1、MS3 Sports Medicine Workshop,Family Medicine Clerkship,Knee Problems,MS3 Family Medicine,Anatomy Review,Femur Medial & lateral Condyles Epicondyles Trochlear groove Intercondylar notchPatella Superior pole (base) Inferior pole (apex) Medial & lateral facets,Tibia Medial & lateral Condyles Gerdys tub
2、ercle Pes anserine area Tibial tuberosity Tibial plateau Tibial spinesFibula Head Neck,Anatomy Major Ligaments & Tendons,Quadriceps tendonPatellar tendonMedial & lateral patellar retinaculua,MCL LCL,Anatomy Menisci of the Knee,Medial meniscus Lateral meniscus Meniscal ligaments Functions of the meni
3、sciMeniscal zones White-white Red-white Red-red,Knee Exam Overview,Inspection Palpation Range of Motion Strength Neurovascular Special Tests,Case 1 Medial Right Knee Pain,16yo HS soccer player, previously healthy Tackled from right side while running Immediate onset of medial jt line pain Delayed on
4、set local medial edema, stiffness Able to bear weight,Key Questions in the History,Mechanism of Injury? Acute or Chronic? Location and level of pain? Able to walk? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries?,Case 1 - Exam,Inspe
5、ction: Mild medial knee edema Palpation: + ttp medial knee ROM: cant bend 80d Strength: mildly decreased Neurovascular: normal Special tests: Neg Lachman, Anterior Drawer, McMurray, varus stress + mild increased gap on valgus stress (compared to left) with good endpoint,Special Tests - ACL Injury,La
6、chman Test,Special Tests - PCL Injury,Posterior Drawer TestSag SignQuad-Active Test,Varus/Valgus stress for LCL and MCL Injury,Features that should prompt an xray after acute knee injury include:,Unable to bear weight Cant flex 90d Patella TTP Fibular head TTP Age 55 All of the above,5 Ottawa Knee R
7、ules i.e. When to order a knee xray after acute injury,Age 55 or 18 Unable to walk TTP on PATELLA TTP on FIBULAR HEAD Unable to flex 90 deg,Case 1 - Imaging,Normal!,Case 1 Differential Diagnosis More Likely Less Likely,Meniscal Tear Ligamentous Injury Which ligament? ACL PCL MCL LCL Muscle Strain,Fr
8、acture Patellofemoral Pain Plica,MCL Sprain,Diagnosis?,What grade of sprain is likely present of the MCL?,Grade 1: no laxity, but hurts Grade 2: mild laxity, still intact Grade 3: complete tear Grade 4: hurts like *%*,MCL Sprain,Treatment? RICE Relative Rest Hinge Brace only if unstable on exam Achi
9、eve full ROM Progressive Strengthening Neuromuscular Control (Balance exercises) Functional Exercises (Sport-specific),Case 2,56 yo retired Army LTC 15 years worsening LR knee pain Former parachutist, no specific trauma No previous knee surgeries Stiffness worse in morning Pain is worse with activit
10、y, better with rest,Case 2 Key Questions,Mechanism of Injury? Acute or Chronic? Where/how bad is pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better?,Insidious Onset Chronic Difficult to
11、localize; mild NoNone Occasional Lots of “Bad Landings” No surgery Activity Rest,Case 2 Physical Exam,Inspection: Genu varus Bony enlargement at Med/Lat joint lines Palp: Posterior medial joint line ttp ROM: Decreased flexion, 110 deg, mild crepitus Strength: normal Neurovascular: normal Special Tes
12、ts: no ligamentous laxity, neg meniscal tests,Special Tests - Meniscal Injuries,Joint line tendernessMcMurray TestsThessaly testBounce-home testFull Squat,Case 2 Plain Films,Joint space narrowingSubchondral SclerosisOsteophytesSubchondral Cysts,What is your diagnosis?,Meniscal tear Plica syndrome Os
13、teoarthritis Bone tumor,Osteoarthritis,Nonpharmacologic Treatment: Nonpainful aerobic activity Weight loss Physical Therapy Improve ROM, increase strength Bracing,Pharmacologic Treatment: APAP Supplements Glucosamine and Chondroitin NSAIDs, COX-2s Tramadol Viscosupplementation Intrarticular Steroids
14、,Case 3,31 year old female, L knee pain Recreational runner Localizes pain to front of knee No trauma, insidious onset Localizes pain “around kneecap” Worse with stairs Worse after prolonged sitting Knee occasionally “gives out”,Case 3 Key Questions,Mechanism of Injury? Acute or Chronic? Where is th
15、e pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better?,Insidious Onset Chronic Anterior knee No, but sometimes gives outNone None None Running, Stairs Multiple days of rest,Physical Exam,
