Knee Sports Med Workshop

7/27/2019 Knee Sports Med Workshop

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MS3 Sports MedicineMS3 Sports Medicine

WorkshopWorkshop

Famil Medicine ClerkshiFamily Medicine Clerkship


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FemurFemur Medial & lateralMedial & lateral

CondylesCondyles EpicondylesEpicondyles

Trochlear grooveTrochlear groove Intercondylar notchIntercondylar notch

PatellaPatella

Superior pole (base)Superior pole (base) Inferior pole (apex)Inferior pole (apex)

Medial & lateral facetsMedial & lateral facets

TibiaTibia Medial & lateralMedial & lateral

CondylesCondyles

Gerdys tubercleGerdys tubercle

Pes anserine areaPes anserine area Tibial tuberosityTibial tuberosity

Tibial plateauTibial plateau

Tibial spinesTibial spines

FibulaFibula HeadHead

NeckNeck


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Anatomy Major Ligaments & TendonsAnatomy Major Ligaments & Tendons

Quadriceps tendonQuadriceps tendon

Patellar tendonPatellar tendon

Medial & lateral patellarMedial & lateral patellarretinaculuaretinaculua


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MCLMCL LCLLCL


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ACL and PCLACL and PCL


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Iliotibial band (ITB)Iliotibial band (ITB)


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Anatomy Menisci of the KneeAnatomy Menisci of the Knee

Medial meniscusMedial meniscus Lateral meniscusLateral meniscus

Meniscal ligamentsMeniscal ligaments

Functions of theFunctions of the

meniscimenisci

Meniscal zonesMeniscal zones White-whiteWhite-white

Red-whiteRed-white

Red-redRed-red


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Knee Exam OverviewKnee Exam Overview

InspectionInspection

PalpationPalpation

Range of MotionRange of Motion StrengthStrength

NeurovascularNeurovascular

Special TestsSpecial Tests


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Case 1 Medial Right Knee PainCase 1 Medial Right Knee Pain

16yo HS soccer16yo HS soccer

player, previouslyplayer, previously

healthyhealthy

Tackled from rightTackled from right

side while runningside while running

Immediate onset ofImmediate onset of

medial jt line painmedial jt line pain

Delayed onset localDelayed onset local

medial edema,medial edema,

stiffnessstiffness

Able to bear weightAble to bear weight


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Key Questions in the HistoryKey Questions in the History

Mechanism of Injury?Mechanism of Injury? Acute or Chronic?Acute or Chronic? Location and level of pain?Location and level of pain? Able to walk?Able to walk? Mechanical Symptoms? (Locking,Mechanical Symptoms? (Locking,

popping, catching?)popping, catching?) Associated instability?Associated instability? Swelling?Swelling? Previous injuries or surgeries?Previous injuries or surgeries?


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Case 1 - ExamCase 1 - Exam

Inspection: Mild medial knee edemaInspection: Mild medial knee edema Palpation: + ttp medial kneePalpation: + ttp medial knee ROM: cant bend >80dROM: cant bend >80d

Strength: mildly decreasedStrength: mildly decreased Neurovascular: normalNeurovascular: normal Special tests:Special tests:

Neg Lachman, Anterior Drawer, McMurray,Neg Lachman, Anterior Drawer, McMurray,varus stressvarus stress

+ mild increased gap on valgus stress+ mild increased gap on valgus stress(compared to left) with good endpoint(compared to left) with good endpoint


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Special Tests - ACL InjurySpecial Tests - ACL Injury Lachman TestLachman Test


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Special Tests - PCL InjurySpecial Tests - PCL Injury Posterior Drawer TestPosterior Drawer Test

Sag SignSag Sign

Quad-Active TestQuad-Active Test


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Varus/Valgus stress forVarus/Valgus stress for

LCL and MCL InjuryLCL and MCL Injury


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Features that should prompt an

xray after acute knee injury include:

Unabletobear

weight

Cant

flex>90d

PatellaTT

P

Fibular

head

TTP

Age55

Allofthe

above

17% 17 17171717%

1. Unable to bearweight

2. Cant flex >90d

3. Patella TTP

4. Fibular headTTP

5. Age 55

6. All of the above


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5 Ottawa Knee Rules5 Ottawa Knee Rulesi.e. When to order a knee xray after acute injuryi.e. When to order a knee xray after acute injury

Age > 55 or < 18Age > 55 or < 18

Unable to walkUnable to walk

TTP on PATELLATTP on PATELLA TTP on FIBULAR HEADTTP on FIBULAR HEAD

Unable to flex 90 degUnable to flex 90 deg


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Case 1 - ImagingCase 1 - Imaging


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Case 1 Differential DiagnosisCase 1 Differential DiagnosisMore LikelyMore Likely Less LikelyLess Likely

Meniscal TearMeniscal Tear

Ligamentous InjuryLigamentous Injury

Which ligament?Which ligament? ACLACL

PCLPCL

MCLMCL

LCLLCL

Muscle StrainMuscle Strain

FractureFracture

Patellofemoral PainPatellofemoral Pain

PlicaPlica


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MCL SprainMCL Sprain


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What grade of sprain is likely

present of the MCL?

