Knee-膝關(guān)節(jié)運動損傷課件

1、MS3 Sports Medicine WorkshopFamily Medicine ClerkshipMS3 Sports Medicine WorkshopFaKnee ProblemsMS3 Family MedicineKnee ProblemsMS3 Family MediciAnatomy ReviewAnatomy ReviewFemurMedial & lateralCondylesEpicondylesTrochlear grooveIntercondylar notchPatellaSuperior pole (base)Inferior pole (apex)Media

2、l & lateral facetsTibiaMedial & lateralCondylesGerdys tuberclePes anserine areaTibial tuberosityTibial plateauTibial spinesFibulaHeadNeckFemurTibiaAnatomy Major Ligaments & TendonsQuadriceps tendonPatellar tendonMedial & lateral patellar retinaculuaAnatomy Major Ligaments & TeMCLLCLMCLLCLKnee-膝關(guān)節(jié)運動損

3、傷課件Knee-膝關(guān)節(jié)運動損傷課件Anatomy Menisci of the KneeMedial meniscusLateral meniscusMeniscal ligamentsFunctions of the menisciMeniscal zonesWhite-whiteRed-whiteRed-redAnatomy Menisci of the KneeMKnee Exam OverviewInspectionPalpationRange of MotionStrengthNeurovascularSpecial TestsKnee Exam OverviewInspection

4、Case 1 Medial Right Knee Pain16yo HS soccer player, previously healthyTackled from right side while runningImmediate onset of medial jt line painDelayed onset local medial edema, stiffnessAble to bear weight Case 1 Medial Right Knee PaiKey Questions in the HistoryMechanism of Injury?Acute or Chronic

5、?Location and level of pain?Able to walk?Mechanical Symptoms? (Locking, popping, catching?)Associated instability?Swelling?Previous injuries or surgeries?Key Questions in the HistoryMeCase 1 - ExamInspection: Mild medial knee edemaPalpation: + ttp medial kneeROM: cant bend 80dStrength: mildly decrea

6、sedNeurovascular: normalSpecial tests:Neg Lachman, Anterior Drawer, McMurray, varus stress+ mild increased gap on valgus stress (compared to left) with good endpointCase 1 - ExamInspection: Mild Special Tests - ACL InjuryLachman TestSpecial Tests - ACL InjuryLachSpecial Tests - PCL InjuryPosterior D

7、rawer TestSag SignQuad-Active TestSpecial Tests - PCL InjuryPostVarus/Valgus stress for LCL and MCL InjuryVarus/Valgus stress for LCL Features that should prompt an xray after acute knee injury include:Unable to bear weightCant flex 90dPatella TTPFibular head TTPAge 55All of the aboveFeatures that s

8、hould prompt an5 Ottawa Knee Rulesi.e. When to order a knee xray after acute injuryAge 55 or R knee painFormer parachutist, no specific traumaNo previous knee surgeriesStiffness worse in morningPain is worse with activity, better with restCase 256 yo retired Army LTCCase 2 Key QuestionsMechanism of

9、Injury?Acute or Chronic?Where/how bad is pain?Mechanical Symptoms? (Locking, popping, catching?)Associated instability?Swelling?Previous injuries or surgeries?What makes it worse?What makes it better?Insidious OnsetChronicDifficult to localize; mildNoNoneOccasionalLots of “Bad Landings” No surgeryAc

10、tivityRestCase 2 Key QuestionsMechanisCase 2 Physical ExamInspection: Genu varusBony enlargement at Med/Lat joint linesPalp: Posterior medial joint line ttpROM: Decreased flexion, 110 deg, mild crepitusStrength: normalNeurovascular: normalSpecial Tests: no ligamentous laxity, neg meniscal testsCase

11、2 Physical ExamInspectiSpecial Tests - Meniscal InjuriesJoint line tendernessMcMurray TestsThessaly testBounce-home testFull SquatSpecial Tests - Meniscal InjurCase 2 Plain FilmsJoint space narrowingSubchondral SclerosisOsteophytesSubchondral CystsCase 2 Plain FilmsJoint spacWhat is your diagnosis?1

12、0Meniscal tearPlica syndromeOsteoarthritisBone tumorWhat is your diagnosis?10MenisOsteoarthritisNonpharmacologic Treatment:Nonpainful aerobic activityWeight lossPhysical TherapyImprove ROM, increase strengthBracingPharmacologic Treatment:APAPSupplementsGlucosamine and ChondroitinNSAIDs, COX-2sTramad

13、olViscosupplementationIntrarticular SteroidsOsteoarthritisNonpharmacologicCase 331 year old female, L knee painRecreational runnerLocalizes pain to front of kneeNo trauma, insidious onsetLocalizes pain “around kneecap”Worse with stairsWorse after prolonged sittingKnee occasionally “gives out”Case 33

14、1 year old female, L knCase 3 Key QuestionsMechanism of Injury?Acute or Chronic?Where is the pain?Mechanical Symptoms? (Locking, popping, catching?)Associated instability?Swelling?Previous injuries or surgeries?What makes it worse?What makes it better?Insidious OnsetChronicAnterior kneeNo, but somet

