www.SouthamptonOrtho.comwww.SouthamptonOrtho.com

Management of Knee PainManagement of Knee Pain

Manish A. Patel, MD,FAAOSManish A. Patel, MD,FAAOSAssistant Professor Eastern Virginia Medical SchoolAssistant Professor Eastern Virginia Medical SchoolChief of Surgery – Southampton Memorial HospitalChief of Surgery – Southampton Memorial Hospital

Office: 757-562-7301Office: 757-562-7301

AnatomyAnatomy

• ACLACL

• PCLPCL

• MCLMCL

• LCLLCL

• MeniscusMeniscus– MedialMedial– LateralLateral

THE KNEE HISTORYTHE KNEE HISTORY

• PainPain

• Contact vs noncontactContact vs noncontact

• EffusionsEffusions

• Mechanical symptomsMechanical symptoms

– LockingLocking

– Instability (falls)Instability (falls)

• Initial treatmentInitial treatment

THE KNEE HISTORYTHE KNEE HISTORY

• Continue Continue work/play?work/play?

• PM/SHxPM/SHx

– MedicationsMedications

• Occupation/SportOccupation/Sport

– Time tablesTime tables

Physical Exam of the Physical Exam of the KneeKnee

• InspectionInspection

• Palpation Palpation

• Range of MotionRange of Motion

• Special testsSpecial tests

• NeurovasculaNeurovascular assessmentr assessment

INSPECTIONINSPECTION

• EffusionEffusion

• ErythemaErythema

• EcchymosisEcchymosis

• EdemaEdema

• Q angleQ angle

• Angular Angular deformitiesdeformities

• Muscular Muscular asymmetryasymmetry

PALPATIONPALPATIONANTERIORANTERIOR

• Tibial tubercleTibial tubercle

• Infrapatellar tendonInfrapatellar tendon

• Quad insertionQuad insertion

• Patellar facetsPatellar facets

• Crepitus ?Crepitus ?

MEDIALMEDIAL• MCLMCL

• MeniscusMeniscus

• Pes anserine Pes anserine insertioninsertion

• Tibial plateauTibial plateau

• Femoral condyleFemoral condyle

PALPATIONPALPATION LATERALLATERAL

• Head of the fibulaHead of the fibula

• LCLLCL

• MeniscusMeniscus

• Tibial plateauTibial plateau

• Femoral condyleFemoral condyle

• Gerdy’s tubercleGerdy’s tubercle

POSTERIORPOSTERIOR• Menisci (posterior Menisci (posterior

horns)horns)

• Popliteal fossaPopliteal fossa

• Hamstring tendonsHamstring tendons

ACL Special TestsACL Special Tests

• Anterior Anterior drawerdrawer

• Lachman testLachman test

• Pivot shift Pivot shift testtest

• Valgus stress Valgus stress test at full test at full extension!extension!

Grading Ligament InjuriesGrading Ligament Injuries

GRADE 1 No instability Good endpoint

GRADE 2 Some instability Fair endpoint

GRADE 3 Opens wide Poor endpoint

ACL: PHYSICAL EXAMACL: PHYSICAL EXAM

• Decreased ROMDecreased ROM

• Effusion-hemarthrosis, immediateEffusion-hemarthrosis, immediate

• + Instability tests+ Instability tests– Lachman: most accurateLachman: most accurate

– Pivot shiftPivot shift

– Anterior drawerAnterior drawer

• ++ MCL and meniscus tests MCL and meniscus tests

LIGAMENT EXAMLIGAMENT EXAMTranslation + Translation + ENDPOINTS!ENDPOINTS!

+ PIVOT SHIFT+ PIVOT SHIFTPalpable clunk as the Palpable clunk as the lateral tibial condyle lateral tibial condyle reduces on the femurreduces on the femur

MRI:MRI:

The Use of MRI in Evaluation The Use of MRI in Evaluation of Knee Injuriesof Knee Injuries

• SensitivitySensitivity M. MeniscusM. Meniscus 73-100%73-100%

L. MeniscusL. Meniscus 55-9055-90

ACLACL 91-10091-100

• SpecificitySpecificity MMMM 55-9755-97

LMLM 94-9894-98

ACLACL 99-10099-100

The REAL Question-The REAL Question-

Is MRI Is MRI thatthat much better than much better than clinical exam?clinical exam?

