Common Ailments and Injuries of the Knee

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Common Ailments and Injuries of the Knee Powered By Docstoc
					 Common Ailments and
Injuries of the Knee, 2011

   Kevin deWeber, MD, FAAFP
Sports Medicine Fellowship Director
       Thanks to: Rodney S. Gonzalez, MD
   Background
   Anatomy
   History
   Physical Examination
   Radiology and Laboratory
   Case Studies
   Patient age
   Current symptoms and duration
   Pain with or after activity/changes in activity
   Catching/locking (“mechanical”) or Instability
   Stairs, squats, “theater sign”
   Exacerbating and relieving factors
   What treatment already tried (Rest, NSAIDs,
    brace, …)
   Prior knee injury or surgery
   PMH
   Knee Examination
   (6-step Msk exam)
 Inspection

 Palpation

 Range  of Motion
 Strength

 Neurovascular (rare)

 Special Tests
                     Knee Examination
   Inspection
       Alignment of lower extremities
            Varus, valgus, recurvatum
       Patellar position and motion (j curve deformity)
       Inspection for asymmetries
            Swelling, torsion, inability to extend knee
            Atrophy
                  Knee Examination
   Palpate for effusion and
   Palpate for tenderness
       Tibial tubercle
       Quadriceps tendons
       Retropatellar tenderness
       Joint line
       Ligaments (MCL/LCL)
       Bursa (incl. pes anserine)
                  Knee Examination
   ROM
       Flexion: 130°/135°
       Extension: 0° to -10°
       Internal Rotation: 10°
       External Rotation: 10°
   Strength
     Hams
     Quads: squat, duck
                 Knee Examination
   Special Tests (ligaments)
       Valgus and Varus Stress
        Tests (MCL/LCL)
       Lachman’s & Anterior
        Drawer (ACL)
       Posterior Drawer &
        Posterior Sag Test (PCL)
       Postero-lateral corner
       Patellar stability
       Flexibility
MCL Stability
Apply Valgus
or Medial

AT 30d
 LCL Stability
 Apply Varus
 or Lateral
Test of ACL

At 90° Flexion

+ is increased translation
or soft end point

At 20-30 ° Flexion
(more sensitive)
              Posterior Sag
Posterior Drawer
                Knee Examination
   Meniscal Tests
     Joint line tenderness
     Thessaly test

     McMurray Test

     Squatting & Duck
   Multiple + tests is
    JUST as predictive of
    meniscal tear as MRI
                    Thessaly Test
   Pt stands on affected leg
   Knee bent at 20 degrees
   Examiner holds pt’s hands
    and rotates pt to both sides
   Positive test: joint line pain
       McMurray test for
        Meniscal injury
   Test Med and Lat meniscus
   3 concurrent maneuvers:
      Grind it (Rotate tibia AWAY
       from it)
      Crunch it (varus or valgus)

      Full ROM (flex/extend knee)

   Positive: Painful “pop”
                 Knee Examination
   Patella Tests
       Patella Apprehension
       Patellofemoral
        Compression Test
                               Patellar Slide
                               nl is 25-50%
                          Patellar Apprehension
                          w/ lateral movement

Patellar Tilt nl is 15°
   Postero-lateral corner (PLC)
            Dial Test
Normal            Abnormal (PLC tear)
             Knee Examination

   Flexibility Tests
              Angle (Hamstring)
     Popliteal

     Thomas Test (Hip flexors and Quads)

     Ober’s Test (IT Band)

Popliteal Angle     Thomas Test
   OBER Test
ITB Tightness (TFL Injury)
Affected side up
Flex knee 90
Hip ABDucted/externally
Allow Limb to passively
Tight ITB will remain
     Value of cross table lateral
   Rule out fracture
       Can reveal fat-fluid level in joint, AKA
         Radiology and Laboratory
   Knee aspiration if suspect:
       Infection
       Crystal arthropathy
       Tense effusion causing symptoms
Injuries and Ailments of the Knee
   Medial Ligament Injury
   Lateral Ligament Injury
   ACL Injury
   PCL Injury
   Meniscal Injury
   Retropatellofemoral Pain Syndrome (RPPS)
   Patellar Subluxation/Dislocation
   Patellar Tendinopathy (Jumper’s Knee)
   Quadriceps Tendinopathy
   Iliotibial Band (ITB) Syndrome
   Osgood-Schlatter “Disease”
              Case Soccer Star
   16 y.o. female soccer player
    presents to clinic 1 week after
   Reports she was coming down
    from header when she twisted on
    landing. Heard a pop in her
    knee and had pain. Taken from
    field and couldn’t return to
    game. Noticed that night knee
    was swollen.
   Now, 1 week later, almost
    normal gait. Knee feels much
           Case Soccer Star
Physical exam
 Joint effusion present

