The document discusses the evaluation and management of knee pain. It covers common causes of knee pain including ACL injury, meniscal tears, osteoarthritis, gout, and Baker's cyst. For ACL injury, the patient reports a pop and inability to bear weight, with positive Lachman and anterior drawer tests. Meniscal tears cause catching, locking, and joint line tenderness, with positive McMurray's test. Osteoarthritis is diagnosed based on chronic pain aggravated by use and relieved by rest, with joint space narrowing on x-ray. Gout and pseudogout present with inflammatory knee pain and identification of crystals in joint fluid. Baker's cysts cause popliteal swelling and tenderness. Conservative management focuses on

1. Approach to Knee pain
Dr. Fariba Eslamian, MD
Associate Professor of
Physical Medicine and
Rehabilitation
Tabriz University of medical
Sciences

2. ACL injury
Anterior Cruciate Ligament Sprain.
Injury to the anterior cruciate ligament usually occurs because of noncontact
deceleration forces, as when a runner plants one foot and sharply turns in the
opposite direction. Resultant valgus stress on the knee leads to anterior
displacement of the tibia and sprain or rupture of the ligament.

The patient usually reports hearing or feeling a “pop” at the time of the injury, and
must cease activity or competition immediately. Swelling of the knee within two
hours after the injury indicates rupture of the ligament and consequent
hemarthrosis.

On PE, the patient has a moderate to severe joint effusion that limits range of
motion. The anterior drawer test may be positive, but can be negative because of
hemarthrosis and guarding by the hamstring muscles. The Lachman test should be
positive and is more reliable than the anterior drawer test.

Radiographs are indicated to detect possible tibial spine avulsion fracture. MRI of
the knee is indicated as part of a presurgical evaluation.


3.  Anterior drawer test
 The subject is supine, hip flexed to 45 degrees with
the knee flexed to 90 degrees. The examiner sits on
the subject's foot, with hands behind the proximal
tibia and thumbs on the tibial plateau. Anterior
force is applied
to the proximal tibia.,
Increased tibial displacement
compared with the opposite
side is indicative on anterior
cruciate ligament tear.

4.  The patient lies supine. The knee is held
between full extension and 15 degrees of
flexion. The femur is stabilized With one
hand while firm pressure is applied to the
posterior aspect of the proximal tibia in an
attempt to translate it anteriorly.

5.  The leg is picked up at the ankle. The knee is flexed
by placing the heel of the hand behind the
fibula. As the knee is extended, the tibia is
supported on the lateral side with a slight valgus
strain. A strong valgus force is placed on the knee by
the upper hand. At approximately 30
degrees of flexion, the displaced tibia will suddenly
reduce, indicating a positive pivot shift test.

6. The patient reports a misstep or collision
that places valgus stress on the knee,
followed by immediate onset pain and
swelling at the medial aspect of the knee.

On PE, the patient with medial
collateral ligament injury has point
tenderness at the medial joint line.
Valgus stress testing of the knee
reproduces the pain .

Medial Collateral Ligament Sprain

7. MCL injury, diagnosis


8. Trauma, (LCL injury)
Lateral Collateral Ligament Sprain
Lateral collateral ligament sprain usually results from varus stress to
the knee, as occurs when a runner plants one foot and then turns
toward the ipsilateral knee.

The patient reports acute onset of lateral knee pain that requires
prompt cessation of activity.
 On PE, point tenderness is present at the lateral joint line. Instability or
pain occurs with varus stress testing of the knee.


9. Varus and valgus stress test

10. Trauma(Meniscal tear)
Meniscal Tear.
The meniscus can be torn acutely with a sudden twisting injury of the
knee, such as may occur when a runner or footbalist suddenly
changes direction.

The patient usually reports recurrent knee pain and episodes of catching
or locking of the knee joint, especially with squatting or twisting of the
knee.

On PE, a mild effusion is usually present, and there is tenderness at the
medial or lateral joint line. Atrophy of the the quadriceps muscle also may
be noticeable. The McMurray test may be positive, but a negative test
does not eliminate the possibility of a meniscal tear.

MRI is the radiologic test of choice because it demonstrates most
significant meniscal tears.


11. Knee Meniscal lnjury Tests
 McMurray test
 With patient lying flat, the knee fully flexed; the foot is
held by grasping the heel. The leg is rotated on the thigh
with the knee still in full flexion. By altering the position of
flexion, Bring the leg from its position of acute flexion to a
right angle while the foot is retained first in full internal
rotation and then in full external rotation. When the click
occurs (in association with a torn meniscus), the patient
is able to state that the sensation is the same as
experienced when the knee gave way previously.

12. Meniscal tear, diagnosis
Meniscal Tear, Mcmurray test





13. McMurray test to assess the
.medial meniscus

14. Meniscal tear, diagnosis
Meniscal Tear, Appley test





15.  Apley grind test
 The foot is grasped in both hands, the knee is bent
to a right angle, and powerful external rotation is
applied Next, the patient's leg is strongly pulled up,
with the femur being prevented from rising off the
couch.
 In this position of distraction, external rotation is
repeated. The examiner leans over the patient and
compresses the tibia downward.
 Again the examiner rotates
 powerfully and if compression
 had produced an
 increase of pain, this grinding
 test is positive and
 meniscal damage
 is diagnosed.

