Stanbridge - T4 - TE2 - W4

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Questions and Answers

What structural condition is associated with an increased Q angle and excessive lateral tracking of the patella?

Femoral retroversion

Genu varum

Coxa vara (correct)

Coxa normalis

Which of the following factors can increase the Q angle?

Genu recurvatum

Hip flexor tightness

Tibial retroversion

External tibial torsion (correct)

Which of the following complaints is commonly reported in individuals with patellofemoral pain syndrome (PFPS)?

Increased pain while performing lunges

Increased pain while squatting (correct)

Increased pain while standing for prolonged periods

Increased pain while running on flat surfaces

What role do the extensor retinaculum and patellofemoral ligaments play in knee stability?

They maintain alignment and stability of the patella. Signup and view all the answers

What is a primary cause of patellar malalignment and tracking problems according to recent research?

Quadriceps strength deficits Signup and view all the answers

What is the primary action of the screw home mechanism of the knee during the final degrees of extension in an open chain posture?

Tibia externally rotates on the femur Signup and view all the answers

Which of the following factors is NOT a contributing cause of osteoarthritis in the knee?

Excessive range of motion Signup and view all the answers

Which of the following symptoms is characteristic of acute knee hypomobility?

Pain with motion Signup and view all the answers

During the posterior to anterior glide to increase knee extension, what movement should also occur at the patella?

Superior glide Signup and view all the answers

In a Total Knee Arthroplasty, which phase of rehabilitation focuses primarily on preventing vascular and pulmonary complications?

Maximum Protection Phase Signup and view all the answers

Which sign is NOT associated with hypomobility of the knee?

Increased balance Signup and view all the answers

What is the main goal of the subacute and chronic phases of rehabilitation for knee hypomobility?

Decrease pain and increase functional mobility Signup and view all the answers

What is a key function of the anteromedial bundle of the ACL?

Checks flexion Signup and view all the answers

Which risk factor significantly increases the likelihood of female athletes sustaining an ACL injury?

Post-pubertal status Signup and view all the answers

Among the following, which is considered a non-contact mechanism of injury for the ACL?

Landing on an extended knee Signup and view all the answers

In sports, which activity is most associated with higher ACL injury rates?

Pivoting and rapid directional changes Signup and view all the answers

What is a common trend observed in male athletes following an ACL injury?

Re-tear of the same graft Signup and view all the answers

Which of the following graft types is NOT mentioned as a surgical option for ACL reconstruction?

Achilles tendon autograft Signup and view all the answers

What is a crucial consideration during non-operative management of ACL injuries?

Avoid anterior tibial shear Signup and view all the answers

What anatomical feature does the ACL originate from?

Posteromedial lateral femoral condyle Signup and view all the answers

Which demographic has a higher incidence of ACL injuries?

Females post-puberty Signup and view all the answers

What is the recommended knee flexion range for prone resisted extension when using an HS autograft post ACL surgery?

Avoid for ~ 6 weeks Signup and view all the answers

What is a necessary criterion to progress from the Maximum Protection Phase to the next phase in ACL management?

Full active knee extension Signup and view all the answers

Which of the following best describes the 'Terrible Triad' injury?

Tears of the medial meniscus, MCL, and ACL Signup and view all the answers

What is the purpose of the immobilization phase following ACL surgery?

To provide maximum joint stability during rehabilitation Signup and view all the answers

Which strength ratio is required to progress during the Moderate Protection/Controlled Motion Phase after ACL surgery?

Hamstring/quadriceps ratio > 65% Signup and view all the answers

Which structure does the posterior cruciate ligament primarily check?

Medial rotation and posterior translation of the tibia Signup and view all the answers

What defines the criteria to progress from the Moderate Protection/Controlled Motion Phase?

Absence of swelling and joint effusion Signup and view all the answers

During the Maximum Protection Phase, which modality is commonly used for managing swelling?

Ice application and compression Signup and view all the answers

After ACL surgery, how long does it generally take for a patient to return to activity?

1 year Signup and view all the answers

What is the primary role of the patella in knee function?

To increase the moment arm of the quadriceps Signup and view all the answers

Which factors influence the alignment of the patellofemoral joint?

