American College of Physicians 2013 Ohio Chapter Scientific Meeting Columbus, OH October 11, 2013 Paul J.
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Transcript American College of Physicians 2013 Ohio Chapter Scientific Meeting Columbus, OH October 11, 2013 Paul J.
American College of Physicians
2013 Ohio Chapter Scientific Meeting
Columbus, OH
October 11, 2013
Paul J. Gubanich, MD, MPH
Assistant Professor of Internal Medicine/Sports Medicine
Team Physician, Ohio State University Athletics, Ohio Machine, Columbus City Schools
Disclosures
I do not have a conflict of interest associated with the
material contained in this presentation.
An Approach to the Patient with
Knee Pain
Most common
complaints
Pain
Instability – (ligament
injury, OA)
Stiffness – (effusion,
OA)
Swelling
Locking (meniscal)
Weakness
Most diagnosis made by:
History
Physical exam
Imaging
Important Historical Components
Age
Chronology, onset
Pain level, characteristics
Exacerbating positions/
movements
Relieving factors
Activity level or recent change,
occupation
Previous injuries, surgeries
Exercise history, goals
Previous treatments
Chronology of Symptoms
Common acute injuries
Acute Pain
Fractures (distal femur,
Sudden onset
patella, proxmial tibia,
Specific mechanism of
fibula)
injury
Dislocations
Direct trauma (fall,
collision, MVA)
Meniscal injuries
Landing, pivoting
Ligamentous injuries
Musculotendious strains
Contusions
Chronic Pain
Often lacks a mechanism
of injury
Symptoms of gradual
onset
Common causes of chronic
knee pain
Arthritis
Tumors (night pain)
Osteosarcoma (adolescents)
Chondrosarcoma (adults)
Giant cell tumor (benign)
Metastatic disease is
uncommon
Sepsis (rare, can be bursal)
Bursitis (overuse)
Tendonitis
Anterior knee pain
Location, Location, Location
Medial Knee
Joint line – meniscus,
OA, osteochondral
defect, osteonecrosis,
medial collateral
ligament
Tibial plateau –
(osteoporosis, post
menopausal)
Pes bursa
Anterior Knee
Anterior
Quad tendon or insertion
Anterior to patella
Patella
Patellar origin, tendon,
insertion
Tibial tubercle
Lateral Knee Pain
Lateral
Femoral condyle –
suggests IT band
Joint line – meniscus,
OA, OCD, lateral
collateral ligament
Posterior Knee
Meniscus – posterior
medial, lateral corner
Posterior lateral –
Baker’s/popliteal cyst,
aneurysm
Physical Exam
Exam both sides
Joint above and below
Most painful part last
Gait
Alignment (varus, valgus)
Squat
Inspection
Swelling
Bruising
Deformity
Physical Exam
Palpation
Effusion
Range of Motion
Patellar tracking
Extension (-5 to 5)
Flexion (135-145)
Crepitus, etc.
Strength
Hamstring
Quad
Functional tests
Physical Exam – Special Maneuvers
Apprehension sign –
patellar instability
Apley grind test –
meniscus
McMurray
circumduction test,
SN 16-58%
SP 77-98%
(Evans 1993, Fowler
1989, Kurasaka 1999,
Anderson 1986)
Physical Exam – Special Maneuvers
Valgus stress test – MCL
SN 86-96%
Varus stress test – LCL
SN 25%
Physical Exam – Special Maneuvers
Lachman’s – ACL
SN 80-99%
(various authors
and conditions)
Physical Exam – Special Maneuvers
Anterior/posterior
drawer – ACL/PCL
Posterior Sag Sign
Radiology
Plain x-rays often
considered part of exam
Helps rule out competing
diagnosis
X-ray views
Standing AP views of both
knees (for comparison)
Lateral
Tunnel at 45 degrees
Merchant/Sunrise – to
evaluate PF joint
Radiology
MRI often not needed
initially
Surgical planning tool
Failure of treatment
Identify
ligamentous/cartilage
injuries of acute or
surgical nature
Risk stratification
General Treatment Pearls
Match disease severity/limitations with treatment
options
Escalate based on time, response in a stepwise fashion
Set realistic expectations for progress and follow-up
Align treatment goals with patient goals/expectations
when possible
Time is a great healer
Common Treatment Recommendations
Activity modification, rest
Mechanical devices –
braces, crutches, lifts,
orthotics, etc.
Ice, pain medication
Nsaids
Acetaminophen
Others
Physical therapy – early
motion progressing to
strengthening and then
functional drills
Injection therapy
Aspiration
Corticosteroids
Hyaluronic acid supplents
(OA)
Glucosamine (OA)
Surgical considerations
Consider additional
imaging options as needed
MRI
Bone scan
CT
Red Flags
Night pain
Abnormal x-ray findings
Fractures, tumor, cartilage
lesions, etc.
Mechanical symptoms
Severe pain, swelling, loss of
motion, or weakness
High grade ligament injuries
Fail to respond to standard
treatments
Multiple joints involved
(Rheum)
Summary
History and Physical Exam are vital to generating a
working differential diagnosis
Imaging may complement/confirm working diagnosis
Treatment should match symptoms and severity and
progress based on progress
Questions?