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Common Musculoskeletal Problems in Primary Care Dae Hyoun Jeong, MD, FAAFP Assistant Professor Director, Sports and Geriatric Musculoskeletal Medicine Director, Geriatrics and Palliative Medicine Director, Point-of-Care Ultrasound Program Department of Family and Community Medicine Southern Illinois University School of Medicine Springfield, Illinois, USA
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disclosure Neither I, Dae Hyoun Jeong, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation.
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objectives To learn how to elicit key components of history and exam for the patient with a musculoskeletal problem To develop differential diagnoses for the patient with an musculoskeletal problem To identify the appropriate diagnostic studies for a patient with an musculoskeletal complaints To develop a management (treatment) plan for the patient with an musculoskeletal condition To demonstrate focused and comprehensive musculoskeletal physical exam
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Key components of MSK history taking Timing - Acute vs chronic (or incidious) - First time vs Recurrence - Duration - Intermittent vs continuous Location - Pinpoint with one finger? - Single or multiple - Any radiation Something looks new (Deformity) Functional debility (weakness) Any injury or trauma Any associated numbness or tingling (nerve involvement)
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Characteristic of the pain Character examples Aching / Burning / Sharp / Pulling / Pressure / Throbbing Any associated numbness or tingling (nerve involvement) Course Better / Worse / Stable Something looks new (Deformity) Functional debility Any injury or trauma
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Alleviating factors –Heat/ice / Medication / Rest / Massage / PT / Equipment (ex. shoes) Aggravating Factors –Activity / Inactivity / Direct pressure Affecting daily activities? (work/school/athletics/sleep/bowel&bladder) Affect sensation? (balance/proprioception/numbness/tingling)
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Past medical history Any other musculoskeletal disorder? –Osteoarthritis, rheumatoid arthritis, fibromyalgia Any rheumatologic disorder? –Systemic lupus erythematosis (SLE), psoriasis Any endocrinopathy? –Diabetes mellitus, thyroid disorder Any neurologic/psychiatric disorder? –Restless leg syndrome, post-cerebral vascular accident, anxiety, depression Other medical conditions? –Cardiac, pulmonary, gastroesophageal reflux disease Any past orthopedic surgeries?
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Principle of msk physical exam IRP MRSP-S Inspection (Erythema/ Edema / Deformity / Asymmetry / Atrophy) Range of motion (Active / Passive) Palpation Muscle strength Reflex Sensation Pulse Special testing
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Imaging studies X-ray : 1st test (quick and cheap), usually AP & Lat CT: Good for bony abnormality MRI: Good for soft tissue / stress fracture Ultrasound: Good alternative of MRI (except for deeper structure under the bone) Bone scan: Good for occult fracture (can be too sensitive) or other lesions EMG with NCV : Good for nerve damage (but not the first line)
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THE KNEE
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Knee - anatomy
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Question: anterior knee pain A 17-year-old female presents to your office with anterior knee pain. She tells you she recently started a running program. She says the pain is worse running down hills, and is vaguely localized just medial to the patella. Examination of the knee shows no effusion or instability, and there is no joint-line pain or patellar tenderness. McMurray’s maneuver is negative. Plain radiographs of the knee appear normal. Which one of the following would be most appropriate at this point? A) MRI of the knee B) Modification of her running program and a quadriceps and hip strengthening program C) Static stretching of the quadriceps and hamstrings prior to running D) A corticosteroid injection in the area of the pes anserine bursa
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Answer : C Anterior Knee Pain Women > Men Usually no swelling Peripatellar and anterior knee pain Pain with prolonged knee flexion Pain with stairs (+) Patellar findings on exam Tight ITB (Ober’s test) Pelvic-femoral dysfunction Gluteal and quad weakness
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Management for Anterior Knee Pain NSAIDs Quadriceps Strengthening Pelvic-femoral rehab Patellar taping for pain relief Bracing(patellar protector)
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D/D : Plica syndrome Plica : normal fold in the synovium of the knee Plica becomes inflamed and thickened from trauma or overuse may interfere with normal joint motion because pathologic structure “bowstrings” over the femoral condyle or other stuctures
