Sunteți pe pagina 1din 60

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