The line of pull of the quadriceps Signup and view all the answers

What is the significance of the Q angle in relation to the patellofemoral joint?

It helps in assessing the alignment of the patella. Signup and view all the answers

What initial contact happens as the knee flexes in relation to the patella?

The inferior margin makes contact first Signup and view all the answers

What is a sesmoid bone, as it relates to the patellofemoral joint?

A bone that is embedded within a tendon Signup and view all the answers

Which component is NOT directly involved in patellar stability?

Hyperextension of the knee Signup and view all the answers

How does the patellofemoral joint alignment affect knee flexion?

Affects load distribution in the knee Signup and view all the answers

What is the primary purpose of monitoring hypomobility post-surgery?

To prevent excessive joint stress Signup and view all the answers

Which statement accurately describes the intercondylar groove during knee flexion?

The patella enters this groove as it flexes Signup and view all the answers

What type of surgical goals are focused on after PCL and ACL surgeries?

Restoring full range of motion Signup and view all the answers

Study Notes

Therapeutic Exercise II: The Knee

This course covers therapeutic exercises for the knee, focusing on common knee pathologies.

Road Map

Students will be able to identify key aspects of knee structure and function.
Students will be able to implement therapeutic exercise programs for soft tissue and joint lesions.
Students will understand how patellofemoral pain relates to abnormalities in the foot/ankle and hip/pelvis.
Students will implement progressive therapeutic exercises for knee surgery patients based on healing stages.
Students will demonstrate exercise progressions to improve range of motion (ROM), muscle performance, and lower extremity function.

Outline

Knee Anatomy and Arthrokinematics: Focuses on knee joint structure and movement.
Hypomobility; Articular Cartilage defects and TKA: Covers restricted movement and cartilage damage, including total knee arthroplasty (TKA).
Meniscus Tears: Discusses meniscus injuries, including types of tears and treatment approaches.
Ligament Injuries: Details various ligament injuries, with emphasis on the ACL and PCL.
Patellofemoral Pathologies: Explores patellar tracking and pain syndromes..
Exercise Techniques: Describes various exercise techniques, including ROM, flexibility, strengthening exercises, and plyometrics.

Bones and Joints of the Knee

The knee is composed of the femur (thighbone), tibia (shinbone), patella (kneecap), and fibula (smaller lower leg bone).
Key joints include the patellofemoral joint, tibiofemoral joint, and proximal tibiofibular joint.
The meniscus is a C-shaped cartilage that cushions the joint.
Ligaments support the knee joint, providing stability.

Screw Home Mechanism of Knee

The knee's screw-home mechanism describes the slight rotation of the tibia on the femur during extension.
Internal rotation of the femur in weight-bearing.
This rotation helps the knee lock into extension to keep it stable when standing or walking.

Applying Arthrokinematics

To improve knee flexion, anterior-posterior glide of the tibia is needed on the femur.
Inferior glide of the patella needed to mimic motion in the trochlear groove.
Posterior-anterior glide of the tibia over femur for extension.
Superior gliding of the patella is associated with extension.

Common Nerve Sources of Nerve Pain

Anterior knee pain – L3 nerve root
Posterior knee pain – S1 and/or S2 nerve root

Osteoarthritis of the Knee

Osteoarthritis (OA) is a degenerative condition causing pain, muscle weakness, and restricted joint motion
Individuals over 65 have a 1/3 chance of developing OA
Genu varum (bowlegs) is a common deformity in people with knee OA.
Obesity, prior joint trauma, and developmental deformities may increase risk of OA

Knee Hypomobility

This describes reduced knee mobility.
Contributing factors include adhesions/contractures, reduced patellar mobility (extensor lag), and swelling.
Symptoms include pain, reduced ROM, and impaired balance.

Acute Phase of Knee Hypomobility

The management focus is pain control, protecting the joint, maintaining soft tissue and joint mobility using PROM and Grades I and II joint mobilization techniques and maintaining muscle function to prevent patellar adhesions.

Subacute and Chronic Phases of Knee Hypomobility

Managing pain from mechanical stressors
Adjusting biomechanics and training
Improving ROM
Strengthening supporting muscles
Functional training and cardiopulmonary endurance using methods based on SAID principle.
Implementing assistive devices as needed.

