Knee Pain And Injuries In Adults W. Dilworth Cannon, M.D. Professor of Clinical Orthopaedic Surgery University of California San Francisco Pain Control Overview Narcotics rarely necessary after 1 st 1-2 days. NSAID s Ice Compression Elevation Rest Page 1
Football Injury Football Injury Ligament Sprains Grade I Grade II Grade III Page 2
Grades of Laxity 1+ = 3-5 mm 2+ = 5-10 mm 3+ = >10 mm Primary Care Physicians: A-P and lateral of knee (occasionally Sunrise view ) My Routine X-rays Include: 1. P-A bent knee standing film both knees (Knees bent 30-45 deg, aim beam 10 deg caudad) 2. Lateral (supine) 3. 30 patello-femoral axial view Page 3
Patello-Femoral View: Don t omit ordering this view Don t order Sunrise View Order Merchant s View (45 deg view), or 30 deg view. Page 4
When should you order an MRI? Locking A block to full extension. Can flex Causes of Locking: Displaced meniscus tear Loose body Swollen knee Fragment of torn ACL Page 5
Management of the ACL Deficient Knee Epidemiology: Natural History of ACL Tear: Approx. 125,000 ACL tears and 40,000-60,000 MCL tears per year. Female:male gymnasts/basketball players: 3-4 times higher incidence in females. Twisting injury and pop Immediate swelling Repeated giving way and effusions Page 6
Telephone Diagnosis Office Sprain 72% are ACL tears Exam substantiates Dx No longer immobilize and pray Fluid in Joint: Immediate = blood After 24 hours = effusion Page 7
Knee Model mpg2 Knee Model mpg 1 Acute ACL Tear: Lachman test Pivot shift or Losee test Arthrometer measurements MRI for assessment of menisci Page 8
Joint Immobilization: Muscle atrophy Adhesions and joint stiffness Decreased ROM Cartilage degeneration Ligament strength deterioration Eriksson: Early Motion (mpg2) Eriksson: Early Motion (mpg 1) Page 9
Losee, Lachman, Pivot Shift Tests Losee Test A gentle test compared to pivot shift. Most useful if MCL and ACL torn. Anterior Drawer: May miss up to 50% of acute ACL tears Non-operative operative treatment of the ACL deficient knee Page 10
Aggressive rehabilitation: Early return of motion Hamstring strengthening Closed kinetic chain quads Don t do this! Rule of Thirds: 1/3 can play recreational sports 1/3 cannot play recreational sports 1/3 have symptoms with ADL Page 11
Sequelae of ACL Tear: Meniscal tears in 30-95% Late arthritis Page 12
Braces decrease, but do not eliminate anterior subluxation If a patient wants to have the best chance of having a more normal (stable) knee, then ACL reconstruction is the best choice. ACL Reconstruction: Delay surgery approx. 6-8 wks until close to FROM obtained, swelling down, and strength returned. Rx of MCL Tears: Non-operative Success rate: 90-95% Page 13
Medial Collateral Ligament Injuries: Tenderness and swelling over medial aspect of knee. Medial opening with valgus stress at 30 degrees flexion: Grade 0-3 +. Beware of ACL injuries in grade 3 lesion. Rehabilitation of MCL Injury: FROM in hinged brace (wear it 24/7). Wt bearing as tolerated. Progressive strengthening and agility program. Return to sports at 5-9 weeks. Page 14
Torn Meniscus Typically twisting or hyperflexion injury With or without a pop Joint line pain and tenderness Swelling Clicking or catching Partial meniscectomy versus Meniscal repair Locking or giving way Post-meniscectomy Patient: Should not jog or run Try speed walking Encourage bicycling Working out is okay Page 15
Posterior Cruciate Ligament (PCL) PCL 3% - 20% of all knee ligament injuries. Associated injuries common. Quad Active Test Mechanism of Injury: Posterior force to anterior tibia (dashboard). Hyperflexion, hyperextension, twist. Page 16
Natural Hx & Rx Controversial: Lateral Collateral Ligament Surgery for some combined injuries, rarely for isolated PCL tears. (LCL) Lateral Collateral Ligament Increased varus laxity at 30 degrees flexion. Non-operative Rx common. Cysts About the Knee Surgical exploration and primary repair for combined injuries. Page 17
Popliteal Cysts Secondary to intra-articular pathology Page 18
Patellar Tendinitis ( Jumper s Knee ) Patellar tendinitis Rest Ice NSAID s No OKC quadriceps exercises Quadriceps stretching No steroid injections Surgery only if non-op Rx fails Page 19
Knee Pain And Injuries In Adults W. Dilworth Cannon, M.D. Professor of Clinical Orthopaedic Surgery University of California San Francisco Pain Control Overview Narcotics rarely necessary after 1 st 1-2 days. NSAID s Ice Compression Elevation Rest Page 1
Football Injury Football Injury Ligament Sprains Grade I Grade II Grade III Page 2
Grades of Laxity 1+ = 3-5 mm 2+ = 5-10 mm 3+ = >10 mm Primary Care Physicians: A-P and lateral of knee (occasionally Sunrise view ) My Routine X-rays Include: 1. P-A bent knee standing film both knees (Knees bent 30-45 deg, aim beam 10 deg caudad) 2. Lateral (supine) 3. 30 patello-femoral axial view Page 3
Patello-Femoral View: Don t omit ordering this view Don t order Sunrise View Order Merchant s View (45 deg view), or 30 deg view. Page 4
When should you order an MRI? Locking A block to full extension. Can flex Causes of Locking: Displaced meniscus tear Loose body Swollen knee Fragment of torn ACL Page 5
