Knee膝关节运动损伤.ppt

MS3SportsMedicineWorkshop FamilyMedicineClerkship KneeProblems MS3FamilyMedicine AnatomyReview FemurMedial lateralCondylesEpicondylesTrochleargrooveIntercondylarnotchPatellaSuperiorpole base Inferiorpole apex Medial lateralfacets TibiaMedial lateralCondylesGerdy stuberclePesanserineareaTibialtuberosityTibialplateauTibialspinesFibulaHeadNeck Anatomy MajorLigaments Tendons QuadricepstendonPatellartendonMedial lateralpatellarretinaculua MCLLCL Anatomy MeniscioftheKnee MedialmeniscusLateralmeniscusMeniscalligamentsFunctionsofthemenisciMeniscalzonesWhite whiteRed whiteRed red KneeExamOverview InspectionPalpationRangeofMotionStrengthNeurovascularSpecialTests Case1 MedialRightKneePain 16yoHSsoccerplayer previouslyhealthyTackledfromrightsidewhilerunningImmediateonsetofmedialjtlinepainDelayedonsetlocalmedialedema stiffnessAbletobearweight KeyQuestionsintheHistory MechanismofInjury AcuteorChronic Locationandlevelofpain Abletowalk MechanicalSymptoms Locking popping catching Associatedinstability Swelling Previousinjuriesorsurgeries Case1 Exam Inspection MildmedialkneeedemaPalpation ttpmedialkneeROM can tbend 80dStrength mildlydecreasedNeurovascular normalSpecialtests NegLachman AnteriorDrawer McMurray varusstress mildincreasedgaponvalgusstress comparedtoleft withgoodendpoint SpecialTests ACLInjury LachmanTest SpecialTests PCLInjury PosteriorDrawerTestSagSignQuad ActiveTest Varus ValgusstressforLCLandMCLInjury Featuresthatshouldpromptanxrayafteracutekneeinjuryinclude UnabletobearweightCan tflex 90dPatellaTTPFibularheadTTPAge55Alloftheabove 5OttawaKneeRulesi e Whentoorderakneexrayafteracuteinjury Age 55or 18UnabletowalkTTPonPATELLATTPonFIBULARHEADUnabletoflex90deg Case1 Imaging Normal Case1 DifferentialDiagnosisMoreLikelyLessLikely MeniscalTearLigamentousInjuryWhichligament ACLPCLMCLLCLMuscleStrain FracturePatellofemoralPainPlica MCLSprain Diagnosis WhatgradeofsprainislikelypresentoftheMCL Grade1 nolaxity buthurtsGrade2 mildlaxity stillintactGrade3 completetearGrade4 hurtslike MCLSprain Treatment RICERelativeRestHingeBraceonlyifunstableonexamAchievefullROMProgressiveStrengtheningNeuromuscularControl Balanceexercises FunctionalExercises Sport specific Case2 56yoretiredArmyLTC15yearsworseningL RkneepainFormerparachutist nospecifictraumaNopreviouskneesurgeriesStiffnessworseinmorningPainisworsewithactivity betterwithrest Case2 KeyQuestions MechanismofInjury AcuteorChronic Where howbadispain MechanicalSymptoms Locking popping catching Associatedinstability Swelling Previousinjuriesorsurgeries Whatmakesitworse Whatmakesitbetter InsidiousOnsetChronicDifficulttolocalize mildNoNoneOccasionalLotsof BadLandings NosurgeryActivityRest Case2 PhysicalExam Inspection GenuvarusBonyenlargementatMed LatjointlinesPalp PosteriormedialjointlinettpROM Decreasedflexion 110deg mildcrepitusStrength normalNeurovascular normalSpecialTests noligamentouslaxity negmeniscaltests SpecialTests MeniscalInjuries JointlinetendernessMcMurrayTestsThessalytestBounce hometestFullSquat Case2 PlainFilms JointspacenarrowingSubchondralSclerosisOsteophytesSubchondralCysts Whatisyourdiagnosis MeniscaltearPlicasyndromeOsteoarthritisBonetumor Osteoarthritis NonpharmacologicTreatment NonpainfulaerobicactivityWeightlossPhysicalTherapyImproveROM increasestrengthBracing PharmacologicTreatment APAPSupplementsGlucosamineandChondroitinNSAIDs COX 2 sTramadolViscosupplementationIntrarticularSteroids Case3 31yearoldfemale