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PATHOLOGIES
100

Which meniscus is more firmly attached to the tibia?

Medial meniscus 

100

Describe the role of the quadricep during the normal gait cycle

What does it do at initial contact and loading response?

What happens towards mid stance?

preswing? 

initial swing?

Loss of function results in what?

  • Controls flexion during initial contact and loading response

  • Extends knee toward midstance

  • Controls flexion during pre swing

  • Prevents excessive heel rise during initial swing


**Loss of function results in lurching trunk anteriorly at initial contact to extend knee


100

Different kind of TKA designs

Unconstrained: no built in ______ to the prosthesis

What needs to be in tact?

Used mainly with what kind of TKA?

Semiconstrained: some stability built in with little compromise to ______

Are these common?

What ligaments are needed?

Fixed bearing/mobile platform: has a ______ platform to allow______ and ______ to reduce premature wearing

Cruciate retaining: _____ is excised except in Unicomp design. _____can be saved for posterior stability

  • Unconstrained: no built in stability to the prosthesis

    • In tact MCL and LCL are needed

    • Used mainly with unicompartmental design

  • Semiconstrained: some stability built in with little compromise to mobility

    • Most TKAs today

    • MCL and LCL ligaments are needed

  • Fixed bearing/mobile platform: has a rotating platform to allow rotation and sliding to reduce premature wearing

  • Cruciate retaining: ACL is excised except in Unicomp design. PCL can be saved for posterior stability

100

Precautions after ACL reconstruction

What are some precautions for resistance training? 

Hamstring graft vs Patellar tendon graft: which should you progress slower with?

What should we keep in mind with CKC training?  (squatting)

Avoid CKC strengthening between what degrees of flexion?

In open chain training avoid applying resistance to what part of the tibia for 4-8 weeks?



  • Resistance training - general precautions

    • Progress slower with hamstring graft than patellar tendon graft

    • Use caution progressing hamstring strength if ham graft is used

      • Hamstrings are extra support for ACL

    • Use caution progressing knee extensor strength if patellar tendon graft is used

  • CKC training

    • Keep knees even or behind toes when squatting to avoid anterior shear forces on graft

    • Avoid CKC strengthening between 60-90 degrees of knee flexion

  • Open chain training

    • During PREs to strengthen hip muscles, place resistance above the knee at first until control is established

      • Controls valgus moment - responsible for which way the femur is going to go

    • Avoid resisted open chain SAQ between 45-0 for 6-12 weeks

    • Avoid applying resistance to distal tibia during quad strengthening (maybe 4-8 weeks)

      • Probably wont do any MRE for ACL recovery

100

A condition described as softening and fissuring of the posterior surface of the cartilaginous area of the patella

Chondromalacia patellae

200

Which femoral condyle is longer

The medial femoral condyle

200

Describe the role of the Hamstrings during the normal gait cycle

Loss of function results in what?

  • Decelerate and control extension during terminal swing


**Loss of function results in genu recurvatum and snapping into extension


200

Cemented vs non-cemented vs hybrid TKA

Which is the gold standard?

Which method provides immediate stability?

Which will last longer? 

Which can you not put weight on right away?

Which combines both?


Cemented

The gold standard for TKA, cemented fixation uses a thin layer of bone cement to secure the prosthesis to the bone. This method provides immediate stability and fixation. However, younger patients who have cemented TKAs have a higher risk of revision.

Non-cemented

Some surgeons use cementless prostheses to reduce aseptic loosening and promote long-term implant survival. However, critics say that cementless implants may have increased rates of periprosthetic and femoral component fractures, and reduced long-term implant survival.

Hybrid

Hybrid fixation combines cemented tibial fixation with cementless femoral fixation. This technique may offer the advantages of cementless fixation while avoiding the risk of tibial loosening that can occur with full-cementless TKA

200

Return to Function Post-ACL reconstruction

How do we know when our patients are ready to return to sport?


