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Nuisance Problems You will Grow to Love

Thomas V Gocke, MS, ATC, PA-C, DFAAPA President & Founder Orthopaedic Educational Services, Inc. Boone, NC [email protected] www.orthoedu.com

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Faculty Disclosures • Orthopaedic Educational Services, Inc. Financial Intellectual Property No off label product discussions

American Academy of Physician Assistants Financial PA Course Director, PA’s Guide to the MSK Galaxy

Urgent Care Association of America Financial Intellectual Property Faculty, MSK Workshops

At the end of this sessions you will be able to: • Recognize nuisance conditions in the Upper Extremity • Recognize nuisance conditions in the Lower Extremity • Recognize common Pediatric Musculoskeletal nuisance problems • Recognize Radiographic changes associates with common MSK nuisance problems • Initiate treatment plans for a variety of MSK nuisance conditions

When does the Inflammatory response occur: • occurs when injury/infection triggers a non-specific immune response • causes proliferation of leukocytes and increase in blood flow secondary to trauma • increased blood flow brings polymorph-nuclear leukocytes (which facilitate removal of the injured cells/tissues), macrophages, and plasma proteins to injured tissues

*Knight KL, Pain and Pain relief during Cryotherapy: Cryotherapy: Theory, Technique and Physiology, 1st edition, Chattanooga Corporation, Chattanooga, TN 1985, p 127-137

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Inflammatory Response* • As a result of the inflammatory process: – redness occurs at the injury site – tissue warmth occurs as result of increased cellular activity – swelling results from increased fluid – pain as a result of tissue injury and stretching of nerve structures – The accumulation of fluid/edema at the injury site, • can limit the healing process by reducing joint range of motion (ROM) • facilitating the formation of scar tissue. *Knight KL, Pain and Pain relief during Cryotherapy: Cryotherapy: Theory, Technique and Physiology, 1st edition, Chattanooga Corporation, Chattanooga, TN 1985, p 127-137 Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. UPPER EXREMITY

• Bursitis: – Synovial pouch that reduces friction between adjacent tissue (structures) – “Nuisance problem” – Onset: sudden, gradual, traumatic, infection – 2 types: Septic vs. Non-septic

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Bursitis • Septic: – 2nd to inoculation bursa with bacteria – Olecranon/Pre-patella most commonly infected bursa – Local cellulitis precipitates – Hematogenous spread – rare – Laborers @ risk for septic bursitis (repetitive motion) – Immune compromised • ETOH abuse/DM/Malignancy • Chronic systemic Glucocorticoid use • Renal Failure – Gout/rheumatoid nodules/hx previous sepsis – Iatrogenic infection due to intra-bursal steroid injection Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Bursitis

• Non-Septic: – Traumatic – Idiopathic – Crystalline-induced – Olecranon/Pre-patella most commonly infected/affected bursa – Inciting event trivial to non-existent – Laborers @ risk for septic bursitis ( repetitive motion) – Same population as Septic bursitis – Crystalline – induced 2nd hx gout – Rheumatoid arthritis may trigger onset bursitis

Musculoskeletal Images are from the University of Washington "Musculoskeletal Atlas: A Musculoskeletal Atlas of the Human Body" by Carol Teitz, M.D. and Dan Graney, Ph.D."

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Rotator Cuff Syndrome • Pathophysiology – Anterosuperior Impingement syndrome • Involves: Acromion, Sub-acromial bursa, Coracoclavicular ligament & Acromioclavicular joint • Supraspinatus tendon inserts greater tuberosity anterior to Coracoacromial arch • Biceps tendon passes under Coracoacromial arch in forward flexion w/ shoulder internally rotated • Neer (1972) felt RTC tears wear 2nd to impingement and aided by down sloping acromial spur OrthopaedicRoy, A: Rotator Cuff Disease; http://emedicine.medscape/article/328253-overview Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Rotator Cuff Syndrome

• Pathophysiology – Progressive, age-related tendon changes – Codman (1934) most tears are after age 40 and significantly increase after age 50 – Articular surfaces tears most at insertion supraspinatus insertion into greater tuberosity

Roy, A: Rotator Cuff Disease; http://emedicine.medscape/article/328253-overview Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Rotator Cuff Syndrome

• All ages • Dull achy pain vs. sharp pain • Gradual onset vs. sudden onset • “Painful arc” 60-120 degrees ROM • Night / sleep pain • Overhead pain & weakness • Deltoid pain • Numbness small fingers affected side - relative • Weakness with daily activity or specific tasks • Atrophy Shoulder Girdle (Supraspinatus & Infraspinatus) • Activity level: variable

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Rotator Cuff Syndrome Physical Examination: • Inspection: skin, muscle atrophy, deformities • Palpation: AC, SC, clavicle, coracoid, posterior RTC • Range-of-Motion: Flex, Ext, IR, ER • Strength: Flex, Ext, IR, ER • Neuro/Vascular: C5-T1 • Orthopaedic Tests: – Speeds: biceps/RTC – Empty Can: RTC (supraspinatus-infraspinatus) – Neer/Hawkins: RTC impingement – Crossover: AC joint – Apprehension/relocation: Stability – Obrien’s: Labrial injury Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Don’t Forget Cervical Disease

