Disclosures • Founder, RunSafe™ Common Injuries of the Knee • Founder, SportZPeak Inc. and Shoulder • Sanofi, Investigator initiated grant A n t h o n y L u k e MD, MPH, CAQ (Sport Med) University of California, San Francisco Primary Care Medicine: Update 2017 Overview Acute Hemarthrosis 1) ACL (almost 50% in children, >70% in • Highlight common adults) presentations • Knee 2) Fracture (Patella, tibial plateau, Femoral supracondylar, Physeal) • Shoulder 3) Patellar dislocation • Discuss basics of conservative and surgical management • Unlikely meniscal lesions 1
Emergencies Urgent Orthopedic Referral 1. Neurovascular injury • Fracture 2. Knee Dislocation • Patellar Dislocation • “ Locked Joint ” - unable to fully extend the – Associated with multiple ligament injuries (posterolateral) knee (OCD or Meniscal tear) – High risk of popliteal artery injury • Tumor – Needs arteriogram 3. Fractures (open, unstable) 4. Septic Arthritis Anterior Cruciate Ligament (ACL) Anterior Cruciate Ligament (ACL) Tear Tear Mechanism Symptoms • Landing from a • Audible pop heard or felt jump, pivoting or • Pain and tense swelling in decelerating minutes after injury suddenly • Feels unstable (bones shifting or giving way) • Foot fixed, valgus stress • “O’Donaghue’s Unhappy Triad” = Medial meniscus tear, MCL injury, ACL tear • Lateral meniscus tears Double fist sign more common than medial 2
ACL physical exam Special Tests ACL LOOK • Effusion (if acute) • Lachman's test – test at 20 ° FEEL Sens 81.8%, Spec 96.8% • “O’Donaghue’s Unhappy Triad” • Anterior drawer – test at = Medial meniscus tear, MCL 90 ° injury, ACL tear • Lateral meniscus tears more Sens 22 - 41%, Spec 97%* common than medial • Pivot shift • Lateral joint line tender - femoral condyle bone bruise Sens 35 - 98.4%*, Spec 98%* Malanga GA, Nadler SF. MOVE Musculoskeletal Physical Examination, Mosby, 2006 • Maybe limited due to effusion * - denotes under anesthesia or other internal derangement X-ray MRI • Sens 94%, Spec 84% • Usually non- for ACL tear diagnostic ACL tear signs • Fibers not seen in • Can help rule in or continuity out injuries • Edema on T2 films • PCL – kinked or • Segond fracture – Question mark sign avulsion over lateral tibial plateau 3
MRI Initial Treatment • Sens 94%, Spec 84% • Referral to Orthopaedics/Sports Medicine for ACL tear • Consider bracing, crutches ACL tear signs • Begin early Physical Therapy • Lateral femoral corner • Analgesia usually NSAIDs bone bruise on T2 • May have meniscal tear (Lateral > medial) ACL Tear Treatment Meniscus Tear Conservative Surgery Mechanism Symptoms • No reconstruction • Reconstruction • Occurs after twisting • Catching • Physical therapy • Depends on activity injury or deep squat • Medial or lateral knee demands • Hamstring • Patient may not recall pain strengthening Reconstruction allows specific injury • Proprioceptive training better return to sports • Usually posterior Reduce chance of • ACL bracing aspects of joint line symptomatic meniscal controversial tear • Swelling Less giving way • Patient should be symptoms asymptomatic with • Recovery ~ 6-9 months ADL ’ s Shea KG, et al. AAOS evidence based reivew, J Bone Joint Surg Am, 2015 4
Special Tests: Meniscus Modified McMurray Testing Fowler PJ, Lubliner JA. Arthroscopy 1989; 5(3): 184-186. Test Sensitivity Specificity • Flex hip to 90 degrees Joint line tender 85.5% 29.4% • Flex knee Hyperflexion 50% 68.2% • Internally or externally Extension block 84.7% 43.75% rotate lower leg with rotation of knee McMurray Classic 28.75% 95.3% (Med Thud) • Fully flex the knee McMurray Classic (Lat 50% 29% with rotations pain) Appley (Comp/Dist) 16% / 5% Courtesy of Keegan Duchicella MD X-ray MRI • May show joint space • MRI for specific exam narrowing and early osteoarthritis changes • Look for fluid (linear bright signal on T2) • Rule out loose bodies into the meniscus 5
