The Painful Knee: Tips and Pearls James H Albers, MD Diplomate, ABPM&R SubcerAficaAon Sports Medicine
What does Newton have to do with knee pain? First Law of MoAon (InerAa) Physics (Lever Arms)
Evalua&on Unfortunately, not this easy
Knee Largest human joint (volume and surface area of araculaang caralage) Two joints Abiofemoral and patellofemoral Modified hinge bends, also slight rotaaon
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
Knee Pain Honest joint If paaent says It hurts here, think about what is there
Anatomy Menisci - FibrocarAlaginous discs - Shock absorbers - Increased congruency between joint surfaces - Aid in stability
Ligaments - Stabilizers - Medial collateral valgus stress - Lateral collateral varus stress - ACL anterior translaaon of Abia (and rotaaon) - PCL posterior translaaon of Abia Anatomy
SorAng it out Pain (Acute vs chronic) Onset (TraumaAc vs non) LocaAon Other symptoms Exam
Trauma Fracture Meniscal injury- - twisang Ligamentous injury pain, swelling, instability Musculotendinous strains pain, swelling, bruising, no instability Contusions pain, bruising
Typical Knee
Chronic Pain ArthriAs Overuse/Overload Tumor Night pain, Xray InfecAon- - Rare
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
Pearls Pain with squayng? Meniscus, Patellofemoral Pain with jumping? Patellofemoral Theater sign Patellofemoral PivoAng/cuYng? ACL
Anterior Knee Pain Upper pole of patella: tendinopathy/tear quads Inferior pole: patellar tendinopathy/overuse General: patellofemoral pain
Medial Knee Pain Joint line: Meniscal tear, arthrias Proximal: Medial collateral ligament tear/ sprain Distal: Pes anserine bursias (oeen associated with OA)
Posteromedial: Meniscal tear, Bakers cyst, gastroc tear Posterior Knee Pain
Lateral Knee Pain Lateral femoral condyle: ilioabial band syndrome Lateral joint line: meniscal tear, OA lateral joint
Pain
Pain
LocaAon, locaaon, locaaon Just like real estate
Instability Tibiofemoral Patellofemoral Gives way, buckles, slips Pseudolaxity with OA ACL tear
SAffness Oeen caused by effusion (distenaon of joint prevents full flexion) OA
Swelling Synovial fluid or blood in knee joint Infrapatellar bursa
Locking True: meniscal tear (oeen bucket handle) Pseudo: patellofemoral OA, Abiofemoral OA, plica
Weakness Muscular: quad tear, patellar tendon tear, fracture Neurologic: radiculopathy, stroke
Exam Observe Gait Squat
Palpate Exam
Exam Valgus stress (25 degree flex and ext) MCL, MCL and others Varus stress (25 degree flex and ext) LCL, LCL and others
Exam McMurray Menisci - Need pain free flexion beyond 90 degrees
Exam Lachman (30 degree flexion) ACL Anterior Drawer(90 degree flexion) ACL Pivot- Shie(Extension)- - ACL (need relaxed pt)
Posterior Drawer PCL Exam
Exam Patellar Apprehension Patellar instability Patellar Grind Patellofemoral pain
Exam Noble s ITB Ober s ITB Aghtness
Exam Neuro Hip Foot
OA Most common Medial primarily
OA
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)
OA Chronic Older Obese Pain with weightbearing, flexing, walking stairs SAffness Angular deformity (usu varus) Joint line tenderness Pes anserinus Mild swelling
OA- - Recommended Low- impact land- based exercise AquaAc exercise Strength training EducaAon Weight loss
OA- - CondiAonal Oral NSAID Topical NSAID Tylenol Intra- aracular steroids Glucosamine/ChondroiAn
OA- - Possible ViscosupplementaAon Unloader braces Shoe wedges PRP Arthroscopy very selecave (younger, non- obese, milder OA, primary diagnosis meniscal tear or loose body)
Patellofemoral Pain Overuse of extensor mechanism Females more than males Training errors, malalignment (patellar malposiaon, poor foot or pelvic mechanics, Aght lateral structures)
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
Patellofemoral Pain- - Recommended Rest acutely, ice, NSAIDs Rehab strength (core, hip abd and ext rot, quads, VMO); stretch (quads, hams, ITB) Taping, orthoacs
Preventable injury ACL Tear
ACL Tear Between 100,000 and 200,000 ACL tears per year in US Costs (medical, other associated) $625 million to $1 billion annually
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 10-15 years, and have pain or limitaaon of acavity
ACL Tear Most oeen noncontact Females greater risk?anatomic, hormonal, geneac component? non- modifiable Biomechanical/neuromuscular component- - modifiable
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
ACL Tear Improve landing technique - No flat foot/extended limb flex hips and knees Strengthen, esp hams, hip abd, trunk Balance training
Bad
Good
The End! Thanks.