MS3 Sports Medicine WorkshopFamily Medicine ClerkshipKneeKnee膝关膝关节节运运动损伤动损伤Knee ProblemsMS3 Family MedicineMS3 Family MedicineKneeKnee膝关膝关节节运运动损伤动损伤Anatomy ReviewKneeKnee膝关膝关节节运运动损伤动损伤n nFemurFemur Medial & lateralMedial & lateraln nCondylesCondylesn nEpicondylesEpicondyles Trochlear grooveTrochlear groove Intercondylar notchIntercondylar notchn nPatellaPatella Superior pole (base)Superior pole (base) Inferior pole (apex)Inferior pole (apex) Medial & lateral facetsMedial & lateral facetsn nTibiaTibia Medial & lateralMedial & lateraln nCondylesCondyles Gerdys tubercleGerdys tubercle Pes anserine areaPes anserine area Tibial tuberosityTibial tuberosity Tibial plateauTibial plateau Tibial spinesTibial spinesn nFibulaFibula HeadHead NeckNeckKneeKnee膝关膝关节节运运动损伤动损伤Anatomy Major Ligaments & Tendonsn nQuadriceps tendonQuadriceps tendonn nPatellar tendonPatellar tendonn nMedial & lateral patellar Medial & lateral patellar retinaculuaretinaculuaKneeKnee膝关膝关节节运运动损伤动损伤n nMCLMCLLCLLCLKneeKnee膝关膝关节节运运动损伤动损伤KneeKnee膝关膝关节节运运动损伤动损伤KneeKnee膝关膝关节节运运动损伤动损伤Anatomy Menisci of the Kneen nMedial meniscusMedial meniscusn nLateral meniscusLateral meniscus Meniscal ligamentsMeniscal ligaments Functions of the Functions of the meniscimeniscin nMeniscal zonesMeniscal zones White-whiteWhite-white Red-whiteRed-white Red-redRed-redKneeKnee膝关膝关节节运运动损伤动损伤Knee Exam Overviewn nInspectionInspectionn nPalpationPalpationn nRange of MotionRange of Motionn nStrengthStrengthn nNeurovascularNeurovascularn nSpecial TestsSpecial TestsKneeKnee膝关膝关节节运运动损伤动损伤Case 1 Medial Right Knee Painn n16yo HS soccer player, 16yo HS soccer player, previously healthypreviously healthyn nTackled from right side Tackled from right side while runningwhile runningn nImmediate onset of Immediate onset of medial jt line painmedial jt line painn nDelayed onset local Delayed onset local medial edema, medial edema, stiffnessstiffnessn nAble to bear weight Able to bear weight KneeKnee膝关膝关节节运运动损伤动损伤Key Questions in the Historyn nMechanism of Injury?n nAcute or Chronic?n nLocation and level of pain?n nAble to walk?n nMechanical Symptoms? (Locking, popping, catching?)n nAssociated instability?n nSwelling?n nPrevious injuries or surgeries?KneeKnee膝关膝关节节运运动损伤动损伤Case 1 - Examn nInspection: Mild medial knee edemaInspection: Mild medial knee edeman nPalpation: + ttp medial kneePalpation: + ttp medial kneen nROM: cant bend 80dROM: cant bend 80dn nStrength: mildly decreasedStrength: mildly decreasedn nNeurovascular: normalNeurovascular: normaln nSpecial tests:Special tests: Neg Lachman, Anterior Drawer, McMurray, Neg Lachman, Anterior Drawer, McMurray, varus stressvarus stressn n+ mild increased gap on valgus stress + mild increased gap on valgus stress (compared to left) with good endpoint(compared to left) with good endpointKneeKnee膝关膝关节节运运动损伤动损伤Special Tests - ACL Injuryn nLachman TestLachman TestKneeKnee膝关膝关节节运运动损伤动损伤Special Tests - PCL Injuryn nPosterior Drawer TestPosterior Drawer Testn nSag SignSag Sign n nQuad-Active TestQuad-Active TestKneeKnee膝关膝关节节运运动损伤动损伤Varus/Valgus stress for LCL and MCL InjuryKneeKnee膝关膝关节节运运动损伤动损伤Features that should prompt an xray after acute knee injury include:1.1.Unable to bear weight2.2.Cant flex 90d3.3.Patella TTP4.4.Fibular head TTP5.5.Age 556.6.All of the aboveKneeKnee膝关膝关节节运运动损伤动损伤5 Ottawa Knee Rulesi.e. When to order a knee xray after acute injuryi.e. When to order a knee xray after acute injuryn nAge 55 or R knee painn nFormer parachutist, no specific trauman nNo previous knee surgeriesn nStiffness worse in morningn nPain is worse with activity, better with restKneeKnee膝关膝关节节运运动损伤动损伤Case 2 Key Questionsn nMechanism of Injury?Mechanism of Injury?n nAcute or Chronic?Acute or Chronic?n nWhere/how bad is pain?Where/how bad is pain?n nMechanical Symptoms? Mechanical Symptoms? (Locking, popping, (Locking, popping, catching?)catching?)n