Knee Pain
And Injuries
In Adults
W. Dilworth Cannon, M.D.
Professor of
Clinical Orthopaedic Surgery
University of California
San Francisco
Pain Control
• Narcotics rarely necessary after 1st 1-2
days.
• NSAID’s
• Ice
• Compression
• Elevation
• Rest
Overview
Page 1
Football Injury
Football Injury
Ligament Sprains
Grade I
Grade II
Grade III
Page 2
Grades of Laxity
Primary Care Physicians:
1+ = 3-5 mm
2+ = 5-10 mm
3+ = >10 mm
“A-P and lateral of knee”
(occasionally “Sunrise view”)
My Routine X-rays Include:
1. P-A bent knee standing film both knees
(Knees bent 30-45 deg, aim beam 10 deg caudad)
2. Lateral (supine)
3. 30°patello-femoral axial view
Page 3
Patello-Femoral View:
• Don’t omit ordering this view
• Don’t order “Sunrise View”
• Order Merchant’s View (45 deg view),
or 30 deg view.
Page 4
When should you order an MRI?
Locking
Causes of Locking:
• Displaced meniscus tear
• Loose body
• Swollen knee
• Fragment of torn ACL
A block to full extension.
Can flex
Page 5
Management
of the
ACL Deficient Knee
Epidemiology:
Natural History of ACL Tear:
• Approx. 125,000 ACL tears and
• Twisting injury and pop
• Immediate swelling
• Repeated giving way and effusions
40,000-60,000 MCL tears per year.
• Female:male gymnasts/basketball players:
–
3-4 times higher incidence in females.
Page 6
“Office Sprain”
“Telephone” Diagnosis
• 72% are ACL tears
• Exam substantiates Dx
• No longer immobilize and
“pray”
Fluid in Joint:
•Immediate = blood
•After 24 hours = effusion
Page 7
Knee Model mpg2
Knee Model mpg 1
Acute ACL Tear:
• Lachman test
• Pivot shift or Losee test
• Arthrometer measurements
• MRI for assessment of menisci
Page 8
Joint Immobilization:
• Muscle atrophy
• Adhesions and joint stiffness
• Decreased ROM
• Cartilage degeneration
• Ligament strength deterioration
Eriksson: Early Motion (mpg 1)
Eriksson: Early Motion (mpg2)
Page 9
Losee, Lachman, Pivot Shift Tests
Losee Test
• A “gentle” test compared to pivot shift.
• Most useful if MCL and ACL torn.
Non--operative treatment
Non
Anterior Drawer:
of the
May miss up to 50% of
ACL deficient knee
acute ACL tears
Page 10
Aggressive rehabilitation:
Don’t do this!
• Early return of motion
• Hamstring strengthening
• Closed kinetic chain quads
Rule of Thirds:
• 1/3 can play recreational sports
• 1/3 cannot play recreational sports
• 1/3 have symptoms with ADL
Page 11
Sequelae of ACL Tear:
• Meniscal tears in 30-95%
• Late arthritis
Page 12
If a patient wants to have the best
Braces decrease, but do not
chance of having a more normal
eliminate anterior subluxation
(stable) knee, then ACL
reconstruction is the best choice.
ACL Reconstruction:
Rx of MCL Tears:
Delay surgery approx. 6-8 wks until
close to FROM obtained, swelling
Non-operative
down, and strength returned.
Success rate: 90-95%
Page 13
Medial Collateral Ligament
Injuries:
• Tenderness and swelling over medial aspect
of knee.
• Medial opening with valgus stress at 30
degrees flexion: Grade 0-3 +.
• Beware of ACL injuries in grade 3 lesion.
Rehabilitation of MCL Injury:
• FROM in hinged brace (wear it 24/7).
• Wt bearing as tolerated.
• Progressive strengthening and agility
program.
• Return to sports at 5-9 weeks.
Page 14
Torn Meniscus
Partial meniscectomy
versus
Meniscal repair
• Typically twisting or hyperflexion injury
– With or without a pop
• Joint line pain and tenderness
• Swelling
• Clicking or catching
• Locking or giving way
Post--meniscectomy Patient:
Post
• Should not jog or run
• Try speed walking
• Encourage bicycling
• Working out is okay
Page 15
PCL
Posterior Cruciate Ligament
• 3% - 20% of all knee ligament injuries.
