Why pay attention today?
MS problems account for 30% of office visits MS teaching accounts for 3% of Top 5 4 knee problems: med school A rational approach to knee pain • 1% of internal medicine Primary Care Sports Medicine 2015 curriculum • 56% Primary Care not Brian Feeley, MD prepared for MSK Associate Professor, Sports Medicine and Shoulder Surgery UCSF Department of Orthopaedic Surgery ‒ AAOS 2014 12/11/2015 MRI is most commonly ordered imaging modality from primary care/IM for MS complaints
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Goals for this presentation Knee anatomy-keep it basic MCL Differential Diagnosis of Knee Problems Understand common knee problems Cartilage ACL • Common symptoms • Acute or degenerative (arthritis) PF Pain • Imaging modalities—when to/not to use them Meniscus • • Treatment options Acute or degenerative (arthritis) Evidence-based approach ACL Meniscus Recent high quality literature (when Collateral Ligaments available) Extensor Mechanism • Acute or activity related Arthritis All others are rare!
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1 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] Case 1 Arthritis is a big problem 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 ARTHRITIS is COMMON! says his knee sometimes swells. 75% • 33% of all adults have arthritis What is his most likely diagnosis? ‒ 70 million people with arthritis A. Osteoarthritis ‒ 50% over the age of 65 have arthritis B. Meniscus tear 16% • Arthritis is more common in women C. Patellofemoral pain 8% D. Hip arthritis 1% • Arthritis prevalence increases with age
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Understanding Arthritis Understanding Arthritis
The articular changes found are IRREVERSIBLE (mostly)
Cartilage properties Normal Cartilage Arthritis Cartilage
Few cells Super smooth Cannot make more cartilage Healthy cartilage Advanced Arthritis No nerve endings Don ’t feel joints move Don ’t sense early Early Arthritis back and forth damage to the cartilage Best way to explain arthritis to patients seems to be this tire analogy.
2 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] History-Osteoarthritis Physical Exam-Osteoarthritis
Symptoms of arthritis Physical Exam findings • Pain—’achy’ • Deformity • Swelling/effusion • Crepitus (grinding, popping) • Loss of range of motion • Loss of range of motion • Deformity 56 year old male with a 7 month history of moderate knee pain , gradually worsening, and described as ‘ achy ’. • Tenderness along the joint line He had a meniscus surgery 4 years ago which helped for a while. He used to run, now mainly biking and • Inability to exercise/performswimming daily. Pain activities/wor is medial, neark the joint line. He says his • Weight gain knee sometimes swells . • Depression
Imaging-Osteoarthritis Imaging-Osteoarthritis
Do I need an MRI? • Advanced arthritis, in general no (get an Xray first and DON’T get an MRI) • Early cartilage injuries yes • Early arthritis maybe yes
Mild arthritis Moderate arthritis Severe arthritis
Get STANDING weight bearing views, bilateral to compare
3 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] Treatment options for arthritis
Summary: both use MRI, possibly better used by ortho Still use it too often for patients with advanced OA 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) Bracing/Unloading Surgeons were less likely than PCPs to order MRIs for patients with substantial osteoarthritis who subsequently underwent total knee arthroplasty (4.3% versus 9.2%; p = 0.048).
1. Activity/Lifestyle changes 1. Activity/Lifestyle changes
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4 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 1. Activity/Lifestyle changes 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 Markers of cartilage turnover Lead to less knee pain And breakdown are decreased After bariatic surgery
IDEA Trial (NIH/NIA) 1. Activity/Lifestyle changes 2. Physical Therapy
What about mild weight loss? Does physical therapy work for patients with knee osteoarthritis?
