Knee conditions Flashcards
Acute swelling around the knee- traumatic synovitis
Any moderately severe injury (e.g., torn meniscus_ can precipitate reactive synovitis
Swelling appears after several hours
Acute swelling around the knee- Post traumatic hemarthrosis
Swelling immediate after injury, means blood in joint
Pain, warm, tense, tender, restriction
X-ray needed to eliminate fracture, if not suspect tear of ACL
Acute swelling around the knee- non-traumatic hemarthrosis
In Pt with clotting disorders, knee is common site for acute bleed
Variety of blood disorders are hereditary, e.g., haemophilia
Chronic joint swelling of entire joint- non-infective arthritis
Commonest cause of swelling is OA + RA
Other signs such as deformity, loss of movement or instability may be present
X-ray needed to show features
Swelling anteriorly- pre patellar bursitis
Fluctuant swelling confined to front of patella, joint itself is normal
Due to constant friction between skin + bone
Treatment= firm bandaging, and avoiding kneeling
Swelling anteriorly- infra patellar bursitis
Swelling below patella
Superficial to patella ligament
Treatment same as prepatellar
Swelling posteriorly- semimembranosus bursa
Bursa between semimembranosus + medial head of gastrocnemius may become enlarged
Presents as painful lump behind knee, slightly medial
Most conspicuous when knee is straight
Knee joint is normal
Usually takes a while to heal
Swelling posteriorly- popliteal cyst
Bulging of posterior capsule + synovial herniation may produce swelling in popliteal fossa
Usually caused by RA or OA
Occasionally ‘cyst’ ruptures + synovial contents spill into muscle planes causing pain + swelling in calf- can be mistaken for deep vein thrombosis
Reoccurrence is common if underlying condition isn’t treated
Swelling posteriorly- popliteal aneurysm
Need to be cautious that popliteal swelling isn’t an aneurysm
Swelling laterally- meniscal cyst
Small, tense swelling, usually on lateral side/just below joint line
Can be mistaken for bony lump
Usually tender to pressure
Swelling laterally- calcification of collateral ligament
Acute painful swelling may suddenly appear
Usually medial side of joint line
Rubbery and tender
When are bow legs common
In babies- considered normal development
When are knock knees common
4 year olds- considered normal development
How to measure bilateral bow-legs
Measure distance between knees with child standing + heels touching- should be less than 6cm
How to measure knock knees
Estimated by measuring distance between medial malleoli when knees are touching with patella facing forward- usually less than 8cm
What to do if deformity is still occurring at age 10
Surgery
Pathological bow-legs and knock-knees in children
Unilateral deformity likely to be pathological as is severe bilateral deformity
Likely cause of unilateral deformity
Eccentric growth from physics of distal femur or proximal tibia
Usually progressive
When should operative treatment be offered for deformity
Near end of pubertal growth
By age 10 deformity is often grown out of
Pathological bow-legs and knock knees in adults
Angular deformities common in adults
Usually bow-legs in men and knock knees in women
Osteochondritis dissecans
Bone underneath cartilage dies due to lack of blood flow
Sometimes separates from femoral condyle and appears as loose body in joint
Epidemiology of Osteochondritis dissecans
Trauma, either single impact with edge of patella or repeated contact with adjacent tibial ridge
Age groups affected by Osteochondritis dissecans
Adolescents involved in competitive sport and children
Usually male aged 15-20
Clinical presentation of Osteochondritis dissecans
Intermittent ache or swelling
Attacks of giving way, knee feels unreliable, may lock
Quadricep muscle wasting
Usually small effusion
Tenderness localised to one femoral condyle
+ve Wilsons test
Prognosis of Osteochondritis dissecans
Early stages with cartilage still intact= no treatment needed but activities reduced for 6-12 months
