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Knee Problems

Cure Conference
Mike Mazzone
Waukesha Family Medicine
Outline
Brief Review of evaluation of the
knee
Discuss Differential Diagnosis
Review Treatment Modalities
Brief Overview
1/3 of all musculo-skeletal problems
seen in Primary Care are about the
Knee
54% of all Atheletes will experience
some knee pain EVERY YEAR
Things to think about in History
Pain characteristics PQRST
Mechanical Symptoms
Locking
Popping
Giving Way
Effusion
Rapid (< 2 hours) hemarthrosis
Slow (24-48 hours) ligamentous strain, meniscal Injury
Mechanism of Injury
Direct blow?
Foot planted
Decelerating or landing from a jump
Twisting
Hyperextension
Medical History
Previous Knee pain or Surgery
Physical Exam
Inspection
Palpation
ROM Normal 0 degrees to 135 degrees
Neuro
Special Tests
Lachman or Drawer for ACL problems
McMurray or Apley Grinder Meniscal Injuries
Milking of Suprapetallar Pouch
PatelloFemoral Tracking
Q angle (>15 degrees predisposes to Patellar
Subluxation
Patellar Aprehension Test push patella laterally
Varus and Valgus Stress MCL and LCL
Ottawa Rules for Obtaining a
radiograph in Acute Knee Injuries
Ottawa Rules Pittsburg Rules
age 55 or over Blunt trauma or a fall as
isolated tenderness of the patella mechanism of injury plus either
(no bone tenderness of the knee of the following:
other than the patella)
tenderness at the head of the Age younger than 12 years or
older than 50 years
fibula
Inability to walk four weight-
inability to flex to 90 degrees bearing steps in the emergency
inability to weight bear both department
immediately and in the ER (4
steps - unable to transfer weight Sensitivity 99%
twice onto each lower limb Specificity 60%
regardless of limping).
Reduced Radiographs by 57%
Sensitivity 97%
Specificity 27%
Reduced Radiographs by 28%
What Radiographs to Order
Most Patients 3 views
AP
Lateral
Merchants
Teenagers with chronic knee pain
and recurrent effusion
Add Tunnel View (PA with knee flexed
40-50 degrees)
Loooks for osteochondritis dissecans on
Femoral Condyles)
AP View Lateral View

Merchants view Tunnel View


Lab
In presence of Warmth, exquisite tenderness and effusion
Consider Septic Arthritis or Acute Inflammatory arthropathy
Labs to order
CBC
ESR
Arthrocentesis for
Cell count and differential
Glucose
Protein
C&S
Polarized light microscopy
If unclear of diagnosis with an effusion Arthrocentesis
If Rheumatoid Arthritis a possibility ESR and RF
Differential Diagnosis by Age
Children and Adults Older Adults
Adolescents Patellofemoral Osteoarthritis
Patellar Pain Syndrome Crystal
Subluxation Medial Plica Induced
Osgood- Syndrome arthropathy
Schlatter Pes Anserine Bakers Cyst
Tibial Bursitis (Popliteal
Apophysitis Traumatic Injury Cyst)
Jumpers Knee Ligamentous
Patellar sprains
Tendonitis Meniscal
Referred Pain Injuries
Slipped Capital Inflammatory
Femoral Arthropathy
Epiphysis Septic Arthritis
Osteochondritis Patellar Bursitis
Dissecan
Iliotibal Band
Syndrome
Differential By Location
Anterior Medial Lateral Posterior
Patellar MCL Sprain LCL Bakers
Subluxation Cyst
Medial Sprain
Osgood- Posterior
Schlatter Meniscal Lateral
Cruciate
Jumpers Tear Meniscal
Ligament
Knee Pes Tear Injury
Patellofemor Anserine Iliotibial
al Pain
Syndrome Bursitis Band
Prepatellar Medial Plica Tendoniti
bursisits Syndrome s
Patellar Subluxation
More common in Girls withLarge Q
angle (> 15 degrees)
History Patella pops or gets stuck
PE Patellar Aprehension Test
Treatment
Physical Therapy cycling
Patellar Bracing
For Severe Surgery
Osgood-Schlatter
(Tibial Apophysitis)
More common Teenage boys
History
Knee pain waxing and waning for months
Worsens with squatting or stairs
PE tender on tibial tuberosity
Treatment
Icing after activity
Decreasing activity may need to stop activity
for 2-3 months
NSAIDs
If severe knee immobilizer for 2-6 weeks
Patellar Tendonitis
History
Teenage boys
Pain is anterior and has persisted for months
PE tender over patellar tendon, pain
with knee extension
Treatment
ICE
NSAIDs
Decreased Activity
Slipped Capital Femoral Epiphysis
(SCFE pronouced Skiffy)
Overweight 10-16 yo Boys or 12-14 yo Girls
History
Vague Knee pain with no trauma
Exam pain on internal rotation of hip
Diagnosis Xray AP/Lat view of Pelvis and b/l
hips
Treatment
Immediate Cessation of weightbearing
Surgical stabilization