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Clinical symptoms Often insidious but may be related to a fall or injury Activity-related aching in the anterior or anteromedial aspect of the knee Painful snapping or popping in the knee Buckling or sense of instability may occur
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Physical exam Inspect knee for tenderness Pathologic plica - palpated as a thickened band with the knee flexed Pop may occur at 60degree of flexion when place the knee in 90 degree of flexion and then extend it. D/D : patellofemoral disorder
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Question : Medial Knee Pain A 45-year-old female presents to your office with knee pain. She was playing volleyball yesterday when she collided with another player and was unable to continue playing because of pain in her knee. The knee was swollen this morning. She is able to walk but not without pain, and she also has pain when she attempts to bend her knee. On examination there is medial joint line tenderness and a positive Thessaly test. Which one of the following is the most likely cause of her knee pain? A) Osteoarthritis B) Anterior cruciate ligament tear C) Collateral ligament tear D) Medial meniscus tear E) Tibial plateau fracture
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Meniscus tear Medial and lateral menisci : fibrocartilaginous pads that funtion as shock absorbers between femoral condyles and tibial plateaus Significant twisting injury to the knee Occur alone or in association with ligament injuries such as ACL tears
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Clinical symptoms Insidious onset of knee swelling and stiffness over 2-3days Locking, catching, and popping Pain on medial or lateral side of knee with twisting or squatting activities. ROM limited by feeling of tightness in the knee 2ndary to the effusion
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Physical exam Tenderness over medial or lateral joint line Younger, traumatic : large effusion or hemarthrosis Degenerative tears : small or absent effusions Limited ROM due to pain or effusion Joint-line Tenderness : Sens 71-78%, Spec 87-90% McMurray test : Sens 50-65%, Spec 86-94% Thessaly Test : 89-92%, spec 96-97%
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Diagnostic test for meniscus tear MRI is specific and sensitive X-ray : Hx of trauma or effusion, older population
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Treatment Locked knee with loss of ROM – should be treated promptly with surgery Degenerative tear – initially RICE, NSAIDs Physical therapy for 6month has the same outcome as arthroscopic procedure. Arthroscopic surgical debridement or repair : indicated in younger patient with significant tears in patient with a locked knee and older patient with poor response to nonsurgical treatment
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Question : Medial Knee Pain A 59-year-old male college professor presents with a 2-month history of right medial knee pain.There is no history of injury or overuse. He has no other specific joint pain except for occasional myalgias and arthralgias of his legs and arms. On most days he has morning stiffness lasting 15–20 minutes after getting out of bed. A review of systems is otherwise negative. On examination the right knee has full range of motion. There is tenderness at the medial joint line, but no clicking or ligamentous instability. There is crepitus with movement in both knees. Which one of the following diagnostic tests would be most appropriate at this time? A) Serologic testing B) Synovial fluid analysis C) Plain radiography D) MRI without contrast E) MRI with contrast
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Osteoarthritis of knee Plain radiography is the initial step for work-up : Narrowing of the medial compartment of knee joint, Osteophytes
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Osteoarthritis - Epidemiology 15% of all musculoskeletal consultations in patient age 45 and older in primary care The most common joint disease in patient age 65 and older , with a radiographic prevalence as high as approximately 90% in women and 80% in men Predominantly affects the knees, hips, hands & feet. The most common type of arthritis found in the United States’ population The knee – the most frequently affected of all joints.
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Diagnosis of OA Primarily a clinical dx History: joint pain worsened by movement Gelling phenomenon AM stiffness <30 min Limited ADLs due to pain and stiffness Usually asymmetric P/E - unique findings at each joint ex: Heberden and Bouchard nodes, limited ROM
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Radiography of OA Kellgren and Lawrence : ranges from 0 to 4 (0 - absence of OA features, 4 - severe OA.)
