Knee Evaluation PDF

Evaluation Knee JUSTIN TRENT UNIVERSITY OF SAINT MARY SO, WE TOOK THIS GREAT HISTORY AND EXAMINATION… NOW WHAT? The Path Ahead 1 The Evaluative Process 2 Conditions Part One: The Process A Line of Logic WHICH ACTIVITIES LIMIT PARTICIPATION TO AN EXTENT THAT THE PATIENT IS SEEKING PT? WHAT ARE THE PA...

Evaluation Knee JUSTIN TRENT UNIVERSITY OF SAINT MARY SO, WE TOOK THIS GREAT HISTORY AND EXAMINATION… NOW WHAT? The Path Ahead 1 The Evaluative Process 2 Conditions Part One: The Process A Line of Logic WHICH ACTIVITIES LIMIT PARTICIPATION TO AN EXTENT THAT THE PATIENT IS SEEKING PT? WHAT ARE THE PATIENT’S SYMPTOMS, AND WHAT MAKES THEM BETTER OR WORSE? ARE THERE ROM IMPAIRMENTS? IF SO, TO WHAT EXTENT? ARE THERE NEURAL IMPAIRMENTS (MOTOR/SENSORY/AUTONOMIC)? IF SO, TO WHAT EXTENT? WHAT WERE THE MOST SALIENT ASPECTS OF THE EXAM? Evaluation: Diagnostic Classification PATIENT MANAGEMENT PATHOANATOMICAL MOVEMENT SYSTEM TREATMENT RESPONSE Evaluation: Personnel The Patient’s Story POSITIVES Young Age Healthy Lifestyle No Red Flags ↓ Comorbidities ↓Severity ↓ Irritability … other IMPAIRMENTS Strength Mobility Coordination Muscle Tightness Pain Guarding …other CHIEF COMPLAINT TREATMENT Patient’s description Two or three general of what brought them types of treatment to for therapy. address your selected impairments PARTICIPATION Patient’s Goal for Therapy Work with your partner. One person will start as the Patient – the other as the Provider – then you switch. The Patient provides a Chief Complaint and goal for therapy (Participation). The Provider should take a second to generate/imagine Positives, Impairments, and Treatments for your patient… then practice telling their story Part Two: Conditions “Hi! There is so much work to do. Let’s just carry on.” — OLIVER TRENT Patellofemoral Pain Syndrome CONDITIONS Annual Prevalence 22.7%/Year Higher for Adolescents (29%) & Athletes (45%) Mechanism of Injury Compression Quads/ITB are too Tight/Active Excessive Lateral Glide/Tilt Unstable Tracking Ligamentous Laxity, ↓ Neuromuscular Control Chondritis/Chondromalacia Inflammation and Pain of Joint Surface Articular Cartilage Breakdown & Softening Plica: Pinching and Pain of Vestigial Synovial Fold Medial Most Common Excessive Compression Patellofemoral Pain Syndrome CLASSIFICATION Retropatellar Pain Extensor Mechanism Dysfunction Chondromalacia Plica Syndrome CHARACTERISTICS Pain Pattern Localized, Anterior Knee Risk Factors Men Observation Poor Patellar Tracking Examination Pain: Squatting/Stairs Hyper/Hypo Joint Play ↓ Flexion ROM (+) Patellar Tilt, Lateral Pull, Clarke’s Grind Test, Resisted Extension (-) Femoral Neural Tension MANUAL THERAPY Patient Education Activity Reduction Ice Switch to Forefoot Running OTC Foot Orthosis If Overly Pronated Joint Mobilization Patella (if Hypo) STM/MFR Quad Muscles ITB Taping THERAPEUTIC EXERCISE Motor Quad Stretching (if hypo) ITB Stretching (if hypo) Glute Max Strength Glute Med Strength Quad Strength Peroneal Strength Posterior Depression PNF Squat/Stair Motor Programming Blood Flow Restriction Sensory Angle Reproduction Neurodynamics: Femoral Nerve Glides Patellar Tendinopathy CONDITIONS Mechanism of Injury Rapid Increase in Knee Extension (Use/Weight) Inner Tendon's Three Phases: Reactive 20’s, Inflammatory, ↑ Proteoglycans Disrepair 30’s, Separation & III Collagen, Neural Ingrowth Degenerative 40’s+, Breakdown, Cell Death Outer Remains Metabolically Active Focus on the Donut, Not the hole! Increase Tendon Thickness on the Outside Improve Capacity to Manage Load Patellar Tendinopathy CLASSIFICATION Jumper’s Knee CHARACTERISTICS Pain Pattern Localized, Proximal Patellar Ligament Risk Factors 35-50 