Transcript Anterior Knee Pain - Delaware Academy of Family Physicians
Primary Care Approach to Knee Pain
Bradley Sandella, DO, ATC Director of Sports Medicine Sports Medicine Fellowship Program Director
Goals of Lecture
Be able to identify the most common causes of knee pain.
Demonstrate several examination techniques to identify different causes of knee pain.
Design a Home Exercise Program for knee pain
Epidemiology of Knee Pain
Accounts for approximately 1/3 of musculoskeletal complaints seen in the primary care setting.
5-10% of all visits With 25% being anterior knee pain Females more commonly get it than males As many as 54 % of athletes have some degree of knee pain each year 25% of all runners will experience
Doc....my knee hurts
Most Common Causes of Knee Pain in Primary Care
Osteoarthritis (34%) Meniscal injury (9%) Collateral ligament injury (7%) Cruciate ligament injury (4%) Gout (2%) Fracture (1.2%) Undifferentiated causes including sprains and strains (42%) Jackson J, O’Malley P, Kroenke K, “Evaluation of Acute Knee Pain in Primary Care”, Ann Intern Med 2003; 139(7):575-588.
Anatomy
Anterior
Patella Posterior facets Alignment Patella Tendon Tibial Tubercle Bursas
Posterior
Gastrocnemius Popliteal vessels
Medial
Medial collateral ligament Medial meniscus
Lateral
Lateral collateral ligament Lateral meniscus
Anatomy
Internal structures
Ligaments
Anterior cruciate ligament
Posterior cruciate ligament
Medial collateral ligament
Lateral collateral ligament
Cartilage
Menisci
Articular
History
Mechanism Acute vs. chronic pain Unilateral vs. bilateral Swelling / effusion Worse with activity vs. prolonged sitting Stairs Mechanical symptoms Giving way Locking / catching
It hurts right here……in the front
Anterior knee pain
Children / adolescent Patellofemoral pain syndrome Patella subluxation Patella tendinitis Tibial apophysitis Adult Osteoarthritis Pes anserine bursitis Gout Inflammatory arthropathy Septic joint
Patellofemoral Syndrome
Also referred to as Anterior knee pain or Idiopathic anterior knee pain or chondromalacia patella Retropatellar or peripatellar pain Results from stresses upon patellofemoral joint
Epidemiology
Leading cause of knee pain < 45 y/o Females > males 25-40% of all knee pain in sports clinics
Anatomy
Patella is sesamoid within quadriceps tendon Articulates with trochlear groove of femur
Predisposing anatomy
Increased Q angle Miserable malalignment VL>VMO muscle imbalance Decreased flexibility
History
Chronic anterior knee pain Often bilateral Usually no history of acute injury Often unable to point to one spot Worse with activity Often worse with stairs Often worse with prolonged sitting
Exam
Observe active knee extension: Lateral tracking Patellar tilt Patella mobility Tight retinaculum Q angle Flexibility testing Strength testing Single leg squat Special testing Patella apprehension Patellar compression Clark’s Inhibition test
Patellar Apprehension
Knee flexed to 30 deg and relaxed across thigh Force patella laterally with thumbs OBSERVE FACE – notice apprehension or discomfort before actual dislocation
Patellofemoral Compression
Clarke’s test Knee in full extension and relaxed Contract quad, ask about pain, relax quad Perpendicular pressure around superior patella with web space between thumb-index Re-contract quad Positive test = pain
Single Leg Squat
Should I order imaging?
X-ray Ottawa Knee Rules MRI MRI arthrogram
But as in life….you have options
Ottawa Knee Rules
Age 55 or over; Isolated tenderness of the patella; Tenderness at the head of the fibula; Inability to flex to 90 degrees; Inability to walk four weight-bearing steps both immediately and in the emergency department.
Pittsburgh Decision Rules
Blunt trauma or a fall as mechanism of injury plus either of the following: Age younger than 12 years or older than 50 years Inability to walk four weight-bearing steps in the emergency department
Efficacy :
Sensitivity: 97% Specificity: 27% Reduced the use of knee radiographs by 28%
Efficacy:
Sensitivity: 99% Specificity: 60% Reduced the use of knee radiographs by 52% Tandeter HB, Shivartzman P. Acute knee injuries: use of decision rules for selective radiograph ordering.
Am Fam Physician
. 1999:
X-ray
Check for: lateral subluxation Patella tilt Degenerative changes
How about an MRI?
American Academy of Orthopaedic Surgeons 2011 Annual Meeting: Abstract 299. Presented February 17, 2011
.
33 patients (31%) underwent MRIs 18 scans (55%) were classified as unnecessary because it was possible to make the diagnosis with history, physical examination, and X-rays alone. Of the remaining 75 patients (69%) who presented without an MRI study only 4 required additional MRI evaluation, for a tentative diagnosis of a meniscal tear in 3 patients and osteonecrosis in 1 patient The most common final diagnosis for this cohort was osteoarthritis in 41 patients (38%), followed by patellofemoral syndrome in 14 patients (13%) and meniscal tears in 8 patients (7%).
