1. Management of Knee Pain
Manish A. Patel, MD,FAAOS
Assistant Professor Eastern Virginia Medical School
Chief of Surgery – Southampton Memorial Hospital
Office:

2. Anatomy
ACL
PCL
MCL
LCL
Meniscus
Medial
Lateral

3. THE KNEE HISTORY Pain Contact vs noncontact Effusions
Mechanical symptoms
Locking
Instability (falls)
Initial treatment

4. THE KNEE HISTORY Continue work/play? PM/SHx Occupation/Sport
Medications
Occupation/Sport
Time tables

5. Physical Exam of the Knee
Inspection
Palpation
Range of Motion
Special tests
Neurovascular assessment

6. INSPECTION Effusion Q angle Erythema Angular deformities Ecchymosis
Edema
Q angle
Angular deformities
Muscular asymmetry

7. PALPATION ANTERIOR MEDIAL Tibial tubercle MCL Infrapatellar tendon
Quad insertion
Patellar facets
Crepitus ?
MEDIAL
MCL
Meniscus
Pes anserine insertion
Tibial plateau
Femoral condyle

8. PALPATION LATERAL POSTERIOR Head of the fibula LCL Meniscus
Tibial plateau
Femoral condyle
Gerdy’s tubercle
POSTERIOR
Menisci (posterior horns)
Popliteal fossa
Hamstring tendons

9. ACL Special Tests Anterior drawer Lachman test Pivot shift test
Valgus stress test at full extension!

11. Grading Ligament Injuries

12. ACL: PHYSICAL EXAM Decreased ROM Effusion-hemarthrosis, immediate
+ Instability tests
Lachman: most accurate
Pivot shift
Anterior drawer
+ MCL and meniscus tests

13. Translation + ENDPOINTS!
LIGAMENT EXAM
Translation + ENDPOINTS!

14. Palpable clunk as the lateral tibial condyle reduces on the femur
+ PIVOT SHIFT
Palpable clunk as the lateral tibial condyle reduces on the femur

15. MRI:

16. The Use of MRI in Evaluation of Knee Injuries
Sensitivity M. Meniscus %
L. Meniscus 55-90
ACL
Specificity MM LM
ACL

17. The REAL Question- Is MRI that much better than clinical exam?
Rose, et al. Arthroscopy, 1996
Compared accuracy of clinical exam vs MRI
In 154 pts, clinical exam was as good as MRI
Many articles comparing MRI to arthroscopy

18. “Partial” ACL tear/strain
> 40% ACL substance
+ Lachman, - pivot shift
Clinically
Most behave functionally as full tears
Continued shifting ↑’s risk of meniscus damage
Rx as full tear

19. The Utility of Arthrocentesis
Indications
Diagnosis in question
? Infectious/Metabolic process
Tense effusion
Indications for surgery
Timing of surgery

20. ACL TREATMENT Grade 3- Nonsurgical ? modify activity PRICES
Hamstrings, gastroc!
Functional bracing ?
months

21. ACL TREATMENT Grade 3 Injuries- Surgery
Indications
Most active people will require surgery to restore adequate function and decrease instability
Recurrent instability
Inability to modify activity
Associated injuries: meniscus
Age?
Wait three weeks due to arthrofibrosis risk
months

22. MCL INJURIES HISTORY Mechanism = valgus stress Medial joint line pain
Lack of large effusion
Difficulty weight-bearing

23. MCL INJURIES PHYSICAL EXAM Tender to palpation along MCL
Pain + instability with valgus stress
30o flexion = MCL
90o flexion = associated ACL
COMPARE SIDES

24. MCL INJURIES Treatment Of Grade 1 &2 Early mobilization
Weight-bearing as tolerated
Hinged knee brace
PRICES
Recovery 4-6 weeks

25. MCL INJURIES Treatment of Grade 3 (full tears)
Isolated = nonsurgical management
Combined = surgery consistent with associated injuries