• Empty Can Test

– Assess resistive strength • Empty can test picture of the Supraspinatus portion RTC – Shoulder flex to 90 degrees & horizontally Abd to 45 degrees – Positive test indicates pain and weakness against resistance Picture courtesy T Gocke, PA-C

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Shoulder Examination • Speed’s Test – Assessment Bicep tendon injury – Forward flex shoulder to 90 degrees w/ elbow fully extended & hand supinated – apply downward force to the distal forearm – Positive test: Pain and weakness indicating biceps tendon Photo courtesy TGocke, PA-C pathology (RTC) Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Shoulder Examination • Neer & Hawkins RTC Impingement Tests – Assess impingement of the greater tubercle-RTC tendon & subacromial bursa as humeral head moves under the Acromion

– Neer: arm max internal rotation Picture courtesyPicture T Gocke, courtesy PA-C TGocke, PA-C go from ext to fully flex position over head – Hawkins: elbow / shoulder flex 90 then passively int / ext rotate – Positive test indicates pain with

impingement maneuvers Picture courtesy T Gocke, PA-C

Orthopaedic Picture courtesy TGocke, PA-C Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Shoulder Examination • Obrien’s Test – Assess integrity of the bicep tendon insertion into the superior glenoid labrium – Shoulder flexed to 90, horizontally ADD to 45 and arm max internal rotation. Downward force applied to hand/distal arm Picture courtesy T Gocke, PA-C – Positive test indicates pain and weakness

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Shoulder Examination • Crossover Test – Assess integrity of the AC joint for laxity and degenerative conditions – Shoulder flexed to 90 & patient reaches over and touches opposite – Positive test indicates

pain and limited motion Picture courtesy T Gocke, PA-C isolated to AC joint region

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Rotator Cuff Syndrome X-ray studies Photo courtesy TGocke, PA-C • AP/Axillary/Outlet • Grashy/External Rotation

MRI Photo courtesy TGocke, PA-C • Soft-tissue assessment • Young adults MRI-arthrogram

CT scan • Alternative for MRI • Needs CT arthrogram

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Rotator Cuff Syndrome Treatment: • Identify condition/Manage Pt. expectations • Modification activities • NSAIDS: oral vs. topical – Ibuprofen/Celecoxib/Meloxicam vs. Diclofenac 1 or 2% • Therapy – strength/ROM • Injection • MRI – further diagnostic acute vs. failed therapies • Surgery – Arthroscopy Sub-acromial decompression vs. Rotator repair Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Subacromial Injections Photo courtesy TGocke, PA-C Posterior Approach: • Posterolateral arthroscopy portal region • Sitting position with arm dependant • Identify posterior rim acromion spine Photo courtesy TGocke, PA-C • Slight cephalad angle • Aim towards coracoid • Select analgesic & steroid preparation

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Olecranon Bursitis • Olecranon bursa lies between bony olecranon & skin • Very superficial bursa and easily traumatized • Acts to decrease friction between bone and skin • Inflammation results from overuse, trauma or infection • Chronic disease states can cause inflammation – Gout – Pseudogout – RA • Repetitive stress positions can cause inflammation – Results for constant contact pressure on bursa – Forward leaning position • Classic finding: Fluctuant bulge over olecranon Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Olecranon Bursitis • Pathophysiology: – Inflamed synovial cells lead to increased fluid production – Increased permeability of capillary membrane allows fluid to accumulate – Hemorrhage occurs as a result of trauma – Local trauma facilitates inoculation of overlying skin with bacteria & can lead to septic bursitis

Physical Examination: • Inspection: skin changes • Palpation: Radial head, epicondyles, CFT/CET, Olecranon • Range-of-Motion: Flex, Ext, pronation/supination • Strength: Flex, Ext, pronation/supination • Neuro/Vascular: C5-T1 • Orthopaedic Tests: – Collateral Ligament stability – Distal Tricep/Bicep tendon (Hook Sign – Bicep)

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Olecranon Bursitis Treatment: Non-septic Bursitis • Recognize potential for infection • Activity modification • ICE/Heat • Compression • NSAIDS: topical vs. oral • Injection/aspiration vs. Incision & drainage • Protective Pad/cushion • Pt. expectations – Surgical excision chronic/recalcitrant bursitis • Manage Acute Gouty flares Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Olecranon Bursitis Treatment: Septic Bursitis • Diagnostic Studies- +* – Blood Studies: CBC w/ diff, BMP, ESR, CRP, Uric acid level – Uric acid level: trending downward – Glucose: bursal fluid glucose is < 50% serum glucose levels (septic bursitis) – Aspirated fluid • WBC < 1000/ul normal ( predominantly mononuclear cells) • WBC 200-1000/ul inflammation ( mononuclear cells) – WBC >1,500/ul infection (polymorphonuclear cells)

*McAfee JH, Smith DL: Olecranon and Prepatellar Bursitis: Diagnosis and Treatment; Topics in Primary Care, West J Med 1988 Nov; 149:607-610 + Aaron DL et al: Four Common Types of Bursitis: Diagnosis and management, JAAOS June 2011, 19(6):359-367 Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Septic Bursitis Non-Septic Bursitis Crystals Fluid Appearance Purulent Straw-Serous Straw-Serous-Bloody Leukocytes per uL 1.500 – 300,000 50-11,000 1-6,000 Mean # 75,000 Mean 1,100 Mean 2,900

WBC/Differential >10,000 <1,000 <1,000 Polymorphonuclear cells Mononuclear cells Variable

Glucose Ratio < 50% blood glucose >50% blood glucose ?