15、imes gives outNoneNoneNoneRunning, StairsMultiple days of restCase 3 Key QuestionsMechanisPhysical ExamInspection: mild genu valgusPalpation: TTP lateral medial patellar facetsROM: full w/o painStrength: normalNeurovascular: normalSpecial Tests:+ patellar grindDecreased patellar glideInflexible hams

16、trings (Popliteal angle)Physical ExamInspection: mild Patellofemoral Joint ExamPatellofemoral Joint ExamPatellofemoral Joint Exam Patellar Grind TestPatellofemoral Joint Exam PaCase 3 Plain FilmsAPLateralCase 3 Plain FilmsAPLateralCase 3 Plain FilmsTunnelSunriseCase 3 Plain FilmsTunnelSunrWhats your

17、 diagnosis?Patellar tendinopathyPatellar instabilityPatellofemoral syndromePlica syndromeWhats your diagnosis?PatellarPatellofemoral SyndromeTreatment:Relative rest; non-painful aerobicsPhysical TherapyImprove Quad/Hamstring flexibilityQuad, Hip abductor strengtheningCore strengtheningPatellar stabi

18、lization brace/tapingFoot orthoticsSurgery (last-ditch effort)Patellofemoral SyndromeTreatmeCase 434 yo Army MAJ training for 1st marathonAtraumatic onset of R lateral knee pain 1 week ago after 10 mile runSharp burning painBetter with rest, returns with runningCase 434 yo Army MAJ training Case 4 K

19、ey QuestionsMechanism of Injury?Acute or Chronic?Where is the pain?Mechanical Symptoms? (Locking, popping, catching?)Associated instability?Swelling?Previous injuries or surgeries?What makes it worse?What makes it better?Insidious OnsetAcuteLateral kneeNo, but sometimes gives outNoneNoneNoneRunningM

20、ultiple days of restCase 4 Key QuestionsMechanisPhysical ExamInspection: normalPalpation: TTP over lateral femoral condyleROM: fullStrength: normalNeurovascular: normalSpecial tests: + Noble testTight on Ober testPhysical ExamInspection: normaOber testNoble test Ober testNoble test Whats your diagno

21、sis?OsteoarthritisMeniscal tearIliotibial band syndromeLCL sprainWhats your diagnosis?OsteoartIliotibial Band SyndromeTreatment:Ice massage, pain medsRelative Rest; nonpainful activityPhysical TherapySpecific ITB stretchesHip abductor strengtheningCore strengthening (Gluteus Medius)Slow return to ac

22、tivityExtrinsic factors: shoes, running surface, training errorsIliotibial Band SyndromeTreatmWhat the heck is a Plica?Congenital thickening of joint capsuleRedundant meniscusLoose piece of intra-articular cartilageFigment of my imaginationWhat the heck is a Plica?CongePlica Syndrome?Plica Syndrome?

23、Questions?Before we break for hands-onQuestions?Special Tests - ACL InjuryLachman TestKnee flexed to 15-30 degreesStabilize distal femurAnteriorly translate tibia on femurWatch & feel for amount of translation & end pointPivot ShiftSpecial Tests - ACL InjuryLachSpecial Tests - PCL InjuryPosterior Dr

24、awer TestKnee flexed to 90 degreesPosteriorly translate tibia on femurWatch & feel for amount of translation & end pointSag SignKnees flexed, quads relaxed compare both sidesLook for tibial posterior “sag” relative to femurQuad-Active TestKnee flexed; hamstrings fully relaxedSlide foot along table (

25、quad active)Observe for anterior relocationSpecial Tests - PCL InjuryPostSpecial Tests - MCL InjuryValgus Stress TestingKnee flexed to 30 degreesRelax ACL/PCL & joint capsuleValgus stress applied to kneeLook and feel for translation and endpointCompare to uninjured sideMay repeat with knee in full e

26、xtensionSpecial Tests - MCL InjuryValgSpecial Tests - LCL InjuryVarus Stress TestingSame test as valgus stress testingExcept applying a varus stress insteadLCL, IT band, & PLC are testedSpecial Tests - LCL InjuryVaruSpecial Tests - Meniscal InjuriesJoint line tendernessFull SquatMcMurray TestsThessa

27、ly testBounce-home testSpecial Tests - Meniscal InjurMcMurray test for Meniscal injuryTest Med and Lat meniscus separately3 concurrent maneuvers:Grind it (Rotate tibia AWAY from it)Crunch it (varus or valgus)Pinch it (flex/extend knee)Positive: Painful “pop”McMurray test for Meniscal injSpecial Test

28、s - Meniscal InjuriesThessaly TestPt stands on affected legKnee bent at 20 degreesExaminer holds pts hands and rotates pt to both sidesMeniscal grindPositive test: pain, painful click.Special Tests - Meniscal InjurAnterior Knee ExamPalpation of patellar facetsGlide and lift patella medially & laterallyPalpate undersurface of patella