Knee Pain - Running

Wednesday, May 27, 2015, 1:00 PM - 3:00 PM Room: 30E 587 Chair: Lauren M. Simon, FACSM. Loma Linda University Medical Center, Loma Linda, CA. (No relationships reported) 588 Discussant: Kelly Lynne Roberts Lane, FACSM. Fix It Physical Therapy, Mahtomedi, MN. (No relationships reported) 589 Discussant: John P. DiFiori, FACSM. UCLA Division of Sports Medicine, Los Angeles, CA. (No relationships reported) 590 May 27, 1:00 PM - 1:20 PM Knee Injury in Division 1 Football Player Anna R. King1, Ramin R. Tabaddor2. 1Maine Medical Center, Portland, ME. 2South County Orthopedics, Wakefield, RI. Email: [email protected] (No relationships reported) HISTORY: A 20-year-old collegiate football player presented after sustaining an injury to his right leg. His right leg was planted, knee slightly flexed, and he was struck forcefully from the left side. He was unable to ambulate. Swelling was evident 20 minutes later. He had no history of prior injury to the knee and no significant medical history. PHYSICAL EXAMINATION: 5 days post-injury, inspection revealed ecchymosis along the medial aspect of the knee and visible patella alta. ROM was limited due to patient guarding. Palpation revealed 3+ effusion and a defect of the patella tendon. He was unable to perform a straight leg raise and was still unable to ambulate. Grade 3 MCL insufficiency was present. He was stable to varus stress. Lachman and pivot shift tests were limited secondary to pain and swelling. DIFFERENTIAL DIAGNOSIS: Patellar tendon rupture MCL tear Meniscal injury ACL tear Tibial plateau fracture Femoral condyle fracture TESTS AND RESULTS: MRI 4 days post-injury: full thickness tear of the proximal ACL, full thickness tear of the distal tibial insertion of the superficial MCL with 2.5cm of retraction, full thickness rupture of the patella attachment of the patellar tendon with 2cm of retraction, and a posterolateral corner meniscal tear. FINAL/WORKING DIAGNOSIS: Simultaneous rupture of patellar tendon, ACL, and MCL. TREATMENT AND OUTCOMES: He was treated in a staged manner with acute primary repair of the patellar tendon followed by a 3-month rehabilitation period during which serial increases in flexion while in the knee immobilizer were permitted. Physical therapy was begun at 2 weeks post-op. At 2 months, patient had 4/5 quadriceps strength, normal patellar tracking and no MCL instability to lateral stress. At 3 months, he returned to the operating room for ACL reconstruction and intraoperative assessment of the MCL and menisci. The MCL was treated conservatively given its stability with 30 degrees valgus load, and the medial and lateral menisci were found to be normal upon probing. He was placed on a standard postop ACL protocol. At 6 months, he had negative Lachman’s, anterior drawer, and pivot shift tests. He had no effusion and only mild quad atrophy. He was able to straight leg raise and was ambulating well. He returned to sport at 12 months after ACL reconstruction. 591 May 27, 1:20 PM - 1:40 PM Knee Pain In Baseball Player Sarah Hagerty. UPMC, Pittsburgh, PA. Email: [email protected] (No relationships reported) HISTORY: A 16 y/o high school baseball pitcher presented with bilateral anterior knee pain for 3 months. He reported sudden onset of pain while pitching and played through the pain. He tried to rest, but the pain slowly worsened. He reported episodes of giving way, but denied locking or swelling. His medical history is significant for Osgood-Schlatter’s disease and osteochondritis dissecans of both knees (2 years ago). The previous osteochronditis dissecans injury responded well to rest and activity modification. PHYSICAL EXAM: There was no significant joint effusion of the knees. Bilateral lateral fat pad was tender to palpation. The quadriceps, patellar and hamstring tendons were non-tender to palpation. Patella facets and medial and lateral retinaculum were non-tender with palpation. The patella apprehension test was negative. Circumduction maneuvers produced pain in the hamstring distally. There was discomfort with both stretch and manual muscle testing of the hamstrings. Lachman test was negative and demonstrated a firm endpoint. There was no pain or laxity with valgus or varus stress at 0 and 30° of flexion. There was full range of motion the knees bilaterally. DIFFERENTIAL DIAGNOSIS: 1. Hamstring tendinopathy/strain 2. Fat pad impingement syndrome 3. Recurrent osteochondritis dissecans lesion TEST AND RESULTS: X-ray PA flexion, lateral, and sunrise views of the left knee: Left knee revealed interval progression of osteochondral defect along the medial femoral condyle with increased fragmentation and further detachment from the base. MRI of the left knee: Development of a new full-thickness hyaline cartilage fissure along the posterior and medial margin of the osteochondral lesion of medial femoral condyle with moderate bone marrow edema and bone-osteochondral lesion junction cyst. Overall findings suggest osteochondral lesion micro-instability. FINAL/WORKING DIAGNOSIS: Symptomatic but stable osteochondritis dissecans of the medial femoral condyle of the left knee. TREATMENT/OUTCOMES: 1.Failed conservative management lead to referral to orthopedic surgery. 