Download - Knee pain physiatric approach
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PHYSIATRIC APPROACH TO KNEE PAIN
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Why Knee is important?The Knee is the largest human joint in terms of its volume and surface area of articulating cartilage. The Knee joint has the greatest susceptibility to injury, age-related wear and tear, inflammatory arthritis, and septic arthritisKnee pain accounts for approximately one third of musculoskeletal problems seen in primary care settings. 54 percent of athletes have some degree of Knee pain each year.
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History
Mechanical symptoms Locking- Meniscal injury, Popping – Ligament injury, Giving way- DislocationJoint effusion
Timing:- Rapid – ACL / Bone #/ Gout , Slow- Meniscal /RA /OA Recurrence:- Meniscal injuryAmount:-Mechanism of injury:-
Characteristics of the patient's pain
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Physical ExaminationInspection & Comparison of the knee
Palpation for point tenderness
Assessment of joint effusion
Range-of-motion testing
Evaluation of ligament and Meniscal integrity
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Investigations
CBC ESRCRPRA FactorUric Acid
X-Ray - Standing AP view & Lateral
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Causes of Knee Pain
• Tendinopathies• Bursitis • Chondromalacia• Meniscal Injuries• Cruciate Ligament Injuries• Medial & Lateral Collateral
Ligament Injuries• Osgood-Schlatter Disease• Iliotibial Band Syndrome• Osteochondritis Dissecans• Arthritis OA / RA
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Tendinopathies
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Palpate these points!
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Palpate these points!
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Palpate these points!
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Tendinopathies
• Painful conditions in and around tendons in response to overuse
• Histo-pathology – Degeneration & disorganization of collagen fibres with no inflammation
• Matrix Metalloproteinases, tendon cell apoptosis, IGF 1, NOS
• Not much benefitted from NSAIDS
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OA KNEES-Grading -0
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OA grade I
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Grade II
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Grade- III
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Grade IV
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Physiatric Management of Knee Pain
• Physical Modalities• Orthotic• Viscous supplementation• Effusion – Ozone therapy• Proliferative injection therapy - Prolotherapy• Intra-Articular steroids• Pharmacotherapy• Weight reduction & Exercises
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Physical Modalities
• TENS• IFT• US• SWD
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Advanced Electrotherapy
Advantages
Different modes in one program
Long lasting
Sympathetic block
Dental to Cancer pains
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Modality-Pulsed Magnetic Field
• High Energy Pulsed Magnetic Field- 400 to 700Gauss
• 20 to 30 mts.
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• Chen CY, Chen CL, Hsu SC, et al. Effect of magnetic knee wrap on quadriceps strength in patients with symptomatic knee osteoarthritis. Arch Phys Med Rehabil. 2008;89:2258-2264
• Harlow T, Greaves C, White A, et al. Randomised controlled trial of magnetic bracelets for relieving pain in osteoarthritis of the hip and knee. BMJ. 2004;329:1450-1454.
• Nicolakis P, Kollmitzer J, Crevenna R, et al. Pulsed magnetic field therapy for osteoarthritis of the knee—a double-blind sham-controlled trial. Wien Klin Wochenschr. 2002;114:678-684.
• Segal NA, Toda Y, Huston J, et al. Two configurations of static magnetic fields for treating rheumatoid arthritis of the knee: double-blind clinical trial. Arch Phys Med Rehabil. 2001;82:1453-1460.
• Trock DH, Bollet AJ, Markoll R. The effect of pulsed electromagnetic fields in the treatment of osteoarthritis of the knee and cervical spine. Report of randomized, double blind, placebo controlled trials. J Rheumatol. 1994;21:1903-1911.
• Trock DH, Bollet AJ, Dyer RH Jr, et al. A double-blind trial of the clinical effects of pulsed electromagnetic fields in osteoarthritis. J Rheumatol. 1993;20:456-460.
