msk services pathway - knee pathology · msk services pathway - knee pathology • septic arthritis...

MSK SERVICES PATHWAY - KNEE PATHOLOGY

• Septic arthritis• Dislocations • Tumours • Infections/Traumatic Swollen Joint

• Acute locked knee• Extensor mechanism disruption• Fractures / Other• Neurological lesion

GPs to follow guidance offered within this pathway and where relevant refer using Ardens templates and within remit of CCG Restricted and Not Routinely funded policy.

RED FLAG

ASSESSMENT & DIAGNOSIS OF OTHER CONDITIONS

Diagnosis to monitor

History &Symptoms

Injury

Medical Professionals seeing patients with MSK complaints in primary care should be trained in assessing for alarming features and red flags in all patients.

Consider admission/urgent referral

Red Flags Screening

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Osteoarthritis

Meniscus Injury – Acute

Meniscus – Degenerative

Ligament Injury

Chondral Injury / Defects

PFPS / AKP

Patella dislocation / Subluxation

ITB Syndrome

Baker’s Cyst

Referred pain from Hip / Lx

Other Soft Tissue

RED FLAG SCREENING: SPECIFIC FOR KNEE PATHOLOGYHistory & Symptoms

Medical Professionals seeing patients with MSK complaints in primary care should be trained in assessing for alarming features and red flags in all patients.

CONSIDER ADMISSION/URGENT REFERRAL IF: • History of cancer or suspected malignancy, investigate and refer as appropriate.

SYMPTOMS SUGGESTIVE OF TUMOURS (PRIMARY OR METASTATIC, BONE TUMOUR, SOFT TISSUE SARCOMA, METASTASES, HAEMATOLOGICAL CANCER OR NEUROBLASTOMA)• PMH of cancer- Bony metastases develop in 2/3 of patients with cancer-specifically those that metastasise such as; prostate, breast, lung, kidney, thyroid, myeloma• Unexplained weight loss • Non-mechanical night pain • Deep, intense pain• Increasing, persistent or unexplained bone pain, tenderness or swelling, especially if it is not in the knee joint itself but adjacent to the knee.• Sudden onset of pain (may indicate a pathological fracture but can also occur in osteonecrosis)• Pain worse at night/nocturnal pain• Fever • Mass presence• Lymphadenopathy• Pain that is worsened by weight bearing through affected joint• Unexplained limp1

• Emergence of bony lump1

• Fatigue1

• Atypical symptoms• PMH of sexual infection/lower GI infection

If there is a history of cancer, needs to be referred urgently for specialist assessment in line with 2 week fast track cancer pathway, with x-ray requested - AP, lateral, sky line, possibly full length femur.

SYMPTOMS SUGGESTIVE OF INFECTION OR SEPTIC ARTHRITIS OR OSTEOMYELITIS • Risk factors for sepsis include: Comorbidities of RA, or OA, prosthetic joint, low socioeconomic level, diabetic, alcoholism, previous intra-articular joint infection, ulcerated skin, IV use• Constant pain• Sudden onset, red, hot, pyrexia or red-hot joint, reduced movement of the joint especially if: - Significant swelling appeared acutely, over less than 24 hours - Only one joint is affected, although in up to a fifth of people with septic arthritis, more than one joint is affected.• Knee pain is severe, or in people with pre-existing joint disease e.g. OA, RA, out of proportion to usual symptoms• High inflammatory markers • Systemic symptoms• Fever not always present; nausea, vomiting, systemically unwell are also possible• Risk factors for infection: recent knee surgery in particular knee replacement, RA, IV drug use, immunosuppression e.g. diabetes, use of long term corticosteroids, alcoholism, or adjacent skin infection / ulceration

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1 Map of Medicine – Bone sarcoma suspected 2010

RED FLAG SCREENING: SPECIFIC FOR KNEE PATHOLOGYHistory & Symptoms

RED FLAGS FOR INFLAMMATORY POLYARTHRITIS• Persistent synovitis, indicated by: - Pain that is worse at rest or during periods of inactivity - Joint swelling, tenderness and warmth - giving a ‘boggy’ feel on palpation - Stiffness in the morning and after inactivity that lasts more than 30 minutes• Synovitis affecting other joints - symmetrical synovitis of the small joints of the hands and feet is typical in rheumatoid arthritis• A history of psoriasis, inflammatory bowel disease, or iritis (uveitis)

Suspected inflammatory condition, investigate and refer to Rheumatology

SYMPTOMS SUGGESTIVE OF LOWER LIMB FRACTURE / DISLOCATIONS • Trauma• Bruising / effusion• Pathological fracture - may result from a low impact trauma in patients with the following co-existing diagnoses:• Past history of cancer - specifically those that metastasise to bone• Multiple myeloma• Osteopenia / osteoporosis• Osteogenesis imperfecta (brittle bone disease)• Gaucher’s disease• Paget’s disease

SPONTANEOUS OSTEONECROSIS OF THE KNEE (SONK) / AVASCULAR NECROSIS (AVN) • Not very common• Most patients will have symptoms out of proportion to X-ray findings • Commonly related to pain on palpation of the femoral condyle• MRI required - once it is reported as AVN or SONK - needs URGENT Orthopaedic Elective Clinic Referral• Large number of SONK incidences are believed to be associated with meniscal root tear• Activity modification should recommended e.g. no running / jumping but can FWB as pain allows

SYMPTOMS SUGGESTIVE OF EXTENSOR MECHANISM DISRUPTION2

• Trauma• Inability to weight bear• Pain • Inability to extend knee

SYMPTOMS SUGGESTIVE OF ACUTE LOCKED KNEE2

• Trauma• Pain• Difficulty weight bearing• Inability to extend knee

Injury INFECTION• Red hot and swollen joint• Possible penetrative trauma• Prosthetic joint

SEE HOT SWOLLEN JOINT PATHWAY IF CONCERNED REFER TO ACCIDENT AND EMERGENCY

2 Map of Medicine – Alarming features Knee assessment 2010⊲ Home Page ⊲ Next Page ⊲ Previous Page

RED FLAG SCREENING: SPECIFIC FOR KNEE PATHOLOGYInjury TUMOUR

• Lump or bony mass of unknown origin• Assess for bony or soft tissue masses• Differential diagnosis to consider: Paget’s disease, cold bone lesion (tuberculosis), benign soft tissue lump (lipoma), benign bone tumourREFER TO 2 WEEK PATHWAY FOR SUSPECTED CANCER - ORTHOPAEDICS

ACUTE INJURY - FRACTURE OR DISLOCATION• Deformity• Bony tenderness• Inability to weight bear (see Ottawa rules)• Neurovascular examination is essential• Deformity and severe pain in any patient known to have metabolic bone disease - highly suspicious of pathological fractureREFER TO ACCIDENT AND EMERGENCY

ACUTE INJURY - EXTENSOR MECHANISM DISRUPTION • Inability to weight bear• Swelling• Deformity• Neurovascular examination is essential• Palpable gap in extensor mechanism• Inability to straight leg raise (SLR)

Quadriceps or patellar tendon rupture• Quadriceps tendon rupture occurs mostly in people older than 45 years of age, whereas patellar tendon rupture occurs mostly in people younger than 45 years of age• More common in men

Symptoms:• Usually occurs during sporting activity or after a fall, but can also occur spontaneously owing to underlying disease• Sudden onset of anterior knee pain / giving way

