Knee膝關(guān)節(jié)運動損傷

Knee膝關(guān)節(jié)運動損傷第1頁/共61頁KneeProblemsMS3FamilyMedicine第2頁/共61頁AnatomyReview第3頁/共61頁FemurMedial&lateralCondylesEpicondylesTrochleargrooveIntercondylarnotchPatellaSuperiorpole(base)Inferiorpole(apex)Medial&lateralfacetsTibiaMedial&lateralCondylesGerdy’stuberclePesanserineareaTibialtuberosityTibialplateauTibialspinesFibulaHeadNeck第4頁/共61頁Anatomy–MajorLigaments&TendonsQuadricepstendonPatellartendonMedial&lateralpatellarretinaculua第5頁/共61頁MCL LCL第6頁/共61頁第7頁/共61頁第8頁/共61頁Anatomy–MeniscioftheKneeMedialmeniscusLateralmeniscusMeniscalligamentsFunctionsofthemenisciMeniscalzonesWhite-whiteRed-whiteRed-red第9頁/共61頁KneeExamOverviewInspectionPalpationRangeofMotionStrengthNeurovascularSpecialTests第10頁/共61頁Case1–MedialRightKneePain16yoHSsoccerplayer,previouslyhealthyTackledfromrightsidewhilerunningImmediateonsetofmedialjtlinepainDelayedonsetlocalmedialedema,stiffnessAbletobearweight第11頁/共61頁KeyQuestionsintheHistoryMechanismofInjury?AcuteorChronic?Locationandlevelofpain?Abletowalk?MechanicalSymptoms?(Locking,popping,catching?)Associatedinstability?Swelling?Previousinjuriesorsurgeries?第12頁/共61頁Case1-ExamInspection:MildmedialkneeedemaPalpation:+ttpmedialkneeROM:can’tbend>80dStrength:mildlydecreasedNeurovascular:normalSpecialtests:NegLachman,AnteriorDrawer,McMurray,varusstress+mildincreasedgaponvalgusstress(comparedtoleft)withgoodendpoint第13頁/共61頁SpecialTests-ACLInjuryLachmanTest第14頁/共61頁SpecialTests-PCLInjuryPosteriorDrawerTestSagSign

Quad-ActiveTest第15頁/共61頁

Varus/Valgusstressfor

LCLandMCLInjury第16頁/共61頁Featuresthatshouldpromptanxrayafteracutekneeinjuryinclude:UnabletobearweightCan’tflex>90dPatellaTTPFibularheadTTPAge<18or>55Alloftheabove第17頁/共61頁5OttawaKneeRules

i.e.WhentoorderakneexrayafteracuteinjuryAge>55or<18UnabletowalkTTPonPATELLATTPonFIBULARHEADUnabletoflex90deg第18頁/共61頁Case1-ImagingNormal!第19頁/共61頁Case1–DifferentialDiagnosis

