examination and imaging of the knee and legforms.acsm.org/tpc/pdfs/30 ireland.pdf · 2013-01-17 ·...

Exam and Imaging of the Knee and LegExam and Imaging of the Knee and Leg Mary Lloyd Ireland, MDMary Lloyd Ireland, MD

ACSM TPC Part 2 ACSM TPC Part 2 •• February 9, 2013February 9, 2013 11

Mary Lloyd Ireland, MDAssociate Professor Dept. of Orthopaedic Surgery &

Sports MedicineUniversity of KentuckyLexington, Kentucky



Examination and Imagingof the Knee and Leg


ACSM TPC Part 2Miami, Florida • February 9, 2013

ACSM TPC Part 2Miami, Florida • February 9, 2013



Examination and Imaging of the Knee and LegExamination and Imaging of the Knee and Leg

IntroductionIntroduction

MeniscusMeniscus

LigamentLigament

ImagingImaging

CasesCases

ConclusionsConclusions QuitQuit



A good History and Physicalis Key

to a Correct Diagnosis

A good History and Physicalis Key

to a Correct Diagnosis



Grab SignGrab Sign

Patellofemoral DisordersPatellofemoral Disorders



FistedKnuckleSign

= ACL Tear

FistedKnuckleSign

= ACL Tear



Normal AlignmentNormal Alignment



Miserable Miserable MalalignmentMalalignment SyndromeSyndrome



Joint line palpation with knee flexed should produce pain if meniscus is tornJoint line palpation with knee flexed should produce pain if meniscus is torn

Externally rotate tibia for medial meniscus tears, Internally rotate for lateral meniscus tearsExternally rotate tibia for medial meniscus tears, Internally rotate for lateral meniscus tears



Bounce Home TestBounce Home Test



Normal Knee Exam: Bounce HomeNormal Knee Exam: Bounce Home



McMurray’s Test: Medial MeniscusMcMurray’s Test: Medial Meniscus



Patient apprehends another lateral patellar dislocationPatient apprehends another lateral patellar dislocation

Positive apprehension test Do the anticipated painful test lastPositive apprehension test Do the anticipated painful test last



Normal Knee Exam: McMurray’s TestNormal Knee Exam: McMurray’s Test



Apley’s Compression TestApley’s Compression Test



Normal Knee Exam: Apley’sNormal Knee Exam: Apley’s



McMurray’s Test: Medial MeniscusMcMurray’s Test: Medial Meniscus



Normal Knee Exam: Lateral AspectNormal Knee Exam: Lateral Aspect



Normal Knee Exam: LigamentsNormal Knee Exam: Ligaments



Valgus Stress Varus StressValgus Stress Varus Stress



Classification of Knee InstabilitiesRotatory, Straight and CombinedClassification of Knee InstabilitiesRotatory, Straight and Combined

• Diagnosis: +1 to +4 by examGrade I to IV

• Diagram• Bird’s eye view of tibia

• Involved Anatomic Structure• Physical findings• Mechanism and forces

• Contact vs. Noncontact• Varus / Valgus, Flexion / Extension• Tibial rotation

• Diagnosis: +1 to +4 by examGrade I to IV

• Diagram• Bird’s eye view of tibia

• Involved Anatomic Structure• Physical findings• Mechanism and forces

• Contact vs. Noncontact• Varus / Valgus, Flexion / Extension• Tibial rotation



Anterior InstabilitiesAnterior Instabilities



Knee InstabilityKnee Instability



Dia gnosis Involved AnatomicStructure

Posterolateral InstabilitiesPosterolateral Instabilities



Straight InstabilitiesStraight Instabilities



Knee InstabilityKnee Instability



Anterior DrawerAnterior Drawer



Normal Knee Exam: LigamentsNormal Knee Exam: Ligaments



Posterior DrawerPosterior Drawer



Normal Knee Exam: PCL ExamNormal Knee Exam: PCL Exam



Normal Knee Exam: Reverse Pivot Shift, ER RecurvatumNormal Knee Exam: Reverse Pivot Shift, ER Recurvatum