nAssociated instability?Associated instability?n nSwelling?Swelling?n nPrevious injuries or Previous injuries or surgeries?surgeries?n nWhat makes it worse?What makes it worse?n nWhat makes it better?What makes it better?n nInsidious OnsetInsidious Onsetn nChronicChronicn nDifficult to localize; mildDifficult to localize; mildn nNoNon nNoneNonen nOccasionalOccasionaln nLots of “Bad Landings” No Lots of “Bad Landings” No surgerysurgeryn nActivityActivityn nRestRestKneeKnee膝关膝关节节运运动损伤动损伤Case 2 Physical Examn nInspection: Inspection: Genu varusGenu varus Bony enlargement at Med/Lat joint linesBony enlargement at Med/Lat joint linesn nPalp: Posterior medial joint line ttpPalp: Posterior medial joint line ttpn nROM: Decreased flexion, 110 deg, mild ROM: Decreased flexion, 110 deg, mild crepituscrepitusn nStrength: normalStrength: normaln nNeurovascular: normalNeurovascular: normaln nSpecial Tests: no ligamentous laxity, neg Special Tests: no ligamentous laxity, neg meniscal testsmeniscal testsKneeKnee膝关膝关节节运运动损伤动损伤Special Tests - Meniscal Injuriesn nJoint line tendernessJoint line tendernessn nMcMurray TestsMcMurray Testsn nThessaly testThessaly testn nBounce-home testBounce-home testn nFull SquatFull SquatKneeKnee膝关膝关节节运运动损伤动损伤Case 2 Plain FilmsJoint space narrowingSubchondral SclerosisOsteophytesSubchondral CystsKneeKnee膝关膝关节节运运动损伤动损伤What is your diagnosis?1.1.Meniscal tear2.2.Plica syndrome3.3.Osteoarthritis4.4.Bone tumorKneeKnee膝关膝关节节运运动损伤动损伤Osteoarthritisn nNonpharmacologic Nonpharmacologic Treatment:Treatment: Nonpainful aerobic Nonpainful aerobic activityactivity Weight lossWeight loss Physical TherapyPhysical Therapyn nImprove ROM, increase Improve ROM, increase strengthstrength BracingBracingn nPharmacologic Pharmacologic Treatment:Treatment: APAPAPAP SupplementsSupplementsn nGlucosamine and Glucosamine and ChondroitinChondroitin NSAIDs, COX-2sNSAIDs, COX-2s TramadolTramadol ViscosupplementationViscosupplementation Intrarticular SteroidsIntrarticular SteroidsKneeKnee膝关膝关节节运运动损伤动损伤Case 3n n31 year old female, L knee painn nRecreational runnern nLocalizes pain to front of kneen nNo trauma, insidious onsetn nLocalizes pain “around kneecap”n nWorse with stairsn nWorse after prolonged sittingn nKnee occasionally “gives out”KneeKnee膝关膝关节节运运动损伤动损伤Case 3 Key Questionsn nMechanism of Injury?Mechanism of Injury?n nAcute or Chronic?Acute or Chronic?n nWhere is the pain?Where is the pain?n nMechanical Mechanical Symptoms? (Locking, Symptoms? (Locking, popping, catching?)popping, catching?)n nAssociated instability?Associated instability?n nSwelling?Swelling?n nPrevious injuries or Previous injuries or surgeries?surgeries?n nWhat makes it worse?What makes it worse?n nWhat makes it better?What makes it better?n nInsidious OnsetInsidious Onsetn nChronicChronicn nAnterior kneeAnterior kneen nNo, but sometimes No, but sometimes gives outgives outn nNoneNonen nNoneNonen nNoneNonen nRunning, StairsRunning, Stairsn nMultiple days of restMultiple days of restKneeKnee膝关膝关节节运运动损伤动损伤Physical Examn nInspection: mild genu valgusInspection: mild genu valgusn nPalpation: TTP lateral medial patellar Palpation: TTP lateral medial patellar facetsfacetsn nROM: full w/o painROM: full w/o painn nStrength: normalStrength: normaln nNeurovascular: normalNeurovascular: normaln nSpecial Tests:Special Tests: + patellar grind+ patellar grind Decreased patellar glideDecreased patellar glide Inflexible hamstrings (Popliteal angle)Inflexible hamstrings (Popliteal angle)KneeKnee膝关膝关节节运运动损伤动损伤Patellofemoral Joint ExamKneeKnee膝关膝关节节运运动损伤动损伤Patellofemoral Joint Exam Patellar Grind Test Patellar Grind TestKneeKnee膝关膝关节节运运动损伤动损伤Case 3 Plain FilmsAPLateralKneeKnee膝关膝关节节运运动损伤动损伤Case 3 Plain FilmsTunnelSunriseKneeKnee膝关膝关节节运运动损伤动损伤Whats your diagnosis?1.1.Patellar tendinopathy2.2.Patellar instability3.3.Patellofemoral