Knee膝關(guān)節(jié)運動損傷課件

1、MS3 Sports Medicine WorkshopFamily Medicine Clerkship第1頁，共60頁。Knee ProblemsMS3 Family Medicine第2頁，共60頁。Anatomy Review第3頁，共60頁。FemurMedial & lateralCondylesEpicondylesTrochlear grooveIntercondylar notchPatellaSuperior pole (base)Inferior pole (apex)Medial & lateral facetsTibiaMedial & lateralCondyles

2、Gerdys tuberclePes anserine areaTibial tuberosityTibial plateauTibial spinesFibulaHeadNeck第4頁，共60頁。Anatomy Major Ligaments & TendonsQuadriceps tendonPatellar tendonMedial & lateral patellar retinaculua第5頁，共60頁。MCLLCL第6頁，共60頁。第7頁，共60頁。第8頁，共60頁。Anatomy Menisci of the KneeMedial meniscusLateral meniscu

3、sMeniscal ligamentsFunctions of the menisciMeniscal zonesWhite-whiteRed-whiteRed-red第9頁，共60頁。Knee Exam OverviewInspectionPalpationRange of MotionStrengthNeurovascularSpecial Tests第10頁，共60頁。Case 1 Medial Right Knee Pain16yo HS soccer player, previously healthyTackled from right side while runningImme

4、diate onset of medial jt line painDelayed onset local medial edema, stiffnessAble to bear weight 第11頁，共60頁。Key Questions in the HistoryMechanism of Injury?Acute or Chronic?Location and level of pain?Able to walk?Mechanical Symptoms? (Locking, popping, catching?)Associated instability?Swelling?Previo

5、us injuries or surgeries?第12頁，共60頁。Case 1 - ExamInspection: Mild medial knee edemaPalpation: + ttp medial kneeROM: cant bend 80dStrength: mildly decreasedNeurovascular: normalSpecial tests:Neg Lachman, Anterior Drawer, McMurray, varus stress+ mild increased gap on valgus stress (compared to left) wi

6、th good endpoint第13頁，共60頁。Special Tests - ACL InjuryLachman Test第14頁，共60頁。Special Tests - PCL InjuryPosterior Drawer TestSag SignQuad-Active Test第15頁，共60頁。Varus/Valgus stress for LCL and MCL Injury第16頁，共60頁。Features that should prompt an xray after acute knee injury include:Unable to bear weightCant

7、 flex 90dPatella TTPFibular head TTPAge 55All of the above第17頁，共60頁。5 Ottawa Knee Rulesi.e. When to order a knee xray after acute injuryAge 55 or R knee painFormer parachutist, no specific traumaNo previous knee surgeriesStiffness worse in morningPain is worse with activity, better with rest第24頁，共60

8、頁。Case 2 Key QuestionsMechanism of Injury?Acute or Chronic?Where/how bad is pain?Mechanical Symptoms? (Locking, popping, catching?)Associated instability?Swelling?Previous injuries or surgeries?What makes it worse?What makes it better?Insidious OnsetChronicDifficult to localize; mildNoNoneOccasional

9、Lots of “Bad Landings” No surgeryActivityRest第25頁，共60頁。Case 2 Physical ExamInspection: Genu varusBony enlargement at Med/Lat joint linesPalp: Posterior medial joint line ttpROM: Decreased flexion, 110 deg, mild crepitusStrength: normalNeurovascular: normalSpecial Tests: no ligamentous laxity, neg me

10、niscal tests第26頁，共60頁。Special Tests - Meniscal InjuriesJoint line tendernessMcMurray TestsThessaly testBounce-home testFull Squat第27頁，共60頁。Case 2 Plain FilmsJoint space narrowingSubchondral SclerosisOsteophytesSubchondral Cysts第28頁，共60頁。What is your diagnosis?10Meniscal tearPlica syndromeOsteoarthri

11、tisBone tumor第29頁，共60頁。OsteoarthritisNonpharmacologic Treatment:Nonpainful aerobic activityWeight lossPhysical TherapyImprove ROM, increase strengthBracingPharmacologic Treatment:APAPSupplementsGlucosamine and ChondroitinNSAIDs, COX-2sTramadolViscosupplementationIntrarticular Steroids第30頁，共60頁。Case

12、331 year old female, L knee painRecreational runnerLocalizes pain to front of kneeNo trauma, insidious onsetLocalizes pain “around kneecap”Worse with stairsWorse after prolonged sittingKnee occasionally “gives out”第31頁，共60頁。Case 3 Key QuestionsMechanism of Injury?Acute or Chronic?Where is the pain?M

