Therapy Information Systems

TIS

Chapter 15
The Problem Knee

Introduction
- medical problems
- physical therapy problems
- two are often related

Osteoarthritis (OA)
- metabolic and enzymatic factors
- "final common pathway" of mechanical deterioration of joint, occurring from an imbalance between the stresses applied to a joint, and the body's ability to withstand those stresses
- can result from excessive (overload) or poorly handled
Progression:
- initial increase in water content of articular cartilage and decrease in GAGs results in softening and subsequently, fissuring of articular cartilage
- with progression, osteogenesis and trabecular thickening occurs (osteoblastic activity); the body is trying to repair and adapt to increased stresses; this is a normal response; however, it is unable to keep pace with the breakdown, and the increased activity results in spurs and osteophytes
- later changes result in physiologic medial-lateral laxity; degenerative meniscal tears occurs and joint space decreases (importance of standing AP films); this results in collapse on one side of the knee and an "opening up" on the opposite side; this results in a physiologic laxity

Rheumatoid arthritis
- connective tissue disease
- onset and extent varies from individual to individual
- may involve single to multiple joints
- characterized by exacerbations and remissions
- symptoms range from mild stiffness and swelling to significant edema and progressive deformity
- inflammatory changes include the synovial membrane, peripheral portions of the articular cartilage, and subchondral spaces; initially, presents as a synovial thickening involving capsular structures
- granulation tissue (pannus) forms, covers and erodes the articular cartilage; adhesions form, resulting in a loss of joint mobility
- eventually, cancellous bone becomes exposed, resulting in a deformity of flexion, internal rotation and posterior displacement of the tibia
- subluxation/instability may follow despite apparent loss of mobility

Physical therapy clinical problems:

Extensor lag
- clinically, patient has full passive extension, but is unable to actively extend the last few degrees
- often able to perform a quadriceps set, but unable to SLR maintaining Q set
- may simply be a strength issue
- MUST assess patellar mobility: is there adequate superior glide? Are they developing infrapatellar contraction syndrome?
Treatment:
- continue to strengthen quads in available range
- Tigny's
- prone TKE
- EMS
- biofeedback
- patellar mobilization
- BAPS
- 4 way hip on involved side
- AP & ML pertubation standing on involved side
- full regimen of CKC activities

Tibio-femoral contractures
- seen less frequently since rehab improvements following ACL
- rationale for delaying acute ACL reconstruction
- usually seen after prolonged immobilization
- MUST evaluate patella
- PF and TF arthritis, osteopenia, abnormal tracking are key issues
- slight flexion contracture places tremendous loads on PF joint
- know how much motion they had under anesthesia
- patient pain tolerance will significantly determine your ability to push these patients
- use good clinical judgement; be clear about your goals versus what the patient is willing to accept
Treatment:
- patellar mobs
- QUAD SETS
- tib-fem mobs (posterior for flexion, anterior for extension)
- bicycle for stretching
- prolonged stretching - minimum 8-10 minutes; this WILL be painful
- isokinetics passive mode
- CPM
- dynasplint
- PRE equipment (patient controlled)

Infrapatellar contracture syndrome
- seen after prolonged immobilization
- seen in many post-op situations where patient "forgets" how to fire quads; patella may or may not have been involved in surgical procedure
- rationale for delaying surgery following acute ACL
- results in loss of tib-fem motion
- patients present with a loss of knee motion, decreased patellar mobility, especially superiorly, ambulation with a flexed-knee gait, anterior knee pain, do instability, occasional palpable firmness in the suprapatellar pouch; if the patient is able to perform a quad set, the patella will begin to glide superiorly, and hit an abrupt stop with pain
Progression:
- begins in suprapatellar pouch, leading to quadriceps sclerosis, retraction of the alar folds of the patella, and patellofemoral adhesions
- end stage is a fixed patella with PF cartilage destruction and tibial articular destruction secondary to invasion by fibrosclerotic pannus
Arthroscopic classification:
Treatment:
- PREVENTION!! Prevention is relatively simple if seen EARLY; KEY is the ability to perform a good, effective Q set to maintain superior glide of the patella; manual superior glide is ineffective
- surgical debridement; but may run into the same problems postop secondary to further surgery around kneecap
Reflex sympathetic dystrophy
- departure from the orderly and predictable response of an extremity to an insult
- departure should include at least two of the following: intense and/or unduly prolonged pain; vasomotor disturbances; delayed functional recovery; and trophic changes that may include edema, atrophy and/or fibrosis
- can be seen in the knee following surgery or something seemingly as simple as a fall
- etiology poorly understood; current theory holds that an initial trauma produces tissue damage, resulting in chronic irritation of a peripheral sensory nerve, increasing the number of afferent impulses to the SC and setting up a normal sympathetic reflex arc to any painful stimuli
Stages (Wattay):

Stage I:
- onset of severe, burning pain
- hyperasthesia
- local edema
- muscle spasm
- stiffness and limited mobility
- vasospasms
- hyperhydration
* average duration = 3 months

Stage II:
- pain becomes more severe and diffuse
- edema spreads
- hair becomes scant and nail become brittle
- spotty osteoporosis
- increased thickness of the joint
- muscle wasting
* may last from 3-6 months

Stage III:
- marked trophic changes eventually become irreversible
- intractable pain throughout entire limb
- muscle atrophy
- marked osteoporosis
Treatment:
- PT treatment is symptomatic; early mobilization and edema control in stage I
- TENS, biofeedback
- active mobility exercises; consider aquatic therapy
- series of nerve blocks

[Back] [Ortho II] [Next]