Transcript www.SouthamptonOrtho.com

Management of Knee Pain
Manish A. Patel, MD,FAAOS
Assistant Professor Eastern Virginia Medical School
Chief of Surgery – Southampton Memorial Hospital
Office: 757-562-7301
www.SouthamptonOrtho.com
Anatomy
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ACL
PCL
MCL
LCL
Meniscus
– Medial
– Lateral
THE KNEE HISTORY
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Pain
Contact vs noncontact
Effusions
Mechanical symptoms
– Locking
– Instability (falls)
• Initial treatment
THE KNEE HISTORY
• Continue
work/play?
• PM/SHx
– Medications
• Occupation/Sport
– Time tables
Physical Exam of the Knee
• Inspection
• Palpation
• Range of Motion
• Special tests
• Neurovascular
assessment
INSPECTION
• Effusion
• Q angle
• Erythema
• Angular
• Ecchymosis
• Edema
deformities
• Muscular
asymmetry
PALPATION
ANTERIOR
• Tibial tubercle
MEDIAL
• MCL
• Infrapatellar tendon • Meniscus
• Quad insertion
• Patellar facets
• Crepitus ?
• Pes anserine
insertion
• Tibial plateau
• Femoral condyle
PALPATION
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LATERAL
Head of the fibula
LCL
Meniscus
Tibial plateau
Femoral condyle
Gerdy’s tubercle
POSTERIOR
• Menisci (posterior
horns)
• Popliteal fossa
• Hamstring tendons
ACL Special Tests
• Anterior
drawer
• Lachman test
• Pivot shift
test
• Valgus stress
test at full
extension!
Grading Ligament Injuries
GRADE 1
No instability
GRADE 2
Some instability Fair endpoint
GRADE 3
Opens wide
Good endpoint
Poor endpoint
ACL: PHYSICAL EXAM
• Decreased ROM
• Effusion-hemarthrosis,
immediate
• + Instability tests
– Lachman: most accurate
– Pivot shift
– Anterior drawer
• + MCL and meniscus tests
LIGAMENT EXAM
Translation +
ENDPOINTS!
+ PIVOT SHIFT
Palpable clunk as the lateral
tibial condyle reduces on the
femur
MRI:
The Use of MRI in Evaluation
of Knee Injuries
• Sensitivity M. Meniscus 73-100%
L. Meniscus
ACL
• Specificity MM
LM
ACL
55-90
91-100
55-97
94-98
99-100
The REAL QuestionIs MRI that much better than clinical
exam?
• Rose, et al. Arthroscopy, 1996
– Compared accuracy of clinical exam vs MRI
– In 154 pts, clinical exam was as good as MRI
• Many articles comparing MRI to arthroscopy
“Partial” ACL tear/strain
• > 40% ACL substance
• + Lachman, - pivot shift
• Clinically
– Most behave functionally
as full tears
– Continued shifting ↑’s
risk of meniscus damage
– Rx as full tear
The Utility of Arthrocentesis
• Indications
– Diagnosis in question
• ? Infectious/Metabolic
process
– Tense effusion
• Indications for surgery
• Timing of surgery
ACL TREATMENT
• Grade 3- Nonsurgical
– ? modify activity
– PRICES
– Hamstrings, gastroc!
– Functional bracing ?
– 100% @ 9-12 months
ACL TREATMENT
• Grade 3 Injuries- Surgery
• Indications
– Most active people will require surgery to
restore adequate function and decrease
instability
– Recurrent instability
– Inability to modify activity
– Associated injuries: meniscus
– Age?
