Common Ailments and Injuries of the Knee

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Common Ailments and Injuries of the Knee

• Thad J. Barkdull, MD
• MAJ, MC, USA
• Primary Care Sports Medicine Fellow

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Objectives

• Background
• Anatomy
• History
• Physical Examination
• Radiology and Laboratory
• Case Studies

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• OK Doc, Why Do I Care?

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Background Anatomy

• Largest articulation in the body
• Modified hinge joint with an extensive range of
  motion
• Joint stability is provided by multiple soft
  tissue structures

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Anatomy
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Anatomy
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Background

• 10-15 of adults report knee symptoms at some
  point in their lives
• Accounts for 3 - 5 of all visits to physicians
• About one-third of outpatient sports medicine
  visits
• Substantial percentage of referrals for advanced
  diagnostic imaging (MRI) or specialty care
• Majority are non-surgical

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History

• Patient age
• Current symptoms and duration
• Pain with or after activity/changes in activity
• Catching/locking or Instability
• Stairs, squats, theater sign
• Exacerbating and relieving factors
• What treatment already tried (Rest, NSAIDs,
  brace, )
• Prior knee injury or surgery
• PMH

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History

• Acute Injury
• Contact or non-contact
• Mechanism
• Able to continue play
• Weight bearing
• Swelling
• Locking, catching or buckling

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History

• Chronic Pain
• Sport/Activity
• Condition of patient
• Level of competition
• Type of surface
• Shoes type and wear pattern
• Stretching/Strengthening
• Supplements
• Joint Supports/braces

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Knee Examination

• Assess ambulation of patient
• Inspect knee
• Swelling
• Eccymosis
• Atrophy
• Asymmetry
• Inspect arch of foot

• Palpate for effusion and warmth
• Palpate for tenderness
• ROM
• Ligament Tests
• Meniscal Tests
• Patella Tests
• Flexibility Tests
• Evaluation of Hip and Foot

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Knee Examination

• Inspection
• Alignment of lower extremities
• Varus, valgus, recurvatum
• Patellar position and motion (j curve deformity)
• Inspection for asymmetries
• Swelling, torsion, inability to extend knee
• Atrophy

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Quadriceps Angle (Q Angle)
The Angle from the ASIS to center of Patella to
the center of the Tibial Tubercle Men 10
Female 15
NORMAL
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Knee Examination

• Inspection
• Foot variations

Pes Planus
Pes Cavus
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Knee Examination

• Palpate for effusion and warmth
• Fluid wave
• Ballotable patella
• Palpate for tenderness
• Tibial tubercle
• Quadriceps tendons
• Retropatellar tenderness
• Joint line
• Ligaments (MCL/LCL)
• Bursa (incl. pes anserine)

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Knee Examination

• ROM
• Flexion 130/135
• Extension 0 to -10
• Internal Rotation 10
• External Rotation 10

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Knee Examination

• Ligament Tests
• Valgus and Varus Stress Tests (MCL/LCL)
• Lachmans Anterior Drawer (ACL)
• Posterior Drawer Posterior Sag Test (PCL)

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MCL Stability Apply Valgus or Medial Stress
LCL Stability Apply Varus or Lateral Stress
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Test of ACL At 90 Flexion At 20-30
Flexion (more accurate)
is increased translation or soft end point
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Posterior Sag
Posterior Drawer
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Knee Examination

• Meniscal Tests
• McMurray Test
• Apley Compression Test
• Squatting Duck Walk

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McMurray

• From the extended knee, take the knee into full
  flexion
• Internally and externally rotate the knee
• Put a valgus stress on the knee and extend while
  externally rotating
• Positive Painful pop

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Apley Compression Test
Compression for Meniscal Injury
Distraction for Ligamentous Injury
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Knee Examination

• Patella Tests
• Patella Apprehension Test
• Patellofemoral Compression Test

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Patellar Slide nl is 50 Patellar Apprehension
w/ lateral movement
Patellar Tilt nl is 15
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Knee Examination

• Flexibility Tests
• Popliteal Angle (Hamstring)
• Thomas Test (Hip flexors and Quads)
• Obers Test (IT Band)

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Flexibility
Popliteal Angle
Thomas Test
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OBER Test ITB Tightness (TFL Injury) Affected
side up Flex knee 90 Hip ABDucted/externally
rotated Allow Limb to passively ADDuct Tight ITB
will remain ABDucted
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Knee Examination

