Musculoskeletal LQ Week 9 - Knee Pathologies

Self-Reported Measures – Knee

• The objective is to identify patient self-report measures for patients with knee diagnoses.
• The objective is to identify key features and self-report measures including MCID, MDC, and other identifying cut-points.
• Lower Extremity Functional Scale (LEFS), Knee injury and Osteoarthritis Outcome Score (KOOS and KOOS-PF), and International Knee Documentation Committee 2000 Subjective Evaluation Form are self-reported measures.
• Anterior Knee Pain Scale, Short Form – 36, Tegner Activity Scale, ACL Return to Sport after Injury Questionnaire (ACL-RSI), Numeric Pain-rating Scale (NPRS), and Visual Analog Scale (VAS) are self-reported measures.

Lower Extremity Functional Scale

• Consists of 20 questions about a person’s ability to complete everyday tasks.
• Used to determine patients’ function at evaluation, set functional goals, and measure progress.
• Patients select an answer from the following scale for each activity listed: Extreme difficulty or unable to perform activity, Quite a bit of difficulty, Moderate difficulty, A little bit of difficulty, and No difficulty.
• Both the MCD and MCID scores, out of 24, are 9 points.

Knee Injury and Osteoarthritis Outcome Score (KOOS)

• It is a 42-item questionnaire with 5 subscales.
• The subscales are Symptoms, Pain, ADLs, Sports and recreation, and Quality of life.
• It can be used for any knee pathology.
• A specific version has been created for patellofemoral syndrome (KOOS-PF).
• It is validated and reliable for advanced osteoarthritis.

International Knee Documentation Committee 2000 subjective Knee Evaluation Form

• Target population: anterior cruciate ligament injuries
• It is a 10 item questionnaire with 3 scales.
• The 3 scales are Symptoms, Sports activities, and Function
• MDC is 8.8-15.6 depending on pathology

Anterior Knee Pain Scale (Kujala Scale)

• It is a 13 item questionnaire and lower scores reflect greater pain and disability
• Scale of 0-100, where 0 = worst symptoms and 100 = no symptoms
• It is a Valid and reliable tool for anterior knee pain
• MCID is 8.5 for function and 13.5 for pain after medial patellofemoral ligament reconstruction
• MDC is 14

Short Form – 36

• It has a 8 scaled scores: Vitality, Physical functioning, Bodily pain, and General health perceptions.
• Additional scores are Physical role functioning, Social role functioning, and Mental health.
• Instrument has 36 items
• Max score is 100 = no disability
• Score of 0 = extreme disability

Tegner Activity Scale

• Used to determine the level of activity before and after injury that can be documented on a numerical scale.
• Designed not to be a stand-alone outcome score, but to be used in conjunction with the Lysholm scale for ACL patients.
• One item score on a scale from 0-10.
• A score of 0 is considered the lowest and 10 is the highest possible score.
• Used for ACL, Meniscus

ACL Return to Sport After Injury Questionnaire (ACL-RSI)

• Used to measure athletes’ psychological readiness in terms of their Emotions, Confidence in performance, and Risk appraisal (with respect to return to sport after ACL reconstruction).
• 12 item questionnaire
• 0-100 scale: 0 = not ready to return and 100 = ready to return
• Score of > 80% to return to sport

Victorian Institute of Sport Assessment Patella Tendon (VISA-P)

• VISA is an 8-item questionnaire to evaluate symptoms of Patella tendinopathy and effect of physical activity
• Score 0-100, where 100 = asymptomatic, fully functional and 0 = not functional
• MCID = 13 points

Numeric Pain Rating Scale (NPRS)

• Patient rates pain on a scale of 0-10 with 0 indicating no pain and 10 representing the worst possible pain.
• All scales demonstrate adequate construct validity as measures of pain intensity.
• MCID = 1.3 points in non-specific patient population

Visual Analog Scale

• A measure of pain intensity
• Scale from 0-10 where 0 is no pain and 10 is worst pain possible
• Has a pediatric version

How to use this information

• Guide physical examination, Guide interventions and plan of care, and Assist in determining prognosis.
• Used at re-evaluation and discharge to determine progress toward goals.

