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Disclosures Disclosures No personal conflicts of interest. Pain - - PDF document

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6/10/2013 Evaluating Injuries of the Evaluating Injuries of the Evaluating Injuries of the Evaluating Injuries of the Knee and Shoulder Knee and Shoulder Knee and Shoulder Knee and Shoulder Massachusetts Medical Society Massachusetts

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Evaluating Injuries of the Evaluating Injuries of the Knee and Shoulder Knee and Shoulder Evaluating Injuries of the Evaluating Injuries of the Knee and Shoulder Knee and Shoulder

Massachusetts Medical Society 11th Annual Men’s Health Symposium Massachusetts Medical Society 11th Annual Men’s Health Symposium

MGH Sports Medicine

Eric Berkson, MD Eric Berkson, MD

MGH Orthopaedic Sports Medicine MGH Orthopaedic Sports Medicine Director, Mass General Sports Performance Center Director, Mass General Sports Performance Center Instructor, Harvard Medical School Instructor, Harvard Medical School Team Physician, Boston Red Sox Team Physician, Boston Red Sox

Disclosures Disclosures

Disclosure Disclosure

  • No personal conflicts of interest.
  • Research supported by:

– Major League Baseball

Pain Swelling Stiffness Locking

MGH Sports Medicine

  • Off label use of some products will be

discussed

Instability

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MGH Sports Medicine MGH Sports Medicine

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Sports Medicine Biomechanics Sports Medicine Biomechanics

MGH Sports Medicine MGH Sports Medicine

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Sports Medicine Biomechanics Sports Medicine Biomechanics

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  • Rising from Chair

2.5 x bodyweight

  • Downstairs

3.3 x bodyweight

  • Walking

3 - 6 x bodyweight

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10 pound weight 10 pound weight loss decreases forces loss decreases forces on

  • n

knee by 30 to 60 pounds with each step knee by 30 to 60 pounds with each step

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  • Force of gravity pulling

you toward Earth you toward Earth

  • Sitting in a chair: 1 g
  • Roller Coaster:

2.5 g’s to 6 g’s

Formula Rossa, UAE (149MPM) Kingda Ka, Six Flags NJ (456 ft) Tower of Terror, Gold Coast Australia (6.3g)

  • Fighter Jet: 9 g’s

MGH Sports Medicine http://www.youtube.com/watch?v=sNu200WkYZw

Biomechan

Shoulder

nics of Throwing Shou

Elbow

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ulder

Wrist

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  • Correlate anatomy, physical

examination, and diagnosis

Sh ld

  • Shoulder
  • Knee
  • Anterior knee pain
  • Lateral knee pain
  • Medial knee pain

When to refer?

MGH Sports Medicine

  • When to refer?
  • When is this arthritis?

– What arthritis can be fixed? – Cartilage defects vs DJD

HISTORY HISTORY

1. Onset 2. Location

History History

2. Location 3. Duration 4. Quality/Quantity

– Swelling – Mechanical symptoms

5. Aggravating Factors

Pain Swelling Stiffness Locking What is the major problem?

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6. Relieving Factors 7. Associated Symptoms 8. Effect on Function **

Instability

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  • Injury

– Torn ligament

History History

Torn ligament – Meniscus – Fracture – Patella dislocation – Rotator cuff tear

  • No Injury

– CMP, tendinitis – DJD – Meniscus Rotator cuff tendinitis

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– Rotator cuff tendinitis – Rotator cuff tear

  • Non -contact

History: Onset History: Onset

  • Pain and Instability

Bl t l t l

  • Blow to lateral

aspect of knee (valgus force)

  • Focal tenderness of

medial knee along course MCL

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course MCL Contact Injury - Torn MCL

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History: Age Matters History: Age Matters

History History

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  • Less than 30-35 years of age

Less than 30 35 years of age

– Dislocations/subluxation common

  • Falls on outstretched arm, abduction injuries
  • Throwing or overhead labral injuries

– A-C joint injuries with direct fall injuries – Rotator cuff sprains common but tears unusual

