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MS3 Sports Medicine Workshop PowerPoint PPT Presentation


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MS3 Sports Medicine Workshop. Family Medicine Clerkship. Knee Problems. MS3 Family Medicine. Anatomy Review. Femur Medial & lateral Condyles Epicondyles Trochlear groove Intercondylar notch Patella Superior pole (base) Inferior pole (apex) Medial & lateral facets. Tibia

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MS3 Sports Medicine Workshop

Family Medicine Clerkship


Knee Problems

MS3 Family Medicine


Anatomy Review


  • Femur

    • Medial & lateral

      • Condyles

      • Epicondyles

    • Trochlear groove

    • Intercondylar notch

  • Patella

    • Superior pole (base)

    • Inferior pole (apex)

    • Medial & lateral facets

  • Tibia

    • Medial & lateral

      • Condyles

    • Gerdy’s tubercle

    • Pes anserine area

    • Tibial tuberosity

    • Tibial plateau

    • Tibial spines

  • Fibula

    • Head

    • Neck


Anatomy – Major Ligaments & Tendons

  • Quadriceps tendon

  • Patellar tendon

  • Medial & lateral patellar retinaculua


  • MCLLCL


ACL and PCL


Iliotibial band (ITB)


Anatomy – Menisci of the Knee

  • Medial meniscus

  • Lateral meniscus

    • Meniscal ligaments

    • Functions of the menisci

  • Meniscal zones

    • White-white

    • Red-white

    • Red-red


Inspection

Palpation

Range of Motion

Strength

Neurovascular

Special Tests

Knee Exam Overview


16yo HS soccer player, previously healthy

Tackled from right side while running

Immediate onset of medial jt line pain

Delayed onset local medial edema, stiffness

Able to bear weight

Case 1 – Medial Right Knee Pain


Key Questions in the History

  • Mechanism of Injury?

  • Acute or Chronic?

  • Location and level of pain?

  • Able to walk?

  • Mechanical Symptoms? (Locking, popping, catching?)

  • Associated instability?

  • Swelling?

  • Previous injuries or surgeries?


Case 1 - Exam

  • Inspection: Mild medial knee edema

  • Palpation: + ttp medial knee

  • ROM: can’t bend >80d

  • Strength: mildly decreased

  • Neurovascular: normal

  • Special tests:

    • Neg Lachman, Anterior Drawer, McMurray, varus stress

  • + mild increased gap on valgus stress (compared to left) with good endpoint


Special Tests - ACL Injury

Lachman Test


Special Tests - PCL Injury

Posterior Drawer Test

Sag Sign

Quad-Active Test


Varus/Valgus stress for LCL and MCL Injury


Features that should prompt an xray after acute knee injury include:

  • Unable to bear weight

  • Can’t flex >90d

  • Patella TTP

  • Fibular head TTP

  • Age <18 or >55

  • All of the above


5 Ottawa Knee Rulesi.e. When to order a knee xray after acute injury

  • Age > 55 or < 18

  • Unable to walk

  • TTP on PATELLA

  • TTP on FIBULAR HEAD

  • Unable to flex 90 deg


Case 1 - Imaging

Normal!


Meniscal Tear

Ligamentous Injury

Which ligament?

ACL

PCL

MCL

LCL

Muscle Strain

Fracture

Patellofemoral Pain

Plica

Case 1 – Differential DiagnosisMore Likely Less Likely


MCL Sprain

Diagnosis?


What grade of sprain is likely present of the MCL?

  • Grade 1: no laxity, but hurts

  • Grade 2: mild laxity, still intact

  • Grade 3: complete tear

  • Grade 4: hurts like *^%*


MCL Sprain

  • Treatment?