26. PCL INJURIES Mechanism Effusion (less than with ACL)
Sports = fall on flexed knee with foot plantarflexed, hyperextension, pivot
MVA = dashboard injury
Effusion (less than with ACL)
Shifting/instability (chronic)
Less distinctive

27. PCL INJURIES PHYSICAL EXAM + Effusion + Posterior drawer test
+ Posterior sag sign
False positive Lachman test
Common to have isolated injuries

28. PCL INJURIES TREATMENT PRICES Functional bracing (early) Rehab
Surgery if continued instability, effusions
Note- 2% of NFL preseason exam with incidental isolated PCL tear

29. Patellofemoral Arthralgia
Often referred to as chondromalacia patella. This term should be reserved for observed articular cartilage damage

30. PFA-HISTORY Pain with: Lack of effusions, locking, instability Stairs
Prolonged sitting
Deep squat activities
Lack of effusions, locking, instability

31. PHYSICAL EXAM Patellar compression/grind tests
No patellar apprehension
Poor hamstring flexibility
+ “J” sign
Normal ligaments, meniscus
Lack of effusion

32. KNEE- TANGENTIAL XRAYS
Assess patellofemoral joint
Patellar tilt
Lateralization
Depth of trochlear
groove

33. PATELLAR INSTABILITY Acute patellar dislocation
Acute patellar subluxation
Patellar tracking dysfunction

34. PATELLAR DISLOCATION History Mechanism = pivot Immediate effusion
May visualize patella dislocated laterally
+ Instability (chronically)
Patella may spontaneously relocate

35. PATELLAR DISLOCATION Physical Exam Tender peripatellar structures
Medial retinaculum
Lateral femoral condyle
Effusion
? Patella dislocated laterally
Xrays- osteochondral fracture, effusion
MRI for loose bodies

36. PATELLAR DISLOCATION Treatment
Knee extension immobilizer x 4 wks, J Sleeve
Early quad setting exercises
Return to sport
Full, painless ROM
Normal strength
Adequate aerobic fitness

37. Biology of the Meniscus
Medial Meniscus
Semilunar
Narrow anteriorly
Adherent to MCL
Lateral Meniscus
Circular
Covers more of tibia
Uniform size
Less adherent

38. Types of Meniscus Tears
Longitudinal
Horizontal
Oblique
Radial

39. MENISCAL INJURIES History
Mechanism = pivot, twist
+ heard a “pop”
Effusion o after injury
Mechanical Sxs- locking, instability

40. MENISCAL INJURIES Physical Exam
Joint line tenderness
IR/ER
Decreased ROM
McMurray’s test
Apley’s compression test

41. MENISCAL INJURIES Ancillary Studies
Plain radiographs
Other causes mechanical Sxs
MRI
Higher vascularity in peds patients
CT-arthrography outdated

42. Meniscus MRI

43. Grading of Meniscal Tears: MRI
I: globular changes
II: linear changes not to margin
III: linear to sup/inf margin
IV: complex linear changes
Only grade III and IV visible on arthroscopy

44. MENISCAL INJURIES Treatment
Nonoperative (Aggressive Nonsurgical)
Acute Rehab
ROM, Quad setting
Subacute Rehab
ROM, PRE’s
Bracing (hinged knee brace)
Continue sport specific drills when tolerable

45. MENISCAL INJURIES Treatment
Operative
Partial Menisectomy
Meniscal Repair (peripheral)
Meniscus Implants
Total Menisectomy- outdated

46. Baker’s Cyst and the Meniscus
Stone, et al (1996)
Case-control study
Over 1700 MRI’s  240 Baker’s cysts
85% had meniscal tears
Data supported by:
Miller, et al (1997)
Sansone ,et al (1995)

47. Discoid Meniscus Programmed cell death More likely to tear
Often Lateral
Male > female
Ages 6-10 yrs
Xray- wide lateral joint space
Rx- may require resection if Sx