Small lesions often heal spontaneously
Loose bodies epidemiology
Injury- child to bone or cartilage
Osteochondritis dissecans
OA
Charcots disease
Synovial chondromatosis
Clinical presentation of loose bodies
May be symptomless or complain of sudden locking
Joint gets stuck in position
Pt can usually wriggle knee to unlock
May be aware of something ‘popping in and out’
May swell
Prognosis of loose bodies
If loose body causing symptom removed, treatment is successful
Tuberculosis epidemiology
Coughing
Sneezing
Age groups affected by TB
Any age but mainly children
Clinical presentation of TB
Pain + limp are early symptoms
Swollen knee or low-grade fever
Thigh muscle wastage
Knee feels warm
Restriction
Prognosis of TB
Active synovitis- knee is rested in bed-splint, exercise intermittently for short spells
Healing stage- wear weight relieving calliper
Aftermath- if joint is painful, arthrodesis recommended
RA epidemiology
May start as synovitis in knee
Age groups affected by RA
40-60
Bit older for men
RA risk factors
Genetics
Obesity
Sex- women
Clinical presentation of RA
Valgus- knees in
Early stage- pain + swelling, may be large effusion + wasting of thigh muscle, restricted ROM
Advancing- joint becomes unstable, muscle wasting and restriction increases, x-ray shows loss of joint space, complete absence of osteophytes
Later stage- joint becomes increasingly deformed
Prognosis of RA
Anti-inflammatory drugs
Once bone destruction is present, joint is unstable and total joint replacement advised
OA epidemiology
Knees most common site
Injury to articular surface, torn meniscus, instability/pre-existing deformity
In many cases no obvious cause can be found
Tend to be overweight + have long standing bow legged deformity
Age groups affected by OA
Usually over 50
Clinical presentation of OA
Pain, worse after activity
After rest joint feels stiff and hurts to ‘get going’
Swelling, giving way, locking
Quadricep wastage
Prognosis of OA
If not severe, treatment is conservative
Analgesics can be prescribed for the pain
Quadricep exercises + heat
Joint loading lessened (walking stick)
If unresponsive to conservative treatment, operative options may be necessary
Recurrent dislocation of patella epidemiology
Stretching of ligaments which normally stabilise
Initial episode thought to have occurred spontaneously
Risk factors of recurrent patella dislocation
Generalised ligament laxity
Under-development of lateral femoral coddle + flattening of intercondylar groove
Maldevelopment of patella
Valgus deformity of knee
Clinical presentation of recurrent patella dislocation
Girls affected more commonly
Condition often bilateral
Knee suddenly gives way + Pt falls
Patella always dislocates laterally
Tenderness on medial side
Swelling
Prognosis of patella dislocation
Quadricep strengthening exercises, in particular vests medialis
Tibial tubercle apophysitis
An inflammation or stress injury to the areas on or around growth plates in children and adolescent
Tibial tubercle apophysitis epidemiology
Traction injury
Age groups affected by tibial tubercle apophysitis
Fairly common in adolescents, particularly those engaged in sports
Risk factors of Tibial tubercle ‘apophysitis’
Sport
Clinical presentation of Tibial tubercle ‘apophysitis’
Pain
Swelling of tibial tubercle
Extension against resistance is often painful
Prognosis of Tibial tubercle ‘apophysitis’
Spontaneous recovery is usual, but it takes time
RICE
Chronic ligamentous instability epidemiology
Sports injury
Chronic ligamentous instability clinical presentation
Giving way during weight bearing activities, sometimes accompanied by pain
Joint looks normal apart from slight wasting, rarely tenderness
Observe gait and knee posture in standing
Prognosis of Chronic ligamentous instability
Most cases operation is not required
Some Pt will accept the use of knee brace
Patella tendinopathy
Patella ligament strain or partial rupture may lead to traction tendonitis
Epidemiology of patellar tendinopathy
