an evidence-based guide to the evaluation and … · “oh my aching knees!” …an evidence-based...

“Oh my aching knees!”…an Evidence-based Guide to the Evaluation

and Treatment of Overuse Knee Injuries in College Health.

“Oh my aching knees!”…an Evidence-based Guide to the Evaluation

and Treatment of Overuse Knee Injuries in College Health.

C.S. Nasin, M.D., CAQ Sports MedicineTeam Physician

University of Rhode Island

• Define the common causes of non-traumatic knee pain encountered in a college health care setting

• Identify the typical history associated with each cause of knee pain

• Describe the physical examination that is appropriate for each cause of knee pain

• Discuss the evidence-based treatment options for each cause of knee pain

Learning Objectives

SORT (Strength of Recommendation Taxonomy)A Recommendation based on consistent and good-quality patient-orientedevidence.**Examples:• Systematic review or meta-analysis of high-quality studies• High-quality randomized controlled trial of treatment†• High-quality diagnostic cohort study ‡• Validated clinical decision rule for diagnostic approach• All-or-none study§

B Recommendation based on inconsistent or limited-quality patient-orientedevidence.**Examples:• Systematic review or meta-analysis of lower-quality studies or studies withinconsistent findings.• Lower-quality clinical trials• Cohort study of treatment• Retrospective cohort study of prognosis• Case-control study

C Recommendation based on consensus, usual practice, opinion, disease-orientedevidence, or on case series for studies of diagnosis, treatment, prevention, orscreening.Examples:• Consensus guidelines• Usual practice or expert opinion• Disease-oriented evidence using only intermediate or physiologic outcomes• Case series

Knee pain (unilateral or bilateral)

Trauma?

Yes

Another lecturealtogether

No

Proceed to the nextslide

r1 Russell Kolton, 4/23/2010

I think I might havetwisted it during a run…

I think it may have Started…

Maybe it wasfrom…

Anterior Knee Pain: Patellofemoral Pain Syndrome (PFPS), patellar tendinopathy, prepatellar bursitis

Medial Knee Pain: Symptomatic medial plica, Pes Anserine bursitis

Lateral Knee Pain: Iliotibial band syndrome

Differential Diagnosis: non-traumatic sources of knee pain in young adults

Patellofemoral Pain

Patellofemoral Pain Syndrome (PFPS)

Synonyms: runner’s knee, anterior knee pain, retropatellar painSyndrome, lateral facet compression syndrome (not chondromalacia)

Epidemiology: females > males (2:1), most commonly in the 2nd

3rd decade of life• Prevalence: 20% of adolescents • Perhaps the most common diagnosis in Sports Medicine• Accounts for 10% of all orthopedic/sports medicine clinic visits• Most common knee injury among runners

Patellofemoral Pain Syndrome (PFPS)Clinical History:•Gradual or acute anterior knee pain•Unilateral or bilateral•Worse with running, squatting, prolonged sitting (theatre sign) and ascending/descending stairs•Pain is typically underneath or around the patella•Pain is typically achy, but may be sharp•May describe “buckling” or “giving way” i.e. psuedoinstability•May complain of “popping” or “catching”

Knee pain experienced upon rising after prolonged sitting (theatre, lectures halls, long car rides)

Patellofemoral Pain Syndrome (PFPS)The Theatre Sign

Percieved instability due to pain inhibiting proper contraction of the quadriceps

Patellofemoral Pain Syndrome (PFPS)Pseudoinstability

• Overload: increased physical activity, new exercise program, ↑BMI, history of sedentary lifestyle

• Malalignment: leg length discrepancy, excessive or inadequate foot pronation, muscular tightness, abnormal patellar mobility, large Q angle, muscle weakness or imbalance (i.e. vastus medialis and hip abductors).

• Trauma: Direct/Indirect trauma

Patellofemoral SyndromePatellofemoral SyndromeEtiologyEtiology

Jacobs S, Burton B. Injuries to runners: A study of entrants to a 10,000 meter race. AJSM. Vol 14, No. 2 1986.