Signs:• Inability to straight leg raise or extend the knee• Change in height / position of the patella • A palpable gap in the patellar or quadriceps tendon (although this may be difficult to detect owing to overlying haematoma)REFER TO ACCIDENT AND EMERGENCY

ACUTE INJURY - ACUTE LOCKED KNEE• Joint line tenderness• Possible effused knee• Inability to straighten knee fully (true block to knee extension)• If after trauma and clinical diagnosis clear REFER TO ACCIDENT AND EMERGENCY

DVT• Pain and swelling in one leg (both legs may be affected)• Tenderness and changes to skin colour / temperature with vein distension• May use 2-level DVT Wells score (link)

REFER TO ACCIDENT AND EMERGENCY

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RED FLAG SCREENING: SPECIFIC FOR KNEE PATHOLOGYInjury SEPTIC BURSITIS

• The bursa is not only inflamed but also infected• Unlike most cases of aseptic bursitis, septic bursitis is a potentially serious medical condition and prompt medical attention is advisable• An estimated 20% of bursitis cases are septic• A bursa may become infected if an infectious bacterium enters the bursa through a cut, scrape, puncture, bug bite or other means• It is possible to have septic bursitis without an obvious entry point on the skin• Certain conditions and medications suppress people’s immune systems or affect circulation, making them more susceptible to developing septic bursitis e.g. people with cancer, HIV/ AIDS, chronic obstructive pulmonary disease (COPD), lupus, alcoholism, or diabetes may have compromised immune systems and be more likely to get septic bursitis• May or may not have trauma / specific event precipitating onset of symptoms• Local pain and/or swelling at the knee joint• Specific indicators that the bursa may be infected such as:• Extreme warmth and redness of the skin at the joint• Acute tenderness of the bursa• Fever or chills• Joint pain• Generally feeling sick

If there is any doubt as to whether a bursa may be infected then refer to ED for oral or intravenous antibiotics

RHEUMATOLOGY• Refer urgently to Rheumatology or via the EIA Pathway if an inflammatory polyarthritis is suspected • Refer anyone with persistent synovitis of undetermined cause to Rheumatology Examples of signs and symptoms that may be present: - The small joints of the hand or feet are affected - More than one joint is affected - There has been a delay of 3 months or longer between symptom onset and seeking medical help

HAEMARTHROSIS • All acute knee injuries with haemarthrosis (where the patient is not on anti-coagulants) should be treated as a torn ACL until proven otherwise and referred to Orthopaedic Knee Consultant • These injuries require x-ray (AP, lateral and skyline views) and an MRI to rule out fracture• If the patient is on anti-coagulants, please refer to the Hot Swollen Joint pathway


DIAGNOSIS: OSTEOARTHRITISTYPE OFINFORMATION GUIDELINES

Background information

• Focal areas of damage to the articular cartilage• Remodelling of underlying bone and the formation of osteophytes; new bone at joint margins• Mild synovitis• Structural changes, symptoms, and disability are often discordant; for example, severe structural changes may be present without symptoms and symptoms may be severe but not disabling• Osteoarthritis can be defined clinically or radiologically• Osteoarthritis has multiple risk factors, but only a few of these are modifiable• Knee osteoarthritis is very variable in its outcome

The natural history of symptomatic knee osteoarthritis has not been well documented, but some people improve, some people stay much the same, and some have progressively worse symptoms and structural changes, and eventually require joint replacement.

Subjective History

• Can be bilateral and symmetrical • Unilateral osteoarthritis of the knee is usually secondary to predisposing trauma or disease• Pain can be localised to the affected compartment: - Medial tibiofemoral: anteromedial pain, mainly on walking - Lateral tibiofemoral: anterolateral pain, mainly on walking - Patellofemoral: localized anterior knee pain that is worse on inclines or stairs, particularly when going down; progressive aching on prolonged sitting that is relieved by standing• Stiffness after rest is common • ‘Giving way’ is a common complaint: - ‘Giving way’ is related to altered patella tracking, weak quadriceps muscles (pain inhibition), severe patellofemoral osteoarthritis, and altered load bearing mechanics• Locking of the knee joint is a characteristic feature: - Pseudo locking prevents the knee from being straightened - True locking suggests that there is loose meniscal cartilage in the joint

Examination findings

• Crepitus and tenderness along the joint line or with pressure on the patella are common• Flexion and extension are usually restricted• Weakness of the quadriceps is suggested if passive extension of the knee joint is greater than active extension• Small-to-moderate effusions are not uncommon• With advanced osteoarthritis of the knee there may be: o Bony swelling of the femoral condyles and lateral tibial plateau o Varus deformity, or less commonly, valgus deformity• Functional assessment of activities / movements which, the patient specifies as problematic, for example, sit to stand, going up steps, walking• Assess joints above and below • Differential diagnoses: - Inflammatory arthritis - Suspect if: - Stiffness lasts longer than 30 minutes, pain is worse at night, or stiffness and pain are relieved by activity - Metacarpophalangeal (MCP), wrist, elbow, or ankle joints are involved - Consider: Rheumatoid arthritis, Psoriatic arthritis, Ankylosing spondylitis, Gout, Pseudogout (pyrophosphate arthropathy - may coexist with osteoarthritis, reactive arthritis, Arthritis associated with connective tissue disorders such as systemic lupus erythematosus, fibromyalgia, septic arthritis - Major ligamentous injury (recent and old injuries) - Bursitis - Cancer



Investigations A working diagnosis of osteoarthritis can be made without radiological or laboratory investigations• If the person is 45 years of age or more and symptoms and signs clearly suggest osteoarthritis: - Affected joints are painful when used - the person may also have pain at rest, crepitus, or a limited range of movement - Affected joints become stiff after resting - There are no obvious signs of inflammation, such as severe and prolonged morning stiffness, a large effusion, or a hot joint• Structural changes (found on examination or shown by radiological imaging) often correlate poorly with symptoms and disability• Imaging and other special investigations are not definitely required as they do not confirm the diagnosis or alter decision making• MRI is only indicated if symptoms don’t correlate with clinical picture • Imaging and special tests may be useful for excluding other conditions

Conservative management

• Assess the severity of pain and the effect of osteoarthritis on the individual’s function, quality of life, occupation, mood, relationships, and leisure activities• Formulate an individualised management plan in partnership with the person with osteoarthritis, taking into account: o Comorbidities that compound the effect of osteoarthritis or the risk of adverse effects from treatments o The person’s expectations, needs, and anxieties

The core treatment to be offered to everyone with osteoarthritis is education, advice, and access to information:• Information on osteoarthritis and advice on self-management should be offered repeatedly• Give people printed information and advise them where they can find more information about osteoarthritis and its treatment, including self-management; for example: - The National Institute for Health and Care Excellence (NICE) publication Osteoarthritis: Understanding NICE guidance, www.nice.org.uk (pdf) - Arthritis Care, 0808 800 4050, www.arthritiscare.org.uk - Arthritis Research UK, 0870 850 5000, www.arthritisresearchuk.org - NHS Choices, www.nhs.uk - Arthritis and Musculoskeletal Alliance (ARMA), www.arma.uk.net• Explain how osteoarthritis is diagnosed, and that X-rays are not always needed to make the diagnosis• Explain about the condition and its prognosis• Provide individualised advice about the options for treatment• The underlying message is that something can be done to help





