Deck 21: The Knee

Question 1

You are seeing a patient to initiate exercises 5 days after reconstruction of the ACL with a patellar tendon autograft.During the first phase of the postoperative exercise program, your primary concern is:

A)Preventing contractures at the knee.
B)Preventing atrophy and reflex inhibition of the quadriceps.
C)Imposing controlled loads on the knee while protecting the graft from excessive stresses.
D)Preventing joint swelling.

Answer 1

C

Question 2

A surgical procedure for a repair of a chondral defect of the medial femoral condyle involves the following: harvesting multiple plugs of intact articular cartilage along with some subchondral bone of the patient's own tissue from a donor site (typically a nonweight-bearing portion of the joint surface) and implanting the plugs (using a press fit) into the site forming a bone-to-bone graft.This procedure is called:

A)Autologous chondrocyte implantation.
B)Mosaicplasty.
C)Microfracture.
D)Débridement and lavage.

Answer 2

B

Question 3

Your patient has only 50° of passive and active knee flexion (but full passive extension) 2 weeks after removal of a cast for a fracture of the tibia.The bone is now radiologically healed.Each of the following techniques will be of value to increase the range of knee flexion except:

A)The hold-relax technique, with isometric contraction of the hamstrings with the knee at 45°, followed by relaxation, then passive movement into more flexion.
B)Low-load, long-duration self-stretching of the quadriceps.
C)Posterior glide of the tibia.
D)Caudal glide of the patella.

Answer 3

A

Question 4

Each of the following is true about guidelines for rehabilitation after a procedure to repair an articular cartilage defect except:

A)ROM exercises (within a protected range) typically are begun a few days postoperatively.
B)Protective bracing is worn during early weight bearing and exercises.
C)The larger the articular defect is, the slower the progression of postoperative rehabilitation will be.
D)Swimming and cycling are allowed and encouraged within 2 weeks to stimulate circulation and healing with limited weight bearing.

Question 5

Which of the following is true about managing a tear of the medial or lateral meniscus?

A)A tear of the peripheral portion (outer zone) of a meniscus does not lend itself well to surgical repair because this portion of the meniscus is avascular and does not heal well.
B)A potential complication of a medial meniscus repair is intraoperative damage to or postoperative entrapment of the saphenous nerve.
C)After meniscus repair, initially avoid knee flexion beyond 60° to 70° during weight-bearing exercises for about 2 months because flexion beyond this range can displace the repaired meniscus in a posterior direction.
D)After meniscus repair, the knee is immobilized in approximately 45° of flexion.

Question 6

Your patient has a capsular pattern, decreased joint play in the knee, and restricted mobility of the patella after a prolonged period of immobilization following a fracture.Which of the following mobilization techniques can be used to increase knee flexion?

A)Posterior glide of the tibia on the femur with the tibia positioned in lateral rotation; caudal glide of the patella
B)Posterior glide of the tibia on the femur with the tibia positioned in lateral rotation; superior glide of the patella
C)Posterior glide of the tibia on the femur with the tibia positioned in medial rotation; superior glide of the patella
D)Posterior glide of the tibia on the femur with the tibia positioned in medial rotation; caudal glide of the patella

Question 7

Each of the following is an expected outcome of conservative management of osteoarthritis of the knees except:

A)Maintaining functional range of motion and strength.
B)Relieving pain.
C)Regenerating worn articular cartilage.
D)Preventing deformity.

Question 8

Although interventions used to manage patellofemoral pain syndrome are based on an examination of each patient on an individual basis, each of the following interventions is commonly employed except:

A)Strengthening the knee and hip extensors in weight-bearing and non-weight-bearing positions.
B)Lateral gliding of the patella.
C)Stretching the tensor fasciae latae (TFL) and iliotibial (IT) band.
D)Using an insert (orthotic device) in a patient's shoe to correct excessive foot pronation.

Question 9

A patient with a history of recurrent dislocation of the patella underwent a surgical procedure for realignment of the extensor mechanism.Considering the position of immobilization postoperatively, you would expect to find each of the following impairments when it is permissible to begin exercises except:

A)Lack of full or almost full passive knee extension.
B)Quadriceps (extensor) lag.
C)Lack of full knee flexion.
D)Weakness of the quadriceps and hamstrings.

