Meniscus Meniscus Evidence-based approach Collateral Ligaments - - PowerPoint PPT Presentation

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A rational approach to knee pain Primary Care Sports Medicine 2015

12/11/2015

Brian Feeley, MD Associate Professor, Sports Medicine and Shoulder Surgery UCSF Department of Orthopaedic Surgery

Top 5 4 knee problems:

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Why pay attention today?

MS problems account for 30% of

• ffice visits

MS teaching accounts for 3% of med school

• 1% of internal medicine

curriculum

• 56% Primary Care not

prepared for MSK ‒ AAOS 2014 MRI is most commonly ordered imaging modality from primary care/IM for MS complaints

Goals for this presentation

Understand common knee problems

• Common symptoms
• Imaging modalities—when to/not to use

them

• Treatment options

Evidence-based approach Recent high quality literature (when available)

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MCL MCL ACL ACL PF Pain PF Pain

Meniscus Meniscus Arthritis Arthritis

Knee anatomy-keep it basic

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Cartilage

• Acute or degenerative (arthritis)

Meniscus

• Acute or degenerative (arthritis)

ACL Collateral Ligaments Extensor Mechanism

• Acute or activity related

All others are rare!

Differential Diagnosis of Knee Problems

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Case 1

56 year old male with a 7 month history of moderate knee pain, gradually worsening, and described as ‘achy’. He had a meniscus surgery 4 years ago which helped for a while. He used to run, now mainly biking and swimming. Pain is medial, near the joint line. He says his knee sometimes swells. What is his most likely diagnosis?

• A. Osteoarthritis
• B. Meniscus tear
• C. Patellofemoral pain
• D. Hip arthritis

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75% 1% 8% 16%

Arthritis is a big problem

12/11/2015 Source: CDC 6

ARTHRITIS is COMMON!

• 33% of all adults have arthritis

‒ 70 million people with arthritis ‒ 50% over the age of 65 have arthritis

• Arthritis is more common in women
• Arthritis prevalence increases with age

Understanding Arthritis

Cartilage properties Normal Cartilage Arthritis Cartilage Few cells Super smooth Cannot make more cartilage No nerve endings Don’t feel joints move back and forth Don’t sense early damage to the cartilage

Understanding Arthritis

The articular changes found are IRREVERSIBLE (mostly) Healthy cartilage Early Arthritis Advanced Arthritis Best way to explain arthritis to patients seems to be this tire analogy.

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History-Osteoarthritis

Symptoms of arthritis

• Pain—’achy’
• Swelling/effusion
• Loss of range of motion
• Deformity
• Inability to exercise/perform daily activities/work
• Weight gain
• Depression

w 56 year old male with a 7 month history of moderate knee pain, gradually worsening, and described as ‘achy’. He had a meniscus surgery 4 years ago which helped for a

• while. He used to run, now mainly biking and
• swimming. Pain is medial, near the joint line. He says his

knee sometimes swells.

Physical Exam-Osteoarthritis

Physical Exam findings

• Deformity
• Crepitus (grinding, popping)
• Loss of range of motion
• Tenderness along the joint line

Imaging-Osteoarthritis

Mild arthritis Moderate arthritis Severe arthritis Get STANDING weight bearing views, bilateral to compare

Imaging-Osteoarthritis

Do I need an MRI?

• Advanced arthritis, in general no (get an Xray first and DON’T get an MRI)
• Early cartilage injuriesyes
• Early arthritismaybe yes

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 12/11/2015 4 25% of knee visits resulted in MRI in ortho, 24% in Primary Care Orthopaedic surgeons ordered MRIs for patients who were more likely to benefit from arthroscopic intervention including patients who were younger (mean age, 45.1 years versus 56.5 years for those with PCP-ordered MRIs; p < 0.001) Surgeons were less likely than PCPs to order MRIs for patients with substantial

• steoarthritis who subsequently underwent total knee arthroplasty (4.3% versus 9.2%;

p = 0.048). Summary: both use MRI, possibly better used by ortho Still use it too often for patients with advanced OA

Treatment options for arthritis

Bracing/Unloading

• 1. Activity/Lifestyle changes

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• 1. Activity/Lifestyle changes

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• 1. Activity/Lifestyle changes

The most important thing you Can tell her is that she needs to Lose weight Surgery does not lead to Weight loss (JBJS 2015) Weight loss DOES Lead to less knee pain

• 1. Activity/Lifestyle changes

M A A Markers of cartilage turnover And breakdown are decreased After bariatic surgery

• 1. Activity/Lifestyle changes

What about mild weight loss?

