MS3 Sports Medicine Workshop
Family Medicine Clerkship
Knee Problems
MS3 Family Medicine
Anatomy Review
Tibia Femur
Medial & lateral Trochlear groove Pes anserine area Intercondylar notch Tibial tuberosity Tibial plateau Tibial spines Patella Superior pole (base) Fibula Inferior pole (apex) Medial & lateral facets Head Neck
Condyles Epicondyles Gerdys tubercle
Anatomy Major Ligaments & Tendons
Quadriceps tendon Patellar tendon Medial & lateral patellar retinaculua
MCL
LCL
ACL and PCL
Iliotibial band (ITB)
Anatomy Menisci of the Knee
Medial meniscus Lateral meniscus
Meniscal ligaments Functions of the menisci
Meniscal zones
White-white Red-white Red-red
Knee Exam Overview
Inspection Palpation Range of Motion Strength Neurovascular Special Tests
Case 1 Medial Right Knee Pain
16yo HS soccer player, previously healthy Tackled from right side while running Immediate onset of medial jt line pain Delayed onset local medial edema, stiffness Able to bear weight
Key Questions in the History
Mechanism of Injury? Acute or Chronic? Location and level of pain? Able to walk? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries?
Case 1 - Exam
Inspection: Mild medial knee edema Palpation: + ttp medial knee ROM: cant bend >80d Strength: mildly decreased Neurovascular: normal Special tests:
Neg Lachman, Anterior Drawer, McMurray, varus stress
+ mild increased gap on valgus stress (compared to left) with good endpoint
Special Tests - ACL Injury
Lachman Test
Special Tests - PCL Injury
Posterior Drawer Test
Sag Sign Quad-Active Test
Varus/Valgus stress for LCL and MCL Injury
Features that should prompt an xray after acute knee injury include:
1.
2. 3. 4.
5.
6.
Un ab le
be ar w ei gh Ca t n tf le x> 90 d Pa te lla Fib TT ul P ar he ad TT Ag P e < 18 or Al > lo 55 ft he ab ov e
Unable to bear weight Cant flex >90d Patella TTP Fibular head TTP Age <18 or >55 All of the above
17% 17% 17% 17% 17% 17%
to
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 TTP on FIBULAR HEAD Unable to flex 90 deg
Case 1 - Imaging
Case 1 Differential Diagnosis
More Likely
Less Likely
Meniscal Tear Ligamentous Injury
Which ligament?
ACL PCL MCL LCL
Fracture Patellofemoral Pain Plica
Muscle Strain
MCL Sprain
What grade of sprain is likely present of the MCL?
25% 25% 25% 25%
1. 2. 3. 4.
Grade Grade Grade Grade
1: 2: 3: 4:
no laxity, but hurts mild laxity, still intact complete tear hurts like *^%*
MCL Sprain
Treatment?
RICE Relative Rest Hinge Brace only if unstable on exam Achieve full ROM Progressive Strengthening Neuromuscular Control (Balance exercises) Functional Exercises (Sport-specific)
Case 2
56 yo retired Army LTC 15 years worsening L>R knee pain Former parachutist, no specific trauma No previous knee surgeries Stiffness worse in morning Pain is worse with activity, better with rest
Case 2 Key Questions
Mechanism of Injury? Acute or Chronic? Where/how bad is pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better?
Insidious Onset Chronic Difficult to localize; mild No None Occasional Lots of Bad Landings No surgery Activity Rest
Case 2 Physical Exam
Inspection:
Genu varus Bony enlargement at Med/Lat joint lines
Palp: Posterior medial joint line ttp ROM: Decreased flexion, 110 deg, mild crepitus Strength: normal Neurovascular: normal Special Tests: no ligamentous laxity, neg meniscal tests
Special Tests - Meniscal Injuries
Joint line tenderness McMurray Tests Thessaly test Bounce-home test Full Squat
Case 2 Plain Films
Joint space narrowing Subchondral Sclerosis Osteophytes Subchondral Cysts
What is your diagnosis?
1. 2. 3. 4.
Meniscal tear Plica syndrome Osteoarthritis Bone tumor
25% 25% 25% 25%
M en isc al te ar Pl ica sy nd ro m e
Os te oa rth rit is
Bo ne tu m or
Osteoarthritis
Nonpharmacologic Treatment:
Nonpainful aerobic activity Weight loss Physical Therapy
Pharmacologic Treatment:
APAP Supplements
Improve ROM, increase strength
Glucosamine and Chondroitin
Bracing
NSAIDs, COX-2s Tramadol Viscosupplementation Intrarticular Steroids
Case 3
31 year old female, L knee pain Recreational runner Localizes pain to front of knee No trauma, insidious onset Localizes pain around kneecap Worse with stairs Worse after prolonged sitting Knee occasionally gives out
Case 3 Key Questions
Mechanism of Injury? Acute or Chronic? Where is the pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better?
