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Osteoarthritis

  • Cause/Pathophysiology

    • Chronic degeneration of articular cartilage

    • Can be post-traumatic

  • History and symptoms

    • Usually gradual increase pain and stiffness, but can have more of a sudden onset

    • Usually more symptomatic after periods of rest and improves with activity

    • Usually more symptomatic with prolonged standing

  • Exam Findings

    • +/- antalgic gait

    • +/- lack of full ROM

    • +/- valgus or varus deformity

    • +/- TTP

  • Imaging

    • X-Rays

      • AP, Lateral, Tangential at minimum.  I add a Rosenberg view for patients I suspect may have arthritic changes 

      • Evaluate for joint space narrowing, osteophyte formation, subchondral sclerosis and cysts

  • Treatment​

    • Conservative options

      • NSAIDs​, if appropriate for patient

      • Acetaminophen

      • PT

      • Knee sleeve, Off-the-shelf or custom OA bracing​

      • Corticosteroid injection

      • Hyaluronic Acid injection​

    • Surgery

      • Total or Unicompartmental knee arthroplasty​

    • Arthroscopy is not a beneficial surgery for arthritis

    • Narcotics are not indicated in OA treatment

  • Common ICD-10 codes

    • M17.10

 

 

 

 

 

 

 

 

Collateral Ligament Sprain (MCL, LCL)

  • Cause/Pathophysiology

    • Ligament stressed to the point of stretch or failure

    • Medial Collateral Ligament (MCL) - excessive valgus force (blow to the outside of the knee)

    • Lateral Collateral Ligament (LCL) - excessive varus force (blow to the inside of the knee)

    • Graded on 1 to 3 scale, with grade 3 being a complete rupture and grade 1 being no instability, just pain

  • History and symptoms

    • MOI

    • Pain and/or instability 

  • Exam Findings

    • +/- antalgic gait

    • +/- swelling

    • +/- ecchymosis

    • TTP over ligament distribution

    • Possible defect of ligament, specifically the LCL

    • Pain and/or instability with valgus (MCL)/varus (LCL) stress testing 

  • Imaging

    • X-Ray - may show avulsion injury

    • MRI - if significant injury, clinically

      • If clinical mild/moderate injury, MRI not necessary​

  • Treatment​

    • Most injuries

      • Hinged knee bracing​

      • RICE

      • NSAIDs

      • PT

    • Surgery

      • Grade 3 LCL​​​

      • Grade 3 MCL that does not recover conservatively

  • Common ICD-10 codes​​

    • S83.419S - MCL

    • S83.429s - LCL

 

 

 

 

 

 

Anterior Cruciate (ACL) Sprain/Tear

  • Cause/Pathophysiology

    • Femoral internal rotation on a fixed tibia

    • Usually result of a sudden stop with a change of direction 

    • Commonly will have meniscal injury in addition

  • History and symptoms

    • Commonly occurs in sport with making a cut or coming down from a jump

    • Frequently feel a pop at onset

    • Difficulty weightbearing early on, but may have no issues if not acute

    • Complaints of non-focal pain

    • Frequently 

    • If not acute, may note shifting episodes due to instability

  • Exam Findings

    • Effusion if acute/subacute

    • +/- lateral joint TTP (may have lateral proximal tibial or joint line TTP due to bone contusion associated with joint subluxation at the time of injury)

    • + Lachman, Anterior drawer, Pivot-shift

  • Imaging

    • X-Ray

      • May see a small bony avulsion off of the ​lateral tibial plateau (Segond sign)

    • MRI - standard for diagnosis

  • Treatment​

    • Conservative​

      • Focus on PT and ACL bracing​

      • Less active, older patients may do well

    • Surgery

      • ACL reconstruction​

      • Younger, active patients generally do better with surgery

  • Common ICD-10 codes​​

    • S83.519S​

 

 

 

 

Posterior Cruciate ligament (PCL) Sprain/Tear

  • Cause/Pathophysiology

    • Posterior tibial translation to the point of failure

    • Frequently a hyper extension to the knee or direct anterior blow to the tibia 

  • History and symptoms

    • MOI

    • May or may not feel a pop

    • Difficulty weightbearing early on, but may have no issues if not acute

  • Exam Findings

    • +/- effusion

    • + posterior drawer

    • + Sag sign

    • Possible false positive Lachman - excessive anterior tibial translation due to posterior start point secondary to lack of posterior stabilization

  • Imaging

    • X-Ray

      • essentially negative, but the tibia may slightly posteriorly​ subluxed

    • MRI - imaging standard for diagnosis

  • Treatment​

    • Conservative​

      • Focus on PT​

      • Bracing

      • Many can functionally recover 

    • Surgery

      • PCL reconstruction​

      • If conservative efforts fail to resolve symptoms or instability

  • Common ICD-10 codes​​

    • S83.529S​

 

 

 

 

 