RadiographsRadiographs

• Standing 45º PA, bilateral• Patellar Views: Merchant or Sunrise Bilateral• Lateral 45º Flexion• Notch for Osteophytes

• Standardize Your Views for All Physicians• Use Goniometer• Know Your XRay Technicians

• Standing 45º PA, bilateral• Patellar Views: Merchant or Sunrise Bilateral• Lateral 45º Flexion• Notch for Osteophytes

• Standardize Your Views for All Physicians• Use Goniometer• Know Your XRay Technicians



Osteoarthritis grading systems:Osteoarthritis grading systems:

• Kellgren and Lawrence • Fairbanks• Joint space narrowing JSM –standing radiographs• Ahlback classification

• Numerous studies comparing different classifications—there is disagreement on the definition and grading of osteoarthritis, as well as poor correlation with patient symptoms and progression of osteoarthritis.

• Kellgren and Lawrence • Fairbanks• Joint space narrowing JSM –standing radiographs• Ahlback classification

• Numerous studies comparing different classifications—there is disagreement on the definition and grading of osteoarthritis, as well as poor correlation with patient symptoms and progression of osteoarthritis.



ReferencesReferences

Mazzuca SA, Brandt KD, Schauwecker DS, Buckwalter KA,Katz BP, Meyer JM, et al. Bone scintigraphy is not a better predictor of progression of knee osteoarthritis than Kellgren and Lawrence grade. J Rheumatol 2004;31:329-332.

Oiestad BE, Holm I, Engebretsen L, Risberg MA. The association between radiographic knee osteoarthritis and knee symptoms, function and quality of life 10-15 years after anterior cruciate ligament reconstruction. Br J Sports Med 2011;45:583-588.

Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg [Am] 1969;51-A:517-26.

Mazzuca SA, Brandt KD, Schauwecker DS, Buckwalter KA,Katz BP, Meyer JM, et al. Bone scintigraphy is not a better predictor of progression of knee osteoarthritis than Kellgren and Lawrence grade. J Rheumatol 2004;31:329-332.

Oiestad BE, Holm I, Engebretsen L, Risberg MA. The association between radiographic knee osteoarthritis and knee symptoms, function and quality of life 10-15 years after anterior cruciate ligament reconstruction. Br J Sports Med 2011;45:583-588.

Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg [Am] 1969;51-A:517-26.



45 Degree Flexed Weight-Bearing PA View is most sensitive for detecting joint space loss

45 Degree Flexed Weight-Bearing PA View is most sensitive for detecting joint space loss

Cole BJ, Harner CD, Degenerative arthritis of the knee in active patients: evaluation and treatment. JAAOS 1999, Nov.-Dec. 7(6):389-402.

Dervin GF, Feibel RJ, Rody K, Grabowski J., 3-Foot standing AP versus 45 degrees PA radiograph for osteoarthritis of the knee. Clin J Sports Med. 2001 Jan;11(1):10-6.



14 YO punter was crushed by defensive line14 YO punter was crushed by defensive line



16 YO WM Football AthleteStruck from Lateral Side of Knee16 YO WM Football AthleteStruck from Lateral Side of Knee



Angular Deformity from 20° Malunion from Proximal tibial growth arrestAngular Deformity from 20° Malunion from Proximal tibial growth arrest



MRI scan at time of initial injuryMRI scan at time of initial injury



JamesAaronMatthews.mpgJamesAaronMatthews.mpg



Anterior opening wedge osteotomyAnterior opening wedge osteotomy



Post op: ~ 1 week 22 weeks 28 weeksPost op: ~ 1 week 22 weeks 28 weeks



19 YO Female19 YO Female

• Collegiate basketball athlete• Landed awkwardly in a game• PE: ACL Tear, Left knee

• Collegiate basketball athlete• Landed awkwardly in a game• PE: ACL Tear, Left knee



Suspected osteochondral fracture LFC, possible anterior aspect LTP fractureSuspected osteochondral fracture LFC, possible anterior aspect LTP fracture



42 YO Male: ACL Tear 42 YO Male: ACL Tear

• Injured playing soccer• Beware articular surface injuries• Injured playing soccer• Beware articular surface injuries



Technetium Bone Scan LETechnetium Bone Scan LE

• Informative for MD + Patient• Informative for MD + Patient



Bone BruiseBone Bruise

Does That Predict Development of OA?Does That Predict Development of OA?



