​Kembara Xtra - Medicine - Knee Pain

​Kembara Xtra - Medicine - Knee Pain 
a typical outpatient issue with a wide disparity
Trauma, overuse, and degenerative change are common reasons of knee pain, which can also be acute or chronic or an acute exacerbation of a chronic problem.
 A thorough and focused examination of the knee (as well as the back, hips, and ankles) helps to establish the correct diagnosis and appropriate treatment. A detailed history, including patient's age, pain onset and location, mechanism of injury, and associated symptoms, can help narrow the differential diagnosis.


 Incidence
Every year, 12.5 million primary care visits are related to knee issues.
Knee osteoarthritis (OA) has a prevalence of 240 cases per 100,000 person-years.
Prevalence
The most frequent causes of knee discomfort in runners are patellar tendinopathy and patellofemoral syndrome. OA of the hip/knee is the 11th leading cause of global disability and the 38th leading cause of disability-adjusted life years (DALYs).


Pathophysiology and Etiology 
Tendinopathy, patellofemoral syndrome, bursitis, and apophysitis are examples of overuse injuries. Trauma (ligament or meniscal damage, fracture, dislocation) is another.  Age (apophysitis in younger people; arthritis and degenerative diseases in elderly ones) Rheumatologic (systemic lupus erythematosus [SLE] and rheumatoid arthritis [RA]) Infectious (bacterial, postviral, Lyme disease), crystal arthropathies (gout, pseudogout), and infectious diseases Referred pain in the hip or back
Others (tumor, cyst, plica), vascular (popliteal artery aneurysm, deep vein thrombosis)

Risk factors include: muscular imbalance, weakness, or poor flexibility; rapid increases in training frequency and intensity; improper footwear, training surfaces, or technique; and activities that require cutting, jumping, pivoting, decelerating, or kneeling. Previous injuries are another risk factor.

Prevention 
Keep a healthy body mass index.
 Use the right equipment, volume, and workout technique; refrain from overtraining.
 Treat imbalances in postural strength and flexibility.

Tendinopathy, bursitis, fracture, contusion, effusion, hemarthrosis, patellar dislocation/subluxation, meniscal or ligamentous injury, osteochondral injury, OA, septic arthritis, and muscle strain are associated conditions.

Diagnosis: Diagnostic reasoning is guided by the location, kind, and mechanism of the pain: - Pain that is widespread: OA, patellofemoral pain syndrome, and chondromalacia
- Patellofemoral pain syndrome, meniscal damage, and pain going up/down stairs - Patellofemoral pain syndrome: pain while standing up after sitting for a long time. - Meniscal damage and mechanical symptoms (locking)
 Injury mechanism:
- Injury to the anterior cruciate ligament (ACL) caused by hyperextension, braking, and cutting - Hyperflexion, falling on a flexed knee, and "dashboard injury": damage to the PCL. - Medial collateral damage from lateral force (valgus load)
- Twisting on a foot that is planted: meniscal damage
The effusion
- ACL injury, patellar subluxation/dislocation, significant meniscal tear, and tibial plateau fracture with rapid onset (2 hours). Hemarthrosis occurs frequently.
- Smaller, slower-acting (onset in 24 to 36 hours): arthritis, sprained ligaments, meniscal damage - Popliteal (Baker) cyst: swelling behind the knee

Clinical evaluation 
Pay attention to your gait (antalgia); track your patella.  Check for erythema, atrophy, edema, ecchymosis, or misalignment.
Look for effusion, warmth, and tenderness by palpating.
Assess the quadriceps' and hamstrings' flexibility as well as their active and passive range of motion (ROM).
 Determine your muscular strength and tone.
Note the locking, catching, and instability of the joints.
Assess hip range of motion, strength, and stability.
 Additional tests:
- Patellar grind test: patellofemoral pain or OA; patellar apprehension test: patellar instability (1) - Lever sign, anterior drawer, pivot shift, and Lachman test (more sensitive and specific): ACL integrity - PCL integrity: posterior drawer, posterior sag sign
- Medial/lateral collateral ligament (MCL/LCL) integrity during valgus/varus stress test - Meniscal injury: McMurray test, Apley grind test, and Thessaly test
- The Ober test for iliotibial band (ITB) tightness
- Dial test results show posterolateral corner laxity, which is positive.
Squatting and the patellar tilt test may be used to diagnose patellofemoral pain syndrome.
- Patellofemoral pain syndrome or OA are both suggested by patella facet soreness.