Treatment
Physical Therapy Modalities Alternative Surgery
Physical Therapy
Strengthen VMO Closed chain exercises Hip abductor/external rotator strengthening IT band/ hamstring flexibility
Other modalities
Taping Widely employed, multiple trials have shown not significant benefit* McConnell taping Bracing No good data to demonstrate benefit Patella stabilizing brace Palumbo knee brace Corticosteroid injection * Aminaka N, Gribble, PA. A Systematic Review of the Effects of Therapeutic Taping…. J. of Athl Train: 2005
Alternative treatments
Acupuncture In randomized study, placebo group showed equal benefit Benefit at four weeks Chiropractic patellar mobilization No statistical improvement Manipulation Decreased quadriceps inhibition
Referral to Specialist
Conservative Trial Fails- 4-6 weeks Effusion associated w/ AKP Important to Answer before referral Is Pain Reflex Inhibition gone?
Is there evidence of VMO hypertrophy ? If no, compliance issues must be addressed.
Surgical intervention
Lateral release 17-92% pt satisfaction Tibial tubercle advancement Vastus Medialis transposition Microfracture procedures for chondromalacia
It is not so much pain…..but more of an unsteady felling
Knee instability
Ligament sprain Meniscal tear Reflexive pain arc Osteoarthritis Loose body Osteochondral defect Osteochondritis desiccants
Statistics
100,000 ACL injuries a year Female athletes at 2-8 times increased risk for ACL injury than male athletes in comparable sports Women experience ACL tears up to nine times more often then men.
American Family Physician; 2010 Non contact and contact mechanisms are different 70% of ACL injuries are the result of non-contact situations
Anatomy and Function
Anatomy 2 bundles Runs from the anterior intercondyle region of the tibia to the medial aspect of the lateral condyle of the femur Function Maintain rotary stability Prevent anterior tibial translation on the femur
Anatomy and Function
Anatomy Crescent-shaped pads of fibrocartilage located between the femoral condyles and the tibial plateaus Function Aid in dissipating loading forces placed on the knee stabilizing the knee during rotation lubricating the knee joint
Mechanism of Injury
Three non-contact ACL injury mechanisms Cutting Deceleration Landing Non-contact injury will often occur with jumping or landing from a jump
Theories
Neuromuscular Hamstring strength Proprioception Muscular activation Biomechanical dynamics Anatomy Femoral notch width Q angle Hormonal Estrogen receptors on the ACL Extrinsic factors
One plausible cause
Dynamic Neuromuscular Imbalance Women run, land, and jump differently Female athletes land with greater maximal valgus angle* Significant differences between dominant and non dominant knees* Female athletes rely less on hamstring and more on quadriceps and gastrocnemius++ Upon landing, women tend to land with less knee flexion* * Mandelbaum BR et al. Effectiveness of a Neuromuscular and Proprioceptive Training …Amer Journal of Sports Medicine. 2005 ++ Harmon KG, Ireland ML. Gender differences in noncontact anterior cruciate ligament injuries. Clinics in Sports Medicine. 2000
History
Acute injury Unilateral Immediate Pain – often Diffuse swelling – occurring 1-2 hours after activity Popping – audible or felt Instability – knee giving way Catching / locking
Special Tests for Ligaments
ACL Lachman 87% sensitive / 93 % specific Anterior Drawer 48% sensitive / 87% specific PCL Posterior Drawer Sag/ Gravity Test MCL Valgus Stress @ 0&30 LCL Varus Stress @ 0&30 Jackson J, O’Malley P, Kroenke K. Evaluation of Acute Knee Pain in Primary Care. Ann Intern Med: 2003; 139(7):575-588.
Special Tests for Menisci
McMurray 52% sensitive / 97% specific Apley Grind Flick Several studies have concluded that a negative physical exam can reliable exclude meniscal pathology Jackson J, O’Malley P, Kroenke K. Evaluation of Acute Knee Pain in Primary Care. Ann Intern Med: 2003; 139(7):575-588 Ellis M, Meadows S, “For knee pain, how predictive is physical examination for meniscal injury?”, J Fam Pract 2004; 53(11)
Radiology
X-ray Often normal Effusion Segond Fracture
Radiology
MRI Torn ligament Wavy appearance Complete void Loss of PCL arc Bone bruising Lateral femoral condyle and tibial plateau
Radiology
MRI Linear density change Intra-substance, horizontal, or vertical High degree injury if tear involves travels to joint surface Extruded tissue sensitivity and specificity 91.4% and 81.1% - medial meniscal tear 76% and 93.3% -lateral meniscal tear Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull. 2007
Treatment for an ACL Injury
Surgery Athletes and active women Mechanical symptoms Graft selection Autograph – patella tendon vs. hamstring Allograph Non-invasive Physical therapy Bracing
Physical Therapy
Strength training Quadriceps – hamstring ratio Flexibility Quadriceps and hamstring Proprioception
Bracing?
No evidence that pain, range of motion, graft stability, or protection from subsequent injury were affected by brace use.
