Knee Problems

Ghias Bhattee, FRCS(Tr&Orth)

Consultant Knee & Hip Surgeon

Northwick Park & Central Middlesex Hospitals

Outline

•Review of Evaluation of the Knee •Discuss Differential Diagnoses •Review Treatment Modalities •Summary of Approach to Knee Pain

Brief overview

• 10-15% of Primary Care presentations are MSK

• 1/3 of all MSK problems seen in Primary Care are about the Knee

• 54% of all Athletes will experience some knee pain EVERY YEAR

• 90% managed solely in Primary Care

History

•Onset: Insidious or Traumatic?

•Pain characteristics

•Locking

• Instability

•Effusion (<2 hours, or >24 hours)

•Previous episodes or surgery?

Mechanism of Injury

• Direct Blow • Foot planted • Deceleration or landing

from a height • Hyperextension • Twist

Examination

• Look – Healed surgical incisions & scars, “attitude” and symmetry, muscle wasting. Q-angle.

• Feel – Warmth, tenderness, effusion.

•Move – ROM, SLR, J-sign

Patellar tracking

Q-Angle J-Sign

Special tests

• Lachmann/Drawer & Dial tests

• (Pivot shift)

• Varus/Valgus LCL/MCL

• McMurray test

• Clarke’s test & patellar apprehension

Radiographs in acute injury?

• Ottawa:

• Age >55

• Tenderness at head of fibula

• Isolated tenderness of patella

• Inability to flex greater than 90°

• Inability to bear weight (4 steps)

• Sens – 97%

• Spec – 27%

• Pittsburgh:

• Blunt trauma or fall

AND

• Age <12 or >50

OR

• Inability to bear weight (4 steps)

• Sens – 99%

• Spec – 60%

Which views?

• STANDING AP if OA suspected

• Lateral

• Patellar skyline/Merchant view

Special views

• Tunnel View

MRI

Instability

Locking

In younger patients/following acute trauma

“In patients >50 years with non-acute knee pain, x-ray examination is much more useful to orthopaedic surgeons than MRI as OA usually dominates clinical symptoms” – Arthritis Research UK

Other investigations

• In presence of warmth, exquisite tenderness and effusion • Consider Septic Arthritis or Acute Inflammatory arthropathy • Blood tests to order

• FBC • CRP • ESR

• If inflammatory arthropathy possibility – ESR and RF

• Consider aspiration • Aspirate for

• White Cell count and differential • Glucose • Protein • C&S • Polarized light microscopy

Patellar maltracking/subluxation/dislocation

• Spectrum of anterior knee pain, to “click/clunk”, to dislocation

• First/traumatic episode may mimic ACL rupture history

•More common in adolescent females

• Large Q-angle (>15⁰)

• Patellar apprehension test

Chondromalacia Patellae/PFJ pain syndrome

• History • Anterior knee pain worse after sitting (cinema-goer’s knee)

• Exam • PFJ crepitus • Positive Clarke’s test • Raised Q angle

• Treatment • Relative rest • Ice 20 minutes after activity • Quadriceps/VMO strengthening (consider hip, hamstring, calf and IT band stretching) • Evaluation of Footwear • Consider NSAID’s • Consider Knee braces • Consider Knee taping – Kinesio/McConnell Taping

Patellar stabilisation

•Mainstay of treatment is targeted physiotherapy regimen

• Focus on vastus medialis oblique (VMO)

• One of 4 Quadriceps femoris

• Improves medialisation in lateral tracking

Key imaging parameters

• Lateral tracking my be associated with surgically correctable factors. • TT-TG distance >15-20mm •MPFL tear • Trochlear dysplasia

Surgical intervention

Fat Pad Impingement/Inflammation

• Hoffa’s pad plays a protective role, plus provides vascular supply

• Can become entrapped

• Inflammation results

• Often results from post op scarring

• Clinical diagnosis. High signal on MRI

• Guided injection

Osgood-Schlatter disease (Tibial Apophysitis)

• More common Teenage boys

• History • Knee pain waxing and waning for months • Worsens with squatting or stairs

