Disclaimer. Evaluation & Treatment of Hip & Knee Pain in the Adult Patient. Subjective/History. Objectives. Subjective/History. Subjective/History*

Transcription

1 Evaluation & Treatment of Hip & Knee Pain in the Adult Patient William T. Crowe, RN-C, FNP, MSN, MBA Disclaimer! I, William T Crowe, have relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation as follows: None Objectives! Define elements of subjective history! Where does it hurt? Subjective/History! Describe basic exam of the hip & knee! Discuss current treatment regimens for common problems Subjective/History*! Anterior hip (most common) Pathology of hip joint Muscle strains Subjective/History! Posterior hip (least common) Pathology usually outside of hip Check lumbar spine and SI joints! Lateral hip Greater trochanteric pain syndrome Iliotibial band syndrome 1

2 Subjective/History! Where does it hurt?! When did it start?! What happened?! If injury, able to WB after?! Previous injury Subjective/History*! Severity rest & activity! popping in/out! Alleviating/Aggravating factors! Childhood diseases of hip SCFE, trauma, DDH to date! Review of PMH/MEDS/DA! Where does it hurt? Subjective/History Location of Pain! Patellofemoral Pain (Runner s Knee) Jumper s Knee! Lateral Knee Pain Iliotibial Band Syndrome Lateral meniscal tears OA! Medial Knee pain Medial meniscal tears OA MCL sprains Subjective/History! Where does it hurt?! When did it start?! What happened?! If injury, able to WB after?! Previous injury 2

3 Subjective/History! Severity rest & activity! Clicks! Locking! Instability Pseudo pain True ligamental injury! Giving way mechanical (rotating) - tear functional (going up stairs) quad weakness! Post-inertial Dyskinesia Theater sign Subjective/History! Swelling 0-12 hrs! ACL tear, PCL tear, patellar dislocation, fracture hrs! Meniscal tears Recurring! Chronic/degenerative meniscal tear, OA! Pop at time of injury (felt/heard) If assoc with twisting motion ACL injury (80%), meniscal injury (15%),? fx Subjective/History! Alleviating/Aggravating factors to date! Review of PMH/MEDS/DA! Observation Gait Standing! Palpation Standing! Lumbar spine, SI joint Seated! Greater trochanter! Knee Supine! Greater trochanter! Groin! Measure leg length! Knee! Maneuvers Standing! Spinal flexion/extension! Spinal rotation! Spinal lateral bending Seated! Slump test! Knee extension/flexion 3

4 ! Maneuvers Supine! Internal/external rotation! Flexion! FABER Lateral (injured side up)! Abduction! Ober s Test! Observation can t see, can t treat! Observation Standing! Alignment! Swelling! Ecchymosis! Atrophy! Valgus/varus thrust! Palpation Sitting! Bony structures! Ligaments! Joint lines Supine! Patellar mobility! Patellar facets Sports Medicine Institute University of Minnesota Orthopedics! Maneuvers Seated position! Flex/ext of the knee! Patellofemoral crepitus! Maneuvers Supine! Patellar tracking! ROM! Valgus stress (30)! Varus stress (30)! McMurray test! Posterior Drawer test (90)! Lachman s test (20) 4

5 ! Maneuvers Lateral! Ober s test Standing! Thessilly! Radiographs! CT scan! MRI Objective/Studies! Nuclear bone scans! Gait Objective/Studies! Radiographs! CT scan! MRI Objective/Studies Objective/Studies Objective/Studies! MRI Consider for soft tissue evaluation Do not order to evaluate for pain Don t order without plain x-rays General waste of time and money in patients over age 40 (2011) Robert J. Dimeff, MD - Medical Director of Sports Medicine, Professor of Orthopaedic Surgery, Pediatrics, and Family Medicine, UT Southwestern 5

6 Avascular Necrosis! Prevalence 10-20K annually y/o Male 4:1 female 50% bilateral Avascular Necrosis Pain (groin) is gradual as bone collapses Pain increases with movement Pain decreases with rest! Causes Post traumatic Alcoholism, smoking Excess steroid use Hypertension, diabetes Antalgic gait FABER + Avascular necrosis 6

7 Avascular necrosis Symptom relief! NSAIDs! Physical Therapy! Limited weight-bearing Surgical! Core decompression 65%! Joint replacement 95% *! Prevalence Males higher incidence! Causes Hereditary (~60%) Weight-bearing High intensity physical loading Chronic pain (groin) Pain increases with movement Pain decreases with rest Antalgic gait FABER + Pain with passive IR/ER Conservative! Weight control, rest, exercise Medical! NSAIDs! Physical therapy Surgical! Joint replacement 7

8 Joint Replacement* Trochanteric bursitis! Prevalence Females higher incidence (wider hips)! Causes Trauma, contusion Trochanteric bursitis Pain with activity and rest Trochanteric bursitis Pain on palpation of the greater trochanter Normal IR of hip Trochanteric bursitis Medical! NSAIDs! Physical therapy! Cortisone injection to site Posterior hip! Primarily from lumbosacral and SI joints 8

