EI: Knee exam

What is the inability to maintain full knee extension during SLR flex?

Extensor lag

Describe the different variations in squatting that can help reduce load on ACL strain

Forward trunk tilt will recruit the hamstrings which helps to unload ACL by decreasing anterior tibial translation. Gluteal musculature has higher activation, which may aid in medial/lateral control at knee

Kinetic chain abnormalities usually lead to knee pain. Describe the typical presentation in the femur and hindfoot with a genu valgus

Genu valgus leads to hindfoot pronation Genu valgus leads to femur IR

Would a genu varum or genu valgum more likely lead to ITB friction syndrome?

Genu varum

What muscles typically get weak in the LE leading to anterior knee pain?

Gluteus medius and Quads

At 20 degrees of knee flexion, what part of the patella comes in initial contact with the femur?

Inferior aspect of patella (both medial and lateral facets)

Describe a 3rd degree LCL sprain

Ligament is ruptured. Pain not increased with laxity testing. Significant laxity present

What are the 5 common symptoms of a PCL tear?

Minimal to no pain Usual full ROM contusion over anterior tibia Posterior tibial sag Posterior sag during extension

A bone bruise following an ACL injury is a high predictor of what pathology?

OA

Why is a PCL injury not very common?

PCL is 2x size of ACL and posterior translator force on tibia is not very common

What is important to understand about the joint capsule of the knee, that most clinicians tend to underestimate?

Joint capsule of knee extends much further proximally on the femur and distallly on tibia than we realize

Weight bearing can act as muscle pumping for a post-op ACL knee. This light loading response can help get ride of what TSI in the knee?

Joint effusion

Why is reducing pain one of the most important functions to restore, 1 week after post-op ACL surgery?

Prevent pain from persisting, as it may effect interventions and eventually lead to chronic pain if felling of pain is not overcome

After Gradually increasing applied loads on a patient, what should we progress to as the last principle of ACL rehabilitation?

Progress to sport-specific training

By the end of week 2 following a ACL surgery repair? you should progress mini squats in what way?

Progress to unstable surface on foam surface or tilt board

A brace is worn after ACL surgery repair until what is demonstrated?

Quadriceps control

Effusion and pain can lead to what problems in the quadriceps in the acute phase of a post-op rehab?

Quadriceps inhibition

What is the critical goal of the second week ACL surgery repair?

Train patient to assume full WB between 10-14 days

What is the most important thing to train when landing from a jump?

Train to land in knee flexion

What are the 2 most important considerations of rehabilitation following ACL reconstruciton on someone with an underlying articular cartilage injury are what?

WB restrictions and progressive ROM

What is chondromalacia?

Degeneration of cartialge due to poor knee alignement

One of the main functions of the meniscus is load transmission. What does this help with?

Distributing and dissipating the forces equally throughout the knee

When is a locked brace used?

During ambulation and sleeping during the first 2 weeks

According the the Ottawa knee rules a patient needs a knee x-ray if they report pain in location of knee, and they have tenderness in what 2 spots?

Head of fibula Isolated tenderness of patella

Why should you begin initial OKC knee exercises within the ranges of 90-45 degrees of knee flexion?

You have a greater contact area on the patellofemoral joint, which can help create a larger distribution of forces. Also you have less of a load from the quadriceps pull

When training to land properly, which of the following should you recommend: a. Land with slight abduction, ER b. Land with slight adduction, IR

a. Land with slight abduction, ER

At full knee extension the meniscus transmits how much of the compressive loads?

50%

The common peroneal nerve give motor innervation to what muscles?

Ankle dorsiflexors and evertors

The saphenous nerve provides sensation to what part of the leg?

Anteriomedial aspect of knee and lower leg. Contributes to knee joint

What is the main component motion to restore knee flexion beyond 100-120 degrees of knee flexion?

Anterior tilt of tibia

Is the knee joint considered uni-condylar or bi-condylar?

Bi-condylar (pretty sure)

Joint nutrition is one of the functions of the meniscus. How the body normally get nutrition to tissues?

Loading and unloading

Effective treatment of a meniscus tear primarily consists of having an understanding of what?

Loads that are transmitted through meniscus

In the presence of an ACL tear what provides restraint to anterior tibial translation?

MCL

What acts as the primary restraint to ER of the tibia in the knee?

MCL

What structure is wedge-shaped and sits on the tibial surface. It also moves with the tibia?

Meniscus

The chock-block effect is one of the 7 main functions of a meniscus tear. What is the chock-block effect?

Meniscus is wedge shape and acts to stabilize and support the knee. Also supports with total joint gliding (like when you have a wedge block to stabilize a tire)

If your patient has a meniscus pathology, why should you avoid the initial ranges of deep knee flexion? >80 degrees

Meniscus transmits over 90% of force with knee flexion over 80 degrees

What portions are contacting the femur at 45 degrees of knee flexion?

Middle of patella and medial and lateral side (not odd facet)

Describe the etiology of Plica

Mimics patellofemoral or meniscal pathologies Plica is thickened and fibrotic Tissue changes as a result of trauma and may result in synovitis or meniscal tears Pain often intermittent and increases with activity

What are the 3 things that can combine to lead to OA?

Muscle weakness Mobility impairments Cartilage breakdown (any order/combination of the 3)

Inhibition (lack) of quadriceps extension is can lead to what pathology?

OA

It is almost guaranteed that someone who sustained an ACL tear will develop what later in life?

OA

What are the 6 other tissues that have been shown to resist against a varus load at 0 and 30 degrees?

Posterolateral capsule Arcuate-popliteus complex biceps femoris tendons ACL PCL Lateral gastrocenmius muscle ITBand

In addition to restoring full passive knee extension and patellar mobility, it is imperative to control what?

Postoperative pain, inflammation and swelling during first week of rehab

The accelerated approach to rehab is utilized for the young and/or athletic patient. What is the main differences between this program and the regular program for patellar tendon reconstruction?

