Sports KneeOrthosports Injury Effusions MRI Orthosports
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Orthosports Sporting Knee Effusions and MRI Learning Objectives
•Anatomy Orthosports •History Taking • Clinical Examination Orthosports •Imaging Orthosports •Treatment Orthosports • Effusions •WhenOrthosports to refer
Orthosports Sporting Knee Effusions and MRI Anatomy Orthosports
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Orthosports Sporting Knee Effusions and MRI Anterior Patella Removed
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Orthosports Sporting Knee Effusions and MRI Flexed Lateral
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Orthosports Sporting Knee Effusions and MRI Chondral Cartilage Orthosports
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Orthosports Sporting Knee Effusions and MRI Cartilage
Orthosports •Type II collagen Orthosports •Cross linked type IX collagen • 80% water Orthosports •20Orthosports‐40% dry weight of glycosaminoglycans • Chondrocytes and a composite gel •No Orthosportsblood supply
Orthosports Sporting Knee Effusions and MRI Outerbridge Classification
•1‐ softening of cartilage •2‐ fibrillation superficial Orthosports •3‐ fibrillation down to subchondral bone •4‐ exposed bone Orthosports
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Orthosports Sporting Knee Effusions and MRI Meniscus Orthosports
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Orthosports Sporting Knee Effusions and MRI Meniscus - Anatomy
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Orthosports Sporting Knee Effusions and MRI Structural Anatomy
• Type I collagen Orthosports – strong in tensile stress – Oriented in a circumferential directionOrthosports –Prevent radial extrusion (Radial,longitudinal & oblique) – Maintain structural integrity during load bearing Orthosports •Orthosports Lateral meniscus more important in weight bearing, more mobile too • MedialOrthosports meniscus contributes to joint stability
Orthosports Sporting Knee Effusions and MRI Meniscus ‐ Function Orthosports • Load distribution • Shock absorption Orthosports • Joint stability • Joint lubrication Orthosports Orthosports
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Orthosports Sporting Knee Effusions and MRI Meniscal Function Orthosports • Lateral meniscus covers 76% of the Orthosports articular cartilage Orthosports •Orthosports Medial meniscus
covers 60% Orthosports
Orthosports Sporting Knee Effusions and MRI Meniscal Function
• Load transmission Orthosports –45 – 50% load transmitted to menisci in extension – 85% load transmitted to menisci inOrthosports flexion – Medial side, MM and MTP share load – Lateral side, LM takes 80% load Orthosports Orthosports
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Orthosports Sporting Knee Effusions and MRI Mechanical Function Orthosports –Removing MM decreases contact area MFC by 50 – 70% Orthosports • 100% stress increase on MTP Orthosports Orthosports–Removing LM 45 – 50% decrease in contact area Orthosports• 235 – 335% increase in local contact pressures LTP
Orthosports Sporting Knee Effusions and MRI Swelling and Meniscus Tears Orthosports • Isolated meniscal tears do not cause recurrent swelling Orthosports
•If the knee is swollen there is almostOrthosports Orthosportscertainly chondral damage
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Orthosports Sporting Knee Effusions and MRI Knee Biomechanics
•ACL is primary stabiliser Orthosports • Menisci secondary stabilisers –Medial meniscectomy •ACL‐intact ‐ little effect on AP motion Orthosports •ACL‐deficient ‐Increased AP translation up to 58% at 90° of flexion. Orthosports •HingeOrthosports joint ‐ only slight rotation and translation possible • SynovialOrthosports layer secretes fluid – Lubrication and nutrition for articular cartilage.
Orthosports Sporting Knee Effusions and MRI History Taking
• Activity level Orthosports • Employment • Pain profile Orthosports • Joint profile Orthosports • Functional profile Orthosports • Remember referred pain Orthosports – Back or Hip
Orthosports Sporting Knee Effusions and MRI Pain
• Location Orthosports •Rest •Night Orthosports • Stair climbing Orthosports •After sitting PF jt involved Orthosports • Squatting •BarometricOrthosports pressure changes
Orthosports Sporting Knee Effusions and MRI Symptoms Orthosports • Swelling •Catching Orthosports • Instability •Onset of symptoms Orthosports Orthosports
• ResponseOrthosports to prior treatment
Orthosports Sporting Knee Effusions and MRI Giving way
Primary Instability SecondaryOrthosports Instability •Joint actually gives way •Pain within the joint. –Ligament deficiency – QuadsOrthosports relax involuntarily –Not painful but knee –Leg buckles hurts afterwards /swells –SensationOrthosports of giving way –Orthosports Repeated giving way –Remove the pain = no leads to arthritis. giving way Orthosports –Meniscal tear, loose body, arthritis, or synovitis.
