Knee disorders
David Logerstedt, PT, MPT, PhD
Associate Professor
Objectives
● Compare the etiology, signs/symptoms of patellar tendonitis,
quad tendonitis, knee bursitis, IT band friction syndrome, and
osteoarthritis.
Bursitis
• Prepatellar
• “housemaid’s knee”
• “carpenter’s knee”
• Etiology
• Traumatic
• Overuse/overload
• Infection
• osteoarthritis, gout
• Pes Anserine
• repetitive trauma
• degenerative knee
• pain/swelling/tenderness
anterior-medial tibia
• resisted testing of pes anserine
mm cause sx
• Less common:
• Infrapatellar
• Intervention: PEACE and LOVE, NSAIDs, ADL modification
Iliotibial Band Friction Syndrome
• Friction of IT Band over lateral
condyle of femur
• Pain localized over lateral femoral
condyle
• Discomfort initially relieved by rest
• Pain may radiate toward the lateral
joint line and proximal tibia
• Noble Compression test
• Tightness of IT Band
• Hip weakness
• ? Inc. Hip Add./IR? Powers CM, 2010
• Runners
• training error – running on 1
side of road
• Worse if a person continues to
run
• Symptoms frequently develop
during downhill running
• No symptoms of internal
derangement
Stretching Techniques for ITB
• self-stretching is rarely sufficient for ITB problems at the knee
• stretching with an external load
• therapist
• partner
• props
Therapist/partner stretches
• patient lying on the uninvolved side
• hip and knee of the bottom limb are flexed
into the chest and held
• hip of the limb to be stretched (upper) is
flexed and abducted than extended with the
knee flexed
• therapist behind the patient one hand on
pelvis , other hand applies downward
pressure at the knee
Prop stretches
• Standing holding on to a counter or desk
• leg to be stretched crossed behind
• bend front knee using desk for balance
Osteoarthritis
• OA: most prevalent form of arthritis
• 23-33% of adults in USA
• > 70 million Americans
• Leading cause of disability - adults
• > 65 yrs
• Knee: TF joint
• Adults > 55 yrs with knee pain
• 35% males, 42% females – mod-severe
• OA
• 21 million Americans
• Etiology: multifactorial
• Biomechanical & biochemical
• Injury, obesity
• Genetics, aging
• Affects entire joint
Knee OA: Radiographic Signs
• Osteophytosis
• Nonuniform joint space loss
• Bony sclerosis
• Bony cyst formation
Knee OA: Risk Factors
• Obesity
• Joint injury
• Occupation/recreation
•
•
•
•
•
• Repeated overuse
Aging
Lack of physical activity
Female
Heredity
Developmental malalignment
Symptoms & Clinical Signs
• Pain
• Crepitus
• AM stiffness - < 30 minutes
• Intermittent joint swelling
• Bony osteophytes
• Pain
• Joint effusion
• Decreased muscle strength
(quadriceps)
• Limited ROM
• Decreased proprioception
Knee OA: Functional Limitations &
Disability
• ADLs
• Ambulation, stair climbing, transfers, etc.
• Self-care
• IADLs
• Work
• Recreation
Physical Performance Measures
• Recommended core set of PPM for pts with knee and hip OA
(OARSI):
• 30” Chair Stand Test
• 40 meter Fast Paced Walk
• Stair-climb Test
• Additional recommended PPM
• TUG
• 6-minute Walk Test
Patient reported outcome measures
• Performance Does Not Equal Perception
1 month after TKA walking distance and
speed decreases, but walking ability
reportedly improved
1 month after TKA patients take longer to
go up and down stairs and more people
require a handrail, but stair climbing
ability reportedly improved
1 month after TKA patients take longer to
get up and out of a chair, but ability to
rise from a chair reportedly improved
Interventions Used to Address the Identified
Impairments
• Pain
• Swelling/effusion
• Joint mobility/ROM
• Tibiofemoral
• Patellofemoral
• Muscle strengthening
Knee OA: Non-PT Interventions
• Pharmacologic
• Neutraceuticals
• Injections
• Hyaluronic acid
• Surgical
Indications of total knee arthroplasty
• Severe knee pain or stiffness
•
•
•
•
• Limits ADL
Moderate knee pain while resting
Chronic knee inflammation/swelling
Knee deformity
Failure of non-operative management
• Anti-inflammatory, cortisone/lubricating injections, PT,
other surgeries
(Refer even if X-ray shows only mild disease)
Incidence of TKA
Men
Women
Types of knee arthroplasty
• Unicompartmental
• Bicompartmental
• Tricompartmental
Surgical Procedure
• Different surgical approaches
• Replace surface of:
• Femoral condyle
• Patella
• Tibia plateau
Femoral/Tibial Osteotomy
Prosthesis Component
PCL problem
• Absence of PCL affects knee
stability
• Implants with a posterior cam
to substitute for PCL
• New surgery
techniques/implants that
preserve PCL
Complications
• Deep vein thrombosis
• Symptoms:
• Pain, swelling, redness, dilation
of the surface veins.
