Knee Injuries

Knee InjuriesPatellofemoral pain syndromePatellar pain resulting from physical or biomechanical changes in the patellofemoral jointMany forces interact to keep the patella aligned

Patellofemoral pain syndromePatella not only moves up and down, but rotates and tilts

Many points of contact between patella and femoral structures

Patellofemoral pain syndromeHx:Vague anterior knee pain with insidious onset Common cause of anterior knee pain in womenTend to point to front of knee when asked to localize painWorse with certain activities, i.e. ascending or descending hills & stairsPain with prolonged sitting theater signNo meniscal or ligamentous sxs

Patellofemoral pain syndrome

PE:Positive Clarkes or Patellar Grind testPatellar crepitus with ROMMild effusion possibleMay see tenderness with patella facet palpation medial, lateral, superior, inferiorRemainder of knee exam unremarkable

Patellofemoral pain syndromePE:Check hamstring flexibility

Patellofemoral pain syndromePE:Check for flat feet (pes planus) or high-arch feet (pes cavus)

Pes PlanusPes CavusPatellofemoral pain syndromePE:Check heel cord (achilles) flexibilityCheck for a tight iliotibial band (obers test)

Obers testAchilles stretchPatellofemoral pain syndromeTx:Physical therapyImprove flexibilityQuad strengthening, especially VMOOther modalities, i.e. soft tissue release, U/SPatellar taping

Patellofemoral pain syndromeTx:Relative rest/Modification of activitiesIcingNSAIDSPatellar bracesAddressing foot problems with foot wear and orthoticsSurgery

Iliotibial band tendonitisExcessive friction between iliotibial band (ITB) & lateral femoral condyle

Iliotibial band tendonitisCommon in runners and cyclists

Tight ITB, foot pronation, genu varum are risk factors

Iliotibial band tendonitisHx:Pain at lateral kneeAt first, sxs only after a certain period of activityProgresses to pain immediately with activityIliotibial band tendonitisPE:Tender at lateral femoral epicondyle, ~3cm proximal to joint lineSoft tissue swelling & crepitusNo joint effusion

Iliotibial band tendonitisPE:Obers test

Nobles test

Nobles testIliotibial band tendonitisTx:Relative restIceNSAIDSStretchingCortisonePlatelet-Rich Plasma

Iliotibial band tendonitisPrognosis:Improves with restExpect long recovery timeWhen to refer:Intractable painSurgery = release

Osgood-Schlatters DiseaseApophysitis of patellar tendon @ tibial tuberosityOnly occurs in adolescents. Why?Rapid Growth or increase in Quad strengthOsgood-Schlatters DiseaseHxPain @ tibial tuberosity of insidious onsetPain with running, jumping, or kneelingOsgood-Schlatters DiseasePEEnlarged tibial tuberosityPoint tenderness of tibial tuberositySwelling over tibial tuberosityPain with Active knee extensionDecreased Hamstring flexibilityPain and weakness on MMT of QuadsOsgood-Schlatters DiseaseTxReduce ActivityIceStretch HamstringsAnterior cruciate ligament (ACL) injuryMost are non-contact injury, 2 to deceleration forces or hyperextensionPlanted foot & sharply rotating If 2 to contact, may have associated injury (MCL, meniscus)

Anterior cruciate ligament (ACL) injuryFemales playing soccer, gymnastics and basketball are at highest riskRisk of injury 2 8 times in women~250,000 injuries/year in general populationGender difference not clearJoint laxity, limb alignmentNeuromuscular activationAnterior cruciate ligament (ACL) injuryHx:Hearing or feeling a pop & knee gives waySignificant swelling quickly (< 1 hours)Unstable range of motionAchy, sharp pain with movement

Anterior cruciate ligament (ACL) injuryPE:Large effusion, ROMDifficult to bear weightPositive anterior drawerPositive Lachmans

Anterior cruciate ligament (ACL) injuryImaging:X-ray alwaysMRI

Anterior cruciate ligament (ACL) injury

MRIAnterior cruciate ligament (ACL) injuryTreatment:RICEHinged knee braceCrutchesPain medicationROM/RehabilitationAvoid most activities (stationary bike o.k.)Surgery (in most cases)

Anterior cruciate ligament (ACL) injuryPrognosis:Usually an isolated injuryPost-op: 8-12 months until full activityReferral:Almost all young, athletic patients will prefer surgical reconstruction?Increased risk of DJD if not treatedCan still get DJD if reconstructed

Meniscal TearMeniscus = little moon in greekAbsorbs shock, distributes load, stabilizes jointThick at periphery thin centrally

LateralMedialMeniscal TearCauses:Sudden twisting Young athletesSimple movements Older knee

Meniscal TearHx:Clicking, catching or lockingWorse with activityTends to be sharp pain at joint lineEffusionMeniscal TearPE:mild-moderate effusionpain with full flexiontender at joint line+ McMurrays