16. INFECTION
Infection of the knee joint may occur in patients of any age but
is more common in those whose immune system has been
weakened by cancer, diabetes mellitus, alcoholism, acquired
immunodeficiency syndrome, or corticosteroid therapy.

The patient with septic arthritis reports abrupt onset of pain and
swelling of the knee with no antecedent trauma.

On PE, the knee is warm, swollen, and exquisitely tender. Even
slight motion of the knee joint causes intense pain.


17. Synovial fluid analysis in septic arthritis
Arthrocentesis reveals turbid synovial fluid.

Analysis of the fluid yields a WBC count higher than 50,000 per

mm3 with more than 75 percent PMN cells, an elevated protein
content , and a low glucose concentration.
Gram stain of the fluid may demonstrate the causative
organism.

Hematologic studies show an elevated WBC, an increased
number of immature PMN cells (i.e., a left shift), and an
elevated ESR.


18. Older Adults
Ostheoarthritis(OA)

Crystal induced
Inflammatory arthropathy; gout,
psudogout

Rheumatoid arthritis
Popliteal cyst
tumor




19. OSTEOARTHRITIS
The patient presents with knee pain that is aggravated by weight-
bearing activities and relieved by rest.

The patient usually awakens with morning stiffness that dissipates
somewhat with activity. In addition to chronic joint stiffness and
pain, the patient may report episodes of acute synovitis.

Findings on PE include decreased range of motion, crepitus, a mild
joint effusion, and palpable osteophytic changes at the knee joint.

Weight-bearing radiograph is recommended. Radiographs show
joint-space narrowing, subchondral bony sclerosis, cystic changes,
and hypertrophic osteophyte formation.


20. QuickTime™ and a
Photo CD Decompressor
are needed to use this picture
 Natural history of OA: Progressive cartilage loss,
subchondral thickening, marginal osteophytes

22. OSTEOARTHRITIS
Weight-bearing radiograph is recommended. Radiographs show
joint-space narrowing, subchondral bony sclerosis, cystic changes,
and hypertrophic osteophyte formation.

23. OA OF KNEE JOINT (Knee DjD)
 More common in obese females
 over 50 years of age
 Joint stiffness (<30 minutes)
 Mechanical pain
 Physical examination findings: Crepitus
 Pain on pressure
 Painful ROM and functional limitation
 Limitation of ROM in later stages of OA (first
extension)
 Laboratory analysis within normal limits

24. Genu
varum

25. CRYSTAL-INDUCED INFLAMMATORY
ARTHROPATHY
Patient with gout or pseudogout presents with pain, and

swelling in the absence of trauma
On PE, the knee joint is erythematous, warm, tender, and
swollen. Even minimal range of motion is exquisitely painful.

Microscopy of the synovial fluid displays negatively birefringent
rods in the patient with gout and positively birefringent
rhomboids in the patient with pseudogout.


26. (Popliteal cyst)
(Baker’s cyst)
The patient reports insidious onset of mild
pain in the popliteal area of the knee
to moderate

On PE, palpable fullness is present at the medial aspect
of the popliteal area. The McMurray test may be positive
if the medial meniscus is injured.

Definitive diagnosis of a popliteal cyst may be made with
arthrography, ultrasonography, and, MRI.


27. Management of OA
• Establish the diagnosis of OA on the basis of
history and physical and x-ray examinations
• Decrease pain to increase function
• Prescribe progressive exercise to
• Increase function
• Increase endurance and strength
• Reduce fall risk
• Patient education: Self-Help Course
• Weight loss
• Heat/cold modalities

28. Non-Pharmacologic Treatment of OA
 Patient education
 Weight loss (if overweight)
 Aerobic exercise programs
 Physical therapy
 Range-of-motion exercises
Muscle-strengthening exercises
 Assistive devices for ambulation
Patellar taping
Appropriate footwear
Lateral-wedged insoles (for genu varum)
 Bracing
 Occupational therapy
 Joint protection and energy conservation

29. SYMPTOMATIC TREATMENT OF OA
 Decrease of joint loading
- Weight control
- Splinting
- Walking sticks
 Exercises
- Swimming
- Walking
- Strengthening
 Patient education

30.  biomechanic correction:
 kinseiotaping
 insole with lateral wedge

31. Muscles strengthening exercises

33. Pharmacologic Management of OA
 Nonopioid analgesics
 Topical agents
 Intra-articular agents
 Opioid analgesics
 NSAIDs
 Unconventional therapies

34. PHARMACOLOGIC TREATMENT OF OA
 Intra-articular agents:
Hyaluronan
Glucocorticoids (effusion)
PRP(plasma rich placate)

35. INDICATIONS OF SURGICAL
INTERVENTION
 Severe joint pain,
resistant to conservative treatment methods
 Limitation of daily living activities
 Deformity, angular deviations, instability

36. INVASIVE METHODS
 Joint lavage
 Arthroscopy
 Cartilage grefting- genetic engineering
 Surgery
Osteotomy
Joint replacement

38. Thank you