1. A Case Report
Knee Pain

2. History
53 year old (5’2”, 168 lbs) female presents in the office with pain in the medial and posterior right knee.
The pain started about 5 years ago and is progressively getting worse.
She remembers the pain starting after she fell into a drainage ditch while walking across her lawn.
She has been to a physical therapist (12 visits after fall) , a chiropractor (6 months, last visit 1 year ago), an orthopedist (at time of fall) and a massage therapist (a few visits in the past year) for help with her knee pain.

3. History
Sometimes she notices some relief with massage and ice, but mostly the pain is relieved with rest.
The pain bothers her mostly when she walks or stands for more than 10 minutes at a time. It used to be 30 minutes but recently she notices the pain coming on more often than it used to. She finds it hard to go up or down stairs.
She is a machinist and has to stand at her job, although recently, she has been given a stool to sit on during some of the aspects of her job.

4. History
She had an MRI and x-rays of her knee when the injury first occurred.
At that time she was diagnosed with a sprained medial collateral ligament and anterior cruciate ligament. No meniscus tears were seen on the MRI.

5. Provide your Differential Diagnosis
Minimum of 2
Examinations for DDx
What examinations would you perform on your patient?

6. About the knee

7. About the knee exam What should we ask the patient?
Is there any locking, popping, or giving way of the knee?
A history of locking episodes suggests a meniscal tear.
A sensation of popping at the time of injury suggests ligamentous injury, probably complete rupture of a ligament. (third-degree tear)
Episodes of giving way are consistent with some degree of knee instability and may indicate patellar subluxation or ligamentous rupture.
Joint Swelling?
Rapid onset (within two hours) of a large, tense effusion suggests rupture of the anterior cruciate ligament or fracture of the tibial plateau.
Slower onset (24 to 36 hours) of a mild to moderate effusion is consistent with meniscal injury or ligamentous sprain.
Recurrent knee effusion immediately after activity is consistent with meniscal injury.

8. Examination (comparing the good knee to the bad knee)
Inspection:
The right knee has mild swelling around the medial patella and popliteal fossa.
The musculature of both thighs and legs are symmetric bilaterally. (VMO)
The quadriceps angle (Q angle) is within normal limits (A Q angle greater than 15 degrees is a predisposing factor for patellar subluxation).
Palpation:
Check for pain, warmth, and effusion.
Point tenderness at the medial knee and in the popliteal fossa.
No pain on the left knee.
CALMBACH W and HUTCHENS M. Evaluation of Patients Presenting with Knee Pain: Part I. Am Fam Physician 2003; 68: Copyright © 2003 American Academy of Family Physicians.

9. Examination Range of motion: Right Knee: Left Knee:
Extension = 0 Extension = 0
Flexion = Flexion = 130
(normal range of motion: extension, zero degrees; flexion, 135 degrees).

10. Examination
Tissues?
Bone
Ligament
Meniscus
Muscle

11. Examination Bone: Fracture? Arthritis?
After the initial trauma, she was evaluated by x-ray and MRI.
No fractures at that time, no trauma since.

12. Examination Muscle: Meniscus and ligaments:
Muscle testing was normal for both the quadriceps and biceps famous (5/5)
Meniscus and ligaments:

13. Examination Orthopedics: Patella: Cruciates: Collaterals: Meniscus:
patellar apprehension test, Ballottement Test, Clarke's Sign (Patellar Scrape test)
Cruciates:
Drawer Test, Lachman's Test    
Collaterals:
Varus, Valgus, Apley's Distraction Test
Meniscus:
Apley's Compression Test, Bounce Home Test, McMurray Sign 

14. Examination: Patella: Cruciates: Collaterals: Meniscus:
Patellar apprehension test = negative
Ballottement Test = Positive
Clarke's Sign (Patellar Scrape test) = Positive Bilateral
Cruciates:
Drawer Test = negative
Collaterals:
Varus = negative (no movement or pain at 0 and 30 degrees)
Valgus = no pain with slight movement at o degrees and pain at 30 degrees
Apley's Distraction Test = positive for pain at the MCL
Meniscus:
Apley's Compression Test = negative
McMurray Sign  = negative