    • RICE

    • Relative Rest

    • Hinge Brace only if unstable on exam

    • Achieve full ROM

    • Progressive Strengthening

    • Neuromuscular Control (Balance exercises)

    • Functional Exercises (Sport-specific)


Case 2

  • 56 yo retired Army LTC

  • 15 years worsening L>R knee pain

  • Former parachutist, no specific trauma

  • No previous knee surgeries

  • Stiffness worse in morning

  • Pain is worse with activity, better with rest


Mechanism of Injury?

Acute or Chronic?

Where/how bad is pain?

Mechanical Symptoms? (Locking, popping, catching?)

Associated instability?

Swelling?

Previous injuries or surgeries?

What makes it worse?

What makes it better?

Insidious Onset

Chronic

Difficult to localize; mild

No

None

Occasional

Lots of “Bad Landings” No surgery

Activity

Rest

Case 2 – Key Questions


Case 2 – Physical Exam

  • Inspection:

    • Genu varus

    • Bony enlargement at Med/Lat joint lines

  • Palp: Posterior medial joint line ttp

  • ROM: Decreased flexion, 110 deg, mild crepitus

  • Strength: normal

  • Neurovascular: normal

  • Special Tests: no ligamentous laxity, neg meniscal tests


Special Tests - Meniscal Injuries

Joint line tenderness

McMurray Tests

Thessaly test

Bounce-home test

Full Squat


Case 2 – Plain Films

Joint space narrowing

Subchondral Sclerosis

Osteophytes

Subchondral Cysts


10

What is your diagnosis?

  • Meniscal tear

  • Plica syndrome

  • Osteoarthritis

  • Bone tumor


Nonpharmacologic Treatment:

Nonpainful aerobic activity

Weight loss

Physical Therapy

Improve ROM, increase strength

Bracing

Pharmacologic Treatment:

APAP

Supplements

Glucosamine and Chondroitin

NSAIDs, COX-2’s

Tramadol

Viscosupplementation

Intrarticular Steroids

Osteoarthritis


Case 3

  • 31 year old female, L knee pain

  • Recreational runner

  • Localizes pain to front of knee

  • No trauma, insidious onset

  • Localizes pain “around kneecap”

  • Worse with stairs

  • Worse after prolonged sitting

  • Knee occasionally “gives out”


Mechanism of Injury?

Acute or Chronic?

Where is the pain?

Mechanical Symptoms? (Locking, popping, catching?)

Associated instability?

Swelling?

Previous injuries or surgeries?

What makes it worse?

What makes it better?

Insidious Onset

Chronic

Anterior knee

No, but sometimes gives out

None

None

None

Running, Stairs

Multiple days of rest

Case 3 – Key Questions


Physical Exam

  • Inspection: mild genu valgus

  • Palpation: TTP lateral > medial patellar facets

  • ROM: full w/o pain

  • Strength: normal

  • Neurovascular: normal

  • Special Tests:

    • + patellar grind

    • Decreased patellar glide

    • Inflexible hamstrings (Popliteal angle)


Patellofemoral Joint Exam


Patellofemoral Joint Exam

Patellar Grind Test


Case 3 – Plain Films

Lateral

AP


Case 3 – Plain Films

Sunrise

Tunnel


What’s your diagnosis?

  • Patellar tendinopathy

  • Patellar instability

  • Patellofemoral syndrome

  • Plica syndrome


Patellofemoral Syndrome

  • Treatment:

    • Relative rest; non-painful aerobics

    • Physical Therapy

      • Improve Quad/Hamstring flexibility

      • Quad, Hip abductor strengthening

      • Core strengthening

    • Patellar stabilization brace/taping

    • Foot orthotics

    • Surgery (last-ditch effort)


Case 4

  • 34 yo Army MAJ training for 1st marathon

  • Atraumatic onset of R lateral knee pain 1 week ago after 10 mile run

  • Sharp burning pain

  • Better with rest, returns with running


Mechanism of Injury?

Acute or Chronic?

Where is the pain?

Mechanical Symptoms? (Locking, popping, catching?)

Associated instability?

Swelling?

Previous injuries or surgeries?

What makes it worse?

