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NEWS ISSUE 19 I WINTER 2016

Welcome to the Winter edition of Orthosports News. Dr John Negrine’s article on discusses simplifying WHO ORTHOSPORTS diagnosis, with some thought provoking facts on diagnostic ARE WE? LOCATIONS imaging. Following the & Ankle theme, Dr Todd Gothelf Orthosports is > Concord 02 9744 2666 reviews the available imaging options for the foot and ankle. a professional > Hurstville 02 9580 6066 The management of Acute Rotator Cuff Tears is discussed association of > Penrith 02 4721 7799 in Dr Todd Gothelf’s article on page 2. AOA Orthopaedic > Randwick 02 9399 5333 A USTRAL I A N ORTHOPA EDIC Surgeons based Or visit our website We welcome Dr David Lieu to the Concord Practice. Dr Lieu A S S O CIA T I O N in Sydney. www.orthosports.com.au specialises in , and surgery. We hope you enjoy this issue – The Team at Orthosports

Simplifying Ankle In Sydney every day approximately 450 people sprain their .

patient with a “complete full Examination: The patient often cannot not need surgery, do not cause arthritis A thickness tear of the anterior weight bear so a examination and are an inconvenience rather than talo-fibular ” has a sprained is not possible. Orthopaedics is simple being dangerous. Physiotherapists ankle readily diagnosed clinically and the signs readily elicited: Look, are good at treating ankle by talking to the patient and Feel, Move, X-ray. and failure to improve after 6 weeks, despite good physiotherapy, may be an examining them. Look: Where is the swelling and indication for further investigation. The Ottawa rules (1992) state that bruising? Most ankle sprains swell most patients don’t even need an x-ray. laterally and many medially. Most The objectives of treatment are to Why then do patients regularly arrive bruising is lateral beneath the lateral acutely relieve (5 days on crutches at your office and mine with an xray, . Bruising in the proximal leg is standard treatment). may indicate a syndesmotic or an and an MRI that shows An ankle splint that allows movement is “”. “a complete full thickness tear of more effective than an immobilisation the anterior talo-fibular ligament” Feel: Where are they tender? In front plaster or boot after the first 5 days. (). of the most commonly, though Allowing protected movement The growth in diagnostic imaging is in 25% of ankle sprains the medial decreases stiffness, decreases unsustainable. In 2013/14 we spent malleolus impacts the medial wall of the chance of DVT, decreases muscle $3 billion dollars on diagnostic imaging, the talus causing pain on the medial wasting, lessens the chance of a pain up 8% on the previous year. MRI side. Are they tender at the base of syndrome and does not compromise increased by 30% in the last 12 months 5th metatarsal? Are they tender more ligament healing. proximally in the leg? and accounted for $320 million dollars After 2 weeks a physiotherapy of this spend. I propose that many Move: Gently now!! Does the ankle program concentrating on of these foot and ankle MRI scans move up and down? Is the subtalar balancing and strengthening were unnecessary and do not alter joint mobile? is often helpful to patient outcomes. prevent re-injury. I often X-ray: In general, err on the side of History: suggest sports people tape The patient will describe an taking a plain x-ray (AP, lateral and 15º their ankle or use an ankle inversion injury where they heard internal rotation oblique view). Sydney brace on their return a snap or pop. They may be able to in 2016 has many more voracious to sport usually at weight-bear initially but invariably the lawyers than Ottawa did in 1992! ankle will swell. 4 – 6 weeks. Treatment: You all know RICE. The vast majority of lateral ligament injuries do Dr John Negrine www.orthosports.com.au 1 The Acute Rotator Cuff tears can be either acute or chronic in nature. More common is a chronic tear, which occurs by attrition of the rotator cuff over time.

he tendon degenerates and eventually tears with a Tgradual onset of pain. On the contrary, an acute tear is one that occurs abruptly. Patients with an acute tear usually recall a particular injury, such as falling on the , or heavy lifting and the shoulder giving way. Patients usually have no symptoms prior to the inciting trauma. The injury may result in a considerable amount of pain Above: MR arthrogram of and change in function. Tears are usually larger in nature a complete full thickness supraspinatus tear. than with chronic tears. The acute loss of function and Right: X-rays are usually normal. large size of these tears make early diagnosis particularly important so that prompt treatment can be administered. TREATMENT: CLINICAL SIGNS: Surgery is usually indicated in most Patients with acute rotator cuff tears are generally younger cases of an acute, full in age, on average in their 50s. The history of a traumatic thickness rotator cuff event leading to pain and change in function gives clues to tear. It is ideal to operate this diagnosis. within 3 months of the injury. Most of these : patients previously had Loss of ACTIVE overhead motion is a common sign for an ‘normal’ function, and acute rotator cuff tear. Passive overhead motion is usually are young and active. The goal of surgery is to restore the normal. Patients will usually have positive impingement attachment of the rotator cuff so that the muscle/tendon signs and with rotator cuff strength testing. function is preserved. Without urgent surgery, the tear will remain, resulting in atrophy of the rotator cuff muscle and permanent irreversible change. Delayed repair will be more difficult due to retraction of the tendon. Even large or massive tears of the rotator cuff in the acute setting should be repaired. Often these large tears are easily repaired acutely as they are flexible early on and can be reattached to their original position with little tension on the repair.