13、echanical Symptoms? (Locking, popping, catching?)Associated instability?Swelling?Previous injuries or surgeries?What makes it worse?What makes it better?Insidious OnsetChronicAnterior kneeNo, but sometimes gives outNoneNoneNoneRunning, StairsMultiple days of rest第32頁，共60頁。Physical ExamInspection: mi

14、ld genu valgusPalpation: TTP lateral medial patellar facetsROM: full w/o painStrength: normalNeurovascular: normalSpecial Tests:+ patellar grindDecreased patellar glideInflexible hamstrings (Popliteal angle)第33頁，共60頁。Patellofemoral Joint Exam第34頁，共60頁。Patellofemoral Joint Exam Patellar Grind Test第35

15、頁，共60頁。Case 3 Plain FilmsAPLateral第36頁，共60頁。Case 3 Plain FilmsTunnelSunrise第37頁，共60頁。Whats your diagnosis?Patellar tendinopathyPatellar instabilityPatellofemoral syndromePlica syndrome第38頁，共60頁。Patellofemoral SyndromeTreatment:Relative rest; non-painful aerobicsPhysical TherapyImprove Quad/Hamstring

16、 flexibilityQuad, Hip abductor strengtheningCore strengtheningPatellar stabilization brace/tapingFoot orthoticsSurgery (last-ditch effort)第39頁，共60頁。Case 434 yo Army MAJ training for 1st marathonAtraumatic onset of R lateral knee pain 1 week ago after 10 mile runSharp burning painBetter with rest, re

17、turns with running第40頁，共60頁。Case 4 Key QuestionsMechanism of Injury?Acute or Chronic?Where is the pain?Mechanical Symptoms? (Locking, popping, catching?)Associated instability?Swelling?Previous injuries or surgeries?What makes it worse?What makes it better?Insidious OnsetAcuteLateral kneeNo, but som

18、etimes gives outNoneNoneNoneRunningMultiple days of rest第41頁，共60頁。Physical ExamInspection: normalPalpation: TTP over lateral femoral condyleROM: fullStrength: normalNeurovascular: normalSpecial tests: + Noble testTight on Ober test第42頁，共60頁。Ober testNoble test 第43頁，共60頁。Whats your diagnosis?Osteoart

19、hritisMeniscal tearIliotibial band syndromeLCL sprain第44頁，共60頁。Iliotibial Band SyndromeTreatment:Ice massage, pain medsRelative Rest; nonpainful activityPhysical TherapySpecific ITB stretchesHip abductor strengtheningCore strengthening (Gluteus Medius)Slow return to activityExtrinsic factors: shoes,

20、 running surface, training errors第45頁，共60頁。What the heck is a Plica?Congenital thickening of joint capsuleRedundant meniscusLoose piece of intra-articular cartilageFigment of my imagination第46頁，共60頁。Plica Syndrome?第47頁，共60頁。Questions?Before we break for hands-on第48頁，共60頁。Special Tests - ACL InjuryLa

21、chman TestKnee flexed to 15-30 degreesStabilize distal femurAnteriorly translate tibia on femurWatch & feel for amount of translation & end pointPivot Shift第49頁，共60頁。Special Tests - PCL InjuryPosterior Drawer TestKnee flexed to 90 degreesPosteriorly translate tibia on femurWatch & feel for amount of

22、 translation & end pointSag SignKnees flexed, quads relaxed compare both sidesLook for tibial posterior “sag” relative to femurQuad-Active TestKnee flexed; hamstrings fully relaxedSlide foot along table (quad active)Observe for anterior relocation第50頁，共60頁。Special Tests - MCL InjuryValgus Stress Tes

23、tingKnee flexed to 30 degreesRelax ACL/PCL & joint capsuleValgus stress applied to kneeLook and feel for translation and endpointCompare to uninjured sideMay repeat with knee in full extension第51頁，共60頁。Special Tests - LCL InjuryVarus Stress TestingSame test as valgus stress testingExcept applying a

24、varus stress insteadLCL, IT band, & PLC are tested第52頁，共60頁。Special Tests - Meniscal InjuriesJoint line tendernessFull SquatMcMurray TestsThessaly testBounce-home test第53頁，共60頁。McMurray test for Meniscal injuryTest Med and Lat meniscus separately3 concurrent maneuvers:Grind it (Rotate tibia AWAY fro

25、m it)Crunch it (varus or valgus)Pinch it (flex/extend knee)Positive: Painful “pop”第54頁，共60頁。Special Tests - Meniscal InjuriesThessaly TestPt stands on affected legKnee bent at 20 degreesExaminer holds pts hands and rotates pt to both sidesMeniscal grindPositive test: pain, painful click.第55頁，共60頁。Anterior Knee ExamPalpation of patellar facetsGlide and lift patella medially & laterallyPalpate undersurface of patella for tenderness第