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IDEA Trial (NIH/NIA)

• 2. Physical Therapy

Does physical therapy work for patients with knee

• steoarthritis?

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N A G ts, O W No single PT intervention was best…aerobic Aquatic, strengthening worked well Gimmicky things—didn’t work well (magnets, Orthotics, ultrasound) Wang et al, AIM 2015

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• 2. Physical Therapy

Ettinger, et al. JAMA. 1997 439 community ambulators >60 yo Randomized to aerobic, resistive exercises vs. nothing Outcomes with pain, daily function scores Conclusion: Significant improvement in daily outcome measurements and knee pain scores with either exercises. Benefits were best in those with mild to moderate OA

12/11/2015 Ettinger, et al. JAMA 1997. 21

• 3. Orthotics for Osteoarthritis

12/11/2015 AAOS Clinical Guidelines 2013 22

• 4. Injections for Osteoarthritis

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• 4. Corticosteroid Injections

Risks:

• Can kill cartilage cells

‒ Lidocaine and steroid

• Transiently increase blood

sugar Not Risks:

• Will not turn you into this:

Cartilage cells After lidocaine Healthy cartilage cells UCSF Orthopaedic Research

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• 4. Corticosteroid Injections

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Summary: Favors Steroid

• 4. Viscosupplementation
• 4. Viscosupplementation

Viscosupplementation (Synvisc, Euflexxa)

• Lubricates and cushions joint
• Made from a natural substance similar to healthy joint fluid

Improves viscosity

• Increases molecular weight and quantity of synovial

fluid synthesized by the synovium

Decrease pain (mechanism uncertain)

• Decreases inflammatory mediators?
• 4. Viscosupplementation

Who does it work for?

• Mild to moderate arthritis
• Already on an exercise/weight loss program but with continued pain
• Low to moderate demand activities

‒ Limit high impact sports (running)

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• 4. Injections

“The expert achieved unanimous agreement in favor of the following statements: VS is an effective treatment for mild to moderate knee OA; VS is not an alternative to surgery in advanced hip OA; VS is a well-tolerated treatment of knee and other joints OA”

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• 4. Injections

NEJM-2015 In this clinical setting of a prevalent disabling disease, for which the therapy in question has, at best, modest efficacy for relief of pain, the tolerance for treatment expense and adverse events is limited. Therefore, the current evidence base would not advocate the use of intraarticular hyaluronate for the management of knee osteoarthritis.

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Conclusions— mild benefit, often less than MCID May be worth trying in younger people with OA, mild disease

• 4. Injections—What’s next?

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3 meta-analyses Works better for people with less arthritis Higher rate of side effects Limited data, mildly promising

• 5. Surgery

Surgery to debride meniscus/cartilage is not effective in the setting of arthritis

• Kirkley et al NEJM 2007
• Moseley et al NEJM 2002

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Knee Replacement

Final common pathway for all people with moderate to severe arthritis

Knee Replacement

How does it work?

• Designed cuts in the knee joint to remove injured cartilage
• Replacement of cartilage surface with metal and plastic (Polyethylene)

surface

Knee Replacement Knee Replacement

Excellent procedure for low to moderate demand patients

• Pain relief immediate (no more injured cartilage)
• Good range of motion
• 90-95% good to excellent results at 10-15 years

Knee Surgery 6 weeks ‘50% better’ 3 months ‘75% better’ 6 months ‘90% better’ 1 year ‘98% better’

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CASE 2

A 35 year-old recreational basketball player makes a rapid pivot on his fixed leg and feels a tearing sensation in his knee. He tries to continue playing but has a moderate amount of discomfort in his knee along the medial (inner) joint line. His knee swells a moderate amount

• ver the next few days. He notes pain along the joint line with squatting and climbing up and

down stairs. The most likely diagnosis is: A. Meniscus tear B. Patellar tendon rupture C. Chondromalacia patella/patella maltracking D. Anterior Cruciate Ligament Tear

