overview primary care sports medicine - ucsf · pdf filethe knee and shoulder overview •...
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A n t h o n y L u k e MD, MPH, CAQ (Sport Med)
Associate Professor, Director Primary Care Sports Medicine
University of California, San Francisco
Advances in Internal Medicine 2008
Primary Care Sports Medicine
Unlocking the Mysteries of the Knee and Shoulder
Overview
• Anatomy and injury biomechanics
• Highlight common presentations
• Discuss high yield physical exam tips
• Discuss basics of conservative and surgical management
Take Home Messages
• History is Key
• Confirm the
diagnosis with PE
• Think
– Age
– Traumatic or
Atraumatic
History is Key
• Numbness
• Fever
Instability Dysfunction
Pain
Who?
What?
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History is Key
When?
• Acute vs Chronic (2 weeks? 6 weeks?)
Where?
• Think anatomy
• One finger test
How?
• Mechanism of injury
Physical Exam
LOOK – Observation
• Swelling, Erythema, Atrophy,
Deformity, Surgical Scars
(SEADS)
FEEL – Palpate important
structures
MOVE – Assess Range of
Motion
SPECIAL TESTS
Provocative tests • Reproduce patient’s pain
Stress tests • Stress structures for instability
(i.e. ligaments)
Functional tests • Assess functional movements
(i.e. weight bearing activity)
Treatment Options
Conservative
• MICE (Modified activity,
Ice, Compression,
Elevation)
• Medications/Analgesia
• Rehabilitation therapy
• Casting/ Braces /
Orthoses
• Crutches
Surgery
• Reconstruction
• Repair
• Re-align
• Remove internal derangement
Case - Knee Swelling
22 year old girl comes has twisting injury in her knee skiing. Develops immediate swelling after injury and has to be brought down by ski patrol
LOOK - effusion
FEEL • Lateral joint line tender -
femoral condyle bone bruise
MOVE
• Maybe limited due to effusion or other internal derangement
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Q1: The first step for the
diagnosis in this case is: 1) Lachman test
2) Anterior Drawer test
3) X-ray
4) MRI
5) McMurray test
Physical Exam = MRI • Physical exam is as sensitive as MRI
• Full agreement Clinical vs MRI 61%,
Clinical vs Arthroscopy 39%, MRI vs
Arthroscopy 50% Clinical and MRI examination correlation (percentage) with
Arthroscopic findings n = 109 patients
Test Meniscus ACL
Sensitivity 38 / 59 100 / 54
Specificity 93 / 50 97 / 92
Positive predictive
value
93 / 76 85 / 43
Negative
predictive value
35 / 32 97 / 95
Madhusudhan,
Journal Orthop Surg Research,
2008
Special Tests ACL
• Lachman's test – test at 20°
• Anterior drawer – test at 90°
• Pivot shift
Malanga GA, Nadler SF. Musculoskeletal Physical
Examination, Mosby, 2006
* - denotes under anesthesia
Sens 81.8%, Spec 96.8%
Sens 35 - 98.4%*, Spec 98%*
Sens 22 - 41%, Spec 97%*
Anterior Cruciate Ligament (ACL)
Tear
Mechanism
• Landing from a
jump, pivoting or
decelerating
suddenly
• Foot fixed, valgus
stress
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L i g a m e n t Anatomy and Biomechanics
Ultimate Ligament Tension
Failure
• ACL: 2200 N (Anterior)
• PCL: 2500 N (Posterior)
• MCL: 4000N (Valgus)
• LCL: 750N (Varus)
• Posteromedial Corner
• Posterolateral Corner
Biomechanical Studies
Forces on the ACL/Graft
• Level Walking = 169 N
• Ascending Stairs = 67 N
• Descending Stairs = 445 N Morrison, Biomech, 1970
Morrison, Bio Eng,1968,1969
• Normal Walking = 400 N
• Sharp Cutting = 1700 N Butler, Clin Orthop, 1985
• Sports = 2000+ N
Anterior Cruciate Ligament (ACL)
Tear
Symptoms
• Audible pop heard or felt
• Pain and tense swelling in minutes after injury
• Feels unstable (bones shifting or giving way)
• “O’Donaghue’s Unhappy Triad” = Medial meniscus tear, MCL injury, ACL tear
• Lateral meniscus tears more common than medial
Double fist sign
X-ray
• Usually non-
diagnostic
• Can help rule in or
out injuries
• Segond fracture –
avulsion over
lateral tibial plateau
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MRI
ACL tear signs
• Fibers not seen in
continuity
• Edema on T2 films
• PCL – kinked or
Question mark sign
MRI
ACL tear signs
• Lateral femoral corner
bone bruise on T2
• May have meniscal
tear (Lateral > medial)
Sens = 64%
Spec = 95%
PPV = 58%
NPV = 96%
Thomas et al. Knee Surg Sports Traumatol Arthrosc, 2007; 15: 533-536.