Patient History Considerations

• The objectives are to apply concepts discussed in patient history to knee diagnoses and determine the physical therapy examination based on the patient history for knee diagnoses.
• In addition to the questions for patient history, these are special consideration for the knee: Patient age, Mechanism of injury, and Surface playing on, for athlete.
• Previous injury, Brace worn, Speed of injury (acceleration, deceleration, constant speed), Knee stability (“giving away” or “lock”), and Joint swelling are additional considerations.
• Gait is also a consideration.

Mechanism of Injury

• Can indicate the type of injury or the injury that may have occurred
• Consider: Varus or valgus, Varus or valgus with rotation?
• Dictates where you’re going to go with tests that you do to confirm when thinking about pain.
• The type of pain can be associated with a type of diagnosis.
• The type of pain must be taken into consideration with a full evaluation to indicate what that diagnosis is.

Patient History – Nature of Pain; Location and Type

• Considerations are: Where the pain is located and the Type of pain.
• Aching pain indicates degenerative changes.
• Sharp “catching” pain indicates a mechanical problem.
• Arthritic pain is associated with morning stiffness and eases with activity.
• Patellofemoral pain tends to be insidious and spontaneous while pain at rest is NOT mechanical.
• Pain with activity indicates structural abnormalities while pain after activity or overuse indicates an inflammatory disorder.
• Pain all over is associated with contusions or partial tears of muscles of ligaments while Instability indicates a ligamentous injury.
• Determine if the patient can point to the spot with one finger or is the pain more diffuse.

Anterior Knee Pain

• Could indicate: ACL injury, Patellar dislocation, Patellar tendinopathy, Patellofemoral pain syndrome (PFPS), Meniscus Tears, Knee osteoarthritis, Osgood Schlatter’s Syndrome, or Osteochondritis Dissecans

Medial Knee Pain

• Could indicate: MCL sprain, Median meniscus tear, Pes anserine bursitis, or Medial plica syndrome

Lateral Knee Pain

• Could indicate: LCL sprain, Lateral meniscus tear, ITB syndrome, or Common Peroneal Neuropathy

Posterior Knee Pain

• Could indicate: PCL injury, Hamstring strain, or Popliteal Cyst

Patient History – Nature of Pain; Behavior of Symptoms

• Behavior of symptoms to consider: Increase or decrease in pain with certain positions or activities, Duration of activity that causes pain, Positions that ease pain, and Does pain ease when activity ceases.
• Investigate any “clicking” or “pop” or “grating” with movement.

Patient History – Nature of Pain; Functional Capabilities

• Functional capabilities to consider: Running, Cutting, Pivoting, Twisting, Ascending or descending stairs.

Health History

• Consider additional conditions or related injuries and related surgical history, including Lumbar, hip, knee, and ankle
• Medications also need to be considered.

Social History and Patient Goals

• Living environment aspects to consider: Stairs, bedroom location, shower, or tub
• Occupation aspects to consider: Ergonomics, Workplace set-up; standing, sitting, etc., Activities; lifting, managing heavy equipment, etc.
• Activity history considerations: Sports; weekend warrior vs. Past professional sports, contact vs. non-contact, Repeated activities, and Previous falls.
• Perceptions and expectations relative to previous imaging studies or family history, and Patient goals are important to understand.

Physical Exam Planning

• Prioritize your physical examination based on the most likely hypotheses and the S.I.N.S.S (severity, intensity, nature, stage, stability)
• Listen, the patient will likely tell you what’s wrong and provide first-line intervention insights

Wrap Up

• Clarify any additional questions and patient concerns and review your understanding of the patient history
• Transition into physical exam, provide explanation of next steps, and ask permission to proceed
• Determine tests to confirm or negate possible PT diagnoses

Screening for Medical Referral

• The objectives are to evaluate a patient’s signs and symptoms to determine whether a patient is appropriate for physical therapy or requires an outside referral and analyze a patient’s signs and symptoms to determine the most appropriate healthcare practitioner for referral and most appropriate initial imaging, if warranted.

Red Flag Pathologies

• Cellulitis, Deep vein thrombosis, Septic arthritis, Compartment syndrome, Fractures, and Peripheral arterial occlusive disease.

Cellulitis

• Rapidly spreading bacterial infection of the skin and subcutaneous tissue
• Symptoms include pain, advancing erythema (reddish streaks), local edema, elevated temperature of affected skin, fever, chills, and malaise.
• People at increased risk for cellulitis include Older adults and Immunocompromised individuals, e.g., owing to diabetes, malnutrition, chemotherapy, autoimmune diseases, steroid or immunosuppressant medications.
• Other predisposing factors include: Venous insufficiency, Thrombophlebitis, Obesity, Edema, Surgery, Substance abuse, Cutaneous inflammation, skin irritation, and open wounds; e.g., tinea, eczema, burns, trauma, bug bites.

