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Management of Knee Pain Manish A. Patel, MD,FAAOS Assistant Professor Eastern Virginia Medical School Chief of Surgery – Southampton Memorial Hospital Office: 757-562-7301 www.SouthamptonOrtho.com Anatomy • • • • • ACL PCL MCL LCL Meniscus – Medial – Lateral THE KNEE HISTORY • • • • Pain Contact vs noncontact Effusions Mechanical symptoms – Locking – Instability (falls) • Initial treatment THE KNEE HISTORY • Continue work/play? • PM/SHx – Medications • Occupation/Sport – Time tables Physical Exam of the Knee • Inspection • Palpation • Range of Motion • Special tests • Neurovascular assessment INSPECTION • Effusion • Q angle • Erythema • Angular • Ecchymosis • Edema deformities • Muscular asymmetry PALPATION ANTERIOR • Tibial tubercle MEDIAL • MCL • Infrapatellar tendon • Meniscus • Quad insertion • Patellar facets • Crepitus ? • Pes anserine insertion • Tibial plateau • Femoral condyle PALPATION • • • • • • LATERAL Head of the fibula LCL Meniscus Tibial plateau Femoral condyle Gerdy’s tubercle POSTERIOR • Menisci (posterior horns) • Popliteal fossa • Hamstring tendons ACL Special Tests • Anterior drawer • Lachman test • Pivot shift test • Valgus stress test at full extension! Grading Ligament Injuries GRADE 1 No instability GRADE 2 Some instability Fair endpoint GRADE 3 Opens wide Good endpoint Poor endpoint ACL: PHYSICAL EXAM • Decreased ROM • Effusion-hemarthrosis, immediate • + Instability tests – Lachman: most accurate – Pivot shift – Anterior drawer • + MCL and meniscus tests LIGAMENT EXAM Translation + ENDPOINTS! + PIVOT SHIFT Palpable clunk as the lateral tibial condyle reduces on the femur MRI: The Use of MRI in Evaluation of Knee Injuries • Sensitivity M. Meniscus 73-100% L. Meniscus ACL • Specificity MM LM ACL 55-90 91-100 55-97 94-98 99-100 The REAL QuestionIs MRI that much better than clinical exam? • Rose, et al. Arthroscopy, 1996 – Compared accuracy of clinical exam vs MRI – In 154 pts, clinical exam was as good as MRI • Many articles comparing MRI to arthroscopy “Partial” ACL tear/strain • > 40% ACL substance • + Lachman, - pivot shift • Clinically – Most behave functionally as full tears – Continued shifting ↑’s risk of meniscus damage – Rx as full tear The Utility of Arthrocentesis • Indications – Diagnosis in question • ? Infectious/Metabolic process – Tense effusion • Indications for surgery • Timing of surgery ACL TREATMENT • Grade 3- Nonsurgical – ? modify activity – PRICES – Hamstrings, gastroc! – Functional bracing ? – 100% @ 9-12 months ACL TREATMENT • Grade 3 Injuries- Surgery • Indications – Most active people will require surgery to restore adequate function and decrease instability – Recurrent instability – Inability to modify activity – Associated injuries: meniscus – Age? • Wait three weeks due to arthrofibrosis • risk 100% @ 6-12 months MCL INJURIES HISTORY • Mechanism = valgus stress • Medial joint line pain • Lack of large effusion • Difficulty weight-bearing MCL INJURIES • • • PHYSICAL EXAM Tender to palpation along MCL Pain + instability with valgus stress – 30o flexion = MCL – 90o flexion = associated ACL COMPARE SIDES MCL INJURIES Treatment Of Grade 1 &2 • Early mobilization • Weight-bearing as tolerated • Hinged knee brace • PRICES • Recovery 4-6 weeks MCL INJURIES Treatment of Grade 3 (full tears) • Isolated = nonsurgical management • Combined = surgery consistent with associated injuries PCL INJURIES • Mechanism – Sports = fall on flexed knee with foot plantarflexed, hyperextension, pivot – MVA = dashboard injury • Effusion (less than with ACL) • Shifting/instability (chronic) • Less distinctive PCL INJURIES PHYSICAL EXAM • + Effusion • + Posterior drawer test • + Posterior sag sign • False positive Lachman test • Common to have isolated injuries PCL INJURIES • • • • TREATMENT PRICES Functional bracing (early) Rehab Surgery if continued instability, effusions • Note- 2% of NFL preseason exam with incidental isolated PCL tear Patellofemoral Arthralgia Often referred to as chondromalacia patella. This term should be reserved for observed articular cartilage damage PFA-HISTORY • Pain with: – Stairs – Prolonged sitting – Deep squat activities • Lack of effusions, locking, instability PHYSICAL EXAM • Patellar compression/grind tests • • • • • No patellar apprehension Poor hamstring flexibility + “J” sign Normal ligaments, meniscus Lack of effusion KNEE- TANGENTIAL XRAYS • Assess patellofemoral joint • Patellar tilt • Lateralization • Depth of trochlear groove PATELLAR INSTABILITY • Acute patellar dislocation • Acute patellar subluxation • Patellar tracking dysfunction PATELLAR DISLOCATION • • • • History Mechanism = pivot Immediate effusion May visualize patella dislocated laterally + Instability (chronically) Patella may spontaneously relocate PATELLAR DISLOCATION Physical Exam • Tender peripatellar structures – Medial retinaculum – Lateral femoral condyle • Effusion • ? Patella dislocated laterally Xrays- osteochondral fracture, effusion MRI for loose bodies PATELLAR DISLOCATION Treatment • Knee extension immobilizer x 4 wks, J Sleeve • Early quad setting exercises • Return to sport – Full, painless ROM – Normal strength – Adequate aerobic fitness Biology of the Meniscus • Medial Meniscus • Semilunar • Narrow anteriorly • Adherent to MCL • Lateral Meniscus • Circular • Covers more of tibia • Uniform size • Less adherent Types of Meniscus Tears • Longitudinal • Horizontal • Oblique • Radial MENISCAL INJURIES History • Mechanism = pivot, twist • + heard a “pop” • Effusion- 12-36o after injury • Mechanical Sxs- locking, instability MENISCAL INJURIES Physical Exam • Joint line tenderness – IR/ER • Decreased ROM • McMurray’s test • Apley’s compression test MENISCAL INJURIES Ancillary Studies • Plain radiographs – Other causes mechanical Sxs • MRI – Higher vascularity in peds patients • CT-arthrography outdated Meniscus MRI Grading of Meniscal Tears: MRI • I: globular changes • II: linear changes not to margin • III: linear to sup/inf margin • IV: complex linear changes • Only grade III and IV visible on arthroscopy MENISCAL INJURIES Treatment • Nonoperative (Aggressive Nonsurgical) • Acute Rehab – ROM, Quad setting • Subacute Rehab – ROM, PRE’s • Bracing (hinged knee brace) • Continue sport specific drills when MENISCAL INJURIES Treatment • Operative – Partial Menisectomy – Meniscal Repair (peripheral) – Meniscus Implants – Total Menisectomy- outdated Baker’s Cyst and the Meniscus • • • • • Stone, et al (1996) Case-control study Over 1700 MRI’s 240 Baker’s cysts 85% had meniscal tears Data supported by: – Miller, et al (1997) – Sansone ,et al (1995) Discoid Meniscus • Programmed cell death • • • • • • More likely to tear Often Lateral Male > female Ages 6-10 yrs Xray- wide lateral joint space Rx- may require resection if Sx Discoid Meniscus Discoid Meniscus Assorted Knee Problems • Osgood-Schlatter Syndrome • Patellar, Quad Tendinitis • Plica • Iliotibial Band Syndrome • Osteoarthritis • Osteochondritis dessicans (OCD) TENDINITIS Quadriceps and Patellar History • Pain with: – Jumping – Stairs – Prolonged sitting • Mechanism = overuse TENDINITIS Quadriceps and Patellar Physical Exam • Tender superior/inferior pole of patella • Tender tibial tubercle • Tight hams, Achilles, quads • Pain with resisted action of muscle TENDINITIS Quadriceps and Patellar • • • • • • Treatment P: protection, pain meds R: rest I: ice C: compression E: elevation S: support, strength/stretch exercises Traction Apophysitis • Osgood-Schlatter “disease” BURSITIS • Prepatellar bursa • Infrapatellar bursae • Pes anserine bursa • Mechanism = direct blow, overuse • Physical exam- point tender, nonintraarticular effusion BURSITIS Treatment NSAID’s • • Ice • Flexibility exercises • Steroid injections • Surgery for chronic cases (prepatellar) Impact of DJD • Impact of Arthritis Annually: (CDC statistics) – 9,500 deaths – 750,000 hospitalizations – 8 million people with limitations – 36 million ambulatory care visits – $51 billion in medical costs and $86 billion in total costs Impact of Knee DJD • Leading cause of • • disability Affects leisure, work, activities of daily living $86 billion annually to health care economy in U.S. Various forms of Arthritis • Osteoarthritis most common What is DJD of Knee? • Wear and tear of • • • Hyaline cartilage leads to exposed bone Subchondral Cysts Joint Space Narrowing Pain with rest, swelling, “instability”,mechanical symptoms Etiology of Knee DJD • • • • • • • Heredity Obesity Malalignment Injury Female gender Muscle weakness Overuse / wear and tear Diagnosis of Knee DJD • Clinical Exam • Weight bearing X- • rays-indicates loss of joint space / articular cartilage