Patellofemoral Syndrome: OverloadPatellofemoral Syndrome: Overload

• Patellofemoral compression test

• Patella facet tenderness

Patellofemoral Pain Syndrome Examination

• Leg length discrepancy• Gait analysis• Popliteal angle• Q angle• Abnormal patellar mobility• Muscle

weakness/imbalance

Patellofemoral Pain: MalalignmentPatellofemoral Pain: MalalignmentAdvanced ExaminationAdvanced Examination

Acute Phase:Activity Modification. Can maintain aerobic fitness with bike, pool, water running

NSAIDs. Limited evidence supports their use short term (2-3 weeks) SORT: B

Modalities: Although Ice is likely effective at reducing pain, no evidence supports US, iontophoresis, phonophoresis or e-stim.

Patellofemoral Pain SyndromePatellofemoral Pain SyndromeTreatmentTreatment

Recovery Phase:

•Supervised Physical therapy more effective than home exercise program. SORT: B•Stretching. Quad/Hamstring/Iliotibial band SORT: C

•Hip Abductor strengthening. SORT: B

•Quadriceps strengthening. SORT: A

•Core Stability SORT: C


Adjunctive Therapy:•Foot orthotics SORT B

•Bracing and patellar taping Inconclusive evidence. Some researcher feel a particular subgroup may benefit from bracing•Intra-articular corticosteroids and glycosaminoglycans No evidence


Design: single–blind, randomized controlled trial of 1500 UK army troops during 14 week basic trainingIntervention: group performed daily 4 closed kinetic chain quad/gluteal strengthening exercises plus 4 static stretches of the quadriceps, ITB, hamstring, and gastrocnemius

Outcome measure: incidence of anterior knee pain during the training periodResults: Incidence of PFS 1.3% vs. 4.8% (p<0.01)Conclusions: Daily preventative exercise can reduce the incidence of anterior knee pain in military recruits

Patellofemoral Pain SyndromePatellofemoral Pain SyndromePreventionPrevention

Coppack R, Etherington J, Wills A. AM J Sports Med2011; 22: 288-948.

SORT: B

Iliotibial Band Syndrome

• Anatomy: the IT band is a continuation of the tendinous portion of the tensor fascia lata (TFL) muscle, crossing the knee at the lateral femoral epicondyle and inserting at Gerdy’s tubercle on the lateral tibia.

• Epidemilogy: most common cause of lateral knee pain in runners, accounts for up to 22% of all lower extremity injuries

Iliotibial Band Friction SyndromeIliotibial Band Friction Syndrome

Posterior edge of ITB impinges on the lateral femoral epicondyle just after foot strike (≈ 30º flexion)

Repetitive irritation leads to chronic inflammation, esp. beneath the posterior fibers which are thought to be tighter against the epicondyle.

Iliotibial Band Friction SyndromeIliotibial Band Friction SyndromeEtiologyEtiology

Pain:Vague lateral knee pain progressing to a sharp, burning focal area of pain 2cm superior to the lateral joint line

Activity:Initially hurts toward the end of a run or several minutes into the run; progressing to pain with ambulation and while sitting or resting

Iliotibial Band Friction SyndromeIliotibial Band Friction SyndromeHistoryHistory

Running Factors:•High weekly mileage•Excessive running in the same direction on a track•Downhill running•Abrupt increase in running (frequency or distance)

Biomechanical Factors:•Tight IT band•Weak hip Abductors•Leg length discrepancy

Iliotibial Band Friction SyndromeIliotibial Band Friction SyndromeRisk FactorsRisk Factors

Noble compression test

Ober test

Iliotibial Band Friction SyndromeIliotibial Band Friction SyndromeExaminationExamination

• Leg length discrepancy

• Trendelenburg test

Iliotibial Band Friction SyndromeIliotibial Band Friction SyndromeAdvanced ExaminationAdvanced Examination

• Rest• Ice• NSAIDs• Corticosteroid

Injection SORT B

Iliotibial Band Syndrome: TreatmentIliotibial Band Syndrome: TreatmentAcute PhaseAcute Phase

Increase the length of the TFL/ITB complex SORT B

Treat myofascial restrictions along the lateral thigh and femur (foam roller)

Iliotibial Band Friction SyndromeIliotibial Band Friction SyndromeTreatmentTreatment

Subacute PhaseSubacute Phase

Emphasis of gluteus medius strengthening is useful in treatment SORT B

Iliotibial Band Friction SyndromeIliotibial Band Friction SyndromeTreatmentTreatment

