Patellofemoral Syndrome History and Symptoms Diffuse _____ in the ______ of the knee (major symptom) ______ onset and typically v_____ in nature Aggravated by specific daily activities including C_____ or descending st____ Prolonged sitting with knee ____ (known as “______ sign”) S______ or kneeling Cr_______ / Mechanical symptoms (anteriorly)

Diffuse pain in the anterior of the knee (major symptom) Gradual onset and typically vague in nature Aggravated by specific daily activities including Climbing or descending stairs Prolonged sitting with knee bent (known as “theatre sign”) squatting or kneeling Crepitus / Mechanical symptoms (anteriorly)

Patellofemoral Syndrome PE Pain with com______ of patella with knee range of motion or resisted knee _______ Signs of patellar _____ Lateral ______ of patella in extension, _______ in flexion (compare motion to contralateral side) Positive patellar __________ test (discomfort with ______ force)

Pain with compression of patella with knee range of motion or resisted knee extension Signs of patellar instability Lateral subluxation of patella in extension, reduces in flexion (compare motion to contralateral side) Positive patellar apprehension test (discomfort with lateral force)

Patellofemoral Conditions Operative Treatment Operative Very ____ results seen with debridements and “lateral releases” In cases of significant deformity, soft tissue and bony re______ can be done When to refer?

Operative Very poor results seen with debridements and “lateral releases” In cases of significant deformity, soft tissue and bony realignments can be done Refer Symptoms not responsive to NSAIDs, PT, activity modification

Meniscal Tears History and Symptoms Pain localized to m_____ or l____ joint _____ Mechanical symptoms (l_____ and cl______), especially with f_____ / squatting Intermittent sw_______

Pain localized to medial or lateral joint line Mechanical symptoms (locking and clicking), especially with flexion / squatting Intermittent swelling

Meniscal Tears Non-Op Treatment R___, Rx (1), re________, in_______ Indications Indicated as ______ line treatment for almost all tears Outcomes Improvement in knee ______ following _ _ "Non_____" when compared to arthroscopic partial meniscectomy

Rest, NSAIDS, rehabilitation, injection Indications Indicated as first line treatment for almost all tears Outcomes Improvement in knee function following physical therapy "Noninferior" when compared to arthroscopic partial meniscectomy

Orthopedics Knee Flashcards by Felita Salim

Normal Anatomy Knee

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Physical Exam

Both knees appear _______.
Sw______ /Effusions?
________ to palpation?
ROM (~0 - ____); patellar motion / instability
Distal ______vascular exam (no different than hip)
_______: Anterior/Posterior/Va____/Va____ - +definition?

Both knees appear symmetric.
Swelling / Effusions?
Tenderness to palpation?
ROM (~0 - 120); patellar motion / instability
Distal neurovascular exam (no different than hip)
Stability: Anterior/Posterior/Varus/Valgus

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Common Conditions

(3)

Conditions 1 slide each

(7)

Patellofemoral syndrome / chondromalacia patella / patellar instability
Meniscal tears
Degenerative joint disease / Arthritis (huge category of diagnoses!)
- Inflammatory v. noninflammatory…(outside the scope of this lecture)
Ligament injuries
Septic arthritis (can be any joint…)
Patellar tendon rupture
Quadriceps tendon rupture
Patellar fracture
Pes anserine bursitis
Osgood-Schlatter

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Patellofemoral syndrome / chondromalacia patella / patellar instability

_______ common, especially in ad______ and _____adults (____ > ____ gender)

Can be idiopathic (i.e. no _______) with or without changes in the articular cartilage (1)
Can be a result of patellar ___stability
Diagnosis → ______ knee pain, ______ with kneeling, squatting, prolonged sitting, stairs, patellar compression
Treatment
- In general, responds very well to directed _______ / ______ceps strengthening
- Surgery reserved for significant anatomic mal______ or severe in______ only
Some consider these conditions a precursor of patellofemoral ________

Anterior Knee pain

Extremely common, especially in adolescents and young adults (women > men)

