Knee

incidence of ACL injuries

• 150,000 ACL injuries per yea in the U.S. • female athletes are more susceptible • soccer and basketball tend to be the leading sports that result in ACL tears in females • females are 2-8x more likely to sustain an ACL tear than males

diagnosis of patellar dislocation

skyline view (from superior to inferior) x-ray shows alignment of patella and femoral groove - allows physican to decide if patella is seated where it should be

clinical picture: articular cartilage injury

- varying degrees of effusion - vague knee pain - activity may be difficult or impossible - stiffness of the joint sets in - over time, ROM deficits

Apley's compression test

- assesses the integrity of the menisci - axially loading the tibia against femur and rotating it - inducing compression and shear at the knee, causing menisci to deform - positive = painful or clicking

Apley's distraction test

- assessing MCL and LCL - hold the femur down and lift up the tibia, rotate the tibia - external rotation stresses the medial meniscus, internal rotation stresses the lateral meniscus

rehab considerations for hamstring tendon autograft

- avoid active contraction of the hamstrings - be careful with knee extension

rehab considerations for patellar tendon autograft

- avoid active extension (contraction of quad puts stretch on graft) - passively, extension ROM is our priority, but we can't do it actively - extension should be full 1-2 weeks post-op, due to concern for scar tissue forming in and around the notch, which would necessitate a second surgery

Elmslie-Trillat-Macquet

- elevating tibial tubercle with intention to change the stress and compressive forces on the patellofemoral joint - Lateral release, medial capsular reefing, medialization and elevation of tibial tubercle with bone graft

etiology of MCL tear

- external rotation and/or an abduction force applied to the flexed weight bearing limb

lateral collateral ligament (LCL)

- lies under the tendon of the biceps - it is taut throughout the full ROM, but especially so at full extension - LCL is taut with tibial IR and lax with tibial ER

patella baja

- low riding patella - sits inferiorly relative to where it is normally supposed to be

diagnosis of articular cartilage injury

- made by MRI - x-rays do not help to define and identify articular cartilage defects, but may be able to pick up other degenerative changes like spurring

infrapatellar bursitis

- this bursa lies between the patellar tendon and the anterior surface of the tibia

etiology of articular cartilage injury

- traumatic - wear and tear - activity level - the more pounding your joint takes, the more you may potentially have this occur

meniscal anatomy

- two menisci - medial meniscus is more firmly attached than the other

history taking for internal derangement

- what was the position of the knee when they were hit? - was it a mechanism of indirect/direct? - were they able to continue to play? - did they demonstrate immediate swelling in the joint (tend to see with hemarthrosis- blood causing swelling from trauma)? - did the swelling occur at some time after the injury (tends to reflect synovial type of fluid in joint)?

total meniscectomy

- you are left with bone on bone - pt will become symptomatic with arthritic changes in a short time, will require arthroplasty

etiology of internal derangement

2 types of etiologies • direct/contact - limb is CKC and weight bearing, there is some direct contact with fixed limb - direct anterior/ lateral/ medial/ posterior/ rotary forces contacting weight bearing limb • indirect/non-contact - typically a cutting maneuver with a sudden change in direction and/or speed involving deceleration followed by torque generation and acceleration to the weight bearing area (running, stopping quickly, changing direction, and acceleration again on a weight bearing limb)

abrasion arthroplasty

go in and roughen area up with a drill to stimulate an inflammatory response from the subchondral bone to stimulate healing

patella alta

high riding patella

etiology of ACL injuries

in CKC: • External rotation, abduction, and straight anterior forces applied to tibia • IR of femur on tibia • Hyperextension of knee

Osgood Schlatter disease diagnosis

in x-ray or MRI, you can start to see tibial tubercle separating from the underlying bone

other structures injured with MCL injury

• ACL injured in approximately 20% of grade 1 injuries and as many as 78% of grade 3 injuries • The medial meniscus is injured 5-25% of the time - incidence increases with severity of the MCL injury • The extensor mechanism, including VMO and retinacular fibers, is also injured in 9-21% of the cases.

medial proximal procedures

• All attempt to recreate appropriate physiologic mechanism by improving integrity of structures that provide medially directed forces on the patella to oppose lateral directed forces • restore appropriate medial stability to PF joint and minimize potential for PF lateral displacement • Plication medial patellar retinaculum • Anatomic repair of medial PF ligament - medial PF ligament provides 2/3 of medial restraint force • Plasty surgery of VMO

patellar tendon autograft

• BPTB (bone-patellar tendon-bone graft) • take middle 1/3 of patellar tendon out, and that becomes the graft; they will also take a piece of bony plug on either end • they will create a tunnel where the old ACL was; put bone plugs of harvested patellar tendon into the tunnel; use interference screw to secure bony plugs to the rest of the bone - BPTB autografts with interference screw fixations are the most stable ACL graft • problem with patellar tendon autograft is that you have to violate the extensor mechanism of the knee - complication: develop PF issues - may fracture patella during surgery to harvest this graft

Unhappy triad of O'Donoghue

• CL • ACL • medial mensicus • more recently, they are seeing more lateral meniscal tears than medial as part of the triad

management of articular cartilage injuries

• Cartilage injuries that do not extend to bone usually will not heal on its own - may not be symptomatic at this point, but the tendency to progress to the subchondral bone is an issue • Injuries extending to bone may heal - Type of cartilage laid down is structurally unorganized and does not have strength to function as articular cartilage • Defects < 2 cm. have best prognosis & treatment options - smaller defects that are asymptomatic - no surgery, will wait and watch • Larger defects may require transplant of cartilage from other areas of knee

combined proximal procedures

• Combines medial reconstruction and lateral release - Medial Reefing with lateral release • medial reefing is another stabilizing technique - medial reefing is when they pull the patella toward the midline by tightening the medial retinaculum

etiology of chondromalacia patella (CP)

• Genu valgum - this posture increases valgus vector at the knee, making pt more prone to lateral instability • Femoral anteversion/internal femoral rotation • Lax med. capsular retinacular • Tight lat. retinaculum (classic etiology) • Foot pronation or external tibial torsion • Weakness VMO - only dynamic medial stabilize of the patella - insufficiency can cause excessive lateral patellar tracking • Acute/chronic subluxation

etiology of recurrent patellar subluxation/dislocation

• Genu valgum • Femoral anteversion/internal femoral rotation • Lax med. capsular retinacular • Tight lat. retinaculum • Foot pronation or external tibial torsion • Weakness VMO • Acute/chronic subluxation • Hypermobility of the patella • patella alta • more laterally inserted patellar tendon

articular cartilage response to injury

• Has no direct blood supply, innervation, or lymphatic drainage - this means it has a slow regeneration rate • Partial thickness cartilage injury - Repair process limited or non-existent - because of the lack of a vascular supply, there is no inflammatory response or cellular response that occurs - Defect is not repaired • Full thickness articular surface defect (to subchondral bone) - Symptomatic with pain, swelling & catching which tend to worsen with time

increased risk of ACL injury in female due to:

• Hormonal • Anatomic • Environmental Factors • Playing style • Gender

lateral proximal procedures

• Lateral release - very common procedure - essentially go in and divide the lateral retinaculum - lateral retinaculum has become tight, increasing tendency for lateral displacement - releasing that tissue will negate the pull from the retinaculum onto the patella

diagnosing meniscal tears

• MRI is probably diagnostic imaging of choice, along with clinical exam and x-ray to rule out associated fxs - menisci show up as black triangles on MRI; disruption appears as a gray line, indicative of mensical tear • clinical exam may often give a false positive or false negative - will probably elect to do a diagnostic arthroscopic procedure (they go in and they look and if they find something they'll deal with it when they get in there)

proximal procedures

• Medial procedures - not likely to see medial procedures very commonly • Lateral release - lateral release is very common • Combined proximal procedures - may see some combined procedures • many ways to promote normal tracking at PF joint and minimize tendency for lateral instability • for most PF procedures, return to activity in 4-6 months

etiology of lateral patellar instability

• More laterally inserted patellar tendon • Excessive internal tibial torsion • Femoral anteversion/Internal femoral rotation • Weak med. retinaculum • Weak VMO • Patella alta • Genu valgum • Hypermobile patella • Increase Q angle These also contribute to chondromalacia and patellar tracking problems

OA braces

• OA of the knee usually involves the medial compartment • medial compartment is usually the worst if both compartments are involved • these braces unload the medial compartment, very effective in alleviating pain from weight bearing forces to medial compartment • monarch - small bladder that comes with a pump, as you blow it up it creates a valgus stress that tends to unload the medial compartment • gill express - for sedentary, in home amb and short community amb

distal patellar procedures

• Tibial tubercle transfers • Osseus distal realignment procedures - Elmslie-Trillat: Lateral release, medial capsular reefing, medialization of tibial tubercle • Elmslie-Trillat-Macquet • Combined Procedures - Multiple variations of these procedures used combining: Distal medialization of tibial tubercle combined with proximal procedure, usually medial reconstruction and lateral release

tibial tubercle transfers

• Typically performed in conjunction with proximal procedures • purpose is to realign the patella so that it is going to remain more central and track in a more normal fashion • some of the procedures are used to improve the Q angle, make it more acute

primary mechanisms of injury in CKC at the knee

• Varus force will likely injure - LCL - Posterolatereal capsule - PCL • Valgus force (with or without rotation) will likely injure - MCL, Often accompanied by injury to posteromedial capsule - Medical meniscus - ACL • Flexion with posterior translation - PCL • Hyperextension - ACL, often with associated meniscal tears

pre-patellar bursitis

• also called nun's knee and housemaid's knee • bursa lies anterior to the lower 1/2 of the patella and the upper 1/2 of the patellar ligament • it is inflamed by trauma (fall directly on front of knee), prolonged kneeling

Helfet Test

• also called screw home test • indicated to assess patellar tracking and tibial rotation during open chain knee extension • pt is seated with 90 degrees hip flexion (may need towel roll under distal thigh to be sure it is at 90) • palpate medial and lateral patellar borders, find midpoint, use skin marker to put a dot at midpoint of patella • palpate tibial tuberosity, find the midpoint and mark with skin marker • the knee in 90 degrees of flexion, these two dots should line up directly one over the other - then ask pt to actively extend their knee through the range - at the end point of extension, palpate tibial tuberosity and mark the midpoint - at the end of extension, the midpoint of the tibial tuberosity should be lateral to the one you identified in 90 degrees of flexion (tibial ER during OKC); don't use same dot as a reference because bone will move under the skin • positive = if you don't see second tibial dot lying lateral to the first dot at the end of knee extension (something is not allowing that ER to occur normally: meniscal tear, cruciate injury)

patellar glide test

• also called the Sage sign • this test is designed to evaluate the integrity of the medial and lateral restraints • pt supine, 30 degrees of knee flexion (larger towel roll) • once pt is relaxed, passively displace patella through it's range medially. allow it to return to resting position, and then displace laterally • patella is divided into 4 sections; by feel, identify how many of these 1/4 sections did it displace • laterally, normal displacement is from 0-2.5 quadrants • if you have lateral displacement greater than 3 quadrants, it is an indication that you have incompetent medial restraints • after assessing lateral, let go and let patella reseat itself - then go from resting position and passively displace the patella medially • normal medial displacement of the patella is 1-2.5 quadrants • if the medial displacement is less than 1 quadrant, it is indicative of a tight lateral restraint • if the medial displacement exceeds 3 quadrants, that is considered to be hypermobility

Sag sign

• also called the drop back sign • check and balance test, so you don't test a false positive for ACL insufficiency if pt actually has PCL insufficiency • same position as anterior drawer • if insufficiency is significant enough, you can see that one tibia has sagged posteriorly relative to the other tibia - when they are in this position, if they have posterior instability of the knee, just by virtue of positioning and the weight of the leg, it will sag backwards because of the instability • when you grab a hold of it for anterior drawer, check joint space and make sure that they are lined up at the true neutral before assessing ACL • positive sag sign - tibia is posteriorly displaced relative to femoral condyles • also stresses arcuate popliteus complex, posterior oblique ligament, and ACL

patellar tendinitis

• also referred to as jumper's knee • etiology - excessive quadriceps contraction in a repetitive manner which leads to microruptures and local degeneration • clinical picture - localized discomfort over the proximal or distal patella at the attachments of the quadriceps or patellar tendon - if the irritation is at the attachment of the quadriceps tendon, it is technically and quadriceps tendinitis/tendinopathy - if the irritation is at the attachment of the patellar tendon, it is a patellar tendinopathy

Clarke's test

• also referred to as the patellofemoral grinding test • test is designed to assess the irritability of the posterior patella - specifically, we use this test to determine the presence of chondromalacia • pt is supine, towel roll under knee • examiner lays web space just proximal to the superior border of the patella - pt must stay relaxed - passively push that patella inferiorly (when extended, patella is most superior, so you will have a large amount of inferior displacement) - ask pt to slowly do a quad set - examiner will resist the superior movement of the patella, but do not impede or block the movement of the patella • is best to keep your forearm on their anterior thigh, that allows examiner to control the direction of the forces, we don't want to push posteriorly and push patella into trochlear groove - if they are already irritable on the underside of the patella and you push posteriorly, you are going to hurt them and you are not going to accomplish anything • positive = pain, with or without crepitus • positive test indicates chondromalacia • a lot of times, when the pt feels the pain or crepitus, they will stop and not even complete the test

anterior cruciate ligament (ACL)