Strengthening PhaseStrengthening Phase

• Most patients can RTR once they can perform strengthening exercises with proper form and without pain

• Run QOD for the first week• Avoid hills for first few weeks• Gradually increase distance and frequency

over the next 3-4 weeks

Iliotibial Band Friction SyndromeIliotibial Band Friction SyndromeReturn to Running (RTR)Return to Running (RTR)

Patellar Tendinopathy


Synonyms: patellar tendinitis, jumper’s knee, patellar tendon overuse syndrome, patellar tendinosis (pathologic diagnosis)

Epidemiology: males > females (2:1), typically presents in the early to mid twenties, with a range from 15-45yrs• Prevelance: 8.5% of non-elite athletes• Encountered in athletic patients whose sporting activities involve repetitive sudden ballistic motion of the knee• Typical sports: basketball, volleyball, track and field (esp.jumping events), football, soccer, tennis. Also now seen in newer exercise workouts (P90X, Insanity, Crossfit)


Clinical History:•Generally has an insidious onset•Dull, achy pain develops after activity•Generally becomes localized to the inferior pole of the patella•May be precipitated by an increase in frequency or intensity of repetitive ballistic movements of the knee

Phase 1: Pain after practice/competitionPhase 2: Pain at the start of activity disappearing after the warm up and reappearing after activityPhase 3: Pain during and after activity, athlete unable to participate in sportPhase 4: Complete tear of patellar tendon

Patellar Tendinopathy:Clinical Classification

Blazina M, Kerlan R, Jobe F. Orthop Clin. 1973; 4: 665-78.

• Palpation of the patellar tendon just near the inferior pole of the patella (with the knee in extension).

• Apply pressure to the superior patella to tilt the inferior patella anteriorly, allowing for palpation of the tendon origin.

• In symptomatic tendons, the PPV=68%

• Moderate/Severe tenderness is a better predictor of abnormal ultrasound evidence of tendon pathology than absent or minimal tenderness (p<0.001)

Patellar TendinopathyExamination

Cook J, Khan K, Kiss Z, Purdam C, Griffiths L. Br. JSports Med 2001; 35: 65-69

• Decline (30°) squat test – to test the strength of the quadriceps muscles and to reproduce pain or patellar tendinopathy

• Single leg squat test – to assess the strength of the gluteal muscles

• Assess the strength and endurance of the calf muscles (calf-raise test)-calf strength and endurance plays an important role in shock absorption of the lower limb during impact activities

• Observe for quadriceps wasting (esp. the VMO) – indicates chronicity

• Assess flexibility of quadriceps, ITB, hamstrings and calf muscles – muscular tightness increases the load on the patellar tendon.

Patellar TendinopathyAdvanced Examination

• Extrinsic factors: overload (repetitive ballistic knee motion)

• Intrinsic factors: malalignment, patella alta, abnormal patellar laxity, and muscular tightness and imbalance.

Patellar TendinopathyEtiology

• Tendinosis: typically involves the deep posterior portion of the patellar tendon adjacent to the lower pole of the patella

• Characterized by progressive tissue degeneration with a failed reparative response and complete absence of inflammatory cells

• “Mucoid degeneration” is seen grossly: yellow-brown disorganized appearance

Patellar TendinopathyEtiology

Ultrasonography: readily available, quick, and inexpensive. Tendon examined using high-frequency linear transducer with the knee flexed or semiflexed. Diseased tendon is reflected by decreased echogenicity, tendon thickening, and intratendinous calcification.

Patellar Tendinopathy: Imaging

MRI: provides high intrinsic tissue contrast that can differentiate normal tendons from abnormal tendons.•Patellar tendinopathy is characterized by focal increases in signal within the tendon and alteration in tendon size.



Sensitivity Specificity

US 58% 94%MRI 78% 86%

Imaging is not a gold standard for diagnosis

Positive MRI and Ultrasound findings for patellar tendinopathy have been shown in asympotmatic tendons; conversely symptomatic tendons can have normal imaging.

Numerous authors have shown no correlation between the Severity and of symptoms and tendon appearance on US

Eccentric muscular contractionsimpart a greater force on the muscular tendon, it is theorized that tenocytes in the tendon respond to mechanical forces by altering their gene expression patterns, protein synthesis and cell phenotype, which can be used to aid the healing process.

