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Approach to Knee Pain

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Approach to Knee Pain

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Approach to Knee Pain

  1. 1. Approach to Knee Pain Dr.RAJAT JANGIR Consultant Arthroscopy and Sports Injury MS Ortho (Ahmedabad) Fellow Arthroscopy( South Korea) Dip Sports Med IOC (UK)
  2. 2. 22
  3. 3.  Fibrocartilaginous structures Vascular periphery (2-3 mm) Medial meniscus Cresent-shaped Lateral meniscus Circular
  4. 4.  MCL  LCL  ACL  PCL  MPFL Meniscofemoral ligament
  5. 5. History PAIN CHARACTERISTICS  Onset (rapid or insidious)  Location (anterior, medial, lateral, or posterior)  Duration  Severity  Quality (e.g., dull, sharp, achy)  Aggravating and alleviating  Able to continue activity or bear Immediately.
  6. 6. History MECHANICAL SYMPTOMS  Locking  Popping  Giving way EFFUSION  Timing (rapid/slow onset)  Amount of joint effusion (mild/moderate/severe)
  7. 7. History MECHANISM OF INJURY  direct blow to the knee  foot was planted  decelerating or stopping suddenly  landing from a jump  Twisting injury  hyperextension
  8. 8. Ottawa knee rules • Age 55 or over • Isolated tenderness of the patella • Tenderness at fibular head, • Inability to flex to 90 degrees • Inability to bear weight
  9. 9. Differential Diagnosis Children and Adolescents.    Patellar subluxation Tibial apophysitis (Osgood- Schlatter lesion) Patellar tendonitis (Jumper’s knee) Adults    Overuse syndromes Trauma Infection Older Adults    Osteoarthritis Crystal-induced Inflammatory arthropathy Popliteal cyst (Baker’s cyst)
  10. 10. Children and Adolescents  Patellar subluxation  Tibial apophysitis (Osgood- Schlatter lesion)  Patellar tendonitis (Jumper’s knee)
  11. 11. PATELLAR SUBLUXATION  Occurs more often in teenage girls  giving-way episodes of knee.  Pain on patellar apprehension test.
  12. 12. TIBIAL APOPHYSITIS • 13-14 year old boy (10-11yr girl)- growth spurt • Anterior knee pain TT • squatting, walking up or down stairs • TT is tender & swollen • Radiographs are usually negative, rarely show avulsion of apophysis at TT.
  13. 13. PATELLAR TENDONITIS  Teenage boys- growth spurt.  Vague anterior knee pain persisted for months and worsens after activities  Patellar tendon tender, and pain is reproduced by resisted knee extension.  Radiographs are not indicated.
  14. 14. Adults 1. Overuse syndromes    Patellofemoral pain syndrome Medial plica syndrome Iliotibial band tendonitis 2. Trauma     Anterior Cruciate Ligament Sprain Medial Collateral Ligament Sprain Lateral Collateral Ligament Sprain Meniscal Tear 3. Infection
  15. 15. Patellofemoral pain syndrome  Anterior knee pain occurs after prolonged periods of sitting (“theater sign”).  Slight effusion, Patellar crepitus.  Pain may be reproduced by applying direct pressure at anterior aspect of patella.  Radiographs usually are not indicated.
  16. 16. Medial plica syndrome  The plica, a redundancy of the joint synovium medially, can become inflamed with repetitive overuse  Acute onset of medial knee pain after a marked increase of usual activities.  Tenderness MFC  Radiographs are not indicated.
  17. 17. Iliotibial band tendonitis  Runners & cyclists  Pain at lateral aspect of knee aggravated by activity, particularly running downhill and climbing stairs.  Tenderness -lateral epicondyle Noble’s test – supine position, pain when physician places thumb on lateral epicondyle as the patient repeatedly flexes and extends the knee.  Radiographs are not indicated.
  18. 18. Trauma ACL  Noncontact deceleration forces  “Pop” at the time of the injury must cease activity or competition immediately. Swelling of the knee within two hours.  Joint effusion Anterior drawer test Lachman test
  19. 19. Anterior Cruciate Ligament  Most common knee injury among athletes  AM fibers taut in flexion  Check anterior displacement  PL fibers taut in extension  Check rotation  Hyperextension, internal rotation – rarely isolated injury from contact force  Intersubstance (70%) (LEFT KNEE)
  20. 20. ACL Diagnosis: Examination  large hemarthrosis  Anterior drawer test  NOT RELIABLE BY ITSELF  Lachman test  Knee only flexed 30  Pivot shift
  21. 21.  X-ray  Segond fracture of lateral tibial condyle  Tibial spine avulsion in young patients  MRI – 95% accuracy Normal ACL Torn ACL ACL: Diagnosis: Imaging
  22. 22. Posterior Cruciate Ligament  Broader, longer, stronger  PM and AL fiber bundles  Receives better vasc. from MGA, synovial membrane  Tears much less frequently  Only in isolation when “dashboard knee” injury  Hyperextension in sports, especially Posterior view Anterior view Medial femoral condyle
  23. 23. PCL: Diagnosis  Posterior drawer test  Neutral start vital!  Gravity or sag test  X-ray to confirm sag test  MRI negative positive
  24. 24. Trauma Medial Collateral Ligament Sprain  Collision that places valgus stress on knee  Immediate onset of pain and swelling at medial aspect of knee  Point tenderness at the medial joint line  Valgus stress test
  25. 25. Varus and valgus stress test
  26. 26. Trauma Lateral Collateral Ligament Sprain  varus stress to the knee  lateral knee pain that requires prompt cessation of activity.  Point tenderness Varus stress test  MRI
  27. 27. Trauma Meniscal Tear  Acute- Twisting injury Chronic- Degenarative  Recurrent knee pain catching or locking especially with squatting or twisting of knee.  Tests  MRI
  28. 28. McMurray test to assess the .medial meniscus
  29. 29. INFECTION  any age but is more common immunodeficiency cancer, diabetes mellitus, corticosteroid  Warm, swollen, and exquisitely tender.
  30. 30. Older Adults  Osteoarthritis  Crystal-induced Inflammatory arthropathy (gout or pseudogout)  Popliteal cyst (Baker’s cyst)
  31. 31. OSTEOARTHRITIS  knee pain aggravated by weight- bearing activities and relieved by rest.  morning stiffness that dissipates somewhat with activity Acute flare  Decreased ROM, crepitus, mild joint effusion, and palpable osteophytes
  32. 32. CRYSTAL-INDUCED INFLAMMATORY ARTHROPATHY  Gout or pseudogout presents with pain, and swelling in the absence of trauma  Redness, warm, tender, and swollen. Even minimal range of motion is exquisitely painful.  Microscopy negatively birefringent gout positively birefringent pseudogout
  33. 33. Popliteal cyst -Baker’s cyst  Insidious onset of mild to moderate pain in the popliteal area  palpable fullness  MRI USG
  34. 34. Take home message • Age • Injury • Loaction • Tests
  35. 35. Thank you and Questions?

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