Primary Care of Musculoskeletal Problems in the Outpatient Setting - part 8 potx

syndrome may include weakness of the hip girdle, increased quadriceps (Q) angle, high-riding patella, imbalance between the vastus lateralis and the weaker VMO, and misalignment of the lower extremity. The Q angle is meas- ured by drawing a line from the anterior superior iliac crest through the mid- point of the patella. Draw another line from the tibial tuberosity through the midpoint of the patella. The angle formed at the intersection of the two lines is the Q angle (Figure 12.14). 12. Knee Problems 247 Anterior superior iliac spine Quadriceps muscle Q-angle Midpoint of patella Tibial tubercle FIGURE 12.14. Drawing of the Q angle. (Reproduced from Richmond J, Shahady E, eds. Sports Medicine for Primary Care. Cambridge, MA: Blackwell Science; 1996: 398, with permission.) 8.3. Imaging Imaging is only needed to rule out other entities. The PFPS diagnosis is clinical. 8.4. Treatment of Patellar Femoral Pain Syndrome Quadriceps strengthening especially the VMO is the cornerstone of treat- ment to help improve the tracking of the patella. Quadriceps exercises are described at the end of the chapter. Exercise 3, straight leg raising, is very helpful for PFPS. Ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and arch supports to correct ankle pronation are also suggested interventions. Patella bracing and bands are commonly used with varying effectiveness. The great majority of the time, conservative measures are effective. Surgery is a rare option for resistance cases. 8.5. Iliotibial Band Syndrome Iliotibial band syndrome (ITBS) is another common overuse syndrome asso- ciated with running and other knee flexion activities such as cycling, skiing, or weightlifting. It is the most common overuse syndrome in distance runners and the most common cause of lateral knee pain. It is more common in men than in women. Iliotibial band syndrome is caused by faulty training tech- niques (running on hilly terrain) and anatomic malalignment. The usual presentation is a sharp burning lateral knee pain that may radi- ate up into the lateral thigh or down to Gerdy’s tubercle of the tibia (is eas- ily palpated on the tibia just lateral to the distal portion of the patellar tendon, Figure 12.15). Runners often describe a specific, reproducible time when their symptoms start. They also note more pain with downhill run- ning because of the increased time spent in the impingement or friction zone. This zone is the area between 20° and 30° of flexion that the iliotib- ial band (ITB) crosses over the lateral femoral condyle. Friction from exces- sive flexion and extension produces inflammation of the ITB. Fast running and sprinting does not cause pain because the athletes’ knee spends more time in angles greater than 30° and not in the impingement zone. Riding a bike can increase the time spent in the impingement zone and produce or aggravate ITBS. Physical examination should begin with an observation for swelling and atrophy especially the vastus medialis muscle. The vastus medialis will atro- phy with many knee injuries. Range of motion of the hip and knee should be evaluated and any limitation of the injured side when compared with the nor- mal side should be noted and used to follow treatment progress. Be on the lookout for hip abductor weakness as it is common with ITBS. Physical examination in ITBS usually reveals tenderness over the lateral femoral epi- condyle when the knee is flexed greater than 30° (Figure 12.16). A Noble 248 J.R. Gravlee and E.J. Shahady compression test is performed by applying pressure to the lateral femoral epi- condyle while the knee is fully extended (Figure 12.17A). The knee is slowly flexed. The compression test is positive if the patient reports pain at 30° of knee flexion (Figure 12.17B) and/or the examiner palpates a rubbing or snap- ping sensation as the ITB passes over the lateral femoral epicondyle. Ober’s 12. Knee Problems 249 FIGURE 12.15. Gerdy’s tubercle. FIGURE 12.16. Lateral femoral condyle of ITB. 250 J.R. Gravlee and E.J. Shahady FIGURE 12.17. (A) Noble test at full extension. (B) Noble test at 30° of flexion. test (Figure 12.18) assesses ITB tightness that is associated with ITBS. The patient lies on the unaffected side. The unaffected hip and knee are both flexed to 120°. The involved knee is flexed to 90°, and the hip is abducted and hyperextended. After helping the patient do the maneuvers let the leg drop. A tight ITB will prevent the extremity from dropping below the imaginary hor- izontal noted in Figure 12.18. 