Oh My Aching Knee

Jeffrey Rosenberg MDJeffrey Rosenberg MD

Department of Family MedicineDepartment of Family Medicine

Montefiore HospitalMontefiore Hospital

Bronx NYBronx NY

Objectives

Learn to evaluate an adolescent’s knee Learn to evaluate an adolescent’s knee Learn to evaluate an acutely injured kneeLearn to evaluate an acutely injured knee Learn to evaluate an older patient’s kneeLearn to evaluate an older patient’s knee Learn How to examine the KneeLearn How to examine the Knee

Anterior Knee

Posterior Knee

Adolescent Knee Pain

15 year old male, plays multiple sports with 15 year old male, plays multiple sports with insidious onset of anterior knee pain. insidious onset of anterior knee pain. Worse after sitting in class, up and down Worse after sitting in class, up and down stairs. No instabilitystairs. No instability

On exam, no effusion, non tender at tibial On exam, no effusion, non tender at tibial tubercle, but peripatellar tissues are tender. tubercle, but peripatellar tissues are tender. Increased Q angle, increased patellar laxityIncreased Q angle, increased patellar laxity

Adolescents Non Traumatic

Osgood-Schlaters Disease-Pain at Tibial Osgood-Schlaters Disease-Pain at Tibial TubercleTubercle

Patellar Tendonitis-Usually Proximal Patellar Tendonitis-Usually Proximal Patellar-Athletes that JumpPatellar-Athletes that Jump

Ilio-Tibial Band:RunnersIlio-Tibial Band:Runners All the Rest: Patellar Femoral SyndromeAll the Rest: Patellar Femoral Syndrome

Patellar Femoral Syndrome

Mal-alignment-Q Mal-alignment-Q Repetitive ForcesRepetitive Forces Muscle TightnessMuscle Tightness Exam: Patellar GlideExam: Patellar Glide

Patellar CompressionPatellar Compression

Patellar Tilt Patellar Tilt ROM/FlexibilityROM/Flexibility

Q Angle

Should be <20 male, Should be <20 male, <25 Female<25 Female

Flat feet, wide pelvis Flat feet, wide pelvis widen angle widen angle

Treatment: VMO Treatment: VMO strengthening, strengthening, stretching, McConnell stretching, McConnell TapingTaping

Case #2 Acute Traumatic Knee

23 yo female soccer player comes in two 23 yo female soccer player comes in two hours after being slid into from the side. hours after being slid into from the side. No pop felt, but not able to bear weight No pop felt, but not able to bear weight immediately afterwards, feels unstable immediately afterwards, feels unstable

On exam, tense effusion, limited ROM, On exam, tense effusion, limited ROM, lachmans’ positive with loss of endpoint lachmans’ positive with loss of endpoint and increased movement on Anterior and increased movement on Anterior DrawerDrawer

Acute Knee Injuries

Patellar Dislocation: Patellar Dislocation: Traumatic vs Non Traumatic; RecurrentTraumatic vs Non Traumatic; Recurrent All need Bracing for 2 to 4 weeks, PTAll need Bracing for 2 to 4 weeks, PT

Collateral Ligaments: If Laxity with Stress, may Collateral Ligaments: If Laxity with Stress, may be complete tear. Functional Brace, PTbe complete tear. Functional Brace, PT

ContusionContusion ACLACL Meniscus TearMeniscus Tear

ACL Injury Non Traumatic vs TraumaticNon Traumatic vs Traumatic

Women have more non traumatic ACL Women have more non traumatic ACL tearstears

High Impact, Planted Foot, Valgus Force or High Impact, Planted Foot, Valgus Force or Medial Rotation of TibiaMedial Rotation of Tibia

Field Sports, SkiingField Sports, Skiing Pop (60-70%)Pop (60-70%) Swells < 2 hours, feels well in a few daysSwells < 2 hours, feels well in a few days Recurrent Instability with twisting/stairsRecurrent Instability with twisting/stairs

Anterior Cruciate Testing

ACL should feel taught, like rope stretched to its maximum. Loss of this endpoint is consistent with tear

ACL ACL

TestiTestingng

SensitivitySensitivity SpecificitySpecificity Positive Positive LRLR

Negative Negative LRLR

CompoCompositesite

82%82% 94%94% 2525 0.040.04

AnteriAnterior or DraweDrawerr

62% 62%

(9-93%)(9-93%)

67% 67% (23-100%)(23-100%)

3.83.8 0.300.30

LachLachmansmans

84%84%(60-100%)(60-100%)

100% 100% (POOR (POOR QUALITY)QUALITY)

4242 0.100.10

PivotPivot 38% 38%

(27-95%)(27-95%)Solomon, et al: JAMA 286:13

Meniscus Tear

Twisting Injury with knee in flexionTwisting Injury with knee in flexion Can be degenerative tears-non traumaticCan be degenerative tears-non traumatic Pain with Stairs/SquattingPain with Stairs/Squatting Instability/giving way/true lockingInstability/giving way/true locking

Meniscus Test

Start with knee in flexion. Place Start with knee in flexion. Place thumb and index finger along thumb and index finger along joint line.joint line.

