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Primary Care Approach to Knee Pain Bradley Sandella, DO, ATC Director of Sports Medicine Sports Medicine Fellowship Program Director.

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Presentation on theme: "Primary Care Approach to Knee Pain Bradley Sandella, DO, ATC Director of Sports Medicine Sports Medicine Fellowship Program Director."— Presentation transcript:

1 Primary Care Approach to Knee Pain Bradley Sandella, DO, ATC Director of Sports Medicine Sports Medicine Fellowship Program Director

2 Goals of Lecture ä Be able to identify the most common causes of knee pain. ä Demonstrate several examination techniques to identify different causes of knee pain. ä Design a Home Exercise Program for knee pain

3 Epidemiology of Knee Pain ä Accounts for approximately 1/3 of musculoskeletal complaints seen in the primary care setting. ä 5-10% of all visits ä With 25% being anterior knee pain ä Females more commonly get it than males ä As many as 54 % of athletes have some degree of knee pain each year ä 25% of all runners will experience

4 Doc....my knee hurts

5 Most Common Causes of Knee Pain in Primary Care ä Osteoarthritis (34%) ä Meniscal injury (9%) ä Collateral ligament injury (7%) ä Cruciate ligament injury (4%) ä Gout (2%) ä Fracture (1.2%) ä Undifferentiated causes including sprains and strains (42%) Jackson J, O’Malley P, Kroenke K, “Evaluation of Acute Knee Pain in Primary Care”, Ann Intern Med 2003; 139(7):

6 Anatomy ä Anterior ä Patella ä Posterior facets ä Alignment ä Patella Tendon ä Tibial Tubercle ä Bursas ä Posterior ä Gastrocnemius ä Popliteal vessels ä Medial ä Medial collateral ligament ä Medial meniscus ä Lateral ä Lateral collateral ligament ä Lateral meniscus

7 Anatomy ä Internal structures ä Ligaments ä Anterior cruciate ligament ä Posterior cruciate ligament ä Medial collateral ligament ä Lateral collateral ligament ä Cartilage ä Menisci ä Articular

8 History ä Mechanism ä Acute vs. chronic pain ä Unilateral vs. bilateral ä Swelling / effusion ä Worse with activity vs. prolonged sitting ä Stairs ä Mechanical symptoms ä Giving way ä Locking / catching

9 It hurts right here……in the front

10 Anterior knee pain ä Children / adolescent ä Patellofemoral pain syndrome ä Patella subluxation ä Patella tendinitis ä Tibial apophysitis ä Adult ä Osteoarthritis ä Pes anserine bursitis ä Gout ä Inflammatory arthropathy ä Septic joint

11 Patellofemoral Syndrome ä Also referred to as Anterior knee pain or Idiopathic anterior knee pain or chondromalacia patella ä Retropatellar or peripatellar pain ä Results from stresses upon patellofemoral joint

12 Epidemiology ä Leading cause of knee pain < 45 y/o ä Females > males ä 25-40% of all knee pain in sports clinics

13 Anatomy ä Patella is sesamoid within quadriceps tendon ä Articulates with trochlear groove of femur

14 Predisposing anatomy ä Increased Q angle ä Miserable malalignment ä VL>VMO muscle imbalance ä Decreased flexibility

15 History ä Chronic anterior knee pain ä Often bilateral ä Usually no history of acute injury ä Often unable to point to one spot ä Worse with activity ä Often worse with stairs ä Often worse with prolonged sitting

16 Exam ä Observe active knee extension: ä Lateral tracking ä Patellar tilt ä Patella mobility ä Tight retinaculum ä Q angle ä Flexibility testing ä Strength testing ä Single leg squat ä Special testing ä Patella apprehension ä Patellar compression ä Clark’s Inhibition test

17 Patellar Apprehension ä Knee flexed to 30 deg and relaxed across thigh ä Force patella laterally with thumbs ä OBSERVE FACE – notice apprehension or discomfort before actual dislocation

18 Patellofemoral Compression Clarke’s test ä Knee in full extension and relaxed ä Contract quad, ask about pain, relax quad ä Perpendicular pressure around superior patella ä with web space between thumb-index ä Re-contract quad ä Positive test = pain