Similar to clinical exam !!
Initial Treatment
• Referral to Orthopaedics/Sports Medicine
• MICE = Modified activity, Ice,
Compression, Elevation
• Consider bracing, crutches
• Begin early Physical Therapy
• Analgesia usually NSAIDs
ACL Tear Treatment
Conservative
• No reconstruction
• Physical therapy • Hamstring
strengthening
• Proprioceptive training
• ACL bracing controversial
• Patient should be asymptomatic with ADL’s
Surgery
• Reconstruction
• Depends on activity demands
• Reconstruction allows better return to sports
• Reduce chance of symptomatic meniscal tear
• Less giving way symptoms
• Recovery ~ 6 months
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Acute Hemarthrosis
1) ACL (almost 50% in children, >70% in adults)
2) Fracture (Patella, tibial plateau, Femoral supracondylar, Physeal)
3) Patellar dislocation
• Unlikely meniscal lesions
Medial Collateral Ligament (MCL)
Injury
Mechanism
• Valgus stress to
partially flexed knee
• Blow to lateral leg
Symptoms
• Pain medially
• May feel unstable
with valgus
Medial Collateral Ligament (MCL)
Injury
Physical Exam
• Tender medially over
MCL (often proximally)
• May lack ROM
“pseudolocking”
• Valgus stress test – test
at 20°
Malanga GA, Nadler SF.
Musculoskeletal Physical
Examination, Mosby, 2006
Sens = 86 - 96 %
MCL Treatment
Conservative
• Analgesia
• Protected motion
+/- hinged brace
+/- crutches
• Early physical therapy
Imaging
• X-ray non-diagnostic
(rarely avulsion)
• MRI not usually
necessary
Surgery
• Rarely needs surgery
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Q2. The most common sign of
meniscal tear is:
1) Joint line tenderness
2) Effusion
3) Positive McMurray Test
4) Loss of range of motion
5) Limp
Special Tests: Meniscus Fowler PJ, Lubliner JA. Arthroscopy 1989; 5(3): 184-186; Yelland, Evidence Based Medicine, 2007.
Test Sensitivity Specificity
Joint line tender 67 to 92% 29 to 97%
Hyperflexion 50% 68.2%
McMurray Classic
(Med Thud)
16 to 67% 69 to 98%
Thessaly 66 to 92% 91 to 97%
Appley (Comp/Dist) 16 to 41% 80 to 93%
MRI 40 to 100% 66 to 100%
Meniscus Tears
Mechanism
• Occurs after twisting
injury or deep squat
• Patient may not recall
specific injury
Symptoms
• Catching
• Medial or lateral knee
pain
• Usually posterior
aspects of joint line
• Swelling
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Meniscus Tears
Traumatic tears
• Younger patients
• Frequently associated with ACL tear
• Vertical longitudinal common
Degenerative tears
• Older patients
• Frequently no trauma
• Frequently horizontal cleavage, flap, or complex tears
• Reduced healing potential
Modified McMurray Testing
• Flex hip to 90
degrees
• Flex knee
• Internally or externally
rotate lower leg with
rotation of knee
• Fully flex the knee
with rotations
Courtesy of Keegan Duchicella MD
Thessaly Test
• Hold patient’s hands for
support
• Patient bends knee to 5°
while he/she twists on knee
• Twisting movement will
reproduce pain from meniscal injury
• Repeat with 20° knee
flexion
Medial side: Sens 89%, Spec 97%
Lateral side: Sens. 92%; Spec 96%
Karachalios et al. J Bone Joint Surg Am, 2005; 87: 955-962