• anteromedial bundle is taut in both flexion and extension of the knee • posterolateral bundle is taut in extension • least amount of stress on the ligament as a whole is between 30-60 degrees of knee ROM • ACL will become lax with tibial ER and taut with tibial IR

management of pre-patellar bursitis

• anti-inflammatories • aspirate the bursa • ice • if it feels good to wear a compression sleeve, let them wear a compression sleeve • if we treat them, it will be short term to restore motion and get them moving again

articular cartilage injury

• articular cartilage injuries in the hip and knee • articular cartilage has no direct blood supply, no innervation, and no lymphatic drainage capacity • defect within the articular cartilage may be partial thickness relative to the depth of the articular cartilage • full thickness articular cartilage defect - defect has gone completely through the articular cartilage and is at the subchondral bone

articular cartilage

• articular cartilage is hyaline cartilage • characteristically, it tends to be only a few mm thick • in the knee, it has a function of distributing the load between the femur and the tibia • we also expect it to function and decrease or avoid high stresses to smaller areas of weight bearing • coefficient of friction in articular cartilage has been found to be less than that of gliding along ice

fluctuation test

• assesses for the presence of a minor effusion • pt is supine, quads relaxed, knee extended • examiner puts their web space along the suprapatellar pouch • push down and inferior at the same time, essentially milking the fluid from this area by compressing it and pushing it inferiorly, keep this pressure • take index finger, which is on medial side of the joint and compress and move in to the medial patellar border, pushing fluid away from medial side • fluid is all now on lateral side, so while you are holding these positions, push with thumbs on lateral side, feels like you are pushing into a water balloon • you will feel fluid come back against your fingers on the medial side • positive = if when you pushed on lateral side, it traversed back over the joint and you could feel it displace against the fingers on the medial side

valgus stress test

• assesses integrity of MCL • pt is supine, start by doing test with knee positioned in 30 degrees of flexion • examiner places one hand (pivot) on lateral aspect of the joint, other hand (creating valgus stress) on distal aspect of medial leg • positive result - pain and/or gapping (1st - 3rd degree ligamentous sprain) • valgus tress at 30 degrees flexion specifically assesses MCL and posterior oblique ligament, PCL, and the posteromedial capsule • repeat test with knee in fully extended position • tibiofemoral joint at full extension is in a closed pack position, very stable • if test is positive (pain and/or gapping), pt has more trouble because other structures are now involved in contributing to that stability: in addition or previous structures, ACL, semimembranosus m., and medial quadricep expansion • if valgus stress is negative at 30 degrees, there is no need to repeat the test at 0 degrees

varus stress test

• assesses integrity of the LCL • assess at both 30 degrees knee flexion and at full extension • pt is supine on table • pivot hand on medial aspect of knee, hand delivering stress is distal on lateral leg • if the varus stress if positive at 30 degrees, structures implicated: LCL, ITB, posterolateral capsule, biceps femoris and the arcuate popliteus complex • in full extension, these same structures as above are assessed plus: PCL, ACL, and lateral gastroc • more play with valgus stress than varus stress

McMurray's Test

• assesses symptomatic tears of the menisci • there are a number of variations on this • pt is supine, test limb is flexed comfortably to end range • put fingers over the top of the tibiofemoral joint, with thumb dropping on medial-lateral joint line and fingers on the other side • IR and ER tibia passively, feel for a click, ask about pain • positive = pain and or clicking (lateral sxs = lateral meniscus, medial sxs = medial meniscus) • rationale for movement into flexion and extension - as you move the joint, different parts of the menisci will be stressed

genu varum

• bow-legged appearance • tibia is deviating toward the midline relative to the femur • observe from front or back • observed in? natural stance with symmetrical weight bearing • seen very commonly with babies when they start to walk, eventually they will grow out of that

other braces

• breg PTO (patellar tendon orthosis) - horseshoe • hinge brace - early stage arthritics as they are becoming symptomatic, provides some medial-lateral stability or a compression sleeve

hamstring autograft

• can also use a hamstring graft - semitendinosus tendon - or the semitendinosus with the gracilis • double bundle - fold tendon over itself

patellar reflex (L4)

• can do it seated with knee hanging over edge of table - nice to have a towel roll under distal thigh for 90 degree angle • can also do this in supine as well

loose bodies

• can occur anywhere in the body, they are pretty common in the knee - also referred to as "joint mice" • can be caused by disease or trauma • little flecks of bone or cartilage floating around within the capsule; when they start to come between articular surfaces that is painful and could cause the joint to lock

autograft vs allograft for ACL reconstruction

• can take autograft or allograft • autografts are typically the most common grafts that are selected by the surgeon and pt - different tissues that can be harvested from the pt's own body and be used for implantation as the pts ACL • allografts - they don't use your tissue, use tissue form cadaver bank - less invasive (not harvesting from your own body), quicker recovery times overall • can use Achilles tendons, tib anterior tendon form cadavers - may decide to irradiate the graft to get viruses and bacteria out of structures, but it weakens the graft somewhat

Godfrey test

• check and balance test, so you don't test a false positive for ACL insufficiency if pt actually has PCL insufficiency • pt is supine, hips flexed 90 degrees, knee flexed 90 degrees • grab leg at level of ankle, let pt hang there in 90-90 • weight of limb/gravity • look from side to see if tibia has dropped • do both legs at the same time to compare • positive = tibia has dropped posteriorly • also stresses arcuate popliteus complex, posterior oblique ligament, and ACL

clinical picture: osteochondritis dissecans

• children and adolescents are the most affected • average age of involvement is between 10-20 yo • in 30-40% of cases, it is bilateral vmales are more affected than females (2-3 males per 1 female) • usually no associated trauma • pain • inflammation • feeling of weakness • locking • discomfort and pain associated with this is vague and poorly localized

Osgood Schlatter disease

• chronic apophysitis of the tibial tubercle due to recurrent traction forces • pathology is a partial separation or osteochondritis of the tibial tuberosity • this is a growth related disorder - we tend to see it during periods of rapid growth in folks doing sports related activities • we tend to see this more often in boys than in girls - between ages of 10-16

unicompartmental arthroplasty

• common procedure • often done for medial compartment which tends to have the most involvement • this may be sufficient in a good number of people that have medial compartment disease

functional knee braces

• consider these toward the end of rehab as you are starting to move into functional drills • you never order a functional brace early in the rehab process - quad atrophy after surgery, so measurements you take for custom brace early in rehab will not fit pt when they are done with rehab - swelling will also affect measurements • donjoy extreme - attempts to control rotary stability component • there is NO brace that controls rotary instability • there are people that will prophylactically brace

collateral ligament injuries

• cord like LCL • broader, triangular MCL • MCL - most commonly injured knee ligament - the MCL is the primary restraint to valgus force in any position of the knee - also helps to provide anterior stability when the ACL is insufficient

Baker's cyst

• defined as a accumulation of synovial fluid that is formed in the popliteal area of the knee - relatively common • essentially it is a cyst • in older adults, we tend to see it associated with the DJD process • in the younger population, we see it when there has been a meniscal tear • sometimes it just forms idiopathically • pt c/o pain in popliteal area of the knee - some Baker's cysts, depending on where they are situated, are palpable if they are superficial enough; will be tender to palpation