48. Discoid Meniscus

49. Discoid Meniscus

50. Assorted Knee Problems
Osgood-Schlatter Syndrome
Patellar, Quad Tendinitis
Plica
Iliotibial Band Syndrome
Osteoarthritis
Osteochondritis dessicans (OCD)

51. TENDINITIS Quadriceps and Patellar
History
Pain with:
Jumping
Stairs
Prolonged sitting
Mechanism = overuse

52. TENDINITIS Quadriceps and Patellar
Physical Exam
Tender superior/inferior pole of patella
Tender tibial tubercle
Tight hams, Achilles, quads
Pain with resisted action of muscle

53. TENDINITIS Quadriceps and Patellar
Treatment
P: protection, pain meds
R: rest
I: ice
C: compression
E: elevation
S: support, strength/stretch exercises

54. Traction Apophysitis
Osgood-Schlatter “disease”

55. BURSITIS Prepatellar bursa Infrapatellar bursae Pes anserine bursa
Mechanism = direct blow, overuse
Physical exam- point tender, nonintraarticular effusion

56. BURSITIS Treatment NSAID’s Ice Flexibility exercises
Steroid injections
Surgery for chronic cases (prepatellar)

57. Impact of DJD Impact of Arthritis Annually: (CDC statistics)
9,500 deaths
750,000 hospitalizations
8 million people with limitations
36 million ambulatory care visits
$51 billion in medical costs and $86 billion in total costs

58. Impact of Knee DJD Leading cause of disability
Affects leisure, work, activities of daily living
$86 billion annually to health care economy in U.S.

59. Various forms of Arthritis
Osteoarthritis most common

60. What is DJD of Knee?
Wear and tear of Hyaline cartilage leads to exposed bone
Subchondral Cysts
Joint Space Narrowing
Pain with rest, swelling, “instability”,mechanical symptoms

61. Etiology of Knee DJD Heredity Obesity Malalignment Injury
Female gender
Muscle weakness
Overuse / wear and tear

62. Diagnosis of Knee DJD Clinical Exam
Weight bearing X-rays-indicates loss of joint space / articular cartilage
MRI rarely indicated (More for soft tissue)

63. Arthritis of the Knee: Treatment
Most treatment is conservative
Weight loss
Muscle strengthening - PT
NSAIDS
Supplements
Bracing and orthotics
Injection

64. Arthritis of the Knee: Treatment
Weight loss
Decreases impact
6-8 times body weight is felt in knees
Very important for stairs!
Affects flexibility
Impacts risk of surgery and long-term results
Affects overall health

65. Arthritis of the Knee: Treatment
Exercise and PT
Strong muscles cushion joint
Flexibility
Improves recovery from injury or surgery
Low-impact (cycling) preferred
Pool therapy possibly best

66. Arthritis of the Knee: Treatment
Anti-inflammatories and analgesics
NSAIDS (Motrin, Aleve, etc)
Excellent track record
Some side effects – take as needed
Cheaper than prescription drugs and equally effective
Analgesics
Tylenol
Do not use narcotics for chronic pain

