Evaluation of Knee Problems

Transcription

1 Evaluation of Knee Problems

2 OBJECTIVES Review knee anatomy Explain tests to look for pathology Briefly introduce knee problems

3 Only by a thorough knowledge of anatomy and functional testing can one make an accurate diagnosis and direct effective care to an injured knee.

4 Ligamentous Anatomy Hinged Joint ACL: Ant Stability PCL: Post Stability Lat/Med Stability: LCL/MCL Menisci: Medial/Lateral

5 EXTENSOR MECHANISM The Quadriceps ORIGINS: Rectus Femoris: AIIS Vastus Group: Linea Aspera INSERTIONS: Patella Patellar Retinaculum

6 Always have the patient perform a straight leg raise to rule out an extensor mechanism rupture after acute trauma

7 FLEXOR MECHANISM The Hamstring COMMON ORIGIN: Ischial Tuberosity INSERTIONS: Biceps: Fibular Head Semimembranosus: Medial Tibial Condyle Semitendinosus: Pes Anserinus

8 History Chief Complaint Antecedent event/repetitive activity Previous injuries to affected area Attempted therapies Review of symptoms/past medical history Occupation/Treatment Goals

9 Inspection Lower extremity alignment Foot structure Effusion/Erythmea Q Angle Thigh atrophy

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11 Foot Structure Variants Pes Planus Pes Cavus

12 Ballotment Test for Effusion

13 Causes of Traumatic Effusion 1. ACL tear 2. Meniscal tear 3. Patellar dislocation 4. Fracture 5. Others (PCL, MCL, LCL)

14 Quadriceps Angle (Q Angle) = The Angle between: 1) ASIS to center of Patella and 2) Patella to Tibial Tubercle NORMAL Men <10 Women <15

15 Thigh Atrophy Possible sign of intra-articular pathology Measure either hand breadth above patella or 10cm above patella Measure 2 times > 1 cm different is abnormal

16 Leg Length FUNCTIONAL METHOD: Compare heights of ASIS & PSIS Add foot shims in small adjustments until level ANATOMICAL METHOD: Measure from ASIS to Medial Malleous > 1 cm difference is significant Pelvic Obliquity will confuse issue RADIOLOGIC METHOD: Scanogram (X-ray) most definitive but usually not needed

17 Range Of Motion

18 Palpation of key structures Medial: MCL Pes anserinus Medial meniscus Plica (ant-med) Anterior: Patellar tendon Patella Tibial tubercle Fat pad Lateral: LCL ITB/lateral femoral condyle Lateral meniscus Fibular head Posterior: Popliteus Baker s cyst

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21 Osgood-Schlatter s Disease Clinical Description The most common overuse injury seen in young athletes Traction apophyseal injury seen in running/jumping athletes during periods of rapid growth

22 Osgood-Schlatter s Disease Clinical Features History young athlete complains of painful enlargement of the tibial tuberosity pain worse with activity, esp. run/jump Exam tender tibial tuberosity tight quads +/- hamstrings Imaging: usually not necessary

23 Osgood-Schlatter s Disease Use in severe or persistent cases to rule out other problems Not used to make the diagnosis in most cases May show fragmentation of the anterior tibial tuberosity Imaging

24 Osgood-Schlatter s Disease Differential Diagnosis Sinding-Larsen-Johansson Disease Tibial neoplasm e.g. osteochondroma Patellofemoral pain syndrome Patellar tendonosis Tibial tuberosity avulsion fracture

25 Osgood-Schlatter s Disease Treatment Relative rest; cross-training Ice Hamstring stretching Strapping of patellar tendon Rare: temporary immobilization Return to play: Pain-free with sports activity

26 Osgood Schlatter s Disease Surgery Indications Persistent, painful os after growth complete

27 Sinding-Larsen-Johanssen Disease Apophysitis of distal patella Pain with kneeling and squatting. Tender at distal patellar pole Calcification is sometimes present at site of tenderness. Natural history: resolution in 6 to 10 months. Tx: ice, relative rest, ham/quad stretching

28 Patellar Grind Test Detects pain from patellar pressure against femur Compress patella against femoral groove Gentle way: pressure with fingers Most sensitive way: press down above patella; have patient contract quads POSITIVE: Pain Crepitus

29 Management of Patello-Femoral Syndrome Cross-training; avoid painful activity VMO strength ex s Flexibility ex s (quad, hams, ITB, Achilles) Retinaculum stretching Patellar sleeve w/ cutout Correct hyper-pronation Referral: refractory cases w/ high Q angle, tight retinaculum,severecrepitus

30 Lateral Patellar Glide: nl is 25-50% of width. POSITIVE TESTS: Inflexibility Subluxation (+ Apprehension)

31 Management of Patellar Dislocation X-rays to r/o shearing fracture AP, lat, sunrise Knee immobilizer/cast in ext 3 weeks ROM/strength ex s as pain allows Refer for: Locking Fracture Recurrent dislocations

32 Medio-Patellar Plica

33 Management of Medio-Patellar Plica Syndrome Cross-training/relative rest NSAID 1-2 weeks Phonopheresis Injection w/ anesthetic/steroid Referral: failed 6 months tx

34 Management of Patellar Tendinopathy Avoid NSAID overuse Restrict from further abuse Patellar strap (ChoPat) Progressive eccentric strength ex s 3-6 mos

35 Treatment of Pre-Patellar Bursitis Aspirate fluid (culture, cell count) Compressive dressing Treat suspected septic bursitis with oral antibiotics Dicloxacillin or fluoroquinolone NSAIDs F/U at 4 days Consider intra-bursal steroid injection