74% 20% 2% 4%

History--Meniscal Tears

Classic descriptions

• Swelling after event, usually able to continue
• Pain with activity
• Joint line soreness
• Lower level of activity
• Able to pinpoint pain

Physical Exam—Meniscus Tears

Rational exam steps

• 1. Joint line tenderness
• 2.Thessaly (or apley) test
• 3. Deep squat
• 4. Duck walk

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Imaging-Meniscal Injury

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Treatment options for meniscus tear

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Acute vs Chronic Active, younger person Refer for surgical evaluation Active, older person Sedentary, older person OA on Xray imaging PT, activity modification

Non operative management for degenerative meniscus tears

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54 years, no difference in functional or clinical outcomes at 2 years In the intention-to-treat analysis, we did not find significant differences between the study groups in functional improvement 6 months after randomization; however, 30% of the patients who were assigned to physical therapy alone underwent surgery within 6 months.

Management of degenerative meniscus tears

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“No differences at 1 year in the intent to treat group”

Meniscus Tear Treatment

Treatment based on mechanical symptoms

• f patient

If meniscal tear disrupts mechanics of knee and patient does not respond to physical therapy, surgery is indicated Surgical options: Debridement (remove as little as possible) vs Repair Older patients with arthritis (cartilage wear)

• ften are treated with physical therapy and

injections

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Outcomes of meniscus debridement

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Excellent procedure for higher demand patients who fail non op

• Pain relief immediate (no more injured cartilage)
• Good range of motion
• 90-95% good to excellent results at 10-15 years (Syndgard KSSTA 2013)

Knee Surgery 1 week ‘50% better’ 6 weeks ‘75% better’ 12 weeks‘90% better’ 1 year ‘98% better’

Meniscus tears—what not to miss (Dr. Ma’s Talk!)

Bucket handle tears

• Locked knee
• Often with ACL tear
• Younger (<40) more active

Crutches, refer immediately Meniscus root tears

• Older patient (50-65)
• Often prodromal period
• Acute worsening with swelling

Protected weight bearing, refer to

• rtho immediately

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A. a Meniscus tear B. b Anterior Cruciate Ligament tear C. c Patello-femoral maltracking/pain D. d Patellar dislocation

Case #3

A 41 year-old, 210 pound male presents complaining of bilateral knee pain, L>R. He complains of anterior knee pain with stair climbing, long walks, and after sitting for long periods. Sometimes his legs feel weak, as if they might “give out” on him while walking down the stairs. He has faint swelling

• n occasion. The most likely diagnosis is:

0% 0% 91% 9%

A. a Meniscus tear B. b Anterior Cruciate Ligament tear C. c Patello-femoral maltracking/pain D. d Patellar dislocation

Case #3

A 41 year-old, 210 pound male presents complaining of bilateral knee pain, L>R. He complains of anterior knee pain with stair climbing, long walks, and after sitting for long periods. Sometimes his legs feel weak, as if they might “give out” on him while walking down the stairs. He has faint swelling

• n occasion. The most likely diagnosis is:

0% 0% 90% 10%

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History of patellofemoral problems

Often bilateral pain Anterior/anteromedial pain Pain with down stairs/hills Can be associated with changes in activity No specific injury mechanism

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Physical Examination

Normal body habitus / + ligament laxity Squat 90 deg-pain anterior No specific tenderness Can have quad atrophy Possible mild effusion Pronated feet tight hamstrings and IT band Poor Core stability

If exam is not reliable, how to I test? SLS Video

Etiology of Patellofemoral pain

Valgus knees (exam) Trochlea hypoplasia (x-ray) Foot Pronation Non-modifiable risk factors Weight Core stability Flexibility Activities

• Shoe wear (shoe fit)
• Biking (bike fit)

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Modifiable risk factors

Radiographs? MRI?

Useful to rule out other factors, but usually negative.

• -I would recommend start with PT with no swelling
• -MRI if patients fail PT, have swelling

Chondromalacia very common Does not usually change treatment options initially

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Does PT work for patellofemoral pain?

720 patients Both groups did better overall PT works better and faster with hip/CORE stability Improvement at 6 weeks

Does PT work for patellofemoral pain?