Take Home Point ALWAYS EXAMINE HIP IN


KIDS WITH KNEE PAIN
Osteochondritis Dissecans
History
Vague knee pain,
morning stiffness and recurrent effusion
possibly locking or catching
Exam
possible quad atrophy
effusion
chondral tenderness
Radiographs to include Tunnel view
MRI test of choice if unclear diagnosis
Treatment
Rest
Bracing
Low Impact PT
Surgery if symptoms persist >2-3 months despite therapy
Patellofemoral Pain Syndrome
History
Anterior knee pain worse after sitting (theatre sign)
PE
patellar crepitus
pain on contracting quad while putting pressure on Patella
Widened Q angle
Treatment
Relative rest
Ice 20 minutes after activity
Quadracep strengthening (consider hip, hamstring, calf and IT
band stretching)
Evaluation of Footwear
Consider NSAIDs
Consider Knee braces
Consider Knee taping McConnell Taping
Medial Plica Syndrome
Plica A redundancy of the joint synovium
Hx Acute onset medial knee pain
PE tender mobile nodularity
Treatment
NSAIDs
ICE
PT including phonophoresis and iontophoresis
Quad Strengthening Exercises
Pes Anserine Bursitis
Pes Anserine insertion of Sartorius,
gracilis and semitendinosus muscles
Hx pain on medial side of knee
worsened with flexion and extension
PE tenderness posterior and distal to
medial joint line valgus stress may
reproduce pain
Treatment
NSAIDs
ICE
Iliotibial Band Tendonitis
Friction between IT band and Lateral
Femoral Condyle
Hx Lateral Knee pain aggrevated by
activity
PE Tenderness over lateral epicondyle of
femur while flexing and extending knee
(Noble test)
Treatment
IT band stretching exercises
NSAIDs
ICE
Anterior Cruciate Ligament
Plant and turn injury
HX- often hears a pop and notes swelling in Knee
PE Joint Effusion + Anterior Drawer or Lachman if torn
(most sensitive directly after injury or about 2 weeks later)
Radiographs looking for tibial spine avulsion
MRI prior to surgery if torn
Treatment
Initial Treatment
RICE
Knee Immobilization
Crutches
NSAIDs
Definitive treatment
Based on Age, Activitity level and degree of injury
Surgery vs prolonged immobilization
Medial Collateral Ligament (MCL)
Due to valgus stress
Hx valgus stress then immediate pain and
swelling medially
PE valgus stress testing
Grade 1 clearly defined endpoint and < 5m laxity
Grade 2 5-10 mm of laxity with endpoint
Grade 3 no clear endpoint (complete tear)
Treatment
Grade 1 RICE and crutches as needed
Grade 2 RICE, crutches and hinged bracing
Grade 3 RICE, hinged brace gradual return to
weightbearing over 4 weeks
Lateral Collateral Ligament (LCL)
Similar to MCL but much less
common
HX Varus stress then immediate
pain
PE Varus stress test
Treatment
Grade 1 and 2 same as MCL
Grade 3 may require surgery
Meniscal Tear
Can be acute or chronic
Hx Recurrent knee pain with episodes of
catching, locking or giving way
PE Mild effusion and positive McMurray
test
MRI best imaging test if diagnosis unclear
Treatment
If no locking or instability RICE, NSAIDs for
2-3 weeks
Otherwise referral for surgical debridement
Septic Knee
Predisposing factors cancer, DM, Etoh, AIDS,
corticosteroid therapy
Hx Abrupt onset of pain and swelling no trauma
PE warm, swollen, very tender
Lab
CBC left shift
ESR > 50 mm/hr
Arthrocentesis
Turbid synovial Fluid WBC > 50 000 Neutrophils >75 percent
Protein > 3 g/dL
Glucose - 50 percent or less or serum glucose level
Treatment
common pathogens Staphyloccus aureus, Streptococcus,
Haemophilus influenzae, Neisseria gonorrhoeae
IV antibiotics
Ortho referral for possible debridement
Osteoarthritis
Common > 60 years of age
Hx Knee pain aggrevated by weight bearing relieved by
rest, morning stiffness
PE decreased ROM, crepitus, osteophytic changes
Radiographs
Weightbearing AP, PA tunnel
Nonweightbearing Merchants and lateral view
Treatment
NSAIDs
Corticosteroid injections
Referral for Knee replacement if
Significant and disabling pain
Dysfunction significantly inhibiting quality of life
Should exhaust all clinical measures before considering surgery
Crystal-Induced Inflammatory
Arthropathy
Gout (sodium urate crystals) and Pseudogout
(calcium pyrophosphate crystals)
Hx- Acute onset, red hot and very tender knee
PE erythematous, warm, tender swollen
Arthrocentesis
Clear or slightly cloudy WBC 2K to 75K
Protein high >32 g/dL
Glucose 75% of serum
Polarized-light microscopy of synovial fluid shows
Gout - negatively birefringent rods
PseudoGout positively birefringent rhomboids
Treatment
NSAIDs
Colchicine
Bakers Cyst
Outpouching of synovial fluid
Hx
insidious onset of mild to moderate pain in posterior
aspect of knee
Ruptured cyst may present like DVT red swollen and
tender calf