Bone Bruise PatternsBone Bruise Patterns

• Acute patellar dislocation

• Medial patella anterolateral femoral condyle

• No OA from bone bruise, but from articular cartilage injury and mal-tracking

• Acute patellar dislocation

• Medial patella anterolateral femoral condyle

• No OA from bone bruise, but from articular cartilage injury and mal-tracking



Bone Bruise PatternsBone Bruise Patterns

• In soccer, medial tibial plateau bone bruise no long term risk of OA

• In degenerative posterior horn root avulsions, medial tibial bone bruise often seen

? Long-term follow-up for bone bruises needed to determine significance for development of OA

• In soccer, medial tibial plateau bone bruise no long term risk of OA

• In degenerative posterior horn root avulsions, medial tibial bone bruise often seen

? Long-term follow-up for bone bruises needed to determine significance for development of OA



What is the significance of Bone Bruises?

Unknown. . .

What is the significance of Bone Bruises?

Unknown. . .

• Long term Bone Bruise ≠ OA• In ACL injuries noncontact compartments:

• Lateral / acute• Medial / chronic OA

• Classification systems for bone bruises need further development

• Long term Bone Bruise ≠ OA• In ACL injuries noncontact compartments:

• Lateral / acute• Medial / chronic OA

• Classification systems for bone bruises need further development



Late Results After MeniscectomyLate Results After Meniscectomy

Mayo clinic retrospective review• 1005 patients undergoing meniscectomy• 1936-1956• 113 examined, 100 questionnaires

• Males did better• Best results in bucket-handle resection leaving

peripheral rim• Do not leave posterior horn if torn

Mayo clinic retrospective review• 1005 patients undergoing meniscectomy• 1936-1956• 113 examined, 100 questionnaires

• Males did better• Best results in bucket-handle resection leaving

peripheral rim• Do not leave posterior horn if torn

Tapper EM, Hoover NW, “Late Results after Meniscectomy,” J Bone Joint Surg Am, 1969 Apr 01;51(3):517-603.



• Discussion by Dr. Don H. O’Donoghue, Oklahoma City, Oklahoma

• I would therefore not accept the conclusion that:• Delay in operation does not affect the ultimate result• Patients under twenty years of age have fewer satisfactory

results• Leaving the peripheral ring will give the best results in

bucket-handle fractures• Conclusions are not valid based on evidence presented


• I would therefore not accept the conclusion that:• Delay in operation does not affect the ultimate result• Patients under twenty years of age have fewer satisfactory

results• Leaving the peripheral ring will give the best results in

bucket-handle fractures• Conclusions are not valid based on evidence presented





• I think the authors are to be congratulated on their efforts to obtain a valid series. As I have indicated, it is extremely difficult to get an uncontaminated series. Probably a study should be initiated, not after operation but before operation, on patients whose surgery would qualify as relatively uncomplicated meniscectomy.


• I think the authors are to be congratulated on their efforts to obtain a valid series. As I have indicated, it is extremely difficult to get an uncontaminated series. Probably a study should be initiated, not after operation but before operation, on patients whose surgery would qualify as relatively uncomplicated meniscectomy.




History & PEHistory & PE

• 55 YO Female • Difficulty walking due to left knee out of

alignment • Fell 10 years ago and was told she had

meniscal tears• PE: Height 5’ 5½”, weight 303: BMI 43 • Bilateral Knees:

• Diffuse crepitus and pain• Mild effusion• No calf tenderness

• 55 YO Female • Difficulty walking due to left knee out of

alignment • Fell 10 years ago and was told she had

meniscal tears• PE: Height 5’ 5½”, weight 303: BMI 43 • Bilateral Knees:

• Diffuse crepitus and pain• Mild effusion• No calf tenderness



Left KneeLeft Knee



Right KneeRight Knee

What test would you do next?