8.6. Imaging X-rays are not needed to make the diagnosis of ITBS. Magnetic resonance imaging is done to rule out other causes. If the patient is not responding to conservative measures after 3 months an MRI is helpful to rule out other causes of the pain. 8.7. Treatment of Iliotibial Band Syndrome Most patients with ITBS respond to nonoperative measures. Activity modi- fication, exercises to strengthen hip abductor weakness, and hamstring and ITB stretching should be instituted. The exercises at the end of Chapter 11 and this chapter contain those exercises. Prescribe a short course (7 to 10 days) of NSAIDs. If excessive foot pronation is present suggest that the 12. Knee Problems 251 FIGURE 12.18. Ober test. patient use orthotics. Chapter 15 has a more extensive discussion of the use of orthotics. After a short period of avoiding running or cycling for 7 to 10 days (okay to walk) patients slowly start back with their running and biking. Symptoms and conditioning guide this process. Stretching of the ITB and strengthening of the medial abductors should start with the diagnosis and should be continued after return to activity. Most patients’ symptoms improve by 3 to 6 weeks. A corticosteroid injection (Figure 12.19) into the underlying bursa can be considered in refractory cases. Treatment and pre- vention of future injury can be accomplished by looking for training errors. This may involve decreasing mileage, altering stride length, avoiding hills, or periodically changing direction when running on a sloped surface. In cyclists, the seat height or the foot position may need to be changed. Surgery may be considered after at least 6 months of nonoperative man- agement. After arthroscopy to exclude intra-articular pathology, surgical excision of a portion of the ITB is performed. 9. Infrapatellar Tendonitis (Jumper’s Knee) Anatomically this is not a tendon but a ligament because it goes from bone to bone. Tradition refers to it as a tendon so for the sake of communication between health professionals it will be referred to as a tendon. This overuse injury is seen more commonly in patients who participate in activities that 252 J.R. Gravlee and E.J. Shahady FIGURE 12.19. Injection of the ITB. require a lot of jumping or squatting like basketball, volleyball, and weight lifting. The patellar tendon originates on the inferior pole of the patella and attaches to the tibial tubercle. Look at Figure 12.3 for all of these landmarks. Repeated forces at the inferior pole of the patella or the tibial tubercle cause microtrauma that results in microscopic tearing of the fibers and tendonitis. Direct palpation of the inferior pole of the patella, the patellar tendon, or less commonly over the tibial tubercle will cause pain, as will resisted knee extension. Be sure the tendon is intact and not ruptured by having the patient perform a straight leg raise with the knee in extension. A patient with a torn tendon would not be able to extend the knee and lift the leg. The rest of the examination for meniscal tears and ligamentous instability should be normal. X-rays are usually normal, but may demonstrate calcification within the patellar tendon or a small avulsion fracture from the inferior pole of the patella. In a younger patient the tibial tubercle may be tender and look unusual because of an entity known as Osgood–Schlatter disease. This will be discussed in the pediatric section. 9.1. Treatment of Patellar Tendonitis Activity modification along with ice and NSAIDs are the mainstays of treat- ment. The patient should avoid leg extension exercises, as this puts an unnec- essary load on the patellar tendon. Physical therapy for long-term treatment focuses on hamstring and quadriceps muscle strength, Achilles tendon stretching and ankle dorsiflexion flexibility. Steroid injection is not recom- mended due to the increased risk of tendon rupture. 10. Bursitis There are several bursas around the knee. Two of them, the pes anserine and the prepatellar, can become inflamed and present to the primary care clini- cian. Being able to differentiate these two problems from other knee problems is an important skill. Figure 12.20 depicts the location of the bursa. 10.1. Pes Anserine Bursitis This bursitis can be confused with a MCL sprain, medial meniscus tear, and OA because it causes medial knee pain. The bursa overlies the tibial attach- ment site of the sartorious, gracilis, and semitendinosus muscles and is located about 2 in. below the medial joint line. It is most common in middle- aged to older patients who are overweight. It can become inflamed from over- use or a direct contusion. The symptoms usually include sense of fullness in the area of the bursa and pain that can worsen with repetitive flexion and extension. Valgus stress testing in the supine position or resisted knee flexion in the prone position may reproduce the pain. 12. Knee Problems 253 Treatment is directed at decreasing the inflammation of the pes bursa area. Limitation of or change in any aggravating activity, use of moist heat, ultra- sound, iontophoresis, and a stretching and strengthening program are usually successful. Use the hamstring and calf stretching and strengthening exercises described at the end of the chapter. Physical therapy consultation for ion- tophoresis and ultrasound with progression to resistance exercises can be helpful. Cortisone injections into the bursa are usually successful (Figure 12.21). Return to recreational activities and work is dependent on regaining muscle strength and flexibility in addition to decreasing inflammation. Some of the patients with this bursitis may also have OA so be alert for the dual diagnosis. Imaging plays no role in making this diagnosis but may be helpful to rule out other entities. 