Download OMT Lecture/Workshop - Florida Osteopathic Medical Association

Steven Ma, D.O.
Post Graduate Fellow in Neuromuscular Medicine
Larkin Community Hospital
September 24, 2016
Overview:
o
Basic Knee Anatomy
o
Types of Knee Pain
o
General Approach
o
Special Tests
o
Basic Workup
o
Treatment Options
o
Commonly Seen Dysfunctions
Case Presentation:
“Mrs. Smith” presents to the office with the chief complaint of a severe
8/10 left lateral knee pain. The pain started one month ago when she was
visiting home in New York. The pain was a gradual onset, aggravated by
going up and down flights of stairs, and ambulating. She noted that there
was associated decreased mobility, lack of strength, and a constant
“cracking of the knees.” The patient also stated that the pain resulted with
her having difficulty walking, and getting out of bed had become an
increasingly hard task for her.
The patient was seeing a Chiropractor for adjustments, which provided
temporary relief. Massage, Heat, and Therapeutic Ultrasound Treatments
have also helped temporarily. The patient was also seeing an Orthopedic
Surgeon, who scheduled her for a Left Knee Arthroscopy for a Lateral
Meniscus Tear seen on MRI. The patient came to our office for evaluation
and for a second opinion before proceeding with the surgery.
Basic Anatomy:
o
Largest Joint in the Body (Tibiofemoral Joint)
o
Modified Hinge Joint: Flexion and Extension
o
o
with Slight Internal and External Rotation
Compound Joint: Three Parts of Articulation
o
o
o
1. Between Femur and Tibia (Tibiofemoral Joint)
2. Between Femur and Patella (Patellofemoral Joint)
3. Between Tibia and Fibula (Tibiofibular Joint)
Basic Anatomy:
o
Tibiofemoral Joint:
o 2 “C” Shaped Menisci: Medial + Lateral
o Act as Shock Absorbers and Aid in Nutrition and Lubrication
o 4 Ligaments:
o Anterior Cruciate Ligament (ACL)
o Posterior Femur to Anterior Tibia: Prevents Anterior Translation of Tibia on Femur
o Posterior Cruciate Ligament (PCL)
o Anterior Femur to Posterior Tibia: Prevents Posterior Translation of Tibia on Femur
o Medial Collateral Ligament (MCL)
o Femur to Tibia: Stabilizes the Knee Medially
o Lateral Collateral Ligament (LCL)
o Femur to Fibula: Stabilizes the Knee Laterally
Basic Anatomy:
o
Tibiofemoral Joint:
o Medial Meniscus
o Lateral Meniscus
o Anterior Cruciate Ligament (ACL)
o Posterior Cruciate Ligament (PCL)
o Medial Collateral Ligament (MCL)
o Lateral Collateral Ligament (LCL)
Basic Anatomy:
o
Patellofemoral Joint:
o Space between the Patella and the Patellar Groove of the Femur
Basic Anatomy:
o
Tibiofibular Joint:
o The Fibular Head Glides Anteriorly
with Pronation of the Foot.
o Pronation = Dorsiflexion, Eversion,
and ABduction of Foot
o The Fibular Head Glides Posteriorly
with Supination of the Foot.
o Supination = Plantarflexion,
Inversion, and ADDuction of Foot
Biomechanics:
o
o
o
Function:
Flexibility for Walking
Stability while Standing
Biomechanics:
o
Range of Motion:
o Flexion: 135-155 Degrees
o Extension: 0-10 Degrees
o Internal/External Rotation: Up to 10 Degrees
Biomechanics:
o
o
o
Between Each Joint is
Cartilage and Connective
Tissue.
Joint Capsule: The Knee
Joint is contained inside a
membrane, bathed in
Synovial Fluid.
Together, they allow for
Smooth, Friction-Free
Motion.
Biomechanics:
o
Cartilage Have No Nerve Endings.
o So there should be no pain with Regular Physiology.
o
Bone Has Nerve Endings. Pain is caused when these
nerve endings are exposed due to a breakdown or
disruption of the normal Cartilage tissue.
Initial Evaluation:
o
Must Determine:
o Acute vs. Chronic
o Traumatic vs. Overuse vs. Pathologic Disease
o Do We Treat or Do We Refer???