• Wait three weeks due to arthrofibrosis
•
risk
100% @ 6-12 months
MCL INJURIES
HISTORY
• Mechanism = valgus stress
• Medial joint line pain
• Lack of large effusion
• Difficulty weight-bearing
MCL INJURIES
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PHYSICAL EXAM
Tender to palpation along MCL
Pain + instability with valgus stress
– 30o flexion = MCL
– 90o flexion = associated ACL
COMPARE SIDES
MCL INJURIES
Treatment Of Grade 1 &2
• Early mobilization
• Weight-bearing as tolerated
• Hinged knee brace
• PRICES
• Recovery 4-6 weeks
MCL INJURIES
Treatment of Grade 3 (full
tears)
• Isolated = nonsurgical management
• Combined = surgery consistent with
associated injuries
PCL INJURIES
• Mechanism
– Sports = fall on flexed
knee with foot
plantarflexed,
hyperextension, pivot
– MVA = dashboard injury
• Effusion (less than with
ACL)
• Shifting/instability
(chronic)
• Less distinctive
PCL INJURIES
PHYSICAL EXAM
• + Effusion
• + Posterior drawer test
• + Posterior sag sign
• False positive Lachman test
• Common to have isolated injuries
PCL INJURIES
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TREATMENT
PRICES
Functional bracing (early)
Rehab
Surgery if continued instability,
effusions
• Note- 2% of NFL preseason exam
with incidental isolated PCL tear
Patellofemoral
Arthralgia
Often referred to as
chondromalacia patella. This
term should be reserved for
observed articular cartilage
damage
PFA-HISTORY
• Pain with:
– Stairs
– Prolonged sitting
– Deep squat
activities
• Lack of effusions,
locking, instability
PHYSICAL EXAM
• Patellar compression/grind
tests
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No patellar apprehension
Poor hamstring flexibility
+ “J” sign
Normal ligaments, meniscus
Lack of effusion
KNEE- TANGENTIAL XRAYS
• Assess patellofemoral
joint
• Patellar tilt
• Lateralization
• Depth of trochlear
groove
PATELLAR
INSTABILITY
• Acute patellar dislocation
• Acute patellar
subluxation
• Patellar tracking
dysfunction
PATELLAR
DISLOCATION
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History
Mechanism = pivot
Immediate effusion
May visualize patella dislocated laterally
+ Instability (chronically)
Patella may spontaneously relocate
PATELLAR
DISLOCATION
Physical Exam
• Tender peripatellar structures
– Medial retinaculum
– Lateral femoral condyle
• Effusion
• ? Patella dislocated laterally
Xrays- osteochondral fracture, effusion
MRI for loose bodies
PATELLAR
DISLOCATION
Treatment
• Knee extension immobilizer x 4
wks, J Sleeve
• Early quad setting exercises
• Return to sport
– Full, painless ROM
– Normal strength
– Adequate aerobic fitness
Biology of the Meniscus
• Medial Meniscus
• Semilunar
• Narrow anteriorly
• Adherent to MCL
• Lateral Meniscus
• Circular
• Covers more of
tibia
• Uniform size
• Less adherent
Types of Meniscus Tears
• Longitudinal
• Horizontal
• Oblique
• Radial
MENISCAL INJURIES
History
• Mechanism = pivot, twist
• + heard a “pop”
• Effusion- 12-36o after
injury
• Mechanical Sxs- locking,
instability
MENISCAL INJURIES
Physical Exam
• Joint line
tenderness
– IR/ER
• Decreased ROM
• McMurray’s test
• Apley’s
compression test
MENISCAL INJURIES
Ancillary Studies
• Plain radiographs
– Other causes
mechanical Sxs
• MRI
– Higher vascularity
in peds patients
• CT-arthrography
outdated
Meniscus MRI
Grading of Meniscal Tears:
MRI
• I: globular changes
• II: linear changes not to
margin
• III: linear to sup/inf margin
• IV: complex linear changes
• Only grade III and IV
visible on arthroscopy
MENISCAL INJURIES
Treatment
• Nonoperative (Aggressive
Nonsurgical)
• Acute Rehab
– ROM, Quad setting
• Subacute Rehab
– ROM, PRE’s
• Bracing (hinged knee brace)
• Continue sport specific drills when
MENISCAL INJURIES
Treatment
• Operative
– Partial Menisectomy