9 Femoroacetabular impingement (cam and pincer, hip impingement) Femoroacetabular impingement (cam and pincer) Cam Pincer Fascia lata! Popping over the greater trochanter! Tx Physical Therapy Stress Fracture! Leg pain?? >> check Rx hx Bisphosphonates (can detect in bone 7-10 yrs after stopping) Stress Fracture! FDA (Oct 2010) New statement in labels uncertainty of optimal duration of use HCP should:! be aware of the possible risk of atypical femoral fractures! evaluate any patient who presents with new thigh/ groin pain! consider periodic reevaluation of the need for continued therapy, esp. those treated for > 5 yrs! Most occur around femoral neck! Subcapital or transcervical! Less common in intertrochanteric region Stress Fracture! SURGERY! Risk of displacement - HIGH 9

10 Stress Fracture! Pelvic fracture usually involves ramus Does not require surgery Rest, walking aids, analgesics May take several months Fractures *! Prevalence ~ 25% of general population! Anterior knee pain syndrome! Patellofemoral malalignment! Chondromalacia patella Most common in teen-age females Also seen in > 40 y/o Pain increases with walking up/down stairs or hills Instability with walking or running Theater sign + Crepitus Patellar facet pain Lateral tracking of the patella (J-sign)! 24 y/o female with R knee pain for the past 2 weeks 10

11 ! 24 y/o F with R knee pain x 2 weeks! 28 y/o F with R knee pain x several years - Lateral Subluxation / Patellofemoral Syndrome Conservative! REST STOP the offending activity! RICE! Patellar buttress brace! Physical therapy! NSAIDs! Gradual return to activity - Lateral Subluxation / Patellofemoral Syndrome Failure! Refer to orthopedic specialist - Chondromalacia Conservative! Patellar buttress brace! Physical therapy! NSAIDs! Cortisone injection (joint) Failure! Refer to orthopedic specialist! thick, fibrous connective tissue! attaches proximally at the iliac crest Tensor fascia latae muscle! attaches distally to the tibia! at ~ degrees, moves across the lateral femoral epicondyle. Moves back when knee is straightened.! helps hold us upright walking/running IT Band 11

12 IT Band Syndrome! Common cause of pain in runners (hip/knee)! Causes Overuse Increasing training too quickly IT Band Syndrome Lateral knee pain Pain worsens by running, particularly downhill Painful flexion or extension of the knee IT Band Syndrome POP lateral knee (at or around the lateral epicondyle of the femur) Painful flexion or extension of the knee Ober s Test +! Studies none IT Band Syndrome IT Band Syndrome Rest relative RICE NSAIDs PT IT band stretches Meniscal Injury! Prevalence Most common reason for knee scope Injury! Rare in childhood! Occurs in late teens! Peaks in 30 s and 40 s After age 50, probably due to arthritis 12

13 Meniscal Injury Pain to the joint line (medial > lateral) Locking Popping Meniscal Injury Pain on palpation of the joint line Varus/valgus stress with pain McMurray test positive (Bragard s sign)! Medial - sensitivity 35.7%, specificity 85.7%! Lateral sensitivity 22.2%, specificity 100% Thessilly test (full ext & 30)! ~ 1/3 with documented tears have NO sig findings on exam! Studies XR MRI Meniscal Injury Meniscal Injury Refer to orthopedic specialist! Post-meniscectomy Medial compartment degenerates within yrs Lateral compartment degenerates with 2-5 yrs Ligamental Injury Immediate swelling Inability to weightbear afterwards Loss of stability Ligamental Injury Swelling Pain on palpation of ligaments Varus/valgus stress unstable! Valgus sensitivity 86% Posterior Drawer test +! Sensitivity 90%, specificity 99% Lachman s test +! Sensitivity 78.6%, specificity 100% 13

14 ! Studies XR MRI Ligamental Injury Ligamental Injury RICE NWB with use of crutches Hinged knee brace Physical therapy NSAIDs and analgesics Referral to orthopedic specialist! Prevalence Most common joint disorder worldwide ~80% of those > 75 years of age! Radiographic evidence ~11% of those > 64 years of age! Symptomatic Manek, NJ, & Lane, NE (2000). American Family Physician. (61) Pain Time! Chronic v. acute Swelling Stiffness! Morning! Immediately after rest Joint instability Altered gait Joint effusion Crepitus Limited ROM Instability! Studies XR 14

15 * Physical therapy Medication! Acetaminophen! NSAIDs nonselective! COX-2 Inhibitors! Opioids * Physical therapy Medication Intra-articular injection! Cortisone! Hyaluronic Acid Physical therapy Medication Intra-articular injection External bracing Referral to orthopedic specialist Fracture 15