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Knee Problems
Ghias Bhattee, FRCS(Tr&Orth)
Consultant Knee & Hip Surgeon
Northwick Park & Central Middlesex Hospitals
Outline
•Review of Evaluation of the Knee •Discuss Differential Diagnoses •Review Treatment Modalities •Summary of Approach to Knee Pain
Brief overview
• 10-15% of Primary Care presentations are MSK
• 1/3 of all MSK problems seen in Primary Care are about the Knee
• 54% of all Athletes will experience some knee pain EVERY YEAR
• 90% managed solely in Primary Care
History
•Onset: Insidious or Traumatic?
•Pain characteristics
•Locking
• Instability
•Effusion (<2 hours, or >24 hours)
•Previous episodes or surgery?
Mechanism of Injury
• Direct Blow • Foot planted • Deceleration or landing
from a height • Hyperextension • Twist
Examination
• Look – Healed surgical incisions & scars, “attitude” and symmetry, muscle wasting. Q-angle.
• Feel – Warmth, tenderness, effusion.
•Move – ROM, SLR, J-sign
Patellar tracking
Q-Angle J-Sign
Special tests
• Lachmann/Drawer & Dial tests
• (Pivot shift)
• Varus/Valgus LCL/MCL
• McMurray test
• Clarke’s test & patellar apprehension
Radiographs in acute injury?
• Ottawa:
• Age >55
• Tenderness at head of fibula
• Isolated tenderness of patella
• Inability to flex greater than 90°
• Inability to bear weight (4 steps)
• Sens – 97%
• Spec – 27%
• Pittsburgh:
• Blunt trauma or fall
AND
• Age <12 or >50
OR
• Inability to bear weight (4 steps)
• Sens – 99%
• Spec – 60%
Which views?
• STANDING AP if OA suspected
• Lateral
• Patellar skyline/Merchant view
Special views
• Tunnel View
MRI
Instability
Locking
In younger patients/following acute trauma
“In patients >50 years with non-acute knee pain, x-ray examination is much more useful to orthopaedic surgeons than MRI as OA usually dominates clinical symptoms” – Arthritis Research UK
Other investigations
• In presence of warmth, exquisite tenderness and effusion • Consider Septic Arthritis or Acute Inflammatory arthropathy • Blood tests to order
• FBC • CRP • ESR
• If inflammatory arthropathy possibility – ESR and RF
• Consider aspiration • Aspirate for
• White Cell count and differential • Glucose • Protein • C&S • Polarized light microscopy
Patellar maltracking/subluxation/dislocation
• Spectrum of anterior knee pain, to “click/clunk”, to dislocation
• First/traumatic episode may mimic ACL rupture history
•More common in adolescent females
• Large Q-angle (>15⁰)
• Patellar apprehension test
Chondromalacia Patellae/PFJ pain syndrome
• History • Anterior knee pain worse after sitting (cinema-goer’s knee)
• Exam • PFJ crepitus • Positive Clarke’s test • Raised Q angle
• Treatment • Relative rest • Ice 20 minutes after activity • Quadriceps/VMO strengthening (consider hip, hamstring, calf and IT band stretching) • Evaluation of Footwear • Consider NSAID’s • Consider Knee braces • Consider Knee taping – Kinesio/McConnell Taping
Patellar stabilisation
•Mainstay of treatment is targeted physiotherapy regimen
• Focus on vastus medialis oblique (VMO)
• One of 4 Quadriceps femoris
• Improves medialisation in lateral tracking
Key imaging parameters
• Lateral tracking my be associated with surgically correctable factors. • TT-TG distance >15-20mm •MPFL tear • Trochlear dysplasia
Surgical intervention
Fat Pad Impingement/Inflammation
• Hoffa’s pad plays a protective role, plus provides vascular supply
• Can become entrapped
• Inflammation results
• Often results from post op scarring
• Clinical diagnosis. High signal on MRI
• Guided injection
Osgood-Schlatter disease (Tibial Apophysitis)
• More common Teenage boys
• History • Knee pain waxing and waning for months • Worsens with squatting or stairs
