KNEE PAIN KNEE PAIN

Presented by Charles J. Holcomb

Bryant SaenzPeter Tresize

• Chondromalacia patellae• Rheumatoid arthritis • Reiter's syndrome • Septic arthritis• Osteoarthritis • Gout • Pseudogout • Popliteal cyst (Baker's cyst)• Gonorrhea• Popliteus tendonitis• Superior tibial fibular

subluxation• Neoplasms• Fracture

OLDER POPOLDER POP• Patellar subluxation • Tibial apophysitis (Osgood-

Schlatter lesion)• Jumper's knee (patellar

tendonitis) • Slipped capital femoral

epiphysis • Osteochondritis dissecans• Medial plica syndrome • Pes anserine bursitis • Ligamentous sprains • Anterior cruciate tear • Medial collateral tear • Lateral collateral tear • Meniscal tear (medial/lateral)• ITB Syndrome

YOUNGER POPYOUNGER POP

MOST COMMON KNEE PROBLEMS YOU’LL MOST COMMON KNEE PROBLEMS YOU’LL SEE IN YOUR PRACTICESEE IN YOUR PRACTICE

• ACL, MCL tear• Meniscal tear• ITB syndrome• Patellofemoral Arthralgia and CMP• Osteoarthritis• Jumper’s knee• Osgood-Schlatter disease• Osteochondritis dissecans

You’re a team doctor for a College level athletic team. Lindsay McHaha tackled on the field in a game of field hockey. She is grabbing her knee and sais that she was struck from the side and felt a pop in her knee. She is unable to bear weight or walk on this leg. There is immediate swelling, and pain

MEDIAL COLLATERAL LIGAMENTMEDIAL COLLATERAL LIGAMENT

Patients w/ injury to the MCL will demonstrate some of these symptoms: * Pain / Tenderness * Stiffness * Swelling (typical, but not necessary) * Instability

The MCL functions to provide knee stability against valgus stresses (preventing the knee from buckling inwards).

Complicating Factors!

MCL tears commonly occur with ACL tears or Medial Meniscus tears so it is a good idea to test for those injuries as well (AKA The Terrible Triad)

Orthopedic TestsValgus Stress Test - MCLApply’s Distraction Test - MCL/LCLLachman’s - ACLMcMurry’s - Medial MeniscusApply’s Compression Test - Medial and Lateral MeniscusAnterior/Posterior Drawer - ACL/PCL

Diagnostic ImagingX-rays are useful in ruling out other knee pathology, but this is not the gold standard for evaluating ligament damage

MRI is the Gold standard for seeing the extent of damage done to the MCL (or for any of the ligaments in the knee for that matter) - 90% accuracy of diagnosing MCL

Grade I MCL Tear- Incomplete tear of the MCL. - Tendon is still in continuity- Symptoms are usually minimal- Patients usually complain of pain with pressure on the MCL- Most athletes miss 1-2 weeks of play.

Grading MCL Tears

Grade II MCL Tear- Incomplete tear of the ligament- Complain of instability when attempting to cut or pivot- Pain and swelling is more significant- a period of 3-4 weeks of rest is necessary.

Grade III MCL Tear-Complete tear of the MCL- Significant pain and swelling- Complete instability (inability to stand on that leg)- Knee brace/immobilizer is needed & surgery is eminent

Grade I MCL Tear

Grade II MCL Tear

Grade II MCL Tear

• A 16 year old male basketball player limps into the office complaining of right knee pain. His mother says that he’s been complaining of this pain for quite some time now. She says she’s tired of his complaining and that you need to figure out what his problem is and fix him!

