Knee-膝關(guān)節(jié)運動損傷-PPT幻燈片

KneeProblemsMS3FamilyMedicineAnatomyReviewFemurMedial&lateralCondylesEpicondylesTrochleargrooveIntercondylarnotchPatellaSuperiorpole(base)Inferiorpole(apex)Medial&lateralfacetsTibiaMedial&lateralCondylesGerdy’stuberclePesanserineareaTibialtuberosityTibialplateauTibialspinesFibulaHeadNeckACLandPCLIliotibialband(ITB)

Anatomy–MeniscioftheKneeMedialmeniscusLateralmeniscusMeniscalligamentsFunctionsofthemenisciMeniscalzonesWhite-whiteRed-whiteRed-redKneeExamOverviewInspectionPalpationRangeofMotionStrengthNeurovascularSpecialTestsCase1–MedialRightKneePain16yoHSsoccerplayer,previouslyhealthyTackledfromrightsidewhilerunningImmediateonsetofmedialjtlinepainDelayedonsetlocalmedialedema,stiffnessAbletobearweightKeyQuestionsintheHistoryMechanismofInjury?AcuteorChronic?Locationandlevelofpain?Abletowalk?MechanicalSymptoms?(Locking,popping,catching?)Associatedinstability?Swelling?Previousinjuriesorsurgeries?Case1-ExamInspection:MildmedialkneeedemaPalpation:+ttpmedialkneeROM:can’tbend>80dStrength:mildlydecreasedNeurovascular:normalSpecialtests:NegLachman,AnteriorDrawer,McMurray,varusstress+mildincreasedgaponvalgusstress(comparedtoleft)withgoodendpointSpecialTests-ACLInjuryLachmanTestSpecialTests-PCLInjuryPosteriorDrawerTestSagSign

Quad-ActiveTest

Varus/Valgusstressfor

LCLandMCLInjuryFeaturesthatshouldpromptanxrayafteracutekneeinjuryinclude:UnabletobearweightCan’tflex>90dPatellaTTPFibularheadTTPAge<18or>55Alloftheabove5OttawaKneeRules

i.e.WhentoorderakneexrayafteracuteinjuryAge>55or<18UnabletowalkTTPonPATELLATTPonFIBULARHEADUnabletoflex90degCase1-ImagingNormal!Case1–DifferentialDiagnosis

MoreLikely LessLikelyMeniscalTearLigamentousInjuryWhichligament?ACLPCLMCLLCLMuscleStrainFracturePatellofemoralPainPlicaMCLSprainDiagnosis?WhatgradeofsprainislikelypresentoftheMCL?Grade1:nolaxity,buthurtsGrade2:mildlaxity,stillintactGrade3:completetearGrade4:hurtslike*^%*MCLSprainTreatment?RICERelativeRestHingeBraceonlyifunstableonexamAchievefullROMProgressiveStrengtheningNeuromuscularControl(Balanceexercises)FunctionalExercises(Sport-specific)Case256yoretiredArmyLTC15yearsworseningL>RkneepainFormerparachutist,nospecifictraumaNopreviouskneesurgeriesStiffnessworseinmorningPainisworsewithactivity,betterwithrestCase2–KeyQuestionsMechanismofInjury?AcuteorChronic?Where/howbadispain?MechanicalSymptoms?(Locking,popping,catching?)Associatedinstability?Swelling?Previousinjuriesorsurgeries?Whatmakesitworse?Whatmakesitbetter?InsidiousOnsetChronicDifficulttolocalize;mildNoNoneOccasionalLotsof“BadLandings”NosurgeryActivityRestCase2–PhysicalExamInspection:GenuvarusBonyenlargementatMed/LatjointlinesPalp:PosteriormedialjointlinettpROM:Decreasedflexion,110deg,mildcrepitusStrength:normalNeurovascular:normalSpecialTests:noligamentouslaxity,negmeniscaltestsSpecialTests-MeniscalInjuriesJointlinetendernessMcMurrayTestsThessalytestBounce-hometestFullSquatCase2–PlainFilmsJointspacenarrowingSubchondralSclerosisOsteophytesSubchondralCystsWhatisyourdiagnosis?10MeniscaltearPlicasyndromeOsteoarthritisBonetumorOsteoarthritisNonpharmacologicTreatment:NonpainfulaerobicactivityWeightlossPhysicalTherapyImproveROM,increasestrengthBracingPharmacologicTreatment:APAPSupplementsGlucosamineandChondroitinNSAIDs,COX-2’sTramadolViscosupplementationIntrarticularSteroidsCase331yearoldfemale,LkneepainRecreationalrunnerLocalizespaintofrontofkneeNotrauma,insidiousonsetLocalizespain“aroundkneecap”WorsewithstairsWorseafterprolongedsittingKneeoccasionally“givesout”Case3–KeyQuestionsMechanismofInjury?AcuteorChronic?Whereisthepain?MechanicalSymptoms?(Locking,popping,catching?)Associatedinstability?Swelling?Previousinjuriesorsurgeries?Whatmakesitworse?Whatmakesitbetter?InsidiousOnsetChronicAnteriorkneeNo,butsometimesgivesoutNoneNoneNoneRunning,StairsMultipledaysofrestPhysicalExamInspection:mildgenuvalgusPalpation:TTPlateral>medialpatellarfacetsROM:fullw/opainStrength:normalNeurovascular:normalSpecialTests:+patellargrindDecreasedpatellarglideInflexiblehamstrings(Poplitealangle)PatellofemoralJointExamPatellofemoralJointExamPatellarGrindTestCase3–PlainFilmsAPLateralCase3–PlainFilmsTunnelSunriseWhat’syourdiagnosis?PatellartendinopathyPatellarinstabilityPatellofemoralsyndromePlicasyndromePatellofemoralSyndromeTreatment:Relativerest;non-painfulaerobicsPhysicalTherapyImproveQuad/HamstringflexibilityQuad,HipabductorstrengtheningCorestrengtheningPatellarstabilizationbrace/tapingFootorthoticsSurgery(last-ditcheffort)Case434yoArmyMAJtrainingfor1stmarathonAtraumaticonsetofRlateralkneepain1weekagoafter10milerunSharpburningpainBetterwithrest,returnswithrunningCase4–KeyQuestionsMechanismofInjury?AcuteorChronic?Whereisthepain?MechanicalSymptoms?(Locking,popping,catching?)Associatedinstability?Swelling?Previousinjuriesorsurgeries?Whatmakesitworse?Whatmakesitbetter?InsidiousOnsetAcuteLateralkneeNo,butsometimesgivesoutNoneNoneNoneRunningMultipledaysofrestPhysicalExamInspection:normalPalpation:TTPoverlateralfemoralcondyleROM:fullStrength:normalNeurovascular:normalSpecialtests:+NobletestTightonObertestObertest Nobletest