– Meniscal Repair (peripheral)
– Meniscus Implants
– Total Menisectomy- outdated
Baker’s Cyst and the Meniscus
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Stone, et al (1996)
Case-control study
Over 1700 MRI’s  240 Baker’s cysts
85% had meniscal tears
Data supported by:
– Miller, et al (1997)
– Sansone ,et al (1995)
Discoid Meniscus
• Programmed cell death
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More likely to tear
Often Lateral
Male > female
Ages 6-10 yrs
Xray- wide lateral joint space
Rx- may require resection if Sx
Discoid
Meniscus
Discoid
Meniscus
Assorted Knee Problems
• Osgood-Schlatter Syndrome
• Patellar, Quad Tendinitis
• Plica
• Iliotibial Band Syndrome
• Osteoarthritis
• Osteochondritis dessicans (OCD)
TENDINITIS
Quadriceps and Patellar
History
• Pain with:
– Jumping
– Stairs
– Prolonged sitting
• Mechanism = overuse
TENDINITIS
Quadriceps and Patellar
Physical Exam
• Tender superior/inferior pole of
patella
• Tender tibial tubercle
• Tight hams, Achilles, quads
• Pain with resisted action of
muscle
TENDINITIS
Quadriceps and Patellar
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Treatment
P: protection, pain meds
R: rest
I: ice
C: compression
E: elevation
S: support, strength/stretch
exercises
Traction Apophysitis
• Osgood-Schlatter “disease”
BURSITIS
• Prepatellar bursa
• Infrapatellar bursae
• Pes anserine bursa
• Mechanism = direct blow,
overuse
• Physical exam- point
tender, nonintraarticular
effusion
BURSITIS
Treatment
NSAID’s
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• Ice
• Flexibility
exercises
• Steroid injections
• Surgery for
chronic cases
(prepatellar)
Impact of DJD
• Impact of Arthritis
Annually: (CDC statistics)
– 9,500 deaths
– 750,000 hospitalizations
– 8 million people with
limitations
– 36 million ambulatory care
visits
– $51 billion in medical costs and
$86 billion in total costs
Impact of Knee DJD
• Leading cause of
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disability
Affects leisure, work,
activities of daily living
$86 billion annually to
health care economy in
U.S.
Various forms of Arthritis
• Osteoarthritis most
common
What is DJD of Knee?
• Wear and tear of
Hyaline cartilage leads
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to exposed bone
Subchondral Cysts
Joint Space Narrowing
Pain with rest, swelling,
“instability”,mechanical
symptoms
Etiology of Knee DJD
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Heredity
Obesity
Malalignment
Injury
Female gender
Muscle weakness
Overuse / wear and
tear
Diagnosis of Knee DJD
• Clinical Exam
• Weight bearing X-
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rays-indicates loss
of joint space /
articular cartilage
MRI rarely indicated
(More for soft
tissue)
Arthritis of the Knee:
Treatment
• Most treatment is conservative
– Weight loss
– Muscle strengthening - PT
– NSAIDS
– Supplements
– Bracing and orthotics
– Injection
Arthritis of the Knee:
Treatment
• Weight loss
– Decreases impact
– 6-8 times body weight is felt
in knees
– Very important for stairs!
– Affects flexibility
– Impacts risk of surgery and
long-term results
– Affects overall health
Arthritis of the Knee:
Treatment
• Exercise and PT
– Strong muscles
cushion joint
– Flexibility
– Improves recovery
from injury or
surgery
– Low-impact (cycling)
preferred
– Pool therapy possibly
best
Arthritis of the Knee:
Treatment
• Anti-inflammatories and
analgesics
– NSAIDS (Motrin, Aleve,
etc)
• Excellent track record
• Some side effects –
take as needed
• Cheaper than
prescription drugs and
equally effective
– Analgesics
• Tylenol
• Do not use narcotics
for chronic pain
NSAID Facts
• Only 1 in 5 who have a serious problem from NSAIDs, have
warning symptoms
• Nonselective NSAIDs -16,500 deaths annually in the U.S.
