Ortho 2: Knee

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Knee Outcome Survey (KOS)

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Knee Outcome Survey (KOS)

ADL and sport scale 0-100, 100=fully functional

MDC 8.4

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Lower Extremity Functional Scale (LEFS)

For any LE Ortho problem

0-80, 80=fully functional

MDC 9

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Knee Injury and OA Outcome Scale (KOOS)

Pain, daily function, sport and recreation function, knee related quality of life

0-100, 100=fully functional

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Tegner Activity Level Scale

0-10 scale, 0=on sick leave/disability, 10=participation in competitive sports at national elite level

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Marx Activity Level Scale

0-16 scale

High level activities like running, cutting, decelerating, and pivoting

Each rated on 4 point scale

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Osteosarcoma

Most common malignant bone tumor

Onset: 10-25 y/o

50% located in femur above the knee

Pain, swelling/mass, decreased ROM

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Chondrosarcoma

Second most common malignant tumor in adults

Common in long bones

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Ewigs Sarcoma

2nd most common bone tumor in children

Onset: 5-16 y/o

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Laxity

Movement of tibia relative to femur in a specific direction

(anterior/posterior translation, varus/valgus angulation)

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Instability

Excessive joint laxity

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Structural Instability

Instability based on testing

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Functional Instability

Instability the impacts function (does not allow functional activity)

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Frequency of Ligamentous Injury

MCL>ACL>PCL & LCL

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MCL Injury

>80% are contact injuries with valgus stress (direct blow to lateral knee with planted foot)

Non-contact: Valgus and rotational force

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LCL Injury

Contact injury with varus force with or without rotation stress to knee

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Why Are LCL Injuries Less Common

Shielded on inside of knee

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Collateral Ligament Conservative Intervention: Phase 1

Pain and swelling control

WBAT with crutches in brace if grade 2 & 3

Isometric quad and hamstring exercise

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Collateral Ligament Conservative Intervention: Phase 2

Progress to FWB

Isotonic open and closed chain exercise

Stationary cycling, stair climber, swimming

Proprioceptive exercise

Monitor ROM, pain, and swelling

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Collateral Ligament Conservative Intervention: Phase 3

Functional/skill training

Full ROM

Strength 75-85% of contralateral limb

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Collateral Ligament Conservative Intervention Return to Play Time: Grade 1

10 days-2 weeks

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Collateral Ligament Conservative Intervention Return to Play Time: Grade 2

3-8 weeks

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Collateral Ligament Conservative Intervention Return to Play Time: Grade 3

8-12 weeks (may require surgery)

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Indications For Collateral Ligament Surgery

Avulsion fracture

Combined ligament injury

Grade 3 tear with functional instability

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ACL MOI: Non-contact

Rotation of fixed foot, Deceleration with knee hyperextension

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ACL MOI: Contact

Valgus/Varus force

Hyperextension force

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ACL Injury Risk Factors

Increased BMI, Hyperlaxity, Female, Narrow femoral notch

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What Is The Terrible Triad

ACL/MCL/Meniscus

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Why Females Have Higher ACL Risk

Greater knee valgus, Quad dominant, Slower muscle activation, Jump mechanics

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ACL Surgical Indications

Multiple structures injured, Desire to return to specific demand activities

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ACL Non-surgical Indications

Little exposure to high risk activities, >40 y/o, Prolonged deficiency with no functional instability

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Graft Ligamentization: Phase 1

Incorporation

Inflammatory response, graft degenerates, fibroblasts die, remaining tissue is scaffold

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Graft Ligamentization: Phase 2

Revascularization

Ingrowth of capillaries from synovium, migration of host fibroblasts into the graft tissue

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Graft Ligamentization: Phase 3

Graft healing and maturation

Graft strength and stiffness drops very low, but improves over time, Increase in collagen content and realignment

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PCL Function

Resists posterior translation of tibia

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PCL Non-surgical Intervention: Phase 1

Pain/swelling control

Ambulation starting WBAt with crutches moving to FWB

Isometric quad exercie, Mini-squats

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What ROM is PCL Rehab Limited To

0-60 degrees

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PCL Non-surgical Intervention: Phase 2

