Disclosures Update 2018 April 1-6, 2018 No relevant financial - - PDF document

4/3/18 1

UCSF CME PRIMARY CARE MEDICINE: Update 2018

April 1-6, 2018

Common Knee and Ankle Conditions You Will See in Office Practice

Cindy J. Chang M.D.

Primary Care Sports Medicine Clinical Professor of Orthopaedics and Family and Community Medicine

Disclosures

No relevant financial relationship exists

Objective

■

Develop strategies to diagnose and manage common

• ffice problems

including knee and ankle injuries Later, those who knew the ligament would describe her as friendly, and the quiet

• type. Not at all the kind you’d expect to

suddenly just snap.

Goals of this talk

■ Quick approach to MSK problems

◆ A GOOD HISTORY is important ◆ Know basic anatomy

■ Highlight common presentations and clinical exam

findings

■ Discuss basics of non-surgical and surgical

management

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MS OLDCARTS

Mechanism of Injury Symptoms Onset Location Duration Character Aggravating/Alleviating Radiation Timing/Treatments Severity

www.fammedref.org/mnemonic/pain-hx-old-carts-p

Why? = Prevention

Intrinsic Risk Factors

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Growth

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Anatomy

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Muscle/Tendon imbalance

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Illness

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Nutrition

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Conditioning

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Psychology Extrinsic Risk Factors

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Training

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Technique

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Footwear

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Surface

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Occupation

Knee Anatomy Anterior Knee

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Medial Knee Lateral Knee Knee: Case #1

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40 yo male playing in family reunion touch football game

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Tackled by his brother-in-law (“who never really liked me”) and his knee twisted under him

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Now seeing you 1 week later and using an ACE wrap and borrowed cane

Which next question would be the least helpful in terms of determining the severity of injury?

• 1. How long did it take before it swelled?
• 2. Were you able to continue playing?
• 3. Does your knee give out?
• 4. Did you feel a pop?

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Which next question would be the least helpful in terms of determining the severity of injury?

• 1. How long did it take before it swelled?
• 2. Were you able to continue playing?
• 3. Does your knee give out?
• 4. Did you feel a pop?

Knee: Case #1

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40 yo male playing in family reunion touch football game

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Tackled by his brother-in-law (“who never really liked me”) and he felt a pop as his knee twisted under him

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Hard to put weight on leg and was unable to continue playing

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The knee swelled “like a melon” within 2 hours despite ice

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His knee shifts when he puts more weight on it

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Now seeing you 1 week later and using an ACE wrap and borrowed cane

Knee: Case #1

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Differential Diagnosis

◆ Ligament tear

✦ ACL tear ✦ MCL tear ✦ Less likely LCL tear, PCL tear

◆ Tendon rupture ◆ Meniscus tear ◆ Patellar dislocation ◆ Chondral injury ◆ Bone contusion/Fracture

Knee: Case #1

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Physical Exam – Trauma

◆ First: Point to where it hurts ◆ Effusion vs. Soft tissue swelling ◆ Superficial abrasions ◆ Active straight leg raise

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Knee: Case #1

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Physical Exam – Trauma

◆ Check Ligament stability ◆ ACL

✦ Lachman (at 20 deg)

• Highest sensitivity (87.1%)
• High NPV--rules out ACL tear

✦ Anterior drawer

• Inconclusive

Scholten RJPM et al. J Fam Pract 2003; Huang W et al. Acta Ortho Traum Turc 2016; Brady MP et al. J Sport Rehab 2017

Knee: Case #1

◆Lateral Pivot shift ◆Highest specificity

(97.5%)

◆High PPV--rules in

ACL tear

Scholten RJPM et al. J Fam Pract 2003; Huang W et al. Acta Ortho Traum Turc 2016; Brady MP et al. J Sport Rehab 2017

Knee: Case #1

■

MCL

◆ Tender medially over

MCL (often proximally)