• Rose, et al. Arthroscopy, 1996Rose, et al. Arthroscopy, 1996

– Compared accuracy of clinical exam vs MRICompared accuracy of clinical exam vs MRI

– In 154 pts, clinical exam was In 154 pts, clinical exam was as good asas good as MRI MRI

• Many articles comparing MRI to arthroscopyMany articles comparing MRI to arthroscopy

““Partial” ACL tear/strainPartial” ACL tear/strain

• > 40% ACL substance> 40% ACL substance

• + Lachman, - pivot shift+ Lachman, - pivot shift

• ClinicallyClinically

– Most behave Most behave functionally as full functionally as full tearstears

– Continued shifting ↑’s Continued shifting ↑’s risk of meniscus risk of meniscus damagedamage

– Rx as full tearRx as full tear

The Utility of ArthrocentesisThe Utility of Arthrocentesis

• IndicationsIndications

– Diagnosis in questionDiagnosis in question

•? Infectious/Metabolic ? Infectious/Metabolic processprocess

– Tense effusionTense effusion

• Indications for surgeryIndications for surgery

• Timing of surgeryTiming of surgery

ACL TREATMENTACL TREATMENT•Grade 3- NonsurgicalGrade 3- Nonsurgical

– ? modify activity? modify activity

– PRICESPRICES

– Hamstrings, gastroc!Hamstrings, gastroc!

– Functional bracing ?Functional bracing ?

– 100% @ 9-12 months100% @ 9-12 months

ACL TREATMENTACL TREATMENT•Grade 3 Injuries- SurgeryGrade 3 Injuries- Surgery• IndicationsIndications

– Most active people will require surgery to Most active people will require surgery to restore adequate function and decrease restore adequate function and decrease instabilityinstability

– Recurrent instabilityRecurrent instability– Inability to modify activityInability to modify activity– Associated injuries: meniscusAssociated injuries: meniscus– Age?Age?

• Wait three weeks due to arthrofibrosis riskWait three weeks due to arthrofibrosis risk• 100% @ 6-12 months100% @ 6-12 months

MCL INJURIESMCL INJURIES

HISTORYHISTORY

• Mechanism = valgus stressMechanism = valgus stress

• Medial joint line painMedial joint line pain

• Lack of large effusionLack of large effusion

• Difficulty weight-bearing Difficulty weight-bearing

MCL INJURIESMCL INJURIESPHYSICAL EXAMPHYSICAL EXAM

• Tender to palpation along MCLTender to palpation along MCL• Pain Pain ++ instability with valgus stress instability with valgus stress

– 3030oo flexion = MCL flexion = MCL– 9090oo flexion = associated ACL flexion = associated ACL

• COMPARE SIDESCOMPARE SIDES

MCL INJURIESMCL INJURIES

Treatment Of Grade 1 &2Treatment Of Grade 1 &2• Early mobilizationEarly mobilization

• Weight-bearing as toleratedWeight-bearing as tolerated

• Hinged knee braceHinged knee brace

• PRICESPRICES

• Recovery 4-6 weeksRecovery 4-6 weeks

MCL INJURIESMCL INJURIES

Treatment of Grade 3 (full Treatment of Grade 3 (full tears)tears)

• Isolated = nonsurgical Isolated = nonsurgical managementmanagement

• Combined = surgery consistent Combined = surgery consistent with associated injurieswith associated injuries

PCL INJURIESPCL INJURIES• MechanismMechanism

– Sports = fall on flexed Sports = fall on flexed knee with foot knee with foot plantarflexed, plantarflexed, hyperextension, pivothyperextension, pivot

– MVA = dashboard injuryMVA = dashboard injury

• Effusion (less than with Effusion (less than with ACL)ACL)