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Non-Operative Management of the Knee OA Goal-oriented visits - improved weight & time spent on physical activity. focusing on education on OA and treatment management information on physical exercises information on weight loss
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Foot orthoses Lateral wedge insoles with arch support - Reduce KAM -> decrease medial knee joint loading Mixed results -> significant pain reduction and improvements in function& QOL
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Knee brace Valgus bracing Knee sleeve
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Assistive device - Cane
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Supplementary Methods in the Nonsurgical Treatment of Osteoarthritis M. A. PERCOPE DE ANDRADE et al, The Journal of Arthroscopic and Related Surgery, 2015 Glucosamine/chondroitin - most extensively studied supplement for knee OA. OA pain relief with glucosamine and chondroitin sulfate - excellent safety profile -> consider as initial treatment. Glucosamine hydrochloride - no effect on pain Glucosamine sulfate formulation has a moderate effect. Avocado and soybean unsaponifiables(ASUs) may have positive effects on knee and hip OA Hyaluronic acid in OA - some benefits in the knee in some systematic reviews. (despite the AAOS’ recommendation against the use) Some of these agents seem to reduce pain and improve function
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Pharmacological treatment Acetaminophen : superior to placebo in 5 of 7 RCTs. NSAIDs - superior to acetaminophen for the treatment of knee OA. good short-term treatment to manage symptomatic knee OA Side effect profile - poor long-term treatment. (Cochrane systematic review)
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Question: Inferiormedial Knee Pain In patients with pes anserine bursitis, tenderness is most likely to be noted A) over the medial epicondyle B) over the lateral pelvic/hip region C) over the medial proximal tibia D) just posterior to the medial malleolus E) just distal to the lateral malleolus
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Bursitis of the knee Bursa : sacs located between the skin and bony prominences or between tendons, ligaments, and bone Decrease friction between adjacent structures. Chronic pressure or friction (overuse) causes thickening of this synovial lining and subsequent excessive fluid formation, leading to localized swelling and pain
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Question : Lateral Knee Pain A 20-year-old female distance runner presents with a 1-month history of left knee pain. The pain is worse with her first few steps in the morning and when going down stairs. Examination of the knee reveals no deformity, effusion, or ligamentous laxity. The knee joint and surrounding tissues are not tender to palpation, with the exception of an area 2 cm proximal to the left lateral joint line. What is the most likely cause of this patient’s pain? A) Osteoarthritis of the knee joint B) Pes anserine bursitis C) Iliotibial band syndrome D) Chronic lateral meniscal tear E) Osgood-Schlatter disease
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11. Iliotibial band syndrome ITB is a dense, fibrous band of tissue that originates from the ASIS region, extends down the lateral portion of the thigh, and inserts on the lateral tibia at the Gerdy tubercle. ITB syndrome develops when the distal portion of the ITB rubs against the lateral femoral epicondyle, causing irritation and subsequent inflammation of the ITB Most common in long-distance runners and cyclists, but any athlete may develop this syndrome Pain at anterolateral aspect of the knee that worsens with running, especially downhill, or cycling. Pain is usually most intense at heel strike. Audible popping in the knee with walking or running Usually asymptomatic at rest
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Physical exam and Diagnostic testing Tenderness to direct palpation directly over the lateral femoral epicondyle, 2 to 3cm proximal to the lateral joint line Ober test to confirm diagnosis Functional testing such as eliciting lateral knee pain when patient hops with a flexed knee X-ray is usually negative, but should be ordered to exclude other pathology presenting as lateral knee pain.
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Treatment Nonsurgical : physical therapy, short-term course of NSAIDs, ICE and activity modifications Corticosteroids injection : only when the symptoms do not respond to stretching, physical therapy and exercise modification.
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Question : Knee – ACL Which one of the following is true concerning anterior cruciate ligament (ACL) tears? A) The incidence of ACL tears is higher in males than in females B) ACL tears are not associated with early-onset osteoarthritis C) The majority of ACL tears are caused by physical contact D) Strength training can prevent ACL tears
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ACL Injury Isolated ACL disruption is less then 10% 70% are by noncontact mechanism Female athletes at higher risk Neuromuscular training reduces risk of injury in female and male athletes History : Audible pop sound, Early onset knee swelling, Contact/non contact Segond fracture (lateral capsular sign)
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Question : Knee – ACL You see a 22-year-old female who sustained a right knee injury in a recent college soccer game. She is a defender and executed a sudden cutting maneuver. With her right foot planted and her ankle locked, she attempted to shift the position of her body to stop an oncoming ball and felt her knee pop. She has had a moderate amount of pain and swelling, which began within 2 hours of the injury, but she is most concerned about the loss of knee hyperextension. Which one of the following tests is most likely to be abnormal in this patient? A) Anterior drawer B) Lachman C) McMurray D) Pivot shift
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Physical exam Lachman test : Most sensitive test for ACL injury flex knee to 30degree and pull tibia gently forward while the femur stabilized Anterior drawer`s test : negative in 50% of acute ACL tears. Pivot shift test : sensitivity 62%