◆ May lack ROM

pseudolocking

◆ Valgus stress test –

test at 20

Sens = 86 - 96 %

Malanga GA, Nadler SF. Musculoskeletal Physical Examination, Mosby, 2006

Posterior Cruciate Ligament (PCL) Injury

Physical Exam

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Sag sign

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Posterior drawer test Sens 79%, Spec 100% Sens 90%, Spec 99%

Rubenstein et al., AJSM 1994; 22: 550-557

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Knee: Case #1

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Physical Exam – Trauma

◆ Joint line tenderness

✦ Meniscus ✦ Bone bruise ✦ Chondral injury

◆ McMurray testing

Special Tests: Meniscus

Test Sensitivity Specificity Joint line tender 85.5% 29.4% Hyperflexion 50% 68.2% Extension block 84.7% 43.75% McMurray Classic (Med Thud/Click) 28.75% 95.3% McMurray Classic (Lat pain) 50% 29%

Fowler PJ, Lubliner JA. Arthroscopy 1989; 5(3): 184-186

Knee: Case #1

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Physical Exam – Trauma

◆ Patellar apprehension

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Knee: Case #1

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Xrays for traumatic injury

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+/- MRI

MRI

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Sens 94%, Spec 84% for ACL tear ACL tear signs

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Fibers not seen in continuity

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Edema on T2 films

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PCL – kinked or Question mark sign

Initial Treatment

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Referral to Orthopaedics/Sports Medicine

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Consider bracing, crutches

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Begin early Physical Therapy

◆ Protected motion

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Analgesia usually NSAIDs

ACL Tear Treatment

Non-Surgical

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No reconstruction

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Physical therapy

✦ Hamstring

strengthening

✦ Proprioceptive

training

✦ Coper?

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ACL bracing controversial

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Patient should be asymptomatic with ADLs Surgery

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Reconstruction

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Depends on activity demands

• Reconstruction

allows better return to sports

• Reduce chance of

symptomatic meniscal tear

• Less giving way

symptoms

• Prevent more OA

■

Recovery ~ 9-12 months

Shea KG, et al. AAOS evidence based review, J Bone Joint Surg Am, 2015

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Knee: Case #2

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40 yo male joined a gym in January with his brother-in-law

■

Began working with a personal trainer and they started a program of Olympic lifting (squatting, cleans) and plyometrics (box jumps)

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After 2 weeks began having left knee pain after workouts but continued training

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Now seeing you 2 weeks later because now it hurts during training and even with walking, especially on the stairs

What is the least likely diagnosis?

• 1. Patellar tendonitis
• 2. Pes anserine bursitis
• 3. MCL sprain
• 4. Patellofemoral syndrome
• 5. Hamstring strain

What is the least likely diagnosis?

• 1. Patellar tendonitis
• 2. Pes anserine bursitis
• 3. MCL sprain
• 4. Patellofemoral syndrome
• 5. Hamstring strain

Patellofemoral Pain

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Will point to kneecap region

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Pain associated with running, lunging, squats

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Pain with sitting for prolonged period

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Pain going down stairs may be worse than up stairs

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Soft tissue swelling often described as puffiness

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Patellofemoral Pain

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Positive patellar compression test

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Pain on palp of medial facet of patella

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Increased patellar mobility

Patellofemoral Pain

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Single Leg Squat to evaluate for weak quads, gluts

Patellofemoral Pain

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Thomas test to evaluate tight hip flexors, quads, ITB

Patellar Tendinitis

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Pain with

◆ resisted knee

extension

◆ resisted straight leg

raise

◆ single leg squat

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May have swelling at inferior pole of the patella

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Tenderness at prox patellar tendon

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Osgood Schlatters

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Pes Anserine Bursitis

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Primary flexors of the knee

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Protects knee against rotatory and valgus stress

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Pain often acute

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Can occur with sports and exercise