15. Modified Thomas Test
Tests for flexibility for the ITB, iliopsoas, Quadriceps
SLR: hamstrings
Our patient had tight hamstrings and ITBs

16. What do the test results mean?
Positive tests?
Negative tests?
What else should we test?

17. Evidence Based Clinical Evaluation
Koos Knee Survey:
Knee and Osteoarthritis Outcome Score
Symptoms, Pain, ADLs, Sports and recreation, Quality of life
42 Questions
Never Rarely Sometimes Often Always
(0) (1) (2) (3) (4)
Add it up and divide by 168
Her score was 67
VAS was a 5 out of 10

18. X-rays

19. X-ray report
A mild decrease in joint space involving the medial compartment. The lateral and retropatellar compartments are within normal limits.
There is no unusual soft tissue calcification visualized. The articular surfaces are within normal limits.
Impressions: Mild reduction of joint space involving the medial compartment – degenerative joint disease.

20. Final Dx 726.61 Pes anserinus tendinitis or bursitis
Pes anserinus is the anatomic term used to identify the insertion of the conjoined tendons into the anteromedial proximal tibia. From anterior to posterior, pes anserinus is made up of the tendons of the sartorius (F), gracilis (A), and semitendinosus (C) muscles. The term literally means "goose's foot," describing the webbed footlike structure. The conjoined tendon lies superficial to the tibial insertion of the medial collateral ligament (MCL) of the knee.

21. pes anserine bursitis
The bursa can become inflamed as a result of overuse or a direct contusion. Pes anserine bursitis can be confused easily with a medial collateral ligament sprain or, less commonly, osteoarthritis of the medial compartment of the knee.
The patient with pes anserine bursitis reports pain at the medial aspect of the knee. This pain may be worsened by repetitive flexion and extension. On physical examination, tenderness is present at the medial aspect of the knee, just posterior and distal to the medial joint line.
No knee joint effusion is present, but there may be slight swelling at the insertion of the medial hamstring muscles. Valgus stress testing in the supine position or resisted knee flexion in the prone position may reproduce the pain. Patient may report pain when walking up or down stairs.
CALMBACH W and HUTCHENS M. Evaluation of Patients Presenting with Knee Pain: Part I. Am Fam Physician 2003; 68: Copyright © 2003 American Academy of Family Physicians.

22. Final Dx: 726.61 Pes anserinus tendinitis or bursitis
739.6 Lower extremities, Nonallopathic lesions, not elsewhere classified

23. Patient Management Plan
3 times per week for 2 weeks followed by 2 times per week for 2 weeks.
To reduce the pain in the right knee (lowering the KOOS score by 20 points)
Allow for mild limitation of ALDs.
Adjust the knee (posterior medial Tibia)
Give stabilizing exercises and stretches
Instruct use of supports

24. Daily Visits Adjust the posterior tibia
Icing instructions (3 times per day for 20 minutes)
Stretching instructions for the ITB and Hamstrings
Tape or Brace

25. Daily Visits
The patient returned 2 days later with a VAS rating of a 0
No pain in the knee. She was able to go up and down steps
without pain.
She was not using a brace or the tape.
She did ice and was stretching.
No adjustment was indicated, she was put on resisted quadriceps and hamstring exercises.
The patient was told to come back in 1 week or if the pain came back, which ever came first.

26. Daily Visits
She returned a week later with complaints of right knee pain.
A mild pain started the night before our appointment due to walking around at her grandson’s baseball game.
Her knee was evaluated and adjusted for a posterior medial tibia.
She was scheduled to return in a week or if the pain returned.

27. Daily Visits 1 week later she returned with no pain.
She was doing the exercises and stretching, but no longer icing
She was walking 2 miles a day with her husband for the last 4 days without pain.
Her knee was evaluated and no adjustment was indicated.
A re-evaluation of the KOOS was taken.

28. Evidence Based Clinical Evaluation
Koos Knee Survey:
Her initial score was 67
After weeks of care it was a 12

29. Patient Management
The patient was released from active care and told to return in 6 weeks for a follow up visit.
She has continued with chiropractic care for her knee and occasional low back pain for the past 3 years. She is now see once every 5 to 6 months.
She has referred at least 6 patients to the clinic for their knee complaints. She calls us the knee clinic

30. Questions?
Comments?
Concerns?