Orthosports Sporting Knee Effusions and MRI Giving way
Primary Instability SecondaryOrthosports Instability • Surgery required to fix • Generally not causing the problem furtherOrthosports damage –ACL • Patella subluxing can be –PCL felt as givingOrthosports way –LCLOrthosports • Giving way often non‐ –PLC specific –PFJOrthosports – Loose bodies, patellar chondromalacia, and quads weakness Orthosports Sporting Knee Effusions and MRI Patella Orthosports
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Orthosports Sporting Knee Effusions and MRI Patella Stability Orthosports • Bones most important structures • Quads also important Orthosports
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Orthosports Sporting Knee Effusions and MRI Patella Dislocation Orthosports •Direct blow or twist •Often hear two clicks Orthosports • Notice lump •May require hospital reductionOrthosports •Orthosports Predisposing factors
– Shallow trochlear Orthosports –Femoral torsion – Patella Alta Orthosports Sporting Knee Effusions and MRI Patella Dislocation
Orthosports •Xrayfor fracture •Rice Orthosports • Splint 1‐2 weeks comfort •Physio Orthosports •Orthosports Quads strengthening
•RarelyOrthosports require surgery
Orthosports Sporting Knee Effusions and MRI Patella Dislocation ‐ Earlier Referral
•Dislocation and large effusion or crepitus implies articular cartilage damage Orthosports •>3 dislocations •Audible crepitus Orthosports • Mechanical symptoms Orthosports • These days surgery more reliable and smaller Orthosports
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Orthosports Sporting Knee Effusions and MRI Extensor Mechanism Orthosports
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Orthosports Sporting Knee Effusions and MRI Extensor Mechanism Orthosports • Quadriceps or patella tendon rupture • Unable to straight leg raise Orthosports • Tenderness • Defect Orthosports Orthosports
• EarlyOrthosports referral
Orthosports Sporting Knee Effusions and MRI Medial & Lateral Jt Line Pain Orthosports • Meniscus • Articular cartilage Orthosports •MCL •Avascular necrosis Orthosports •Orthosports Plica
•BursaOrthosports • Tib fib joint • ReferredOrthosports Sporting Knee Effusions and MRI Anterior Knee Pain Orthosports • Chondromalacia • Subluxation Orthosports • Maltracking •Traumatic Orthosports •NonOrthosports specific
–(see overuse later) Orthosports
Orthosports Sporting Knee Effusions and MRI Anterior Cruciate Ligament Orthosports
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Orthosports Sporting Knee Effusions and MRI ACL Orthosports • Controls 90% of stability to anterior displacement of the tibiaOrthosports • Varus, valgus, rotational restraint • Anteromedial bundle tightens Orthosportsin flexion Orthosportsand the posterolateral becomes lax
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Orthosports Sporting Knee Effusions and MRI ACL ‐ HISTORY Orthosports • Usually twisting injury •Older patients often no trauma Orthosports • Swelling several hours later or next day •Pain Orthosports •ClickingOrthosports •Locking • GivingOrthosports way • Swelling ‐effusions only 50% cases
Orthosports Sporting Knee Effusions and MRI ACL
•Best time to examine isOrthosports immediate •Worst is 3‐7 days •No need for urgent referralOrthosports •Not everyone needs surgery Orthosports •No harm at all in watching the older Orthosports patients to see if they have instability
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Orthosports Sporting Knee Effusions and MRI Refer Earlier If
• Competitive sports Orthosports • Articular surface damage particularly Orthosports patellofemoral and medial compartment •Medial meniscus loss Orthosports •HeavyOrthosports people who are more likely to stretch secondary restraints •VarusOrthosports alignment •Younger
Orthosports Sporting Knee Effusions and MRI ACL – Operate if: Orthosports • Giving way with activities of daily living •Want to get back to pivotingOrthosports sports •Meniscal injury Orthosports BestOrthosports to have relatively full painfree ROM prior to surgery Orthosports
Orthosports Sporting Knee Effusions and MRI ACL Orthosports
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Orthosports Sporting Knee Effusions and MRI Locked Knee •True locking is lack of 10 –15 degrees of extension Orthosports •Not unable to flex •Try and work out if it is a mechanicalOrthosports block or pain Orthosports • Patella pathology often mimics locked Orthosportsknee
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Orthosports Sporting Knee Effusions and MRI MCL • Common from acute trauma. –Misstep / collision Orthosports –Valgus stress – Immediate pain and swellingOrthosports • Point tenderness medial joint line / mcl Orthosports 0 •Orthosports Valgus stress at 30 reproduces pain • Clearly defined end point = grade 1 or gradeOrthosports 2 sprain • Complete medial instability = full rupture or gradeOrthosports 3 sprain Sporting Knee Effusions and MRI MCL Injury: Grades Orthosports • Usually secondary to Orthosports valgus strain •Grades I, II & III Orthosports Orthosports