syndrome4.4.Plica syndromeKneeKnee膝关膝关节节运运动损伤动损伤Patellofemoral Syndromen nTreatment:Relative rest; non-painful aerobicsRelative rest; non-painful aerobicsPhysical TherapyPhysical Therapyn nImprove Quad/Hamstring flexibilityImprove Quad/Hamstring flexibilityn nQuad, Hip abductor strengtheningQuad, Hip abductor strengtheningn nCore strengtheningCore strengtheningPatellar stabilization brace/tapingPatellar stabilization brace/tapingFoot orthoticsFoot orthoticsSurgery (last-ditch effort)Surgery (last-ditch effort)KneeKnee膝关膝关节节运运动损伤动损伤Case 4n n34 yo Army MAJ training for 1st marathonn nAtraumatic onset of R lateral knee pain 1 week ago after 10 mile runn nSharp burning painn nBetter with rest, returns with runningKneeKnee膝关膝关节节运运动损伤动损伤Case 4 Key Questionsn nMechanism of Injury?Mechanism of Injury?n nAcute or Chronic?Acute or Chronic?n nWhere is the pain?Where is the pain?n nMechanical Mechanical Symptoms? (Locking, Symptoms? (Locking, popping, catching?)popping, catching?)n nAssociated instability?Associated instability?n nSwelling?Swelling?n nPrevious injuries or Previous injuries or surgeries?surgeries?n nWhat makes it worse?What makes it worse?n nWhat makes it better?What makes it better?n nInsidious OnsetInsidious Onsetn nAcuteAcuten nLateral kneeLateral kneen nNo, but sometimes No, but sometimes gives outgives outn nNoneNonen nNoneNonen nNoneNonen nRunningRunningn nMultiple days of restMultiple days of restKneeKnee膝关膝关节节运运动损伤动损伤Physical Examn nInspection: normalInspection: normaln nPalpation: TTP over lateral femoral condylePalpation: TTP over lateral femoral condylen nROM: fullROM: fulln nStrength: normalStrength: normaln nNeurovascular: normalNeurovascular: normaln nSpecial tests: Special tests: + Noble test+ Noble test Tight on Ober testTight on Ober testKneeKnee膝关膝关节节运运动损伤动损伤Ober testNoble test KneeKnee膝关膝关节节运运动损伤动损伤Whats your diagnosis?1.1.Osteoarthritis2.2.Meniscal tear3.3.Iliotibial band syndrome4.4.LCL sprainKneeKnee膝关膝关节节运运动损伤动损伤Iliotibial Band Syndromen nTreatment:Ice massage, pain medsIce massage, pain medsRelative Rest; nonpainful activityRelative Rest; nonpainful activityPhysical TherapyPhysical Therapyn nSpecific ITB stretchesSpecific ITB stretchesn nHip abductor strengtheningHip abductor strengtheningn nCore strengthening (Gluteus Medius)Core strengthening (Gluteus Medius)Slow return to activitySlow return to activityExtrinsic factors: shoes, running Extrinsic factors: shoes, running surface, training errorssurface, training errorsKneeKnee膝关膝关节节运运动损伤动损伤What the heck is a Plica?1.1.Congenital thickening of joint capsule2.2.Redundant meniscus3.3.Loose piece of intra-articular cartilage4.4.Figment of my imaginationKneeKnee膝关膝关节节运运动损伤动损伤Plica Syndrome?KneeKnee膝关膝关节节运运动损伤动损伤Questions?Before we break for hands-onBefore we break for hands-onKneeKnee膝关膝关节节运运动损伤动损伤Special Tests - ACL Injuryn nLachman TestLachman Test Knee flexed to 15-30 degreesKnee flexed to 15-30 degrees Stabilize distal femurStabilize distal femur Anteriorly translate tibia on Anteriorly translate tibia on femurfemur Watch & feel for amount of Watch & feel for amount of translation & end pointtranslation & end pointn nPivot ShiftPivot ShiftKneeKnee膝关膝关节节运运动损伤动损伤Special Tests - PCL Injuryn nPosterior Drawer TestPosterior Drawer Test Knee flexed to 90 degreesKnee flexed to 90 degrees Posteriorly translate tibia on Posteriorly translate tibia on femurfemur Watch & feel for amount of Watch & feel for amount of translation & end pointtranslation & end pointn nSag SignSag Sign Knees flexed, quads relaxedKnees flexed, quads relaxed compare both sides compare both sides Look for tibial posterior “sag” Look for tibial posterior “sag” relative to femurrelative to femurn nQuad-Active TestQuad-Active Test Knee flexed; hamstrings Knee flexed; hamstrings fullyfully relaxedrelaxed Slide foot along table (quad Slide