Knee Problems Cure Conference Mike Mazzone Waukesha Family

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 about the Knee 54% of all Atheletes will experience some knee pain EVERY YEAR

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

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

Ottawa Rules for Obtaining a radiograph in Acute Knee Injuries 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 weightbearing steps in the emergency department Sensitivity – 99% Specificity – 60% Reduced Radiographs by 57%

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)

AP View Merchant’s view Lateral View Tunnel View

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

Differential Diagnosis by Age Children and Adolescents – Patellar Subluxation – Osgood. Schlatter – Tibial Apophysitis – Jumper’s Knee – Patellar Tendonitis – Referred Pain – Slipped Capital Femoral Epiphysis – Osteochondritis Dissecan 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 Older Adults – Osteoarthritis – Crystal Induced arthropathy – Baker’s Cyst (Popliteal Cyst)

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

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

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

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

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

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

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 – Mc. Connell Taping

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

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

Iliotibial Band Tendonitis Friction between IT band 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

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

Medial Collateral Ligament (MCL) Due to valgus stress Hx – valgus stress then immediate pain and swelling medially PE – valgus stress testing – – – Grade 1 2 3 – – – clearly defined endpoint and < 5 m laxity 5 -10 mm of laxity with endpoint 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

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

Meniscal Tear Can be acute or chronic Hx – Recurrent knee pain with episodes of catching, locking or giving way PE – Mild effusion and positive Mc. Murray 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

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/d. L 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

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

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 2 K to 75 K Protein high >32 g/d. L Glucose 75% of serum Polarized-light microscopy of synovial fluid shows Gout - negatively birefringent rods Pseudo. Gout – positively birefringent rhomboids Treatment – NSAID’s – Colchicine

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

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

Prophylactic Brace Functional Brace Patello. Femoral Brace

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

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))