Deep Vein Thrombosis

• Partial or complete occlusion of a vein by a thrombus (clot)
• A pulmonary embolism can occur when part of a thrombus in a DVT breaks loose and travels through the right side of the heart into the pulmonary artery
• Risk factors: recent surgery, CVA, immobility, trauma, kidney disease, pregnancy and postpartum
• Symptoms: leg or calf swelling, pain or tenderness, dilation of the superficial veins, and pitting edema, warmth, skin can be cyanotic if severe
• Calf pain aggravated by standing or walking and relieved with rest and elevation; loss of dorsalis pedis pulse possible
• Wells criteria is used to make decisions regarding deep vein thromboses.
• A score of 0 to 2 has a low probability of DVT, while a score greater than or equal to 3 has a high probability of DVT and would require referral.

DVT Clinical Signs and Symptoms

• Unilateral tenderness of leg pain and Unilateral swelling distal to site
• Warmth and Redness
• Other symptoms: Dilated veins, Low-grade fever, Chills, and Malaise

DVT - Homan’s Sign

• Dorsiflexion of foot = pain in posterior calf
• Sensitivity:.35-.48
• Specificity:.41

Actions for Suspected DVT

• If you notice signs and symptoms that may indicate a DVT, perform the Wells criteria for the lower extremity.
• If it shows a DVT is unlikely, you can perform the D-dimer test.
• If that’s negative, you can encourage mobility and physical activity but if positive, refer for further medical diagnostic testing.
• If the Wells criteria shows that a DVT is likely, then you would do further medical testing.
• If negative, then go back to PT and movement and if it is positive, then the patient would need to consider medical interventions to address that DVT prior to beginning a mobility program with you in physical therapy.

Pulmonary Embolism

• Symptoms: Dyspnea, Chest pain, Pre-syncope or syncope, and Hemoptysis (coughing blood)
• Risk Factors: Surgery, Trauma, Immobility, Cancer, and Hormone therapy

Septic Arthritis

• Bacterial infection that causes inflammation of a joint
• Primary risk factor: abnormal synovium from rheumatoid or degenerative conditions
• Acute onset of joint pain, swelling, tenderness and loss of motion.
• Physical examination may reveal warmth, swelling, redness, and loss of function
• Unwillingness to weight bear or move the involved limb and acute rapid onset of intense pain

Fractures

• 2 rules to determine how we assess fractures: Ottawa Knee Rule and Pittsburg Knee Rules

Ottawa Knee Rule

• Determines if the patient requires a knee x-ray. A radiography is required with any of the following criteria:
• If patient is 55 years or older
• Isolated tenderness of the patella
• Tenderness at the head of the fibula
• Inability to flex knee to 90 degrees
• Inability to bear weight both immediately and in the emergency department

Pittsburg Knee Rules

• Looks at mechanism of injury at the start; was it a fall or blunt-trauma? If yes, proceed to next step.
• What's the age of patient? If patient is more than 50 or less than 12, a radiography is needed.
• Do they have the ability to walk and weight bear? If not, knee radiography is needed.

Peripheral Arterial Occlusive Disease

• Usually occurs because of atherosclerosis; narrowing of the arteries of the legs and feet.
• Risk factors: History of diabetes and hypercholesterolemia, History of smoke, Older age, Sedentary lifestyle, Family history of peripheral arterial disease, Elevated inflammatory biomarkers, and Increased homocysteine.
• Symptoms occur distal to the obstruction and can include Pain (typically cramping and/or burning), Pallor, Paresthesia, and Paralysis.
• Loss of pulse and arterial ulcers may develop as a result of ischemia; usually located over a bony prominence on the toes or feet.
• The skin is shiny and atrophic, and fissures and cracks are common; loss of hair on the feet and toes is also common.
• Silent ischemia has a systolic blood pressure lower extremity over the systolic blood pressure upper extremity and an ankle brachial index < 0.90
• Intermittent claudication occurs when diameter of vessel is narrowed > 50% with a capillary refill time > 2 sec

Knee Pathologies

• The objective is to use location of knee pain to detail which knee pathologies should most likely be considered.

