Knee Pain Flashcards
Common knee conditions in children
Patellar subluxation Tibial apophysitis (Osgood-Schlatter) Patellar tendonitis
Common knee conditions for adults
Patellofemoral syndrome - Dx of exclusion for anterior knee pain Overuse syndromes Trauma Inflammatory arthropaties
Hx of trauma
Increased risk of injury to ligaments and meniscal tears
Impair ability to squat
Effusion
Arthritis
Ligament damage
Ability to duck waddle
Rules out
- ligament instability
- Effusion
- Significant damage to meniscal cartilage
Work-up for septic arthritis
CBC w/ differential ESR Arthrocentesis - Cell count w/ differential - Glucose - Protein - Culture - Polarized light microscopy
Clear, straw-colored transudate
Simple joint effusion
- Osteoarthritis
- Degenerative meniscal injuries
Bloddy knee aspirate
Hemarthrosis
- Ligament tear
- Fracture
Hemarthrosis with fat goblets
Osteochondral fracture
Work-up for RA
RF
Side effects of NSAIDs
GI upset
Worsens HTN
Increases the effect of sulfonylureas
Can NSAIDs and ASA contribute to hepatictoxicity
yes
- They also contribute to coagulopathy
Screening for 74 year old women
Colonoscopy to 75 Mammograms to 74 Depression HTN Lipids - This is only if they are at risk of CAD
Immunization for 74 year-old
Tdapt: q10 yrs
Pneumococcal- > 65 gets a one time dose
Flu: Annual
Zoster: > 60
Knee exam
Inspection
Palpation
ROM
Assess tenderness and ROM of hip
Points of palpation
Patella
Tibial tubercle
All tendons
Joint lines (Anterior, Medial, and lateral)
Stability of the ACL only
Lachmann’s test
- Flex to 30
- Stabilize distal femur
Stability of ACL and PCL
Drawer testing
- Flex knee to 90 degrees
- Stabilize foot
- Thumbs on tibial tubercle
Stability of MCL and LCL
Valgus and Varus Stress tests
- Do with leg in full extension and knee flexed to 30
- Place hands on medial/lateral knee
- Apply pressure to distal tibia
Assess the medial and lateral menisci
- Sens and Spec for tears
- Positive test is pain, click, or clunk
McMuray Test
- Flex the knee as far as possible
- Rotate tibia either internal or external
- Bring knee to 90
- Apply a varus or a valgus stress to knee while extending
Tap median nerve of wrist
Tinel’s sign
Flex wrists and press dorsal surface together
Hold for 30 to 60 seconds
Phalen’s test
Anterior knee pain
Patellofemoral pain syndrome
- Overuse
- Typical in women as “theater sign”
Lateral knee
IT band tendonitis - Overuse LCL sprain - Varus stress - Immediate onset Meniscal tear - Twisting injury - Mild effusion - Catching and locking
General knee pain
ACL - Deceleration forces - Effusion and swelling Septic arthritis - Swelling - Turbid synovial fluid OA - Aggrevated by weight-bearing activity - Chronic stiffness - Crepitus
Medial pain
MCL - Misstep or collision - Swelling Meniscus -Meniscal tear - Twisting injury - Mild effusion - Catching and locking
Posterior pain
Popliteal cyst
- insidious onset
- Pain in the popliteal area
Extreme pain with any movement
Gout/Psuedogout
- Clear or cloudy synovial fluid
- (-) birefringent rod = gout
- (+) birefringent rhomboid = pseudogout
Top differential for chronic knee pain
Sprain OA RA Gout/pesudogout Psoriatic arthritis
Subcutaneous nodules that are firm and tender
Joint stiffness in morning lasting for more than 30 minutes
Bilateral joint pain involving 3 or more joints
RA
Psoriatic plaques on extensor surface
Oligo (2 to 4) or poly (5+)
Psoriatic arthritis
- Plaques are required for diagnosis
- Arthritis often presents first
Acute monoarticular joint pain
Exposure to tick bite
History of rash
Lyme disease
HLA-B27 association
Chronic back pain and progressive loss of motion of the spine
Ankylosing spondylitis
Fever, skind rashes, raynauds phenomenon, pleuritis, or chest pain
Butterfly rash
Discoid lesions
Migratory
SLE
When to get an x-ray for OA
Questionable diagnosis
Assess severity and location
No improvement with conservative therapy
When to get an MRI
Locking
Popping
Joint instability
- Unless X-ray shows significant joint space narrowing
X-ray features of OA
Joint space narrowing
Subchondral sclerosis
Osteophytes
Subchondral cysts
What corrolates the best with pain? What corrolates best with disease severity?
Patellofemoral or tibiofemoral joint osteophytes = pain
Joint space narrowing = disease progression
Diagnositc test of choice for carpel tunnel
Nerve conduction studies
- Expensive
- Often unnecessary
When are nerve conduction tests necessary
Symptoms do not improve with treatment
Motor dysfunction
Thenar atrophy
Most helpful findings to dx carpel tunnel
hand symptom diagrams - Digits 1, 2, or 3 (need 2) Hypalgesia - Decreased sensitivity to pain Weak thumb abduction
Pain management for OA
Exercise Acetaminophen - First line agent NSAIDs - Second line agent Intra-articular injection - Only when inflammed Acupuncture Glucosamine SAM-e Tramadol
Opiods for chronic pain
Oxycodone or morphine
Other options for chronic pain
TCAs
Anticonvulsants
- Good for neuropathic pain
OA pain management when conservative management fails
Tramadol
Long-acting opiod with short acting for break through
TCAs