25

25

25

25 1. Grade 1: no laxity, but hurts

2. Grade 2: mild laxity, still intact

3. Grade 3: complete tear4. Grade 4: hurts like *^%*


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MCL Sprain

Treatment?Treatment? RICERICE

Relative RestRelative Rest

Hinge Brace only if unstable on examHinge Brace only if unstable on exam Achieve full ROMAchieve full ROM

Progressive StrengtheningProgressive Strengthening

Neuromuscular Control (BalanceNeuromuscular Control (Balanceexercises)exercises)

Functional Exercises (Sport-specific)Functional Exercises (Sport-specific)
http://www4.army.mil/OCPA/uploads/large/2006/CSA-2006-05-26-084718.jpg


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Case 2Case 2

56 yo retired Army LTC56 yo retired Army LTC

15 years worsening L>R knee pain15 years worsening L>R knee pain

Former parachutist, no specificFormer parachutist, no specifictraumatrauma

No previous knee surgeriesNo previous knee surgeries

Stiffness worse in morningStiffness worse in morning Pain is worse with activity, betterPain is worse with activity, better

with restwith rest
http://www4.army.mil/OCPA/uploads/large/2006/CSA-2006-05-26-084718.jpg


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Case 2 Key QuestionsCase 2 Key Questions

Mechanism of Injury?Mechanism of Injury? Acute or Chronic?Acute or Chronic? Where/how bad is pain?Where/how bad is pain? Mechanical Symptoms?Mechanical Symptoms?

(Locking, popping,(Locking, popping,catching?)catching?)

Associated instability?Associated instability? Swelling?Swelling?

Previous injuries orPrevious injuries orsurgeries?surgeries?

What makes it worse?What makes it worse? What makes it better?What makes it better?

Insidious OnsetInsidious Onset ChronicChronic

Difficult to localize; mildDifficult to localize; mild

NoNo

NoneNone

OccasionalOccasional

Lots of Bad Landings NoLots of Bad Landings Nosurgerysurgery

ActivityActivity

RestRest


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Case 2 Physical ExamCase 2 Physical Exam

Inspection:Inspection: Genu varusGenu varus

Bony enlargement at Med/Lat joint linesBony enlargement at Med/Lat joint lines

Palp: Posterior medial joint line ttpPalp: Posterior medial joint line ttp ROM: Decreased flexion, 110 deg, mildROM: Decreased flexion, 110 deg, mild

crepituscrepitus

Strength: normalStrength: normal Neurovascular: normalNeurovascular: normal Special Tests: no ligamentous laxity, negSpecial Tests: no ligamentous laxity, neg

meniscal testsmeniscal tests


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Special Tests - Meniscal InjuriesSpecial Tests - Meniscal Injuries

Joint line tendernessJoint line tenderness McMurray TestsMcMurray Tests

Thessaly testThessaly test

Bounce-home testBounce-home test

Full SquatFull Squat


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Case 2 Plain FilmsCase 2 Plain Films

Joint space narrowing

Subchondral Sclerosis

Osteophytes

Subchondral Cysts


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What is your diagnosis?What is your diagnosis?

Meniscaltear

Plicasyndrom

e

Osteoarthritis

Bone

tumo

r

25 2525251.1. Meniscal tearMeniscal tear

2.2. Plica syndromePlica syndrome

3.3. OsteoarthritisOsteoarthritis4.4. Bone tumorBone tumor


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OsteoarthritisOsteoarthritis

NonpharmacologicNonpharmacologic

Treatment:Treatment:

Nonpainful aerobicNonpainful aerobic

activityactivity

Weight lossWeight loss Physical TherapyPhysical Therapy

Improve ROM, increaseImprove ROM, increase

strengthstrength

BracingBracing

PharmacologicPharmacologic


APAPAPAP

SupplementsSupplements Glucosamine andGlucosamine and

ChondroitinChondroitin

NSAIDs, COX-2sNSAIDs, COX-2s

TramadolTramadol ViscosupplementationViscosupplementation

Intrarticular SteroidsIntrarticular Steroids


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Case 3Case 3

31 year old female, L knee pain31 year old female, L knee pain Recreational runnerRecreational runner Localizes pain to front of kneeLocalizes pain to front of knee No trauma, insidious onsetNo trauma, insidious onset Localizes pain around kneecapLocalizes pain around kneecap Worse with stairsWorse with stairs Worse after prolonged sittingWorse after prolonged sitting Knee occasionally gives outKnee occasionally gives out


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Mechanism of Injury?Mechanism of Injury? Acute or Chronic?Acute or Chronic? Where is the pain?Where is the pain? MechanicalMechanical

Symptoms? (Locking,Symptoms? (Locking,popping, catching?)popping, catching?)