Total Knee Arthroplasty

Indications for surgery include severe joint pain, significant cartilage destruction, gross instability or motion limitation, and treatment failure after non-surgical interventions.
Post-operative management involves immobilization, controlled weight-bearing, and progressive CPM and exercises as tolerated according to the rehabilitation protocol.
Rehabilitation phases include a maximum protection phase, a moderate protection phase, and a minimum protection phase leading to return to activity.

Maximum Protection Phase

Manage vascular/pulmonary complications
Control joint pain and swelling
Maintain/improve strength of the contralateral limb
Regain ROM in the knee
Improve trunk stability/balance
Establish functional mobility

Moderate Protection Phase

Strength & endurance of knee and hip.
Maintaining and increasing knee ROM.
Improve stability in standing postures
Improve function
Improve cardiopulmonary endurance

Minimum Protection Phase

Improving task specific strengthening exercises for functional activities
Proprioceptive & balance training
Advance functional training
Improving cardiopulmonary endurance

Mobility Exercises

Traditional/static stretching
AAROM (active assisted range of motion)
LLLD (lying-leg-lowering) stretches

Review Questions

Questions cover the screw-home mechanism, common knee deformities (genu varum), impairments associated with knee hypomobility, and treatment options for various knee conditions.

Articular Cartilage Defects

Cartilage damage frequently associates with ligament or meniscus injuries.
Surgical options include microfractures, osteochondral autograft/mosaicplasty, autologous chondrocyte implantation, or osteochondral allograft implantation,.

Microfracture

Arthroscopic repair method to treat minor cartilage defects.
Improves fibrocartilage over the damaged area by stimulating bone marrow-based repair processes.

Osteochondral Autograft Transplantation/ Mosaicplasty

An arthroscopic or mini-open procedure, transplanting intact articular cartilage with underlying bone.
Utilizes plugs to fill gaps in cartilage.

Autologous Chondrocyte Implantation

Two-stage procedure: harvest and culture cartilage cells, followed by implantation and patch covering damaged area.

Osteochondral Allograft Transplantation

Used for larger defects transferring intact cartilage from a cadaver.
Critical to use fresh grafts ,as freezing processes damage the chondrocytes.

Postoperative Management (Articular Cartilage Defects)

Check operative report & protocol to know treatment plans and activities that are contraindicated.
Confirm weight-bearing status
Determine treatment based on tissue affected, location of tissue, function of tissue affected

Vascularity of the Menisci

Peripheral meniscus outer third is highly vascularized, while the center and inner portions are relatively avascular.

Common Impairments/Functional Limitations: Meniscus Tears

Locking, catching, restricted range of motion, springy end feel on passive extension, swelling, and/or pain and giving way during weight bearing.

Operative Management: Meniscus Tears

Partial meniscectomy
Meniscus repair
ROM is restricted in the first 4 weeks from 0 to 90 degrees
NWB (non weight bearing) x 4-6 weeks, with a knee brace in extension,.

Meniscectomy vs. Repair

Meniscectomy patients have a maximum protection phase of 3-4 weeks.
Meniscus repair involves a maximum protection phase for 4-8 weeks. Weight bearing protocol is altered based on the location of the meniscus repair.

Meniscal and Articular Cartilage Lesions: Evidence-Based Treatment

Key components of successful rehabilitation include therapeutic exercises that target neuromuscular stimulation of quadriceps, progressive knee motion, and progressive return to activity exercises.

Review (general)

Review questions cover articular defects, total knee replacement rehabilitation, meniscus tear diagnoses, and activity modifications post meniscus repair or surgery, providing a complete look at all knee rehabilitation phases.

Knee Anatomy and Arthrokinematics

Covers the structure and biomechanics of the knee, detailed knee anatomy, and arthrokinematics of the knee joint.

Ligament Injuries

Overview of various ligament injuries in the knee, focusing on the ACL, PCL, MCL, LCL.
Origin, insertion, roles, and common mechanisms of injuries (MOI) for each ligament are discussed.
Key motions are considered for each ligament for acute and subacute phases.
The rehabilitation goals for surgical interventions (PCL, ACL) in healing phases are described .