  • No knee pain or effusion during final stage of rehab

  • Full active ROM

  • Quad strength is 90% of non-surgical leg

  • Hamstring strength is 100% of other leg

  • Negative pivot shift test (surgeon does this)

  • Passes functional testing of hopping, jumping, squat at 90% of other leg

200

Articular cartilage degeneration

  • Most common disease affecting weight bearing joints

  • 33% over 65 have radiographic evidence of OA

  • Pain, medial joint laxity, limited ROM, weakness, knee buckling sensation, genu varum deformity

Osteoarthritis

  • Factors that influence:

    • Excess weight

    • Joint trauma

    • Weak quads

    • Abnormal tibia rotation

300

Plica syndrome

condition in which a fold of synovial tissue in the knee, called a plica, becomes irritated or inflamed. The plica is a normal structure found in the knee, and in most people, it is asymptomatic. However, if it becomes thickened or irritated due to overuse, trauma, or repetitive movements, it can lead to pain and dysfunction.

300

Describe the role of the soleus during the normal gait cycle

  • Controls amount of knee flexion during pre swing by controlling forward movement of tibia

300

Goals, interventions, and presentation of a TKA in the maximum protection phases

ROM will be limited to?

WBAT with what kind of TKA?

Delayed WBAT with what kind of TKA?

How strong should we want there quads to be?

Why ankle pumps?

Muscle setting of what?

Stretching what?

  • Presentation

    • ROM will be limited to 10-60 degrees

    • WBAT with cemented; delayed with hybrid or non-cemented

  • Goals

    • Control pain and swelling

    • Gain ROM to 0-90*; at least ⅗ quad strength

    • Ambulate with/without assistive device

    • Establish a HEP

  • Interventions

    • Pain modulation modalities

    • Compression wraps

    • Ankle pumps to minimize DVTs

    • AAROM/AROM

    • Muscle setting of quads, hams, add

    • Gait training

    • Stretching of hams, calf, IT band

    • Trunk/pelvis stabilization exercises  

300

Posterior Cruciate Ligament (PCL).

How common is an injury of this ligament?

What kinds of grafts are used?

Open chain knee flexion is delayed for how long?

Emphasis on strengthening what?

Will this take longer or shorter to recover than an ACL injury?

Take precaution with exercises that place what kind of force on the tibia?


  • Rare form of injury

  • Uses same types of grafts as ACL with addition of achilles tendon, anterior tibialis

  • Knee usually be immobilized in extension for 4-8 weeks to prevent accidental posterior translation of tibia by knee flexors - evidence is poor to support this theory

  • Open chain knee flexion delayed 6-12 weeks

  • Rehab is mostly the same as ACL except:

    • Emphasis on quad strengthening in functional positions

    • Closed chain activities are delayed due to WB being restricted for a longer period

    • May take up to 3 months longer for full return than ACL injuries

    • Need to take caution with exercises that place posterior shear forces on tibia

      • Hamstrings pulling back

300

Occurs in response to trauma to the knee joint and structures

Posttraumatic arthritis

400

Describe the role of the gastroc during the normal gait cycle

  • Provides muscle tension to post knee when its in extension (end of loading response)

400

 TKA Management Moderate Protection Phase (Week 4-8)

What is ROM be limited to?

How much pain will they have?

FWB except with what type of TKA design?

What are some goals?

What are some interventions?

What mobs?

  • Presentation

    • Pain in minimal

    • ROM 0-90*

    • FWB except with uncemented

    • Joint effusion controlled

    • Balance and functional mobility is impaired

    • Diminished cardio

  • Goals

    • Reduce swelling

    • ROM 0-110 

    • ⅘ MMT

    • HEP

    • Good balance and functional mobility

  • Interventions

    • Patellar mobs

    • LE stretching

    • CKC strengthening

    • Limited range PREs

    • Tib-fem joint mobs

    • Proprio training

    • Stabilization/balance exercises

    • Swimming/walking/biking

400

PCL Rehab

Avoid exercises that place what kind of force on the tibia?

What to consider in early and immediate rehab?

Avoid leaning forward too much during squatting why?

Avoid knee flexion past 60-70* when squatting why?

Where should resistance be in relationship to the knee when performing standing hip exercises?

IN ADVANCE TRAINING 

Is jogging down hill okay?

How long to wait before returning to vigorous activities?


