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Evaluation & Treatment of Hip & Knee Pain in the Adult

Patient©

William T. Crowe, RN-C, FNP, MSN, MBA

Disclaimer ! I, William T Crowe, have relevant financial

relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation as follows:

– None

Objectives ! Review anatomy of the hip & knee

! Define elements of subjective history

! Perform basic exam of the hip & knee

! Discuss current treatment regimens for various problems

Anatomy - hip ! Bony structures

– Pelvis (ilium) – Femur

Anatomy – hip ! Connective tissue

– Ligaments ! Iliofemoral (Y

ligament of Bigelow) ! Pubofemoral

– Hyaline cartilage – Fibrocartilage

(labrum)

Anatomy – hip ! Connective tissue

– Ligaments ! Iliofemoral ! Ischiofemoral

– Hyaline cartilage

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Anatomy - hip ! Passive stabilizers

– Ligaments – Joint capsule

Anatomy - hip ! Active stabilizers

– Extensors group (gluteus maximus, hamstrings)

– Lateral rotator group (obturator internus and externus, gemellus superior and inferior, quadratus femoris and piriformis

Anatomy - hip ! Active stabilizers

– Adductor group (pectineus, adductor brevis, longus and magnus gluteus maximus, hamstrings)

– Flexor group (iliopsoas, rectus femoris, tensor fascia lata and sartorius)

Anatomy - hip ! Active stabilizers

– Abductor group (gluteus medius and minimus)

Anatomy - hip ! Ball and joint

– Connects lower limb to axial skeleton – 2nd largest ROM joint (1st ??)

Anatomy - hip ! Planes of motion

– Flexion & extension – Internal & external rotation – Abduction/adduction – Circumduction (combination of above)

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Anatomy - hip ! Normal ROM

– 110 - 120 degrees flexion – 10 - 15 degrees extension – 30 - 50 degrees abduction – 30 degrees adduction – 40 – 60 degrees lateral rotation – 30 – 40 degrees medial rotation

Anatomy - knee ! 3 compartments

– Medial – Lateral – Patellofemoral

Anatomy – knee* ! Bony structures

– Femur – Patella – Tibia – Fibula

Anatomy - knee ! Connective tissue

– Ligaments ! LCL, MCL, ACL, PCL

– Hyaline cartilage – Meniscus

Anatomy - knee ! Passive stabilizers

– MCL, LCL, ACL, PCL – Meniscus – Joint capsule

Anatomy - knee ! Active stabilizers

– Extensor mechanism – Popliteus muscle – Hamstrings

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Anatomy - knee ! Hinge joint?

Anatomy - knee ! 3 articulations in 1

– 1 between each femoral condyle & corresponding tibial tuberosity

– 1 between patella & femur

Anatomy - knee ! Planes of motion

– Flexion & extension – Internal & external rotation – Varus/valgus – Anterior & posterior translation

Anatomy - knee ! Normal ROM

– 135 degrees flexion – 0 to -10 degrees extension

Subjective/History ! Where does it

hurt?

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Subjective/History* ! Anterior hip (most common)

– Pathology of hip joint – Muscle strains

! Lateral hip – Greater trochanteric pain syndrome – Iliotibial band syndrome

Subjective/History ! Posterior hip (least common)

– Pathology usually outside of hip – Check lumbar spine and SI joints

Subjective/History Location of Pain ! Anterior Knee Pain

–  Patellofemoral Pain (Runner’s Knee) –  Jumper’s Knee

! Lateral Knee Pain –  Iliotibial Band Syndrome –  Lateral meniscal tears –  OA

! Medial Knee pain –  Medial meniscal tears –  OA –  MCL sprains

Subjective/History ! Where does it hurt? ! When did it start? ! What happened? ! If injury, able to WB after? ! Previous injury

Subjective/History* ! Severity – rest & activity ! “popping in/out” ! Childhood diseases of hip

– SCFE, trauma, DDH

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Subjective/History ! Severity – rest & activity ! Clicks ! Locking ! Instability

– Pseudo – pain – True – ligamental injury

! Giving way – mechanical (rotating) - tear –  functional (going up stairs) – quad weakness

! Post-inertial Dyskinesia – Theater sign

Subjective/History ! Swelling

– 0-12 hrs ! ACL tear, PCL tear, patellar dislocation, fracture

– 12-24 hrs ! Meniscal tears

– Recurring ! Chronic/degenerative meniscal tear, OA

! Pop at time of injury (felt/heard) –  If assoc with twisting motion – ACL injury

(80%), meniscal injury (15%), ? fx

Subjective/History ! Alleviating v Aggravating factors ! Treatment to date ! Review of PMH/PSH/MEDS/DA