Courtesy of Keegan Duchicella MD
MRI
• Look for fluid (linear
bright signal on T2) into
the meniscus
Fox M, Radiol Clin N Am,
2007; 1033-1053
Sens = 88 - 90 %
Spec = 87 - 90 %
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• Medial meniscus: 10-30 % of width
• Lateral meniscus: 10-25 % of width
• From geniculate arteries
• Posterior horns have increased vascularity
Vascular Penetration
Lat
Med
Courtesy of Steve Arnocsky
Meniscus can heal
Red zone tears:
• Blood supply promotes healing
• Heals with cellular fibrovascular scar
• Mechanical strength may never return to normal
White zone tears: • Minimal reparative
response
Fibrocartilage present at 6
months
Courtesy of Steve Arnocsky
Meniscal Tear Treatment
Conservative
• Often if degenerative tear in older patient
• Similar treatment to mild knee osteoarthritis
• Analgesia
• Physical therapy • General Leg
Strengthening
Surgery
• Operate if internal
derangement
symptoms
• Meniscal repair if
possible
Meniscectomy
• Partial meniscectomy preserves some function
• Partial meniscectomy of 15-34% of meniscus increases contact pressures about 350%
• Arthritis proportional to amount of meniscus removed
• 50 % or greater reduction in contact area
• Increased load/area = degeneration
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Knee Emergencies
1. Neurovascular injury
2. Knee Dislocation
– Associated with
multiple ligament
injuries (posterolateral)
– High risk of popliteal
artery injury
– Needs arteriogram
3. Fractures (open,
unstable)
4. Septic Arthritis
Urgent Orthopedic Referral
• Fracture
• Patellar Dislocation
• “Locked Joint” - unable to fully extend the
knee (OCD or Meniscal tear)
• Tumor
Q2. The most common cause of
acute hemarthrosis is:
1) Patellar fracture
2) Bucket handle meniscal tear
3) Anterior cruciate ligament tear
4) Tibial plateau fracture
5) Hemophilia
Cartilage Damage
Outerbridge Classification, 1961
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Osteoarthritis Patellofemoral Pain
• Excessive compressive forces over articulating surfaces of PFP joint
Mechanism
• Too loose/hypermobile
• Too tight – XS pressure
Symptoms
• Anterior knee pain
• Worse with bending (5x body wt), stairs (3x body wt)
• Crepitus under kneecap
• May sublux if loose
PFP Syndrome
• Tender over facets of
patella
• Apprehension sign
suggests possible
instability
• Merchant view
• X-rays may show lateral subluxation or tilt
• Average sulcus angle 142º
Too Loose?
Hypermobility
• Associated with subluxation of the patellae
• Medial facet more commonly affected
• Medial patellar ligament – Tight in extension and lax
in flexion
– Mean tensile strength of 208 N
– Reconstruction controversial?
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Too Tight?
Popliteal Angle
(Hamstrings)
Thomas
Test (Hip
Flexor) Ely’s
Test (Quads)
Ober’s
Test (ITB)
Lateral hyperpressure
syndrome
Patellar Tendon
• 90% type 1 collagen
• Tendon blends into medial and lateral retinacula
• Thicker distally than proximally
• Insertion strain is 3-4 times greater than in the midsubstance
Woo et al, Injury and repair of the MSK soft tissues, AAOS, 1988.