Acute– MCL– LCL– ACL– PCL– Quadricep tendon– Meniscus med/lat– Patellar ligament

Chronic– CMP– Osgood Schlatter– Patellar Tendonitis– Pes Anserine– Muscle imbalance– Subluxation– Sprain strain– Ligament Laxity

HXHX

• No previous history of injuries or surgeries• Pain was a gradual build up and started to affect

playing basketball• He states “I can’t jump as high”• Resting helps ease the pain• Jumping exacerbates the pain

RULE OUT / RULE INRULE OUT / RULE IN

Acute– MCL– LCL– ACL– PCL– Quadricep tendon– Meniscus med/lat– Patellar ligament

Chronic– CMP– Osgood Schlatter– Patellar Tendonitis– Pes Anserine – Muscle imbalance– Subluxation– Sprain strain– Ligament Laxity

OBSERVATIONOBSERVATION

• There is minimal swelling of the knee• Patient cringes every time has to get up from a

seated position

EXAMEXAM

• Compression/distractiv (-)

• Valgus/varus stress test (-)

• Ant/post drawer test (-)

• Patella grind test (-)

• + tenderness palpation

• Weakness of the Quadriceps

• Knee extension increased pain

X-RAY REVEALX-RAY REVEAL

MRIMRI

PATELLAR TENDONITISPATELLAR TENDONITIS

• Aka “Jumper’s Knee”• d/t eccentric strain of patellar tendon• May cause fragmentation of inferior pole of

patella (Sinding-Larsen-Johansson disorder)

4 CATEGORIES4 CATEGORIES

Grade 1- Pain only after trainingGrade 2- Pain before and after training but pain

eases once warmedGrade 3- Pain during training which limits your

performanceGrade 4- Pain during every day activities

KNEE PAINKNEE PAIN

• Knee Pain in Older Patietnts

• 62 year-old female piano teacher comes in with right knee pain. It started out as just stiffness and pain in her knee but it has gradually been getting worse. She has an increase in her pain and stiffness when she wakes up in the morning but it lasts less than 30 min. She also notices a great deal of pain when getting up from a seated position after she has been sitting for an extended period of time. In her younger days she was a roller derby girl and she sustained many knee injuries while doing this. Those days are long gone and she is now obese.

• What’s the diagnosis?

KNEE PAINKNEE PAIN

• Diff DX

– RA• R/I because it causes pain and stiffness in joints,

especially in the morning.• R/O because the pain only lasted less than 30 min in

the morning. RA is a systemic disease, patient reports no fever, malaise, or severe fatigue.

KNEE PAINKNEE PAIN

• Diff Dx

– CMP• R/I because of history of mild to moderate anterior

knee pain that usually occurs after prolonged periods of sitting.

• R/O through negative Clark’s sign, negative Patella Grind, negative Waldron’s.

KNEE PAINKNEE PAIN

• Diff Dx

– Bursitis• R/I because of the limited and painful movement of

the knee.• R/O because there was no real swelling and Bursitis is

more common in carpenter/gardeners (people who spend a lot of time on their knees) our patient spends a lot of time sitting at the piano.

DIAGNOSISDIAGNOSIS

•Osteoarthritis• Osteoarthritis is the most common joint disorder.

– Deterioration of articular cartilage due to overuse is the main problem associated with knee osteoarthritis.

OSTEOARTHRITISOSTEOARTHRITIS

– Occurs with age– Being overweight increases the risk – Fractures or other joint injuries can lead to

osteoarthritis later in life – Long-term overuse at work or in sports can

lead to osteoarthritis – Varying degrees of pain, especially when you

stand or walk– Pain in the morning that lasts less than 30 min.

(a good way to differentiate from RA, stiffness will last a lot longer with RA)

• Exam findings

– Varus angulation may be apparent (bow-legged)

– Palpation may uncover osteophytic development at joint line

– With early OA the anterior drawer test will demonstrate a loose joint

– Advanced OA = less movement than normal on drawer testing

RADIOLOGYRADIOLOGY

• Radiology views– AP weight-bearing– Lateral Knee– Tunnel Projection

• Radiology findings may include– Decreased medial joint space (m/c finding)– Subchondral cysts– Osteophyte formation