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Orthosports Sporting Knee Effusions and MRI LCL
•LCL injury <<< MCL Orthosports •Varus stress to the knee – Runner plants one foot and turnsOrthosports toward the ipsilateral knee. •Acute onset of lateral knee painOrthosports / stop the Orthosportsactivity • Point tenderness at lateral joint line. • InstabilityOrthosports or pain occurs with varus stress testing of the knee at 30 degrees. Orthosports Sporting Knee Effusions and MRI Overuse Syndromes • Lateral Knee Pain – Aggravated by activity Orthosports • Running downhill and climbing stairs. • Excessive friction between the Orthosportsiliotibial band and the lateral femoral condyle •Commonly occurs in runners and cyclists,Orthosports •Orthosports Tightness of the iliotibial band, excessive foot pronation, genu varum, and tibial Orthosportstorsion
Orthosports Sporting Knee Effusions and MRI Overuse Syndromes (cont)
•PF pain syndrome (chondromalaciaOrthosports patellae) –Vague history of mild to moderate pain –After prolonged sitting Orthosports •Almost always tight hamstrings Orthosports Orthosports •Treatment – PhysiotherapyOrthosports to stretch the hamstrings and unload the patellofemoral joint
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Orthosports Sporting Knee Effusions and MRI Children –Most Commonly • Patella instability •Anterior knee pain Orthosports • Osgood schlatters •OCD Orthosports
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Orthosports Sporting Knee Effusions and MRI Children ‐ Don’t miss these Orthosports • Referred pain from the Hip • Growth plate fractures Orthosports • Tumour • Infection Orthosports •Orthosports Inflammatory Arthritis
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Orthosports Sporting Knee Effusions and MRI Children ‐ Don’t miss these
• Referred pain from the HipOrthosports –Can have both hip and knee pathology – Restricted abduction in flexionOrthosports indicates hip pathology until proven otherwise. • Growth plate fractures Orthosports Orthosports–Isolated injury rare under 14 yrs (ligaments are stronger than the physes) •LimpsOrthosports or unable to weight bear suspect a fracture even if initial X ray is normal Orthosports Sporting Knee Effusions and MRI Kids continued Orthosports • Tumour • Present with pain, swelling or pathological fracture Orthosports •If symptoms and signs are atypical think of this • Infection (same as adult) Orthosports •Orthosports Inflammatory Arthritis
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Orthosports Sporting Knee Effusions and MRI Clinical Examination Orthosports
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Orthosports Sporting Knee Effusions and MRI Clinical Examination Orthosports •Remove socks and expose thighs Orthosports •Try standing and walking •Examine the good leg first Orthosports Orthosports
OrthosportsLOOK – FEEL ‐ MOVE
Orthosports Sporting Knee Effusions and MRI Functional Anatomy / Assessment Orthosports • Gait • Alignment Orthosports •Range of Motion •Hip Orthosports •KneeOrthosports • Ankle/Foot
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Orthosports Sporting Knee Effusions and MRI Clinical Assessment
–Body habitus Orthosports –Gait –antalgic, thrust, stiff etc – Swelling Orthosports –Scars –Muscle Wasting Orthosports Orthosports– Tenderness – Instability Orthosports – Neurovascular status
Orthosports Sporting Knee Effusions and MRI Ligamentous laxity Orthosports
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Orthosports Sporting Knee Effusions and MRI Check for effusion Orthosports
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Orthosports Sporting Knee Effusions and MRI Anterior Drawer
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Orthosports Sporting Knee Effusions and MRI PCL: Posterior Drawer Test Orthosports
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Orthosports Sporting Knee Effusions and MRI Thessaly’s test Orthosports • Patient stands on affected foot •Examiner holds pt’s outstretchedOrthosports hands •Ptrotates knee & body internally and externally three times with the Orthosportsknee in Orthosportsvariable degrees of flexion • Medial or lateral joint line discomfort or a senseOrthosports of locking or catching constitutes a positive test Orthosports Sporting Knee Effusions and MRI Orthosports
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Orthosports Sporting Knee Effusions and MRI Med Meniscus Clinical Findings
