Disclosures. Knee Anatomy. Objective. Five Common Knee and Ankle Conditions You Will See in Office Practice 8/11/2016

Transcription

1 ESSENTIALS OF PRIMARY CARE: A Core Curriculum for Ambulatory Practice August 7-12, 2016 Five Common Knee and Ankle Conditions You Will See in Office Practice I have nothing to disclose Disclosures Cindy J. Chang M.D. UCSF Primary Care Sports Medicine Associate Clinical Professor of Orthopaedics and Family and Community Medicine Objective Develop strategies to diagnose and manage common office problems including knee and ankle injuries Knee Anatomy 1

2 Anterior Knee Medial Knee Lateral Knee Knee: Case #1 40 yo male playing in family Thanksgiving Day touch football game Tackled by his brother-in-law ( who never really liked me ) and his knee twisted under him Now seeing you 1 week later and using an ACE wrap and borrowed cane 2

3 Which next question would be the least valuable in terms of determining the diagnosis? A. How long did it take before it swelled? B. Were you able to continue playing? 43% C. Does your knee give way? D. Did you feel a pop? E. Have you ever injured that knee in the past? W e r e y o u a b l e t o c o n t i... H o w l o n g d i d i t t a k e b e f o.. 19% 13% 14% 10% D o e s y o u r k n e e g i v e w a y? D i d y o u f e e l a p o p? H a v e y o u e v e r i n j u r e d t h.. Knee: Case #1 40 yo male playing in family Thanksgiving Day touch football game Tackled by his brother-in-law ( who never really liked me ) and he felt a pop as his knee twisted under him Hard to put weight on leg and was unable to continue playing The knee swelled like a melon within 2 hours despite ice His knee shifts when he puts more weight on it Now seeing you 1 week later and using an ACE wrap and borrowed cane Knee: Case #1 Differential Diagnosis Ligament tear ACL tear MCL tear Less likely LCL tear, PCL tear Tendon rupture Meniscus tear Patellar dislocation Chondral injury Bone contusion/fracture Physical Exam Trauma Knee: Case #1 First: Point to where it hurts Effusion vs. Soft tissue swelling Superficial abrasions Active straight leg raise 3

4 Knee: Case #1 Knee: Case #1 Physical Exam Trauma Ligament stability Lachman Posterior drawer Valgus stress Varus stress/figure of 4 Joint line tenderness Physical Exam Trauma Joint line tenderness Meniscus Bone bruise Chondral injury Physical Exam Trauma Patellar apprehension Knee: Case #1 Knee: Case #1 Xrays for traumatic injury +/- MRI 4

5 Knee: Case #2 40 yo male joined a gym in January with his brother-in-law Began working with a personal trainer and they started a program of Olympic lifting (squatting, cleans) and plyometrics (box jumps) After 2 weeks began having left knee pain after workouts but continued training Now seeing you 2 weeks later because now it hurts during training and even with walking, especially on the stairs What is the least likely diagnosis? A. Patellar tendonitis B. Pes anserine bursitis C. MCL sprain D. Patellofemoral syndrome E. Hamstring strain P a t e l l a r t e n d o n i t i s 4% P e s a n s e r i n e b u r s i t i s 8% M C L s p r a i n 38% P a t e l l o f e m o r a l s y n d r o m e 11% H a m s t r i n g s t r a i n 39% Patellofemoral Pain Patellofemoral Pain Will point to kneecap region Pain associated with running, lunging, squats Pain with sitting for prolonged period Pain going down stairs may be worse than up stairs Soft tissue swelling often described as puffiness Positive patellar compression test Pain on palp of medial facet of patella Increased patellar mobility 5

6 Patellofemoral Pain Patellofemoral Pain Single Leg Squat to evaluate for weak quads, gluts Thomas test to evaluate tight hip flexors, quads, ITB Patellar Tendinitis Pes Anserine Bursitis Pain with resisted knee extension resisted straight leg raise single leg squat May have swelling at inferior pole of the patella Tenderness at prox patellar tendon Primary flexors of the knee Protects knee against rotatory and valgus stress Pain often acute Can occur with sports and exercise Can also occur in sedentary Osgood Schlatters 6

7 Iliotibial Band Syndrome Management of Knee Pain Trauma Diagnosed/suspect ligament, tendon, meniscus, bony injury Brace, consider crutches, ice and ACE wrap, NSAIDs for short duration Refer Surgery possible due to instab, mech symptoms, fx Overuse Suspect moderate to severe sprain/strain Patient request PFS, patellar tendinitis, Pes anserine bursitis, ITB Brace, Ice/ACE wrap, NSAIDs Stretches, foam roller, strengthening, x-train, internet Make a PT referral and f/u with you in 4-8 wks or after 4-6 PT visits Which of the following is an indication to order Xrays? 16 yo female playing in basketball game and turned her ankle inwards after a rebound when she came down on another foot She felt a pop, and was unable to bear weight She had immediate swelling on the outside and front of her ankle She is able to limp into your exam room the next day. She points to her lateral ankle as the area of most pain and she is very tender when you palpate the distal tip of the fibula A. Feeling or hearing a pop B. Inability to walk for 4 steps immediately after the injury C. Any bruising along the lateral and/or medial malleolus D. Tenderness on palpation along tip of lateral malleolus E. Numbness around the area of swelling 6% 44% 7% 38% 6% F e e l i n g o r h e a r i n g a p o p I n a b i l i t y t o w a l k f o r 4 s t e.. A n y b r u i s i n g a l o n g t h e l a... T e n d e r n e s s o n p a l p a t i o n... N u m b n e s s a r o u n d t h e a r.. 7