What’syourdiagnosis?OsteoarthritisMeniscaltearIliotibialbandsyndromeLCLsprainIliotibialBandSyndromeTreatment:Icemassage,painmedsRelativeRest;nonpainfulactivityPhysicalTherapySpecificITBstretchesHipabductorstrengtheningCorestrengthening(GluteusMedius)SlowreturntoactivityExtrinsicfactors:shoes,runningsurface,trainingerrorsWhattheheckisaPlica?CongenitalthickeningofjointcapsuleRedundantmeniscusLoosepieceofintra-articularcartilageFigmentofmyimaginationPlicaSyndrome?Questions?Beforewebreakforhands-onSpecialTests-ACLInjuryLachmanTestKneeflexedto15-30degreesStabilizedistalfemurAnteriorlytranslatetibiaonfemurWatch&feelforamountoftranslation&endpointPivotShiftSpecialTests-PCLInjuryPosteriorDrawerTestKneeflexedto90degreesPosteriorlytranslatetibiaonfemurWatch&feelforamountoftranslation&endpointSagSignKneesflexed,quadsrelaxed

comparebothsidesLookfortibialposterior“sag”relativetofemurQuad-ActiveTestKneeflexed;hamstringsfullyrelaxedSlidefootalongtable(quadactive)ObserveforanteriorrelocationSpecialTests-MCLInjuryValgusStressTestingKneeflexedto30degreesRelaxACL/PCL&jointcapsuleValgusstressappliedtokneeLookandfeelfortranslationandendpointComparetouninjuredsideMayrepeatwithkneeinfullextensionSpecialTests-LCLInjuryVarusStressTestingSametestasvalgusstresstestingExceptapplyingavarusstressinsteadLCL,ITband,&PLCaretestedSpecialTests-MeniscalInjuriesJointlinetendernessFullSquatMcMurrayTestsThessalytestBounce-hometestMcMurraytestforMeniscalinjuryTestMedandLatmeniscusseparately3concurrentmaneuvers:Grindit(RotatetibiaAWAYfromit)Crunchit(varusorvalgus)Pinchit(flex/extendknee)Positive:Painful“pop”SpecialTests-MeniscalInjuriesThessalyTestPtstandsonaffectedlegKneebentat20degreesExaminerholdspt’shandsandrotatespttobothsidesMeniscalgrindPositivetest:pain,painfulclick.AnteriorKneeExamPalpationofpatellarfacetsGlideandliftpatellamedially&late