Repeated stress on patella tendon
Obesity
Sudden increase in body weight
Age groups affected by patella tendinopathy
Adolescents- particularly athletes
Risk factors of patella tendinopathy
Sport
Tight leg muscles
Muscular imbalance
Clinical presentation of patella tendinopathy
Repeated episodes of pain and local tenderness
Prognosis of patella tendinopathy
If persistent, may lead to calcification within ligament
Usually resolves spontaneously
Chondromalacia Patella
Softening and degeneration of articular cartilage of patella
Chondromalacia Patella epidemiology
Post-traumatic injury
Microtrauma- wear + tear
Age groups affected by Chondromalacia Patella
Young females
Risk factors of Chondromalacia Patella
Patella Alta (high rising)
High Q angle that may lead to malt racking
Clinical presentation of Chondromalacia Patella
Tenderness of inferior angle of patella
Crepitation
Anterior pain following flexion and prolonged pain
Increased Q angle
Potential hyper mobility of patella
Pt should be able to extend knee
Prognosis of Chondromalacia Patella
Once it starts its irreversible
Involves breakdown of surface layer of cartilage surface, which is progressive
Can be treated with isometric exercises and activity modification
Patella taping may be useful
Prepatella bursitis
Inflammation, swelling and enlargement of prepatellar bursitis
Prepatellar bursitis epidemiology
As a result of frequent kneeling
Acute trauma to anterior knee
Risk factors of prepatellar bursitis
Occupation- e.g., carpet laying
Clinical presentation of pre patella bursitis
Pain when directly kneeling on it
Swelling, tenderness, and redness of tissues overlying patella
Prognosis of pre patella bursitis
Infectious (pyogenic) bursitis may develop
Occasionally resolves with rest, icing, NSAIDs, compression wraps, and avoidance of kneeling
Very rarely is surgery necessary
Pyogenic bursitis may require drainage
Overuse syndromes
Refers to musculoskeletal pain or dysfunction following physical activity that exceeds strength of musculoskeletal tissues such as bones, tendons, ligaments, joints and bursa
Epidemiology of overuse syndrome
Vigorous physical activity with no distinct history of trauma
Exercise may cause microtrauma to structures
Clinical presentation of overuse syndrome
Symptoms are variable
Pain often achy and most pronounced 1-2 days after intense physical activity, especially when Pt has not warmed up/stretched
Pain may be vague and poorly localised
Structures that have suffered microtrauma will be tender and inflamed
Stretching will elicit pain
Prognosis of overuse syndrome
Can cause tendonitis
Should heal with elimination of offending activity
Time frame resolution is variable, often within 8 weeks
If symptoms last longer than this, reconsider diagnosis
DDX of overuse syndrome
Patella tendon rupture
Tibial stress fracture
Patella fracture
ACL rupture
Meniscal tear
Medial/lateral collateral ligament strain epidemiology
Following trauma
Report of history of twisting injury with ‘pop’ or ‘snap’
M/LCL strain age groups
20-34 and 55-65
Risk factors of M/LCL strain
Contact sports
Clinical presentation of M/LCL strain
Pain may be worsened with weight bearing
Tenderness of medial/lateral side of knee
Compare to symptomatic
Grade 1 M/LCL strain symptoms
Tenderness, minimal swelling, and ecchymosis
Grade 2 M/LCL strain symptoms
More pain and tenderness that can be localised to tibia or femoral insertion of MCL
Grade 3 M/LCL strain symptoms
Complete rupture of MCL, knee joint swelling and effusion will be minimal as much of haemorrhage diffuses into surrounding soft tissue
Prognosis of M/LCL strain
Grade 1- no specific treatment
2+3 should be protected for 6 weeks
3 or severe instability should be evaluated for reconstruction pf possible associated ligament injury
Importance of meniscus
Improve articular cartilage congruency + stability
Control complex rolling + gliding actions of the joint
Distributing load during weight bearing
Then meniscus epidemiology
