5History Patient age Current symptoms and duration Pain with or after activity/changes in activityCatching/locking (“mechanical”) or InstabilityStairs, squats, “theater sign”Exacerbating and relieving factorsWhat treatment already tried (Rest, NSAIDs, brace, …)Prior knee injury or surgeryPMHStandingAlignment 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 evaluationTrendelenburg testSittingPatellar position in the trochlear grooveActive patellar motion (r/o j curve deform/test quad balance)Neurological exam PRN (back pain, radiation of pain)Supine-Patellofemoral JointInspection for patellar positionPalpation for effusionPalpation for retropatellar tenderness (superolaterally)Evaluation of patellar mobilityPalpation of quadricep and patellar tendons(tibial tubercle)VMO bulk and tonePalpation of peripatellar soft tissuesSupine-Tibiofemoral JointLachmanValgus and varus stress testPosterior sag sign or loss of tibial step-offHyperflexion of knee/McMurray's test (Apley's compression)Palpation of MCL/LCLPalpation of joint linePalpation of pes anserine areaPalpation of popliteal spaceFlexibilityPopliteal angle/hamstringsNoble's test-IT Band inflammationOber's Test-IT Band flexibilityThomas test-Hip flexor/QuadHip ROM
6Knee Examination (6-step Msk exam) InspectionPalpationRange of MotionStrengthNeurovascular (rare)Special Tests
7Knee Examination Inspection Alignment of lower extremities Varus, valgus, recurvatumPatellar position and motion (j curve deformity)Inspection for asymmetriesSwelling, torsion, inability to extend kneeAtrophy
8Knee Examination Palpate for effusion and warmth Palpate for tendernessTibial tubercleQuadriceps tendonsRetropatellar tendernessJoint lineLigaments (MCL/LCL)Bursa (incl. pes anserine)
9Knee Examination Strength ROM Hams Quads: squat, duck walk Flexion: 130°/135°Extension: 0° to -10°Internal Rotation: 10°External Rotation: 10°StrengthHamsQuads: squat, duck walk
10Knee Examination Special Tests (ligaments) Valgus and Varus Stress Tests (MCL/LCL)Lachman’s & Anterior Drawer (ACL)Posterior Drawer & Posterior Sag Test (PCL)Postero-lateral cornerPatellar stabilityFlexibility
11AT 30d FLEXION MCL Stability Apply Valgus or Medial Stress LCL StabilityApply Varus or Lateral Stress
12Test of ACL At 90° Flexion At 20-30 ° Flexion (more sensitive) + is increased translation or soft end point
14Knee Examination Meniscal Tests Joint line tendernessThessaly testMcMurray TestSquatting & Duck WalkMultiple + tests is JUST as predictive of meniscal tear as MRI
15Thessaly Test Pt stands on affected leg Knee bent at 20 degrees Examiner holds pt’s hands and rotates pt to both sides 3xPositive test: joint line pain
16McMurray test for Meniscal injury Test Med and Lat meniscus separately3 concurrent maneuvers:Grind it (Rotate tibia AWAY from it)Crunch it (varus or valgus)Full ROM (flex/extend knee)Positive: Painful “pop”Patient supineHeel of patient’s injured leg held while knee fully flexedFingers of other hand palpate medical joint line while thumb palpates lateral aspect of jointValgus stress appliedPatient’s knee extended with tibia held externally rotatedPain or palpable click over medial joint line indicates medical meniscal tear
17Knee Examination Patella Tests Patella Apprehension Test Patellofemoral Compression Test
18Patellar Slidenl is 25-50%Patellar Apprehension w/ lateral movementPatellar Tilt nl is 15°
19Postero-lateral corner (PLC) Dial Test Normal Abnormal (PLC tear)
20Knee Examination Flexibility Tests Popliteal Angle (Hamstring) Thomas Test (Hip flexors and Quads)Ober’s Test (IT Band)
27Injuries and Ailments of the Knee Medial Ligament InjuryLateral Ligament InjuryACL InjuryPCL InjuryMeniscal InjuryRetropatellofemoral Pain Syndrome (RPPS)Patellar Subluxation/DislocationPatellar Tendinopathy (Jumper’s Knee)Quadriceps TendinopathyIliotibial Band (ITB) SyndromeOsgood-Schlatter “Disease”
28Case Soccer Star16 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.
29Case Soccer Star Physical exam Joint effusion present No sag No joint line tendernessNo LCL/MCL laxityNegative McMurray/ThessalyPositive LachmanSoccer 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
30Anterior Cruciate Ligament Injury Clinical symptoms1/3 report audible popMechanism of injuryNon-contact--twisting with the foot plantedContact--valgus stress with twistingImmediate swelling (hemarthrosis)Usually non-ambulatory after injuryAs 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.
