Eval Tx of Common hip & knee problems in the Adult patient ... · William T. Crowe, RN-C, FNP, MSN,...
Transcript of Eval Tx of Common hip & knee problems in the Adult patient ... · William T. Crowe, RN-C, FNP, MSN,...
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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 ! Review anatomy of the hip & knee
! Define elements of subjective history
! Perform basic exam of the hip & knee
! Discuss current treatment regimens for various problems
Anatomy - hip ! Bony structures
– Pelvis (ilium) – Femur
Anatomy – hip ! Connective tissue
– Ligaments ! Iliofemoral (Y
ligament of Bigelow) ! Pubofemoral
– Hyaline cartilage – Fibrocartilage
(labrum)
Anatomy – hip ! Connective tissue
– Ligaments ! Iliofemoral ! Ischiofemoral
– Hyaline cartilage
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Anatomy - hip ! Passive stabilizers
– Ligaments – Joint capsule
Anatomy - hip ! Active stabilizers
– Extensors group (gluteus maximus, hamstrings)
– Lateral rotator group (obturator internus and externus, gemellus superior and inferior, quadratus femoris and piriformis
Anatomy - hip ! Active stabilizers
– Adductor group (pectineus, adductor brevis, longus and magnus gluteus maximus, hamstrings)
– Flexor group (iliopsoas, rectus femoris, tensor fascia lata and sartorius)
Anatomy - hip ! Active stabilizers
– Abductor group (gluteus medius and minimus)
Anatomy - hip ! Ball and joint
– Connects lower limb to axial skeleton – 2nd largest ROM joint (1st ??)
Anatomy - hip ! Planes of motion
– Flexion & extension – Internal & external rotation – Abduction/adduction – Circumduction (combination of above)
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Anatomy - hip ! Normal ROM
– 110 - 120 degrees flexion – 10 - 15 degrees extension – 30 - 50 degrees abduction – 30 degrees adduction – 40 – 60 degrees lateral rotation – 30 – 40 degrees medial rotation
Anatomy - knee ! 3 compartments
– Medial – Lateral – Patellofemoral
Anatomy – knee* ! Bony structures
– Femur – Patella – Tibia – Fibula
Anatomy - knee ! Connective tissue
– Ligaments ! LCL, MCL, ACL, PCL
– Hyaline cartilage – Meniscus
Anatomy - knee ! Passive stabilizers
– MCL, LCL, ACL, PCL – Meniscus – Joint capsule
Anatomy - knee ! Active stabilizers
– Extensor mechanism – Popliteus muscle – Hamstrings
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Anatomy - knee ! Hinge joint?
Anatomy - knee ! 3 articulations in 1
– 1 between each femoral condyle & corresponding tibial tuberosity
– 1 between patella & femur
Anatomy - knee ! Planes of motion
– Flexion & extension – Internal & external rotation – Varus/valgus – Anterior & posterior translation
Anatomy - knee ! Normal ROM
– 135 degrees flexion – 0 to -10 degrees extension
Subjective/History ! Where does it
hurt?
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Subjective/History* ! Anterior hip (most common)
– Pathology of hip joint – Muscle strains
! Lateral hip – Greater trochanteric pain syndrome – Iliotibial band syndrome
Subjective/History ! Posterior hip (least common)
– Pathology usually outside of hip – Check lumbar spine and SI joints
Subjective/History Location of Pain ! Anterior Knee 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
Subjective/History* ! Severity – rest & activity ! “popping in/out” ! Childhood diseases of hip
– SCFE, trauma, DDH
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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
– 12-24 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 v Aggravating factors ! Treatment to date ! Review of PMH/PSH/MEDS/DA
Objective/Exam ! Observation
– “can’t see, can’t treat”
Objective/Exam - hip ! Observation
– Gait
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Objective/Exam - hip ! Palpation
– Seated ! Greater trochanter ! Lumbar spine, SI joint
– Supine ! Greater trochanter ! Groin
Objective/Exam - hip ! Maneuvers
– Supine ! Internal/external rotation ! Flexion ! FABER
– Lateral (injured side up) ! Abduction ! Ober’s Test
Objective/Exam - knee ! Observation
– Swelling – Ecchymosis – Atrophy – Valgus/varus thrust – Alignment
Sports Medicine Institute University of Minnesota Orthopedics
Objective/Exam - knee ! Palpation
– Sitting ! Bony structures ! Ligaments ! Joint lines
Objective/Exam - knee ! Palpation
– Supine ! Patellar mobility ! Patellar facets
Objective/Exam - knee ! Maneuvers
– Seated position ! Flex/ext of the knee ! Patellofemoral crepitus
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Objective/Exam - knee ! Maneuvers
– Supine position ! Patellar tracking ! ROM
Objective/Exam - knee ! Maneuvers
– Supine ! Valgus stress (30) ! Varus stress (30) ! McMurray test ! Anterior & Posterior Drawer test (90)
! Gait
Objective/Studies ! Radiographs ! CT scan ! MRI ! Nuclear bone scans
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
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Avascular Necrosis - hip ! Prevalence
– 10-20K annually – 30-50 y/o – Male 4:1 female – 50% bilateral
! Causes – Post traumatic – Alcoholism, smoking – Excess steroid use – Hypertension, diabetes
Avascular Necrosis - hip ! Subjective
– Pain (groin) is gradual as bone collapses – Increases with movement – Alleviated with rest
Avascular necrosis - hip ! Objective
– Antalgic gait – FABER +
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Avascular necrosis - hip ! Treatment