Meniscus tear

  • Cause/Pathophysiology

    • Usually a compressive and rotational force to the meniscus (knee twists with a planted foot)

    • Degenerative tears can occur over time with repeated wear and tear 

    • Medial more common than lateral

  • History and symptoms

    • Acute tears caused by an acute MOI, frequently are associated with a grinding, popping, or tearing sensation

    • When not acute, pain with deep flexion or twisting are common complaints

    • Large, unstable tears can cause recurring popping (usually painful), and possibly locking (knee cannot fully straighten)

  • Exam Findings

    • Joint line TTP

    • +/- McMurray's (if small stable tear test may be negative)

    • +/- decreased ROM

    • +/- pain with deep flexion

  • Imaging

    • X-Ray negative

    • MRI is standard exam for diagnosis

  • Treatment​

    • Conservative​

      • I usually attempt conservative treatment for older (>35-ish), less active people, with no clinical or historical concern for large unstable tears, ie - no mechanical symptoms​ and/or notable arthritic X-Ray evidence

      • NSAIDs, if no contraindication

      • PT

      • Cortisone injection

    • Surgical

      • Young, active, mechanical symptoms​, no X-Ray evidence of arthritis

      • Arthroscopic partial menisectomy vs. repair

  • Common ICD-10 codes​​

    • M23.305 - med​ial meniscus 

    • M23.302 - lateral meniscus 

 

 

 

 

 

 

Patello-femoral Syndrome

  • Cause/Pathophysiology

    • Generally chronic overuse mechanical issue caused by patellar maltracking

  • History and symptoms

    • Anterior knee pain

    • Worsens with stairs, hills, or sitting with knees bent for extended periods

    • May be traumatic after a direct blow to the anterior knee 

  • Exam Findings

    • +/- Patellar facet TTP

    • Hip flexor weakness

    • Overall, relatively benign exam

  • Imaging

    • X-Ray

      • +/- patellar tilt or lateralization

  • Treatment​

    • Conservative​

      • PT - KEY to treatment

      • +/- bracing, taping

  • Common ICD-10 codes​​

    • M22.40

 

 

 

 

 

 

 

 

 

Patellar and Quadriceps tendonitis/tendonopathy

  • Cause/Pathophysiology

    • Tendonitis - inflammation of the tendon structure

    • Tendonopathy - chronic microtrauma to the tendon

  • History and symptoms

    • Anterior knee pain

      • Above patella for quadriceps tendon​

      • Below patella for patellar tendon

    • Symptoms worse with flexion/extension activity, running, jumping

  • Exam Findings

    • TTP over tendon

    • +/- swelling

    • +/- limited ROM due to pain, particularly flexion

    • Painful strength testing with extension

  • Imaging

    • X-Rays 

      • Generally negative but may have enthesopathy (spurring) if chronic​

  • Treatment​

    • Conservative​

      • RICE​

      • NSAIDs or Steroid taper

      • PT

      • +/- bracing/tendon strap, may need immobilizer for short duration if acut

      • NO CORTISONE INJECTION

      • ? PRP 

  • Common ICD-10 codes​​

    • M76.50

 

 

 

 

Extensor (Patellar/Quadriceps) Tendon Rupture

  • Cause/Pathophysiology

    • Usually a non-traumatic excessive eccentric load on a flexed knee (example - landing from a jump)

  • History and symptoms

    • Anterior knee pain 

    • Felt a pop, snap, or tearing sensation

    • Weakness or inability to extend the knee

    • Knee "gives way"

  • Exam Findings

    • High riding patella (patella alta) - patella tendon rupture

    • Low riding patella (patella baja) - Quadriceps tendon rupture

    • Palpable tendon defect

    • TTP over tendon

    • + swelling when acute

    • No active knee extension, if complete rupture

    • Painful, weak strength testing with knee extension, if partial injury

  • Imaging

    • X-Rays 

      • Generally negative for fracture but will show patella alta or baja​

    • MRI if suspected partial injury.  Ultrasound if patient cannot have MRI.

  • Treatment​

    • RICE​​

    • Immobilizer or Hinged brace that can be locked in extension

    • Requires surgical reapair, ideally within the first two weeks after injury

  • Common ICD-10 codes

    • M67.869

 

 

 

 

 

 

 

 

 

Bursitis (Pre-patellar, Pes Anserine)

  • Cause/Pathophysiology

    • Inflammatory (more common) or infectious condition of the bursa

    • Can be due to chronic/repetitive use or repeated direct pressure

    • "Housemaid's Knee" or "Clergyman's Knee"

    • IMPORTANT to distinguish septic bursitis from common

  • History and symptoms

    • +/- pain

    • +/- swelling

    • +/- precipitating factors - recent work on knees, trauma, etc

  • Exam Findings

    • Inflammatory

      • + superficial, focal, well-defined swelling over the anterior knee

      • Minimal to no TTP of bursa

    • Infectious (Septic)