MRI rarely indicated (More for soft tissue) Arthritis of the Knee: Treatment • Most treatment is conservative – Weight loss – Muscle strengthening - PT – NSAIDS – Supplements – Bracing and orthotics – Injection Arthritis of the Knee: Treatment • Weight loss – Decreases impact – 6-8 times body weight is felt in knees – Very important for stairs! – Affects flexibility – Impacts risk of surgery and long-term results – Affects overall health Arthritis of the Knee: Treatment • Exercise and PT – Strong muscles cushion joint – Flexibility – Improves recovery from injury or surgery – Low-impact (cycling) preferred – Pool therapy possibly best Arthritis of the Knee: Treatment • Anti-inflammatories and analgesics – NSAIDS (Motrin, Aleve, etc) • Excellent track record • Some side effects – take as needed • Cheaper than prescription drugs and equally effective – Analgesics • Tylenol • Do not use narcotics for chronic pain NSAID Facts • Only 1 in 5 who have a serious problem from NSAIDs, have warning symptoms • Nonselective NSAIDs -16,500 deaths annually in the U.S. • Nonselective NSAIDs -103,000 hospitalizations annually in the U.S. • Four Times more Americans die from NSAIDs annually than from cervical cancer • More Americans die from NSAIDs annually than from AIDS • Clinically important UGI events occur in 3- 4.5% of regular NSAID takers Wolfe MM, et al. N Engl J Med.1999;340:1888-1899. Laine L. et al. Gastroenterology. 2001;120:594-606. Fries JF. , Journal of Rheumatology. 1991. 18 (suppl 28):7. Glucosamine • Symptomatic • • • • relief Slows disease progression? No formula proven better than another Cost ($20/mo) GI upset Chondroitin • Gives cartilage elasticity • From shark cartilage or animal tracheas • Less proven than glucosamine but usually packaged together WD40 • No proven benefit • May cause skin irritation • Not recommended Braces • Knee braces – Support sleeves • Warm joint • Help balance – Functional braces • Stabilize joint • Transfer stress GII unloader Guidelines for Managing Knee OA SEVERE OA surgery COX-2’s JFT High Dose NSAIDS + Gastroprotectant IA-Steroids MODERATE OA simple analgesics, low dose NSAID’s Exercise, Physical Therapy, Weight Loss, Orthotics, Nutraceuticals MILD OA Adapted from Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee, ACR, 2000 Who is a candidate for VS? • Active patients who have early osteoarthritis • Post arthroscopy patients with residual symptoms – rather than re-operation! • Patients who are too young, heavy &/or not ready for TKR • Non-operative candidates Where to inject? What to inject with: How I inject: When all else fails: Arthroscopy of the Knee • Useful for mild or • moderate arthritis with mechanical symptoms (catching) Not as helpful for: – Severe arthritis Osteotomy (Realignment) • Realigns leg to • transfer weight bearing away from affected area of knee Useful for younger patient with only one part of the joint affected Partial Knee Replacement • Replaces only damaged portion of knee • Recovery 70% faster than total knee • More natural feel • Patient selection critical Total Knee Replacement • Involves resurfacing of joint • • • • • surfaces with metal and plastic Newer techniques less invasive 3-4 day hospital stay 6-8 weeks for recovery 90% success at 10-15 years Muscle Sparing Approach “Kinetic Knee References: • Cherry Juice, Chicken Combs, and Chondroitin: The Truth About Arthritis Cures--Gregory J. Golladay, M.D., Orthopaedic Associates of Grand Rapids, P.C. • A New Look at OA Knee Pain -Treatment Options for Today’s Orthopaedic Practice, Dr. Dave Atkin, M.D. Chief, Orthopedic DivisionSt.Luke’s Hospital San Francisco, California V Strand MD, PG Conaghan MB, BS, PhD, L.S Lohmander MD, PhD, A.D Koutsoukos PhD, F L Hurley PhD, H Bird MD, P Brooks MD, R Day MD, W Puhl MD and P A Band PhD. An integrated analysis of five double-blind, randomized controlled trials evaluating the safety and efficacy of a hyaluronan product for intra-articular injection in osteoarthritis of the knee. OsteoArthritis and Cartilage (2006) Volume 14, 859866. Gaetano P. Monteleone, Jr., M.D., Dept of Family Medicine, Director, Division of Sports Medicine, West Virginia University School of Medicine (online slides) • • Useful Web Sites • American Academy of Orthopaedic Surgeons • • www.aaos.org Arthritis Foundation www.arthritis.org NIH www.niams.nih.gov