MGH Sports Medicine

unusual – Fractures only in high energy injuries

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  • Greater than 40 years of age

Greater than 40 years of age

– Fractures more common – Arthritic conditions of A-C joint and glenohumeral joint – Rotator cuff injuries more common

  • Strains, partial thickness tears

MGH Sports Medicine

  • Full thickness tears

Symptoms -Patella

  • Click / snap

History History

  • Click / snap
  • Grind
  • Pain stairs
  • “Movie Theatre sign”

MGH Sports Medicine

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Symptoms - ACL Symptoms - ACL

–Instability

History History

(giving way) –Can run straight ahead but

MGH Sports Medicine

ahead but cannot pivot

  • ACL
  • Patellar sleeve

fracture History History

  • ACL
  • ACL

fracture

  • Joint capsule tear
  • PVNS
  • Sickle Cell
  • Hemophilia
  • Patellar

dislocation

  • Osteochondral

MGH Sports Medicine

  • Anticoagulant

therapy

  • Ruptured aneurysm

Timing matters…

fracture

  • Peripheral

meniscal tear

  • PCL
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  • Cervical radiculitis/radiculopathy
  • Myofascial pain
  • Myofascial pain
  • Viral brachial plexopathy
  • Thoracic outlet syndrome
  • Pancoast tumor
  • Neoplasm of humerus/shoulder girdle (mets)
  • Thoracic disc herniation

MGH Sports Medicine

  • Abdominal problems (gall bladder,

pancreatitis, etc.)

  • Diaphragm irritation

Hi P i

  • Hip Pain

– Child/Adolescent – Arthritis

  • Lumbar

MGH Sports Medicine

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  • Hip / Lumbar spine exam
  • Gait

Physical Ex Physical Ex Gait

  • Alignment
  • Effusion
  • ROM
  • Stability

xam xam

MGH Sports Medicine

  • Palpation
  • PF Crepitus
  • Special tests
  • Lateral

Radiograph Radiograph

  • Merchant view(Patella)

Not more than 30°!

  • Standing Bilateral AP
  • Standing PA view @ 45

hy hy

MGH Sports Medicine

Sta d g e @ 5 deg flex

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6/10/2013 13 Radiograph Radiography hy

MGH Sports Medicine

Imaging alone should not dictate treatment

Radiograph Radiography hy

For suspected intra-articular abnormalities

MGH Sports Medicine

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MGH Sports Medicine

Imaging alone should not dictate treatment

  • Medial meniscus
  • Pes anserinus

Medial Knee Medial Knee

  • OA / DJD
  • MCL Sprain
  • Osteonecrosis
  • Osteochondritis

d i (OCD) Pes anserinus bursitis

  • Semimembranosis

tendinitis

  • Stress fracture
  • Physeal Injury

e Pain e Pain

MGH Sports Medicine

dessicans (OCD)

  • Physeal Injury
  • Popliteal cyst
  • Saphenous Neuritis
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MGH Sports Medicine

Medial Knee Medial Knee Pain e Pain

MGH Sports Medicine

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6/10/2013 16 Medial Knee Medial Knee Pain e Pain

MGH Sports Medicine

Medial Knee Medial Knee Pain e Pain

MGH Sports Medicine

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6/10/2013 17 Medial Knee Medial Knee Pain e Pain

MGH Sports Medicine

Medial Knee Medial Knee Pain e Pain

MGH Sports Medicine

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Symptoms - Meniscus Symptoms - Meniscus

Meniscus DJD DJD

Medial Knee Medial Knee

  • Pain

Pain

– – medial medial – – lateral lateral

  • Clicking

Clicking

  • Aching
  • Stiffness
  • Pain
  • Aching
  • Stiffness
  • Pain

e Pain e Pain

MGH Sports Medicine

  • Popping

Popping

  • Locking

Locking

Medial Knee Medial Knee

  • “Popping” sensation
  • Knee feels painful and

e Pain e Pain

p tight

  • Stiffness and swelling
  • Exam:

– Tenderness at joint line – Pain with extension or flexion – Effusion

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Effusion

  • Meniscus can loosen drift into joint

– Locking or catching of knee – “Pebble in the knee”

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  • MRI diagnosed meniscal

tears evident in 40%

Medial Knee Medial Knee

tears evident in 40% asymptomatic patient

  • lder than 50 years1
  • 56% in 70-90yrs old2
  • Arthritis

– 63% : if knee pain, aching stiffness most

e Pain e Pain

MGH Sports Medicine

aching, stiffness most days – 60% without those symptoms

1 Jerosh Archive Orthop Trauma Sug 1996

  • 2. Eglund NEJM 2008

Eglund NEJM 2008

  • Ineffective pain / arthritis alone

D t lt th t l hi t f t th iti

Medial Knee Medial Knee

  • Does not alter the natural history of osteoarthritis
  • Mechanical symptoms1, loose bodies
  • Factors to consider

– Prior arthroscopy2 – Correlation of symptoms to pathology – Severity of cartilage loss and bone marrow edema in the same compartment of meniscal tear3

e Pain e Pain

MGH Sports Medicine

compartment of meniscal tear – Severity of meniscal extrusion – Meniscal root tear – Age > 704 – Alignment

1Chang Arthritis Rheum 1993 2Spahn Arthroscopy 2006 3Kijowski Radiology 2011 4Wai JBJS 2002

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  • Diagnostic

Medial Knee Medial Knee

g

  • Therapeutic

e Pain e Pain

MGH Sports Medicine

  • Injections NSAIDS
  • Injections, NSAIDS
  • Meniscectomy
  • Meniscal Repair

– Young person – Acute injury C id i

MGH Sports Medicine

– Consider repair – Tear has to be in “red zone”

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6/10/2013 21 Medial Knee Medial Knee Pain e Pain

MGH Sports Medicine MGH Sports Medicine

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  • Popliteal cyst (?ruptured)

P lit t Posterior K Posterior K

  • Popliteus rupture
  • Torn meniscus
  • DVT
  • Popliteal artery aneurysm
  • Hamstring strain (?)

nee Pain nee Pain

MGH Sports Medicine

g ( )

  • Referred pain

– Swelling in knee – Chondromalacia patella

  • Osgood Schlatter’s disease
  • Patella tendinitis

“jumper’s knee” Anterior Kn Anterior Kn

  • Patella tendinitis – jumper s knee

– Sinding-Larsen-Johannson

  • Patella instability
  • Pre-patellar bursitis
  • Patella or trochlea chondrosis (CMP)
  • Patellofemoral Syndrome

nee Pain nee Pain

MGH Sports Medicine

  • Patellofemoral Syndrome
  • Bipartite patella
  • (Synovial plica)
  • Referred pain – back/hip/femur/foot
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Patellar Tendinitis

  • “Jumpers knee”

Anterior Kn Anterior Kn

  • Sinding-Larsen-Johannson
  • Examination - Tenderness

inferior pole of patella

nee Pain nee Pain

MGH Sports Medicine

Patellar Tendinitis Patellar Tendinitis

Anterior Kn Anterior Knee Pain nee Pain

MGH Sports Medicine

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  • Very common

Anterior Kn Anterior Kn

  • Very common
  • Usually non-op Tx
  • Surgery in <1% - excise

abnormal tissue at inferior pole of patella nee Pain nee Pain

MGH Sports Medicine

Malalignment

  • Bony alignment

J i t t

Abnormally directed Anterior Kn Anterior Kn

  • Joint geometry
  • Soft tissue restraints
  • Neuromuscular control
  • Functional demands

Abnormally directed load nee Pain nee Pain

MGH Sports Medicine

Exceed physiological threshold

PAIN

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Etiology

  • Acute trauma
  • Overuse
  • Abnormal lower limb

alignment / mechanics

  • Immobilization

Soft tissue tightness

Despite uniform clinical picture - the etiology of PF problems is multifactorial and not consistent for all pts.

