MS3 Sports Medicine Workshop

1. MS3 Sports Medicine Workshop Family Medicine Clerkship

2. Knee Problems MS3 Family Medicine

3. Anatomy Review

4. Femur • Medial & lateral • Condyles • Epicondyles • Trochlear groove • Intercondylar notch • Patella • Superior pole (base) • Inferior pole (apex) • Medial & lateral facets • Tibia • Medial & lateral • Condyles • Gerdy’s tubercle • Pes anserine area • Tibial tuberosity • Tibial plateau • Tibial spines • Fibula • Head • Neck

5. Anatomy – Major Ligaments & Tendons • Quadriceps tendon • Patellar tendon • Medial & lateral patellar retinaculua

6. MCL LCL

7. ACL and PCL

8. Iliotibial band (ITB)

9. Anatomy – Menisci of the Knee • Medial meniscus • Lateral meniscus • Meniscal ligaments • Functions of the menisci • Meniscal zones • White-white • Red-white • Red-red

10. Inspection Palpation Range of Motion Strength Neurovascular Special Tests Knee Exam Overview

11. 16yo HS soccer player, previously healthy Tackled from right side while running Immediate onset of medial jt line pain Delayed onset local medial edema, stiffness Able to bear weight Case 1 – Medial Right Knee Pain

12. Key Questions in the History • Mechanism of Injury? • Acute or Chronic? • Location and level of pain? • Able to walk? • Mechanical Symptoms? (Locking, popping, catching?) • Associated instability? • Swelling? • Previous injuries or surgeries?

13. Case 1 - Exam • Inspection: Mild medial knee edema • Palpation: + ttp medial knee • ROM: can’t bend >80d • Strength: mildly decreased • Neurovascular: normal • Special tests: • Neg Lachman, Anterior Drawer, McMurray, varus stress • + mild increased gap on valgus stress (compared to left) with good endpoint

14. Special Tests - ACL Injury Lachman Test

15. Special Tests - PCL Injury Posterior Drawer Test Sag Sign Quad-Active Test

16. Varus/Valgus stress for LCL and MCL Injury

17. Features that should prompt an xray after acute knee injury include: • Unable to bear weight • Can’t flex >90d • Patella TTP • Fibular head TTP • Age <18 or >55 • All of the above

18. 5 Ottawa Knee Rulesi.e. When to order a knee xray after acute injury • Age > 55 or < 18 • Unable to walk • TTP on PATELLA • TTP on FIBULAR HEAD • Unable to flex 90 deg

19. Case 1 - Imaging Normal!

20. Meniscal Tear Ligamentous Injury Which ligament? ACL PCL MCL LCL Muscle Strain Fracture Patellofemoral Pain Plica Case 1 – Differential DiagnosisMore Likely Less Likely

21. MCL Sprain Diagnosis?

22. What grade of sprain is likely present of the MCL? • Grade 1: no laxity, but hurts • Grade 2: mild laxity, still intact • Grade 3: complete tear • Grade 4: hurts like *^%*

23. MCL Sprain • Treatment? • RICE • Relative Rest • Hinge Brace only if unstable on exam • Achieve full ROM • Progressive Strengthening • Neuromuscular Control (Balance exercises) • Functional Exercises (Sport-specific)

24. Case 2 • 56 yo retired Army LTC • 15 years worsening L>R knee pain • Former parachutist, no specific trauma • No previous knee surgeries • Stiffness worse in morning • Pain is worse with activity, better with rest

25. Mechanism of Injury? Acute or Chronic? Where/how bad is pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better? Insidious Onset Chronic Difficult to localize; mild No None Occasional Lots of “Bad Landings” No surgery Activity Rest Case 2 – Key Questions

26. Case 2 – Physical Exam • Inspection: • Genu varus • Bony enlargement at Med/Lat joint lines • Palp: Posterior medial joint line ttp • ROM: Decreased flexion, 110 deg, mild crepitus • Strength: normal • Neurovascular: normal • Special Tests: no ligamentous laxity, neg meniscal tests