• Joint line tenderness Orthosports – Medial in cross leg position – Lateral at 300 flexion Orthosports • Pain on forced flexion Orthosports •Orthosports McMurray’s / Thessaly’s Test • Loss of extension • ClunkingOrthosports of meniscus
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Orthosports Sporting Knee Effusions and MRI Meniscus tear types
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Orthosports Sporting Knee Effusions and MRI Meniscal tears • Younger patients are moreOrthosports likely to have an acute traumatic event as the cause of their meniscal pathologyOrthosports
Orthosports •Acute ACL injury Orthosports –Lat> Med • ChronicOrthosports ACL –Med > Lat
Orthosports Sporting Knee Effusions and MRI Meniscal Tears ‐ Diagnosis Orthosports • Diagnosis made from a careful history •The onset of symptoms andOrthosports mechanism of injury are often clues to the diagnosis –Twisting injury Orthosports Orthosports– Hyperflexion • Acute pain and swelling. –PainOrthosports when kneeling or standing from sitting
Orthosports Sporting Knee Effusions and MRI Meniscal tears ‐ Diagnosis
• Locking /catching Orthosports –Also from chondral injury or patellofemoral chondrosis Orthosports • Loss of motion / mechanical block to extension Orthosports Orthosports– displaced bucket handle meniscal tear (or a loose body) – UsuallyOrthosports requires acute surgical treatment. It can also be caused by a loose body though.
Orthosports Sporting Knee Effusions and MRI Degenerative Tears Orthosports •Older patients (>40 years) – Atraumatic chronic mild jointOrthosports swelling –Joint line pain – Mechanical symptoms Orthosports Orthosports–Often associated with some chondral damage. •Try to reproduce Snaps, clicks, catches or jerksOrthosports when examining
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Orthosports •Traumatic (acute) Orthosports • Systemic disease (acute or recurrent) Orthosports •OveruseOrthosports (recurrent)
The historyOrthosports provides the diag nosis the majority of the time and is confirmed with a careful clinical examination Orthosports Sporting Knee Effusions and MRI Spontaneous Swelling
•Often the first sign of arthritis Orthosports •Tumouror infection – Systemic symptoms Orthosports • fevers or chills, intravenous drug use, sexual contact, night pain or weight loss • monoarticular arthritis with joint redness, Orthosportsswelling, pain and loss of motion Orthosports– Infiltrative disorders such as gout and pseudogout – sometimes the only way to differentiate between themOrthosports is with a joint aspiration –Most common joint involved in both benign and malignant tumors. Orthosports Sporting Knee Effusions and MRI Effusion
• Rapid onset (<2 hrs) large, tense effusion Orthosports – Lig rupture or fracture Orthosports • Slower onset (24 ‐ 36 hrs) mild to mod – Meniscal injury / lig sprain/tear /Orthosports infection Orthosports • Isolated meniscal tears do not always cause swellingOrthosports and tend to indicate some chondral damage Orthosports Sporting Knee Effusions and MRI Effusion
• Non‐traumatic Orthosports – Arthritis – Crystal deposition (gout/pseudogout) Orthosports – Infection –Tumour Orthosports Orthosports A joint effusion without trauma is a very specificOrthosports sign of joint inflammation but other symptoms include pain, warmth and erythema Orthosports Sporting Knee Effusions and MRI Crystal‐Induced Inflammatory Arthropathy
Orthosports • Gout or Pseudogout –Acute inflammation Orthosports –Pain and swelling –No trauma Orthosports • GoutOrthosports ‐ sodium urate crystals • Pseudogout ‐ calcium pyrophosphate Orthosports
Orthosports Sporting Knee Effusions and MRI Infection
• Sudden onset of pain andOrthosports swelling •No history of trauma •Warm, swollen, exquisitely tenderOrthosports • Slight motion causes intense pain Orthosports •AnyOrthosports age • Immunocompromised – (diabetes, alcoholism, AIDS, or corticosteroid therapy) Orthosports
Orthosports Sporting Knee Effusions and MRI Diagnosis
• Blood tests Orthosports • Aspiration –Crystals / organisms / cultureOrthosports (M,C&S)
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Orthosports Sporting Knee Effusions and MRI Blood Tests Orthosports • Spontaneous effusion •With normal x‐ray: Orthosports – FBC, EUC, LFTs, ESR, CRP, ANA, Rh Factor, Anti CCP, Serum Immunoglobulins andOrthosports HLA B27. Orthosports
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Orthosports Sporting Knee Effusions and MRI Is it infected? Orthosports •Elevated blood WBC, ESR and CRP – Remember Fungi, TB and LymeOrthosports disease • Fluid cell counts of 50‐100x109/L suggestive of infection Orthosports •Crystal‐induced arthritis can present in a Orthosports similar fashion as an infection
• SodiumOrthosports urate crystals precipitate in the knee joint and cause an intense
inflammatoryOrthosports response Sporting Knee Effusions and MRI Is it infection or crystals?
