9/28/2016

Disclosures

I have nothing to disclose. of the and UCSF Primary Care Medicine: Principles and Practice

Carlin Senter, MD Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthopaedics

October 12, 2016

Objectives Case #1

Upon completion of this session, participants should be able to: 25 y/o man with medial-sided pain and swelling of the R knee for 6 weeks since he twisted the knee playing soccer. No locking, no 1. Name 4 exam maneuvers to use when suspecting a instability. tear. 2. Identify 6 clinical criteria that raise the likelihood of a diagnosis of knee (OA) in a patient with . 3. Identify indications for knee in patients with knee OA, knee OA with , and meniscus tear without knee OA. 4. Name 2 causes of shoulder pain when both active and passive are limited. 5. Identify a full thickness on physical exam.

1 9/28/2016

All of the following tests, if positive, 4 tests for meniscus tear would raise concern for a meniscus tear except… 1. Isolated line tenderness 2. McMurray

A. Joint line tenderness 3. Thessaly B. Pain when he stands and pivots on the knee 4. C. Pain when you axially load and rotate the knee D. Pain when you flex the R knee and extend the R with the patient lying on his left side. E. Pain when he squats

Joint line tenderness Meniscus: McMurray

Sensitivity medial 65%, Specificity medial 93%*

Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008.

http://www.ski-injury.com/kneeanat.gif, Accessed 10/04/05. Accessed 10/4/05 Video used with permission from Anthony Luke, MD

2 9/28/2016

Meniscus: Thessaly Meniscus: squat

Sensitivity 90%, Specificity 98% (Harrison BK et al. CJSM, 2009) Sensitivity 75-77%%, Specificity 36-42% Sensitivity 51-67%, Specificity 38-44% (Snoeker BAM et al. JOSPT, 2015) (Snoeker BAM et al. JOSPT, 2015)

Video used with permission from Anthony Luke, MD

Ober’s Test for tight IT Band Case #2

60 y/o woman presents with 3 months of medial knee pain. (+) swelling, and instability. No frank locking. Pain is worse with weight bearing. Better with rest, ice, and NSAIDs. She brings a knee MRI for your review.

Exam: Neutral knee alignment when standing. Knee is not warm. There is tenderness of the medial joint line + medial femoral condyle + medial tibial plateau. Small effusion. ROM 0-120, limited by pain. (+) crepitus. (+) medial McMurray, medial knee pain with squat and Thessaly tests. No .

3 9/28/2016

Case #2: MRI results Clinical criteria for diagnosis of knee OA

. Small effusion . Moderate chondrosis medial femoral condyle and medial tibial plateau . Degenerative tear

Altman R et al. Rheum. 1986 Aug;29(8):1039-49.

Case #2 What do you recommend?

60 y/o woman presents with 3 months of medial knee pain. (+) A. Refer for arthroscopic debridement of meniscus tear and swelling, and instability. No frank locking. Pain is worse with weight lavage bearing. Better with rest, ice, and NSAIDs. She brings a knee MRI for your review. B. Nonoperative knee OA program C. Refer for total knee arthroplasty

Exam: Neutral knee alignment when standing. Knee is not warm. There is tenderness of the medial joint line + medial femoral condyle + medial tibial plateau. Small effusion. ROM 0-120, limited by pain. (+) crepitus. (+) medial McMurray, medial knee pain with squat and Thessaly tests. No ligamentous laxity.

4 9/28/2016

Interventions

.Control .Arthroscopic surgery • PT: 1 hour/week x 12 • Irrigation with saline weeks • 1 or more of the following: • Home ex program 2x/day ‒ Debridement or excision of • Instruction on ADLS degenerative meniscus tears • Self management arthritis ‒ Removal loose bodies, chondral flaps, bone spurs education reading + . 188 patients followed x 2 years videotape • Medical and like controls . Primary endpoint WOMAC score (knee pain + fxn) • Medications (APAP, NSAIDs, hyaluronic acid . Avg age 60, 2/3 female, BMI 31 injections) . Excluded bucket handle meniscus and severe varus or valgus alignment Kirkley et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee, NEJM, 2008.

Results

Kirkley et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee, NEJM, 2008.

5 9/28/2016

Surgery vs PT for meniscal tear and OA Interventions .Control (PT) .Arthroscopic partial . Multicenter RCT • Usually 6 weeks meniscectomy (APM) . 351 patients with meniscus tear + OA • 3-stage program • Trim damaged meniscus . Meniscus sxs (clicking, popping, catching, giving way, joint line back to stable rim pain, pain with twisting) . APAP, NSAIDs, • Remove loose . Avg. age 60 years intraarticular steroid and bone injections as needed . 50% men, 50% women .PT protocol . Primary outcome = change in WOMAC physical-function score between groups at 6 mo .APAP, NSAIDs, intraarticular steroid injections as needed Katz JN et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2; Katz JN et al. N Engl J Med. 2013 May 2; 368(18):1675-84. 368(18):1675-84.

