Anatomy
During an ACL graft, the graft is commonly comprised of one of these 3 options...
1. Bone-patella tendon-bone (B-PT-B) graft (PRO: faster healing. CONS: anterior knee p!, potential knee ext deficit)
2. Hamstring graft (semitendinosis + Gracilis) (PRO: fewer symptoms/earlier rehab. CON: chronic tendonitis/HS strains)
3. Allografts (achilles tendon, anterior tib)
Describe the screw home mechanism. When does it occur?
The screw home mechanism is the locking mechanism of the knee that occurs in the last 20 degrees of terminal knee extension. (open chain = tibia ER on femur) (closed chain = femur IR on tibia)
You are seeing a patient with increased bilateral knee valgus. Which hip movements/muscle groups would you expect to be weak (2)? And, because of the increased valgus, you could expect increased ______ at the ankle and foot.
increased knee valgus = weak HIP ABD and ER
increased knee valgus = increased ankle/foot PRONATION
Your patient has pain with palpation to her lateral knee and a positive Ober's Test. Which diagnosis comes to mind?
ITB Syndrome
Patient with PFPS (patellar femoral pain syndrome), to correct their muscular imbalance, you would want to stretch what and strengthen which structures?
PFPS Patient:
Strengthen: hip ABD/ER, quads, glutes
Stretch (increase mobility): ITB/TFL, HS
The _(connective structure)___ is attached to the medial meniscus and capsule and, resists _______ (valgus/varus) forces.
The MCL is attached to the medial meniscus and capsule and, it resists VALGUS forces.
Review: connective structures of the knee and their function
Being "knock-kneed" is the lay term for _____ _____ and you would expect to see excessive _______ (medial or lateral) patellar positioning in these patients.
knock-kneed = GENU VALGUS, you would expect to see excessive LATERAL patellar positioning.
Time to progress and incorporate balance and proprioception tasks! Name one balance task/exercise and how to progress it.
-bilateral --> unilateral (on WBing LE)
-slight fleion --> increased flexion (on WBing LE)
-stable surface -->unstable surface (foam pad, trampoline)
-undistracted --> distracted (throwing/catching ball, body blade)
If the foot is fixed/planted and the femur pivots with abnormal force which structure is at high risk for injury?
BONUS: which injury to this structure is most common?
The meniscus is at high risk for injury
BONUS: medial meniscus injuries are most common and are commonly associated with ACL injury
A Chopat strap may provide temporary relief of symptoms for patients with which knee pathology?
BONUS: if you can explain why the Chopat strap provides relief/what is it's purpose?
A Chopat strap may provide temporary relief for a patient with PATELLAR TENDONITIS (and Osgood-Schlatter)
BONUS: it can provide relief because of it applies pressure to patellar tendon, stabilizing it and decreasing excessive movement/irritation
The medial meniscus is ____ shaped and attaches to which main ligament?
The medial meniscus is C shaped and attaches to the MCL.
The ACL prevents excessive _______ (anterior/posterior) translation of the tibia and is taught in ________ (flexion/extension)
**BONUS: Name the "Big 5" in ACL rehab
The ACL prevents excessive anterior translation of the tibia and is taught in extension.
BONUS:
1.swelling/effusion/pain control
2.ROM (extension/flexion)
3.Quad activation
4.Increase WBing
5.Normalized Gait
Describe one way you could instruct a patient in self knee flexion stretching.
-seated edge of table
-supine with strap/towel
-supine with LE inclined, foot on swill ball/towel
-prone with strap
-supine with LE up against wall, pulling foot toward floor
If the foot/tibia is fixed and excessive VALGUS force is exerted on the knee, which structure is likely to be injured?
MCL
(excessive VARUS force = LCL injury)
Review: mechanisms of injury and associated treatments/protocols
Your patient has a grade II MCL sprain and you want to put his MCL on slack for pain relief. How should you position his leg to decrease tension on the ligament?
Place hip into IR to put MCL on slack
(place hip into ER to put LCL on slack)
Which 3 muscles make up the pes anserine?
Sartorius, Gracilis, Semitendinosus
Which muscles are responsible for flexion of the knee? (need to name 4 primary - bonus for naming any assistants (3))
Primary: biceps femoris, semitendinosus, semimembranosus, gastrocnemius
Assistants: gracilis, sartorius, popliteus (unlocks TKE)
Time to progress your s/p knee sx patient! You are progressing to open chain strengthening exercises. What is considered the ROM "safe zone" during open chain exercises for a post-surgical knee patient?
open chain safe zone: 45-90 degrees of flexion
(closed chain safe zone: 0-45 degrees of flexion)
This knee pathology is defined as, "traction apophysitis at the tibial tuberosity" and can be caused by repetitive overloading, jumping/landing.
BONUS: where do patients usually complain of pain with this diagnosis?
Osgood-Schlatter Disease
BONUS: patients usually complain of pain at the patellar tendon insertion
When treating patients with chronic patellar dislocation/subluxation, you would want to focus on strengthening _______ to control patella movement/positioning.
Focus on strengthening the QUADS to control patella movement/positioning.
During knee flexion, the patella glides _______.
During knee flexion, the patella glides INFERIORLY.
(and it glides superiorly during knee extension)
The _(muscle(s)____ controls where the patella goes and the _(muscle(s)___ control how the femur rolls.
the QUAD controls where the patella goes and the GLUTES control how the femur rolls.
Which structures comprise the "terrible triad"?
ACL, MCL, medial meniscus
Your patient has PFPS (patellar femoral pain syndrome). You could expect to see:
*___(increased/decreased)____ Q angle
*weak ___(muscle groups)___ name at least 2
*tight ___(connective structure)____ and
*pain with ___(flexion/extension)___
PFPS Patient:
-increased Q angle
-weak quads/glutes/hip ABD/ER
-tight ITB
-pain with flexion
Following meniscus repair, knee flexion is limited to ___ degrees during the first 4 weeks and limited to ___ degrees from weeks 4-8.
limited to 45 degrees flexion during first 4 weeks and limited to 90 degrees flexion during weeks 4-8