• Shifting/instability Shifting/instability (chronic)(chronic)

• Less distinctiveLess distinctive

PCL INJURIESPCL INJURIES PHYSICAL EXAMPHYSICAL EXAM

• + Effusion+ Effusion

• + Posterior drawer test+ Posterior drawer test

• + Posterior sag sign+ Posterior sag sign

• False positive Lachman testFalse positive Lachman test

• Common to have Common to have isolatedisolated injuries injuries

PCL INJURIESPCL INJURIES

TREATMENTTREATMENT• PRICESPRICES

• Functional bracing (early)Functional bracing (early)

• RehabRehab

• Surgery if continued instability, Surgery if continued instability, effusionseffusions

• Note- 2% of NFL preseason exam Note- 2% of NFL preseason exam with incidental isolated PCL tearwith incidental isolated PCL tear

Patellofemoral Patellofemoral ArthralgiaArthralgia

Often referred to as Often referred to as chondromalacia patella. This chondromalacia patella. This term should be reserved for term should be reserved for observed articular cartilage observed articular cartilage

damagedamage

PFA-HISTORYPFA-HISTORY• Pain with:Pain with:

– StairsStairs

– Prolonged sittingProlonged sitting

– Deep squat Deep squat activitiesactivities

• Lack of effusions, Lack of effusions, locking, instabilitylocking, instability

PHYSICAL EXAMPHYSICAL EXAM• Patellar compression/grind Patellar compression/grind

teststests

• No patellar apprehensionNo patellar apprehension

• Poor hamstring flexibilityPoor hamstring flexibility

• ++ “J” sign “J” sign

• Normal ligaments, meniscusNormal ligaments, meniscus

• Lack of effusionLack of effusion

KNEE- TANGENTIAL XRAYSKNEE- TANGENTIAL XRAYS

• Assess patellofemoral Assess patellofemoral jointjoint

• Patellar tiltPatellar tilt

• LateralizationLateralization

• Depth of trochlearDepth of trochlear

groovegroove

PATELLAR INSTABILITYPATELLAR INSTABILITY

•Acute patellar dislocationAcute patellar dislocation

•Acute patellar subluxationAcute patellar subluxation

•Patellar tracking Patellar tracking dysfunctiondysfunction

PATELLAR PATELLAR DISLOCATIONDISLOCATION

HistoryHistory

• Mechanism = pivot Mechanism = pivot

• Immediate effusionImmediate effusion

• May visualize patella dislocated May visualize patella dislocated laterallylaterally

• ++ Instability (chronically) Instability (chronically)

Patella may spontaneously Patella may spontaneously relocaterelocate

PATELLAR PATELLAR DISLOCATIONDISLOCATION

Physical ExamPhysical Exam

• Tender peripatellar structuresTender peripatellar structures– Medial retinaculumMedial retinaculum– Lateral femoral condyleLateral femoral condyle

• EffusionEffusion

• ? Patella dislocated laterally ? Patella dislocated laterally

XraysXrays- osteochondral fracture, effusion- osteochondral fracture, effusion

MRI for loose bodiesMRI for loose bodies

PATELLAR PATELLAR DISLOCATIONDISLOCATION

TreatmentTreatment

• Knee extension immobilizer x 4 Knee extension immobilizer x 4 wks, J Sleevewks, J Sleeve

• Early quad setting exercisesEarly quad setting exercises

• Return to sportReturn to sport– Full, painless ROMFull, painless ROM– Normal strengthNormal strength– Adequate aerobic fitnessAdequate aerobic fitness

Biology of the MeniscusBiology of the Meniscus• Medial MeniscusMedial Meniscus

• SemilunarSemilunar

• Narrow anteriorlyNarrow anteriorly

• Adherent to MCLAdherent to MCL

• Lateral MeniscusLateral Meniscus

• CircularCircular

• Covers more of Covers more of tibiatibia

• Uniform sizeUniform size

• Less adherent Less adherent

Types of Meniscus TearsTypes of Meniscus Tears

• LongitudinalLongitudinal

• Horizontal Horizontal

• ObliqueOblique

• RadialRadial

MENISCAL INJURIESMENISCAL INJURIESHistoryHistory

• Mechanism = pivot, twistMechanism = pivot, twist

• ++ heard a “pop” heard a “pop”