ITB syndrome

• defined as irritation of the ITB over the lateral knee • we often see this in athletes: cyclists, runners, long distance walkers - in these groups, often an overuse onset • classically refer to ITB syndrome at the level of the femoral condylar area, it is also at times associated with this same type of issue at the greater trochanter

Noble compression test

• designed to assess for ITB syndrome • pt is supine, examiner has palpating thumb on the lateral side about 1-2 cm proximal to the lateral femoral condyle - hold thumb above femoral condyle with gentle amount of compression - while maintaining compression pressure, passively extend and flex the pts knee • positive = at about 30 degrees knee flexion, pt will experience pain underneath your thumb (ITB is going to cross over the lateral femoral condyle when then knee is in about 30 degrees of flexion) • as that band is displacing forward with flexion and extension, it will cross under thumb; since we have compressive force there, it will elicit pain at 30 degrees • pain at any other angle is not a positive test

posterior drawer test

• designed to assess the integrity of the PCL • same position as anterior drawer, just change hand placement - bring thenar eminence more anteriorly at the proximal tibia, thumbs up over joint line • push posteriorly on proximal tibia - you have a pretty bony surface, so you don't have to take up soft tissue • you will feel significantly less posterior displacement than you do anteriorly - compare excursion to uninvolved side • primarily assessing PCL - also stresses arcuate popliteus complex, posterior oblique ligament, and ACL • if the medial tibial plateau displaces more posteriorly compared to the lateral = posteriomedial rotary instability • if the lateral tibial plateau displaces more posteriorly than the medial = posteriorlateral rotary instability

Lachman test

• developed by Dr. John Lachman at Temple University • considered to be the clinical gold standard test for assessing the integrity of the ACL - it is especially specific to the posterolateral band - secondary restraint stressed is arcuate popliteal complex • 95-100% accurate • pt is supine, knee starts at 20 degrees of flexion (allows posterior horns of menisci to clear from under the femoral condyles) • examiner places stabilizing hand on the distal thigh, hand creating force is on the proximal tibia, very close to joint surfaces - force hand draws the tibia forward - can rotate hip so that you can pull toward yourself instead of pulling toward ceiling - big leg little hands: can drop leg off, put it between examiner legs to stabilize, stabilize over femur • positive = excessive anterior tibial displacement, mushy end feel • positive test indicates ACL insufficient or deficient knee • same grading system as with other ligaments: grade 1-3 - people commonly don't have pain with ACL or PCL, so you may need to just go by your feel

diagnosis of ACL injuries

• dx is based on history, MOI, clinical exam, tissue tension exam, clincial tests (Lachmen is gold standard), KT-2000 studies • was the individual able to get up and continue to play? typically 85-90% of people that tear ACL are unable to continue to play • we tend to see the onset of an immediate hemarthrosis because of the vascularity of a midsubstance tear • there will be instability • they will demonstrate a positive Lachmen on clinical exam • can use KT-1000 or KT-2000 arthrometer to measure ACL insufficiency - measures mm of displacement - this is an objective measure of displacement, it is an instrument whose test results are permitted in legal cases

hormonal risk factors of ACL injuries

• estrogen can cause relaxation of soft tissue • we know that there are estrogen receptors in the ACL - these estrogen receptors have been found to reduce collagen synthesis and fibroblast proliferation • on top of that, the female will be at greater risk during certain times of their cycle

LCL injury

• etiology of LCL injury - direct blow to the anteromedial aspect of the knee (contact/direct mechanism) - non-contact varus or hyperextension injury • generally pain is localized to the fibular head or the lateral femoral condyle

clinical picture: quadriceps rupture

• extension of the knee is usually impossible, no integrity left to the structure • in the acute stages, inflammatory material and swelling: flexion is uncomfortable and limited • once you are beyond acute stages: flexion will be not painful after swelling and exudate have dissipated

management of ITB syndrome

• figure out the cause to effectively plan a course of treatment - tight tensor ITB - abnormal mechanics • these typically do not require surgical intervention

Thessaly test

• found to be a very reliable test for meniscal tears - McMurray's test is not very reliable • this involves some degree of balance, not for everyone • pt stands on one leg, should test uninvolved limb first - give pt your hands in case they lose their balance • while pt is unilaterally weight bearing, ask them to just bend their knee to 20 degrees of knee flexion - while in that position, IR and ER the femur 3 times on the fixed tibia • positive = pain over the medial or lateral joint line, sense of clicking or catching or feeling as though it will lock • make sure they maintain 20 degrees knee flexion and that they rotate enough to get a stress on the knee

management of ACL injury

• generally people that are of the gumby persuasion (red-headed, freckles = Irish population), must be aware of the joint laxity that they have - it could have a detrimental affect on the integrity of the reconstruction down the road • if you delay surgery for ACL tear a couple of weeks from onset of injury, the outcomes will be better - it gives the inflammatory response time to go through, pain becomes less of an issue, pre-op rehab • decision to surgically reconstruct the ACL is not a decision based on instability, it is based upon the disability - some people tear ACLs and have instability, but if it does not disable them in terms of what they have to do (pt is not athletic, no manual labor demands), we will not go in surgically; send them to rehab - when ACL tear becomes a disability, that surgery becomes the preferred option • orthopods, if they get a pt that has an ACL deficient knee, will send the person for rehab; try to get a measure of how compliant pt is with rehab - if they are not following through, that is a big red flag for surgery, may not do well post-op

surgical management of lateral patellar instability

• generally surgery for lateral patellar instability is divided into distal, proximal, and combined procedures

postural deformities at the knee

• genu valgum • genu varum • genu recurvatum • patella alta • patella baja • winking patella

management of LCL injury

• grades 1 & 2 are typically managed conservatively (PT, anti-inflammatories, brace for function) • grade 3 tear of LCL is usually repaired - due to concern over integrity of posterolateral corner of the knee

clinical picture: chondromalacia patella

• gradual onset of diffuse, achy pain over the anterior or anteromedial aspects of the knee • may or may not demonstrate inflammatory signs • likely going to have positive movie/theater sign • crepitus • will c/o pain that increases with squatting, climbing stairs, and may talk about knee giving way or catching

genu recurvatum

• hyperextended posture at the knee • appreciated from a lateral viewpoint

management of contusion

• ice, compression, elevation to try to promote reabsorption of these byproducts as quickly as possible • contusion like this = possibility of developing myositis ossificans - get jump on it with US for reabsorption, compressive wrap • if the area is at risk for getting hit again (athlete or laborer), must protect this area - thermal type plastic you can mold to create a relief so that when the pad is on the pt and they get hit, they aren't hit directly on contused area again • if myositis extends into articular or becomes extensive enough to impair function, surgical considerations will be made at that point

management of Baker's cyst

• if it is not interfering with functional mobility, they will leave it alone • may try to aspirate it - if that doesn't work, next step is to remove the cyst • sometimes they are painless, sometimes they are uncomfortable - depends on location, how big it is, pain tolerance

