1. Common Ailments and Injuries of the Knee, 2011
Kevin deWeber, MD, FAAFP
Sports Medicine Fellowship Director
Thanks to: Rodney S. Gonzalez, MD

2. Objectives Background Anatomy History Physical Examination
Radiology and Laboratory
Case Studies
Various knee injuries occur frequently, careful hx and pe can help determine etiology

3. Anatomy

4. Anatomy

5. History Patient age Current symptoms and duration
Pain with or after activity/changes in activity
Catching/locking (“mechanical”) or Instability
Stairs, squats, “theater sign”
Exacerbating and relieving factors
What treatment already tried (Rest, NSAIDs, brace, …)
Prior knee injury or surgery
PMH
Standing
Alignment of lower extremities
(varum,valgus,recurvatum)
Patellar position
(r/o miserable malalignment)
Inspection for asymmetries
(swelling,torsion,inability to extend knee)
Deep squat test pain meniscus,w/rise & squat PFPS)
Gait evaluation
Trendelenburg test
Sitting
Patellar position in the trochlear groove
Active patellar motion (r/o j curve deform/test quad balance)
Neurological exam PRN (back pain, radiation of pain)
Supine-Patellofemoral Joint
Inspection for patellar position
Palpation for effusion
Palpation for retropatellar tenderness (superolaterally)
Evaluation of patellar mobility
Palpation of quadricep and patellar tendons(tibial tubercle)
VMO bulk and tone
Palpation of peripatellar soft tissues
Supine-Tibiofemoral Joint
Lachman
Valgus and varus stress test
Posterior sag sign or loss of tibial step-off
Hyperflexion of knee/McMurray's test (Apley's compression)
Palpation of MCL/LCL
Palpation of joint line
Palpation of pes anserine area
Palpation of popliteal space
Flexibility
Popliteal angle/hamstrings
Noble's test-IT Band inflammation
Ober's Test-IT Band flexibility
Thomas test-Hip flexor/Quad
Hip ROM

6. Knee Examination (6-step Msk exam)
Inspection
Palpation
Range of Motion
Strength
Neurovascular (rare)
Special Tests

7. Knee Examination Inspection Alignment of lower extremities
Varus, valgus, recurvatum
Patellar position and motion (j curve deformity)
Inspection for asymmetries
Swelling, torsion, inability to extend knee
Atrophy

8. Knee Examination Palpate for effusion and warmth
Palpate for tenderness
Tibial tubercle
Quadriceps tendons
Retropatellar tenderness
Joint line
Ligaments (MCL/LCL)
Bursa (incl. pes anserine)

9. Knee Examination Strength ROM Hams Quads: squat, duck walk
Flexion: 130°/135°
Extension: 0° to -10°
Internal Rotation: 10°
External Rotation: 10°
Strength
Hams
Quads: squat, duck walk

10. Knee Examination Special Tests (ligaments)
Valgus and Varus Stress Tests (MCL/LCL)
Lachman’s & Anterior Drawer (ACL)
Posterior Drawer & Posterior Sag Test (PCL)
Postero-lateral corner
Patellar stability
Flexibility

11. AT 30d FLEXION MCL Stability Apply Valgus or Medial Stress
LCL Stability
Apply Varus or Lateral Stress

12. Test of ACL At 90° Flexion At 20-30 ° Flexion (more sensitive)
+ is increased translation or soft end point

13. Posterior Sag
Posterior Drawer

14. Knee Examination Meniscal Tests
Joint line tenderness
Thessaly test
McMurray Test
Squatting & Duck Walk
Multiple + tests is JUST as predictive of meniscal tear as MRI

15. Thessaly Test Pt stands on affected leg Knee bent at 20 degrees
Examiner holds pt’s hands and rotates pt to both sides 3x
Positive test: joint line pain

16. McMurray test for Meniscal injury
Test Med and Lat meniscus separately
3 concurrent maneuvers:
Grind it (Rotate tibia AWAY from it)
Crunch it (varus or valgus)
Full ROM (flex/extend knee)
Positive: Painful “pop”
Patient supine
Heel of patient’s injured leg held while knee fully flexed
Fingers of other hand palpate medical joint line while thumb palpates lateral aspect of joint
Valgus stress applied
Patient’s knee extended with tibia held externally rotated
Pain or palpable click over medial joint line indicates medical meniscal tear