• Effusion- 12-36Effusion- 12-36oo after after injuryinjury

• Mechanical Sxs- locking, Mechanical Sxs- locking, instabilityinstability

MENISCAL INJURIESMENISCAL INJURIESPhysical ExamPhysical Exam

• Joint line Joint line tenderness tenderness

– IR/ERIR/ER

• Decreased ROMDecreased ROM

• McMurray’s testMcMurray’s test

• Apley’s Apley’s compression testcompression test

MENISCAL INJURIESMENISCAL INJURIESAncillary StudiesAncillary Studies

• Plain radiographsPlain radiographs

– Other causes Other causes mechanical Sxsmechanical Sxs

• MRIMRI

– Higher Higher vascularity in vascularity in peds patientspeds patients

• CT-arthrography CT-arthrography outdatedoutdated

Meniscus MRIMeniscus MRI

Grading of Meniscal Tears: Grading of Meniscal Tears: MRIMRI

• II: globular changes: globular changes

• IIII: linear changes not to : linear changes not to margin margin

• IIIIII: linear to sup/inf margin: linear to sup/inf margin

• IVIV: complex linear changes: complex linear changes

• Only grade III and IV Only grade III and IV visible on arthroscopyvisible on arthroscopy

MENISCAL INJURIESMENISCAL INJURIESTreatmentTreatment

• Nonoperative (Aggressive Nonsurgical)Nonoperative (Aggressive Nonsurgical)

• Acute RehabAcute Rehab

– ROM, Quad settingROM, Quad setting

• Subacute RehabSubacute Rehab

– ROM, PRE’sROM, PRE’s

• Bracing (hinged knee brace)Bracing (hinged knee brace)

• Continue sport specific drills when Continue sport specific drills when tolerabletolerable

MENISCAL INJURIESMENISCAL INJURIESTreatmentTreatment

• OperativeOperative

– Partial MenisectomyPartial Menisectomy

– Meniscal Repair (peripheral)Meniscal Repair (peripheral)

– Meniscus ImplantsMeniscus Implants

– Total Menisectomy- outdatedTotal Menisectomy- outdated

Baker’s Cyst and the Baker’s Cyst and the MeniscusMeniscus

• Stone, et al (1996)Stone, et al (1996)

• Case-control studyCase-control study

• Over 1700 MRI’s Over 1700 MRI’s 240 Baker’s cysts 240 Baker’s cysts

• 85% had meniscal tears85% had meniscal tears

• Data supported by:Data supported by:– Miller, et al (1997)Miller, et al (1997)– Sansone ,et al (1995) Sansone ,et al (1995)

Discoid MeniscusDiscoid Meniscus• Programmed cell deathProgrammed cell death

• More likely to tearMore likely to tear

• Often LateralOften Lateral

• Male > femaleMale > female

• Ages 6-10 yrsAges 6-10 yrs

• Xray- wide lateral joint spaceXray- wide lateral joint space

• Rx- may require resection if Rx- may require resection if SxSx

Discoid Discoid MeniscusMeniscus

Discoid Discoid MeniscusMeniscus

Assorted Knee ProblemsAssorted Knee Problems• Osgood-Schlatter SyndromeOsgood-Schlatter Syndrome

• Patellar, Quad TendinitisPatellar, Quad Tendinitis

• PlicaPlica

• Iliotibial Band SyndromeIliotibial Band Syndrome

• OsteoarthritisOsteoarthritis

• Osteochondritis dessicans (OCD)Osteochondritis dessicans (OCD)

TENDINITISTENDINITIS Quadriceps and Patellar Quadriceps and Patellar

HistoryHistory

• Pain with: Pain with:

