PATELLOFEMORAL ARTHRALGIA Osteochondritis Dissecans (OCD)

-”patellofemoral pain syndrome” (PFPS) - 80% of OCD is knee

- any pain in jt. between patella and the - lesion subchondral bones -
femur chondrocytes (tendinous bones)
- non surgical, that causes pain to the - grade 1: compression of subchondral
knee trabeculae w/ preservation of the
- knee in flexion, patella goes proximally cartilage
and distally - grade 2: incomplete detachment of an
- distinct MOI: due to mechanical loading osteochondral fragment
(similar to TFCC), - grade 3: complete avulsion of an
- tight quads make patella move upward osteochondral fragment w/o dislocation
during flex/ext -- patella is fixed - grade 4: complete avulsion of an
superiorly osteochondral fragment w/ dislocation
- tight ITB responsible for pulling , pulls (loose bodies)
patella goes lateral side (biomechanics - OCD is a problem in chondrocytes, in
are affected) - causes pain cartilage
- common cause of this condition: - there is pain, clicking and popping
tightness to ITB / second cause: inside the knee
weakness of VMO (vastus medialis - chondrocytes can become loose
oblique) bodies in the knee,
- if there's pain around patella, check - most common site for OCD is inferior
tightness of ITB portion of medial femoral condyle
- ITB and VMO has a "tug of war" - if - symptoms: pain, swelling and
vmo is weak, ITB is pulled laterally mechanical lacking and grinding
- pes planus: tibia rotates internally, - tx: arthroscopic debridement (insert
patella in medial side (causing camera in the knee)
patellofemoral pain syndrome) - ONLY ONE SPECIAL TEST FOR OCD:
- if you have anteverted hip, no muscle WILSON TEST
inhibits medial rotators (hip does internal
rotation, causing Meniscal Injuries
abnormal patellofemoral tracking) -- also - MOI: acute trauma or gradual
leads to ITB tightness because of degeneration
increase of load on ITB - twisting motion w/ planted foot
- main causes: tightness of ITB and (basketball players are injured when
weakness of VMO landing a jump -- while body is
SYMPTOMS of PFPS rotating, the foot is the on floor)
- pain in flexion/extension - meniscus is sort of cartilaginous, any
- anterior knee pain (pain under injury to that part leads to clicking and
kneecap) mechanical locking
- movement of patella medially and - pt tells you that there is always clicking
laterally, if it causes pain -- it is PFPS and popping
- MOST COMMON TEST: SINGLE LEG - most common type of meniscal tear:
AND DOUBLE LEG SQUATS AND bucket handle meniscus tear
LUNGES (do squats first, then - "medial jt line tenderness" or "medial jt
double leg, then single leg, then lunges) line" - specific to meniscal injury
- weak abdominals can cause PFPS - + McMurray Test
(correlation to obese or sudden increase - best diagnostic tool: MRI (magnetic
of weight) -- causes pain intermediate jt. resonance imaging)
- core strengthening when pt has gained - meniscal tear outside: it is good
weight (core strengthening enables to compared to having a meniscal tear
correct PFPS)- modify the pt's activity inside
due to mechanical loading and overload - tear outside vascularized “red zone”
- avascular “whitezone”
- outside has vascular side (better
prognosis)
- meniscus has avascular and vascular Ligamentous Injuries (ACL)
- young pt: arthroscopy - career-ending
- old pt: 3-6 weeks rest - AIR displacement (anterior internal
- if partial tear and MRI says tear is inner: rotation)
tx is REST and PT- meniscus can cause - MOI: occurs as result of contact or
mechanical locking, and can be forever noncontact injuries
- meniscus limits motion inside if there is - classic MOI for ACL: foot is planted on
loose bodies the floor, knee is flex and body rotated
- MOST COMMON IS EXTENSION - effusion is usually present
- MECHANICAL LOCKING NEEDS - Lachman's Test (MOST SPECIFIC
SURGERY TEST), followed by Anterior Drawer test
- if full tear, menisectomy - Segond fracture (small capsular
- if partial tear, arthroscopic debridement avulsion fracture of the lateral tibial
plateau)- pathognomic of ACL
Ligamentous Injuries (MCL) - diagnostic tool: MRI
- most common in MCL (medial - management of acute ACL. use of ice.
collateral ligament) and ACL (anterior elevation, compression -- knee
cruciate ligament) immobilizers, hinged knee brace
- unhappy triad of o'donoghue (ACL, (to provide stability)
MCL and medial meniscus) -- (you can - quads are atrophied during ACL injury
have one of them, or two, or - SLR w/ knee immobilizer - initial tx to
three) maintain mm tone of quadriceps
- MOI: pain and tenderness over MCL - pre-rehabiliation/pre-surgery program -
- most common stress is valgus (medial) doing this to pt before their surgery
-- (from lateral side going medial) - if pt had a pre-PT program prior to
- most common in MCL surgery, they have a better diagnosis for
- too much valgus causes ligamentous recovering to sports
tear - doctor delays for 2 weeks before
- can feel there is a "catch" at the end -- surgery
injury is a grade 1 sprain
- if medial jt line opens up, there is Ligamentous injuries (PCL)
complete disruption - PCL is less common compared to ACL
- firm end feel (grade 1 sprain) - Common MOI: "dashboard injury"
- cannot feel anything at end (complete - Positive posterior drawer test
disruption -- grade 3 sprain) - diagnostic tool: MRI
- MCL are extracollateral, there is no - PCL good prognostic factor, can
effusion (fluid swells) recover easier and return to sports
- DIAGNOSTIC TOOL: MRI - if you are not an athlete (even though
= PT and conservative management, there is complete tear), surgery is not
and a knee mobilizer (2 weeks) required
- knee immobilizer - promotes weight - if you ARE an athlete with a complete
bearing and also restricts movement tear, you need surgery
(immobilization) -- allows - functional instability of the knee for
collateral ligaments to heal athlete, immediate surgery required
- can do ROM exercises
- partial or near to complete tear - delay Posterolateral Corner Injuries
therapy up to 4 weeks - Common
- if not elite athlete, no need for surgery - common mm affect: popliteus tendon,
unless it causes an unstable knee LCL, and gastrocs (lateral head)
- if elite athlete has a grade 3 sprain, - most structures are in the
surgery is required posterolateral corner -- can lead to ACL
-Valgus stress test injury and knee dislocation
- difficult to diagnose bc of too many
structures affected
- forces come from posterolateral or - do core strengthening with pt that has
posteromedial aspect, knee problems
- if force comes from anteromedial, it will - no need for imaging studies
go posterolateral - tx: steroids injection
- if force comes from anterolateral, it will - "Popliteal bursitis" or "Baker's cyst" --
go posteromedial there is localized swelling or tenderness
- most common: POSTEROLATERAL at the back of knee
- rotatory instability of pt:
POSTEROMEDIAL ROTATORY Patellar Tendinopathy
INSTABILITY is the ANSWER - "Jumper's knee" - put jopats strap
- what direction of forces: anterolateral - Inferior pull of patella
forces is the ANSWER - If there is pain under the knee
(especially when jumping)
- MRI and US for diagnosis
- tx: ice, NSAIDS, cross-friction
massage, modalities, quad stretching
- weakness or tightness of quadriceps
(STREGTHEN THE QUADS)

