Evaluation and Management of
Knee Issues in the Primary
Care Setting
Sheila M. Algan, M.D.
Clinical Associate Professor
Department of Orthopedic
Surgery
Topics
Tips on Evaluation and Management
Appropriate testing
Case Presentations
History
Age
Gender
Occupation / Sport
Inciting injury
Symptoms
Treatments
Knee Exam
General/ Gait
Neurovascular
Skin
Effusion
Ligamentous
Meniscal
Patellofemoral
Knee Exam
Effusion:
– Sweep test
– Suprapatellar pouch ballotment
Ligamentous:
– Lachman’s
– Varus/valgus stress
– Anterior/posterior drawer
– Dial test
– Posterolateral drawer
Knee Examination
Meniscal:
– Joint line tenderness
– Mcmurray’s
Patellofemoral
– Ober’s
– Patellar mobility/apprehension
– J tracking
– Patellar tilt
– Plica
– Popliteal angle
Which of the following is the
best test to diagnose ACL tear?
1.
2.
3.
4.
5.
Anterior drawer
Posterior drawer
Ober’s test
Lachman’s
McMurray’s
Radiographic Evaluation
Adult:
– PA Flexed Standing* view of both knees
– Lateral of involved knee
– Bilateral sunrise views
Child:
– AP + lateral + sunrise
– “tunnel” view (supine w/ knee flexed 20
degrees)
– *nonweightbearing for acute injury
Which of the following best describes
rationale for plain x-rays in children with
acute knee injury?
1. May demonstrate physeal
fracture
2. Too swollen for MRI
3. Less ionizing radiation than MRI
4. Patient won’t lie still for MRI
Radiographic Evaluation
MRI, if you suspect:
– Cruciate/collateral tear
– Acute meniscus tear
– Osteochondral injury
– Patellar dislocation
– AVN
– Unexplained effusion (think PVNS)
– Suspicious lesion in bone (ie poorly
defined enchondroma, lytic lesion etc)
Radiographic Evaluation
CT
– Peri-articular fracture
– MRI contra-indicated
– Bone lesion
Which of the following scenarios
is best evaluated by MRI
1. suspected tibial plateau fracture
in 35 yo
2. ACL tear in 15 yr old
3. 75 yr old with intermittent knee
pain for 6 months
4. Anterior knee pain present for 3
months in an 11 yr old
RK
11 yo boy w/ 5 month h/o lateral
knee pain and popping after injury
playing football
Exam
– No effusion
– Tender lateral femur and knee
– FROM
– Stable ligaments
RK intra-op
RK post-op
KB
15 yo male soccer player w/ pain and
popping medial knee x 1 yr
No specific injury
Exam:
– No effusion
– Stable ligaments
– Tender medial joint line
– Negative mcmurrays
Osteochondritis Dissecans
History
– “spontaneous” vs traumatic
– +/- Swelling (Effusion)
– +/- Mechanical sx
– Pain
Exam
– +/- Effusion
– +/- Block to motion
– +/- Loose fragment
OCD- Management
If loose fragment or locked knee,
refer to Ortho (urgent-1 week), knee
immobilizer, nonweightbearing
If nondisplaced fragment, restrict
weight-bearing, hinged knee brace,
refer to ortho (routine)
Check vitamin D
Case #2
History
– 20 yo male soccer player struck at medial
aspect of knee 2 days ago. He was unable to
continue play, knee swelled, felt unstable
Exam
–
–
–
–
Soft tissue swelling, ecchymosis lateral
Grade 3 varus laxity
Decreased ROM
Tender fibular head
mri
AS
17 yo male heavyweight wrestler had
opponent take him down, injured left
knee
Exam:
– obvious deformity
– unable to examine due to pain
– Pulses intact
Collateral Ligament Injury
History
– Injury event
– Localized swelling, pain (not effusion)
– Usually cannot continue event
(instability)
Exam
– Varus/valgus laxity
– Min effusion but localized swelling,
ecchymosis
– Tender to palpation
Collateral Ligament tearManagement
Grade 1:
– crutches until pain free, hinged knee brace for
sports x 6 weeks, progress sports participation
based on symptoms
Grade 2:
– crutches until pain-free, hinged knee brace for
ambulation x 4-6 weeks, PT; usually out of
sports 3-6 weeks; progress based on stability,
symptoms; protect w/ functional sports type
brace for 3 months, refer to Ortho (urgent—