MRIMRI

Are more tests needed?



MRI Scan in the Arthritic Knee After 50 yearsMRI Scan in the Arthritic Knee After 50 years

• Not Helpful for Articular Cartilage• Meniscal Signal Will Usually Be Abnormal

and come to the tibial surface.

• Not Helpful for Articular Cartilage• Meniscal Signal Will Usually Be Abnormal

and come to the tibial surface.



MRI Scan in the Arthritic Knee After 50 yearsMRI Scan in the Arthritic Knee After 50 years• Is the root of the Medial Meniscus Avulsed? • What about my Baker’s Cyst?• Think tree - MRI Scan

• In a Big Forest – Arthritis—The Plain Xrays show us the reason for stiffness & pain: Arthritis

• Is the root of the Medial Meniscus Avulsed? • What about my Baker’s Cyst?• Think tree - MRI Scan

• In a Big Forest – Arthritis—The Plain Xrays show us the reason for stiffness & pain: Arthritis



IMAGING THE ARTHRITIC KNEEIMAGING THE ARTHRITIC KNEE• Use goniometer to assure comparable

Xrays year to year and for outcome studies

• Let the Orthopaedist Order the MRI Scan in the Arthritic Knee Patient. • May want DESS or special articular cartilage

sequences. • In most cases MRI scans in patients over age

50 would not change treatment plan. • I don’t need an MRI scan to know what to do

arthroscopically! I was scoping knees prior to MRI scans!

• Use goniometer to assure comparable Xrays year to year and for outcome studies

• Let the Orthopaedist Order the MRI Scan in the Arthritic Knee Patient. • May want DESS or special articular cartilage

sequences. • In most cases MRI scans in patients over age

50 would not change treatment plan. • I don’t need an MRI scan to know what to do

arthroscopically! I was scoping knees prior to MRI scans!



ConclusionsConclusions

• Make the connection between:• Anatomy• Function• History and Physical Exam

• In relation to:• Functional disability• Specific diagnosis

• Make the connection between:• Anatomy• Function• History and Physical Exam

• In relation to:• Functional disability• Specific diagnosis



“The Knee as a Biologic Transmission with an Envelope of Function”

“The Knee as a Biologic Transmission with an Envelope of Function”

Scott Dye. The Knee as a Biologic Transmission with an Envelope of Function. Clin Orthop Rel Res 1996;325:(April): 10-18.Scott Dye. The Knee as a Biologic Transmission with an Envelope of Function. Clin Orthop Rel Res 1996;325:(April): 10-18.

Envelope of Knee FunctionEnvelope of Knee Function• Factors:

• Anatomy• Kinetics• Physiology• Treatment

• Factors:• Anatomy• Kinetics• Physiology• Treatment



The Knee as a Biologic Transmission with an Envelope of FunctionThe Knee as a Biologic Transmission with an Envelope of Function

A Knee Injury is like a car wreckA Knee Injury is like a car wreck



Goal of Treatment of Knee DisordersGoal of Treatment of Knee Disorders

• Broaden envelope of function• Resume activity safely• Inform patients of “lowered threshold” of

function

• Broaden envelope of function• Resume activity safely• Inform patients of “lowered threshold” of

function



Pyramid Approach to the Management of Osteoarthritis

Pyramid Approach to the Pyramid Approach to the Management of OsteoarthritisManagement of Osteoarthritis

Creamer P and Hochberg MC, “Osteoarthritis” (Seminar). Lancet 1997;350:503-509.Creamer P and Hochberg MC, Creamer P and Hochberg MC, ““OsteoarthritisOsteoarthritis”” (Seminar). (Seminar). LancetLancet 1997;350:5031997;350:503--509.509.