environmental risk factors of ACL injury

• if the playing surface is grass with bumps and divots, can contribute to abnormality in ground reaction forces creating abnormal motion and ACL tear • shoe-surface interface - depends upon the type of cleats in the shoe, weather, and type of surface - longer cleats (help grab ground) make you fixed to the ground - lower shoe cleat interface gives you more mobility to compensate when there are forces to the weight bearing limb

etiology of ITB syndrome

• if the tensor ITB is tight, it will likely accentuate the amount of friction of the ITB on the femoral condyle • it can also be caused by issues within the kinematic chain - pronated feet are associated with ITB - patellofemoral dysfunction is also associated • direct trauma can also cause ITB syndrome

management of loose bodies

• if they are not bothering the person, causing locking or giving way, they will leave it alone • if it is problematic, they will go in with an arthroscope and take them out

quick clinical check for patella alta and patella baja

• if you look at someone's patella and patellar tendon, generally the top to bottom distance of the patella in mm should be symmetrical to the length of the patellar tendon • in patella alta, the length of the patellar tendon exceeds the length of the patella measured from top to bottom • in patella baja, patellar tendon length is less than the top to bottom distance of the patella

anterior drawer vs. Lachman test

• if you use an anterior drawer as your assessment of the ACL in the presence of an acute injury, the presence of intact menisci may block the tibia from displacing forward • position for Lachman test: menisci will not block translation • Lachman test also negates effect of hamstrings in muscle spasm, that will hold tibia back due to the line of pull with the knee flexed 90 degrees during anterior drawer test • if only the ACL is torn, there is support to the drawer test resulting in a false negative; secondary restraints (such as posterior capsule, posteriorlateral and posteromedial structures) may be able to limit that anterior translation, so it won't look as bad as it may actually be

bursas at the knee

• in and around the knee, there are in excess of 24 bursas • clinically significant bursas - pre-patellar bursa - suprapatellar bursa - pes anserine bursa

surgical managment for articular cartilage injury

• in some cases, the surgeon may opt to go in and debride the area • another option is to perform a chondroplasty, an abrasion arthroplasty, or microfracture surgery • autologus chondrocyte implantation

management of lateral patellar instability

• in the case of a dislocation, it must be reduced • we will see a lot of these folks with recurrent instability of the PF joint • we have to decide if we can effect a change in terms of what caused it

recurrent patellar subluxation/dislocation

• in the patellofemoral joint, the direction of subluxation or dislocation is usually lateral • we know that the medial patellofemoral ligament provides more than 1/2 of the restraining force that prevents abnormal lateral translation • we also know that in about 80% of the people that have acute patellar dislocations, the ligament is torn away from the adductor tubercle - lost a good portion of the lateral restraint in a dislocation • pt will c/o catching or giving way • patella sits way out on the lateral side • can lead to issues such as bone bruising

anterior drawer test

• indicated to assess the integrity of the ACL • pt is supine, knee flexed about 90 degrees, hip around 45 degrees flexion, foot is flat on the treatment table, neutral rotation of the leg - the ACL is parallel to the tibial plateau in that position • examiner sits on the table and sits on pt's foot to stabilize the leg on the table - with your hands, come proximally on the leg as close to the knee joint as you can - wrap fingers around the back of the calf - thumbs rest across the joint space of the tibiofemoral joint, up and down so they cross over joint line - take up the soft tissue of the calf, then pull the tibia anteriorly relative to the femur - translation will occur, up to 6 mm of anterior translation is normal (compare to unaffected side); must feel an abrupt endpoint to be normal • positive = excess of normal mm of anterior translation, esp when compared to other side; no firm endpoint (with insufficient ACL, feels like you are pulling into mush) • characteristically an ACL test (esp specific to anteromedial bundle) • other structures that may be stressed: posteromedial and posteriolateral capsule, deep fibers of the MCL, ITB, posterior oblique ligament, arcuate popliteal complex • test is a straight plane instability test (in sagittal plane) • when you pull the tibia forward, you should get a result of equal forward displacement between medial and lateral tibial plateaus - if the medial tibial plateau moves further forward than the lateral plateaus = anteromedial rotary instability - if the lateral tibial plateau moves more forward than the medial = anterolateral rotary instability

clinical picture: loose bodies

• inflammation • varying effusion • pain • weakness (due to pain or guarding) • intermittent locking • pt may have lateral knee pain on one visit, then anterior, then medial - the body is floating around and causes pain it hits a tissue that is viable or gets pinched between articular surfaces

clinical picture: pre-patellar bursitis

• inflammatory signs: pain, swelling • decreased passive knee flexion, pain free and full extension • contractile testing: painfree and strong 48 min

platelet rich plasma (PRP)

• injection of platelet rich plasma into the knee • tries to promote ongoing function and alleviate pain in the joint • delays arthroplasty • also used for shoulder, hip, etc.

etiology of meniscal injury

• injuring a mensicus usually involves rotation forces, leg is planted with weight bearing • generally, will see a varus or valgus force directed to a flexed weight bearing knee - if we have a valgus force applied to a flexed weight bearing knee, that causes internal femoral rotation, that mechanism may lead to lateral meniscal tears - if the weight bearing flexed knee is subjected to a varus force with the femur externally rotated, that may lead to a medial meniscal injury/tear

clinical picture: PFPS

• insidious onset of peripatellar and/or retropatellar pain • pain tends to manifest with activities that require knee flexion and forceful quadriceps contraction (squatting, stairs, high stepping) • tends to occur in young active females more than males • common to see pain exacerbated with periods of prolonged sitting with the knee flexed (movie/theater sign)

genu valgum

• knock kneed appearance • tibia is deviating away from teh midline in relation to the femur • observed from anteriorly or posteriorly

management of patellar tendinitis

• like other tendinopathies: - NSAIDs - injection - physical therapy • consider some type of compressive orthosis to provide support and warmth to the area during functional activity and rehab

tests for instability of ligaments

• many tests for instability of ligaments • straight plane instability tests - presence of instability in one plane • rotational instability

osteochondral autograft transfer (OATS)

• may also hear this called a mosaic plasty • essentially they take a plug of bone, usually on the lateral side of the femoral condyle (non weight bearing surface) • clean out defect and put the plug of healthy bone in its place • pretty good outcomes • this point, no synthetic viable alternative for these bone plugs

treatment options for Osgood Schlatter disease

• may have to recommend revision of activity (if they keep running, it will be continually aggravated) • if it is really severe, the physician may elect to immobilize them in a position of extension with cast or knee brace (minimizing the force of any quad contraction) • do what you need to for pain/inflammatory control • for ther ex, start out in submax isometrics if needed, progress to short arcs and long arcs (sxs guide this progression) • you will only need surgical intervention if you pull the tibial tuberosity or patellar tendon right off the bone; very very rare • could use a compression sleeve; keeps compression of tendon against tubercle, and keeps area warm

