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KNEE PAIN Calvary Health Care Sydney Updated May 2013.

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Presentation on theme: "KNEE PAIN Calvary Health Care Sydney Updated May 2013."— Presentation transcript:

1 KNEE PAIN Calvary Health Care Sydney Updated May 2013

2 Outline Knee pain and common causes Differential diagnosis Baker’s Cyst Osgood-Schlatter Lesion ACL & PCL Examination Investigations

3 Knee Pain Knee pain is a common presenting complaint with many possible causes. Teenage girls and young women: more likely to have patellar tracking problems such as patellar subluxation and patellofemoral pain syndrome. Teenage boys and young men: more likely to have knee extensor mechanism problems such as tibial apophysitis (Osgood-Schlatter lesion) and patellar tendonitis. Older adults: Osteoarthritis of the knee joint is common. Referred pain resulting from hip joint pathology, such as slipped capital femoral epiphysis, also may cause knee pain. Active patients: more likely to have acute ligamentous sprains and overuse injuries such as pes anserine bursitis and medial plica syndrome. Trauma: may result in acute ligamentous rupture or fracture, leading to acute knee joint swelling and hemarthrosis. Septic arthritis may develop in patients of any age, but crystal-induced inflammatory arthropathy is more likely in adults.

4 Common Causes of Knee Pain by Age Group Children and AdolescentsAdultsOlder Adults Patellar subluxationPatellofemoral pain syndrome (chondromalacia patellae) Osteoarthritis Tibial apophysitis (Osgood-Schlatter lesion) Medial plica syndrome Crystal-induced inflammatory arthropathy: gout, pseudogout Jumper's knee (patellar tendonitis) Pes anserine bursitisPopliteal cyst (Baker's cyst) Referred pain: slipped capital femoral epiphysis Trauma: ligamentous sprains (anterior cruciate, medial collateral, lateral collateral), meniscal tear Osteochondritis dissecansInflammatory arthropathy: rheumatoid arthritis, Reiter's syndrome Septic arthritis

5 Causes of Acute Knee Pain CommonLess CommonNot to be missed Medial Meniscus TearPatellar tendon ruptureFracture of the Tibial Plateau MCL SprainAcute Patellofemoral Joint Injury Avulsion fracture ACL ruptureCoronary Ligament SprainOsteochondritis Dissecans Lateral Meniscus TearBursal hematoma / bursitis Reflex Sympathetic Dystrophy (post injury) Articular Cartilage InjuryAcute fat pad impingement PCL SprainLow Quadriceps Haematoma Patellar DislocationAvulsion of Biceps Femoris Tendon Dislocated Superior Tibiofibular Joint

6 Surrounding Musculature Muscles surrounding the knee joint further contribute to knee stabilization during lower extremity movements Primary muscles include the quadriceps anteriorly, hamstrings posteriorly, gluteus medius and tensor fascia lata/IT band laterally and the hip adductors medially The repetitive, eccentric nature of muscular activity about the knee during sports may lead to fatigue related injuries

7 Differential Diagnosis of Knee Pain by Anatomic Site Anterior Knee PainPosterior Knee Pain Patellar subluxation or dislocationPopliteal cyst (Baker's cyst) Tibial apophysitis (Osgood-Schlatter lesion) Posterior cruciate ligament injury Jumper's knee (patellar tendonitis) Patellofemoral pain syndrome (chondromalacia patellae)

8 Differential Diagnosis of Knee Pain by Anatomic Site Medial Knee PainLateral Knee Pain Medial collateral ligament sprainLateral collateral ligament sprain Medial meniscal tearLateral meniscal tear Pes anserine bursitisIliotibial band tendonitis Medial plica syndrome

9 The Relationship of Swelling to Diagnosis ImmediateDelayedNo Swelling 0-2 Hours (hemarthrosis) ACL rupture Patellar Dislocation 6-24 hours (effusion) Meniscus MCL Sprain

10 Baker's Cyst

11 Baker’s Cyst Definition: A Chronic Knee Joint effusion A Baker cyst, also called a popliteal cyst, is a synovial cyst located posterior to the medial femoral condyle between the tendons of the medial head of the gastrocnemius and semimembranosus muscles. It results from the abnormal collection of fluid inside the gastrocnemio-semimembranosus bursa. A Baker cyst is lined by a true synovium, as it is an extension of the knee joint. Popliteal cysts range from 1-40 cm3 (median 3 cm3).

