **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\*\***
88
Meniscal Special Tests: ## Footnote **5 "Cluster" Dx Tests** **REVIEW YOUR LAB NOTES!!!!** **YOU GOT THIS SHIT!!!**
* 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**
89
Clinical Composite Score for Meniscal Patho. **\*\*accurately detects meniscal patho.**
* 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**
90
Mensical Special Tests ## Footnote **Thessaly Test**
see pics ## Footnote **The "Dancing" one**
91
Meniscal Special Tests ## Footnote **Apley's Compression** **Apley's Distraction**
Exactly what it sounds like.....the Med/Lat rotate Tibia
92
NON-OP Tx of Meniscus Tears ## Footnote **What did MeTEOR Study find?**
* 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 \*\*\*\***
93
Sx vs. PT for Meniscal Tear w/ OA The New England Journal of Medicine BIG DEAL TO BE PUBLISHED BY THEM!!!
* **NOTE:** * **​equivalent outcomes in WOMAC scores AND KOOS Pain Scores b/w the 2 methods!!!**
94
Summary of PT Regimen **Sx vs. PT for Meniscal Tear and OA** **New England Journal of Medicine**
**PHASE I**
95
Summary of PT Regimen ## Footnote **Sx vs. PT for Meniscal Tear and OA** **New England Journal of Medicine**
**PHASE II** & **PHASE III**
96
Knee--Meniscal Injuries **Partial Menisectomy** When?
* 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**
97
Rehab Following Arthroscopic Debridement (**Menisectomy)** ## Footnote **\*NOTE: these are EASIER to rehab** **3 things we focus on:**
1. Muscle Strengthening and Joint Mobility 2. Ambulation 3. Return to Activity
98
Rehab Following Arthroscopic Debridement (Menisectomy) \*NOTE: these are EASIER to rehab **Muscle strengthening and joint mobility**
* Isometrics, AROM, **PF mobs IMMEDIATELY** * Soft tissue manip. of **portal scars when healed** * Progress to PREs **when tolerated** * consider **NMES**
99
Rehab Following Arthroscopic Debridement (Menisectomy) \*NOTE: these are EASIER to rehab **Ambulation**
* WBAT IMMED. **w/ least restrictive AD** * progress to FWB when **walking w/out limp** * **​usually 1-2 wks** * **​want NEGATIVE quad lag**
100
Rehab Following Arthroscopic Debridement (Menisectomy) \*NOTE: these are EASIER to rehab **Return to Activity**
* 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**
101
Meniscal **Repair** ## Footnote **When considered?**
* 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**
102
Indications and Contraindications for Meniscus Repair **NOTE: ACL + Meniscus** **_together_===\> MORE blood supply ===\> better healing**
see table
103
Superior Vertical divergent suture Inferior vertical divergent suture
see pics
104
Radial Meniscus Tear Repair
see pics
105
Repair for Flap Tears
see pics
106
Meniscal Repair of **Avascular, Central Region** **\*Becoming MORE COMMON** **\*Want to _preserve meniscus when possible!!!_**
* Mods. of Sx tech's to **enhance healing in this area used:** * **​**Fibrin clot * Rasping of synovial fringe * Creating **vascular access channels**
107
Meniscal Repair of **Avascular, Central Region** ## Footnote **Older Pts 40+** **What did this study show?**
30 repairs in pts 40+ 26 pts asymptomatic; **had NO further Sx after mean of 34 mos** **see pics for Rehab program + Conclusions**
108
Meniscal Repair of **Avascular, Central Region** ## Footnote **Younger pts \<20yo** **what did this study find?**
* 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:**
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 \*\*\*\***
* 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**
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Meniscal Repair and **Transplantation**
* **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!!!_**
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Explain Cartilage **Cyclic Loading**
* Cartilage is like a **sponge** * **​****Load ON==** * **​push BAD stuff OUT** * **UNLOAD==** * **​GOOD stuff comes IN**
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Articular Cartilage Explain...