Conservative Treatment• Exercise, weight loss (if needed), paracetamol, and topical nonsteroidal anti-inflammatory drugs (NSAIDs)• Advise on joint protection and emphasise the importance of aerobic and strengthening exercise (whatever the person’s age, comorbidity, level of pain, or disability) - this may require referral to physiotherapy• Advise on coping with restricted activities of daily living such as washing, dressing, and toileting - this may require referral to occupational therapy• If appropriate, advise about protective footwear, hot/cold packs, and TENS• Provide information about the drugs (topical NSAIDs, capsaicin, paracetamol) that are used to treat pain, and how the risk of adverse effects can be minimised• Provide information about how to use simple analgesia to gain maximum benefit• Start using analgesia before the pain is unbearable• Use paracetamol regularly as prescribed, to prevent the pain becoming unbearable

Strengthening Exercise and Aerobic Fitness Training• Referral to Physiotherapy: assessment of individuals’ goals, functional limitations and expectations to enable plan which is meaningful to the patient and realistic for them to adhere to• Gradual loading, strengthening, group environment e.g. OA knee class if available, pacing / prioritising, graded return to activity, variety of lower limb and whole body exercise• Aerobic fitness training

Orthotics / Assistive Devices • Supports and braces for people with biomechanical joint pain or instability e.g. medial off loader brace• Appropriate footwear for people with lower limb osteoarthritis• Walking aids

Weight loss If the person is overweight or obese refer to Change Point - Everyone Healthhttp://www.nottshelpyourself.org.uk

Drug Treatments • Paracetamol - regular dosing is more effective than use ‘as required’• Topical nonsteroidal anti-inflammatory drugs (NSAIDs) • If paracetamol and/or topical NSAIDs are ineffective:• Oral NSAIDs • If low-dose aspirin is being used, avoid NSAIDs if possible.• Opioids - Codeine should be tried first, alone or together with paracetamol.• Topical capsaicin • Intra-articular corticosteroids

Referral on for orthopaedic opinion:

• Before considering referral, check that the person wishes to be referred, and that they are fit for surgery• Refer if the person has symptoms that have a substantial impact on their quality of life and are refractory to non-surgical treatment• Refer before there is prolonged and established functional limitation or severe pain• Refer for arthroscopic lavage and debridement only if the person has knee osteoarthritis with a clear history of mechanical locking • Partial, total or patella knee replacements will be considered after exhausted all other avenues


DIAGNOSIS: MENISCUS INJURY – ACUTETYPE OFINFORMATION GUIDELINES


• Medial meniscus injury 2-5 x more often than lateral• Posterior horn in 80% of cases• History and joint line tenderness to palpate posterior to MCL are strong indicators of meniscal injury• Acute - In young people usually meniscal injury is an associated injury, present with other ligamentous / bony involvement - Always suspect that the ACL has been injured, menisci are often injured during weight bearing and twisting - Most meniscal tears occur during sporting injuries that involve a twisting movement while standing on a bent knee

Subjective history

• Traumatic onset Typically with tibial rotation whilst weight bearing with the knee in flexion (*ask about ability to weight bear at time of onset, consider fracture/red flags)• May occur as result of repetitive action such as repeated squatting• Sharp/stabbing pain, well localised on the medial or lateral joint line• May describe: - Locking – knee getting stuck, reduced range of extension movement - +/- Giving way • Swelling can occur: the volume of swelling is mild to moderate, and occurs several hours after the injury• Over the following weeks, there may be recurrent swelling• A firm bulge originating from the joint line is indicative of a cyst


• Joint line tenderness on palpation• Loss of passive extension – blocked / hard end feel• May have positive Meniscal tests: McMurrays / Thessaly’s / DD Scoop • Effusion is possible • Consider referral from other regions e.g. hip, lumbar spine, distal neurovascular assessment may be necessary*N.B. https://cks.nice.org.uk/knee-pain-assessment

Investigations • X-Ray to exclude fracture if suspected• MRI to confirm if clinical uncertainty – for acute, not degenerative• Root tear or Bucket Handle tears should be referred to Orthopaedics for repair (classed as URGENT) *they will have mechanical symptoms


• Conservative management• Advice, education around condition, management of expectations especially regarding conservative vs surgery • Physiotherapy – load management, gradual loading, strengthening, proprioception, patient specific / led goals, return to meaningful activity / work• Analgesia• Injection – to settle intraarticular inflammation and allow improved pain management & compliancy to rehabilitation (especially if pseudo locking)• Injection would not interfere with arthroscopic time frame


DIAGNOSIS: MENISCUS – DEGENERATIVETYPE OFINFORMATION GUIDELINES


• Medial meniscus injury 2-5 x more often than lateral• Posterior horn in 80% of cases• History and joint line tenderness to palpate posterior to MCL are strong indicators of meniscal injury• They can also occur in association with a degenerative process with little or no perceptible trauma: these may be asymptomatic• Poor vascularity results in poor healing

40% of 40+ year olds will have a degenerative meniscus 50% of 50+ year olds will have a degenerative meniscus 60% of 60+ year olds will have a degenerative meniscus

Subjective history

• Degenerative in nature – may be insidious or identifiable onset• May occur as result of repetitive action such as repeated squatting• Sharp/stabbing pain, well localised on the medial or lateral joint line• May describe: - Locking – knee getting stuck, reduced range of extension movement - Giving way• Swelling usually occurs: the volume of swelling is mild to moderate, and occurs several hours after the injury.• Recurrent swelling may occur with activity


• Joint line tenderness on palpation especially behind MCL• Loss of passive extension• May have positive Meniscal tests: painful joint line palpation, possibly positive McMurrays / Thessaly’s / DD Scoop • There may be an effusion• Consider referral from other regions e.g. hip, lumbar spine, distal neurovascular assessment may be necessary

Investigations • X-ray to exclude fracture if suspected• MRI not required unless X-Ray findings do not match symptoms

DIAGNOSIS: MENISCUS INJURY – ACUTETYPE OFINFORMATION GUIDELINES

Referral on for orthopaedic opinion

• If acute and presents with true locking, refer to Secondary Care URGENT • If diagnosis is unclear refer to MSK Hub for further investigation • If there is severe pain and high impact on function refer to MSK Hub• Failure to improve with conservative management after 3-6/12 • Surgery may be offered if poor response to an injection • May consider sooner referral for patients under 35 years of age whose occupation, livelihood or sport is affected


DIAGNOSIS: MENISCUS – DEGENERATIVETYPE OFINFORMATION GUIDELINES


DEGENERATIVE MENISCAL TEARS3

Over the long term, patients who undergo knee arthroscopy versus those who receive conservative management strategies do not have important benefits in pain or function4

• A systematic review of 13 RCTs and 12 observational studies showed - With respect to pain, the review identified high-certainty evidence that knee arthroscopy results in a very small reduction in pain up to 3 months and very small or no pain reduction up to 2 years when compared with conservative management. - With respect to function, the review identified moderate-certainty evidence that knee arthroscopy results in a very small improvement in the short term and very small or no improved function up to 2 years. - Patients with true locking (unable to fully extend their knee) may still benefit from arthroscopy5

Conservative management - Advice, education around condition, management of expectations especially regarding conservative vs surgery - Physiotherapy – load management, gradual loading, strengthening, proprioception, patient led goals, return to meaningful activity/work - Analgesia - Injection – if not able to engage in exercise/advice due to pain


• If diagnosis is unclear• If there is severe pain and high impact on function, may consider referral without true locking• Failure to improve with conservative management after 3/12 • May consider sooner referral for patients under 35 years of age whose occupation, livelihood or sport is affected

DIAGNOSIS: MENISCUS – LIGAMENT INJURYTYPE OFINFORMATION GUIDELINES


ACL• The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee• Injuries occur predominantly in a young and sports-active population • Patients can be left with significant disability following injury to the ACL• The injury leads to alteration in the mechanics of the knee• This mechanical deficit can lead to an increased risk of meniscal injury and / or early onset osteoarthritis • Joint preservation is the aim• ACL rupture with early return to sport when not ready leads to meniscal bucket handle tear

3 Map of Medicine – Meniscal tears (2010)4 BrignardelloPetersen R et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open 2017;7:e0161145 Siemieniuk, R et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a practice guideline. The BMJ 2017;357:1982.