12 Symptoms of Baker’s Cyst SymptomsFrequency Popliteal Mass or Swelling29/3876% Aching12/3832% Knee Effusion12/3832% Thrombophlebitis5/3813% Clicking of the knee4/3811% Buckling of the knee4/3811% Locking of the knee1/383%

13 Popliteal Mass The most common presenting complaint or symptom It is usually visible as a bulge behind the knee, which is particularly noticeable on standing and comparing to the opposite uninvolved knee. They are generally soft and minimally tender Baker cysts can become complicated by protrusion of fluid down the leg between the muscles of the calf (dissection). The cyst can rupture, leaking fluid down the medial leg to sometimes give the medial ankle the appearance of a painless bruise. Baker cyst dissection and rupture are frequently associated with swelling of the leg and can mimic phlebitis of the leg

14 Phlebitis in the Leg Inflammation of a vein, leading to the formation of a thrombus in the vein Will cause the leg to swell with oedema fluid and feel stiff and painful Significant number of patients (13%) have symptoms simulating deep venous thrombosis (DVT), a syndrome termed pseudothrombophlebitis Therefore, exclude DVT in patients with popliteal cyst and leg swelling

15 Medical Conditions Associated with Popliteal Cysts Medical conditions associated with popliteal cysts, in descending order of frequency, are as follows: Arthritides: Osteoarthritis, RA, Juvenile RA, Gout, Reiter syndrome, psoriasis & systemic lupus erythematosus. Internal derangement: meniscal tears, ACL tears, osteochondral fractures Infection: septic arthritis, tuberculosis Chronic dialysis Hemophilia Hypothyroidism Pigmented villonodular synovitis Sarcoidosis

16 Baker’s Cyst & Arthritis Arthritis is the most common condition associated with Baker cyst. Of the arthritides, osteoarthritis is probably the most common cause of popliteal cyst. Although prevalence of Baker cyst in patients with inflammatory arthritis is higher than in patients with osteoarthritis, osteoarthritis is much more common than inflammatory arthritis. Fam et al demonstrated that the occurrence of Baker cysts relates directly to the presence of knee effusion and severity of osteoarthritis. In 99 consecutive patients with RA, Andonopoulos et al demonstrated Baker cysts on US in 47 patients (48%). Twenty patients (20%) had bilateral cysts. Of 198 patients' knees, 67 (34%) had popliteal cysts, yet only 29 cysts (43%) were diagnosed clinically.

17 Diagnosis of a Baker’s Cyst Arthrography (a type of x-ray examination that uses a contrast agent to image an anatomical joint): 5-46% Ultrasound: 40-42% Arthoscopy: 37% Cadaveric dissections 30% MRI 5-18%

18 Treatment of Baker’s Cyst Often no treatment is necessary and the practitioner can observe the cyst over time. If the cyst is painful, treatment is usually aimed at correcting the underlying problem, such as arthritis or a meniscus tear. Baker cysts often resolve with removal of excess knee fluid in conjunction with cortisone injection. Medications are sometimes given to relieve pain and inflammation. When cartilage tears or other internal knee problems are associated, surgery can be the best treatment option. During a surgical operation the surgeon can remove the synovium that leads to the cyst formation.

19 Patellofemoral Pain Syndrome (Chondromalacia patellae) Patellofemoral Syndrome is the term used to describe pain in and around the patella Functional Anatomy  Full extension: Patella sits lateral to the trochlea  During Flexion: Patella moves medial and comes to lie within the intercondylar notch until 130º, when it starts to move lateral again. Patella excursion is controlled by the quadriceps, particularly VMO & VL With increasing knee flexion, a greater area of patellar articular surface comes into contact with the femur, therefore offsetting the increased load that comes with flexion

20 Patellofemoral Pain Syndrome Cont. Loaded knee flexion activities subject the patellofemoral joint to loads many times the body weight. Anatomically, the lateral structures of the PFJ are much stronger than the medial structures, so any imbalance in the forces will cause the patella to drift laterally. ActivityForce through PFJ Level Walking0.5 x body weight Going up stairs3-4 x body weight Squat7-8 x body weight

21 Predisposing Factors FactorsCause Abnormal BiomechanicsExcessive Pronation Femoral anteversion (internal femoral torsion) High small patella (patella alta) Increased Q angle Soft tissue tightnessMuscles: Gastroc, H’strings, Rec Fem & ITB Lateral Structures: Lateral retinaculum, ITB & VL Muscle DysfunctionVMO Hip abductors / External rotators (glut med) TrainingDistance running Hills, stairs

22 Tibial Apophysitis (Osgood- Schlatter Lesion) The typical patient is a 13- or 14-year-old boy (or a 10- or 11-year-old girl) who has recently gone through a growth spurt. Aggravated by: – Squatting – Walking up / down stairs – Forceful contraction of the quadriceps – Exacerbated by jumping and hurdling, because repetitive hard landings place excessive stress on the insertion of the patellar tendon.