Anterior Cruciate Ligament (ACL)

Key characteristics/ functions—originates on the medial aspect of the lateral femoral condyle.
It runs through the intercondylar notch, connecting to the anterior aspect of the tibial.
The ACL has 2 bundles with specific functions (Anteromedial- checks flexion. Posterolateral—checks extension.)
The ACL is critically important for maintaining stability
The ACL plays key roles in checking extension, medial rotation and anterior tibial translation of the tibia (ranges in degrees).
Epidemiology- Frequency and high rates associated with pivoting, quick cuts, pivots, rapid stopping and directional changes affecting mostly female athletes. -Mechanism of Injury (MOI): Contact (high incidence in females) and non-contact injuries (more common in females), with excessive valgus(knock-knees) are major factors
Females have 4-6 times greater risk to suffer ACL injury than male athletes.
Treatment options include non-operative methods to avoid anterior tibial shear or operative methods (including hamstring autograft, patellar tendon autograft, and cadaver allograft).
The study highlights that there are no significant differences among various graft types after 5 years

Posterior Cruciate Ligament (PCL)

Functionally checks extension, medial rotation, and posterior tibial translation -Epidemiology, MOI, and Treatment (non-surgical versus surgical; importance of resistance exercises; and initial resistance placement are highlighted)

Collateral Ligaments (MCL & LCL)

Knee stability: MCL and LCL stabilizes medial rotation, hyperextension, etc and valgus (knee stress) ( MCL and varus (knee stress) (LCL).
Management: Conservative treatment protocols related to tissue healing phases (Chapter 10) including Table 21.4.

Knee Ligament Sprain Evidence

Evidence-based treatment approaches, including the use of therapeutic exercises, immediate versus delayed mobilization, supervised rehabilitation, neuromuscular electrical stimulation, accelerated rehabilitation (ACL reconstruction), and eccentric strengthening.

PFJ Pain

Common causes for PFJS (Patellofemoral Joint Syndrome).
Structures affected/ involved in PFJS (Q Angle—patellar position—muscle and fascia weakness and tightness).
Symptoms and treatment options covered by the lectures.

PFJ Pain Management

Acute phase—modalities to address pain.
Sub acute and Chronic phase—modifying biomechanical factors, exercises that increase endurance, strength, and dynamic control, as well as addressing pain-free mobility and altering movement strategies or patterns.
Focus on improving stability of trunk, pelvis, and balance abilities.

Review (PFJ) Questions

Comprehensive review questions regarding PFJS—including the mechanics of pain, identifying contact areas, and determining most beneficial strength training angles.

Exercise Techniques

ROM, Flexibility, OKC (open kinetic chain), CKC (closed kinetic chain), Plyometrics drills.

Plyometrics

Stretch shortening drills
Increasing muscle strength and power output, through improving neuromuscular reactions; and coordinating movement patterns.

Plyometrics Progressions

Begin with movements (DL-dominant leg) and progress to more complex movements (SL-single leg) by adding step counts, while maintaining proper form and mechanics.
Training can begin by adding movement to the base of support, such as jumping squats and/or jumping over obstacles.
Exercises can progress by beginning bilateral movements (DL) then moving to unilateral (SL) by alternating legs, and adding more reps within a set time.
The key is to maintain proper form, and progressing to include more distance/speed over time (by adding distance within a step progression.

Plyometric Determinants

Speed and intensity—important factors requiring gradual increases in resistance and/or speed to help avoiding decreased activity.

Plyometric Contraindications

Contraindications—presence of pain or inflammation or significant joint instability.
Precaution—the use of proper precautions and protocols must be taken to avoid injuries

Criteria to Implement Plyometrics

80-85% strength of contralateral limb
90-95% pain-free ROM in joints
Adequate strength and stability of proximal joints

Plyometrics Determinants

Number of reps that should be completed within a specified time; increasing reps gradually and number of activities.
Frequency—2x/week
Duration—8-10 weeks (maximum benefit)

Review (General)

Comprehensive review questions encompassing general topics in knee rehabilitation, including the function, mechanisms of injury, healing phases and treatment strategies for each condition and related surgeries.

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Stanbridge - T4 - TE2 - W4 - The Knee

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