Rate of progressions through various phases of rehab

List the typical diagnosis examination findings for a mensicus tear

Twisting injury while in weightbearing Tearing or popping sensation at time of injury Delayed effusion (6-24) Reports of "catching" or "locking" Pain with forced hyperextension Pain with maximum flexion Pain or audible click with McMurray test Joint line tenderness Pain or sense of catching/locking with Thessaly test

What is a key rehabilitation aspect for female athletes?

Train hip extensors, external rotators, abductors and core stabilized, while emphasizing a flexed knee posture, while running cutting and jumping

Since ACL injury is a valgus-stress with rotation, what should be the rehabilitation intervention specialized for females

Train patient to stabilize knee through coactivation of quad and hamstings using various exercises such as tilt board balance and throw and catch

What is initiated during the first 2 weeks and progressed as tolerated after an ACL surgery?

WB and non-WB activities, proprioceptive training and strengthening exercises

What are the primary signs of early OA?

Weakness of Quads Inability of knee to fully extend Excessive effusion

What is the typical MOI of an acute meniscus tear?

Weight bearing with rotation injury secondary to improper movement

Because females tend to land with increased knee extension and decreased hip flexion after jumping, what should be performed, with the knee flexed approximately 30° to promote better alignment and activation of the quadriceps and hamstrings?

dynamic stabilization drills

The ACL and PCL are considered extra-capuslar yet still _______________

intra-articular

Why do you have no restrictions to the meniscus during an open kinetic chain activity?

Meniscus is a weight bearing structure, so you don't need to worry about open kinetic chain activities

The common peroneal nerve give sensory innervation to what muscles?

Distal lateral leg and dorsum of foot

What are the isokinetic test parameters for a return to play program?

80% or greater quad contralateral comparison 65% quad torque-body ratio Acceleration rate of 80% of quad peak torque

At 90 degrees of flexion the meniscus transmits how much of a load?

85%

The functional hop test should be ___% or greater of contralateral side?

85%

For Open kinetic chain exercises on the knee, what degrees of ROM would be the best to initially start with for someone with a patellofemoral pathology?

90-45 degrees of knee flexion

You 16 year old patient describes a pain in the medial side of there knee. You also notice, clicking, catching and locking in the knee. What injury would you assume?

Acute medial meniscus tear

Weight bearing and rotation on a meniscus may lead to what type of meniscus tear?

Acute tear

What are the 2 primary types of tears of a meniscus pathology?

Acute tear Degenerative tear

Single-leg stance exercises on a flat ground in post-op ACL surgery repair should begin at 3 weeks for dynamic stability. How would you progress this exercise?

Add perturbations on the unaffected sides to alter position of center of mass

As the saphenous nerve descends along the medial aspect of the thigh, the nerve enters what canal?

Adductor canal (hunter's canal)

What is used during the 2nd post-op week following a ACL surgery repair to restore neuromuscular control?

Adequate normalization of pain, swelling and quadriceps control

When using the Pitt knee rules, the clinician asks if there was any blunt force or trauma to the knee. If the answer is "yes" then what other criteria would warrant a x-ray?

Age younger than 12 Age greater than 50 Inability to walk 4 steps at time of injury or in clinic

What nerve gives sensory innervation to the distal lateral leg and dorsum of the foot?

Common peroneal nerve

A hyper or hypo mobility at the fibular head can lead to what nerve entrapement?

Compression of common peroneal nerve

Why is gaining full knee extension one of the most important functions to restore, 1 week after post-op ACL surgery?

Concern of arthrofibrosis and avoiding scar tissue

What major function is associated with poor post-op results

Full knee extension

What are some imperative functions to restore to normal for the first week of a post-op ACL patient?

Full knee extension Patellar mobility Pain Inflammation

What do current rehabilitation programs emphasize immediately after ACL surgery?

Full passive knee extension Immediate motion Immediate partial weight bearing Functional exercise

What are the 3 main structural impairments that will result in hypermobility of the patellofemoral joint?

Genu valgum leading to increased lateral mobility of patella and Q-angle Small lateral femoral condyle, which increases lateral movement of patella Patella alta

After proprioception and neuromuscular control, how should you progress the ACL rehabilitation?

Gradually increase applied loads

Consgarea compared the effects of post-op bracing in our ACL article. What were the findings?

Group braced at 45 degrees: 1 week prior to beginning ROM exercise have 23% increase in complications Group braced at 0 degrees: Much less complications (3%)

What muscles typically get tight in the LE leading to anterior knee pain?

Hamstrings Adductors Gastrocnemeius

The preoperative phase before an ACL surgery can be beneficial for a successful outcome and may take up to 21 days. What does this help regain after surgery?

Helps regain ROM and diminished symptoms in earlier phases of reconstruction

What are the clinical implications the hip and ankle/foot have on the influence of the patellofemoral joint? Use hip anteversion as an example. Think of what kinetic chain problem at the foot could lead to a change of position on the knee

Hip anteversion can lead to a valgus which can increase compression on the lateral side of knee and increase tension on medial knee Ankle/foot supination or pronation can change knee positions as well

What are the 4 main steps in the examination to help diagnosis a meniscus tear?

History Prescence of effusion PFT of meniscus Special tests

What are the 5 findings that lead to a 99% specificity for a meniscus tear?

History of "catching" or locking Pain with force hyperextension Pain with maximum flexion Pain with click with McMurray test Joint line tenderness

Below is a cluster of findings a clinician may identify throughout their examination to support a generated hypothesis of a meniscus tear. Those findings include: Symptoms of clicking/locking within the knee Joint line tenderness with palpation Pain with knee flexion Pain with knee hyperextension Positive McMurray's special test Describe the specificity rules you can use with these findings

If 3 of the above symptoms are present the Specificity is 90% for a meniscus tear. If 4 of the above symptoms are present the Specificity is 96% for a meniscus tear. If 5 of the above symptoms are present the Specificity is 99% for a meniscus tear

The distal portion of the ITBand can become irritated as it compresses and rubs against the lateral femoral epicondyle. What is this condition termed?