  • General Precautions

    • Avoid exercises that places shear forces posterior

  • Early and immediate rehab considerations

    • To restore knee flexion early on, begin in seats allowing gravity to assist, and allowing hams to remain inactive

    • Avoid leaning forward too much during squatting because it increases ham activity

    • Avoid knee flexion past 60-70* when squatting because it causes post translation

    • Place resistance above the knee when performing hip exercises in standing

    • Postpone open chain knee flexion against gravity for 6-12 weeks

  • Advanced rehabilitation considerations

    • Postpone resistance training for knee flexors using ham curl machine for 5-6 months AND use low loads

    • Avoid downhill inclines during walking, jogging, or hiking

    • Avoid activities that involve knee flexion combined with rapid deceleration when one or both feet are planted

    • Wait 9-12 months before returning to vigorous activities

400

  • Manifests early in hands and feet

  • Later moves to knees

  • Presents with warm swollen knees with limited ROM and genu valgum deformity

Rheumatoid arthritis

500

Does the MCL attach to the medial meniscus 

Yes

500

Explain pathological gait when there is a hip flexure contractures 

What is there a loss of?

How will this affect gait?

  • Loss of hip extension = flexed knee at terminal stance

500

TKA Management Minimum Protection Phase (beyond week 8)

How much muscle function will they have compared to the non-involved leg?

Will the pt. still present with pain?

What will be impaired?

What are some goals?

What kind of interventions? 

  • Presentation

    • Muscle function is 70% of non-involved

    • No pain or swelling

    • Impaired balance and functional mobility

  • Goals

    • Develop maintenance program

    • Community ambulation

    • Improve cardio

  • Interventions

    • Continue as previous phase and advance as appropriate

    • Progression of balance and advanced functional activities

500

Meniscus injuries.

How much of the meniscus is vascular?

What kind of tear can cause knee lock?

Which side of the meniscus is fixed more firmly to the tibia plateau?

Both menisci have a degree of movement with flexion and extension of the knee

Flexion - moves ______

Extension - moves ______

Part of what knee ligament attaches to the medial meniscus?

Which menisci do the hamstrings attach too? 

Meniscus repair will require a period of _____ while meniscectomy will not


  • Mechanism

    • Can be degenerative tears or traumatic

    • If traumatic, usually flexion or rotation forces are involved

  • Meniscus is vascular in outer ⅓ and has the ability to heal itself if the tear is in this portion - most tears are not in this red zone (blood supply zone)

    • Bucket handle tear can cause knee to lock - sometimes responds to manipulation

  • Medial meniscus is fixed more firmly to tibial plateau than lateral meniscus

    • Medial more prone to injury because it doesn’t move as much

  • Both menisci have a degree of movement with flexion and extension of the knee

    • Flexion - moves posterior

    • Extension - moves anterior

  • Important to note that part of deep MCL attaches to medial meniscus

  • Hamstring musculature has attachment sites to both menisci

  • Meniscus repair will require a period of NWB while meniscectomy will not

500

What happens with immobilization?

  • Contractures of capsule, muscles, soft tissue

  • Adhesions restrict caudal glide of patella limiting knee flexion

  • If patella does not glide proximally with quad contraction = extensor lag

    • Extensor lag = can’t hold extension actively but ROM is there passively

600

Knee Basics

What type of joint is the knee?

Cruciate ligaments provide stability in which direction?

Collateral ligaments provide stability in which direction?

What do coronary ligaments attach to?

  • Biaxial modified hinge joint

  • Anterior-posterior stability provided by cruciate ligaments

  • Mediolateral stability provided by collateral ligaments

  • Menisci improve articulation - attached to joint capsule by coronary ligaments

600

Explain pathological gait when there is length/strength imbalances

What can a length/strength imbalance do to the knee? (or any part of the body)

example?

  • Changes stresses on structures of the knee

    • Ex: tight TFL = lateral knee pain = maltracking of patella (abnormal alignment or movement during walking)

600

Activities with a Post-TKA

What kind of activities are highly recommended?

What kind of activities are recommended? 

What kinds of activities are not recommended? 

  • Highly recommended

    • Stationary bike, swimming, water aerobics, walking, golf with cart, ballroom dancing, table tennis

  • Recommended

    • Road cycling, speed/power walking, low impact aerobics, cross country skiing, doubles tennis, rowing, bowling, canoeing

  • Not recommended

    • Jogging, basketball, volleyball, singles tennis, baseball, high impact aerobics, water skiing, football, soccer

700

Explain the screw home mechanism during extension close packed (think baseball) 

  • Femur rotates internally, hip moved into extension

  • As knee is unlocked, femur rotates laterally

  • Hip extension is important to achieve full knee extension

700

Explain pathological gait when there is a foot impairment

What is pes planus?