* SELF-lubricating * **Load Applied=== Fluid RELEASED** * **Load Released===Fluid ABSORBED** * **_Lack of intermittent loading REDUCES lubrication process_**
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Articular Cartilage Respone to Loads **in Knee** **when REDUCED LOADING**
* **Reduced Nutrition** * **​==** degen changes * **Reduced Lubrication** * **​**== INCs friction b/w jt surfs * == degen changes * **LOW coeff. of friction**
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Articular Cartilage Response to Loads **in Knee** **when EXCESSIVE LOADING**
* \*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**
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Articular Cart. Response to Loads in Knee **when IMPACT LOADING**
* Occurs when loads applied **@ FAST RATE** * Cart. becomes **stiffer** * now **unable to deform and redistribute loads fast enough**
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The Knee--Art. Cart. Response to **Immobilization**
see pics for REVIEW
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Physical Stress Theory
**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
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Joint Stress/Tissue Stress== **Force/Area of Force Application**
* **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
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Osteoarthritis OA
* **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\*\*\*\*
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OA **Self-Report Symptoms**
* \*\*\***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_**
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OA **S/S**
* 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
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Altman's Criteria for OA ## Footnote **Clinical**
6 Criteria * Age \>50yrs * Stiffness \>30mins * Crepitus * Bony tenderness * Bony enlargement * No palpable warmth
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Altman's Criteria **Clinical and Laboratory**
**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
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Altman's Criteria ## Footnote **Clinical and Radiographic**
**Knee Pain and _@ least 1 of 3 Criteria_** * Age \>50yrs * Stiffness \>30mins * Crepitus * Osteophytes
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OA
Look @ picture specifically @: **Osteophyte formation** **Sclerotic (hardening) subchondral (below cart.) bone** **Narrowing of jt. space (loss of art. cartilage)**
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OA ## Footnote **Basic Tx Approach**
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**
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Osteochondral Lesions
* 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\***
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Risk Factors Assoc'd w/ **Articular Cart. Lesions**
* 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**
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Traumatic Osteochondral (OC) lesions **Lateral Patellofemoral Dislocation**
* 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.**
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Traumatic OC Lesions ## Footnote **ACL Rupture**
* 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**
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Osteochondritis Dessicans (OCD)
* 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**
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OCD
OCD w/
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OCD ## Footnote **Presentation, Signs, Symptoms**
* 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
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OCD ## Footnote **Tx**
* 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
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Art. Cart. Repair Procedures ## Footnote **More for Osteochondral defects:**
* 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
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Basic Science and Sx Tx Options for **Articular Cartilage Injuries of the KNEE**
written by physicians for PT's
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Abrasion Arthroplasty ## Footnote **to joint OR jt. surf.** **one small portion**
* 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**
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Micro-Fx Procedure ## Footnote **Abrasion Arthroplasty ON STEROIDS!!!!**
* 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.
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Mosaicplasty (OATS) Procedure **Osteochondral Autograph Transplant Sx**
* **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)**
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NOTE: **Fibrocartilage vs. Hyaline Cartilage**
Fibrocartilage is **WEAKER** Hyaline Cartilage is **STRONGER**
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Autologous Chondrocyte Transplantation w/ Periosteal Graft **\*graft==something put over top of something else (think skin grafts w/ burns)**
* 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
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Autologous Chondrocyte Transplantation w/ Periosteal Graft ## Footnote **\*graft==something put over top of something else (think skin grafts w/ burns)**
Another Pic of procedure
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KNEE Re-alignment Procedures **Tibial Osteotomy (tomy==cutting)**
* Closing Wedge * Opening Wedge * Mechanical Axis shifted AWAY from **affected compartment** * **​**totally re-align joint * arthrokinematics changed
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Cartilage Repari Proced's ## Footnote **Post-OP Rehab**
* 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
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Current Concepts for Rehab and Return to Sport after Knee Art. Cart. Repair in Athlete
Tables 1 & 2
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Current Concepts for Rehab and Return to Sport after Knee Art. Cart. Repair in Athlete
Table 3
MSPT I
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