9/24/2012. Greg Bennett, PT, DSc Excel Physical Therapy Marymount University
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1 Greg Bennett, PT, DSc Excel Physical Therapy Marymount University Hx often diagnostic Least to most threatening Sx trump exam Develop consistent routine Don t inflame inflamed tissue 1
2 1. ESTABLISH OR CONFIRM DIAGNOSIS 2. ESTABLISH TREATMENT 3. LIMIT PROGRESSION 4. BASELINE PATIENT STATUS HISTORY THOROUGHNESS/ ACCURACY KNOWLEDGE of ANATOMY and MECHANICS EXPERIENCE Adequate history taking can often be diagnostic; include discovery of previous injuries. Mechanism of injury/ knee position Pop, snap or click? Swelling-onset Post-injury function History of injury Onset during what? Noisy knee? Locking/ buckling Stairs painful? ADL/sports Swelling/pain Swelling Instability Pain Dysfunction 2
3 When How much? Rapid: Major trauma vascular tissue injury Gradual: PFJS, DJD, tendonitis, chronic instabilities Sudden-trauma Gradual- no trauma Sudden-no trauma Gradual-trauma Meniscal tear Collateral ligament strain or sprain. ACL or PCL tear Fracture TF or PF Dislocation Neoplasm Sub-clinical injury Overuse Final Straw Meniscus Subluxation or dislocation PFJS, DJD, tendonitis Impingement; Plica 3
4 Grade I or II Sprain/Strain Subluxation PFJS, DJD Impingement Sudden: Trauma: major injury Prolonged sitting: PFJS, AKPS Stairs/squats: PFJS, tendonitis ACL deficiency Changing direction: Instability; subluxation; meniscal lesions Locking, popping Grating, cracking Sharp Dull Morning pain With activity Meniscus PFJS Many PFJS, instability DJD Synovitis/tendonitis Cutting, twisting Hyperextension Deceleration Lateral collateral is a pencil-like cord Popliteus tendon The capsule here is open, weak and prone to injury Together with the anterior cruciate 4
5 Direct blow Hyperflexion Valgus stress Weight bearing, foot fixed CKC Varus stress Weight bearing, foot fixed CKC Direct blow Twisting, cutting Twisting, cutting Weight bearing 5
6 Mild symptoms Min. tender Normal motion Re-occurs Min. tearing Mod. Symptoms Loss of function Loss of motion Unstable Becomes arthritic? Partial tear Severe symptoms Loss of unction Marked loss of motion Unstable Arthritis Complete tear R/O referral Scan spine Analysis Confirmation Diagnosis Problem list (goals) Gait/ activities Posture Deformity/ alignment Swelling Atrophy Rubor/redness Stress 6
7 Calor/temperatur e TTP Swelling Sensation Structure/ patella Pulses Crepitus Varus/valgus Drawer Lachman Pivot shift/rps Meniscal Sensitivity is a statistical measure of how well a classification test correctly identifies a condition Sensitivity is one measure of how good a test is. It is the number of "true positives" plus "false negatives," divided by the percent of cases picked up by the test. Specificity: Are you testing what you think you are testing? Specificity is a statistical measure of how well a test correctly identifies the negative cases, or those cases that do not meet the condition under study. It is defined as the number of "true negatives" plus the number of "false positives" divided by the percent of negative results that are really negative. Lachman Test Gold Standard 30 flexion 7
8 Sensitivity Range: % Specificity Range: 100% Less sensitive 45 hip flexion 90 knee flexion Sources: Dehaven 80; Donaldson 85; Liu 95; others Sensitivity Range: 10-76% Specificity Range: 50-86% Influenced by secondary restraints START Extension IR Valgus ITB dependent Sources: Dehaven 80; Rubenstein 94; Torg 76; Kim 95; others FINISH Flexion IR valgus Sensitivity Range: 27-71% Specificity Range: % (Torg) Influenced by secondary restraints Sources: Galway 80; Rubenstein 94; Torg 76; Donaldson 85; others 8
9 START Flexion ER Valgus MCL+dependent FINISH Extension ER valgus Poorly Studied (Rubenstein 94) Sensitivity: 26% Specificity: 95% (PCL) Influenced by secondary restraints At 30 flexion, the cruciates are in their most relaxed state, and pathologic laxity palpated is capsular laxity Medial capsular layers provide stability to valgus stresses at knee & are primary stabilizer at 0-30 of flexion Role of LCL increases w/ joint flexion, as posterolateral structures become lax With joint flexion, resistance by ACL decreases, but large forces are found in PCL at 90 degrees of flexion 9
