Knee 膝关节运动损伤.ppt

MS3 Sports Medicine MS3 Sports Medicine WorkshopWorkshop Family Medicine ClerkshipFamily Medicine Clerkship Knee ProblemsKnee Problems MS3 Family MedicineMS3 Family Medicine Anatomy ReviewAnatomy Review n n FemurFemur Medial mildDifficult to localize; mild n n NoNo n n NoneNone n n OccasionalOccasional n n Lots of “Bad Landings” No Lots of “Bad Landings” No surgerysurgery n n ActivityActivity n n RestRest Case 2 Physical ExamCase 2 Physical Exam n n Inspection: Inspection: Genu varusGenu varus Bony enlargement at Med/Lat joint linesBony enlargement at Med/Lat joint lines n n Palp: Posterior medial joint line ttpPalp: Posterior medial joint line ttp n n ROM: Decreased flexion, 110 deg, mild ROM: Decreased flexion, 110 deg, mild crepituscrepitus n n Strength: normalStrength: normal n n Neurovascular: normalNeurovascular: normal n n Special Tests: no ligamentous laxity, neg Special Tests: no ligamentous laxity, neg meniscal testsmeniscal tests Special Tests - Meniscal InjuriesSpecial Tests - Meniscal Injuries n n Joint line tendernessJoint line tenderness n n McMurray TestsMcMurray Tests n n Thessaly testThessaly test n n Bounce-home testBounce-home test n n Full SquatFull Squat Case 2 Plain FilmsCase 2 Plain Films Joint space narrowing Subchondral Sclerosis Osteophytes Subchondral Cysts What is your diagnosis?What is your diagnosis? 1.1.Meniscal tearMeniscal tear 2.2.Plica Plica syndromesyndrome 3.3.OsteoarthritisOsteoarthritis 4.4.Bone tumorBone tumor OsteoarthritisOsteoarthritis n n Nonpharmacologic Nonpharmacologic Treatment:Treatment: Nonpainful aerobic Nonpainful aerobic activityactivity Weight lossWeight loss Physical TherapyPhysical Therapy n n Improve ROM, increase Improve ROM, increase strengthstrength BracingBracing n n Pharmacologic Pharmacologic Treatment:Treatment: APAPAPAP SupplementsSupplements n n Glucosamine and Glucosamine and ChondroitinChondroitin NSAIDs, COX-2sNSAIDs, COX-2s TramadolTramadol ViscosupplementationViscosupplementation Intrarticular SteroidsIntrarticular Steroids Case 3Case 3 n n 31 year old female, L knee pain31 year old female, L knee pain n n Recreational runnerRecreational runner n n Localizes pain to front of kneeLocalizes pain to front of knee n n No trauma, insidious onsetNo trauma, insidious onset n n Localizes pain “around kneecap”Localizes pain “around kneecap” n n Worse with stairsWorse with stairs n n Worse after prolonged sittingWorse after prolonged sitting n n Knee occasionally “gives out”Knee occasionally “gives out” Case 3 Key QuestionsCase 3 Key Questions n n Mechanism of Injury?Mechanism of Injury? n n Acute or Chronic?Acute or Chronic? n n Where is the pain?Where is the pain? n n Mechanical Mechanical Symptoms? (Locking, Symptoms? (Locking, popping, catching?)popping, catching?) n n Associated instability?Associated instability? n n Swelling?Swelling? n n Previous injuries or Previous injuries or surgeries?surgeries? n n What makes it worse?What makes it worse? n n What makes it better?What makes it better? n n Insidious OnsetInsidious Onset n n ChronicChronic n n Anterior kneeAnterior knee n n No, but sometimes No, but sometimes gives outgives out n n NoneNone n n NoneNone n n NoneNone n n Running, StairsRunning, Stairs n n Multiple days of restMultiple days of rest Physical Exam nInspection: mild genu valgus nPalpation: TTP lateral medial patellar facets nROM: full w/o pain nStrength: normal nNeurovascular: normal nSpecial Tests: + patellar grind Decreased patellar glide Inflexible hamstrings (Popliteal angle) Patellofemoral Joint ExamPatellofemoral Joint Exam Patellofemoral Joint ExamPatellofemoral Joint Exam Patellar Grind Test Patellar Grind Test Case 3 Plain FilmsCase 3 Plain Films AP Lateral Case 3 Plain FilmsCase 3 Plain Films Tunnel Sunrise Whats your diagnosis? 1.Patellar tendinopathy 2.Patellar instability 3.Patellofemoral syndrome 4.Plica syndrome Patellofemoral SyndromePatellofemoral Syndrome n n Treatment:Treatment: Relative rest; non-painful aerobicsRelative rest; non-painful aerobics Physical TherapyPhysical Therapy n n Improve Quad/Hamstring flexibilityImprove Quad/Hamstring flexibility n n Quad, Hip abductor strengtheningQuad, Hip abductor strengthening n n Core strengtheningCore strengthening Patellar stabilization brace/tapingPatellar stabilization brace/taping Foot orthoticsFoot orthotics Surgery (last-ditch effort)Surgery (last-ditch effort) Case 4Case 4 n n 34 yo Army MAJ training for 34 yo Army MAJ training for 1 1 stst marathon marathon n n Atraumatic onset of R Atraumatic onset of R lateral knee pain 1 week lateral knee pain 1 week ago after 10 mile runago after 10 mile run n n Sharp burning painSharp burning pain n n Better with rest, returns Better with rest, returns with runningwith running Case 4 Key QuestionsCase 4 Key Questions n n Mechanism of Injury?Mechanism of Injury? n n Acute or Chronic?Acute or Chronic? n n Where is the