should be seen within 1 week) for LCL
Grade 3:
– Urgent referral to Ortho (seen w/i 1 week)
Patients with an acute knee dislocation
should have all of the following except:
1. neurologic exam
2. check pulses
3. immediate CT angiogram
4. ankle-brachial index
5. attempted reduction as quickly as
possible
Case #3
History
– 48 yo woman involved in MVA, knees hit
dashboard. Rt knee painful, unable to
move actively, swollen
Exam
– Knee pos swelling, abrasion ant knee,
unable to perform straightleg lift,
+posterior sag, +post drawer
xray
PCL Tear- Management
Be alert for posterior knee dislocation
Knee immobilizer/ crutches until leg
control
PT for ROM, strengthening
Refer to Ortho (routine)
Case #4
History
– 27 yo female w/ 6 month history of
anterior knee pain
– No injury
– No swelling
– No locking, catching, giving way
Case #4
Exam
– No effusion
– Stable ligamentous exam
– Positive passive patellar tilt
– Positive Ober’s test
– Tender lateral patellar facet
– Slight crepitation
– 40 deg popliteal angle
Which of the following should be considered
with a dashboard injury?
1.
2.
3.
4.
5.
PCL tear
bimalleolar ankle fracture
patellar fracture
meniscus tear
A & C above
YW
14 yo female felt R kneecap pop out
while jumping on trampoline 3 weeks
ago, feels something moving around
in knee
Exam:
– Effusion
– Limited ROM
– Stable ligaments
– Joint lines nontender
What is the next best step?
1.
2.
3.
4.
rest, ice, elevation
physical therapy
MRI knee
CT knee
LSM
12 yo female soccer player w/
anteromedial popping and pain; no
major injury, has fallen on it a few
times
Exam:
– No effusion
– FROM, stable ligaments
– Painful, pop anteromedial knee
Patellofemoral Tracking Problems
History
– Anterior pain
– Occ patellar instability
– Rarely effusion
Exam
–
–
–
–
–
Min effusion
J tracking
Pos passive patellar tilt
Pos Ober’s
Pos popliteal angles
Patellofemoral tracking problemsManagement
Pain only: PT, taping, patellar brace
– (If isolated lateral patellar overload, may consider lateral
release, rarely needed)
Lateral subluxation:
– as above; rehab for 4-6 months minimum, if still
symptomatic, refer for surgical mgt (routine)
Patellar dislocation
– Acute, 1st episode: knee immobilizer x 3 weeks,
therapy, patellar brace; refer to Ortho (routine unless
loose fragment), MRI
– Recurrent: PT, knee brace, refer to Ortho (routine)
Which of the following is most likely true of
anterior knee pain?
1. It will cause a life time of knee
problems
2. It leads to early arthritis
3. It responds well to therapy
focused on hip strength
4. There is usually a structural
problem identified on MRI
Case # 5
History
– 54 yo woman w/ left knee pain for
years, intermittent
– Some swelling
– No locking, giving way
Case # 5
Exam
– ROM: -5 to 125
– Stable ligaments
– Tender medial joint line
– Trace effusion
– Neg McMurray’s
xray
KL
35 yo female w/ 5 yrs of bil knee
pain; no injury. No mechanical sx.
Some swelling w/ activity
Exam:
– Overweight, mild varus
– ROM 0-125, No effusion
– Stable ligaments, Joint lines nontender
– Pos PF crepitation, neg mcmurrays
EC
54 yr old female w/ many yrs of right
knee pain; poor historian otherwise
Exam:
– Mod overweight, valgus r knee, severe
limp (walking aid)
– ROM very limited by pain
– Mild valgus laxity
Osteoarthritis
History
– Pain
– Swelling
Exam
– Varus or valgus alignment +/- thrust
– Effusion small
– Loss of motion
– Joint line tenderness
Osteoarthritis- Management
1st line treatment
–
–
–
–
–
–
EDUCATE patient
Weight loss
Glucosamine, chondroitin,
Tylenol
NSAIDS
Physical therapy: land/water exercise program, brace
2nd line treatment
– Cortisone: may repeat q 4-6 months
– Viscosupplementation**
3rd line treatment
– TKR
– UKR
Which of the following is true of
osteoarthritis of the knee?
