Download Orthopaedics for the Practicing Internist

American College of Physicians
2013 Ohio Chapter Scientific Meeting
Columbus, OH
October 11, 2013
Paul J. Gubanich, MD, MPH
Assistant Professor of Internal Medicine/Sports Medicine
Team Physician, Ohio State University Athletics, Ohio Machine, Columbus City Schools
Disclosures
 I do not have a conflict of interest associated with the
material contained in this presentation.
An Approach to the Patient with
Knee Pain
 Most common
complaints
 Pain
 Instability – (ligament
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injury, OA)
Stiffness – (effusion,
OA)
Swelling
Locking (meniscal)
Weakness
 Most diagnosis made by:
 History
 Physical exam
 Imaging
Important Historical Components


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Age
Chronology, onset
Pain level, characteristics
Exacerbating positions/
movements
Relieving factors
Activity level or recent change,
occupation
Previous injuries, surgeries
Exercise history, goals
Previous treatments
Chronology of Symptoms
 Common acute injuries
 Acute Pain
 Fractures (distal femur,
 Sudden onset
patella, proxmial tibia,
 Specific mechanism of
fibula)
injury
 Dislocations
 Direct trauma (fall,
collision, MVA)
 Meniscal injuries
 Landing, pivoting
 Ligamentous injuries
 Musculotendious strains
 Contusions
 Chronic Pain
 Often lacks a mechanism
of injury
 Symptoms of gradual
onset
 Common causes of chronic
knee pain
 Arthritis
 Tumors (night pain)
 Osteosarcoma (adolescents)
 Chondrosarcoma (adults)
 Giant cell tumor (benign)
 Metastatic disease is
uncommon
 Sepsis (rare, can be bursal)
 Bursitis (overuse)
 Tendonitis
 Anterior knee pain
Location, Location, Location
Medial Knee
 Joint line – meniscus,
OA, osteochondral
defect, osteonecrosis,
medial collateral
ligament
 Tibial plateau –
(osteoporosis, post
menopausal)
 Pes bursa
Anterior Knee
 Anterior
 Quad tendon or insertion
 Anterior to patella
 Patella
 Patellar origin, tendon,
insertion
 Tibial tubercle
Lateral Knee Pain
 Lateral
 Femoral condyle –
suggests IT band
 Joint line – meniscus,
OA, OCD, lateral
collateral ligament
Posterior Knee
 Meniscus – posterior
medial, lateral corner
 Posterior lateral –
Baker’s/popliteal cyst,
aneurysm
Physical Exam
 Exam both sides
 Joint above and below
 Most painful part last
 Gait
 Alignment (varus, valgus)
 Squat
 Inspection
 Swelling
 Bruising
 Deformity
Physical Exam
 Palpation
 Effusion
 Range of Motion
 Patellar tracking
 Extension (-5 to 5)
 Flexion (135-145)
 Crepitus, etc.
 Strength
 Hamstring
 Quad
 Functional tests
Physical Exam – Special Maneuvers
 Apprehension sign –
patellar instability
 Apley grind test –
meniscus
 McMurray
circumduction test,
 SN 16-58%
 SP 77-98%
 (Evans 1993, Fowler
1989, Kurasaka 1999,
Anderson 1986)
Physical Exam – Special Maneuvers
 Valgus stress test – MCL
 SN 86-96%
 Varus stress test – LCL
 SN 25%
Physical Exam – Special Maneuvers
 Lachman’s – ACL
 SN 80-99%
 (various authors
and conditions)
Physical Exam – Special Maneuvers
 Anterior/posterior
drawer – ACL/PCL
 Posterior Sag Sign
Radiology
 Plain x-rays often
considered part of exam
 Helps rule out competing
diagnosis
 X-ray views
 Standing AP views of both
knees (for comparison)
 Lateral
 Tunnel at 45 degrees
 Merchant/Sunrise – to
evaluate PF joint
Radiology
 MRI often not needed
initially
 Surgical planning tool
 Failure of treatment
 Identify
ligamentous/cartilage
injuries of acute or
surgical nature
 Risk stratification
General Treatment Pearls
 Match disease severity/limitations with treatment
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options
Escalate based on time, response in a stepwise fashion
Set realistic expectations for progress and follow-up
Align treatment goals with patient goals/expectations
when possible
Time is a great healer
Common Treatment Recommendations
 Activity modification, rest
 Mechanical devices –
braces, crutches, lifts,
orthotics, etc.
 Ice, pain medication
 Nsaids
 Acetaminophen
 Others
 Physical therapy – early
motion progressing to
strengthening and then
functional drills
 Injection therapy
 Aspiration
 Corticosteroids
 Hyaluronic acid supplents
(OA)
 Glucosamine (OA)
 Surgical considerations
 Consider additional
imaging options as needed
 MRI
 Bone scan
 CT
Red Flags
 Night pain
 Abnormal x-ray findings
 Fractures, tumor, cartilage
lesions, etc.
 Mechanical symptoms
 Severe pain, swelling, loss of
motion, or weakness
 High grade ligament injuries
 Fail to respond to standard
treatments
 Multiple joints involved
(Rheum)
Summary
 History and Physical Exam are vital to generating a
working differential diagnosis
 Imaging may complement/confirm working diagnosis
 Treatment should match symptoms and severity and
progress based on progress
Questions?