27. Special Tests - Meniscal Injuries Joint line tenderness McMurray Tests Thessaly test Bounce-home test Full Squat

28. Case 2 – Plain Films Joint space narrowing Subchondral Sclerosis Osteophytes Subchondral Cysts

29. 10 What is your diagnosis? • Meniscal tear • Plica syndrome • Osteoarthritis • Bone tumor

30. Nonpharmacologic Treatment: Nonpainful aerobic activity Weight loss Physical Therapy Improve ROM, increase strength Bracing Pharmacologic Treatment: APAP Supplements Glucosamine and Chondroitin NSAIDs, COX-2’s Tramadol Viscosupplementation Intrarticular Steroids Osteoarthritis

31. Case 3 • 31 year old female, L knee pain • Recreational runner • Localizes pain to front of knee • No trauma, insidious onset • Localizes pain “around kneecap” • Worse with stairs • Worse after prolonged sitting • Knee occasionally “gives out”

32. Mechanism of Injury? Acute or Chronic? Where is the pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better? Insidious Onset Chronic Anterior knee No, but sometimes gives out None None None Running, Stairs Multiple days of rest Case 3 – Key Questions

33. Physical Exam • Inspection: mild genu valgus • Palpation: TTP lateral > medial patellar facets • ROM: full w/o pain • Strength: normal • Neurovascular: normal • Special Tests: • + patellar grind • Decreased patellar glide • Inflexible hamstrings (Popliteal angle)

34. Patellofemoral Joint Exam

35. Patellofemoral Joint Exam Patellar Grind Test

36. Case 3 – Plain Films Lateral AP

37. Case 3 – Plain Films Sunrise Tunnel

38. What’s your diagnosis? • Patellar tendinopathy • Patellar instability • Patellofemoral syndrome • Plica syndrome

39. Patellofemoral Syndrome • Treatment: • Relative rest; non-painful aerobics • Physical Therapy • Improve Quad/Hamstring flexibility • Quad, Hip abductor strengthening • Core strengthening • Patellar stabilization brace/taping • Foot orthotics • Surgery (last-ditch effort)

40. Case 4 • 34 yo Army MAJ training for 1st marathon • Atraumatic onset of R lateral knee pain 1 week ago after 10 mile run • Sharp burning pain • Better with rest, returns with running

41. Mechanism of Injury? Acute or Chronic? Where is the pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better? Insidious Onset Acute Lateral knee No, but sometimes gives out None None None Running Multiple days of rest Case 4 – Key Questions

42. Physical Exam • Inspection: normal • Palpation: TTP over lateral femoral condyle • ROM: full • Strength: normal • Neurovascular: normal • Special tests: • + Noble test • Tight on Ober test

43. Ober test Noble test

44. What’s your diagnosis? • Osteoarthritis • Meniscal tear • Iliotibial band syndrome • LCL sprain

45. Iliotibial Band Syndrome • Treatment: • Ice massage, pain meds • Relative Rest; nonpainful activity • Physical Therapy • Specific ITB stretches • Hip abductor strengthening • Core strengthening (Gluteus Medius) • Slow return to activity • Extrinsic factors: shoes, running surface, training errors

46. What the heck is a Plica? • Congenital thickening of joint capsule • Redundant meniscus • Loose piece of intra-articular cartilage • Figment of my imagination

47. Plica Syndrome?

48. Questions? Before we break for hands-on

49. Special Tests - ACL Injury Lachman Test Knee flexed to 15-30 degrees Stabilize distal femur Anteriorly translate tibia on femur Watch & feel for amount of translation & end point Pivot Shift

50. Special Tests - PCL Injury Posterior Drawer Test Knee flexed to 90 degrees Posteriorly translate tibia on femur Watch & feel for amount of translation & end point Sag Sign Knees flexed, quads relaxed  compare both sides Look for tibial posterior “sag” relative to femur Quad-Active Test Knee flexed; hamstrings fully relaxed Slide foot along table (quad active) Observe for anterior relocation