What is pes cavus?

How would these deformities impact the position of the knee and hip?

  • Impact position of the knee and position of the hip

    • Ex: Pes planus = genu valgus = coxa vara

    • Ex: Pes cavus = genu varum = coxa valgus

700

Ligament Injuries.

Generally happens to what ages?

Which is the most common?

Which is the most rare?

What is the terrible triad?

A forceful blow to anterior tibia usually injures this ligament...

Which ligament would get injured from a valgus force?


  • Generally happen between 20-40 yrs old

  • ACL is most common

    • Contact or non-contact

    • Terrible triad - ACL, MCL, medial meniscus (usually go together)

    • What forces cause ACL tear?

      • Valgus with ER of tibia (weak glutes, hip abductors)

      • Forced hyperextension

  • PCL

    • Usually from forceful blow to anterior tibia - pushes tibia posteriorly

  • MCL (deep and superficial)

    • From valgus forces - straight blow from the lateral side

    • Tears can be partial or complete

    • Deep MCL can heal well - lock in 0* brace 

    • In flexion there is more movement - ligament isn’t taut

    • MCL attaches to the medial meniscus

  • LCL (rare)

    • From medial blow

    • Varus force

800

Which meniscus is more firmly attached?

Which is more prone to injury? 

  • Medial meniscus is more firmly attached      Higher weight bearing stress and higher risk of injury


800

Describe the protection phase of joint hypomobility management as pertains to the knee.

What to teach me?

What should they avoid?

How can we maintain soft tissue integrity and joint mobility?

How can we maintain muscle functions and prevent patellar adhesions?

  • Control pain and protect the joint

    • Teach patient how to protect the joint, bed positioning, ROM and muscle setting

    • Instruct patient to minimize stair climbing, avoid sitting on low surfaces, minimize excessive flexion ranges with weight bearing

  • Maintain soft tissue integrity and joint mobility

    • PROM, AAROM, AROM within pain free range

    • Gr I, II joint distractions or A/P glides in loose packed position

    • Stretching is contraindicated at this stage

  • Maintain muscle function and prevent patellar adhesions

    • Pain free muscle setting

    • Quad sets with SLF

    • Patella mobilization

800

Ligament injuries and female athletes

What type of ACL injury is much more prevalent for women? (3x more likely than men)

What role does hormonal changes play in injury?

T/F: Women have a larger femoral notch- A shaped rather than U shaped. 

  • Non contact ACL injuries much more prevalent (3x more likely than men)

    • Increased Q angle - more chance of landing incorrectly from a jump

    • Valgus moment at landing after a jump and decreased use of hip extensors

    • Hormonal changes (increased risk of injury during ovulation)

    • Smaller femoral notch - A shaped rather than U shaped - causes ACL to contact bones sooner from blow and tear easier

      • Notchplasty to fix shape and size of femoral notch

    • ACL is less elastic in females

900

The meniscus moves _______ in flexion and _______ in extension

1.posteriorly

2.anteriorly

900

Describe the controlled motion and return to function Phase of joint hypomobility management as pertains to the knee.

What would you educate the patient on?

What would be in the HEP?

How would you decrease pain from mechanical stress?

What kind of stretching if any?

What kind of exercises?

How can we improve their cardio endurance?  

  • Patient education

    • Talk to them about recovery and what to expect

    • Provide HEP with strengthening, ROM, stretching, low impact exercises, stationary bike

  • Decrease pain from mechanical stress

    • Use assistive devices as necessary

  • Increase joint play/ROM (tib-fem & patellar mobs) MWM (lab)

  • Stretching

    • PNF stretching; low load long duration stretching (grocery bag hanging)

  • Improve muscle performance in supporting muscles

  • Progressive stretching

    • Start with multiple angle isometrics and progress to open and closed chain exercises

    • Open chain are less painful with lighter loads and faster reps instead of the opposite 

    • Resistance through midrange (45-90) tends to increase PFP due to compression 

    • Strengthen both hip and ankle

    • Include endurance

  • Functional training

    • Steps, squats, sit-stands, partial lunges, balance activities

  • Improve cardio endurance

    • Bike, swimming, water aerobics

900

ACL Reconstruction

What are some indications?