Results Results

Katz JN et al. N Engl J Med. 2013 May 2; 368(18):1675-84. Katz JN et al. N Engl J Med. 2013 May 2; 368(18):1675-84.

6 9/28/2016

Conclusions Osteoarthritis with meniscus tear

. 30% crossed over from PT to APM at 6mo . Meniscus tear is part of the natural history of osteoarthritis • These people had WOMACs that didn’t improve until crossover . Treat as osteoarthritis initially . No sig difference in adverse events . Imaging: Start with xray. Consider referral vs MRI if exam c/w meniscus tear and not improving with PT . PT and APM are reasonable options with similar outcomes for these patients (with allowed cross over if not achieving relief with . Could consider arthroscopic meniscus surgery if weight loss, PT, PT) medications, injections not helping or if patient prefers surgical treatment. . Starting with conservative approach is reasonable

Katz JN et al. N Engl J Med. 2013 May 2; 368(18):1675-84.

Case #3 What do you recommend?

60 y/o woman presents with 4 months of medial knee pain and A. Refer for arthroscopic debridement of meniscus tear swelling. Pain is worse with weight bearing and twisting activities. Better with ice, NSAIDs. She has done physical therapy . B. Physical therapy, medication for pain as needed C. Refer for total knee arthroplasty

Exam: Neutral on standing exam, tender medial joint line without bony tenderness, small knee effusion. ROM 0-120, limited due to pain. (+) McMurray, squat, and Thessaly testing. No ligamentous laxity.

MRI: small effusion. Normal cartilage. Degenerative medial meniscus tear.

7 9/28/2016

.Improvement in Results both groups at 12 mo .No significant between-group differences in 3 primary outcomes . 35-65 y/o (n = 146) . Inclusion: > 3 months medial joint line pain, tried conservative care first, exam consistent the MMT, MRI with MMT confirmed on arthroscopy . Exclusion: traumatic onset of symptoms, locked or unstable knee, previous surgery, OA by ACR criteria or x-ray

Published 12/26/13

Would she benefit if she had locking or Degenerative meniscus tear, no OA catching of the knee? . FIDELITY studies suggest no benefit from arthroscopic partial meniscectomy, even with mechanical symptoms, over sham arthroscopic surgery. . Limitations • Definition of degenerative meniscus tear? • No radiographic OA but these patients had some mild cartilage . FIDELITY post hoc analysis wear . Same exclusion and inclusion criteria . Resection of torn meniscus did not result in greater relief of knee catching and locking compared to sham arthroscopy

Published 4/5/16

8 9/28/2016

Who to refer for knee arthroscopy Case #4

. Younger patients 50 y/o RHD woman with type 2 diabetes presents with 3 months of severe R shoulder pain. No . Waking up at night due to pain. . Traumatic onset of symptoms Shoulder feels very stiff. She is having trouble reaching behind and . Bucket handle meniscus tears raising above head. • Knee locked due to meniscus blocking joint movement . Locking (knee stuck, cannot move it) On exam she has no and no point tenderness. There is decreased active and passive range of motion of the right . Not improving despite conservative treatment (?) shoulder. Her rotator cuff strength is 5/5 though difficult to perform due to limited range of motion and pain. A R shoulder xray is . Patient prefers surgery to conservative treatment (?) normal.

How would you treat this patient? Adhesive capsulitis

A. Provide R shoulder sling to use for comfort. B. Provide shoulder steroid injection to reduce pain. C. Obtain shoulder MRI. D. Obtain PET CT. E. Refer to surgeon for arthroscopy.

http://www.aurorahealthcare.org/healthgate/images/si55551230.jpg

9 9/28/2016

Shoulder: diagnosis driven exam Shoulder active range of motion

Active ROM

Normal Decreased

Rotator cuff disease Labral tear Passive ROM Biceps tendinitis AC joint OA Normal Decreased Abduction Frozen Xray GH joint shoulder arthritis Normal Abnormal Adapted from: O'Kane and Toresdahl. Flexion The evidenced-based shoulder evaluation. Cur Sports Med Rep. 2014.