Can be idiopathic (i.e. no instability) with or without changes in the articular cartilage (chondromalacia)
Can be a result of patellar instability
Diagnosis → anterior knee pain, worse with kneeling, squatting, prolonged sitting, stairs, patellar compression
Treatment
- In general, responds very well to directed exercises / quadriceps strengthening
- Surgery reserved for significant anatomic malalignment or severe instability only
Some consider these conditions a precursor of patellofemoral arthritis

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Patellofemoral Syndrome History and Symptoms

Diffuse _____ in the ______ of the knee (major symptom)
______ onset and typically v_____ in nature
Aggravated by specific daily activities including
- C_____ or descending st____
- Prolonged sitting with knee ____ (known as “______ sign”)
- S______ or kneeling
Cr_______ / Mechanical symptoms (anteriorly)

Diffuse pain in the anterior of the knee (major symptom)
Gradual onset and typically vague in nature
Aggravated by specific daily activities including
- Climbing or descending stairs
- Prolonged sitting with knee bent (known as “theatre sign”)
- squatting or kneeling
Crepitus / Mechanical symptoms (anteriorly)

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Patellofemoral Syndrome PE

Pain with com______ of patella with knee range of motion or resisted knee _______
Signs of patellar _____
Lateral ______ of patella in extension, _______ in flexion (compare motion to contralateral side)
Positive patellar __________ test (discomfort with ______ force)

Pain with compression of patella with knee range of motion or resisted knee extension
Signs of patellar instability
Lateral subluxation of patella in extension, reduces in flexion (compare motion to contralateral side)
Positive patellar apprehension test (discomfort with lateral force)

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Patellofemoral Syndrome Imaging

XR:
- Recommended views: AP, ____ral, S_____
Look for:
- Lateral patellar t____
- _______ trochlear groove
- Signs of PFJ DJD =
- Keep in mind:
  - Even with severe lateral subluxation, the patella reduces with flexion (sunrise view)
  - AP view can be deceiving (positioning / rotation of the x-ray)
CT / MRI: ______ planning

XR:
- Recommended views: AP, Lateral, Sunrise
Look for:
- Lateral patellar tilt
- Shallow trochlear groove
- Signs of PFJ DJD = patellofemoral joint degenerative joint disease
- Keep in mind:
  - Even with severe lateral subluxation, the patella reduces with flexion (sunrise view)
  - AP view can be deceiving (positioning / rotation of the x-ray)
CT / MRI: surgical planning

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Patellofemoral Conditions Non-Op Treatment

Mainstay of treatment and should be done for a minimum of one year: R___/ P_/N_____
- NSAIDS are more effective than ______
- ______ modification
- Rehabilitation with emphasis on
  - V _ _ strengthening
  - _______ strengthening: controversial → externally rotated leg

Mainstay of treatment and should be done for a minimum of one year: Rest/ PT/NSAIDs
- NSAIDS are more effective than steroids
- Activity modification
- Rehabilitation with emphasis on
  - Vastus medialis obliquus strengthening
  - Quadriceps strengthening: controversial → externally rotated leg

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Patellofemoral Conditions Operative Treatment

Operative
- Very ____ results seen with debridements and “lateral releases”
- In cases of significant deformity, soft tissue and bony re______ can be done
When to refer?

Operative
- Very poor results seen with debridements and “lateral releases”
- In cases of significant deformity, soft tissue and bony realignments can be done
Refer
- Symptoms not responsive to NSAIDs, PT, activity modification

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Meniscal Tears

Common _____-related injuries in young athletes and can also present as a ______ condition in older patients
Diagnosis can be suspected clinically with joint ____ tenderness and a positive (1) test, and can be confirmed with (1) imaging.
Treatment can be nonoperative versus operative ((1) versus (1)) depending on the morphology of the meniscus tear, root involvement, patient symptoms, and patient activity demands.
- Most are treated ______ surgery

NOTE: Degenerative tears are a ______ part of the ______ process, are not separate injuries, and should not be treated in isolation (i.e. almost never MRI; never surgery)

Common sports-related injuries in young athletes and can also present as a degenerative condition in older patients
Diagnosis can be suspected clinically with joint line tenderness and a positive McMurray’s test, and can be confirmed with MRI imaging.
Treatment can be nonoperative versus operative (partial meniscectomy versus repair) depending on the morphology of the meniscus tear, root involvement, patient symptoms, and patient activity demands.
- Most are treated without surgery

