Orthopedic surgeon Elly LaRoque, MD, presents a guide to the knee problems frequently seen by PCPs, including tips on distinguishing complaints by typical histories and physical exam findings. She clarifies when physical therapy is the right first option versus when prompt referral is warranted, explains how to get useful X-rays, and explores the value of proper care for everyday knee arthritis.
mm. All right. And first I just wanted to introduce my team. So we actually have a very large sports medicine department Now with UCSF. These are all of my partners, some of them are other orthopedic surgeons and then some of them are primary care sports medicine specialists specializing in for example injections such as PRP. And we all work together. So definitely a lot of us to refer to for any of your knee patients. And today I'm going to be talking about diagnosis and treatment of common knee injuries for the primary care provider. These are my disclosures and goals for today is to review common acute knee complaints in terms of diagnosis and also coming up with appropriate treatment options and also to understand differences in presentation that might prompt early referral. So what are some of the most common knee problems? Here are some examples. These are the ones we're going to cover today. So arthritis is very common, acute cartilage injuries. Meniscus injury. A cl tears, M. C. L. Sprains or tears and patella femoral pain. So we'll start with meniscal tears. These are very common. So mechanism of injury for a Meniscus terror is usually rotation of the femur against a fixed tibia during flexion and extension. Usually with a twisting mechanism. So often these patients come in they have a history of a twisting squatting or cutting injury. The clinical signs can be joint line pain giving way if the terror is unstable and shifting around the knee for example clicking and sometimes effusions and occasional locking where the knee literally gets stuck and we'll talk about one of those types in a few minutes. Mhm. So treatment of meniscus terrors as really all over the map and we really cater the treatment to the individual patient. So treatment for these terrors is based on the amount of pain and also if the patients have any mechanical symptoms such as catching or locking and also the tear pattern. So if the meniscus tear disrupts the mechanics of the knee and the patient does not respond to physical therapy, then surgery is usually indicated. And there are two main surgical options debridement, which is trimming. If we do that, we remove as little as possible, but then we also do repair meniscus tissue where we actually put internal stitches into the meniscus within the joint that then allows it to heal properly. And older patients with arthritis who don't have mechanical symptoms are usually treated with physical therapy and or injections. So here's some indications for knee surgery for a meniscus terrors. Meniscus terrors that are not degenerative or chronic. So in acute meniscus terror, a bucket handle tear and meniscus root tear. So these ones in red, we're gonna dive into a little a little further. All right case number one um I hurt my knee. This is a 52 year old woman with right knee pain. She felt a pop three weeks ago when stepping off a curb. The pain is located on the inside part of her knee. So medial, it's worse with activity and her knee has been very swollen On physical exam, she has slight various alignment on standing, that means she's a little bit bowlegged range of motion is from 0 to 125°. So decreased with flexion, she is stable to various and bogus stress. So side to side she is tender to palpitation along the medial joint line. And she has pain with flexion and a moderate effusion. So she's still very swollen even three weeks out from her injury. So what are we thinking is the likely diagnosis? Well, I would definitely think about meniscus tear and in this particular situation I would think about a meniscus root tear. So these are some keys from her history. So this was a low energy mechanism for a meniscus injury. So she just stepped off a curb. It's still swollen even though it's been three weeks. She's also tender to palpitation along the medial joint line. She has pain with flexion that that fits with a meniscus tear and she is still swollen. So moderate effusion. So I'm gonna tell you a little bit about meniscus route tears and what makes these unique. Um and so again this patient was 40-60 years old and these meniscus route tears often occur in people in this age group and more commonly in female than male patients. Usually these patients um do have an acute event, but it's a relatively minor event. So really the last few patients I've had with these tears that came into my clinic just say how to make a step or step off a curb. They usually here feel a pop. Their pain is usually more posterior than just medial joint line and they do swell a lot now why these terrors are important to recognize is that if missed and not repaired, these terrors can lead to rapid development of arthritis as if the patient had a total mastectomy, meaning as if the patient had their whole meniscus removed in that area. However, root repair restores normal contact forces and is indicated urgently in patients who don't have arthritis. So to explain a little more, this is looking at say the tibia. These