Shoulder active range of motion Limited ER key finding

Internal rotation

External rotation

10 9/28/2016

Supine shoulder passive range of Adhesive capsulitis is associated with motion • Diabetes  screen for this if hasn’t been done recently • Hyper and hypothyroidism • Hypoadrenalism • Parkinson’s disease • Cardiac disease • Pulmonary disease •Stroke • Surgery (cardiac, cardiac cath, neurosurgery, radical dissection)

Adhesive capsulitis is a clinical diagnosis 3 stages of adhesive capsulitis

.No need for MRI .Xrays helpful to r/o GH joint arthritis Freezing Frozen Thawing

3-9 months 4-12 months 12-42 months ↑ pain ↓ pain Gradual ↑ ROM Resolution ↓ ROM Stable, Average time Pain at rest, decreased ROM to resolution: sleep 1-3 years

11 9/28/2016

Treatment for adhesive capsulitis Case #5

. Pain control: NSAIDs, oral or injected corticosteroids 57 y/o RHD man presents with R shoulder pain that started after • Does not change disease course he slipped and fell 3 months ago. Pain at R deltoid. He tried • Does help significantly with pain control physical therapy without benefit. Waking at night from sleep due to pain. . +/- physical therapy to help restore ROM . Capsular distention injections Exam: Point tenderness just below the acromion. AROM intact with . Surgery pain on abduction between 60 and 120 degrees. Difficulty fully abducting the R arm. Moderate pain with resisted internal and • Manipulation under anesthesia external rotation of the shoulder. (+) External rotation lag test, (+) • Arthroscopic release and repair internal rotation lag test.

Manske and Prohaska, Curr Rev Musculoskeletal Med, 2008. Griesser MJ et al. Adhesive capsulitis …a systematic review of intraarticular injections. J Bone Joint Surg Am. Sep 2011.

Differential diagnosis? What is rotator cuff disease?

.Impingement .Tendinitis/tendinopathy .Partial thickness tear .Full thickness tear

12 9/28/2016

Rotator cuff disease treatment Physical exam maneuvers that increase likelihood of rotator cuff disease Most do well with conservative treatment 1. Painful arc . Impingement PT 2. Drop arm test . Tendinitis, tendinopathy +/- Injection +/- Medication . Partial tear . Full thickness tear  Consider ortho referral. • Caveat: atraumatic full thickness tears can do well without surgery. (Kuhn JE et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Surg. 2013 Oct;22(10):1371-9.)

Pain test: Painful arc Pain/strength test: Drop arm test

If painful, positive LR 3.7 for rotator cuff disease. Positive LR 3.3, negative If not painful, negative LR 0.36 for rotator cuff disease. LR 0.82 for rotator cuff disease.

JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

13 9/28/2016

Physical exam maneuvers that increase Strength test: likelihood of External rotation lag test full thickness rotator cuff tear

1. External rotation lag test Positive LR 7.2, Negative LR 0.57 2. Internal rotation for full thickness lag test rotator cuff tear

https://www.healthbase.com/hb/images/cm/procedures/orthopedics/rotator_cuff_te ar.jpg JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

Strength test: Case #5 Subscapularis = internal rotation lag test

57 y/o RHD man presents with R shoulder pain that started after Positive LR he slipped and fell 3 months ago. Pain at R deltoid. He tried physical therapy without benefit. Waking at night from sleep due to 5.6, negative pain. LR 0.04 for full thickness Exam: Point tenderness just below the acromion. AROM intact with pain on abduction between 60 and 120 degrees. rotator cuff Difficulty fully abducting the R arm. Moderate pain with tear resisted internal and external rotation of the shoulder. (+) External rotation lag test, (+) internal rotation lag test.

JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

14 9/28/2016

What is the next step? Objectives

A. Refer for surgical consult. Upon completion of this session, participants should be able to: 1. Name 4 exam maneuvers to use when suspecting a meniscus B. Repeat trial of physical therapy. tear. 2. Identify 6 clinical criteria that raise the likelihood of a diagnosis of C.2 week trial of NSAIDs. knee osteoarthritis (OA) in a patient with knee pain. 3. Identify indications for knee arthroscopy in patients with knee D.Give subacromial injection. OA, knee OA with meniscus tear, and meniscus tear without knee OA. 4. Name 2 causes of shoulder pain when both active and passive range of motion are limited. 5. Identify a full thickness rotator cuff tear on physical exam.

Name 4 exam maneuvers to use when Clinical criteria for diagnosis of knee OA suspecting a meniscus tear. 1. Joint line tenderness 2. McMurray 3. Thessaly 4. Squat

Altman R et al. Arthritis Rheum. 1986 Aug;29(8):1039-49.

15 9/28/2016

Identify indications for knee arthroscopy in Name 2 causes of shoulder pain when both patients with knee OA, knee OA with active and passive range of motion are meniscus tear, and meniscus tear without limited. knee OA. .Arthritis of glenohumeral joint . Knee OA: knee arthroscopy not indicated .Adhesive capsulitis . Knee OA and meniscus tear in same compartment: conservative treatment first . Degenerative meniscus tear, no OA: conservative treatment first, may not benefit from knee arthroscopy

Identify a full thickness rotator cuff tear on Thank you! physical exam. Carlin Senter, MD [email protected] . Internal rotation lag test

. External rotation lag test

16