Knee: Overuse Injuries. Michael Petrizzi, MD, CAQ

Transcription

1 Knee: Overuse Injuries Michael Petrizzi, MD, CAQ 97

2 Knee: Overuse Injuries Michael J. Petrizzi, MD Clinical Professor of Family Medicine Virginia Commonwealth University Objectives Review epidemiology of knee injuries Review normal anatomy & kinesiology Review injuries that alter the anatomy or kinesiology Discuss when to treat and when to refer Discuss treatment options Principles of Exam History is very important Build trust pain minimal and at end if needed. Do not raise head/use distraction Exam at time of injury is best Ask patient to show the instability Examine everyone and learn Firm endpoint=intact or partial rupture Soft endpoint=complete rupture 98

3 Epidemiology One of the most commonly injured joints in the body Less than 5% need surgery Overuse injuries are common in running and aerobic activities Trauma - contact/collision sports and deceleration injuries Epidemiology Acute Knee Injuries Ligament Injuries 45% Isolated ACL - 50% Isolated MCL - 30% ACL & MCL - 10% Combined & PCL - 10% Combined & LCL - 10% Patella Injuries 27% Meniscal Injuries 12% Miscellaneous 28% Basic Anatomy of the Knee 3 compartments - Medial, Lateral, Patella-Femoral Bones Articular cartilage Menisci Plicae Capsule thickening, posterior-lateral, posterior-medial & medial retinaculum Ligaments 99

4 Anatomy - Bones Femur Medial is larger Trochlear groove for patella-femoral articulation Tibia Tibial Tubercle (apophysis is located here in the adolescent) Patellar tendon attachment Gerdy s Tubercle illiotibial band insertion Pes Anserine Attachment Fibula No articulation with the femur Patella Superior attachments to the quadriceps Inferior attachments to patellar tendon Anatomy - Cartilage Medial meniscus C-Shaped around the periphery of the larger medial plateau Lateral meniscus Smaller, more circular, less adherent to tibia and surrounds a hill Plica Embryonic remnants only significant when inflamed, less stability Capsular thickening Posterolateral, Posteromedial, Medial Retinaculum Anatomy - Ligaments Medial collateral ligament Acts as 1 restraint at 30 flexion Has fibers that are part of joint capsule and medial meniscus (deep MCL) Lateral collateral ligament Acts as 1 restraint at 30 flexion Has no intra-articular attachments Anterior cruciate ligament Acts as 1 restraint at 30 flexion Posterior cruciate ligament 1 restraint that limits posterior tibial displacement Arcuate ligament Part of Postero-lateral Complex 100

5 Anatomy - Muscles Extensor mechanism Quadriceps Patella Patellar tendon Gastrocnemius and Plantaris Most powerful calf muscle Hamstrings Pes Anserinus Gracilis, Sartorius (and semitendinosus), attach medially Popliteus Anatomy - Neurovascular Neurologic Concerns Common peroneal nerve courses along biceps femoris tendon then across the fibular head site of neurapraxia or damage by casting Vascular Concerns Collateral Circulation Deep vein thrombosis at or above knee = higher risk for Pulmonary embolism Kinesiology Flexion degree, Extension - 0 degrees Patella-Femoral compartment - lever arm Medial compartment - more stable Remember Lower extremity - closed kinetic chain principle Foot -> Ground -> Sub-Talar -> Tibial Glide and roll allows more bend than rolling only Medial compartment - more stable 101

6 History Attempted therapy Previous injuries Ipsilateral and contralateral joints Other joint pain, or dysfunction? Remember - referred pain L4 Radiculopathy DJD Hip Slipped capital femoral epiphysis Physical Observe Atrophy, deformity, ecchymosis, effusion, recurvatum, redness Active range of motion 0 extension 140 flexion Passive range of motion? Limited by swelling, pain or intra articular derangement Palpate Effusion = Ballottement Test Compare with other knee Physical Plicae band-like tissue 102

7 Palpate Patellar tendon Physical Upper vs. lower pole Patellofemoral palpate for defect MCL/LCL tenderness Physical Palpate Joint line from anterior to posterior to localize tenderness & swelling Swelling or mass in posterior knee Baker s Cyst Popliteal aneurysms Tumor Physical Palpate for: Pes Anserinus bursitis Popliteal tendon insertion discrete point vs. Band like with iliotibial band Iliotibial band crosses knee and inserts on Gerdy s Tubercle 103