Not all patellar malalignment causes pain,

MGH Sports Medicine

  • Soft-tissue tightness
  • Excessive weight
  • Muscle weakness
  • Prolonged synovitis

Not all anterior knee pain is from malalignment

Treatment- Patellofemoral Treatment- Patellofemoral

Avoid excess load S t L d Anterior Kn Anterior Kn

C li

  • Squats, Lunges, deep

knee bends

  • Stairmaster
  • High impact aerobics
  • Step aerobics

nee Pain nee Pain

Cycling Rowing Walking Swimming

MGH Sports Medicine

  • Plyometrics
  • Dryland training, stadium

steps

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  • Lateral meniscus tear

Lateral Kne Lateral Kne

– Discoid – (Torn ACL)

  • Runner’s knee - ITB syndrome
  • OA / DJD
  • Proximal tibiofibular joint

e Pain e Pain

MGH Sports Medicine

j

  • Pain or burning located over the lateral

t f th k Runner’s Knee Lateral Kne Lateral Kne aspect of the knee

  • Aggravated by activity with repeated knee

motion and relieved by rest

  • Caused by friction of the ITB as it rubs over

the lateral femoral condyle-may pop/snap e Pain e Pain

MGH Sports Medicine

  • Pain may radiate to thigh or hip
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6/10/2013 27 Lateral Kne Lateral Knee Pain e Pain

MGH Sports Medicine

  • Physical Examination

– tenderness over the ITB at the lateral femoral condyle

Lateral Kne Lateral Kne

condyle – tightness with positive Ober’s test – possible snapping with flexion/extension – no instability and usually no swelling – Hip examination

e Pain e Pain

MGH Sports Medicine

Hip examination – Core Strength – Standing limb alignment: Femoral version, tibial torsion, hindfoot varus /valgus – Shoe examination

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  • Treatment

physical therapy

Lateral Kne Lateral Kne

– physical therapy

  • U/S, massage, stretch, strengthen muscle

imbalance – relative rest – ice – NSAID’s

e Pain e Pain

MGH Sports Medicine

– correct biomechanical or training errors

  • Change shoes!

ACL Tears ACL Tears

MGH Sports Medicine

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ACL Tear ACL Tear

  • Common sports injury
  • Most are non-contact

ACL Tears ACL Tears

  • basketball, football,

skiing, soccer

  • Hx:
  • twisted knee
  • heard or felt a “pop”
  • Deceleration to a stop
  • r landing
  • Landing from a jump
  • Cuts and pivots

MGH Sports Medicine

heard or felt a pop

  • immediate swelling
  • difficult to walk initially

Effusion Anterior Drawer

S iti it 0 2 S ifi it 0 88

ACL Tears ACL Tears

Sensitivity 0.2 Specificity 0.88

MGH Sports Medicine

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Lachman Pivot Shift ACL Tears ACL Tears

Sensitivity 0.86 Specificity 0.91 Sensitivity 0.40 Specificity 0.98

MGH Sports Medicine

ACL Tears ACL Tears

MGH Sports Medicine

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MGH Sports Medicine

  • Definitions:

1 Injured but functional ACL ACL Tears ACL Tears

  • 1. Injured but functional ACL
  • Appropriate injury mechanism, asymmetric

KT-1000 difference, MRI suggestive of ACL injury AND negative pivot shift

2 One bundle injury

MGH Sports Medicine

  • 2. One bundle injury
  • Anatomic Location: anterolateral vs

posteromedial bundle1

  • A rare event

1 Zantop CORR 2007

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  • Treatment should fit individual patient’s

d ACL Tears ACL Tears needs

  • Therapeutic decision based on occupation,

activity, amount of time in high demanding activities, presence of associated knee lesions

MGH Sports Medicine

  • Physiological age and activity more important

than chronological age Who Benefits? ACL Tears ACL Tears Differentiate: “Pain” from “Instability” from “Pain from instability”

  • Surgical options: Prevent recurrent instability

MGH Sports Medicine

Surgical options: Prevent recurrent instability leading to higher quality of life

  • Nonsurgical Options: (Older)No high demand

activities, coping well with instability, pain

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  • Patients who return to

preinjury level activity may be ACL Tears ACL Tears p j y y y significant risk for re-injury

  • Bracing in higher risk

activities considered

  • May not be successful in

preventing re-injury

MGH Sports Medicine

p e e t g e ju y

– Reliance on a brace to return to pre-injury levels of activity may lead to significant re- injury rates.