NOTE: Degenerative tears are a normal part of the arthritis process, are not separate injuries, and should not be treated in isolation (i.e. almost never MRI; never surgery)

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Meniscal Tears History and Symptoms

Pain localized to m_____ or l____ joint _____
Mechanical symptoms (l_____ and cl______), especially with f_____ / squatting
Intermittent sw_______

Pain localized to medial or lateral joint line
Mechanical symptoms (locking and clicking), especially with flexion / squatting
Intermittent swelling

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Meniscal Tears Physical Exam

Joint _____ tenderness (most sensitive physical examination finding)
Eff_____

Provocative tests

(1) Prone-flexion compression
(1) standing at 20 degrees of knee flexion on the affected limb, the patient twists with knee external and internal rotation with positive test being discomfort or clicking
(1) flex the knee and place a hand on medial side of knee, externally rotate the leg and bring the knee into extension.
- a palpable pop / click + pain is a positive test and can correlate with a medial meniscus tear.

Joint line tenderness (most sensitive physical examination finding)
Effusion

Provocative tests

Apley Compression: Prone-flexion compression
Thessaly Test standing at 20 degrees of knee flexion on the affected limb, the patient twists with knee external and internal rotation with positive test being discomfort or clicking
McMurray’s Test flex the knee and place a hand on medial side of knee, externally rotate the leg and bring the knee into extension.
- a palpable pop / click + pain is a positive test and can correlate with a medial meniscus tear.

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Meniscal Tears Imaging

XR:
- Should be _____ in young patients with an acute meniscal injury
  - Meniscal ________ may be seen in crystalline arthropathy
(1)
- Most ______ diagnostic test but also high false positive rate
  - “Over-calls” it…
- Look for _____ signal on the T2s
  - Joint ______ making its way into the substance of the meniscus

XR:
- Should be _____ in young patients with an acute meniscal injury
  - Meniscal calcifications may be seen in crystalline arthropathy
MRI:
- Most sensitive diagnostic test but also high false positive rate
  - “Over-calls” it…
- Look for bright signal on the T2s
  - Joint fluid making its way into the substance of the meniscus

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Meniscal Tears Non-Op Treatment

R___, Rx (1), re________, in_______
- Indications
  - Indicated as ______ line treatment for almost all tears
Outcomes
- Improvement in knee ______ following _ _
- “Non_____” when compared to arthroscopic partial meniscectomy

Rest, NSAIDS, rehabilitation, injection
- Indications
  - Indicated as first line treatment for almost all tears
Outcomes
- Improvement in knee function following physical therapy
- “Noninferior” when compared to arthroscopic partial meniscectomy

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Meniscal Tears Operative Treatment

Indicatated when?

(2) options

Persistent painful mechanical symptoms that correspond with the anatomic location of the tear

Debridement vs. Repair

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Degenerative Joint Disease/Arthritis

________ disease of the knee joint that causes progressive ____ of articular ________.
Diagnosis can be made with plain (1) of the knee. (advanced imaging is not typically helpful)
Treatment is observation, NSAIDs, tr_____ and cortico______ for minimally symptomatic patients. Knee (1) is indicated for progressive symptoms with severe degenerative disease.
The most common types of arthritis are (2), but there are more than 100 different forms.
- I will focus on osteoarthritis

Degenerative disease of the knee joint that causes progressive loss of articular cartilage.
Diagnosis can be made with plain radiographs of the knee. (advanced imaging is not typically helpful)
Treatment is observation, NSAIDs, tramadol and corticosteroids for minimally symptomatic patients. Knee arthroplasty is indicated for progressive symptoms with severe degenerative disease.
The most common types of arthritis are osteoarthritis and rheumatoid arthritis, but there are more than 100 different forms.
- I will focus on osteoarthritis

Degenerative Joint Disease/Arthritis History and Symptoms

A__, f_______ activity, p______ of arthritic involvement, overall health and du_____ of symptoms
Function-limiting knee _____
- l_____ walking distances
Activity induced sw_____
Knee s____ness
Mechanical symptoms → more cr_____ than what is seen with meniscal tears