(PCL)
• Associated injuries common.
Quad Active Test
Mechanism of Injury:
• Posterior force to anterior tibia (dashboard).
• Hyperflexion, hyperextension, twist.
Page 16
Natural Hx & Rx Controversial:
Lateral Collateral Ligament
Surgery for some combined injuries,
(LCL)
rarely for isolated PCL tears.
Lateral Collateral Ligament
• Increased varus laxity at 30 degrees flexion.
Cysts About the Knee
• Non-operative Rx common.
• Surgical exploration and primary repair for
combined injuries.
Page 17
Popliteal Cysts
Secondary to intra-articular
pathology
Page 18
Patellar Tendinitis
(“Jumper’s Knee”)
Patellar tendinitis
•
•
•
•
•
•
•
Page 19
Rest
Ice
NSAID’s
No OKC quadriceps exercises
Quadriceps stretching
No steroid injections
Surgery only if non-op Rx fails
Knee Pain
And Injuries
In Adults
W. Dilworth Cannon, M.D.
Professor of
Clinical Orthopaedic Surgery
University of California
San Francisco
Pain Control
• Narcotics rarely necessary after 1st 1-2
days.
• NSAID’s
• Ice
• Compression
• Elevation
• Rest
Overview
Page 1
Football Injury
Football Injury
Ligament Sprains
Grade I
Grade II
Grade III
Page 2
Grades of Laxity
Primary Care Physicians:
1+ = 3-5 mm
2+ = 5-10 mm
3+ = >10 mm
“A-P and lateral of knee”
(occasionally “Sunrise view”)
My Routine X-rays Include:
1. P-A bent knee standing film both knees
(Knees bent 30-45 deg, aim beam 10 deg caudad)
2. Lateral (supine)
3. 30°patello-femoral axial view
Page 3
Patello-Femoral View:
• Don’t omit ordering this view
• Don’t order “Sunrise View”
• Order Merchant’s View (45 deg view),
or 30 deg view.
Page 4
When should you order an MRI?
Locking
Causes of Locking:
• Displaced meniscus tear
• Loose body
• Swollen knee
• Fragment of torn ACL
A block to full extension.
Can flex
Page 5
Management
of the
ACL Deficient Knee
Epidemiology:
Natural History of ACL Tear:
• Approx. 125,000 ACL tears and
• Twisting injury and pop
• Immediate swelling
• Repeated giving way and effusions
40,000-60,000 MCL tears per year.
• Female:male gymnasts/basketball players:
–
3-4 times higher incidence in females.
Page 6
“Office Sprain”
“Telephone” Diagnosis
• 72% are ACL tears
• Exam substantiates Dx
• No longer immobilize and
“pray”
Fluid in Joint:
•Immediate = blood
•After 24 hours = effusion
Page 7
Knee Model mpg2
Knee Model mpg 1
Acute ACL Tear:
• Lachman test
• Pivot shift or Losee test
• Arthrometer measurements
• MRI for assessment of menisci
Page 8
Joint Immobilization:
• Muscle atrophy
• Adhesions and joint stiffness
• Decreased ROM
• Cartilage degeneration
• Ligament strength deterioration
Eriksson: Early Motion (mpg 1)
Eriksson: Early Motion (mpg2)
Page 9
Losee, Lachman, Pivot Shift Tests
Losee Test
• A “gentle” test compared to pivot shift.
• Most useful if MCL and ACL torn.
Non--operative treatment
Non
Anterior Drawer:
of the
May miss up to 50% of
ACL deficient knee
acute ACL tears
Page 10
Aggressive rehabilitation:
Don’t do this!
• Early return of motion
• Hamstring strengthening
• Closed kinetic chain quads
Rule of Thirds:
• 1/3 can play recreational sports
• 1/3 cannot play recreational sports
• 1/3 have symptoms with ADL
Page 11
Sequelae of ACL Tear:
• Meniscal tears in 30-95%
• Late arthritis
Page 12
If a patient wants to have the best
Braces decrease, but do not
chance of having a more normal
eliminate anterior subluxation
(stable) knee, then ACL
reconstruction is the best choice.
ACL Reconstruction:
Rx of MCL Tears:
Delay surgery approx. 6-8 wks until
close to FROM obtained, swelling
Non-operative
down, and strength returned.
