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get rid of swelling ASAP ----_____ method?
RICE
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what will contribute to a contracture at the knee
putting pillows underneath the knee
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true or false – physical therapist want knee extension as soon as possible
- true
- Quad sets, straight leg raises TKE, stretch gastroc, soleus, walk backwards, femur dorsal glides, patellar mobs
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true or false – physical therapist want to get to 90° as soon as possible
- true
- heel slides, knee flexion stretch, prone knee bands, table/stool scoots, bike, tibial dorsal mobs, CMP
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true or false – it is important to look above and below the knee
true
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normal gait mechanics
- motion before strength – precursor to all other ambulatory movements
- no pain, no limp, match assistive devices
- want to be functional in all three planes
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balance/proprioceptive training
- want to work in all three planes
- multiple moving parts – arm and leg drivers, works balance or static leg
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exercise progression
- if no soreness from last visit, modify exercises by one variable
- if soreness is present but gone after warm-up, stay put
- if soreness remains, increased swelling, backoff progression
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range of motion norms for ADLs
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normal gait and stairs
2 – 70°
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rising from seated position
93° flexion
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tying shoelace
106° flexion
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taking a bath
135° flexion
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anterior cruciate ligament
- primary restraint to anterior tibial translation
- Lockman's test; test only the integrity of ACL
- anterior drawer – shows integrity of all other ligaments capsule – rotate feet to look at other ligaments
- pivot shift – strictly anterior lateral rotary instability (ALRI)
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posterior cruciate ligament
- prevents posterior tibial translation – twice as strong as ACL
- posterior drawer test
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medial collateral ligament
- valgus restraint
- grades I, II, III – posterior oblique ligament, valgus opening in full extensions
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treatment
mostly nonoperative, brace to protect range of motion
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areas most commonly injured
most common injuries and anterior lateral quad, anterior medial quad, and posterior lateral quad
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accelerated ACL protocol
0 – 3
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goals
protect draft, full and gentle range of motion by sixth week, quad function, minimize the swelling, normalize gait
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cautions
- vigorous OKC the extension for six weeks
- hamstrings autographs – avoid vigorous resisted knee flexion until six weeks
- avoid twisting for six weeks
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range of motion
- two weeks;0– 90°
- three weeks; 0 – 120°
- six weeks; full flexion
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brace / weight-bearing
- immediate weight-bearing – brace 0 – 90, locked in extension for ambulation
- after one week unlocked when quad control appears to allow normal gait
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accelerated ACL protocol
4 - 12 weeks
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goals
- protect graph from extreme forces
- gradually increase functional activities
- full range of motion, build a straight
- proprioception
- cardiovascular fitness
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cautions
- avoid quick and uncontrolled twisting
- 10 – 12 weeks
- avoid extremes shearing stress
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true or false – 30% of people can function without ACL
true
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true or false – ACL deficit needs get early onset of arthritis
true
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true or false ACL ruptures are often associated with posterior cruciate tears
false – meniscal tears
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true or false –allograph maybe a little behind autograph because of slower capillary generation
true
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when is the knee the weakest
weakest at about four weeks when patient thinks that they're fine
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ACL pathology facts continued
- bracing not a bad idea, but won't prevent injury
- over 100,000 injuries in US; 2-8 risks for females, most noncontact mechanism
- healing; 6-8 weeks= weak link because of vascular part hasn't grown all the way back yet, return to place six months – one year
- ACL prevention – strengthen hip and knee extensors, and hip abductors – avoidance, flexibility, strengthening, plyometrics, agility
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posterior cruciate ligament
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protection
- get full extension
- avoid hyperextension
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precautions
active forcible flexion for six weeks
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range of motion
- gradual range of motion into flexion 0 – 60 for 1 to 2 weeks
- 90° 2 to 3 weeks,
- full range of motion six-day weeks
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other
similar to ACL protocols, only opposite precautions
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tear type
- radial
- longitudinal
- vertical
- bucket handle
- degenerative
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precautions
- weight-bearing restrictions
- don't ruin the repair with sharing activities
- twisting or flexed the ambulation can disrupt repair
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associative conditions
- ACL reconstruction
- arthritis
- malalignment
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testing
McMurray's test – does it show specific medial or lateral meniscus
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treatment options
- activity modifications
- NSAIDs
- injections
- surgery
- will mask, not heal
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Tear locations
- white tears probably won't heal so removed torn portion
- red white and red tears can heal, the further out the increased ability to heal
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meniscectomy
can increase risk of arthrosis, total meniscectomy me increases joint load 300%
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repair
suture repair, all inside, protected weight-bearing, high repair rates
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characteristics
- 43 million Americans
- 100 types – OA= wear and tear, most common type
- geriatric role = 40 to 65%
- women are more than 60%, the less likely to have knee replacements
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symptoms
- effusion
- malalignment (varus)
- limited range of motion
- crepitus
- tenderness
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treatment
- viscosupplementation
- arthroscopy
- cartilage transplants
- knee replacement surgery
- NSAIDs
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rehab suggestions
- load sharing ( hip/gastroc/soleus strength
- extensibility ( hip – ankle foot)
- heel wedges/orthotics
- Unloader braces
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when is the surgery considered?
