This blog consists of posts of my medical study notes.
So today I’m making for myself “My Minicourse On Knee Injury and Kee Pain”.
I’m listing and reviewing all my posts on knee injury and knee pain and also other resources.
(1) “Curbsider Supplement: The 30 Second Knee Exam with Dr. Ted Parks” – Great YouTube Video
Posted on October 6, 2018
I just watched it again and it is wonderful. That video is the place to start.
(2) ACR Appropriateness Criteria®: Chronic Knee Pain Revised 2018. And I reviewed it as it is a great resource. This excellent guideline covers the appropriate imaging of five different clinical variants:
- Variant 1: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial imaging.
- Variant 2: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph negative or demonstrates joint effusion. Next imaging procedure.
- Variant 3: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee
radiograph demonstrates osteochondritis dissecans (OCD), loose bodies, or history of
cartilage or meniscal repair. Next imaging procedure.
- Variant 4: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee
radiograph demonstrates degenerative changes or chondrocalcinosis. Next imaging procedure.
- Variant 5: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee
radiograph demonstrates signs of prior osseous injury (ie, Segond fracture, tibial spine avulsion, etc). Next imaging procedure.
(3) “Fewer US Adults Getting Unnecessary Knee Surgery” – Reuters News Report From Medscape Posted on November 3, 2018 by Tom Wade MD
(4) Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline [PubMed Abstract] [Full Text HTML] [Full Text PDF]. BMJ. 2017 May 10;357:j1982. doi: 10.1136/bmj.j1982. Here are excerpts from this article:
WHAT YOU NEED TO KNOW [from the above article]
• We make a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on linked systematic reviews; further research is unlikely to alter this recommendation
• This recommendation applies to patients with or without imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptom onset.
• Healthcare administrators and funders may use the number of arthroscopies performed in patients with degenerative knee disease as an indicator of quality care.
• Knee arthroscopy is the most common orthopaedic procedure in countries with available data
• This Rapid Recommendation package was triggered by a randomised controlled trial published in The BMJ in June 2016
which found that, among patients with a degenerative medial meniscus tear, knee arthroscopy was no better than exercise therapy.
(5) And because the vast majority of chronic knee pain is due to osteoarthritis I’ve included a link to the National Institute For Health And Care Excellence (NICE) Osteoarthritis: care and management-Clinical guideline [CG177] Published date: February 2014:
This guideline includes recommendations on:
- education and self-management
- non-pharmacological management
- pharmacological management
- referral for joint surgery
- follow-up and review
(6) Here is a resource on how to perform joint injections.
According to the reviews on Amazon, Injection Techniques in Musculoskeletal Medicine: A Practical Manual for Clinicians in Primary and Secondary Care 4th Edition is an excellent how-to manual. There is a new 5th edition coming November 15, 2018 which will have a number of excellent upgrades including a website with an online trainer and access to over 50 instructional video clips – order the 5th edition.
(7) A great resource for patients with knee pain is Robin McKenzie’s book, Treat Your Own Knee.
(8) And finally, because exercise is the recommended treatment for knee osteoarthritis, here is a link to the YouTube video, McKenzie Method to Treat Your Own Knee Pain (Exercises).
(9) “Knee Pain” [Chronic] – Episode #98 From The Curbsiders With Additional Resources On Treatment Posted on October 5, 20
As Dr. Parks [orthopedic surgeon educator] reminds us in the Curbsiders’ podcast, therapy for an exacerbation of chronic knee pain consists of non-pharmacologic management [and the NICE Osteoarthritis guideline reminds us to consider a TENS unit], NSAIDS, and steroid injection of the knee joint.
- First, rule out emergencies e.g. septic arthritis–the knee will be red, swollen, tense, and “really uncomfortable”. The patient may not be able to bear any weight. Mechanism of injury also heightens urgency e.g. severe trauma. -Dr Parks
- History taking: chronicity (will push you more towards osteoarthritis), pain on descending the stairs (patellofemoral joint pain), swelling, mechanism of injury and whether pain is relieved with oral anti-inflammatory agents. Morning stiffness isn’t as useful. -Dr Parks expert opinion
- Ask about mechanical symptoms–locking, catching, instability–instability is a strong clue for ligament involvement. “Giving out”–Ask them to describe it in greater detail. Could have a number of causes: ligament injury, muscle weakness, reflex giving way due to pain in “sweet spot”. -Dr Parks
Next we want to fit the patient into one of five buckets that “will cover almost everything that comes into the orthopedics office”:
- Ligament injury: it requires a lot of violence/force to tear ligaments, which are wide as a pinky finger. Easy to detect with physical exam, and with a history of trauma. -Dr Parks
- Meniscus injury: a significant number, upwards of 50% of adults >60, have incidental meniscus tears identified on MRI. (Englund et al. Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons. N Engl J Med. 2008; 359:1108-1115). It is hard to know in a middle-aged/older person whether the meniscus tear is an incidental finding or is really causing the symptoms so the threshold for intervention is much higher. Conversely, a 33-year-old with a meniscus tear, might warrant an invasive orthopedic intervention. -Dr Parks
- Osteoarthritis: Chronic, bilateral, exacerbated by recent trauma or joint stressor.