Objective/Exam ! Observation

– “can’t see, can’t treat”

Objective/Exam - hip ! Observation

– Gait

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Objective/Exam - hip ! Palpation

– Seated ! Greater trochanter ! Lumbar spine, SI joint

– Supine ! Greater trochanter ! Groin

Objective/Exam - hip ! Maneuvers

– Supine ! Internal/external rotation ! Flexion ! FABER

– Lateral (injured side up) ! Abduction ! Ober’s Test

Objective/Exam - knee ! Observation

– Swelling – Ecchymosis – Atrophy – Valgus/varus thrust – Alignment

Sports Medicine Institute University of Minnesota Orthopedics

Objective/Exam - knee ! Palpation

– Sitting ! Bony structures ! Ligaments ! Joint lines

Objective/Exam - knee ! Palpation

– Supine ! Patellar mobility ! Patellar facets

Objective/Exam - knee ! Maneuvers

– Seated position ! Flex/ext of the knee ! Patellofemoral crepitus

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Objective/Exam - knee ! Maneuvers

– Supine position ! Patellar tracking ! ROM

Objective/Exam - knee ! Maneuvers

– Supine ! Valgus stress (30) ! Varus stress (30) ! McMurray test ! Anterior & Posterior Drawer test (90)

! Gait

Objective/Studies ! Radiographs ! CT scan ! MRI ! Nuclear bone scans

Objective/Studies

Objective/Studies Objective/Studies ! MRI

– Consider for soft tissue evaluation – Do not order to evaluate for pain – Don’t order without plain x-rays – General waste of time and money in patients

over age 40

(2011) Robert J. Dimeff, MD - Medical Director of Sports Medicine, Professor of Orthopaedic Surgery, Pediatrics, and Family Medicine, UT Southwestern

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Avascular Necrosis - hip ! Prevalence

– 10-20K annually – 30-50 y/o – Male 4:1 female – 50% bilateral

! Causes – Post traumatic – Alcoholism, smoking – Excess steroid use – Hypertension, diabetes

Avascular Necrosis - hip ! Subjective

– Pain (groin) is gradual as bone collapses – Increases with movement – Alleviated with rest

Avascular necrosis - hip ! Objective

– Antalgic gait – FABER +

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Avascular necrosis - hip ! Treatment

– Symptom relief ! NSAIDs ! Physical Therapy ! Limited weight-bearing

– Surgical ! Core decompression – 65% ! Joint replacement – 95%

Osteoarthritis – hip* ! Prevalence

– Males higher incidence

! Causes – Hereditary (~60%) – Weight-bearing – High intensity physical loading

Osteoarthritis - hip ! Subjective

– Chronic pain (groin) – Increases with movement – Alleviated with rest

Osteoarthritis - hip ! Objective

– Antalgic gait – FABER + – Pain with passive IR/ER

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Osteoarthritis - hip ! Treatment

– Conservative ! Weight control, rest, exercise

– Medical ! NSAIDs ! Physical therapy

– Surgical ! Joint replacement

Joint Replacement*

Trochanteric bursitis ! Prevalence

– Females higher incidence (wider hips)

! Causes – Trauma, contusion

Trochanteric bursitis ! Subjective

– Pain with activity and rest

Trochanteric bursitis ! Objective

– Pain on palpation of the greater trochanter

– Normal IR of hip

Trochanteric bursitis ! Treatment

– Medical ! NSAIDs ! Physical therapy ! Cortisone injection to site

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Posterior hip ! Primarily from lumbosacral and SI

joints

Femoroacetabular impingement (cam and pincer, hip impingement)

Femoroacetabular impingement (cam and pincer)

Cam Pincer

Fascia lata ! Popping over the greater trochanter ! Tx

– Physical Therapy

Stress Fracture ! Leg pain?? >> check Rx hx

– Bisphosphonates (can detect in bone 7-10 yrs after stopping)

Stress Fracture ! FDA (Oct 2010)

– New statement in labels – uncertainty of optimal duration of use

– HCP should: ! be aware of the possible risk of atypical femoral

fractures ! evaluate any patient who presents with new thigh/

groin pain ! consider periodic reevaluation of the need for

continued therapy, esp. those treated for > 5 yrs

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Stress Fracture ! Most occur around

femoral neck ! Subcapital or

transcervical ! Less common in

intertrochanteric region

! SURGERY ! Risk of

displacement - HIGH

Stress Fracture ! Pelvic fracture

usually involves ramus – Does not require

surgery – Rest, walking aids,

analgesics – May take several

months

Fractures

Anterior Knee Pain* ! Prevalence

– ~ 25% of general population ! Anterior knee pain syndrome ! Patellofemoral malalignment ! Chondromalacia patella

