American College of Physicians 2013 Ohio Chapter Scientific Meeting Columbus OH October 11 2013 Paul J Gubanich MD MPH Assistant Professor of Internal MedicineSports Medicine Team Physician Ohio State University Athletics Ohio Machine Columbus City Schools ID: 685618
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Orthopaedics for the Practicing Internist
American College of Physicians
2013 Ohio Chapter Scientific Meeting
Columbus, OH
October 11, 2013
Paul J.
Gubanich
, MD, MPH
Assistant Professor of Internal Medicine/Sports Medicine
Team Physician, Ohio State University Athletics, Ohio Machine, Columbus City SchoolsSlide2
Disclosures
I do not have a conflict of interest associated with the material contained in this presentation. Slide3
An Approach to the Patient with Knee Pain
Most common complaints
Pain
Instability – (ligament injury, OA)
Stiffness – (effusion, OA)
SwellingLocking (meniscal)Weakness
Most diagnosis made by:HistoryPhysical examImagingSlide4
Important Historical Components
Age
Chronology, onset
Pain level, characteristics
Exacerbating positions/ movements
Relieving factorsActivity level or recent change, occupationPrevious injuries, surgeriesExercise history, goals
Previous treatments Slide5
Chronology of Symptoms
Acute Pain
Sudden onset
Specific mechanism of injury
Direct trauma (fall, collision, MVA)
Landing, pivoting
Common acute injuriesFractures (distal femur, patella,
proxmial
tibia, fibula)
Dislocations
Meniscal
injuries
Ligamentous
injuries
Musculotendious
strains
ContusionsSlide6
Chronic PainOften lacks a mechanism of injury
Symptoms of gradual onset
Common causes of chronic knee pain
Arthritis
Tumors (night pain)
Osteosarcoma
(adolescents)Chondrosarcoma (adults)
Giant cell tumor (benign)
Metastatic disease is uncommon
Sepsis (rare, can be
bursal
)
Bursitis (overuse)
Tendonitis
Anterior knee painSlide7
Location, Location, LocationSlide8
Medial Knee
Joint line – meniscus, OA,
osteochondral
defect,
osteonecrosis
, medial collateral ligamentTibial
plateau – (osteoporosis, post menopausal)Pes bursaSlide9
Anterior Knee
Anterior
Quad tendon or insertion
Anterior to patella
Patella
Patellar origin, tendon, insertion
Tibial tubercleSlide10
Lateral Knee Pain
Lateral
Femoral
condyle
– suggests IT band
Joint line – meniscus, OA, OCD, lateral collateral ligamentSlide11
Posterior Knee
Meniscus – posterior medial, lateral corner
Posterior lateral – Baker’s/
popliteal
cyst, aneurysmSlide12
Physical Exam
Exam both sides
Joint above and below
Most painful part last
Gait
Alignment (varus, valgus)Squat
InspectionSwellingBruisingDeformitySlide13
Physical Exam
Palpation
Effusion
Range of Motion
Patellar tracking
Extension (-5 to 5)Flexion (135-145)Crepitus, etc.Strength
HamstringQuadFunctional testsSlide14
Physical Exam – Special Maneuvers
Apprehension sign – patellar instability
Apley grind test – meniscus
McMurray circumduction test,
SN 16-58%
SP 77-98%(Evans 1993, Fowler 1989, Kurasaka 1999, Anderson 1986)Slide15
Physical Exam – Special Maneuvers
Valgus stress test – MCL
SN 86-96%
Varus stress test – LCL
SN 25%Slide16
Physical Exam – Special Maneuvers
Lachman’s – ACL
SN 80-99%
(various authors and conditions)Slide17
Physical Exam – Special Maneuvers
Anterior/posterior drawer – ACL/PCL
Posterior Sag SignSlide18
Radiology
Plain x-rays often considered part of exam
Helps rule out competing diagnosis
X-ray views
Standing AP views of both knees (for comparison)
LateralTunnel at 45 degreesMerchant/Sunrise – to evaluate PF jointSlide19
Radiology
MRI often not needed initially
Surgical planning tool
Failure of treatment
Identify
ligamentous/cartilage injuries of acute or surgical natureRisk stratificationSlide20
General Treatment Pearls
Match disease severity/limitations with treatment options
Escalate based on time, response in a stepwise fashion
Set realistic expectations for progress and follow-up
Align treatment goals with patient goals/expectations when possible
Time is a great healerSlide21
Common Treatment Recommendations
Activity modification, rest
Mechanical devices – braces, crutches, lifts, orthotics, etc.
Ice, pain medication
Nsaids
AcetaminophenOthers Physical therapy – early motion progressing to strengthening and then functional drills
Injection therapyAspirationCorticosteroids
Hyaluronic
acid
supplents
(OA)
Glucosamine (OA)
Surgical considerations
Consider additional imaging options as needed
MRI
Bone scan
CTSlide22
Red Flags
Night pain
Abnormal x-ray findings
Fractures, tumor, cartilage lesions, etc.
Mechanical symptoms
Severe pain, swelling, loss of motion, or weaknessHigh grade ligament injuriesFail to respond to standard treatmentsMultiple joints involved (Rheum)Slide23
Summary
History and Physical Exam are vital to generating a working differential diagnosis
Imaging may complement/confirm working diagnosis
Treatment should match symptoms and severity and progress based on progress
Questions?