31Anterior Cruciate Ligament Injury Half occur with medial meniscal tearCan occur with MCL tearRare with LCL or PCL tear
32Features that should prompt an xray after acute knee injury include: Unable to bear weightCan’t flex >90dPatella TTPFibular head TTPAge <18 or >55All of the above
335 Ottawa Knee Rules i.e. When to order a knee xray after acute injury Age > 55 or < 18Unable to walkTTP on PATELLATTP on FIBULAR HEADUnable to flex 90 deg
34ACL: Radiographic Findings Avulsion of the intercondylar tubercleAnterior displacement of the tibia with respect to the femurSegond fracture (a thin sliver of bone avulsed from the proximal lateral tibia with the lateral capsular ligament)
36Anterior Cruciate Ligament Injury ManagementBrace knee first week (immobilizer)Crutches for comfort, advance to toe-touch and wean from crutches as toleratedF/U 10 days to reexamine and begin physical therapyIf posterolateral bruising, consider more serious injury to include damage to posterolateral corner – REFER (Dial Test)ImagingInitially, plain filmsOrder MRI at 10 day mark – no urgency
38Case 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 lockerHappened a few months agoUnusual feeling in knee with jogging, “sliding”, “gliding”No locking
39Case Security Force Iraq Physical examinationNo joint effusionNo joint line tendernessSwelling and tenderness of popliteal fossaNo LCL/MCL laxityNegative McMurray, ThessalyNegative Lachman
41Posterior Cruciate Ligament Tear Mechanism of injuryFall onto flexed knee with plantar flexed foot and impact on tibial tubercleDashboard injury—posteriorly directed force to anterior knee in flexion(fall onto flexed knee– dorsiflexed foot results in patellofemoral impact)Injury sometimes unknown
42Make sure to rule out Postero-Lateral Corner injury Dial test
43Posterior Cruciate Ligament Tear Treatment Isolated PCL tearNon-surgicalSymptomatic treatment with crutches/immobilization first week as needed (often not needed)Physical therapy/range of motionPCL + other ligament or PLC injuryOrthopedic referral(fall onto flexed knee– dorsiflexed foot results in patellofemoral impact)Injury sometimes unknown
44Case Basketball Player Basketball player presents day after game for knee painRemembers painful twist with planted foot during the game, but kept playingSwelled up overnightNow feels “locked”
45Case Basketball Player Physical examEffusionJoint line tendernessLimited knee range of motionMcMurray and Thessaly tests positive with painful clickEffusion with disruption of peripheral blood supply.Degenerative tears or central (avascular) tears small or absent effusionDiagnosis:Meniscal Injury
46Meniscal Tear Anatomy Avascular inner 2/3, partly vascular outer 1/3 Minimal innervationHeld in place by coronary ligaments, painful when torn (meniscotibial ligaments)Lateral meniscus less firmly attached, less prone to injury
47Meniscal Tear Function Lubrication Nutrition of joint Shock absorption Reduce frictionDisperse stress / weightDecrease cartilage wear
49Meniscal Tear Clinical symptoms Traumatic tears Twisting or hyperflexion injuryDegenerative tearsIn older patients, minimal or no traumaInsidious swelling (overnight or 2-3 days)Mechanical symptoms: locking, catching, poppingPain medial or lateral sides of knee, particularly with twisting or squatting
50Meniscal Tear Management Physical therapy, maximize ROM/strength Non-surgical if no mechanical symptomsSurgery for:LockingExtension or flexion blockPersistent painMRI – wait for four weeks, if not considering surgery, do not need to imageEffusion with disruption of peripheral blood supply.Degenerative tears or central (avascular) tears small or absent effusion
51Case 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.
52Case Knee “came out of socket” Physical examPatellar apprehensionMedial patellar tendernessIncreased patellar mobilityPatellar mobility– lateral translation greater than ½ width of patella.Diagnosis:Patellar Subluxation
53Patellar dislocation/subluxation Clinical symptomsSevere painSometimes popOccasionally see a deformity, usually lateral dislocationOften reduces spontaneouslySwellingLoss of motion
54Patellar dislocation/subluxation Mechanism of injuryDirect traumaRotation over planted foot (ie. softball swing)Sudden cutting movements“Stretched out” tissues from prior injury predispose for recurrence
55Patellar dislocation/subluxation ManagementStraight leg immobilization x 1-2 weeksWeight bearing as toleratedCylinder cast if question complianceMRI if skeletally immature to r/o sleeve fracture (peeling off sleeve of cartilage and periosteum) requiring surgical repairPhysical therapy after immobilization to return strength/motionRefer to Ortho for fracture, ligament injury, recurrencePatellar mobility– lateral translation greater than ½ width of patella.
57Case: 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.