8 Ankle Anatomy- Anterior Ankle Anatomy-Lateral Ankle Case #1 Differential Dx Fracture Distal fibula Other Ligament sprain Lateral ligaments Other Tendon strain Peroneal Achilles Moderate swelling of a fusiform nature ankle and anterolateral and lateral ankle region Ecchymosis inferior to lateral malleolus + Squeeze test No pain Fibular head 5 th MT 8

9 Syndesmosis injury high ankle sprain +2 anterior drawer +2 lateral talar tilt +2 anterior drawer +2 lateral talar tilt Stable medial tilt Stable talar shift 9

10 Significantly decreased range of motion Decreased strength secondary to pain Pain over: Medial ankle Dorsal ankle Lateral malleolus ATFL, CFL AITFL, PITFL Pain with Squeeze test 10

11 a b Patient is 10 yo Patient also has 5 th MT pain Ankle: Case #2 A 35 yo female has begun a walking program to get more fit and lose her 20# baby weight She lives with her family in a hilly part of the city; time-wise it is easier to walk in her neighborhood She has exactly 45 minutes, after her workday and before her spouse comes home with the kids from daycare, to walk a 3 mile loop After 1 week she began to have pain in her medial ankle at the end of walking Now it hurts her even during, in the morning out of bed, and if she gets up from her chair at work after prolonged sitting What other questions would be helpful in arriving at the diagnosis? A. Is there any radiation of pain? B. Have you ever injured this ankle before? C. What type of shoes are you wearing during your power walks? D. Did you build up to the 45 minutes every day? E. All of the above I s t h e r e a n y r a d i a t i o n o f... 0% 1% H a v e y o u e v e r i n j u r e d t h.. W h a t t y p e o f s h o e s a r e... 5% D i d y o u b u i l d u p t o t h e.. 2% A l l o f t h e a b o v e 92% 11

12 Ankle Anatomy-Medial Ankle: Case #2 Posterior Tibial Tendinitis Etiology Typically Overuse syndrome (too much, too soon) Poor shoeware on pronated feet Ankle: Case #2 Posterior Tibial Tendinitis History: Initially may warm-up Stiff after inactivity Can also occur after returning back to activity too quickly after ankle injury or after incomplete rehab Before achieving full DF range of motion Exam: Ankle: Case #2 Posterior Tibial Tendinitis Pain with resisted inversion Tightness of posteromedial compartment of LE May also have shin splints Evaluate heel raise bilat Too many toes sign 12

13 Ankle Case #3 Ankle Anatomy-Posterior 35 yo female almost one year later, has now decided to try to jog her route She has motion control running shoes to control her pronation Once again, the pain initially began at the end of jogging, then it started to hurt at the beginning but then would warm-up only to return towards the end. Hurts again in the morning out of bed But this time the pain is in the back of her ankle Etiology Ankle: Case #3 Achilles Tendinitis New onset of an activity or increased level of intensity or increased duration Change in surface/terrain Change in footwear Flats or lower heels than usual Physical Exam Ankle: Case #3 Achilles Tendinitis Swelling and pain over Achilles tendon, approx. 2-5 cm proximal to insertion Crepitus on palpation and with ROM Thickening of tendon Pain with resisted PF and passive DF Limited DF due to pain 13

14 Ankle Case #4 Ankle Case #4 35 yo female, still just walking for exercise, and now playing in her work softball league First game of the season and during sprint to first base after hitting grounder, felt a rock hit her ankle and she stumbled and fell Needed assistance to get to the bench Iced and elevated and ACE wrap and NSAID Next day she could walk as long as she kept the ankle stiff, so she wore her hiking boots Management of Ankle Pain Thank you for your attention Trauma Diagnosed/suspect ligament, tendon, bony injury Brace/splint/walking boot, consider crutches, ice and ACE wrap, NSAIDs for short duration Refer Surgery possible due to instab, mech symptoms, fx Suspect moderate to severe sprain/strain Overuse Patient request Achilles tendonitis, post tib tendonitis Brace, Orthotics or heel lifts, Ice/ACE wrap, NSAIDs Stretches, theraband, strengthening, x-train, internet Make a PT referral and f/u with you in 4-8 wks or after 4-6 PT visits 14