Knee Pain: Evaluation and Cost Conscious Management · Knee Pain: Evaluation and Cost Conscious...
Transcript of Knee Pain: Evaluation and Cost Conscious Management · Knee Pain: Evaluation and Cost Conscious...
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Knee Pain: Evaluation and Cost Conscious
Management Ted Parks, MD
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Common knee problems
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Common knee conditions
Ligament injuries
Meniscal injuries
Arthritis (osteoarthritis)
Problems of the patello-femoral joint
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ANATOMY: Building a Knee
Parts List:
4 Bones
2 Tendons
4 Ligaments
2 Types of Cartilage
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Building a Knee
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Ligament Injuries
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Ligament Injuries: History
High Energy Injuries Sometimes feel a “pop” Swelling (within an hour or two) Once the pain subsides: INSTABILITY
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Ligaments: Physical Exam
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Physical Exam: MCL
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Physical Exam: LCL
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ACL Tests
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Iliotibial (IT) band
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ACL Tests
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PCL Test
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PCL Test “Sag Sign”
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Studies
X-ray: Yes (mechanism)
MRI (maybe)
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Physical Exam vs MRI for suspected
ligament tears
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Treatment of Ligament Injuries
Collateral Ligaments heal without surgery
Cruciate Ligaments require surgery
Torn
Torn
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Rx = “Hinged Knee Brace”
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ACL Tears
Relatively Common
Don’t Heal If untreated, result in arthritis
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Treatment Option #1: Brace
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Treatment Option #2: Surgery
•End to End Repairs Don’t Work
•Ligament Must be Replaced with a Graft
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ACL Reconstructive Surgery
Over 90% Success for restoring stability
75-80% Success for returning to sports
Significant (Predicted) decrease in Arthritis later in life
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MENISCUS TEARS
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Meniscus Tears: History
“Sided” pain Trauma +/- Mechanical symptoms +/- Swelling, other +/-
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Meniscus Physical Exam
Joint line tenderness
Joint line pain with deep flexion
McMurray’s test
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Studies
X-rays (If age over 40: YES)*
MRI (Maybe)
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Should I order an MRI ?
50% of meniscus tears are asymptomatic in 6 weeks
If ALL signs and symptoms are positive after 6 weeks: SURGERY
If uncertain after 6 weeks, MRI
Usually NOT cost effective in patients over 70
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Surgical Treatment of Meniscus Tears
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Arthroscopy for Meniscus Tears
30 minute Operation 80 – 90% Patient Satisfaction 80 – 90 % Return to Sports Good results for decreasing development of
Arthritis
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ARTHRITIS (osteoarthritis)
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Arthritis History
Age (High Mileage) Past trauma Rheumatic disease Previous surgery
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Physical Exam
Angular deformities
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Physical Exam
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Physical Exam
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Making the Diagnosis
History: Age (“high mileage” joints) Physical Exam
X-RAYS
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Meniscus Tear vs Arthritis?
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X RAYS
Don’t Order: “knee series” •Non-weight bearing AP •Lateral •Obliques
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X Rays
Wt bearing AP Wt bearing 60 deg PA Lateral Merchant’s view (aka “sunrise)
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Getting the right x-ray views
Wt bearing AP Wt bearing 60 deg PA Lateral Merchant’s (aka
“sunrise”) view
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Getting the right x-ray views
Wt bearing AP Wt bearing 60 deg PA Lateral Merchant’s (aka
“sunrise”) view
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Image Access
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Treatment: Non-Surgical
Anti-inflammatory Medicines………….$/++ Supplements………………………….. $/+ Braces………………………………….$$$/+ Cortisone Shots………………………...$/+++ Viscosupplementation Shots…………... $$$/+ Weight Loss…………………………….?/? Cane, Crutches, Walker…………………$/+ Physical Therapy………………………..$$/++
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Arthritis Treatment: Surgical
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Total Knee Replacement
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Treatment Options?
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Unicompartmental Knee Replacement
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Problems of the patello-femoral joint
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History
More common in females Often bilateral Pain is anterior Worse with stairs (esp descending) Worse with squatting Worse with prolonged sitting (theater sign)
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Physical Exam
Test patello-femoral mobility
Check for “noise”
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X-Ray
Merchants/sunrise/subpatellar view
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Normal
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Arthritis
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Tracking problem
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Tracking problem and arthritis
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End Stage
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Treatment
Physical therapy/NSAIDs -strengthen the medial quad -stretch the lateral retinaculum Braces
Cortisone injections
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Treatment (surgical)
Lateral release Tibial tubercle transfer Maquette tibial tubercle osteotomy Knee replacement
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Lateral Release
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Tibial Tubercle Transfer
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Diagnosis: Unknown
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Stage 1
OTC NSAIDs
Simple home stretches: (Ham/Quad, hold for 30 seconds each, 3 sets twice a day)
Stationary bike: 20 min/day, 5 days/week for 6 weeks
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Stage 2
Do nothing Cost=0
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Do nothing Cost=0 Physical Therapy Cost=$720 ($80 initial visit, $60per f/u visit, 10 visits, medicare)
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Do nothing Cost=0 Physical Therapy Cost=$720 MRI Cost=$460 (medicare rate)
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Do nothing Cost=0 Physical Therapy Cost=$720 MRI Cost=$460 Cortisone Injection Cost=$66.47 ($4.67 supplies, $62 injection fee, medicare CPT code 20610)
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Cortisone Injection $66.47
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Corticosteroid Injections
1cc 4cc
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Syringe and Needle
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Prep
Betadine Alcohol Gloves Lidocaine Cold Spray (ethyl
chloride) Infection rate=1:15,000 Clin Fam Prac,Vol 7,2:2005
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General Rules…
No more than one injection per month No more than 3 injections per year
Don’t inject infected areas J Bone Joint Surg Am 1975;57:70-6 Curr Opin Rheumatol 1999;11:417-21 ACTA Orthop Scand 1997;132-4
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Knee Joint Injection Technique
Pt supine on table Knee extended Muscles relaxed Lateral approach Sub-patellar Jackson et al, J. Bone Joint Surg. AM., 84:1522-
1527 (2002)
1cc Steroid, 4cc Lidocaine
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Thank You!
Ted Parks, MD (303) 321-1333
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Physical Exam
SEATED Crepitation SUPINE Patella mobility/irritability Extension/Flexion ROM Hip internal/external ROM Joint line tenderness/McMurray’s test ACL and Collateral exam