Types of Knee Pain:
o
Acute Knee Pain:
o <6 weeks
o Usually Traumatic
o
Chronic Knee Pain
o >6 weeks
o Overuse
o
Other
Acute Knee Pain:
o
o
o
o
o
o
o
o
o
Medial/Lateral Collateral Ligament Tear
ACL Tear
Meniscus Tear
Patellar Dislocation
Patellar Tendon Tear
Intra-Articular Fracture
PCL Tear
Quadriceps Tendon Tear
Knee Dislocation
Chronic Overuse Knee Pain:
o
o
o
o
o
Bursitis
Capsulitis
Synovitis
Tendonitis
Chondromalacia Patellae
(Patellofemoral Pain Syndrome)
Other Causes:
o
o
o
o
o
o
Osteoarthritis
Rheumatoid Arthritis
Gout
Osgood-Schlatter’s Disease
Hip Dysfunction
Ankle Dysfunction
Evaluating the Knee:
o
History
o Mechanism of Injury Usually Suggests Diagnosis
o Where, What, When, How???
o Key Symptoms: Pop, Lock, & Drop
o Trauma or Overuse
Evaluating the Knee:
o
Physical Exam (Always Perform Bilaterally!)
o Inspection
o Palpation
o Range of motion
o Strength
o Special Tests
Evaluating the Knee:
o
Inspection:
o Gait: Limp, Pain, Guarding, Favoring One Side
o Anatomy: Position of Hips, Feet, Genu Varus/Valgus
o Deformities?
o Swelling?
Evaluating the Knee:
o
Palpation:
o Temperature: Inflammation?
o Pulses: Intact?
o Pain: Location! Location!! Location!!!
o Defects: Ruptured Quadriceps Tendons?
Evaluating the Knee:
o
Evaluate the Hip AND Ankle!!!
o Hips: FABER’s (Patrick’s) Test, ASIS Compression, etc.
o Ankle: Anterior/Posterior Glide, Supination/Pronation
Where is the Pain?
o
Medial Joint Line: Medial Collateral Ligament
o
Lateral Joint Line: Lateral Collateral Ligament
o
o
Lateral Patellar Edge, or When Pressing Patella
Down Firmly: Chondromalacia
Posterior Fossa: Baker’s Cyst
Where is the Pain?
o
At the Tibial Tuberosity: Osgood-Schlatter’s
Disease
o
Superior to Tibial Tubercle: Patellar Tendinitis
(“Jumper’s Knee”)
o
Medial to Tibial Tuberosity: Pes Anserine
Bursitis/Tendonitis
Range of Motion:
o
Flexion
o
Extension
o
Perform Bilaterally!
o
Acute Limitation may be due to Injury of Somatic
Dysfunction
Range of Motion:
o
Chronic Limitation in both Flexion and Extension:
THINK CAPSULITIS!!!
ACL Tear
Special Testing:
Meniscus Tear
Collateral Ligament Tear
http://orthoinfo.aaos.org/topic.cfm?topic=a00549
ACL Injury:
o
History: Mechanism of
Injury
o
o
o
Sudden Change in
Direction
Landing After A Jump
Lateral Blow to a
Partially Flexed Knee
ACL Injury:
o
Key Symptoms
o
o
“Pop” Sound at Time of Injury
Slipping Out of Place
http://a2.espncdn.com/combiner/i?img=%2Fphoto%2F2015%2F0822%2Fusatsi_8760978_r3417_1296x729_16%2D9.jpg&w=570
ACL Special Tests:
o
Lachman Test
o
Anterior Drawer Test
PCL Injury:
o
o
o
It is stronger than the ACL and is injured less often.
They are often subtle and more difficult to evaluate than the
other ligament injuries.
Usually occur along with injuries to other structures in the
knee.
o
o
Causes: A direct blow to the front of a bent knee (such as
hitting the dashboard in a car accident or a football player
falling on a bent knee.
Symptoms: the knee feeling unstable, like it may "give out."
PCL Special Testing:
Meniscus Tear:
o
History:
o An Acute Forceful Injury Involving Twisting of the Knee
while the Foot is Planted.
Meniscus Tear:
o
Key Symptoms:
o Complaining of popping, locking, catching, and
the knee "giving out"
Meniscus Tests:
o
Thessaly Test:
o Patient and Examiner face each other, holding hands for
support.
o Patient stands on one leg with their knee flexed to 20
degrees.
o Patient rotates the knee and body while maintaining
knee flexion, (which internally and externally rotates the
knee, while loading the meniscus.)
o Reproduction of the Catching, Clicking, or Pain is a
Positive Test.
o Apley’s Compression Test:
o
o
Compression of the Tibia onto the Knee
Joint while Externally Rotating.
Production of pain is a Positive Test.