are the two meniscus disks right here in purple. The meniscus is only securely attached to bone in the very front and the very back and those are called the roots. The rest of the meniscus is just loosely attached to um to the joint to the joint lining. So if for example, you tear the posterior root right here. The meniscus is then detached from the tibia other than in the front. So the meniscus over time with weight bearing will start to extrude and start to just swing out of the joint. So you end up with a gap in the back and extruded meniscus and no more shock absorbing ability in this compartment. So a little more about meniscus function and biomechanics. So the meniscus is very important. We know that it protects the articular cartilage by decreasing the contact pressure. And again with the with the route the meniscus route is the bony attachment in the and turn poster aspects of the meniscus. So right here and right here and Meniscus route Terror is equivalent to total menace. Ectomy can lead to rapid development of arthritis. So we do recommend prompt orthopedic referral if you have a patient um where you're suspicious that they might have a root tear. This is what these root tears look like on MRI. So here's an example of the medial Meniscus route Terror. This is what we call a corona view. Looking at the need from the front here is the femur, here is the tibia. Okay uh this is lateral, there's the fibula and this is medial. So this patient had a medial root tear. So you can see this medial meniscus tissue all the way down to the root here. And then you see this blank area. This is where the root is torn and over time the meniscus will actually swing out of the joint and extrude and it will be located for example over here and it's not shock absorbing anymore. This is an example of a medial root tear on a sagittal image. We actually call this a ghost sign because you see the anterior root tissue here and the in the back. You just don't see it very well. It looks hazy and that's because it's not present or it's torn. So we repair meniscus route tears differently than we do other types of meniscus tears. So we actually repair these tears through bone tunnels in the tibia. So we put structure through the route here and then we dunk that into the tibia in a trough and run a tunnel with the future's all the way out to the front cortex of the tibia and secure the future's here with either a button or an anchor. So here's an example in one of my patients um we luggage tag or lawsuit these permanent futures to this torn root tissue and then we cinch it down to the tibia here and hold it to the tibia through a tunnel with an anchor or a button. Now this study looked at meniscus tears treated with non operative treatment versus just clean up, which we call debridement versus repair. And this is pretty staggering. So at 10 years, the rates of osteoarthritis were as follows. So 95% with non operative treatment, 99% with menace ectomy. So menace ectomy of these terrors actually makes the arthritis worse. And then 53% with meniscus root repair. So this just shows that meniscus root repair is cost saving and can decrease the likelihood of knee replacement surgery. So here's the again this just helps demonstrate the natural history of root tears. So here's a picture of a weight bearing X ray after say a twisting low energy injury right here. You see this patient has a little bit of medial narrowing but not too bad. Here is the patient's MRI. So you see they do have a ghost sign here where you don't see the back of the medial meniscus very clearly. By the route there's actually some bone bruising here probably because the meniscus is now torn and not shock absorbing the bone properly. And then you see uh the route on this uh the root tear on this communal view as well. Now four months later look what happens, this is just four months later. So you're getting more and more narrowing and within 10 years often that will go to bone on bone. Okay, so again just the importance of recognizing the root tears and prompt MRI and probably prompt referral to Ortho. So the next type of meniscus terror I just want to highlight is called a bucket handle. Meniscus terror. Now these are more common in young people. So I'd say people under around the age of 30 or 40 more active patients usually an acute injury usually medial but rarely lateral. Um these terrors can actually cause a locked knee and the most common way the knee locks is that the patient cannot straighten the knee all the way they usually have an effusion. And what happens is if this is say a normal meniscus disc always tell patients that looks like a half rubber O ring um that you'll have this bucket handle tear. And this bucket handle can literally flip around and most commonly tears in the back and flips to the front. So then you get this chunk of flipped minusca tissue in the front where it shouldn't be there and then it locks the knee where they cannot extend all the way. So these tears also benefit from a more urgent repair. Here's an MRI example. So this is a sagittal view. So this is the back of the knee, this is the front of the knee, this is the femur and the tibia. Normally you want a big black meniscus robust triangle back here and you see here you see the meniscus triangle in the front, but you see almost like a double meniscus in the front. So this