Knee 膝关节运动损伤

MS3SportsMedicineWorkshopFamilyMedicineClerkshipKneeProblemsMS3FamilyMedicineAnatomyReviewFemurMedial&lateralCondylesEpicondylesTrochleargrooveIntercondylarnotchPatellaSuperiorpole(base)Inferiorpole(apex)Medial&lateralfacetsTibiaMedial&lateralCondylesGerdy’stuberclePesanserineareaTibialtuberosityTibialplateauTibialspinesFibulaHeadNeckAnatomy–MajorLigaments&TendonsQuadricepstendonPatellartendonMedial&lateralpatellarretinaculuaMCL LCLACLandPCLIliotibialband(ITB)

Anatomy–MeniscioftheKneeMedialmeniscusLateralmeniscusMeniscalligamentsFunctionsofthemenisciMeniscalzonesWhite-whiteRed-whiteRed-redKneeExamOverviewInspectionPalpationRangeofMotionStrengthNeurovascularSpecialTestsCase1–MedialRightKneePain16yoHSsoccerplayer,previouslyhealthyTackledfromrightsidewhilerunningImmediateonsetofmedialjtlinepainDelayedonsetlocalmedialedema,stiffnessAbletobearweightKeyQuestionsintheHistoryMechanismofInjury?AcuteorChronic?Locationandlevelofpain?Abletowalk?MechanicalSymptoms?(Locking,popping,catching?)Associatedinstability?Swelling?Previousinjuriesorsurgeries?Case1-ExamInspection:MildmedialkneeedemaPalpation:+ttpmedialkneeROM:can’tbend>80dStrength:mildlydecreasedNeurovascular:normalSpecialtests:NegLachman,AnteriorDrawer,McMurray,varusstress+mildincreasedgaponvalgusstress(comparedtoleft)withgoodendpointSpecialTests-ACLInjuryLachmanTestSpecialTests-PCLInjuryPosteriorDrawerTestSagSign

Quad-ActiveTest

Varus/Valgusstressfor

LCLandMCLInjuryFeaturesthatshouldpromptanxrayafteracutekneeinjuryinclude:UnabletobearweightCan’tflex>90dPatellaTTPFibularheadTTPAge<18or>55Alloftheabove5OttawaKneeRules

i.e.WhentoorderakneexrayafteracuteinjuryAge>55or<18UnabletowalkTTPonPATELLATTPonFIBULARHEADUnabletoflex90degCase1-ImagingNormal!Case1–DifferentialDiagnosis

MoreLikely LessLikelyMeniscalTearLigamentousInjuryWhichligament?ACLPCLMCLLCLMuscleStrainFracturePatellofemoralPainPlicaMCLSprainDiagnosis?WhatgradeofsprainislikelypresentoftheMCL?Grade1:nolaxity,buthurtsGrade2:mildlaxity,stillintactGrade3:completetearGrade4:hurtslike*^%*MCLSprainTreatment?RICERelativeRestHingeBraceonlyifunstableonexamAchievefullROMProgressiveStrengtheningNeuromuscularControl(Balanceexercises)FunctionalExercises(Sport-specific)Case256yoretiredArmyLTC15yearsworseningL>RkneepainFormerparachutist,nospecifictraumaNopreviouskneesurgeriesStiffnessworseinmorningPainisworsewithactivity,betterwithrestCase2–KeyQuestionsMechanismofInjury?AcuteorChronic?Where/howbadispain?MechanicalSymptoms?(Locking,popping,catching?)Associatedinstability?Swelling?Previousinjuriesorsurgeries?Whatmakesitworse?Whatmakesitbetter?InsidiousOnsetChronicDifficulttolocalize;mildNoNoneOccasionalLotsof“BadLandings”NosurgeryActivityRestCase2–PhysicalExamInspection:GenuvarusBonyenlargementatMed/LatjointlinesPalp:PosteriormedialjointlinettpROM:Decreasedflexion,110deg,mildcrepitusStrength:normalNeurovascular:normalSpecialTests:noligamentouslaxity,negmeniscaltestsSpecialTests-MeniscalInjuriesJointlinetendernessMcMurrayTestsThessalytestBounce-hometestFullSquatCase2–PlainFilmsJointspacenarrowingSubchondralSclerosisOsteophytesSubchondralCystsWhatisyourdiagnosis?10MeniscaltearPlicasyndromeOsteoarthritisBonetumorOsteoarthritisNonpharmacologicTreatment:NonpainfulaerobicactivityWeightlossPhysicalTherapyImproveROM,increasestrengthBracingPharmacologicTreatment:APAPSupplementsGlucosamineandChondroitinNSAIDs,COX-2’sTramadolViscosupplementationIntrarticularSteroidsCase331yearoldfemale,LkneepainRecreationalrunnerLocalizespaintofrontofkneeNotrauma,insidiousonsetLocalizespain“aroundkneecap”WorsewithstairsWorseafterprolongedsittingKneeoccasionally“givesout”Case3–KeyQuestionsMechanismofInjury?AcuteorChronic?Whereisthepain?MechanicalSymptoms?(Locking,popping,catching?)Associatedinstability?Swelling?Previousinjuriesorsurgeries?Whatmakesitworse?Whatmakesitbetter?InsidiousOnsetChronicAnteriorkneeNo,butsometimesgivesoutNoneNoneNoneRunning,StairsMultipledaysofrestPhysicalExamInspection:mildgenuvalgusPalpation:TTPlateral>medialpatellarfacetsROM:fullw/opainStrength:normalNeurovascular:normalSpecialTests:+patellargrindDecreasedpatellarglideInflexiblehamstrings(Poplitealangle)PatellofemoralJointExamPatellofemoralJointExamPatellarGrindTestCase3–PlainFilmsAPLateralCase3–PlainFilmsTunnelSunriseWhat’syourdiagnosis?PatellartendinopathyPatellarinstabilityPatellofemoralsyndromePlicasyndromePatellofemoralSyndromeTreatment:Relativerest;non-painfulaerobicsPhysicalTherapyImproveQuad/HamstringflexibilityQuad,Hipabductorstrengthening