Bone-Up on Orthopedics Paul D. Giles, DO, MS

7/28/2014

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Paul D. Giles, DO, MS Primary Care Sports Medicine

Johns Hopkins Community Physicians, Bowie MD

Office Medical Director

Deaflympics 2013 – USA Team Physician (Bulgaria)

To review high volume musculoskeletal injuries seen by family physicians

To review the proper diagnostic tests, including physical exam and radiologic test, as well as treatment of these injuries.

To discuss information found within question stems and assign meaning found therein.

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Diagnosis?

HPI ◦ No injury

◦ Intermittent sharp pain lat and ant shoulder

Overhead

Sleeping on side

Work (carpenter)

◦ No numb/ting

◦ OTC NSAIDs without relief

◦ No h/o prior injury

PMH, PSH, Meds, All, Soc hx, ROS n/c

PE ◦ Active ROM 180/180

Pain in all planes

IR L shoulder to T6

◦ Pain with resisted ER

◦ +Empty Can, Impingement signs

Neg Crossover, O’Briens, Speed’s

◦ +TTP ant shoulder

Rad-4 view x-ray ◦ Normal

Rotator Cuff Tendonosis/Impingement Syn ◦ Can be from chronic microtrauma or acute

macrotrauma ◦ c/o pain, weakness and loss of motion

Difficulty reaching behind and overhead

Painful laying on affected side

◦ Physical Exam + Empty can test, Hawkin’s test, Neer’s Test

+Speed’s Test=Biceps Tendonosis

+O’Briens Test=SLAP Lesion

◦ Treatment Rest, NSAIDs, PT, Corticosteroid inj

Surgery for complete tears

Rotator

Cuff

Interval

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Diagnosis?

HPI ◦ Started after raking leaves

in fall

◦ Constant lat forearm/elbow ache

Gripping/lifting

Computer

◦ No swelling/numb/ting

◦ Ibuprofen with some relief

◦ No h/o sig injury

PMH, PSH, Meds, All, Soc hx, ROS n/c

PE ◦ No effusion/ecchymosis/

erythema ◦ TTP lat epicondyle ◦ Full, painless PROM at

elbow: flex/ext/pro/sup ◦ 5/5 mm strength

Pain with elbow ext, forearm pro, wrist ext, grip

◦ Neg valgus/varus stress ◦ Neg Tinels ulnar groove

X-ray 3 view elbow ◦ Neg

Lateral Epicondylitis (Tennis Elbow) ◦ Overload of tendon-bone junction ◦ Present with pain and tenderness over lateral

epicondyle ◦ Physical exam

Tender over lateral epicondyle

Pain with resisted wrist extension and extension of middle finger

◦ Treatment PT, bracing (wrist or counterforce), NSAIDs, cort inj

Medial Epicondylitis (Golfer’s Elbow) ◦ Pain with resisted wrist flexion

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Extensors

Flexors

Lateral Epicondyle

Medial Epicondyle

Diagnosis?

HPI ◦ No injury

Offensive lineman football

◦ Intermittent ache middle of low back

Wt lifting

Playing football

Running

◦ No numb/ting

◦ Chiropractor x6 mos without relief

◦ No meds

◦ No prev inj

PMH, PSH, Meds, All, Soc hx, ROS n/c

PE ◦ TTP b/l paraspinals L4-5

◦ Pain with ext

+Stork b/l

◦ 5/5 mm strength b/l LE

◦ Sensation intact

◦ DTRs 2+/4

◦ Neg straight leg raise

◦ Normal gait

X-ray 4 view (AP/Lat/Obl) ◦ Neg

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Spondylolysis-defect in pars interarticularis ◦ Caused by repeated hyperextension of the lumbar spine ◦ History-Adolescents

Strenuous athletic participation LBP often without radiation Insidious onset, progresses to chronic, dull, midline L/S pain

PE ◦ Tenderness to palpation over defect

Can have step-off with spondylolisthesis ◦ ROM ◦ Stork test-key PE test for diagnosis

Dx ◦ X-rays-oblique view will show chronic defect ◦ Bone Scan vs CT Scan vs MRI

TX ◦ Rest vs Brace

spondyloLISTHESIS

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Diagnosis?

