CM II Week 8 (Orthopedic/MSK Disorders)

bursitis definition

Painful or painless swelling of the bursa, that function as cushions at major joints

most common locations of bursitis

- Subacromial bursitis (shoulder)

- Olecranon bursitis (elbow)

- Trochanteric Bursitis (hip)

- Prepatellar Bursitis (knee)

history consistent with bursitis

- Overuse, repetitive activity, trauma

- Pain with ROM

- Stiffness, achy, painful, swelling not cosmetically appealing

PE for bursitis

Edema at bursa site, mild tenderness

Rule out infection!! bursa can become infected

Warm to touch, pain with palpation, edema with erythema to surrounding tissues, and pain with ROM

treatment for bursitis

- NSAIDs, stretching, PT, corticosteroid injections

- Bursa aspiration and Ace wrap

- Aspiration, gram stain, culture, and antibiotics if infection is suspected

tendonitis

condition where a tendon (tissue that connects muscles to bone) becomes inflamed and causes pain

most common locations for tendonitis

- Shoulder tendonitis

- Tennis/Golfers elbow

- Achilles tendonitis

- Patella/Quad tendonitis

- Wrist tendonitis

- De Quervain's tenosynovitis

history consistent with tendonitis

- Overuse, repetitive activity, trauma

- Pain, worse with ROM and activity

PE of tendonitis

Pain to palpation localized at tendon site. May have associated swelling.

treatment for tendonitis

- Rest

- NSAIDS

- stretching

- PT

- corticosteroid injections (be careful of tendon rupture)

what are the three bones of the shoulder?

- Scapula

- Humerus

- Clavicle

joints of the shoulder

- Glenohumeral

- Acromioclavicular

- Sternoclavicular

- Scapulothoracic

epidemiology of subacromial impingement syndrome

- Most common cause of shoulder pain

- Accounts for 44-65% of shoulder disorders

what is the pathophysiology of subacromial impingement syndrome?

Combination of....

Extrinsic compression: Rotator cuff is between humeral head, anterior acromion, coracoacromial ligaments, and acromioclavicular joint

Intrinsic degeneration: Supraspinatus- constant microtrauma of the supraspinatus leads to degeneration and imbalance of the glenohumeral joint causing superior migration of the humeral head and narrowing of the subacromial space

Inflammatory process: Inflammation of subacromial bursa causing impingement surrounding structures (humerus, rotator cuff, and acromion)

subacromial impingement is the first stage of

rotator cuff disease which is a continuum of disease:

- Impingement, bursitis, tendonitis

- Partial to full-thickness tear

- Massive rotator cuff tears

- Rotator cuff arthropathy

hx consistent with subacromial impingement syndrome

- Overuse, repetitive activity

- Shoulder pain, worse with overhead lifting or reaching, can radiate to lateral upper arm (deltoid area)

PE findings of subacromial impingement syndrome

May have pain to palpation along subacromial joint space

Range of motion (ROM) typically normal (if not think adhesive capsulitis)

+/- weakness secondary to pain with abduction or supraspinatus strength testing

PE findings of subacromial impingement syndrome - special tests

- Hawkins test - positive if internal rotation and passive forward flexion to 90° causes pain

- Neer impingement test - positive if passive forward flexion >90° causes pain

imaging for subacromial impingement syndrome

XR: AP and lateral (Y-view)

- +/- Proximal migration of the humerus

- Traction osteophytes

- Calcification of the coracoacromial ligament

- Cystic changes within the greater tuberosity

treatment for subacromial impingement syndrome

- Anti-inflammatory (NSAIDs), Ice, activity modifications

- Physical therapy (rotator cuff strengthening)

- Subacromial steroid injection

- DO NOT put patients in a sling for impingement syndrome!!! to avoid stiffness and adhesive capsulitis

If patients fail conservative management, order an MRI of the shoulder to evaluate for underlining rotator cuff injury

what are the four muscles that cover the scapula?

SITS!

- Supraspinatus

- Infraspinatus

- Teres minor

- Subscapularis

epidemiology of rotator cuff tears

- Age > 60: 28% have full-thickness tear

- Age > 70: 65% have full-thickness tear

risk factors of rotator cuff tears

- age

- smoking

- hypercholesterolemia

- family history

pathophysiology of rotator cuff tears

Chronic degenerative tear:

- Older patients: usually involves supraspinatus, infraspinatus, and teres minor (SIT)

Chronic impingement

- Bursal surface or within the tendon

Acute avulsion injuries:

- Acute subscapularis tears seen in younger patients following a fall

- Acute SIT tears seen in patients > 40 yrs following a shoulder dislocation

hx consistent with rotator cuff tears

- Pain located anterior and lateral shoulder

- Pain radiating to the deltoid and down the arm (pain does not radiate below elbow)

