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