OCS Knee - 1

What menicus is more likely to get injured?

What is the avascular portion of the lateral menicsus?

Medial due to reduced mobility.

Posterolateral corner

Which part of the patella is in contact with the femur during the performance of a squat to a depth of 80-90° of knee flexion?

• Inferior 1/3 of patella

• Middle aspect of patella

• Medial and lateral facets of patella

• Superior 1/3 of patella

Superior 1/3 of patella

LCL is responsible for resisting:

Varus forces at 0-30 flexion.

MCL is responsible for resisting:

Valgus forces at 0-30 flexion

What combo of knee ligament damage results in the greatest valgus laxity?

MCL + PCL 

ACL:

When posterolateral bundle is intact, but AMB bundle is torn _____ ________ test will be positive

anterior drawer

ACL

PLB is taut in ________ and prevents anterior translation in extension up to ___ degrees of knee _____.

What band gets tighter as knee flexion increases?

extension; 20 degrees of knee flexion; AMB

Majoity of ACL injuries MOI: 

non contact deceleration injury that occur with slight knee flexion and tibia in IR and ER

PCL:

ALB is taut in ______. Prevents posterior translation of the tibia on the femur between ______-_________ degrees of knee flexion

Flexion; 30-90

MOI of PCL

Hyperflexion (dashboard injury)

3 static stablizers of Posterolateral corner:

LCL, popliteus tendon, and popliteofibular ligament

Posterolateral corner injuries MOI:

Forced directed at anteromedial aspect of knee with foot planted in the ground.

Screw Home Mechism - Open Chain

Locking and Unlocking 

TOLL - Lateral rotation of tibia to achive extension (locking). Medial rotation of tibia to flex (unlocking)

Screw Home Mechism - Closed Chain

Medial rotation of femur on tibia to achive extension (locking) and lateral rotation of femur on tibia to achieve flexion

In the case of patellofemoral pain, to avoid compressive forces → avoid

terminal 30 degree of extension during open chain and avoid flexion beyond 90 degrees in closed chain

How to measure Q angle? What is normal for men and women? What is abnormal?

ASIS to midpoint of patalla and line from midpoint of patella to tibial tuberosity.

10-15 for men and 15-20 for women. >20 causes lateral patellar forces and displacement

Ottawa Knee Rules: 

100% Sensitivity! If non of the factors are present they do not need a x-ray. if they have 1, send them for an x-ray.

Age >55, isolated tenderness of patella or fibular head, inability to flex knee to 90 degrees, inability to bear weight immediately and in emergency room.

ACL Special Tests:

What is the most SENSITIVE test?

What is the most SPECIFIC test?

Lachman, anterior drawer, and pivot shift test.

Lachman
Pivot shift

PCL Special Tests

What test has the best testing properties?

What is the most SPECIFIC combo?

Posterior drawer test, posterior sag, quadriceps activating test

Quadriceps activating test

Posterior Sag and Quadriceps activating

PLC Special Tests:

What is the most specific test?

Posterior drawer, dial test, reverse pivot shift test
Dial test

When performing the posterior drawer test, what would cue you to think about a posterolateral injury?

Posterior translation increased at 30 degrees flexion but normal at 90 degrees flexion

What is a positive dial test? (prone external rotation test)

ER that exceeds 10 degrees at 30 but not at 90 is an isolated PLC injuury. positive of both includes to PCL.

How to check  for isolated MCL injury?

Valgus stress test >5 mm laxity at 30 degrees knee flexion

If laxity is >10 mm at 30 degrees knee flexion during valgus stress test what should you do?

Check ACL

If laxity is >5 mm at 30 degrees knee flexion during varus stress test what should you do?

Check ACL and PCL

How to check  for isolated LCL injury?

Varus stress test >5 mm laxity at 30 degrees knee flexion.

Knee ligament sprain CPG

deceleration or cutting injury, pop felt, swelling within 0 to 12 hours, sense of knee instability

Return to sport criteria

>90% on single hop, triple hop, 6-m hop, cross hop, >90% quad strength, and KOS-ADL score, global rating scale, and IKDC 2000 score.

Best dynamic balance tests for ACL return to sport

Star Excusion Balance Test and Y balance tes. Make sure they are less than 4cm difference between limbs. 