No single PT intervention was bestbest…aerobic Aquatic,A strengthening worked well
Gimmicky things—didn’tthings didn’t work well (magnets, Orthotics,O ultrasound) Wang et al, AIM 2015
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5 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 2. Physical Therapy 3. Orthotics for Osteoarthritis
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
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4. Injections for Osteoarthritis 4. Corticosteroid Injections Risks: Not Risks: • Can kill cartilage cells • Will not turn you into this: ‒ Lidocaine and steroid • Transiently increase blood sugar
Healthy cartilage Cartilage cells cells After lidocaine UCSF Orthopaedic Research
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6 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4. Viscosupplementation 4. Corticosteroid Injections
Summary:
Favors Steroid
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4. Viscosupplementation 4. Viscosupplementation
Viscosupplementation (Synvisc, Euflexxa) Who does it work for? • Lubricates and cushions joint • Mild to moderate arthritis • Made from a natural substance similar to healthy joint fluid • Already on an exercise/weight loss program but with continued pain Improves viscosity • Low to moderate demand activities ‒ Limit high impact sports (running) • Increases molecular weight and quantity of synovial fluid synthesized by the synovium Decrease pain (mechanism uncertain) • Decreases inflammatory mediators?
7 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4. Injections 4. Injections
“The expert achieved unanimous agreement in favor of NEJM-2015 the following statements: VS is an effective treatment for mild to moderate knee OA; VS is not an alternative to In this clinical setting of a prevalent disabling disease, for which the therapy surgery in advanced hip OA; VS is a well-tolerated in question has, at best, modest efficacy for relief of pain, the tolerance for treatment of knee and other joints OA” 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.
Conclusions— mild benefit, often less than MCID May be worth trying in younger people with OA, mild disease
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4. Injections—What’s next? 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 3 meta-analyses Works better for people with less arthritis Higher rate of side effects
Limited data, mildly promising
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8 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] Knee Replacement Knee Replacement
Final common pathway for all people with moderate to severe arthritis 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
3 months Knee ‘75% 1 year ‘98% Surgery better’ better’
6 weeks 6 months ‘50% ‘90% better’ better’
9 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] CASE 2 History--Meniscal Tears 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 Classic descriptions over the next few days. He notes pain along the joint line with squatting74% and climbing up and down stairs. The most likely diagnosis is: • Swelling after event, usually able to continue • Pain with activity A. Meniscus tear • Joint line soreness B. Patellar tendon rupture 20% • Lower level of activity C. Chondromalacia patella/patella maltracking 4% 2% • Able to pinpoint pain D. Anterior Cruciate Ligament Tear
Physical Exam—Meniscus Tears Imaging-Meniscal Injury
Rational exam steps • 1. Joint line tenderness • 2.Thessaly (or apley) test • 3. Deep squat • 4. Duck walk
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10 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] Treatment options for meniscus tear Non operative management for degenerative meniscus tears Active, younger person Refer for surgical evaluation
54 years, no difference in functional or clinical outcomes at 2 years Acute vs Chronic
Active, older person PT, activity modification In the intention-to-treat analysis, we did not find significant differences between the study groups in functional improvement 6 months after Sedentary, older person randomization; however, 30% of the patients who were assigned to physical OA on Xray imaging therapy alone underwent surgery within 6 months.
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Management of degenerative meniscus tears Meniscus Tear Treatment
Treatment based on mechanical symptoms of 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) “No differences at 1 year in the intent to treat group” often are treated with physical therapy and injections
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11 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] Outcomes of meniscus debridement Meniscus tears—what not to miss (Dr. Ma’s Talk!) Excellent procedure for higher demand patients who fail non op • Pain relief immediate (no more injured cartilage) • Good range of motion Bucket handle tears Meniscus root tears • 90-95% good to excellent results at 10-15 years ( Syndgard KSSTA 2013) • Locked knee • Older patient (50-65) • Often with ACL tear • Often prodromal period 6 weeks Knee ‘75% 1 year ‘98% • Younger (<40) more active • Acute worsening with swelling Surgery better’ better’
Crutches, refer immediately Protected weight bearing, refer to 1 week 12 ortho immediately ‘50% weeks‘90% better’ better’
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Case #3 Case #3 A 41 year-old, 210 pound male presents complaining of bilateral knee pain, 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, 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 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 faint91% swelling might “give out” on him while walking down the stairs. He has faint90% swelling on occasion. The most likely diagnosis is: on occasion. The most likely diagnosis is: A. a Meniscus tear A. a Meniscus tear B. b Anterior Cruciate Ligament tear B. b Anterior Cruciate Ligament tear 9% 10% C. c Patello-femoral maltracking/pain 0% 0% C. c Patello-femoral maltracking/pain 0% 0% D. d Patellar dislocation D. d Patellar dislocation
12 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] History of patellofemoral problems Physical Examination If exam is not reliable, how to I test?