"Q" angle

• measurement the pull of the quadriceps on the patella and therefore its influence on patellar tracking - the bulk of the pull with quadriceps contraction displaces the patella superolaterally • measuring this angle - axis of goniometer is on midpoint of patella - proximal arm goes up and sites the ASIS - distal arm bisects the tibial tubercle • pt is supine on the table; whole LE is lying flat on the table - the problem is that in doing this, the quads are not active - this measurement is supposed to represent quad pull on the patella - just have pt do a quad set while you take the measurement - static Q vs dynamic Q • normal Q angles are less in males than in females - there is a fair amount of variety in the normal ranges for males: 5-15 degrees - for females, more consistent: 15-20 degrees • this is a measure that you should take in people with patellofemoral type sxs - abnormalities of the Q angle may give you some info about patellar tracking, sx provocation

menisci

• medial meniscus is more C-shaped, larger • lateral meniscus is more ovoid shaped • attached onto tibial plateau • in cases of certain meniscal tears, we are able to get our fingers in enough to appreciated some tenderness, esp anteromedial and anterolaterally • you cannot palpate directly on the menisci

meniscal repair

• meniscal repair has become a viable option over the last 15-20 years - the more vascular the torn area, the better the results with this procedure • they will go in and repair the tear, using darts or sutures • generally there are post-op limitations after meniscal repair -bracing locked in position of extension - pt may be non weight bearing for a period of time • longer rehab than a partial meniscectomy • if you have someone with a meniscal tear and an ACL tear (which is not uncommon), there is sufficient literature that says if you do a meniscal repair and do not reconstruct the ACL, the failure rate for this repair is higher - trend has become to repair both

ACL anatomy

• most of the tears of the ACL are midsubstance tears (rather than at the proximal or distal insertions) • if you have a tear of the ACL in its midsubstance, you get a lot of bleeding, it is very vascular

management of quadriceps rupture

• must be surgically repaired • when you have a tear, you don't have clean ends • must go in and clean it up, so when you repair and reattach, the structure will be shortened • generally a long rehab • likely in a cast brace at the knee, may be immobilized in extension for a period of time to let repair heal • PT will see them post-op: biggest problems are restoring flexion (because structure has been shortened) and restoring contractile effectiveness of quadriceps

osteochondritis dissecans

• occurs when we have a fragment of subchondral bone that becomes necrotic • if that progresses, that necrotic bone can become dislodged and become a loose body • the most common location for osteochondritis dissecans is on the lateral aspect of the medial femoral condyle (85%) - occasionally you will see involvement of the lateral femoral condyle

clinical presentation: meniscal tears

• often have joint line pain in acute phase • may be tender to palpation along joint line - discomfort to palpation is not coming as a result of integrity of the cartilage, it is coming form the peripheral attachments of the mensici that are stretched or torn, causing the synovial reaction • in the case of meniscal tears, we tend to see joint effusion typically a few hours later • may c/o locking or knee giving way - locking with knee between 20-45 degrees flexion (like from flap tear that gets between articular surfaces)

contusion of anterolateral thigh

• over the quadriceps is a common area to have contusions • usually occur secondary to a direct blow to the area • will see localized bleeding • for quads, will have limited ROM in flexion until this resolves • will have discomfort in extension

clinical picture: ITB syndrome

• pain and inflammatory signs on lateral aspect of the knee in the area of the lateral femoral condyle and a little bit above that • Ober test, Noble compression test

clinical picture: MCL injury

• pain to palpation over medial epicondylar area, middle 1/3 of joint line, and the tibial insertion of the ligament (just below the tendons of the pes anserinus) - depending on where the ligament is torn will dictate which region is reactive to palpation • may present with pseudo-locking - MCL is most taut in last 10-15 degrees of extension; if it is torn and you create passive tension, that last 10-15 degrees is often not there for these pts

bracing/taping options for patellofemoral tracking

• patella should track within femoral groove - if patella has excessive lateral tracking, every time that happens the patella is abrading up and over femoral condyle • can do McConnell taping or braces that help to guide patellar tracking • brace contains horseshoe that creates a block for the patella displacing laterally - consider mechanics when selecting a brace and putting the brace on - make sure patella's normal tracking is not blocked by the brace • Palumbo brace is well known for patellar tracking

tests for effusion

• patellar ballotment - designed to detect the presence of a major effusion; ironic because you can visually observe a major effusion • fluctuation test - assesses for the presence of a minor effusion; can't see visually

patellar tendon avulsion

• patellar tendon has come off the bone, the patella is not longer fixated distally, so it will sit more superiorly • will have to be surgically brought back down and attached to the bone, usually with a screw • this can occur during activity, similar to quadriceps rupture • you have lost integrity of quadriceps mechanism - patella is superior to where it is supposed to be

clinical picture: Osgood Schlatter disease

• present with pain/tenderness over the tibial tubercle • may or may not have effusion • will have pain with functional activities that involve extension of the knee • because of the location of this pathology, they will have discomfort with kneeling • the body responds to repetitive tractions stresses on bone by laying down more bone - this population will have big, bumpy tibial tubercles as a result of this

clinical picture: lateral patellar instability

• pt experience acute pain after direct contact or a sudden change of direction (such as when cutting) • sudden change in direction causes the femur to medially rotate on the tibia which is fixed to the ground • typical direction of instability is laterally

patellar ballotment

• pt is supine, knee extended and quads relaxed • a lot of fluid is sitting under the patella • examiner pushes middle of the patella posteriorly, as we push it down into trochlear groove, it forces fluid that was under there to be flushed out • examiner takes finger off, and fluid again flushes underneath patella and pushes it back up • positive patellar ballotment test = fluid pushing patella back up • usually by the time they get to you they have been aspirated or the fluid has dissipated • more likely you will see more subtle amounts of effusion that you can't appreciate by looking, for that you use the fluctuation test

rehab from autologus chondrocyte implantation

• rehab is so long • protected from full weight bearing up to 12 weeks post • up to 6 months after that for light impact and jogging • 1 year post for high level sports

types of meniscal tears

• there are some distinct patterns of meniscal tears - bucket handle tear, radial tears and flap tears are common - flap tears are still attached, so they may move in and out between articular surfaces • in older pts, we tend to see more degenerative types of meniscal tears because tissue is less resilient, tends to be weaker, more likely to tear - additionally, because of weakened degenerated structure of meniscus, it takes less force to tear a meniscus in older pts

anatomical risk factors for ACL injury

• small/narrow intercondylar notches - ACL can get impinged against wall of the notch, over timer resulting in tearing • women have a wider pelvis compared to males, so females have a larger Q angle - collectively, you see an increase in the valgus moment/posturing of the knee in women • females tend to be more flexible than males • females also have been found to have greater quadriceps to hamstring deficiencies - normal relationship of quad to hamstring strength: quad is 2/3 stronger than the hamstrings - if you have a discrepancy (often coming from training), the more you increase that discrepancy, the greater the predisposition to injury - hamstring strength returns quicker than quad strength, so if you are working at the knee, you need to spend more work on the quads