Years Old Repetitive Movements Heavy Body Mass Observation Swelling Examination Pain: Palpation/Contraction Palpation: Tissue Changes (+) Stair Climbing, Jumping (+) Resisted Knee Extension (-) Patellofemoral Testing MANUAL THERAPY Patient Education Activity Reduction Ice (If Inflammatory) Orthotics Patellar Tendon Strap Joint Mobilization Patella (If Hypo) STM/MFR Quad and ITB Stretching Glute Max Strengthening Calf Strengthening Tendon: Pain should not exceed 5/10 Decline Slant Board Isometrics Cross-friction Massage THERAPEUTIC EXERCISE Motor 1 Direction 2 min light, 2 min heavy Quadriceps Instrument Assisted Bend/Pin & Stretch Eccentric Training 2 sets of 15, with 2RiR >24 Hour Rest Energy Storage If pain reducing, 4-5 sets of 45 sec hold Rapid Eccentrics Energy Release Rapid Concentrics Neurodynamics: Femoral Nerve Glides Tibial Tubercle Apophysitis CONDITIONS Similar Pathology (Pictured in Blue à) Thrower’s (Little Leaguer’s) Elbow Medial Epicondyle Osgood-Schlatter Disease Tibia Sever Disease Calcaneus Apophysis Site of bone growth, not connected to joint line 2-5x weaker than surrounding bone/tendon Mechanism of Injury Rapid bone growth without muscle lengthening Excessive Force Too High/Repetitive Poorly Controlled Tibial Tubercle Apophysitis CLASSIFICATION CHARACTERISTICS Osgood-Schlatter Disease Pain Pattern Localized, Tibial Tubercle Risk Factors 8-15 Years Old Boys > Girls Repetitive Knee Extension Heavy Body Mass Observation Focal Swelling Examination Palpation: Swelling, Pain (+) Stair Climbing, Squatting, Running, Jumping, Resisted Leg Extension (-) Patellofemoral Testing (-) Patellar Ligament Palpation MANUAL THERAPY Patient Education Activity Reduction “Strategic Rest” Ice STM/MFR Quadriceps Instrument Assisted Bend/Pin & Stretch Petrissage THERAPEUTIC EXERCISE Motor Quad and ITB Stretching Glute Strengthening Spot-treat Poor Functional Mechanics: Stairs Squat Lunge Deadlift Sports Meniscus Injury CONDITIONS Fiber Types 1. Meshwork of Thin Fibers 2. Lamellar Layer 3. Deep Circumferential Fibers + Radial ‘Tie’ Fibers Mechanism of Injury Excessive Rotation Closed Chain >>> Open Chain ~ Petersen, 1998 Neurovascular Supply Primarily in Outer 1/3 and Ant/Post Horns MAJORITY OF CASES GET BETTER WITH CONSERVATIVE CARE, AND IN POTENTIALLY OPERATIVE CASES, PT PERFORMS AS WELL AS SURGERY. ~ Skalski Meniscus Injury CLASSIFICATION Meniscus Tear Anterior/Posterior Horn Lesion CHARACTERISTICS Pain Pattern Vague, Medial or Lateral MANUAL THERAPY Patient Education Risk Factors Women > Men Work: Kneeling, Bending, Stairs Soccer or Rugby Observation Swelling at Joint Line Guarded or Stiff Knee Leg Gives Out Examination Pain: Palpation Pain: Functional Motion (+) McMurray’s, Ege’s, Thessaly’s, Apley’s, Steinmann I & II, or Bounce Home Activity Reduction Avoid Closed-Chain Rotation Ice (If Inflammatory) THERAPEUTIC EXERCISE Motor Progressive RoM Weight-bearing Rotational Motor Control Joint Mobilization Meniscofemoral I-IV Meniscotibial I-IV STM/MFR Cross-friction Massage Menisotibial Ligaments Patellomeniscal Ligament 1 Direction 2 min light, 2 min heavy Open à Closed Chain Lumbar Hip Hamstrings/Gastroc Peroneals/Intrinsics Quad Strength Hamstring Strength Sensory Angle Reproduction and Reflex Reactivation Turning Car Entrance/Exit Stairs/Squatting/Jumping Sport-Specific ACL Injury CONDITIONS Mechanism of Injury Non-contact is Most Common (70+%) Rapid Deceleration in Low Flexion Angle (0-30°) Tibial Ant Shear >>> Valgus + Tibial IR Minimal Help from Hamstrings at (0-15°) Impact 175,000-200,000/year 2 Billion Dollar Industry Secondary Damage of Surrounding Tissues Possibility of Knee Instability >50% Develop OA by Middle-age 60-65% Full Recovery +