Iliotibial band friction syndrome

The following patient has symptoms associated with what disorder? Pain Assessment: Pain radiating down proximal tibia PROM classical: pain with knee flexion at 30 degrees Special test: positive noble's compression test PFT: Pain over gerdy's tubercle

Iliotibial band friction syndrome

What is the current emphasis for ACL surgery rehabilitation?

Immediate weight bearing, ROM and progressive muscular strengthening, proprioception and dynamic stability.

What are the 3 common immediate interventions of an ACL tear?

Immoblization and possible surgery PT prior to surgery to reduce edema/effusion and allow for better outcomes post-op Bracing before surgery, since some fibers of ACL blend with joint capsule, effusion must be treated first before increasing strength

Why do we start ACL rehabilitation before surgery?

Imperative to reduce swelling, inflammation and pain, restore normal ROM and normalize gait. Prevent muscle atrophy as well

A locked knee brace has been shown to improve what functions after a post-op ACL?

Improve proprioception and functional outcome scores

Describe the difference in outcomes between supervised rehabilitation compared to no supervised rehabilitation

Improved outcomes- greater motion, improved muscular strength and enhanced earlier function

What are the 7 most common signs and symptoms of an ACL tear?

Inability to ambulate Rotational instability and knee "giving way" Pain more severe when stress tested with 2nd degree sprain 3rd degree sprain, pain is less sever when stressed Effusion Minimal to significant hemarthrosis Incomplete functional ROM with extension

What is an extensor lag?

Inability to maintain full knee extension during SLR flex

Why is patellar mobility, one of the most important functions to restore, 1 week after post-op ACL surgery?

Patellar mobility is necessary to restore knee extension

What is one of the primary knee complaints seen by physical therapist at the knee?

Patellofemoral joint pain

Your patient comes to your clinic with the following presentation: Gradual onset of knee pain Pain in the anterior knee Pain with sitting Pain with descending stairs. What are the symptoms classically associated with?

Patellofemoral pain syndrome

The MCL is frequently considered the primary restraint to genu ________

valgus

What degrees of flexion represents the least aggressive loading of the patellofemoral joint during closed kinetic chain squats?

0-45 degrees

For closed kinetic chain exercises on the knee, what degrees of ROM would be the best to initially start with for someone with a patellofemoral pathology?

0-45 degrees of knee flexion

Why should you avoid an Open kinetic chain knee extension between 45-0 degrees following an ACL repair?

0-45 degrees represents the most aggressive loading on the patellofemoral joint

How much ROM with knee flexion should a patient have following an ACL surgery repair?

0-90 degrees 5-7 days 0-100 degrees 7-10 days

At what % of distention is quadriceps inhibition noted?

5%

Anteiror knee translation beyond the toes, especially more than __ cm will increase ACL loading during squatting and lunging exercises

8 cm

How much more likely are females to injure their ACL compared to males?

8 times more likely for basketball and 6 times more likely for soccer

Is there a greater peak ACL tensile strain with NWBE or with WBE from 10-30 degrees of knee flexion?

NWBE

At what % of distention is knee joint effusion visible to the naked eye?

10-20%

During knee flexion, when does the posterior glide of the tibia on the femur cease and tibia anterior tilting begin to occur?

100-120 degrees of knee flexion

Diagnosis the following injury as a 1st degree, 2nd degree or 3rd degree MCL injury: PROM accessory: Normal Ligamentous end feel PFT: pain over medial joint line Special test: Pain with valgus stress test

1st degree MCL injury

Localized lateral knee pain is a common sign of ITB friction syndrome. Where would pain likely be produced?

2 cm above joint line over condyle when knee flexes to 30. Or over diffuse anterior knee pain

During what degree of knee flexion does the patella begin to contact the knee?

20 degrees

What amount of knee joint effusion will lead to a inhibition of the vastus medialis and inhibition of the entire quadriceps?

20-30 mL of effusion: inhibition of vastus medialis 50-60 mL of effusion: inhibition of entire quadriceps

Diagnosis the following injury as a 1st degree, 2nd degree or 3rd degree MCL injury: History: non-contact twisting injury 2 days ago PFC: Swelling noted on medial side PROM accessory: Laxity present PFT: 6/10 pain with medial knee palpation

2nd degree MCL injury

Wilk showed that the greatest amount of hamstring and quadriceps cocontraction occurred at how many degrees?

30 degrees of knee fl

The noble's test is used to indicated ITband friction syndrome. What specific degrees does this special test say will likely provoke pain?

30 degrees of knee flexion

What is the optimal position to activate co-contraction of the hamstrings and the quadriceps?

30 degrees of knee flexion

Explain the amount of surface area contact during knee flexion of 30 degrees, and 90 degrees

30 degrees: contact area is small (2 cm) 90 degrees: contact area triples (6 cm)

Diagnosis the following injury as a 1st degree, 2nd degree or 3rd degree MCL injury: History: pt. describes "excruciating pain, secondary to leg planting injury" PROM accessory: laxity present PFC: swelling and knee is hot to touch Movement analysis: knee is unstable during activity

3rd degree MCL sprain

At what degrees of flexion does the middle of the patella contact the femur?

45 degrees of knee flexion

How much of the overall body weight does the meniscus transmit during normal weight bearing?

50% Other 50% is through articular cartilage

Two patients come into your clinic, which one would you determine needs a knee x-ray according to the Ottawa knee rules: (Both have pain in location of the knee) 54 year old male with 91 degrees of knee flexion 54 year old female with 88 degrees of knee flexion

54 year old female with 88 degrees of knee flexion **Inability to flex to 90 degrees

Two patients come into your clinic, which one would you determine needs a knee x-ray according to the Ottawa knee rules: (Both have pain in location of the knee) 56 year old female 54 year old male

56 year old female

During normal activities, a healthy meniscus will transmit how much of a load?

70%

The ACL and PCL are considered extra-caspular yet still intra-articular due to the posterior invagniation of the joint capsule. Describe where the fibers of the ACL blend with the joint capsule

ACL fibers blend with joint capsule along anterior medial aspect along insertion onto the tibia

Desribe how knee flexion angles can affect ACL loading

ACL loading primarily occurs between 0-50 degrees of knee flexion Performing between 50-100 degrees minimizes ACL loading

The MCL will provide restraint to anterior tibial translation in the case of what pathology?