Subjective history

• Injury at onset of symptoms traumatic in nature - Typically of decelerating nature or change in direction on a fixed foot, hyperextension - A popping sensation, or a sensation that the knee ‘came apart’, or dislocated at the time of the injury - Common in skiing due to knee position and impact/twisting injuries - Significant swelling within a few hours of the injury6 7

• Main complaints: - Instability of the knee – ‘giving way/buckling’ - Description of knee ‘not feeling right’ - Compromised quality of life - Early development of a large haemarthrosis often suggests ACL injury6


• Swelling• Palpation for joint line tenderness• Assess all ligament integrity – valgus stress, Varus stress, Lachman’s, Pivot Shift, posterior drawer test, recurvatum test, dial test, ER recurvatum test6

• The Lachman test is often positive, but its accuracy and utility in primary care settings is not known• An anterior drawer test may be positive6 7 • Dial test – positive with more than 10 degrees difference side to side

N.B guarding due to pain can give false negatives

Investigations • X-Ray – AP, lateral and skyline views to rule out fracture• MRI - early MRI is indicated


ACL injury with MCL injury requires brace (0-90 degrees for 6/52 FWB)*Currently available at KMH and Newark MSK Hub sites* If patient has not been seen at fracture / soft tissue clinic a referral to secondary care is indicated

Consider need for surgery when:• Instability with ADLs• High severity of disability• Failure of conservative treatment• Based on patients age/sporting level and disability

Conservative Management• PRICE• Analgesia• Physiotherapy to commence functional rehabilitation - Functional strengthening - Psychological confidence improving treatment - Proprioception treatment - Achieve FROM - Avoid electrotherapy - Protocols to use available at KMH and Newark hub sites - Info and Prehab classes currently available at KMH and Newark Physiotherapy departments

6 Map of Medicine : Knee ligament tears (2010)7 Clinical Knowledge Summaries : Knee pain assessment




Surgical Management• There is variation in technique across the UK - Autograft – most common and used most frequently include: bone-tendon-bone (patellar tendon) or 4 strand hamstrings - Allograft - Synthetic ligaments• Aim / indication: to restore functional stability to the knee without compromising other aspects of the knee including ROM• Knee should be ‘quiet’ at operative time – settled post-injury inflammatory response with full ROM• Age and degenerative change are not contraindications to surgery


• Early stabilisation of ACL reduces incidence of meniscal pathology with return to sport too soon • Consider referral to the MSK Hub / Orthopaedics in Secondary Care if grossly unstable or not responding to conservative measures


LCL / POSTERO-LATERAL CORNER (PLC)• PLC injuries are always combined with other injury in the knee• Lateral collateral ligament injury - A lateral collateral ligament injury is less common than a medial collateral ligament injury - Injury to the lateral collateral ligament can occur in combination with other posterolateral complex structures including the peroneal nerve due to their proximity - The lateral collateral ligament is a strong connection between the lateral epicondyle of the femur and the head of the fibula - Its function is to resist Varus stress on the knee and tibial external rotation and is thus a stabiliser of the knee - When the knee is flexed to more than 30°, the LCL is loose. The ligament is strained when the knee is in extension

Subjective history

• Symptoms: - The mechanism of injury may be a direct blow to the medial aspect of the knee, or other Varus stress. - There is usually acute onset of lateral knee pain and cessation of activities• Grading of injury: - Grade 1 - Mild tenderness and minor pain over the lateral collateral ligament - Usually no swelling - The Varus test in 30° is painful but doesn’t show any laxity (< 5 mm laxity) - Grade 2 - Significant tenderness and pain on the lateral collateral ligament and on medial side of the knee - Swelling in the area of the ligament - The varus test is painful and there is laxity in the joint with a clear endpoint. (5 -10mm laxity) - Grade 3 - The pain can vary and can be less than in grade II - Tenderness and pain at the medial side of the knee and at the injury - The Varus test shows a significant joint laxity (>10mm laxity) - The feeling of having a very unstable knee - Swelling



• Tenderness over the lateral collateral ligament (at the lateral joint line)• Instability or pain on Varus stress test• ‘Pop’ heard or felt in the knee at time of injury - this can be symptomatic of root meniscal injury which requires early MRI scan • May have swelling, bruising, stiffness, erythema or deformity of the knee• Neurological examination if signs of peroneal nerve involvement• Increased rotation of the tibia

Investigations • X-Ray to rule out fracture• MRI – investigate detail of injury to LCL / PLC


• If LCL tear with PLC is suspected urgent MRI is required• Referral should be made to Secondary Care Orthopaedics for assessment


• Referral on for Orthopaedic opinion• Surgical management t be determined in secondary care


MCL• The medial collateral ligament is one of the most commonly injured ligaments of the knee • It is the primary biomechanical restraint to valgus laxity against valgus stress at 0° - 30° of knee flexion• MCL injury often occurs when an acute valgus load is applied and may occur in isolation or involve multiple ligaments• As the severity of the injury increases, so does the likelihood of injury to other associated ligamentous and meniscal structures

Subjective history

• Most injuries result from a valgus force on the knee from direct contact or with cutting manoeuvres when an athlete plants their foot and then forcefully shifts directions• The location of swelling is a clue to the extent of injury - Isolated MCL injuries often present as localised soft tissue swelling - Whereas combined ACL/PCL tears result in significant hemarthrosis and generalised knee effusion


• To assess MCL laxity the patient should be relaxed and the contralateral leg is used as a control for any medial joint line opening.• A gentle valgus force should be applied to the leg with the knee in 30 degrees of flexion thereby isolating the MCL - If lax in 30 degrees knee flexion = conservative treatment - If lax in full extension refer to Orthopaedics as this suggests a multi-ligament injury • MCL injuries can be graded 1-3; assessed by a valgus force in 30 degrees flexion: - Grade 1 – 1 to 5mm laxity - Grade 2 - 6 to 10mm laxity - Grade 3 >10mm laxity (compared to the other knee)• In general, an isolated MCL tear leads to valgus laxity in flexion, while additional injury to the secondary valgus restraints (PCL or ACL) leads to increased laxity in extension.• High-energy injuries resulting in MCL injury frequently damage other knee ligaments in conjunction with the MCL: - 78% of grade 3 MCL sprains will include injury to an associated structure - Approximately 95% of these concomitant MCL injuries involve the anterior cruciate ligament (ACL)8

8 Grant JA, Tannenbaum E, Miller BS, Bedi A. Treatment of combined complete tears of the anterior cruciate and medial collateral ligaments. Arthroscopy. ⊲ Home Page ⊲ Next Page ⊲ Previous Page


Investigations • X-Ray - Weight bearing AP, lateral and sky line views - Bony avulsions or chondral fragments may be present - Lateral tibial plateau fractures can also result from valgus stress to the knee and may mimic valgus instability on examination• MRI - Useful to assess the location, grade, and other concomitant injuries to the knee such as ACL tear or medial meniscus tear


