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Knee Problems

Knee Problems. Cure Conference Mike Mazzone Waukesha Family Medicine. Outline . Brief Review of evaluation of the knee Discuss Differential Diagnosis Review Treatment Modalities . Brief Overview . 1/3 of all musculo-skeletal problems seen in Primary Care are about the Knee

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Knee Problems

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  1. Knee Problems Cure Conference Mike Mazzone Waukesha Family Medicine

  2. Outline • Brief Review of evaluation of the knee • Discuss Differential Diagnosis • Review Treatment Modalities

  3. Brief Overview • 1/3 of all musculo-skeletal problems seen in Primary Care are about the Knee • 54% of all Atheletes will experience some knee pain EVERY YEAR

  4. Things to think about in History • Pain characteristics – PQRST • Mechanical Symptoms • Locking • Popping • Giving Way • Effusion • Rapid (< 2 hours) – hemarthrosis • Slow (24-48 hours) – ligamentous strain, meniscal Injury • Mechanism of Injury • Direct blow? • Foot planted • Decelerating or landing from a jump • Twisting • Hyperextension • Medical History • Previous Knee pain or Surgery

  5. Physical Exam • Inspection • Palpation • ROM – Normal 0 degrees to 135 degrees • Neuro • Special Tests • Lachman or Drawer – for ACL problems • McMurray or Apley Grinder – Meniscal Injuries • Milking of Suprapetallar Pouch • PatelloFemoral Tracking • Q angle (>15 degrees predisposes to Patellar Subluxation • Patellar Aprehension Test – push patella laterally • Varus and Valgus Stress – MCL and LCL

  6. Ottawa Rules age 55 or over isolated tenderness of the patella (no bone tenderness of the knee other than the patella) tenderness at the head of the fibula inability to flex to 90 degrees inability to weight bear both immediately and in the ER (4 steps - unable to transfer weight twice onto each lower limb regardless of limping). Sensitivity – 97% Specificity – 27% Reduced Radiographs by 28% Pittsburg Rules Blunt trauma or a fall as mechanism of injury plus either of the following: Age younger than 12 years or older than 50 years Inability to walk four weight-bearing steps in the emergency department Sensitivity – 99% Specificity – 60% Reduced Radiographs by 57% Ottawa Rules for Obtaining a radiograph in Acute Knee Injuries

  7. What Radiographs to Order • Most Patients 3 views • AP • Lateral • Merchants • Teenagers with chronic knee pain and recurrent effusion • Add Tunnel View (PA with knee flexed 40-50 degrees) • Loooks for osteochondritis dissecans on Femoral Condyles)

  8. AP View Lateral View Merchant’s view Tunnel View

  9. Lab • In presence of Warmth, exquisite tenderness and effusion • Consider Septic Arthritis or Acute Inflammatory arthropathy • Labs to order • CBC • ESR • Arthrocentesis for • Cell count and differential • Glucose • Protein • C&S • Polarized light microscopy • If unclear of diagnosis with an effusion – Arthrocentesis • If Rheumatoid Arthritis a possibility – ESR and RF

  10. Children and Adolescents Patellar Subluxation Osgood-Schlatter – Tibial Apophysitis Jumper’s Knee – Patellar Tendonitis Referred Pain – Slipped Capital Femoral Epiphysis Osteochondritis Dissecan Older Adults Osteoarthritis Crystal Induced arthropathy Baker’s Cyst (Popliteal Cyst) Differential Diagnosis by Age • Adults • Patellofemoral Pain Syndrome • Medial Plica Syndrome • Pes Anserine Bursitis • Traumatic Injury • Ligamentous sprains • Meniscal Injuries • Inflammatory Arthropathy • Septic Arthritis • Patellar Bursitis • Iliotibal Band Syndrome

  11. Anterior Patellar Subluxation Osgood-Schlatter Jumper’s Knee Patellofemoral Pain Syndrome Prepatellar bursisits Medial MCL Sprain Medial Meniscal Tear Pes Anserine Bursitis Medial Plica Syndrome Differential By Location Lateral • LCL Sprain • Lateral Meniscal Tear • Iliotibial Band Tendonitis Posterior • Baker’s Cyst • Posterior Cruciate Ligament Injury

  12. Patellar Subluxation • More common in Girls withLarge Q angle (> 15 degrees) • History – Patella pops or gets stuck • PE – Patellar Aprehension Test • Treatment – • Physical Therapy – cycling • Patellar Bracing • For Severe – Surgery