ACL tear

The inability to fully extend the knee results in what abnormalities?

Abnormal joint arthorkinematics Scar tissue formation in anterior aspect of knee Increases in patellofemoral/tibiofemoral joint contact pressure

Describe the outcomes measures of using a accelerated approach rather than a conservative approach

Accelerated approach exhibited better strength and range of motion with few complications, such as laxities and patellofemoral complaints

How should the progression of ACL rehabilitation be different from allograft tissue compared to normal autogenous graft repair?

Allograft tissue should have a slower progression to aggressive activities

Why is the loading by way of the quadriceps the greatest as the knee moves towards terminal knee extension in open kinetic chain?

Amount of surface area of patella is smallest towards knee extension

The sartorius muscle makes up what boarder of the adductor canal?

Anterior aspect of canal

During flexion, what band of the ACL becomes taut?

Anterior band is taut and posterior band is loose

What are the classical symptoms associated with PFPS?

Anterior knee pain Pain with sitting Pain with descending stairs Gradual onset of pain

What motions of the tibia does the ACL restrict?

Anterior translation of tibia on femur

Which way does the meniscus move during knee flexion? knee extension?

Anterior with knee extension Posterior with knee flexion

Scar tissue is most common in what part of the knee, after an ACL repair?

Anterior. This is why passive full knee extension, is important to help prevent scar tissue from forming.

What are the 2 portions of the ACL?

Anteromedial and posterolateral band

Describe the different MOI for the anteromedial ligament bundle and the posterolateral bundle

Anteromedial bundle injured during uncontrolled flexion Posterolateral bundle injured with uncontrolled extension

What are the 3 main special tests to help diagnosis a meniscus tear?

Apley's Compression McMurry's Thessaly's

When does the inferior aspect of the patella come in contact with the femur?

At 20 degrees knee flexion, medial and lateral facet are in contact with femur

Would you avoid an open chain knee extension between 0-45 or a closed chain knee extension between 0-45 after an ACL repair?

Avoid open kinetic chain between 0-45 degrees

How do we incorporate proprioceptive training following a ACL surgery repair?

Basic exercises such as joint repositioning and WB weight shifting in medial/lateral and diaganol patterns

When is there an applied load on the odd and lateral facets of the patella?

Beyond 90 degrees of knee flexion

The majority of individuals who sustain an ACL injury also sustain an injury to what osseous structures?

Bone bruise to lateral femoral condyle and lateral tibial plateau

Describe the impairment cycle of OA

Cartilage breakdown --> muscle weakness --> mobility impairments --> cartilage breakdown

Softening of the cartilage causes anterior knee pain and may be misdiagnosed as PFPS. What is this called?

Chondromalacia

What are some common interventions uses to treat a plica?

Conservative therapy addressing extensor mechanism Transverse friction massage Swelling management Redirection of compression of anterior knee during function Address muscle imbalances Arthroscopic excision if interventions fail

Why is full OKC knee extension a bad idea, when initially starting knee exercises on the patellofemoral joint?

Contact area decreases which puts a large load on a focal area. Also you have an increased load by way of quadriceps pull

What hold the meniscus firmly in place to the tibia?

Coronary ligaments

The knee joint capsule has a posterior invagination, where what structures are location?

Cruciate ligaments

Describe the main interventions of ITB friction syndrome

Decrease lateral stresses on knee with massage, bracing or taping Soft tissue manipulations of muscles attaching to ITB Stretching of associated muscle impairments Strengthening for closed chain activities Address associated dysfunctions in hip/ankle

Diagnosis the following patient: 65 year old pt. Complains of Lateral knee pain. Also describe a feeling of increased pressure in knee. You notice a swelling end-feel during A/P and P/A PROM accessory of knee. His has a prior history of knee injuries, and is currently retired and inactive. You notice locking of the knee during gait.

Degenerative meniscus tear

Describe the demographics, MOI and symptoms of a degenerative meniscus tear

Demographics: Older individuals, may or may not be inactive MOI: prior history of knee injury, may be part of normal aging process Symptoms: Pain, pressure secondary to effusion, may have clicking/catching/locking

Describe the demographics, moi and symptoms of an acute meniscus tear

Demographics: Younger, active individuals MOI: weight bearing with rotation injury secondary to improper movement Symptoms: Pain, clicking, catching, locking

At what degrees of knee ROM should you perform strengthening in the presence of a patellofemoral pathology?

Depends on patients clinical compliants. See if they have more pain with CKC or OKC knee exercises: OKC: 45-90 degrees of knee flexion CKC: 0-45 degrees of knee extension

What is a dashboard injury and what ligament is usually damaged?

Direct contact of tibia into dashboard which can injury PCL

What are some things that can lead to direct impairment of the common peroneal nerve?

Direct trauma to area Pressure from cast or brace Lateral ankle sprain leading to tensioning the nerve

What are the 6 componenet motions/joint plays at the tibiofemoral joint can improve knee extension?

Distraction Anterior glide Posterior glide lateral condyle anterior glide medial condyle Medial tilt Lateral tilt

Where are the component motions and joint plays at the knee to improve tibiofemoral internal rotation?

Distraction Anterior glide lateral condyle Posterior glide medial condyle Medial tilt Lateral tilt

What are the 7 component motions/joint plays at the tibiofmeoral joint to increase knee flexion?

Distraction Posterior glide Anterior glide lateral condyle Posterior glide medial condyle Anterior tilt Medial tilt Lateral tilt

Where are the component motions and joint plays at the knee to improve tibiofemoral external rotation?

Distraction Posterior glide lateral condyle Anterior glide medial condyle Medial tilt Lateral tilt

The MCL acts as a primary restraint to what motion?

ER of tibia

In order to train muscles while empahisizing a flexed knee for females in ACL rehabilitation, we use what kind of exercise?