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Imaging studies Segond fracture (lateral capsular sign)
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Treatment for ACL injury Initial treatment : Rest, ICE, use of clutches until patient is able to ambulate without a limp Knee immobilizer or Hinged knee brace Early range of motion exercise are important Young, active patient : ACL reconstruction Older and less active : physical therapy aimed at controlling the instability, ACL functional bracing
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Posterior Cruciate Ligament Tear - PCL : primary restraint to posterior translation of the tibia relative to the femur - Stretch injury or a complete rupture - Less common than ACL injury
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Clinical symptoms Effusion within first 24 hours Limited ROM Pain and instability with weight bearing
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Physical exam Effusion, decreased ROM, Tenderness Most sensitive test : Posterior drawer test Without PCL injury – Tibial plateau :1cm anterior to the femoral condyles With a PCL injury, tibia will be in a posterior position relative to the femur due to gravity (Sagging sign)
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Diagnostic tests X-ray – in acute setting, to identify bony pathology(including avulsions) MRI – confirming PCL tears and concomitant injuries to ligaments, menisci, and articular cartilage
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Patella/Quadriceps tendinopathy overuse or overload syndrome involving quadriceps tendon at insertion on sup. Pole of patella or patellar tendon at inf. Pole of patella Jumping or kicking sports in younger adults Lifting strain or significant change in exercise level in older patients
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Clinical symptoms Anterior knee pain, tender spot Pain with Prolonged sitting, squatting, or kneeling Climbing or descending stairs, running, jumping or squatting increases pain
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Physical exam Tenderness at bony attachment of quadriceps tendon or infrapatellar tendon Incrased heat, mild swelling and soft-tissue crepitus Pain is exacerbated by hyperflexion of the knee Other general knee exams are negative
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Imaging X-ray : usually negative, but lateral views may show small osteophytes or heterotopic ossificaiton at the upper or lower pole of patella MRI – reserved for recalcitrant cases
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Treatment Period of relative rest from aggravating activities(3-5 days to 3-6 weeks) May need to use knee immobilizer intermittently NSAIDs , analgesic creams, ICE after activity, heat before activity Should avoid local injections or corticosteroids Then regaining pain-free ROM, flexibility of quadriceps and hamstrings and strength Gradual resumption of activities that caused the symptoms while continuing exercises that have restored strength and flexibility. Using heat before activity and ice after.
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THE LUMBAR SPINE
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Question : Lumbar Spine A 22-year-old male has acute low back pain without paresthesias or other neurologic signs. There is no lower extremity weakness. Which treatment has been shown to be of most benefit initially? A) Complete bed rest for 2 weeks B) Bed rest plus local injection of corticosteroids C) A low-back strengthening program D) Resumption of physical activity as tolerated
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Anatomy of lumbar spine
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ROM of thoracolumbar spine
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Sensory motor distribution of nerve roots
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Special tests for evaluating low back pain
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Question : Lumbar Spine A healthy 47-year-old female presents with a 3-day history of moderately severe low back pain after attempting to lift a heavy container of potting soil in her garden. She has no history of back problems. Her pain is in the right lower back with radiation to the buttock. She denies urinary or bowel incontinence, urinary retention, and numbness or tingling. A physical examination confirms low back muscular strain. Which one of the following interventions has been shown to be beneficial in this situation? A) Bed rest B) Massage therapy C) Lumbar traction D) Prednisone E) Cyclobenzaprine (Flexeril)
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Beneficial therapies for Acute LBP NSAIDs (SOR A) Remaining Active (SOR A) Muscle relaxants (SOR B) Epidural steroid injections for discogenic pain or physical therapy is also likely to be beneficial.
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Most acute episodes of low back pain resolve with conservative therapy within 4 to 6 weeks 5 to 10% develop chronic symptoms (>3months)
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Red Flags for LBP : Strong indications for Imaging Urinary or fecal incontinence Urinary retention Progressive lower extremity motor or sensory loss Significant trauma related to age Severe pain and Recent Hx of lumbar spine surgery Cancer metastatic to bone Major motor weakness or sensory loss Saddle anesthesia Loss of anal sphincter tone Fever, urinary tract Infection, or wound in spine region
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Causes of Lbp warranting Emergent evaluation
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Red flags 14studies evaluating 53 red flags; 5 studies evaluated combinations of red flags. * The red flags with the highest post test probability for detection of fracture older age (9%, 95% confidence interval 3% to 25%) prolonged use of corticosteroid drugs (33%,10% to 67%) severe trauma (11%, 8% to 16%), presence of a contusion or abrasion (62%, 49% to 74%). Higher probability of spinal fracture when multiple red flags were present * The red flag with the highest post-test probability for detection of spinal malignancy - history of malignancy (33%, 22% to 46%).
