1. Knee Pain
Presented by
Charles J. Holcomb
Bryant Saenz
Peter Tresize

2. Younger Pop Older Pop Patellar subluxation Chondromalacia patellae
Tibial apophysitis (Osgood-Schlatter lesion)
Jumper's knee (patellar tendonitis)
Slipped capital femoral epiphysis
Osteochondritis dissecans
Medial plica syndrome
Pes anserine bursitis
Ligamentous sprains
Anterior cruciate tear
Medial collateral tear
Lateral collateral tear
Meniscal tear (medial/lateral)
ITB Syndrome
Chondromalacia patellae
Rheumatoid arthritis
Reiter's syndrome
Septic arthritis
Osteoarthritis
Gout
Pseudogout
Popliteal cyst (Baker's cyst)
Gonorrhea
Popliteus tendonitis
Superior tibial fibular subluxation
Neoplasms
Fracture

3. Most common Knee Problems you’ll see in your Practice
ACL, MCL tear
Meniscal tear
ITB syndrome
Patellofemoral Arthralgia and CMP
Osteoarthritis
Jumper’s knee
Osgood-Schlatter disease
Osteochondritis dissecans

4. You’re a team doctor for a College level athletic team
You’re a team doctor for a College level athletic team. Lindsay McHaha tackled on the field in a game of field hockey. She is grabbing her knee and sais that she was struck from the side and felt a pop in her knee. She is unable to bear weight or walk on this leg. There is immediate swelling, and pain

5. Medial Collateral Ligament
Patients w/ injury to the MCL will demonstrate some of these symptoms:
* Pain / Tenderness
* Stiffness
* Swelling (typical, but not necessary)
* Instability
The MCL functions to provide knee stability against valgus stresses (preventing the knee from buckling inwards).

6. Complicating Factors! Orthopedic Tests Diagnostic Imaging
MCL tears commonly occur with ACL tears or Medial Meniscus tears so it is a good idea to test for those injuries as well (AKA The Terrible Triad)
Orthopedic Tests
Valgus Stress Test - MCL
Apply’s Distraction Test - MCL/LCL
Lachman’s - ACL
McMurry’s - Medial Meniscus
Apply’s Compression Test - Medial and Lateral Meniscus
Anterior/Posterior Drawer - ACL/PCL
Diagnostic Imaging
X-rays are useful in ruling out other knee pathology, but this is not the gold standard for evaluating ligament damage
MRI is the Gold standard for seeing the extent of damage done to the MCL (or for any of the ligaments in the knee for that matter)
- 90% accuracy of diagnosing MCL

7. Grading MCL Tears Grade I MCL Tear - Incomplete tear of the MCL.
Tendon is still in continuity
Symptoms are usually minimal
Patients usually complain of pain with pressure on the MCL
Most athletes miss 1-2 weeks of play.
Grade II MCL Tear
Incomplete tear of the ligament
Complain of instability when attempting to cut or pivot
Pain and swelling is more significant
a period of 3-4 weeks of rest is necessary.
Grade III MCL Tear
Complete tear of the MCL
Significant pain and swelling
Complete instability (inability to stand on that leg)
Knee brace/immobilizer is needed & surgery is eminent

8. Grade I MCL Tear
Grade II MCL Tear
Grade II MCL Tear

9. A 16 year old male basketball player limps into the office complaining of right knee pain. His mother says that he’s been complaining of this pain for quite some time now. She says she’s tired of his complaining and that you need to figure out what his problem is and fix him!

10. Acute Chronic MCL LCL ACL PCL Quadricep tendon Meniscus med/lat
Patellar ligament
Chronic
CMP
Osgood Schlatter
Patellar Tendonitis
Pes Anserine
Muscle imbalance
Subluxation
Sprain strain
Ligament Laxity

11. Hx No previous history of injuries or surgeries
Pain was a gradual build up and started to affect playing basketball
He states “I can’t jump as high”
Resting helps ease the pain
Jumping exacerbates the pain

12. Rule out / Rule in Acute Chronic MCL LCL ACL PCL Quadricep tendon
Meniscus med/lat
Patellar ligament
Chronic
CMP
Osgood Schlatter
Patellar Tendonitis
Pes Anserine
Muscle imbalance
Subluxation
Sprain strain
Ligament Laxity

13. Observation There is minimal swelling of the knee
Patient cringes every time has to get up from a seated position

14. Exam Compression/distractiv (-) Valgus/varus stress test (-)
Ant/post drawer test (-)
Patella grind test (-)
+ tenderness palpation
Weakness of the Quadriceps
Knee extension increased pain

16. X-ray reveal

17. MRI

18. Patellar Tendonitis Aka “Jumper’s Knee”
d/t eccentric strain of patellar tendon
May cause fragmentation of inferior pole of patella (Sinding-Larsen-Johansson disorder)

19. 4 Categories Grade 1- Pain only after training
Grade 2- Pain before and after training but pain eases once warmed
Grade 3- Pain during training which limits your performance
Grade 4- Pain during every day activities

20. Knee Pain Knee Pain in Older Patietnts
62 year-old female piano teacher comes in with right knee pain. It started out as just stiffness and pain in her knee but it has gradually been getting worse. She has an increase in her pain and stiffness when she wakes up in the morning but it lasts less than 30 min. She also notices a great deal of pain when getting up from a seated position after she has been sitting for an extended period of time. In her younger days she was a roller derby girl and she sustained many knee injuries while doing this. Those days are long gone and she is now obese.
What’s the diagnosis?

21. Knee Pain
Diff DX RA
R/I because it causes pain and stiffness in joints, especially in the morning.
R/O because the pain only lasted less than 30 min in the morning. RA is a systemic disease, patient reports no fever, malaise, or severe fatigue.

22. Knee Pain
Diff Dx
CMP
R/I because of history of mild to moderate anterior knee pain that usually occurs after prolonged periods of sitting.
R/O through negative Clark’s sign, negative Patella Grind, negative Waldron’s.

23. Knee Pain Diff Dx Bursitis
R/I because of the limited and painful movement of the knee.
R/O because there was no real swelling and Bursitis is more common in carpenter/gardeners (people who spend a lot of time on their knees) our patient spends a lot of time sitting at the piano.

24. Osteoarthritis Diagnosis
Osteoarthritis is the most common joint disorder.
Deterioration of articular cartilage due to overuse is the main problem associated with knee osteoarthritis.

25. Osteoarthritis Occurs with age Being overweight increases the risk
Fractures or other joint injuries can lead to osteoarthritis later in life
Long-term overuse at work or in sports can lead to osteoarthritis
Varying degrees of pain, especially when you stand or walk
Pain in the morning that lasts less than 30 min. (a good way to differentiate from RA, stiffness will last a lot longer with RA)

26. Exam findings
Varus angulation may be apparent (bow-legged)
Palpation may uncover osteophytic development at joint line
With early OA the anterior drawer test will demonstrate a loose joint
Advanced OA = less movement than normal on drawer testing

27. Radiology Radiology views AP weight-bearing Lateral Knee
Tunnel Projection
Radiology findings may include
Decreased medial joint space (m/c finding)
Subchondral cysts
Osteophyte formation