How long should you delay Return to Sport for ACL?

At least 9 months.

Interventions for ACL Rehab

A Level 

OKC/CKC concentric and eccentric exercises within 4 to 6 weeks, 2-3/week for 6 to 10 months, NMES for 6-8 weeks post surgery, and post ACLR

Interventions for ACL Rehab

B level

immediate ROM 1 week after, ice, and supervised rehab

What is a functional brace going to beneficial for?

ACL reconstruction population or ACL deficient population?

ACL deficient knee.

CPG for history of diagnosing knee meniscus injury:

pain w/ hx of twisting, “catching” or “locking”, delayed onset of effusion 6-24 hours

CPG for objective measures of diagnosing knee meniscus injury:

how many do you need for positive test

Knee catching, joint line tenderness, pain with forced hyperextension, pain with maximal passive knee flexion, +mcmurray test

3 or more

Effusion due to a meniscus injury should occur:

Effusion due to a ligment injury should occur:

Effusion due to a osteochrondral fracture injury should occur:

6-24 hours after injury

0-12 hours after injury

0-2 hours aftery injury

Milking Maneuver:

None. Milk out swelling distal to proximal several times:

Sweep proximal to distal on the lateral side

View the medial sulcus for return of swelling

Grade 0

Milking Maneuver:

Milk medially sweep laterally, small amount back

Trace

Milking Maneuver:

You can milk out the swelling and it does not return on its own but returns with lateral sweep

1+ 

Milking Maneuver:

You milk out the swelling and it returns immediately to fill the pouch

2+

Milking Maneuver:

You cannot milk the swelling out

3+

Meniscus CPG: 

Younger patients. Conservative or surgerical?

Menicus repair over partial meniscectomy 

Meniscus CPG: 

Degenerative menicus patients. Conservative or surgerical?

No surgery, no MRI, no arthroscopy. convervative!

Meniscus CPG: 

Return to sport timelines - menisectomy

<30 likely to return to sport <2 months after partial meniscectomy. >30 =3 month return

Rehab for Meniscectomy:

work on quadriceps insufficiency. no precautions. 2-6 weeks.

Rehab for Meniscal Rehab:

How long is weight bearing limited and progressed?

Most important components.

What should be avoided in first 4-8 weeks

weight bearing over 8 weeks. Controlled weight bearing and ROM.

weight bearing activities in angle >45 flexion such as squatting are avoided. loaded knee flexion beyond 90 is limited for 8 weeks

How to distinguish between meniscus and cartilage injuries in knee?

Meniscus is twisting injury and delayed swelling (6-24 hours). intermittent swelling is a cartilage injury

Indications for Meniscal Transplant

<40, minimal OA, poor candidate for TKA, at least 2 mm of joint space.

How to differential Meniscal vs. Articular lesions:

For meniscus look for twisting injury, delaying swelling, and meniscal composite score. Suspect articular cartilage only after ruling out meniscal and ligament injuries

Best outcome measures for Meniscus and Artticular cartilage:

30 second chair-stand, stair climb, TUG, 6 min walk

Best Self Report Outcome Measures for Meniscus:

IKDC and KOOS

Most common location of Articular Cartilage Injuries:

Medial femoral condyle and patellar surface

Most common Articular Cartilage surgery:

Chondroplasty followed by microfracture.

Indications for microfracture procedure: Articular cartilage

Full thickness lesion <2cm² with no osseous defect, young patients with low demand sports

Indications for OATS procedure:

Small osteochondral lesions <2cm² but sports goals

Indications for ACI (osteochondral allograft transplantation)

Lesions measuring between 1 to 10 cm² and people who have failed microfracture or OATS.

MDC for KOOS with Chondral Lesions

10% (7.4%-12.1%)

Knee Effusion Test:

No fluid w/ down stroke

0

Knee Effusion Test:

Small bulge mediallly

Trace

Knee Effusion Test:

Large bulge w/ down sweep

1+

Knee Effusion Test:

medial returns w/o down sweep

2+

Knee Effusion Test:

excess fluid can not stroke

3+

What will you see with an Increased Q angle?

Anteversion, genu valgum, coxa vara, and pronation (more valgus + more lateral pull)

What will you see with a decreased Q angle?

Retroversion, genu varum, coxa valga, and supination (more varus + more medial pull)