Anterior Knee Pain Pathologies

• Knee osteoarthritis, ACL injury, Meniscus tears, Patella tendinopathy (jumper’s knee), Patellofemoaral pain (PFP), and Osgood Schlatter’s Syndrome

Medial Knee Pain Pathologies

• MCL sprain, Medial meniscal tear, and Pes anserine bursitis

Posterior Knee Pain Pathologies

• PCL injury

Lateral Knee Pain Pathologies

• LCL sprain, Lateral Meniscal tear, and ITB syndrome

Knee Osteoarthritis; Knee Pain with Mobility Deficits

• The objectives are to identify key clinical findings associated with knee osteoarthritis and understand appropriate treatment considerations based on clinical findings.

Pathophysiology of Knee Osteoarthritis

• Osteoarthritis (OA), aka degenerative joint disease, is a slowly evolving articular disease originating in the cartilage and affects underlying bone, soft tissues, and synovial fluid

Knee OA Classification

• Symptomatic OA is defined by the presence of pain, aching, or stiffness in a joint alongside radiographic evidence.
• Radiographic OA is consistently associated with severity of pain, stiffness, and physical function, especially when there is advanced structural damage, however, 50% of individuals with radiographic knee OA do not have symptoms.

Prevalence of Knee Osteoarthritis

• Overall prevalence: 14.6%; increases with age and women are more likely to have knee OA than men.
• Women with an early onset of knee OA have increased risk of also developing cardiovascular disease

Risk Factors for Knee Osteoarthritis

• Age, Ethnicity (African descent > Caucasian), Lower socioeconomic status, and Obesity are risk factors.
• History of prior trauma followed by surgery, Lower limb imbalance, High-impact sports participation are associated with a moderate to high risk of development (Long-distance running, soccer, weightlifting and wrestling).

Ethnic Disparities with Diagnosed Knee OA

• White, non-Hispanic/Latino: Prevalence of doctor-diagnosed arthritis = 22.6% and prevalence of arthritis-attributable activity limitations = 40.1%
• African American, non-Hispanic/Latino: Prevalence of doctor-diagnosed arthritis = 22.2% and prevalence of arthritis-attributable activity limitations = 48.6%
• Hispanic/Latino: Prevalence of doctor-diagnosed arthritis = 15.4% and prevalence of arthritis-attributable activity limitations = 44.3%
• Asian, non-Hispanic/Latino: Prevalence of Doctor-diagnosed arthritis = 11.8% and prevalence of arthritis-attributable activity limitations = 37.6%
• Multi-race, non-Hispanic/Latino: Prevalence of doctor diagnosed arthritis = 25.2% and prevalence of arthritis-attributable activity limitations = 50.5%

Reported Findings

• Pain is worse in morning, or after prolonged stationary period, or after prolonged weight bearing; pain improves after 15-20 minutes of joint motion
• Crepitus with motion or stiffness lasting greater than 30 minutes
• Warmth in the joint, generally OA does not produce palpable warmth
• History of previous knee injury, playing sports or a physically demanding job
• Personal and family history of OA
• Current use of any assistive device
• Current level of function with activities of daily living
• Need for home environment set-up and assistance
• Medications, History of surgeries, previous chondral defects, or medical complications

Examination Findings

• ROM loss – more loss of flexion than extension
• Hypomobility of the tibiofemoral joint with accessory motion testing
• Pain at end ranges
• Palpable deformity of the tibiofemoral joint
• Possible varus angulation of the tibiofemoral joint
• Presence of varus thrust in gait
• Possible decreased strength of quadriceps muscle
• Possible decreased strength of gluteus maximus and Medius muscles
• Possible short or stiff hamstrings and gastrocnemius muscles

Movement Faults

• Observe 2 specific movements: Squat and Gait
• Avoid a squat that has a lot of anterior translation of the knee over the toes as this increases the stress that comes through the knee joint as the patient squats.
• Gait assessment includes decreased range of motion and the tendency to land flat footed. Encourage that heel to toe gait pattern, encourage knee extension, and decrease the strain through the knee.