– Most common in teen-age females – Also seen in > 40 y/o

Anterior Knee Pain ! Subjective

– Pain increases with walking up/down stairs or hills

–  Instability with walking or running – Theater sign +

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Anterior Knee Pain ! Objective

– Crepitus – Patellar facet pain – Lateral tracking of the patella (J-sign)

Anterior Knee Pain ! 24 y/o female with

R knee pain for the past 2 weeks

Anterior Knee Pain ! 24 y/o F with R

knee pain x 2 weeks

Anterior Knee Pain ! 28 y/o F with R

knee pain x “several years”

Anterior Knee Pain ! Treatment - Chondromalacia

– Conservative ! Patellar buttress brace ! Physical therapy ! NSAIDs ! Cortisone injection (joint)

– Failure ! Refer to orthopedic specialist

Anterior Knee Pain ! Treatment - Lateral Subluxation /

Patellofemoral Syndrome – Conservative

! REST – STOP the offending activity ! RICE ! Patellar buttress brace ! Physical therapy ! NSAIDs ! Gradual return to activity

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Anterior Knee Pain ! Treatment - Lateral Subluxation /

Patellofemoral Syndrome – Failure

! Refer to orthopedic specialist

IT Band ! thick, fibrous connective

tissue ! attaches proximally at

the –  iliac crest –  Tensor fascia latae

muscle ! attaches distally to the

tibia ! at ~ 20-30 degrees,

moves across the lateral femoral epicondyle. Moves back when knee is straightened.

! helps hold us upright – walking/running

IT Band Syndrome ! Subjective

– Lateral knee pain – Pain worsens by running, particularly downhill – Painful flexion or extension of the knee

IT Band Syndrome ! Objective

– POP lateral knee (at or around the lateral epicondyle of the femur)

– Painful flexion or extension of the knee – Ober’s Test +

IT Band Syndrome ! Studies

– none

IT Band Syndrome ! Treatment

– Rest – relative – RICE – NSAIDs – PT –  IT band stretches

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Meniscal Injury ! Prevalence

– Most common reason for knee scope – Injury

! Rare in childhood ! Occurs in late teens ! Peaks in 30’s and 40’s

– After age 50, probably due to arthritis

Meniscal Injury ! Subjective

– Pain to the joint line (medial > lateral) – Locking – Popping

Meniscal Injury ! Objective

– Pain on palpation of the joint line – Varus/valgus stress with pain – McMurray test positive (Bragard’s sign)

! Medial - sensitivity 35.7%, specificity 85.7% ! Lateral – sensitivity 22.2%, specificity 100%

– Thessilly test (full ext & 30)

! ~ 1/3 with documented tears have NO sig findings on exam

Meniscal Injury ! Studies

– XR – MRI

Meniscal Injury ! Treatment

– Refer to orthopedic specialist

! Post-meniscectomy – Medial compartment degenerates within 10-15

yrs – Lateral compartment degenerates with 2-5 yrs

Ligamental Injury ! Subjective

– Immediate swelling – Inability to weightbear afterwards – Loss of stability

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Ligamental Injury ! Objective

– Swelling – Pain on palpation of ligaments – Varus/valgus stress unstable

! Valgus sensitivity 86%

– Posterior Drawer test + ! Sensitivity 90%, specificity 99%

– Lachman’s test + ! Sensitivity 78.6%, specificity 100%

Ligamental Injury ! Studies

– XR – MRI

Ligamental Injury ! Treatment

– RICE – NWB with use of crutches – Hinged knee brace – Physical therapy – NSAIDs and analgesics – Referral to orthopedic specialist

Osteoarthritis - knee ! Prevalence

– Most common joint disorder worldwide – ~80% of those > 75 years of age

! Radiographic evidence – ~11% of those > 64 years of age

! Symptomatic

Manek, NJ, & Lane, NE (2000). American Family Physician. (61) 1795-1804.

Osteoarthritis - knee ! Subjective

– Pain – Time

! Chronic v. acute – Swelling – Stiffness

! Morning ! Immediately after rest

– Joint instability

Osteoarthritis - knee ! Objective

– Altered gait – Joint effusion – Crepitus – Limited ROM – Instability

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Osteoarthritis - knee ! Studies

– XR

Osteoarthritis – knee* ! Treatment

– Physical therapy – Medication

! Acetaminophen ! NSAIDs – nonselective ! COX-2 Inhibitors ! Opioids

Osteoarthritis – knee* ! Treatment

– Physical therapy – Medication – Intra-articular injection

! Cortisone ! Hyaluronic Acid

Osteoarthritis - knee ! Treatment

– Physical therapy – Medication – Intra-articular injection – External bracing – Referral to orthopedic specialist

Fractures - hip

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Fracture - knee