Age, functional activity, pattern of arthritic involvement, overall health and duration of symptoms
Function-limiting knee pain
- limited walking distances
Activity induced swelling
Knee stiffness
Mechanical symptoms → more crepitus than what is seen with meniscal tears

Degenerative Joint Disease/Arthritis PE

Inspection
- Body h______
- G____ (often protects the affected side)
- Ef_____?
- Alignment
  - Va___ or Va____?
Range of motion (compare to _____lateral side)
______ exam (stiffness of arthritis usually precludes any significant issues with ligament laxity)

Inspection
- Body habitus
- Gait (often protects the affected side)
- Effusion?
- Alignment
  - Varus or Valgus?
Range of motion (compare to contralateral side)
Stability exam (stiffness of arthritis usually precludes any significant issues with ligament laxity)

Degenerative Joint Disease/Arthritis Imaging

XR:
- Recommended views
  - Weight-______ views of affected joint
- Optional views
  - S______ view
  - _ _ view in 30 degrees of flexion
- Look for:
  - Joint _____ narrowing
  - Osteo_____
  - Subchondral s______
  - Subchondral c_____
MRI: ______ the urge, especially in advanced disease

XR:
- Recommended views
  - Weight-bearing views of affected joint
- Optional views
  - Sunrise view
  - PA view in 30 degrees of flexion
- Look for:
  - Joint space narrowing
  - Osteophytes
  - Subchondral sclerosis
  - Subchondral cysts
MRI: Resist the urge, especially in advanced disease

Degenerative Joint Disease/Arthritis Non-Op Treatment

R___, N_____, _____ilitation, ____tion
- Note on injections:
  - ______ is the ______
  - Strong evidence ______ HA injections (e.g. Synvisc, Hyalgan) but most insurance still covers this…
  - Strong evidence against glucosamine/chondroitin

Rest, NSAIDs, rehabilitation, injection
- Note on injections:
  - Cortisone is the mainstay
  - Strong evidence against HA (hyaluronic acid) injections (e.g. Synvisc, Hyalgan) but most insurance still covers this…
  - Strong evidence against glucosamine/chondroitin

Degenerative Joint Disease/Arthritis Operative Treatment

High tibial ______
- Younger patients with isolated medial disease (uncommon)
____compartmental arthroplasty (much less common than TKA)
_____ Knee Arthroplasty
- Approaching 1 million per year in the US!
- Projected 855% increase by 2050…(will it bankrupt the system!?)

High tibial osteotomy
- Younger patients with isolated medial disease (uncommon)
Unicompartmental arthroplasty (much less common than TKA)
Total Knee Arthroplasty
- Approaching 1 million per year in the US!
- Projected 855% increase by 2050…(will it bankrupt the system!?)

Surgical Steps

Meet the patient in the ___-op holding area
___ the leg
N______ and a_____ meets with the patient as well. This is almost always the first (and only) time the patient meets their anesthesiologist
To OR
Anesthesia (usually s_____)
Position (leg t______)
Prep/drape
Time-____
Incision, cut distal ______, cut proximal _____ (both perpendicular to the mechanical axis of the leg, either using mechanical jigs or computer navigation).

Meet the patient in the pre-op holding area
Mark the leg
Nursing and anesthesia meets with the patient as well. This is almost always the first (and only) time the patient meets their anesthesiologist
To OR
Anesthesia (usually spinal)
Position (leg tourniquet)
Prep/drape
Time-out
Incision, cut distal femur, cut proximal tibia (both perpendicular to the mechanical axis of the leg, either using mechanical jigs or computer navigation).