- Patellofemoral joint issues: May overlap with arthritis. Conditions include: patellofemoral syndrome, chondromalacia, and other non-arthritic diagnoses. The typical pain is anterior, worse with descending stairs or prolonged sitting (Theater sign), and notable for crepitation under patella. -Dr Parks
- None of the above: Tendonitis (e.g. pes anserine, iliotibial band, patellar/quadriceps), or referred pain from the hip or spine (e.g. lumbosacral radiculopathy).
The Knee Exam Breakdown: This should take around 30 seconds to administer. See Dr. Parks’ video! [The video is outstanding and the steps below are completely followed in the video.]
- Watch the patient walk. Look for a limp, and gait abnormalities.
- Look at the skin for scars, redness/swelling.
- Have the patient sit on the edge of exam table with knees bent. Put a hand on the kneecap, and flex and extend the knee. Crepitus may not be clinically consequential unless it’s worse on the side with pain or abnormal mobility. (And don’t bet your money on the value of Fine vs. Coarse distinctions).(Song et al. Noise around the knee. Clin Orthop Surg. 2018. 10(1):1-8.)
- Have the patient lie on their back in a supine position with legs extended and note whether their extension is full or limited.
- Bend their knee so their heel moves towards their bottom. This will tell you their flexion range of motion limit. If they have a meniscus tear, this flexion will recreate pinpoint pain and joint line tenderness on the side of the torn meniscus
- Next, while they’re in that position in flexion, put one hand on their foot, other hand on their knee, and rotate hip joint through full ROM to rule out hip disease.
- In the same position, with your hand on the patient’s knee, feel and press on joint line to check for joint line tenderness. Perform McMurray’s test for finding meniscus tears (See Dr. Parks’ video).
- Medial Collateral Ligament (MCL)/ Lateral Collateral Ligament (LCL): Put the knee in extension, hold the top segment (thigh) with one hand, put other hand down at ankle, and push the leg toward the midline or away from the midline. Stretching toward the midline will stretch the LCL, stretching away from the midline will stretch the MCL.
- N.b. there is tons of variability in how flexible individuals are, person to person, in this direction when uninjured. Test the uninjured knee and compare that side to the injured side since there is very little variability between sides: If there’s increased laxity, >3 mm in excess of the other side, that suggests pathology. (Phisitkul et al. MCL Injuries of the Knee: Current Concepts Review. Iowa Orthop J. 2006;26:77-90)
- Anterior Cruciate Ligament (ACL): the ACL exists to prevent the tibia from translating anteriorly in relation to the patella/femur.
- Lachman’s test [Link is to the YouTube video on how to perform the Lachman’s test] is better than the Drawer test, which can be confounded by the iliotibial (IT) band. Do an anterior pull, but with the knee at 30 degrees flexion. This is the position of maximal relaxation of the IT band and other secondary structures, so it will amplify the tibia’s anterior motion if patient lacks an intact ACL. (Koster et al. ACL Injury: how do the physical examination tests compare? J Fam Pract. 2018. 67(3):130-134.)
- Posterior collateral ligament, pathology is pretty rare, so we won’t discuss the ligament tests for that one in this quick knee exam.
And now we move to acute knee pain and trauma.
(9) American College of Radiology ACR Appropriateness Criteria® Clinical Condition: Acute Trauma to the Knee Date of origin: 1998 Last review date: 2014. This excellent guideline covers the appropriate imaging of six different clinical variants:
Clinical Condition: Acute Trauma to the Knee
- Variant 1: Adult or child >1 year old. Fall or twisting injury, no focal tenderness, no effusion; able to
walk. First study.
- Variant 2: Adult or child >1 year old. Fall or twisting injury, with one or more of the following: focal
tenderness, effusion, inability to bear weight. First study.
- Variant 3: Adult or child >1 year old. Fall or twisting injury with either no fracture or a Segond
fracture seen on a radiograph, suspect internal derangement. Next study.
- Variant 4: Adult or child >1 year old. Fall or twisting injury with a tibial plateau fracture on a
radiograph, with additional bone or soft-tissue injury suspected. Next study.
- Variant 5: Adult or child >1 year old. Injury to knee, mechanism unknown. Focal patellar tenderness,
effusion, able to walk.
- Variant 6: Adult or child >1 year old. Significant trauma to the knee from motor vehicle accident,
suspect knee dislocation.
(10) Acute Knee Trauma – EMC’s Episode 91 Occult Knee Injuries Pearls and Pitfalls With Additional Resources
Posted on October 4, 2018
Note to myself – The post is very long and needs to be reviewed completely. Therefore go to the post and study it carefully.
Here is an excerpt from from Resource (9) (9) American College of Radiology ACR Appropriateness Criteria® Clinical Condition: Acute Trauma to the Knee Date of origin: 1998 Last review date: 2014.
(11) More on Acute Knee Injuries from Evidence-Based Orthopedics
Posted on January 19, 2012
This post must also be reviewed in its entirety [Note to myself]. Here are excerpts from the post that ask five questions and each of these questions is answered in the post.
In the chapter “Initial Management of the Sports Injured Knee”*, the authors consider five questions regarding acute knee injury:
1. “What is the relative frequency of various injuries when patients present with a knee hemarthrosis?”
2. “What is the effectiveness of physical examination in diagnosing an ACL rupture in an acutely injured knee?”
3. “What is the role of MRI vs. arthroscopy in the diagnosis of acute knee injury?”
4. “What is the role for aspiration in the acutely injured knee with hemarthrosis?”
5. “Is there evidence in favor of surgical reconstruction of an acute (<3 weeks) ACL injury?”
See the post for the answers to each of those questions.