  13. Osgood-Schlatter (Tibial Apophysitis) • More common Teenage boys • History • Knee pain waxing and waning for months • Worsens with squatting or stairs • PE – tender on tibial tuberosity • Treatment • Icing after activity • Decreasing activity – may need to stop activity for 2-3 months • NSAID’s • If severe – knee immobilizer for 2-6 weeks

  14. Patellar Tendonitis • History • Teenage boys • Pain is anterior and has persisted for months • PE – tender over patellar tendon, pain with knee extension • Treatment • ICE • NSAID’s • Decreased Activity

  15. Slipped Capital Femoral Epiphysis(SCFE – pronouced Skiffy) • Overweight 10-16 yo Boys or 12-14 yo Girls • History • Vague Knee pain with no trauma • Exam – pain on internal rotation of hip • Diagnosis – Xray AP/Lat view of Pelvis and b/l hips • Treatment – • Immediate Cessation of weightbearing • Surgical stabilization • Take Home Point – ALWAYS EXAMINE HIP IN KIDS WITH KNEE PAIN

  16. Osteochondritis Dissecans • History • Vague knee pain, • morning stiffness and recurrent effusion • possibly locking or catching • Exam • possible quad atrophy • effusion • chondral tenderness • Radiographs to include Tunnel view • MRI test of choice if unclear diagnosis • Treatment • Rest • Bracing • Low Impact PT • Surgery if symptoms persist >2-3 months despite therapy

  17. Patellofemoral Pain Syndrome • History • Anterior knee pain worse after sitting (theatre sign) • PE • patellar crepitus • pain on contracting quad while putting pressure on Patella • Widened Q angle • Treatment • Relative rest • Ice 20 minutes after activity • Quadracep strengthening (consider hip, hamstring, calf and IT band stretching) • Evaluation of Footwear • Consider NSAID’s • Consider Knee braces • Consider Knee taping – McConnell Taping

  18. Medial Plica Syndrome • Plica – A redundancy of the joint synovium • Hx – Acute onset medial knee pain • PE – tender mobile nodularity • Treatment • NSAID’s • ICE • PT including phonophoresis and iontophoresis • Quad Strengthening Exercises

  19. Pes Anserine Bursitis • Pes Anserine – insertion of Sartorius, gracilis and semitendinosus muscles • Hx – pain on medial side of knee worsened with flexion and extension • PE – tenderness posterior and distal to medial joint line valgus stress may reproduce pain • Treatment • NSAID’s • ICE

  20. Iliotibial Band Tendonitis • Friction between IT band and Lateral Femoral Condyle • Hx – Lateral Knee pain aggrevated by activity • PE – Tenderness over lateral epicondyle of femur while flexing and extending knee (Noble test) • Treatment • IT band stretching exercises • NSAID’s • ICE

  21. Anterior Cruciate Ligament • Plant and turn injury • HX- often hears a pop and notes swelling in Knee • PE – Joint Effusion + Anterior Drawer or Lachman if torn (most sensitive directly after injury or about 2 weeks later) • Radiographs looking for tibial spine avulsion • MRI prior to surgery if torn • Treatment • Initial Treatment • RICE • Knee Immobilization • Crutches • NSAID’s • Definitive treatment • Based on Age, Activitity level and degree of injury • Surgery vs prolonged immobilization

  22. Medial Collateral Ligament (MCL) • Due to valgus stress • Hx – valgus stress then immediate pain and swelling medially • PE – valgus stress testing • Grade 1 – clearly defined endpoint and < 5m laxity • Grade 2 – 5-10 mm of laxity with endpoint • Grade 3 – no clear endpoint (complete tear) • Treatment • Grade 1 – RICE and crutches as needed • Grade 2 – RICE, crutches and hinged bracing • Grade 3 – RICE, hinged brace – gradual return to weightbearing over 4 weeks

  23. Lateral Collateral Ligament (LCL) • Similar to MCL but much less common • HX – Varus stress then immediate pain • PE – Varus stress test • Treatment • Grade 1 and 2 – same as MCL • Grade 3 – may require surgery

  24. Meniscal Tear • Can be acute or chronic • Hx – Recurrent knee pain with episodes of catching, locking or giving way • PE – Mild effusion and positive McMurray test • MRI best imaging test if diagnosis unclear • Treatment • If no locking or instability – RICE, NSAID’s for 2-3 weeks • Otherwise referral for surgical debridement