23 Anterior & Posterior Cruciate Ligaments Two important intra-articular ligaments that provide static support to the knee are the anterior (ACL) and posterior (PCL) cruciate ligaments. The PCL and ACL are intra-articular but extrasynovial The ACL originates from the medial and anterior aspect of the tibial plateau and runs superiorly, laterally, and posteriorly toward its insertion on the lateral femoral condyle The ACL is composed of the anteriomedial and posteriolateral bundles. Together, these bundles provide approximately 85% of total restraining force of anterior displacement of the tibia on the femur To a lesser degree, the ACL checks extension and hyperextension. Together with the posterior cruciate ligament (PCL), It also prevents excessive tibial medial and lateral rotation, as well as varus and valgus stresses The ligaments are tense in all positions, but increase their tension in the extremes of flexion and extension

24 Anterior Cruciate Ligament The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee. Each year, approximately 100,000 people sustain ACL injuries with basketball, soccer, skiing, and gymnastics being the sports with the highest incidence ACL injury rates are estimated to be two to eight times higher in females than males participating in the same sports Numerous studies exploring why females are at a higher risk cite both intrinsic and extrinsic differences between genders

25 Anatomy and Biomechanics 1.Smaller notch width index. A smaller notch width index has been found to predispose females to ACL injuries. The smaller notch likely causes a shearing effect on the ACL by the femur. Although this smaller, A-shaped notch has been shown to be related to ACL injuries, there is no evidence that the relationship is causal 2.Increased ligamentous laxity. Females in general have ligaments that are more lax than males, which increases the risk of ACL rupture. In addition, it has been suggested that within the first year after surgery when “ligamentization” of the tendon occurs, females undergo a different remodeling response than males 3.Increased Q angle. The female pelvis is wider than the male pelvis, which increases the Q angle of the knee. This leads to increase stresses at the knee, and causes other compensatory deviations in the surrounding joints. Other changes that occur include femoral anteversion, tibial external torsion, and subtalar pronation

26 Neuromuscular Imbalances Research has shown disparity among females and males in knee proprioception and neuromuscular control Quadriceps dominance pattern. Females demonstrate strength imbalance between quadriceps and hamstrings. Female athletes tend to rely on their quadriceps and gastrocnemius and less on their hamstrings when compared to males. In addition, females exhibited a delayed firing pattern of the hamstrings Landing strategies. Females use different strategies when running, landing, or jumping than males and tend to land with an increased valgus moment. This may cause significant differences between their dominant and non-dominant knee. However, both knees may potentially be at an increased risk for ACL rupture. The dominant knee works to limit gravitational forces, while the non-dominant knee may be too weak to withstand such forces

27 Hormonal Influences Female hormones have been suggested as a possible risk factor for ACL rupture. It has been hypothesized that these hormones increase ligament laxity and decrease ligament strength during the weeks prior to and immediately following the menstrual cycle. However, further research is needed to confirm or deny the role of female sex hormones in ACL injury.

28 Mechanism of Injury The ACL is usually torn as a result of a quick deceleration, hyperextension or rotational injury that usually does not involve contact with another individual. This injury often occurs following a sudden change of direction When hit from the side, injuries to the ACL are often associated with medial meniscus and medial collateral ligament (MCL) tears, collectively known as the “unhappy triad.” In adolescents, the ACL may avulse from the tibial spine instead of rupturing

29 Signs and Symptoms An acute ACL rupture is characterized by pain, hemarthrosis, and instability. At the moment of injury, many people report hearing or feeling a popping sensation Common impairments typically include immediate swelling (0-2 hours), decreased strength and range of motion, inability to weight-bear and poor balance and coordination Considerable pain in the knee that does not go away within the first few hours after the injury Patients are functionally limited in their ability to ambulate, negotiate stairs, and perform basic and instrumental ADLs. If not properly addressed, these impairments could become chronic conditions A feeling of unsteadiness and a tendency for the knee to "give-way," or an inability to bear weight on the injured leg An audible "pop" or the perception of something snapping or breaking at the moment of injury A feeling of "fullness or tightness" in the knee

30 Examination Observation: Standing, walking & Supine Active Movements: Flexion & Extension Passive Movements: Flexion & Extension Palpation: PFJ, MCL, LCL, Medial & Lateral Joint line, & in prone (hamstring tendons, Bakers Cyst, Gastroc origins) Special tests Presence of Effusion Stability tests: MCL, LCL  ACL: Lachmans test, Anterior drawer test & Pivot shift test  PCL: Posterior Sag, reverse Lachmans test & posterior drawer test Flexion / Rotation (McMurrays test) Patellar Apprehension Test PFJ

31 Investigations: X-ray The specific indications for x-ray following acute knee injury are: High speed injuries (suspect a tibial plateau fracture Children or adolescents (who may avulse a bony fragment instead of tearing of a cruciate ligament) If there is clinical suspicion of loose bodies If hemarthrosis is present If surgery is indicated

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