Finishing Cuts, Trials

St______ in flexion, extension, midflexion
Full extension, flexion to ~____ degrees
- Regardless _____ ROM is best predictor of post-op…
Remove trials
Wash
Ce_____ in real components
Wash
Close
R_____ room

Stability in flexion, extension, midflexion
Full extension, flexion to ~120
- Regardless pre-op ROM is best predictor of post-op…
Remove trials
Wash
Cement in real components
Wash
Close
Recovery room

Other Knee Conditions (1 slide each)

(7)

Ligament injuries
Septic arthritis (can be any joint…)
Patellar tendon rupture
Quadriceps tendon rupture
Patellar fracture
Pes anserine bursitis
Osgood-Schlatter

Knee Ligament Injuries ## Footnote * Goal here is to highlight that there are 4 main ligaments of the knee: * (ACL) = * (PCL) = * (MCL) = * (LCL) = * To test them: * _____ → ACL * _______ → PCL * V\_\_\_\_\_→ MCL * V\_\_\_\_\_\_ → LCL

* Goal here is to highlight that there are 4 main ligaments of the knee: * Anterior Cruciate Ligament (ACL) * Posterior Cruciate Ligament (PCL) * Medial Collateral ligament (MCL) * Lateral Collateral ligament (LCL) * To test them: * Anterior → ACL * Posterior → PCL * Varus → MCL * Valgus → LCL

Septic Arthritis ## Footnote * **Inflammation of the joints secondary to an ______ etiology** * Diagnosis is made with an ______ of joint fluid with a ____ count of ________ **being considered diagnostic for septic arthritis.** * Lower counts may still indicate infection in the presence of _____ gram stains or cultures results. * Treatment is usually urgent surgical (1) followed by culture directed (1). * Can be any joint, but knee represents ~\_\_\_% of cases * Then hip, shoulder, elbow, ankle, sternoclavicular joint

* **Inflammation of the joints secondary to an infectious etiology** * Diagnosis is made with an aspiration of joint fluid with a WBC count **50,000 being considered diagnostic for septic arthritis.** * Lower counts may still indicate infection in the presence of positive gram stains or cultures results. * Treatment is usually urgent surgical irrigation and debridement followed by culture directed IV antibiotics. * Can be any joint, but knee represents ~50% of cases * Then hip, shoulder, elbow, ankle, sternoclavicular joint

Septic Arthritis ## Footnote * (1) \>50% of cases * (1) ~20% of cases * Most common organism in otherwise healthy sexually active adolescents and young adults * Pain, effusion, warm, unable to bear weight, unable to tolerate passive range of motion * Not always systematically sick * Sometimes...its (1)! * Crystal analysis is diagnostic * BUT...can have septic arthritis in the presence of it as well...

* Staphylococcus aureus, \>50% of cases * Neisseria gonorrhea, ~20% of cases * Most common organism in otherwise healthy sexually active adolescents and young adults * Pain, effusion, warm, unable to bear weight, unable to tolerate passive range of motion * Not always systematically sick * Sometimes...Gout! * Crystal analysis is diagnostic * BUT...can have septic arthritis in the presence of gout as well...

Next 3 conditions ## Footnote All disruptors of the ______ mechanism of the knee * Patellar tendon rupture * Quadriceps tendon rupture * Patella fracture

Extension

Patellar Tendon Rupture ## Footnote * A tr\_\_\_\_\_\_\_ rupture of the patellar tendon caused by a t\_\_\_\_\_\_ overload during activity in a patient at risk. * Diagnosis can be confirmed by physical exam and radiographs for ______ tears. ______ tears may need an MRI to confirm the diagnosis. * Treatment for complete tears is timely (1) to optimize the chance of healing. Partial tears with an intact extensor mechanism may be treated with (1).

* A traumatic rupture of the patellar tendon caused by a tension overload during activity in a patient at risk. * Diagnosis can be confirmed by physical exam and radiographs for complete tears. Partial tears may need an MRI to confirm the diagnosis. * Treatment for complete tears is timely surgical repair to optimize the chance of healing. Partial tears with an intact extensor mechanism may be treated with immobilization.

Patellar Tendon Rupture ## Footnote * Most commonly in ___ and __ decade * Male\_\_ Female * Quadriceps tendon rupture is _____ common than patella tendon rupture (\_:\_ ratio) * _Patella alta_ =

* Most commonly in 3rd and 4th decade * Male \> Female * Quadriceps tendon rupture is more common than patella tendon rupture (2:1 ratio) * _Patella alta_ = *abnormally high patella in relation to femur*

Quadriceps Tendon Rupture ## Footnote * A tr\_\_\_\_\_\_ injury of the quadriceps ______ on the patella leading to a disruption in the knee extensor mechanism. * Diagnosis is made clinically with a p\_\_\_\_\_\_ defect __ cm proximal to the superior pole of the patella with inability to perform a (1) test and presence of patella ____ on knee radiographs. * Treatment may be nonoperative in patients with _____ tears and _____ extensor mechanism. Operative repair is indicated if there is disruption of the extensor mechanism.

