MSK 1- Knee

Active movements will give us information on:

-AROM ability/ quality of movement -restriction -hypermobility -pain (endrange, painful arc) -crepitus -willingness to move -structured stress (contractile/ non-contractile)

which tests can we use to determine if a knee pain is d/t ACL inj?

-Lachman's test (most sensitive for 1-plane ant instability, tests posterolateral band) -Anterior draw test (anteromedial band) -lever sign test (Lelli's test) -Macintosh lateral pivot shift test (more specific than lachman)

passive movements will give us information on:

-PROM/ patterns of restriction -guarding -pain/ irritability (before, at resist., after resist.) -end feel (normal vs abnormal) -structures stressed = non-contractile

how do we treat ACL tears?

-a combination of OKC and COC exercises are recommended -NMES- quad (early on)

what are normal end feels?

-bony (ex elbow) -soft-tissue approximation, 2 muscles (ex knee/ elbow flex) -elastic- soft stretch (ex MCP) -capsular- hard capsule or ligament (ex knee ext)

How do we treat an ACL sprain non surgically?

-bracing (derotation) -strengthening quads and hamstrings -perturbation training: dynamic control -activity modification

non-contractile tissues produce pain via stretch and pinch, and include examples such as:

-bursa -joint capsule -ligament -local adhesion -internal derangement -cartilage -bone/ osteophyte -blood vessel -dura mater

an UQ/LQ screen consists of:

-cervical or lumbar spine AROM/PROM/ resisted isometric movements -AROM of peripheral joints -myotome screen -dermatome screen (light touch)

how do we treat MCL sprain?

-conservative is better than surgical -early controlled motion ex: bracing, ROM, strengthening quads, gradual return to sport/activity

how do we treat LCL injury?

-conservative, like MCL - surgical repair along with ACL +/- pcl reconstruction -- there is a high risk for persistent disability and stiffness

LCL sprain will often occur in conjunction to

-cruciate ligaments -posterolateral knee joint capsule -peroneal nerve- in severe injuries

in females, most ACL noncontact injuries occur during 3 types of movements:

-deceleration -lateral pivoting -landing

why do we test end feel?

-determine nature of pathology -severity -direct POC -prognosis

which tests can we use for meniscal injury?

-joint line tenderness (sn, not sp) -McMurray test (sp, not sn) -Thessaly test (sn AND sp) -meniscal pathology composite score -apley compression/distraction

ICF classifications of ligament sprain/ tear

-knee instability -movement coordination impairments ---> must be prepared to explain why patient is places in these categories

6 techniques of MTT (manual therapy technique)

-manual lymph drainage -manual traction -massage (CT massage or therapeutic massage) -mobilization/ manipulation (dry needling, soft tissue, spinal and peripheral joints) -neural tissue mobilization -PROM

what are the attachments of MCL?

-medial epicondyle of femur -medial condyle and surface of tibia

MCL sprains often occur in conjunction with

-medial meniscus tear -acl -medial knee joint capsule (posterior oblique joint capsule) -"unhappy triad"

when would you do a scanning exam entail? (UQ/ LQ screen)

-no h/o trauma -radicular signs (nerve root) -altered sensation -spinal cord signs -abnormal pain pattern --> we do this to rule out spinal source of symptoms

post-op rehab for meniscectomy includes:

-progressive ROM exercises, WBing, and return to ADL -therapeutic exercise (quads, hamstrings, improving function)

when should you not test end feel?

-severe pain at end range (empty end feel) -irritable condition -early post-op or s/p fracture

when would you do a focused exam?

-specific peripheral tissue source of symptom -confirmed by history of injury, sx/fx, symptom pattern

Evaluating if spinal or peripheral nerve problem:

-spinal spinal motion reslts in impact of CC dermatomal pattern of pain +/- altered sensation myotomal pattern of weakness -peripheral no impact on CC from spine non-dermatomal pattern non-myotomal pattern

what are abnormal end feels?

-springy block (hard, unexpected) -boggy (squishy, viscous fluid in joint) - muscle spasm (protective, hard) -empty -capsular (earlier than expected) -bony (early, unexpected)

what are the two layers of the MCL? which is the primary restraint for valgus stress?

-superficial * -deep (add stability, attached to medial meniscus)

When is it a good time to consider surgery for ACL sprain?

-the knee "gives way"= instability -high- level athletes

When performing a musculoskeletal exam, we should use a systematic approach first, beginning broadly and then focusing on the area in question, develop a differential diagnosis list and lastly....

... rule in/ rule out via exam findings

What are the grades of mobility for joint play?