• Tender over tibial tuberosity

• Treatment • Icing after activity • Decreasing activity – may need to stop

activity for 2-3 months • NSAID’s • If severe – knee brace for 2-6 weeks

Slipped Upper/Capital Femoral Epiphysis (SUFE) • Overweight 10-16♂ or 12-14♀ • History

• Vague Knee pain with no trauma

• Exam – pain on internal rotation of hip

• Diagnosis – Xray AP neutral and abduction both hips

• Treatment – • Immediate Cessation of weightbearing • Surgical stabilization

• ALWAYS EXAMINE HIP IN CHILDREN WITH KNEE PAIN

SUFE fixation

Osteochondritis Dissecans

• History • Vague knee pain, • morning stiffness and recurrent effusion • possibly locking or catching

• Exam • possible quad atrophy • effusion • chondral tenderness

• Radiographs to include Tunnel view

• MRI test of choice if unclear diagnosis

• Treatment • Rest • Bracing • Low Impact PT • Surgery if symptoms persist >2-3 months despite

therapy

Traumatic Chondral injuries

• Twist, turn, impact injuries

• Segment of joint surface plus underlying subchondral bone “fractures”

• May/may not be visible on plain films

• More common in adolescents and young adults

• Can be devastating for professional athletes

Surgical options

Meniscal Tears

• Acute or chronic

• Recurrent knee pain with episodes of catching, locking or giving way

• Mild effusion and positive McMurray test

• MRI best imaging test if diagnosis unclear

• Treatment • If no locking or instability – RICE, NSAID’s for 2-

3 weeks • Otherwise referral for surgical debridement

Anterior Cruciate Ligament • Plant and twist injury

• Often hears a pop and notes swelling in Knee (<1 hour)

• Joint Effusion + Anterior Drawer or Lachman if torn (most sensitive directly after injury or about 2 weeks later)

• Radiographs looking for tibial spine avulsion

• MRI

• Be mindful of recurrent pivoting

• Treatment • Initial Treatment

• RICE • Crutches • NSAID’s

• Definitive treatment • Based on Age, Activity level and degree of injury • Surgery vs Rehab • Surgery often indicated in multiligament injury

Other Ligament Injuries

• MCL – Valgus Injury • Pain, swelling and valgus instability • Acute surgery rarely indicated • Hinged knee brace • Reconstruction for chronic instability

• PCL – Hyperextension • Less common • Athletes may require reconstruction

• LCL/PLC – a large complex of structures • provides varus/rotational stability

Medial Plica Syndrome

• Plica – A remnant of embryonic connective tissue

• Hx – Acute onset medial knee pain

• Exam – tender mobile nodularity

• Treatment

• NSAID’s

• ICE

• Quad Strengthening Exercise

• Surgery only indicated in the presence of “kissing lesions”

Pes Anserine Bursitis

• Pes Anserine – insertion of Sartorius, gracilis and semitendinosus muscles

• Hx – pain on medial side of knee worsened with flexion and extension

• Exam – tenderness posterior and distal to medial joint line valgus stress may reproduce pain

• Treatment • NSAID’s

• ICE

• Guided aspiration

• (Surgical excision)

Iliotibial Band Tendonitis

• Friction between IT band and Lateral Femoral Condyle

• Hx – Lateral Knee pain aggrevated by activity

• PE – Tenderness over lateral epicondyle of femur while flexing and extending knee (Noble test)

• Treatment • IT band stretching exercises • NSAID’s • ICE

Baker’s/Popliteal Cyst

• Benign swelling of the semimembranosus (or rarely some other synovial) bursa

• Hx • insidious onset of mild to moderate pain in posterior aspect of

knee • Ruptured cyst may present like DVT – red swollen and tender

calf

• Exam – palpable fullness present medial aspect of popliteal area

• Imaging – US, MRI may help if diagnosis unclear

• Treatment • Aspiration may cause temporary relief but recurrence rate is

high • Surgery if pain persistent and intolerable

Septic Knee

• Predisposing factors – Ca, DM, ETOH, HIV, corticosteroid therapy

• Hx – Abrupt onset of pain and swelling no trauma

• Exam – warm, swollen, very tender, extremely painful ROM

• Lab • Raised inflammatory markers • ESR > 50 mm/hr • Arthrocentesis

• Turbid synovial Fluid – WBC > 50 000 Neutrophils >75 percent • Protein > 3 g/dL • Glucose - 50 percent or less or serum glucose level