PT rehab after ACL reconstruction

• some physicians do not brace their pts post-op, others want them braced, esp during vulnerable time period • if you close the chain, you can do wall slides or elliptical - must be more careful with open chain • just ask the physician what you can and can't do

functional forces causing injury at the knee

• someone that is involved in a deceleration movement often implicates the cruciates • injury sustained when someone accelerates quickly and twists on the planted foot is a common mechanism for meniscal tears • a cutting maneuver (when someone is running at a relatively constant speed) is often an ACL tear

playing style risk factors for ACL injury

• studies show that women play sports in a more erect position compared to their male counterparts - downside of that is that it increases the ground reaction forces that are transmitted tot eh knee as well as increasing the anterior shear forces imposed to the ACL • point of no return from valgus collapse when coming down from a jump - valgus collapse is seen more often and is more pronounced in females, women let their legs come in on the landing - males tend to land with more sagittal plane movement - this valgus collapse is a real prominent mechanism for ACL disruption

etiology of Osgood Schlatter disease

• sudden or continuing/ongoing strain placed upon the tibial tubercle by the patellar tendon • repetitive extension activities associated running, kicking a ball, etc. require contraction of quads, creating traction stress, patellar tendon exerting a traction force relative to the tibial tubercle • single episode of forced knee extension, causing tearing away of patellar tendon

suprapatellar bursa

• suprapatellar bursa is actually an upward extension of the synovium that lies beneath the quadriceps tendon • bursa lies under contractile mechanism - tissue tension exam will show pain with active knee extension, pain with passive knee flexion

surgical management of chondromalacia patella

• surgeon will shave the undersurface of the patella, smoothes it out • some folks do OK, some folks have more problems after that procedure

total knee arthroplasty (TKA)

• surgeons are becoming more receptive to doing bilateral TKAs in some pts • many different prosthetic components - some have a patellar button, some retain the pts patella - plastic with metal, and other materials • new: minimally invasive knees - some of the newer techniques work around the patellar tendon to maintain the integrity of that = quicker rehab • for any surgical pt, you need to know what they did, call and get the op report any time you have a post-surgical pt

management of MCL injury

• surgery is usually not indicated in an isolated tear - it should be considered with co-existing ACL or PCL insufficiency • for isolated MCL sprain (grade 1 or 2), recovery takes 1-2 weeks • in a grade 3, handled conservatively, recovery takes 6 weeks (3-4 weeks at the very least)

surgical management of meniscal tears

• surgical options (arthroscopic or open arthrotomy approach) - excise the meniscus - repair the mensicus - leave it alone • least desirable option is the total menisectomy • meniscal transplantation tissues - synthetic or from cadaver tissue - very controversial

surgical management of ACL injury

• surgical options: - arthroscopic recosntruction - arthrotomy incision • consists of using a graft to replace the deficient ACL • midsubstance tear will require reconstruction with graft • the ACL is only going to be considered for repair in the case of an avulsion off of one of its attachment - they will go in and reattach ti to the bone with a screw

synvisc injections

• synvisc is a series of injections (usually 3) over a 2 week period • it is an anti-inflammatory analgesic substance that gives people time before they need to think about a TKA • people that have these synvisc injections may get relief for a period of months (2-8) afterwards • if you are relatively young, surgeons are not quick to want to replace your joints because these joints have a longevity to them - at some point you will have to replace the components again, every time you do that you have less bone to work with

posterior cruciate ligament (PCL)

• taut as a whole through the full ROM • bulk of fibers are taut at 30 degrees of knee flexion • posterolateral fibers are lax in the early stages of knee flexion • this ligament is going to become lax with tibial ER and taut with tibial IR

healing of meniscal tears

• tears in the red-red zone will heal by invasion of scar tissue • in the red-white zone, you will see varying degrees of healing • in the white-white zone, you have no healing because you don't have a blood flow

rehab braces at the knee

• the rehab braces are more cumbersome than the functional braces • they typically have dials that you can set safe areas of movement for the pt, or block them in extension • nice wide thigh and calf cuff, uprights, pretty stable

etiology of quadriceps rupture

• there are both direct and indirect MOI • direct - typically occurs when the knee is in a position of flexion and there is a forceful blow to the quadriceps in CKC • indirect - typically when there is a forceful quadriceps contraction while the knee is being forcefully flexed

meniscal vascularity

• there are identified areas of vascualrity within the menisci - peripheral zone = red-red zone, most vascular - central zone = red-white zone - inner zone = white-white zone, no blood supply • when someone tears a mensicus, the key to management is where in the meniscus did the tear occur and whether or not healing an expected response

positions of tension within MCL

• there is some degree of tension within the MCL throughout the ROM at the knee, although there are points where the stresses are greater - all fibers are taut at full extension - in midrange, posterior fibers are most taut - in full flexion, anterior fibers are most taut - ligament as a whole is taut with tibial ER and lax with tibial IR

diagnosis and management of PCL injury

• these folks can usually get up and keep playing • knee pain, but it is not incapacitating • varying degrees of instability posteriorly • if they have an effusion, it is relatively mild and a little bit bloody • clinically, posterior drawer test to assess instability • in the case of isolated PCL tears, 80-85% can be successfully managed conservatively • general rule is that a grade 3 injury should be reconstructed

patellar fxs

• these fxs occur due to direct blow, falling on patella • we may see it with patellofemoral issues due to forces generated by the extensor mechanism - that's generally in those with predisposition of osteoporosis/osteopenia or a compromised patella • nondisplaced by be managed by a short period of immobilization • displaced patellar fractures will likely require some surgical fixation - Krishner wire • post-op: concern for mobility of PF joints as well as restoring the integrity of the tibiofemoral joint

autologus chondrocyte implantation

• they are going to harvest chondrocytes from the pt which they culture and then reimplant back into the pts knees with the intent that over time this will develop into articular cartilage • the problem with this is that it is a long recovery • 2-6 months post, the reimplanted cells closely resemble hyaline cartilage • between 1-2 years post, it is hard to differentiate what was reimplanted from actual hyaline cartilage • good to excellent intermediate follow-up results over a 10 year period

partial (subtotal) meniscectomy

• they will go in and cut the portion of meniscus involved in the tear, bevel down edges of remaining meniscus • healthy portion of mensicus continues to do what it is supposed • portion of the meniscus that is removed is replaced by dense collagen fibers from the remaining part of the mensicus • usually not weight bearing restrictions post-op - not uncommon to see people bounce back within a week or two

pes anserine bursitis

• this bursa lies under the conjoined tendons of the semitendionosus, gracilis, and sartorius • generally becomes inflamed due to trauma, direct blow • sits beneath conjoined tendons and superficial to MCL • painful with movements that the sartorious and adductors are involved in

progression of Osgood Schlatter disease

• this condition is self-limiting - if you do absolutely nothing, when they stop their growth spurt, it will resolve • we may see repeat offender here, or a person that remains somewhat symptomatic throughout their growth spurt • generally by the time a person reaches 18 years of age, this pathology is self-limiting and goes away

chondromalacia patella

• this is a deterioration/degeneration of the articular cartilage on the posterior surface of the patella • tend to see that cartilage starts to become weakened and softened, surfaces become irregular