Insidious OnsetInsidious Onset ChronicChronic

Anterior kneeAnterior knee

No, but sometimesNo, but sometimes

gives outgives out

NoneNone

NoneNone NoneNone

Running, StairsRunning, Stairs

Multiple days of restMultiple days of rest


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Physical Exam

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)


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Patellofemoral Joint ExamPatellofemoral Joint Exam


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Patellofemoral Joint ExamPatellofemoral Joint Exam

Patellar Grind TestPatellar Grind Test


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AP

Lateral


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Tunnel

Sunrise


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Whats your diagnosis?

Patellartendin

opathy

Patellar

instability

Patellofem

oralsyn

drome

Plica

syndrome

25 25%25251. Patellartendinopathy

2. Patellar instability

3. Patellofemoralsyndrome

4. Plica syndrome


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Patellofemoral SyndromePatellofemoral Syndrome


Relative rest; non-painful aerobicsRelative rest; non-painful aerobics

Physical TherapyPhysical Therapy Improve Quad/Hamstring flexibilityImprove Quad/Hamstring flexibility

Quad, Hip abductor strengtheningQuad, Hip abductor strengthening

Core strengtheningCore strengthening

Patellar stabilization brace/tapingPatellar stabilization brace/taping Foot orthoticsFoot orthotics

Surgery (last-ditch effort)Surgery (last-ditch effort)


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Case 4Case 4

34 yo Army MAJ training for34 yo Army MAJ training for

11stst marathonmarathon

Atraumatic onset of RAtraumatic onset of R

lateral knee pain 1 weeklateral knee pain 1 week

ago after 10 mile runago after 10 mile run

Sharp burning painSharp burning pain

Better with rest, returnsBetter with rest, returns

with runningwith running


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Mechanism of Injury?Mechanism of Injury? Acute or Chronic?Acute or Chronic? Where is the pain?Where is the pain? MechanicalMechanical

Symptoms? (Locking,Symptoms? (Locking,popping, catching?)popping, catching?)




Insidious OnsetInsidious Onset AcuteAcute

Lateral kneeLateral knee

No, but sometimesNo, but sometimes

gives outgives out

NoneNone

NoneNone

NoneNone

RunningRunning

Multiple days of restMultiple days of rest


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Physical Exam

Inspection: normal

Palpation: TTP over lateral femoralcondyle

ROM: full Strength: normal

Neurovascular: normal

Special tests: + Noble test

Tight on Ober test


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Ober testOber test Noble testNoble test


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Whats your diagnosis?

Osteo

arthritis

Meniscaltear

Iliotibialband

syndrome

LCLsprain

25% 25%25251. Osteoarthritis

2. Meniscal tear

3.

Iliotibial bandsyndrome

4. LCL sprain


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Iliotibial Band SyndromeIliotibial Band Syndrome

Treatment:Treatment: Ice massage, pain medsIce massage, pain meds

Relative Rest; nonpainful activityRelative Rest; nonpainful activity

Physical TherapyPhysical Therapy Specific ITB stretchesSpecific ITB stretches Hip abductor strengtheningHip abductor strengthening Core strengthening (Gluteus Medius)Core strengthening (Gluteus Medius)

Slow return to activitySlow return to activity Extrinsic factors: shoes, runningExtrinsic factors: shoes, running

surface, training errorssurface, training errors


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What the heck is a Plica?

Congenitalth

ickening

of...

Redundantm

eniscus

Loosepieceofin

tra-arti...

Figmentofm

yima

gination

25 25%25%25%1. Congenitalthickening of jointcapsule

2. Redundant meniscus

3. Loose piece of intra-articular cartilage

4. Figment of myimagination


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Plica Syndrome?