Eccentrically train these muscle groups to help control excessive adduciton and IR of femur during WB

What interventions help facilitate the active contraction of the quadriceps because of joint effusion?

Electrical stimulation and biofeedback

Why do we recommend a drop-lock knee brace during ambulation?

Empathize full knee extension to assist the patient during the gait cycle while the quadriceps are inhibited

What causes Quad inhibition? and what classical motion is limited with quad inhibition or weak quads?

Excessive effusion Lacks knee extension

What causes decreased patellar mobility following an ACL surgery repair?

Excessive scar tissue adhesions from fat pad restrictions and harvesting the patellar tendon for ACL graft

Describe a plica of the knee

Excessive synovial fold that is not reabsorbed with development growth

Plyometric jumping drills have been used for what purpose post-op ACL surgery repair?

Facilitate dynamic stabilization and nueromuscular control. 22% decrease in peak ground reaction force 50% decrease in abd/add movements at the knee Increase in isometric hamstring strength

Who is at a greater risk for an ACL injury, males or females?

Females

Weak hip abductors and external rotators have been shown to be a major contributor to what part of the knee?

Increase genu valgum at knee leading to increased knee pain

Why is weight bearing important to begin immediately after post-op ACL surgery?

Increase proprioception of muscles

When will a patient most likely have symptoms of ITB friction syndrome?

Increased during activity

What unique characteristics increase a females chance of an ACL injury?

Increased genu valgum Poor hamsting-quad ratio Running and landing on more extended knee Hip/core weakness

What are the disadvantages of using a hamstring autograft or patellar tendon allograft?

Increased graft laxity or graft failure to do inappropriate healing

Genu valgum, a small lateral femoral condyle and patella alta will also lead to what problem?

Increased lateral hypermobility of patella causing PFPS and anterior knee pain

What are the special considerations for an ACL injury combined with an MCL injury?

Increased pain and Excessive scar tissue should lead to more accelerated progression for full ROM, with emphasis on achieving full passive knee extension

When is the contraction of the quadriceps and the load it applies on the patella into the femur the greatest during closed kinetic chain activities?

Increases as knee goes into greater degrees of knee flexion

The meniscus functions to increase joint surface contact area. How does this help with load transmission?

Increasing the joint surface area increases the opportunity for load trasnmission

What are the 5 component motions/joint plays at the patella femoral joint to increase knee flexion?

Inferior glide Medial glide Lateral glide Transverse axis rock (med/lat tilt) Longitudinal axis rock (sup/inf tilt)

A patella tendinopathy would lead to PFT pain at what area?

Inferior pole of patella, at the tendon itself or tibial tuberosity

The loss of patellar mobility is referred to as what syndrome?

Infrapatella contracture syndrome

What portion of the saphenous nerve gives sensory innervation to the medial side of the knee joint capsule?

Infrapatellar branch

Joint effusion/distention or meniscus tear can lead to compression of what nerve, leading to a change in sensation in the medial knee?

Infrapatellar branch of saphenous nerve

An onset of 50-60 mL of knee effusion will lead to what?

Inhibition of entire quadriceps

An onset of 20-30 mL of knee effusion will lead to what?

Inhibition of the vastus medialis

What are the 5 most common clinical signs and symptoms of Iliotibial band friction syndrome?

Involves localize lateral knee pain. (2 cm over condyle with knee flexed to 30) Pain radiates down proximal tibia Pain increases with continued activity Tenderness over lateral epicondyle, gerdy's tubercle or lateral retinaculum Positive Noble's compression test

What causes Iliotibial band syndrome?

Irritation to distal portion of ITBand as it compresses and rubs against lateral femoral epicondyle

Is the common peroneal nerve sensory or motor?

It is both sensory and motor

What are the risk factors of a meniscus tear?

It unknown but there are links to previous ACL injury

Where is the most aggressive range of motion on the ACL during a open kinetic chain exercise?

Knee extension between 45-0 degrees

Full passive knee extension is recommended right after post-op ACL surgery, while gradually restoring what knee motion?

Knee flexion

Plica can be a significant source of knee pain, especially with what motion?

Knee flexion

Explain the ottawa knee rules

Knee x-ray required if: Patient reports pain in location of knee and 1 of the following: Patient is older than 55 Tendernees at the head of fibula Inability to flex to 90 Isolated tenderness of the patella Inability to weight-bear after MOI or in ER

Iliotibial band friction occurs with repetitive flexion and extension of the knee. Irritation may also occur secondary to what?

Lack of flexibility and/or strength of quadriceps/hamstrings

What is the benefit of a large surface area contact during patellofemoral knee joint motions?

Large distribution of forces across the area contacting

The vastus medialis muscle makes up what boarder of the adductor canal?

Lateral aspect of canal

What tissue plays the primary role of resisting a varus force to the knee?

Lateral collateral ligament

Tenderness over the lateral knee is a common sign of ITB friction syndrome. Where are the specific landmarks to palpate?

Lateral epicondyle Gerdy's tubercle Lateral retinaculum

The common peroneal nerve can be tensioned during what injury at the ankle?

Lateral inversion ankle sprain

Which meniscus moves the greatest in an anterior to posterior direction on top of the tibial plateau?

Lateral meniscus moves about twice as much

While the coronary ligaments hold the menisci in place to the tibia, they do have some movement on top of the tibial plateau. Does the medial or lateral meniscus move more?

Lateral moves more (Lateral 11 mm; medial 5 mm)

What are the signs and symptoms of a 3rd degree MCL sprain?

Ligament rupture and pain is initially excruciating Significant laxity, but no increase in pain Joint is unstable and activity must be haltered Hemoarthrosis and increase in fluid in the joint

Studies have shown that quadriceps-tohamstring muscle strength imbalances lead to increased risk of what?

Ligamentous injury

What is the role of the quadriceps on the patellofemoral joint?

Load patellofemoral joint and stabilize it

What are the 7 main functions of the meniscus?

Load transmission Increasing joint surface contact area Assist with joint gliding Limit hyper extension Joint nutrition Shock absorption Chock-Block effect

What extrinsic factor can help a patient with a post-op ACL, improve proprioception and functional outcome scores?