Management for Knee OA

• Joint protection involves reducing load and time in use of inflamed joints, improving movement techniques, posture, and joint alignment, avoiding prolonged time in one position and planning difficult activities.
• Therapeutic exercise focus is on strengthening, low-impact aerobic exercises and walking, and using a HEP daily exercise routine with strengthening
• Manual therapy can be used in conjunction with therapeutic exercise
• Neuromuscular rehabilitation consists of Proprioception training in non-weightbearing and in weightbearing

Knee Ligament Sprain

• The objectives are to identify key clinical findings associated with knee ligament sprains and understand appropriate treatment consideration based on clinical findings

Classification of Sprain

• Severity Grading
• Grade I (mild) stable: Pathology = mild stretch, no instability, single ligament involved
• Grade II (moderate) stable: Pathology = large spectrum of injury, mild to moderate instability, usually a partial tear of the ligaments
• Grade III (severe) two-ligament, unstable: Pathology = significant instability, complete tear

Incidence of Knee Ligament Sprain

• ~ 80,000-250,000 ACL injuries annually
• PCL injury ~ 0.65 - 44% of all knee ligament injuries
• MCL lesions 7.9% of all athletic injuries
• LCL 4% of all knee ligament injuries
• ACL and MCL injury rates high in physically active individuals where ACL injuries are more common in young female athletes than male athletes of similar age and noncontact injuries are more common than contact injuries.
• Rate of second ACL (same or contralateral knee) progressively rises

Diagnosis and Examination of Knee Ligament Sprain

• Clinical Findings: Deceleration, cutting, or valgus motion associated with injury , Audible “pop” that was heard, and Hemoarthrosis within 0 to 12 hours of the injury.
• Knee effusion and swelling and a sense of knee instability reported
• In stance or in gait, if it is complete, they will have complete instability and probably fall on standing and excessive tibiofemoral laxity.
• Perform integrity tests to see pain and symptoms, lower leg strength and coordination deficits
• Determine the irritability (Frequency, Intensity, Length of time or duration, and Type)
• The goal is to choose exercises and treatment to match the level of irritability the patient is at

Examination for Knee Ligament Sprain

• Use IKDC 2000 or KOOS and Lysholm scale ot assess knee symptoms and function
• Use the Tegner scale or Marx Activity Scale to assess activity level, before and after interventions
• Use the ACL-RSI for psychological factors that may hinder return to sports before and after interventions

Activity Limitations

• Administer appropriate clinical of field test that reproduce pain and assess lower limb movement coordination, such as single-legged hop tests; e.g. single hop for distance, crossover hop for distance, triple hop for distance, and 6-meter timed hop

Management for Knee Ligament Sprain

• Therapeutic exercises include Optimal ROM, strength, flexibility training, progression specifically addressing the knee but also ankle/foot, hip, and trunk regions
• Neuromuscular rehabilitation includes optimal neuromuscular training progression and field and court sports performance
• Education/counseling strategies: Indications for surgical interventions, Athletic or occupational activity modification, Return to sport readiness and risk appraisal

Anterior Cruciate Ligament (ACL) Injuries

• The objectives are to identify key clinical findings associated with anterior cruciate ligament injuries and understand appropriate treatment consideration based on clinical findings

ACL Injury

• Most common ligamentous injury of the knee, typically a non-contact injuring during deceleration, cutting, and landing movements
• Can occur with a mechanism of knee valgus, tibial rotation, and decreased knee flexion.
• Usually occurs to individuals involved in high-level cutting and pivoting sports and many < 25 years of age where 73.2-83% of athletes return to sport with only 50% at prior level.
• 4-15% changes of recurrent ligamentous disruption and a 5.24% chance of injury to the contralateral limb post-surgery.
• Females > males
• Increased risk of developing knee OA after ACL injury

Reported Findings

• Participation in sports involving cutting, pivoting, sudden stops or landing from a jump
• Mechanism of injury consisting of deceleration and acceleration motions with noncontact valgus load at or near full knee extension
• Hearing or feeling a “pop” at time of injury
• Immediate effusion after injury; hemarthrosis within 0 to 12 hours following injury
• Feeling of instability and giving way with weight bearing

Clinical Findings for ACL Injury

• (+) Lachman test and (+) Pivot Shift Test
• 6-meter single-limb timed hop test result that is less than 80% of the uninvolved limb
• Reported history of giving-way episodes with 2 or more activities of daily living
• Impairment measures should include those with asymmetries (i.e. may include knee laxity/stability, coordination, strength, swelling, ROM, etc.)
• Appropriate clinical or field tests, such as single leg hop tests, that can identify a patient’s baseline status relative to pain, function and disability, detect side to side asymmetries, readiness to return to activities, and monitor changes through course of treatment

