Evaluation and of Common Knee Problems Greg I. Nakamoto MD, FACP, Department of Orthopedics and Sports Medicine, Virginia Mason Medical Center Alaska Academy of Family Physicians, 17 th Annual Winter Update, 3/14/2015 ABBREVIATED DIFFERENTIAL DIAGNOSIS (AND RELEVANT EXAMINATION POINTS) Osteoarthritis bony and synovial hypertrophy, diffuse tenderness, x-rays Patellofemoral syndrome feet, alignment, quadriceps atrophy, patellar facet pain, patellar grind Patellar instability patellar apprehension Meniscal injury joint line tenderness, McMurray s test Collateral ligament sprain (MCL, LCL) tenderness, pain and/or laxity with valgus or varus stress Cruciate ligament sprain (ACL, PCL) drawer testing, Lachman s test Fracture x-rays OSTEOARTHRITIS Chronically slowly progressive, generalized pain; swelling, stiffness; catching, instability; decreased walk tolerance Acutely sudden worsening of baseline symptoms; increased pain and swelling; often secondary to overuse, trauma Bony and synovial hypertrophy Pain not confined to joint lines; patellar facet pain Possible effusion X-rays 4 views of the knee (weightbearing): AP, notch view, lateral, Merchant s Findings: 1) joint space loss; 2) subchondral sclerosis; 3) osteophytes; 4) subchondral cysts Chronically 1) Tylenol 1g TID prn pain; 2) glucosamine 1000-1500mg qd; 3) NSAIDs; 4) Synvisc injections; 5) unloader bracing; 6) exercise (gentle motion); 7) weight control; 8) joint replacement Acutely 1) NSAIDs; 2) cortisone PATELLOFEMORAL SYNDROME Part of continuum patellofemoral syndrome; chondromalacia patellae; patellofemoral compartment osteoarthritis Anterior knee pain; worse going down stairs; +theater sign Female, overpronator, runner/overuse Overpronation, valgus alignment at the knee Vastus medialis atrophy Possible effusion; patellar facet tenderness X-rays Patellar subluxation Rest, ice, NSAIDs Physical therapy stretching, strengthening Bracing, Cho-pat strap, orthotics Surgery lateral release
MENISCAL TEAR Can be traumatic or degenerative Hyperflexion or plant and twist Joint line pain, swelling, catching or locking Often has joint effusion Joint line tenderness Positive McMurray s X-ray X-rays normal MRI meniscal tear Trial of symptomatic treatment RICE Surgery arthroscopic meniscal debridement MEDIAL COLLATERAL LIGAMENT SPRAIN Valgus stress of the knee Medial sided pain; with/without swelling; feelings of instability Tenderness to palpation along the course of the MCL Pain and/or laxity with valgus stress testing o Grade 1: pain but no laxity o Grade 2: mild laxity but definite endpoint o Grade 3: complete tear, poor endpoint X-ray X-rays normal, possibly a bony avulsion MRI usually not necessary for the diagnosis, but will show the sprain/tear Grade 1: early active motion; RICE; hinged knee brace for comfort; early rehab as tolerated Grade 2: early active motion: knee immobilizer x 2 weeks, then same as for grade 1 Grade 3: orthopedic referral; knee immobilizer, RICE, quad sets and straight leg raises ANTERIOR CRUCIATE LIGAMENT TEAR Hyperextension or awkward stress; audible pop; rapid swelling; nonspecific pain Pain and swelling start to settle down over several days; instability may persist +/- effusion; +/- tenderness Laxity on Lachman s test and anterior drawer testing X-ray X-rays normal (possible lateral capsule bony avulsion aka Segond s sign) MRI ACL tear RICE Presurgical rehabilition range of motion, quadriceps strength Surgery ACL reconstruction
SELECTED BIBLIOGRAPHY Bracker M, ed. The 5-Minute Sports Medicine Consult. Lippincot Williams & Wilkins, Philadelphia, 2001. Hoppenfeld S. ination of the Spine and Extremities. Appleton & Lange, Norwalk, Connecticut, 1976. Lillegard W, Butcher J, and Rucker K. Handbook of Sports Medicine: A Symptom-Oriented Approach, 2 nd edition. Butterworth Heinemann, Boston, 1999. Magee D. Orthopedic Physical Assessment, 2 nd edition. W.B. Saunders Company, Philadelphia, 1992. McKinnis L. Fundamentals of Orthopedic Radiology. F.A. Davis Company, Philadelphia, 1997. Netter F. Atlas of Human Anatomy. Ciba-Geigy Corporation, Summit, New Jersey, 1993. Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale ME, McLaughlin S, Einhorn TA, Felson DT. The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone Joint Surg Am 2003 Jan;85-A(1):4-9. Points out that asymptomatic meniscal tears are very common. Also, osteoarthritic knees with a meniscal tear are no more painful than those without a tear. They conclude that the data does not support the routine use of MRI to evaluate for meniscus tears in patients with osteoarthritis. Calvert G, Wright R. The use of arthroscopy in the athlete with knee osteoarthritis. Clin Sports Med 2005;24:133-152. In addition to a review of the literature, the authors include their preferred treatment methods for managing patients with meniscal tears in the setting of early osteoarthritis. They obtain weight bearing x-rays on all their patients. If symptoms are suspicious for a meniscus tear and there is no joint space narrowing, they proceed with MRI to confirm the meniscus tear in anticipation of surgery. If the patient already has joint space narrowing, they begin by maximizing conservative management for osteoarthritis. In these patients, if normal alignment and greater than 50% joint space remaining (that is, evidence of only mild osteoarthritis on x-rays), and rapid return of symptoms after cortisone or viscosupplementation, then they consider arthroscopic debridement. If, however, they obtain several months of relief with conservative measures, then they would recommend continued conservative management for osteoarthritis as the presumed primary problem. Englund M, Guermazi A, Gale D, Hunter DJ, Aliabadi P, Clancy M, Felson DT. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med 2008; 359:1108-1115. Found that mensical damage is common among middle-aged and elderly persons, irrespective of knee symptoms, and often accompanies knee osteoarthritis. Clinicians who order MRI of the knee should take into account the high prevalence of incidental tears when interpreting the results and planning therapy. Surgical resection of damaged parts of the meniscus is unlikely to reduce pain substantively in patients in whom osteoarthritis is causing or contributing to the symptoms, and evidence is lacking to support the approach of meniscal resection, as compared with nonsurgical treatment, in these patients. Marx R. Arthroscopic surgery for osteoarthritis of the knee? N Engl J Med 2008;359:1169-1170. Gives two hypothetical cases illustrating the great range of possible presentations of knee pain in two patients. Both patients have meniscus tears as well as x-ray evidence of osteoarthritis, but prognosis with arthroscopy is markedly different between the two patients. Points out that while osteoarthritis is not an indication for surgery, that it is not an absolute contraindication either, and that patient care must be individualized.
From: Lillegard W, Butcher J, and Rucker K. Handbook of Sports Medicine: A Symptom-Oriented Approach, 2 nd edition. Butterworth Heinemann, Boston, 1999.
From: Bracker M, ed. The 5-Minute Sports Medicine Consult. Lippincot Williams & Wilkins, Philadelphia, 2001.