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Imaging study guideline for Acute LBP * Adult with Acute LBP without red flags 4-6 weeks of conservative management/therapy If symptoms improve, then no need of imaging If symptoms persists, then get X-ray If there is Neurologic deficit, then get MRI If not, then no need of MRI
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Indications for Diagnostic Imaging for Acute LBP Stat Imaging : Acute LBP with possible cauda equina syndrome or severe progressive neurological deficit Imaging after trial of therapy : minor risk factors for cancer, risk factors for inflammatory back disease, radiculopathy or symptomatic spinal stenosis Repeated Imaging : only for patients with new or worsening/changing low back symptoms
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Indication for early imaging for patients with lbp
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Medications NSAIDs First line management in acute and chronic low back pain without sciatica ( 2008 Cochrane review) Higher rate of side effects compared with acetaminophen. Acetaminophen First line management option for low back pain Less effective than NSAIDs Tramadol More effective than placebo, short term improvements in pain and function (2007 Cochrane review)
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Systemic corticosteroids Variable evidence regarding use in acute low back pain with radiculopathy May be beneficial Muscle relaxants Effective for short-term symptomatic relief TCAs Variable evidence. Useful in patients with neurogenic pain. May help sleep Gabapentin / Lylica Possible small benefits in some trials for chronic back pain with radiculopathy
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Other conservative managements Bed rest may be recommended for 1 to 2 days Physical therapy (McKinzie Method / Williams Method) Typically recommended if symptoms persist for more than 2 weeks. Heat therapy : beneficial in reducing pain associated with acute low back pain, especially when combined with exercise Cold therapy : minimal evidence TENS : current evidence does not support TENS based on 2010 review
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Other treatment modalities Prolotherapy Stem cell therpy Facet injections and medial branch nerve blocks Epidural steroid injections Acupuncture Chiropractic Manipulation Massage Yoga
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Refferal and surgical indications The National Institutes of Health-supported Spine Patient Outcomes Research Trial(SPORT) - Randomized, prospective, multicenter trials - Evaluated the surgical and nonsurgical treatment Favored surgical options for intervertebral disk herniations degenerative spondylolisthesis lumbar spinal stenosis
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Herniated disc of lumbar spine 80% of all adult LBP resolves within 90 days 90% lumbar HNP starts to improve at 6 wks and resolve by 12 wks Avoid bedrest Oral corticosteroids and NSAIDs have weak evidence for benefit LESI can be beneficial for pain relief Indications for surgery Severe progressive motor deficits Cauda equina syndrome Radiculopathy more than 6 weeks. (Surgery gives much better improvements in pain and disability for the first 2 years compared to non surgical treatment.)
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Question : Spinal Stenosis (2011) Which one of the following is consistent with spinal stenosis but not with a herniated vertebral disk? A) Numbness B) Muscle weakness C) Pain relieved by sitting D) Pain relieved by standing
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Degenerative lumbar spine disease
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Facet joint syndrome
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Therapies for chronic LBP Beneficial for both Pain and Function Massage therapy (SOR A) Intensive multidisplinary treatment program(SOR B) Tramadol (SOR B) Exercise (SOR B) Behavioral therapy (SOR B) Beneficial for pain only Antidepressants, NSAIDs, Analgesics, Narcotics, Back school, Manipulation
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CERVICAL SPINE
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Question : Cervical Spine A 55-year-old male presents with a 2-year history of persistent, worsening neck stiffness. Over the past month, the stiffness has been associated with left thumb tingling. After completing a thorough history and physical examination, which one of the following studies would be the most appropriate next step in further evaluating the patient’s complaints? A) Lateral neck radiography B) A cervical spine series C) Neck MRI D) CT myelography E) Diskography
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Chronic Neck Pain - Indication for imaging Complete cervical spine series(5 views) in patient with chronic neck pain with no history of trauma, malignancy or surgery. If X-rays are normal and Patient has neurologic signs or symptoms, then MRI (or CT myelography if MRI is contraindicated)
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Question : Cervical Spine An 80-year-old male comes to your office for evaluation of neck stiffness with a sensation of grinding when turning his head. He has had this for several years, and has now developed dull aching in his arms and numbness in his fingers. He also has noted stiffness in his legs. Examination reveals that flexion of the neck results in a sensation that the patient says feels like an electric shock going down his back. You note some wasting of the intrinsic musculature of the hands, as well as hyperreflexia. Which one of the following should you do now? A) Order EMG of both upper extremities B) Order plain films of the cervical spine C) Order MRI of the cervical spine D) Refer for cervical corticosteroid injections E) Reevaluate the patient after 4 weeks of cervical bracing
