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

2. 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

3. Anterior Knee

4. Posterior Knee

5. 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

6. 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

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

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

9. 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

10. 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

11. 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

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

13. 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

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

15. 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

16. 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

17. 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

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

19. 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

20. 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?

21. 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

22. 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, % specific.
Does not miss fracture, decrease xray by 25%

23. 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?

24. 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