Orthopaedics for the Practicing Internist

American College of Physicians2013 Ohio Chapter Scientific Meeting

Columbus, OHOctober 11, 2013

Paul J. Gubanich, MD, MPHAssistant Professor of Internal Medicine/Sports MedicineTeam Physician, Ohio State University Athletics, Ohio Machine, Columbus City Schools

DisclosuresI do not have a conflict of interest associated

with the material contained in this presentation.

An Approach to the Patient with Knee PainMost common

complaintsPainInstability –

(ligament injury, OA)Stiffness – (effusion,

OA)SwellingLocking (meniscal)Weakness

Most diagnosis made by:HistoryPhysical examImaging

Important Historical ComponentsAgeChronology, onsetPain level, characteristicsExacerbating positions/

movementsRelieving factorsActivity level or recent

change, occupationPrevious injuries, surgeriesExercise history, goalsPrevious treatments

Chronology of SymptomsAcute Pain

Sudden onsetSpecific mechanism

of injury Direct trauma (fall,

collision, MVA) Landing, pivoting

Common acute injuriesFractures (distal

femur, patella, proxmial tibia, fibula)

DislocationsMeniscal injuriesLigamentous injuriesMusculotendious

strainsContusions

Chronic PainOften lacks a

mechanism of injurySymptoms of

gradual onset

Common causes of chronic knee painArthritisTumors (night pain)

Osteosarcoma (adolescents) Chondrosarcoma (adults) Giant cell tumor (benign) Metastatic disease is

uncommonSepsis (rare, can be

bursal)Bursitis (overuse)TendonitisAnterior knee pain

Location, Location, Location

Medial KneeJoint line –

meniscus, OA, osteochondral defect, osteonecrosis, medial collateral ligament

Tibial plateau – (osteoporosis, post menopausal)

Pes bursa

Anterior KneeAnterior

Quad tendon or insertion

Anterior to patellaPatellaPatellar origin, tendon,

insertionTibial tubercle

Lateral Knee PainLateral

Femoral condyle – suggests IT band

Joint line – meniscus, OA, OCD, lateral collateral ligament

Posterior KneeMeniscus – posterior

medial, lateral corner

Posterior lateral – Baker’s/popliteal cyst, aneurysm

Physical ExamExam both sides

Joint above and belowMost painful part last

GaitAlignment (varus,

valgus)Squat

InspectionSwellingBruisingDeformity

Physical ExamPalpation

EffusionRange of Motion

Patellar trackingExtension (-5 to 5)Flexion (135-145)Crepitus, etc.

StrengthHamstringQuad

Functional tests

Physical Exam – Special Maneuvers Apprehension sign –

patellar instabilityApley grind test –

meniscusMcMurray

circumduction test, SN 16-58%SP 77-98%(Evans 1993, Fowler

1989, Kurasaka 1999, Anderson 1986)

Physical Exam – Special Maneuvers Valgus stress test –

MCLSN 86-96%

Varus stress test – LCLSN 25%

Physical Exam – Special Maneuvers Lachman’s –

ACLSN 80-99% (various

authors and conditions)

Physical Exam – Special Maneuvers Anterior/posterior

drawer – ACL/PCLPosterior Sag Sign

RadiologyPlain x-rays often

considered part of examHelps rule out

competing diagnosisX-ray views

Standing AP views of both knees (for comparison)

LateralTunnel at 45 degreesMerchant/Sunrise – to

evaluate PF joint

RadiologyMRI often not

needed initiallySurgical planning

toolFailure of treatmentIdentify

ligamentous/cartilage injuries of acute or surgical nature

Risk stratification

General Treatment PearlsMatch disease severity/limitations with

treatment optionsEscalate based on time, response in a

stepwise fashionSet realistic expectations for progress and

follow-upAlign treatment goals with patient

goals/expectations when possible Time is a great healer

Common Treatment RecommendationsActivity modification, restMechanical devices –

braces, crutches, lifts, orthotics, etc.

Ice, pain medicationNsaidsAcetaminophenOthers

Physical therapy – early motion progressing to strengthening and then functional drills

Injection therapyAspirationCorticosteroidsHyaluronic acid supplents

(OA)Glucosamine (OA)Surgical considerationsConsider additional

imaging options as neededMRIBone scanCT

Red FlagsNight painAbnormal x-ray findings

Fractures, tumor, cartilage lesions, etc.

Mechanical symptomsSevere pain, swelling, loss of

motion, or weaknessHigh grade ligament injuriesFail to respond to standard

treatmentsMultiple joints involved

(Rheum)

Summary History and Physical Exam are vital to

generating a working differential diagnosisImaging may complement/confirm working

diagnosisTreatment should match symptoms and

severity and progress based on progress

Questions?