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​

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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

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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​

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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​

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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 

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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​

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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​

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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​

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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​

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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 

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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

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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​

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