0-ankylosed 1- considerable limitation 2- slight limitation 3- normal 4- slight increase 5- considerable increase 6-pathologically unstable

3 major contributors to gender disparity of ACL tears:

1- anatomical (anthropometric) 2- hormonal (follicular and ovulatory phase) 3- neuromuscular (lower limb biomechanics -also females less likely to cocontract quads and hamstrings than males

ACL restrains which movements? (primary/2)

1- anterior translation and medial rotation (of tibia on femur) 2- secondary restraint to valgus and varus

PCL restrains which movements? (primary/2)

1- posterior translation and medial rotation (TIB ON FEMUR) 2-valgus and varus rotation

what are two goals of movement assessment exam?

1- to reproduce symptoms to determine which tissues are involved 2- to determine impairments (ROM? strength? balance?)

LCL restrains which movements? (primary/2)

1-varus stress lateral rotation 2- anterior and posterior translation

what are the four patterns of ROM and pain?

1.ROM WNL, painfree --normal tissue 2.pain and limitation --all directions --capsulitis -- arthritis 3. pain and limitations -- some directions --noncapsular pattern (lig sprain, internal derangement) 4.limited ROM, painfree --symptomless OA, healed fx (osteophytes)

MCL restrains which movements? (primary/2)

1:valgus lateral rotation 2: anterior and posterior translation

how many adults in the general population experience knee pain?

20%- it is a significant disability *most often injured in football

When are ACL injuries most common?

3rd decade of life (20s)

what % prevalence is ACL/PCL injury?

4%

selective tissue tension exam consists of: (2)

>contractile vs non-contractile >comparing active, passive, resistent tests

What is included in a systems review?

CV/ Pulm exam integumentary musculoskeletal neuromuscular communication/cognition

posterolateral corner includes (3)

LCL popliteus tendon popliteofibular ligament

LEFS

Lower Extremity Functional Scale

What is the most common ligament injured?

MCL aka tibial collateral ligament -often combined inj with ACL

PCL tears often occur in conjunction to

MCL and Arcuate ligament complex also with mcl, lcl, knee dislocations

which ligamentous group injury is most prevalent?

MCL/ LCL -7% adults

how does a PCL injury occur?

MOI: anteromedial blow to flexed knee (fall onto tibial tubercle, MVA dashboard inj, kick to ant tibia)

how does the MCL become injured?

MOI: valgus force CKC valgus force with knee at 0-<90 degrees ex: blow to the knee when athlete cutting maneuver s/s: swelling (localized), tender, pain with valgus, no hemarthrosis

how does LCL injury occur?

MOI: varus force CKC varus force with knee at extension or partially flexed -no hemarthrosis

meniscal tear may occur in conjunction with...

OA (after age 50)

what tests can we use to see if a sprain is PCL?

Posterior drawer test gravity (Godfrey) sign

resisted movements have 4 combinations:

SPL (no contractile, nerve lesion) SPF (contractile lesion, muscle/tendon) WPL (nerve lesion or contractile rupture) WPF (severe lesion- fx, strain, ex)

SINSS

Severity Irritability Nature Stage Stability

How do ACL injuries occur?

Valgus and ER forces in CKC!!!!! -excessive IR or combo of IR and hyperextension -blow to knee while performing cutting movement -sudden deceleration -non-contact more than contact inj

microtrauma

a series of incidents of submax loading, which can experience signs and symptoms produced after a period of time -excessive normal forces -abnormal forces -excessive abnormal forces

What are Mennell's Rules for Joint Play?

a. Patient should be relaxed and supported b. Examiner should be relaxed and should use a firm, but comfortable grasp c. One joint should be examined at a time d. The unaffected side should be tested first e. One articular surface is stabilized while the other surface is moved f. Movement should be normal and not forced g. Movements should not cause undue discomfort h. Never mobilize in the closed packed position

normal laxity within a synovial joint that allows arthrokinematic movement to occur -not under voluntary control -obtained passively by examiner

accessory movement

when examining movement, what do we look at?

acute, irritable conditions test uninvolved side first test painful movements last warn patient about possible exacerbation

what are the PCL bands?

anterolateral and posteromedial

which band is taught in extension and flexion?

anteromedial

what are the three bands of the ACL?

anteromedial intermediate posterolateral

Which ACL bands are taught in extension?

anteromedial and posterolateral

the movement that occurs between joint surfaces -described in terms of motion of mobile segment -ex: caudal femoral glide, spin, roll, compression, distraction

arthrokinematics

what are ACL surgical techniques?

autograft (midthird of patellar tendon) (gracilis and semitendinosus tendon) allograft (midthird of patellar tendon)

once determined that source of pain is spinal, what should you do?