piece of meniscus is flipped to the front and actually should be the rest of the meniscus triangle back here. So here's an example of an unstable bucket handle tear with meniscus tissue flip to the front of the knee. So this patient probably has difficulty with full extension. Here's an example of what we see in surgery. So this is me say trying to enter the medial compartment here is the media former condo with the cartilage, here's the top of the medial plateau. You're not supposed to see a chunk of meniscus tissue here. So here is the torn and flipped. Meniscus tissue that's locked in the front where it should be in the back. We can actually take a trow car or a probe and we reduce it. So here I pushed it back where it belongs in the back of the medial compartment. And then we actually repair it with internal permanent futures. So these are the different futures that we put in. And then usually with these tears and root tears after repair. The patients are on crutches and have limited weight Marion limited flexion for about six weeks. Okay, here's another meniscus terror example of one of my patients. So this is a 54 year old male. He's had three years of mild medial knee pain but it really only bothers him when he plays tennis but he can still play and you can see this tear to me just looks more degenerative. It just looks more irregular, maybe afraid. Terror complex terror. His knees not locking his symptoms are mild. This is one that I actually just recommended physical therapy and they leave alone unless it gets worse. So a lot of my meniscus tear patients, even though they have some symptoms, they do not need surgery. So here's another another case. This is case number to my knee hurts. So 28 year old woman comes in with a new bilateral knee pain. She tells you she's recently increased her running mileage. The pain is vague and located towards the front of the knee. It's worth worse with stairs and hills worse. Was sitting for prolonged periods of time and no swelling on exam. She has full range of motion, good standing alignment, no patellar instability and she's tender along the patella laterally. You check her hip abductor and it's weak and she does not have an effusion in either knee. So, what am I thinking about with this patient? Patella femoral pain syndrome? I'm sure many of you have seen a lot of patients with patella femoral pain syndrome, one of the most common new patient visits that I get as well. So here's some keys here. It's bilateral knee pain recently increased mileage. Okay, so a nickname for this is runner's knee. So sometimes when people increase their mileage or all of a sudden, they moved to san Francisco from Chicago where it's flat. And now they're all of a sudden running on all these hills that can set it off as well, worse with stairs and hills worse after sitting for prolonged periods of time. No swelling tender along the patella patella laterally. Usually it's the lateral facet that hurts more than the medial. They often have weakness with their hip abductor and usually don't swell. All right, so again, a little more about patella femoral pain syndrome, demographics, it's the most common diagnosis for knee pain in the outpatient setting. It occurs in about 16 to 25% Or it encompasses 16- 25% of injuries and runners. It's usually an a traumatic onset. Often associated with change in activity level. So again increased mileage or all of a sudden running a lot more hills or stairs, maybe unilateral or bilateral activity related pain, worse with stairs and inclines but also pain was sitting. The pain is located behind the patella, towards the front of the knee and often vague pain and no swelling and no catching. These patients can get grinding but no locking or catching. So here's some common exam findings with these patients. Um They're standing alignment usually would either look fairly neutral or naive august meaning they might be a little bit knock me that makes the kneecap track more laterally. Um I always check the feet in these patients so I just have them stand up with socks or bare feet and just see if they look like they have flat arches or are prone ated. Um You can look at dynamic patellar tracking so to do this you just have the patients sit on the exam table with their knee bent at about 90 degrees and relaxed and then you can have them actively extend their knee into extension and there is something called a J. Sign where sometimes you'll see as they get closer to extension the kneecap will start to track more laterally. Sometimes they have muscle atrophy in the VM. O. Area not not that common. I do check hip abductor strength in these patients and usually it's weak. Usually they have full range of motion. They might have some crevice with range of motion. Or if you push on their kneecap that's called the patellar grind test. That can suggest just inflammation but also that they might have a little cartilage wear and the kneecap joint. And then sometimes their I. T. Bands and hamstrings are tight. Sometimes their quadriceps are tight as well. Those are also risk factors for patella femoral pain syndrome. And then usually we get X rays on these patients including what we call a merchant or sunrise view that allows us to look at the kneecap joint. And it's common that you'll see a little bit of lateral patellar tilt. Such as on this patient. So treatment