You May Not Have Seen It, But It Has Seen You

You May Not Have Seen It, But It Has Seen You



Right distal femur osteosarcomaRight distal femur osteosarcoma



S/P Excision Curettage CementationS/P Excision Curettage Cementation



You Look for What You Knowand You Find What You Look For

You Look for What You Knowand You Find What You Look For









ACSM TPC Part 2Miami, Florida

February 9, 2013

ACSM TPC Part 2Miami, Florida

February 9, 2013

The End . . . Thank You!The End . . . Thank You!

EXAMINATION AND IMAGING OF THE Mary Lloyd Ireland, M.D. KNEE AND LEG UK Healthcare - Orthopaedics ACSM TPC II & Sports Medicine Miami, Florida 601 Perimeter Drive #200 February 9, 2013 Lexington, KY 40517 (859) 218-3131 Fax: (859) 323-2255

_________________________________________________________________________

BIBLIOGRAPHY

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EXAMINATION & IMAGING OF THE KNEE 5 Eckstein F et al. Quantitative MR imaging of cartilage and trabecular bone in osteoarthritis. Radiol Clin North Am 2009;47(4):655-673. Eckstein F, Cicuttini F, Raynauld JP, Waterton JC, Peterfy C. Magnetic resonance imaging (MRI) of articular cartilage in knee osteoarthritis (OA):morphological assessment. Osteoarthritis Cartilage 2006;14:A46-75. Englund M, Guermazi A, Gale D, Hunter DJ, Aliabadi P, Clancy M, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med 2008;359(11):1108-1115. Filippucci E et al. Ultrasound imaging for the rheumatologist. XXV. Sonographic assessment of the knee in patients with gout and calcium pyrophosphage deposition disease. Clin Exp Rheumatol 28(1):2-5. Frobell RB, Roos HP, Roos EM, Hellio LGM, Buck R, Tamez-Pena J, et al. The acutely ACL injured knee assessed by MRI: are large volume traumatic bone marrow lesions a sign of severe compression injury? Osteoarthritis Cartilage 2008;16(7):829-836. Fukui N et al. Relationship between radiographic changes and symptoms or physical examination findings in subjects with symptomatic medial knee osteoarthritis: a three-year prospective study. BMC Musculoskelet Disord 2010;11:269. Fukuta S et al. Clinical significance of meniscal abnormalities on magnetic resonance imaging in an older population. Knee 2009;16(3):187-190. Gil HC, Levine SM, Zoga AC. MRI findings in the subchondral bone marrow: a discussion of conditions including transient osteoporosis, transient bone marrow edema syndrome, SONK, and shifting bone marrow edema of the knee. Semin Musculoskelet Radiol 2006;10(3):177-186. Grelsamer RP, Weinstein CH, Gould J, Dubey A. Patellar tilt: the physical examination correlates with MR imaging. Knee 2008;15(1):3-8. Hayashi D et al. Osteoarthritis year 2010 in review: imaging. Osteoarthritis Cartilag 2011;19(4):354-360. Hayes CW, Conway WF. Normal anatomy and magnetic resonance appearance of the knee. Top Magn Reson Imaging 1993;5(4):207-227. House CV et al. Posteromedial corner injuries of the knee. Clin Radiol 2007;62(6):539-546.