• Acute isolated MCL injuries are treated non-operatively unless bony avulsion, tibial plateau fracture or chondral fragments are present• PRICE• Weight bearing as pain allows (with hinged knee brace if needed) - AROM, concomitant strengthening exercises, proprioception - Return to activity within: Grade 1: 3/52; Grade 2: 6/52; Grade 3: 9/52• Combined acute MCL and ACL injuries – treatment via MSK Hub / Secondary Care• Consider Electrotherapy treatment (US) with patients not responding to exercise• Consider MCL Steroid injection for pain relief


• Surgical management is not indicated unless part of the unhappy tirade


PCL• The PCL is the major stabilising ligament of the knee and prevents the tibia from moving backwards too far• It is twice as thick as the ACL and therefore less commonly injured• Its primary function is resisting the posterior displacement of the tibia in relation to the femur• Its secondary function is preventing hyperextension and limiting Varus or Valgus rotation

Subjective history

• The most common mechanisms of PCL injuries include pretibial trauma, hyperflexion, and hyperextension of the knee.• In most of the PCL injuries caused by hyperflexion, the posteromedial bundle remains intact and only the anterolateral bundle is ruptured9

• PCL tears can occur in isolation but are mostly in combination with other injuries• The PCL can also be torn in a car accident where a posterior force is applied to the tibia when the knee in a flexed position hits the dashboard• If only the PCL is injured (in the absence of injury to the posterolateral complex), the person may be relatively asymptomatic immediately after the injury with little pain and swelling• There may be posterior pain (or pain on kneeling), although the person may complain of anterior pain with a chronic PCL injury


• A careful vascular examination of the lower extremities is essential because a PCL injury can be accompanied by a popliteal artery injury• If the pulses are weak or the ankle-brachial index is ≤0.8, an intimal tear should be suspected, and arteriography should be performed• If blood flow disruption below the knee is obvious, arteriography should be omitted to prevent delay in treatment• Acute PCL injuries present with joint swelling and about 10° to 20° of restriction in further flexion due to pain• Chronic PCL injuries may present with limited activity such as having difficulty in climbing slopes due to lethargy and pain in the anterior and medial areas of the knee rather than instability

9 Lee BK, Nam SW. Rupture of Posterior Cruciate Ligament: Diagnosis and Treatment Principles. Knee Surgery and Related Research. 2011 Sep;23(3):135-141




• The posterior drawer test is the most accurate test for PCL injuries: at 90° of knee flexion, posterior sagging of the tibia is observed on the affected side (severe swelling can give you a false negative)• The posterior drawer test will often be positive, and the posterior sag test may be positive• Posterior drawer test, dial test, Varus and Valgus test should be done especially if the patient complains of severe posterior knee pain in >90° of flexion • The dial test, posterolateral drawer test, external rotation recurvatum test, and reverse pivot shift test can also be used to assess injuries to the posterolateral structures • A positive external rotation recurvatum test is more indicative of an ACL injury than a PCL injury and the reverse pivot shift test should be used with care because the test may yield positive results in about 30% of normal knees

Investigations • X ray - The presence of a fracture can be determined on the anteroposterior, lateral, and skyline views of the knee - The lower limb alignment, especially the presence of Varus malalignment, can be evaluated on the standing radiographs• MRI - To assess for associated ligament injuries. - Bone bruise patterns on MRI can be helpful in identifying the mechanism of injury. In acute PCL injuries, bone bruises are often located anterior to the tibia. In chronic PCL injuries MRI scans may appear to be normal if the ligament healed spontaneously.


• To be determined in secondary care • Conservative treatment is indicated for PCL injuries with 5 to 10 mm posterior instability (grade I and II) • Surgical treatment is recommended for PCL injuries with ≥10 mm posterior instability (grade III) or with combined collateral ligament injuries or avulsion fractures


• If PCL tear is suspected, referral should be made to secondary care Orthopaedics for assessment and consideration of PLC involvement

DIAGNOSIS: CHONDRAL INJURY / DEFECTSTYPE OFINFORMATION GUIDELINES


Chondral DefectA detachment of bone or cartilage most commonly in the femoral condyle. Symptoms are related to softening of the cartilage rather than hardening as in OA. • Hyaline articular cartilage is an avascular structure, which results in poor healing; it is not innervated • Varies in thickness; the cartilage on the articular surface of the patella can reach a thickness of up to 7-8mm • A large retrospective study10 analysed a large database of arthroscopies (25.124 arthroscopies performed from 1989 to 2004) - Chondral lesions were found in 60% of patients. They were classified as localised focal osteochondral or chondral lesions (67%), osteoarthritis (29%), osteochondritis dissecans (2%) and other types in 1% - The most common associated articular lesions were meniscus tear (37%) and injury of the ACL (36%)

10 Widuchowski W. et al., Articular cartilage defects: Study of 25.124 knee arthroscopies, ScienceDirect, The Knee 14 (2007) 177-182




- The analysis of the onset of symptoms revealed that in 58% it was a traumatic non-contact onset, usually connected with a day living activity (45%) and with sports participation (46%, especially football and skiing)

Osteochondritis Dissecans A relatively common, idiopathic condition where crack form in the articular cartilage affecting the subchondral bone.• Most commonly occurs in people 13–21 years of age, but can affect younger children and adults• The condition is usually unilateral, but can affect both knees (can affect other joints)

Subjective history

Chondral Defect • Can range from asymptomatic to severely limiting pain• There may be a history of ligament injury (often the ACL), patellar dislocation, or a traumatic “dashboard” injury to the knee• Pain increases on physical activity• Intermittent swelling, related to activity in more chronic cases• Pain with prolonged sitting, stair climbing, and kneeling may localise the pain to the patella or femoral trochlea

Osteochondritis Dissecans• Symptoms will initially be vague, poorly-localised knee pain, which may be aggravated by activity• There may also be morning stiffness and recurrent swelling• They may describe locking, catching, or giving way; these symptoms suggest that a loose body is present


Chondral Defect• Haemarthrosis are seen in almost all acute injuries that create a full thickness chondral injury• May exhibit symptoms to suggest loose body – loss of end range movement and locking

Osteochondritis Dissecans• There may be quadriceps weakness and atrophied, focal bony tenderness, a small knee effusion and limitation of knee extension• Wilson’s test may be positive: with the knee flexed to 90 degrees and the tibia rotated medially (internally), the person is asked to extend the knee against resistance• The test is considered positive if pain occurs at approximately 30 degrees of flexion; pain is usually relieved when the tibia is released from medial (internal) rotation

Investigations Chondral Defect Staging on MRI / X-Ray as below:• Stage I MRI Subchondral oedema Stage I X-Ray None • Stage II MRI Associated subchondral fracture without detachment Stage II X-Ray Osteopenic Area • Stage III MRI Detached non-displaced fragment + joint effusion Stage III X-Ray Slight lucency + possible loose body• Stage IV MRI Osteochondral Fragment displaced + joint effusion Stage IV X-Ray Increased lucency + loose body• Stage V MRI Subchondral cyst formation + degenerative changes Stage V X-Ray Secondary degenerative change



Investigations Osteochondritis DissecansX-Rays• Offer X-rays of both knees• Ensure that the X-ray request form states that osteochondritis dissecans is suspected• There may be no abnormality detected, or the X-rays may show a radiolucent lesion or a loose body and indicated the need for MRI


• Advice, education around condition, management of expectations especially regarding conservative vs surgery • Physiotherapy – load management, gradual loading, strengthening, proprioception, patient led goals, return to meaningful activity/work• Analgesia• Injection – if not able to engage in exercise/advice due to pain


