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Michael H. Boothby, MDSouthwest Orthopedic Associates

Fort Worth, Texas

Goals

Our Real…Goals

Perform a basic, logical, history and physical exam

on a patient with knee painon a patient with knee pain

Learn through cases, some common knee injuries and their associated treatments

Know when to acutely refer a patient for further

orthopaedic care

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Knee Injury OverviewI. Evaluation• History• Physical Exam• Radiographic Exams• Radiographic Exams

II. Treatment of common knee injuries

• Patellofemoral Syndrome• Collateral ligament injury (MCL v LCL)• Meniscus injury• Cruciate ligament injury (ACL v PCL)

Case History

Patient is a 25yo male professional basketball playeryPatient was playing basketball and had a fall which resulted in knee pain and deformity with immediate effusionYOU, are asked to evaluate the patient courtside and render appropriate care

Case History- Video

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Knee Evaluation – History6 Questions for Every Patient

Acute or ChronicMechanism of injury

Varus or ValgusgRotation or Hyperextension

Pain – nature and locationSwelling (when and how long)Locking or catching Buckling or giving way

Knee Evaluation – Physical Exam6 Exam Points for Every Patient

SkinEffusionEffusionAlignmentRange of motionStability Tenderness to Palpation

Physical Exam Breakdown PointsSkin:

Open/ClosedWarm/Cool

EffusionSwelling inside joint capsuleTraumatic, Hematologic, Infectious, Pathologic

AlignmentVarus/ValgusProcrevatum/Recrevatum

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Range of MotionPassive versus Active

Typically 0-135 DegreesLoss of extension

Meniscus tearACL tear

Loss of flexion may be only due to effusionMay be posterior meniscus injury

Beware the arthritic patient

Stability- Cruciate LigamentsEvaluate at 30 and 90 of flexionLachman is most sensitive test to isolate ACL ruptureAnterior Drawer requires relaxationPosterior Drawer may not be positive if Tibial Sag

h f f l f b d ff lPivot Shift is useful for ACL rupture, but difficult

Stability- Collateral LigamentsEvaluate at 0 and 30 of flexionIn extension laxity indicates injury to posterior capsular structuresC i t i j i l it i t iCruciate injury may increase laxity in extensionLaxity at 30° isolates the MCL and LCL

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Tenderness to PalpationMedial Joint LineLateral Joint LineMedial/Lateral Femoral CondyleMedial/Lateral Tibial PlateauProximal/Distal Pole PatellaPatella-femoral Grind

Be Systematic!

Radiographic EvaluationThree views of the knee

AP Lateral Sunrise

Case Study- Break25 yo professional football player seen on the field after a tackle with the following physical exam…

That’s an Orthopaedic consultation!!

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Cases and Treatments for Difficult Knee Injuries

Patelofemoral SyndromeCollateral Ligament Injury

MCLLCL

Meniscus InjuryMedial meniscus tearLateral meniscus tear

Cruciate Ligament InjuryACLPCL

Case #116 yo girl with 2 month history of worsening bilateral knee pain. She can’t describe when or where it bothers her the most, but says she has trouble bending her knee with soccer and has significant pain during gymknee with soccer, and has significant pain during gym workouts.

Audience Response-a. Refer to Orthopaedics b. X-rayc. More specific H & P d. MRI

Answer

C. More specific H & P

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Case #1 ContinuedAfter further specific history you find…

Pain worse with stairs, car rides, leg kept in bent positionPain located in the front of the knee, not on either sidePain worse with when squatting or lifting activities in the gymPain worse with when squatting or lifting activities in the gym

After physical exam you find…Pain with full flexion anterior kneeNo pain along medial or lateral joint line, or either pole of patellaNo ligamentous instabilityPositive patella femoral grind test

Audience Response:

A. Medial meniscus injury

B. Patella Femoral Syndrome

C. Patellar Tendinitis (Jumpers knee)

D. Anterior Cruciate Tear

Correct Answer

B Patellar Femoral SyndromeB. Patellar Femoral Syndrome

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Patellofemoral Syndrome

Typically young women

The Patient:

Pain in the anterior kneeStairs, Airplanes, Movies

InstabilityLateralization of patella with increased “Q” angle

Crepitance: functionally and on exam

Patellofemoral Syndrome

4-5 x’s your body weight in force between the patella and femur during stair climbing or squatting

The Reason:

Lateralization of the patella multiplies this force by localizing it over a smaller area of the patella

The Treatment:NSAIDS, Therapy, Taping, BracingSurgery??

Case #236 yo man with pain on the outside of his knee after being checked in to the boards at his father/son floor hockey game. Knee did not swell up immediately. Now with continued pain despite OTC NSAID use andNow with continued pain despite OTC NSAID use and crutches.

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Case #2 ContinuedAfter further questioning and an organized examination you learn...

Pain to palpation is limited to lateral aspect of kneeNo feeling of locking or catching although knee feels “a littleNo feeling of locking or catching, although knee feels a little loose”Pain and slight instability with varus stress to the kneeNegative Lachman and Posterior drawer testing

Your thoughts???

