MS3 Sports Medicine Workshop

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MS3 Sports Medicine Workshop

• Family Medicine Clerkship

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Knee Problems

• MS3 Family Medicine

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Anatomy Review
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• Femur
• Medial lateral
• Condyles
• Epicondyles
• Trochlear groove
• Intercondylar notch
• Patella
• Superior pole (base)
• Inferior pole (apex)
• Medial lateral facets

• Tibia
• Medial lateral
• Condyles
• Gerdys tubercle
• Pes anserine area
• Tibial tuberosity
• Tibial plateau
• Tibial spines
• Fibula
• Head
• Neck

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Anatomy Major Ligaments Tendons

• Quadriceps tendon
• Patellar tendon
• Medial lateral patellar retinaculua

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• MCL LCL

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ACL and PCL
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Iliotibial band (ITB)
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Anatomy Menisci of the Knee

• Medial meniscus
• Lateral meniscus
• Meniscal ligaments
• Functions of the menisci
• Meniscal zones
• White-white
• Red-white
• Red-red

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Knee Exam Overview

• Inspection
• Palpation
• Range of Motion
• Strength
• Neurovascular
• Special Tests

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Case 1 Medial Right Knee Pain

• 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

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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?

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Case 1 - Exam

• Inspection Mild medial knee edema
• Palpation ttp medial knee
• ROM cant bend gt80d
• 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

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Special Tests - ACL Injury

• Lachman Test

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Special Tests - PCL Injury

• Posterior Drawer Test
• Sag Sign
• Quad-Active Test

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Varus/Valgus stress for LCL and MCL Injury
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Features that should prompt an xray after acute
knee injury include

1. Unable to bear weight
2. Cant flex gt90d
3. Patella TTP
4. Fibular head TTP
5. Age lt18 or gt55
6. All of the above

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

• Age gt 55 or lt 18
• Unable to walk
• TTP on PATELLA
• TTP on FIBULAR HEAD
• Unable to flex 90 deg

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Case 1 - Imaging
Normal!
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Case 1 Differential DiagnosisMore Likely
Less Likely

• Meniscal Tear
• Ligamentous Injury
• Which ligament?
• ACL
• PCL
• MCL
• LCL
• Muscle Strain

• Fracture
• Patellofemoral Pain
• Plica

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MCL Sprain
Diagnosis?
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What grade of sprain is likely present of the MCL?

1. Grade 1 no laxity, but hurts
2. Grade 2 mild laxity, still intact
3. Grade 3 complete tear
4. Grade 4 hurts like

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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)

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Case 2

• 56 yo retired Army LTC
• 15 years worsening LgtR knee pain
• Former parachutist, no specific trauma
• No previous knee surgeries
• Stiffness worse in morning
• Pain is worse with activity, better with rest

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Case 2 Key Questions

• Insidious Onset
• Chronic
• Difficult to localize mild
• No
• None
• Occasional
• Lots of Bad Landings No surgery
• Activity
• 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?

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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

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Special Tests - Meniscal Injuries

• Joint line tenderness
• McMurray Tests
• Thessaly test
• Bounce-home test
• Full Squat

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Case 2 Plain Films
Joint space narrowing Subchondral
Sclerosis Osteophytes Subchondral Cysts
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What is your diagnosis?

1. Meniscal tear
2. Plica syndrome
3. Osteoarthritis
4. Bone tumor

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Osteoarthritis

• Nonpharmacologic Treatment
• Nonpainful aerobic activity
• Weight loss
• Physical Therapy
• Improve ROM, increase strength
• Bracing

• Pharmacologic Treatment
• APAP
• Supplements
• Glucosamine and Chondroitin
• NSAIDs, COX-2s
• Tramadol
• Viscosupplementation
• Intrarticular Steroids

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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

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Case 3 Key Questions

• Insidious Onset
• Chronic
• Anterior knee
• No, but sometimes gives out
• None
• None
• None
• Running, Stairs
• Multiple days of rest

• 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?

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Physical Exam

• Inspection mild genu valgus
• Palpation TTP lateral gt medial patellar facets
• ROM full w/o pain
• Strength normal
• Neurovascular normal
• Special Tests
• patellar grind
• Decreased patellar glide
• Inflexible hamstrings (Popliteal angle)

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Patellofemoral Joint Exam
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Patellofemoral Joint Exam
Patellar Grind Test
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Case 3 Plain Films
Lateral
AP
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Case 3 Plain Films
Sunrise
Tunnel
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Whats your diagnosis?

1. Patellar tendinopathy
2. Patellar instability
3. Patellofemoral syndrome
4. Plica syndrome

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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)

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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

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Case 4 Key Questions

• Insidious Onset
• Acute
• Lateral knee
• No, but sometimes gives out
• None
• None
• None
• Running
• Multiple days of rest

• 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?

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Physical Exam

• Inspection normal
• Palpation TTP over lateral femoral condyle
• ROM full
• Strength normal
• Neurovascular normal
• Special tests
• Noble test
• Tight on Ober test

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Ober test Noble test
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Whats your diagnosis?

1. Osteoarthritis
2. Meniscal tear
3. Iliotibial band syndrome
4. LCL sprain

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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

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What the heck is a Plica?

1. Congenital thickening of joint capsule
2. Redundant meniscus
3. Loose piece of intra-articular cartilage
4. Figment of my imagination

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Plica Syndrome?
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Questions? Before we break for hands-on
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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

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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

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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

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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

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Special Tests - Meniscal Injuries

• Joint line tenderness
• Full Squat
• McMurray Tests
• Thessaly test
• Bounce-home test

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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

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Special Tests - Meniscal Injuries

• Thessaly Test
• Pt stands on affected leg
• Knee bent at 20 degrees
• Examiner holds pts hands and rotates pt to both
  sides
• Meniscal grind
• Positive test pain, painful click.

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Anterior Knee Exam

• Palpation of patellar facets
• Glide and lift patella medially laterally
• Palpate undersurface of patella for tenderness

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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

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Anterior Knee Exam

• Patellar Grind Test
• Knee 10 deg flexion
• Glide patella distally, and firmly compress
  patella against trochlear groove
• Active quadriceps contraction ? pain

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Special Tests Obers 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

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Special Tests

• Nobles test
• Palpate lateral femoral condyle
• Flex and Extend Knee
• Test is pain at site of palpation