• Evaluation of Hip and Foot
• Dont forget pain may originate from other joint

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Radiology and Laboratory

• Radiology
• AP and lateral
• Sunrise/Merchant View
• Tunnel View
• Cross-table lateral
• AP weight bearing

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Value of cross table lateral

• Rule out fracture
• Can reveal fat-fluid level in joint, AKA
  lipohemarthrosis

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Radiology and Laboratory

• Knee aspiration if suspect
• Infection
• Crystal arthropathy
• Tense effusion causing symptoms

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Questions?
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Injuries and Ailments of the Knee

• Medial Ligament Injury
• Lateral Ligament Injury
• ACL Injury
• PCL Injury
• Meniscal Injury
• Patellofemoral Syndrome (RPPS)
• Patellar Subluxation/Dislocation
• Infrapatellar Tendinitis (Jumpers Knee)
• Quadriceps Tendinitis
• Iliotibial Band (ITB) Sydrome
• Osgood-Schlatter Disease

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Clinical Cases
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Case Soccer Star

• 16 y.o. female soccer player presents to clinic 1
  week after injury.
• Reports she was coming down from header when she
  twisted on landing. Heard a pop in her knee and
  had pain. Taken from field and couldnt return
  to game. Noticed that night knee was swollen.
• Now, 1 week later, almost normal gait. Knee
  feels much better.

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Case Soccer Star

• Physical exam
• Joint effusion present
• No sag
• No joint line tenderness
• No LCL/MCL laxity
• Negative McMurray
• Positive Lachman

Diagnosis
ACL Injury
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Anterior Cruciate Ligament Injury

• Clinical symptoms
• 1/3 report audible
• pop at injury
• Mechanism of injury
• Non-contact--twisting with the foot planted
• Contact--valgus strees with twisting
• Immediate swelling (hemearthrosis)
• Usually non-ambulatory after injury

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Anterior Cruciate Ligament Injury

• Half occur with medial meniscal tear
• Can occur with MCL tear
• Rare with LCL or PCL tear

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ACL Radiographic Findings

• Avulsion of the intercondylar tubercle
• Anterior displacement of the tibia with respect
  to the femur
• Segond fracture (a thin sliver of bone avulsed
  from the proximal lateral tibia with the lateral
  capsular ligament)

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Segond Fracture
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Anterior Cruciate Ligament Injury

• Management
• Brace knee first week (immobilizer)
• Crutches for comfort, advance to toe-touch and
  wean from crutches as tolerated
• F/U 10 days to reexamine and begin physical
  therapy
• If posterolateral bruising, consider more serious
  injury to include damage to posterolateral corner
  REFER (Dial Test)
• Imaging
• Initially, plain films
• Order MRI at 10 day mark no urgency

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Case Soccer Star

• Physical exam - Dial test
• Prone patient
• At 30 degrees, rotate feet externally, increased
  motion compared to opposite side and soft
  endpoint suggest posterolateral corner injury
• At 90 degrees, increase motion and soft endpoint
  PCL tear and posterolateral corner injury
• Usually present with overlying bruising

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With the knee over the side of the examining
table, one hand stabilizes the thigh while the
other applies an external rotation force across
the knee, through the foot / ankle.
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Questions?
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Case Security Force Iraq

• 37 y/o male security forces Chief Master Sgt c/o
  knee pain and giving out after tripping over a
  wire and falling onto a gear locker
• Happened a few months ago
• Unusual feeling in knee with jogging, sliding,
  gliding
• No locking

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Case Security Force Iraq

• Physical examination
• No joint effusion
• No joint line tenderness
• Swelling and tenderness of popliteal fossa
• No LCL/MCL laxity
• Negative McMurray
• Negative Lachman

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Case Security Force Iraq
Navy pointing to the wrong knee
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Case Security Force Iraq
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Case Security Force Iraq
Diagnosis
PCL Injury
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Posterior Cruciate Ligament Tear

• Clinical symptoms
• Mechanism of injury
• Fall onto flexed knee with plantar flexed foot
  and impact on tibial tubercle
• Dashboard injuryposteriorly directed force to
  anterior knee in flexion
• Physical examination
• Swelling and tenderness of popliteal fossa

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Posterior Cruciate Ligament Tear

• Management
• Symptomatic treatment with crutches/immobilization
  first week as needed (often not needed)
• Physical therapy/range of motion
• Non-surgical