67. NSAID Facts
Only 1 in 5 who have a serious problem from NSAIDs, have warning symptoms
Nonselective NSAIDs -16,500 deaths annually in the U.S.
Nonselective NSAIDs -103,000 hospitalizations annually in the U.S.
Four Times more Americans die from NSAIDs annually than from cervical
cancer
More Americans die from NSAIDs annually than from AIDS
Clinically important UGI events occur in % of regular NSAID takers
As mentioned, here is what we know today regarding the risks of NSAIDs as are reported in the literature;
Only 1 in 5 who have a serious problem from NSAIDs, have warning symptoms
Nonselective NSAIDs account for at least 16,500 deaths annually in the U.S.
Nonselective NSAIDs account for 107,000 hospitalizations annually in the U.S.
Four Times more Americans die from NSAIDs annually than from cervical cancer
More Americans die from NSAIDs annually than from AIDS
Clinically important UGI events occur in % of regular NSAID takers
In North America the economic consequences of NSAID use
results in $0.66 to $1.25 spent on UGI toxicities for each dollar spent on
NSAIDs.1,3
REFERENCES related to above
1 Laine L. Approaches to nonsteroidal anti-inflammatory drug use in the high-risk patient. Gastroenterology. 2001;120:
Del Valle J, Chey WD, Scheiman JM, et al. Acid peptic disorders. In: Yamada T, Alpers DH, Kaplowitz N, et al, eds.
Textbook of Gastroenterology, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2003:
3 Chan FK, Leung WK. Peptic ulcer disease. Lancet. 2002;360:
4 Hawkey CJ. Nonsteroidal anti-inflammatory drug gastropathy. Gastroenterology. 2000;119:
5. Fries JF. , Journal of Rheumatology.  (suppl 28):7.
Wolfe MM, et al. N Engl J Med.1999;340:
Laine L. et al. Gastroenterology. 2001;120:
Fries JF. , Journal of Rheumatology.  (suppl 28):7.

68. Glucosamine Symptomatic relief Slows disease progression?
No formula proven better than another
Cost ($20/mo)
GI upset
May take 3 months

69. Chondroitin Gives cartilage elasticity
From shark cartilage or animal tracheas
Less proven than glucosamine but usually packaged together

70. WD40
No proven benefit
May cause skin irritation
Not recommended

71. Braces GII unloader Knee braces Support sleeves Warm joint
Help balance
Functional braces
Stabilize joint
Transfer stress
GII unloader

72. Guidelines for Managing Knee OA
SEVERE OA
surgery
COX-2’s
High Dose
NSAIDS +
Gastroprotectant
JFT
IA-Steroids
MODERATE OA
simple analgesics, low dose NSAID’s
This is the ACR treatment algorithm, constructed and still in use. Perhaps, (click the mouse) this should be the paradigm. If we consider the risk/benefit analysis that we as practitioners consider daily, NSAID’s, Cox-2’s (and the added cost of gastroprotective agents) , cortico steroid effectiveness and or potential adverse effects must be considered. What makes sense is that JFT is moved earlier on in the treatment of OA knee pain…
Medicare covers SUPARTZ IF IT is administered and gets 6 months of documented pain relief after the last injection, and there is documented pain relief. This is a local treatment for a local disease and is extremely safe and does not have the potential effects of pills or corticosteroids in treating knee OA. Perhaps, we need to treat OA of the knee with a treatment that can cause more damage to the patient than the underlying disease that we are treating.
To Make this clear:
NSAIDS/Cox 2’s can cause serious and lifethreatening consequences even death – 16,500 per year
SUPARTZ = LOCALIZED TREATMENT FOR A LOCALIZED DISEASE = 0 deaths… safe, effective, compliance that is absolute, Medicare covers and now I the doctor can choose the therapy and determine when my patients needs have been met. Typically I will start out with 5 injections as I want everyone to get the maximum opportunity to get pain relief and miss the TKR. Then it will be up to me and my patients to determine the next steps…. What is best for the patients…
Adapted from: Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee; AMERICAN COLLEGE OF RHEUMATOLOGY SUBCOMMITTEE ON OSTEOARTHRITIS GUIDELINES; ARTHRITIS & RHEUMATISM, Vol. 43, No. 9, September 2000, pg , © 2000,
An alternative approach to the use of oral agents in the palliation of joint pain is the use of intraarticular therapy such as hyaluronan (hyaluronic acid) or glucocorticoids. Two preparations of intraarticular hyaluronan have been approved by the FDA for the treatment of knee OA patients who have not responded to a program of nonpharmacological therapy and acetaminophen. To date, differences in clinical efficacy between these preparations as a function of molecular weight have not been demonstrated (70). Because the duration of benefit reported for these agents exceeds their synovial half-life, their mechanisms of action are unclear; proposed mechanisms include inhibition of inflammatory mediators such as cytokines and prostaglandins, stimulation of cartilage matrix synthesis and inhibition of cartilage degradation, and a direct protective action on nociceptive nerve endings.
In clinical trials of intraarticular hyaluronan preparations, pain relief among those who completed the study was significantly greater than that seen after intraarticular injection of placebo, and comparable with that seen with oral NSAIDs (71-73). In addition, pain relief among those who completed the study was comparable with or greater than that with intraarticular glucocorticoids (73). Although pain relief is achieved more slowly with hyaluronan injections than with intraarticular glucocorticoid injections, the effect may last considerably longer with hyaluronan injections (73). Intraarticular hyaluronan therapy is indicated for use in patients who have not responded to a program of nonpharmacologic therapy and simple analgesics; intraarticular hyaluronan injections may be especially advantageous in patients in whom- nonselective NSAIDs and COX-2-specific inhibitors are contraindicated, or in whom they have been associated either with a lack of efficacy or with adverse events. Limited data are available concerning the effectiveness of multiple courses of intraarticular hyaluronan therapy (74). Transient mild-to-moderate pain at the injection site may occur; occasionally, mild-to-marked increases in joint pain and swelling have been noted following hyaluronan injection.
AAOS Clinical Guideline on Osteoarthritis of the Knee Support Document (2003)
“Viscosupplementation (we refer to this as Joint Fluid Therapy) (“C” recommendation) may have a role in the treatment of knee pain due to osteoarthritis during the initial 12 weeks in the hands of physicians technically proficient in arthrocentesis.
MILD OA
Exercise, Physical Therapy, Weight Loss, Orthotics, Nutraceuticals
Adapted from Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee, ACR, 2000