Acute + chronic
Acute- rotational or twisting injury to flexed knee resulting in audible pop with concurrent localised sharp pain
Chronic- degenerative changes to menisci, often no discrete history of trauma
Age groups affected by torn menisci
Acute 20-40
Chronic older
Usually younger person who sustains twisting injury
Risk factors of menisci tear
Pivoting sports
Clinical presentation of torn menisci
Acute- effusion, moderate pain, may describe mechanical symptoms (catching, locking) resulting in difficulty with flex/ext
Large tears- knee can become locked in flexion, severe pain caused from squatting/pivoting
Chronic- symptoms exacrberated by activity and improved with rest
Effusion may be relevant to recent activity
Tenderness with palpation along joint line
Prognosis of meniscal tears
McMurray test will identify tear
Treatment based on side of tear, as well as Pt age and activity level
Small tears- RICE, NSAIDs, activity modification, stretching + strengthening
Degenerative joint disease
Most common cause of knee pain in elderly Pt
Knee most commonly affected by OA
Epidemiology of DJD
Rarely evidence of history or trauma
May present after aggravating knee with minimal twist or contusion
Younger Pt with previous knee trauma at increased risk at an early age due to post traumatic arthritis
May be in occurrence with chronic metabolic conditions (gout) and obesity
Age groups affected by DJD
50-80
Clinical presentation of DJD
Pain, swelling and stiffness that gradually becomes worse
Pain may be worse on cold days
Often exacerbated by activity and relieved with rest
Common to have night pain after day of activity, severe shoulder wise alternate diagnosis
Observe gait (antalgic gait)
Bowed legs (genus vacuum), or knocked knees (genus valium)
Tenderness to palpation is unlikely
Crepitus with flex/ext
Prognosis of DJD
Initial treatment involves weight loss, activity modification, and NSAIDs
High impact activities such as running should be avoided
Swimming is beneficial
End-stage OA requires total knee replacement
Pes anserine bursitis
Pes anserine bursa located on medial side of knee at proximal tibia
Provides cushioning to tendons during activity
Epidemiology of pes anserine bursitis
Pain often insidious on onset, no history of trauma (unlike MCL sprain)
Report of history of overuse, commonly in sports such as breastroke- repetitive strain on tendons –>bursitis
Risk factors of pes anserine bursitis
Sports involving reparative strain on medial tendons
Clinical presentation of pes anserine bursitis
Medial knee pain
Tenderness to palpation of proximal medial tibia at attachment of pes anserine tendon
Prognosis of pes anserine bursitis
RICE and NSAIDs initially
Identify stress aetiology
Often resolution of symptoms, however occasionally becomes chronic
Refer after 6 weeks of rest, NSAIDs and activity modification
ACL tear Hx
Direct trauma with valgus hyperextension
Audible pop
Playing sport with quick stops or sharp cutting on non slip surafces
ACL tear SSx
Severe Jt effusion
+ve ant drawer
Feeling of instability
PCL tear Hx
Direct trauma with posterior to anterior stress
Audible pop
PCL SSx
Effusion in popliteal fossa
Reduced ROM
Instability/feeling of giving way
Chrondromalacia patella
Prior trauma
Retropatellar P
Worse with prolonged walking
Going down stairs
Chrondro SSx
Knee tenderness
Worse after prolonged sitting
P going upstairs
Meniscus tear
Painful clicking or snapping
Deep Jt line P
Jt locking
Local tenderness to palpation
Osgood Schlatters
Active preteen/teem
Insidious onset or after intense activity
Local tenderness
Swelling
Red
P with PROM
P brought on by activity
Osgood DDX
Osteochondroma- an overgrowth of cartilage and bone that happens at the end of the bone near the growth plate
ITB friction rub
Recent inc inc running distance, intensity, frequency
Lateral knee P
Local tenderness, +ve Nobles
Plica syndrome
P over lateral or medial condyle
Snapping sensation
Tender band or cord from patella to condyle