– JumpingJumping

– StairsStairs

– Prolonged sittingProlonged sitting

• Mechanism = overuseMechanism = overuse

TENDINITISTENDINITISQuadriceps and PatellarQuadriceps and Patellar

Physical ExamPhysical Exam

• Tender superior/inferior pole of Tender superior/inferior pole of patellapatella

• Tender tibial tubercle Tender tibial tubercle

• Tight hams, Achilles, quadsTight hams, Achilles, quads

• Pain with resisted action of musclePain with resisted action of muscle

TENDINITISTENDINITISQuadriceps and PatellarQuadriceps and Patellar

TreatmentTreatment• PP: protection, pain meds: protection, pain meds

• RR: rest: rest

• II: ice: ice

• CC: compression: compression

• EE: elevation: elevation

• SS: support, strength/stretch : support, strength/stretch exercisesexercises

Traction Traction ApoApophysitisphysitis

• Osgood-Schlatter “disease”Osgood-Schlatter “disease”

BURSITISBURSITIS• Prepatellar bursaPrepatellar bursa

• Infrapatellar bursae Infrapatellar bursae

• Pes anserine bursaPes anserine bursa

• Mechanism = direct blow, Mechanism = direct blow, overuseoveruse

• Physical exam- point Physical exam- point tender, nonintraarticular tender, nonintraarticular effusioneffusion

BURSITISBURSITIS TreatmentTreatment

• NSAID’sNSAID’s

• IceIce

• Flexibility exercisesFlexibility exercises

• Steroid injectionsSteroid injections

• Surgery for chronic Surgery for chronic cases (prepatellar)cases (prepatellar)

Impact of DJDImpact of DJD

• Impact of Arthritis Annually: Impact of Arthritis Annually: (CDC statistics)(CDC statistics)– 9,500 deaths 9,500 deaths – 750,000 hospitalizations 750,000 hospitalizations – 8 million people with limitations 8 million people with limitations – 36 million ambulatory care 36 million ambulatory care

visits visits – $51 billion in medical costs and $51 billion in medical costs and

$86 billion in total costs $86 billion in total costs

Impact of Knee DJDImpact of Knee DJD

• Leading cause of Leading cause of disabilitydisability

• Affects leisure, work, Affects leisure, work, activities of daily activities of daily livingliving

• $86 billion annually to $86 billion annually to health care economy health care economy in U.S.in U.S.

Various forms of ArthritisVarious forms of Arthritis

• Osteoarthritis most Osteoarthritis most commoncommon

What is DJD of Knee?What is DJD of Knee?

• Wear and tear of Wear and tear of Hyaline cartilageHyaline cartilage leads leads to exposed boneto exposed bone

• Subchondral CystsSubchondral Cysts

• Joint Space NarrowingJoint Space Narrowing

• Pain with rest, Pain with rest, swelling, swelling, “instability”,mechanic“instability”,mechanical symptomsal symptoms

Etiology of Knee DJDEtiology of Knee DJD

• HeredityHeredity

• ObesityObesity

• MalalignmentMalalignment

• InjuryInjury

• Female genderFemale gender

• Muscle weaknessMuscle weakness

• Overuse / wear and Overuse / wear and teartear

Diagnosis of Knee DJDDiagnosis of Knee DJD

• Clinical Exam Clinical Exam

• Weight bearing X-Weight bearing X-rays-indicates loss rays-indicates loss of joint space / of joint space / articular cartilagearticular cartilage

• MRI rarely MRI rarely indicated (More for indicated (More for soft tissue)soft tissue)

Arthritis of the Knee: Arthritis of the Knee: TreatmentTreatment

• Most treatment is conservativeMost treatment is conservative– Weight lossWeight loss– Muscle strengthening - PTMuscle strengthening - PT– NSAIDSNSAIDS– SupplementsSupplements– Bracing and orthoticsBracing and orthotics– InjectionInjection

Arthritis of the Knee: Arthritis of the Knee: TreatmentTreatment• Weight lossWeight loss

– Decreases impact Decreases impact – 6-8 times body weight is 6-8 times body weight is

felt in kneesfelt in knees– Very important for stairs!Very important for stairs!– Affects flexibilityAffects flexibility– Impacts risk of surgery Impacts risk of surgery

and long-term resultsand long-term results– Affects overall healthAffects overall health

