Diagnosis and Management of Knee Conditions Jenny Love / Lynn Robertson AFLAR Oct 2009
AIMS Review 4 common Knee Conditions: Anterior knee pain Meniscal Injuries Ligament injuries ACL Osteoarthritis Discuss Presentation and Management Clinical Assessment Special Tests
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
Aggravating factors Start up pain Sit- stand Stairs Hills ( often worse downhill) Squatting Driving In /out car
Onset Gradual insidious onset Trauma- direct blow, post dislocation Growth spurt Pre disposition patella alta, tilting patella, hypermobility
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
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
Management.. Physiotherapy Respond well to closed chain progressive exercises Takes time
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
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)
Examination Findings Effusion Block to extension Pinpoint medial / lateral joint line X-ray- normal
Management Trauma theatre same / next day Urgent MRI +/- Physiotherapy Theatre
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
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
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
Management Physiotherapy and review Can improve over time MRI Arthroscopy
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
Signs and symptoms Instability- uneven surface/flat/ running Ongoing / recurrent effusion ( following giving way) Lack of confidence Unable to return to sport
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
Pivot Shift
Lachmans test
Anterior tibial translation Anterior Draw
PCL Posterior drawer test at 90 0 Grade 1 0-5mm (tibial condyles anterior) Grade 2 5-10mm (condyles in line) Grade 3 10+mm (tibial condyles posterior)
MCL/posteromedial corner Valgus stress at 30 0 Grade 1 0-5mm Grade 2 5-10mm Grade 3 10+mm Grade 3+ Valgus in extn Grade 3+ suspect posteromedial corner and cruciate injury
Dial Test (PCL) Dial test at 30 only at 30 +90 Posterolateral corner PCL+ posterolateral corner
Management Physiotherapy + review Physiotherapy +/- MRI +ve MRI, ongoing instability = ACL reconstruction Decision to have reconstruction depends on many factors
Osteoarthritis Widespread common complaint in older adults. Primary or secondary - inflammatory ( RA ) - infective ( septic arthritis ) - traumatic ( post # ) Age : 50 + Male = female
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
Examination Effusion - possible Red. ROM - possible Deformity P/F - +ve / -ve Ligaments - maybe laxity Joint line tenderness Xray : red. Joint space, osteophytes, subchondral sclerosis
Management Physiotherapy Education Medication I/A injection Surgery
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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