Differential diagnosis includes the following: Acute onset: fracture, contusion, cruciate or collateral ligament tear, meniscal tear, patellar dislocation/subluxation; if systemic symptoms are present: septic arthritis, gout, pseudogout, Lyme disease, osteomyelitis; Insidious onset: patellofemoral pain syndrome/chondromalacia, ITB syndrome, OA, RA, bursitis, tumor, tendinopathy,  Medial pain: MCL injury, medial meniscal injury, pes anserine bursitis, medial plica syndrome, OA Lateral pain: LCL injury, lateral meniscal injury, ITB syndrome, OA Posterior pain: PCL injury, posterior horn meniscal injury, popliteal cyst or aneurysm, hamstring or gastrocnemius injury, deep venous thrombosis (DV 

Laboratory Results 

Initial examinations (lab, imaging)
Suspected pseudogout, gout, and septic joint: - Arthrocentesis with synovial fluid analysis, protein/glucose analysis, Gram stain, culture, and cell count Erythrocyte sedimentation rate (ESR), rheumatoid factor, and CBC for suspected RA
Think about the Lyme titer.
● In patients with recent knee injuries, radiographs are used to rule out fractures (Ottawa Rules). - Over-55 years old; - Tenderness around the patella or fibular head; - Unable to walk four steps without assistance; - Unable to bend knee 90 degrees
 Radiographs aid in the diagnosis of patellofemoral pain syndrome, osteochondral lesions, and OA: - Weight-bearing, lateral, merchant/sunrise, upright anteroposterior, and views in the tunnel Tests in the Future & Special Considerations
The "gold standard" for soft tissue imaging is MRI, whereas ultrasound may be able to identify tendinopathy and CT might aid to clarify fractures.
Other Diagnostic Techniques Arthroscopy may be helpful in the diagnosis of some disorders, such as meniscus and ligament damage.
Aspects of Geriatrics
Gout, OA, and degenerative meniscal tears are more prevalent in middle-aged and elderly people.
Child Safety Considerations
Every year, 3 million children suffer sports-related injuries.
 In skeletally immature individuals, look for physeal/apophyseal and joint surface injuries: - Acute: ACL tear, patellar subluxation, and avulsion fractures
Overuse injuries include stress fractures, patellar tendonitis, osteochondritis dissecans, apophysitis, and patellofemoral pain syndrome. Other injuries include neoplasms, juvenile RA, infections, and referred pain from a slid capital femoral epiphysis.

Treatment for acute injuries: PRICEMM treatment (modalities, medicines, ice, compression, and elevation)

First Line of Medicine
Drugs used orally:
Acetaminophen: safe and effective in treating OA up to 3 g/day Nonsteroidal anti-inflammatory medications (NSAIDs):
200 to 800 mg TID of ibuprofen
Naproxen: BID doses of 250–500 mg
 Beneficial for sudden sprains and strains
Useful for OA pain relief in the short term. Given the potential negative effects, prolonged use is not advised.
 Not advised for fractures, stress fractures, or chronic muscular injuries; may cause a delay in healing; use a low dose and short duration of treatment only if necessary - Tramadol and other opioids aren't advised as first-line treatments, but they can be used for severe pain from recent wounds.
- Celecoxib: 200 mg QD may treat OA more effectively than NSAIDs while having less GI side effects.

Topical NSAIDs may be more bearable than oral pain relievers in the treatment of OA pain.
– Topical capsaicin might function as an adjuvant for treating OA pain.

Injections: In knee OA stage 2 or 3, an intra-articular corticosteroid injection may be beneficial in the short term.
- Viscosupplementation may help OA patients feel less pain and function better. 5 to 13 weeks is when it is most effective.
- Comparing platelet-rich plasma (PRP) and viscosupplementation: equivocal evidence - Injections used in prolotherapy may offer some long-term comfort.
- Stem cell treatment without enough evidence

Salter-Harris physeal fractures (pediatrics) Acute trauma, young athletic patient Joint instability Lack of progress with conservative therapy

Further Treatments 

Physical therapy is advised as the first line of defense against tendinopathies and patellofemoral discomfort.
Strengthening your muscles can help with OA.
 Acupuncture, taping, and foot orthoses
 Bracing may be required for stability.

Surgery For some conditions, such as an ACL tear in a competitive athlete or grade IV OA, surgery may be necessary.
 Surgical intervention may be necessary for chronic diseases that are resistant to conservative therapy.

Additional Drugs 

may lessen discomfort and enhance function in early OA:
Turmeric or curcumin 1,000 mg/day; Collagen hydrolysates 10 g/day; Glucosamine sulfate (500 mg TID); Chondroitin (400 mg TID); Chondroitin chondroitin sulfate (400 mg TID); S-adenosyl-l-methionine (SAMe); Ginger extract; Methylsulfonylmethane: less reliable improvement with inconsistent supporting evidence;

Activity modification in overuse situations: follow-up Exercise for recovery in OA
- Low-impact exercises including cycling, walking, and swimming
- Patient monitoring, proprioception training, and strength exercises
 Following initial acute injury treatment, rehabilitation At a follow-up appointment, evaluate functional status, adherence to therapy, and pain management in cases with chronic and overuse problems.
DIET A 10% weight loss increased function by 28%.

Modification of Lifestyle 

Review activity modifications, promote participation in the recovery process, and go over the advantages and disadvantages of taking medications.

The prognosis depends on the diagnosis, the seriousness of the damage, the duration of the illness, the patient's willingness to engage in rehabilitation, and whether surgery is necessary.

Complications, disability, chronic joint instability, arthritis, and deconditioning