Examination – Associated Impairments with ACL Injury

• Edema assessment - comparing swelling on one side that is affected to the side that is not affected and seeing what the difference is so that you can continue to retest to see how swelling improves or does not.
• Focus on muscle strength and muscle performance, balance and proprioception, and return to sport testing

Ottawa Knee Rules for ACL Injury

• The Ottawa Knee Rule was developed and validated to assist clinicians in determining when to order radiography in individuals with acute knee injury.
• According to the Ottawa knee rule, a knee radiography series is required with any of the following criteria: 55 years of age or older, Isolated tenderness of the patella, Tenderness of head of the fibula, Inability to flex knee to 90 degrees, and Inability to bear weight, both immediately and in the emergency department, for 4 steps regardless of limping

Classification of Patient with ACL disruption

• Patients with an ACL disruption can be categorized into one of 3 groups: One third (“copers”) compensate adequately and return to their physical activities, with ligament deficiency, One third (“adapters”) compensate but will have to give up or mitigate their activities to do so, and One third (“noncopers”) will likely not compensate for ligament deficiency and will require reconstructive surgery.

Management for ACL Injury

• Acute treatment: Interventions focused on reducing patient discomfort and swelling such as rest, ice, compression, and elevation; recommended that the patient use crutches or other appropriate assistive devices to limit weight through the injured limb.

Knee Meniscal and Articular Cartilage Lesions

• The objectives are to identify key clinical findings associated with knee meniscal and articular cartilage lesions and understand appropriate treatment considerations based on clinical findings

Meniscal and Articular Cartilage Lesions

• Meniscal injuries are damage of the medial or lateral meniscus where the meniscus covers the superior aspect of the tibia.
• Each meniscus is composed of fiber cartilage and is wedge shaped with the lateral meniscus more circular and the medial meniscus more crescent shaped.
• The lateral meniscus is more mobile than media, function to distribute stress across the knee during weight bearing, provide shock absorption, serve as secondary joint stabilizers, and provide articular cartilage nutrition and lubrication.
• Meniscal injuries are classified as either traumatic tears or degenerative tears.
• Rate of medial meniscus tears increases over time whereas lateral meniscus tears do not.
• Patients report feeling a “pop” while suddenly changing direction with or without contact (similar to ACL).

Articular Cartilage Lesions

• Injuries be the result of acute trauma or repetitive minor trauma with many lesions being non-progressive and remain asymptomatic.
• The articular cartilage that covers the gliding surfaces of the knee joint is hyaline in nature and hyaline cartilage decreases the friction between surfaces that glide.
• Articular cartilage withstands compression by acting as a shock absorber and resists wear during normal situations.

Prevalence Meniscal Injuries

• It is the 2nd most common knee injury with a prevalence of 12-14%.
• High incidence occur with ACL injury (22-86%)
• High school athletes: girls > boys
• Older individuals > younger individuals
• Lateral meniscus tears > younger athletes
• Medial meniscus tears > older people
• A high prevalence of meniscus tears are present in individuals undergoing primary and revision ACL reconstruction.
• Individuals older than 45 years of age are more likely to have meniscectomy, whereas individuals younger than 35 years of age are more likely to have meniscus repair.

Prevalence Articular Cartilage Injuries

• Prevalence: 60-70% where 32-58% of lesions are the result of a traumatic, noncontact mechanism of injury.
• The prevalence of articular cartilage lesions in athletes’ knees ranges from 17% to 59%, some of those athletes being asymptomatic.
• The incidence rate of articular cartilage lesions is high after partial meniscectomy or second ACL injury

Reported and Clinical Findings – Meniscus

• Reported findings of joint locking, inability to fully bend or straighten the knee, and “clicking” in the knee.
• Examination findings include joint line tenderness (symptoms reproduced), guarding, clicking, or pain with hyperflexion, hyperextension, or Thessaly Test.

