knee pain physiatric approach
DESCRIPTION
Knee pain management without surgery.TRANSCRIPT
PHYSIATRIC APPROACH TO KNEE PAIN
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.
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
Physical ExaminationInspection & Comparison of the knee
Palpation for point tenderness
Assessment of joint effusion
Range-of-motion testing
Evaluation of ligament and Meniscal integrity
Investigations
CBC ESRCRPRA FactorUric Acid
X-Ray - Standing AP view & Lateral
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
Tendinopathies
Palpate these points!
Palpate these points!
Palpate these points!
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
OA KNEES-Grading -0
OA grade I
Grade II
Grade- III
Grade IV
Physiatric Management of Knee Pain
• Physical Modalities• Orthotic• Viscous supplementation• Effusion – Ozone therapy• Proliferative injection therapy - Prolotherapy• Intra-Articular steroids• Pharmacotherapy• Weight reduction & Exercises
Physical Modalities
• TENS• IFT• US• SWD
Advanced Electrotherapy
Advantages
Different modes in one program
Long lasting
Sympathetic block
Dental to Cancer pains
Modality-Pulsed Magnetic Field
• High Energy Pulsed Magnetic Field- 400 to 700Gauss
• 20 to 30 mts.
• 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.
Modality – LASER Therapy
• Mechanisms of action
• Photons – Energy –Repair• Fibroblast proliferation• Vasodilatation- Lymphatic drain• Blocking neuronal transmission• Endorphin secretion• Angiogenesis
PHOTOMECHANICAL EFFECT
Pressure waves stimulate the lymph draining system leading to dissolution of inflammatory mediators
PHOTOCHEMICAL EFFECT
Chemical homeostasis is restored.Leaking of inflammatory mediatorsis prevented leading to analgesia and repair of damaged tissues
PHOTOTHERMAL EFFECT
Laser delivers photons providing energy for repair and promotes angiogenesis
Combination of different wavelengths
Laser Apparatus
LASER Application
•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
Thermogram before and after 8 sessions of LASER Therapy
Acupuncture
Orthotic management –Knee PainKNEE TRCTION
Knee Supports-Patella Stabilizing
Knee supports-Varus- valgus Preventing
Knee Supports Varus-Valgus correcting
Valgus deformity -Left
Foot-wear Modifications-Lateral or Medial wedges
Viscous supplementationHyaluronate sodium
Management of EffusionOZONE THERAPY
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
Kumar Centres 41
Ozone Generator
Collecting Ozone directly into the syringe
Kumar Centres 43
Mixing Ozone with 2% Xylocaine
Kumar Centres 44
Injecting Ozone
Proliferative Inj. TherapyPROLOTHERAPY
• 25% Dextrose
• Fibroblast proliferation – Strengthening of ligaments – increases stability of Knee joint in OA.
• Regenerate damaged meniscii.• Repair ligament injuries
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
Hyper mobility & OA Knees
Kumar Centres 47
Prolotherapy sites Knee
Prolotherapy sites Knee
Prolotherapy sites Knee
Knee prolo video
• http://youtu.be/nYeMAIv8bbY
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
Intra-Articular Steroids
• Depo-Medrol / Triamcinolone
• Indications- RA & Waiting for TKR
• Side effects – Cartilage damage
• Stigmatized
Chondroprotective agents• Glucosamine• Chondroitin• Diacerine• S-Adenosyl Methionine• Type II Collagen Peptide• Vit. D
• NSAIDS, Tramadol & Paracetamol
Management of Obesity
• Most useful single intervention
• Diet
• Sleeve Gastrectomy
Exercises
Non-weight bearing exercises
Cycling
Height Adjustment
Seat width
When to refer for Surgery!
• Major Meniscal Injury
• Complete ACL tear
• Stage III and IV OA knees
• Recurrent Patellar Dislocation
Kumar Centres 60