4/3/18 UCSF CME PRIMARY CARE MEDICINE: Disclosures Update 2018 April 1-6, 2018 No relevant financial relationship exists Common Knee and Ankle Conditions You Will See in Office Practice Cindy J. Chang M.D. Primary Care Sports Medicine Clinical Professor of Orthopaedics and Family and Community Medicine Objective Goals of this talk ■ Quick approach to MSK problems Develop ■ strategies to ◆ A GOOD HISTORY is important diagnose and ◆ Know basic anatomy manage common ■ Highlight common presentations and clinical exam office problems findings including knee and ankle injuries ■ Discuss basics of non-surgical and surgical management Later, those who knew the ligament would describe her as � friendly � , and � the quiet type. � Not at all the kind you’d expect to suddenly just snap. 1
4/3/18 Why? = Prevention MS OLDCARTS Intrinsic Risk Factors Extrinsic Risk Factors M echanism of Injury Growth Training ■ ■ S ymptoms Anatomy Technique ■ ■ O nset Muscle/Tendon Footwear ■ ■ L ocation imbalance Surface ■ D uration Illness Occupation ■ ■ C haracter Nutrition ■ A ggravating/ A lleviating Conditioning ■ R adiation Psychology ■ T iming/ T reatments S everity www.fammedref.org/mnemonic/pain-hx-old-carts-p Knee Anatomy Anterior Knee 2
4/3/18 Lateral Knee Medial Knee Knee: Case #1 Which next question would be the least helpful in terms of determining the severity of injury? 40 yo male playing in family reunion touch football ■ game Tackled by his brother-in-law (“who never really ■ liked me”) and his knee twisted under him 1. How long did it take before it swelled? Now seeing you 1 week later and using an ACE ■ wrap and borrowed cane 2. Were you able to continue playing? 3. Does your knee give out? 4. Did you feel a pop? 3
4/3/18 Which next question would be the Knee: Case #1 least helpful in terms of determining the severity of injury? 40 yo male playing in family reunion touch football ■ game Tackled by his brother-in-law (“who never really ■ 1. How long did it take before it swelled? liked me”) and he felt a pop as his knee twisted under him 2. Were you able to continue playing? Hard to put weight on leg and was unable to ■ continue playing 3. Does your knee give out? The knee swelled “like a melon” within 2 hours ■ despite ice His knee shifts when he puts more weight on it 4. Did you feel a pop? ■ Now seeing you 1 week later and using an ACE ■ wrap and borrowed cane Knee: Case #1 Knee: Case #1 Physical Exam – Trauma ■ ◆ First: Point to where it hurts Differential Diagnosis ■ ◆ Effusion vs. Soft tissue swelling ◆ Ligament tear ◆ Superficial abrasions ✦ ACL tear ◆ Active straight leg raise ✦ MCL tear ✦ Less likely LCL tear, PCL tear ◆ Tendon rupture ◆ Meniscus tear ◆ Patellar dislocation ◆ Chondral injury ◆ Bone contusion/Fracture 4
4/3/18 Knee: Case #1 Knee: Case #1 Physical Exam – Trauma ■ ◆ Check Ligament stability ◆ Lateral Pivot shift ◆ Highest specificity (97.5%) ◆ ACL ◆ High PPV--rules in ✦ Lachman (at 20 deg) ACL tear • Highest sensitivity (87.1%) • High NPV--rules out ACL tear ✦ Anterior drawer • Inconclusive Scholten RJPM et al. J Fam Pract 2003; Huang W et al. Acta Ortho Traum Turc 2016; Scholten RJPM et al. J Fam Pract 2003; Huang W et al. Acta Ortho Traum Turc 2016; Brady MP et al. J Sport Rehab 2017 Brady MP et al. J Sport Rehab 2017 Knee: Case #1 Posterior Cruciate Ligament (PCL) Injury Physical Exam MCL Sag sign ■ ■ ◆ Tender medially over Sens 79%, Spec 100% MCL (often proximally) Posterior drawer test ■ ◆ May lack ROM Sens 90%, Spec 99% � pseudolocking � ◆ Valgus stress test – test at 20 � Sens = 86 - 96 % Rubenstein et al., AJSM 1994; 22: 550-557 Malanga GA, Nadler SF. Musculoskeletal Physical Examination, Mosby, 2006 5
4/3/18 Knee: Case #1 Physical Exam – Trauma ■ ◆ Joint line tenderness ✦ Meniscus ✦ Bone bruise ✦ Chondral injury ◆ McMurray testing Special Tests: Meniscus Knee: Case #1 Test Sensitivity Specificity Physical Exam – Trauma ■ ◆ Patellar apprehension Joint line tender 85.5% 29.4% Hyperflexion 50% 68.2% Extension block 84.7% 43.75% McMurray Classic 28.75% 95.3% (Med Thud/Click) McMurray Classic 50% 29% (Lat pain) Fowler PJ, Lubliner JA. Arthroscopy 1989; 5(3): 184-186 6
