OCS - Knee 2

What is the best diagnostic indicator of Patellofemoral pain

Anterior or retro knee pain during squatting, stairs, and sitting with a flexed knee.

Risk factors for PFPS:

female, limited quad flexibility, hypermobile patellofemoral joint, decresaed knee extension strentgth, diminshed quad explosive strength.

Outcome measures for PFPS:

AKPS, KOOS-PF, VAS, NPRS

Scrrening Tool for psychosocial contributors in difficulties for Return to Sport

ACL-RSI (ACl return to sport after injury scale)

What is the WOMAC outcome measure used for?

How is it scored?

OA

higher score, worse outcome

Best outcome measure for Patellar Tendinopathy

VISA-P (victorian institute of Sport Assessment Questionnaire, Patellar Tendon)

Knee Arthrofibrosis Grades:

<10 degree extension loss, normal flexion

Grade I

Knee Arthrofibrosis Grades:

>10 degree extension loss, normal flexion

Grade II

Knee Arthrofibrosis Grades:

>10 degree extension loss, >25 flexion loss w/o short patellar tendon

Grade III

Knee Arthrofibrosis Grades:

>10 degree extension loss, >30 flexion loss w/ patellar tendon contracture

Grade IV

Most specific test for PFPS: 

step down test

Patellofemoral Pain Syndrome Categories: 

Eccentric step down test (+) 

Reproduction of anterior knee pain

Overuse/Overload without other impairment 

Patellofemoral Pain Syndrome Categories: 

Lateral step-down test >2 score

Frontal plane valgus - Single-leg squat - >10 degree increase in FPPA

Movement Coordination Deficits

In Patellofemoral Pain w/ Movement Coordination Deficits:

What does their lateral step-down test score need to be to be positive?

What about Frontal plane valgus?

>2; >10 valgus

Patellofemoral Pain Syndrome Categories: 

What Muscles are weak in PFP w/ Muscle Performance Deficits

Abductors, external rotators, extensors

Patellofemoral Pain Syndrome Categories: 

Foot mobility: >11 mm difference between NWB and WB

Foot posture index >6 aka pronated foot

>11 mm difference

SLR <79, Ankle DF <7, Ankle DF knee flexed <14, Obers Test <11

PFP w/ Mobility impairments

Intervention:

PFPS w/ Overuse/Overload without other impairment 

Taping (push patella medially), exercise, and activitiy modiciation

Intervention:

PFPS w/ Movement Coordination Deficits

Gait and movement retraining (increase forefoot strike, reduce hip adduction, increase cadence, and reduce load)

Intervention:

PFPS w/ Muscle performance deficits

Hip/gluteal/quad strengthening

Intervention:

PFPS w/ Mobility Impairments

Foot orthorsis 4 weeks if they have hypermobility, taping, stretching tight muscles

A level interventions for Patellofemoral pain

no needling in isolation, no manual therapy in isolation, hip + knee exercises, foot orthosis for hypermobility , combined interventions.

How to differentiate Osgood Schlatter Disease vs. Sinding Larsen Johannsson Syndrome?

OSG - tibial tuberosity, SLJ, inferior pole of patella

Seen in Males.

ØLocalized pain over the patella tendon

ØUS/ Corticosteroid injection is not recommended

ØProgressive tendon loading ( isometric à concentric à Eccentric)

Patellar tendinopathy

Hilly terrain, downhill biking, Repetitive running

Ø Pain at lateral femoral condyle at 20-40 degrees of knee flexion à Noble

compression test

Ø Manage by strengthening and flexibility, hip and knee motor control exercises

IT band friction syndrome

Special Test for IT band fricton syndrome

Noble Compression Test

Signifincant predictor of development of patellofemoral OA

Hx of patellar dislocation or hx of adolescent knee pain

To distinguish patellofemoral arthritis from patellofemoral pain syndrome:

consider the age of patient (young females have PFPS)and presence of knee/patellar deformitie s

Criteria of Tibiofemoral OA:

Knee pain + any 3 of the following:
>50, <30 min of morning stiffness, crepitus, bony tenderness, bony enlargement, no palpable warmth

Kellgren-Lawerence Classification of Knee OA:

no OA with definite absence of x-ray changes of osteoarthritis.

Grade 0

Kellgren-Lawerence Classification of Knee OA:

means doubtful OA with doubtful joint space narrowing and possible osteophytic

lipping (small osteophytes)

Grade 1

Kellgren-Lawerence Classification of Knee OA:

means minimal OA with definite osteophytes and possible joint space narrowing

Grade 2

Kellgren-Lawerence Classification of Knee OA:

means moderate OA with moderate multiple osteophytes, definite narrowing of joint space and some sclerosis and possible deformity of bone ends

Grade 3

Kellgren-Lawerence Classification of Knee OA:

means severe OA with large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone ends

Grade IV

Knee OA Grades:

When do osteophytes become definitive?

When does joint space narrowing become definitive?