Meniscus Tests:
o
McMurray Test:
o External Rotation with a Valgus Stress: Medial Meniscus
o Internal rotation with a Varus Stress: Lateral Meniscus
o Slowly Extend The Knee
o Production of a “Click” Sound is a Positive Test
Collateral Ligament Injury:
o
History:
o Trauma involving Twisting of the Leg or a Direct Blow
leading to a Varus or Valgus Displacement.
http://bleacherreport.com/articles/1322157-2012-fantasy-football-injuries-10-players-owners-should-be-worried-about
Collateral Ligament Injury:
o
Varus and Valgus Stress Test:
Collateral Ligament Injury:
o
Apley’s Distraction Test:
o Stabilizethe patient’s leg with your knee on the posterior thigh.
o Distract the Tibia, and Externally and Internally Rotate the leg.
o Excessive Motion on Rotation is a Positive Test.
For ACL, Meniscus, & Collateral
Ligament Injuries:
o
Acute Treatment: PRICES
o Protection
o Rest
o Ice
o Compression
o Elevate
o Support (Crutches)
For ACL, Meniscus, & Collateral
Ligament Injuries:
o
Imaging:
o X-Ray: 3 Views- AP, Lateral, and Sunrise Views
o MRI
For ACL, Meniscus, & Collateral
Ligament Injuries:
o
o
o
Based on the findings, formulate a Plan of Care.
Treat and manage what you are comfortable
doing.
Refer to a Specialist if the Severity of Injury is
Warranted.
Capsulitis:
o
o
o
Painful Disorder that results from the Chronic
Inflammation, Scarring, Thickening and Shrinkage
of the Capsule that Surrounds the Involved Joint.
Severely Restricted, with Progressive Loss of
Both Active and Passive Range of Motion.
For the Knee: A Remarkably Decrease in both
Flexion AND Extension.
Pes Anserine Tendonitis/Bursitis
o
Pes Anserine-The conjoining of the three tendons of the
Sartorius, Gracilis and Semitendosus Muscles.
o
Presents as Chronic Pain and Weakness Inferomedial to
the Knee Joint.
o
Commonly caused by Overuse in Athletes.
o
Often coexists with other Knee Disorders.
Chondromalacia
(Patellofemoral Syndrome)
o
o
Patellofemoral Syndrome: Retropatellar or
Peripatellar Pain resulting from Physical and
Biochemical Changes in the Patellofemoral Joint.
Chondromalacia: When there is Fraying and Damage
to the underlying Patellar Cartilage.
Chondromalacia
(Patellofemoral Syndrome):
o
o
o
Presents as Anterior Knee pain that typically occurs
with activity, and often worsens when they are walking
down steps or hills.
It can also be triggered by prolonged sitting.
Usually due to Weakness of the Medial Quadriceps,
Tight Iliotibial Bands, Tight Hamstrings, Weakness of
the Hip ADDuctors, and/or Tight Calf Muscles.
Chondromalacia
(Patellofemoral Syndrome):
o
Patellar Grind Test: A Positive Test indicates
Patellofemoral Syndrome.
Chondromalacia
(Patellofemoral Syndrome):
For Overuse Injuries:
o
Treatment:
o Rest
o Ice
o NSAIDs, Anti-inflammatory Medications
o OMT
o Stretches
o Exercises
o Therapeutic Ultrasonography
o Injections
Injection Therapies:
o
o
Corticosteroid Injections: can offer fast-acting
relief of inflamed muscles, joints, tendons, and
bursa.
Prolotherapy: also known as Regenerative
Injection Therapy, involves the injection of
substances into degenerated or injured areas to
stimulate healing.
o Commonly used solutions include Hyperosmolar
Dextrose, Glycerine, Lidocaine, and Homeopathic
Solutions such as TRAUMEEL.
Injection Therapies:
o
Platelet-Rich Plasma: A concentration of Platelet
cells extracted from blood, containing several
different Growth Factors and Cytokines that can
stimulate healing.
Injection Therapies:
Somatic Dysfunctions:
Anterior Tibial Dysfunction
(on the Femur):
o
o
o
Symptoms: Knee Discomfort, Inability to
Comfortably Extend the Knee.
Inspection: Restricted Posterior Spring with Loss of
Anterior Motion.
Palpation: Prominence of the Tibial Tuberosity.
Anterior Tibial Dysfunction
(on the Femur):
Dysfunction: Tibia “Stuck” forward.