 No sag

 No joint line tenderness

 No LCL/MCL laxity

 Negative
 Positive Lachman

  Diagnosis: ACL Injury
   Anterior Cruciate
   Ligament Injury
Clinical symptoms
 1/3 report audible pop

 Mechanism of injury

Non-contact--twisting with the foot planted
Contact--valgus stress with twisting
 Immediate swelling (hemarthrosis)

 Usually non-ambulatory after injury
      Anterior Cruciate Ligament
   Half occur with
    medial meniscal tear
   Can occur with
    MCL tear
   Rare with LCL or
    PCL tear
 Features that should prompt an xray
   after acute knee injury include:
1.   Unable to bear weight
2.   Can’t flex >90d
3.   Patella TTP
4.   Fibular head TTP
5.   Age <18 or >55
6.   All of the above
        5 Ottawa Knee Rules
i.e. When to order a knee xray after acute injury

     Age > 55 or < 18
     Unable to walk
     TTP on PATELLA
     Unable to flex 90 deg
     ACL: Radiographic Findings
   Avulsion of the
    intercondylar tubercle
   Anterior displacement of
    the tibia with respect to
    the femur
   Segond fracture (a thin
    sliver of bone avulsed
    from the proximal lateral
    tibia with the lateral
    capsular ligament)
Segond Fracture
       Anterior Cruciate Ligament
   Management
     Brace knee first week (immobilizer)
     Crutches for comfort, advance to toe-touch and
      wean from crutches as tolerated
     F/U 10 days to reexamine and begin physical
     If posterolateral bruising, consider more serious
      injury to include damage to posterolateral corner –
      REFER (Dial Test)
     Imaging
        Initially, plain films
        Order MRI at 10 day mark – no urgency
        Case Security Force Iraq
   37 y/o male security forces Master Chief c/o
    knee pain and giving out after tripping over a
    wire and falling onto a gear locker
   Happened a few months ago
   Unusual feeling in knee with jogging, “sliding”,
   No locking
       Case Security Force Iraq
Physical examination
 No joint effusion

 No joint line tenderness

 Swelling and tenderness of popliteal
 No LCL/MCL laxity

 Negative McMurray, Thessaly

 Negative Lachman
             Posterior Sag

Posterior Drawer, + Quad activation
              Diagnosis: PCL Injury
Posterior Cruciate Ligament Tear
   Mechanism of injury
     Fall onto flexed knee with plantar flexed foot
      and impact on tibial tubercle
     Dashboard injury—posteriorly directed
      force to anterior knee in flexion
     Make sure to rule out
 Postero-Lateral Corner injury
Dial test
Posterior Cruciate Ligament Tear
    Isolated PCL tear
      Non-surgical
      Symptomatic treatment with
       crutches/immobilization first week as needed
       (often not needed)
      Physical therapy/range of motion

    PCL + other ligament or PLC injury
        Orthopedic referral
         Case Basketball Player
   Basketball player presents
    day after game for knee
   Remembers painful twist
    with planted foot during
    the game, but kept playing
   Swelled up overnight
   Now feels “locked”
      Case Basketball Player
Physical exam
 Effusion

 Joint line tenderness

 Limited knee range of
 McMurray and Thessaly
  tests positive with
  painful click

      Diagnosis: Meniscal Injury
              Meniscal Tear
 Avascular inner 2/3, partly vascular outer 1/3

 Minimal innervation

 Held in place by coronary ligaments, painful
  when torn (meniscotibial ligaments)
 Lateral meniscus less firmly attached, less
  prone to injury
                Meniscal Tear
   Function
      Lubrication

      Nutrition of joint

      Shock absorption

      Reduce friction

      Disperse stress / weight

      Decrease cartilage
Meniscal Tear
              Meniscal Tear
Clinical symptoms
 Traumatic tears
    Twisting or hyperflexion injury
 Degenerative tears
    In older patients, minimal or no trauma
 Insidious swelling (overnight or 2-3 days)
 Mechanical symptoms: locking, catching,
 Pain medial or lateral sides of knee, particularly
  with twisting or squatting
                 Meniscal Tear
   Management
     Physical therapy, maximize ROM/strength

     Non-surgical if no mechanical symptoms

     Surgery for:

        Locking

        Extension or flexion block

        Persistent pain

     MRI – wait for four weeks, if not considering
      surgery, do not need to image
Case Knee “came out of socket”
   16 y.o. male lacrosse player made sharp cut
    yesterday. Felt knee “come out of socket”.
    Immediate pain and swelling.
   Went to ER and x-rays negative for fracture.
   One week out can’t fully bend knee due to
 Case Knee “came out of socket”
Physical exam
 Patellar apprehension

