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

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Presentation on theme: "Common Ailments and Injuries of the Knee, 2011 Kevin deWeber, MD, FAAFP Sports Medicine Fellowship Director Thanks to: Rodney S. Gonzalez, MD."— Presentation transcript:

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

3 Objectives Background Background Anatomy Anatomy History History Physical Examination Physical Examination Radiology and Laboratory Radiology and Laboratory Case Studies Case Studies

4 Anatomy

5

6 History Patient age Patient age Current symptoms and duration Current symptoms and duration Pain with or after activity/changes in activity Pain with or after activity/changes in activity Catching/locking (“mechanical”) or Instability Catching/locking (“mechanical”) or Instability Stairs, squats, “theater sign” Stairs, squats, “theater sign” Exacerbating and relieving factors Exacerbating and relieving factors What treatment already tried (Rest, NSAIDs, brace, …) What treatment already tried (Rest, NSAIDs, brace, …) Prior knee injury or surgery Prior knee injury or surgery PMH PMH

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

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

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

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

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

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

13 Test of ACL At 90° Flexion At ° Flexion (more sensitive) + is increased translation or soft end point

14 Posterior Sag Posterior Drawer

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

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

17 McMurray test for Meniscal injury Test Med and Lat meniscus separately Test Med and Lat meniscus separately 3 concurrent maneuvers: 3 concurrent maneuvers: Grind it (Rotate tibia AWAY from it) Grind it (Rotate tibia AWAY from it) Crunch it (varus or valgus) Crunch it (varus or valgus) Full ROM (flex/extend knee) Full ROM (flex/extend knee) Positive: Painful “pop” Positive: Painful “pop”

18 Knee Examination Patella Tests Patella Tests Patella Apprehension Test Patella Apprehension Test Patellofemoral Compression Test Patellofemoral Compression Test

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

20 Postero-lateral corner (PLC) Dial Test NormalAbnormal (PLC tear) NormalAbnormal (PLC tear)

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

22 Flexibility Popliteal AngleThomas Test

23 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

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

26 Radiology and Laboratory Knee aspiration if suspect: Knee aspiration if suspect: Infection Infection Crystal arthropathy Crystal arthropathy Tense effusion causing symptoms Tense effusion causing symptoms

27 Questions?

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

29 Case Soccer Star 16 y.o. female soccer player presents to clinic 1 week after injury. 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. 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. Now, 1 week later, almost normal gait. Knee feels much better.

30 Case Soccer Star Physical exam Joint effusion present Joint effusion present No sag No sag No joint line tenderness No joint line tenderness No LCL/MCL laxity No LCL/MCL laxity Negative McMurray/Thessaly Negative McMurray/Thessaly Positive Lachman Positive Lachman Diagnosis: ACL Injury

31 Anterior Cruciate Ligament Injury Clinical symptoms 1/3 report audible pop 1/3 report audible pop Mechanism of injury Mechanism of injury Non-contact--twisting with the foot planted Contact--valgus stress with twisting Immediate swelling (hemarthrosis) Immediate swelling (hemarthrosis) Usually non-ambulatory after injury Usually non-ambulatory after injury

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

33 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 All of the above

34 5 Ottawa Knee Rules i.e. When to order a knee xray after acute injury Age > 55 or 55 or < 18 Unable to walk Unable to walk TTP on PATELLA TTP on PATELLA TTP on FIBULAR HEAD TTP on FIBULAR HEAD Unable to flex 90 deg Unable to flex 90 deg

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

36 Segond Fracture

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

38 Questions?

39 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 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 Happened a few months ago Unusual feeling in knee with jogging, “sliding”, “gliding” Unusual feeling in knee with jogging, “sliding”, “gliding” No locking No locking

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

41 Posterior Sag Posterior Drawer, + Quad activation PCL Injury Diagnosis:

42 Posterior Cruciate Ligament Tear Mechanism of injury Mechanism of injury Fall onto flexed knee with plantar flexed foot and impact on tibial tubercle Fall onto flexed knee with plantar flexed foot and impact on tibial tubercle Dashboard injury—posteriorly directed force to anterior knee in flexion Dashboard injury—posteriorly directed force to anterior knee in flexion

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

44 Posterior Cruciate Ligament Tear Treatment Posterior Cruciate Ligament Tear Treatment Isolated PCL tear Isolated PCL tear Non-surgical Non-surgical Symptomatic treatment with crutches/immobilization first week as needed (often not needed) Symptomatic treatment with crutches/immobilization first week as needed (often not needed) Physical therapy/range of motion Physical therapy/range of motion PCL + other ligament or PLC injury PCL + other ligament or PLC injury Orthopedic referral Orthopedic referral

