Diagnosis and Management of Knee Conditions. Jenny Love / Lynn Robertson AFLAR Oct 2009

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1 Diagnosis and Management of Knee Conditions Jenny Love / Lynn Robertson AFLAR Oct 2009

2 AIMS Review 4 common Knee Conditions: Anterior knee pain Meniscal Injuries Ligament injuries ACL Osteoarthritis Discuss Presentation and Management Clinical Assessment Special Tests

3 Anterior Knee Pain Pain arising from Patello femoral joint often due to biomechanics and movement Major contributing Factors Malalignment lower extremity and or patella, muscular imbalance, overactivity (Roland et al 1999) Age teens upwards Pain intermittent or constant Pain location- poorly localised: anterior, anteromedial, anterolateral, posterior. Common to be bilateral

4 Aggravating factors Start up pain Sit- stand Stairs Hills ( often worse downhill) Squatting Driving In /out car

5 Onset Gradual insidious onset Trauma- direct blow, post dislocation Growth spurt Pre disposition patella alta, tilting patella, hypermobility

6 Mechanical features Pseudolocking Occurs at 30 flex Frequent Transient No swelling No after effects Pseudogiving Quads inhibition Frequent Hyperextension sensation Patellar click Often descending stairs

7 Examination findings No effusion May have end range pain flexion, often pain on end range extension / hyperextension No ligamentous instability Positive patella stress / restraint test Pain medial patella facet Joint line may have anteromedial / anterolateral tenderness X-ray normal, patella alta, tilting patella

8 Management.. Physiotherapy Respond well to closed chain progressive exercises Takes time

9 Meniscal Injuries Acute or chronic Acute Age young / active <25yrs Male >female( now seeing more females) Recent history of trauma, twisting injury Football planted foot twisted, tackle

10 Signs and Symptoms Pain localised medial or lat joint line ( pinpoint) +/- P/F Effusion- develops over time Giving way uncommon Often complain of locking or present locked (true locking can flex but unable to extend)

11 Examination Findings Effusion Block to extension Pinpoint medial / lateral joint line X-ray- normal

12 Management Trauma theatre same / next day Urgent MRI +/- Physiotherapy Theatre

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14 Chronic / Degenerative Meniscal tear Age teenager- 60 s ( physiological age) Localised joint pain +/-PF Often preceding trauma-twisting, squatting One event or repeated min trauma May be minor initial event followed by more significant event

15 Signs and Symptoms Pain well localised to joint line Intermittent swelling, post activity or locking Intermittent locking self manipulates/ wiggles to release May be long standing lack of extension ( locked) Difficulty squatting, kneeling

16 Examination Findings Effusion ROM- squat unable, may have pain end range flex, may lack end range extension P/F ve No ligamentous instability Pin point joint line tenderness

17 Management Physiotherapy and review Can improve over time MRI Arthroscopy

18 Anterior Cruciate ligament Male>female Late teens 20 s -30 s Main complaint of instability +/-pain Clear history of trauma Contact or non contact Flexed knee with twist Hear /feel pop Immediate swelling Unable to play on/ weight bear

19 Signs and symptoms Instability- uneven surface/flat/ running Ongoing / recurrent effusion ( following giving way) Lack of confidence Unable to return to sport

20 Examination Findings +/_ effusion May lack ROM ( if acute) -ve P/F +ve anterior draw, =+ve lachmans, +ve pivot shift Collateral ligaments may / may not be involved +/- joint lines ( if associated meniscal) X-ray Normal/ mild OA/avulsion of tibial spine/ flattened tibial condyles

21 Pivot Shift

22 Lachmans test

23 Anterior tibial translation Anterior Draw

24 PCL Posterior drawer test at 90 0 Grade 1 0-5mm (tibial condyles anterior) Grade mm (condyles in line) Grade 3 10+mm (tibial condyles posterior)

25 MCL/posteromedial corner Valgus stress at 30 0 Grade 1 0-5mm Grade mm Grade 3 10+mm Grade 3+ Valgus in extn Grade 3+ suspect posteromedial corner and cruciate injury

26 Dial Test (PCL) Dial test at 30 only at Posterolateral corner PCL+ posterolateral corner

27 Management Physiotherapy + review Physiotherapy +/- MRI +ve MRI, ongoing instability = ACL reconstruction Decision to have reconstruction depends on many factors

28 Osteoarthritis Widespread common complaint in older adults. Primary or secondary - inflammatory ( RA ) - infective ( septic arthritis ) - traumatic ( post # ) Age : 50 + Male = female

29 Signs & Symptoms Pain - Int or constant ; episodic flares Pain location specific or diffuse Loss of function Possible deformity valgus / varus - flexion weight bearing initially rest prolonged sitting medication walking stairs sit - stand

30 Examination Effusion - possible Red. ROM - possible Deformity P/F - +ve / -ve Ligaments - maybe laxity Joint line tenderness Xray : red. Joint space, osteophytes, subchondral sclerosis

31 Management Physiotherapy Education Medication I/A injection Surgery

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35 Knee Assessment Subjective : Key Questions Age Pain, location Constant / I/M Mechanism of injury, timescale Swelling, I/M / gradual Locking / giving way Agg / ease Previous injury, history, treatment Occupation, activities

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37 THANK YOU