Examination of Meniscal and Articular Cartilage Lesions

• Self-report questionnaires – IKDC 2000 or KOOS
• Activity level (before and after intervention) - Tegner scale or Marx activity rating scale; SF-36 or EQ-5D for general health measures.
• Physical performance – single-legged hop tests (e.g. single hop for distance, crossover hop for distance, triple hop for distance, 6m time hop)

Interventions for Meniscal Lesions

• Early rehabilitation strategies: Progressive motion (Progressive active and passive knee motion following knee meniscal surgery).
• Early to late rehabilitation strategies: Progressive weight bearing (Progressive return to activity and Supervised rehabilitation).
• Therapeutic exercises: Supervised, progressive ROM exercises, progressive strength training of the knee and hip muscles, and neuromuscular training.
• Neuromuscular electrical stimulation/biofeedback: Provide neuromuscular stimulation/re-education to increase quadriceps strength, functional performance, and knee function.

Interventions for Articular Cartilage Lesions

• Early rehabilitation strategies: Progressive motion (Progressive active and passive knee motion following knee articular cartilage surgery).
• Early to late rehabilitation strategies: Progressive weight bearing (Reach full weight bearing by 6 to 8 weeks after matrix-supported auto logous chondrocyte implantation and progressive return to activity which is dependent on type of surgery).
• Therapeutic exercises: Supervised, progressive ROM exercises, progressive strength training of the knee and hip muscles, and neuromuscular training.
• Neuromuscular electrical stimulation/feedback: Provide neuromuscular stimulation/re-education to increase quadriceps strength, functional performance, and knee function.

Management for Meniscal (M) and Articular Cartilage (AC) lesions

• Knee motions: M and AC: early progressive active and passive knee motion
• Weight bearing: M: early progressing weight bearing and AC: stepwise progression of weight bearing to reach full weight beating by 6-8 weeks.
• Return to activity: M: early progressive return to activity and AC: may delay return to activity depending on type of AC surgery
• Therapeutic exercises: Progressive ROM, Progressive strength training (knee and hip), and Neuromuscular training.
• NMES/Biofeedback: Following meniscus procedures (quad strength, functional performance, knee function)

Pes Anserine Bursitis

• The objectives are to identify key clinical findings associated with Pes Anserine Bursitis and understand appropriate treatment considerations based on clinical findings

Pes Anserine Bursitis Characteristics

• An acute, painful inflammation of a tendon or the bursa it runs over, just distal to the medial knee joint which is typically secondary to overuse, trauma, gout, or infection.

Prevalence of Pes Anserine Bursitis

• 20% prevalence rate in patients with symptomatic knee OA
• It is more common in older women
• 2.5% of 488 patients suspected to have internal derangement of the knee

Reported Findings

• Insidious-onset of pain over the medial proximal tibial metaphysis approximately 2 to 4 cm below the joint line.
• There may be a history of acute trauma to the medial knee related to repetitive sporting activities involving lateral movements like cutting; basketball, soccer, racket sports
• Common in patients 50-80 years old with OA of the knees and maybe associated with diabetes and obesity
• Reported findings indicating pain along the medial joint line mimicking a medial meniscus tear.

Examination of Pes Anserine Bursitis

• Observable local swelling
• Pain with palpation of the medial tibia, just inferior to the plateau
• Pain with contraction of the knee flexors against resistance
• Observed valgus knee deformity with or without collateral instability

Management for Pes Anserine Bursitis

• Patient education to avoid activities that increase pain and stress on the leg.
• Use modalities for pain reduction.
• Therapeutic exercise: Mobility, Muscle coordination, and Functional movement
• Manual therapy to decrease adductor stiffness, decrease hamstring stiffness, and with gluteal muscle facilitation.

Iliotibial Band (ITB) Syndrome

• The objectives are to identify key clinical findings associated with ITBS and understand appropriate treatment considerations based on clinical findings

Iliotibial Band Syndrome (ITSB) Characteristics

• It is the most common source of lateral knee pain and a non-traumatic overuse injury caused by repeated flexion and extension of the knee that causes irritation in the structures around the knee.
• ITBS is usually diagnosed on the basis of a detailed history and physical examination.

Prevalence of Iliotibial Band Syndrome (ITSB)

• 10.5% of running injuries from training and 4.7% of running injuries that occur during ultra-marathon races.
• It is common in runners and cyclists and also occurs in weightlifters, skiers and soccer players

History and Reported Findings

• Onset of lateral knee pain with new repetitive activity such as running or cycling and/or a recent increase in intensity or frequency of the sports above.
• Running around the track in only one direction
• Recent change in fitting for cycling where the seat height has been raised
• Reported findings include Pain at the lateral knee with increased distances running or cycling and is usually most acute at 30 degrees of knee flexion.