36 Joint Stability Testing MCL: Valgus Load LCL: VarusLoad ACL: Lachman, Ant drawer, Pivot Shift PCL: Posterior Drawer, Sag sign, Quadriceps Active Postero-lateral complex: Ext Rot

37 MCL Stability Apply Valgus or Medial Stress Test in 30 flexion LCL Stability Apply Varus or Lateral Stress

38 Grading collateral ligament injuries Grade I: mild; no laxity Grade II: partial tear; laxity w/ firm endpoint Grade III: complete tear; laxity w/o firm endpoint Why does it matter? Prognosis

39 Treatment of MCL/LCL injuries PRICEMM Grades I-II knee immobilizer until pain gone ROM/strength ex s as pain allows Grade III: r/o associated injuries knee immobilizer at 30 NWB 3 weeks knee immob NWB 4 wks progressive ROM/strength ex s

40 ACL anatomy

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43 Tests of ACL At 90 Flexion + is increased translation or soft end point At Flexion (more sensitive)

44 Lachman test

45 Pivot Shift: ACL Injury 1. Knee extended 2. Internally rotate tibia 3. Apply valgus load 4. Flex Knee 5. At 20-30, if you feel a jerk at Ant/Lat proximal tibia, test +

46 Management of ACL tears PRICEMM ROM/strength ex s as pain allows MRI Referral to Orthopedics Surgery once edema gone Graft options Bone-patella-bone autograft Hamstring autograft Cadaver allograft

47 PCL Tear

48 PCL TESTS: Posterior Sag Quad Active Test Posterior Drawer

49 Management of PCL tears PRICEMM Immobilize; refer to Ortho If no associated injuries: ROM /strength ex s as pain allows If associated with other injuries: Surgical repair MCL Postero-lateral corner

50 Injury to Postero-Lateral Corner External Rotation Test Flex knees to 30. Externally rotate tibia. Injured limb will have external rotation. Repeat at 90 flexion (persistent incr is from combined PLC/PCL injury)

51 Popliteus Tendonitis Function: resists posterior translation of tibia Pain postero-lateral Garrick Test: pain with resisted ext rotation of leg Seen w/ downhill running Treatment: Modify running NSAID/ice Hamstring stretching Eccentric quad strength Refer for injection if not responding Popliteus

52 Flexibility testing Inflexibility is a common culprit in overuse Hamstring Quadriceps Ilio-tibial band (ITB) Gastro-soleus complex Patellar glide and tilt

53 Quadriceps flexibility

54 Hamstring flexibility: Popliteal Angle Goal: 0

55 Gastro-soleus flexibility

56 ITB flexibility: Ober test Tight ITB will remain ABducted Pain = ITB injury

57 Ilio-Tibial Band Friction Syndrome

58 Management of ITB Friction Syndrome Reduce run mileage/hills/banked surfaces NSAID/ice massage/phonopheresis ITB stretching Correct overpronation Gradual return-to-running program Referral for injection if fail above

59 Miscellaneous Tests McMurray: Meniscal injury Apley Test: Meniscal vs ligament injury Bounce Home Test: meniscal injury, effusion Patellar grind test: PFS, chondromalacia

60 Normal Meniscus Meniscal Tear

61 McMurray Test MEDIAL MENISCUS: Flex knee maximally Externally rotate tibia Varusstress Extend Knee LATERAL MENISCUS: Flex knee Internally rotate tibia Valgus stress Extend knee + is painful pop over Medial or Lateral Joint Line

62 McMurray Test

63 Apley test Compression for Meniscal Injury Distraction for Ligamentous Injury

64 Full Flexion Test Pain at full flexion suggestive of posterior horn tear

65 Bounce Home Test 1. Flexion Normal 2. Passive Extension Abnormal is lack of full extension (meniscal tear, loose body, effusion)

66 The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee: A meta-analysis. Bijl D et al. JFP Nov 2001;50(11) The diagnostic accuracy of meniscal tests is poor These tests are of little value for clinical practice. McMurray test and joint line tenderness indicated little discriminative power for these tests. Only the predictive value of a positive McMurray test was favorable.

67 Management of Meniscal Tears Weight-bearing as tolerated ROM/strength ex s as pain allows MRI to confirm if recovery not prompt Indications for referral: Elite athletes Symptomatic after 3 months Locking Unable to fully extend knee

68 Who needs knee xrays after trauma? Ottawa Knee Rules: Any of the following: Age < 1 or >55 Tenderness over patella Tenderness over fibular head Inability to walk 4 steps immediately and when examined Unable to flex knee 90d 100% sensitivity and neg predictive value

69 Osteochondritis Dissecans Clinical Features History Vague activity-related knee pain +/- clicking, locking, giving way Physical Exam Decreased or painful motion May be effusion Poorly localized joint line tenderness

70 Wilson Test THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 8 - AUGUST 98

71 Imaging Tunnel View reveals radiolucent area Bone scan if x-rays negative MRI best for staging, prognosis

72 Osteochondritis Dissecans Treatment Orthopedic Consultation Stage 1: Conservative Activity restriction or immobilization 6-8 wks Surgery if fails to heal Stage 2: Controversial Stages 3 & 4: Operative

73 THE PHYSICIAN AND SPORTSMEDICINE -VOL 26 -NO. 8 -AUGUST 98

74 Review Only by a thorough knowledge of anatomy and functional testing can one make an accurate diagnosis and direct effective care to an injured knee.