ALL OSTEOCHONDRAL DEFECTS SHOULD BE REFERRED TO SECONDARY CARE • Refer on if true locking• Surgical interventions offered locally are chondroplasty, microfracture11, osteochondral autographs, allographs and primary repair if a large defect• Out of area - Implantation (ACI) may be offered for patients – to be referred by Orthopaedic surgeon. Osteochondritis DissecansIf suspected on the basis of clinical or radiographic features, refer to an orthopaedic surgeon or other musculoskeletal specialist for confirmation of the diagnosis (for example by MRI) and for treatment planning (surgery may be required if conservative measures fail)

DIAGNOSIS: PATELLOFEMORAL PAIN SYNDROME PFPS / ANTERIOR KNEE PAIN AKPTYPE OFINFORMATION GUIDELINES


Patellofemoral Pain Syndrome• Patellofemoral pain is a diagnosis of exclusion - Exclude any red flags for more serious pathology - Consider other causes of anterior knee pain• Synonyms for patellofemoral pain syndrome are ‘anterior knee pain syndrome’, ‘patellar dysfunction’, ‘chondromalacia patellae’ or ‘chondropathy’• Factors that have recently been described as associated with PFPS are - a lower knee extension strength, a lower hip extension strength and decreased flexibility of the lower extremity muscles - contribution of patellofemoral joint mechanics and surrounding tissues to patellofemoral pain - contribution of foot and ankle mechanics - contribution of hip, pelvis and trunk mechanics• However, the aetiology of the condition is still unclear, as is the origin of the pain12

May be associated with Infrapatellar fat pad impingement/Hoffa’s fat pad:• Intracapsular, extra synovial structure that fills the anterior knee compartment, and is richly vascularized and innervated• Injury to the fat pad is often caused where it becomes pinched (impinged) between the patella and distal femur• Can be result of knee trauma / direct trauma to fat pad• Can develop gradually, usually caused by repeated hyperextension of the knee

11 Cochrane Surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults 2016.

12 Cochrane - Exercise Therapy for patellofemoral pain syndrome 2015 ⊲ Home Page ⊲ Next Page ⊲ Previous Page


Subjective history

Patellofemoral Pain Syndrome• Anterior or anteromedial pain that is: - Dull and aching - Gradual in onset - Aggravated by ascending or (particularly) descending stairs, rising after squatting or sitting for prolonged periods (especially with the knees flexed), or sporting activities (especially running or jumping) - Associated with a sensation of giving way. This is not true instability, which occurs in meniscal or ligamentous injury, when the person describes instability occurring on pivoting or twisting; in patellofemoral pain, the sensation of giving way occurs whilst ascending or descending stairs or when walking on an incline• Other features in the history: - The pain is commonly bilateral, but may affect the dominant knee more than the non- dominant knee - The pain may be associated with mild swelling, crepitus, snapping, or clicking, but these features are not specific to patellofemoral pain

Infrapatellar Fat Pad Impingement • Ache/burning at inferior pole of patella• Pain worsens on activity• Pain may be aggravated in knee extension


Patellofemoral Pain Syndrome• There are no features specific to patellofemoral pain• There may be no abnormal findings, or there may be a mild effusion, tenderness over medial or lateral peri-patellar regions, crepitus and anterior knee pain on active or passive movements• Pain on patellar glide (movement of the patella medially and laterally with the knee slightly flexed)• Tests for patellar maltracking and patellofemoral alignment, and measurement of the quadriceps (Q) angle are of limited value for diagnosing patellofemoral pain

Infrapatellar Fat Pad Impingement• May be tender to palpate at inferior patella/over patella tendon• Swelling may be present• May have loss of terminal extension• Pain with direct pressure on the medial or lateral side of the patella with the knee extended • Pain can often be reproduced with manoeuvres designed to produce impingement

Investigations Patellofemoral Pain Syndrome• X-Ray can be used to rule out other conditions • Relevant investigation for clinical suspicion of other diagnosis as per guidelines• Poor reliability or correlation between X ray/MRI findings of knees with PSFS and symptoms)13

Infrapatellar Fat Pad Impingement • X-Ray can be used to rule out other conditions • MRI to measure patella height Tibial Tubercle – Trochlea Grove (TT-TG) and assess articular cartilage

13 Cochrane – Exercise therapy for patellofemoral pain syndrome 2003




Patellofemoral Pain Syndrome• Self-help information arthritisresearchukPFPS • GP for advice on pharmacological treatment• Refer to Physiotherapy: - Advice/education - Exercise therapy – Systematic review concluded that people with PFPS have lower knee extension strength, lower hip extension strength and decreased flexibility of the lower extremity muscles compared with people without PFPS14. - Exercise programmes that comprise static and dynamic muscular exercises for both quadriceps and hip muscles aim to improve the strength of these muscles and consequently reduce pain by decreasing the load on the patellofemoral joint and improve function by normalising the kinematics - Proprioception - Return to usual level of activities• Electrotherapy – ultrasound not beneficial15 • Steroid Injection if unable to engage in exercise/advice due to pain

Infrapatellar Fat Pad Impingement • Physiotherapy - Taping can be used to unload an inflamed IFP - Closed chain quadriceps exercises can improve lower limb control and patellar congruence - Training of the gluteus medius and stretching the anterior hip may help to decrease internal rotation of the hip and valgus force at the knee - Gait training and avoiding hyperextension can also be used for long-term management


Patellofemoral Pain Syndrome• Any red flags• Non-progression of symptoms after 3-6/12 of conservative management• Severe level of pain or function impairment, not managed in primary care

Infrapatellar Fat Pad Impingement• If no progression or improvement after 3-6/12 rehabilitation• Diagnostic uncertainty• Worsening symptoms• In recalcitrant cases, patients can be surgically treated with arthroscopic fat pad resection

DIAGNOSIS: PATELLA DISLOCATION (ACUTE) / SUBLUXATION (SUB-ACUTE)TYPE OFINFORMATION GUIDELINES


• Patellar instability is a term used to encompass disorders in which the patella subluxes or dislocates from its normal position - Patella subluxation or dislocation may occur during sporting activities, or during activities of daily living, in people who are at risk - usually teenage girls (for example due to joint hypermobility syndrome) - The patella usually relocates spontaneously - Recurrent dislocations without traumatic cause may be associated to anomalies of the patellofemoral joint including trochlear dysplasia, patella alta, lateralisation of the tibial tuberosity

14 Lankhorst NE et al Factors associated with patellofemoral pain syndrome: a systematic review. British Journal of Sports Medicine 2012;42(2):81-94.15 Cochrane – Therapeutic Ultrasound for patellofemoral pain syndrome 2009




- Important secondary factors contributing to patellofemoral instability are femorotibial malrotation, genu recurvatum (hyperextended knee), and ligamentous laxity caused by Ehlers-Danlos syndrome, and Marfan syndrome16.