Patellar Tendinopathy: The Use of Eccentric Muscular Contraction

Wang QW, Chen ZL, Piao YJ. Mesenchymal stem cells differentiate into tenocytes by bone morphogenetic protein (BMP) 12 gene transfer. J Biosci Bioeng 2005;100:418-22.

Eccentric exercise: High quality RCT has shown that 12 wk of 25°-decline squats achieved results at 12 months equivalent to the results of open surgery with a well designed rehab programSORT: A

Patellar Tendinopathy:Treatment

Bahr R, Fossan B et al. J. Bone Joint Surg. Am. 2006; 88: 1689-98.

Steroid injections: delivered adjacent to the patellar tendon under US guidance reduce walking pain after 1 week, but are significantly inferior to exercised based interventions at 6 mos.

Extracorporeal shock wave therapy (ESWT): delivers a pressure wave into the affected tissue. May be an effective modality for off-season athletes, but shows no long term improvement

Do Not lead to long term improvement and therefore cannot be recommended.

Platelet-rich plasma: delivers a cocktail of growth factors and cytokines to the injured area of the tendon, theoretically leading to improved tissue repair.No high quality evidence that PRP injections are useful in patellar tendinopathy, and is best described as unproven and experimental.

Hyperosmolar dextrose injection, Dry needling and autologous blood injection also lack high quality evidence to support effectiveness.


“Treatment effectiveness is inversely related to the number of available treatment choices”

-Cook J. In search of the tendon holy grail: predictable clinical outcomes. Br. J. Sports Med. 2009; 43: 235.


Medial Plica Irritation


Synonyms: plica syndrome, symptomatic medial plica

Epidemiology: Poorly studied, may be involved in 27%acute anterior knee pain (Brushoj C. Br. J. Sports Med 200842: 1 64-67)

Anatomy: well vascularized intraarticular synovial fold overthe medial aspect of the knee. Proximally it is attached to the medial quadriceps and genu articularis muscle, spanning medially to attach to anterior horn of the medial meniscus andand the medial edge of the retropatellar fat pad.

Symptoms: pain and “popping” or “snapping”when rising from a seated position. May complain of catching, locking, or pseudolocking (50% of cases)•Pain with stairs, squating and prolonged sitting


Plica snap test: roll the medial plica (ribbon like band of tissue between the medial border of the patella and medical femoral condyle) against the medial condyle. It is important to ascertain whether or not the snap test reproduced the patient’s symptoms.

Medial Plica IrritationExamination

Biomechanical: poor quadriceps tone, tight hamstringsPost-operative: after arthroscopy for medial compartment pathologyInflammatory: intraarticular effusions can decrease the viscosity of the synovial fluid and predispose to plica symptoms.

Medial Plica IrritationEtiology

Physical Therapy: 6-8 week program with focus on quadriceps strengthening and hamstring flexibility SORT CIntraarticular corticosteroid injection: if P.T. fails or is too painful to fully participate in P.T. SORT CArthroscopic surgery: only if conservative measures fail. May be useful if the plica is acting as a shelf on the medial femoral condyle and causing erosion of the articular cartilage SORT C

Medial Plica IrritationTreatment

Pes Anserine Bursitis

Anserine bursa: can be found 6cm below the medial jointline and between the insertion of the MCL and conjoined tendon.Symptoms: focal, aching pain, typically worse a night and with climbing/descending stairsRisk Factors: Abnormality in gait, overload, and osteoarthritis


Conservative measures: RICE (avoid crossing legs, pillow b/t knees at night for comfort)NSAIDs: Short trial of nonselective NSAIDs superior to placebo when treating bursitis. SORT CCorticosteroid injection: if above fails. Studies shown superiority over NSAIDs when treating olecranon/subacromial bursitis. SORT C


Prepatellar Bursitis

Prepatellar bursitis: inflammation of the largest knee bursa between the patella and overlying skinSymptoms: pain and swelling over the anterior kneeRisk Factors: trauma, direct pressure and friction from repetitive kneeling (i.e. housemaid’s knee), infection Exam: Fluid is extraarticular and knee ROM is preserved