 Medial patellar
 Increased patellar
Patellar Subluxation
 Patellar dislocation/subluxation
Clinical symptoms
 Severe pain
 Sometimes pop
 Occasionally see a
  deformity, usually lateral
 Often reduces
 Swelling
 Loss of motion
  Patellar dislocation/subluxation
Mechanism of injury
 Direct trauma

 Rotation over planted foot
  (ie. softball swing)
 Sudden cutting movements

 “Stretched out” tissues
  from prior injury
  predispose for
    Patellar dislocation/subluxation
   Management
      Straight leg immobilization x 1-2 weeks
      Weight bearing as tolerated

      Cylinder cast if question compliance

      MRI if skeletally immature to r/o sleeve fracture
       (peeling off sleeve of cartilage and periosteum)
       requiring surgical repair
      Physical therapy after immobilization to return
   Refer to Ortho for fracture, ligament injury,
Case: Petty Officer can’t run
    Case: Petty Officer can’t
           run PRT
   Active duty Navy petty officer. Pain
    started during boot camp march.
    Relieved by stopping running. Returns
    with return to running.
   Pain generalized to anterior knee.
   Pain worse with stairs and after
    prolonged sitting.
   No clicking, locking or instability.
   Can’t run and has gained 50 pounds.
Petty Officer can’t run
Physical exam
 No effusion

 No ligamentous laxity

 Pain reproduced by direct
  pressure and rocking of patella
 Patellar tracking abnormal

 Patellar retinacula tight

 Vastus medialis oblique atrophy

 Relative weakness hip abd/adductors
  Diagnosis: Patellofemoral Syndrome (Runner’s knee)
         Patellofemoral Syndrome
   Patellofemoral Syndrome is:
      Diagnosis in nearly 25% of all knee injuries

      Most common diagnosis made in runners

      Most common orthopedic reason for failing
       Army Basic Training
      Most common diagnosis in primary care sports
       medicine clinics
Causes of PFS

      Patellofemoral Syndrome
Clinical symptoms
 Diffuse anterior knee pain
 Worsened by patellofemoral loading– stairs,
  prolonged sitting, squatting
 “Theater sign”
 May occasionally give out
 Symptoms frequently bilateral
 Swelling generally absent
 Usually no trauma hx, rare hx direct blow
          Patellofemoral Syndrome
Physical exam
 Pain reproduced by direct pressure over patella
  and rocking in femoral groove
       Patellar grind test
   Patellar glide (retinacular flexibility)
   Vastus medialis oblique atrophy?
   Patellar tracking—lateral movement of patella
    near full knee extension
   Relative weakness in hip abductors/external
        Patellofemoral Syndrome
   Tight—
       Med   or Lat retinaculum
       Iliotibial band

       Quadriceps

       Hamstrings

       Achilles
         Patellofemoral Syndrome
   Management
     Decrease painful activities 1-3 months

     Strengthening

     Flexibility
          Patellar retinacula
          Quads & hams

          ITB, Achilles

       Misc: knee sleeve, orthotics
     Weight      loss (incr friction under patella)
    Case: Airman Can’t Run PRT
   Active duty Airman. Pain in
    front of knee started during
    boot camp march.
   Relieved by stopping running
    on profile. Returns with
    profile expiration and return
    to running.
   Sharp burning pain below knee cap.
   Worse going down stairs/jumping/landing.
   No clicking, locking or instability.
    Case Airman can’t run PRT
Physical exam
 Tenderness to palpation of the
  patellar tendon
 Painful resisted full extension

 o/w normal

Diagnosis: Jumper’s Knee
  Patellar tendinopathy/Jumper’s knee
Clinical symptoms
 Antero-inferior pain

 Often can point to
  tender spot
 Pain immediately at end
  of exercise, or
  following sitting
  preceded by exercise
 Stairs, running, jumping
  increase pain
    Patellar tendinopathy/Jumper’s knee
   Management
     Physical therapy: eccentric quad exercise
          “drop-squats”
     Activity  modification
     Ice after activity

     Consider inflammatory injection
        Autologous blood
        Platelet-rich plasma (PRP)

     Surgery     for intractable
                      Prolotherapy for
                   Patellar Tendinopathy

   Traditional Prolotherapy
       Haksrud et al. 2006 case
            Pilodocanol; good results
   PRP
       Kon et al. 2009 case series
            Good results
       Filardo et al. 2009
            Good results, poorly designed
    Case – 37 yo male wants to run
   c/o lateral burning knee pain
    that started at mile 15 of a
    long run. He walked back to
    his car.
   Has rested 2 weeks. Every
    couple days tries to run but
    pain returns.
   Patient is following a marathon
    training program
  Case – 37 yo male wants to run
Physical exam
 Lateral femoral condyle
  tenderness just above
  joint line
 + Noble test, + Ober’s