CONCLUSION: Acute rotator cuff tears can be large

A right shoulder acute rotator cuff tear. The patient cannot actively lift his tears and can result arm overhead. in considerable change in function INVESTIGATIONS: in young patients. Early recognition X-rays should always be ordered initially to rule out fracture of these tears is or dislocation of the shoulder but are usually normal. An crucial to ensure urgent MR arthrogram should be ordered to assess the early surgical treatment rotator cuff for an acute tear. An ultrasound does not and better outcomes. contribute to surgical decision-making and is therefore not a useful test to order. Dr Todd Gothelf

2 www.orthosports.com.au KEY EXAMINATION POINTS IMAGING OF THE FOOT AND ANKLE Part I: Plain Radiographs

Plain radiographs are important Peroneal to obtain during the diagnostic tendinopathy work-up of almost all conditions of the foot and ankle. Even when the presumptive diagnosis may be related, such as a lesion or neuroma, x-rays help to rule out AP x-ray demonstrating Freiberg’s infraction at conditions such as joint destruction, the 3rd MTP joint. Patient had 3rd MTP joint pain. stress fractures, lesions eroding Part IV: CT scan . Order WEIGHTBEARING or This MRI demonstrates peroneal tendinopathy. STANDING radiographs of the foot or A simple x-ray should be the first ankle when possible. The purpose of an MRI, I specify great , central test ordered to look for fractures this is to assess the alignment of the forefoot (to look at the lessor ), before a CT scan. A CT scan identifies , which may also give clues to a midfoot, hindfoot, or ankle. An MRI BONE detail well, but is not the best diagnosis. of the foot and ankle is a specialized test for soft tissue pathology. When evaluating an ankle after injury, for The views asked for when requesting test, and it is recommended to request for a musculoskeletal instance, an MRI would be more a STANDING foot xray are an AP, helpful than a CT scan as it will help lateral, and oblique. The standing radiologist to read the results for greater accuracy. to identify bone , cartilage x-rays for an ankle are also AP, lateral, injury, peroneal tendon tears, or and oblique. occult fractures just as well. A CT scan is a significant dose of radiation, Part II: MRI and therefore should only be ordered MRI is excellent to look at soft tissue for specific purposes. structures as well as stress fractures within bones that cannot be seen on plain radiographs. MRI can identify neuromas, ligamentous injury, tendinopathy, arthritis, cartilage lesions in a joint, and all tumourous lesions. MRI is a LOCALISED test, so it is better if pain or deformity is limited to either the forefoot, midfoot, hindfoot, or ankle. When ordering CT scan image of a comminuted calcaneus fracture. CT gives the best detail of fractures. MRI demonstrating a stress fracture of the 2nd metatarsal. Part V: Ultrasound Part III: Bone Scan Ultrasound can be very useful to look for soft tissue lesions around the foot A bone scan is helpful when and ankle. The two main benefits of considering diagnoses of bony ultrasound over MRI are: 1) cortisone pathology. For example, if a stress injections can be ordered at the same fracture is suspected when an x-ray time if pathology is found, as with looks normal, a bone scan can neuromas of the forefoot; and 2) it is demonstrate a stress fracture. A bone a dynamic study, so can demonstrate scan is advantageous when painful a problem with movement, such areas are NOT localised to one area, as snapping peroneal or as a bone scan assesses the entire tendon tears. MRI demonstrating Achilles tendinosis, and skeleton. Soft tissue lesions will not normal bony anatomy, no joint arthritis. be evident on a bone scan. Dr Todd Gothelf

www.orthosports.com.au 3 Orthopaedic Surgeons and their Interests

CONCORD PENRITH 47-49 Burwood Road Concord NSW 2137 Suite 5B, 119-121 Lethbridge Street, Penrith NSW 2750 Tel: 02 9744 2666 Tel: 02 4721 7799

Dr Todd Gothelf Foot & Ankle, Shoulder Dr Todd Gothelf Foot & Ankle, Shoulder Dr David Lieu Knee, Shoulder and Elbow Hand, Upper Limb and Dr Kwan Yeoh Dr John Negrine Foot & Ankle (Adult) General Orthopaedics Paediatrics and General Dr Rodney Pattinson Orthopaedics Dr Doron Sher Knee, Shoulder and Elbow RANDWICK Hand, Upper Limb and 160 Belmore Road Randwick NSW 2031 Dr Kwan Yeoh General Orthopaedics Tel: 02 9399 5333 Dr Jerome Goldberg Shoulder Dr Todd Gothelf Foot & Ankle, Shoulder HURSTVILLE Spine, Trauma, and Dr Andreas Loefler Waratah Private 29-31 Dora Street Hurstville NSW 2220 Knee Tel: 02 9580 6066 Dr John Negrine Foot & Ankle (Adult) Paediatrics and General Dr Jerome Goldberg Shoulder Dr Rodney Pattinson Orthopaedics Dr Todd Gothelf Foot & Ankle, Shoulder Dr Ivan Popoff Shoulder, Knee and Elbow Spine, Trauma, Hip and Dr Andreas Loefler Dr Doron Sher Knee, Shoulder and Elbow Knee Dr John Negrine Foot & Ankle (Adult) Paediatrics and General Dr Rodney Pattinson Orthopaedics Sport & Medicine Physicians Dr Ivan Popoff Shoulder, Knee and Elbow Dr Paul Annett Hurstville Dr Allen Turnbull Hip and Knee Dr John Best Randwick Hand, Upper Limb and Concord | Hurstville | Randwick Dr Kwan Yeoh Dr Mel Cusi General Orthopaedics Penrith

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