58Petty Officer can’t run PRT Physical examNo effusionNo ligamentous laxityPain reproduced by direct pressure and rocking of patellaPatellar tracking abnormalPatellar retinacula tightVastus medialis oblique atrophyRelative weakness hip abd/adductorsPatellar tracking—j-pointDiagnosis:Patellofemoral Syndrome (Runner’s knee)
59Patellofemoral Syndrome Patellofemoral Syndrome is:Diagnosis in nearly 25% of all knee injuriesMost common diagnosis made in runnersMost common orthopedic reason for failing Army Basic TrainingMost common diagnosis in primary care sports medicine clinics
60? Causes of PFS “Theater sign” Giving out—pain induced reflex inhibition of quadricepsForces 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.
61Patellofemoral Syndrome Clinical symptomsDiffuse anterior knee painWorsened by patellofemoral loading– stairs, prolonged sitting, squatting“Theater sign”May occasionally give outSymptoms frequently bilateralSwelling generally absentUsually no trauma hx, rare hx direct blow patella“Theater sign”Giving out—pain induced reflex inhibition of quadricepsForces 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.
62Patellofemoral Syndrome Physical examPain reproduced by direct pressure over patella and rocking in femoral groovePatellar grind testPatellar glide (retinacular flexibility)Vastus medialis oblique atrophy?Patellar tracking—lateral movement of patella near full knee extensionRelative weakness in hip abductors/external rotators“Theater sign”Giving out—pain induced reflex inhibition of quadricepsForces 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.
63Patellofemoral Syndrome CommonlyTight—Med or Lat retinaculumIliotibial bandQuadricepsHamstringsAchilles“Theater sign”Giving out—pain induced reflex inhibition of quadricepsForces 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.
64Patellofemoral Syndrome ManagementDecrease painful activities 1-3 monthsStrengtheningQuads/core/hipsFlexibilityPatellar retinaculaQuads & hamsITB, AchillesMisc: knee sleeve, orthoticsWeight loss (incr friction under patella)“Theater sign”Giving out—pain induced reflex inhibition of quadricepsForces 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.
65Case: 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.
66Case Airman can’t run PRT Physical examTenderness to palpation of the patellar tendonPainful resisted full extensiono/w normalDiagnosis:Jumper’s Knee
67Patellar tendinopathy/Jumper’s knee Clinical symptomsAntero-inferior painOften can point to tender spotPain immediately at end of exercise, or following sitting preceded by exerciseStairs, running, jumping increase pain
68Patellar tendinopathy/Jumper’s knee ManagementPhysical therapy: eccentric quad exercise“drop-squats”Activity modificationIce after activityConsider inflammatory injectionAutologous bloodPlatelet-rich plasma (PRP)Surgery for intractable
69Prolotherapy for Patellar Tendinopathy Traditional ProlotherapyHaksrud et al case seriesPilodocanol; good resultsPRPKon et al case seriesGood resultsFilardo et al case/controlGood results, poorly designedHoksrud, (alfredson’s group), used polidocanol, sclerosed neovessels, good resultsKon, 20 males, hx 20.7 months average, sf36 scores improved in all parameters. No controlFilardo, 15 patients, 16 controls, three injections 2 wks apart…all did PT6 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…
70Case – 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
71Case – 37 yo male wants to run marathon Physical examLateral femoral condyle tenderness just above joint line+ Noble test, + Ober’sDiagnosis:ITB Syndrome
75Iliotibial Band Friction Syndrome TreatmentSTRETCH, STRETCH, STRETCHAvoid offending activitiesIce massage – 8 minutes 6 times dailyNSAIDsCounterforce strap?
76Iliotibial Band Friction Syndrome Treatment – return to playNO running until pain free with stairsNext start with light run, stopping when stiff or tight (next sensation will be pain, and lead to setback)Stretch after runPost-run ice for 20 minutes
77Iliotibial Band Friction Syndrome If conservative management failsDOUBLE THE STRETCHINGCortisone injectionRERE: Surgical resection of lateral section of ITB
78Case – painful bump on knee Diagnosis:Osgood-Schlatter
80Case: Stock broker runner History32 yo male stock broker training for Boston marathonR knee pain for 9 mosh/o “old football injury”Swells after playing softballNo locking or giving wayNeg PMHx/PSHxNo fevers, rash, other joint pain
84Glucosamine 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 space1500 mg/day
85Glucosamine & Chondroitin: My Take I recommend in all patients with knee OA4 week trial of daily dosingEvaluate efficacy; continue if helpingConsider indefinite use even if no pain relief for joint space preservation
86Intra-articular Corticosteroids Beneficial in KNEELOE 1aShort-duration benefits: 2-4 weeks
87Intra-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 othersMay delay need for joint replacement
89Arthroscopy with Lavage and Debridement Two Randomized trials showing NO BENEFIT over conservative txMoseley 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.
91Take 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 InjuryACL InjuryPatellar SubluxationPLC injuryThessaly testITB SyndromePatellar tendinopathyTry LOTS of thingsTry LOTS of things: exercise, glucosamineViscosupp injection, etc.
93ReferencesBirrer 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)