PT rehab for CP

• this is a mechanical problem - look at the whole kinematic chain from the foot up to the spine • don't just treat sxs, treat all abnormalities found in biomechanical exam • for retinacular tightness - work on improving extensibility of retinaculum, flexibility work for ITB • for VMO weakness - cannot target with extension (even terminal extension) - target this by using FES or hip adduction • bracing or taping for patellar tracking

Fairbank's Apprehension test

• this is a test to determine lateral instability of the patella • if we find it to be positive, it will be indicative of a subluxation/dislocation occurring at the patellofemoral joint • most of the patellofemoral instability that we see is of a lateral nature • pt laying on table, legs extended - put your thumbs on one side of the patella and your index fingers on the other side of the patella (gives pt a sense of security because you can control displacement) - make sure pt is relaxed, but a towel roll under their knee so you have an unlocking of the extension - gently and slowly passively displace the patella laterally, keeping fingers on lateral surface of patella • positive = pt exhibits an apprehensive response as you passively move the patella laterally, because they feel as though it will sublux or dislocate; may tighten quad, grab your arm, frightened look on their face

internal derangement

• this is an umbrella term, referring to a group of clinical lesions that produce mechanical dysfunction at a joint • can occur at any of the joints of the body, but you tend to see it most at the knee • in the case of a hemarthrosis, if it is significant enough that it is creating pressure/pain in the joint, they will aspirate that and then inject that blood into an emesis basin - look for fat in the blood, indicative of fx

quadriceps rupture

• this structure can be disrupted at the level of the muscle belly, the tendon (quadriceps or patellar tendons), or at the tendo-osseus junction of the upper and lower patellar poles or at tibial tubercle • like in the biceps, you will be able to palpate divot from recoil where structure has lost its integrity

patellar tilt test

• this test is designed to evaluate the tension in the lateral restraints of the patellofemoral joint, primarily the lateral retinaculum • if the lateral restraints are tight, it will have a tendency to pull that patella laterally • pt is supine, towel roll under knee • examiner puts their thumbs laterally on the patella, index fingers on medial side - with thumbs on lateral side, try to lift the lateral side up toward the ceiling, away from the femur - while you are doing that, take index fingers on medial side and create a counterforce pushing medial patella posteriorly • normal patellar tilt is 0-20 degrees • those with patellofemoral issues, you likely can't even get them to the horizontal • positive = can't get the patella to horizontal

winking patella

• tibial torsion is a twisting of the bone about it's long axis • assess with the pt standing, symmetrically weight bearing, natural base of support, feet pointed directly forward • with excessive or abnormal torsion, you will see that the patellas are facing inward, as if they were looking at each other (called winking patellas, grasshopper eyes) • with the feet facing straight forward, we would normally expect the two patellas to face forward - in order for these two patellas to be sitting anteriorly in pt with tibial torsion, this person will have to toe out on both feet • average external tibial torsion of 12-15 degrees is normal

factors contributing to PFPS

• tightness of soft tissues, bony alignment, and VMO function can cause patellofemoral malalignment (static or dynamic) - this causes decreased patellofemoral contact area - areas of increased force will have resultant tissue overload/injury - areas of decreased force will suffer dissuse and early degeneration - both lead to patellofemoral pain • overuse can cause increased patellofemoral joint forces, also leading to tissue overload/injury • acute injury can also cause patellofemoral pain

etiology of PCL injuries

• trauma - dashboard injury: person is seated in front seat of car, no seatbelt, impact throws them forward so tibia strikes the dashboard - if the force is sufficient, it can cause the tibia to posteriorly translate relative to femur • fall onto flexed knee when ankle is in a position of plantarflexion - proximal tibia hits the ground first, ground reaction force pushes tibia posteriorly • hyperextesion or hyperflexion movements • severe torsional movements combined with a varus or valgus force

management of meniscal tears

• treatment for meniscal tears is dependent on the presentation of the pt - if their knee is giving out or locking, they will likely end up in surgery sooner • PT after the meniscal tear - may do well over course of rehab - others improve, become more active again, but are unable to do what they would like to, or exacerbate injury in some way

medial collateral ligament (MCL)

• two layers: superficial and deep • deep layer is a thickening of the capsule, blends with the medial meniscus • superficial layer tends to be more broad and triangular in its shape - runs from adductor tubercle to the medial tibia to about 6 cm below the joint line, blends with the posterior capsule • palpation: MCL is much broader than LCL

patellofemoral pain syndrome (PFPS)

• umbrella term that represents a general category of anterior knee pain attributed to patella malalignment • etiology - overuse - overloading • surgery for patellofemoral pain syndrome is rare

counterforce bands

• used to treat patellar tendinitis - similar to treatment for epicondylitis • circumferential • pt will likely not be compliant if they are not comfortable - if they are too tight, more blood increases girth during exercise, will become uncomfortable

PT treatment for knee OA

• we can't fix this so we try to minimize sxs and maximize function • modalities (essentially a band-aid over the problem) - ice and cold for temporary relief • try to retain the ROM at the knee - may be able to get some increases if it is not too severe • obesity problem - refer back to hip • make ADL easier - higher chairs - raised toilet seats - tub benches • can try orthotics - anything from a compression sleeve to knee brace with medial-lateral hinge uprights: just for support and a little bit of compression and warmth

Knee OA

• weight bearing joint, so OA is more significant here • erosion or degradation of the articular cartilage - bone on bone at the articular surfaces, very painful

remodeling of autograft

• when you implant this graft, it has to undergo the process of remodeling • human graft remodeling is a process that occurs over a period of three years • at the time of the graft implantation, it is relatively strong • about 4-6 weeks post-op, the graft undergoes some degree of necrosis and becomes very vulnerable and weakened during that period - we will have to back off on intensity of rehab during this period • remodeling process is pretty rapid during first 10 months • then 2 year maturation period of graft

tib-fib fx

• when you see tibial fxs in the distal 1/3 of the bone, the blood supply here is not very good • distal tibial fxs are much slower to heal vs fractures that are more proximal in the bone

diagnosis of MCL injury/tear

• x-ray doesn't give info about status of ligament, but does show associated fx - can do stress films to show degree of instability caused by ligamentous tear

diagnosis of OA at the knee

• x-ray is an easy diagnosis - decreased joint space - osteophytes - usually the medial compartment that is involved and is the most painful

management of osteochondritis dissecans

• you have to do something about the dying bone - abrasion arthroplasty - microfracture surgery - take a pin (if the segment is still viable) and pin fragment back into the femur - OATs procedure • generally the younger the pt, the better the outcome

knee dislocation

• you have torn the integrity of everything ligamentous - cruciates, collaterals, meniscal involvement • requires surgical intervention to repair as much as can be repaired and restored • long, slow rehab process back