Office Orthopaedics: MSK or not MSK? That is the Question UCSF - - PDF document

7/23/2015 1

Office Orthopaedics: MSK or not MSK? That is the Question

Anthony Luke MD, MPH Essentials of Primary Care 2015

UCSF Orthopedics Primary Care Sports Medicine

Disclosures

• Founder, RunSafe™
• Founder & CEO, SportZPeak Inc.
• Sanofi, Investigator initiated grant
• Intel, Industry grant

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Outline

• Approach to MSK complaints
• How do you use symptoms?
• Discussion = Differential Diagnosis & Approach
• Neck
• Nerve
• Scapular dyskinesis
• Vascular -TOS
• Mobility

History: Demographics

Who?

• Age
• Occupation
• Recreation /

Sports

• Hand Dominance

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History is Key

• Numbness
• Fever

Instability Dysfunction Pain

History is Key

When?

• Acute vs Chronic (2 weeks? 6 weeks?)

Where?

• Think anatomy

How?

• Mechanism of injury

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Red Flag Symptoms

• Severe disability
• Numbness and tingling
• Night pain
• Constitutional symptoms (fever, wt loss)
• Swelling with no injury
• Systemic illness
• Multiple joint injury

Case 1

• Who? 15 year old male football player
• When? Last season
• What? Had a right arm “stinger” last

year after getting hit; sometimes gets some neck pain with contact but not everytime

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Spurling’s test - Cervical radiculopathy

Sens = 64% Spec = 95% PPV = 58% NPV = 96%

Burners / Stingers

• Axial loading, hyperflexion,

hyperextension or sudden rotation can cause injury to cervical spine and surrounding soft tissues

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C e r v i c a l S p i n e

• Atlantoaxial instability
• Multiple level fusion
• Significant cervical

stenosis

• Consider risk of

spinal cord injury during sports participation

• Select low risk sport
• Discuss with

specialist

Torg Ratio = y/z = 0.8

Posture

• Lines: ear lobe-

acromion-iliac crest

• Lordosis,

kyphosis

• Pelvic inclination -

ASIS lower than PSIS

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LOOK

“SEADS”

• Swelling
• Erythema
• Atrophy
• Deformity
• Surgical Scars

Suprascapular Nerve

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Ulnar nerve – Cubital tunnel syndrome

• Elbow Flexion

test

• Tinel sign
• Ulnar nerve

subluxation

TIPS Peripheral Neuropathy

• Look for occult onset of pain, weakness,

numbness

• Might follow acute trauma
• Think compression or traction
• Look for specific muscle atrophy
• Check for dermatomal numbness or

focal weakness

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Case 2

• Who? 48 year old female, looks

exhausted

• What? Has had severe 12/10 pain
• When? 2 nights
• Where? Diffuse shoulder pain, will NOT

let you move it

• How? No trauma, woke with the pain

WHAT DO YOU DO?

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Impingement/Rotator Cuff Tears

Impingement Partial Cuff Tear Full Thickness Tear

Calcific tendinosis

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Calcific Tendinosis

• Severe acute pain in shoulder
• Patient unwilling to move shoulder
• X-ray may show calcium deposits
• Ultrasound more sensitive than MRI
• Can consider subacromial steroid

injection

Tendon Pain

• May be present at the start of an activity then

“warm-up”

• Sore when the muscle is used
• May occur in “compensation” for other

structural problems near by

• Check for underlying spondyloarthropathy:

Psoriasis, GI symptoms, STD

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3 Basic P/E findings for tendinopathy

• 1. Tenderness on direct palpation
• 2. Reproduction of pain with resisted

contraction (eccentric loading)

• 3. Reproduction of pain with passive

stretch Elbow Tendinopathies

Lateral epicondylosis

• Tender lateral epicondyle
• Resisted third digit

extension

• Resisted wrist extension

Medial epicondylosis

• Resisted pronation/wrist

flexion Distal biceps

• Resisted supination

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Bone Pain

• Constant
• Sharp
• Greater load =

greater pain (i.e. weightbearing)

• May have

pressure features

Greater tuberosity fractures

• Indications for Greater tuberosity fractures

> 2 mm

• Isolated axillary nerve injury
• Subacromial impingement (common)- due to

displacement of fragment or even scar tissue formation, especially extension and external rotation

Green A, Norris TR. Skeletal Trauma: Basic science, management, and reconstruction (3rd edition). Elsevier Science, 2003, p. 1558.

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Other problems in the area

• Acromioclavicular joint osteoarthritis
• Sternoclavicular joint injuries
• Osteolysis of the distal clavicle

Take Home Points - Symptoms

• Ask More About Function (as well as Pain)
• How does this problem affect your day to day

function?

• What can’t you do that makes this a problem?
• If you could take this problem away immediately

(magic), how would your life be?

