Knee Injuries

Knee Injuries
Daniel A. Clearfield, DO, MS, CAQSM
Primary Care Sports Medicine & Concussion Management
Assistant Professor – Department of Orthopedic Surgery
Program Director – UNTHSC-TCOM Sports Medicine Fellowship
UNTHSC-TCOM / UNT Health Bone & Joint Institute
Objectives
Review knee anatomy
Develop a DDx for knee
injuries
Learn appropriate Hx & PE
evaluation of knee injuries
Know when additional
imaging is needed
Understand management
options
Anatomy
Clinical History
Location of pain
Onset & Timing
Acute vs. Chronic
Traumatic vs. Overuse
Characterize pain
Night pain
Morning stiffness
Weakness
Deformity
Instability / Giving Way
Locking / Clicking / Popping /
Catching / Clunking
Alleviating / Exacerbating Factors
Previous treatments
Sport & Exercise / Training
equipment & habits
Occupation
History of prior injury
Other symptoms (ROS)
Physical Examination
Observation/Inspection
– Undress waist → down
– Shorts
Palpation
Active & passive ROM
Strength/Manual muscle testing
Neurovascular assessment
Special tests
– Extensor mechanism, effusions, &
anterior knee
– ACL & PCL
– MCL & LCL
– Meniscal tests
– Contracture testing
Diagnostic Workup
Most can be done with H&P
alone!
X-ray
MRI
MSK/Sports-US
Arthrogram
Diagnostic/ therapeutic
injection
Electrodiagnostics
CT
Technetium bone scan
Findings do NOT always = symptoms!!!
Treatment/Management
PRICEMM
Mother nature & father time
APAP > NSAIDs
Activity modification/avoidance
Physical therapy
Injections
– CS, RIT, visco
ECSW
NTG patches
Surgery
Kiss from mom
RTP - FITT
ACL Injury
Mechanism of Injury
– 80% - Non-contact
Plant, deceleration, & pivot on a planted foot
Symptoms
–
–
–
–
Pain, audible “pop”
Unable to RTP
Swelling within minutes to hours
Symptoms of instability
PE:
– Anterior Drawer Test
– Lachman Test
– Pivot-Shift
Tx/Management:
– PRICEMM
– No rush to get MRI
Let swelling regress
MRI and surgical referral if instability, high-demand
athlete/occupation
Meniscal Injuries
Physical Exam
–
–
–
–
–
–
Joint line tenderness
Squat & duck-walk
McMurray & Wilson Tests
Steinmann Test
Modified McMurray’s/Steinmann test
Thessaly
Symptoms
– Pain
Medial
Lateral
Poorly localized
– Pain usually worse with
squatting & stairs
– Popping, catching, locking, or
buckling
– Delayed effusion
Unless peripheral tear
Mechanism of Injury
– Non-contact cutting, deceleration,
hyper-flexion
– Poorly landing from jump
– Medial > Lateral
– “Unhappy triad”
Arthritis Flare
Hx:
–
–
–
–
–
Insidious but can be traumatic
Weather changes
Change in activity level
Weight gain
Mechanical symptoms present?
Tx:
–
–
–
–
–
Mainstay  exercise & weight loss
Palliate with CSI/visco
Rehabilitate with PT/HEP
Rebuild/stabilize with RIT
Recalcitrant pain/instability – joint replacement referral
Collateral Ligament Injury
MOI:
–
–
–
–
Valgus blow  MCL
Varus blow  LCL\
Plant & twist
Terrible triad
PE:
– + valgus/varus stress testin
@ 30° flexion
Tx/Mgmt:
– Grade 1-2  PRICEMM
– Grade 3  sx with instability
Patellar Subluxation/Dislocation
MOI:
– Rotation over planted foot, direct
trauma, sudden cutting
movements
– Can spontaneously relocate
PE:
– Lateral patellar pull
predominance
– Weak/atrophied VMO
– + patellar apprehension
XR:
– Hypoplastic lateral trochlea
– r/o fx, chondral injury
Patellar Tendonitis/
Tendinopathy/ Tendinosis
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
Management
–
–
–
–
–
PT: eccentric quad exercise
Activity modification
Ice after activity
Consider RIT: PRP, prolo, NTG patch
Surgery for intractable
PFPS
Clinical symptoms
– Diffuse anterior knee pain
– Worsened by stairs, prolonged sitting,
squatting
– + Movie theater sign
– May occasionally “give out”
– Symptoms frequently bilateral
PE:
–
–
–
–
+ Patellar grind, J sign
VMO atrophy/ extensor imbalance
Weak hip abductors/Ers
Foot/ankle hyperpronation
Tx:
– PT/functional strengthening
– Arch support
ITBS
Hx:
– Lateral knee pain
– Associated with hills and banked
surfaces
– Common running injury
Tx:
– STRETCH, STRETCH,
STRETCH
– Avoid offending activities
– Ice massage
– NSAIDs/topical agents
– Proper arch support
Pediatric Apophyseal Injuries
Pediatric overuse injury
Self-limited, heals once done
growing
Dx:
Osgood
Schlatter
– PE typically sufficient
– XR shows fragmentation
Tx/Mgmt:
– PRICEMM, PT/HEP, FITT
Recalcitrant cases:
– RIT
– Surgery
Sinding
Larsen
Johannson
Bursitis
14 total knee bursa
Most commonly irritated:
– Pes anserine (subsartorial)
– Semimembranosus (aka: Baker’s
cyst)
– Prepatellar (“Preacher’s/
carpetlayer’s, prostitute’s knee”)
– Infrapatellar (deep > subQ)
– Suprapatellar
Often contiguous with knee joint
Non-Traumatic Effusion
OCD (pediatric)
Gout
Septic arthropathy
– GC, staph
Pseudogout
Reiter’s
OA
RA
Referred Pain
Hip
SCFE (peds)
Lumbar HNP
Trigger point
Saphenous neuropathy
References
Birrer R. and O’Connor F. Sports Medicine for the Primary Care Physician.
Boca Raton: CRC Press, 2004.
Calmbach WL and Hutchens MH. Evaluation of Patients Presenting with Knee
Pain: Part I: History, Physical Examination, Radiographs, and Laboratory
Tests: Am Fam Physician. 2003 Sep 1;68(5):907-912.
Calmbach WL and Hutchens MH. Evaluation of Patients Presenting with Knee
Pain: Part II: Differential Diagnosis: Am Fam
Physician. 2003 Sep 1;68(5):917-922.
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, 976;59-74.
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.
QUESTIONS?
Contact me:
–
–
–
–
–
[email protected]
Offices – TCOM MET 567 / Bone & Joint Institute
(614) 735-1100 – cell
(817) 735-2643 – TCOM MET
(817) 735-2900 – Bone & Joint Institute