for patella femoral syndrome. Uh The real work forces physical therapy. So the physical therapist will focus on patellar mechanics and control. Quarter step strengthening especially the VM. O. Stretching for the lateral structures like the IT band hip hop. Doctor strengthening. They'll often experiment with patellar taping and see if that helps at least temporarily. And then um also consider shoe inserts or arch supports. Just even over the counter. Not necessarily custom orthotics. And then if patients patients ask about well what should my activities be? Well I'm being treated for this. Um You do want to identify the inciting activities such as running. Um And then just have them go back to their prior level of running. Say their prior distance and then gradually ramp up again. But they can also hold off on running until they get started with physical therapy. So does physical therapy really work for Patel ephemeral pain? Well I I say yes, so for example with this study they looked at female patients and they just did hip strengthening. So 28 people randomized to hip strengthening versus control over an eight week program and pain health status and bilateral hip strength improved in the exercise group. And improvements in pain and health status were sustained at the six month follow up in the exercise group. So physical therapy really does work for patella femoral syndrome. However, there are some refractory patella femoral cases. So if say your patient has done physical therapy and they are just not improving, feel free to even order an MRI and or refer to us in sports medicine. Sometimes the patients have a lot of rough or warm cartilage under the kneecap, that might be why they're not getting better. Um It actually looks like crab meat and so sometimes then they need, for example in arthroscopy for what we call a condo plast e where we can clean up the cartilage in these cases this is me cleaning up the rough patella femoral cartilage in this patient. And sometimes for example we could do an injection as well. Okay here's case three. So this is a female patient who was playing soccer, she's 26 years old, she had an acute right knee injury while she was playing soccer three days ago it was a contact injury when another player slid into her leg she does not think she heard her felt a pop. She has pain on the inside part of her knee. She was unable to keep playing but did not really notice any swelling in the knee and her knee has been overall feeling a lot better but not yet back to normal on exam. She has range of motion 0 to 100 degrees. She's tender along the medial femur and medial aspect of the joint. So also along the medial joint line. No effusion and pain with Valdez stressing but no gapping. So she has pain when you value stress her but it doesn't open up a lot and her Lockman which is a test for a cl is negative. So what do we think is happening here? I would be suspicious for an M. C. L. Spring and here's some of the key points. So an M. C. L. Sprain. It's usually a contact injury when somebody slides into say the outside aspect of your leg. You have pain on the inside part of the knee. She was unable to keep playing. Sometimes you are but did not notice any swelling at the knee. That's different from some other situations and pain with Valdez stressing. Okay so M. C. L. Injuries. Again it's usually a contact injury hit on the outside of the knee. Sometimes they're isolated but sometimes associated with for example tears of the A. C. L. Medial lateral meniscus or a patellar dislocation. And often with these patients if you end up getting imaging they will have a contusion or a hairline fracture in the lateral compartment of the knee. Um Do to do to impact their because they essentially have a valdas impact type type stress to the knee and M. C. L. Is the most commonly injured knee ligament. So here's an example of a football player. This player hit the lateral or outside part of the knee and the knee goes into Vegas and stresses or strains the M. C. L. So here's the M. C. L. Here it runs from the femur to the tibia. So again these patients usually will have medial sided pain. It'll hurt if they twist. They usually have tenderness along the femur or the the ephemeral attachment of the M. C. L. Is the most common. They can have some stiffness but not into articular swelling. So the M. C. L. Is actually a broad ligament that is outside of the knee joint. So if you detect an intra articular effusion fluid in the super patellar pouch under the kneecap there's probably something else going on. Um So this will all help you differentiate between an M. C. L. Sprain and a medial meniscus tear based on the injury mechanism, presence or absence of fluid and also clinical exam. So um you want to stretch or to test these patients with the values stress test. So the value stress test is applied at 30°. And you note if the patient has pain and also if the patient has any instability and we grade the instability based on how loose it feels. So how much the joint space opens and also endpoint feel. And we always compare this to the contra lateral need. So if if if the ligament feels loose to you or there's just not a good end point feel free to refer to us if it feels stable. But the patient just has a little bit of pain when you do the test and they don't really have much swelling then you can actually