Arthritis of the Knee: Arthritis of the Knee: TreatmentTreatment

• Exercise and PTExercise and PT– Strong muscles Strong muscles

cushion jointcushion joint– FlexibilityFlexibility– Improves recovery Improves recovery

from injury or from injury or surgerysurgery

– Low-impact Low-impact (cycling) preferred(cycling) preferred

– Pool therapy Pool therapy possibly bestpossibly best

Arthritis of the Knee: Arthritis of the Knee: TreatmentTreatment• Anti-inflammatories and Anti-inflammatories and

analgesicsanalgesics– NSAIDS (Motrin, Aleve, etc) NSAIDS (Motrin, Aleve, etc)

• Excellent track recordExcellent track record

• Some side effects – Some side effects – take as neededtake as needed

• Cheaper than Cheaper than prescription drugs and prescription drugs and equally effectiveequally effective

– AnalgesicsAnalgesics

• TylenolTylenol

• Do not use narcotics for Do not use narcotics for chronic painchronic pain

NSAID FactsNSAID Facts• Only 1 in 5 who have a serious problem from NSAIDs, have Only 1 in 5 who have a serious problem from NSAIDs, have

warning symptomswarning symptoms

• Nonselective NSAIDs -16,500 deaths annually in the U.S.Nonselective NSAIDs -16,500 deaths annually in the U.S.

• Nonselective NSAIDs -103,000 hospitalizations annually in the Nonselective NSAIDs -103,000 hospitalizations annually in the U.S.U.S.

• Four Times more Americans die from NSAIDs annually than from Four Times more Americans die from NSAIDs annually than from cervical cervical

cancercancer

• More Americans die from NSAIDs annually than from AIDS More Americans die from NSAIDs annually than from AIDS

• Clinically important UGI events occur in 3- 4.5% of regular NSAID Clinically important UGI events occur in 3- 4.5% of regular NSAID takerstakers

Wolfe MM, et al. N Engl J Med.1999;340:1888-1899. Laine L. et al. Gastroenterology. 2001;120:594-

606. Fries JF. , Journal of Rheumatology.  1991. 18 (suppl

28):7.

GlucosamineGlucosamine

• Symptomatic reliefSymptomatic relief

• Slows disease Slows disease progression?progression?

• No formula proven No formula proven better than anotherbetter than another

• Cost ($20/mo)Cost ($20/mo)

• GI upsetGI upset

• May take 3 monthsMay take 3 months

ChondroitinChondroitin

• Gives cartilage Gives cartilage elasticityelasticity

• From shark From shark cartilage or cartilage or animal tracheasanimal tracheas

• Less proven than Less proven than glucosamine but glucosamine but usually packaged usually packaged togethertogether

WD40WD40

• No proven No proven benefitbenefit

• May cause skin May cause skin irritationirritation

• Not Not recommendedrecommended

BracesBraces

• Knee bracesKnee braces– Support sleevesSupport sleeves

•Warm jointWarm joint

•Help balanceHelp balance– Functional bracesFunctional braces

•Stabilize jointStabilize joint

•Transfer stressTransfer stress

GII unloader

surgery

COX-2’s

High Dose NSAIDS +Gastroprotectant

IA-Steroids

simple analgesics, low dose NSAID’s

Exercise, Physical Therapy, Weight Loss,

Orthotics, Nutraceuticals

MILD OA

SEVERE OA

MODERATE OA

Guidelines for Managing Knee Guidelines for Managing Knee OAOA

Adapted from Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee, ACR, 2000

JFT

Who is a candidate for Who is a candidate for VSVS??

• Active patients who have early Active patients who have early osteoarthritisosteoarthritis

• Post arthroscopy patients with Post arthroscopy patients with residual symptoms – residual symptoms – rather than re-rather than re-operationoperation!!

• Patients who are too young, heavy Patients who are too young, heavy &/or not ready for TKR &/or not ready for TKR

• Non-operative candidatesNon-operative candidates

Where to inject?Where to inject?