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Can also occur in sedentary

Iliotibial Band Syndrome Management of Knee Pain

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Trauma

◆ Diagnosed/suspect ligament, tendon, meniscus, bony

injury

◆ Brace, consider crutches, ice and ACE wrap, NSAIDs

for short duration

◆ Refer

✦ Surgery possible due to instab, mech symptoms, fx ✦ Suspect moderate to severe sprain/strain ✦ Patient request ■

Overuse

◆ PFS, patellar tendinitis, Pes anserine bursitis, ITB ◆ Brace, Ice/ACE wrap, NSAIDs ◆ Stretches, foam roller, strengthening, x-train, internet ◆ Make a PT referral and f/u with you in 4-8 wks or after

4-6 PT visits

Ankle: Case #1

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16 yo female playing in basketball game and turned her ankle inwards after a rebound when she came down on another foot

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Felt a pop; was unable to bear weight

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Immediate swelling on the outside and front of ankle

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Able to limp into your exam room the next day; points to her lateral ankle as the area of most pain

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Which of the following is an indication to order Xrays?

• 1. Feeling or hearing a pop
• 2. Inability to walk for 4 steps immediately after the

injury

• 3. Any bruising along the lateral and/or medial

malleolus

• 4. Tenderness on palpation along tip of lateral

malleolus

• 5. Numbness around the area of swelling

Which of the following is an indication to order Xrays?

• 1. Feeling or hearing a pop
• 2. Inability to walk for 4 steps immediately after the

injury

• 3. Any bruising along the lateral and/or medial

malleolus

• 4. Tenderness on palpation along tip of lateral

malleolus

• 5. Numbness around the area of swelling

Ankle Anatomy- Anterior Ankle Anatomy-Lateral

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Ankle – Case #1

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Differential Dx

◆ Fracture

✦ Distal fibula ✦ Other

◆ Ligament sprain

✦ Lateral ligaments ✦ Other

◆ Tendon strain

✦ Peroneal ✦ Achilles

Ankle: Case #1

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Moderate swelling of a fusiform nature ankle and anterolateral and lateral ankle region

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Ecchymosis inferior to lateral malleolus

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+ Squeeze test

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No pain

◆ Fibular head ◆ 5th MT

Ankle: Case #1

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Syndesmosis injury

◆ “high” ankle sprain

Ankle: Case #1

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2+ anterior drawer

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2+ lateral talar tilt

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Ankle: Case #1

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2+ anterior drawer Sens = 80% Spec = 74% PPV = 91% NPV = 52%

van Dijk et al. J Bone Joint Surg-Br, 1996

Ankle: Case #1

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2+ lateral talar tilt

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Stable medial tilt

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Stable talar shift

Ankle: Case #1

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Significantly decreased range of motion

Ankle: Case #1

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Pain over:

◆ Medial ankle ◆ Dorsal ankle ◆ Lateral malleolus ◆ ATFL, CFL ◆ AITFL, PITFL

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Pain with Squeeze test

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Ankle: Case #1 Grading Ankle Sprains

Grade Drawer/Tilt Test results Pathology Functional Recovery in weeks 1 Drawer and tilt negative, but tender Mild stretch with no instability 2 – 4 2 Drawer lax, tilt with good end point ATFL torn, CFL and PTFL intact 4 – 6 3 Drawer and tilt lax ATFL and CFL injured/torn 6 – 12

Ottawa Ankle Rules

■ Inability to weight bear immediately and in the

emergency / office (4 steps)

■ Bone tenderness at the posterior edge of the medial

• r lateral malleolus (Obtain Ankle Series)

■ Bone tenderness over the navicular or base of the

fifth metatarsal (Obtain Foot Series) Sens 97%, Spec 31-63%, NPV 99%, PPV <20%

Am J Emerg Med 1998; 16: 564-67

Ankle: Case #1a

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Patient is 10 yo

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Ankle: Case #1b

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Patient also has 5th MT pain

Ankle: Case #2

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35 yo female has begun a walking program to get more fit and lose her 20# “baby” weight

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Lives with her family in a hilly part of the city; time-wise easier to walk in her neighborhood

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She has exactly 45 minutes, after her workday and before her spouse comes home with the kids from daycare, to walk a 3 mile loop

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After 1 week she began to have pain in her medial ankle at the end of walking

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Now it hurts her even during, in the AM out of bed, and if she gets up from her chair at work after prolonged sitting

What other questions would be helpful in arriving at the diagnosis?