4/3/18 MRI Knee: Case #1 Xrays for traumatic injury Sens 94%, Spec 84% for ■ ■ +/- MRI ACL tear ■ ACL tear signs Fibers not seen in ■ continuity Edema on T2 films ■ PCL – kinked or Question ■ mark sign ACL Tear Treatment Initial Treatment Non-Surgical Surgery Referral to Orthopaedics/Sports Medicine ■ No reconstruction Reconstruction Consider bracing, crutches ■ ■ ■ Physical therapy Depends on activity Begin early Physical Therapy ■ ■ ■ demands ✦ Hamstring ◆ Protected motion strengthening • Reconstruction allows better return Analgesia usually NSAIDs ✦ Proprioceptive ■ to sports training • Reduce chance of ✦ Coper? symptomatic ACL bracing ■ meniscal tear controversial • Less giving way Patient should be ■ symptoms asymptomatic with ADLs • Prevent more OA Recovery ~ 9-12 months ■ Shea KG, et al. AAOS evidence based review, J Bone Joint Surg Am, 2015 7
4/3/18 Knee: Case #2 What is the least likely diagnosis? 40 yo male joined a gym in January with his ■ brother-in-law 1. Patellar tendonitis Began working with a personal trainer and they ■ started a program of Olympic lifting (squatting, cleans) and plyometrics (box jumps) 2. Pes anserine bursitis After 2 weeks began having left knee pain after ■ workouts but continued training 3. MCL sprain Now seeing you 2 weeks later because now it hurts ■ during training and even with walking, especially on 4. Patellofemoral syndrome the stairs 5. Hamstring strain Patellofemoral Pain What is the least likely diagnosis? Will point to kneecap ■ region 1. Patellar tendonitis Pain associated with ■ running, lunging, squats 2. Pes anserine bursitis Pain with sitting for ■ prolonged period Pain going down stairs 3. MCL sprain ■ may be worse than up stairs 4. Patellofemoral syndrome Soft tissue swelling often ■ described as puffiness 5. Hamstring strain 8
4/3/18 Patellofemoral Pain Patellofemoral Pain Positive patellar compression Single Leg Squat to evaluate for ■ ■ test weak quads, gluts Pain on palp of medial facet of ■ patella Increased patellar mobility ■ Patellofemoral Pain Patellar Tendinitis Thomas test to evaluate tight Pain with ■ ■ hip flexors, quads, ITB ◆ resisted knee extension ◆ resisted straight leg raise ◆ single leg squat May have swelling at ■ inferior pole of the patella Tenderness at prox ■ patellar tendon Osgood Schlatters ■ 9
4/3/18 Pes Anserine Bursitis Iliotibial Band Syndrome Primary flexors of the ■ knee Protects knee against ■ rotatory and valgus stress Pain often acute ■ Can occur with sports ■ and exercise Can also occur in ■ sedentary Management of Knee Pain Ankle: Case #1 Trauma ■ ◆ Diagnosed/suspect ligament, tendon, meniscus, bony 16 yo female playing in basketball game and injury ■ turned her ankle inwards after a rebound when she ◆ Brace, consider crutches, ice and ACE wrap, NSAIDs came down on another foot for short duration Felt a pop; was unable to bear weight ◆ Refer ■ Immediate swelling on the outside and front of ✦ Surgery possible due to instab, mech symptoms, fx ■ ankle ✦ Suspect moderate to severe sprain/strain ✦ Patient request Able to limp into your exam room the next day; ■ Overuse points to her lateral ankle as the area of most pain ■ ◆ PFS, patellar tendinitis, Pes anserine bursitis, ITB ◆ Brace, Ice/ACE wrap, NSAIDs ◆ Stretches, foam roller, strengthening, x-train, internet ◆ Make a PT referral and f/u with you in 4-8 wks or after 4-6 PT visits 10
4/3/18 Which of the following is an Which of the following is an indication to order Xrays? indication to order Xrays? 1. Feeling or hearing a pop 1. Feeling or hearing a pop 2. Inability to walk for 4 steps immediately after the 2. Inability to walk for 4 steps immediately after the injury injury 3. Any bruising along the lateral and/or medial 3. Any bruising along the lateral and/or medial malleolus malleolus 4. Tenderness on palpation along tip of lateral 4. Tenderness on palpation along tip of lateral malleolus malleolus 5. Numbness around the area of swelling 5. Numbness around the area of swelling Ankle Anatomy- Anterior Ankle Anatomy-Lateral 11
4/3/18 Ankle – Case #1 Ankle: Case #1 Differential Dx Moderate swelling of a fusiform nature ankle and ■ ■ anterolateral and lateral ankle region ◆ Fracture ✦ Distal fibula Ecchymosis inferior to lateral malleolus ■ ✦ Other + Squeeze test ■ ◆ Ligament sprain No pain ■ ✦ Lateral ligaments ◆ Fibular head ✦ Other ◆ 5 th MT ◆ Tendon strain ✦ Peroneal ✦ Achilles Ankle: Case #1 Ankle: Case #1 Syndesmosis injury 2+ anterior drawer ■ ■ ◆ “high” ankle sprain 2+ lateral talar tilt ■ 12
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