EXAMINATION & IMAGING OF THE KNEE 6 Hunter DJ. Insights from imaging on the epidemiology and Pathophysiology of osteoarthritis. Radiol Clin North Am 2009;47(4):539-551. Hunter DJ, Wilson DR. Role of alignment and biomechanics in osteoarthritis and implications for imaging. Radiol Clin North Am 2009;47(4):553-566. Iagnocco A et al. Ultrasound imaging for the rheumatologist. XXIX. Sonographic assessment of the knee in patients with osteoarthritis. Clin Exp Rheumatol 2010;28(5):643-646. Janow GL et al. Detection of active disease in juvenile idiopathic arthritis: sensitivity and specificity of the physical examination vs ultrasound. J Rheumatol 2011;38(12):2671-2674. Jurgensen I, Bachmann G, Schleicher I, Haas H. Arthroscopic versus conservative treatment of osteochondritis dissecans of the knee: Value of magnetic resonance imaging in therapy planning and follow-up. Arthroscopy 2002;18(4):378-86. Kim MG, Kim BH, Choi JA, Lee NJ, Chung KB, et al. Intra-articular ganglion cysts of the knee: clinical and MR imaging features. Eur Radiol 11:834. Kocabey Y, Tetik O, Isbell WM, Atay OA, Johnson DL. The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy 2004;20(7):696-700. Malone WJ, Koulouris G. MRI of the posterolateral corner of the knee: normal appearance and patterns of injury. Semin Musculoskelet Radiol 2006;10(3):220-228. Mazzuca SA, Brandt KD, Schauwecker DS, Buckwalter KA,Katz BP, Meyer JM, et al. Bone scintigraphy is not a better predictor of progression of knee osteoarthritis than Kellgren and Lawrence grade. J Rheumatol 2004;31:329-332. Meenagh G et al. Ultrasound imaging for the rheumatologist XXX. Sonographic assessment of the painful knee. Clin Exp Rheumatol 2010;28(6):803-805. Merchant AC. Radiography of the patellofemoral joint. Oper Tech Sports Med 1999;7(2):59-64. Pandit S et al. Magnetic resonance imaging assessment of tibial tuberosity-trochlear groove distance: normal values for males and females. Int Orthop 2011;35(12):1799-1803.

EXAMINATION & IMAGING OF THE KNEE 7 Park GY et al. The value of ultrasonography in the detection of meniscal tears diagnosed by magnetic resonance imaging. Am J Phys Med Rehabil 2008;87(1):14-20. Peterfy CG, Gold G, Eckstein F, Cicuttini F, Dardzinski B, Stevens R. MRI protocols for whole-organ assessment of the knee in osteoarthritis. Osteoarthritis Cartilage 2006;14(Suppl A):95-111. Phillips CL et al. The measurement of patellar height: a review of the methods of imaging. J Bone J Surg Br 2010;92(8):1045-1053. Potter HG, Weinstein M, Allen AA, Wickiewicz TL, Helfet DL. Magnetic resonance imaging of the multiple-ligament injured knee. J Orthop Trauma 2002;16:330. Rauschning W. Popliteal cysts and their relation to the gastrocnemio-semimembranosus bursa. Studies on the surgical and functional anatomy. Acta Orthop Scand Suppl 1979;179:1-43. Recondo JA et al. Lateral stabilizing structures of the knee: functional anatomy and injuries assessed with MR imaging. Radiographics 2000;20 Spec No:S91-S102. Samoto N, Kozuma M, Tokuhisa T, Kobayashi K. Diagnosis of discoid lateral meniscus of the knee on MR imaging. Magn Reson Imaging. 2002;20(1):59-64. Schafer H. The synovial cavity of the knee joint and its major communicating bursae. Rofo 1989;150(1):32-38. Schneider E et al. Magnetic resonance imaging evaluation of weight-bearing subchondral trabecular bone in the knee. Skeletal Radiol 2011;40(1):95-103. Shagam JY. Medical imaging and osteoarthritis of the knee. Radiol Technol 2011;83(1):37-56. Sherman PM, Penrod BJ, Lane MJ,Ward JA. Comparison of knee magnetic resonance imaging findings in patients referred by orthopaedic surgeons versus nonorthopaedic practitioners. Arthroscopy 2002;18(2):201-5. Sonin AH et al. MR imaging appearance of the extensor mechanism of the knee: functional anatomy and njury patterns. Radiographics 1995;15(2):367-382. Toms AP et al. Imaging the femoral sulcus with ultrasound, CT and MRI: reliability and generalizability in patients with patellar instability. Skeletal Radiol 2009;38(4):329-338.

EXAMINATION & IMAGING OF THE KNEE 8 Trieshmann HWJ, Mosure JC. The impact of magnetic resonance imaging of the knee on surgical decision making. Arthroscopy 1996;12(5):550-5. Wenham CY, Conaghan PG. Imaging the painful osteoarthritis knee joint: what have we learned? Nat Clin Pract Rheumatol 2009;5(3):149-158.

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