Question 10

The "minimally invasive knee arthroplasty" is one type of surgical approach for performing TKA.When the surgeon chooses this approach, it is because:

A)It is easier to perform and therefore is the choice of the less-experienced surgeon.
B)The incidence of intraoperative complications is lower.
C)It is an arthroscopic procedure, so the rehabilitation is shorter.
D)It is less disruptive to the soft tissue, with increased rate of postoperative recovery and less postoperative pain.

Question 11

Which of the following correctly identifies biomechanical abnormalities that contribute to patellofemoral pain or patellar instability?

A)Genu varum, overstretched lateral retinaculum, weakness of the vastus medialis obliques (VMO) muscle, excessive supination of the feet, weakness of the hip adductors and internal rotators
B)Weakness of the VMO, tight lateral retinaculum, genu valgum, excessive external tibial torsion, excessive pronation of the feet, weakness of the hip abductors and external rotators
C)Excessive internal tibial rotation, genu varum, weakness vastus lateralis muscle, tight lateral retinaculum, excessive supination of the feet, weakness of the hip adductors and internal rotators
D)Excessive external tibial torsion, genu valgum, weak vastus lateralis muscle, overstretched lateral retinaculum, excessive pronation of the feet, weakness of the hip abductors and external rotators

Question 12

During closed-chain strengthening of the quadriceps, knee ROM in which the greatest amount of patellofemoral compression occurs is:

A)At all portions of the ROM (i.e., compressive forces are equal throughout the ROM).
B)Between 30° of knee flexion to full extension.
C)Between 60° of knee flexion to 30° of knee flexion.
D)Between 60° of knee flexion to full knee flexion.

Question 13

Each of the following is true about patellar tendon versus hamstring tendon autografts for ACL reconstruction except:

A)A longer healing time and a more slowly progressed rehabilitation program are required with a hamstring tendon graft than with a patellar tendon graft.
B)A patellar tendon graft is most appropriate for the skeletally immature patient.
C)Anterior knee pain and difficulty kneeling are somewhat frequent complications with a patellar tendon graft but not with a hamstring tendon graft.
D)A patellar tendon graft involves bone-to-bone fixation, whereas a hamstring tendon graft involves tendon-to-bone fixation.

Question 14

Which of the following is true about total knee arthroplasty (TKA)?

A)When a cruciate-retaining prosthesis/procedure is used for a TKA, the anterior cruciate ligament (ACL) is not excised, thus providing greater anterior-posterior stability to the knee.
B)A tricompartmental TKA involves replacing not only the articulating surfaces of the proximal tibia and distal femur but also the tibiofibular articulation.
C)If a semiconstrained or unconstrained prosthetic implant is used, the medial and lateral collateral ligaments (MCL and LCL) must be intact or repairable for adequate postoperative medial-lateral stability of the replaced joint.
D)A mobile-bearing prosthesis typically is selected for the elderly, relatively sedentary patient because this design permits full weight bearing immediately.

Question 15

The primary value of a patient performing quadriceps setting exercises when the knee is immobilized in a long leg cast for an extended period of time is to:

A)Strengthen the quadriceps muscle.
B)Maintain mobility of the patella.
C)Stretch the anterior portion of the knee capsule.
D)Prevent a knee extension contracture.

Question 16

Your patient has degenerative joint disease of the knees.Although currently her left knee is asymptomatic, she has been experiencing pain and periodic "giving way" of her right knee for the past week.Her physician prescribed anti-inflammatory medication to reduce joint swelling and pain and has referred the patient to you for evaluation and treatment.The patient is experiencing significant stiffness of the knee, especially in the morning and after sitting for an extended period of time.Although she indicates that pain and swelling have decreased during the past few days since she began taking the prescribed medication, pain is still notable during walking and with movement toward the end of the range of motion (ROM) (more so in flexion than extension).Knee ROM is limited (active and passive knee flexion 100°; passive knee extension lacks 10°; active knee extension lacks 20°).Strength of knee musculature is 4/5.She exhibits an antalgic gait pattern.Which of the following interventions is most appropriate for this patient at this time?