Iliotibial band friction syndrome
• 10-21% of running overuse injuries
• ITB crosses the lateral femoral epicondyle at 30°
• Not a discrete structure, but a thickened part of the fascia lata
• Associated with “varus” moment at the knee
Treatment Options
Too Loose/Weak
• Strengthen quads (Vastus Medialis Obliquus)
• Correct alignment (+/-orthotics)
• Support (McConnell Taping, Bracing)
Too Tight
• Stretch hamstring, quadriceps, hip flexor
• Strengthen quads, hip abductors
• Correct alignment (+/-orthotics)
Surgical (RARE)
• Last resort
• Lateral release
• Patellar
realignment
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Weak Hip Abductors
(Gluteus Medius)
• Increased varus moment and internal rotation at the knee
Osteoarthritis
Symptoms
• Pain
• Mechanical – Grinding
– Catching
– Locking
– Giving Way
• Swelling
Diagnosis - Radiographs
In
Extensi
on
FWB
XR
Surgical Treatment
Arthroscopy for OA
• Prospective, Randomized Placebo Controlled Study
• 180 Patients
• 165 VA Patients
• Placebo vs Lavage vs
Debridement had similar Knee
Specific Pain Scores at 1 and 2
years follow up
Moseley, New Engl J Med, 2002
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Surgical Treatment
• Prospective, Randomized
Controlled Study
• N = 86 vs 86 controls
• Patients randomly assigned to
surgical lavage and arthroscopic
débridement + optimized
physical and medical therapy
versus physical and medical
therapy alone Kirkley, New Engl J Med, 2008
RCT 2008 Arthroscopy for OA
• No difference in outcomes: WOMAC, SF-36 Physical component
summary score
Kirkley, New Engl J Med, 2008
Total Knee Arthroplasty
Meta Analysis – 11 Series
• 3 – 18 yr f/u of 682 Knees
• 93% Good – Excellent
• 11% Complications
• 4% Revision
• 21% Radiolucent Lines
• Survivorship 90 – 95% @ > 10 – 15 yrs
Total Knee Arthroplasty
159 pts (2//08 knees)
• 65% Played Sports Pre-Op, RTS
• Lower Impact Level – Bowling 91%
– Golf 57%
– Tennis 20%
– Bradbury, AJSM 1998
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Q3. Which of the following can
cause shoulder impingement:
1) AC joint osteoarthritis
2) Rotator cuff tear partial tear
3) Rotator cuff full-thickness tear
4) Shoulder instability
5) Bicipital tendinopathy
Shoulder Pain Differential
Diagnosis
• Rotator cuff tendinopathy
• Rotator cuff tears
• SLAP Lesion
• Calcific tendinopathy
• “Frozen” shoulder (adhesive capsulitis)
• Acromioclavicular joint problems
• Scapular weakness
• Cervical radiculopathy
Mechanism
• Impingement under
acromion with flexion
and internal rotation of
the shoulder
• Rotator cuff,
subacromial bursa and
biceps tendon
Shoulder Impingement Syndrome Impingement Symptoms Problems with:
• Overhead activities?
• Sleep?
• Putting on a jacket?
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MOVE
Flexion and External
rotation
Painful Arc 60 - 120°
Impingement Signs
Neer
• Passive full flexion
• Positive is
reproduction of
shoulder pain
Sens = 83 %
Spec = 51 %
PPV = 40 %
NPV = 89 %
MacDonald et al. J Shoulder
Elbow Surg, 2000; 9: 299-301.
Impingement Signs
Hawkin’s test
• Flex shoulder to 90º
• Flex elbow to 90º
• Internally rotate
• Positive - reproduce
shoulder pain
Sens = 88 %
Spec = 43 %
PPV = 38 %
NPV = 90 % MacDonald et al. J Shoulder
Elbow Surg, 2000; 9: 299-301.
Impingement Signs
• Spurling’s test for
cervical radiculopathy
Sens = 64%
Spec = 95%
PPV = 58%
NPV = 96%
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Rotator Cuff Tear vs Tendinosis?
• Difficulty lifting
– Pain vs weakness ?
• Drop arm sign
• Fail conservative Tx
• Tears uncommon < 40
y.o.
Sens = 10 %
PPV = 100 % Bryant et al. J Shoulder Elbow
Surg, 2002; 11: 219-224.
Rotator Cuff strength testing
Supraspinatus
• Empty can
• Thumbs down abducted
to 90º
• Horizontally adduct to 30º
For tendonitis
Sens = 77 %
Spec = 38 % For tears,
Sens = 19 %
Spec = 100 % Naredo et al. Ann Rheum Dis,
2002; 61: 132-136.
Rotator Cuff strength testing
Infraspinatus/teres minor -
External rotation
• Keep elbows at 90º
• Patte’s test at 90º
shoulder abduction
For tendonitis,
Sens = 57 %
Spec = 71 % For tears,
Sens = 36 %
Spec = 95 %
Naredo et al. Ann Rheum Dis,
2002; 61: 132-136.
X-ray AP Scapula
• Avulsion
• Calcific tendinosis
• Enthesopathy
(traction spurs)
• Alignment
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Ultrasound
• Dynamic test
• Operator dependent
• Areas of tendinosis
hypoechoic
• Tears
MRI
Tear
How good for full thickness tears?