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Special Tests - ACL InjurySpecial Tests - ACL Injury Lachman TestLachman Test

Knee flexed to 15-30 degreesKnee flexed to 15-30 degrees Stabilize distal femurStabilize distal femur Anteriorly translate tibia onAnteriorly translate tibia on

femurfemur Watch & feel for amount ofWatch & feel for amount of

translation & end pointtranslation & end point

Pivot ShiftPivot Shift


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Special Tests - PCL InjurySpecial Tests - PCL Injury

Posterior Drawer TestPosterior Drawer Test Knee flexed to 90 degreesKnee flexed to 90 degrees Posteriorly translate tibia onPosteriorly translate tibia on

femurfemur Watch & feel for amount ofWatch & feel for amount of

translation & end pointtranslation & end point

Sag SignSag Sign Knees flexed, quads relaxedKnees flexed, quads relaxed

compare both sidescompare both sides Look for tibial posterior sagLook for tibial posterior sag

relative to femurrelative to femur

Quad-Active TestQuad-Active Test Knee flexed; hamstringsKnee flexed; hamstrings fullyfully

relaxedrelaxed Slide foot along table (quadSlide foot along table (quad

active)active) Observe for anterior relocationObserve for anterior relocation


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Special Tests - MCL InjurySpecial Tests - MCL Injury

Valgus Stress TestingValgus Stress Testing

Knee flexed to 30 degreesKnee flexed to 30 degrees Relax ACL/PCL & jointRelax ACL/PCL & joint

capsulecapsule

Valgus stress applied to kneeValgus stress applied to knee

Look and feel for translationLook and feel for translationand endpointand endpoint

Compare to uninjured sideCompare to uninjured side

May repeat with knee in fullMay repeat with knee in fullextensionextension


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Special Tests - LCL InjurySpecial Tests - LCL Injury

Varus StressVarus StressTestingTesting

Same test asSame test asvalgus stressvalgus stress

testingtesting

Except applying aExcept applying avarus stressvarus stressinsteadinstead

LCL, IT band, &LCL, IT band, &PLC are testedPLC are tested


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Joint line tendernessJoint line tenderness

Full SquatFull Squat

McMurray TestsMcMurray Tests

Thessaly testThessaly test

Bounce-home testBounce-home test


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McMurray test forMcMurray test for

Meniscal injuryMeniscal injury Test Med and Lat meniscusTest Med and Lat meniscus

separatelyseparately

3 concurrent maneuvers:3 concurrent maneuvers: GrindGrind it (Rotate tibiait (Rotate tibiaAWAY from it)AWAY from it)

CrunchCrunch it (varus orit (varus or

valgus)valgus) PinchPinch it (flex/extendit (flex/extend

knee)knee) Positive: Painful popPositive: Painful pop


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Thessaly TestThessaly Test

Pt stands onPt stands on

affected legaffected leg

Knee bent at 20Knee bent at 20degreesdegrees

Examiner holds ptsExaminer holds pts

hands and rotateshands and rotates

pt to both sidespt to both sides Meniscal grindMeniscal grind

Positive test: pain,Positive test: pain,

painful click.painful click.

A t i K EA t i K E


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Anterior Knee ExamAnterior Knee Exam

Palpation of patellarPalpation of patellar

facetsfacets Glide and lift patellaGlide and lift patella

medially & laterallymedially & laterally

Palpate undersurfacePalpate undersurface

of patella forof patella for

tendernesstenderness

P t ll EP t ll E


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Patellar ExamPatellar Exam

Patellar GlidePatellar Glide Knee in extension, relaxedKnee in extension, relaxed

Medial & lateral patellarMedial & lateral patellar

displacementdisplacement

Measured in quadrantsMeasured in quadrants

Normal: 1-2 quadrantsNormal: 1-2 quadrants Patellar ApprehensionPatellar Apprehension

Lateral patellar displacementLateral patellar displacement

patient apprehensionpatient apprehension

or guardingor guarding

A t i K EA t i K E


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Anterior Knee ExamAnterior Knee Exam

Patellar Grind TestPatellar Grind Test

Knee 10 deg flexionKnee 10 deg flexion

Glide patella distally,Glide patella distally,and firmly compressand firmly compress

patella againstpatella against

trochlear groovetrochlear groove

Active quadricepsActive quadriceps

contractioncontraction painpain

S i l T t Ob T tS i l T t Ob T t


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Special Tests Obers TestSpecial Tests Obers Test

Lateral decubitus withLateral decubitus withtesting side up, testingtesting side up, testingknee flexedknee flexed

Adduct and fully flex hipAdduct and fully flex hip

Abduct, externally rotate,Abduct, externally rotate,& extend hip& extend hip

Slowly release supportSlowly release supportagainst gravity from leg,against gravity from leg,

allowing gravity to take legallowing gravity to take legtowards tabletowards table

Positive test: leg remainsPositive test: leg remainsabducted despite examinerabducted despite examiner

releasing legreleasing leg


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Special TestsSpecial Tests

Nobles testNobles test

Palpate lateralPalpate lateral

femoral condylefemoral condyle

Flex and ExtendFlex and Extend

KneeKnee

+ Test is pain at+ Test is pain at

site of palpationsite of palpation

Knee Sports Med Workshop

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