complicated knee injury/pain

[indytravl]

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hi,

does anyone have thoughts about improving pain & function for young pt.
mid 20's male who was found to have a medial meniscus tear & chondral fracture of lateral tibial plateau & chondromalacia patella. underwent arthroscopy wtih partial medial meniscectomy & chondroplasty of the tib plateua # & patella ~1-2y ago.

he continues to have antalgic gait & pain. fairly chronic knee pain "right under the kneecap" with "pretty much any activity", stairs, walking, even sitting for extended perioid in car. does say there's locking & catching but no giving out/falls. +itnermittent effusion but no instability.

seen by different orthopod a few months ago for continued knee pain & was recommended icing. 10/07 for knee pain & recommended icing.

thought maybe a SC +/- medial offloader knee brace....

appreciate any help; thank you

 

[buddy 2004]

How about Kinesio Tape?

http://kinesiotaping.com/legs.php

 

[PMR 4 MSK]

Quad strengthening, hamstring stretching and more quad strengthening. It's hard to get these youngsters to truely work on it on a daily basis, what with all the beer that needs drinking and women that need chasing...

Seriously though, the quads and hams are the ticket almost every time.

 

[MN1]

Quad strengthening, hamstring stretching and more quad strengthening. It's hard to get these youngsters to truely work on it on a daily basis, what with all the beer that needs drinking and women that need chasing...

Seriously though, the quads and hams are the ticket almost every time.

Although the quads are important, I think they are overrated, especially when it comes to knee pain. Strength the hips, hips, hips.....especially abductors and external rotators. Its amazing how relatively weak many "trained athletes" are with these muscles. Watch their pelvis and lower extremity on a single leg squat. The days of "quad strengthening, VMO strengthening, hamstring stretching" is outdated.....see recent patellofemoral literature.

 

[dc2md]

"locking and catching with effusion"? sounds like he needs another scope. just b/c the meniscus is repaired doesn't mean he didn't re-injure it...esp. if we're assuming he has poor hip and knee muscle strength and coordination (dysfunctional LE kinetic chain).
so how bout MRI --> scope (if needed from MRI) --> quad/ham/"hip"/core training, with pain meds and bracing if needed for pain control in the mean time. and an apple a day wouldn't hurt either.

 

[indytravl]

dc2md,
ok, strengthen proximally with hip & optimize nutiriton...what type of brace are you thinking?
thanks

 

[dc2md]

indytravl,
i don't think we need to get too technical here. i appears this guy has an antagic gait either b/c it hurts with every weightbearing step on the bad leg, or b/c he THINKS it's gonna hurt when he bears weight. i think we underestimate (and underutilize) the positive psychological effects we can give to patients. a simple hinged knee brace would likely limit vagus and varus motion and possibly some anterior and posterior translations at the knee...but more importantly, it'll make him FEEL like it's protecting him and this may in turn lessen his apprehension during gait. so my idea for the brace is more of a psychological (or placebo) effect.
and one important thing i didn't mention yet is the importance of stretching the tight muscles. test him. are his hamstrings actually too tight? are his hip flexors too tight?
and if all else fails, pixie dust works (except the damn FDA hasn't approved it yet).

 

[drusso]

I agree with MN1 ( 😉 reluctantly), but here's a thought: Has anyone taken the time to actually diagnose what is *causing* the pain? Yes, he has altered anatomy and pathomechanics, but what about his overall clinical picture is generating the pain versus reflecting the pain?

Put some 0.75% bupi in his knee right before a PT session and then put him through his paces to get sense of what components of his pain/weakness are biomechanical, compensatory, or inhibitory in nature.

 

[MN1]

I agree with MN1 ( 😉 reluctantly), but here's a thought: Has anyone taken the time to actually diagnose what is *causing* the pain? Yes, he has altered anatomy and pathomechanics, but what about his overall clinical picture is generating the pain versus reflecting the pain?

Put some 0.75% bupi in his knee right before a PT session and then put him through his paces to get sense of what components of his pain/weakness are biomechanical, compensatory, or inhibitory in nature.

drusso, about time you come to your senses and agree with me.........

Not sure about putting bupiv in his knee......"I couldn't feel anything during PT, now my meniscal tear is worse after I trashed it during my exercises"

 

[drusso]

drusso, about time you come to your senses and agree with me.........