HPI ◦ Heard pop in knee landing

from jump in basketball Immediate swelling

ER-x-rays neg

Knee immobilizer. NSAIDs

◦ Constant pain Any WB

Using crutches (?giving out)

◦ +swelling

-ecchymosis/erythema

◦ No prev inj

PMH, PSH, Meds, All, Soc hx, ROS n/c

PE ◦ Large effusion

◦ TTP med/lat jt line

◦ Ext to 10/flex to 90

◦ Sig guarding

?laxity on ant drawer/Lachman’s test

Neg valgus/varus stress

Unable to do McMurray’s

◦ Antalgic gait

X-ray 4 view wt bearing (AP/Lat/Tunnel/ Sunrise)-neg

ACL injury ◦ Primary stabilizer of knee

◦ Prevents anterior translation of tibia on femur

◦ Can be contact or noncontact

◦ Increased incidence in adolescent females

◦ Will often hear pop followed by immediate effusion

◦ + Lachman test, Pivot Shift and Anterior Drawer Tests

◦ Surgery based on associated injuries and patient preference

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Diagnosis?

HPI ◦ Rolled ankle playing soccer

◦ Immediate swell/bruise

Unable to cont playing

Urg care-x-rays neg

Stirrup brace/crutches

◦ Inter sharp pain lat ankle Worse walking

+ limp

◦ + swell/bruise

◦ NSAIDs with some relief

◦ h/o 3 ankle sprains-no tx

PMH, PSH, Meds, All, Soc hx, ROS n/c

PE ◦ +swelling

◦ Ecchymosis lat ankle

◦ TTP ATFL,CFL No medial TTP

◦ Dec ROM due to stiffness/pain

◦ Weak IR/ER with pain

◦ -ant drawer, +Talar tilt, -ER/Eversion test, -syndesmosis squeeze, -Thompson’s test

X-ray 3 view wt bearing (AP/Obl/Lat) ◦ Neg

Lateral ankle sprain ◦ 80-85% of all ankle sprains ◦ Inversion + plantarflexion of ankle ◦ 3 ligaments stabilize the lateral ankle

Injured in order based on severity: ATFLCFLPTFL ◦ Present with swelling, ecchymosis and variable weight-

bearing tolerance Anterior Drawer Test for ATF/Talar Tilt Test for CF

◦ Ottawa ankle rules guide need for x-ray ◦ Treatment

#1 rule is control swelling: RICE Crutches if limping Aggressive PT to regain strength and stability Bracing can be used as an adjunct to rehab and to prevent

future injury ◦ Associated Injury ◦ Fracture to the base of the 5th Metatarsal

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Dislocation ◦ Complete dissociation of humeral head from glenoid

fossa Subluxation is a transient displacement without complete

dissociation ◦ 95% are anterior dislocations ◦ Treatment

Stabilize arm, multiple relocation techniques Surgery vs Nonsurgical management 90% of young athletes will re-dislocate

◦ Associated injuries Joint capsule Labrum tear-Bankart Lesion Humeral fracture-Hill Sachs Deformity Axillary nerve or artery

AC joint separation (separated shoulder) ◦ Multiple ligaments and mm stabilize joint

◦ Fall on top of shoulder

◦ Graded I-VI (I-III most common)

◦ Evaluation

Tender over AC Joint

+ Crossover Test

◦ Treatment

Grades I-III: Ice, sling for comfort, PT to regain ROM

Grades IV-VI: Refer for surgery

I II IV V VI

Sprain/Strain vs Radiculopathy ◦ Presentation of pain/stiffness limited to neck and

upper back most likely sprain/strain ◦ Radicular symptoms include pain,

numbness/tingling and weakness into shoulder and arm to the hand

◦ + Spurlings sign = radiculopathy ◦ Imaging

X-ray, MRI, EMG

◦ Tx NSAIDs, muscle relaxers and PT

Epidural inj

Surgery

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Fall on outstretched arm

Limited flex/ext and pronation/supination ◦ Tenderness over lateral elbow

◦ Swelling may or may not be present

Often missed on initial x-ray ◦ Important to re-xray after 2-3 wks

Treatment ◦ Sling for 3-7 days

◦ Early ROM

◦ Surgery rarely necessary

Little leaguer’s elbow ◦ Spectrum of injuries to elbow

◦ Also overuse and poor mechanics

◦ Caused by medial stress or lateral compression

◦ Pitch counts

◦ Treatment is rest followed by strength exercises

Focus on correcting mechanics

Progressive throwing program

Distal radius fracture ◦ Very common-17% of all fractures in ER

◦ Treatment based on multiple anatomical factors

◦ Cast up to 6wks

Scaphoid fracture ◦ 70% of true wrist fractures

◦ Risk of nonunion or AVN

◦ Pain in anatomical snuff box

◦ May not be seen on initial x-rays

◦ Long arm vs short arm cast

◦ Can take up to 4 months to heal

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Carpal Tunnel Syndrome ◦ numb/ting and pain in radial 3 digits ◦ (+) Tinel and Phalen tests ◦ Confirmed by EMG with NCV ◦ Treatment