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Cervical spondylotic myelopathy (CSM) most common cause of spinal cord dysfunction in the elderly Degenerative changes in the cervical spine, such as osteophyte formation, stiffened and hypertrophied ligamentum flava, and spinal stenosis neck stiffness, pain in the arm(s), tingling or numbness in the hands, and weakness of the hands or legs. Lhermitte’s sign. Hyperreflexia. atrophy of the intrinsic muscles of the hands primary diagnostic test is MRI of the cervical spine. Cervical bracing for mild cases, and surgical intervention for frank myelopathy
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THE SHOULDER
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Shoulder
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Question : Shoulder A 35-year-old white female complains of severe pain in her right shoulder. She notes that at night the pain intensifies if she rolls onto her right side. P/E : marked pain with no weakness on abduction of the shoulder; ROM of the shoulder is normal. The most likely cause of her pain is A) bicipital tendinitis B) complete rotator cuff tear C) osteoarthritis of the shoulder D) subacromial bursitis E) frozen shoulder
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Rotator cuff tendinitis, shoulder bursitis, Age>35 Inflammation of the subacromial bursa and underlying rotator cuff tendons : common cause of shoulder pain in middle-aged patients. Rotator cuff pathology : from edema and hemorrhage to chronic inflammation and fibrosis to microscopic tendon fiber failure progressing to full-thickness rotator cuff tears Gradual onset of anterior and lateral shoulder pain exacerbated by overhead activity Night pain and difficulty sleeping on the affected side Impingement syndrome
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Testing Tenderness to palpation over greater tuberosity and subacromial bursa Crepitus with shoulder motion Pain is worse between 90-120degree of abduction when lowerinig the arm Positive Neer and Hawkins sign Diagnostic injection (Local anesthetic) and re-exam : Complete pain relief supports a diagnosis of impingment.
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Treatment NSAIDs and rest from offending activity for acute exacerbation of pain Stretching program with emphasis on posterior capsule stretching Home exercise program 3-4X/week X 6 weeks Subacromial corticosteroid injection then continue stretching Rotator cuff strengthening program should be added to the stretching program once the shoulder is supple and pain is improved. Avoid repetitive overhead activities
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Question : Shoulder A 73-year-old white female asks you to evaluate her right shoulder because of pain and limited range of motion. Further history reveals that 2 months ago she slipped in her kitchen and caught onto the refrigerator door handle to avoid falling to the floor. On examination she has pain and weakness at 45° of abduction and weakness on external rotation. She should be treated for A) bicipital tendinitis B) disruption of the glenoid fossa C) rotator cuff tear D) acromioclavicular separation E) incomplete fracture of the humeral head
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Most common mechanism of injury in an acute rotator cuff tear : forced abduction of the arm with significant resistance. Often occur when a person attempts to break a fall with an outstretched hand. A sudden sensation of tearing pain in the shoulder. Pain and muscle spasm will limit shoulder motion. Patients with a large tear cannot initiate shoulder abduction and will have a discrepancy between active and passive motion. Positive drop arm test. Rotator cuff tear
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Tests Passive ROM is near normal Atrophy of back of the shoulder – long standing infraspinatus muscle tear Most of patients cannot hold the arm elevated when it is lifted by examiner parallel to the floor Grating sensation about the tip of the shoulder with raising arm. Tenderness to palpation over the greater tuberosity Full can test, Empty can test, Drop arm test
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Imaging study
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Rotator Cuff Tears Mostly partial tear Positive signs of rotator cuff tear Supraspinatus weakness Weakness in external rotation Positive impingement signs (Neer`s, Hawkin`s) If the patient has 3 (+) signs at any age, or 2 positive signs and age is greater than 60 => suggests 98% probability of Rotator cuff tear.
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Treatment Nonsurgical treatment : NSAIDs, Rehab with strengthening and stretching exercises, avoiding overhead activities. Corticosteroid injections should be used judiciously Surgery : if fails rehab over 3 months If acute traumatic full thickness cuff tear or younger patient (<55 years), then rotator cuff repair is best performed acutely or no later than within 6-8 weeks of injury.
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Question : Shoulder A 58-year-old female with diabetes mellitus complains of 2 years of right shoulder pain, which is worse with activity. There has been no trauma. She tells you one of her friends had a similar problem and was treated successfully with “some sort of shock wave treatments.” Which one of the following diagnoses is most likely to be successfully treated with extracorporeal shock wave therapy? A) Calcific tendinitis B) Gout C) Partial rotator cuff tear D) Frozen shoulder E) Hooked acromion
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calcium deposit within the tendons of the rotator cuff. Age 40-50. More common in diabetics and females. Not always painful, and even when painful they will often spontaneously resolve after a period of 1-4 weeks. Almost always resolves eventually without surgery. Precalcification Stage No symptoms. Calcific Stage calcium looks chalky, it is not a solid piece of bone. not a painful period and may last a varied length of time. After the resting phase, a resorptive phase begins--this is the most painful phase (toothpaste like) Postcalcific Stage painless stage as the calcium deposit disappears and is replaced by more normal appearing rotator cuff tendon.