• Tender over tibial tuberosity
• Treatment • Icing after activity • Decreasing activity – may need to stop
activity for 2-3 months • NSAID’s • If severe – knee brace for 2-6 weeks
Slipped Upper/Capital Femoral Epiphysis (SUFE) • Overweight 10-16♂ or 12-14♀ • History
• Vague Knee pain with no trauma
• Exam – pain on internal rotation of hip
• Diagnosis – Xray AP neutral and abduction both hips
• Treatment – • Immediate Cessation of weightbearing • Surgical stabilization
• ALWAYS EXAMINE HIP IN CHILDREN WITH KNEE PAIN
SUFE fixation
Osteochondritis Dissecans
• History • Vague knee pain, • morning stiffness and recurrent effusion • possibly locking or catching
• Exam • possible quad atrophy • effusion • chondral tenderness
• Radiographs to include Tunnel view
• MRI test of choice if unclear diagnosis
• Treatment • Rest • Bracing • Low Impact PT • Surgery if symptoms persist >2-3 months despite
therapy
Traumatic Chondral injuries
• Twist, turn, impact injuries
• Segment of joint surface plus underlying subchondral bone “fractures”
• May/may not be visible on plain films
• More common in adolescents and young adults
• Can be devastating for professional athletes
Surgical options
Meniscal Tears
• Acute or chronic
• Recurrent knee pain with episodes of catching, locking or giving way
• Mild effusion and positive McMurray test
• MRI best imaging test if diagnosis unclear
• Treatment • If no locking or instability – RICE, NSAID’s for 2-
3 weeks • Otherwise referral for surgical debridement
Anterior Cruciate Ligament • Plant and twist injury
• Often hears a pop and notes swelling in Knee (<1 hour)
• Joint Effusion + Anterior Drawer or Lachman if torn (most sensitive directly after injury or about 2 weeks later)
• Radiographs looking for tibial spine avulsion
• MRI
• Be mindful of recurrent pivoting
• Treatment • Initial Treatment
• RICE • Crutches • NSAID’s
• Definitive treatment • Based on Age, Activity level and degree of injury • Surgery vs Rehab • Surgery often indicated in multiligament injury
Other Ligament Injuries
• MCL – Valgus Injury • Pain, swelling and valgus instability • Acute surgery rarely indicated • Hinged knee brace • Reconstruction for chronic instability
• PCL – Hyperextension • Less common • Athletes may require reconstruction
• LCL/PLC – a large complex of structures • provides varus/rotational stability
Medial Plica Syndrome
• Plica – A remnant of embryonic connective tissue
• Hx – Acute onset medial knee pain
• Exam – tender mobile nodularity
• Treatment
• NSAID’s
• ICE
• Quad Strengthening Exercise
• Surgery only indicated in the presence of “kissing lesions”
Pes Anserine Bursitis
• Pes Anserine – insertion of Sartorius, gracilis and semitendinosus muscles
• Hx – pain on medial side of knee worsened with flexion and extension
• Exam – tenderness posterior and distal to medial joint line valgus stress may reproduce pain
• Treatment • NSAID’s
• ICE
• Guided aspiration
• (Surgical excision)
Iliotibial Band Tendonitis
• Friction between IT band and Lateral Femoral Condyle
• Hx – Lateral Knee pain aggrevated by activity
• PE – Tenderness over lateral epicondyle of femur while flexing and extending knee (Noble test)
• Treatment • IT band stretching exercises • NSAID’s • ICE
Baker’s/Popliteal Cyst
• Benign swelling of the semimembranosus (or rarely some other synovial) bursa
• Hx • insidious onset of mild to moderate pain in posterior aspect of
knee • Ruptured cyst may present like DVT – red swollen and tender
calf
• Exam – palpable fullness present medial aspect of popliteal area
• Imaging – US, MRI may help if diagnosis unclear
• Treatment • Aspiration may cause temporary relief but recurrence rate is