10.2. Prepatellar Bursitis The prepatellar bursa is located directly above the patella (Figure 12.20). Its superficial location makes it susceptible to acute and chronic trauma. Acute injury is not as common as chronic microtrauma. In both acute and chronic bursitis the examination is similar but the history is different. An acute fall will produce bleeding, immediate swelling, and the appearance of a baseball-sized mass directly over the knee cap. The appearance can sometimes be quiet fright- ening to the patient and the novice practitioner. The chronic microtrauma is usually occupational. Any occupation that requires patients to be working on their knees can cause this bursitis. The chronic microtrauma usually appears 254 J.R. Gravlee and E.J. Shahady Prepatellar bursa Deep infrapatellar bursa Pes anserine bursa Superficial infrapatellar bursa FIGURE 12.20. Drawing of the knee bursa. (Reproduced from Richmond J, Shahady E, eds. Sports Medicine for Primary Care. Cambridge, MA: Blackwell Science; 1996: 431, with permission.) the day after patients have spent a long time on their knees with their occupa- tion. This is why this entity is sometimes called housemaid’s knee. The examination reveals a tight tender baseball-sized mass over the patella. Flexion and extension of the knee may be limited because of the mass. Be sure no other cystic structures like a Baker’s cyst (bulge behind the knee) or a meniscal cyst (bulge lateral to joint line) are present. Another rare entity to rule out is septic prepatellar bursitis. Septic patients complain of sudden onset of redness, warmth and swelling, fever, and/or chills. Examination reveals ery- thema and swelling over the patella with surrounding soft tissue edema. All patients with prepatellar bursitis will have some degree of tenderness and warmth but not the extensive amount that is associated with septic bursitis. Aspirating the bursa is the key to diagnosis and treatment. The fluid in acute trauma is bloody and may clot. In chronic microtrauma the fluid is dark red but does not clot. The fluid in septic bursitis is usually turbid but can also be blood-tinged. Obtain cultures and smears for bacteria if sepsis is suspected. Most of the time the diagnosis is chronic microtrauma. Treatment consists of draining the fluid and injecting a steroid and lido- caine. A large-bore needle (18 gauge) is used because the fluid is thick and may be difficult to drain. Advise the patient to avoid kneeling and if that is not possible protect the knee with some type of padding. Occasional surgery may be required for recurrent prepatellar bursitis. This is usually because of the synovial thickening similar to olecrenon bursitis (see 12. Knee Problems 255 FIGURE 12.21. Injection of the pes anserine bursa. Chapter 6) that will not to respond to conservative treatment. Excision of the bursa may be indicated in these patients. Pigtail catheter drainage of the bursa, inserted under computerized tomography (CT) guidance, is an alter- native approach to surgery. 11. Case 11.1. History and Exam A 65-year-old man with a history of hypertension and diabetes has been hav- ing right knee pain off and on for the past 3 years. He usually mentions the knee pain as an “oh, by the way” complaint but today the primary reason for the visit is knee pain. Previously you recommended that he take Tylenol for the discomfort and that has helped until recently. There is no history of recent trauma or past injury to the knee. He was told 1 year ago that he had gout in his big toe because it was tender and swollen. His uric acid has never been elevated and he had no prior bouts of gout. He is not on any medica- tion for gout. He also has had some knee stiffness and pain in his back and left hip. The stiffness is worse in the morning and takes about 10 min to wear off. The pain is now impacting his life as it keeps him from exercising and his blood sugar is running over 200 in the morning. He has no complaints of buckling or catching of his right knee but he does note periodic swelling espe- cially after he tries to walk. When walking he has a significant limp and does not want to bear weight on the right leg. He is afebrile. When reclining on the examination table you note that the right knee is mildly swollen and he is holding the knee in about 15° of flexion. The knee joint seems warmer than the rest of the leg but no redness is present. Milking down the suprapatellar pouch is positive for fluid, his VMO is weaker on the right by palpation, flexion is limited to 90° by pain, and he is not able to fully extend his knee without pain. Examination does not suggest ligamentous laxity but all maneuvers for ligamentous and menis- cal damage are difficult because of the pain. The rest of the examination is negative. He does have Heberden’s nodes on the distal interphalangeal (DIP) joints of multiple fingers. Aspiration of the knee joint fluid reveals a light straw-colored fluid. When the fluid-filled tube is placed next to newsprint you can read newsprint. The white cell count of the fluid is 500 mm 3 and no crys- tals are noted. An X-ray of his right knee compared with that of the left knee reveals narrowing of the medial joint space and osteophytes. 