McMurrays TestMeniscal TearImaging:MRI

Meniscal TearTreatment:RICESurgical repair or excision (arthroscopic)CrutchesNSAIDsKnee sleeveAsymptomatic tears do not require treatment

Meniscal TearPrognosis:Results of surgical repair/excision are very goodReturn to full activities 2-4 months after surgery; tends to be quicker for athletesWhen to refer:Most symptomatic meniscal injuries require surgery

Medial Collateral ligament (MCL) InjuryImportant in resisting valgus movementCommon in contact sports, i.e. football, soccerHit on outside of knee while foot plantedAssociated injuries common, depending on severity

Medial Collateral ligament (MCL) InjuryHx:Immediate pain over medial kneeWorse with flexion/extension of kneePain may be constant or present with movement onlyKnee feels unstableSoft tissue swelling, bruisingMedial Collateral ligament (MCL) InjuryPE:no effusionmedial swellingpain with flexiontender over medial femoral condyle, proximal tibiaValgus stress at 0 & 30 PAIN, possible laxity

Medial Collateral ligament (MCL) InjuryImaging:obtain radiographs to r/o fractureMRI if other structures involved or if unsure of diagnosis

Medial Collateral ligament (MCL) Injury

Treatment: Grade Ino laxity @ 0or 30 Grade IIno laxity @ 0,but lax @ 30RICEHinged-knee brace (Grade II)CrutchesAggressive rehabilitationNSAIDsTreatment: Grade III lax @ 0 & 30Same as aboveConsider Orthopedic referral

Medial Collateral ligament (MCL) InjuryPrognosis:Grade I -- 10 daysGrade II -- 3-4 weeksGrade III -- 6-8 weeksWhen to refer:Other ligamentous injuries (surgical)Severe MCL injuryNot progressing as expected

Patellar dislocation/instabilityPatella may dislocate or sublux laterallyYoung, active patients at highest risk (~ages 13-20)Common in football & basketball > Recurrence is common, especially if first dislocation < 15 yoPatellar dislocation/instabilityIndirect trauma most common mechanismStrong quad contraction while leg is in valgus and foot plantedOther knee ligament injuries can occur

Patellar dislocation/instabilityRisk factors:TraumaPes planusGenu valgumWeak VMO

Patellar dislocation/instabilityHx:Feel a pop and immediate painObvious knee deformityPainful, difficult to bend kneeMay spontaneously relocate, left with feelings of instabilityPatellar dislocation/instabilityPE:Laterally shifted patellaPatellar apprehensionSwelling

Patellar dislocation/instabilityImaging:Standard knee x-rays a good start

Likely need an MRI if injury seems significant or associated injuries seem possible

MRI

Patellar dislocation/instabilityTreatment:NSAIDSIcePatellofemoral knee brace/rigid bracePTROM quickly (~ 2week)Quad strengtheningElec. StimSurgeryRecurrent instability

Patellar dislocation/instabilityPrognosisRecurrent instability is common, but rehab is mainstay and very usefulWhen to referAssociated fracturePoor response to rehabMultiple dislocations (#?) & skill level

Lateral Collateral SprainLess common than MCL sprainTorn via varus stress

LCL SprainHxPain over LCLMay hear or feel a pop

LCLPESwelling+ Varus testPain w/ flexion and extension

LCL SprainTreatment: Grade Ino laxity @ 0or 30 Grade IIno laxity @ 0,but lax @ 30RICEHinged-knee brace (Grade II)CrutchesAggressive rehabilitationNSAIDsTreatment: Grade III lax @ 0 & 30Same as aboveConsider Orthopedic referral

Posterior Cruciate LigamentPrevents posterior translation of tibiaInjured when knee is flexed to 90Could also tear with rotationPCL SprainHxPop in back of kneeUnstable range of motion

PCL SprainPEMinor swelling in popliteal fossa+ Posterior Drawer+ Godfrey/Sag

PCL SprainTxRICECrutchesIncrease Quad StrengthNSAIDsKnee Brace

Osteochondral DefectFx of articular cartilage and underlying boneCaused by direct trauma or rotationSeen most often in adolescentsOCDHxDiffuse pain in joint lineImmediate effusionPain increased while WBMay lock up (Osteochondritis)May give out

OCDPEPain on palpation of joint lineEffusionCrepitusNeed CT scan or MRINo + special testsOCD

Osteochondritis

OCDTxDepends on location of defect and if defect is intactLoose Bodies=surgeryConservative=cast and then rehabMost people have microfracture surgeryPatellar TendinitisInsidious onsetPain inferior to patellaAKA Jumpers KneeCaused by repetitive activity and overusePatellar TendinitisHxStage I- Pain after activityStage II- Pain during and after, but not affecting performanceStage III- Pain all the time

Patellar TendinitisPESwelling around inferior poleSwelling around patellar tendonMay have pain on active extension in severe casesMay have pain @ end of passive flexionPain on MMT of quadsInflexible hamstringsNo + special tests

Patellar TendinitisTxRest, IceUltrasoundStretch HamstringsFriction MassageQuad strengthening