• Nonselective NSAIDs -103,000 hospitalizations annually in the
U.S.
• Four Times more Americans die from NSAIDs annually than from
cervical
cancer
• More Americans die from NSAIDs annually than from AIDS
• Clinically important UGI events occur in 3- 4.5% of regular
NSAID takers
Wolfe MM, et al. N Engl J Med.1999;340:1888-1899.
Laine L. et al. Gastroenterology. 2001;120:594-606.
Fries JF. , Journal of Rheumatology. 1991. 18 (suppl
28):7.
Glucosamine
• Symptomatic
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relief
Slows disease
progression?
No formula proven
better than
another
Cost ($20/mo)
GI upset
Chondroitin
• Gives cartilage
elasticity
• From shark
cartilage or animal
tracheas
• Less proven than
glucosamine but
usually packaged
together
WD40
• No proven benefit
• May cause skin
irritation
• Not recommended
Braces
• Knee braces
– Support sleeves
• Warm joint
• Help balance
– Functional braces
• Stabilize joint
• Transfer stress
GII unloader
Guidelines for Managing Knee OA
SEVERE
OA
surgery
COX-2’s
JFT
High Dose
NSAIDS +
Gastroprotectant
IA-Steroids
MODERATE
OA
simple analgesics,
low dose NSAID’s
Exercise, Physical Therapy,
Weight Loss, Orthotics,
Nutraceuticals
MILD OA
Adapted from Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee, ACR, 2000
Who is a candidate for VS?
• Active patients who have early
osteoarthritis
• Post arthroscopy patients with residual
symptoms – rather than re-operation!
• Patients who are too young, heavy &/or
not ready for TKR
• Non-operative candidates
Where to inject?
What to inject with:
How I inject:
When all else fails:
Arthroscopy of the Knee
• Useful for mild or
•
moderate arthritis
with mechanical
symptoms (catching)
Not as helpful for:
– Severe arthritis
Osteotomy (Realignment)
• Realigns leg to
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transfer weight
bearing away from
affected area of
knee
Useful for younger
patient with only one
part of the joint
affected
Partial Knee Replacement
• Replaces only
damaged portion
of knee
• Recovery 70%
faster than total
knee
• More natural feel
• Patient selection
critical
Total Knee Replacement
• Involves resurfacing of joint
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surfaces with metal and
plastic
Newer techniques less
invasive
3-4 day hospital stay
6-8 weeks for recovery
90% success at 10-15 years
Muscle Sparing Approach
“Kinetic Knee
References:
•
Cherry Juice, Chicken Combs, and Chondroitin:
The Truth About Arthritis Cures--Gregory J.
Golladay, M.D., Orthopaedic Associates of Grand
Rapids, P.C.
•
A New Look at OA Knee Pain -Treatment Options
for Today’s Orthopaedic Practice, Dr. Dave Atkin,
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M.D. Chief, Orthopedic DivisionSt.Luke’s Hospital
San Francisco, California
V Strand MD, PG Conaghan MB, BS, PhD, L.S
Lohmander MD, PhD, A.D Koutsoukos PhD, F L Hurley
PhD, H Bird MD, P Brooks MD, R Day MD, W Puhl MD
and P A Band PhD. An integrated analysis of five
double-blind, randomized controlled trials evaluating
the safety and efficacy of a hyaluronan product for
intra-articular injection in osteoarthritis of the knee.
OsteoArthritis and Cartilage (2006) Volume 14, 859866.
Gaetano P. Monteleone, Jr., M.D., Dept of Family
Medicine, Director, Division of Sports Medicine, West
Virginia University School of Medicine (online slides)
Useful Web Sites
• American Academy of Orthopaedic Surgeons
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www.aaos.org
Arthritis Foundation www.arthritis.org
NIH www.niams.nih.gov