1
Q
Condition?
- Friction irritation due to repetitive A-P movement of the iliotibial band over the lateral femoral condyle (e.g. cross country running, cycling)
- Faulty biomechanics
A
Iliotibial Band “Friction” Syndrome
2
Q
ITB Friction Syndrome
- Inflammation of the ITB at the point wher it passes over what?
A
Passes over lateral epicondyle of the femur
3
Q
3 predisposing factors to ITB “Friction Syndrome”
A
- Tight IT band
- Genu varum (bowlegged)
- Foot pronation → internal tibial rotation
4
Q
Clinical Presentation of what?
- Localized tenderness over lateral femoral condyle (esp. w/ palpation at 30˚ knee flexion)
- Pain with active knee flexion / extension (walk with “stiff” knee)
- No limitation of end range active or passive knee flexion/extension
- No weakness with resisted knee range of motion
- No pain or instability with collateral ligament laxity testing
A
Iliotibial Band “Friction” Syndrome
5
Q
What test? / For what Condition?
- Pt supine
- Knee is flexed to 90°
- Pressure applied to lateral femoral condyle
- Knee is passively extended
- c/o pain at 30° similar to that during activity
A
Noble Compression Test
6
Q
Tx for ITB “Friction” syndrome?
A
- NSAIDs
- Ice WITH motion
- Activity Modification
- Therapy:
- improve gluteal & iliotibial band flexibility
- gluteal (hip abductor strength)
- evaluate biomechanics
- If fail conservative –> corticosteroid injection (risky bc/ tendon rupture)
7
Q
Which condition?
- MC from repetitive contact/trauma
- Repetitive contact
- Carpet / tile layers
- Grappling sports (wrestling)
- Trauma
- Fall
- Forceful contact with hard object (coffee table)
A
Prepatellar Bursitis
8
Q
Prepatellar Bursitis
- Tightness at end range of active & passive knee flexion
- Restricted ROM should be pain free
- Should not have pain w/ _____ of the patella
- What special test will be positive?
A
- lateral compression of the patella
- Patellar Ballotement is +
9
Q
Tx for Prepatellar Bursitis
A
- Aspiration/injection
- Compression
- Ice
- NSAIDs
- Surgical excision (if recurrent problems)
- Prevention (Knee pads)
10
Q
Aspiration / Injection for Prepatellar Burisitis Treatment
- 3 things you do to eval for Infection?
- Post aspiration care:
- no direct water exposure for ___ hours
- Continuous compression for __ hours/ day for ___ days
- During the first 7 days:
- ice daily
- avoid pressure/contact
- No repetitive LE exercise
A
- Visualize fluids for clarity, color, viscosity
- Leukocyte count
- Culture & gram stain
- no water: 48-72 hours
- compression: 48 hrs / 5 - 7 days
11
Q
2 types of Infectious Arthritis
A
- Non-gonococcal acute bacterial arthritis (septic)
- Gonococcal arthritis
12
Q
Infectious Arthritis - Non-gonococcal
- MC etiology?
- MC organism?
- RFs? (7)
A
- MC etiology: Hematogenous
- Organism: Staph aureus
- RFs:
- •Immunosuppression
- Diabetes Mellitus
- Sickle cell anemia
- Prosthetic joint
- Previous or pre-existing arthritis
- Trauma
- Bacteremia
13
Q
Clinical Px of what condition?
- Acute onset of monoarticular inflammatory arthritis (knee MC)
- Erythema, swelling/effusion, warmth and pain
- Limited function
- +/- fever
- +/- leukocytosis
A
Infectious Arthritis - Non-gonococcal
14
Q
Infectious Arthritis - Non-gonococcal
- Mainstay of dx?
- Analysis consistent w/ what?
- Blood cultures positive in what %?
- Imaging?
A
- Mainstay: synovial fluid analysis w/ wide bore needle (16 G)
- Analysis: Bacterial Infection
- >50,000 WBCs
- >75% PMNs
- Low glucose
- culture
- 50% of blood cultures are +
- Imaging usually NOT very helpful
15
Q
Which condition?
- > 60 years
- High prevalence of RA
- Average of 4 joints (Knee, elbow, shoulder and hip predominate)
- Staph and Strep most common (Blood cultures positive in 75%)
- Synovial fluid culture positive in 90%
- Poor prognosis (32% mortality (compared to 4% with monoarticular disease)
A
Polyarticular infectious arthritis (Non-gonococcal)
16
Q
IV drug users w/ Non-gonoccoal Infectious Arthritis
- What 3 joints are affected?
- # 1 MC organism?
- # 2 MC organism?
A
- sternoclavicular, costochondral, pubic symphysis
- #1: S. aureus
- #2: pseudomonas
17
Q
Tx for Non-Gonococcal Infectious Arthritis?