LkneepainRecreationalrunnerLocalizespaintofrontofkneeNotrauma insidiousonsetLocalizespain aroundkneecap WorsewithstairsWorseafterprolongedsittingKneeoccasionally givesout Case3 KeyQuestions MechanismofInjury AcuteorChronic Whereisthepain MechanicalSymptoms Locking popping catching Associatedinstability Swelling Previousinjuriesorsurgeries Whatmakesitworse Whatmakesitbetter InsidiousOnsetChronicAnteriorkneeNo butsometimesgivesoutNoneNoneNoneRunning StairsMultipledaysofrest PhysicalExam Inspection mildgenuvalgusPalpation TTPlateral medialpatellarfacetsROM fullw opainStrength normalNeurovascular normalSpecialTests patellargrindDecreasedpatellarglideInflexiblehamstrings Poplitealangle PatellofemoralJointExam PatellofemoralJointExam PatellarGrindTest Case3 PlainFilms AP Lateral Case3 PlainFilms Tunnel Sunrise What syourdiagnosis PatellartendinopathyPatellarinstabilityPatellofemoralsyndromePlicasyndrome PatellofemoralSyndrome Treatment Relativerest non painfulaerobicsPhysicalTherapyImproveQuad HamstringflexibilityQuad HipabductorstrengtheningCorestrengtheningPatellarstabilizationbrace tapingFootorthoticsSurgery last ditcheffort Case4 34yoArmyMAJtrainingfor1stmarathonAtraumaticonsetofRlateralkneepain1weekagoafter10milerunSharpburningpainBetterwithrest returnswithrunning Case4 KeyQuestions MechanismofInjury AcuteorChronic Whereisthepain MechanicalSymptoms Locking popping catching Associatedinstability Swelling Previousinjuriesorsurgeries Whatmakesitworse Whatmakesitbetter InsidiousOnsetAcuteLateralkneeNo butsometimesgivesoutNoneNoneNoneRunningMultipledaysofrest PhysicalExam Inspection normalPalpation TTPoverlateralfemoralcondyleROM fullStrength normalNeurovascular normalSpecialtests NobletestTightonObertest ObertestNobletest What syourdiagnosis OsteoarthritisMeniscaltearIliotibialbandsyndromeLCLsprain IliotibialBandSyndrome Treatment Icemassage painmedsRelativeRest nonpainfulactivityPhysicalTherapySpecificITBstretchesHipabductorstrengtheningCorestrengthening GluteusMedius SlowreturntoactivityExtrinsicfactors shoes runningsurface trainingerrors WhattheheckisaPlica CongenitalthickeningofjointcapsuleRedundantmeniscusLoosepieceofintra articularcartilageFigmentofmyimagination PlicaSyndrome Questions Beforewebreakforhands on SpecialTests ACLInjury LachmanTestKneeflexedto15 30degreesStabilizedistalfemurAnteriorlytranslatetibiaonfemurWatch feelforamountoftranslation endpointPivotShift SpecialTests PCLInjury PosteriorDrawerTestKneeflexedto90degreesPosteriorlytranslatetibiaonfemurWatchhamstringsfullyrelaxedSlidefootalongtable quadactive Observeforanteriorrelocation SpecialTests MCLInjury ValgusStressTestingKneeflexedto30degreesRelaxACL PCL jointcapsuleValgusstressappliedtokneeLookandfeelfortranslationandendpointComparetouninjuredsideMayrepeatwithkneeinfullextension SpecialTests LCLInjury VarusStressTestingSametestasvalgusstresstestingExceptapplyingavarusstressinsteadLCL ITband PLCaretested SpecialTests MeniscalInjuries JointlinetendernessFullSquatMcMurrayTestsThessalytestBounce hometest McMurraytestforMeniscalinjury TestMedandLatmeniscusseparately3concurrentmaneuvers Grindit RotatetibiaAWAYfromit Crunchit varusorvalgus Pinchit flex extendknee Positive Painful pop SpecialTests MeniscalInjuries ThessalyTestPtstandsonaffectedlegKneebentat20degreesExaminerholdspt shandsandrotatespttobothsidesMeniscalgrindPositivetest pain painfulclick AnteriorKneeExam PalpationofpatellarfacetsGlideandliftpatellamedially la