What to inject with:What to inject with:

How I inject:How I inject:

When all else fails:When all else fails:

Arthroscopy of the KneeArthroscopy of the Knee

• Useful for mild or Useful for mild or moderate arthritis moderate arthritis with mechanical with mechanical symptoms symptoms (catching)(catching)

• Not as helpful for:Not as helpful for:– Severe arthritisSevere arthritis

Osteotomy (Realignment)Osteotomy (Realignment)

• Realigns leg to Realigns leg to transfer weight transfer weight bearing away from bearing away from affected area of affected area of kneeknee

• Useful for younger Useful for younger patient with only patient with only one part of the one part of the joint affectedjoint affected

Partial Knee ReplacementPartial Knee Replacement

• Replaces only Replaces only damaged portion damaged portion of kneeof knee

• Recovery 70% Recovery 70% faster than total faster than total kneeknee

• More natural feelMore natural feel• Patient selection Patient selection

criticalcritical

Total Knee ReplacementTotal Knee Replacement

• Involves resurfacing of Involves resurfacing of joint surfaces with metal joint surfaces with metal and plasticand plastic

• Newer techniques less Newer techniques less invasiveinvasive

• 3-4 day hospital stay3-4 day hospital stay• 6-8 weeks for recovery6-8 weeks for recovery• 90% success at 10-15 90% success at 10-15

yearsyears• Muscle Sparing Approach Muscle Sparing Approach

“Kinetic Knee“Kinetic Knee

References:References:• Cherry Juice, Chicken Combs, and Chondroitin:Cherry Juice, Chicken Combs, and Chondroitin:

The Truth About Arthritis Cures--Gregory J. The Truth About Arthritis Cures--Gregory J. Golladay, M.D., Orthopaedic Associates of Grand Golladay, M.D., Orthopaedic Associates of Grand Rapids, P.C.Rapids, P.C.

• A New Look at OA Knee Pain -Treatment A New Look at OA Knee Pain -Treatment Options for Today’s Orthopaedic Practice, Options for Today’s Orthopaedic Practice, Dr. Dave Atkin, M.D. Chief, Orthopedic Dr. Dave Atkin, M.D. Chief, Orthopedic DivisionSt.Luke’s Hospital San Francisco, DivisionSt.Luke’s Hospital San Francisco, CaliforniaCalifornia

• V Strand MD, PG Conaghan MB, BS, PhD, L.S V Strand MD, PG Conaghan MB, BS, PhD, L.S Lohmander MD, PhD, A.D Koutsoukos PhD, F L Lohmander MD, PhD, A.D Koutsoukos PhD, F L Hurley PhD, H Bird MD, P Brooks MD, R Day MD, Hurley PhD, H Bird MD, P Brooks MD, R Day MD, W Puhl MD and P A Band PhD. An integrated W Puhl MD and P A Band PhD. An integrated analysis of five double-blind, randomized analysis of five double-blind, randomized controlled trials evaluating the safety and controlled trials evaluating the safety and efficacy of a hyaluronan product for intra-efficacy of a hyaluronan product for intra-articular injection in osteoarthritis of the knee. articular injection in osteoarthritis of the knee. OsteoArthritis and Cartilage (2006) Volume 14, OsteoArthritis and Cartilage (2006) Volume 14, 859-866.859-866.

• Gaetano P. Monteleone, Jr., M.D., Dept of Family Gaetano P. Monteleone, Jr., M.D., Dept of Family Medicine, Director, Division of Sports Medicine, Medicine, Director, Division of Sports Medicine, West Virginia University School of Medicine West Virginia University School of Medicine (online slides)(online slides)

Useful Web SitesUseful Web Sites

• American Academy of Orthopaedic American Academy of Orthopaedic Surgeons www.aaos.orgSurgeons www.aaos.org

• Arthritis Foundation www.arthritis.orgArthritis Foundation www.arthritis.org

• NIH www.niams.nih.govNIH www.niams.nih.gov