Stationary cycling, stair climber, LE concentric/dynamic strengthening, proprioceptve exercise, Monitor ROM, pain, and swelling

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PCL Non-surgical Intervention: Phase 3

Running program, continued strengthening, functional/sport specific training

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Criteria For Return From PCL

Full ROM

Strength 75-85% contralateral limb

Possible bracing

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PCL Surgical Intervention

If avulsion fracture

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MCL-ACL Combined Ligament Injury

AMRI

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PCL-LCL Combined Ligament Injury

PLRI

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Knee Dislocation

High Trauma, Medical Emergency, Requires surgical intervention, usually includes vascular and neuro injury

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Meniscus Function

Distributes load

Removal can lead to increase load and lead to OA

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Non-contact Meniscus Injury

Rotation of flexed knee of planted foot

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Is Medial or Lateral Tear of Meniscus More Common

Medial (3x more)

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Bucket Handle Tear

Flap of meniscus can flip over joint space and cause locking/catching

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Meniscus Cluster Tests

Locking

Joint Line Tenderness

McMurray’s

Pain with Flexion

Pain with Hyper Extension

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Discoid Meniscus

Anatomical variant, May be complete or incomplete, May have lateral compartment pain or loss of ROM, Surgery can reshape

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Osteochondritis Dissecans (OCD)

Defect of articular cartilage due to Trauma, Ischemic necrosis, or Genetic Factors

Medial Femoral Condyle, Patella, Lateral Femoral Condyle

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Signs/Sx of OCD

Not well localized pain

Variable swelling

Mechanical locking

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Knee OA

60+ y/o

Major cause of stair navigation difficulty

2nd to heart disease as cause of work disability in men 50+ y/o

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Knee OA Risk Factors

BMI >30, Increased age, Female, Black, Knee Trauma, Physical workload, Bone mineral density

Decreased space, subchondral sclerosis, bone spurs on imaging

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Patellar Tendinopathy

Prevalent in Athletes (volleyball, basketball, high and long jumpers)

Palpation of inferior patellar pole has high sensitivity and moderate specificity

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Patellar Tendinopathy Risk Factors

Decreased eccentric quad muscle performance

Decreased quad/hamstring flexibility

Increased foot pronation velocity

Excessive training volume

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Phases of Patellar Tendinopathy Intervention: Phase 1

Isometrics

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Phases of Patellar Tendinopathy Intervention: Phase 2

Slow heavy load

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Phases of Patellar Tendinopathy Intervention: Phase 3

Power

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Phases of Patellar Tendinopathy Intervention: Phase 4

Sport specific/elastic function

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IT Band Syndrome

Short ITB/TFL, Glute and hip lateral rotator weakness, Pain over lateral femoral epicondyle

Common in runners and cyclists

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Bursitis

Overuse

Traumatic

Infection: Staph aureus

Pain and Swelling

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Fat Embolism

Medical Emergency

Shortness of breath, tachypnea, tachycardia, chest pain

Complication of Fracture

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Saphenous Nerve Entrapments

Inpingement of cutaneus branch of femoral nerve at adductor canal

Pain in medial calf and knee

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Fibular Nerve Entrapments

Entrapmet at fibular head

Pain in lateral calf

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Patellofemoral Pain

Common in young, physically active pts

Females>males

Pain with squatting and jumping

Quad weakness, pes planus

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Biomechanical Theories for PFP: Structural Malalignment

How you’re built

Q-angle not associated with PFP

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Biomechanical Theories for PFP: Dynamic Malalignment

How you move

Impairment driven: Muscle strength impairment, flexibility issues, Neuromuscular, Etc

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Tibiofemoral Alignment’s Contribution to PFP

Tibiofemoral rotation, Genurecurvatu, Tibial Torsion

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Lateral Compression’s Contribution to PFP

Increased loading lateraly

“tight joint”

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Patellar Instability’s Contribution to PFP

Lateral Subluxation, Increased lateral loading, Increased tension medially

“lose joint”

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Chondromalacia

Excessive cartilage degeneration on posterior side of patella

Cartilage is pitted, soft, and fragmented

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