Subjective history

Patella dislocation - Leading mechanism of an acute dislocation of the patella is knee flexion with internal rotation on a planted foot with a valgus component - A common finding related to acute, primary, traumatic patellar dislocations is hemarthrosis of the knee, caused by rupture of the medial ligamentous stabilisers of the patella

• Patellar subluxation - The main symptom is recurrent episodes of the knee giving way - The person may also complain of anterior knee pain, locking, catching sensations, and recurrent mild swelling - Pain can be aggravated by activities such as up and down the stairs, sports such as running, hopping and jumping, and changing direction


• Patellar dislocation - If there is moderate or severe swelling, refer to the accident and emergency department to exclude an associated fracture

• Patellar subluxation - There may be a small joint effusion - Signs may be similar to those seen in patellofemoral pain - Several clinical tests have been suggested, but their diagnostic accuracy is unclear

• Assessment - Lower limb alignment in coronal, sagittal and axial planes - Evidence of joint hyper laxity: measured by the Beighton hypermobility score - Measurement of the Q-angle: an increase in Q-angle results in an increased valgus vector: this is associated with an increased risk of instability, due to more laterally orientated forces - Palpation of the patella: may reveal a palpable defect at the medial patellar margin and tenderness along the course or at the insertion of the MPFL - Patellar-glide test: A medial / lateral displacement of the patella greater than or equal to 3 quadrants, with this test, is consistent with incompetent lateral / medial restraints - Lateral patellar instability is more frequent than medial instability - Fairbanks patellar apprehension test: the test is positive when there is pain and defensive muscle guarding when the patella is passively moved laterally in 20°–30° of knee flexion; a positive test indicates lateral patellar instability. 100% sensitivity, 88.4% specificity, and overall accuracy of 94.1%

Investigations • X-ray to rule out fracture (with true dislocation, not subluxation) • MRI – only if recurrent event


IF FIRST TIME OR RECURRENT DISLOCATION, REFER TO ORTHOPAEDICS.No immobilisation – hinge knee brace within restricted range for 6/52 then commence movement.• The aim of rehabilitation is to restore knee range of motion and improve patellar stability by reinforcing the quadriceps• Patellar subluxation – refer to Physiotherapy: strengthening, quadriceps, proprioception, patient led goals, return to previous activities/sport• 3-6/12 of rehab then refer to Orthopaedics if still problematic

16 Diederichs G, Issever A, Scheffler S. MR Imaging of Patellar Instability: Injury Patterns and Assessment of Risk Factors. RadioGraphics. 2010;30(4):961-981.




• Refer a person to an orthopaedic surgeon if patellar dislocation occurs in a person with recurrent dislocation (>3), and is associated with moderate or severe swelling, regardless of timeframe of dislocations• If first-time traumatic patellar dislocation suspected - this recommendation is pragmatic as investigations to assess for internal injury such as fracture, and initial immobilisation are generally recommended10

• If patellar dislocation has not reduced spontaneously, reduction in an emergency department is recommended

DIAGNOSIS: ITB SYNDROMETYPE OFINFORMATION GUIDELINES


• Non-traumatic overuse injury• Extends from iliac crest down the lateral thigh to connect to Gerdy’s tubercle at the lateral knee,• Also incorporates a lateral patella attachment• Debate over whether there is friction involved at the lateral knee between the ITB and femoral condyle, particularly at 20-30 degrees of knee flexion or of it is irritation of a highly innervated layer of fat that lies between the ITB and femoral condyle• Possible non-modifiable causes – prominence of lateral epicondyles and leg length difference• Possible other modifiable causes – reduced flexibility, muscle weakness particularly of hip abductors, biomechanical alterations – hip adduction, knee internal rotation and foot position

Subjective history

• Load, stress and frequency of load must be considered when looking at cause of symptom onset• New activity may coincide with symptoms onset• Repetitive activities involving knee flexion-extension are usually reported• Burning pain at the level of (or just underneath) the lateral femoral epicondyle• Sharp pain on the outer aspect of the knee that can radiate into the outer thigh or calf


• Ober’s test / Modified Ober’s test• Noble compression test

Investigations • Not indicated unless diagnosis unclear


• Rest, ice – initially to settle symptoms• Look at changes in activity/exercise – address how to incorporate change at a rate which doesn’t cause symptoms, patient advice/education• Adaptations for future training/activity planning• Address muscle weakness – glutes and quads• Address muscle stiffness – TFL, hip flexors, quads• Proprioception / movement control• Biomechanics • Look at running style if appropriate– narrow step width may be a factor in increasing ITB strain, also increasing step rate with a proportional decrease in step length assuming a constant speed. Study findings (Heiderscheit et al 2011) indicate that a substantial reduction in loading occurs at the hip and knee when step rate is increased to 10% above preferred with a constant running speed, while a 5% increase appears to reduce the total work performed by the knee.

10 Rhee S, Pavlou G, Oakley J, Barlow D, Haddad F. Modern management of patellar instability. International Orthopaedics. 2012;36(12):2447-2456


DIAGNOSIS: ITB SYNDROMETYPE OFINFORMATION GUIDELINES


• If diagnosis unclear, symptoms not responding to conservative management within 6/12 or if symptoms are severely affecting quality of life• Injection – if not able to engage in exercise / advice due to pain

ReferencesIs iliotibial band syndrome really a friction syndrome? Fairclough J et al. April 2007Volume 10, Issue 2, Pages 74–76Aderem and Louw Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review. BMC Musculoskeletal Disorders (2015) 16:356 DOI 10.1186/s12891-015-0808-7Effects of Step Rate Manipulation on Joint Mechanics during Running. Bryan C. Heiderscheit et al. Med Sci Sports Exerc. 2011 Feb; 43(2): 296–302.

DIAGNOSIS: BAKER’S CYSTTYPE OFINFORMATION GUIDELINES


• A Baker’s cyst17 (also known as a popliteal cyst) is not a true cyst but a distension of the gastrocnemius-semimembranosus bursa behind the knee• Baker’s cysts are usually secondary to: - Osteoarthritis or inflammatory arthropathies such as rheumatoid arthritis - Meniscal tears - Anterior cruciate ligament damage• Complications of Baker’s cyst include: - Dissection or rupture. - Consider ruptured Baker’s cyst as differential diagnosis for DVT - Haemorrhage can occur, in particular in people taking anticoagulants - Compartment syndrome, lower limb ischaemia, and symptoms of nerve entrapment are also possible - Infection - can occur spontaneously or following corticosteroid injection

Subjective history

• Swelling - An asymptomatic swelling behind the knee may be the only feature• Pain and tightness - Non-specific posterior knee pain and a feeling of tightness - Symptoms may be aggravated by walking (as fluid passes between the knee joint and the cyst)


• Baker’s cysts are typically found in the medial popliteal fossa• Round, smooth, and fluctuant — they may be tender on palpation• Check for signs of underlying knee pathology such as joint instability, and ligament or meniscal damage

Investigations • X-Ray of the knee is of limited value in confirming or excluding a diagnosis of Baker’s cyst• It may be appropriate as part of an assessment of underlying knee joint disease


• Treatment of the underlying knee joint disease often leads to regression of Baker’s cysts


• May aspirate if very big - generally these are left alone

17 CKS Baker’s Cyst 2016


DIAGNOSIS: REFERRED PAIN FROM HIP / LUMBAR SPINETYPE OFINFORMATION GUIDELINES


• Always examine the hip in people who present with knee pain• Several conditions of the hip or lumbosacral spine can cause referred pain in the knee

