Community Musculoskeletal Services Barnet - PowerPoint Presentation

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Community Musculoskeletal Services BarnetPrimary Care Sessions

The knee

Common knee conditions

When to investigate & what modality

Time limited assessment

Further tests

2 case studies – medial knee painDegenerative meniscal tearsInjections

Christine BilsboroughConsultant PhysiotherapistClinical Lead CLCH MSK Services

Clinical Reasoning Flow Chart

Common knee conditions

Joint

Mechanism

Investigations

ManagementOA

Patellofemoral (age)Bakers cyst (OA)(Suprapatella effusion)DegenDegen or if young biomechanicalAssociated with degen changes

Xray if considering surgical work-upSkyline x-ray

USS for differential diagnosisLifestyle/weight/focussed muscle strengthening/function/CVE/surgeryPt education. Not injected/aspiratedLigament

ACL

PCL (uncommon)

MCL (Trauma)

LCL

High impact trauma skiing/football/torsion

Varus/valgus forces

X-ray MRI if instability suspected

USS

ACL Prehab: physiotherapy guided

Brace

Brace

Cartilage

Medial meniscus

Lateral meniscus/posterior corner

Degenerative

Non-degenerative

X-ray to confirm

degen

changes

MRI

MRI

Loading/lifestyle. Poor surgical outcomes

Tendon

Overload

Hamstring

Patella

Quadriceps

Overload/trauma/anabolic steroids

USS if early conservative management not helped. May change management

Tendon loading programme: physiotherapy guided

Referred Knee Pain

Ottowa knee rules for xray: over 55, 4 steps, <90° flex, pain

HoF

, isolated pain patella https://cks.nice.org.uk/topics/knee-pain-assessment/references/ Function antalgic gait/decrease/weightbearing/squat/knee dip – guarding/ROM

quads atrophy/effusion/deformity – disuse/degree of trauma or inflammatory/degen or structuralTestInstability Lachman’s test is only test that can rule in/out ACL rupture (Decary, Ouellet et al. 2017)

Time limited objective assessment

Further tests

Move away from terminology ‘

special tests’ Not so specialBased on two SR, a complete physical examination performed by a trained health provider was found to be diagnostically valid for ACL

and meniscal injuries as well as for cartilage lesions (Decary, Ouellet et al. 2017)

Structure ACL

Specificity 81.0% - 100%Test Lachman’sMedial meniscus86%McMurrays

Medial knee pain 1

Case study:

19 yo, playing football, tackled, knee pain, able weight bear, swelling later or next day

. X-ray not indicated as able wb. Management: Usually don’t need crutches. Refer to the acute knee injury pathway (ICMSK), MRI and early rehabilitation. Potential orthopaedic referral if meniscal lesion, posterior corner or high grade MCL. Rule out ACLr

Medial knee pain 2

Case study

: 53 yo, walking briskly down underground escalator on way to work.Knee starts to hurt and by time gets to office, pain severe.

Swelling later that day and worse following day. Able to wb but limping. Management: reassure x-ray not needed initially as able WB, analgesia/start moving as able/urgent physiotherapy.If progress slow: x-ray to assess for degen

. changes. If changes present continue to manage conservatively. Managing patient expectation around MRIs important at start of patient journey

Degenerative Meniscal Tears

Surgery versus rehabilitation

Multicentre RCT351 symptomatic patients aged over 45Known degenerative meniscal tearSurgery and physiotherapy OR Physiotherapy

Primary OM WOMAC at 6 and 12 monthsResultsNo signif differences in pain or function at 6 months30% patients crossed over to have surgery

No difference 12 months(Katz 2013)

Evidence

230 asymptomatic knees

MRI97% abnormalities30% meniscal tears (3% complex, 1% bucket handle)Also:Moderate and severe cartilage lesions were common, in 19% and 31% knees

Horga

(2020)

Degenerative meniscal tears – risk factors

Strong Evidence

Over 60 years of age (OR = 2.32; 95% CI: 1.80, 3.01). Almost 3-fold greater risk for men compared to women (pooled OR = 2.98; 95% CI: 2.30, 3.85)Individuals who performed work involving kneeling or squatting more than 1 hour per day (pooled OR = 2.69; 95% CI: 1.64, 4.40)

STAIRS OR of 2.28 (95% CI: 1.56, 3.31) SITTING for less than 2 hours/day increased risk OR of 0.68 (95% CI: 0.50, 0.92)

BMI (Moderate evidence) >25 kg(Snoeker 2013)

Moderate Evidence

STANDING/WALKING MORE 2HRS/DAY

OR of 1.63 (95% CI: 1.17, 2.27)

CARRYING WEIGHTS >10ks 10 times/

wk

1.89 (95% CI: 1.41, 2.55) and 25kg 10 times/

wk

further increased the risks

(OR = 1.58; 95% CI: 1.15, 2.16) and 50kg

OR of 3.0 was calculated (95% CI: 1.7, 5.1)

BMI

>25 kg/m2 for degenerative meniscal tears

No Difference

Driving

Smoking or alcohol

(

Snoeker

2013)

02/11/2020

McAlindon (2017)

140 participants OAK

RCT Double blind

40mg steroid (TA)

V

Placebo/saline

Every 3/12 for 2 years

Outcomes: WB x-ray/MRI/USS/pain/function

Significant cartilage loss in steroid group

Between-group difference of −0.11mm (95% CI, −0.20 to −0.03mm)

Pain = Same

Klocke (2018)

80 participants OAK

40mg TA

Outcomes: Biomarkers uCTX-11 lower 3 weeks post injection (

p

= 0.0020)

Protective in the short term. May reduce cartilage breakdown

Pain = Same

Useful for short term pain relief and meniscal irritation 

Knee injections

NICE recommend 3-4

inj

p.a

Patient expectation

MULTIPLE

BENEFITS

OF EXERCISET2 diabetesCVDFallsDepression

DementiaJoint and back painCa (colon and Br)(Dean & Soderlund 2015, Kyu 2016)CLCH website MSK patient and GP information and advicehttps://clch.nhs.uk/services/musculoskeletal-physiotherapy

References

Dean &

Soderlund (2015a and b) Outcomes are improved for people who participate in regular physical activity

Dean, E. and A. Söderlund (2015). What is the role of lifestyle behaviour change associated with non-communicable disease risk in managing musculoskeletal health conditions with special reference to chronic pain? BMC Musculoskeletal Disorders.

Decary, S., et al. (2017). "Diagnostic validity of physical examination tests for common knee disorders: An overview of systematic reviews and meta-analysis." Phys Ther Sport 23: 143-155Horga, L. M., et al. (2020). "Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI." Skeletal Radiol 49(7): 1099-1107.Katz, J. N., et al. (2013). "Surgery versus physical therapy for a meniscal tear and osteoarthritis." N Engl

J Med 368(18): 1675-1684.Klocke, R., et al. (2018). "Cartilage turnover and intra-articular corticosteroid injections in knee osteoarthritis." Rheumatol Int 38(3): 455-459.Kyu et al (2016) Physical activity & risk of breast/colon Ca, diabetes, IHD/ ischaemic stroke events.(McAlindon, LaValley et al. 2017)McAlindon, T. E., et al. (2017). "Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial." JAMA 317(19): 1967-1975.Snoeker, B. A., et al. (2013). "Risk factors for meniscal tears: a systematic review including meta-analysis." J Orthop Sports Phys

Ther 43(6): 352-367.https://pathways.nice.org.uk/pathways/osteoarthritis https://cks.nice.org.uk/topics/knee-pain-assessment/references/