8 Patella Patella-Femoral tracking syndrome (Chondromalacia Patella) Check for Crepitus Displace medially and distally Then ask patient to contract quadriceps Patellar Dislocation Test and Procedures X-ray AP, lat - *sunrise view for PFTS patients Arthrogram Arthroscope diagnostic vs therapeutic MRI only as good as coil and radiologist both false positives and negatives Primary Interventions PRICE regimen Can include knee immobilizer Remember ace wraps offer very little stability mostly just compressive forces Pharmacologic NSAID s 104

9 Physical therapy Rehabilitation Structured but can be done at home short arc exercises avoids placing undue stress on knee, i.e. extend knee from 30o to 15o to strengthen quads ROM exercise Strength Immediately start isometrics quads can atrophy in 24 hrs Cardiovascular fitness Maintain this if at all possible *Correct underlying structural (flat feet) or functional (weak vastus medialis) problem, or injury will recur Psychological Aspects Awareness, get inside athletes head or recommendation for rest will be ignored relative rest, i.e. decreased mileage may be adhered to Ms. M.J. is a 37-year old cheerleading coach who presents to her family physician with both knees aching. The left one really bothers her and she can t sit for a very long time. She says her knees make a noise when she goes up the stairs. She also says her left knee has giving way before. Her shoes are also really worn out on the medial heel. 105

10 Patella-Femoral Tracking Syndrome PE - +1 swelling; crepitus; tender when the patella is distracted distally, and/or medially VMO - weak Feet - Pes Planus Pseudo locking Movie Sign Q Angle RX ice, NSAIDs,? orthotics, MacConnel Taping, VMO, strength and timing of contractions Patella-Femoral Tracking Syndrome Patella-Femoral Stress Syndrome RX ice, NSAIDs?, orthotics, MacConnel Taping, VMO strength and timing of contractions 106

11 WIC Jr. is a 16-year old would be lineman for your local high school football squad, he comes to your office despondent. He can barely come out of his stance because of knee pain. He s noticed a bump on his upper shin. Osgood Schlatter Disease Apophysitis no effect on linear growth Probably secondary to forced extension RX Protection NSAID Ice Limit extension exercises SJ is a 17-year old star volleyball athlete at your local high school who complains of pain at the bottom of her knee cap after a weekend tournament. PE tender at distal pole of patella Similar to patellar tendonitis in a skeletally mature individual RX similar to Osgood Schlatter Disease 107

12 Sinding-Larsen-Johansson Syndrome PE Tender at distal pole of patella Similar to patellar tendonitis in a skeletally mature individual RX Similar to Osgood Schlatter Disease Mr. PE has been a star center his whole career. He presents c/o pain just below his knee cap. Things really got bad after coach had team do one extra session of rebound drills each day last week. Eccentric Contractions tendon poor blood supply RX Ice NSAID Evaluate, flexibility and quad/hamstring ratio Patellar Tendonitis 108

13 A 34-year old aerobics instructor presents with anterior left knee pain. She was asked to sub for a friend and so she taught two extra sessions per day. Her knee began to catch as she shifted the clutch. She denies any pain located under her knee cap. Plicae PE tender band of tissues rides under finger History of sudden overuse RX Ice NSAIDS Decrease exercise? Injection Surgeons say surgery Dr. MLB c/o right anterior, medial pain below the knee after performing for the first time as his son s soccer coach. 109

14 Pes Anserinus Bursitis PE can palpate area of tenderness Mild swelling Even crepitus RX Treat with relative rest Ice NSAIDs Mr. Gill is a Lawyer who is training for his first marathon. He combined some downhill speed work with treacherous footing on an icy day and now has c/o pain radiating from behind the knee to a point on the lateral aspect of the femur. Popliteal Tendonitis Downhill = need for check reign Remember popliteus a weak joint, flexor also opens joint Slippery footing = poor timing of hamstring contraction RX Difficult-try NSAIDs Ice (often get referred discomfort from common peroneal nerve) Rehab Stretching remember origin and insertion 110

15 A 27-year old housestaff officer presents with left lateral knee pain. He recently increased his weekly running schedule from 20 miles a week to 50 miles a week in crash preparation for a marathon. It began hurting near the end of his 40 th mile. It made his knee feel weak. Now it hurts after the 2 nd mile of any workout (All of it while running facing traffic.) Iliotibial Band Friction Syndrome Iliotibial Band Friction Syndrome PE Cross over test Band of pain, a click May need to go out running Check for leg length discrepancy Tight lateral structures 111

16 Iliotibial Band Friction Syndrome RX Ice NSAIDs? lateral heel lift? Change direction and relative rest Injection Conclusion Knee - One of the most common injuries Better understanding of Anatomy & Kinesiology Alterations of Anatomy or Kinesiology = Injury Accurate physical = good diagnosis skills When to treat and when to refer Understanding treatment options Teamwork = Success! 112