Normal body habitus / + ligament laxity Often bilateral pain Squat 90 deg-pain anterior Anterior/anteromedial pain SLS Video No specific tenderness Pain with down stairs/hills Can have quad atrophy Can be associated with changes in activity Possible mild effusion Pronated feet No specific injury mechanism tight hamstrings and IT band Poor Core stability
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Etiology of Patellofemoral pain Radiographs? MRI? Non-modifiable risk factors Modifiable risk factors Valgus knees (exam) Weight Useful to rule out other factors, but usually negative. Trochlea hypoplasia (x-ray) Core stability --I would recommend start with PT with no swelling Foot Pronation Flexibility --MRI if patients fail PT, have swelling Activities Chondromalacia very common • Shoe wear (shoe fit) Does not usually change treatment options initially • Biking (bike fit)
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13 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] Does PT work for patellofemoral pain? Does PT work for patellofemoral pain?
720 patients Both groups did better overall Rx for patellofemoral pain What do I write? PT works better and faster with hip/CORE stability 28 people randomized to hip strengthening Improvement at 6 weeks vs control-8 week program Knee ROM Hip/CORE stability exercises Pain, health status, and bilateral hip strength Modalities OK improved in the exercise group Improvements Return to sports in pain and health status were sustained at 6- Assess with single leg squat month follow-up in the exercise group.
Winter Sports 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 down89% and his knee swelled up on the way home. What is his most likely diagnosis?
A. a Meniscus tear
B. b Patellar tendon rupture 1% 5% 1% 5% C. c Chondromalacia patella/patella maltracking D. d Anterior Cruciate Ligament Tear E. e Pathologic liar-expert skiers don’t go to Boreal
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14 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] ACL Injury History--ACL injuries
History Add nml and inj MRI • Non contact, twisting • 70% hear a pop • Swelling within 1 hr • Do not return to play • Often doing well when they come into office (if more than 1-2 weeks out)
Physical Exam-ACL tear—Dr. Allen’s and Hands on Talks X-ray
Usually non-diagnostic Swollen Lack ROM Lateral Tenderness Can help rule in or out injuries Unstable on exam
Segond fracture – avulsion over Lachman Test lateral tibial plateau
15 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] ACL—MRI findings ACL Tears—Treatment options
Treatment options • Non-operative Operative Indication ‒ Low Demand People Cutting and pivoting sports High demand jobs Activity modification Young people Bracing for activity Treatment of associated injuries Lateral meniscus Cartilage injuries Medial meniscus
Summary: Outcomes of ACL injury in olderIn higher athletes level older patients Reasonable to consider ACL reconstruction
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 Tell your patients this is STILL a bad idea
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16 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 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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MCL Injury Bonus Slides Extra-Other Knee Problems
What else can go wrong in the knee? • MCL Sprain • Pes bursitis • Pre-patellar bursitis • Hamstring Injuries • ITB friction syndrome
17 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] MCL Injury MCL--History Mechanisms: Patients will have medial sided pain Hit on outside of knee Pain when foot gets caught in covers, lifting knee May be associated with tears of the ACL and the medial Tenderness usually along the femoral attachment meniscus, or patella dislocation, but is often an isolated Swelling not as common 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 70 12/11/2015 Ligament injury in the knee
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)
18 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] Patellar Tendinitis Iliotibial Band Tendinitis Pain and snapping over •Pain at tendon insertion into kneecap outer aspect of knee •Due to eccentric load in running Very common in runners (running down hills), repetitive jumping Due to overtraining, tight (basketball), weight lifting IT band. Hip adduction & internal rotation, and knee •Pain with squat, stair climbing extension during running •Pain with palpation of tendon tighten IT band and accentuate snapping •Tight hamstrings
Iliotibial Band Tendinitis Pes Bursitis
Treatment: Pain at hamstring insertion •IT band stretching Often with swelling at attachment Treatment •Ice ice massage •NSAIDS Hamstring stretching •Cortisone injection (rare) Avoid offending activity •Orthotics •Address biomechanics/PT
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19 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] Other locations for pain: Treatment with rest/PT
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