Knee膝关节运动损伤

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

Quad-ActiveTest第15页/共61页

Varus/Valgusstressfor

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

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

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

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

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