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Questions?
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Case Basketball Player

• Basketball player presents day after game for
  knee pain
• Remembers painful twist with planted foot during
  the game, but kept playing
• Swelled up overnight
• Now feels locked

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Case Basketball Player

• Physical exam
• Joint line tenderness
• Effusion
• Limited knee range of motion
• McMurray test positive with painful click

Diagnosis
Meniscal Injury
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Meniscal Tear

• Anatomy
• Avascular inner 2/3, partly vascular outer 1/3
• Minimal innervation
• Held in place by coronary ligaments, painful when
  torn (meniscotibial ligaments)
• Lateral meniscus less firmly attached, less prone
  to injury

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Meniscal Tear

• Function
• Lubrication
• Nutrition of joint
• Shock absorption
• Reduce friction
• Disperse stress / weight
• Decrease cartilage wear

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Meniscal Tear
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Meniscal Tear

• Clinical symptoms
• Traumatic tears
• Twisting or hyperflexion injury
• Degenerative tears
• In older patients, minimal or no trauma
• Insidious swelling (overnight or 2-3 days)
• Mechanical locking, catching, popping
• Pain medial or lateral sides of knee,
  particularly with twisting or squatting

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Meniscal Tear

• Management
• Physical therapy
• Non-surgical if no mechanical symptoms
• Surgery for
• Locking
• Persistent pain
• MRI wait for four weeks, if not considering
  surgery, do not need to image

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Questions?
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Case Knee came out of socket

• 16 y.o. male lacrosse player made sharp cut
  yesterday. Felt knee come out of socket.
  Immediate pain and swelling.
• Went to ER and x-rays negative for fracture.
• One week out cant fully bend knee due to pain.

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Case Knee came out of socket

• Physical exam
• Patellar apprehension
• Medial patellar tenderness
• Increased patellar mobility

Diagnosis
Patellar Subluxation
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Patellar dislocation/subluxation

• Clinical symptoms
• Severe pain
• Sometimes pop
• Occasionally see a deformity, usually lateral
  dislocation
• Often reduces spontaneously
• Swelling
• Loss of motion

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Patellar dislocation/subluxation

• Mechanism of injury
• Direct trauma
• Rotation over planted foot (ie. softball swing)
• Sudden cutting movements
• Stretched out tissues from prior injury
  predispose for recurrence

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Patellar dislocation/subluxation

• Management
• Straight leg immobilization x 6 weeks
• Weight bearing as tolerated
• Cylinder cast if question compliance
• MRI if skeletally immature to r/o sleeve fracture
  (peeling off sleeve of cartilage and periosteum)
  requiring surgical repair
• Physical therapy after immobilization to return
  strength/motion

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Questions?
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Case Petty Officer cant run PRT
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Case Petty Officer cant run PRT

• Active duty Navy petty officer. Pain started
  during boot camp march. Relieved by stopping
  running. Returns with return to running.
• Pain generalized to anterior knee.
• Pain worse with stairs and after prolonged
  sitting.
• No clicking, locking or instability.
• Cant run and has gained 50 pounds.

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Case Petty Officer cant run PRT

• Physical exam
• No effusion
• No ligamentous laxity
• Pain reproduced by direct
  pressure over patella and rocking
• Vastus medialis oblique atrophy
• Patellar trackinglateral movement of patella
  near full knee extension
• Relative weakness hip abd/adductors

Diagnosis
RPPS
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Patellofemoral Pain

• Patellofemoral Pain is
• Diagnosis in nearly 25 of all knee injuries
• Most common diagnosis made in runners
• Most common orthopedic EPTS diagnosis in Army
  Basic Training
• Most common diagnosis in primary care sports
  medicine clinics

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Why PFPS?
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Patellofemoral Knee Pain

• Clinical symptoms
• Diffuse anterior knee pain
• Worsened by patellofemoral loading stairs,
  prolonged sitting, squatting
• Theater sign
• May occasionally give out
• Symptoms frequently bilateral
• Swelling generally absent
• Usually no trauma hx, rare hx direct blow patella

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Patellofemoral Knee Pain

• Physical exam
• Pain reproduced by direct pressure over patella
  and rocking in femoral groove
• Vastus medialis oblique atrophy
• Patellar trackinglateral movement of patella
  near full knee extension
• Relative weakness hip abd/adductors

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Patellofemoral Knee Pain

• Physical exam
• Tight
• Lateral retinaculum
• Iliotibial band
• Quadriceps
• Hamstrings

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Patellofemoral Knee Pain

• Management
• Weight loss
• 6 x the body weight with stairs
• 6 x 200 lbs 1200 lb force on patella!
• Strengthening
• Quad/core/hips
• Flexibility

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Questions?
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Case Airman Cant Run PRT

• Active duty Airman. Pain in front of knee
  started during boot camp march.
• Relieved by stopping running on profile. Returns
  with profile expiration and return to running.

