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Knee Pain: A Practical Session
Professor Sanjiv Jari BSc(Hons), MBChB, FRCS [Eng], FRCS[Tr&Orth]
Consultant Lower Limb & Orthopaedic Sports Medicine Surgeon
Professor, Faculty of Engineering, Science & Sports, University of Bolton
Founder & Director, Manchester Sports Medicine Clinic
Hope Hospital (University of Manchester Teaching Hospital)
Honorary Senior Lecturer University of Manchester
FDA Conference
Feb 2017
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Outline
♦ Diagnosis
♦ Examination tips
♦ Investigations
♦ Some common knee conditions
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Diagnosis
♦ History
● Pain – localised vs generalised
● Swelling
● Instability / giving way
● Locking
● Limitation of function
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MECHANISM OF INJURY
♦ Foot planted or off the ground
♦ Direct blow - MCL, ACL/MCL, contusion
♦ Twisting - ACL, patellar dislocation, meniscus
♦ Jumping or landing - ACL
♦ Changing directions - ACL
♦ Fall on the knee
● foot dorsiflexed - PF
● foot plantar flexed - PCL
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Diagnosis
♦ Examination – compare to other leg
● Gait and leg alignment
● Swelling
● Muscle wasting
● Areas of tenderness
● Provocative tests
● Range of motion
● Stability
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Examination
♦ Always compare to the other knee
♦ If in doubt as to what is normal for the patient,
compare it to other limb
♦ Gives patient an idea of what you are going to
do to them on the problematic side if you
assess good side first
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See patients standing
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ROM
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Patella
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Squat and duck walk
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Tenderness
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McMurrays
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Lachman’s
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Modified Lachman’s
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Drawer
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MCL
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Lateral side
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SLR
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Extensor lag
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Knee extension against
gravity
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Lachman’s Test
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Stability - EUA
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Investigations
♦ Plain x-rays
♦ MRI +/- arthrogram – soft tissues
♦ Ultrasound scan – soft tissues
♦ CT – bone
♦ Bone scan – bone turnover / inflammation
♦ White cell scan – infection
♦ KT-1000 – measure AP laxity of knee
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Knee Xrays
♦ Should always
request 3 views:
● AP standing
● 60 deg lateral
● 30 deg Merchant’s
view (skyline)
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MRI – articular cartilage
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MRI – bone bruising pattern
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MRI – bone bruising pattern
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MRI – Ligament injuries
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Common Knee Problems
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Meniscal tears
♦ Localised mechanical pain worse on twist
♦ Irritates knee to cause swelling
♦ Conservative treatmentIce, NSAIDs, activity modification, ?? Steroid injection
♦ Consider surgery ifLimp, swelling persists, quad atrophy, on-going pain
♦ Degenerate meniscus tears Non-functional
Cannot heal
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Meniscus tears
♦ Principle:
● Repair if possible
● If have to excise,
conserve as much as
possible
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ACL Tear
♦ Most ACL tears can be diagnosed by a thorough history of the injury and patient’s reaction to it
♦ Usually non-contact, twisting injury with immediate disability and feeling that a severe injury has occurred
● 95% unable to continue to play
● 80% felt like a major injury occurred
● 80% develop acute immediate haemarthrosis
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ACL Tear - Treatment
♦ Playing with brace and activity modification
does not work for young athletes with acute
ACL tears
♦ Prehab the knee and patient
♦ Reconstruct the ACL – most patients
♦ Graft – (contralateral) Patella tendon
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Indications for ACL recon
♦ Instability with ADL or recreation
♦ High risk sports
♦ Young age
♦ ? Upper age limit
♦ ? OA
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PCL Injuries
♦ PCL injuries often missed or misdiagnosed
♦ Compared with ACL injuries
● Not as common
● Not as disabling
● Difficult to diagnose
● Will heal with non-operative treatment
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PCL Injury: Posterior Drawer
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Isolated PCL Injury
♦ From dashboard in RTA
♦ Direct blow to proximal tibia most common
mechanism
♦ Can also occur with twisting (PCL) and lateral
blow to the knee (PCL/MCL)
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Isolated PCL Injury
♦ Fall with foot plantar
flexed
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Lateral Side Complex
♦ Lateral capsule
♦ IT band
♦ Biceps tendon
♦ LCL
♦ Popliteus
♦ Lateral head of gastrocnemius
♦ All contribute to lateral stability
♦ Rarely injured (isolated and in combination)
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Patellar Dislocation
♦ ACL tear frequently misdiagnosed as patellar
dislocation
♦ Twisting injury
♦ 2 “pops”
♦ Medial pain
♦ Acute haemarthrosis
♦ Tender over VMO
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MPFL
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Chondral defects
♦ Common – PFJ dislocation, ACL, PCL, OCD
♦ Treatment
● Stimulate to bleed – microfracture, drill
● Mosaicplasty
● Chondrocyte Transplantation
Only one to produce hyaline-like tissue
Expensive
Only done in NICE run studies – few surgeons
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Tendonopathy
♦ Patella, ITB, Hamstring, Gluteals
♦ Treatment – non interventional
● Rehab without pain
● Eccentrics, stretching, shock wave, etc
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Tendonopathy
♦ Interventional treatment
● Platelet Rich Plasma (PRP)
● Dry needling
● Autologous blood injection
● Surgery
♦ Rehab post-intervention essential
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Arthritis
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Traditional treatments
♦ Analgesia
♦ Activity modification
● Stop impact exercise
♦ Weight loss
♦ Strengthening and Extension exercises
♦ Steroid injections
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Newer Treatments
♦ Hyaluronic Acid injections
♦ nSTRIDE injections
● Anti-TNF and IL-1 blockers – can slow arthritis
progression ? Reverse it ?
♦ Sub-chondroplasty
● For painful bone marrow lesions
♦ Stem cells
♦ Articular cartilage regeneration
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Knee replacements
♦ Traditional
♦ Patient specific instrumentation
♦ Customised / Bespoke implants
● Latter two are less invasive, less bleeding and
swelling, less pain, quicker recovery, shorter LOS,
better alignment (longer survivorship), less patient
dissatisfaction.
● Not available on NHS
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Patient specific instruments
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Patient Specific
Instrumentation
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Bespoke TKR and uni
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Benefits of Bespoke TKR
♦ Less invasive
♦ Less pain
♦ Less bleeding
♦ Shorter LOS
♦ Quicker recovery
♦ Better alignment
● Longer survivorship
♦ Cosmesis
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Arthritis summary
♦ Many early interventions and treatments
available
♦ Knee OA treatment is no longer the domain of
● “wait till you are old enough to have a knee
replacement”
♦ Refer early as many options are time limited
www.sportsmedclinic.com
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Who to refer?
♦ Giving way post injury – ACL, PFJ, LB
♦ Meniscal tears
♦ PF dislocations
♦ OA – especially early OA / failed conservative
treatment
♦ Acute swollen knee
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Knee Red flags
♦ Unable to SLR after injury
♦ Immediate swelling post injury
♦ True giving way or locking
♦ Worsening pain without injury
♦ Specific night pain
♦ Pain with fever / night sweats / wt loss
♦ ? Infection knee joint / TKR
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Questions