Grade 2; Grade 3

Management of unicompartmental Knee OA:

Bracing, lateral heel wedges, and tibial osteotomy

Bracing for valgus offloading for medial compartment OA, do NOT use lateral heel wedges, tibial osteotomy is weakly recommended

Conservative Management of Knee OA:

Exercise recommendations

hip and knee strengthening and general aerobic conditioning COMBINDED, high intensity training is more beneficial than low intensity, quad exercises include OKC and CKC

Conservative Management of Knee OA:

Modalitiy recommendations

short term benefit of low level laser, ultrasound, manual therapy only with exercise, diet and exercise for weight loss together, use of AD, NSAIDs are best

If pt has knee OA + at least one or two of the following, they are likely to benefit from hip mobilization:

Hip or groin pain or paresthesia, anterior thigh pain/passive knee flexion less than 122 degrees, passive hip IR <17, pain with hip distraction

What are the Pittsburg knee rules?

Radiographs requires if there is a fall or blunt trauma and either one of the following: 

age<12 or >50, inability to walk weight bearing steps in ER

more efficient in trauma situations

ACL Prevention CPG:

When should you start (what age?)

<18 females soccer players

ACL Prevention CPG:

What does this entail and how long should the sessions be, how long through the season should it go?

Combo of strength and plyometric exercises, multiple times per week >20 minutes, start in the preseason and go through the regular season.

How to qualify to be part of the screening process as a Coper for ACL Tear?

Isolated tear of ACL, 70% quad strength, full-pain-free knee ROM, no joint effusion

What are the 4 steps of screening the be considered a ACL Tear Coper?

>80% on all hop tests, >80% on KOS, >60% Global rating of knee function, and no more than 1 episode of giving way

How to determine if a adolscent needs ACL reconstruction?

Partial tear

MRI, if ACL is partial (<50% AM bundle) and age <14 try conservative

How to determine if a adolscent needs ACL reconstruction?

Complete ACL tear options

<12 male or <11 female with growth remaining. Physeal-sparing autograft technique (IT Band)

>13 male, >12 female with limited growth. Transphyseal autograft with soft tissue autograft and metaphyseal fixation

What outcome measures are used for ligament injuries?

Self-reported for knee symptoms and function:

IKDC 2000 and KOOS

What outcome measures are used for ligament injuries?

Activity Level

Tegner, Mark’s, Lysoms

What outcome measures are used for ligament injuries?

Performance

SL for distance, cross over hop, triple hop, 6m hop 

PCL Tears:

Grade I and II tears have a rapid recovery, and the goal is to RTS within __ - __ weeks

restoration of _____ is critical to recovery

2 to 4; quadriceps

PCL Tears:

Grade III PCL tears recovery more slowly and may be immobilized in _____ for - weeks to reduce:

extension for 2 to 4 weeks to reduce posterior subluxation caused by hamstring contraction.

PCL Tears:Grade III tears What should be initally avoided:

Patients are usually RTS at about 3 months

Knee flexion past 70 and isolated hamstring exercies.

Reconstruction of the PCL is generally performed with an _______ allograft?

What is the focus of rehab program? The graft is typically tensioned:

achilles tendon allograft; slow progression of ROM especially knee flexion; 70 to 90 degrees of flexion

PLC Rehab:

Postop restrictions:

non-weight bearing for the first 6 weeks in a knee immobilizer.

dynamic stabilizers of PLC

lateral head gastroc, biceps femoris, ITB, and fabellofibular ligament

PLC Rehab:

When do exercises begin?

CKC exercises in less than 70 flexion at week 7. No isolated hamstrings until 4 months post surgery

MCL Rehab: 

Is conservative or surgical better?

No benefit of surgical management

Knee Soreness Rules for knee rehab:

Sorness during warm-up that continues

2 days off, drop down 1 step

Knee Soreness Rules for knee rehab:

Sorness during warm-up that goes away

Stay at step that led to soreness

Knee Soreness Rules for knee rehab:

Sorness during warm-up that goes away but redevelops during session

2 days off, drop down 1 step

Knee Soreness Rules for knee rehab:

Sorness the day after lifting (not muscle soreness)

1 day off, do not advance program to the next step

Knee Soreness Rules for knee rehab:

No soreness

Advance 1 step per week or as instructed by health care provider

TKA CPG Summary: 

Strong Strength Recommendatinons:

Include motor function training (balance, walking, movement symmetry)

TKA CPG Summary: 

Moderate Strength Recommendatinons:

design pre-op programs, do NOT use CPM, use cryotherapy, and start within 24 hours of surgery, NMES as adjunct, high intensity strength training, and kneeling training.

TKA CPG Summary: 

What factors are associated with poorer prognosis?

Is diabetes associated with poor prognosis?

Higher BMI, depression, and greater degree of comorbidity

No.

TKA CPG Summary: 

What factors are associated with better prognosis?

Preop ROM and strength

Best TKA Self Report Outcome Measure:

What performance based outcome measures are best?

KOOS-JR and WOMAC

30 Sec StS and TUG