* A traumatic injury of the quadriceps insertion on the patella leading to a disruption in the knee extensor mechanism. * Diagnosis is made clinically with a palpable defect 2 cm proximal to the superior pole of the patella with inability to perform a straight leg raise and presence of patella baja on knee radiographs. * Treatment may be nonoperative in patients with partial tears and intact extensor mechanism. Operative repair is indicated if there is disruption of the extensor mechanism.

Quadriceps Tendon Rupture ## Footnote * Usually occurs in patients \> ___ years of age * _____ \> ______ (gender) (up to 8:1) * _____ occur with very little or no trauma (esp. diabetics) * Patella \_\_\_\_\_

* Usually occurs in patients \> 40 years of age * Males \> Females (up to 8:1) * Can occur with very little or no trauma (esp. diabetics) * Patella Baja

Patella Fracture ## Footnote * Caused by direct tr\_\_\_\_\_ or rapid con\_\_\_\_\_\_ of the quadriceps with a _______ knee that can lead to loss of the extensor mechanism. * Diagnosis can be made clinically with inability to perform a (1) and confirmed with _______ of the knee. * Treatment is either (1) or (1) depending on fracture displacement and integrity of the extensor mechanism.

* Caused by direct trauma or rapid contracture of the quadriceps with a flexed knee that can lead to loss of the extensor mechanism. * Diagnosis can be made clinically with inability to perform a straight leg raise and confirmed with radiographs of the knee. * Treatment is either immobilization or surgical fixation depending on fracture displacement and integrity of the extensor mechanism.

Pes Anserine Bursitis ## Footnote * Especially in \_\_\_\_\_\_\_, can be a non-articular cause of knee pain * “G\_\_\_\_\_ Foot” * Sartorius, Gracilis, Semitendinosus (“Say Grace before Tea”) * Inflammation of the bursa located between the shinbone (\_\_\_\_\_) and three tendons of the h\_\_\_\_\_\_\_ muscle at the inside of the knee * Pain and tenderness on the \_\_\_\_side of your knee, approximately 2 to 3 inches _______ the joint * RICE, NSAIDs, PT, Injection

* Especially in athletes, can be a non-articular cause of knee pain * “Goose Foot” * Sartorius, Gracilis, Semitendinosus (“Say Grace before Tea”) * Inflammation of the bursa located between the shinbone (tibia) and three tendons of the hamstring muscle at the inside of the knee * Pain and tenderness on the inside of your knee, approximately 2 to 3 inches below the joint * RICE, NSAIDs, PT, Injection

Osgood Schlatter's Disease (Tibial Tubercle Apophysitis) ## Footnote **Osgood-Schlatter disease is osteo\_\_\_\_\_\_\_ or traction _______ of the tibial tubercle, commonly presenting as _______ knee pain in the ________ population.** * **Diagnosis** is made clinically with an _______ tibial tubercle and supplemented with _______ of the knee that reveal \_\_\_regularity and \_\_\_\_\_mentation of the tibial tubercle. * **Treatment** is \_\_\_operative with NSAIDs, activity modification with quadriceps stretching and typically resolves with **physeal closure**

**Osgood-Schlatter disease is osteochondrosis or traction apophysitis of the tibial tubercle, commonly presenting as anterior knee pain in the pediatric population.** * **Diagnosis** is made clinically with an enlarged tibial tubercle and supplemented with radiographs of the knee that reveal irregularity and fragmentation of the tibial tubercle. * **Treatment** is nonoperative with NSAIDs, activity modification with quadriceps stretching and typically resolves with **physeal closure** *Notes: Osteochondrosis = group of disorders that affect the growing skeleton Traction apophysitis = an injury to the cartilage and bony attachments of tendons in children and adolescents*