8/11/2016 � ESSENTIALS OF PRIMARY CARE: Disclosures A Core Curriculum for Ambulatory Practice August 7-12, 2016 I have nothing to disclose Five Common Knee and Ankle Conditions You Will See in Office Practice Cindy J. Chang M.D. UCSF Primary Care Sports Medicine Associate Clinical Professor of Orthopaedics and Family and Community Medicine Knee Anatomy Objective Develop strategies to diagnose and manage � common office problems including knee and ankle injuries 1 �
8/11/2016 � Anterior Knee Medial Knee Lateral Knee Knee: Case #1 40 yo male playing in family Thanksgiving Day � touch football game Tackled by his brother-in-law (“who never really � liked me”) and his knee twisted under him Now seeing you 1 week later and using an ACE � wrap and borrowed cane 2 �
8/11/2016 � Which next question would be the Knee: Case #1 least valuable in terms of determining the diagnosis? 40 yo male playing in family Thanksgiving Day � touch football game Tackled by his brother-in-law (“who never really � A. How long did it take before it swelled? liked me”) and he felt a pop as his knee twisted 43% B. Were you able to continue playing? under him C. Does your knee give way? Hard to put weight on leg and was unable to � continue playing D. Did you feel a pop? 19% The knee swelled “like a melon” within 2 hours E. Have you ever injured that knee in � 14% 13% despite ice the past? 10% His knee shifts when he puts more weight on it � Now seeing you 1 week later and using an ACE � Did you feel a pop? Does your knee give way? How long did it take befo.. Have you ever injured th.. Were you able to conti... wrap and borrowed cane Knee: Case #1 Knee: Case #1 Physical Exam – Trauma � Differential Diagnosis � First: Point to where it hurts � � Ligament tear � ACL tear � Effusion vs. Soft tissue swelling � MCL tear � Superficial abrasions � Less likely LCL tear, PCL tear � Active straight leg raise � Tendon rupture � Meniscus tear � Patellar dislocation � Chondral injury � Bone contusion/Fracture 3 �
8/11/2016 � Knee: Case #1 Knee: Case #1 Physical Exam – Trauma Physical Exam – Trauma � � � Ligament stability � Joint line tenderness � Lachman � Meniscus � Posterior drawer � Bone bruise � Valgus stress � Chondral injury � Varus stress/Figure of 4 � Joint line tenderness Knee: Case #1 Knee: Case #1 Xrays for traumatic injury � Physical Exam – Trauma � +/- MRI � Patellar apprehension � 4 �
8/11/2016 � Knee: Case #2 What is the least likely diagnosis? 40 yo male joined a gym in January with his � A. Patellar tendonitis brother-in-law 39% 38% B. Pes anserine bursitis Began working with a personal trainer and they � started a program of Olympic lifting (squatting, C. MCL sprain cleans) and plyometrics (box jumps) D. Patellofemoral syndrome After 2 weeks began having left knee pain after � E. Hamstring strain workouts but continued training 11% 8% Now seeing you 2 weeks later because now it hurts 4% � during training and even with walking, especially on n the stairs s s e n i i i m i t t i a a i s r r n r p o t o u r s s d d b L g n n n e C y e n M i t s r i l t r r a s a e m l s r l n o a e m t a H a e s P e f o P l l e t a P Patellofemoral Pain Patellofemoral Pain Positive patellar compression � Will point to kneecap � test region Pain on palp of medial facet of � Pain associated with � patella running, lunging, squats Increased patellar mobility � Pain with sitting for � prolonged period Pain going down stairs � may be worse than up stairs Soft tissue swelling often � described as puffiness 5 �
8/11/2016 � Patellofemoral Pain Patellofemoral Pain Thomas test to evaluate tight � Single Leg Squat to evaluate for � hip flexors, quads, ITB weak quads, gluts Patellar Tendinitis Pes Anserine Bursitis Pain with Primary flexors of the � � knee � resisted knee extension Protects knee against � � resisted straight leg rotatory and valgus raise stress � single leg squat Pain often acute � May have swelling at � Can occur with sports � inferior pole of the and exercise patella Can also occur in � Tenderness at prox � sedentary patellar tendon Osgood Schlatters � 6 �
8/11/2016 � Management of Knee Pain Iliotibial Band Syndrome 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 Which of the following is an indication Ankle: Case #1 to order Xrays? 16 yo female playing in basketball game and A. Feeling or hearing a pop � turned her ankle inwards after a rebound when she B. Inability to walk for 4 steps came down on another foot immediately after the injury She felt a pop, and was unable to bear weight � C. Any bruising along the lateral and/or 44% 38% She had immediate swelling on the outside and medial malleolus � front of her ankle D. Tenderness on palpation along tip of She is able to limp into your exam room the next lateral malleolus � day. She points to her lateral ankle as the area of E. Numbness around the area of most pain and she is very tender when you palpate 7% swelling 6% 6% the distal tip of the fibula p . . . . . o . . . . p e . n r t a o a a s l i e g 4 e t h h a n r p t i o t r g a l d a f n e k n p o u h a l n o l o r w a r o a g s g o n s s t i e s n s n e i y i l t u r n e i e b e l r d b i b m F n a y u n n e T N I A 7 �
8/11/2016 � Ankle Anatomy- Anterior Ankle Anatomy-Lateral Ankle – Case #1 Ankle: Case #1 Differential Dx Moderate swelling of a fusiform nature ankle and � � anterolateral and lateral ankle region � Fracture � Distal fibula Ecchymosis inferior to lateral malleolus � � Other + Squeeze test � � Ligament sprain No pain � � Lateral ligaments � Fibular head � Other � 5 th MT � Tendon strain � Peroneal � Achilles 8 �
8/11/2016 � Ankle: Case #1 Ankle: Case #1 Syndesmosis injury +2 anterior drawer � � � “high” ankle sprain +2 lateral talar tilt � Ankle: Case #1 Ankle: Case #1 +2 anterior drawer +2 lateral talar tilt � � Stable medial tilt � Stable talar shift � 9 �
8/11/2016 � Ankle: Case #1 Ankle: Case #1 Significantly decreased range of motion Decreased strength secondary to pain � � Ankle: Case #1 Ankle: Case #1 Pain over: � � Medial ankle � Dorsal ankle � Lateral malleolus � ATFL, CFL � AITFL, PITFL Pain with Squeeze test � 10 �
8/11/2016 � Ankle: Case #1a Ankle: Case #1b Patient also has 5 th MT pain Patient is 10 yo � � What other questions would be Ankle: Case #2 helpful in arriving at the diagnosis? A 35 yo female has begun a walking program to � get more fit and lose her 20# “baby” weight A. Is there any radiation of pain? She lives with her family in a hilly part of the city; � B. Have you ever injured this ankle time-wise it is easier to walk in her neighborhood 92% before? She has exactly 45 minutes, after her workday and � C. What type of shoes are you wearing before her spouse comes home with the kids from during your power walks? daycare, to walk a 3 mile loop D. Did you build up to the 45 minutes After 1 week she began to have pain in her medial � every day? ankle at the end of walking E. All of the above 5% Now it hurts her even during, in the morning out of 2% 0% 1% � bed, and if she gets up from her chair at work after Have you ever injured th.. All of the above Is there any radiation of ... What type of shoes are ... Did you build up to the .. prolonged sitting 11 �
8/11/2016 � Ankle: Case #2 Ankle Anatomy-Medial Posterior Tibial Tendinitis Etiology � � Typically Overuse syndrome (too much, too soon) � Poor shoeware on pronated feet Ankle: Case #2 Ankle: Case #2 Posterior Tibial Tendinitis Posterior Tibial Tendinitis History: � Exam: � � Initially may “warm-up” � Pain with resisted inversion � Stiff after inactivity � Tightness of posteromedial � Can also occur after returning compartment of LE back to activity too quickly � May also have “shin splints” after ankle injury or after � Evaluate heel raise bilat incomplete rehab � “Too many toes” sign � Before achieving full DF range of motion 12 �
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