Arthroscopy Benefit? Exercise as Good as Arthroscopy? • An RCT showed that physical therapy vs • RCT found that patients with degenerative arthrosopic partial meniscectomy had meniscus tears but no signs of arthritis on similar outcomes at 6 months imaging treated conservatively with supervised exercise therapy had similar • 30% of the patients who were assigned to outcomes to those treated with physical therapy alone, underwent surgery arthroscopy with 2 year follow up. within 6 months. – Katz JN et al. N Engl J Med. 2013 – Sihvonen R et al; N Engl J Med. 2013 Kise NJ et al., BMJ, 2016 Medial Collateral Ligament (MCL) Meniscal Tear Treatment Injury Conservative Surgery Mechanism Symptoms • Often if degenerative • Operate if internal • Valgus stress to • Pain medially tear in older patient derangement partially flexed knee • May feel unstable • Similar treatment to symptoms • Blow to lateral leg with valgus mild knee • Meniscal repair if osteoarthritis possible • Analgesia • Physical therapy • General Leg Strengthening 6
Medial Collateral Ligament (MCL) MRI Injury Physical Exam • Tender medially over • X-ray non-diagnostic MCL (often (rarely avulsion) proximally) • MRI not usually • May lack ROM necessary “ pseudolocking ” • Rule out meniscal • Valgus stress test tear Posterior Cruciate Ligament (PCL) MCL Treatment Injury Conservative Surgery Mechanism Symptoms • Analgesia • Rarely needs surgery • Fall directly on knee • Pain with activities with foot plantarflexed • “ Disability ” > • Protected motion • “ Dashboard injury ” “ Instability ” +/- hinged brace +/- crutches • Early physical therapy 7
Posterior Cruciate Ligament (PCL) PCL Treatment Injury Conservative Surgery Physical Exam • Sag sign • Acute: hinged • May require surgery post-op brace in if complete Grade 3 Sens 79%, Spec 100% extension (0-10 ° tear and symptomatic • Posterior drawer test flexion) Sens 90%, Spec 99% • Crutches • Needs urgent surgery Rubenstein et al., Am J Sports Med, • Early physical if lateral side is 1994; 22: 550-557 unstable postero- therapy X-ray- often non-diagnostic lateral corner injury MRI is test of choice Early and urgent referral!! Patellofemoral Pain PFP Syndrome • Excessive Symptoms • Tender over facets of compressive forces • Anterior knee pain patella over articulating • Worse with bending • Apprehension sign surfaces of PFP joint (5x body wt), stairs suggests possible (3x body wt) instability Mechanism • Crepitus under • Too kneecap • X-rays may show loose/hypermobile • May sublux if loose lateral deviation or tilt • Too tight – XS pressure 8
Treatment Options What’s Hip? Too Loose/Weak Surgical (RARE) • Strengthen quads (Vastus • Last resort Medialis Obliquus) • Lateral release • Correct alignment (+/-orthotics) • Support (McConnell Taping, • Patellar Bracing) realignment Too Tight • Stretch hamstring, quadriceps, hip flexor • Strengthen quads, hip abductors • Correct alignment (+/-orthotics) Prevalence of Knee Osteoarthritis Cartilage Damage • As the number of persons over age 65 years, prevalence estimated to double to more than 70 million by 2030. • The incidence of knee OA in the United States is 240 per 100,000 person-years. Outerbridge Classification, 1961 9
Arthroscopy Arthroscopy Osteoarthritis What is Osteoarthritis? • OA is a disease characterized by Superficial Zone cartilage Transition Zone degeneration • Cartilage loss and Radial Zone OA symptoms are preceded by damage to the collagen- Tidemark Calcified cartilage proteoglycan (PG) Subchondral bone plate matrix Vascular plexus 10
Diagnosis - History Concepts Symptoms Arthritis • Pain • Irreversible Articular • Mechanical Cartilage Change – Grinding • Cure Not Possible – Catching • Try To Maintain Activity – Locking Level – Giving Way • Swelling Diagnosis - Radiographs In FWB Extension XR 11
Treatment Options • Conservative • Surgical Try Conservative Management Conservative Treatment First Unloader Brace • Lifestyle • Shoe Wear • Off Load Arthritic • Brace Wear Compartment • Pain Relief • Rehabilitation/PT Lindenfield, et al Pollo / HSS, AJSM 2002 12
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