17. Knee Examination Patella Tests Patella Apprehension Test
Patellofemoral Compression Test

18. Patellar Slide
nl is 25-50%
Patellar Apprehension w/ lateral movement
Patellar Tilt nl is 15°

19. Postero-lateral corner (PLC) Dial Test
Normal Abnormal (PLC tear)

20. Knee Examination Flexibility Tests Popliteal Angle (Hamstring)
Thomas Test (Hip flexors and Quads)
Ober’s Test (IT Band)

21. Flexibility
Popliteal Angle
Thomas Test

22. OBER Test ITB Tightness (TFL Injury) Affected side up Flex knee 90
Hip ABDucted/externally rotated
Allow Limb to passively ADDuct
Tight ITB will remain ABDucted

24. Value of cross table lateral
Rule out fracture
Can reveal fat-fluid level in joint, AKA lipohemarthrosis

25. Radiology and Laboratory
Knee aspiration if suspect:
Infection
Crystal arthropathy
Tense effusion causing symptoms
Various knee injuries occur frequently, careful hx and pe can help determine etiology

26. Questions?

27. Injuries and Ailments of the Knee
Medial Ligament Injury
Lateral Ligament Injury
ACL Injury
PCL Injury
Meniscal Injury
Retropatellofemoral Pain Syndrome (RPPS)
Patellar Subluxation/Dislocation
Patellar Tendinopathy (Jumper’s Knee)
Quadriceps Tendinopathy
Iliotibial Band (ITB) Syndrome
Osgood-Schlatter “Disease”

28. Case Soccer Star
16 y.o. female soccer player presents to clinic 1 week after injury.
Reports she was coming down from header when she twisted on landing. Heard a pop in her knee and had pain. Taken from field and couldn’t return to game. Noticed that night knee was swollen.
Now, 1 week later, almost normal gait. Knee feels much better.

29. Case Soccer Star Physical exam Joint effusion present No sag
No joint line tenderness
No LCL/MCL laxity
Negative McMurray/Thessaly
Positive Lachman
Soccer player says coming down from header and twisted on landing. Heard a pop in her knee. Had pain. Taken from field and couldn’t return to game. Noticed that night knee was swollen. 1 week later almost normal gait. Knee feels much better now.
Diagnosis:
ACL Injury

30. Anterior Cruciate Ligament Injury
Clinical symptoms
1/3 report audible pop
Mechanism of injury
Non-contact--twisting with the foot planted
Contact--valgus stress with twisting
Immediate swelling (hemarthrosis)
Usually non-ambulatory after injury
As swelling resolves, may temporarily have no trouble moving the knee; however, if tear is left untreated, recurrent instability develops, particularly with attempts to return to sport.

31. Anterior Cruciate Ligament Injury
Half occur with medial meniscal tear
Can occur with MCL tear
Rare with LCL or PCL tear

32. Features that should prompt an xray after acute knee injury include:
Unable to bear weight
Can’t flex >90d
Patella TTP
Fibular head TTP
Age <18 or >55
All of the above

33. 5 Ottawa Knee Rules 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

34. ACL: Radiographic Findings
Avulsion of the intercondylar tubercle
Anterior displacement of the tibia with respect to the femur
Segond fracture (a thin sliver of bone avulsed from the proximal lateral tibia with the lateral capsular ligament)

35. Segond Fracture

36. Anterior Cruciate Ligament Injury
Management
Brace knee first week (immobilizer)
Crutches for comfort, advance to toe-touch and wean from crutches as tolerated
F/U 10 days to reexamine and begin physical therapy
If posterolateral bruising, consider more serious injury to include damage to posterolateral corner – REFER (Dial Test)
Imaging
Initially, plain films
Order MRI at 10 day mark – no urgency

37. Questions?

38. Case Security Force Iraq
37 y/o male security forces Master Chief c/o knee pain and giving out after tripping over a wire and falling onto a gear locker
Happened a few months ago
Unusual feeling in knee with jogging, “sliding”, “gliding”
No locking

39. Case Security Force Iraq
Physical examination
No joint effusion
No joint line tenderness
Swelling and tenderness of popliteal fossa
No LCL/MCL laxity
Negative McMurray, Thessaly
Negative Lachman

40. Posterior Drawer, + Quad activation
Posterior Sag
Posterior Drawer, + Quad activation
Diagnosis:
PCL Injury

41. Posterior Cruciate Ligament Tear
Mechanism of injury
Fall onto flexed knee with plantar flexed foot and impact on tibial tubercle
Dashboard injury—posteriorly directed force to anterior knee in flexion
(fall onto flexed knee– dorsiflexed foot results in patellofemoral impact)
Injury sometimes unknown