2.Patient underwent a diagnostic arthroscopy and retrograde drilling of OCD lesion. 3.He is currently in a locked brace in full extension and he is weight bearing as tolerated 4.He will begin formal physical therapy 4 weeks post-op. 592 May 27, 1:40 PM - 2:00 PM Traumatic Knee Pain Kylee Phillips, FACSM. University of Michigan, Ann Arbor, MI. (No relationships reported) HISTORY: A 46-year-old male with no past medical or surgical history presented to the Emergency Department (ED) with left knee pain after being robbed and assaulted. While running away he fell and landed on his flexed left knee. This caused immediate sharp pain in his anterior knee and he could not extend his knee. Bystanders called police who transported him to the ED. PHYSICAL EXAM: Musculoskeletal: Left knee effusion and patellar tenderness to palpation. Patella retracted proximally. No tenderness to palpation of proximal tibia. Unable to extend left knee against gravity, knee flexion of 120 degrees. Weight bearing limited by pain. 2+ DP and PT pulses. Full range of motion of left hip and ankle. Neurologic: Oriented x 3, sensation intact. Skin: Abrasions to left forehead and left knee. DIFFERENTIAL DIAGNOSIS: 1. Patellar Tendon Rupture 2. Patellar Tendon Fracture 3. Quadriceps Tendon Rupture 4. Tibial Plateau Fracture 5. Tibial Tubercle Fracture TESTS AND RESULTS: Knee X-rays: No fractures or dislocations, significant infrapatellar soft tissue swelling, and patella alta. Emergency Medicine Physician Knee Ultrasound: With the patient’s knee extended a hypoechoic area within the proximal patellar tendon that transversed the entire tendon was seen. Dynamic ultrasound was performed while the knee was passively flexed showing a separation of the proximal and distal parts of the patellar tendon with anechoic fluid filling the gap. FINAL WORKING DIAGNOSIS: Patellar Tendon Rupture TREATMENT AND OUTCOME: Orthopedic Surgery was consulted and took the patient directly to the Operating Room. A rupture in the patellar tendon near the insertion into the inferior pole of the patella was identified and direct primary repair was performed. He was placed in a straight leg cylinder cast after surgery, allowed to bear weight and discharged on post-operative day three. After two weeks the cast and sutures were removed and he was placed in a knee immobilizer locked in extension. He began rehabilitation with the goals of symmetric quadriceps strength and full active range of motion, which he met after three months. He then began gradual progression of the physical activities he enjoyed. 593 May 27, 2:00 PM - 2:20 PM Knee Injury-rugby James E. Crownover, Michael Casey. University of Tennessee Medical Center Knoxville, Knoxville, TN. Email: [email protected] (No relationships reported) HISTORY: A 20 year old collegiate rugby player sustained a right knee injury. A defender struck the front of his right knee resulting in hyperextension and an audible pop. He was unable to ambulate off of the field. Initial exam revealed a dislocated knee which was reduced on the field. He was taken to the ED where a CT angiogram ruled out vascular injury. He was provided with an immobilizer, crutches and was referred to a sports medicine trained orthopedic surgeon. PHYSICAL EXAM: Examination in clinic demonstrated a marked effusion. Passive range of motion showed flexion to 50 degrees, and hyperextension into mild recurvatum. Varus and valgus stress revealed increased laxity for both. Lachman’s was markedly positive. He demonstrated a complete foot drop with 0/5 strength for dorsiflexion, eversion, and extensor hallicus longus (EHL). Plantarflexion and inversion had full strength. Sensory testing showed diminished light-touch over the lateral lower leg and the dorsum of the foot. DIFFERENTIAL DIAGNOSIS: 1. Anterior cruciate ligament (ACL) tear 2. Posterior cruciate ligament (PCL) tear 3. Medial collateral ligament (MCL) tear 4. Lateral collateral ligament (LCL) tear 5. Sciatic nerve injury 6. Common peroneal nerve injury 7. Superficial peroneal nerve injury 8. Deep peroneal nerve injury TESTS AND RESULTS: Right Knee MRI: -ACL tear -PCL tear -LCL tear -Popliteus tendon tear -Posterior lateral capsule tear -Both gastrocnemius tears -Posterior capsule tear FINAL WORKING DIAGNOSIS: -ACL tear, PCL tear, LCL tear, Popliteal tendon tear, posterior capsule tears, gastrocnemius tears, and a common peroneal nerve injury TREATMENT AND OUTCOMES: 1. The patient underwent arthroscopic reconstruction of his ACL and PCL, open LCL reconstruction, posterior lateral corner reconstruction, and a common peroneal nerve decompression. 2. He is undergoing physical therapy and he has advanced his range of motion back to normal. He continues to work on his quadriceps strength, hip flexor strength, balance and neuromotor control of the knee. 3. The patient experienced improved sensation in the peroneal nerve distribution and slight EHL activation at 52-days post surgery. This has continued to improve and the patient is able to dorsiflex, evert and activate his EHL against resistance at four months post surgery. Sensation is much improved. 594 May 27, 2:20 PM - 2:40 PM Knee Pain - Running Alexandre Fuentes1, Robert Pontbriand2, Marc Therrien1, Philippe Landry1. 