Osgood Schlatter Disease

- pain at the tibial tuberosity
- common in young boys
- commonly bilateral
- main cause is overload, most load
goes to tibial tuberosity (tibial tuberosity
becomes tender)
- bone fragmentation during severe
cases

Prepatellar Bursitis (SHORT Sinding Larsen Johansson Disease

KNEELING) - almost the same as Osgood bc it's
- 6 to 8 bursa in knee commonly seen in young pt
- "housemaid's knee" - inferior pull of patella, but for children
- position of kneeling, "short kneeling" - ask pt to stop doing the activity for 2
sitting on your butt essentially weeks
- swelling w/in the bursa - let patella heal by it's own
- best tx: steroid injection - when epiphyseal plate closes, sinding
- aspiration: when there is high effusion larson johansson disease is gone
rate
- deep infrapatellar bursitis: Pelligrini Steida Disease
"clergyman's knee", "vicar's knee", - condition of children
"nun's knee" - ossification of medial collateral
-tall kneeling ligament (MCL)
- there is small bone on MCL
Pes Anserine Bursitis (ossification of MCL) -- BONE SPUR ON
- subset mm, one hamstring mm MCL
(semiten) and two adductor mm (sartor. - Myositis Ossificans - bone formation in
and gracilis) the muscle
- very specific and localize - In UE, common in posterior elbow
- swelling and tenderness just above (brachialis)
anteromedial of knee - In LE, common in quadriceps (rectus
- common biomechanical deficits: weak femoris) heterotopic ossification (HO) -
core mm, weak medial hamstrings, repetitive microtrauma ,, common in
weak hip adductors shoulder, ankle (calcaneus)
Quadriceps and Patella Tendon
Rupture
- pt has unstable knee
- patellar tendon is strong
- pt unable to extend the knee due to
tendon rupture
- ask pt to extend the knee in high
standing, if they cannot do it -- its a full
tear (patella moves
superiorly, but pt cant do extension)
- the pt will be unable to extend the knee.
when the pt is asked to do so, the patella
will not move if there is quads tendon
rupture
- patella will elevate without causing
knee extension in the setting of
a patella tendon rupture
- a pt with an acute quads or patella
tendon rupture should be placed in a
knee immobilizer and made non-weight
bearing with crutches. rupture of the
quads or patella tendons requires
surgical repair within a few days for
optimal results