Disclosures A Core Curriculum for Ambulatory Practice August 7-12, - - PowerPoint PPT Presentation

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ESSENTIALS OF PRIMARY CARE: A Core Curriculum for Ambulatory Practice

August 7-12, 2016

Five Common Knee and Ankle Conditions You Will See in Office Practice

Cindy J. Chang M.D.

UCSF Primary Care Sports Medicine Associate Clinical Professor of Orthopaedics and Family and Community Medicine

Disclosures

I have nothing to disclose

Objective

• Develop strategies to diagnose and manage

common office problems including knee and ankle injuries

Knee Anatomy

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Anterior Knee Medial Knee Lateral Knee Knee: Case #1

• 40 yo male playing in family Thanksgiving Day

touch football game

• Tackled by his brother-in-law (“who never really

liked me”) and his knee twisted under him

• Now seeing you 1 week later and using an ACE

wrap and borrowed cane

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Which next question would be the least valuable in terms of determining the diagnosis?

• A. How long did it take before it swelled?
• B. Were you able to continue playing?
• C. Does your knee give way?
• D. Did you feel a pop?
• E. Have you ever injured that knee in

the past?

How long did it take befo.. Were you able to conti... Does your knee give way? Did you feel a pop? Have you ever injured th..

43% 19% 14% 13% 10%

Knee: Case #1

• 40 yo male playing in family Thanksgiving Day

touch football game

• Tackled by his brother-in-law (“who never really

liked me”) and he felt a pop as his knee twisted under him

• Hard to put weight on leg and was unable to

continue playing

• The knee swelled “like a melon” within 2 hours

despite ice

• His knee shifts when he puts more weight on it
• Now seeing you 1 week later and using an ACE

wrap and borrowed cane

Knee: Case #1

• Differential Diagnosis

Ligament tear

ACL tear MCL tear Less likely LCL tear, PCL tear

Tendon rupture Meniscus tear Patellar dislocation Chondral injury Bone contusion/Fracture

Knee: Case #1

• Physical Exam – Trauma

First: Point to where it hurts Effusion vs. Soft tissue swelling Superficial abrasions Active straight leg raise

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Knee: Case #1

• Physical Exam – Trauma

Ligament stability

Lachman Posterior drawer Valgus stress Varus stress/Figure of 4

Joint line tenderness

Knee: Case #1

• Physical Exam – Trauma

Joint line tenderness

Meniscus Bone bruise Chondral injury

Knee: Case #1

• Physical Exam – Trauma

Patellar apprehension

Knee: Case #1

• Xrays for traumatic injury
• +/- MRI

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Knee: Case #2

• 40 yo male joined a gym in January with his

brother-in-law

• Began working with a personal trainer and they

started a program of Olympic lifting (squatting, cleans) and plyometrics (box jumps)

• After 2 weeks began having left knee pain after

workouts but continued training

• Now seeing you 2 weeks later because now it hurts

during training and even with walking, especially on the stairs

What is the least likely diagnosis?

• A. Patellar tendonitis
• B. Pes anserine bursitis
• C. MCL sprain
• D. Patellofemoral syndrome
• E. Hamstring strain

P a t e l l a r t e n d

• n

i t i s P e s a n s e r i n e b u r s i t i s M C L s p r a i n P a t e l l

• f

e m

• r

a l s y n d r

• m

e H a m s t r i n g s t r a i n

4% 8% 39% 11% 38%

Patellofemoral Pain

• Will point to kneecap

region

• Pain associated with

running, lunging, squats

• Pain with sitting for

prolonged period

• Pain going down stairs

may be worse than up stairs

• Soft tissue swelling often

described as puffiness

Patellofemoral Pain

• Positive patellar compression

test

• Pain on palp of medial facet of

patella

• Increased patellar mobility

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Patellofemoral Pain

• Single Leg Squat to evaluate for

weak quads, gluts

Patellofemoral Pain

• Thomas test to evaluate tight

hip flexors, quads, ITB

Patellar Tendinitis

• Pain with

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

Pes Anserine Bursitis

• 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

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Iliotibial Band Syndrome Management of Knee Pain

• Trauma

Diagnosed/suspect ligament, tendon, meniscus, bony

injury

Brace, consider crutches, ice and ACE wrap, NSAIDs

for short duration

Refer

Surgery possible due to instab, mech symptoms, fx Suspect moderate to severe sprain/strain Patient request

• Overuse

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

Ankle: Case #1

• 16 yo female playing in basketball game and

turned her ankle inwards after a rebound when she came down on another foot

• She felt a pop, and was unable to bear weight
• She had immediate swelling on the outside and

front of her ankle

• She is able to limp into your exam room the next
• day. She points to her lateral ankle as the area of

most pain and she is very tender when you palpate the distal tip of the fibula

Which of the following is an indication to order Xrays?