• Treatment • common pathogens Staphyloccus aureus, Streptococcus, Haemophilus influenzae, Neisseria

gonorrhoeae • IV antibiotics under ID • Ortho referral for possible debridement

Crystal-Induced Inflammatory Arthropathy

• Gout (sodium urate crystals) and Pseudogout (calcium pyrophosphate crystals)

• Hx- Acute onset, red hot and very tender knee

• PE – erythematous, warm, tender swollen

• Arthrocentesis • Clear or slightly cloudy – WBC 2K to 75K • Protein high >32 g/dL • Glucose 75% of serum • Polarized-light microscopy of synovial fluid shows

• Gout - negatively birefringent rods • PseudoGout – positively birefringent rhomboids

• Treatment • NSAID’s • Colchicine

Osteoarthritis

• Common > 60 years of age • Hx – Knee pain aggrevated by weight bearing

relieved by rest, morning stiffness. Symptoms often triggered by minor trauma. • Exam – decreased ROM, crepitus, osteophytic

changes • Radiographs – • Weightbearing AP plus lateral & skyline

Treatments for Osteoarthritis

• Treatment • NSAID’s • Wt loss • Non load bearing exercise • Corticosteroid injections (beware arthroplasty

within 6-7 months)

• Referral for Knee replacement if • Significant and disabling pain • Dysfunction significantly inhibiting quality

of life

Knee Surgery for Osteoarthritis

• Knee replacement satisfaction rates reach 90% at 2 years

• Expectation of 60-90 minutes walking

• End to oral analgesics/sleep disturbance

• High flexion activities/kneeling likely to NOT be possible

• Longevity 90-95% achieve 12-15 years lifespan

Common Differential Diagnoses by Age

Childhood/

Adolescence

• PFJ Maltracking

• PFJ Instability

• “Jumper’s knee”

• Osgood Schlatters

• Osteochondritis dissecans

• Chondral defect/loose body

• Referred pain SUFE

• Sepsis

Older Adults

• Popliteal cysts

• Osteoarthritis

• Crystal arthropathy

• Sepsis

Adulthood

• Tendonitis • Chondromalacia

patellae • Meniscal pathology • Ligamentous injury • Medial plica

syndrome • Pes Anserine bursitis • Prepatellar Bursitis • ITB syndrome

Site of pain

Anterior

• PFJ OA

• Tendonitis

• Chondromalacia patellae

• PFJ Maltracking

• PFJ Instability

• “Jumper’s knee”

• Osgood Schlatters

• Bursitis

• Fat pad impingement

Posterior

• Popliteal cysts

• Posterior/meniscal root pathology

• PCL injury

Medial Lateral

• Medial OA • Medial meniscal

pathology • MCL injury • Medial plica

syndrome • Pes Anserine

bursitis

• Lateral meniscal pathology

• Lateral OA • ITB Friction

syndrome • LCL/PLC injury

Summary

• Up to 5% of primary care presentations are regarding the knee

• Vast majority treatable within primary care setting

• Careful attention to be paid to key history features: • Age • Site of pain • Mechanism of injury • Timing of effusion

• Examination focused on features of history

• Radiographs Investigation of choice in chronic pain >50

• Consider referral with persistent symptoms, proven internal derangement or failure to resolve with first line therapies

The aim is to prevent...

…and therefore…

References

• https://www.youtube.com/watch?v=oHgu5e9K3Ww

• https://www.youtube.com/watch?v=xKpm6DlgWj0

• https://www.youtube.com/watch?v=FynIg-KbJAE

• Foss, Myer, et al - J Athl Train. 2012 Sep-Oct; 47(5): 519–524

• National Joint Registry 13th Annual Report 2016

Thank you

londonkneeconsultant@gmail.com