Examination of Iliotibial Band Syndrome

• Sharp burning pain with palpation of the lateral femoral epicondyle during knee flexion and extension.
• Possible strength deficits of the gluteus maximus and, or medius
• Motor coordination impairments of the hip, leg, ankle, and foot with a possible excess femoral adduction and internal rotation during stance phase.
• Possible Trendelenburg gait and a possible excess tibial rotation in stance phase and/or a possible excess foot pronation.

Management for Iliotibial Band Syndrome

• Patient education to modify activities in the short term to avoid reproduction of symptoms.
• Therapeutic exercise: Mobility, Motor coordination, and Functional movement
• Manual therapy improving TFL/ITB flexibility and with Gluteal muscle facilitation
• Modalities as indicated

Patellofemoral Pain (PFP)

• The objectives are to identify key clinical findings associated with patellofemoral pain and understand appropriate treatment considerations based on clinical findings

Patellofemoral Pain Characteristics

• The diagnosis of patellofemoral pain should be confirmed when there is a presence of retropatellar or peripatellar pain, Reproduction of retropatellar or peripatellar pain with squatting, stair climbing, prolonged sitting, or other functional activities loading the PFJ in a flexed position, and Exclusion of all other conditions that may cause anterior knee pain, including tibiofemoral pathologies

PFP Classification System

• Overuse/overload: Patient presents with a history suggesting an increase in magnitude and/or frequency of PFJ loading at a rate that surpasses the ability of his or her PFJ tissues to recover
• Muscle performance deficits: Patient presents with lower extremity muscle performance deficits in the hip and quadriceps
• Movement coordination deficits: Patient presents with excessive or poorly controlled knee valgus during a dynamic task, but not necessarily due to weakness of the lower extremity musculature
• Mobility impairments: Patient presents with higher than normal foot mobility and/or flexibility deficits of 1 or more of the following structures: Hamstring, quadriceps, gastrocnemius, soleus, lateral retinaculum, or IT band

PFP Classification System (Tests)

• Overuse/overload without other impairment: Eccentric step-down test (Reproduction of anterior knee pain)
• PFP with movement coordination deficits: Dynamic valgus on lateral step-down test (> 2 point score on quality of movement), Frontal plane valgus during single leg squat, and > 10 degrees increase in Functional Physical Performance Assessment or FPPA (change in FPPA from the start position to the point of peak knee flexion)
• PFP with muscle performance deficits: HipSIT and Hip muscle strength testing (isometric (Abductors, External rotators, and Extensors)) and Thigh strength testing (isometric (Knee extensors and Knee flexors))
• PFP with mobility impairments: Hypermobility (Foot mobility testing and Midfoot width in non-weight bearing (NWB) and weight bearing (WB) (> 11 mm difference between NWB and WB and Foot posture index score > 6)) and Hypomobility (Patellar tilt test of lateral patellar retinaculum and Muscle length testing (Hamstrings, Gastrocnemius, Soleus, Quadriceps, Iliotibial band, and Hip internal rotation and external rotation ROM testing)

PFP History and Reported Findings

• Insidious onset of anterior knee pain with a report of pain “behind the knee cap” that may be precipitated by trauma (subluxation), unaccustomed weight bearing activities, and/or repetitive sporting activities involving squatting, jumping, and lunging.
• Reported finding is that it worsens with activities with bent knees and pain is reproduced during squatting, climbing/descending stairs, or running, as well as prolonged sitting

PFP Examination - Self-Report Questionnaires

• For activity: Anterior knee pain scale (AKPS) and Patellofemoral pain and osteoarthritis subscale of the knee injury and Osteoarthritis Outcome Score and Visual analog scale.
• For pain and function: Eng and Pierrynowski Questionnaire (EPQ)
• For pain: VAS for worst pain, VAS for usual pain, and Numeric pain-rating scale (NPRS) to measure pain

PFP Clinical Findings

• Possible hypo or hyper mobility of the patella
• Excess femoral internal rotation/adduction observable during squat or jumping and landing or step down
• Excess tibiofemoral rotation observable during squat or jumping and landing or step down
• Excess dynamic valgus angle observable during squat or jumping and landing or step down

PFP - Additional Clinical Findings

• Administer appropriate clinical of field test that