- Tears are mostly atraumatic, with progression of pain and weakness over time

- Acute tears are associated with trauma (sports injures, direct blow to shoulder or fall on outstretched hand)

- Pain at night or inability to sleep

- +/- Arm weakness

PE findings of rotator cuff tears

- +/- Limited active ROM, passive ROM is generally full

- +/- Neer and Hawkins impingement signs

Mainstay of PE -- special tests to evaluate each rotator cuff tendon:

- Drop arm test (inability to hold the arm in an abducted position against gravity) indicates large rotator cuff tear

- Positive Empty can or Jobe test (weakness with resisted abduction) indicates supraspinatus tear

- Weakness with resisted external rotation indicates infraspinatus tear

- Positive lift-off or belly press test indicates subscapularis tear

belly press test, bear hug test, lift off test pic

Imaging for rotator cuff tear

XRAY

MRI (gold standard)

Ultrasound

rotator cuff tear XRAY findings

Calcific tendonitis

Cystic changes in greater tuberosity

Proximal migration of humerus head seen with chronic cuff tears

MRI findings in rotator cuff tear

Able to accurately evaluate muscle quality (size, shape, degree of retraction of tear) and atrophy

Ultrasound findings in rotator cuff tear

inexpensive

user dependent

Rotator cuff tear treatment

•Tx determined by size of tear

•Initial tx may be the same as subacromial impingement (partial tears involving less than 60% of tendon)

Arthroscopic or mini-open rotator cuff repair is the treatment of choice for full thickness tears

What can advanced rotator cuff disease lead to

glenohumeral DJD

which leads to rotator cuff arthopathy and advanced shoulder osteoarthritis

how do anterior shoulder dislocation occur

Forceful traumatic injury that occurs when the shoulder is in an abducted and externally rotated position

epi/risk factors of anterior shoulder dislocation

•One of the m/c shoulder injuries

•Anterior dislocation >> posterior dislocation

•80-90% in teenagers

RF:

contact sport

military

collagen disorder (Ehlers-Danlos and marfan)

anterior shoulder dislocation can lead to secondary injuries such as

•Labrum & cartilage Injuries (Bankart)

•Bone defects or fractures (Hill-Sachs)

•Nerve injuries (axillary nerve)

•Rotator cuff tears

Important hx for anterior shoulder dislocation

loss of motion

arm feeling "dead"

history of traumatic event leading to sx

PE for anterior shoulder dislocation

Visible deformaties and LOM

Decreased sensation along deltoid (early finding)

Shoulder dislocation special tests

•Load and Shift test

https://youtu.be/txARar71h5E

•Apprehension sign

https://youtu.be/jZ29dAXKA5M

•Relocation sign

https://youtu.be/YX1uJhjhwWg

•Sulcus sign

https://youtu.be/vV7u2JtdYWI

Anterior shoulder dislocation imaging

XRAY - Gold standard for shoulder dislocations

MRI +/- arthrogram

MRI +/- arthogram

help diagnose shoulder pathology secondary to dislocation (labral, rotator cuff tears)

anterior shoulder dislocation treatment

conservative management

Reduction – May need to do this in the ER for conscious sedation

• Techniques: Kocher, Hippocratic, Stimson's

Short term immobilization less than 1 week

PT

anterior shoulder dislocation treatment

surgery

Arthroscopic/open shoulder surgery

posterior shoulder dislocation occurs when

trauma that occurs when the shoulder is in a flexed, adducted and internally rotated position

Which is more common an anterior or posterior dislocation and why?

Anterior bc there is more muscle and ligaments in the posterior side

epi/risk factors for posterior shoulder dislocation

•Posterior << anterior dislocations (but more commonly missed)

•50% are undiagnosed in ER

•Chronic microtrauma from overuse seen in football Lineman, weightlifters, and overhead athletes

RF:

seizures

electric shock

collagen disorders: Ehler's-Danlos and marphan

Important hx in posterior shoulder dislocstions

•Loss of motion

•History of repetitive pushing with the arm in forward flexed position

•History of traumatic event leading to symptoms

•Vague pain

PE findings with posterior shoulder dislocation

•Visible deformity and loss of motion

•Limited external rotation

•Shoulder locked in internal rotation

Posterior shoulder location special tests

•Jerk test

https://youtu.be/j_qG1MNOws8

•Kim test

https://youtu.be/-knsALCdv_A

•Posterior stress test

https://youtu.be/CHzJk5IeCkk

•Posterior load and shift test

https://youtu.be/txARar71h5E

Posterior shoulder dislocation imaging

XRAY (gold standard)