What makes it better?

Insidious Onset

Acute

Lateral knee

No, but sometimes gives out

None

None

None

Running

Multiple days of rest

Case 4 – Key Questions


Physical Exam

  • Inspection: normal

  • Palpation: TTP over lateral femoral condyle

  • ROM: full

  • Strength: normal

  • Neurovascular: normal

  • Special tests:

    • + Noble test

    • Tight on Ober test


Ober testNoble test


What’s your diagnosis?

  • Osteoarthritis

  • Meniscal tear

  • Iliotibial band syndrome

  • LCL sprain


Iliotibial Band Syndrome

  • Treatment:

    • Ice massage, pain meds

    • Relative Rest; nonpainful activity

    • Physical Therapy

      • Specific ITB stretches

      • Hip abductor strengthening

      • Core strengthening (Gluteus Medius)

    • Slow return to activity

    • Extrinsic factors: shoes, running surface, training errors


What the heck is a Plica?

  • Congenital thickening of joint capsule

  • Redundant meniscus

  • Loose piece of intra-articular cartilage

  • Figment of my imagination


Plica Syndrome?


Questions?

Before we break for hands-on


Special Tests - ACL Injury

Lachman Test

Knee flexed to 15-30 degrees

Stabilize distal femur

Anteriorly translate tibia on femur

Watch & feel for amount of translation & end point

Pivot Shift


Special Tests - PCL Injury

Posterior Drawer Test

Knee flexed to 90 degrees

Posteriorly translate tibia on femur

Watch & feel for amount of translation & end point

Sag Sign

Knees flexed, quads relaxed

 compare both sides

Look for tibial posterior “sag” relative to femur

Quad-Active Test

Knee flexed; hamstrings fully relaxed

Slide foot along table (quad active)

Observe for anterior relocation


Special Tests - MCL Injury

Valgus Stress Testing

Knee flexed to 30 degrees

Relax ACL/PCL & joint capsule

Valgus stress applied to knee

Look and feel for translation and endpoint

Compare to uninjured side

May repeat with knee in full extension


Special Tests - LCL Injury

Varus Stress Testing

Same test as valgus stress testing

Except applying a varus stress instead

LCL, IT band, & PLC are tested


Special Tests - Meniscal Injuries

Joint line tenderness

Full Squat

McMurray Tests

Thessaly test

Bounce-home test


McMurray test for Meniscal injury

Test Med and Lat meniscus separately

3 concurrent maneuvers:

Grind it (Rotate tibia AWAY from it)

Crunch it (varus or valgus)

Pinch it (flex/extend knee)

Positive: Painful “pop”


Special Tests - Meniscal Injuries

Thessaly Test

Pt stands on affected leg

Knee bent at 20 degrees

Examiner holds pt’s hands and rotates pt to both sides

Meniscal grind

Positive test: pain, painful click.


Anterior Knee Exam

  • Palpation of patellar facets

    • Glide and lift patella medially & laterally

    • Palpate undersurface of patella for tenderness


Patellar Exam

  • Patellar Glide

    • Knee in extension, relaxed

    • Medial & lateral patellar displacement

      • Measured in quadrants

    • Normal: 1-2 quadrants

  • Patellar Apprehension

    • Lateral patellar displacement

       patient apprehension

      or guarding


Anterior Knee Exam

Patellar Grind Test

  • Knee 10 deg flexion

  • Glide patella distally, and firmly compress patella against trochlear groove

  • Active quadriceps contraction  pain


Special Tests – Ober’s Test

  • Lateral decubitus with testing side up, testing knee flexed

  • Adduct and fully flex hip  Abduct, externally rotate, & extend hip

  • Slowly release support against gravity from leg, allowing gravity to take leg towards table

  • Positive test: leg remains abducted despite examiner releasing leg


Noble’s test

Palpate lateral femoral condyle

Flex and Extend Knee

+ Test is pain at site of palpation

Special Tests


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