The Painful Knee: Tips and Pearls. James H Albers, MD Diplomate, ABPM&R SubcerAficaAon Sports Medicine

Transcription

1 The Painful Knee: Tips and Pearls James H Albers, MD Diplomate, ABPM&R SubcerAficaAon Sports Medicine

2 What does Newton have to do with knee pain? First Law of MoAon (InerAa) Physics (Lever Arms)

3

4 Evalua&on Unfortunately, not this easy

5 Knee Largest human joint (volume and surface area of araculaang caralage) Two joints Abiofemoral and patellofemoral Modified hinge bends, also slight rotaaon

6 Sustains high forces and moments (1.5 x body weight walking, 8 x body weight squayng) Located between the body s two longest lever arms SuscepAble to injury, wear and tear, inflammatory arthrias, sepac arthrias Knee Joint

7 Knee Pain Honest joint If paaent says It hurts here, think about what is there

8 Anatomy Menisci - FibrocarAlaginous discs - Shock absorbers - Increased congruency between joint surfaces - Aid in stability

9 Ligaments - Stabilizers - Medial collateral valgus stress - Lateral collateral varus stress - ACL anterior translaaon of Abia (and rotaaon) - PCL posterior translaaon of Abia Anatomy

10 SorAng it out Pain (Acute vs chronic) Onset (TraumaAc vs non) LocaAon Other symptoms Exam

11 Trauma Fracture Meniscal injury- - twisang Ligamentous injury pain, swelling, instability Musculotendinous strains pain, swelling, bruising, no instability Contusions pain, bruising

12 Typical Knee

13 Chronic Pain ArthriAs Overuse/Overload Tumor Night pain, Xray InfecAon- - Rare

14 Pearls Injury? Ligament, meniscus Noncontact? ACL Contact? MulAple possible Pop? ACL Swelling? Rapid ACL, overnight meniscal Locking? Meniscus Give- way(buckle)? Weak quad, instability (ACL), patellar instability

15 Pearls Pain with squayng? Meniscus, Patellofemoral Pain with jumping? Patellofemoral Theater sign Patellofemoral PivoAng/cuYng? ACL

16 Anterior Knee Pain Upper pole of patella: tendinopathy/tear quads Inferior pole: patellar tendinopathy/overuse General: patellofemoral pain

17 Medial Knee Pain Joint line: Meniscal tear, arthrias Proximal: Medial collateral ligament tear/ sprain Distal: Pes anserine bursias (oeen associated with OA)

18 Posteromedial: Meniscal tear, Bakers cyst, gastroc tear Posterior Knee Pain

19 Lateral Knee Pain Lateral femoral condyle: ilioabial band syndrome Lateral joint line: meniscal tear, OA lateral joint

20 Pain

21 Pain

22 LocaAon, locaaon, locaaon Just like real estate

23 Instability Tibiofemoral Patellofemoral Gives way, buckles, slips Pseudolaxity with OA ACL tear

24 SAffness Oeen caused by effusion (distenaon of joint prevents full flexion) OA

25 Swelling Synovial fluid or blood in knee joint Infrapatellar bursa

26 Locking True: meniscal tear (oeen bucket handle) Pseudo: patellofemoral OA, Abiofemoral OA, plica

27 Weakness Muscular: quad tear, patellar tendon tear, fracture Neurologic: radiculopathy, stroke

28

29 Exam Observe Gait Squat

30 Palpate Exam

31 Exam Valgus stress (25 degree flex and ext) MCL, MCL and others Varus stress (25 degree flex and ext) LCL, LCL and others

32 Exam McMurray Menisci - Need pain free flexion beyond 90 degrees

33 Exam Lachman (30 degree flexion) ACL Anterior Drawer(90 degree flexion) ACL Pivot- Shie(Extension)- - ACL (need relaxed pt)

34 Posterior Drawer PCL Exam

35 Exam Patellar Apprehension Patellar instability Patellar Grind Patellofemoral pain

36 Exam Noble s ITB Ober s ITB Aghtness

37 Exam Neuro Hip Foot

38 OA Most common Medial primarily

39 OA

40 OA Greater than 50 y/o Morning saffness less than 30 minutes Crepitus Bony tenderness Bony enlargement No palpable warmth (Per ACR 3/6 of above)

41 OA Chronic Older Obese Pain with weightbearing, flexing, walking stairs SAffness Angular deformity (usu varus) Joint line tenderness Pes anserinus Mild swelling

42 OA- - Recommended Low- impact land- based exercise AquaAc exercise Strength training EducaAon Weight loss

43 OA- - CondiAonal Oral NSAID Topical NSAID Tylenol Intra- aracular steroids Glucosamine/ChondroiAn

44 OA- - Possible ViscosupplementaAon Unloader braces Shoe wedges PRP Arthroscopy very selecave (younger, non- obese, milder OA, primary diagnosis meniscal tear or loose body)

45 Patellofemoral Pain Overuse of extensor mechanism Females more than males Training errors, malalignment (patellar malposiaon, poor foot or pelvic mechanics, Aght lateral structures)

46 Patellofemoral Pain Anterior knee pain Worse with knee flexion (squayng, jumping, running hills, walking down stairs, siyng too long) Tenderness (peripatellar, patellar tendon) J sign Occ abnormal posiaon of patella Occ femoral anteversion, foot pronaaon, Aght lateral band

47 Patellofemoral Pain- - Recommended Rest acutely, ice, NSAIDs Rehab strength (core, hip abd and ext rot, quads, VMO); stretch (quads, hams, ITB) Taping, orthoacs

48 Preventable injury ACL Tear

49 ACL Tear Between 100,000 and 200,000 ACL tears per year in US Costs (medical, other associated) $625 million to $1 billion annually

50 ACL Tear- - Sequella Up to ¼ high school athletes tear contralateral or retear reconstructed ACL in one year ½ to ¾ show radiographic changes of OA in years, and have pain or limitaaon of acavity

51 ACL Tear Most oeen noncontact Females greater risk?anatomic, hormonal, geneac component? non- modifiable Biomechanical/neuromuscular component- - modifiable

52 Mechanical Factors Females: Quadriceps dominance in deceleraaon (less effecave than hams in prevenang anterior Abial translaaon)=stress on ACL Increased valgus at knee during landing and direcaon changes=stress on ACL Weak trunk/hip stabilizers also contribute

53 ACL Tear Improve landing technique - No flat foot/extended limb flex hips and knees Strengthen, esp hams, hip abd, trunk Balance training

54 Bad

55 Good

56 The End! Thanks.

57