42. Make sure to rule out Postero-Lateral Corner injury
Dial test

43. Posterior Cruciate Ligament Tear Treatment
Isolated PCL tear
Non-surgical
Symptomatic treatment with crutches/immobilization first week as needed (often not needed)
Physical therapy/range of motion
PCL + other ligament or PLC injury
Orthopedic referral
(fall onto flexed knee– dorsiflexed foot results in patellofemoral impact)
Injury sometimes unknown

44. Case Basketball Player
Basketball player presents day after game for knee pain
Remembers painful twist with planted foot during the game, but kept playing
Swelled up overnight
Now feels “locked”

45. Case Basketball Player
Physical exam
Effusion
Joint line tenderness
Limited knee range of motion
McMurray and Thessaly tests positive with painful click
Effusion with disruption of peripheral blood supply.
Degenerative tears or central (avascular) tears small or absent effusion
Diagnosis:
Meniscal Injury

46. Meniscal Tear Anatomy Avascular inner 2/3, partly vascular outer 1/3
Minimal innervation
Held in place by coronary ligaments, painful when torn (meniscotibial ligaments)
Lateral meniscus less firmly attached, less prone to injury

47. Meniscal Tear Function Lubrication Nutrition of joint Shock absorption
Reduce friction
Disperse stress / weight
Decrease cartilage wear

48. Meniscal Tear

49. Meniscal Tear Clinical symptoms Traumatic tears
Twisting or hyperflexion injury
Degenerative tears
In older patients, minimal or no trauma
Insidious swelling (overnight or 2-3 days)
Mechanical symptoms: locking, catching, popping
Pain medial or lateral sides of knee, particularly with twisting or squatting

50. Meniscal Tear Management Physical therapy, maximize ROM/strength
Non-surgical if no mechanical symptoms
Surgery for:
Locking
Extension or flexion block
Persistent pain
MRI – wait for four weeks, if not considering surgery, do not need to image
Effusion with disruption of peripheral blood supply.
Degenerative tears or central (avascular) tears small or absent effusion

51. Case Knee “came out of socket”
16 y.o. male lacrosse player made sharp cut yesterday. Felt knee “come out of socket”. Immediate pain and swelling.
Went to ER and x-rays negative for fracture.
One week out can’t fully bend knee due to pain.

52. Case Knee “came out of socket”
Physical exam
Patellar apprehension
Medial patellar tenderness
Increased patellar mobility
Patellar mobility– lateral translation greater than ½ width of patella.
Diagnosis:
Patellar Subluxation

53. Patellar dislocation/subluxation
Clinical symptoms
Severe pain
Sometimes pop
Occasionally see a deformity, usually lateral dislocation
Often reduces spontaneously
Swelling
Loss of motion

54. Patellar dislocation/subluxation
Mechanism of injury
Direct trauma
Rotation over planted foot (ie. softball swing)
Sudden cutting movements
“Stretched out” tissues from prior injury predispose for recurrence

55. Patellar dislocation/subluxation
Management
Straight leg immobilization x 1-2 weeks
Weight bearing as tolerated
Cylinder cast if question compliance
MRI if skeletally immature to r/o sleeve fracture (peeling off sleeve of cartilage and periosteum) requiring surgical repair
Physical therapy after immobilization to return strength/motion
Refer to Ortho for fracture, ligament injury, recurrence
Patellar mobility– lateral translation greater than ½ width of patella.

56. Case: Petty Officer can’t run PRT

57. Case: Petty Officer can’t run PRT
Active duty Navy petty officer. Pain started during boot camp march. Relieved by stopping running. Returns with return to running.
Pain generalized to anterior knee.
Pain worse with stairs and after prolonged sitting.
No clicking, locking or instability.
Can’t run and has gained 50 pounds.

58. Petty Officer can’t run PRT
Physical exam
No effusion
No ligamentous laxity
Pain reproduced by direct pressure and rocking of patella
Patellar tracking abnormal
Patellar retinacula tight
Vastus medialis oblique atrophy
Relative weakness hip abd/adductors
Patellar tracking—j-point
Diagnosis:
Patellofemoral Syndrome (Runner’s knee)

59. Patellofemoral Syndrome
Patellofemoral Syndrome is:
Diagnosis in nearly 25% of all knee injuries
Most common diagnosis made in runners
Most common orthopedic reason for failing Army Basic Training
Most common diagnosis in primary care sports medicine clinics

60. ? Causes of PFS “Theater sign”
Giving out—pain induced reflex inhibition of quadriceps
Forces on articular surface of patella in 200 lb man can vary from 600 to 3, 000 ob per square inch in activities from walking to running.
Multifactorial etiology of overuse and overload of patellofemoral joint.