• A. Feeling or hearing a pop
• B. Inability to walk for 4 steps

immediately after the injury

• C. Any bruising along the lateral and/or

medial malleolus

• D. Tenderness on palpation along tip of

lateral malleolus

• E. Numbness around the area of

swelling

F e e l i n g

• r

h e a r i n g a p

• p

I n a b i l i t y t

• w

a l k f

• r

4 s t e . . A n y b r u i s i n g a l

• n

g t h e l a . . . T e n d e r n e s s

• n

p a l p a t i

• n

. . . N u m b n e s s a r

• u

n d t h e a r . .

6% 44% 6% 38% 7%

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Ankle Anatomy- Anterior Ankle Anatomy-Lateral Ankle – Case #1

• Differential Dx

Fracture

Distal fibula Other

Ligament sprain

Lateral ligaments Other

Tendon strain

Peroneal Achilles

Ankle: Case #1

• Moderate swelling of a fusiform nature ankle and

anterolateral and lateral ankle region

• Ecchymosis inferior to lateral malleolus
• + Squeeze test
• No pain

Fibular head 5th MT

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Ankle: Case #1

• Syndesmosis injury

“high” ankle sprain

Ankle: Case #1

• +2 anterior drawer
• +2 lateral talar tilt

Ankle: Case #1

• +2 anterior drawer

Ankle: Case #1

• +2 lateral talar tilt
• Stable medial tilt
• Stable talar shift

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Ankle: Case #1

• Significantly decreased range of motion

Ankle: Case #1

• Decreased strength secondary to pain

Ankle: Case #1

• Pain over:

Medial ankle Dorsal ankle Lateral malleolus ATFL, CFL AITFL, PITFL

• Pain with Squeeze test

Ankle: Case #1

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Ankle: Case #1a

• Patient is 10 yo

Ankle: Case #1b

• Patient also has 5th MT pain

Ankle: Case #2

• A 35 yo female has begun a walking program to

get more fit and lose her 20# “baby” weight

• She lives with her family in a hilly part of the city;

time-wise it is easier to walk in her neighborhood

• She has exactly 45 minutes, after her workday and

before her spouse comes home with the kids from daycare, to walk a 3 mile loop

• After 1 week she began to have pain in her medial

ankle at the end of walking

• Now it hurts her even during, in the morning out of

bed, and if she gets up from her chair at work after prolonged sitting

What other questions would be helpful in arriving at the diagnosis?

• A. Is there any radiation of pain?
• B. Have you ever injured this ankle

before?

• C. What type of shoes are you wearing

during your power walks?

• D. Did you build up to the 45 minutes

every day?

• E. All of the above

Is there any radiation of ... Have you ever injured th.. What type of shoes are ... Did you build up to the .. All of the above

0% 1% 92% 2% 5%

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Ankle Anatomy-Medial Ankle: Case #2

Posterior Tibial Tendinitis

• Etiology

Typically Overuse syndrome (too much, too soon) Poor shoeware on pronated feet

Ankle: Case #2

Posterior Tibial Tendinitis

• History:

Initially may “warm-up” Stiff after inactivity Can also occur after returning

back to activity too quickly after ankle injury or after incomplete rehab

Before achieving full DF range

• f motion

Ankle: Case #2

Posterior Tibial Tendinitis

• Exam:

Pain with resisted inversion Tightness of posteromedial

compartment of LE

May also have “shin splints”

Evaluate heel raise bilat “Too many toes” sign

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Ankle – Case #3

• 35 yo female almost one year later, has now

decided to try to jog her route

• She has motion control running shoes to control

her pronation

• Once again, the pain initially began at the end of

jogging, then it started to hurt at the beginning but then would “warm-up” only to return towards the end.

• Hurts again in the morning out of bed
• But this time the pain is in the back of her ankle

Ankle Anatomy-Posterior Ankle: Case #3 Achilles Tendinitis

• Etiology

New onset of an activity or increased level of

intensity or increased duration

Change in surface/terrain Change in footwear

Flats or lower heels than usual

Ankle: Case #3 Achilles Tendinitis

• Physical Exam

Swelling and pain over Achilles tendon, approx. 2-5

cm proximal to insertion

Crepitus on palpation and with ROM Thickening of tendon Pain with resisted PF and passive DF Limited DF due to pain

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Ankle – Case #4

• 35 yo female, still just walking for exercise, and

now playing in her work softball league

• First game of the season and during sprint to first

base after hitting grounder, felt a rock hit her ankle and she stumbled and fell

• Needed assistance to get to the bench
• Iced and elevated and ACE wrap and NSAID
• Next day she could walk as long as she kept the

ankle stiff, so she wore her hiking boots

Ankle – Case #4

Management of Ankle Pain

• Trauma

Diagnosed/suspect ligament, tendon, bony injury Brace/splint/walking boot, consider crutches, ice and

ACE wrap, NSAIDs for short duration

Refer

Surgery possible due to instab, mech symptoms, fx Suspect moderate to severe sprain/strain Patient request

• Overuse

Achilles tendonitis, post tib tendonitis Brace, Orthotics or heel lifts, Ice/ACE wrap, NSAIDs

Stretches, theraband, strengthening, x-train, internet

Make a PT referral and f/u with you in 4-8 wks or after

4-6 PT visits

Thank you for your attention