only when nonsurgical interventions aren't alleviating pain and symptoms are bad enough to do surgery
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what are the four different options
- uni– compartmental arthroplasty
- patellofemoral arthroplasty
- bicompartmental arthroplasty
- total knee arthroplasty
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Unicompartmental arthroplasty
- used for isolated medial> Lateral compartmental disease
- all ligaments need to be intact
- thin, elderly, females have best outcomes
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patellofemoral arthroplasty
- used for isolated patellofemoral arthritis -often get total knee arthroplasty after this procedure
- all ligaments must be intact
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bicompartmental arthroplasty
- used when medial compartment and the patellofemoral joint are involved – not done often because durability questioned
- all ligaments must be intact
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total knee arthroplasty
three designs based on keeping PCL or not, all remove ACL – all outcomes are similar
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cruciate retaining – most common Louisville
- uses patients PCL to help balance knee
- small risk of late PCL rupture resulting in instability requiring revision
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cruciate substituting or posterior stabilized – second most common
- typically easier to balance flexion and extension gaps
- with clunk with posterior drawer test
- risk of jumping the post and dislocation
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rotating platform
- increase surface area to reduce contact stresses
- increase conformity to tibiofemoral articulation
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what's hot
- minimally invasive
- gender specific knee to pick different sizes
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follow-up for total knee replacement – torture to get motion back
- within two weeks want; 5 – 90°
- within first six weeks want about 95% motion – 115°
- hip easier to cover than knee
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important need facts as they are related to rehab
- surgically pick procedures; used need rehab must, but be careful not to get the PF mad
- transplantation procedures; talk to physician but more than likely range of motion and weight-bearing restrictions
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characteristics
- quads and 60 – 70 year olds
- Patella under 40 year old
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symptoms
typically avulse from patella, paplable defect, extensor lag, operative treatment
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differential diagnosis
- extensor mechanism
- cruciate injury
- meniscal tear
- osteochondral fracture
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characteristics
- instability and giving out
- extensor lag
- minimal defect if reduced
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pathology
- medial patella femoral ligament
- bone bruise
- osteochondral fragment
- congenital/anatomical issue
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treatment
- nonoperative – bracing, taping, therapy (VMO and abductor strengthening
- operative – fix what's broken, trend toward anatomical restoration of MPFL
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congenital issues
- females age 10 – 17 have high-risk of dislocation
- first time this locators may likely the participatingin sports – afterwords happens more often
- risk factors; prior dislocation,younger age at initial injury, family history, hip dysplasia
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anatomical issues – anything making knee more valgus
- increased Q angle - leads to reflects lateral force on the patella
- patellofemoral bony constraints - trochlear depth, patella congruency
- TT-TG ( tibial tubercle trochlear groove distance) - increases distance protective against patellar instability
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characteristics
soft tissue and biomechanical issues – both can be a result of each other
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classification system
- Wilk
- Merchant
- Fulkerson and Schutzer
- Insall
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Wilk classification
patellar compression syndromes, patellar instability, biomechanical dysfunction,direct patellar trauma, soft tissue lesion/overuse syndromes, osteochondritis, neurological disorders
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general risk factors
decreased quad flexibility, hyper mobile patella, patella alignment (alta vs baja), week abductors and external rotators, altered biomechanical alignment, altered VMO response
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Global Patellar Pressure
avoid: patellar taping or bracing, bike, stairs or steppers, OKC exercises, squatting
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excessive lateral pressure; lateral rectinacular pain and medial peripatellar pain
- pain increases on stairs, squatting, stooping, painful crepitus
- patellar tilt higher with atrophy of VMO
- ROM and MMT: grossly within limits, decreased length of ITB/quads/hamstrings, and pain and week quads
- reflex and sensation normal
- tenderness over lateral and medial retinaculum, decreased medial glide of patella
- intervention; stretch tight lateral retinaculum structures, medial patellar glide and tilts, patellar taping, racing, stretching upper leg muscles, straighten quads (VMO, anti-inflammatory treatments
- avoid: bike, stairs or steppers, OKC exercises, squatting
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