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

46 Case Basketball Player Physical exam Effusion Effusion Joint line tenderness Joint line tenderness Limited knee range of motion Limited knee range of motion McMurray and Thessaly tests positive with painful click McMurray and Thessaly tests positive with painful click Diagnosis: Meniscal Injury

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

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

49 Meniscal Tear

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

51 Meniscal Tear Management Management Physical therapy, maximize ROM/strength Physical therapy, maximize ROM/strength Non-surgical if no mechanical symptoms Non-surgical if no mechanical symptoms Surgery for: Surgery for: Locking Locking Extension or flexion block Extension or flexion block Persistent pain Persistent pain MRI – wait for four weeks, if not considering surgery, do not need to image MRI – wait for four weeks, if not considering surgery, do not need to image

52 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. 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. Went to ER and x-rays negative for fracture. One week out can’t fully bend knee due to pain. One week out can’t fully bend knee due to pain.

53 Case Knee “came out of socket” Physical exam Patellar apprehension Patellar apprehension Medial patellar tenderness Medial patellar tenderness Increased patellar mobility Increased patellar mobility Diagnosis: Patellar Subluxation

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

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

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

57 Case: Petty Officer can’t run PRT

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

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

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

61 Causes of PFS ?

62 Patellofemoral Syndrome Clinical symptoms Diffuse anterior knee pain Diffuse anterior knee pain Worsened by patellofemoral loading– stairs, prolonged sitting, squatting Worsened by patellofemoral loading– stairs, prolonged sitting, squatting “Theater sign” “Theater sign” May occasionally give out May occasionally give out Symptoms frequently bilateral Symptoms frequently bilateral Swelling generally absent Swelling generally absent Usually no trauma hx, rare hx direct blow patella Usually no trauma hx, rare hx direct blow patella

63 Patellofemoral Syndrome Physical exam Pain reproduced by direct pressure over patella and rocking in femoral groove Pain reproduced by direct pressure over patella and rocking in femoral groove Patellar grind test Patellar grind test Patellar glide (retinacular flexibility) Patellar glide (retinacular flexibility) Vastus medialis oblique atrophy? Vastus medialis oblique atrophy? Patellar tracking—lateral movement of patella near full knee extension Patellar tracking—lateral movement of patella near full knee extension Relative weakness in hip abductors/external rotators Relative weakness in hip abductors/external rotators

64 Patellofemoral Syndrome Commonly Tight— Tight— Med or Lat retinaculum Med or Lat retinaculum Iliotibial band Iliotibial band Quadriceps Quadriceps Hamstrings Hamstrings Achilles Achilles

65 Patellofemoral Syndrome Management Management Decrease painful activities 1-3 months Decrease painful activities 1-3 months Strengthening Strengthening Quads/core/hips Quads/core/hips Flexibility Flexibility Patellar retinacula Patellar retinacula Quads & hams Quads & hams ITB, Achilles ITB, Achilles Misc: knee sleeve, orthotics Misc: knee sleeve, orthotics Weight loss (incr friction under patella) Weight loss (incr friction under patella)

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

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

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

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

70 Prolotherapy for Patellar Tendinopathy Traditional Prolotherapy Traditional Prolotherapy Haksrud et al case series Haksrud et al case series Pilodocanol; good results Pilodocanol; good results PRP PRP Kon et al case series Kon et al case series Good results Good results Filardo et al case/control Filardo et al case/control Good results, poorly designed Good results, poorly designed

71 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. 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. Has rested 2 weeks. Every couple days tries to run but pain returns. Patient is following a marathon training program Patient is following a marathon training program

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

73 Iliotibial band

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

75 Case – Iliotibial Band Sydrome Treatment

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

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

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

79 Case – painful bump on knee Diagnosis: Osgood-Schlatter

80 Osgood-Schlatter

81 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 Case: Stock broker runner History History

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

83 Xrays

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

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

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

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

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

89 Arthroscopy Arthroscopy Joint replacement Joint replacement Cartilage transplantation Cartilage transplantation Surgery

90 Two Randomized trials showing NO BENEFIT over conservative tx 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. 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. Kirkley A et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. NEJM Sep 2008;359:1097. Arthroscopy with Lavage and Debridement

91 Questions???

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

93 Questions?

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


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