• Slightly cloudy synovial fluid –WBC count 2 ‐ 75 ×109/L Orthosports –Polarized‐light microscopy – Negatively birefringent rods with gout Orthosports – Positively birefringent rhomboids with pseudogout. Orthosports •The presence of crystals does not rule out an infection, as Orthosportsthe two may co‐exist –No Abs unless infection proven Orthosports
Orthosports Sporting Knee Effusions and MRI Rheumatic disease (Inflammatory)
Orthosports • Synovial Fluid 9 –WBC count 2 ‐ 50 ×10/L suggestOrthosports an inflammatory process Orthosports OrthosportsRheumatology referral within 6 weeks is recommended for patients in whom Orthosportsinflammatory arthritis is suspected
Orthosports Sporting Knee Effusions and MRI Treatment Orthosports • General measures to relieve knee pain and swelling Orthosports – Splinting, assisted weight bearing, ice packs, and NSAID’s Orthosports –No AB’s until specimens taken Orthosports –No HC if suspect infection • ArthroscopyOrthosports is rare with acute swelling of the knee without trauma
Orthosports Sporting Knee Effusions and MRI Knee Injection Orthosports Extended lateral approach Orthosports
•Target Orthosports Orthosports–Retro‐patellar space
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Orthosports Sporting Knee Effusions and MRI Knee Injection: Knee extended: Medial Approach Orthosports • Patient relaxes quads. •Examiner pushes patella Orthosports medially • Needle Position: Orthosports Orthosports–midway between superior and inferior pole of patella Orthosports – Needle Horizontal
Orthosports Sporting Knee Effusions and MRI Knee Injection:
Flexed Medial Approach Orthosports Orthosports •Target: – Intercondylar notch Orthosports •Orthosports Landmarks: – Hollow along the joint lineOrthosports just medial to the patellar tendon
Orthosports Sporting Knee Effusions and MRI Knee Injection: Flexed Medial Approach Orthosports • Patient sitting: BEWARE syncope!!! Orthosports • Needle Position: – 300 laterally and slightly Orthosports Orthosportssuperiorly • Resistance: –causedOrthosports by bone or cruciates redirect Orthosports Sporting Knee Effusions and MRI Orthosports
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Orthosports Sporting Knee Effusions and MRI Swelling outside the knee • Prepatella bursa (housemaids knee) –Treated with splinting /NSAIDSOrthosports / antibiotics – Swelling localized anterior to the patella •Does not involve the knee jointOrthosports itself –ROM usually OK Orthosports Orthosports
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Orthosports Sporting Knee Effusions and MRI Popliteal Cyst Orthosports • Swelling behind the knee (Baker’s Cyst) •Most common synovial cystOrthosports of the knee – Fluid production in the knee –Treat the cause of the swelling (oftenOrthosports arthritis) Orthosports
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Orthosports Sporting Knee Effusions and MRI Popliteal Cyst
•Origin – posteromedial ‐ GastrocnemiusOrthosports / Semimembranous bursa – Insidious onset of mild to moderateOrthosports pain posteriorly – Usually symptomatic when very largeOrthosports or Orthosportsrupture – Rupture ‐ quite severe calf pain and swelling andOrthosports difficulty walking may look like a DVT.