Audience Response

A. Lateral meniscus tear

B. Hamstring Strain

C. Loose Body in Knee

D. Lateral Collateral Ligament Injury

Correct Answer

D. Lateral Collateral Ligament Injuryg j y

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Collateral Ligament Injury

Grade 1Tenderness

Grade 2Increased laxity – solid end point (5-10mm opening)

Grade 3Complete disruption (>10mm opening)

Collateral Ligament InjuryMedial Collateral Ligament

Superficial; deep portions80% of valgus stability at 25 flexionN i i i iNon-isometric insertionPain along ligament, but mostly at the condyles

Collateral Ligament InjuryMCL Injury Treatment

Non-operativeImproved collagen and strength with motionI NSAIDSIce: NSAIDSReestablish ROMBrace grade 2 and 3

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Collateral Ligament Injury

Lateral Collateral Ligament InjuryVarus stabilityDiffi lt t diDifficult to diagnoseIsometric insertionGrade 3 injuries require reconstruction or repair

Associated injury commonPCLPosterolateral corner

Case #354 yo man had a twisting injury to the L knee when he stumbled in a hole mowing his lawn. He had significant pain but was able to finish mowing his yard He now has continued pain for 4 weeks evenyard. He now has continued pain for 4 weeks even though he has tried ice, rest, and some anti-inflammatories.

Case #3 ContinuedOn further evaluation you note…

• The patient reports inability to completely straighten out the legstraighten out the leg

• Has worsening pain with twisting activities• Has periods of exquisite pain and then periods of

relative comfort• Pain to palpation directly over the medial joint line• Positive McMurray’s Test

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Audience ResponseA. ACL Tear

B. Meniscus Tear

C. Baker’s Cyst

D. Gout

Correct Answer

B. Meniscus Tear

Meniscus InjuryJoint line tendernessLocalized pain with full flexionTibial rotation- McMurryLoss of extension (locked)Effusion- worse with exercise

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Meniscus FunctionLoad transmissionShock absorptionJoint stabilityJoint lubricationProprioception

Surgical Indications

Non-operative Indications

Meniscus Tears

Restriction of ADLs or sportsConfirmatory examAbsence of other causes of knee painFailed conservative management

Activity modificationPhysical therapy

Meniscus TearsSurgical Management

Location of tearAge of patientACL tear?

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Meniscus TearsOperative Management: Bucket Handle Meniscus Tear

Meniscus Tears

Operative Management: Degenerative Meniscus Tear

Meniscus Tears

Operative Management: Meniscus Repair

Special Thanks to Dr. Alan Barber for this arthroscopic footage

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Menisectomy

Normal50% of load in extension85% of load in flexion

MenisectomyIncrease in contact stress

related to amount of tissue removed

Case #418 yo running back for your local HS football team twists awkwardly through the line and sustains a twisting injury to his R knee. He is unable to ambulate without assistance and his knee swells immediatelywithout assistance and his knee swells immediately. After suffering though a night of ibuprofen and ice he meets you the office the following day…

Case #4 continuedAfter examining the patient and speaking with his parents you find…

Difficulty with complete terminal extensionUnable to ambulate without crutchesUnable to ambulate without crutchesX-rays are negative for fracture Has equivocal lachman test that is difficult to performMild medial joint line painNeurovascular intact throughout extremity

IDEAS???

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Audience ResponseA. Knee Dislocation

B Medial Meniscus TearB. Medial Meniscus Tear

C. Patella Fracture

D. ACL Rupture

Correct Answer

D. ACL Rupture

Cruciate Injury: PCLOften missedConfused with ACL tear due to increased tibial translation from posterior starting positionP i f ibi l b l ( )Posterior sag of tibial tubercle (90°)Most likely treated with Rehabilitation because of ligaments broad insertion and ability to healMaybe reconstructed surgically in cases of multiple ligament injury

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PCL Injury: MRI

Cruciate Injury: ACLLarge effusion immediately after injuryAnterior drawer

Watch for hamstring spasmd h d fMay diminish 2-7 days after injury

Lachman30° flexionDegree of anterior tibial translationEnd point?? (soft, firm, none)

ACL Tests

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ACL Injury: MRI

ACL Reconstruction

When to refer ….Uncomfortable with anatomy/diagnosisContinued stiffnessFailure to progressMRI evidence of meniscus or cruciate injuryMultiple ligament injury

ACL- PCLKnee Dislocations

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Lets Review-What did we learn?

Physical Exam

HistoryDuration, Mechanism, Where is the pain, Locking, Giving way or buckling

Physical ExamSkin, Effusion, ROM, Stability, Tenderness

Basic Knee InjuriesPatellofemoral Syndrome, Collateral Ligament Injury, Meniscus Injury, Cruciate Ligament Injury

When to ReferUnsure of anatomy or diagnosis, failure to progress, radiographic confirmation of injury, any question about patient

817-731-9400