  ITB Syndrome
Iliotibial band
 Case – Iliotibial Band Sydrome
Clinical symptoms
 Lateral knee pain

 Associated with hills
  and banked surfaces
 Common running
Case – Iliotibial Band Sydrome
        Iliotibial Band Friction

 Avoid offending activities

 Ice massage – 8 minutes 6 times daily


 Counterforce strap?
      Iliotibial Band Friction
Treatment – return to play
 NO running until pain free with stairs

 Next start with light run, stopping when stiff
  or tight (next sensation will be pain, and
  lead to setback)
 Stretch after run

 Post-run ice for 20 minutes
        Iliotibial Band Friction
   If conservative management fails

      Cortisone injection

      RERE: Surgical resection of lateral
       section of ITB
Case – painful bump on knee
      Diagnosis: Osgood-Schlatter
Case: Stock broker

32 yo male stock broker         –   No locking or giving
    training for Boston             way
         marathon               –   Neg PMHx/PSHx
–   R knee pain for 9 mos       –   No fevers, rash, other
–   h/o “old football injury”       joint pain
–   Swells after playing
    Case: Stock broker
–   Full ROM
–   Mild effusion
–   Mild medial joint line ttp
–   Neg McMurray/Thessaly
–   No ligamentous laxity
    Treatment of Osteoarthritis Overview

   Nonpharmocologic Measures
       Education, Weight loss, Exercise, & Bracing
   Pharmacologic Measures
       Analgesics, Glucosamine, Injectables
   Alternative Therapies
       Accupuncture, Dietary Supplementation
   Surgery
     Glucosamine in Knee OA

   LOE 1a for modest pain reduction
       Significant differences in results between
        preparations (G. sulfate more effective)
   LOE 1a for preservation of joint space
       1500 mg/day
     Glucosamine & Chondroitin:
             My Take
   I recommend in all patients with knee OA
   4 week trial of daily dosing
   Evaluate efficacy; continue if helping
   Consider indefinite use even if no pain relief for
    joint space preservation
    Intra-articular Corticosteroids
   Beneficial in KNEE
       LOE 1a
   Short-duration benefits: 2-4 weeks
    Intra-articular Viscusopplements
   Effective in knee and hip (LOE 1a)
   Delayed effect (1-3 weeks)
   Long duration (6 months)
   One-time injection (SynviscOne)
       Weekly injections 3-5x for others
   May delay need for joint replacement

 Arthroscopy

 Joint replacement
 Cartilage transplantation
                  Arthroscopy with
               Lavage and Debridement
   Two Randomized trials
    showing NO BENEFIT over
    conservative tx
       Moseley JB et al. A controlled trial of
        arthroscopic surgery for osteoarthritis
        of the knee. N Engl J Med 2002 Jul
        11; 347(2):81-8.
       Kirkley A et al. A randomized trial of
        arthroscopic surgery for osteoarthritis
        of the knee. NEJM Sep
            Take home points….
   Positive “theater sign”. Patellofemoral Syndrome
   Knee pain with locking. Meniscal Injury
   Twisted planted foot and heard “pop”. ACL Injury
   Knee “came out of socket”. Patellar Subluxation
   What to rule out in PCL injury (hint: dial test):
                                                    PLC injury
   Good test for meniscal tears (hint: Disco) Thessaly test
   Lateral knee pain training for marathon. ITB Syndrome
   Anterior knee pain worse with jumping. Patellar tendinopathy
   PFS best treatment: Try LOTS of things
   Knee OA: Try LOTS of things: exercise, glucosamine
               Viscosupp injection, etc.
   Birrer R. and O’Connor F. Sports Medicine for the Primary Care
    Physician. Boca Raton: CRC Press, 2004.
   Greene W. Essentials of Musculoskeletal Care. Rosemont:
    American Academy of Orthopaedic Surgeons, 2001.
   Hoppenfeld S. Physical Examination of the Spine and
    Extremities. East Norwalk: Appleton-Century-Crofts, 1976;59-
   Lillegard W. Evaluation of Knee Injuries. In W Lillegard (ed),
    Handbook of Sports Medicine. Boston: Butterworth-Heinemann,
    1999: 233-249.
   Netter F. Atlas of Human Anatomy. West Caldwell: CIBA-
    Geigy, 1989.
   Tandeter H. et al. Acture Knee Injuries: Use of Decision Rules
    for Selective Radiograph Ordering. American Family Physician.
    Dec 1999; 60: 2599-608. (For Radiograph Images)

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