MS3 Sports Medicine Workshop,Family Medicine Clerkship,Knee Problems,MS3 Family Medicine,Anatomy Review,Femur Medial & lateral Condyles Epicondyles Trochlear groove Intercondylar notchPatella Superior pole (base) Inferior pole (apex) Medial & lateral facets,Tibia Medial & lateral Condyles Gerdys tubercle Pes anserine area Tibial tuberosity Tibial plateau Tibial spinesFibula Head Neck,Anatomy Major Ligaments & Tendons,Quadriceps tendonPatellar tendonMedial & lateral patellar retinaculua,MCL LCL,Anatomy Menisci of the Knee,Medial meniscus Lateral meniscus Meniscal ligaments Functions of the menisciMeniscal zones White-white Red-white Red-red,Knee Exam Overview,Inspection Palpation Range of Motion Strength Neurovascular Special Tests,Case 1 Medial Right Knee Pain,16yo HS soccer player, previously healthy Tackled from right side while running Immediate onset of medial jt line pain Delayed onset local medial edema, stiffness Able to bear weight,Key Questions in the History,Mechanism of Injury? Acute or Chronic? Location and level of pain? Able to walk? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries?,Case 1 - Exam,Inspection: Mild medial knee edema Palpation: + ttp medial knee ROM: cant bend 80d Strength: mildly decreased Neurovascular: normal Special tests: Neg Lachman, Anterior Drawer, McMurray, varus stress + mild increased gap on valgus stress (compared to left) with good endpoint,Special Tests - ACL Injury,Lachman Test,Special Tests - PCL Injury,Posterior Drawer TestSag SignQuad-Active Test,Varus/Valgus stress for LCL and MCL Injury,Features that should prompt an xray after acute knee injury include:,Unable to bear weight Cant flex 90d Patella TTP Fibular head TTP Age 55 All of the above,5 Ottawa Knee Rules i.e. When to order a knee xray after acute injury,Age 55 or R knee pain Former parachutist, no specific trauma No previous knee surgeries Stiffness worse in morning Pain is worse with activity, better with rest,Case 2 Key Questions,Mechanism of Injury? Acute or Chronic? Where/how bad is pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better?,Insidious Onset Chronic Difficult to localize; mild NoNone Occasional Lots of “Bad Landings” No surgery Activity Rest,Case 2 Physical Exam,Inspection: Genu varus Bony enlargement at Med/Lat joint lines Palp: Posterior medial joint line ttp ROM: Decreased flexion, 110 deg, mild crepitus Strength: normal Neurovascular: normal Special Tests: no ligamentous laxity, neg meniscal tests,Special Tests - Meniscal Injuries,Joint line tendernessMcMurray TestsThessaly testBounce-home testFull Squat,Case 2 Plain Films,Joint space narrowingSubchondral SclerosisOsteophytesSubchondral Cysts,What is your diagnosis?,Meniscal tear Plica syndrome Osteoarthritis Bone tumor,Osteoarthritis,Nonpharmacologic Treatment: Nonpainful aerobic activity Weight loss Physical Therapy Improve ROM, increase strength Bracing,Pharmacologic Treatment: APAP Supplements Glucosamine and Chondroitin NSAIDs, COX-2s Tramadol Viscosupplementation Intrarticular Steroids,Case 3,31 year old female, L knee pain Recreational runner Localizes pain to front of knee No trauma, insidious onset Localizes pain “around kneecap” Worse with stairs Worse after prolonged sitting Knee occasionally “gives out”,Case 3 Key Questions,Mechanism of Injury? Acute or Chronic? Where is the pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better?,Insidious Onset Chronic Anterior knee No, but sometimes gives outNone None None Running, Stairs Multiple days of rest,Physical Exam,Inspection: mild genu valgus Palpation: TTP lateral medial patellar facets ROM: full w/o pain Strength: normal Neurovascular: normal Special Tests: + patellar grind Decreased patellar glide Inflexible hamstrings (Popliteal angle),Patellofemoral Joint Exam,Patellofemoral Joint Exam,Patellar Grind Test,Case 3 Plain Films,AP,Lateral,Case 3 Plain Films,Tunnel,Sunrise,Whats your diagnosis?,Patellar tendinopathy Patellar instability Patellofemoral syndrome Plica syndrome,