19 Single Leg Squat

20 Should I order imaging? ä X-ray ä Ottawa Knee Rules ä MRI ä MRI arthrogram

21 But as in life….you have options Ottawa Knee Rules ä Age 55 or over; ä Isolated tenderness of the patella; ä Tenderness at the head of the fibula; ä Inability to flex to 90 degrees; ä Inability to walk four weight-bearing steps both immediately and in the emergency department. ä Efficacy : Sensitivity: 97% Specificity: 27% Reduced the use of knee radiographs by 28% Pittsburgh Decision Rules ä Blunt trauma or a fall as mechanism of injury plus either of the following: ä Age younger than 12 years or older than 50 years ä Inability to walk four weight-bearing steps in the emergency department ä Efficacy: Sensitivity: 99% Specificity: 60% Reduced the use of knee radiographs by 52% Tandeter HB, Shivartzman P. Acute knee injuries: use of decision rules for selective radiograph ordering. Am Fam Physician. 1999:

22 X-ray ä Check for: ä lateral subluxation ä Patella tilt ä Degenerative changes

23 How about an MRI? ä American Academy of Orthopaedic Surgeons 2011 Annual Meeting: Abstract 299. Presented February 17, ä 33 patients (31%) underwent MRIs ä 18 scans (55%) were classified as unnecessary because it was possible to make the diagnosis with history, physical examination, and X-rays alone. ä Of the remaining 75 patients (69%) who presented without an MRI study ä only 4 required additional MRI evaluation, for a tentative diagnosis of a meniscal tear in 3 patients and osteonecrosis in 1 patient ä The most common final diagnosis for this cohort was osteoarthritis in 41 patients (38%), followed by patellofemoral syndrome in 14 patients (13%) and meniscal tears in 8 patients (7%).

24 Treatment ä Physical Therapy ä Modalities ä Alternative ä Surgery

25 Physical Therapy ä Strengthen VMO ä Closed chain exercises ä Hip abductor/external rotator strengthening ä IT band/ hamstring flexibility

26 Other modalities ä Taping ä Widely employed, multiple trials have shown not significant benefit* ä McConnell taping ä Bracing ä No good data to demonstrate benefit ä Patella stabilizing brace ä Palumbo knee brace ä Corticosteroid injection * Aminaka N, Gribble, PA. A Systematic Review of the Effects of Therapeutic Taping…. J. of Athl Train: 2005

27 Alternative treatments ä Acupuncture ä In randomized study, placebo group showed equal benefit ä Benefit at four weeks ä Chiropractic patellar mobilization ä No statistical improvement ä Manipulation ä Decreased quadriceps inhibition

28 Referral to Specialist ä Conservative Trial Fails- 4-6 weeks ä Effusion associated w/ AKP ä Important to Answer before referral ä Is Pain Reflex Inhibition gone? ä Is there evidence of VMO hypertrophy? If no, compliance issues must be addressed.

29 Surgical intervention ä Lateral release ä 17-92% pt satisfaction ä Tibial tubercle advancement ä Vastus Medialis transposition ä Microfracture procedures for chondromalacia

30 It is not so much pain…..but more of an unsteady felling

31 Knee instability ä Ligament sprain ä Meniscal tear ä Reflexive pain arc ä Osteoarthritis ä Loose body ä Osteochondral defect ä Osteochondritis desiccants

32 Statistics ä 100,000 ACL injuries a year ä Female athletes at 2-8 times increased risk for ACL injury than male athletes in comparable sports ä Women experience ACL tears up to nine times more often then men. American Family Physician; 2010 ä Non contact and contact mechanisms are different ä 70% of ACL injuries are the result of non-contact situations

33 Anatomy and Function ä Anatomy ä 2 bundles ä Runs from the anterior intercondyle region of the tibia to the medial aspect of the lateral condyle of the femur ä Function ä Maintain rotary stability ä Prevent anterior tibial translation on the femur

34 Anatomy and Function ä Anatomy ä Crescent-shaped pads of fibrocartilage located between the femoral condyles and the tibial plateaus ä Function ä Aid in dissipating loading forces placed on the knee ä stabilizing the knee during rotation ä lubricating the knee joint

35 Mechanism of Injury ä Three non-contact ACL injury mechanisms ä Cutting ä Deceleration ä Landing ä Non-contact injury will often occur with jumping or landing from a jump