Prepatellar Bursitis

Conservative measures: PRICE (Protection: knee pad)Aspiration and drainage: mandatory if septic bursitis is suspectedNSAIDs: short course in conjunction with PRICE: SORT C Corticosteroid injection: should be considered if recurrent nonseptic bursitis or there is chronic bursal thickening: SORT C

Prepatellar bursitis

Osteochondritis Dessicans

Osteochondritis dessicans (OCD): is a condition in which a segment of the articular cartilage (with underlying subchondral bone) gradually separates from the articular surface.Symptoms: pain with activity, intermittent swelling and possible locking of the kneeEpidemiology: 29 per 100,00 cases of adolescent/young adult men (18 per 100K females); ¾ cases involve the lateral aspect of the medial femoral condyle


Etiology: Unknown, theories include: family history, repetitive microtrauma, growth abnormalities, and ischemiaExam: tenderness along the affected femoral condyle, may be accompanied by a joint effusionTreatment: Unstable or displaced OCD lesions may benefit from surgery: SORT C


Condition Diagnostic Examination Treatment(Supported by the literature)

PFPS Patellar compression testFacet tenderness

NSAIDs, Formal PT, Hip Abductor/Quadriceps/Core strengthening, stretching, foot orthotics

ITB syndrome Noble compression testOber exam

ITB stretching, Gluteus medius strengthening, and corticosteroid injection

Patellar tendinopathy Palpation of the patellar tendon (knee in ext.)

Eccentric strengthening exercises

In SummaryKnee Overuse Injuries

Bits & Pieces

A few words about the evidence behind footwear

Cook SD, Kester MA, Brunet ME. Shock absorption characteristics of running shoes.Am J Sports Med. 1985;13(4):248.

After 250-500 miles of running, shoes retain less than 60% of their initial shock absorption capacity

SORT C

Shock absorption characteristics of running shoes

2 large studies of military recruits assigned to a specific shoe type based on foot arch shows no reduction in running injuriesA recent systematic review provides the same conclusionSORT B

Design of Running Shoes Based on Arch Type

Richards CE, Magin PJ, Callister R. Is your prescription of distance running shoes evidence-based?Br J Sports Med. 2009;43(3):159.

Can prevent running injuries in military recruits SORT BLikely reduce the risk of stress fracture in military trainees SORT BHave been shown to reduce the pain associated with PFPS and pes cavus SORT B

Foot Orthotics

Franklyn-Miller A, Wilson C, Bilzon J, McCrory P Foot orthoses in the prevention of injury in initial military training: a randomized controlled trial. Am J Sports Med. 2011;39(1):30.Rome K, Handoll HH, Ashford RInterventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults.Cochrane Database Syst Rev. 2005;Fields K, Sykes C et al. Prevention of Running Injuries. Current Sport Med Reports. 2010; vol 9, no 3

Pros: shorter running stride and lower impact mid to forefoot strike (as opposed to heel strike in cushioned shoes)Cons: less cushioning while running on hard surfaced

Minimalist Shoes/Barefoot running

Jenkins DW, Cauthon DJ. Barefoot running claims and controversies: a review of the literature.J Am Podiatr Med Assoc. 2011;101(3):231.

No controlled to date shows negative or positive effects on runningor reduction of injury rates.

Questions?

ReferencesO’Conner F, Mulvaney S. Patellofemoral Pain syndrome. Up To Date. Last updated April 30th, 2012.

Jacobs S, Burton B. Injuries to runners: A study of entrants to a 10,000 meter race. AJSM. Vol 14, No. 2 1986.

Heintjes E, Berger MY, Bierma-Zeinstra SM, Bernsen RM, Verhaar JA, Koes B. Pharmacotherapy for patellofemoral pain syndrome. Cochrane Database Syst Rev. 2004;

Van Linschoten R, van Middelkoop M, Berger MY, Heintjes EM, Verhaar JA, Willemsen SP, Koes BW, Bierma-Zeinstra SM. Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open label randomised controlled trial.. BMJ. 2009;339:b4074.

Peeler J, Anderson JE. Effectiveness of static quadriceps stretching in individuals with patellofemoral joint pain. Clin J Sport Med. 2007;17(4):234.

Avraham F, Aviv S, Ya'akobi P, Faran H, Fisher Z, Goldman Y, Neeman G, Carmeli E The efficacy of treatment of different intervention programs for patellofemoral pain syndrome--a single blinded randomized clinical trial. Pilot ScientificWorldJournal. 2007;7:1256.

