Objectives. The BIG Joint. Case 1. Boney Architecture. Presenter Disclosure Information. Common Knee Problems

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1 3:30 4:15 pm Common Knee Problems SPEAKER Christopher J. Visco, MD Presenter Disclosure Information The following relationships exist related to this presentation: Christopher J. Visco, MD: Speaker s Bureau for Terason. Off-Label/Investigational Discussion In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. Objectives Following this talk participants will be able to: Understand the most common kneeproblems Describe the impact of the patella on everyday knee function Improve clinical decision making for knee pain Largest joint in the body Tibiofemoral joint Patellofemoral joint Tibiofibular joint The BIG Joint Boney Architecture Femoral Condyles Intercondylar notch Tibial plateaus Spines Case 1 38 y/o female with a 2 month h/o knee Pain with walking down stairs Tenderness around the patella, no effusion Fibula

2 Kinetic Chain Rolling and Gliding Cervical spine Lumbar spine Hip Knee Foot/Ankle Rolling and Gliding - Open Rolling and Gliding - Closed ROM Flexion 160 deg Extension 0 Internal rotation 10 External rotation 10 Quadriceps Angle Q-angle Angle between ASIS to patella patella to tibial tubercle Males 13 deg Females 18 deg Pathologic if >20

3 Lateral intercondylar notch on femur Posteriorly Open Chain: Limits anterior tibial translation ACL Closed Chain: Limits posterior femur translation Limits internal rotation of the femur ACL during knee flexion: tibia rolls posteriorly, elongating ACL. ACL's pull on tibia causes it to glide posteriorly. Mechanism of ACL tears Rapid awkward stop with twisting Landing (decelerating) and pivoting PCL Medial intercondylar notch on femur Anterior to posterior Excessive valgus at the knee during knee extension: tibia rolls anteriorly, elongating PCL. PCL's pull on tibia causes it to glide anteriorly. MCL and LCL MCL Femoral condyle to tibia Attaches to meniscus Restrains Valgus LCL Femoral condyle to fibula No attachment to meniscus Restrains Varus Oblique popliteal ligament Arcuate Ligament Can be mistaken for a lateral meniscus post horn tear Capsule, etc.

4 Patellar Contact Initial contact at 10 to 20 degrees Area of contact gradually increases with flexion to 90 degrees Why Patella? Sesamoid bone in extensor unit Increases efficiency through mechanical advantage Area of contact shifts from inferior to superior with increasing flexion Medial facet has the most contact until 90 degrees Lengthens the moment arm of the quads Acts as a pulley Up to a 50% dec. in strength without it First class lever The Cuff Deltoid Pulls UP Rotator Cuff Pulls DOWN Supraspinatus Infraspinatus Teres Minor Subscapularis Biceps Long Head GH Muscular Stability Deltoid Prime mover All positions Supraspinatus, infraspinatus, teres minor, subscapularis Biceps Force couples the Cuff pulls down and in Force vectors nearly cancel Helps create pure rotation Allows for spinning of humeral head around a fixed axis.

5 Problem with dynamic stabilization One disruption of a stabilizing factor accelerates degenerative changes Weak gluteals = more lateral gliding of patella Compresses pain! Common Problems at the Knee Tendon Joint Femorotibial Tibfib patellofemoral Nerve Sciatic Tibial Fibular (peroneal) Vascular Integrated Motion Knee flexion and extension Which imaging to get Radiograph AP, Lateral, True AP Merchant view Musculoskeletal Ultrasound Often applied point of care for sports medicine Helpful to evaluate quad or patellar tendon MRI When meniscus tear is suspected Other mass lesions Exercise Key Points Maintain Range of motion Can not strengthen through restricted range of motion Medications NSAIDs Poor choice for most kneepain Could be helpful for 2-3 days Nonselective = Selective Acetaminophen Better choice for pain relief 1 gram 2-3x/day

6 infrapatellar Bursa Injections Tendon treatments - Regenerative Treatments including percutaneous needle tendon injection, platelet rich plasma Resources Levangie and Norkin, Joint Structure and Function, 3 rd Ed Almakinders 2002 Seitz 2011 Kibler 2012 Manske 2013