Anterior Tibial Dysfunction
(on the Femur):
Treatment
Posterior Tibial Displacement
(on the Femur):
o
o
Symptoms: Knee Discomfort, Inability to
Comfortably Flex the Knee.
Inspection: Restricted Posterior Spring with Loss
of Anterior Motion.
Posterior Tibial Displacement
(on the Femur):
Treatment
Posterior Tibial Displacement
(on the Femur):
Treatment
Anterior Fibular Head:
o
Symptoms:
o Lateral leg Pain and Soreness.
o Tenderness over the Proximal Fibula.
o
Inspection:
o Increased Anterior Glide of the Proximal Fibular Head,
with Resisted Posterior Springing.
o Distal Fibula may be Posterior.
o Talus Externally Rotated, causing the foot to Evert and
Dorsiflex.
o
History:
o Commonly follows a Medial Ankle Sprain or Forced
Dorsiflexion of the Ankle.
Anterior Fibular Head:
Posterior Fibular Head:
o
Symptoms:
o Lateral leg Pain and Soreness.
o Tenderness at the Fibular Head.
o Persistent Ankle Pain Beyond that of a Normal Ankle Injury.
o
Inspection:
o Increased Posterior Glide of the Proximal Fibular Head, with
Restricted Anterior Glide.
o Proximal Fibular Head Prominent Posteriorly.
o Talus Internally Rotated, causing the foot to Invert and
Plantarflex.
o
History:
o Commonly follows an Inversion Ankle Sprain.
Posterior Fibular Head
Posterior Fibular Head:
Treatment
So What Happened to
“Mrs. Smith???”
Case Presentation:
“Mrs. Smith” was diagnosed with Left Posterior
Fibular Head and Bilateral Pes Anserine Bursitis.
Her First Treatment Session consisted of
Osteopathic Manipulative Treatment to Correct
all Somatic Dysfunction, including her Posterior
Fibular Head.
Case Presentation:
Just after the one treatment session, “Mrs.
Smith’s” pain went from an 8/10 to a 3/10.
“Mrs. Smith” pain improved so dramatically that
she called the Orthopedic Surgeon the very next
day to cancel the Left Knee Arthroscopy.
Case Presentation:
Subsequent treatment sessions consisted of
Prolotherapy with Homeopathic Solutions to the
Pes Anserine Bursas and more Osteopathic
Manipulation. Her pain continued to improve.
After her last treatment session, “Mrs. Smith”
informed us that she was planning a trip back to
New York, something that she did not think that
she was going to do ever again out of fear of
having to walk up and down stairs.
In Conclusion:
o
o
o
A good history of the Mechanism of Action can
give a good indication of the Injury.
Perform a good physical exam, using Special
Testing to confirm your diagnosis.
Formulate a Plan of Care.
In Conclusion:
o
o
Osteopathic Medicine can make a difference!!!
There is a lot that we, as Osteopaths, can do to
help our patients.
“To find health should be the object of the doctor.
Anyone can find disease.”
– A.T. Still MD, DO
Resources:
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Kinetic Anatomy, Third Edition. Robert S. Behnke. 2012. Human Kinetics Inc.
Atlas of Osteopathic Techniques, 2nd Edition. Alexander S. Nicholas, D.O., FAAO.
Evan A. Nicholas, D.O. 2012. Lippincott Williams and Wilkins.
OMT Review, Third Edition. Robert G. Savarese, D.O. 1998.
Bates' Guide to Physical Examination and History Taking, 9th Edition. Lynn S.
Bickley. 2007. Lippincott Williams and Wilkins.
Clinically Oriented Anatomy, Fifth Edition. Keith L. Moore. Arthur F. Dalley.
2005. Lippincott Williams and Wilkins.
Netter's Clinical Anatomy, 2nd Edition. John T. Hansen, PhD. 2009. Saunders.
Musculoskeletal Medicine, 3rd Edition. Jeffrey Gross, MD. Joseph Fetto, MD.
Elaine Rosen, PT, DHSc, OCS. 2009. Wiley-Blackwell.
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http://www.aafp.org/afp/1999/1101/p2012.html
http://orthoinfo.aaos.org/topic.cfm?topic=a00549
Resources:
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http://www.painmd.com/frozen-joint-syndrome-adhesive-capsulitis/
http://emedicine.medscape.com/article/308694-treatment#d9
http://www.usatoday.com/story/sports/nfl/2012/12/06/acl-injuries-hips-recovery-nfl/1752419/
http://a2.espncdn.com/combiner/i?img=%2Fphoto%2F2015%2F0822%2Fusatsi_8760978_r3417_1
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