61. Patellofemoral Syndrome
Clinical symptoms
Diffuse anterior knee pain
Worsened by patellofemoral loading– stairs, prolonged sitting, squatting
“Theater sign”
May occasionally give out
Symptoms frequently bilateral
Swelling generally absent
Usually no trauma hx, rare hx direct blow patella
“Theater sign”
Giving out—pain induced reflex inhibition of quadriceps
Forces on articular surface of patella in 200 lb man can vary from 600 to 3, 000 ob per square inch in activities from walking to running.
Multifactorial etiology of overuse and overload of patellofemoral joint.

62. Patellofemoral Syndrome
Physical exam
Pain reproduced by direct pressure over patella and rocking in femoral groove
Patellar grind test
Patellar glide (retinacular flexibility)
Vastus medialis oblique atrophy?
Patellar tracking—lateral movement of patella near full knee extension
Relative weakness in hip abductors/external rotators
“Theater sign”
Giving out—pain induced reflex inhibition of quadriceps
Forces on articular surface of patella in 200 lb man can vary from 600 to 3, 000 ob per square inch in activities from walking to running.
Multifactorial etiology of overuse and overload of patellofemoral joint.

63. Patellofemoral Syndrome
Commonly
Tight—
Med or Lat retinaculum
Iliotibial band
Quadriceps
Hamstrings
Achilles
“Theater sign”
Giving out—pain induced reflex inhibition of quadriceps
Forces on articular surface of patella in 200 lb man can vary from 600 to 3, 000 ob per square inch in activities from walking to running.
Multifactorial etiology of overuse and overload of patellofemoral joint.

64. Patellofemoral Syndrome
Management
Decrease painful activities 1-3 months
Strengthening
Quads/core/hips
Flexibility
Patellar retinacula
Quads & hams
ITB, Achilles
Misc: knee sleeve, orthotics
Weight loss (incr friction under patella)
“Theater sign”
Giving out—pain induced reflex inhibition of quadriceps
Forces on articular surface of patella in 200 lb man can vary from 600 to 3, 000 ob per square inch in activities from walking to running.
Multifactorial etiology of overuse and overload of patellofemoral joint.

65. Case: Airman Can’t Run PRT
Active duty Airman. Pain in front of knee started during boot camp march.
Relieved by stopping running on profile. Returns with profile expiration and return to running.
Sharp burning pain below knee cap.
Worse going down stairs/jumping/landing.
No clicking, locking or instability.

66. Case Airman can’t run PRT
Physical exam
Tenderness to palpation of the patellar tendon
Painful resisted full extension
o/w normal
Diagnosis:
Jumper’s Knee

67. Patellar tendinopathy/Jumper’s knee
Clinical symptoms
Antero-inferior pain
Often can point to tender spot
Pain immediately at end of exercise, or following sitting preceded by exercise
Stairs, running, jumping increase pain

68. Patellar tendinopathy/Jumper’s knee
Management
Physical therapy: eccentric quad exercise
“drop-squats”
Activity modification
Ice after activity
Consider inflammatory injection
Autologous blood
Platelet-rich plasma (PRP)
Surgery for intractable

69. Prolotherapy for Patellar Tendinopathy
Traditional Prolotherapy
Haksrud et al case series
Pilodocanol; good results
PRP
Kon et al case series
Good results
Filardo et al case/control
Good results, poorly designed
Hoksrud, (alfredson’s group), used polidocanol, sclerosed neovessels, good results
Kon, 20 males, hx 20.7 months average, sf36 scores improved in all parameters. No control
Filardo, 15 patients, 16 controls, three injections 2 wks apart…all did PT
6 month f/u. Exp group all improved after prp, continued at six months.
Improved in time to recovery, satisfaction, and sporting level achieved….5 complete resolutn, 2 w/o. Only beat control with greater sporting level achieved…but….
Poor control group – control group had NOT failed therapy, ex group all had…

70. Case – 37 yo male wants to run marathon
c/o lateral burning knee pain that started at mile 15 of a long run. He walked back to his car.
Has rested 2 weeks. Every couple days tries to run but pain returns.
Patient is following a marathon training program

71. Case – 37 yo male wants to run marathon
Physical exam
Lateral femoral condyle tenderness just above joint line
+ Noble test, + Ober’s
Diagnosis:
ITB Syndrome

72. Iliotibial band

73. Case – Iliotibial Band Sydrome
Clinical symptoms
Lateral knee pain
Associated with hills and banked surfaces
Common running injury

74. Case – Iliotibial Band Sydrome
Treatment

75. Iliotibial Band Friction Syndrome
Treatment
STRETCH, STRETCH, STRETCH
Avoid offending activities
Ice massage – 8 minutes 6 times daily
NSAIDs
Counterforce strap?