Locked knee brace during ambulation and sleeping, 2 weeks after surgery

What are some special tests used to identify an ACL tear?

Lockman's test Anterior drawer test Pivot shift test

The presence of knee joint effusion leads to a loss in what?

Loss of muscular activation

What are the 3 main examination steps for diagnosis of a tendinopathy?

MSTT MLT PFT

The following is a MOI for what injury: Foot or lower leg is held in fixed position, while upper leg and body moves or twists in relation to lower leg

Medial collateral ligament injury

Which meniscus is more often injured?

Medial meniscus

Why is the medial meniscus, thoretically, more prone to injure than the lateral meniscus?

Medial meniscus moves less and is unable to "move away" from injury

Which meniscus is more frequently torn?

Medial meniscus, since it can't move out of the way of the rolling femoral condyle

Where is the most common place for a plica?

Medial patellar plica

What structure in the knee is usually injured during weight bearing with rotation injuries secondary to improper movement?

Meniscus

What is the most common complication and cause of poorer outcomes following ACL reconstruction?

Motion loss Loss of full knee extension

How can the meniscus help contribute to proprioception?

Movement of meniscus can help promote proprioception and therefore a meniscus problem can lead to decreased proprioception

What are the 6 main causes of anterior knee pain?

Muscle weakness, muscle tightness, edema/effusion, tendonitis, hypermobility and hypomobility

What would a demonstration of a proper SLR flexion, be a good indicator of to take of a locked knee brace, for a post-op ACL patient?

Neuromusclular contribution is appropriate and quad function is at a high enough level

What is proven to be more efficient than exercise alone to improve quad strength?

Neuromuscular electrical stimulation combined with exercise

What special test did you learn in Ortho that is useful for confirming an ITBand friction syndrome?

Noble's compression test

Plicae occur secondary to injury or overuse. Describe what happens what a plica becomes inflammed

Normal plica may hypertrophy and become fibrotic, becoming a pathological structure. Leads to anterior knee pain

Is patellofemoral syndrome a TSI?

Obviously NO several different impairments and tissues can lead to PFS

Beyond 90 degrees of knee flexion, the patella shifts from the superior 1/3 of patella to inferior and lateral aspects of patella. This applies a load on what structures?

Odd and lateral facets

When can a patient officially return to sport after an ACL injury?

Once patient demonstrates at least 85% of contralateral strength in the quadriceps and hamstrings

Is the saphenous nerve sensory/ motor or both?

Only sensory

Symptoms of PFPS have been identified as not being ___________ or ___________ in nature

Osseous or Cartilagninous

What is the screeing tool for fractures around the knee?

Ottawa knee rules

What are some common causes of iliotibial band friction syndrome?

Overuse of flexion and extension of knee causes ITB moving against lateral femoral epicondyle History of trochanteric bursitis Leg length discrepancy Adhesion of ITB Tightness of TFL or glut max Genu varum Excissive hindfoot pronation Inappropriate shoe wear Hip musculature imbalance

Falling on a flexed knee or a dashboard injury are common MOI for what ligament?

PCL

What ligament has the primary role to prevent posterior tibial translation?

PCL

What immediately follows post-op ACL reconstruction surgery

PROM WB activities

Post-OP rehabilitation of an ACL begins with what 2 interventions?

PROM and weight-bearing

What are some specific exercises to assist in getting full passive knee extension?

PROM exercises via rehab specialists Supine hamstrings stretches with wedge under the heel and gastrocenmius stretches

What are the signs and symptoms of a 1st degree MCL sprain?

Pain at site of damage with touch Stressing ligament with valgus force is painful

Why is there no "typical" treatment intervention for patellofemoral joint line pain?

Pain can be from biomechanical deficit at places other than the knee that are more proximal or distal portions of the kinetic chain

Describe a 2nd degree LCL sprain

Pain is moderate to severe with palpation Laxity and pain noted with varus stress,

What are the signs and symptoms of a 2st degree MCL sprain?

Pain is severe when touched with laxity present Usual swelling after 24 hours

Describe a 1st degree LCL sprain

Pain with palpation Stressing varus force will be painful without laxity

What does the term Patellofemoral pain syndrome imply?

Pain within anterior aspect of knee

In what motion would a patella tendinopathy lead to a positive MSTT finding?

Painful and strong with knee extension

What biomechanical function happens at 20 degrees of knee flexion?

Patella contacts the femur

What is the most commonly used graft for ACL reconstruction?

Patellar bone-tendon-bone

According to the Pittsburgh Yinzer knee rules, which of the following patients would need a knee x-ray: (All of the following answered "yes" when asked if they had blunt force or trauma to the knee) Patient A: 13 year old male, who can only walk 3 steps at a time Patient B: 11 year old female who can run a mile Patient C: 55 year old male with arthritis Patient D: 12 year old can only walk 5 steps in office Patient E: 49 year old male with history of knee fractures. Can only walk 4 steps in clinic Patient F: 51 year old female who can run a mile

Patient A, B, C and F Age younger than 12 Age greater than 50 Inability to walk 4 steps at time of injury or in your office)

When is a locked knee brace to be discontinued when working with a post-op ACL patient?

Patient can show proper performance of SLR flex?

According to the ottawa knee rules, a patient knee x-ray is required if a patient reports pain in the location in the knee AND one of what 5 things?

Patient is older than 55 Tenderness at head of fibula Isolated tenderness of patella Inability to flex to 90 Inability to weight bear following MOI

According to young... how did local anesthesia change outcomes after a medial meniscectomy?

Patients in control group had significant post-op pain and quad inhibition. Patients with local anesthesia reported minimal pain and only mild quadriceps inhibition

Chmielwki evaluated several WB activities in individuals with ACL-deficient and ACL reconstructed knees to show a strong correlation between functional outcome scores and the ability to do what?

Perform the fornt step-down exercise

The common peroneal nerve will divide into the superficial and deep peroneal nerve. What does the superficial peroneal nerve innervate?