36 Theories ä Neuromuscular ä Hamstring strength ä Proprioception ä Muscular activation ä Biomechanical dynamics ä Anatomy ä Femoral notch width ä Q angle ä Hormonal ä Estrogen receptors on the ACL ä Extrinsic factors

37 One plausible cause ä Dynamic Neuromuscular Imbalance ä Women run, land, and jump differently ä Female athletes land with greater maximal valgus angle* ä Significant differences between dominant and non- dominant knees* ä Female athletes rely less on hamstring and more on quadriceps and gastrocnemius++ ä Upon landing, women tend to land with less knee flexion* * Mandelbaum BR et al. Effectiveness of a Neuromuscular and Proprioceptive Training …Amer Journal of Sports Medicine Harmon KG, Ireland ML. Gender differences in noncontact anterior cruciate ligament injuries. Clinics in Sports Medicine. 2000

38 History ä Acute injury ä Unilateral ä Immediate Pain – often ä Diffuse swelling – occurring 1-2 hours after activity ä Popping – audible or felt ä Instability – knee giving way ä Catching / locking

39 Special Tests for Ligaments ä ACL ä Lachman ä 87% sensitive / 93 % specific ä Anterior Drawer ä 48% sensitive / 87% specific ä PCL ä Posterior Drawer ä Sag/ Gravity Test ä MCL ä Valgus 0&30 ä LCL ä Varus 0&30 Jackson J, O’Malley P, Kroenke K. Evaluation of Acute Knee Pain in Primary Care. Ann Intern Med: 2003; 139(7):

40 Special Tests for Menisci ä McMurray ä 52% sensitive / 97% specific ä Apley Grind ä Flick ä Several studies have concluded that a negative physical exam can reliable exclude meniscal pathology Jackson J, O’Malley P, Kroenke K. Evaluation of Acute Knee Pain in Primary Care. Ann Intern Med: 2003; 139(7): Ellis M, Meadows S, “For knee pain, how predictive is physical examination for meniscal injury?”, J Fam Pract 2004; 53(11)

41 Radiology ä X-ray ä Often normal ä Effusion ä Segond Fracture

42 Radiology ä MRI ä Torn ligament ä Wavy appearance ä Complete void ä Loss of PCL arc ä Bone bruising ä Lateral femoral condyle and tibial plateau

43 Radiology ä MRI ä Linear density change ä Intra-substance, horizontal, or vertical ä High degree injury if tear involves travels to joint surface ä Extruded tissue ä sensitivity and specificity ä 91.4% and 81.1% - medial meniscal tear ä 76% and 93.3% -lateral meniscal tear Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull. 2007

44 Treatment for an ACL Injury ä Surgery ä Athletes and active women ä Mechanical symptoms ä Graft selection ä Autograph – patella tendon vs. hamstring ä Allograph ä Non-invasive ä Physical therapy ä Bracing

45 Physical Therapy ä Strength training ä Quadriceps – hamstring ratio ä Flexibility ä Quadriceps and hamstring ä Proprioception

46 Bracing? ä No evidence that pain, range of motion, graft stability, or protection from subsequent injury were affected by brace use. Bracing after ACL Reconstruction: A Systematic Review. Clinical Orthopaedics and Related Research. 2007

47 Prevention ä Proper training – proprioception and neuromuscular training exercises ä Decelerate in a more controlled fashion by taking smaller steps than one sudden step ä Round off turns when pivoting, keeping legs inside body shape ä Concentrate on core strength

48 Prevention ä Prevention programs ä Prevent Injury, Enhance Performance ä Aim of program ä Diminish the effect of fatigue on neuromuscular control ä 88% reduction in ACL injuries* ä FIFA 11+ ä Complete warm-up to prevent ACL injuries * Mandelbaum BR et al. Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior Cruciate Ligament Injuries in Female Athletes: 2-year follow-up. American Journal of Sports Medicine. 2005; 33(7):