11.2. Thinking Process The patient’s age, morning stiffness that rapidly clears, and Heberden’s nodes of the DIP suggest OA but other diagnoses should be ruled out. No history of injury, buckling, or catching, and a stable knee on examination helps rule 256 J.R. Gravlee and E.J. Shahady [...]... Once the quadriceps strength has increased the patient usually does well For the injection the lateral approach is most commonly used For this approach, lines are drawn along the lateral and proximal borders of the patella The needle is inserted into the soft tissue between the patella and the femur near the intersection point of the lines (Figure 12.22) and directed at a 45° angle toward the middle of. .. the foot and ankle 3 Focused Physical Examination Begin by comparing the injured leg with the uninjured one Look for erythema, swelling, and atrophy of the musculature Have the patient walk without shoes and socks and observe from behind for pronation Pronation is excessive eversion (Figure 13.3) Ask the patient to point with one finger to the site of the pain Pinpoint pain is more characteristic of. .. pain suggests MTSS Location of the pain is also diagnostic, as will be pointed out when specific problems are discussed Use a tuning fork above the area of pain to see if the vibrations reproduce the patient’s pain The tuning fork test helps diagnose stress fractures Hopping up and down on the foot of the involved leg is usually painful in tibial stress fractures Plantar flexion aggravates the pain of. .. Quadriceps strengthening exercises, many times, are all that is needed to reduce the pain and return the patient to an acceptable level of function Unfortunately, most patients with knee OA are like the patient above They have other medical problems that bring them to the clinician and the knee complaints are mentioned casually at the end of the visit (“oh, by the way”) The clinician is about out of the door... is the usual position for tears of the gastrocnemius muscle The location of the pain in the popliteal fossae and tenderness over 280 E.J Shahady FIGURE 13.7 Location of pain in gastrocnemius tear the head of the gastrocnemius muscle suggests a tear of that muscle A desire to keep the foot plantar-flexed and inability to perform a single toe raise with his left leg further indicates a problem with the. .. medial head of the gastrocnemius muscle It is most common in middle-aged tennis players, but may also be seen in other racket sports, basketball, running, and skiing The patients are usually between 20 and 50 years of age, and are always engaged in physical activity at the time of the injury Predisposing factors include increasing age, inadequate stretching, fatigue, and previous muscle injury The injury... complaints include a sudden pain in the back of the leg over the medial head of the gastrocnemius muscle The muscle is usually stretched and not contracted when the tear occurs The patient prefers not to dorsiflex the foot because this movement aggravates the pain The patient may walk with the foot plantar-flexed and on examination be unable to stand on the tiptoe of the affected leg If examined immediately... vulnerability of the physis or growth plate makes it the site of injury rather than ligaments or cartilage when there is trauma to the knee So the same mechanism of injury that produces tears of the knee ligaments and their insertions in an adult will injure the physis in a young person who has open growth plates This is sometimes forgotten in skeletally immature adolescents who sustain injuries to their knees... Shahady Of the growth plates, the distal femoral physis is most frequently injured In this injury the adolescent may report being hit on the lateral side of the knee and experiences immediate medial knee pain and inability to bear weight Examination reveals point tenderness in the vicinity of the attachment of the MCL A valgus stress produces discomfort similar to a medical collateral ligament tear and there... eating behaviors until a reasonable degree of trust exists with their clinician The history is similar to the MTSS but the examination helps differentiate the two issues The pain is usually exertional and located on the posteromedial aspect of the tibia The pain and tenderness may be alleviated by rest initially, but with time continues in the resting state If the exertional activity is not modified the . meas- ured by drawing a line from the anterior superior iliac crest through the mid- point of the patella. Draw another line from the tibial tuberosity through the midpoint of the patella. The. along the lateral and prox- imal borders of the patella. The needle is inserted into the soft tissue between the patella and the femur near the intersection point of the lines (Figure 12.22) and. is doing well. 11.3. Imaging When OA is suspected, recommended radiographs include weight-bearing and non-weight-bearing views. Some of the classical findings include joint space narrowing, subchondral