feel free to treat these yourselves and not necessarily get an MRI. So the overall treatment depending on how bad the sprain is for M. C. L. Is a brace Uh non weight bearing or weight bearing an extension just until the pain decreases. And we usually do get these patients and physical therapy to help them regain their range of motion and strength more quickly. And it's usually about 6-12 weeks for return to sports. So indications for imaging with what you think is an M. C. L. Sprain. If they have a joint effusion, any blocked emotion or concern for another ligament injuries such as A. C. L. P. C. L. L. C. L. Or Postrel lateral corner. But again no need for routine MRI with an isolated grade one or two or what we consider a mild spring. This is what uh what M. C. L. Springs look like radio graphically. So here's the inside of the knee. This is the medial meniscus here. This is all M. C. L tissue. Usually you want it to look more like just a thick black rope and see how with this one there's a lot of white and gray on it. It just looks thickened from medial to lateral. This would be an M. C. L. Sprain and the under surface of the N. C. L. Actually attaches to the medial meniscus. So um if you have questions at the end, I can help differentiate to how do you differentiate between san mgl sprain versus a medial meniscus terrorists? And as people have both. Um But again with M. C. L. Sprains you really don't get fluid Um in the joint and often you have more pain and tenderness on the femur here than you do at the actual joint line. And with an M. C. L. sprained, you'll have pain with val just stressing at 30°. Usually you do not have that with the meniscus tear. Okay so for this next case this is also a a soccer injury but some of these details are different. So this is a 26 year old male with a right knee injury while playing soccer three days ago it was a non contact twisting injury he felt to pop. He mostly has pain on the outside of his knee, he was unable to keep playing lots of swelling shortly after the injury and the knee is starting to feel better but still not yet back to normal on exam, his range of motion is 0 to 100 degrees. He's tender along the lateral joint, moderate diffusion, he's stable to verisign, values stress. Okay, so unlike the last patient and he does have a positive Lockman. So we call it A to B. But a positive Lachman. So with this patient I would be suspicious of an A. C. L. Tear. Here's some key points. Most a cl tears occur in a non contact injury. Okay, about 80% or so. Um you usually feel or hear a pop. The patient was unable to keep playing and these swell a lot early on. So a few days later the patient still has a moderate effusion. And Lachman is the most sensitive physical exam test for a cl terror and he had a positive Lachman. So, diagnosis of facial injuries with the history again, usually noncontact twisting or jump landing. Usually they hear a pop swell right away, they don't return to play and if you end up seeing a patient a few weeks after this injury, often they all of a sudden feel better, their knee might feel unstable but pain wise they feel better. So even chronic untreated a cl chair patients will often have little to no pain. So in this case though if you do have a patient with a large and acute traumatic effusion these are other things you want to think about. It's not always a meniscus tear. Okay so um or an A. C. L. Tear. Often it is an A. C. L. Terror but you also want to think about patellar dislocation. Patellar or quadriceps tendon rupture or a fracture or a major control injury such as knocking out a piece of articular cartilage that's floating around the knee that will cause the need to swell. So on exam these are some additional things. In addition to say the Lockman that you can test to help differentiate from these other potential injuries. So you'd want to check the extension mechanism function to do that. You can just have the patient sit and then straighten the knee actively. Or you could also have them just lay down and with the knee straight. Just try to lift the leg off the table. Okay that would prove that the patellar tendon and quadriceps tendons are intact. You can also test the Lockman and see if that's positive that would be an A. C. L. Tear. And then if you're suspicious for say a patellar dislocation you can just gently move the kneecap back and forth and see if it feels looser than the other side and if that causes them to feel apprehensive and then any acute knee injury with an infusion we usually want to at least get an X ray for these patients. Usually we get an MRI as well. Okay and then this is just showing the Lachman test. So you want to do it at 30 degrees and you always want to compare to the contra lateral side because everybody's ligaments feel different and you want to check how much the tibia is moving in terms of excursion but also how firm the endpoint feels and it's the most sensitive tests for a cl rupture. These are some findings for an act of terror on an MRI once the MRI is obtained. So when I show these two patients, I'll often show them what the PCL looks like. Okay so this is a satchel view. Here's the femur, here's the tibia. This is what the PCL looks like. A big thick black rope. Okay the A. C. L. Should be on this view and look very similar to the PCL. So you can see on this view this is the A. C. L. Tear