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

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

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

Doc....my knee hurts

Most Common Causes of Knee Pain in Primary Care Osteoarthritis (34%) Meniscal injury (9%) Collateral ligament injury (7%) Cruciate ligament injury (4%) Gout (2%) Fracture (1.2%) 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):575-588.

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

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

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

It hurts right here……in the front

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

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

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

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

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

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

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

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

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

Single Leg Squat

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

But as in life….you have options Ottawa Knee Rules Pittsburgh Decision Rules Age 55 or over; Isolated tenderness of the patella; Tenderness at the head of the fibula; Inability to flex to 90 degrees; Inability to walk four weight-bearing steps both immediately and in the emergency department. Efficacy : Sensitivity: 97% Specificity: 27% Reduced the use of knee radiographs by 28% Blunt trauma or a fall as mechanism of injury plus either of the following: Age younger than 12 years or older than 50 years Inability to walk four weight-bearing steps in the emergency department Efficacy: Sensitivity: 99% Specificity: 60% Reduced the use of knee radiographs by 52% The Pittsburgh Decision Rules are more sensitive and more specific (1). Validated - ANNALS OF EMERGENCY MEDICINE 3 8 : 4 OCTOBER 2001 Tandeter HB, Shivartzman P. Acute knee injuries: use of decision rules for selective radiograph ordering. Am Fam Physician. 1999:

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

How about an MRI? American Academy of Orthopaedic Surgeons 2011 Annual Meeting: Abstract 299. Presented February 17, 2011. 33 patients (31%) underwent MRIs 18 scans (55%) were classified as unnecessary because it was possible to make the diagnosis with history, physical examination, and X-rays alone. Of the remaining 75 patients (69%) who presented without an MRI study only 4 required additional MRI evaluation, for a tentative diagnosis of a meniscal tear in 3 patients and osteonecrosis in 1 patient 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%). the diagnosis could be established using plain X-rays alone, the patient had patellofemoral pain with a normal ligamentous and meniscal exam, the patient's knee pain resolved before he or she was seen by an orthopedic surgeon, or the MRI findings had no effect on treatment outcome.

Treatment Physical Therapy Modalities Alternative Surgery

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

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

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

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

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

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

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

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

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

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

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

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

One plausible cause Dynamic Neuromuscular Imbalance Women run, land, and jump differently Female athletes land with greater maximal valgus angle* Significant differences between dominant and non-dominant knees* Female athletes rely less on hamstring and more on quadriceps and gastrocnemius++ 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. 2005 ++ Harmon KG, Ireland ML. Gender differences in noncontact anterior cruciate ligament injuries. Clinics in Sports Medicine. 2000

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

Special Tests for Ligaments ACL Lachman 87% sensitive / 93 % specific Anterior Drawer 48% sensitive / 87% specific PCL Posterior Drawer Sag/ Gravity Test MCL Valgus Stress @ 0&30 LCL Varus Stress @ 0&30 Jackson J, O’Malley P, Kroenke K. Evaluation of Acute Knee Pain in Primary Care. Ann Intern Med: 2003; 139(7):575-588.

Special Tests for Menisci McMurray 52% sensitive / 97% specific Apley Grind Flick 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):575-588 Ellis M, Meadows S, “For knee pain, how predictive is physical examination for meniscal injury?”, J Fam Pract 2004; 53(11)

Radiology X-ray Often normal Effusion Segond Fracture

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

Radiology MRI Linear density change Extruded tissue Intra-substance, horizontal, or vertical High degree injury if tear involves travels to joint surface Extruded tissue sensitivity and specificity 91.4% and 81.1% - medial meniscal tear 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

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

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

Bracing? 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

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

Prevention Prevention programs Prevent Injury, Enhance Performance Aim of program Diminish the effect of fatigue on neuromuscular control 88% reduction in ACL injuries* FIFA 11+ 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): 1003-1010

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

Treatment for a Meniscal Injury Non-surgical consideration Surgical consideration Symptoms develop over 24 to 48 hours after the acute injury Able to bear weight Minimal swelling Knee has full range of movement with pain only at or near full flexion Pain on McMurray testing occurs only with deep knee flexion MRI demonstrates small intra-substance and vertical tears After a severe twisting injury, activity could not be resumed Locked or restricted motion Pain after minimal flexion in McMurray testing An associated ACL tear Little improvement after 3 weeks of non-invasive treatment 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

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

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

Chronic Degenerated Meniscal Injury Medial meniscectomy in patients over the age of fifty: a six year follow-up study 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;.

Chronic Degenerated Meniscal Injury A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the knee 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. 2008.

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

References American Academy of Orthopaedic Surgeons 2011 Annual Meeting: Abstract 299. Presented February 17, 2011. Aminaka N, Gribble, PA. A Systematic Review of the Effects of Therapeutic Taping on Patellofemoral Pain Syndrome. Journal of Athletic Training: 2005 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). Calmbach W, Hutchens M, “Evaluation of Patients Presenting with Knee Pain: Part II. Differential Diagnosis”, Am Fam Physician 2003; 68(5). 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. Cooper, R, Crossley, K, Morris, H.. Acute knee injuries. In: Clinical Sports Medicine, 2nd edition, Brukner, P, Khan, K (Eds), McGraw-Hill, 2000. p.426 Ellis M, Meadows S. For knee pain, how predictive is physical examination for meniscal injury?” J Fam Pract 2004; 53(11). Harmon KG, Ireland ML. Gender differences in noncontact anterior cruciate ligament injuries. Clinics in Sports Medicine, vol. 19, no. 2, pp. 287–302, 2000.

References Jackson J, O’Malley P, Kroenke K. Evaluation of Acute Knee Pain in Primary Care. Ann Intern Med: 2003; 139(7):575-588. Kirkley A, et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. The New England Journal of medicine. 2008; 359(11):10971107. 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): 1003-1010. 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. Tandeter HB, Shivartzman P. Acute knee injuries: use of decision rules for selective radiograph ordering. Am Fam Physician. 1999: Dec;60(9):2599-608. Wright R, Fetzer G. Bracing after ACL Reconstruction: A Systematic Review. Clinical Orthopeadics and Related Research. 2007

Increased Q angle Measurement Normal angle ASIS to mid patella Mid patella to tibial tubercle Normal angle 10-20 degrees Lateral pull leads to abnormal tracking

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