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Management of the calcific tendinitis • Physical therapy : Beneficial for pain and function • Subacromial Injection improves abduction and pain • NSAIDs are Likely to be beneficial compared to placebo (SOR B) • Extracorporeal shockwave therapy : ECSWT helpful in chronic shoulder pain with calcific tendonitis
Slide 101-

Question : Upper extremity A 53-year-old male presents with 1-day history of swelling in his upper arm. The swelling appeared after a sudden painful “pop” as he was lifting a heavy box. A physical examination reveals a soft to firm, nontender mass in the anterior aspect of the arm, and weakness of forearm supination. Shoulder radiographs are normal. Which one of the following is the most likely diagnosis? A) Acute anterior shoulder dislocation B) Lateral epicondylitis C) Biceps tendinitis D) Biceps tendon rupture
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Biceps Tendon Rupture Long head of the biceps tendon is the most common for rupture Risk factor : older age, overuse injury, overhead activity, smoking, steroid Pop, bruising, weakness of supination Indication for surgery : Athletes, Manual Laborer, Those who require maximal supination strength
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THE WRIST
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Question : Wrist Which one of the following has the highest sensitivity and specificity for carpal tunnel syndrome? A) A positive Phalen maneuver B) Distal tingling with percussion (Tinel’s sign) C) A history of shaking the hand or flicking the wrist to alleviate nighttime pain (the flick sign) D) Thenar atrophy
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Carpal Tunnel Syndrome Risk factor – thyroid, DM, pregnancy Compression of the median nerve Flick test is the most sensitive finding for CTS (Sens 93%, Spec 96%) Weak thumb abduction/phalen`s/Tinnels Treatment Options Short term benefit : wrist splints, Ultrasound, carpal bone mobilization Steroid injection : bettern than oral corticosteroids. Beneficial at 1 and 4 month Surgical release : Beneficial over splinting at 6 month
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Question : Wrist - Carpal bone A 35-year-old male comes to your office because of wrist pain following a fall on the ice 10 days ago. Examination of the wrist shows no deformity or swelling, but extension is decreased and he has diffuse tenderness over the dorsum of the wrist, particularly just distal and dorsal to the radial styloid. Which one of the following does the radiograph show? A) A hamate fracture B) A scaphoid fracture C) A lunate dislocation D) A scapholunate dislocation
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Question : Wrist – Scaphoid fracture A 29-year-old white male comes to your office complaining of pain in the right wrist since falling 2 weeks ago. He is tender in the anatomic snuffbox. A radiograph reveals a nondisplaced fracture of the distal 1/3 of the carpal navicular bone(scaphoid). Which one of the following is the most appropriate management at this time? A) A bone scan B) Physical therapy referral C) A Velcro wrist splint D) A short arm cast E) A thumb spica cast
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Scaphoid fracture Mid or Distal fracture – conservative management with thumb spica splint initially and then thumb spica cast(10-12 weeks) Proximal fracture – surgical referal due to non-union/javascular necrosis risk
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Question : Wrist A 32-year-old secretary complains of wrist pain at rest and when holding a pen. She says it feels like her thumb locks up at times. On examination you note tenderness on the radial side of her right wrist. A radiograph shows multiple sesamoid bones around her first metacarpophalangeal joint. You suspect A) rheumatoid arthritis B) carpal joint arthritis C) de Quervain’s tenosynovitis D) cervical radiculopathy E) carpal tunnel syndrome
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De Quevain`s tenosynovitis Tenosynovitis of the first dorsal compartment of the wrist (EPB / APL) Diagnosis : physical exam Pain tenderness, occasional swelling on radial side of wrist Finkelstein test Thumb Spica splint, Steroid injection
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Question : Finger An 20-year-old basketball player comes to your office for evaluation of finger pain. During a basketball game yesterday he was hit on the tip of his right second digit and now has finger pain and difficulty moving his finger. On examination he has bruising and tenderness over the distal interphalangeal (DIP) joint. His DIP joint is in the flexed position and he is unable to extend the joint. A radiograph shows a fracture at the dorsal surface of the proximal distal phalanx involving 10% of the joint space. What is the most appropriate management of this injury? A) Taping the finger to the adjacent finger B) Splinting in full extension C) Splinting in 45° of flexion D) Urgent surgical management E) Intermittent splinting for comfort
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Mallet finger Rupture of extensor tendon at DIP joint Sometimes with avulsion fracture Usually treated non-surgically with finger splint 24/7 for 6-8 weeks then hand therapy Surgery referal if no improvement of ROM or large avulsion fracture