76. Iliotibial Band Friction Syndrome
Treatment – return to play
NO running until pain free with stairs
Next start with light run, stopping when stiff or tight (next sensation will be pain, and lead to setback)
Stretch after run
Post-run ice for 20 minutes

77. Iliotibial Band Friction Syndrome
If conservative management fails
DOUBLE THE STRETCHING
Cortisone injection
RERE: Surgical resection of lateral section of ITB

78. Case – painful bump on knee
Diagnosis:
Osgood-Schlatter

79. Osgood-Schlatter

80. Case: Stock broker runner
History
32 yo male stock broker training for Boston marathon
R knee pain for 9 mos
h/o “old football injury”
Swells after playing softball
No locking or giving way
Neg PMHx/PSHx
No fevers, rash, other joint pain

81. Case: Stock broker runner
Exam
Full ROM
Mild effusion
Mild medial joint line ttp
Neg McMurray/Thessaly
No ligamentous laxity

82. Xrays

83. Treatment of Osteoarthritis Overview
Nonpharmocologic Measures
Education, Weight loss, Exercise, & Bracing
Pharmacologic Measures
Analgesics, Glucosamine, Injectables
Alternative Therapies
Accupuncture, Dietary Supplementation
Surgery

84. Glucosamine in Knee OA LOE 1a for modest pain reduction
Significant differences in results between preparations (G. sulfate more effective)
LOE 1a for preservation of joint space
1500 mg/day

85. Glucosamine & Chondroitin: My Take
I recommend in all patients with knee OA
4 week trial of daily dosing
Evaluate efficacy; continue if helping
Consider indefinite use even if no pain relief for joint space preservation

86. Intra-articular Corticosteroids
Beneficial in KNEE
LOE 1a
Short-duration benefits: 2-4 weeks

87. Intra-articular Viscusopplements
Effective in knee and hip (LOE 1a)
Delayed effect (1-3 weeks)
Long duration (6 months)
One-time injection (SynviscOne)
Weekly injections 3-5x for others
May delay need for joint replacement

88. Surgery
Arthroscopy
Joint replacement
Cartilage transplantation

89. Arthroscopy with Lavage and Debridement
Two Randomized trials showing NO BENEFIT over conservative tx
Moseley JB et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002 Jul 11; 347(2):81-8.
Kirkley A et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. NEJM Sep 2008;359:1097.

90. Questions???

91. Take home points…. Patellofemoral Syndrome Positive “theater sign”.
Knee pain with locking.
Twisted planted foot and heard “pop”.
Knee “came out of socket”.
What to rule out in PCL injury (hint: dial test):
Good test for meniscal tears (hint: Disco)
Lateral knee pain training for marathon.
Anterior knee pain worse with jumping.
PFS best treatment:
Knee OA:
Meniscal Injury
ACL Injury
Patellar Subluxation
PLC injury
Thessaly test
ITB Syndrome
Patellar tendinopathy
Try LOTS of things
Try LOTS of things: exercise, glucosamine
Viscosupp injection, etc.

92. Questions?

93. References
Birrer R. and O’Connor F. Sports Medicine for the Primary Care Physician. Boca Raton: CRC Press, 2004.
Greene W. Essentials of Musculoskeletal Care. Rosemont: American Academy of Orthopaedic Surgeons, 2001.
Hoppenfeld S. Physical Examination of the Spine and Extremities. East Norwalk: Appleton-Century-Crofts, 1976;59-74.
Lillegard W. Evaluation of Knee Injuries. In W Lillegard (ed), Handbook of Sports Medicine. Boston: Butterworth-Heinemann, 1999:
Netter F. Atlas of Human Anatomy. West Caldwell: CIBA-Geigy, 1989.
Tandeter H. et al. Acture Knee Injuries: Use of Decision Rules for Selective Radiograph Ordering. American Family Physician. Dec 1999; 60: (For Radiograph Images)