right here. It just looks like somebody set a bomb off in it. It just looks like a rope that's blown up and it's not in continuity. So this is A. A. C. L. Tear. You also see the extra fluid here and then with A. C. L. Tears they often have a lateral joint line pain acutely because they get this bone bruising pattern. So you see some bone bruising in the lateral federal con dial and the back of the lateral tibial plateau and that's indicative of an acute A. C. L. Tear. Okay so treatment options for a cl terrorist now do we do surgery on everybody Know um There is a patient group where I would definitely talk to them about non operative treatment. These tend to be older more low demand people. Um And with these patients they can try physical therapy and activity modify. So do mostly straight ahead activities like hiking, jogging, biking, walking. Those patients might be okay long term without an A. C. L. Reconstruction and then you can also get them uh A. C. L. Knee brace to help them with stability for certain higher level activities. Um And then who do we who do we recommend surgery on for a cl terrace? Well definitely any patient who participates in cutting pivoting or jump landing sports. They will not have confidence in their knee with those activities without an A. C. L. And the other issue is even if they went out and just tried some of those sports without an A. C. L. Then he will give out and then they can damage meniscus and cartilage and other structures in the knee. So it's actually dangerous to participate in those sports without a competent A. Cl. Also patients in high demand jobs we usually recommend um A. C. L. Reconstruction most young people and if say the patient has a large meniscus terror that needs to be repaired. Usually in that patient we would also fix the A. C. L. Because if we fix the meniscus and the knee is still very unstable. That terrible. Probably retire later here a couple of pictures from an A. C. L. Reconstruction case. So this is one that's torn. The stump is right here. It's not attached to the femur anymore and then this is what it looks like after reconstruction right here. Um Now if a patient has an A. C. L. Reconstruction we always tell them that they can target running at about 4 to 5 months post op but return to pivoting cutting sports such as soccer is 9 to 12 months. So that is one kind of major downside with the surgery as we think it just takes a long time for the patient to regain all of their strength and for the graph to biologically incorporate. So we do hold them back for a long time in terms of return to sports activities. Okay so this next case number five Um this patient presents to say your clinic with with knee pain but it's worsening and aching. So this is a 66 year old woman with right knee pain. She did have some mild nip in here and there but she never even mentioned it. It wasn't that bad for about three years. But now all of a sudden she has moderate acute pain after a misstep in that same name. Same name she recalls. She may have had an old injury to that knee in high school with meniscus surgery. The pain is located on the inside part of the journey and it's worse with activity and stares, her knee feels stiff and she has some mild swelling on physical exam. She's slightly bowlegged. We call that barris And her range of motion is from 0 to 125°, so a little bit stiff and she stayed, she is stable to garrison dogus when you stress her. What is the most likely diagnosis? So, I'm thinking here knee osteoarthritis, part of the reason is that she's 66, she has Acute on some chronic pain. She also potentially injured her knee when she was younger with meniscus surgery. So way back when surgeons used to remove a lot of meniscus and now 20 plus years later a lot of these patients are now getting arthritis in that compartment. So arthritis is very prevalent. Okay, it's the most common cause of disability in the US. And about 23% of adults have doctor diagnosed arthritis in in their body. 43% of patients with arthritis report activity limit limitations due to this disease. And patients with knee osteoarthritis have the lowest health related quality of life scores compared to other musculoskeletal conditions. And it's estimated that Um in 2030 There will probably be about 3.5 million total knee replacements done per year in the us and that would be about a 673% increase from 2005. So what is arthritis? I get questions from this from my patients all the time and I just explained to them that it's where and thinning of the cartilage and it's often associated with cartilage roughness, which can cause some grinding. But all arthritis means is just where and thinning of the articular cartilage. So this is what it looks like kind of splotchy worn. The patients have pain sometimes a limp with more severe arthritis swelling, They get stiff and eventually they can also get some deformity. So for example, if the arthritis is just on one side of the knee, like the medial arthritis, they will eventually start to get bow legged or go into various as the cartilage keeps wearing. So these articular cartilage changes unfortunately right now are progressive and irreversible. So this is more normal cartilage at the end of the femur. This is with some pothole moderate wear. And then this is with end stage where where you actually see pink bone on the tibia. Pink