knee

  • what three muscle groups demand increases with running speed

    • soleus

    • quadriceps

    • hip complex

  • what plane of movement does an ACL strain most often occur in

    the sagittal plane

  • what is the main protective muscle group for the ACL

    the hamstrings

  • patella instability diagnostic tests

    • ottawa knee rules

    • sweep test

    • apprehension test - gliding patella laterally

    • medial joint palpation (MPFL tenderness)

    • joint glides and compressions



  • what are the muscles that oppose ACL loading

    • hamstrings

    • soleus

    • gluteus Medius

  • what are the muscles likely to increase ACL load

    • quadriceps

    • gastrocnemius

  • are previous mild knee strains a risk factor for ACL rupture

    in animal studies it found that there was a

    • decreased ACL strength and knee joint remodelling

    • altered movement control

  • what cartilage affects happen post ACL

    • cartilage homeostasis is affected

    • increase in non healthy cartilage growth

      • cartilage hypertrophy (swelling) = increased water content

    • cartilage doesn’t recover as well

  • neuro-biomechanical adaptations following ACL injury , ACLR

    • kinematics

      • increased knee extension and external tibial rotation

    • kinetics

      • decreased external knee flexion moments

      • increase and decreased knee adduction moments

    • neuromuscular

      • weakness

      • atrophy

      • decreased vasti activation

      • increased co-contraction

      • decreased quad force control

  • do ACLR patients underload TFJ



ACL reheb

 

Phase 1 - recovery from surgery

Goals to

  • PWB-FWB

  • Get rid of swelling

  • Get to 100 deg knee flexion

  • Get quad strength to 4+/5

  • 5/5 hamstring strength

 

Phase 2 - strength and neuromuscular control - 2-12 weeks

Goals to

  • Have no swelling

  • Full knee hyperextension

  • Knee flexion 130 degrees

  • Full squat

  • Good balalnce and control

  • Unrestricted walking

 

Phase 3 - running, agility and landings

Goals to

  • Full ROM

  • Full strength

  • Jogging

  • Running

  • Agility

  • Sport specific skills

Phase 4 return to sport


  • what is patellofemoral pain

    anterior or retropatellar pain in the absence of other pathology

  • List PFP typical symptoms

    • typically non-traumatic

    • diffuse ache in anterior knee

    • pain exacerbated by loading activities like squatting, stairs, run

    • ache with prolonged sitting

    • crepitus (popping, cracking)

    • giving way

    • swelling

    • locking

  • what is the structural contributors to the pain

    it is unclear ?

  • what are the potential pathways that link to PFP

    • elevated PFJ stress

    • psychological factors

    • pain adaptations

  • what are the two main causes of elevated PFJ stress

    • decreased PFJ contact area

      • caused by patella malalignment / maltracking

    • increased PFJ reaction forces

      • caused by altered joint kinetics / kinematics / muscle tightness

  • what anatomical changes can lead to PFP

    • patella

      • unusual shapes more likely to develop PFP

    • trochlear

      • lateral wall deficient

      • trochlear shallow or areas of convexity

  • what direction of patellar translation is common amongst people with PFP

    lateral

  • what are the passive soft tissue restraints to patellar tracking

    • lateral retinaculum - tightness

    • ITB - tightness

    • medial weakness

  • explain the quadricep muscle relationship to patella maltracking

    the VL has a great CSA and larger velocity producing properties than the VMO and can often result in a greater pull on the patella laterally by overpowering the VMO. this can alter PF rotation and tilt which may alter the contact area of the patellar within the trochlear which can result in increasing PFJ stress

  • how does vast neuromotor control relate to PFP

    those with PFP can have VMO delayed activation leading to increase PFJ stress

  • how does an increased hip internal rotation relate to PFP

    leads to

    • increased tightness of ITB

    • increased lateral quadriceps moment

    • changed orientation of femoral trochlea

  • what can cause increased hip internal rotation

    • glute medius dysfunction

    • femoral anteversion

  • what is hamstrings and gastrocs relationship to PFP

    • decreased length of hamstrings and gastrocs increases the knee flexion moment and increases PFJ reaction force and PFP