  25. Septic Knee • Predisposing factors – cancer, DM, Etoh, AIDS, corticosteroid therapy • Hx – Abrupt onset of pain and swelling no trauma • PE – warm, swollen, very tender • Lab • CBC – left shift • ESR > 50 mm/hr • Arthrocentesis • Turbid synovial Fluid – WBC > 50 000 Neutrophils >75 percent • Protein > 3 g/dL • Glucose - 50 percent or less or serum glucose level • Treatment • common pathogens Staphyloccus aureus, Streptococcus, Haemophilus influenzae, Neisseria gonorrhoeae • IV antibiotics • Ortho referral for possible debridement

  26. Osteoarthritis • Common > 60 years of age • Hx – Knee pain aggrevated by weight bearing relieved by rest, morning stiffness • PE – decreased ROM, crepitus, osteophytic changes • Radiographs – • Weightbearing – AP, PA tunnel • Nonweightbearing –Merchant’s and lateral view • Treatment • NSAID’s • Corticosteroid injections • Referral for Knee replacement if • Significant and disabling pain • Dysfunction significantly inhibiting quality of life • Should exhaust all clinical measures before considering surgery

  27. Crystal-Induced Inflammatory Arthropathy • Gout (sodium urate crystals) and Pseudogout (calcium pyrophosphate crystals) • Hx- Acute onset, red hot and very tender knee • PE – erythematous, warm, tender swollen • Arthrocentesis • Clear or slightly cloudy – WBC 2K to 75K • Protein high >32 g/dL • Glucose 75% of serum • Polarized-light microscopy of synovial fluid shows • Gout - negatively birefringent rods • PseudoGout – positively birefringent rhomboids • Treatment • NSAID’s • Colchicine

  28. Baker’s Cyst • Outpouching of synovial fluid • Hx • insidious onset of mild to moderate pain in posterior aspect of knee • Ruptured cyst may present like DVT – red swollen and tender calf • PE – palpable fullness present medial aspect of popliteal area • Imaging – US, CT may help if diagnosis unclear • Treatment • Aspiration may cause temporary relief but recurrence rate is high • Surgery if pain persistent and intolerable

  29. Knee Braces • Types • Prophylactic – prevent injury to uninjured knee (most common used by football lineman) • Evidence mixed as to their effectiveness • Choose the longest brace that fits the athelete’s leg • Custom brace offer little extra benefit to off-the-shelf models • Price vary considerably • Need to wear brace with hinge near epicondyles • Strength training, flexibility and technique refinement much more important • DO not prevent rotation injures • Functional – provide stability to unstable knee • No great studies • No studies showing custom fit better than pre-sized • More limitation than prophylactic braces ( do prevent rotation injuries as well) • Limiting extension to 10-20 degress may prevent hyperextension injuries • Rehabilitative – allow protected and controlled motion during knee rehabilitation • Patellofemoral Braces – improve patellar tracking • Studies mixed on effectiveness • Typically made of neoprene with butresses that support the patella – relatively inexpensive

  30. Prophylactic Brace PatelloFemoral Brace Functional Brace

  31. Tips for Icing Knee • Recommend 10-20 minutes per session (when it feels numb you are done) • Recommend 2-3 times per day • Ways to manage ice • Plastic bag with some water • Freeze water in styrofoam or dixie cup – then peel cup away from top of ice for use • Wet towel in Freezer • Commercially available ice packs

  32. References • Calmbach, W: Evaluation of Patients Presenting with Knee Pain: Part I. History, Physical Examination, Radiographs, and Laboratory Tests (AFP:68(5)) • Calmbach, W: Evaluation of Patients Presenting with Knee Pain: Part II. Differential Diagnosis (AFP:68(5)) • Johnson, M: Acute Knee Effusions: A Systematic Approach to Diagnosis (AFP:Vol 16(8)) • Juhn, M: Patellofemoral Pain Syndrome: A Review and Guidelines for Treatment (AFP:60(7)) • Paluska, S: Knee Braces: Current Evidence and Clinical Recommendations for Their Use (AFP: 61(2)) • Solomon, D: Does the Patient have a torn Meniscus or Ligament of the Knee? Value of the Physical Examination (JAMA:(286(13)) – needs MCW proxy • Tandeter, H: Acute Knee Injuries: Use of Decision Rules for Selective Radiograph Ordering (AFP: Vol 60(9)) • Zuber, T: Knee Joint Aspiration and Injection (AFP:66(8))

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