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Orthosports Sporting Knee Effusions and MRI Post Knee Pain DDx Orthosports • Arterial popliteal aneurysm • Adipose tissue Orthosports • Tumour •DVT Orthosports Orthosports
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Orthosports Sporting Knee Effusions and MRI Traumatic Injury
•Can’t WB = fracture Orthosports • Pop/giving = ACL tear •Pain with twisting, kneeling or standingOrthosports from sitting = meniscal injury • Isolated meniscal tears do not causeOrthosports swelling Orthosports– Chondral injuries do • Haemarthrosis becomes less bloodstained and Orthosportsmore serous in appearance with time
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Orthosports Sporting Knee Effusions and MRI Ottawa knee rules •After acute knee injury knee x‐rays are indicated if any of the followingOrthosports criteria present: – aged 55 years or over Orthosports – tenderness at the head of the fibula – isolated tenderness of the patellaOrthosports Orthosports– inability to flex knee to 90 degrees
– inability to bear weight (defined as an inability toOrthosports take four steps, ie. two steps on each leg, regardless of limping) immediately and at presentationOrthosports Sporting Knee Effusions and MRI Ottawa knee rules
• Majority of acute knee injuries are soft tissue injuries not identifiableOrthosports on plain radiographs. Orthosports •A normal looking knee X‐ray after acute trauma does not exclude a fractureOrthosports Orthosports– Tibial plateau fractures, Segond fractures Salter‐Harris type 1 fractures are easily missed if not complemented with clinical findings Orthosports – Follow up should be recommended if symptoms persist. Orthosports Sporting Knee Effusions and MRI Investigation
Orthosports •Xray •Xray Orthosports •Xray •Xray Orthosports •XrayOrthosports
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Orthosports Sporting Knee Effusions and MRI Routine Imaging •Weight Bearing AP • Lateral • Notch View Orthosports • Skyline Patella Orthosports
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Orthosports Sporting Knee Effusions and MRI Investigations / Imaging Orthosports • Plain radiography •Stress radiography Orthosports • Ultrasound •CT Scan Orthosports •MRIOrthosports Scan
• BoneOrthosports Scan
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Orthosports MRI Scan Full Leg X-Ray Orthosports Orthosports
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Orthosports Sporting Knee Effusions and MRI ™Trademark of Smith & Nephew. Imaging
•After doing a plain xray: Orthosports –MRI • 30% of asymptomatic contralateral knees have torn
menisci on MRI – Am J Rheum 2003 Orthosports
• 76% matched control volunteers with tears JBJS 2003
• 13% healthy volunteers under 45yrsOrthosports ‐ Clin Orthop Rel Res 1992
Orthosports• 36% over 45yrs had tears – Clin Orthop Rel Res 1992 – Check that the MRI correlates with clinical symptomsOrthosports
Orthosports Sporting Knee Effusions and MRI MRI
• Noninvasive nature Orthosports •Multiple planes •No ionizing radiation Orthosports •See other structures within the joint Orthosports •Orthosports Relatively high cost • Overcalls pathology • NotOrthosports all magnets and reports equal
Orthosports Sporting Knee Effusions and MRI MRI • Accuracy >95% • Unfortunately being usedOrthosports as the first investigation for a painful knee •Common to see meniscal tear &Orthosports chondral damage •Weight bearing xrays show arthritis, which is actually what the patient needs treatment for Orthosports –Normal clinical exam = MRI only 5% chance of Orthosportsshowing a meniscal tear – Asymptomatic patients: Orthosports•<45 yrs old, 13% have a meniscal tear •>45 years old, 36% have a meniscal tear Orthosports Sporting Knee Effusions and MRI Reading an MRI Orthosports •T1 •T2 Orthosports • Gadolinium Orthosports Orthosports
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Orthosports Sporting Knee Effusions and MRI Imaging Orthosports •MRI Orthosports
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Orthosports Sporting Knee Effusions and MRI Arthritis vs Meniscal Tear Orthosports • Clinical exam less reliable in these pts – Different, less acute mechanismOrthosports of injury – Numerous other possible degenerative causes contributing to their intra‐articularOrthosports knee pain Orthosports–Very high incidence of meniscal tears on MRI scanning with OA
–TheOrthosports decision as to whether or not to operate is often difficult
Orthosports Sporting Knee Effusions and MRI Arthritis vs Meniscal Tear Orthosports –A meniscal tear can lead to knee OA, but knee OA can also lead to a spontaneous meniscal tear Orthosports –A degenerative meniscal lesion often suggests early‐stage knee OA Orthosports Orthosports– Surgical resection of non ‐obstructive degenerate lesions may merely remove evidenceOrthosports of the disorder while the OA and associated symptoms proceed.