Operative versus nonoperative treatment of anterior cruciate ligament rupture in patients ACL Tears ACL Tears anterior cruciate ligament rupture in patients aged 40 years or older: an expected-value decision analysis.

Seng et al. Arthroscopy 2008

– 69 Subjects S i l t ti ti l t t t

MGH Sports Medicine

– Surgical reconstruction was optimal treatment strategy in patients 40 and older – Averse to risk of possible re-injury, instability

  • r modified return to activity
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The Shoulder

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  • 1. Glenohumeral Joint (Shoulder)
  • 2. Acromioclavicular Joint (AC)
  • 3. Sternoclavicular Joint (SC)
  • 4. Scapulothoracic Joint (ST)

4 Articulations:

Dynamic Factors Dynamic Factors

–Rotator Cuff Rotator Cuff Th –Scapular Rotators Scapular Rotators –Long Head Biceps Long Head Biceps –Ligament Ligament Dynamization Dynamization –Proprioception Proprioception e Shoulder

MGH Sports Medicine

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  • Dynamic Factors

Dynamic Factors

–Rotator Cuff Rotator Cuff Th Rotator Cuff Rotator Cuff

  • Primary Function

Primary Function –Stabilize humeral head Stabilize humeral head

  • Secondary Function

Secondary Function –Glenohumeral motion Glenohumeral motion

  • Dynamic Joint Compression

Dynamic Joint Compression –Increased stability Increased stability e Shoulder

MGH Sports Medicine

y –Stabilizes against Stabilizes against inferior translation inferior translation

» »Warner, JBJS 1997 Warner, JBJS 1997 » » Hsu, JSES 1997 Hsu, JSES 1997

  • Range of Motion (Passive and Active)

– Shoulder – Forward Flexion – Abduction – External Rotation – Internal Rotation

MGH Sports Medicine

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Forward Flexion

MGH Sports Medicine

Supine Eliminates Scapular Motion

External Rotation External Rotation

In Adduction In Adduction In Abduction In Abduction

MGH Sports Medicine

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External Rotation External Rotation

MGH Sports Medicine

T I f i A l

MGH Sports Medicine

  • T7 – Inferior Angle
  • T3 – Spine Scapula
  • T1 – Superior Angle
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  • ROM:

– If PASSIVE range of motion is restricted

  • Arthritis

(xray: true AP)

  • Adhesive capsulitis (frozen shoulder)

– If ACTIVE range of motion restricted (but not passive)

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(but not passive)

  • Pain
  • Rotator cuff tear (partial versus full)

– Lag (bounce back): If passive > active

MGH Sports Medicine

True AP Standard AP

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MGH Sports Medicine

Strength: Supraspinatus Strength: Supraspinatus

  • Forward Flexion
  • Pain & Weakness

w/ Resisted Abduction in Scapular Plane

MGH Sports Medicine

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Strength: Infraspinatous Strength: Infraspinatous

External Rotation

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Strength: Subscapularis Strength: Subscapularis

Lift-off

MGH Sports Medicine

Belly-Press

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Sternoclavicular (SC) joint Pain Acromioclavicular (AC) joint Pain Biceps Tendinitis Bicipital groove/tendon Greater tuberosity (supraspinatus

MGH Sports Medicine

Greater tuberosity (supraspinatus insertion)

IMPINGEMENT SYNDROME IMPINGEMENT SYNDROME

  • Cuff, bursa impinged by :

anterior acromion CA lig.