bone on the femur here, and this would be the equivalent analogy of healthy cartilage, early arthritis is the tire is uh somewhat worn out and then advanced arthritis is the tire is just bald. So on exam, for example, this patient you sometimes do see some bootleg deformity. Okay, we call that various crepin dis grinding popping because the cartilage gets rough. They sometimes get bone spurs to that can grind and pop loss of range of motion and tender tenderness along the affected joint line. So at this patient I would expect they would be tender along the medial joint line. And one key thing I want to point out here whenever you're ordering X rays just in general, but especially if you're suspicious of arthritis, um you always want to get at least one weight bearing view. So the weight bearing view that we prefer the nickname for it is a Rosenberg view. Um But it's a weight bearing view. It's a p a view Uh where the knee is bent at about 30°. So you can always just order a Rosenberg view and we like to get a bilateral Rosenberg Rosenberg view. So you just see what they're more normal knee looks like too. So here's an example of just mild arthritis. Media li it actually looks pretty decent here in terms of joint space, moderate arthritis, it's more thin and here's severe bone on bone arthritis. I have had some patients where they've seen me and they had saying outside X ray and none of them were weight bearing and the X ray look like this because it wasn't weight bearing. And then when I made them repeat the view. Weight bearing, it actually looks like this. So please get weight bearing views. Um Yeah otherwise it's it's just hard to justify with the insurance and it just takes extra time. Um So weight bearing views are very helpful especially with that 30 degree bent Rosenberg view and get it bilaterally. So what are treatments that we think work for? Knee arthritis? Well these are the treatments recommended by our american Academy of Orthopedic surgeons. So formal physical therapy um usually followed then by a home exercise program. Anti inflammatories and Tylenol at least initially. Or for flare ups. Intra articular steroid injections. I'll touch on some other injections, weight loss and activity modifications. So trying to do more low impact type of activities and physical therapy for me, osteoarthritis does work. These studies show significant improvement in outcome measures and knee pain scores with exercises compared to not exercising. And the benefits are best in those with mild to moderate osteoarthritis. If somebody has very painful bone on bone severe arthritis, just exercise might not be enough to help them with their pain. You can also think about bracing for a certain arthritis patterns. So here's an example of a patient that could benefit from a medial unloading brace. Okay, so um this patient has medial compartment arthritis say their kneecap compartment looked pretty good And the outside of their knee they have good cartilage space here but see it's maybe 80% thinned immediately. They only hurt immediately. You can think about ordering a medial unloading brace. It's also called an off load or brace. Um these do work better than neutral braces or sleeves if a patient is a good candidate. However, they do not help with knee stiffness and there's poor compliance and actual use. One study showed about 20% compliance at a year but something to at least talk to your patient about as an option. Alright, now I'm going to talk a little bit about injections for arthritis. So what are corticosteroid injections? Well, it is an anti inflammatory. We think that they work by inhibiting cox two in foster like a two which are both inflammatory mediators. There are powerful anti inflammatory can be delivered directly into the joint space. They can improve pain, decrease inflammation. They're cheap, safe, generally effective. Some other parts, they're usually covered by insurance. And um what how I describe that these injections to patients is we're just throwing a bucket of water on the fire. Okay. On average they helped for maybe 6-8 weeks. But some of my patients get a lot longer relief. And it's also just like injecting liquefied Advil in the joint is just a lot more targeted and effective than taking anti inflammatories orally. What about how your ionic acid injections? They're also called H. A. Injections or visco injections. Those are all the same. Um So I described these two patients like thick artificial cartilage injections that only helped temporarily. So we think these injections act as a lubricant, they might stimulate the patient's own knee to create more normal synovial fluid. We think some of them have a mild anti inflammatory effect. But there's variable evidence in the studies on the impact with the symptoms in arthritis. So when I first started practice 14 years ago, nearly every insurance plan, including Kaiser also would would cover hyaluronic acid injections. Now almost none of them do other than often Medicare. Um And the reason is just the studies are just mix and match in terms of how effective we think they are. What about PRP? We're getting more and more questions from our patients about PRP and I'm happy to um to answer some questions about PRP in the end. But this was uh a really important study in our literature looking at PRP for knee arthritis versus hyaluronic acid. And