Peroneus longus and brevis

Any type of dysfunction with what muscle can compress the common peroneal nerve

Peroneus longus muscle

The ottawa ankle rules are a good screening tool to rule out a fracture. What is another good screening tool?

Pittsburgh knee rules (damn yinzers)

What is characterized as a, "synovial fold that is not reabsorbed with development growth"

Plica

What special test identifies a plica problem? Is this a good test or bad?

Plica stutter test Bad test since many things causes a stutter in the knee

In our ACL article, Hewett reported a significant decrease in amount of knee injuries in female athletes due to what program?

Plyometric program

PFPS is attributed to the surround soft tissue around the knee. The pain is secondary to what?

Poor tracking of patella Poor muscular balances Poor muscular activation Poor kinetic chain positioning and funcitoning

Describe the biomechanics of knee flexion, and what happens when the knee gets closer to 100-120 degrees of knee flexion

Posterior glide of tibia on femur At 100 degrees, posterior glide ceases and tilting of tibia occurs

Even though the MCL is considered a primary restraint to knee valgus, what are the other tissues that resist a valgus load to 0 and 30 degrees of knee flexion?

Posterior oblique ligament Posterior medial joint capsule ACL PCL Medial quadriceps expansion Semimembranosus

The adductor magnus muscle makes up what boarder of the adductor canal?

Posterior/medial aspect of canal

What are the 4 component motions/joint plays at the tibia fibular joint that can improve knee extension and knee flexion? (all are joint plays)

Posterior/medial glide Anterior/lateral glide Inferior glide Superior glide

During extension, what band of the ACL becomes taut?

Posterolateral band is taut

What 5 factors are important to limit immediately after an ACL injury?

Prevent muscle atrophy Maintain ROM Reduce Swelling and Inflammation Normalize Gait Restore and Control homeostasis

Why are proprioceptive and nueromuscular control important to work on at the end of treatment?

Proprioception decreases toward end of work-out , so we recommend drill at end to challenge neuromuscular control of knee joint when dynamic stabilizers are fatigued

What technique do we utilize to maintain and improve knee extension and prevent a flexion contracture following ACL recontrustion surgery?

Pt. in supine while low-load, long duration stretch is applied

Following ACL surgery repair we immediately use E-stim following surgery while performing isometric and isotonic exercise to strengthen what muscle?

Quadriceps Use quad sets, SLR hip adduction and abduction and knee extension from 90-40

Describe how knee joint distension and effusion can limit muscles in the leg.

Quadriceps activation decrease with joint effusion Inhibition of vastus medialis at 20-30 mL Inhibition of rect fem and vastus lateralis at 50-60 mL

At 10% of distention is when the amount of effusion is first visible to the naked eye, but at 5% of distention quadriceps inhibition can be seen. What is the clinical significance of this information?

Quadriceps inhibition may be occurring prior to out ability to see or measure effusion

Infrapatella contracture syndrome leads to what problems in the knee?

ROM complications and difficulty moving quadriceps

Why is full motion restored before surgery?

Reduce risk of postoperative arthrofibrosis

What are the 10 key principles of PFPS rehabilitation?

Reduce swelling Reduce pain Restore volitional muscle control Emphasize quad strength Control knee through hip and ankle/foot Enhance soft tissue flexibility Improve soft tissue mobility Enhance proprioception and neuromuscular control Normalize gait Gradually progress back to activities

What functioning in early rehab do the authors of the article feel is imperative to a successful outcome and an asymptomatic knee after an ACL surgery?

Restoring hypertension of knee

The ottawa knee rules have a sensitivity of 98% and a specificity of 48%. What are these rules useful for?

Ruling out a fracture around the knee

Why would a small surface area lead to increased loading on the patellofemoral joint?

Same amount of force is being distributed through a smaller area of contact

What nerve is the longest sensory branch that comes off the femoral nerve at the location of the femoral triangle?

Saphenous nerve

What nerve provides sensory innervation to the anteriomedial aspect of knee and lower leg. Also contributes to the knee joint

Saphenous nerve

A patient may have medial knee pain, due to pathology with what nerve?

Saphenous nerve may be entrapped in adductor canal

What makes up the boarders of the adductor canal (hunter's canal)?

Sartorius Adductor magnus Vastus medialis

What 3 muscles can become tight leading to a saphenous nerve entrapement?

Sartorius Vastus medialis Adductor magnus

What are the 5 criteria for return to play according to the ACL article?

Satisfactory clinical examination Symmetrical range of motion with pain Isokinetic test parameters KT 2000 test within 2/5 mm of contralateral leg Functional hop test

The ottawa knee rules have a sensitivity of 98%. Does this make the rules a better diagnostic test or screening test?

Screening tool

According to our ACL article, Performing a leg press with 40% body weight resistance, climbing stairs and lunging forward all produced less ACL strain than performing what?

Seated knee extension with no external resistance

What is the primary MOI of a PCL injury?

Secondary to outside force by way of direct contact to tibia forcing it posteriorly

Describe the Pittsburgh knee rules

Series of questions to decide necessity of a radiograph: Any blunt force or trauma to knee? If no: no radiograph needed If yes: identify if one of things are present Age younger than 12 Age greater than 50 Inability to walk 4 steps at time of injury If yes to any, then radiograph is needed

Shock absorption is 1 of the 7 main functions of the meniscus. Why is this one of the weakest functions, and what could this eventually lead to?

Shock absorption may lead to degeneration of the knee, therefore it only plays a small role in shock absorption to avoid wear and tear over time

What is the normal MOI for a LCL injury?

Someone applies a force to inside aspect of leg just below knee, typically when foot is planted

What is the most common MOI for an ACL injury?

Sports related activities that place stress on knee joint during cutting or jumping activities

What are the MOI for an ACL?

Stress on knee joint during cutting or jumping activities Non-contact twisting injury with uncontrolled flexion or extension with valgus or varus stress Direct blow to knee with the foot planted on ground NON-CONTACT Inability to control knee during acceleration or deceleration

Are the tendon grafts usually stronger or weaker than the native ACL?