      • + superficial anterior knee swelling​

      • + erythema

      • TTP

      • increased tactile temperature

      • Limited flexion due to pain

      • +/- febrile

  • Imaging

    • X-Ray

      • generally negative​

      • definitely indicated in the setting of trauma

  • Treatment​

    • Inflammatory

      • NSAIDs​

      • RICE

      • +/- temporary immobilizer 

      • Second line - aspiration with cortisone injection

    • Infectious

      • Aspirate if fluctuate and send for cultures​

      • antibiotics

      • immobilizer

      • May need I&D if no quick response to aspiration/antibiotics​

  • Common ICD-10 codes​​

    • M70.40 - prepatellar

 

 

 

 

 

 

Fractures

Patella fracture

  • Cause/Pathophysiology

    • Trauma to anterior knee

    • Avulsion injury of patellar or quadriceps tendons

  • History and symptoms

    • MOI

    • Pain and inability to walk and extend knee

  • Exam Findings

    • + swelling

    • + TTP over patella

    • +/- ecchymosis

    • Decreased flexion due to pain

    • May or may not be able to extend knee, depending on whether the extensor mechanism is intact

  • Imaging

    • X-Ray​ - AP, lateral, tangential

      • Tangential view is important for evaluating vertically oriented fractures​

  • Treatment​

    • Conservative​

      • Extension brace or knee immobilizer - If not displaced and extensor mechanism is intact 

    • Surgery - ORIF

  • Common ICD-10 codes

    • S82.001A - right​

    • S82.002A - left 

 

 

 

 

 

 

 

 

 

Tibial Plateau fracture

  • Cause/Pathophysiology

    • Trauma - usually an axial force with a valgus/varus or rotational component (ex.- fall from a ladder)

  • History and symptoms

    • MOI

    • Inability to WB

  • Exam Findings

    • +/- bony deformity, depending on severity

    • Effusion - hemarthrosis

    • TTP

    • ROM deficit secondary to pain

  • Imaging

    • X-Ray​ - AP, lateral, notch or Rosenberg

    • CT - to evaluate fracture pattern and displacement to determine definitive treatment

  • Treatment​

    • Initially, knee immobilizer, NWB 

    • Conservative or Surgery - Depends on displacement/location/articular involvement and step-off

    • A great reference for treatment guidelines is aosurgery.com.  

  • Common ICD-10 codes

    • Lateral

      • 82.121A - displaced​, right

      • 82.122A - displaced, left

      • 82.124A - non-displaced, right

      • 82.125A - non-displaced, left

    • Medial​

      • 82.131A - displaced​, right

      • 82.132A - displaced, left

      • 82.134A - non-displaced, right

      • 82.135A - non-displaced, left

    • Bicondylar​

      • 82.141A - displaced​, right

      • 82.142A - displaced, left

      • 82.144A - non-displaced, right

      • 82.145A - non-displaced, left

 

 

 

 

 

 

 

 

 

 

 

 

Osteochondral fracture/Osteochondritis Dissecans

  • Cause/Pathophysiology

    • Repetitive micro trauma to subchondral bone causes focal disruption of blood supply which leads to fracture

    • Stable injury has intact cartilage overlying

    • Unstable injury involves disruption of overlying cartilage

    • Frequently on femoral condyles or trochlea

  • History and symptoms

    • Pain with activity

    • +/- pain at rest

    • Swelling

  • Exam Findings

    • +/- antalgic gait

    • +/- effusion

    • +/- TTP of affected compartment

    • Exam can be relatively benign in many cases

  • Imaging

    • X-Ray

      • May or may not be seen​

    • MRI

      • Necessary to evaluate the stability of the injury​

  • Treatment​

    • Conservative​ if cartilage is intact

      • WB restriction if painful to do so​

      • Avoid impact activity until healing

      • Can take 8 months to heal

    • Surgical for unstable lesions in which the cartilage is not intact​​

  • Common ICD-10 codes

    • M94.9

 
 
 
 
 
 
 
 
 
 

Possible Location of Osteoarthritis Symptoms/Tenderness

OA

Possible Location of Symptoms/Tenderness - MCL Sprain

MCL sprain

Possible Location of Symptoms for ACL Injury

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Possible Location of Symptoms/Tenderness - Patellofemoral Syndrome

Anterior PF Syndrome

Possible Location of Symptoms/Tenderness with Medial Meniscus Tear

medial meniscus symptoms

Possible Location of Symptoms/Tenderness - Patellar Tendonitis

Patellar tendonitis

Possible Location of Symptoms for Patellar Tendon Rupture

Patellar tendonitis
 

Possible Location of Symptoms for Bursitis

Knee Bursitis

Possible Location of Symptoms/Tenderness for Patella Fracture

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Possible Location of Symptoms/Tenderness for Tibial Plateau Fracture - Lateral

Lateral Tibial Plateau

Possible Location of Symptoms/Tenderness for Osteochondral Fracture

Lateral OCD

Possible Location of Symptoms for PCL Injury

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