Insidious Onset Chronic Anterior knee No, but sometimes gives out None None None Running, Stairs Multiple days of rest
Physical Exam
Inspection: mild genu valgus Palpation: TTP lateral > medial patellar facets ROM: full w/o pain Strength: normal Neurovascular: normal Special Tests:
+ patellar grind Decreased patellar glide Inflexible hamstrings (Popliteal angle)
Patellofemoral Joint Exam
Patellofemoral Joint Exam
Patellar Grind Test
Case 3 Plain Films
Lateral
AP
Case 3 Plain Films
Sunrise Tunnel
Whats your diagnosis?
1.
2. 3.
4.
Patellar tendinopathy Patellar instability Patellofemoral syndrome Plica syndrome
25% 25% 25% 25%
Pa te lla rt en di no pa th Pa y te lla ri ns Pa ta te bi llo lit fe y m or al sy nd ro m e Pl ica sy nd ro m e
Patellofemoral Syndrome
Treatment:
Relative rest; non-painful aerobics Physical Therapy
Improve Quad/Hamstring flexibility Quad, Hip abductor strengthening Core strengthening
Patellar stabilization brace/taping Foot orthotics Surgery (last-ditch effort)
Case 4
34 yo Army MAJ training for 1st marathon Atraumatic onset of R lateral knee pain 1 week ago after 10 mile run Sharp burning pain Better with rest, returns with running
Case 4 Key Questions
Mechanism of Injury? Acute or Chronic? Where is the pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better?
Insidious Onset Acute Lateral knee No, but sometimes gives out None None None Running Multiple days of rest
Physical Exam
Inspection: normal Palpation: TTP over lateral femoral condyle ROM: full Strength: normal Neurovascular: normal Special tests:
+ Noble test Tight on Ober test
Ober test
Noble test
Whats your diagnosis?
1. 2. 3.
4.
Osteoarthritis Meniscal tear Iliotibial band syndrome LCL sprain
25% 25% 25% 25%
Os te oa rth rit is M en isc Ili ot al ib te ia ar lb an d sy nd ro m e
LC Ls pr ai n
Iliotibial Band Syndrome
Treatment:
Ice massage, pain meds Relative Rest; nonpainful activity Physical Therapy
Specific ITB stretches Hip abductor strengthening Core strengthening (Gluteus Medius)
Slow return to activity Extrinsic factors: shoes, running surface, training errors
What the heck is a Plica?
1.
2. 3.
th ick en in go Re f.. du . nd an Lo tm os en e pi isc ec us e of in Fig tr m aen ar ti. to .. fm yi m ag in at io n
4.
Congenital thickening of joint capsule Redundant meniscus Loose piece of intraarticular cartilage Figment of my imagination
25% 25% 25% 25%
Co ng en ita l
Plica Syndrome?
Special Tests - ACL Injury
Lachman Test
Knee flexed to 15-30 degrees Stabilize distal femur Anteriorly translate tibia on femur Watch & feel for amount of translation & end point
Pivot Shift
Special Tests - PCL Injury
Posterior Drawer Test
Knee flexed to 90 degrees Posteriorly translate tibia on femur Watch & feel for amount of translation & end point Knees flexed, quads relaxed compare both sides Look for tibial posterior sag relative to femur Knee flexed; hamstrings fully relaxed Slide foot along table (quad active) Observe for anterior relocation
Sag Sign
Quad-Active Test
Special Tests - MCL Injury
Valgus Stress Testing
Knee flexed to 30 degrees
Relax ACL/PCL & joint capsule
Valgus stress applied to knee Look and feel for translation and endpoint Compare to uninjured side May repeat with knee in full extension
Special Tests - LCL Injury
Varus Stress Testing
Same test as valgus stress testing Except applying a varus stress instead LCL, IT band, & PLC are tested
Special Tests - Meniscal Injuries
Joint line tenderness Full Squat McMurray Tests Thessaly test Bounce-home test
McMurray test for Meniscal injury
Test Med and Lat meniscus separately 3 concurrent maneuvers: Grind it (Rotate tibia AWAY from it) Crunch it (varus or valgus) Pinch it (flex/extend knee) Positive: Painful pop
Special Tests - Meniscal Injuries
Thessaly Test
Pt stands on affected leg Knee bent at 20 degrees Examiner holds pts hands and rotates pt to both sides
Meniscal grind
Positive test: pain, painful click.
Anterior Knee Exam
Palpation of patellar facets
Glide and lift patella medially & laterally Palpate undersurface of patella for tenderness
Patellar Exam
Patellar Glide
Knee in extension, relaxed Medial & lateral patellar displacement
Measured in quadrants
Normal: 1-2 quadrants Lateral patellar displacement patient apprehension or guarding
Patellar Apprehension
Anterior Knee Exam
Patellar Grind Test
Knee 10 deg flexion Glide patella distally, and firmly compress patella against trochlear groove Active quadriceps contraction pain
Special Tests Obers Test
Lateral decubitus with testing side up, testing knee flexed Adduct and fully flex hip Abduct, externally rotate, & extend hip Slowly release support against gravity from leg, allowing gravity to take leg towards table Positive test: leg remains abducted despite examiner releasing leg
Special Tests
Nobles test
Palpate lateral femoral condyle Flex and Extend Knee + Test is pain at site of palpation