49 Long-term Sequelae ä Osteoarthritis in up to 90% of patients after a previous ACL

50 Treatment for a Meniscal Injury Non-surgical consideration ä Symptoms develop over 24 to 48 hours after the acute injury ä Able to bear weight ä Minimal swelling ä Knee has full range of movement with pain only at or near full flexion ä Pain on McMurray testing occurs only with deep knee flexion ä MRI demonstrates small intra- substance and vertical tears Surgical consideration ä After a severe twisting injury, activity could not be resumed ä Locked or restricted motion ä Pain after minimal flexion in McMurray testing ä An associated ACL tear ä Little improvement after 3 weeks of non-invasive treatment ä MRI demonstrates a large complex meniscal tear Cooper, R, Crossley, K, Morris, H.. Acute knee injuries. In: Clinical Sports Medicine, 2nd edition, Brukner, P, Khan, K (Eds), 2000

51 Physical Therapy ä Strength training ä Quadriceps – hamstring ratio ä Flexibility ä Quadriceps and hamstring ä Proprioception

52 Surgery ä Surgical options ä Partial or total meniscectomy ä Partial meniscectomy is preferred method considering speed of recovery and functional outcome ä Repair of the meniscal tear ä Approach ä Arthroscopic ä Open

53 Chronic Degenerated Meniscal Injury ä Medial meniscectomy in patients over the age of fifty: a six year follow-up study ä 20% of good results after a degenerative meniscal tear Ménétrey J, Siegrist O, Fritschy D. Medial meniscectomy in patients over the age of fifty: a six year follow-up study. Swiss Surg. 2002;.

54 Chronic Degenerated Meniscal Injury ä A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the knee ä Arthroscopic surgery for osteoarthritis of the knee provides no additional benefits to optimized physical and medical therapy Kirkley A, et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. The New England Journal of medicine

55 In Conclusion ä Patellofemoral is a very common problem. An accurate diagnosis and aggressive treatment plan can be helpful to patients. ä ACL injuries can be devastating but we may have some ways to help prevent the injury from occurring ä Not all meniscal injuries need surgery

56 References ä American Academy of Orthopaedic Surgeons 2011 Annual Meeting: Abstract 299. Presented February 17, ä Aminaka N, Gribble, PA. A Systematic Review of the Effects of Therapeutic Taping on Patellofemoral Pain Syndrome. Journal of Athletic Training: 2005 ä Calmbach W, Hutchens M. Evaluation of Patients Presenting with Knee Pain: Part I. History, Physical Examination, Radiographs, and Laboratory Tests. Am Fam Physician: 2003; 68(5). ä Calmbach W, Hutchens M, “Evaluation of Patients Presenting with Knee Pain: Part II. Differential Diagnosis”, Am Fam Physician 2003; 68(5). ä Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull. 2007;84:5. ä Cooper, R, Crossley, K, Morris, H.. Acute knee injuries. In: Clinical Sports Medicine, 2nd edition, Brukner, P, Khan, K (Eds), McGraw-Hill, p.426 ä ä Ellis M, Meadows S. For knee pain, how predictive is physical examination for meniscal injury?” J Fam Pract 2004; 53(11). ä Harmon KG, Ireland ML. Gender differences in noncontact anterior cruciate ligament injuries. Clinics in Sports Medicine, vol. 19, no. 2, pp. 287–302, 2000.

57 References ä Jackson J, O’Malley P, Kroenke K. Evaluation of Acute Knee Pain in Primary Care. Ann Intern Med: 2003; 139(7): ä Kirkley A, et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. The New England Journal of medicine. 2008; 359(11): ä Mandelbaum BR et al. Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior Cruciate Ligament Injuries in Female Athletes: 2-year follow-up. American Journal of Sports Medicine. 2005; 33(7): ä Ménétrey J, Siegrist O, Fritschy D. Medial meniscectomy in patients over the age of fifty: a six year follow-up study. Swiss Surg. 2002;8(3):113. ä Tandeter HB, Shivartzman P. Acute knee injuries: use of decision rules for selective radiograph ordering. Am Fam Physician. 1999: Dec;60(9): ä Wright R, Fetzer G. Bracing after ACL Reconstruction: A Systematic Review. Clinical Orthopeadics and Related Research. 2007

58 Increased Q angle ä Measurement ä ASIS to mid patella ä Mid patella to tibial tubercle ä Normal angle ä degrees ä Lateral pull leads to abnormal tracking

59 Mechanism of Injury ä Anatomic Abnormality ä Malalignment ä Muscle imbalance ä Compensation ä Repetitive Microtrauma ä Overuse ä Growth spurts in children ä Macrotrauma ä Contusion ä Sprain / strain


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