A)Quadriceps setting exercises, active ROM within pain-free ranges, resisted multiple-angle isometrics, dynamic control of the knee with bilateral closed-chain exercises, activity modification, and use of a cane during ambulation
B)Ice, rest, active-assistive ROM through the pain-free range, quads and hamstring setting exercises, ambulation with crutches until pain and swelling subside
C)Low-intensity stretching to increase knee flexion, static and dynamic strengthening with unilateral closed-chain exercises, stationary cycling
D)Activity modification and use for an assistive device during ambulation, vigorous resistance exercises of the asymptomatic knee to improve strength, isometric resistance exercise, eccentric but no concentric resisted exercises of the involved knee, low-intensity stretching

Question 17

Each of the following is true about postoperative management after primary TKA except:

A)Based on the design of the prosthesis, the use of grade III posterior joint gliding techniques may be an appropriate intervention to increase knee flexion after cruciate-excising TKA but not after cruciate-retaining TKA.
B)If the TKA involved cementless fixation, weight-bearing recommendations vary widely from weight bearing as tolerated while using a walker or crutches to touch-down weight bearing for 4 to 6 weeks after surgery.
C)Although straight-leg-raising exercises for the operated lower extremity are initiated in supine and prone positions as soon as possible during the early postoperative period, they often are delayed for several weeks in side-lying positions to avoid varus/valgus stresses on the operated knee.
D)Participation in high-impact physical activities should be avoided after TKA, as it may contribute to mechanical loosening of the implanted prosthesis over time.

Question 18

Your patient reports a sudden onset of severe pain yesterday in the (L) posterior thigh while sprinting.Today he is unable to fully extend his (L) knee while walking because of pain.Which of the following interventions is most appropriate to use when initiating therapy today?

A)Passive knee flexion/extension within the pain-free range with the hip flexed to 90°
B)Passive knee flexion/extension within the pain-free range with the hip positioned in 0° extension
C)Active knee flexion but no passive or active extension
D)Submaximal resisted knee flexion in the prone-lying position

Question 19

Which of the following is true about ligament injuries of the knee and post-injury management?

A)The most common mechanism of injury of the ACL is forceful internal rotation of the tibia while the foot is planted.
B)Under similar noncontact conditions, a man is far more likely to injure the ACL than a woman.
C)MCL injuries are managed nonoperatively more often than are ACL, posterior cruciate ligament (PCL), or LCL injuries.
D)Forceful hyperextension of the knee is the most common mechanism of injury of the PCL.

Question 20

A quadriceps lag may be described as:

A)Patient has full active knee extension but exhibits increased time to peak torque when knee extensors are evaluated on an isokinetic dynamometer.
B)Patient has full passive knee flexion but limited passive knee extension.
C)Patient cannot actively extend the knee to full extension even though there is full passive knee extension.
D)Another term for knee extension contracture.

Question 21

During the initial assessment of a patient who complains of a recent onset of "knee pain" when descending stairs and a sense of "giving way" both on the stairs and when walking, you ask several questions about recent knee injuries.Which of the following injuries would lead you to believe the patient might have injured his ACL?

A)A forward fall onto his knee directly striking his patella
B)A blow to the inside of his knee when his dog was jumping up to greet him
C)A twisting injury when he slipped off the curb and his knee buckled inward
D)A running injury resulting in pain along the inferior border of the patella and the tibial tubercle

Question 22

Research studies in the literature surrounding ACL rehabilitation have coined the terms potential copers and potential noncopers to identify and classify individuals with ACL injury who are good versus poor candidates for nonoperative rehabilitation.True copers applies to individuals who:

A)Resolve personally to use a gait-assistive device and reduce their activity level to avoid surgery and have no incidence of knee buckling for at least 1 year.
B)Complete a course of rehabilitation in preparation for surgical repair of the ACL in order to return to vigorous work or sporting activities within 1 year of injury.
C)Successfully return to full pre-injury activity 1 year after injury with no episodes of knee buckling, following a rehabilitation program without surgery.
D)Do nothing and develop a quad avoidance gait pattern within 1 year of injury.