1. Orthopaedics for the Practicing Internist
American College of Physicians
2013 Ohio Chapter Scientific Meeting
Columbus, OH
October 11, 2013
Paul J. Gubanich, MD, MPH
Assistant Professor of Internal Medicine/Sports Medicine
Team Physician, Ohio State University Athletics, Ohio Machine, Columbus City Schools

2. Disclosures
I do not have a conflict of interest associated with the material contained in this presentation.

3. An Approach to the Patient with Knee Pain
Most common complaints
Pain
Instability – (ligament injury, OA)
Stiffness – (effusion, OA)
Swelling
Locking (meniscal)
Weakness
Most diagnosis made by:
History
Physical exam
Imaging

4. Important Historical Components
Age
Chronology, onset
Pain level, characteristics
Exacerbating positions/ movements
Relieving factors
Activity level or recent change, occupation
Previous injuries, surgeries
Exercise history, goals
Previous treatments

5. Chronology of Symptoms
Acute Pain
Sudden onset
Specific mechanism of injury
Direct trauma (fall, collision, MVA)
Landing, pivoting
Common acute injuries
Fractures (distal femur, patella, proxmial tibia, fibula)
Dislocations
Meniscal injuries
Ligamentous injuries
Musculotendious strains
Contusions

6. Common causes of chronic knee pain Chronic Pain
Arthritis
Tumors (night pain)
Osteosarcoma (adolescents)
Chondrosarcoma (adults)
Giant cell tumor (benign)
Metastatic disease is uncommon
Sepsis (rare, can be bursal)
Bursitis (overuse)
Tendonitis
Anterior knee pain
Chronic Pain
Often lacks a mechanism of injury
Symptoms of gradual onset

7. Location, Location, Location

8. Medial Knee
Joint line – meniscus, OA, osteochondral defect, osteonecrosis, medial collateral ligament
Tibial plateau – (osteoporosis, post menopausal)
Pes bursa

9. Anterior Knee Anterior Quad tendon or insertion Anterior to patella
Patellar origin, tendon, insertion
Tibial tubercle

10. Lateral Knee Pain Lateral Femoral condyle – suggests IT band
Joint line – meniscus, OA, OCD, lateral collateral ligament

11. Posterior Knee Meniscus – posterior medial, lateral corner
Posterior lateral – Baker’s/popliteal cyst, aneurysm

12. Physical Exam Exam both sides Gait Inspection Joint above and below
Most painful part last
Gait
Alignment (varus, valgus)
Squat
Inspection
Swelling
Bruising
Deformity

13. Physical Exam Palpation Range of Motion Strength Functional tests
Effusion
Range of Motion
Patellar tracking
Extension (-5 to 5)
Flexion ( )
Crepitus, etc.
Strength
Hamstring
Quad
Functional tests

14. Physical Exam – Special Maneuvers
Apprehension sign – patellar instability
Apley grind test – meniscus
McMurray circumduction test,
SN 16-58%
SP 77-98%
(Evans 1993, Fowler 1989, Kurasaka 1999, Anderson 1986)

15. Physical Exam – Special Maneuvers
Valgus stress test – MCL
SN 86-96%
Varus stress test – LCL
SN 25%

16. Physical Exam – Special Maneuvers
Lachman’s – ACL
SN 80-99%
(various authors and conditions)

17. Physical Exam – Special Maneuvers
Anterior/posterior drawer – ACL/PCL
Posterior Sag Sign

18. Radiology Plain x-rays often considered part of exam X-ray views
Helps rule out competing diagnosis
X-ray views
Standing AP views of both knees (for comparison)
Lateral
Tunnel at 45 degrees
Merchant/Sunrise – to evaluate PF joint

19. Radiology MRI often not needed initially Surgical planning tool
Failure of treatment
Identify ligamentous/cartilage injuries of acute or surgical nature
Risk stratification

20. General Treatment Pearls
Match disease severity/limitations with treatment options
Escalate based on time, response in a stepwise fashion
Set realistic expectations for progress and follow-up
Align treatment goals with patient goals/expectations when possible
Time is a great healer

21. Common Treatment Recommendations
Activity modification, rest
Mechanical devices – braces, crutches, lifts, orthotics, etc.
Ice, pain medication
Nsaids
Acetaminophen
Others
Physical therapy – early motion progressing to strengthening and then functional drills
Injection therapy
Aspiration
Corticosteroids
Hyaluronic acid supplents (OA)
Glucosamine (OA)
Surgical considerations
Consider additional imaging options as needed
MRI
Bone scan CT

22. Red Flags Night pain Abnormal x-ray findings Mechanical symptoms
Fractures, tumor, cartilage lesions, etc.
Mechanical symptoms
Severe pain, swelling, loss of motion, or weakness
High grade ligament injuries
Fail to respond to standard treatments
Multiple joints involved (Rheum)

23. Summary
History and Physical Exam are vital to generating a working differential diagnosis
Imaging may complement/confirm working diagnosis
Treatment should match symptoms and severity and progress based on progress
Questions?