– Symptom relief ! NSAIDs ! Physical Therapy ! Limited weight-bearing
– Surgical ! Core decompression – 65% ! Joint replacement – 95%
Osteoarthritis – hip* ! Prevalence
– Males higher incidence
! Causes – Hereditary (~60%) – Weight-bearing – High intensity physical loading
Osteoarthritis - hip ! Subjective
– Chronic pain (groin) – Increases with movement – Alleviated with rest
Osteoarthritis - hip ! Objective
– Antalgic gait – FABER + – Pain with passive IR/ER
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Osteoarthritis - hip ! Treatment
– Conservative ! Weight control, rest, exercise
– Medical ! NSAIDs ! Physical therapy
– Surgical ! Joint replacement
Joint Replacement*
Trochanteric bursitis ! Prevalence
– Females higher incidence (wider hips)
! Causes – Trauma, contusion
Trochanteric bursitis ! Subjective
– Pain with activity and rest
Trochanteric bursitis ! Objective
– Pain on palpation of the greater trochanter
– Normal IR of hip
Trochanteric bursitis ! Treatment
– Medical ! NSAIDs ! Physical therapy ! Cortisone injection to site
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Posterior hip ! Primarily from lumbosacral and SI
joints
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
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Stress Fracture ! Most occur around
femoral neck ! Subcapital or
transcervical ! Less common in
intertrochanteric region
! SURGERY ! Risk of
displacement - HIGH
Stress Fracture ! Pelvic fracture
usually involves ramus – Does not require
surgery – Rest, walking aids,
analgesics – May take several
months
Fractures
Anterior Knee Pain* ! 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
Anterior Knee Pain ! Subjective
– Pain increases with walking up/down stairs or hills
– Instability with walking or running – Theater sign +
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Anterior Knee Pain ! Objective
– Crepitus – Patellar facet pain – Lateral tracking of the patella (J-sign)
Anterior Knee Pain ! 24 y/o female with
R knee pain for the past 2 weeks
Anterior Knee Pain ! 24 y/o F with R
knee pain x 2 weeks
Anterior Knee Pain ! 28 y/o F with R
knee pain x “several years”
Anterior Knee Pain ! Treatment - Chondromalacia
– Conservative ! Patellar buttress brace ! Physical therapy ! NSAIDs ! Cortisone injection (joint)
– Failure ! Refer to orthopedic specialist
Anterior Knee Pain ! Treatment - Lateral Subluxation /
Patellofemoral Syndrome – Conservative
! REST – STOP the offending activity ! RICE ! Patellar buttress brace ! Physical therapy ! NSAIDs ! Gradual return to activity
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Anterior Knee Pain ! Treatment - Lateral Subluxation /
Patellofemoral Syndrome – Failure
! Refer to orthopedic specialist
IT Band ! thick, fibrous connective
tissue ! attaches proximally at
the – iliac crest – Tensor fascia latae
muscle ! attaches distally to the
tibia ! at ~ 20-30 degrees,
moves across the lateral femoral epicondyle. Moves back when knee is straightened.
! helps hold us upright – walking/running
IT Band Syndrome ! Subjective
– Lateral knee pain – Pain worsens by running, particularly downhill – Painful flexion or extension of the knee
IT Band Syndrome ! Objective
– POP lateral knee (at or around the lateral epicondyle of the femur)
– Painful flexion or extension of the knee – Ober’s Test +
IT Band Syndrome ! Studies
– none
IT Band Syndrome ! Treatment
– Rest – relative – RICE – NSAIDs – PT – IT band stretches
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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
Meniscal Injury ! Subjective
– Pain to the joint line (medial > lateral) – Locking – Popping
Meniscal Injury ! Objective
– 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
Meniscal Injury ! Studies
– XR – MRI
Meniscal Injury ! Treatment
– Refer to orthopedic specialist
! Post-meniscectomy – Medial compartment degenerates within 10-15
yrs – Lateral compartment degenerates with 2-5 yrs
Ligamental Injury ! Subjective
– Immediate swelling – Inability to weightbear afterwards – Loss of stability
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Ligamental Injury ! Objective
– 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%
Ligamental Injury ! Studies
– XR – MRI
Ligamental Injury ! Treatment
– RICE – NWB with use of crutches – Hinged knee brace – Physical therapy – NSAIDs and analgesics – Referral to orthopedic specialist
Osteoarthritis - knee ! 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) 1795-1804.
Osteoarthritis - knee ! Subjective
– Pain – Time
! Chronic v. acute – Swelling – Stiffness
! Morning ! Immediately after rest
– Joint instability
Osteoarthritis - knee ! Objective
– Altered gait – Joint effusion – Crepitus – Limited ROM – Instability
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Osteoarthritis - knee ! Studies
– XR
Osteoarthritis – knee* ! Treatment
– Physical therapy – Medication
! Acetaminophen ! NSAIDs – nonselective ! COX-2 Inhibitors ! Opioids
Osteoarthritis – knee* ! Treatment
– Physical therapy – Medication – Intra-articular injection
! Cortisone ! Hyaluronic Acid
Osteoarthritis - knee ! Treatment
– Physical therapy – Medication – Intra-articular injection – External bracing – Referral to orthopedic specialist
Fractures - hip
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Fracture - knee