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Modality – LASER Therapy
• Mechanisms of action
• Photons – Energy –Repair• Fibroblast proliferation• Vasodilatation- Lymphatic drain• Blocking neuronal transmission• Endorphin secretion• Angiogenesis
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PHOTOMECHANICAL EFFECT
Pressure waves stimulate the lymph draining system leading to dissolution of inflammatory mediators
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PHOTOCHEMICAL EFFECT
Chemical homeostasis is restored.Leaking of inflammatory mediatorsis prevented leading to analgesia and repair of damaged tissues
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PHOTOTHERMAL EFFECT
Laser delivers photons providing energy for repair and promotes angiogenesis
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Combination of different wavelengths
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Laser Apparatus
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LASER Application
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•Efficacy of different therapy regimes of low-power laser in painful osteoarthritis of the knee: a double-blind and randomized-controlled trial.[Lasers Surg Med. 2003]• Laser acupuncture in knee osteoarthritis: a double-blind, randomized controlled study.[Photomed Laser Surg. 2007]•Low power laser treatment in patients with knee osteoarthritis.[Swiss Med Wkly. 2004]•Influence of various laser therapy methods on knee joint pain and function in patients with knee osteoarthritis.[Orthopedic & Traumatol Rehabil. 2012]•Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials.[Lancet. 2009meta-analysis of randomised placebo or active-treatment controlled trials.
Efficacy of LASER Therapy
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Thermogram before and after 8 sessions of LASER Therapy
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Acupuncture
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Orthotic management –Knee PainKNEE TRCTION
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Knee Supports-Patella Stabilizing
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Knee supports-Varus- valgus Preventing
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Knee Supports Varus-Valgus correcting
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Valgus deformity -Left
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Foot-wear Modifications-Lateral or Medial wedges
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Viscous supplementationHyaluronate sodium
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Management of EffusionOZONE THERAPY
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Kumar Centres 40
OZONE THERAPY
Intra Articular Knee injectionsResistant Effusion, Repeated aspirationsMono-articularRheumatoid Arthritis & OA with effusionBaker’s cyst
30 micr/ml 4cc + 2ml 2% Xylocaine
Repeated 3 to 4 weeks X 5
Ozone- Anti-Bacterial, Anti-Fungal & Virucidal
Proteins in the effusion breaks down – Dehydration
Blocks Phosphodiasterase –A2 – Analgesic & Anti- Inflammatory
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Kumar Centres 41
Ozone Generator
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Collecting Ozone directly into the syringe
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Kumar Centres 43
Mixing Ozone with 2% Xylocaine
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Kumar Centres 44
Injecting Ozone
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Proliferative Inj. TherapyPROLOTHERAPY
• 25% Dextrose
• Fibroblast proliferation – Strengthening of ligaments – increases stability of Knee joint in OA.
• Regenerate damaged meniscii.• Repair ligament injuries
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Kumar Centres 46
Prolotherapy-Knee
• Medial & Lateral Collateral Ligament Injuries.• Meniscal tears• ACL-Partial tear• Osteo-Arthritis• Bursitis• Tendonitis• Jumper’s Knee• Osgood Sh. Disease
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Hyper mobility & OA Knees
Kumar Centres 47
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Prolotherapy sites Knee
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Prolotherapy sites Knee
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Prolotherapy sites Knee
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Knee prolo video
• http://youtu.be/nYeMAIv8bbY
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Steroids VS Prolotherapy
STEROIDS• Anti-Inflammatory• Suppresses natural repair• Expensive & Painful inj.• Only small areas can be
treated• Can change Diabetic status• Degenerate tendon –
Rupture• Cartilage destruction-
Worsening of OA
PROLOTHERAPY• Controlled Inflammation• Enhances natural repair• Cheap, acceptable &
unique• Large areas and more
volume• No change in Glycaemic
status• Safe to give in tendon
insertions and joints
Kumar Centres 52
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Intra-Articular Steroids
• Depo-Medrol / Triamcinolone
• Indications- RA & Waiting for TKR
• Side effects – Cartilage damage
• Stigmatized
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Chondroprotective agents• Glucosamine• Chondroitin• Diacerine• S-Adenosyl Methionine• Type II Collagen Peptide• Vit. D
• NSAIDS, Tramadol & Paracetamol
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Management of Obesity
• Most useful single intervention
• Diet
• Sleeve Gastrectomy
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Exercises
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Non-weight bearing exercises
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Cycling
Height Adjustment
Seat width
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When to refer for Surgery!
• Major Meniscal Injury
• Complete ACL tear
• Stage III and IV OA knees
• Recurrent Patellar Dislocation
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Kumar Centres 60