Evaluation and Management of Knee Pain. Michael Cassat, MD University of Arkansas for Medical Sciences

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1 Evaluation and Management of Knee Pain Michael Cassat, MD University of Arkansas for Medical Sciences

2 Disclosure I have no actual or potential conflict of interest in relation to this program/presentation.

3 Knee Pain- Why? Knee pain accounts for 1/3 of all musculoskeletal complaints in primary care. 54% of athletes have knee pain each year. The incidence of knee osteoarthritis has doubled since the 1950s.

4 Knee Pain- Anatomy

5 Knee Pain- History Traumatic versus atraumatic Associated mechanical symptoms such as catching, locking, instability, or inability to bear weight. Associated concomitant illness such as autoimmune disease, gout, sickle cell anemia, systemic infection. Location Think anatomically. Don t forget lumbar radiculopathy. Exacerbating/relieving activities. Failed treatments. Impact on daily activities.

6 Knee Pain- Exam Inspection- redness, swelling, warmth, previous scars. Palpation- be purposeful, anatomic. Range of motion-side to side discrepancies and actual measurements. Stability Provocative maneuvers. Don t forget the hip and spine.

7 Knee Pain- Radiographs AP weight bearing, lateral, sunrise, PA weight bearing in flexion

8 Knee Pain- Radiographs AP weight bearing, lateral, sunrise, PA weight bearing in flexion

9 Knee Pain- Radiographs AP weight bearing, lateral, sunrise, PA weight bearing in flexion

10 Knee Pain- Radiographs AP weight bearing, lateral, sunrise, PA weight bearing in flexion

11 Knee Pain- Advanced Imaging MRI With and without for tumor, infection. Without for suspected cartilage injury, meniscal tear, ligamentous or tendon tear. Versus CT for suspected non visualized fracture. CT/CT arthrogram For those who cannot have an MRI. Versus MRI for fracture.

12 Cases

13 Knee Pain- Case 1 History 43 y/o male recreational soccer player. He had a sudden stop and pivot injury to his knee. He complains of difficulty bearing weight, instability, sudden onset swelling, and diffuse pain. Denies catching or locking. Has tried ice, rest, NSAIDS since the injury.

14 Knee Pain- Case 1 Physical Exam He is in mild distress with any motion of the knee. The knee is edematous in appearance. There is a large effusion. ROM- 0 deg extension, 90 deg flexion. The knee is tender to palpation diffusely laterally over proximal tibia and distal femur. Stable to varus and valgus stress at both 0 deg and 30 deg. Anterior drawer and lachman without a firm end point.

15 Knee Pain- Case 1 Radiographs Can be normal R/o fx/oa Segond fracture

16 Knee Pain- Case 1 Treatment Rest, Ice, Elevation NSAIDS Toe touch weight bearing on crutches. Knee immobilizer versus hinged post op knee brace. ASAP MRI with prompt surgical referral upon results.

17 Knee Pain- Case 1 MRI Commonly with this injury shows significant bony edema. Evaluate for concomitant injuries.

18 MRI Knee Pain- Case 1

19 Knee Pain- Case 2 History 50 year old female recreational runner with a twisting type injury to her knee. Complains of significant pain, a catching/locking sensation, and loss of motion. She denies instability. Rest, ice, elevation, NSAIDs have not worked. Difficulty walking and bearing weight.

20 Knee Pain- Case 2 Physical Exam She is in mild distress with any motion of the knee. It is edematous in appearance. There is a large effusion. ROM -10 deg extension, 90 deg flexion Tender to palpation over the medial joint line. Stable to varus and valgus stress at both 0 deg and 30 deg. Anterior drawer and lachman normal. McMurry s is positive

21 Knee Pain- Case 2 Radiographs Can be normal R/o fx/oa

22 MRI Knee Pain- Case 2

23 Knee Pain- Case 2 Degenerative meniscal tears Sihvonen et al, NEJM years old, excluded traumatic tears and OA. No difference between sham surgery and partial meniscectomy. Katz et al, NEJM >45 years old, OA only on X-ray, not mri, excluded locked knees. No difference between surgery and PT groups. 30% of PT group crossed over. Traumatic meniscal tears Locked knees need asap referral. Consider early referral for acute mechanical symptoms, or those refractory to conservative measures.

24 Knee Pain- Case 2 Treatment Rest, Ice, Elevation NSAIDS Toe touch weight bearing on crutches. ASAP MRI with prompt surgical referral upon results.

25 Knee Pain- Case 3 History 67 year old male who presents with a 4 month history of gradually increasing knee pain. No known injury. Worse with activity. Doesn t radiate. No instability or other mechanical symptoms. Rest, ice, elevation, NSAIDs have not worked.

26 Knee Pain- Case 3 Physical Exam Visibly edematous in appearance. ROM 0 deg extension, 100 deg flexion. There is a moderate effusion. Tender over medial and lateral joint line. Stable

27 Knee Pain- Case 3 Radiographs Joint space narrowing Osteophyte formation Cystic change

28 Knee Pain- Case 3 Treatment (Based on AAOS guidelines) Self management program including strengthening and low impact exercise. Weight loss for BMI>25. Recommendation for physical therapy is inconclusive. NSAIDS No recommendation for glucosamine/chondroitin. Recommendation for Intraarticular corticosteroids is inconclusive. No recommendation for hyaluronic acid. Refer to discuss arthroplasty at failure of conservative measures, development of flexion contracture. No advanced imaging needed.

29 Knee Pain- Case 4 History 75 year old male who presents with a 6 month history of gradually increasing knee pain. No known injury. Worse with standing and walking. Radiates from the knee to the ankle. No instability or other mechanical symptoms. Rest, ice, elevation, NSAIDs have not worked.

30 Knee Pain- Case 4 Physical Exam Normal in appearance ROM 0 deg extension, 140 deg flexion There is no effusion Nontender Stable

31 Knee Pain- Case 4 Radiographs

32 Knee Pain- Case 4 Issue? Normal exam with an abnormal X-ray. Don t forget the hip and back! An L4/5 central stenosis can reproduce anterior knee pain. Don t treat the X-ray, treat the patient.

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