MRI+/- arthogram

Xray findings in posterior shoulder dislocation

"Light bulb" sign

MRI+/- arthrogram in posterior shoulder dislocation

help diagnose shoulder pathology secondary to dislocation (labral, rotator cuff tears)

Posterior shoulder dislocation tx

Conservative management

•Reduction – May need to do this in the ER for conscious sedation

•Immobilization for 4-6 weeks in external rotation

•PT

Surgery

•Arthroscopic/open shoulder surgery

adhesive capsulitis

Inflammatory process causing fibroblastic proliferation of joint capsule leading to thickening, fibrosis, and adherence of the capsule to itself and humerus

Common age/gender for adhesive capsulitis

women ages 40-60

Factors associated w/ adhesive capsulitis

trauma- status post humerus fracture, long periods of immobilization, chest or breast surgery

idiopathic

Risk factors of adhesive capsulitis

•Diabetes #1 Risk factor

•Rheumatoid arthritis

•Thyroid disorders

•Cervical disc disease

PE of adhesive capsulitis

•Restricted passive and active ROM

•Pain intensifies with full ROM during exam

Dx of adhesive capsulitis

•Adhesive capsulitis is a clinical diagnoses

•Use imaging to rule out differential diagnosis

adhesive capsulitis tx

Conservative management

•Self limiting: 1-2 years

•Physical therapy 3-6 months

•NSAIDS vs. Steroids

•Cortisone injection

Operative management

•Manipulation under anesthesia

•Arthroscopic capsular release

lateral epicondylitis (tennis elbow)

overuse injury caused by repetitive overload at the origin of common extensor tendons which causes inflammation and microtears.

lateral epicondylitis (tennis elbow) epidemiology

-more common cause of elbow pain

-50% of tennis players

-Common in laborers who utilize heavy tools

-pt 35-60 years old

-workers who engage in repetitive gripping and lifting (can dx w grip strength + track progession)

Important hx of tennis elbow

-lateral side elbow pain

-hx of repetitive supination and pronation

-worse w lifting and gripping

-decreased grip strength

PE of tennis elbow

• +/- Edema over lateral epicondyle

• Point tenderness to palpation over lateral epicondyle

• Pain with resisted wrist extension with elbow extension

• Decreased grip strength

imaging findings in tennis elbow

X-ray: Most likely normal

MRI... No need for MRI

•MRI changes often present in sx patients

•Increased signal intensity at ECRB tendon may be seen (50% of cases)

imaging not great for tennis elbow

Tennis elbow tx

•80-90% resolve with or without tx w/in a year

•NSAIDS/Activity modifications

•Bracing: Counterforce brace, wrist brace

•PT

•Injection: Corticosteroid, platelet rich plasma (PRP)

Surgery

•Release and debridement of ECRB origin

•Reserved for those with persistent symptoms for over a year

•70% of patients with good to excellent outcomes

Medial epicondylitis (golfer's elbow)

Tendonitis/overuse of the common flexor-pronator tendon origin at the medial epicondyle

Golfer's elbow epidemiology

5-10x less likely than lateral epicondylitis

common in tennis, golfers and throwing athletes

Golfer's elbow important hx

•Medial sided elbow pain

•Possible reported history of injury or repetitive trauma of common flexor tendon

•Repetitive elbow use, repetitive gripping, repetitive valgus stress

•+/- Numbness or tingling in ulnar digits

Medial Epicondylitis (Golfer's Elbow) PE

•+/- Edema over medial epicondyle

•Point tenderness to palpation over medial epicondyle

•Pain with resisted wrist flexion

•Elbow stable to valgus stress to rule out UCL involvement

•Evaluate ulnar nerve to rule out cubital tunnel syndrome (can coexist)

Golfer's elbow imaging findings

xray- normally unremarkable, used to r/o arthritic changes, UCL calcification or avulsion fracture in acute trauma

MRI- usually not needed, order to evaluate/r/o other caused of medial-sided elbow pain

Golfer's elbow tx

•NSAIDS/Activity modifications/ICE

•Bracing: Counterforce brace, wrist brace, elbow splint

•PT

•Injection: Corticosteroid, platelet rich plasma (PRP)

Surgery: Not typically recommended

•Open debridement of pronator teres/flexor carpi radialis, reattachment of flexor-pronator group

•Must rule out UCL pathology, cubital tunnel syndrome

*Must rule out UCL pathology, cubital tunnel syndrome

carpral tunnel syndrome

compressive neuropathy of the median nerve at the level of the wrist

Carpral tunnel syndrome epidemiology

most common compression neuropathy of the upper extremity

Carpral tunnel risk factors

female

obesity

pregnancy

hypothyroidism

rheumatoid arthritis

advanced age

chronic renal failure, alcoholism

smoking

Carpral tunnel important hx

•Numbness and tingling in the thumb, index finger, middle finger and radial aspect of the ring finger