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Case 3

• Who? 40 year old male with R anterior

shoulder and scapular pain and winging scapular dyskinesis

• What? Pain with overhead activities and

sleeping

• When? He has had pain progressively

worsening over 6 months

• How? Had an injury skiing around 6 months

ago but only vague history; Works as auto mechanic

• Where? Shoulder radiating to lateral arm

Winging

• Long Thoracic

Nerve

– Serratus Anterior

• Less common

– Spinal Accessory Nerve (trapezius) – Dorsal Scapular Nerve (rhomboids)

• Scapular

Dyskinesis – MOST COMMON

– Pain may alter mechanics or vice versa

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Scapular – Dynamic Stabilizers

• Levator scapulae
• Trapezius muscle
• Serratus anterior
• Rhomboids
• Latissimus dorsi
• Pectoralis minor

Scapulohumeral Rhythm

• Ratio of Scapular to Humeral movement
• Occurs via coupled movement of the scapular

muscles

• Through elevation, scapula upwardly rotates,

posteriorly tilts and externally rotates

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Observation

• Rest
• Range of Motion
• Function!!
• Asymmetry
• Four point palpation

MOVE

Flexion, External rotation, and Internal rotation Painful Arc 60 - 120°

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Rotator Cuff Tear vs Impingement?

• 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.

Take Home Points

• Scapular dyskinesis is common as a

pattern of dysfunction, more than neurogenic winging

• Use impingement signs to rule in

shoulder problems

• Rotator cuff strength tests help diagnose

shoulder issues

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Case 4

• Who? 38 year old female secretary
• What? Neck pain with radiating pain to the

right elbow and right arm numbness and some ulnar nerve symptoms

• When? She has had worsening pain over 3

months

• How? Talking on her phone is painful, sleeping

is sore

• Where? Numbness to 4th and 5th fingers

Case 4

• LOOK 5’ 5”, 130

pounds

– Rolled forward shoulder posture, head forward posture

• FEEL

– Tender over cervical spine near R C7 facet joint

• MOVE

– C-spine - ROM 45° flexion 40° extension painful; right rotation 50° left rotation 70° – ROM shoulder 180 flexion bilaterally

• SPECIAL TESTS

– Rotator cuff strength 5/5 – Neer and Hawkin’s negative test – Spurling’s test positive – Roos’ test positive, Adson’s positive on right – Elbow flexion test positive – Tinel’s sign negative – U/E 5/5, Reflexes normal, sensation intact to light touch

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Sudden Death Round Thoracic Outlet syndrome

• Repetitive upper

extremity use

– shoulder, elbow, hand

• assembly line
• computer with

mouse and phone

• Poor posture
• Reaching
• Stress
• Apical breathing

Thoracic Outlet Syndrome tests

• Possible

compression of the subclavian artery between the scalenes and any cervical rib

• Compression of

neurovascular symptoms in the upper extremity by the pectoralis minor

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Adson’s Test

• Seated patient extends and

turns head toward the tested shoulder

• Shoulder is abducted and

extended.

• Subject inhales while the

examiner palpates the ipsilateral radial pulse.

• Positive findings: Diminution
• r elimination of the pulse and

reproduction of the paresthesias

• Studies show poor to good

specificity and good sensitivity.

Wright’s Hyperabduction Test

• With patient seated, the

clinician hyperabducts and externally rotates the patient’s arm while assessing the ipsilateral radial pulse

• Positive findings: Diminution
• r elimination of the radial

pulse and reproduction of the paresthesias

• No studies have examined

validity

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Roos Stress Test

• Patient holds shoulders in

abduction and external rotation at 90 degrees with elbows flexed at 90 degrees and repeatedly open and close their hands for three minutes.

• Positive findings:

Reproduction of their symptoms or a sensation of heaviness and fatigue.

• No studies have examined

validity of the Roos stress test as it pertains to thoracic

• utlet syndrome.

Case 4

• Who? 38 year old female secretary
• What? Neck pain with radiating pain to the

right elbow and right arm numbness and some ulnar nerve symptoms

• When? She has had worsening pain over 3

months

• How? Talking on her phone is painful, sleeping

is sore

• Where? Numbness to 4th and 5th fingers

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What is “Normal” Flexibility?

• Flexibility is the

range of motion available at a joint or series of joints

• Hypermobility vs.

Hypomobility

• Spectrum like

hypertension

Modified Marshall Test

Micheli Score

• Look at passive

thumb abduction

• f the right hand
• Grade 1 = 0°
• Grade 2 = 45°
• Grade 3 = 90°
• Grade 4 = 135°
• Grade 5 = thumb

touches forearm

• Can use + or – for

in between grades

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Common Pictures

Hyperlaxity

• OVERUSE &

Postural problems

• Associations with

subluxation of the hip, patella, shoulder, and proximal cervical spine, osteoarthritis, chondrocalcinosis,

• Bad sprains

Tight

• Patellofemoral

syndrome, hamstring and quad strains

• Tendinopathies
• Osgood-Schlatter’s

disease, Sever’s disease and peripelvic apophyseal avulsion fractures

Multidirectional instability

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Stability Tests

Sulcus sign (MDI)

No Sens / Spec Data

Subtalar Tilt test

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Posture

• Lines: ear lobe-

acromion-iliac crest

• Lordosis,

kyphosis

• Pelvic inclination
• ASIS lower

than PSIS

Rehab, rehab, rehab

Strengthening

• Core stability
• Postural exercises

– Upper Back

• Proprioception exercises
• Endurance / conditioning
• Ergonomic assessment at

work ? Chronic pain

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Take Home Points

• Always think about Posture
• Check for flexibility
• Consider hypermobility syndrome
• Use physical therapy

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

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