MoreLikely LessLikelyMeniscalTearLigamentousInjuryWhichligament?ACLPCLMCLLCLMuscleStrainFracturePatellofemoralPainPlica第20頁/共61頁MCLSprainDiagnosis?第21頁/共61頁WhatgradeofsprainislikelypresentoftheMCL?Grade1:nolaxity,buthurtsGrade2:mildlaxity,stillintactGrade3:completetearGrade4:hurtslike*^%*第22頁/共61頁MCLSprainTreatment?RICERelativeRestHingeBraceonlyifunstableonexamAchievefullROMProgressiveStrengtheningNeuromuscularControl(Balanceexercises)FunctionalExercises(Sport-specific)第23頁/共61頁Case256yoretiredArmyLTC15yearsworseningL>RkneepainFormerparachutist,nospecifictraumaNopreviouskneesurgeriesStiffnessworseinmorningPainisworsewithactivity,betterwithrest第24頁/共61頁Case2–KeyQuestionsMechanismofInjury?AcuteorChronic?Where/howbadispain?MechanicalSymptoms?(Locking,popping,catching?)Associatedinstability?Swelling?Previousinjuriesorsurgeries?Whatmakesitworse?Whatmakesitbetter?InsidiousOnsetChronicDifficulttolocalize;mildNoNoneOccasionalLotsof“BadLandings”NosurgeryActivityRest第25頁/共61頁Case2–PhysicalExamInspection:GenuvarusBonyenlargementatMed/LatjointlinesPalp:PosteriormedialjointlinettpROM:Decreasedflexion,110deg,mildcrepitusStrength:normalNeurovascular:normalSpecialTests:noligamentouslaxity,negmeniscaltests第26頁/共61頁SpecialTests-MeniscalInjuriesJointlinetendernessMcMurrayTestsThessalytestBounce-hometestFullSquat第27頁/共61頁Case2–PlainFilmsJointspacenarrowingSubchondralSclerosisOsteophytesSubchondralCysts第28頁/共61頁Whatisyourdiagnosis?10MeniscaltearPlicasyndromeOsteoarthritisBonetumor第29頁/共61頁OsteoarthritisNonpharmacologicTreatment:NonpainfulaerobicactivityWeightlossPhysicalTherapyImproveROM,increasestrengthBracingPharmacologicTreatment:APAPSupplementsGlucosamineandChondroitinNSAIDs,COX-2’sTramadolViscosupplementationIntrarticularSteroids第30頁/共61頁Case331yearoldfemale,LkneepainRecreationalrunnerLocalizespaintofrontofkneeNotrauma,insidiousonsetLocalizespain“aroundkneecap”WorsewithstairsWorseafterprolongedsittingKneeoccasionally“givesout”第31頁/共61頁Case3–KeyQuestionsMechanismofInjury?AcuteorChronic?Whereisthepain?MechanicalSymptoms?(Locking,popping,catching?)Associatedinstability?Swelling?Previousinjuriesorsurgeries?Whatmakesitworse?Whatmakesitbetter?InsidiousOnsetChronicAnteriorkneeNo,butsometimesgivesoutNoneNoneNoneRunning,StairsMultipledaysofrest第32頁/共61頁PhysicalExamInspection:mildgenuvalgusPalpation:TTPlateral>medialpatellarfacetsROM:fullw/opainStrength:normalNeurovascular:normalSpecialTests:+patellargrindDecreasedpatellarglideInflexiblehamstrings(Poplitealangle)第33頁/共61頁PatellofemoralJointExam第34頁/共61頁PatellofemoralJointExamPatellarGrindTest第35頁/共61頁Case3–PlainFilmsAPLateral第36頁/共61頁Case3–PlainFilmsTunnelSunrise第37頁/共61頁What’syourdiagnosis?PatellartendinopathyPatellarinstabilityPatellofemoralsyndromePlicasyndrome第38頁/共61頁PatellofemoralSyndromeTreatment:Relativerest;non-painfulaerobicsPhysicalTherapyImproveQuad/HamstringflexibilityQuad,HipabductorstrengtheningCorestrengtheningPatellarstabilizationbrace/tapingFootorthoticsSurgery(last-ditcheffort)第39頁/共61頁Case434yoArmyMAJtrainingfor1stmarathonAtraumaticonsetofRlateralkneepain1weekagoafter10milerunSharpburningpainBetterwithrest,returnswithrunning第40頁/共61頁Case4–KeyQuestionsMechanismofInjury?AcuteorChronic?Whereisthepain?MechanicalSymptoms?(Locking,popping,catching?)Associatedinstability?Swelling?Previousinjuriesorsurgeries?Whatmakesitworse?Whatmakesitbetter?InsidiousOnsetAcuteLateralkneeNo,butsometimesgivesoutNoneNoneNoneRunningMultipledaysofrest第41頁/共61頁PhysicalExamInspection:normalPalpation:TTPoverlateralfemoralcondyleROM:fullStrength:normalNeurovascular:normalSpecialtests:+NobletestTightonObertest第42頁/共61頁Obertest Nobletest

第43頁/共61頁What’syourdiagnosis?OsteoarthritisMeniscaltearIliotibialbandsyndromeLCLsprain第44頁/共61頁IliotibialBandSyndromeTreatment:Icemassage,painmedsRelativeRest;nonpainfulactivityPhysicalTherapySpecificITBstretchesHipabductorstrengtheningCorestrengthening(GluteusMedius)SlowreturntoactivityExtrinsicfactors:shoes,runningsurface,trainingerrors第45頁/共61頁WhattheheckisaPlica?CongenitalthickeningofjointcapsuleRedundantmeniscusLoosepieceofintra-articularcartilageFigmentofmyimagination第46頁/共61頁PlicaSyndrome?第47頁/共61頁Questions?Beforewebreakforhands-on第48頁/共61頁SpecialTests-ACLInjuryLachmanTestKneeflexedto15-30degreesStabilizedistalfemurAnteriorlytranslatetibiaonfemurWatch&feelforamountoftranslation&endpointPivotShift第49頁/共61頁SpecialTests-PCLInjuryPosteriorDrawerTestKneeflexedto90degreesPosteriorlytranslatetibiaonfemurWatch&feelforamountoftranslation&endpointSagSignKneesflexed,quadsrelaxed

comparebothsidesLookfortibialposterior“sag”relativetofemurQuad-ActiveTestKneeflexed;hamstringsfullyrelaxedSlidefootalongtable(quadactive)Observeforanteriorrelocation第50頁/共61頁SpecialTests-MCLInjuryValgusStressTestingKneeflexedto30degreesRelaxACL/PCL&jointcapsuleValgusstressappliedtokneeLookandfeelfortranslationandendpointComparetouninjuredsideMayrepeatwithkneeinfullextension第51頁/共61頁SpecialTests-LCLInjuryVarusStressTestingSametestasvalgusstresstestingExceptapplyingavarusstressinsteadLCL,ITband,&PLCaretested第52頁/共61頁SpecialTests-MeniscalInjuriesJointlinetendernessFullSquatMcMurrayTestsThessalytestBounce-hometest第53頁/共61頁McMurraytestforMeniscalinjuryTestMedandLatmeniscusseparately3concurrentmaneuvers:Grindit(RotatetibiaAWAYfromit)Crunchit(varusorvalgus)Pinchit(flex/extendknee)Positive:Painful“pop”第54頁/共61頁SpecialTests-MeniscalInjuriesThessalyTestPtstandsonaffectedlegKneebentat20degreesExaminerholdspt’shandsandrotatespttobothsidesMeniscalgrindPositivetest:pain,painfulclick.第55頁/共61頁AnteriorKneeExamPalpationofpatellarfacetsGlideandliftpatellamedially&