1Emovi, Laval, QC, Canada. 2Centre de medecine sportive de Laval, Laval, QC, Canada. Email: [email protected] Reported Relationships: A. Fuentes: Salary; Emovi. Intellectual Property; Emovi. Ownership Interest; Emovi. HISTORY: 43-years-old man runner feeling pain mainly over anteromedial aspect of his left knee. Pain first appeared while running and progressed to a point he had to stop physical activities and symptoms were felt during daily activities. PHYSICAL EXAMINATION: Fist medical consultation four months after initial symptoms revealed knee redness, swelling and pain. A month later, redness had decreased, McMurray and Thessaly test were negative, reflexes normal but sensation of crepitus on patella mobilization. Pain had decreased, but persisted during daily activities like going up/down stairs. Still could not participate in physical activities. DIFFERENTIAL DIAGNOSIS: 1.Knee synovitis 2.Patellofemoral pain syndrome 3.Medial compartment osteoarthritis 4.Patellofemoral osteoarthritis 5.Pes Anserine tendinitis TEST AND RESULTS: Left knee AP and lateral weight bearing radiographs: -Discreet intra-articular edema -Degenerative changes (grade 1 KL) in medial and patellofemoral compartment Musculoskeletal assessment by physical therapist: -Positive J sign and apprehensive test, tight quadriceps and psoas 3D knee kinematics assessment during gait: - Varus standing functional lower limb alignment of 2.9° - Varus alignment at initial contact of 6.1° decreasing to 3.5° during stance - Dynamic flexion contracture at initial contact of 10.9° FINAL WORKING DIAGNOSIS: Left knee synovitis, grade 1 osteoarthritis of medial and patellofemoral compartment, overuse syndrome TREATMENT AND OUTCOMES: 1. Patient enrolled in multimodal osteoarthritis (OA) management program comprising: a) OA education and self-management program b) Physical therapy to address pain and swelling c) Personalized home based exercises to address biomechanical alignment issues shown by the kinematic evaluation and PT assessment: (core and hip abductors strengthening, squats, stretching of iliotibial band, quadriceps and psoas) d) No medications prescribed but viscosupplementation injection when knee was dry 2. At 12 months follow up: -Patient had returned to a high level of physical activity without impact, showed improved quality of life, function and symptoms on KOOS and WOMAC scores -3D knee kinematic re-evaluation shows correction to a neutral standing and dynamic alignment and reduced dynamic flexion contracture 595 May 27, 2:40 PM - 3:00 PM Left Knee Pain - Military Service Amity Rubeor, Ron Tabaddor, Jeffrey Manning. Memorial Hospital of Rhode Island/Brown University, East Greenwich, RI. (Sponsor: Pierre Rouzier, FACSM) Email: [email protected] (No relationships reported) HISTORY: A 19 year old male was discharged from the Army, unable to meet the physical demands secondary to pain in his left knee. Upon presentation to clinic, he complained of dull constant pain, stiffness, weakness and loss of motion. The pain began without trauma at 11 years of age and was treated conservatively with symptom management. At 15 years of age, he was treated for a left medial tibia plateau stress fracture. With activity modification, the pain improved. Within the next three years, he gradually redeveloped anterior pain and loss of motion. He underwent arthroscopic debridement of a patella chondral defect at 18 years of age. Though he had a short period of relief, his symptoms returned. Failing conservative management, including physical therapy, he was discharged from the army and sought orthopedic evaluation. Recently diagnosed with patella instability, his presentation to the clinic was for another clinical opinion. PHYSICAL EXAMINATION: Left knee examination revealed no soft tissue swelling, ecchymosis, or tenderness at the medial or lateral tibiofemoral joint. Tenderness was noted at the lateral border of the patella and the lateral patellofemoral joint line; extreme tenderness was noted with palpation of a ridge along the anterolateral aspect of the patella. The patella shifted 2 quadrants, consistent with the opposite knee. There was mild weakness noted with left knee extension. DIFFERENTIAL DIAGNOSIS: - Patellofemoral pain syndrome - Chondromalacia patella - Recurrent chondral defect - Unstable bipartite patella TESTS AND RESULTS: - Left knee radiographs (2013): elongation of the patella in the transverse axis; lucency at the superolateral aspect of the patella on the lateral view - 3 phase bone scan (2013): focally abnormal increased activity along the outer margin the left patella - Left knee MRI (2012): bipartite patella with mild edema, stable and unchanged from 2009 - Left knee MRI (2009): bipartite patella with mild edema; medial tibia plateau stress fracture FINAL/WORKING DIAGNOSIS: Unstable, bipartite patella TREATMENT AND OUTCOMES: - Excision of left knee patella os - 10 days non-weight bearing, immobilized in extension - 8 weeks of physical therapy, focusing on quadriceps strengthening - Complete recovery and cleared for return to active military service within 11 months of surgery

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