2 History53 year old (5’2”, 168 lbs) female presents in the office with pain in the medial and posterior right knee.The pain started about 5 years ago and is progressively getting worse.She remembers the pain starting after she fell into a drainage ditch while walking across her lawn.She has been to a physical therapist (12 visits after fall) , a chiropractor (6 months, last visit 1 year ago), an orthopedist (at time of fall) and a massage therapist (a few visits in the past year) for help with her knee pain.
3 HistorySometimes she notices some relief with massage and ice, but mostly the pain is relieved with rest.The pain bothers her mostly when she walks or stands for more than 10 minutes at a time. It used to be 30 minutes but recently she notices the pain coming on more often than it used to. She finds it hard to go up or down stairs.She is a machinist and has to stand at her job, although recently, she has been given a stool to sit on during some of the aspects of her job.
4 HistoryShe had an MRI and x-rays of her knee when the injury first occurred.At that time she was diagnosed with a sprained medial collateral ligament and anterior cruciate ligament. No meniscus tears were seen on the MRI.
5 Provide your Differential Diagnosis Minimum of 2Examinations for DDxWhat examinations would you perform on your patient?
7 About the knee exam What should we ask the patient? Is there any locking, popping, or giving way of the knee?A history of locking episodes suggests a meniscal tear.A sensation of popping at the time of injury suggests ligamentous injury, probably complete rupture of a ligament. (third-degree tear)Episodes of giving way are consistent with some degree of knee instability and may indicate patellar subluxation or ligamentous rupture.Joint Swelling?Rapid onset (within two hours) of a large, tense effusion suggests rupture of the anterior cruciate ligament or fracture of the tibial plateau.Slower onset (24 to 36 hours) of a mild to moderate effusion is consistent with meniscal injury or ligamentous sprain.Recurrent knee effusion immediately after activity is consistent with meniscal injury.
14 Examination: Patella: Cruciates: Collaterals: Meniscus: Patellar apprehension test = negativeBallottement Test = PositiveClarke's Sign (Patellar Scrape test) = Positive BilateralCruciates:Drawer Test = negativeCollaterals:Varus = negative (no movement or pain at 0 and 30 degrees)Valgus = no pain with slight movement at o degrees and pain at 30 degreesApley's Distraction Test = positive for pain at the MCLMeniscus:Apley's Compression Test = negativeMcMurray Sign = negative
15 Modified Thomas TestTests for flexibility for the ITB, iliopsoas, QuadricepsSLR: hamstringsOur patient had tight hamstrings and ITBs
16 What do the test results mean? Positive tests?Negative tests?What else should we test?
17 Evidence Based Clinical Evaluation Koos Knee Survey:Knee and Osteoarthritis Outcome ScoreSymptoms, Pain, ADLs, Sports and recreation, Quality of life42 QuestionsNever Rarely Sometimes Often Always(0) (1) (2) (3) (4)Add it up and divide by 168Her score was 67VAS was a 5 out of 10
19 X-ray reportA mild decrease in joint space involving the medial compartment. The lateral and retropatellar compartments are within normal limits.There is no unusual soft tissue calcification visualized. The articular surfaces are within normal limits.Impressions: Mild reduction of joint space involving the medial compartment – degenerative joint disease.
20 Final Dx 726.61 Pes anserinus tendinitis or bursitis Pes anserinus is the anatomic term used to identify the insertion of the conjoined tendons into the anteromedial proximal tibia. From anterior to posterior, pes anserinus is made up of the tendons of the sartorius (F), gracilis (A), and semitendinosus (C) muscles. The term literally means "goose's foot," describing the webbed footlike structure. The conjoined tendon lies superficial to the tibial insertion of the medial collateral ligament (MCL) of the knee.
22 Final Dx: 726.61 Pes anserinus tendinitis or bursitis 739.6 Lower extremities, Nonallopathic lesions, not elsewhere classified
23 Patient Management Plan 3 times per week for 2 weeks followed by 2 times per week for 2 weeks.To reduce the pain in the right knee (lowering the KOOS score by 20 points)Allow for mild limitation of ALDs.Adjust the knee (posterior medial Tibia)Give stabilizing exercises and stretchesInstruct use of supports
24 Daily Visits Adjust the posterior tibia Icing instructions (3 times per day for 20 minutes)Stretching instructions for the ITB and HamstringsTape or Brace
25 Daily VisitsThe patient returned 2 days later with a VAS rating of a 0No pain in the knee. She was able to go up and down stepswithout pain.She was not using a brace or the tape.She did ice and was stretching.No adjustment was indicated, she was put on resisted quadriceps and hamstring exercises.The patient was told to come back in 1 week or if the pain came back, which ever came first.
26 Daily VisitsShe returned a week later with complaints of right knee pain.A mild pain started the night before our appointment due to walking around at her grandson’s baseball game.Her knee was evaluated and adjusted for a posterior medial tibia.She was scheduled to return in a week or if the pain returned.
27 Daily Visits 1 week later she returned with no pain. She was doing the exercises and stretching, but no longer icingShe was walking 2 miles a day with her husband for the last 4 days without pain.Her knee was evaluated and no adjustment was indicated.A re-evaluation of the KOOS was taken.
28 Evidence Based Clinical Evaluation Koos Knee Survey:Her initial score was 67After weeks of care it was a 12
29 Patient ManagementThe patient was released from active care and told to return in 6 weeks for a follow up visit.She has continued with chiropractic care for her knee and occasional low back pain for the past 3 years. She is now see once every 5 to 6 months.She has referred at least 6 patients to the clinic for their knee complaints. She calls us the knee clinic