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Choose Wisely – The Knee Ultrasound

Quick & Simple: Knee ultrasounds rarely have any use in the diagnosis of acute knee injuries.

Acute knee injuries are a common presentation in the family practice office. Depending on the suspected injury, the most common imaging modalities ordered are X-ray, ultrasound, and MRI. While the exact total cost of imaging is not widely accessible, the cost of each scan includes the technician’s time, radiologist’s report, and machine use. Thankfully, many acute knee injuries can often be diagnosed clinically without need for further imaging.

Knee ultrasounds can most reliably identify injuries to the external tendons and ligaments of the knee due to the limitation of the ultrasound waves from penetrating bones and thereby assessing deeper structures. This fact may appear confusing, as the radiology reports may comment on the meniscus and even the ACL but with very limited accuracy.

This is where an understanding of the literature becomes important. While some studies may report surprisingly high specificities and sensitivities for evaluation of deep knee structures, they often do not reflect true values for imaging done in the community. From our perspective as clinicians, ultrasound offers a partial and often unreliable evaluation of deep knee structures.

In conclusion:

  • Knee ultrasounds are most reliable for evaluations of quadriceps and patellar tendons, MCL, LCL, and bursitis.
  • While reliable, these diagnoses should be made clinically and immediate imaging is often not indicated.
  • While tempting, at this point, ultrasound does not offer reliable assessments of the meniscus and ACL and should not be ordered routinely for these suspected injuries.
  • Given our LHIN resources, knee ultrasounds should rarely be ordered given the cost and minimal impact on prognosis or treatment.

As always, if in doubt, consider contacting your local sport medicine physician for advice regarding which imaging modality is most appropriate.

 

Nitai Gelber, MD, CFPC
PGY-3 Sports and Exercise Medicine, University of Ottawa

Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

 

References

“AIUM Practice Guideline for the Performance of a Musculoskeletal Ultrasound Examination.” Journal of Ultrasound in Medicine, vol. 31, no. 9, 2012, pp. 1473–1488., doi:10.7863/jum.2012.31.9.1473.

Alves, Timothy I., et al. “US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions.” RadioGraphics, vol. 36, no. 6, 2016, pp. 1759–1775., doi:10.1148/rg.2016160019.

Cova, Maria, and Emilio Quaia. “Faculty of 1000 Evaluation for Clinical Indications for Musculoskeletal Ultrasound: A Delphi-Based Consensus Paper of the European Society of Musculoskeletal Radiology.” F1000 – Post-Publication Peer Review of the Biomedical Literature, 2012, doi:10.3410/f.715297848.790852873.

2018 Consensus statement on exercise therapy and physical interventions

Article Review:

2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017

Collins NJ, Barton CJ, van Middelkoop M, et al

Br J Sports Med Published Online First: 20 June 2018. 

doi: 10.1136/bjsports-2018-099397

 

One of the most common sources of knee pain is from patellofemoral pain and is a common condition that family physicians have to manage. Patients often report significant burden due to a limitation in activity and daily tasks, hence it is imperative to have a firm grasp of the evidence behind current treatment. This past year, the 5th International Patellofemoral Research Retreat gathered in Australia to review the interventions for patellofemoral pain and published the 2018 consensus statement for patellofemoral pain treatment.

6 systematic reviews and 13 RCTs that were published since the last meeting were reviewed and used to update the 2016 consensus statement. No significant changes were made from the previous consensus statements but several new statements were added to address new modalities.

Some highlights of the consensus-based recommendations are as follows

  1. Exercise therapy is recommended and reduces pain in the short, medium, and long terms. It also improves function in the medium and long-term.
  2. Combining hip and knee exercises is superior to knee exercises alone
  3. Combined interventions are recommended to reduce pain in the short and medium term. This means exercise therapy in conjunction with other therapies such as foot orthoses, patellar taping, or manual therapy
  4. Foot orthoses are recommended to reduce pain in the short term
  5. Electrophysical agents (ultrasound, phonophoresis, laser therapy) are not recommended
  6. Patellofemoral, knee and lumbar mobilisations are not recommended
  7. in isolation
  8. It is uncertain whether patellar taping and bracing are helpful with pain in the short, medium, or long term.
  9. It is uncertain whether acupuncture or dry needling reduces pain in the short and medium term
  10. It is uncertain whether manual soft tissue techniques are beneficial in the short term
  11. It is uncertain whether blood flow restriction training is superior to exercise therapy with regards to reducing pain in the short term
  12. It is uncertain whether gait retraining is effective in reducing pain and improving function in the short term

Given there are many areas of uncertainty, it is important for the family physician to be aware of these treatment modalities and how they may apply to the individual seeking treatment. However, there remains a lot of questions to be answered and will require physicians to continually update themselves on the latest available evidence.