• 1. Is there any radiation of pain?
• 2. Have you ever injured this ankle before?
• 3. What type of shoes are you wearing during your

power walks?

• 4. Did you build up to the 45 minutes every day?
• 1. All of the above

What other questions would be helpful in arriving at the diagnosis?

• 1. Is there any radiation of pain?
• 2. Have you ever injured this ankle before?
• 3. What type of shoes are you wearing during your

power walks?

• 4. Did you build up to 45 minutes every day?
• 5. All of the above

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Ankle Anatomy-Medial Ankle: Case #2

Posterior Tibial Tendinitis

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Etiology

◆ Typically Overuse syndrome (too much, too soon) ◆ Poor shoeware on pronated feet

Ankle: Case #2

Posterior Tibial Tendinitis

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History:

◆ Initially may “warm-up” ◆ Stiff after inactivity ◆ Can also occur after returning

back to activity too quickly after ankle injury or after incomplete rehab

✦ Before achieving full DF range

• f motion

Ankle: Case #2

Posterior Tibial Tendinitis

■

Exam:

◆ Pain with resisted inversion ◆ Tightness of posteromedial

compartment of LE

✦ May also have “shin splints”

◆ Evaluate heel raise bilat ◆ “Too many toes” sign

4/3/18 17

Ankle – Case #3

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35 yo female almost one year later, has now decided to try to jog her route

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She now has motion control running shoes to control pronation

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Once again, the pain initially began at the end of jogging, then it started to hurt at the beginning but then would “warm-up” only to return towards the end.

■

Hurts again in the morning out of bed

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But this time the pain is in the back of her ankle

Ankle Anatomy-Posterior Ankle: Case #3

Achilles Tendinitis

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Etiology

◆ New onset of an activity or increased level of

intensity or increased duration

✦ Repetitive eccentric load on tendon (landing)

◆ Change in surface/terrain ◆ Change in footwear

✦ Flats or lower heels than usual

Ankle: Case #3

Achilles Tendinitis

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Physical Exam

◆ Swelling and pain over Achilles tendon, approx. 2-5

cm proximal to insertion

◆ Crepitus on palpation and with ROM ◆ Thickening of tendon ◆ Pain with resisted PF and passive DF ◆ Limited DF due to pain

4/3/18 18

Ankle – Case #4

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35 yo female, now just walking for exercise, and now playing in her work softball league

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First game of the season and during sprint to first base after hitting grounder, felt a rock hit her ankle and she stumbled and fell

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Needed assistance to get to the bench

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Iced and elevated and ACE wrap and NSAID

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Next day she could walk as long as she kept the ankle stiff, so she wore her hiking boots

Ankle – Case #4

Management of Ankle Pain

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Trauma

◆ Diagnosed/suspect ligament, tendon, bony injury ◆ Brace/splint/walking boot, consider crutches, ice and

ACE wrap, NSAIDs for short duration

◆ Refer

✦ Surgery possible due to instab, mech symptoms, fx ✦ Suspect moderate to severe sprain/strain ✦ Patient request ■

Overuse

◆ Achilles tendonitis, post tib tendonitis ◆ Brace, Orthotics or heel lifts, Ice/ACE wrap, NSAIDs

Stretches, theraband, strengthening, x-train, internet

◆ Make a PT referral and f/u with you in 4-8 wks or after

4-6 PT visits

Thank you for your attention