What are some treatment options?


  • Indications

    • Severe tear or chronic insufficiency of the ACL

    • Pivot-shift test is abnormal

    • Limitation of functional movements

    • Failed conservative treatment

  • Treatments

    • Patellar tendon graft; allograft; synthetic graft; autograft involving semitendinosus/gracilis tendon

      • Bone-tendon-bone 

  • Chronic instability = early onset OA - proper management is super important 

1000

As the knee extends the patella slides in which direction?

Superiorly 

1000

What role does microfractures play in Repair of articular cartilage defects?

What does arthroscopic mean? 

  • Used for repair of small defects usually to the medial or lateral femoral condyle

  • Arthroscopic - subchondral bone is penetrated to stimulate marrow based response leading to local ingrowth of fibrocartilage to repair the lesion

1000

ACL Rehabilitation

What is a Cyclops lesion?

Types of grafts?

What's the key?

  • Depends on the type of surgical procedure and type of graft

  • Any graft type will be weakest the first 6-8 weeks

  • Key is re-vascularization of the graft

  • Cyclopse lesion

    • Inhibits knee extension - usually when can’t get back through PT

    • Fibrous nodule in intracondylar notch - error in surgery

1100

As the knee flexes what happens to the patella? 

The patella enters the intracondylar groove

1100

What is a osteochondral autograft transplantation?

What surfaces of the knee are they usually done on?

  • MD uses plugs from a site that has part bone and part articular cartilage

  • Used usually on weight bearing surfaces of the knee

1100

Patella graft

What are some advantages?

What are some disadvantages?

Would you be able to return pre injury, high demand activities?


  • Patella BTB (Bone to Bone)

    • Advantages

      • High tensile strength

      • Secure and reliable bone to bone graft fixation with screws

      • Rapid revascularization in 6 weeks at bone to bone interface permitting safe rehab

      • Ability to return to preinjury, high demand activities safely

    • Disadvantages

      • Anterior knee pain in surgical knee

      • Pain with kneeling 

      • Patellofemoral dysfunction

      • Patellar fracture during graft harvest (rare)

      • Patellar tendon rupture (rare)

1200

Does the patella affect knee flexion and extension?

If patellar movement is restricted, interferes with knee flexion and active knee extension.

1200

What are autologous chondrocyte implantations?

They are usually for lesions where?

How many stages is the procedure? 

How long does the whole process take? 

  • Usually for lesions on patella or femoral condyles

  • 2 stage procedure - healthy cartilage is harvested from patient then chondrocytes are extracted and cultured; implanted in the patient under a patch

  • Long process - up to 9 months

1200

Hamstring Graft

What are some advantages?


Will kids get a disturbance in the epiphyseal plate with this type of graft?

What are some disadvantages?

What is the healing time?

  • Advantages

    • High tensile strength, greater than ACL

    • No disturbance of epiphyseal plate in adolescent

      • Patellar BTB can’t be done if epiphyseal plate isn’t fully fused

    • Evidence of ham tendon regeneration at donor site

  • Disadvantages

    • Tendon to bone fixation devices not as reliable as bone to bone fixation

    • Longer healing time at tendon bone interface 12 weeks

    • Hamstring muscle strain early on can happen

      • Ham is active stabilizer of ACL - cautious with hamstring exercises

    • Short and long term knee flexor weakness

    • Possible increased anterior knee translation

1300

What is the Q angle and what forces maintain its alignment 

The Q angle is a measure of the alignment between your hip, knee, and lower leg. It's the angle formed by two lines:

  1. From the hip to the center of the kneecap (patella).
  2. From the kneecap to the shinbone (tibia).

  • normal angle = 15*


  • Forces maintaining alignment:

    • Trochlear groove

    • ITB/lateral retinaculum

    • VMO

    • Patellar ligament


1300

What is a Allograft transplant?

  • Rare - needs a fresh cadaver

  • Freezing kills chondrocytes


A procedure that involves transferring tissue, organs, or cells from a donor to a recipient who is not an identical twin of the donor


1300

ACL rehabilitation Maximum Protection Phase (0-4 weeks)

How will the patient present?

How will they ambulate?

What are the goals of this phase?