Management of the ACL Deficient Knee Epidemiology: Natural History of ACL Tear: Approx. 125,000 ACL tears and 40,000-60,000 MCL tears per year. Female:male gymnasts/basketball players: 3-4 times higher incidence in females. Twisting injury and pop Immediate swelling Repeated giving way and effusions Page 6
Telephone Diagnosis Office Sprain 72% are ACL tears Exam substantiates Dx No longer immobilize and pray Fluid in Joint: Immediate = blood After 24 hours = effusion Page 7
Knee Model mpg2 Knee Model mpg 1 Acute ACL Tear: Lachman test Pivot shift or Losee test Arthrometer measurements MRI for assessment of menisci Page 8
Joint Immobilization: Muscle atrophy Adhesions and joint stiffness Decreased ROM Cartilage degeneration Ligament strength deterioration Eriksson: Early Motion (mpg2) Eriksson: Early Motion (mpg 1) Page 9
Losee, Lachman, Pivot Shift Tests Losee Test A gentle test compared to pivot shift. Most useful if MCL and ACL torn. Anterior Drawer: May miss up to 50% of acute ACL tears Non-operative operative treatment of the ACL deficient knee Page 10
Aggressive rehabilitation: Early return of motion Hamstring strengthening Closed kinetic chain quads Don t do this! Rule of Thirds: 1/3 can play recreational sports 1/3 cannot play recreational sports 1/3 have symptoms with ADL Page 11
Sequelae of ACL Tear: Meniscal tears in 30-95% Late arthritis Page 12
Braces decrease, but do not eliminate anterior subluxation If a patient wants to have the best chance of having a more normal (stable) knee, then ACL reconstruction is the best choice. ACL Reconstruction: Delay surgery approx. 6-8 wks until close to FROM obtained, swelling down, and strength returned. Rx of MCL Tears: Non-operative Success rate: 90-95% Page 13
Medial Collateral Ligament Injuries: Tenderness and swelling over medial aspect of knee. Medial opening with valgus stress at 30 degrees flexion: Grade 0-3 +. Beware of ACL injuries in grade 3 lesion. Rehabilitation of MCL Injury: FROM in hinged brace (wear it 24/7). Wt bearing as tolerated. Progressive strengthening and agility program. Return to sports at 5-9 weeks. Page 14
Torn Meniscus Typically twisting or hyperflexion injury With or without a pop Joint line pain and tenderness Swelling Clicking or catching Partial meniscectomy versus Meniscal repair Locking or giving way Post-meniscectomy Patient: Should not jog or run Try speed walking Encourage bicycling Working out is okay Page 15
Posterior Cruciate Ligament (PCL) PCL 3% - 20% of all knee ligament injuries. Associated injuries common. Quad Active Test Mechanism of Injury: Posterior force to anterior tibia (dashboard). Hyperflexion, hyperextension, twist. Page 16
Natural Hx & Rx Controversial: Lateral Collateral Ligament Surgery for some combined injuries, rarely for isolated PCL tears. (LCL) Lateral Collateral Ligament Increased varus laxity at 30 degrees flexion. Non-operative Rx common. Cysts About the Knee Surgical exploration and primary repair for combined injuries. Page 17
Popliteal Cysts Secondary to intra-articular pathology Page 18
Patellar Tendinitis ( Jumper s Knee ) Patellar tendinitis Rest Ice NSAID s No OKC quadriceps exercises Quadriceps stretching No steroid injections Surgery only if non-op Rx fails Page 19
Patello-Femoral Joint Chondromalacia Patella ( Runner s Knee ) Page 20
Lateral Patellar Facet Compression Syndrome Tight lateral retinaculum. Patellar tilt without subluxation on 30 or 45 deg. views. Consider lateral retinacular release for patients failing nonoperative treatment. Page 21
Physical therapy may help. Exercise within one s envelope of tolerance Patellar Dislocation Page 22
Surgical Options Lat. retinacular release combined with: Medial reefing, or Distal tibial tubercle transfer surgery Ice (rarely heat). NSAID s. Rest or reduction of the aggravating activity. Strengthening program begun when the pain has subsided. Slow resumption of activities and sports. Steroid Injections Pros and cons (No more than 3/yr) Page 23
Rehearsal: 23 min + 6 40 videos = 30 min. Time allotted: 30 min. Videos McCallum 13 Knee model 29 Losee-Lachman 1 20 Eriksson interview 4 28 Quad active test 18 Patellofemoral crepitation 56 Total: 7 44 (=6 39 ) Page 24
Salves, Tiger Baum: Not proven effective Page 25
Overview ACL MCL PCL LCL Meniscus Patello-Femoral Page 26
Arthrometer Measurements: Difference of 3 mm or more on manual maximum or 40 lb testing is associated with a torn ACL in >90% of cases. In my hands, more accurate than MRI. Cutting (lateral movement) may still be a problem Page 27
Non-operative treatment frequently fails to produce successful outcomes. It s an outpatient procedure Graft Choice Hamstrings (Semitendinosis, Gracilis) Bone-patellar tendon-bone autograft Central quadriceps tendon Allografts Page 28
PCL 3% - 20% of all knee ligament injuries. Associated injuries: ACL 75% MCL 50-80% Menisci 30-75% LCL 10% Mechanism of Injury: Posterior force to the anterior tibia. Hyperflexion. Hyperextension (combined with ACL injury). Varus or valgus rotation (combined with collateral ligament and ACL injury). Page 29