pain?Where is the pain? n n Mechanical Mechanical Symptoms? (Locking, Symptoms? (Locking, popping, catching?)popping, catching?) n n Associated instability?Associated instability? n n Swelling?Swelling? n n Previous injuries or Previous injuries or surgeries?surgeries? n n What makes it worse?What makes it worse? n n What makes it better?What makes it better? n n Insidious OnsetInsidious Onset n n AcuteAcute n n Lateral kneeLateral knee n n No, but sometimes No, but sometimes gives outgives out n n NoneNone n n NoneNone n n NoneNone n n RunningRunning n n Multiple days of restMultiple days of rest Physical Exam nInspection: normal nPalpation: TTP over lateral femoral condyle nROM: full nStrength: normal nNeurovascular: normal nSpecial tests: + Noble test Tight on Ober test Ober testOber testNoble testNoble test Whats your diagnosis? 1.Osteoarthritis 2.Meniscal tear 3.Iliotibial band syndrome 4.LCL sprain Iliotibial Band SyndromeIliotibial Band Syndrome n n Treatment:Treatment: Ice massage, pain medsIce massage, pain meds Relative Rest; nonpainful activityRelative Rest; nonpainful activity Physical TherapyPhysical Therapy n n Specific ITB stretchesSpecific ITB stretches n n Hip abductor strengtheningHip abductor strengthening n n Core strengthening (Gluteus Medius)Core strengthening (Gluteus Medius) Slow return to activitySlow return to activity Extrinsic factors: shoes, running Extrinsic factors: shoes, running surface, training errorssurface, training errors What the heck is a Plica? 1.Congenital thickening of joint capsule 2.Redundant meniscus 3.Loose piece of intra -articular cartilage 4.Figment of my imagination Plica Syndrome? Questions?Questions? Before we break for hands-onBefore we break for hands-on Special Tests - ACL InjurySpecial Tests - ACL Injury n n Lachman TestLachman Test Knee flexed to 15-30 degreesKnee flexed to 15-30 degrees Stabilize distal femurStabilize distal femur Anteriorly translate tibia on Anteriorly translate tibia on femurfemur Watch hamstrings Knee flexed; hamstrings fullyfully relaxedrelaxed Slide foot along table (quad Slide foot along table (quad active)active) Observe for anterior relocationObserve for anterior relocation Special Tests - MCL InjurySpecial Tests - MCL Injury n n Valgus Stress TestingValgus Stress Testing Knee flexed to 30 degreesKnee flexed to 30 degrees n n Relax ACL/PCL & joint Relax ACL/PCL & joint capsulecapsule Valgus stress applied to kneeValgus stress applied to knee Look and feel for translation Look and feel for translation and endpointand endpoint Compare to uninjured sideCompare to uninjured side May repeat with knee in full May repeat with knee in full extensionextension Special Tests - LCL InjurySpecial Tests - LCL Injury n n Varus Stress Varus Stress TestingTesting Same test as Same test as valgus stress valgus stress testingtesting Except applying a Except applying a varus stress varus stress insteadinstead LCL, IT band, & LCL, IT band, & PLC are testedPLC are tested Special Tests - Meniscal InjuriesSpecial Tests - Meniscal Injuries n n Joint line tendernessJoint line tenderness n n Full SquatFull Squat n n McMurray TestsMcMurray Tests n n Thessaly testThessaly test n n Bounce-home testBounce-home test McMurray test for McMurray test for Meniscal injuryMeniscal injury n n Test Med and Lat meniscus Test Med and Lat meniscus separatelyseparately n n 3 concurrent maneuvers:3 concurrent maneuvers: GrindGrind it (Rotate tibia it (Rotate tibia AWAY from it)AWAY from it) CrunchCrunch it (varus or it (varus or valgus)valgus) PinchPinch it (flex/extend it (flex/extend knee)knee) n n Positive: Painful “pop”Positive: Painful “pop” Special Tests - Meniscal InjuriesSpecial Tests - Meniscal Injuries n n Thessaly TestThessaly Test Pt stands on Pt stands on affected legaffected leg Knee bent at 20 Knee bent at 20 degreesdegrees Examiner holds pts Examiner holds pts hands and rotates hands and rotates pt to both sidespt to both sides n n Meniscal grindMeniscal grind Positive test: pain, Positive test: pain, painful click.painful click. Anterior Knee ExamAnterior Knee Exam Palpation of patellar Palpation of patellar facetsfacets n n Glide and lift patella Glide and lift patella medially & laterallymedially & laterally n n Palpate undersurface Palpate undersurface of patella for of patella for tendernesstenderness Patellar ExamPatellar Exam Patellar GlidePatellar Glide n n Knee in extension, relaxedKnee in extension, relaxed n n Medial & lateral patellar Medial & lateral patellar displacementdisplacement Measured in quadrantsMeasured in quadrants n n Normal: 1-2 quadrantsNormal: 1-2 quadrants n n Patellar ApprehensionPatellar Apprehension n n Lateral patellar displacementLateral patellar displacement patient apprehension patient apprehension or guarding or guarding Anterior Knee ExamAnterior Knee Exam Patellar Grind Test Patellar Grind Test n n Knee 10 deg flexionKnee 10 deg flexion