Not sure about putting bupiv in his knee......"I couldn't feel anything during PT, now my meniscal tear is worse after I trashed it during my exercises"

Meniscal pain "right under the knee cap?" That's not where my mensicus hurts...

 

[MN1]

Meniscal pain "right under the knee cap?" That's not where my mensicus hurts...

As mentioned above, "locking and catching.....with effusion"......I'd try to clarify the diagnosis.......anterior meniscal pain can certainly present this way.

drusso- if you're the one injecting the bupiv into the knee, it will probably just end up in the fat pad anyways. 🙂

 

[SSdoc33]

most meniscal injuries involve the posterior horn, not antherior.

chrondromalacia in a 20 y/o? try to get an idea how real this is (pictures from the arthroscopy might help).

 

[drusso]

As mentioned above, "locking and catching.....with effusion"......I'd try to clarify the diagnosis.......anterior meniscal pain can certainly present this way.

drusso- if you're the one injecting the bupiv into the knee, it will probably just end up in the fat pad anyways. 🙂

Unlikely, as I do all my peripheral joints under fluoro. 😛

 

[drusso]

most meniscal injuries involve the posterior horn, not antherior.

chrondromalacia in a 20 y/o? try to get an idea how real this is (pictures from the arthroscopy might help).

Agreed.

The problem is that this guy has more than one problem. Apportioning his pain is the first step to rationale treatment/rehabilitation.

 

[MN1]

most meniscal injuries involve the posterior horn, not antherior.

chrondromalacia in a 20 y/o? try to get an idea how real this is (pictures from the arthroscopy might help).

Very true, but someone with an otherwise "trashed" knee can certainly get an anterior tear. My point was, this guy had surgery 1-2 years ago, yet continues to have mechanical sx and effusion. I'd say a new MRI is step #1.

 

[MN1]

Unlikely, as I do all my peripheral joints under fluoro. 😛

I thought you just rubbed some of your hair gel on their joint to cure them???

 

[drusso]

I thought you just rubbed some of your hair gel on their joint to cure them???

What are you talking about? I put it *inside* the joint...

 

[caedmon]

It does sound like there is not really one clear cut answer. I agree that with mechanical symptoms and recurrent swelling sound like a meniscus. Some of the other symptoms sound like an inflamed plica which can have pain with stairs, prolonged sitting etc. and will be anterior. Can become inflamed secondary to other joint pathology such as a meniscal tear and can have some mechanical-ish symptoms. I doubt with the extent of the previous procedure they would have missed it, but you never know.

 

[MN1]

What are you talking about? I put it *inside* the joint...

Makes sense.....works just like Synvisc....as a joint lubricant 🙂

 

[Disciple]

What are PE findings?

 

[caedmon]

I haven't seen many of these, mostly read about them. It seems like they're concomitant with other injuries, specifically twisting type injuries and sometimes medial meniscal tears and often discovered during arthroscopy. The paper below theorizes that they are asymptomatic initially and become inflamed, torn, or fibrosed after injury.

This paper gives 3 cases where exam showed positive McMurray's and +/- other physical exam findings.

S . Kerimoğlu , A . Çıtlak , S . Çavuşoğlu , A . Turhan. Bucket-handle tear of medial plica.
Knee. 2005 Jun;12(3):239-41.

The following is an exam technique from this article:

Kim SJ, Lee DH, Kim TE. The relationship between the MPP test and arthroscopically found medial patellar plica pathology.
Arthroscopy. 2007 Dec;23(12):1303-8.

"The MPP test is conducted while the patient is placed in the supine position. While applying manual force to the inferomedial patellofemoral joint with the examiner’s thumb, the examiner identifies the presence of tenderness. If this tenderness is markedly diminished at 90° of flexion with maintaining manual force, the MPP test is considered to be “positive.” The rationale of the MPP test can be proved by arthroscopic examination through the superolateral portal. The MPP is located on the medial femoral condyle during knee extension. When manual force is applied to the inferomedial patellofemoral joint, the pathologic MPP is inserted and squeezed between the patellar and medial femoral condyle. The entrapped MPP slips away from the medial condyle at 90° of flexion even with maintaining manual compression. The MPP test was performed by the senior author prospectively at preoperative, intra-operative, and follow-up period."