• Sharp burning pain below knee cap.
• Worse going down stairs/jumping/landing.
• No clicking, locking or instability.

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Case Airman cant run PRT

• Physical exam
• Tenderness to palpation of the patellar tendon
• Painful resisted full extension

Diagnosis
Jumpers Knee
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Patellar tendinitis/Jumpers knee

• Clinical symptoms
• Anterior knee pain
• Often can point to tender spot
• Pain immediately at end of exercise, or following
  sitting preceded by exercise
• Stairs, running, jumping increase pain

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Patellar tendinitis/Jumpers knee

• Management
• Physical therapy
• Activity modification
• Surgery for intractable can recur year out if
  activity not scaled back
• Ice after activity

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Questions?
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Case Army Major wants to run 1st marathon

• 37 y.o. male c/o lateral burning knee pain that
  started at mile 15 of a long run. He walked back
  to his car.
• Has rested 2 weeks. Every couple days tries to
  run but pain returns.
• Patient is following a marathon training program
  off the internet.

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Case Army major wants to run 1st marathon

• Physical exam
• Lateral femoral condyle tenderness just above
  joint line
• Noble test, Obers

Diagnosis
ITB Syndrome
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Iliotibial band
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Case Iliotibial Band Sydrome

• Clinical symptoms
• Posterolateral knee pain
• Associated with hills and banked surfaces
• Common running injury

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Case Iliotibial Band Sydrome
Treatment
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Iliotibial Band Friction Syndrome

• Treatment
• NSAIDs
• Ice massage 8 minutes 6 times daily
• Patt-strap
• Stretch

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Iliotibial Band Friction Syndrome

• Stretch
• Hold 60-90 seconds
• Affected knee is close to opposite arm pit
• Rotate foot around towards butt

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Iliotibial Band Friction Syndrome

• Treatment return to play
• NO running until pain free with stairs
• Next start with light run, stopping when stiff or
  tight (next sensation will be pain, and lead to
  setback)
• Stretch after run
• Post-run ice for 20 minutes

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Iliotibial Band Friction Syndrome

• If conservative management fails
• Cortisone injection
• Surgical resection of lateral section of ITB

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Questions?
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Case painful bump on knee
Diagnosis
Osgood-Schlatter
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Osgood-Schlatter
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• Questions???

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Take home points.
Patellofemoral Syndrome

• Positive theater sign.
• Knee pain with locking.
• Twisted planted foot and heard pop.
• Knee came out of socket.
• Unusual feeling of gliding or sliding with
  jogging, doesnt remember injury.
• Twisted planted foot, kept playing, swelled
  overnight.
• Lateral knee pain training for marathon.
• Anterior knee pain worse with jumping.
• The most common orthopedic EPTS diagnosis in Army
  Basic Training.

Meniscal Injury
ACL Injury
Patellar Subluxation
PCL Injury
Meniscal Injury
ITB Syndrome
Jumpers Knee
RPPS
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Take home points.
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References

• Birrer R. and OConnor F. Sports Medicine for the
  Primary Care Physician. Boca Raton CRC Press,
  2004.
• Greene W. Essentials of Musculoskeletal Care.
  Rosemont American Academy of Orthopaedic
  Surgeons, 2001.
• Hoppenfeld S. Physical Examination of the Spine
  and Extremities. East Norwalk Appleton-Century-Cr
  ofts, 197659-74.
• Lillegard W. Evaluation of Knee Injuries. In W
  Lillegard (ed), Handbook of Sports Medicine.
  Boston Butterworth-Heinemann, 1999 233-249.
• Netter F. Atlas of Human Anatomy. West Caldwell
  CIBA-Geigy, 1989.
• Tandeter H. et al. Acture Knee Injuries Use of
  Decision Rules for Selective Radiograph Ordering.
  American Family Physician. Dec 1999 60
  2599-608. (For Radiograph Images)