73. Who is a candidate for VS?
Active patients who have early osteoarthritis
Post arthroscopy patients with residual symptoms – rather than re-operation!
Patients who are too young, heavy &/or not ready for TKR
Non-operative candidates

74. Where to inject?

75. What to inject with:

76. How I inject:

77. When all else fails:

78. Arthroscopy of the Knee
Useful for mild or moderate arthritis with mechanical symptoms (catching)
Not as helpful for:
Severe arthritis

79. Osteotomy (Realignment)
Realigns leg to transfer weight bearing away from affected area of knee
Useful for younger patient with only one part of the joint affected

80. Partial Knee Replacement
Replaces only damaged portion of knee
Recovery 70% faster than total knee
More natural feel
Patient selection critical

81. Total Knee Replacement
Involves resurfacing of joint surfaces with metal and plastic
Newer techniques less invasive
3-4 day hospital stay
6-8 weeks for recovery
90% success at years
Muscle Sparing Approach “Kinetic Knee

82. References:
Cherry Juice, Chicken Combs, and Chondroitin: The Truth About Arthritis Cures--Gregory J. Golladay, M.D., Orthopaedic Associates of Grand Rapids, P.C.
A New Look at OA Knee Pain -Treatment Options for Today’s Orthopaedic Practice, Dr. Dave Atkin, M.D. Chief, Orthopedic DivisionSt.Luke’s Hospital San Francisco, California
V Strand MD, PG Conaghan MB, BS, PhD, L.S Lohmander MD, PhD, A.D Koutsoukos PhD, F L Hurley PhD, H Bird MD, P Brooks MD, R Day MD, W Puhl MD and P A Band PhD. An integrated analysis of five double-blind, randomized controlled trials evaluating the safety and efficacy of a hyaluronan product for intra-articular injection in osteoarthritis of the knee. OsteoArthritis and Cartilage (2006) Volume 14,
Gaetano P. Monteleone, Jr., M.D., Dept of Family Medicine, Director, Division of Sports Medicine, West Virginia University School of Medicine (online slides)

83. Useful Web Sites American Academy of Orthopaedic Surgeons www.aaos.org
Arthritis Foundation
NIH