begin a focused exam of spine: tests/measures repeated movements reflexes sensation joint play functional tests palpation diagnostic imaging/ lab tests

once determined that source of pain is peripheral, what should you do?

begin focused exam of suspected peripheral joint: T&M - joint proximal and distal joint play functional tests palpation diagnostic imaging/ labs

what is the pattern of restriction for capsular vs noncapsular structures?

capsular: entire capsule is involved specific to the joint noncapsular: diff from normal capsular pattern, could imply possible derangement, could indicate inflam of distant tissue, could indicate extra-articular adhesions

which joint position allows maximal joint stability?

close-packed position -should be avoided for joint mobilization

a joint gliding direction same as direction of physiologic movement

concave on convex

how do we treat meniscal tears?

conservatively -modalities (dec swelling and pain) -AROM/PROM: regain motion -strengthen OKC to dec compression of meniscus -activity modification surgical -arthroscopic, partial meniscectomy or surgical repair (only in vascular peripheral zones)

how do we treat PCL tears?

conservatively,- quad strengthening surgically only from allograft 2/3 patellar tendon or achilles( poorer outcome of surgery)

pain with resisted motion: which types of tissues?

contractile

pain with AROM: which types of tissues?

contractile and non-contractile

a joint gliding direction opposite to direction of physiologic movement

convex on concave

ACL non surgical treatment: copers vs non-copers

copers: -more dynamic knee stabilizing movement strategy -returned to full ADL without episodes of instability non-copers: -more cocontraction and joint stiffening

T/F ligaments of the knee are the secondary stabilizers of the knee

false - primary for knee, and secondary of muscles

peripheral focused exam entails

functional tests- whole body performance prix and distal -ADLs/IADLs -joint play

Joint play can be classified as: (3)

hypomobile normal hypermobile (not great-interrater reliability)

diagnostic tests include:

imaging EMG/ NCV Lab tests

What else is observed from a PT during an exam?

integument posture comparing sides movement

KOOS

knee injury and osteoarthritic outcome score

how does a meniscal injury occur?

knee rotation on a flexed knee (weightbearing) -pop/tearing sensation -severe pain -joint swelling -crepitus -dec ROM -difficulty up/down stairs, squatting

when should you palpate?

last -redness, swelling, temp, tenderness, etc

LCL attachments:

lateral epicondyle of femur to head of fibula *no attachment to lat meniscus

what are the attachments for ACL?

lateral femoral condyle (posteromedial surface) anterior to medial intercondylar tubercle

which meniscus is circular?

lateral meniscus

what do we focus on for symptoms of pain?

location description intensity frequency aggravating/ relieving factors (irritability) improving/ worsening symptoms where did it begin-- any chance since then

what are the attachments for PCL?

medial femoral condyle (lateral surface) posterior intercondylar fossa of tibia and posterior horn of lateral meniscus

which meniscus is "c-shaped"

medial meniscus

what is the most common reason for arthroscopic surgery of the knee?

meniscal tear

what is MWM?

mobilization with movement= application of joint glide as patient performs active or passive movement

A manual therapy technique compromising of passive movements that are applied at varying speeds and amplitudes but high velocity

mobilization/ manipulation

pain with PROM: which types of tissues?

non-contractile

Which position of a joint is most common for mobilizations?

open-packed position

the movement of a bone about an axis -described in terms of limb segment motions -ex: flexion, extension, etc

osteokinematics

what can we focus on with symptoms other than pain?

paresthesias weakness instability CNS signs unexplained weight loss

PSFS

patient specific functional scale

the posterolateral corner stabilizes

posterior and ER forces

what are reg flags of exam findings?

severe, constant pain non-mechanical pain (position, movement) severe night pain history of injury severe spasm s/s systemic disease or infection

in contractile tissue, what is pain produced by?

stretch and contraction

The 3rd component of examination is:

tests and measures -confirm or refute -diagnosis classification -prognosis -plan of care -interventions

what is acuity?

the duration of a problem

High velocity, low amplitude therapeutic movement within or at end ROM

thrust

macrotrauma

trauma from one incident of a magnitude that causes immediate clinical signs and symptoms

t/f ACL strength deficits s/p ACLR persist to/beyond 1-2 yr

true

t/f Meniscal injuries are 2nd most common injury to the knee

true with peak occurrences at 3rd and 4th decades

MCL special tests include:

valgus stress test at 0 degrees, at 30 degrees

LCL special tests include:

varus stress test at 0 and [30 degrees and lateral tibial rotation]

When does observation occur for a PT exam? what is looked at?

when patient walks into exam room: gait willingness to move transfers