Orthosports Sporting Knee Effusions and MRI Arthritis vs Meniscal Tear Orthosports • Arthroscopic debridement for chronic OA is no better than a sham procedure in Orthosports relieving knee pain or improving functional status Orthosports •NoOrthosports better than physio WHEN THIS IS THE FIRST FORM OF TREATMENT Orthosports
Orthosports Sporting Knee Effusions and MRI Swedish study Orthosports • 45–64 yrs old, knee pain, meniscal tear on MRI and OA on xray (minor) Orthosports • Rigorous exercise regimen alone vs Exercise regimen with surgery Orthosports •Outcomes 2, 6, 24 and 60 months •BothOrthosports groups improved considerably over the first 6 months and maintained improvements in pain and Orthosportsfunctional status over 60 months
Orthosports Sporting Knee Effusions and MRI Swedish study Orthosports • 30% of the subjects randomised to the non‐ operative arm had persistent pain and Orthosports crossed over to have surgery •And had similar outcomes to thoseOrthosports randomised to receive surgery at the outset. Orthosports
st Try physioOrthosports 1 and operate if they don’t get better
Orthosports Sporting Knee Effusions and MRI MeTeOR •The Meniscal Tear in Osteoarthritis Research (MeTeOR) TrialOrthosports •Aged ≥45 with meniscal tear on MRI and Orthosports underlying OA change on xray or MRI •As in Herrlin et al about 30% of OrthosportsMeTeOR Orthosportssubjects crossed over from non‐operative therapy to surgery. Orthosports
Orthosports Sporting Knee Effusions and MRI Meteor and knee OA
•No role for arthroscopy unless they have clinical and imaging evidence of a tearOrthosports AND mechanical symptoms (Catching, locking, popping etc) • Patients who fail to improve withOrthosports physio can try surgery • Recovery from menisectomy surgeryOrthosports at 1 year: – Worse if female and worse OA Orthosports –No different based on Age, BMI, depth of meniscal excision, involvement of 1 or both menisci, extent of meniscalOrthosports tear
Orthosports Sporting Knee Effusions and MRI Surgical Decision Making for Meniscal Tears
Orthosports • Indications for Arthroscopic Treatment: – Symptoms affecting ADLs, work,Orthosports sports – Positive physical findings •Joint line tenderness, joint effusion,Orthosports limitation of motion, and provocative signs Orthosports – Failure to respond to nonsurgical treatment,
– Absence of other causes of knee pain Orthosports
Orthosports Sporting Knee Effusions and MRI Surgical Decision Making for Meniscal Tears with ACL Orthosports •Most often done concurrently with ACL reconstruction Orthosports – Surgical timing dictated by: •ROM Orthosports • Swelling Orthosports • Quads function •Other Lig injuries Orthosports•Locked knee
Orthosports Sporting Knee Effusions and MRI Rules Of Thumb
• Ongoing pain affectingOrthosports ADL’s • Meniscal pathology will do better than articular cartilage Orthosports •Younger more likely to be meniscal • Clicking more likely to be meniscalOrthosports Orthosports • Sudden onset of pain generally does
better Orthosports • Mechanical symptoms do better
Orthosports Sporting Knee Effusions and MRI Refer Early Locked knee Terrible pain, unable to walk Orthosports for no apparent reason Keep infection in the back of your mind Orthosports Treat the elderly for a bit longer as more likely to be Orthosports articular JointOrthosports line cysts(=meniscal tear) can come and go but most requireOrthosports surgery (LATERAL>>MEDIAL)
Orthosports Sporting Knee Effusions and MRI Urgent Referral Orthosports • Infection • Locked Knee Orthosports • Lateral ligament Orthosports Orthosports
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Orthosports Sporting Knee Effusions and MRI Thank you Orthosports
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Orthosports Sporting Knee Effusions and MRI Doron Sher MBBS, MBiomedE, FRACSOrthosports
www.kneedoctor.com.au Orthosports www.Doron.com.au www.orthosports.com.auOrthosports Orthosports 160 Belmore Rd, Randwick
47‐49 Burwood Rd, Concord Orthosports
Orthosports Sporting Knee Effusions and MRI