high • Surgery if pain persistent and intolerable
Septic Knee
• Predisposing factors – Ca, DM, ETOH, HIV, corticosteroid therapy
• Hx – Abrupt onset of pain and swelling no trauma
• Exam – warm, swollen, very tender, extremely painful ROM
• Lab • Raised inflammatory markers • ESR > 50 mm/hr • Arthrocentesis
• Turbid synovial Fluid – WBC > 50 000 Neutrophils >75 percent • Protein > 3 g/dL • Glucose - 50 percent or less or serum glucose level
• Treatment • common pathogens Staphyloccus aureus, Streptococcus, Haemophilus influenzae, Neisseria
gonorrhoeae • IV antibiotics under ID • Ortho referral for possible debridement
Crystal-Induced Inflammatory Arthropathy
• Gout (sodium urate crystals) and Pseudogout (calcium pyrophosphate crystals)
• Hx- Acute onset, red hot and very tender knee
• PE – erythematous, warm, tender swollen
• Arthrocentesis • Clear or slightly cloudy – WBC 2K to 75K • Protein high >32 g/dL • Glucose 75% of serum • Polarized-light microscopy of synovial fluid shows
• Gout - negatively birefringent rods • PseudoGout – positively birefringent rhomboids
• Treatment • NSAID’s • Colchicine
Osteoarthritis
• Common > 60 years of age • Hx – Knee pain aggrevated by weight bearing
relieved by rest, morning stiffness. Symptoms often triggered by minor trauma. • Exam – decreased ROM, crepitus, osteophytic
changes • Radiographs – • Weightbearing AP plus lateral & skyline
Treatments for Osteoarthritis
• Treatment • NSAID’s • Wt loss • Non load bearing exercise • Corticosteroid injections (beware arthroplasty
within 6-7 months)
• Referral for Knee replacement if • Significant and disabling pain • Dysfunction significantly inhibiting quality
of life
Knee Surgery for Osteoarthritis
• Knee replacement satisfaction rates reach 90% at 2 years
• Expectation of 60-90 minutes walking
• End to oral analgesics/sleep disturbance
• High flexion activities/kneeling likely to NOT be possible
• Longevity 90-95% achieve 12-15 years lifespan
Common Differential Diagnoses by Age
Childhood/
Adolescence
• PFJ Maltracking
• PFJ Instability
• “Jumper’s knee”
• Osgood Schlatters
• Osteochondritis dissecans
• Chondral defect/loose body
• Referred pain SUFE
• Sepsis
Older Adults
• Popliteal cysts
• Osteoarthritis
• Crystal arthropathy
• Sepsis
Adulthood
• Tendonitis • Chondromalacia
patellae • Meniscal pathology • Ligamentous injury • Medial plica
syndrome • Pes Anserine bursitis • Prepatellar Bursitis • ITB syndrome
Site of pain
Anterior
• PFJ OA
• Tendonitis
• Chondromalacia patellae
• PFJ Maltracking
• PFJ Instability
• “Jumper’s knee”
• Osgood Schlatters
• Bursitis
• Fat pad impingement
Posterior
• Popliteal cysts
• Posterior/meniscal root pathology
• PCL injury
Medial Lateral
• Medial OA • Medial meniscal
pathology • MCL injury • Medial plica
syndrome • Pes Anserine
bursitis
• Lateral meniscal pathology
• Lateral OA • ITB Friction
syndrome • LCL/PLC injury
Summary
• Up to 5% of primary care presentations are regarding the knee
• Vast majority treatable within primary care setting
• Careful attention to be paid to key history features: • Age • Site of pain • Mechanism of injury • Timing of effusion
• Examination focused on features of history
• Radiographs Investigation of choice in chronic pain >50
• Consider referral with persistent symptoms, proven internal derangement or failure to resolve with first line therapies
The aim is to prevent...
…and therefore…
References
• https://www.youtube.com/watch?v=oHgu5e9K3Ww
• https://www.youtube.com/watch?v=xKpm6DlgWj0
• https://www.youtube.com/watch?v=FynIg-KbJAE
• Foss, Myer, et al - J Athl Train. 2012 Sep-Oct; 47(5): 519–524
• National Joint Registry 13th Annual Report 2016