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Jersey Finger Avulsion of the FDP insertion in to the distal phalangeal base Football, rugby players Often avulses with a small bone frament 75% occur in the ring finger(anatomically weaker) X-ray(A/P and lateral of finger) Refer to surgeon ASAP(After 10days tendon likely shortened)
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Question : Finger A 25-year-old male presents to your office for evaluation of pain in the right index finger that has been present for the past 4 days. The pain has been getting progressively worse. On examination the finger is swollen and held in a flexed position. The pain increases with passive extension of the finger, and there is tenderness to palpation from the tip of the finger into the palm. Which one of the following is the most appropriate management of this patient? A) Surgical drainage and antibiotics B) Antiviral medication C) Oral antibiotics and splinting D) Needle aspiration E) Corticosteroid injection
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Purulent Tenosynovitis Flexor tendons are most common Kanavel`s signs : slight digital flexion Volar swelling Tenderness on flexor tendon Pain with passive extension Usually caused by S. Aureus or Streptococcus -> IV Antibiotics and Urgent surgical consultation for I&D
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THE FOOT AND ANKLE
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Question : Ankle Sprain A 30-year-old male is seen in the office for ankle pain. While playing basketball he jumped and landed on the lateral edge of his foot. He had immediate pain and did not continue playing, but was able to walk after the injury. P/E : His right ankle has tenderness, swelling, and bruising over the anterior talofibular and calcaneofibular ligaments. There is no bony tenderness. Which one of the following would be most appropriate at this point? A) Taping the ankle for future sports participation B) An elastic compression wrap C) A lace-up ankle support D) A radiograph of the ankle E) A below the knee cast
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Ankle Sprain- Treatment NSAIDs reduce pain and may reduce time for RTP Semi-Rigid ankle support(lace-up) with crutches initially. Graded exercise program and proprioceptive training for prevention for future ankle sprains within first 48hours from the injury after aggressive control of inflammation. Early mobilization and ROM improves recovery for Grade 1 and II Casting will delay RTP by 4-6 weeks.
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Question : Foot pain A 40-year-old female comes to your office with a 1-month history of right heel pain that she describes as sharp, searing, and severe. The pain is worst when she first bears weight on the foot after prolonged sitting and when she gets out of bed in the morning. It gets better with continued walking, but worsens at the end of the day. She does not exercise except for being on her feet all day in the hospital where she works as a floor nurse. She denies any history of trauma. P/E : point tenderness to palpation on the plantar surface of the heel at the medial calcaneal tuberosity. Which one of the following should you recommend as first-line treatment? A) Taping/strapping B) Over-the-counter heel inserts C) Extracorporeal shock wave therapy D) A corticosteroid injection E) A fiberglass walking cast
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Question : Foot pain An overweight 42-year-old female complains of foot pain. Which one of the following would be most suggestive of plantar fasciitis? A) A sudden onset of ecchymosis and plantar heel pain B) Sharp, stabbing pain with palpation of the medial plantar calcaneal area C) Posterior medial ankle pain D) Burning pain in the medial plantar region
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Risk factor for PF Obesity Standing on feet for longer time Limited ankle dorsiflexion Tight Achilles tendon Pes Cavus or Pes Planus Excessive running Treatment : Conservative management! ESWT might be beneficial if recalcitrant
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THE ELBOW
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Question : Elbow A 47-year-old female with no significant past medical history presents to your office with 2 weeks of worsening pain in her right arm. For the past 2 months she has worked on a plastics manufacturing assembly line. A physical examination reveals no swelling and a normal range of motion. She has normal strength in the upper extremity but she experiences increased pain with extension of her right wrist against resistance. Palpation reveals marked tenderness over the lateral epicondyle of the right arm. Which one of the following is most likely to improve the patient’s long-term outcome? A) Physical therapy B) Regular physical activity using her hands and arms C) Use of an inelastic, nonarticular proximal forearm strap D) Modifying her work routines
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Chronic Tendinopathy of common extensor origin Rotator cuff, Patellar tendon, Achilles Tendon, Common extensor origin on Lat. Epicondyle, Post. Tibialis Tendon, Peroneal Tendon Non-inflammatory Degenerative condition Eccentric strengthening (lengthening of a contracting muscle) is beneficial for tendinopathy Steriod injection might be beneficial for pain reduction for short term, but can be harmful if repeated.
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THANK YOU!