Bracing after ACL Reconstruction: A Systematic Review. Clinical Orthopaedics and Related Research. 2007
Prevention
Proper training – proprioception and neuromuscular training exercises Decelerate in a more controlled fashion by taking smaller steps than one sudden step Round off turns when pivoting, keeping legs inside body shape Concentrate on core strength
Prevention
Prevention programs Prevent Injury, Enhance Performance Aim of program Diminish the effect of fatigue on neuromuscular control 88% reduction in ACL injuries* FIFA 11+ Complete warm-up to prevent ACL injuries * Mandelbaum BR et al. Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior Cruciate Ligament Injuries in Female Athletes: 2-year follow-up. American Journal of Sports Medicine. 2005; 33(7): 1003-1010
Long-term Sequelae
Osteoarthritis in up to 90% of patients after a previous ACL
Treatment for a Meniscal Injury
Non-surgical consideration
Symptoms develop over 24 to 48 hours after the acute injury Able to bear weight Minimal swelling Knee has full range of movement with pain only at or near full flexion Pain on McMurray testing occurs only with deep knee flexion MRI demonstrates small intra substance and vertical tears
Surgical consideration
After a severe twisting injury, activity could not be resumed Locked or restricted motion Pain after minimal flexion in McMurray testing An associated ACL tear Little improvement after 3 weeks of non-invasive treatment MRI demonstrates a large complex meniscal tear Cooper, R, Crossley, K, Morris, H.. Acute knee injuries. In: Clinical Sports Medicine, 2nd edition, Brukner, P, Khan, K (Eds), 2000
Physical Therapy
Strength training Quadriceps – hamstring ratio Flexibility Quadriceps and hamstring Proprioception
Surgery
Surgical options Partial or total meniscectomy Partial meniscectomy is preferred method considering speed of recovery and functional outcome Repair of the meniscal tear Approach Arthroscopic Open
Chronic Degenerated Meniscal Injury
Medial meniscectomy in patients over the age of fifty: a six year follow-up study
20% of good results after a degenerative meniscal tear Ménétrey J, Siegrist O, Fritschy D. Medial meniscectomy in patients over the age of fifty: a six year follow-up study. Swiss Surg. 2002;.
Chronic Degenerated Meniscal Injury
A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the knee
Arthroscopic surgery for osteoarthritis of the knee provides no additional benefits to optimized physical and medical therapy Kirkley A, et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. The New England Journal of medicine. 2008.
In Conclusion
Patellofemoral is a very common problem. An accurate diagnosis and aggressive treatment plan can be helpful to patients.
ACL injuries can be devastating but we may have some ways to help prevent the injury from occurring Not all meniscal injuries need surgery
References
American Academy of Orthopaedic Surgeons 2011 Annual Meeting: Abstract 299. Presented February 17, 2011.
Aminaka N, Gribble, PA. A Systematic Review of the Effects of Therapeutic Taping on Patellofemoral Pain Syndrome. Journal of Athletic Training: 2005 Calmbach W, Hutchens M. Evaluation of Patients Presenting with Knee Pain: Part I. History, Physical Examination, Radiographs, and Laboratory Tests. Am Fam Physician: 2003; 68(5).
Calmbach W, Hutchens M, “Evaluation of Patients Presenting with Knee Pain: Part II. Differential Diagnosis”, Am Fam Physician 2003; 68(5).
Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull. 2007;84:5.
Cooper, R, Crossley, K, Morris, H.. Acute knee injuries. In: Clinical Sports Medicine, 2nd edition, Brukner, P, Khan, K (Eds), McGraw-Hill, 2000. p.426
Ellis M, Meadows S. For knee pain, how predictive is physical examination for meniscal injury?” J Fam Pract 2004; 53(11).
Harmon KG, Ireland ML. Gender differences in noncontact anterior cruciate ligament injuries.
Clinics in Sports Medicine
, vol. 19, no. 2, pp. 287–302, 2000.
References
Jackson J, O’Malley P, Kroenke K. Evaluation of Acute Knee Pain in Primary Care. Ann Intern Med: 2003; 139(7):575-588.
Kirkley A, et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. The New England Journal of medicine. 2008; 359(11):10971107.
Mandelbaum BR et al. Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior Cruciate Ligament Injuries in Female Athletes: 2-year follow-up. American Journal of Sports Medicine. 2005; 33(7): 1003-1010.
Ménétrey J, Siegrist O, Fritschy D. Medial meniscectomy in patients over the age of fifty: a six year follow-up study. Swiss Surg. 2002;8(3):113.
Tandeter HB, Shivartzman P. Acute knee injuries: use of decision rules for selective radiograph ordering.
Am Fam Physician
. 1999: Dec;60(9):2599-608. Wright R, Fetzer G. Bracing after ACL Reconstruction: A Systematic Review. Clinical Orthopeadics and Related Research. 2007
Increased Q angle
Measurement ASIS to mid patella Mid patella to tibial tubercle Normal angle 10-20 degrees Lateral pull leads to abnormal tracking
Mechanism of Injury
Anatomic Abnormality Malalignment Muscle imbalance Compensation Repetitive Microtrauma Overuse Growth spurts in children Macrotrauma Contusion Sprain / strain