  • what are the psychosocial features of PFP

    anxiety, depression, catastrophising and fear of movement is increased in people with PFP

  • altered pain processing


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  • management of PFP

    • education

    • passive interventions

    • active rehabilitation

    • psychosocial factors

  • what is important to educate with PFP

    • the contributing factors of PFP

    • the management options

    • the importance of engaging with rehab

    • to manage expectations

    • weight loss advice

    • advice for activity modifications

  • what is involved with active rehab for PFP

    • vasti retraining

    • quadriceps and gluteal strengthening

    • movement pattern re-training

  • what are specific exercises to do

    • VMO retraining

      • learn how to contract VMO

      • use palpation

      • attempt to contract the VMO before the rest of the quads

    • quarter squat

      • about 40 degrees knee flexion

      • focus on glutes

      • ensure correct alignment

    • step downs

      • emphasis control both VMO and proximal

      • may use a mirror

  • what passive rehab can be done

    • tailored patellar taping

    • foot orthoses

    • massage / dry needling of tight lateral structures

    • PFJ mobilisation of hypomobile joint


Skye is a fourteen-year-old who dislocated her right patella five days ago whilst playing softball. She has been partial weight-bearing with crutches since the injury.

5a)       List some of the contributing factors, and describe how these factors may contribute to, patello-femoral joint dysfunction. You may use a flow chart to illustrate your answer.

 

-          Tight lateral structures pulling on the patella such as ITB, lateral retinaculum

-          Abnormal patella positioning such as baja or alta meaning it does not sit in the trochlea optimally

-          Increased Q angle / valgus alignment leading to more lateral patella tracking

-          Trochlear dysplasia / shallow groove leading to reduced bony stability

-          Weak VMO leading to poor medial stabilization

-          Ligament laxity and hypermobility

 

 

 

 

 

 

 

 

 

Structural factors (↑Q-angle, trochlear dysplasia, patella alta)

        ↓

Reduced bony stability

        ↓

Patella prone to lateral displacement

        ↓

Muscle imbalance (weak VMO, tight lateral structures)

        ↓

Dynamic maltracking

        ↓

Pain, swelling, quadriceps inhibition

        ↓

Patellofemoral joint dysfunction

6 marks

5b)       Describe two (2) exercises that may be appropriate to address her problems

i)                    at 5 days post-injury

 

isometric quad strengthening

straight leg raises

sidelying hip abduction

isometric hamstring stretches

ankle pumps



2. Mr C is day 1 post right (R) ACL reconstruction (gracilis / semitendinosis). He is

resting in bed with a Zimmer splint on his right knee and has had his drain tube

removed. The surgeon's protocol indicates that he may full weight bear, without the

splint (if he has good quads control) and to discharge him as soon as possible.

a)      Outline your objective assessment and expected findings for this patient.

 

-          Moderate pain and swelling

•     Limited knee flexion, near full passive extension achievable

•     Reduced quadriceps activation (difficulty with SLR)

•     Hamstring donor site soreness

•     Mobilising with crutches, WBAT if quads control present

 

 

(9 marks)

b)      List your criteria for discharge?

 

-          Safe independent mobility with crutches and weight bearing as tolerates

-          To have good quad control so be able to perform a straight leg raise without any quad lag

-          Patient education on home exercise program, precautions, wound care

-          Pain and swelling controlled

 

 

 

 

(4 marks)

c) Outline 6 potential rehabilitation issues/complications following discharge,

and discuss your principles of management for two (2) of these.

 

 

-          Reduced knee ROM

o   Knee ROM exercises: such as

§  Passive knee extension and flexion

§  Heal slides

§  Patellar mobilizations

-          Reduced quad strength

o   Early isometric quad activation

o   Straight leg raises

-          Hamstring weakness from the donor site

-          Swelling

-          Pain

-          Impaired mobility