28 people randomized to hip strengthening vs control-8 week program Pain, health status, and bilateral hip strength improved in the exercise group Improvements in pain and health status were sustained at 6- month follow-up in the exercise group. R W K H M R A Rx for patellofemoral pain What do I write? Knee ROM Hip/CORE stability exercises Modalities OK Return to sports Assess with single leg squat

Winter Sports

55

CASE

A 42 year-old financial advisor who is an advanced skier comes in one day after an injury at Boreal. He caught an edge and had a ‘grinding’ feeling and fell. He tried to ski but couldn’t. He was tobogganed down and his knee swelled up on the way home. What is his most likely diagnosis? A. a Meniscus tear B. b Patellar tendon rupture C. c Chondromalacia patella/patella maltracking D. d Anterior Cruciate Ligament Tear E. e Pathologic liar-expert skiers don’t go to Boreal

1% 5% 5% 89% 1%

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ACL Injury

Add nml and inj MRI

History--ACL injuries

History

• Non contact, twisting
• 70% hear a pop
• Swelling within 1 hr
• Do not return to play
• Often doing well when they come into
• ffice (if more than 1-2 weeks out)

Physical Exam-ACL tear—Dr. Allen’s and Hands on Talks

Swollen Lack ROM Lateral Tenderness Unstable on exam Lachman Test

X-ray

Usually non-diagnostic Can help rule in or out injuries Segond fracture – avulsion over lateral tibial plateau

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ACL—MRI findings ACL Tears—Treatment options

Treatment options

• Non-operative

‒ Low Demand People Activity modification Bracing for activity Cartilage injuries Medial meniscus Operative Indication Cutting and pivoting sports High demand jobs Young people Treatment of associated injuries Lateral meniscus

Outcomes of ACL injury in older athletes

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Swedish ACL registry Over 40, skiing most common cause Outcomes (KOOS score) similar in younger and older patients 52 years avg age 90% return to sport, 88% satisfied Su I R Summary: In higher level older patients Reasonable to consider ACL reconstruction Tell your patients this is STILL a bad idea

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Summary

Know the 4 most common knee problems with treatment options Arthritis—5 good treatment options Meniscus—know who will benefit from surgery ACL—know how to diagnose, understand expanding indications PF pain—normal exam, anterior pain, treat with PT

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Bonus Slides Extra-Other Knee Problems

• MCL Sprain
• Pes bursitis
• Pre-patellar bursitis
• Hamstring Injuries
• ITB friction syndrome

What else can go wrong in the knee?

MCL Injury

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MCL Injury Mechanisms: Hit on outside of knee May be associated with tears of the ACL and the medial meniscus, or patella dislocation, but is often an isolated injury A contusion/ fx due to impact of the lateral femoral condyle or lateral tibial plateau is common (bone bruise with lateral pain)

MCL injury is the most common Ligament injury in the knee

MCL--History

Patients will have medial sided pain Pain when foot gets caught in covers, lifting knee Tenderness usually along the femoral attachment Swelling not as common

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MCL Injury

MCL-Exam

A Valgus stress is applied both in full extension and in 20-30 ° of flexion Test in 20-30 ° flexion evaluates MCL Grading of Injury based on Jt. Space opening and endpoint feel

Treatment: Brace, non weight bearing or WB in extension PT for ROM and strength Usually 6-12 weeks back to sports (long time if older)

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Patellar Tendinitis

• Pain at tendon insertion into kneecap
• Due to eccentric load in running

(running down hills), repetitive jumping (basketball), weight lifting

• Pain with squat, stair climbing
• Pain with palpation of tendon
• Tight hamstrings

Iliotibial Band Tendinitis

Pain and snapping over

• uter aspect of knee

Very common in runners Due to overtraining, tight IT band. Hip adduction & internal rotation, and knee extension during running tighten IT band and accentuate snapping

Iliotibial Band Tendinitis Treatment:

• IT band stretching
• Ice
• NSAIDS
• Cortisone injection (rare)
• Orthotics
• Address biomechanics/PT

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Pes Bursitis

Pain at hamstring insertion Often with swelling at attachment Treatment ice massage Hamstring stretching Avoid offending activity

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Other locations for pain: Treatment with rest/PT