Heintjes E, Berger MY, Bierma-Zeinstra SM, Bernsen RM, Verhaar JA, Koes BW. Exercise therapy for patellofemoral pain. Cochrane Database Syst Rev. 2003

Earl JE, Hoch AZ . A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Am J Sports Med. 2011;39(1):154.

Crossley K, Bennell K, Green S, McConnell J A systematic review of physical interventions for patellofemoral pain syndrome. Clin J Sport Med. 2001;11(2):103.

Fredericson M, Weir A. Practical Management of Iliotibial Band Friction Syndrome in Runners. Clin J Sport Med. Vol 16, no. . 2006.

Khaund R, Flynn S. Iliotibial Band Syndrome: A common Source of Knee Pain. American Family Physician. Vol 71, No 8, 2005.

Fredericson M, White J et al. Quanitative analysis of the relative effectivenes of 3 iliotibial band stretches. Arch Phys Med Rehabil 2002; 83: 589-92.

Torstensen E, Bray R, and Wiley P. Patellar Tendinitis: A Review of Current Concepts and Treatment. Clin J of Sports Med. 4:77-82. 1994.

Gaida J, Cook J. Treatment Options for Patellar Tendinopathy: Critical Review. Current Sports Med Reports. Vol 10, No. 5. 2011.

Kountouris A, Cook J. Rehabilitation of Achilles and patellar tendinopathies. Best Practices & Research Clin Rheumatology. Vol 21, No. 2. 2007

Cook J, Khan K, et al. Reproduciblity and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players. Br J Sports Med 2001; 35: 65-69.

Warden S, Brukner P. Patellar tendinopathy. Clin Sports Med 22 (2003); 743-759.

Mathijs van Ark, Zwerver J, van denAker-Scheek I. Injection treatments for patellar tendinopathyBr J Sports Med 2011;45: 1068-1076.

References

Griffith C, LaPrade R. Medial Plica Irritation: diagnosis and treatment. Curr Rev Musckuloskeletal Med (2008) 1: 53-60

Larsson LG, Baum J. The syndrome of anserina bursitis: an overlooked diagnosis. Arthritis Rheum. 1985;28(9):1062.

Anderson B. Knee bursitis. Up To Date. Last Updated Nov 20, 2006.

Petri M, Hufman SL, Waser G, Cui H, Snabes MC, Verburg KM Celecoxib effectively treats patients with acute shoulder tendinitis/bursitis. J Rheumatol. 2004;31(8):1614.

Smith DL, McAfee JH, Lucas LM, Kumar KL, Romney DM Treatment of nonseptic olecranon bursitis. A controlled, blinded prospective trial.. Arch Intern Med. 1989;149(11):2527.

Hergenroeder A. Approach to the young athlete with chronic knee pain or injury. Up to Date. Last updated Dec 211.

Cook SD, Kester MA, Brunet ME. Shock absorption characteristics of running shoes. Am J Sports Med. 1985;13(4):248

Richards CE, Magin PJ, Callister R. Is your prescription of distance running shoes evidence-based? Br J Sports Med. 2009;43(3):159.

Franklyn-Miller A, Wilson C, Bilzon J, McCrory P Foot orthoses in the prevention of injury in initial military training: a randomized controlled trial. Am J Sports Med. 2011;39(1):30.

References

Rome K, Handoll HH, Ashford RInterventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults.Cochrane Database Syst Rev. 2005

Fields K, Sykes C et al. Prevention of Running Injuries. Current Sport Med Reports. 2010; vol 9, no 3

Jenkins DW, Cauthon DJ. Barefoot running claims and controversies: a review of the literature. J Am Podiatr Med Assoc. 2011;101(3):231.

Coppack R, Etherington J, Wills A. AM J Sports Med 2011; 22: 288-948.

Wang QW, Chen ZL, Piao YJ. Mesenchymal stem cells differentiate into tenocytes by bone morphogenetic protein (BMP) 12 gene transfer. J Biosci Bioeng 2005;100:418-22

Bahr R, Fossan B et al. J. Bone Joint Surg. Am. 2006; 88: 1689-98.

References

an evidence-based guide to the evaluation and … · “oh my aching knees!” …an evidence-based...

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