Cock-up Splint, NSAIDS, PT Surgery >3 mos conservative care or worsening neurological

symptoms

DeQuervain’s Tenosynovitis ◦ APL & EPB-1st dorsal compartment ◦ Tenderness and swelling over radial styloid ◦ (+) Finkelstein’s Test ◦ Treatment

Thumb spica splint, NSAIDs, PT, Corticosteroid inj Surgical release of 1st dorsal compartment

Sprain/Strain vs Radiculopathy ◦ Presentation of pain/stiffness limited to neck and

upper back of sprain/strain ◦ Radicular symptoms include pain,

numbness/tingling and weakness into buttock and leg to the foot

◦ + Straight Leg Raise = radiculopathy ◦ Imaging

X-ray, MRI, EMG

◦ Tx NSAIDs, muscle relaxers and PT

Epidural inj

Surgery

Meniscus ◦ Traumatic or degenerative

◦ Caused by weight-bearing + rotational forces

◦ c/o knee pain, delayed swelling, locking and catching

Effusion and joint line tenderness on exam

+McMurray and Thessaly (“Twist & Shout”) tests

◦ Treatment

RICE, NSAIDs

Functional symptoms require surgical evaluation

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Osgood-Schlatter Disease ◦ Osteochondritis of the tibial tuberosity ◦ Most commonly seen in ◦ 13-14 y/o boys 11-12 y/o girls

◦ Most common in jumping sports ◦ History

Recent growth spurt Anterior knee pain

◦ Physical Exam Tender over prominent tibial tuberosity

◦ Tx Ice, NSAIDs, Stretch/Strengthen

quads and hams

OK to play to pain tolerance ◦ Self-limited condition

Legg-Calve-Perthes Disease ◦ Interruption of blood supply to femoral

epiphysis ◦ Average age is 4-9 y/o ◦ Present with deep hip, groin or thigh pain

May radiate to knee ◦ Walk with limp, dec IR of hip ◦ Dx with x-ray

MRI/Bone scan if early ◦ Tx-Refer to ortho

Slipped Capital Femoral Epiphysis ◦ Due to shearing forces during growth spurts ◦ Avg age 8-15 y/o ◦ Early dx is key-insidious onset of

hip/groin/thigh/knee pain Dec IR on PE X-rays-ice cream scoop slipping off cone

◦ Refer to Ortho

L-C-P

SCFE

OA

◦GROIN PAIN = HIP JOINT ◦ Pain can radiate to knee or low back, so make

sure to check hip

◦ Tx with NSAIDs, PT, Cort inj, Surgery

Trochanteric Bursitis ◦ Pain/tenderness over greater trochanter

◦ Worse with hip flex/ext

◦ Multiple underlying factors

◦ Tx with PT, NSAIDs rest, cort inj

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Patella femoral pain syndrome ◦ Abnormal tracking of patella in groove between condyles

of femur

◦ Chronic in nature

◦ c/o anterior knee pain Theater sign

Pain going down stairs

◦ Increased Q angle on PE

◦ Treatment Strength, balance and flexibility

exercises

Foot orthotics

Bracing/taping in season

Surgery-rare

Medial Ankle Sprain ◦ Dorsiflexion + eversion of foot ◦ Injury to deltoid ligament

Fracture of tibia more common than ligament tear

Can extend proximally to cause fibular fracture

◦ Similar presentation as a lateral ankle sprain ◦ X-rays required to assess joint stability ◦ Treatment

Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable

Longer healing time than lateral ankle sprains

Plantar Fasciitis ◦ Irritation of the calcaneal attachment of the plantar

fascia

Not caused by heel spur

◦ Insidious onset of pain radiating into arch

Painful 1st steps in AM

◦ Tenderness of anterior-medial calcaneus

Often tight achilles tendon

◦ Treatment

NSAIDs, rest, PT w/ massage, orthotics, night splints

Surgical release is last resort

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Sever Disease ◦ Apophysitis of posterior calcaneus

◦ Epiphysis fuses at 12-15 y/o

◦ History

Insidious onset of heal pain

Boys 10-12 y/o; Girls 8-10 y/o

◦ Physical Exam

Tenderness over insertion of achilles tendon

Decrease passive ankle dorsiflexion

◦ Treatment

Ice, NSAIDs, heel lifts, stretch/strengthen heel cords

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2. Eiff MD, M. Patrice, Robert Hatch MD and Walter Calmbach MD. Fracture Management for Primary Care. Philadelphia. Saunders Elsevier: 2003.

3. DeLee MD, Jesse, David Drez, Jr. MD, Mark Miller MD. Orthopedic Sports Medicine. Philadelphia. Saunders Elsevier: 2010.

4. Magee Ph.D, David. Ortohpedic Physical Assessment, 4th Edition. Philadelphia. Saunders Elsevier: 2002.

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