Subjective history

Osteoarthritis of the hip• A working diagnosis of osteoarthritis can be made without radiological or laboratory investigations:• Affected joints are painful when used - the person may also have pain at rest, crepitus, or a limited range of movement• Affected joints become stiff after resting• There are no obvious signs of inflammatory arthritis, such as severe and prolonged morning stiffness, a large effusion, or a hot jointInflammatory arthritis• Suspect if: - Stiffness lasts longer than 30 minutes, pain is worse at night, or stiffness and pain are relieved by activity - Metacarpophalangeal (MCP), wrist, elbow, or ankle joints are involved• Consider: - Rheumatoid arthritis - Psoriatic arthritis - Ankylosing spondylitis - Gout - Pseudogout (pyrophosphate arthropathy) - may coexist with osteoarthritis - Reactive arthritis - Arthritis associated with connective tissue disorders such as systemic lupus erythematosus - Fibromyalgia - Septic arthritisOther issues to consider:• Fracture of the bone adjacent to the joint• Major ligamentous injury (recent and old injuries)• Bursitis• Cancer• Lumbar radiculopathy • Suspect sciatica if there is: - Radicular Pain - unilateral radiating leg pain - Low back pain - if present, it is less severe than the leg pain - Radiculopathy - numbness / tingling (paraesthesia) / muscle weakness suggests nerve root compression - Positive straight leg raising test • Examination of the hips and knees will reveal most of the conditions with symptoms similar to sciatica• DO NOT routinely X-ray the spine to confirm the diagnosis


See individual pathways

Investigations See individual pathways






DIAGNOSIS: OTHER SOFT TISSUETYPE OFINFORMATION GUIDELINES


Tendon Pain• Patellar tendon• Quadriceps tendon• 2 phases of tendinopathy continuum: - Reactive/early disrepair – tendon response to rapid overloading e.g. increase in training, unaccustomed activity, also direct trauma to the tendon. Tendon swells due to water moving into the tendon matrix rather than inflammatory process. Usually reversible. Early disrepair follows reactive tendinopathy if over loading continues. - Late disrepair/degenerative – over loading continues, may be neuronal growth and increase in vascularity. Progresses to degenerative tendinopathy with changes to tendon structure, making load bearing less efficient. Tendon appears thickened and there is risk of rupture with continued over loading.• Lack of correlation between pain and pathology• Psychosocial factors can play a significant part, especially fear and that tendon pain has a significant impact on life and daily activities• May be association between persistent tendon pain and sensitisation of the nervous system

BursitisBursa are small fluid filled sacs that reduce the friction between two surfaces. They allow muscles to move freely as they contract and relax without being subjected to too much strain or friction.• Prepatellar bursitis – anterior knee, inferior to patella. Also known as Housemaid’s knee• Common problem for people who spend long periods kneeling e.g. carpet layers/roofers• Pes Anserine bursitis – medial knee, sits between MCL and tendons of gracilis, sartorius and semitendinosus - Pes Anserine bursitis of the knee usually develops from overuse and most commonly affects runners• Semimembranosus bursitis – posterior knee, sits between tendon of semimembranosus and medial head of gastrocnemius muscle. Is intimately attached to the posterior capsule of the knee joint and its bordering muscles. It may communicate with the knee joint by a small opening. Also known as Baker’s cyst• Infrapatellar Bursitis - There are two types of infrapatellar bursitis. The superficial infrapatellar bursa sits between the skin and the patellar tendon and the deep infrapatellar bursa sits deeper, behind patellar tendon cushioning it from the tibia behind• Iliotibial Bursitis – Lateral knee, the iliotibial bursa sits between the iliotibial band and the tibia, just below the knee. It is often misdiagnosed as iliotibial band syndrome

Septic Bursitis – see page 5

Subjective history

Tendon Pain• May report increase in loading such as running further/faster/uphill• May have had trauma to tendon• Anterior knee pain• May be reproduced during aggravating activity or up to 24 hours afterwards

Bursitis• Non-septic bursitis - when bursitis is caused by a trauma to the knee, swelling and other symptoms may appear within 24 hours• When bursitis is caused by repetitive actions such as repeated kneeling, symptoms may appear more slowly, over several days or weeks.




Tendon pain• Pain on squatting, increased with increased depth of squat• Tenderness on palpation• Assess hip, knee and ankle/foot also• May be evidence of central sensitisation - 3 major classification criteria; - Evidence of pain or perceived disability that is disproportionate to the nature or extent of the injury or pathology (this is an obligatory criterion) - The presence of diffuse pain, allodynia and hyperalgesia (different to typically tendon pain which is often well localised) - Hypersensitivity of senses unrelated to the musculoskeletal system e.g. bright light, sound smell, heat or cold

Bursitis• Non-septic bursitis - localized swelling - An inflamed prepatellar bursa swells up with fluid, this can be felt and seen through the skin• As it progresses, the knee joint can look double in size. Swelling can feel soft, may appear as obvious lump• Pain level can vary may feel achy, may just feel tenderness with increased pressure on the knee, for example when kneeling or just pressing down on it. Some patients with non- infected (aseptic) knee bursitis report no tenderness or only mild tenderness• Generally, as the swollen bursa increases in size it will become more tender and painful, particularly if the bursa gets squeezed during extreme bending or straightening of the leg

Investigations Tendon pain• X-Ray / MRI if traumatic onset or diagnostic uncertainty• US – commonly show expected changes which do not correlate to symptoms• MRI – Sagittal MRI is the most common imaging technique used to assess IFP pathology including fibrosis, inflammation, oedema, and mass-like lesions• Not all patients have positive imaging

Bursitis• X-ray to rule out patella fracture if symptoms result of trauma• Aspiration if infection is suspected• MRI for rule out soft tissue tumour


Tendon painReactive / early disrepair • Manage load, tensile and compressive e.g. deep knee flexion loads and compresses quadriceps tendon at the femoral condyle.• Reduce load so that healing can occur• Tendons can react during or after exercise, tendon pain can be latent – may also be felt 24 hours later• Ibuprofen thought to inhibit proteins responsible for tendon swelling• Isometric exercise (that does not increase compression) can reduce pain (thought to be centrally driven, supporting theory of central sensitisation’s role) and maintain muscle strength, may be good for early, painful stages• Stretching - compression during stretch may aggravate a reactive tendinopathy


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Tendon painLate disrepair/degeneration• Load management• Concentric / eccentric work• Isometric and strength exercises within tolerable ranges/reps• Some tendon changes may be reversible but is likely to need long term management• Injection – USGI or PRP • Bracing not indicated

Bursitis• Rest, ice, compression, elevation• NSAIDs• Aspiration• Steroid Injection • Physiotherapy – treat as in overuse injuries• Manage load to allow symptoms to settle• Introduce loading gradually• Look at whole kinetic chain


Tendon pain• If non-progression/no improvement after 6-12/12 rehab • Diagnostic uncertainty• Worsening symptoms

Bursitis• If recalcitrant to conservative treatment • Surgery - Bursectomy

ReferencesCook J, Purdam C Is compressive load a factor in the development of tendinopathy? Br J Sports Med 2012;46:163-168.Malliaras P, Cook J, Purdam C, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. The Journal of orthopaedic and sports physical therapy. 2015 Sep:1-33.Mallows A, Debenham J, Walker T, et al Association of psychological variables and outcome in tendinopathy: a systematic review Br J Sports Med 2017;51:743-748.Genin, J et al. Infrapatellar Fat Pad Impingement: A Systematic Review. J Knee Surg 2017; 30(07): 639-646.Dragoo JL1, Johnson C, McConnell J. Evaluation and treatment of disorders of the infrapatellar fat pad. Sports Med. 2012 Jan 1;42(1):51-67.Baumbach, S.F., et al. Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm. Archives of Orthopaedic and Trauma Surgery 2014; 134: 359.Paul Yuh Feng Lee et al. Synovial Plica Syndrome of the Knee: A Commonly Overlooked Cause of Anterior Knee Pain. Surg J 2017; 03(01): e9-e16.

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