Success rate: 90-95%
Page 13
Medial Collateral Ligament
Injuries:
• Tenderness and swelling over medial aspect
of knee.
• Medial opening with valgus stress at 30
degrees flexion: Grade 0-3 +.
• Beware of ACL injuries in grade 3 lesion.
Rehabilitation of MCL Injury:
• FROM in hinged brace (wear it 24/7).
• Wt bearing as tolerated.
• Progressive strengthening and agility
program.
• Return to sports at 5-9 weeks.
Page 14
Torn Meniscus
Partial meniscectomy
versus
Meniscal repair
• Typically twisting or hyperflexion injury
– With or without a pop
• Joint line pain and tenderness
• Swelling
• Clicking or catching
• Locking or giving way
Post--meniscectomy Patient:
Post
• Should not jog or run
• Try speed walking
• Encourage bicycling
• Working out is okay
Page 15
PCL
Posterior Cruciate Ligament
• 3% - 20% of all knee ligament injuries.
(PCL)
• Associated injuries common.
Quad Active Test
Mechanism of Injury:
• Posterior force to anterior tibia (dashboard).
• Hyperflexion, hyperextension, twist.
Page 16
Natural Hx & Rx Controversial:
Lateral Collateral Ligament
Surgery for some combined injuries,
(LCL)
rarely for isolated PCL tears.
Lateral Collateral Ligament
• Increased varus laxity at 30 degrees flexion.
Cysts About the Knee
• Non-operative Rx common.
• Surgical exploration and primary repair for
combined injuries.
Page 17
Popliteal Cysts
Secondary to intra-articular
pathology
Page 18
Patellar Tendinitis
(“Jumper’s Knee”)
Patellar tendinitis
•
•
•
•
•
•
•
Page 19
Rest
Ice
NSAID’s
No OKC quadriceps exercises
Quadriceps stretching
No steroid injections
Surgery only if non-op Rx fails
Chondromalacia Patella
Patello-Femoral Joint
(“Runner’s Knee”)
Page 20
Lateral Patellar Facet
Compression Syndrome
• Tight lateral retinaculum.
• Patellar tilt without subluxation on 30 or
45 deg. views.
• Consider lateral retinacular release for
patients failing nonoperative treatment.
Page 21
Exercise within one’s envelope of
Physical therapy may help.
tolerance
Patellar Dislocation
Page 22
Surgical Options
Lat. retinacular release combined with:
– Medial reefing,
or
– Distal tibial tubercle transfer surgery
• Ice (rarely heat).
Steroid Injections
• NSAID’s.
• Rest or reduction of the aggravating activity.
Pros and cons
(No more than 3/yr)
• Strengthening program begun when the pain
has subsided.
• Slow resumption of activities and sports.
Page 23
Rehearsal: 23 min
+
6’40” videos = 30 min.
Time allotted: 30 min.
Videos
McCallum
13”
Knee model
29”
Losee-Lachman
1’20”
Eriksson interview
Quad active test
4’28”
18”
Patellofemoral crepitation
Total:
56”
7’44”
(=6’39”)
Page 24
Salves, Tiger Baum:
Not proven effective
Page 25
Overview
• ACL
• MCL
• PCL
• LCL
• Meniscus
• Patello-Femoral
Page 26
Arthrometer Measurements:
• Difference of 3 mm or more on manual
maximum or 40 lb testing is associated
with a torn ACL in >90% of cases.
• In my hands, more accurate than MRI.
Cutting (lateral movement)
may still be a problem
Page 27
It’s an outpatient
Non-operative treatment frequently fails
to produce successful outcomes.
procedure
Graft Choice
• Hamstrings (Semitendinosis, Gracilis)
• Bone-patellar tendon-bone autograft
• Central quadriceps tendon
• Allografts
Page 28
PCL
Mechanism of Injury:
• 3% - 20% of all knee ligament injuries.
• Posterior force to the anterior tibia.
• Associated injuries:
• Hyperflexion.
– ACL 75%
• Hyperextension (combined with ACL injury).
– MCL 50-80%
• Varus or valgus rotation (combined with
– Menisci 30-75%
collateral ligament and ACL injury).
– LCL 10%
Page 29