PE palpable fullness present medial aspect of


popliteal area
Imaging US, CT may help if diagnosis unclear
Treatment
Aspiration may cause temporary relief but recurrence
rate is high
Surgery if pain persistent and intolerable
Knee Braces
Types
Prophylactic prevent injury to uninjured knee (most common used by football
lineman)
Evidence mixed as to their effectiveness
Choose the longest brace that fits the atheletes leg
Custom brace offer little extra benefit to off-the-shelf models
Price vary considerably
Need to wear brace with hinge near epicondyles
Strength training, flexibility and technique refinement much more important
DO not prevent rotation injures
Functional provide stability to unstable knee
No great studies
No studies showing custom fit better than pre-sized
More limitation than prophylactic braces ( do prevent rotation injuries as well)
Limiting extension to 10-20 degress may prevent hyperextension injuries
Rehabilitative allow protected and controlled motion during knee rehabilitation
Patellofemoral Braces improve patellar tracking
Studies mixed on effectiveness
Typically made of neoprene with butresses that support the patella relatively
inexpensive
Prophylactic Brace PatelloFemoral Brace
Functional Brace
Tips for Icing Knee
Recommend 10-20 minutes per session
(when it feels numb you are done)
Recommend 2-3 times per day
Ways to manage ice
Plastic bag with some water
Freeze water in styrofoam or dixie cup then
peel cup away from top of ice for use
Wet towel in Freezer
Commercially available ice packs
References
Calmbach, W: Evaluation of Patients Presenting with Knee Pain:
Part I. History, Physical Examination, Radiographs, and Laboratory
Tests (AFP:68(5))
Calmbach, W: Evaluation of Patients Presenting with Knee Pain:
Part II. Differential Diagnosis (AFP:68(5))
Johnson, M: Acute Knee Effusions: A Systematic Approach to
Diagnosis (AFP:Vol 16(8))
Juhn, M: Patellofemoral Pain Syndrome: A Review and Guidelines
for Treatment (AFP:60(7))
Paluska, S: Knee Braces: Current Evidence and Clinical
Recommendations for Their Use (AFP: 61(2))
Solomon, D: Does the Patient have a torn Meniscus or Ligament of
the Knee? Value of the Physical Examination (JAMA:(286(13))
needs MCW proxy
Tandeter, H: Acute Knee Injuries: Use of Decision Rules for
Selective Radiograph Ordering (AFP: Vol 60(9))
Zuber, T: Knee Joint Aspiration and Injection (AFP:66(8))

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