Jim Niu MD, CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor Dr. Taryn Taylor BKIN, MSC, MD, CCFP (SEM), Dip Sport Med

 

 

Don’t have to see it to believe it – The Effect of Magnetic Resonance Imaging Scans on Knee Arthroscopy

Don’t have to see it to believe it:

The Effect of Magnetic Resonance Imaging Scans on Knee Arthroscopy: Randomized Controlled Trial Arthroscopy. 2007 Nov;23(11):1167-1173.e1

Multiple pathologies of the knee cannot be picked up on x-ray and ultrasound. Increasing prevalence of MRI has led to increased use. We as physicians may not see the bill for these investigations but they are still a considerable expense for our system. Due to long wait times, the National Health Service (UK) has started to perform MRIs to try and reduce the number of patients that will actually require surgery while in the US, they are questioning whether MRI will actually add value.

A randomized control trial was performed using 252 patients on a waiting list for knee arthroscopy. All patients had an MRI of their knee performed. They were then randomized into two groups; one had their MRIs read by their surgeons prior to surgery and the other did not. Even though the group whose MRIs were read had a diagnosis change in 47% of cases, compared to 1% in the control group, ultimately, the rate of surgery was the same.

Important to highlight that this is American data and they may be more likely to proceed with arthroscopy than their Canadian colleagues. Important to note that a diagnosis change occurred in 47% meaning information from MRI was still of value.

Take away message to consider: Don’t wait for an MRI report to refer to orthopaedics because it is unlikely to change the management plan in patients you suspect will require arthroscopy but still order the MRI as it can provide valuable information for operative planning.

 

Anthony Caragianis, PGY3

Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

The old knee in the young athlete

Article: The old knee in the young athlete: knowns and unknowns in the return-to-play conversation (Ardern CL, Khan KM, British journal of Sports Medicine November 19, 2015, 10.1136/bjsports-2015-095481.)

Written by: Geneviève Rochette Gratton , MD, CCFP, Fellow in Sport & Exercise Medicine at University of Ottawa

Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

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In Sport Medicine, we found ourselves frequently having to discuss pros and cons of returning to a certain sport after an injury with our athletes. The article recently published by the British journal of Sport Medicine reviews all the aspect that should be included in a return-to-play conversation. As an example, the authors use a young female athlete who recently sustained an ACL rupture playing amateur football.

In order to help the athlete make an informed decision, it is our job as physician to give our patients accurate information, and guide them in making the right decision.

What we know:

  1. Regardless of treatment choice (surgical vs non-surgical), the athlete is able to achieve remarkable physical function (meeting impairment-based and activity-based measures)
  2. Likeliness to return to pre-injury level of sport is doubled in 25 years old and younger compared to older athletes. Young athletes have an increased risk (up to 6 times) of re-rupture or new ACL tear when returning to pivoting sports.
  3. Following an ACL injury, most (up to 90%) will develop symptoms of patellofemoral osteoarthritis or post-traumatic tibiofemoral within 10 to 15 years.

What we don’t know:

  1. Is the risk of subsequent osteoarthritis increased with return to pivoting sport? Especially knowing that a new insult could accelerate and increase knee osteoarthritic changes.
  2. Does retirement for pivoting sport reduce the risk of osteoarthritis?
  3. What is the impact of early retirement or changing sport on the quality of life of the athlete?

In this article, a few recommendations are made in regards to what should be discussed with the athletes to help them make the most informed decision:

  • The athletes are in charge of their return-to-play decision. In order to help them, motivational interviewing has proven efficient to help ease the conversation regarding changing, modifying or stopping their sport as well as helping them understand the risk of going back to pivoting sports.
  • It is important to share the decision making with the athlete by explaining the pros and cons of the different treatment options, and to help them understand what is reasonable. In combination with motivational interviewing, this can empower the athlete in making an informed decision.
  • The context of the athlete needs to be taking into consideration when talking about risks. Salaries, endorsement, athletic identity, level of sport, pressure from piers (coaches, families, teammates…) are some of the factors that should be included.

It is important to remember that being an athlete in a competitive sport does not equal being healthy. As clinician, we should be aware that an athlete perception of treatment success can differ from ours, and we should not let our own biases lead the conversation regarding return-to-play. We should aim toward a shared decision-making approach, also helping the athlete differentiate performing from being healthy in order for him to make the best return-to-play decision.