•Sx worse at night w/ nocturnal awakening or when driving

•Patient reports needs to shake out the hand to get relief

•Weak grip or hand clumsiness

PE of Carpral Tunnel syndrome

•Inspect for thenar atrophy (severe involvement)

•Diminished 2 point discrimination, microfilament testing in median nerve distribution

•Weakness with resisted thumb abduction

Carpral tunnel special tests

Phalen

Tinel

Pressure test

Carpral tunnel syndrome studies

EMG/NCS = GOLD STANDARD

•Can identify median nerve compression and determine severity.

•Make sure to also eval DDX such as cubital tunnel syndrome, cervical radiculopathy and peripheral neuropathy

Carpral tunnel syndrome tx

Nighttime bracing: Adjust wrist positioning when sleeping (avoid flexion)

Steroid injection

-Can be both diagnostic and therapeutic

-80% have transient improvement of symptoms (20% remain symptom-free at one year)

Surgery: Carpel tunnel release

Slipped Capital Femoral Epiphysis (SCFE)

SCFE is a proximal femoral physis condition that involves slippage of the metaphysis relative to the epiphysis

Slipped Capital Femoral Epiphysis (SCFE) epidemiology

•Most common in adolescents 11-14 y/o (puberty)

•African Americans, Pacific islanders, Latinos

•More prevalent in males 2:1

•Left hip more common but could be bilateral

Slipped Capital Femoral Epiphysis (SCFE) etiology (risk factors)

Obesity #1 risk factor

(higher prevalence in obese male children)

important hx in Slipped Capital Femoral Epiphysis (SCFE)

•Chronic atraumatic hip pain (some may be traumatic)

•Hip pain radiates to thigh, groin or knee

•May only present with knee pain (lead to miss diagnosis)

•Limping

Slipped Capital Femoral Epiphysis PE

Inspection: antalgic gait, limp or waddling

Decrease ROM w hip internal rotation, abduction, and flexion

Weakness +/- thigh atrophy

Slipped capital femoral epiphysis Imaging/findings

XRAY

- ice cream falling off cone (L hip in image)

- growth plate widening or lucency

- blurring of proximal femoral metaphysis

Slipped Capital Femoral Epiphysis (SCFE) tx

Refer to ortho for surgery

Surgery: Percutaneous pin fixation

(+/- prophylactic pin fixation of contralateral hip in high-risk patients)

Avascular necrosis

Condition involving decreased blood along the epiphysis of a long bones

avascular necrosis epidemiology

•Most common location is the hip (femoral head) but may occur at the knee, talus, and humeral head

•More prevalent in males

avascular necrosis etiology risk factors

•Trauma- Femoral head fracture most common cause (effecting medial femoral circumflex artery)

•Alcoholism

•Chronic steroid use

•Sickle cell anemia

•Idiopathic

Avascular necrosis important hx

•Gradual onset of pain

•Pain worse with running, stairs or inclines

•Pain along anterior hip

•History similar like hip arthritis

avascular necrosis PE

•Early onset will have normal exam

•In advance stages will have exam like hip arthritis (pain and decrease ROM with hip internal and external rotation)

avascular necrosis imaging and findings

X-ray

•Sclerosis or cystic changes

•Flattening, subchondral radiolucent lines

•Subchondral collapse of the femoral head

MRI-GOLD STANDARD if x-ray is inconclusive and have a high suspicion. Highest sensitivity (99%) and specificity (99%)

•Bone marrow edema and chondral changes

avascular necrosis tx

conservative management

Bisphosphonates: Some studies show in early stages it may prevent femoral head collapse with subchondral lucency

avascular necrosis tx

surgery

Several different surgical interventions. Procedures:

•Total hip arthroplasty

•Decompression +/- bone grafting

•Rotational osteotomy

•Total hip resurfacing

anterior cruciate ligament tear

knee injury that leads to anterior and lateral rotatory instability of the knee

ACL tear epidemiology

•Half of all knee injuries

•More common in female athletes

ACL tear etiology

•Typically noncontact injury: tibia translates anteriorly while knee is in slight flexion while in valgus

•Common activities: soccer, basketball, skiing, and football

What other tear is common in an ACL tear

lateral meniscal tear (54%)

Important hx for ACL tear

•Patient reports feeling or hearing a "POP" at the time of injury

•Immediate pain and effusion/swelling

•Difficulty weightbearing

•Patient unable to continue activity or complete sporting event

•Acute trauma/blow to lateral aspect of the knee