16、Inspection: mild genu valgus Palpation: TTP lateral medial patellar facets ROM: full w/o pain Strength: normal Neurovascular: normal Special Tests: + patellar grind Decreased patellar glide Inflexible hamstrings (Popliteal angle),Patellofemoral Joint Exam,Patellofemoral Joint Exam,Patellar Grind Tes
17、t,Case 3 Plain Films,AP,Lateral,Case 3 Plain Films,Tunnel,Sunrise,Whats your diagnosis?,Patellar tendinopathy Patellar instability Patellofemoral syndrome Plica syndrome,Patellofemoral Syndrome,Treatment: Relative rest; non-painful aerobics Physical Therapy Improve Quad/Hamstring flexibility Quad, H
18、ip abductor strengthening Core strengthening Patellar stabilization brace/taping Foot orthotics Surgery (last-ditch effort),Case 4,34 yo Army MAJ training for 1st marathon Atraumatic onset of R lateral knee pain 1 week ago after 10 mile run Sharp burning pain Better with rest, returns with running,C
19、ase 4 Key Questions,Mechanism of Injury? Acute or Chronic? Where is the pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better?,Insidious Onset Acute Lateral knee No, but sometimes gives out
20、None None None Running Multiple days of rest,Physical Exam,Inspection: normal Palpation: TTP over lateral femoral condyle ROM: full Strength: normal Neurovascular: normal Special tests: + Noble test Tight on Ober test,Ober test Noble test,Whats your diagnosis?,Osteoarthritis Meniscal tear Iliotibial
21、 band syndrome LCL sprain,Iliotibial Band Syndrome,Treatment: Ice massage, pain meds Relative Rest; nonpainful activity Physical Therapy Specific ITB stretches Hip abductor strengthening Core strengthening (Gluteus Medius) Slow return to activity Extrinsic factors: shoes, running surface, training e
22、rrors,What the heck is a Plica?,Congenital thickening of joint capsule Redundant meniscus Loose piece of intra-articular cartilage Figment of my imagination,Plica Syndrome?,Questions? Before we break for hands-on,Special Tests - ACL Injury,Lachman TestKnee flexed to 15-30 degrees Stabilize distal fe
23、mur Anteriorly translate tibia on femur Watch & feel for amount of translation & end pointPivot Shift,Special Tests - PCL Injury,Posterior Drawer Test Knee flexed to 90 degrees Posteriorly translate tibia on femur Watch hamstrings fully relaxed Slide foot along table (quad active) Observe for anteri
24、or relocation,Special Tests - MCL Injury,Valgus Stress TestingKnee flexed to 30 degrees Relax ACL/PCL & joint capsuleValgus stress applied to kneeLook and feel for translation and endpointCompare to uninjured sideMay repeat with knee in full extension,Special Tests - LCL Injury,Varus Stress TestingS
25、ame test as valgus stress testingExcept applying a varus stress insteadLCL, IT band, & PLC are tested,Special Tests - Meniscal Injuries,Joint line tendernessFull SquatMcMurray TestsThessaly testBounce-home test,McMurray test for Meniscal injury,Test Med and Lat meniscus separately 3 concurrent maneu
26、vers: Grind it (Rotate tibia AWAY from it) Crunch it (varus or valgus) Pinch it (flex/extend knee) Positive: Painful “pop”,Special Tests - Meniscal Injuries,Thessaly Test Pt stands on affected leg Knee bent at 20 degrees Examiner holds pts hands and rotates pt to both sides Meniscal grind Positive t
27、est: pain, painful click.,Anterior Knee Exam,Palpation of patellar facets Glide and lift patella medially & laterally Palpate undersurface of patella for tenderness,Patellar Exam,Patellar Glide Knee in extension, relaxed Medial & lateral patellar displacement Measured in quadrants Normal: 1-2 quadra
28、nts Patellar Apprehension Lateral patellar displacement patient apprehensionor guarding,Anterior Knee Exam,Patellar Grind TestKnee 10 deg flexion Glide patella distally, and firmly compress patella against trochlear groove Active quadriceps contraction pain,Special Tests Obers Test,Lateral decubitus
29、 with testing side up, testing knee flexedAdduct and fully flex hip Abduct, externally rotate, & extend hipSlowly release support against gravity from leg, allowing gravity to take leg towards tablePositive test: leg remains abducted despite examiner releasing leg,Special Tests,Nobles test Palpate lateral femoral condyle Flex and Extend Knee + Test is pain at site of palpation,