Stage I: bursitis, edema Stage II: tendinitis, fibrosis (25- 40 yo) St III ff t

MGH Sports Medicine

Stage III: cuff tear

Impingement Signs (Hawkins/Neer)

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  • On autopsy:
  • On autopsy:

– 70% of people over 80 y.o. – 30% of people under 70 y.o.

  • Not all are symptomatic

N t l Hi t

MGH Sports Medicine

  • Natural History:

– Tears tend to get larger – Larger tears correlate level of disability

  • Acute
  • Acute

– Younger patient, associated with trauma

  • Chronic

– “Wear and tear” – Progression of pathology RTC t d iti I i t P ti l

MGH Sports Medicine

  • RTC tendonitis – Impingement – Partial

thickness tear – Full thickness tear – Massive tear – RTC Arthropathy

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  • Pain located lateral arm

P i h hi h d

  • Pain when reaching overhead
  • Can’t sleep at night
  • Night Pain

MGH Sports Medicine

  • INSPECT/PALPATE
  • SHOULDER ROM

– Lag - Difference between Passive and Active Motion

  • SHOULDER STRENGTH**

MGH Sports Medicine

– Weakness, drop-arm

  • IMPINGEMENT SIGNS
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  • MOST COMMON IS SUPRASPINATUS

MGH Sports Medicine

  • +/- Impingement sign
  • Weakness on strength testing
  • Full thickness

– Surgery (depending on chronicity)

MGH Sports Medicine

  • Partial thickness

– PT – NSAID’s – Cortisone Injection – Surgery

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6/10/2013 45

  • Degenerative disease

shoulder

Arthroscopic debridement – Arthroscopic debridement more effective than at the knee1

  • Injections
  • Cartilage procedures
  • Hemiarthroplasty, total

shoulder arthroplasty

MGH Sports Medicine

shoulder arthroplasty

  • Reverse total shoulder

arthroplasty

1 Namdari Arthroscopy 2013

  • Cartilage degeneration

does not necessarily cause pain

  • Synovial / capsular tissues

are primary sources of pain

MGH Sports Medicine

  • Subchondral pain

– late event

… Pain drives osteoarthritis treatment

… Pain drives osteoarthritis treatment

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MGH Sports Medicine

Types of Cartilage Repair Types of Cartilage Repair

1) Bone-marrow stimulation

microfracture

Cartil Cartil

– microfracture

2) Transplantation of osteochondral grafts

– OATS, mosaicplasty, allografts

3) Implantation of autologous cells

(chondrocytes)

lage Procedur lage Procedur

MGH Sports Medicine

– ACI

4) Matrices / scaffolds

– +/- cells, +/- growth factors

res res

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Small defects (<2‐4cm2) Large defects (>2‐4cm2)

Cartilage Proce Cartilage Proce

Very small (<2cm2) Small OATS Microfracture

Microfracture

ACI OA allograft

+ mature articular cartilage + primary bone healing + quicker recovery and return to play than + no donor site morbidity + arthroscopic procedure complex rehab (CPM + In less demanding individuals + Reasonable success in larger lesions + no size limitation + hyaline‐like cartilage arthrotomy + no size limitation + hyaline cartilage ‐ arthrotomy ‐ graft availability

edures edures

MGH Sports Medicine

return‐to‐play than microfracture ‐ technically difficult (mini‐open) ‐ donor site morbidity with multiple plugs ‐ complex rehab (CPM and TDWB 6‐8w) ‐ prolonged Return‐ to‐play 6‐9 months (ACI 80% if this fails) ‐ arthrotomy ‐ high re‐op rate ‐ complex rehab ‐ prolonged RTP 12‐18 months ‐ cost ‐ disease transmission ‐ bone fails ‐ simple rehab ‐ prolonged RTP 9‐ 12 months ‐ longevity ‐ cost

Cartil Cartilage Procedur lage Procedur

MGH Sports Medicine

Provencher J Knee Surgery 2009

res res

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MGH Sports Medicine