Knee Pain: Evaluation and Management. Ted Parks, MD
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1 Knee Pain: Evaluation and Management Ted Parks, MD
2 Financial Disclosures:
3 Common knee conditions Ligament injuries Meniscal injuries Arthritis (osteoarthritis) Problems of the patello-femoral joint DIAGNOSIS: UNKNOWN
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5 ANATOMY: Building a Knee Parts List: 4 Bones 2 Tendons 4 Ligaments 2 Types of Cartilage
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25 Building a Knee
26 Ligament Injuries
27 Ligament Injuries: History High Energy Injuries Sometimes feel a pop Swelling (within an hour or two) Once the pain subsides: INSTABILITY
28 Ligaments: Physical Exam
29 Physical Exam: MCL
30 Physical Exam: LCL
31 ACL Tests
32 Iliotibial (IT) band
33 ACL Tests
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35 PCL Test
36 PCL Test Sag Sign
37 Studies X-ray: Yes (mechanism) MRI (maybe)
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39 Rx = Hinged Knee Brace
40 Frank C, Woo S.L. et al, Am J Sports Med Nov-Dec;11(6): Created ligament injuries in mice Compared immobilization to motion
41 Motion Immobilization
42 ACL Tears Relatively Common Don t Heal If untreated, result in arthritis
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46 Treatment Option #1: Brace
47 Treatment Option #2: Surgery End to End Repairs Don t Work Ligament Must be Replaced with a Graft
48 Graft Options Synthetic (Gortex) Ligament Allograft (Cadaver) Ligament Autograft (patient s own tissue) Hamstrings Patellar (knee cap) tendon
49 Autograft Options Patellar tendon Hamstrings
50 Implanting the Graft
51 ACL Reconstructive Surgery Over 90% Success for restoring stability 75-80% Success for returning to sports Significant (Predicted) decrease in Arthritis later in life
52 MENISCUS TEARS
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54 Meniscus Tears: History Sided pain Trauma +/- Mechanical symptoms +/- Swelling, other +/-
55 Meniscus Physical Exam* Joint line tenderness Joint line pain with deep flexion McMurray s test *(rule out colateral ligament injury with colateral ligament test)
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57 Studies X-rays (If age over 40: YES)* MRI (Maybe)
58 Should I order an MRI? 50% of meniscus tears are asymptomatic in 6 weeks: If ALL signs and symptoms are positive after 6 weeks: SURGERY If uncertain after 6 weeks, MRI Usually NOT cost effective in patients over 70
59 Surgical Treatment of Meniscus Tears
60 Arthroscopy for Meniscus Tears 30 minute Operation 80 90% Patient Satisfaction % Return to Sports Good results for decreasing development of Arthritis
61 ARTHRITIS (osteoarthritis)
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63 Arthritis History Age (High Mileage) Past trauma Rheumatic disease Previous surgery
64 Physical Exam Angular deformities
65 Physical Exam
66 Physical Exam
67 Making the Diagnosis History: Age ( high mileage joints) Physical Exam X-RAYS
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70 Meniscus Tear vs Arthritis?
71 X RAYS Don t Order: knee series Non-weight bearing AP Lateral Obliques
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73 X Rays Wt bearing AP Wt bearing 60 deg PA (Rosenberg) Lateral Merchant s view (aka sunrise )
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78 Getting the right x-ray views Wt bearing AP Wt bearing 60 deg PA (wt bering notch view, Rosenberg) Lateral Merchant s (aka sunrise ) view
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81 Treatment: Non-Surgical Anti-inflammatory Medicines Supplements Braces Cortisone Shots Viscosupplementation Shots Weight Loss Cane, Crutches, Walker Physical Therapy
82 Arthritis Treatment: Surgical
83 Arthritis Treatment: Surgical PAST: (Pre-1970) Knee Fusion Osteotomy
84 Treatment Options: Knee Fusion
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86 Arthritis Treatment: Surgical PRESENT: Total Knee Replacement Unicompartmental Knee Replacement
87 Total Knee Replacement
88 Treatment Options?
89 Unicompartmental Knee Replacement
90 The Future
91 Problems of the patello-femoral joint
92 History More common in females Often bilateral Pain is anterior Worse with stairs (esp descending) Worse with squatting Worse with prolonged sitting (theater sign)
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95 History More common in females Often bilateral Pain is anterior Worse with stairs (esp descending) Worse with squatting Worse with prolonged sitting (theater sign)
96 Physical Exam Test patello-femoral mobility Check for noise
97 X-Ray Merchants/sunrise/subpatellar view
98 Normal
99 Arthritis
100 Tracking problem
101 Tracking problem and arthritis
102 End Stage
103 Treatment Physical therapy/nsaids -strengthen the medial quad -stretch the lateral retinaculum Braces Cortisone injections
104 Treatment (surgical) Lateral release Tibial tubercle transfer Maquette tibial tubercle osteotomy Knee replacement
105 Lateral Release
106 Tibial Tubercle Transfer
107 Diagnosis: Unknown
108 First: Rule out an atypical lumbar radiculopathy Rule out a hip problem that is radiating pain to the knee a) hip windsheild wiper PE test b) AP pelvis xray
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111 Stage 1 OTC NSAIDs Simple home stretches: (Ham/Quad, hold for 30 seconds each, 3 sets twice a day) Stationary bike: 20 min/day, 5 days/week for 6 weeks
112 Stage 2 Physical Therapy Cost=$720 MRI Cost=$460 Cortisone Injection Cost=$66.47 ($4.67 supplies, $62 injection fee, medicare CPT code 20610)
113 Cortisone Injection
114 Therapeutic Injections in your practice A great choice for: Your Patients You Me
115 Therapeutic Injections Me (Orthopedists) Decreases volume of non operative patients
116 Therapeutic Injections You (Primary Care Providers) Satisfaction of rendering effective treatment $
117 Corticosteroid Injections Patients Safe Effective Inexpensive (Cortisone shot=$6.00) Am J Med. 2005;118: Arthritis Rheum. 2002;46:
118 Corticosteroid Injections 1cc 4cc
119 Syringe and Needle
120 Prep Betadine Alcohol Gloves Lidocaine Cold Spray (ethyl chloride) Infection rate=1:15,000 Clin Fam Prac,Vol 7,2:2005
121 General Rules No more than one injection per month No more than 3 injections per year Don t inject infected areas J Bone Joint Surg Am 1975;57:70-6 Curr Opin Rheumatol 1999;11: ACTA Orthop Scand 1997;132-4
122 Knee Joint Injection Technique 1cc Steroid, 4cc Lidocaine Pt supine on table Knee extended Muscles relaxed Lateral approach Sub-patellar Jackson et al, J. Bone Joint Surg. AM., 84: (2002)
123 Thank You! Ted Parks, MD (303)
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125 MRI
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