Presentation on theme: "Orthopaedics for the Practicing Internist"— Presentation transcript:
1 Orthopaedics for the Practicing Internist American College of Physicians2013 Ohio Chapter Scientific MeetingColumbus, OHOctober 11, 2013Paul J. Gubanich, MD, MPHAssistant Professor of Internal Medicine/Sports MedicineTeam Physician, Ohio State University Athletics, Ohio Machine, Columbus City Schools
2 DisclosuresI do not have a conflict of interest associated with the material contained in this presentation.
3 An Approach to the Patient with Knee Pain Most common complaintsPainInstability – (ligament injury, OA)Stiffness – (effusion, OA)SwellingLocking (meniscal)WeaknessMost diagnosis made by:HistoryPhysical examImaging
6 Common causes of chronic knee pain Chronic Pain ArthritisTumors (night pain)Osteosarcoma (adolescents)Chondrosarcoma (adults)Giant cell tumor (benign)Metastatic disease is uncommonSepsis (rare, can be bursal)Bursitis (overuse)TendonitisAnterior knee painChronic PainOften lacks a mechanism of injurySymptoms of gradual onset
12 Physical Exam Exam both sides Gait Inspection Joint above and below Most painful part lastGaitAlignment (varus, valgus)SquatInspectionSwellingBruisingDeformity
13 Physical Exam Palpation Range of Motion Strength Functional tests EffusionRange of MotionPatellar trackingExtension (-5 to 5)Flexion ( )Crepitus, etc.StrengthHamstringQuadFunctional tests
14 Physical Exam – Special Maneuvers Apprehension sign – patellar instabilityApley grind test – meniscusMcMurray circumduction test,SN 16-58%SP 77-98%(Evans 1993, Fowler 1989, Kurasaka 1999, Anderson 1986)
15 Physical Exam – Special Maneuvers Valgus stress test – MCLSN 86-96%Varus stress test – LCLSN 25%
16 Physical Exam – Special Maneuvers Lachman’s – ACLSN 80-99%(various authors and conditions)
17 Physical Exam – Special Maneuvers Anterior/posterior drawer – ACL/PCLPosterior Sag Sign
18 Radiology Plain x-rays often considered part of exam X-ray views Helps rule out competing diagnosisX-ray viewsStanding AP views of both knees (for comparison)LateralTunnel at 45 degreesMerchant/Sunrise – to evaluate PF joint
19 Radiology MRI often not needed initially Surgical planning tool Failure of treatmentIdentify ligamentous/cartilage injuries of acute or surgical natureRisk stratification
20 General Treatment Pearls Match disease severity/limitations with treatment optionsEscalate based on time, response in a stepwise fashionSet realistic expectations for progress and follow-upAlign treatment goals with patient goals/expectations when possibleTime is a great healer
21 Common Treatment Recommendations Activity modification, restMechanical devices – braces, crutches, lifts, orthotics, etc.Ice, pain medicationNsaidsAcetaminophenOthersPhysical therapy – early motion progressing to strengthening and then functional drillsInjection therapyAspirationCorticosteroidsHyaluronic acid supplents (OA)Glucosamine (OA)Surgical considerationsConsider additional imaging options as neededMRIBone scanCT
22 Red Flags Night pain Abnormal x-ray findings Mechanical symptoms Fractures, tumor, cartilage lesions, etc.Mechanical symptomsSevere pain, swelling, loss of motion, or weaknessHigh grade ligament injuriesFail to respond to standard treatmentsMultiple joints involved (Rheum)
23 SummaryHistory and Physical Exam are vital to generating a working differential diagnosisImaging may complement/confirm working diagnosisTreatment should match symptoms and severity and progress based on progressQuestions?
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