the conclusion was that PRP actually worked better for mild arthritis than hyaluronic acid. And the conclusion was also that there were more significant improvements in the knee arthritis, patients with more mild arthritis than um than severe arthritis. Okay, so we actually do think that PRP can work well in patients with mild knee arthritis and probably better then. How you moronic acid. So what about stem cells? I also get so many questions from my patients about stem cells. I just had a patient Friday who paid $11,000 from a physician in the community to have a stem cell treatment for his severe knee arthritis. So um do we think that these work? And what are stem cells? Well stem cells are mesenchymal stem cells is a type of cell that has potential to differentiate into cartilage, bone tendon and muscle. We think that they might then be able to lead to regeneration of tissue. And these cells are present in bone marrow and fat. Mhm. So what are some potential issues though with stem cells While this article came out a few winters ago in the new york times? Um and 12 people were hospitalized with infections from Stem Shell shots from Genentech. So you know a very reputable company and these were amniotic stem cells so not from the patient's own system. And these patients had between 4-58 days of hospitalization. When I read the article these were injected in all different body parts including the spine and the knee and um other unused vials from this batch from Genentech were tested um or tested positive for E. Coli and other fecal bacteria. So obviously there is some type of bad bacterial contamination. So stem cells are not always safe and they are not drugs so they do not need FDA approval. They're not regulated. There are no registries and if you look at most of the stem cell websites um they really advertised based on patient testimonials. So again um talking to the fact that they really are not regulated. There was also an interesting article recently in one of our trusted journals where uh the the journal authors took a bunch of batches of stem cells from a company that we're advertising them as stem cells and selling them to physicians. And in a lot of the batches there were actually no stem cells detected. So there definitely are some efficacy and safety issues with stem cells at this point. This was interesting and shocking article about these. About advertising for stem cells on the internet. Okay. Um so these authors looked at 896 practice websites. So stem cell practice websites and 96% contained at least one statement of misinformation. With a mean of 4.65 statements of misinformation among the sites. So basically false promises or unproven promises And practices associated with an orthopedic surgeon or podiatrist provided 22% fewer statements of misinformation than practices without these specialists. So just scary. I mean, having a board certified orthopedic surgeons or podiatrists involved in the clinic still doesn't necessarily mean that they're advertising ethically and that the stem cells are going to reliably work for these patients. So does arthroscopy surgery, just cleaning up the joint work for osteoarthritis patients. This was a big landmark surgery. Remember this came out when I was in residency? And the answer unfortunately is no, I wish it did work. But just scoping a need for a cleanup scope for arthritis by two years. Just shows that the patients really are no better. So we do not offer knee arthroscopy surgery solely for knee arthritis at this point. Mhm. So what is an option for say moderate to severe knee arthritis where a patient has failed bracing injections? Physical therapy they need a knee replacement. And I have some wonderful partners. I think dr barry gave a talk recently to you on knee arthritis who do perform knee replacements. So we only offer these in refractory cases. A total knee replacement means that the whole knee is replaced, all three compartments, medial lateral and patella femoral. Here's an example of one of my patients who had failed conservative treatment and was still very symptomatic had difficulty even just getting up and down stairs in his own home and he had bilateral knee replacement. He had them both done at the same time which is a little bit unusual but he had an excellent result. So in summary hopefully. Now I've helped you to understand presentation for common acute knee problems and also the importance of getting weight bearing radiographs for optimal evaluation of the joint space, especially in patients who are older where you think they might have arthritis. Also. The importance of recognizing meniscus route tears and understanding the risk of arthritic progression if these tears are left untreated. So please send us your bucket handle and meniscus route tears promptly. And also just work up and differential diagnosis for the presence of an acute effusion with an acute injury and the concern for meniscus cartilage A C. L. Injury. How to differentiate this and other intra articular injuries. Feel free in these patients to get an X ray going and um you're welcome to also get an MRI going in the presence of an acute traumatic effusion. But you're also welcome to send them to us first and then we can differentiate if we think that they need an M. R. I. Or not and thank you very much for your time and I am happy to take questions.