1. MRI is usually needed to make
the diagnosis
2. nonweightbearing films are a
sensitive test for knee arthritis
3. Glucosamine and
viscosupplementation injection are
well-supported in the literature
4. Physical therapy is a well
supported treatment in the literature
Case # 6
History
– 44 yo woman w/ 6 month history of
lateral knee pain
– Positive clicking, no locking
– Some swelling
– Worse w/ squatting, running
Case # 6
Exam
– Full ROM
– Tender lateral joint line
– Pos McMurray’s
– Stable ligaments
– No effusion
xray
JL
15 yo male multisport athlete twisted
knee playing baseball; had some
trouble in fall, but resolved
uneventfully. Pain med joint line,
click
Exam:
– Small effusion, stable ligaments
– Tender medial joint line, pos mcmurrays
Meniscus tear
History
– Acute: event, swelling, mechanical symptoms,
joint line pain
– Degenerative: +/- event, swelling, mechanical
symptoms, joint line pain
Exam
–
–
–
–
Effusion
Joint line tenderness
McMurray
Rarely locked joint (can’t fully extend)
Meniscus Tear- Management
Crutches as needed
Refer to Ortho (routine) for acute
Refer to Ortho (urgent) for locked
meniscus
PT for strengthening if degenerative
tear in middle aged patient w/
minimal mechanical sx
Case # 7
History
– 42 yo male soccer coach stepped over
ball, landed “funny”
– Unable to continue
– Knee swelling
Case # 7
Exam
–
–
–
–
ROM 10-80 deg
pos effusion
pos Lachman’s
pos pivot shift
mri
Meniscus tear is likely to be the source of
symptoms in which of the following patients?
1. An 11 yr old female w/ popping at
the anteromedial knee
2. A 12 yr old boy w/ pain at the
tibial tuberosity w/ sports
3. A 63 yr female w/ pain at the
medial knee
4. A 27 yr old male w/ painful
popping at the lateral joint line
KB
16 yo male, h/o OCD, slide tackled
playing soccer, knee shifted, swelled,
painful, no mechanical sx
Exam:
– Pos effusion, limited ROM 5-85 deg
– Pos lachman’s, stable varus/valgus
– Joint lines nontender
ACL tear
History
– Acute (recent) event
Contact
Noncontact
– Swelling (Effusion)
– Inability to continue event
– Event in past w/ recurrent giving way
and swelling
ACL tear
Exam
– (Drop-leg) lachman
– Effusion
– Pivot shift
– Decreased ROM
– Anterior drawer
ACL tear- Management
crutches until leg control
PT for ROM, strengthening
Refer to Ortho (urgent-routine)
Case # 8
History
– 14 yo football player sent to your office
by the trainer day following injury
– Trainer suspects grade 3 MCL tear
Exam
– Very swollen above knee and
suprapatellar pouch
– Tender to palpation distal femur
l
Peri-articular/ Physeal Fractures
History
– Acute injury
– Inability to bear weight
– “Instability”
– Swelling
Physical Exam
– Swelling, ecchymosis
– Tenderness
– +/-Deformity
Physeal Fractures
Nonweightbearing, crutches, knee
immobilizer
Ortho referral (urgent)
Which of the following is true for acute knee
injury in a skeletally immature athlete with
knee swelling?
1. Soft tissue swelling will obscure
any findings on xray
2. An immediate MRI is the imaging
study of choice
3. Physeal fractures rarely occur
4. AP/lateral knee xray should be
obtained prior to stressing the knee
Conclusions
Systematic/ algorithm approach
Tailor exam to history
Follow evidence-based guidelines
Call with questions!
Contact information
Pager: 559-2028
Clinic: 271-BONE
Office: 271-4426
Email: sheila-algan@ouhsc.edu
Questions?
Thank You!