foot along table (quad active)active) Observe for anterior relocationObserve for anterior relocationKneeKnee膝关膝关节节运运动损伤动损伤Special Tests - MCL Injuryn nValgus Stress TestingValgus Stress Testing Knee flexed to 30 degreesKnee flexed to 30 degreesn nRelax ACL/PCL & joint Relax ACL/PCL & joint capsulecapsule Valgus stress applied to kneeValgus stress applied to knee Look and feel for translation Look and feel for translation and endpointand endpoint Compare to uninjured sideCompare to uninjured side May repeat with knee in full May repeat with knee in full extensionextensionKneeKnee膝关膝关节节运运动损伤动损伤Special Tests - LCL Injuryn nVarus Stress Varus Stress TestingTesting Same test as Same test as valgus stress valgus stress testingtesting Except applying a Except applying a varus stress varus stress insteadinstead LCL, IT band, & LCL, IT band, & PLC are testedPLC are testedKneeKnee膝关膝关节节运运动损伤动损伤Special Tests - Meniscal Injuriesn nJoint line tendernessJoint line tendernessn nFull SquatFull Squatn nMcMurray TestsMcMurray Testsn nThessaly testThessaly testn nBounce-home testBounce-home testKneeKnee膝关膝关节节运运动损伤动损伤McMurray test for Meniscal injuryn nTest Med and Lat meniscus Test Med and Lat meniscus separatelyseparatelyn n3 concurrent maneuvers:3 concurrent maneuvers:GrindGrind it (Rotate tibia it (Rotate tibia AWAY from it)AWAY from it)CrunchCrunch it (varus or it (varus or valgus)valgus)PinchPinch it (flex/extend it (flex/extend knee)knee)n nPositive: Painful “pop”Positive: Painful “pop”KneeKnee膝关膝关节节运运动损伤动损伤Special Tests - Meniscal Injuriesn nThessaly TestThessaly Test Pt stands on Pt stands on affected legaffected leg Knee bent at 20 Knee bent at 20 degreesdegrees Examiner holds pts Examiner holds pts hands and rotates hands and rotates pt to both sidespt to both sidesn nMeniscal grindMeniscal grind Positive test: pain, Positive test: pain, painful click.painful click.KneeKnee膝关膝关节节运运动损伤动损伤Anterior Knee ExamPalpation of patellar Palpation of patellar facetsfacetsn nGlide and lift patella Glide and lift patella medially & laterallymedially & laterallyn nPalpate undersurface Palpate undersurface of patella for of patella for tendernesstendernessKneeKnee膝关膝关节节运运动损伤动损伤Patellar Exam Patellar GlidePatellar Gliden nKnee in extension, relaxedKnee in extension, relaxedn nMedial & lateral patellar Medial & lateral patellar displacementdisplacement Measured in quadrantsMeasured in quadrantsn nNormal: 1-2 quadrantsNormal: 1-2 quadrantsn nPatellar ApprehensionPatellar Apprehensionn nLateral patellar displacementLateral patellar displacement patient apprehension patient apprehension or guarding or guardingKneeKnee膝关膝关节节运运动损伤动损伤Anterior Knee Exam Patellar Grind Test Patellar Grind Testn nKnee 10 deg flexionKnee 10 deg flexionn nGlide patella distally, Glide patella distally, and firmly compress and firmly compress patella against patella against trochlear groovetrochlear grooven nActive quadriceps Active quadriceps contraction contraction pain painKneeKnee膝关膝关节节运运动损伤动损伤Special Tests Obers Test n nLateral decubitus with Lateral decubitus with testing side up, testing testing side up, testing knee flexedknee flexedn nAdduct and fully flex hip Adduct and fully flex hip Abduct, externally rotate, Abduct, externally rotate, & extend hip& extend hipn nSlowly release support Slowly release support against gravity from leg, against gravity from leg, allowing gravity to take leg allowing gravity to take leg towards tabletowards tablen nPositive test: leg remains Positive test: leg remains abducted despite examiner abducted despite examiner releasing legreleasing legKneeKnee膝关膝关节节运运动损伤动损伤Special Testsn nNobles testNobles test Palpate lateral Palpate lateral femoral condylefemoral condyle Flex and Extend Flex and Extend KneeKnee + Test is pain at + Test is pain at site of palpationsite of palpationKneeKnee膝关膝关节节运运动损伤动损伤