Stronger than native ACL Quad is the strongest

Where is the primary area of contact of the patella on the femur as knee flexion progresses to 90 degrees?

Superior 1/3 of patella

What is the major patellar mobilization intervention following an ACL reconstruction surgery?

Superior direction to restore patell's ability to tilt

What 5 component motions/joint plays at the patella femoral joint would help improve knee extension?

Superior glide Medial glide Lateral glide Transverse axis rock (med/lat tilt) Longitudinal axis rock (sup/inf tilt)

How can the dysfunction of excessive hindfoot supination cause ITB friction syndrome?

Supination will cause tibial ER and alter position of distal attachment of ITB and place abnormal stress on it

Pain associated with PFPS is attributed to what causes?

Surrounding soft tissues of knee

The onset of what sign is unpredictable with a meniscus tear?

Swelling or effusion

What are the main cluster of findings to help generate a hypothesis of a meniscus tear?

Symptoms of clicking/locking within knee Joint line tenderness with palpation Pain with knee flexion Pain with knee hyperextension Positive McMurray's or Thessaly's special test

When is the loading of the quadriceps the greatest during open kinetic chain exercises?

Terminal knee extension (0 degrees)

Why should we care about the amount of surface area contacting the patella?

The greater the surface area of contact, the better the load distribution will be across the surface area. Why you should choose certain exercises

The meniscus assists with joint gliding. Describe the functions of the medial and lateral menisucs, that help with the pivoting or screw home mechanisms in the knee.

The greatest amount of rotation occurs when the lateral mensicus moves and allows joint to rotate The true pivoting occurs over the medial meniscus, which leads to the most common cause of MOI

The Thessaly's test, has the best specificity and sensitivity to rule in and rule out a meniscus pathology. Why wouldn't we just use this test all the time? Why even conduct the Apley's or McMurray's test?

The thessaly's test requires the patient to be weight bearing. If your patient is preventing weight bearing through the knee, then it may not be a safe test for the patient. It may provoke further harm to the meniscus Therefore if patient is unwilling to weight-bear than you should try and use the Apley's or McMurray's test

Why is a locked knee brace not always given?

They are expensive and long term studies show that a locked knee brace doesn't change functional outcomes in the long run

Why would a tight lateral retinaculum, tight ITB or tight quadriceps lead to anterior knee pain?

They cause a hypomobility on the patellofemoral joint and increase compression on the lateral aspect of patellofemoral joint

How can you confirm a diagnosis of chondromalacia?

Through radiograph or arthroscope

At what range of motion does the meniscus contact the femoral condyles?

Throughout the full range of motion

The common peroneal nerve will divide into the superficial and deep peroneal nerve. What does the deep peroneal nerve innervate?

Tibialis anterior EDL EHL Peroneus tertius EDB

The joint capsule of the knee primarily encompasses which joints of the knee?

Tibio-femoral joint Patella-femoral joint

What 3 joints make up the knee complex?

Tibiofemoral joint Patellofemoral joint Proximal tibiofibular joint

What are some potential sources that can lead to a hypomobility and lead to PFPS?

Tight lateral retinaculum Tight ITband Tight quadriceps

Describe the common MOI for an acute meniscus tear

Uncontrollable loss of extension or flexion with weight bearing rotation

A lateral ankle sprain may cause a tension on the common peroneal nerve. What intervention would you use to combat the tension force on the nerve.

Use bracing or taping to promote more ankle eversion to take tension off nerve

The following lists the special tests used for meniscus tears. which one would you rely on to rule in a meniscus tear? Which one would you rely on to rule out a meniscus tear? Apley's Compression - poor Sensitivity, ~80-90% Specificity McMurray's - ~48-65% Sensitivity, ~86-94% Specificity Thessaly's - ~66-81% Sensitivity, ~ 91-96% Specificity

Use thessaly's to both rule in and rule out a meniscus tear

The superficial aspect of the MCL has demonstrated a role in restraining what kinds of loads?

Valgus loads at all degrees of knee flexion and primary restraint to ER of tibia

What is the most common MCL MOI?

Valgus stress with/without combined rotaitonal stress to knee

What are the 3 different types of MOI for an MCL injury?

Valgus stress with/without combined rotational stress to the knee most commonly causes injury. May be with/without contact. The foot or lower leg held in a fixed position, and upper leg and body moves or twists in relation to the lower leg. In conjunction with tears of the ACL, PCL, and/or medial joint knee complex

What 3 things can affect ACL loading?

Variations in squatting and lunging Knee flexion angles Anterior knee translation beyond the toes

Why should impact loading be delayed in patients with an ACL/LCL injury?

Varus and valgus stress with lead to increased bone bruises so this should be avoided to allow bone healing

Speed of progression of WB status and ROM may affect pain and swelling in the knee. What are the patient WB restrictions following surgery?

Weight bear as tolerated with 2 crutches and a brace locked into extension following surgery.

WBE and Non-Weight BE have been show to be effective for post ACL surgery repair rehab. Which one tends to lead to less knee pain, more stable knees, generally more satisfaction with the end result and a quicker return to sport?

Weight bearing exercise helps more

Since the screw home mechanism relates to a rotation over the medial meniscus, what is the most common MOI for a meniscus pathology?

Weight bearing with rotation

During OKC, when does the load of the quadriceps pull increase the most?

With greater knee extension (contact area decreases)

During CKC, when does the load of the quadriceps pull increase the most?

With greater knee flexion (contact area increases)

The meniscus functions to limit hyperextension. How does the meniscus limit hyperextension?

Works in conjunction with chock-block effect to wedge and limit further extension

What is the difference between the Pittsburgh "yinzer" knee rules and and Ottawa knee rules?

Yinzer knee rules have not been validated, like most things in the run-down city

Why is full CKC knee flexion a bad idea, when initially starting knee exercises on the patellofemoral joint?

You have an incrased load on the patellofemoral joint, due to pull of the quadriceps

Describe what you would do if you got a negative test after doing to the McMurray test or Apley's test for a meniscus tear

You may still consider a meniscus tear, due to the low sensitivity of these tests