A
- Joint aspiration and irrigation
- Start IV antibiotics - do not wait on culture results
•Empiric = Vancomysin + 3rd generation cephalosporin (Ceftriaxone)
Targeted:
- MSSA = Nafcillin
- MRSA = Vancomysin
•Serial synovial fluid analysis are utilized to confirm clearance of infection
18
Q
Gonococcal - Infectious Arthritis
- Infection w/ what organism?
- Occurs in otherwise healthy people
- ____ arthritis in sexually active adult
- Greater in men or women?
- More common during menses & pregnancy
A
- Neisseria gonorrhoeae
- migratory
- Women
19
Q
Clinical Px of what Condition?
- Migratory non-symmetric polyarthralgias of wrist, knee, ankle, elbow for 1-4 days
- Tenosynovitis
- Necrotic pustules on palms and soles
- Fever occurs in less than half
- Less than one fourth have GU symptoms
- <50% develop purulent arthritis (knee MC)
A
Gonococcal Infectious Arthritis
20
Q
Labs of Gonococcal Infectious Arthritis
- Elevated WBC in less than 1/3 of cases
- Synovial fluid analysis
- elevated ___
- Gram stain positive in 25%
- Culture + in 50%
- Blood cultures positive in 40-70% of cases
- Cultures of what 4 locations need to be done? And are often + w/o sxs
- Imaging?
A
- elevated WBCs
- 4 locations for cultures:
- urethra
- throat
- cervix
- rectum
21
Q
Tx for Gonococcal Infectious Arthritis?
A
- Azithromycin 1 g orally as single dose + third gen cephalosporin (Ceftriaxone)
- After improvement in 24-48 hours, patient must complete 7-14 day course of ceftriaxone IM daily
Prognosis: rapid response to abx
22
Q
Which condition?
- Overuse / repetitive stress (e.g. jumping activities)
- Microtrauma / chronic inflammation of the patellar / quadriceps tendon
- Common in athletes who repeatedly jump or place eccentric stress on the knee
- Imbalance between frequent patellar tendon loading and short-term healing ability
A
Patellar / Quadriceps Tendonitis (-osis)
23
Q
Clinical Px of what condition?
- Localized pain / tenderness on palpation
- Persistent aching after activity
- Pain with resisted knee extension (+/- weakness)
- Pain / tightness at end range of active and passive knee flexion
A
Patellar / Quadricepts Tendonitis (osis)
24
Q
Tx for Patellar / Quad Itis or Osis?
- Activity modification
- NSAIDs
- Ice
- Patellar tendon strap
- PT if not improving w/ self mgmt
A
Tendonitis
25
**Tx for Patellar / Quad _Itis or Osis?_**
* Activity modification
* Physical therapy
* Patellar tendon strap
* NSAIDs NOT beneficial for long term management
Tendonosis
26
**Which condition?**
* 30-60 years old
* MOA: Rapid eccentric overload – fall on partially flexed knee
* MOA: Rapid concentric overload – basketball player jumping
* Sensation of instability or “giving way”
* Feel and/or hear a “pop”
Patellar / Quadriceps Tendon Rupture
27
**Clinical Px of what?**
* Significant pain at the time of injury but during exam they may have minimal to no pain with quadriceps contraction
* Rapid large effusion
* Defect indicating area of rupture may be palpable
* Key to diagnosis is inability to extend knee against gravity or perform straight-leg raise
* DO NOT assess prone passive knee flexion ROM
Patellar / Quadriceps Tendon Rupture
28
**Patellar / Quadriceps Tendon Rupture**
* _R/o what with imaging?_
* _Location of patella?_
* Patella tendon rupture?
* Quadriceps tendon rupture?
* r/o patellar fx
* **Patella:** patella higher than usual
* **Quad:** patella lower than usual
29
What imaging do you order to confirm dx of Patellar/Quad Tendon Rupture?
MRI
30
Tx for Patellar / Quaddriceps Tendon Rupture?
* Straight leg immobilizer
* Non-weight bearing
* Partial tears \<50% may be treated non-surgically
* Surgical repair treatment of choice for complete rupture
* Marked disability will develop secondary to deficient extensor mechanism
31
**Which condition?**
_Repetitive activity w/ faulty biomechanics_
* Vastus medialis oblique (VMO) weakness
* Increased Quadriceps angle (Q angle)
* Hyperpronation
* Poor technique
Patellofemoral Pain Syndrome
## Footnote
(Overuse condition affecting the patellofemoral joint)
32
**Term? Condition?**
* Pathologic changes involving articular surface of patella and femoral condyle
**Chondromalacia**
* Patellofemoral Pain Syndrome
33
**Patellofemoral Pain Syndrome - Quadriceps Angle (Q-angle)**
* Line from the ___ --\> \_\_\_\_
* 2nd line transects the center of the patella and the \_\_\_\_
* Females: ___ in full extension
* Males: ___ degrees in full extension
* ASIS --\> center of patella
* tibial tuberosity
* **F:** \<22 degrees
* **M:** \<18 degrees
34
**Which condition?**
* “Movie theater sign”
* Pain w/ ascending and descending stairs
* Pain w/ repetitive deep knee flexion
* Pain at end range of active and passive knee flexion
* Pain with resisted knee extension (+/- weakness)
* J sign
* + patellar grind
Patellofemoral Pain Syndrome
35
PFPS (patellofemoral pain syndrome) Treatment?