10 If still lax at 0, what does that mean? Secondary restraints also injured. What are they? Meniscii MCL/LCL Capsule Muscles? McMurray (1942) Thessaly test (2009) Apley Grind Point tenderness Scans Supports the patient holding outstretched hands while the patient stands flatfooted. Patient then rotates their knee and body, internally and externally, three times Keep knee flexed at 20 degrees. Suspected meniscal tears will experience joint-line discomfort. Clin J Sport Med Jan;19(1):9-12 Sensitivity 90.3% Specificity 97.7% Positive predictive value of 98.5% Negative predictive value of 86.0% Clin J Sport Med Jan;19(1):9-12 Sensitivity Range: 29-63% Specificity Range: 29-57% Influenced by numerous tissues Pain in the posterior aspect of the knee with maximal flexion may be indicative of a posterior horn meniscal tear. Sources: Anderson 86; Boeree 91; Fowler89; Noble 80; others 10
11 Posterior Drawer Test Sag Sign Quad-Active Test Tibial drop back test: the examiner compares the prominence of the proximal tibia to the femoral condyles with the knee flexed to 80 Also done with hips/knees at 90 Poorly Studied: Rubenstein 94 Sensitivity Range: 79% Specificity Range: 100% Most common knee complaint Need to discern between patellar pain instability both pain and instability Lower Extremity Alignment Generalized Laxity Locations of Tenderness Patellar Alignment Passive Patellar Tilt Lateral and Medial Patellar Glide Patellar Apprehension Crepitation Q angle at 90 degrees Lifting the lateral border of the patella superiorly to assess the tightness of the lateral patellarfemoral retinaculum Inability to achieve horizontal is a positive test (excessively tight lateral structures) 11
12 Lateral Patellar Glide Manually sliding the patella laterally Apprehension sign: when a lateral patellar glide produces fear of dislocation Medial Patellar Glide Manually sliding the patella medially Defined as the angle between the axis of the femur to the center of the patella the center of the patellar to the tibial tubercle Assessment in flexion is more significant Assessed in full knee extension and at 30 and 90º of knee flexion An increased Q angle increases the likelihood of lateral patellar subluxation Lateral patellar subluxation or dislocation knee flexion tibial external rotation valgus Etiologies: an increased Q angle in early flexion incompetent MPFL shallow trochlea short trochlear groove (relative alta) Lateral Radiograph Patellar Height Blumenstaat s line Physeal scar Insall-Salvati Ratio Defined as the length of the patella in relation to the length of the patellar tendon 12
13 Differentiate between pain and instability Instability: -Provide pt with a patellar sleeve, preferably one with a lateral patellar support -Initiate therapy referral for ROM,quad strengthening and hip ER strengthening Perkins Sign (posterior palpation) Grind (2 angles) AROM crepitance Cinema sign Clarkes sign Stability Orientation Muscle Function Crepitation Irritation Girth Ballotment Bounce home Q angle Alta/ baja patella Diagnostic Imaging X-ray MRI CT Scan Deficits Quality Crepitance Apprehension Squatting?? 13
14 Deficits End feel Painful arc Crepitance Joint play Flexibility Contractile vs. non-contractile Interpretation End Feel! Not diagnostic Usually not appropriate with acute injury Hypermobility Joint conditions Neurology Medications Injections/steroid s Allergies Infections Weight Mental status?? History CA LYSHOLM KNEE RATING SCALE Tegner Scale Cincinnati Scale Etc. Adult population, orthopedics 14
15 History Active Movements Passive Movements Resisted Movements Palpation Specific Orthopedic Tests X-Ray Correlation Treatment plan Pignon, Haiti 15
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