•69 to 100 percent sensitive
•88 to 100 percent specific
Tendoninopathy Treatment
Conservative
• Education
• Initial – Sling, Pain control, Actvity modification
• Physical Therapy or home exercise program for 6 – 12 weeks
• If need significant pain relief, consider MRI or steroid injection – slightly better than placebo
(Cochrane Database, 2004)
Surgery
• If full thickness rotator cuff tear suspected, send within 2 weeks
• If rotator cuff tear > 1 cm
• If patient fails conservative treatment for > 6-12 months
• Depends on different factors including age, demand and size of tear
• Subacromial decompression
+/- bursectomy
+/- rotator cuff repair
Rotator Cuff Tear Treatment
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Q4. The best test to identify a
frozen shoulder is:
1) Passive internal rotation
2) Passive external rotation
3) O’Brien’s test (labral test)
4) Pain with resisted supraspinatus testing
5) Decreased sensation in all fingers on the
affected side
6) An axillary temperature
Adhesive Capsulitis
“Frozen Shoulder”
• Women greater than
men (70%)
• Age > 40 years
• Affects 2-5 % of
population
• 20-30% develop
symptoms in opposite
shoulder
Frozen Shoulder
• Gradual loss of range of
motion
• May have had initial trauma
• Pain at the extremes of
motion
• May have history of
diabetes, hypothyroidism,
rheumatoid arthritis
Diagnosis
• Limited range of
motion (usually lose
external rotation,
abduction and flexion)
• Investigations (X-ray,
Ultrasound) usually
negative
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MOVE
Flexion and External
rotation
Painful Arc 60 - 120°
MOVE
External rotation Internal rotation
Natural History
• 0-3 months “typically gradual onset” - painful
• 2-9 months “ freezing”
• 4-12 months “ frozen”
• 5-26 months “thawing”
• Usually self-limited Hannafin & Chiaia, Clin Orthop Rel Res, 2000
Adhesive Capsulitis Treatment
Conservative
• Education and reassurance
• May take 24 months to
unthaw
• Physical therapy
• Oral NSAIDs (or steroids)
• Glenohumeral injection +/-
capsular distension
Surgery
• Exam and
manipulation under
anesthesia
• Arthroscopic release
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Stability Tests
Apprehension test - caution if acute dislocation
• Abduct shoulder to 90°
• Externally rotate arm
Sens = 69 %
Spec = 50 %
For labral tear Rowe CR, Zarins B. J
Bone Joint surg Am,
1981; 63: 863-872.
Stability Tests
Sulcus sign (MDI)
No Sens / Spec
Data
Labral Test (O’Brien Test) Step 2: Palm Up Step 1: Palm Down
For AC joint pathology, +
pain over AC joint
Sens = 100 % Spec = 97 %
For labral tear, + pain
deep in shoulder
Sens = 67-69 % Spec = 41-50 %
Shoulder “Dislocation”
History
• Hit or fall with arm
in abduction
• Shoulder “came
out”
• Still dislocated or
spontaneously
reduced
• How long has it
been dislocated?
Symptoms
• “Dead arm” (due to traction on brachial plexus)
• Pain anteriorly
• Limited motion
• May have decreased sensation to army patch (axillary nerve)
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X-ray and MRI
Hill Sachs Lesion – compression
fracture of posterior humerus
Bankart Lesion – Avulsion of
capsular attachment to the glenoid
Complications after Dislocation
Acute rotator cuff tear
• 40 to 60% incidence of in patients > 40 years old
Frozen shoulder
• Older the patient the stiffer they get mobilize early within 2-3 weeks
Recurrent dislocation
• >90% recurrence < 20 years; 14% > 40 yrs Rowe CR. Prognosis in dislocation of the shoulder. J Bone Joint
Surg Am, 1956.
• Early surgical stabilization still controversial
Initial Treatment
• Sling x 2-4 weeks
with pendulum
exercises
• Early physical therapy
• Modification of
activities
Treatment for Shoulder Instability
• T – Traumatic
• U – Unilateral
• B – Bankart lesion
• S – Surgical
treatment (refer for consultation)
• A – Atraumatic
• M – Multidirectional
• B – Bilateral
• R – Rehabilitation
• I – Inferior capsular
shift
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You may not have seen it, but it
has seen you. • Problem with Look,
Feel, Move ?
• Worry especially if problems greater than 6 months
• No relief or worse with physiotherapy
• Internal derangement symptoms
Everyone will get OA in the knees and rotator cuff problems in the shoulder – Eventually !!!
3rd UCSF Primary Care Sports Medicine
conference
November 21-22, 2008 in San Francisco
St. Francis Hotel