* Activity modifications
* NSAIDs
**•Weight loss if obese\*\*\*\***
* VMO strengthening
* Gluteal strengthening
* Evaluate / correct technique
36
**Which condition?**
* Most commonly due to twisting injury to knee.
* Only 10 % caused by direct trauma
* Subluxation and dislocation may occur with minimal stress (e.g. minor twist with foot planted)
Patellar Dislocation
37
4 RF of Patellar Dislocation?
* Shallow patellofemoral articular groove
* Patella alta
* Excessive Q angle
* Generalized ligamentous laxity
38
**Patellar Dislocation**
* Avg age range?
* Rare over what age?
* Which sex has higher incidence?
* **Avg:** 16 - 20 yrs
* **Rare:** \>30 yrs
* Females
39
**Patellar Dislocation**
* Severe pain, sometimes a “pop”
* Pain and position of the patella contribute to patient being extremely uncomfortable
* Knee held in a ____ position with a prominent _____ condyle
* Reduced by gentle extension of the tibia, forceful ____ pressure on the patella is **avoided**
* After reduction the patient has diffuse peri-patellar tenderness
* flexed position / medial femoral
* forceful medial
40
**Patellar Dislocation**
•Subluxation or dislocation of the patella causes tearing of restraining _______ and \_\_\_\_\_\_\_\_, leading to pain, significant hemarthrosis, and loss of knee motion
* medial retinacular tissue & medial patellofemoral ligament
41
**What test? What condition?**
* Knee in 30° flexion & gently displace patella laterally
* Observe for guarding (reflexive quad contraction and/or reaching towards the knee) and visible apprehension
Patellar Apprehension Sign / Patellar Dislocation
42
**Patellar Dislocation**
* Post reduction x-rays may show\_\_\_\_ or _____ of patella
* \_\_\_\_should be ordered to assess severity of soft tissue injury & screen for osteochondral injury
* lateral tilt or subluxation of patella
* MRI
43
Tx for Patellar Dislocation?
* Knee Immobilizer after reduction
* Stabilization brace post immobilization
* PT to address biomechanical risk factors
* Surgery if there is evidence of loose body on imaging studies or if patient has a history of recurrent dislocations
44
**MCL / LCL injuries**
* Which has greater incidence?
* MC in males or females?
* Result from what 2 mechanisms?
* Use what 2 tests?
* MCL \> LCL
* Males
* Valgus or Varus mechanisms
* Valgus/Varus stress tests (grade 1, 2, or 3)
45
**MCL Injury**
* Force directed to ___ aspect of knee leads to injury of medial collateral ligament
lateral
46
**Clinical Eval of which injury?**
* Instability - Abnormal opening of medial joint space
* Valgus stress test knee fully extended
* Valgus stress test knee flexed 30°
MCL injury
47
What is the "unhappy triad" and what injury?
**MCL injury**
* Medial collateral ligament tear
* Medial meniscal tear
* Anterior cruciate ligament tear
48
What is the name of the MCL avulsion fx?
Steida's Fracture
49
**LCL injury**
* Force directed to the ___ aspect of the knee
* Results in injury to the lateral collateral ligament
* Rare
medial
50
**Clinical eval of which injury?**
* Abnormal opening of lateral joint space
* Varus stress test knee fully extended
* Varus stress test knee flexed 30°
* Check neurological function
LCL injury
51
**Collateral Ligament Tears**
* Pain w/ palpation
* Swelling
* ROM loss varies based on severity/amt of swelling
* Is loss of knee _flexion or extension_ more pronounced?
Loss of flexion is more pronounced
52
**Which grade of Collateral Ligament Tear?**
* Pain with stress testing but no laxity
* RICE, short term NSAIDs and crutches as needed
Grade 1 (Interstitial)
53
**Which grade of Collateral Ligament Tear?**
* Pain and mild laxity with stress testing
* Hinged brace and weight bearing as tolerated
* Therapy
Grade 2 (Partial)
54
**Which grade of Collateral Ligament Tear?**
* Significant laxity and +/- pain with stress testing
* Orthopedic surgery consult
* Hinged brace and gradual return to full weight bearing over 4-6 weeks
* Therapy
Grade 3 (complete)
F3 E2 Shea
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