Department of Family Medicine Oh My Aching Knee Jeffrey Rosenberg MD Department of Family Medicine Montefiore Hospital Bronx NY

Objectives Learn to evaluate an adolescent’s knee Learn to evaluate an acutely injured knee Learn to evaluate an older patient’s knee Learn How to examine the Knee

Anterior Knee

Posterior Knee

Adolescent Knee Pain 15 year old male, plays multiple sports with insidious onset of anterior knee pain. Worse after sitting in class, up and down stairs. No instability On exam, no effusion, non tender at tibial tubercle, but peripatellar tissues are tender. Increased Q angle, increased patellar laxity

Adolescents Non Traumatic Osgood-Schlaters Disease-Pain at Tibial Tubercle Patellar Tendonitis-Usually Proximal Patellar-Athletes that Jump Ilio-Tibial Band:Runners All the Rest: Patellar Femoral Syndrome

Patellar Femoral Syndrome Mal-alignment-Q Repetitive Forces Muscle Tightness Exam: Patellar Glide Patellar Compression Patellar Tilt ROM/Flexibility

Q Angle Should be <20 male, <25 Female Flat feet, wide pelvis widen angle Treatment: VMO strengthening, stretching, McConnell Taping

Case #2 Acute Traumatic Knee 23 yo female soccer player comes in two hours after being slid into from the side. No pop felt, but not able to bear weight immediately afterwards, feels unstable On exam, tense effusion, limited ROM, lachmans’ positive with loss of endpoint and increased movement on Anterior Drawer

Acute Knee Injuries Patellar Dislocation: Traumatic vs Non Traumatic; Recurrent All need Bracing for 2 to 4 weeks, PT Collateral Ligaments: If Laxity with Stress, may be complete tear. Functional Brace, PT Contusion ACL Meniscus Tear

ACL Injury Non Traumatic vs Traumatic Women have more non traumatic ACL tears High Impact, Planted Foot, Valgus Force or Medial Rotation of Tibia Field Sports, Skiing Pop (60-70%) Swells < 2 hours, feels well in a few days Recurrent Instability with twisting/stairs

Anterior Cruciate Testing ACL should feel taught, like rope stretched to its maximum. Loss of this endpoint is consistent with tear

ACL Testing Sensitivity Specificity Positive LR Negative LR 82% 94% 25 Composite 82% 94% 25 0.04 Anterior Drawer 62% (9-93%) 67% (23-100%) 3.8 0.30 Lachmans 84% (60-100%) 100% (POOR QUALITY) 42 0.10 Pivot 38% (27-95%) Solomon, et al: JAMA 286:13

Meniscus Tear Twisting Injury with knee in flexion Can be degenerative tears-non traumatic Pain with Stairs/Squatting Instability/giving way/true locking

Meniscus Test Start with knee in flexion. Place thumb and index finger along joint line. Flex the leg fully, internally rotate foot, abduct the lower leg and extend joint. Feel for click along medial joint line, or pain Repeat for lateral meniscus: externally rotate foot and adduct the leg Appley’s grind test-also not specific

Meniscus Testing Sensitivity Specificity Positive LR Negative LR McMurray 53% (SD 15%) 59% (36) 1.3 0.8 Joint Line Tenderness 79% (4%) 15% (22%) 0.9 1.1 Composite 77% (7%) 91% (3%) Solomon, et al: JAMA 286:13

Case #3 Older Patient 65 year old female with acute knee pain x two weeks. Increases with walking, stairs. Throbbing pain at nighttime (like a tooth ache). Tylenol helpful. On examination mod sized effusion, mildly warm, decreased ROM. What could be the diagnosis

American College of Rheumatology-Osteoarthritis Age > 50 Morning Stiffness < 30 mins Crepitus Bony Enlargement Bony Tenderness Lack of Warmth 34 % prevalence in adult population

Osteoarthritis Glucosamine Chondroitin: 2000 mg/day x 12 weeks, then lower to 1000 mg/day Acetominophen >> NSAIDS Maintain strength, flexibility-swimming, biking, tai chi, etc Steroid Injections: Short term gain Viscosupplementation: Controversial

Osteoarthritis Patient now trips and falls. Presents two days later with increased knee pain, decreased ROM, Pain with all Weight Bearing. On exam, her knee is swollen and very tender? What happened?

Knee Effusion Trauma to previously arthritic knee Arthropathy-Gout/Pseudogout Contusion Fracture Does she need an x-ray? Arthrocentesis/Injection-Will make all of the above (except fracture) better

Ottawa Knee Rules-Validated Multiple Times >1000 pts to ED in Canada; 68 had Fracture Xrays needed if fall/blow to knee and: Age > 55, Isolated Tenderness head of fibula or patella, inability to weight bear for 4 steps,inability to flex > 90 100% sens, 49-55 % specific. Does not miss fracture, decrease xray by 25%

Osteoarthritis She did well for several years, then presents with acute worsening of pain, non traumatic. She is unable to weight bear in the office. On exam mod effusion, exquisitely tender on Medial Femoral Condyle, not the joint space What could be going on?

Avascular Necrosis Usually > 50, often in setting of OA Steroids, Alcoholism, Smoker X-ray often normal initially MRI will show changes before X-ray Non Weight Bearing-can take months to improve If no better -> Hemi or Total Arthroplasty