Flex the leg fully, internally rotate Flex the leg fully, internally rotate foot, abduct the lower leg and foot, abduct the lower leg and extend joint. Feel for click along extend joint. Feel for click along medial joint line, or pain medial joint line, or pain

Repeat for lateral meniscus: Repeat for lateral meniscus: externally rotate foot and adduct externally rotate foot and adduct the leg the leg

Appley’s grind test-also not Appley’s grind test-also not specificspecific

Meniscus Testing

SensitivitySensitivity SpecificitySpecificity Positive Positive LRLR

Negative Negative LRLR

McMurrayMcMurray 53% (SD 53% (SD 15%)15%)

59% (36)59% (36) 1.31.3 0.80.8

Joint Line Joint Line TendernessTenderness

79% (4%)79% (4%) 15% 15% (22%)(22%)

0.90.9 1.11.1

CompositeComposite 77% (7%)77% (7%) 91% (3%)91% (3%)

Solomon, et al: JAMA 286:13

Case #3 Older Patient

65 year old female with acute knee pain x 65 year old female with acute knee pain x two weeks. Increases with walking, stairs. two weeks. Increases with walking, stairs. Throbbing pain at nighttime (like a tooth Throbbing pain at nighttime (like a tooth ache). Tylenol helpful. On examination ache). Tylenol helpful. On examination mod sized effusion, mildly warm, decreased mod sized effusion, mildly warm, decreased ROM. What could be the diagnosisROM. What could be the diagnosis

American College of Rheumatology-Osteoarthritis Age > 50Age > 50 Morning Stiffness < 30 minsMorning Stiffness < 30 mins CrepitusCrepitus Bony EnlargementBony Enlargement Bony TendernessBony Tenderness Lack of WarmthLack of Warmth 34 % prevalence in adult population34 % prevalence in adult population

Osteoarthritis

Glucosamine Chondroitin: 2000 mg/day x Glucosamine Chondroitin: 2000 mg/day x 12 weeks, then lower to 1000 mg/day12 weeks, then lower to 1000 mg/day

Acetominophen >> NSAIDSAcetominophen >> NSAIDS Maintain strength, flexibility-swimming, Maintain strength, flexibility-swimming,

biking, tai chi, etcbiking, tai chi, etc Steroid Injections: Short term gainSteroid Injections: Short term gain Viscosupplementation: ControversialViscosupplementation: Controversial

Osteoarthritis

Patient now trips and falls. Presents two Patient now trips and falls. Presents two days later with increased knee pain, days later with increased knee pain, decreased ROM, Pain with all Weight decreased ROM, Pain with all Weight Bearing. On exam, her knee is swollen and Bearing. On exam, her knee is swollen and very tender? What happened?very tender? What happened?

Knee Effusion

Trauma to previously arthritic kneeTrauma to previously arthritic knee Arthropathy-Gout/PseudogoutArthropathy-Gout/Pseudogout ContusionContusion FractureFracture Does she need an x-ray? Does she need an x-ray? Arthrocentesis/Injection-Will make all of Arthrocentesis/Injection-Will make all of

the above (except fracture) betterthe above (except fracture) better

Ottawa Knee Rules-Validated Multiple Times >1000 pts to ED in Canada; 68 had Fracture>1000 pts to ED in Canada; 68 had Fracture Xrays needed if fall/blow to knee and:Xrays needed if fall/blow to knee and:

Age > 55, Isolated Tenderness head of Age > 55, Isolated Tenderness head of fibula or patella, inability to weight bear fibula or patella, inability to weight bear for 4 steps,inability to flex > 90 for 4 steps,inability to flex > 90

100% sens, 49-55 % specific. 100% sens, 49-55 % specific. Does not miss fracture, decrease xray by Does not miss fracture, decrease xray by

25%25%

Osteoarthritis

She did well for several years, then presents She did well for several years, then presents with acute worsening of pain, non with acute worsening of pain, non traumatic. She is unable to weight bear in traumatic. She is unable to weight bear in the office. On exam mod effusion, the office. On exam mod effusion, exquisitely tender on Medial Femoral exquisitely tender on Medial Femoral Condyle, not the joint spaceCondyle, not the joint space

What could be going on?What could be going on?

Avascular Necrosis

Usually > 50, often in setting of OAUsually > 50, often in setting of OA Steroids, Alcoholism, SmokerSteroids, Alcoholism, Smoker X-ray often normal initiallyX-ray often normal initially MRI will show changes before X-rayMRI will show changes before X-ray Non Weight Bearing-can take months to Non Weight Bearing-can take months to

improveimprove If no better -> Hemi or Total ArthroplastyIf no better -> Hemi or Total Arthroplasty

Teaching File Case: Osteonecrosis/Osteochondrosis

Diagnosis: Spontaneous Osteonecrosis of the Medial Femoral Condyle

Findings: Osteochondral abnormality of the

medial femoral condyle.

Pathology: Finding not evident with loss of overlying cartilage on initial radiograph (05/08/01). Osteochondral defect more evident on follow upradiograph (08/08/01) (arrowhead).

Slide 2 of 3

Clinical History: Acute onset of painin knee.

Teaching File Case: Osteonecrosis/Osteochondrosis

Diagnosis: Spontaneous Osteonecrosis of the Medial Femoral Condyle

Findings: Osteochondral abnormality of the medial femoral condyle clearly.

Pathology: Evident on follow upradiograph (08/08/01) (arrowhead).

Slide 3 of 3

Clinical History: Acute knee pain 3 months prior to this radiograph.