List some interventions:

What does PRICE stand for?

Why ankle pumps?

  • Patient presentation

    • Pain and hemarthrosis

    • Decreased ROM

    • Diminished quad contraction

    • Ambulating with crutches

    • Sometimes use of protective brace

  • Goals

    • Protect healing tissue

    • Prevent muscle inhibition

    • Decrease joint effusion

    • AROM 0-110

    • Active control of ROM

    • WBAT or sometimes 75%

    • Establish HEP

  • Interventions

    • PRICE

    • Gait training with crutches if needed

    • PROM-AAROM; wall slides for flexion

    • Patellar mobilizations

    • Muscle setting with towel under heel for extension

      • Quad sets/quad contractions is the golden ticket for recovery (pre and post)

      • Myotrack - patient has to do contraction (can see on the screen)

    • Assisted SLR supine - quad set first then SLR to keep leg straight (knee will bend without quad contraction)

    • Ankle pumps to prevent DVTs

    • After 2-4 weeks progress to full WB with minisquat (only with quad contraction), heel raises, SLR 4-way, ham curls

    • Open chain knee ext 90-40

    • Aerobic conditioning

    • Trunk stabilization (core) - HEP

1400

Compression against femur rises sharply after __* knee flexion

30

1400

Indications for a TKA

Severe pain with what?

Whats wrong with the articular cartilage?

What is an example of a marked deformity?


  • Severe pain with weight bearing

  • Motion that interferes with functional activity

  • Destruction of articular cartilage (bone-on-bone)

  • Gross instability or limitation of motion, marked deformity (genu valgus or varus)

  • Failure of a previous surgical procedure

1400

Moderate Protection Phase (4-10 weeks) of an ACL repair

What might their MMT test for the knee be?                            

Will they have full ROM?

Can they ambulate independently?

What are some goals of this phase?

What are some interventions to help towards these goals?

After 7-10 week start more advanced what?

Surgery and swelling prevents what from getting to the brain?


  • Patient presentation

    • Decreased swelling and pain

    • Near full ROM

    • 3+/5 to ⅘ MMT

    • Independent ambulation

  • Goals

    • Full pain-free ROM

    • ⅘ MMT

    • Dynamic control of knee

    • Improved kinesthetic awareness

    • Normalize gait pattern and ADL function

    • Adherence to HEP

  • Interventions

    • Multiple angle isometrics 

    • CKC strengthening and PREs (progressive resistive exercises)

    • LE stretching; especially hamstrings, ITB, and plantar flexors

    • Endurance training on bike or elliptical

    • Proprioceptive training in single leg stance

      • Bosu ball, balance board, foam, star balance

    • Stabilization exercises, elastic bands, band walking

    • After week 7-10 start more advanced strengthening, endurance, and flexibility exercises

    • Proprioceptive training (surgery and swelling prevents proprioceptive info getting to the brain - need to be retrained)

      • Stepping drills in high speed

      • Unstable surface challenge drills

      • Initiate a walk/jog program

1500

What is a bicompartmental TKA?

What is a Tricompartmental TKA?


1.Entire tib-fem surfaces are replaces (most common)

2. Addition of the patella

1500

What is a Unicompartmental TKA?

What joint surface(s) is replaced

Generally done with patients in what age range?

  • Only medial or lateral joint surfaces are replaced

    • Generally in patients <55 yrs


1500

Minimum Protection Phase (11-24 weeks)

Will they have pain?

Will they have symmetrical gait?

Goals?

Interventions?


Minimum Protection Phase (11-24 weeks)

  • Patient presentation

    • No joint instability or pain or swelling

    • Muscle function 75% of involved extremity 

    • Symmetrical gait

  • Goals

    • Increase strength, endurance, and power

    • Improve neuromuscular control, dynamic stability, and balance

    • Regain cardio endurance

    • Transition to maintenance program and reduce risk of reinjury

    • Regain ability to function at highest desired level

  • Interventions

    • Continue LE strengthening and advance PREs

    • Advance CKC exercises

    • Initiate plyos - progress


      • Bounding, jumping, skipping, jump rope, box jumps, 4 square

    • Progress agility drills - cones, figure 8

    • Varied running patterns

    • Simulate work/sport specific patterns

    • Transition to full speed jogging, sprints, running, and cutting