• May not cause any clinical
signs and symptoms.
• Use clinical prediction rules
for clinical diagnosis.
Complications
• Neurovascular injury
• Results from direct
compression or from
realignment of the limb.
• Common in knees with
flexion and valgus
deformities.
• Peroneal nerve is the most
commonly involved.
• Popliteal artery could be
injured, but rare.
• Stiff knee
• ≥ 10° flexion contracture. or
total motion arc less than 95°.
• Management
• Intensive PT.
• Splinting.
• Closed manipulation.
• Debridement and revision
surgery
Rehabilitation prior TKA
Rationale
• People awaiting surgery have considerable pain and disability
• Increase time of wait lists
• Preoperative status predict postoperative status
Is rehabilitation before TKA effective?
Rehabilitation prior TKA
Preoperative program
• Teach to patients to implement strengthening and
flexibility exercises
• Provide education on patient expectations during
hospitalization and factors influencing
discharge planning and disposition,
postoperative rehabilitation program, safe
transferring techniques, use of assistive
devices, and fall prevention.
Rehabilitation after TKA
• When should outpatient PT start?
• Low risk patients
• As early as day 1 post-surgery
• High risk patients (70 yrs living alone and 2 comorbidities,
any age and 3 comorbidities)
• As early as day 3
Acute care after TKA
• GOALS:
• Prevention of postoperative complications
• Control pain and swelling
• Regain range of motion
• Prevent muscle atrophy
• Improve function/quality
of life
• Improve independence
Home PT goals
• Home PT is for homebound.
• Progress exercises initiated in the hospital
• Progress ROM
• Patient mobility
• Gait training
• Transfers, including car transfers
• Muscle strength (NMES application)
• When no longer considered homebound, home PT is discontinued.
Outpatient Rehab Considerations
• Discussion
Take home message
• Rehabilitation “journey” won’t be easy
• Needs time and effort/compliance
• From acute care to outpatient
• Start physical therapy as soon as possible
• Use NEMS at highest intensity
• Outpatient PT
• Intense strengthening and functional exercise
• Progressed based on clinical and strength milestones
Return to activities
Fractures
Plain films (radiographs)
1. Site and extent
2. Type (complete/incomplete)
3. Alignment
4. Direction of fx line
5. Presence of special features
6. Associated abnormalities
7. Abnormal stresses/pathological
Tibial Plateau Fracture
Tibial Plateau Fracture
• Lateral – 80-85%
• Associated with MCL & ACL tears
• Medial
• Associated with PCL and LCL tears, peroneal nerve palsy,
popliteal & anterior tibial artery damage
• Mechanism of Injury
• Medial or lateral force
• Compressive axial force
Interventions
• CPM
• ROM ex x 6 weeks
• 6-7 weeks postop: SLR, stationary bike
• 8-12 weeks: begin TTWBing
• Complications:
• Delayed union
• Decreased ROM
• Instability
• Posttraumatic arthritis
Patellar Fracture
• Mechanism of Injury
•
•
•
•
•
• Flexed knee with ankle DR
Fall
Blow to Anterior Knee
Comminuted Fx
Eccentric Quad Contraction
Transverse Fx
Management
• Conservative (external fixation)
• Minimal displacement, articular
surface intact or minimally
disrupted
• ORIF
• Displaced transverse Fx
• Tension band wiring, screw
fixation, partial patellectomy
• NWBing x 4-6 weeks
• ROM ex
Summary