american college of physicians 2013 ohio chapter scientific meeting columbus, oh october 11, 2013...
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Orthopaedics for the Practicing Internist
American College of Physicians2013 Ohio Chapter Scientific Meeting
Columbus, OHOctober 11, 2013
Paul J. Gubanich, MD, MPHAssistant Professor of Internal Medicine/Sports MedicineTeam Physician, Ohio State University Athletics, Ohio Machine, Columbus City Schools
DisclosuresI do not have a conflict of interest associated
with the material contained in this presentation.
An Approach to the Patient with Knee PainMost common
complaintsPainInstability –
(ligament injury, OA)
Stiffness – (effusion, OA)
SwellingLocking (meniscal)Weakness
Most diagnosis made by:HistoryPhysical examImaging
Important Historical ComponentsAgeChronology, onsetPain level, characteristicsExacerbating positions/
movementsRelieving factorsActivity level or recent
change, occupationPrevious injuries, surgeriesExercise history, goalsPrevious treatments
Chronology of SymptomsAcute Pain
Sudden onsetSpecific mechanism
of injury Direct trauma (fall,
collision, MVA) Landing, pivoting
Common acute injuriesFractures (distal
femur, patella, proxmial tibia, fibula)
DislocationsMeniscal injuriesLigamentous injuriesMusculotendious
strainsContusions
Chronic PainOften lacks a
mechanism of injurySymptoms of
gradual onset
Common causes of chronic knee painArthritisTumors (night pain)
Osteosarcoma (adolescents) Chondrosarcoma (adults) Giant cell tumor (benign) Metastatic disease is
uncommonSepsis (rare, can be
bursal)Bursitis (overuse)TendonitisAnterior knee pain
Medial KneeJoint line –
meniscus, OA, osteochondral defect, osteonecrosis, medial collateral ligament
Tibial plateau – (osteoporosis, post menopausal)
Pes bursa
Anterior KneeAnterior
Quad tendon or insertion
Anterior to patellaPatellaPatellar origin, tendon,
insertionTibial tubercle
Lateral Knee PainLateral
Femoral condyle – suggests IT band
Joint line – meniscus, OA, OCD, lateral collateral ligament
Posterior KneeMeniscus – posterior
medial, lateral corner
Posterior lateral – Baker’s/popliteal cyst, aneurysm
Physical ExamExam both sides
Joint above and belowMost painful part last
GaitAlignment (varus,
valgus)Squat
InspectionSwellingBruisingDeformity
Physical ExamPalpation
EffusionRange of Motion
Patellar trackingExtension (-5 to 5)Flexion (135-145)Crepitus, etc.
StrengthHamstringQuad
Functional tests
Physical Exam – Special Maneuvers Apprehension sign –
patellar instabilityApley grind test –
meniscusMcMurray
circumduction test, SN 16-58%SP 77-98%(Evans 1993, Fowler
1989, Kurasaka 1999, Anderson 1986)
Physical Exam – Special Maneuvers
Anterior/posterior drawer – ACL/PCL
Posterior Sag Sign
RadiologyPlain x-rays often
considered part of examHelps rule out
competing diagnosisX-ray views
Standing AP views of both knees (for comparison)
LateralTunnel at 45 degreesMerchant/Sunrise – to
evaluate PF joint
RadiologyMRI often not
needed initiallySurgical planning
toolFailure of treatmentIdentify
ligamentous/cartilage injuries of acute or surgical nature
Risk stratification
General Treatment PearlsMatch disease severity/limitations with
treatment optionsEscalate based on time, response in a
stepwise fashionSet realistic expectations for progress and
follow-upAlign treatment goals with patient
goals/expectations when possible Time is a great healer
Common Treatment RecommendationsActivity modification, restMechanical devices –
braces, crutches, lifts, orthotics, etc.
Ice, pain medicationNsaidsAcetaminophenOthers
Physical therapy – early motion progressing to strengthening and then functional drills
Injection therapyAspirationCorticosteroidsHyaluronic acid supplents
(OA)Glucosamine (OA)Surgical considerationsConsider additional
imaging options as neededMRIBone scanCT
Red FlagsNight painAbnormal x-ray findings
Fractures, tumor, cartilage lesions, etc.
Mechanical symptomsSevere pain, swelling, loss
of motion, or weaknessHigh grade ligament injuriesFail to respond to standard
treatmentsMultiple joints involved
(Rheum)