Knee Problems

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Knee Problems

• Dr. Tony Crane
• Pencoed Medical Centre

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Overview

• Anatomy
• Anterior Knee Pain
• Knee Injuries
• Symptom Algorithm
• OA differential.
• Examination
• Take Home Messages

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Presentations

• 70yr old female. Global knee pain.
• 25yr old male. Knee giving way.
• 14yr old boy. Anterior knee pain.
• 29yr old female. Anterior knee pain.
• 34yr old male. Sharp knee pain, laterally.

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Surface Anatomy
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Anatomy of Knee
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The Q Angle
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Anterior Knee Pain

• Patellofemoral Syndrome
• Patella Tendinopathy
• Fat Pad Impingement (Hoffa Syndrome)
• Bursitis
• Patella Tendon tears
• Osgood Schlatter
• Sindig Larsen Johanson
• Quadriceps Tendinopathy
• Stress Fractures
• Synovial Plica

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Patellofemoral Syndrome

• Chondromalacia patellae
• Patellofemoral pain syndrome
• Patellofemoral joint syndrome
• Anterior knee pain
• Extensor mechanism disorder
• Malalignment v Peripatellar synovitis theory

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Anterior Knee pain

• PF Syndrome
• Running (downhill)
• Prolonged activity/sit
• Vague pain
• Clicks ?give way
• Insidious onset
• Reduced ROM?

• P. Tendinopathy
• Jumping/landing
• Onset of activity
• Inferior patellar pain
• No clicking/clunks
• Gradual onset
• Normal ROM

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Patellofemoral Joint Forces

• Activity
• Level Walking
• Going upstairs
• Squatting

• Force through PFJ
• 0.5 x body wt
• 3-4 x body wt
• 7-8 x body wt

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Factors causing PF syndrome
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Iliotibial Band
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Bursae of Knee
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Acute Knee Injuries
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History

• Precise mechanism of injury
• Current disability
• Pain (localised / diffuse sharp / dull)
• Swelling (timing / current)
• Stiffness
• Giving Way
• Locking

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Onset of swelling

• Immediate (lt2hrs)
• (Blood)
• ACL/PCL rupture
• Patella dislocation
• Peripheral meniscal
• Deep fibres MCL
• Osteochondral
• Acute Fat Pad Imp.
• Bleeding diathesis

• Delayed (6-24hrs)
• (Synovial)
• Meniscal

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Tibial Stability
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ACL Injury

• Landing / pivot / deceleration. Women!
• 60 co-existing meniscal tear (LgtM)
• 7 bilateral meniscal tear
• Pain Effusion Snap or tear
• Widespread tenderness
• Loss of extension Lachman ve
• X-ray to exclude avulsion or tibial plateau

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ACL Treatment

• Conservative v Surgical
• Demands of patient v Functional ability
• Timing of Surgery
• Pre-rehabilitation
• Technique Patella v Hamstring
• Return to Sport

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Meniscal Injury

• Twisting mechanism
• /- ACL injury
• Pain variable Delayed swelling
• Clicking or locking
• Increased squatting
• Joint tenderness / effusion / reduced ROM
• McMurrays Test (MELI)
• Conservative v Surgical treatment.

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MCL Injury

• Valgus strain partially flexed knee
• Grade I III
• /- ACL (Grade III)
• Conservative treatment
• LCL Injury (less common than MCL)
• Direct varus stress
• Diff. diag. Ruptured biceps femoris

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PCL Injury

• Blow to anterior tibia in knee flexion
• or
• Hyperextension injury
• Minimal swelling (extra-synovial)
• Posterior Sag Reverse Lachman.
• Other posterior structures involved?
• X-ray (Avulsion )
• Usually conservative treatment.

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Patella Dislocation

• Moves laterally
• Traumatic v Atraumatic (women)
• Sudden giving way, severe pain swelling
• Popping out
• Medial tenderness / Apprehension test
• Risk factors (Q angle, xs pronation etc)

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Symptom Algorithm

• PAIN
• Well localised? - remember anatomy!
• Character?
• Sharp (stabbing,catching) suggest mechanical or
  well localised problems. E.g. Meniscal tears.
• Dull (Nagging, aching, throbbing) suggest
  degenerative or extra-articular. E.g OA / PFJ

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Symptom Algorithm

• PAIN
• Specific characteristics?
• PFJ worse downhill/stairs, prolonged sitting,
  rising from squat.
• Meniscal worse going up stairs, squatting down.

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Symptom Algorithm

• SWELLING
• 1. Distribution
• Localised Bursae / meniscal cyst / normal
• Generalised Inflammatory versus traumatic
• Frequency
• Intermittent OA / instability / meniscal prob.
• Permanent Degenerative / Inflammatory

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Symptom Algorithm

• STIFFNESS
• Specify differences extending / flexing and is
  the stiffness intermittent or permanent?
• Int. loss extension Locking (See locking)
• Int. loss flexion / both Effusion (See
  swelling)
• (If painful follow pain algorithm. PFJ common)
• Perm. loss extension Capsular (OA/post-op) or
  locked meniscal tear
• Perm. loss flexion / both Capsular or large
  effusion

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Symptom Algorithm

• LOCKING
• Clarify the symptoms to identify true locking.
  Use words like jamming.
• Large meniscal tear
• Loose bodies
• Pseudo-locking pain is usual cause (PFJ)

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Symptom Algorithm

• GIVING WAY
• Almost always painful after the event, but how
  is it at the moment it is about to give way?
• Painless usually ligamentous (ACL). Consider
  quadriceps weakness.
• Painful (see pain algorithm), but commonly a
  sharp, catching pain of meniscal. Also PFJ.

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Knee OA

• Dynamic rather than degenerative
• 50 rule symptoms x-ray findings
• Pain after use / at night
• Stiff / Bony swelling / Crepitus / dec. ROM
• Exercise (strength / flexibility / aerobic)
• Practical help advice
• Glucosamine 1500mg /day (min. 3mths)

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Differential Diagnosis

• Pain with no signs
• Referred (hip/back)
• Bony disease
• Stress fracture
• Osteoma
• Malignancy

• Other knee pain
• Gout
• Pseudogout
• Monoarthritides
• Reactive arthropathy
• Infective arthropathy

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Examination of Knee

• Observation (Symmetry, Gait, Biomech.)
• ROM (Active Passive Resistive)
• Palpation (Anatomy!)
• Ligament Laxity
• MCL / LCL
• ACL / PCL (Drawer Lachman)
• Meniscal (McMurrays)
• Patella Apprehension

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Take Home Messages

• History is crucial.
• Normal x-ray false reassurance.
• Never consider knee in isolation
• Always think hip (other referred)
• Children / Adolescents beware.
• Immediate swelling ACL (UPU)
• Aseptic aspiration imperative.

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Removal of Player

• How not to do it!

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• Thank You