Gram Stain + > 70% Negative Negative (?)

Crystals None (?) None Monosodium urate crystals- Gout Calcium pyrophosphate or hydroxyapatite crystal- Pseudogout Culture Staph Auerus & None Epidermiidis (90%) Streptococcal species

McAfee JH, Smith DL: Olecranon and Pre-patellar Bursitis: Diagnosis & Treatment, Western Journal Medicine Orthopaedic Nov 1988, 149:5;607-610 Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Olecranon Bursitis • Diagnostic studies* – Cultures: • Majority Staphylococcus aureus or epidermidis • Strep species, gram negatives, H. Flu, anaerobes, mycobacteria – Crystals • Monosodium urate crystals- Gout • Calcium pyrophosphate or hydroxyapatite crystal- Pseudogout – Radiographs –concern for bone trauma – AP & Lateral (radial head view) – McAfee & Smith: No hx trauma – x-ray unnecessary

*McAfee JH, Smith DL: Olecranon and Prepatellar Bursitis: Diagnosis and Treatment; Topics in Primary Care, West J Med 1988 Nov; 149:607-610 Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Olecranon Bursitis

Aspiration/Injection or Incision & Drainage • Suspect infection in most cases • Plan to aspirate first and inject depending on fluid aspirated • Aspirate Fluid – Turbid fluid – Send fluid for analysis – Consider I&D and Abx Picture courtesy TGocke PA-C – Admission? Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. LOWER EXREMITY

Illustration demonstrating the anatomy of the prepatellar bursa, which consists of the subcutaneous prepatellar bursa and the superficial infrapatellar bursa. (Adapted with permission from McAfee JH, Smith DL: Olecranon and prepatellar bursitis: Diagnosis and treatment. West J Med 1988;149:607-610.) Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Pes Anserine Bursitis Symptoms • Gradual onset to sudden onset • Localized pain/swelling medial tibial flare • Start-up symptoms – Stiffness better after motion – Swelling – Hamstring pain/stiff with knee ext. – Variable pain locations: joint line/medial tibia – Weakness/giving out – Catching/locking Image courtesy TGocke, PA-C

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Pre-patellar Bursitis Symptoms • Gradual onset to sudden onset • Start-up symptoms Picture courtesy TGocke, PA-C – Hx. repetitive kneeling, squatting, climbing • Nursemaids knee • Clergymen’s knee • Carpet layer’s knee – Swelling anterior knee Picture courtesy Wiki Commons – Redness/warmth – Pain variable

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Pre-patellar Bursitis Physical Examination • Inspections – Swelling pre-patellar region – Skin • Palpation – Redness/warmth – Tender patella region • ROM/Strength – Usually no ROM changes – Normal strength – Hurts to Kneel/squat/climb • Neuro/Vascular Picture courtesy TGocke, PA-C • Ortho exam normal Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Infrapatellar Bursitis

Symptoms Picture courtesy TGocke, PA-C • Less common vs. pre-patella bursitis • Gradual onset to sudden onset • Acts like patellar tendonitis • Start-up symptoms – Stiffness getting better after Picture courtesy TGocke, PA-C some motion – Swelling – Weakness/giving out – Catching/pinching sensation

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Infrapatellar Bursitis Physical Examination • Inspections Picture courtesy TGocke, PA-C – Swelling patellar tendon region – No suprapatella swelling • Palpation – ? Redness/warmth

– Tender patella tendon region Picture courtesy TGocke, PA-C • ROM/Strength – Start-up symptoms – Stiffness • Neuro/Vascular - normal • Orthopaedic Tests - normal Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Pre-patella/Infra-patella Bursitis

• Treatment – Non-Septic Bursitis – Modify activity – ICE – NSAIDS topical vs. oral – Flexibility – Physical Therapy – Protective sleeve vs. pad (pre-patella) – Injection/aspiration vs. Incision & drainage • Manage Acute Gouty flares – Protective Pad/cushion • High recurrence rate in repetitive activity jobs *Pes bursitis- treat knee OA usually treats bursitis Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Pre-Patella/Infra-Patella Bursitis

Treatment: Septic Bursitis • Diagnostic Studies- +* – Blood Studies: CBC w/ diff, BMP, ESR, CRP, Uric acid level – Uric acid level: trending downward – Glucose: bursal fluid glucose is < 50% serum glucose levels (septic bursitis) – Aspirated fluid • WBC < 1000/ul normal ( predominantly mononuclear cells) • WBC 200-1000/ul inflammation ( mononuclear cells) – WBC >1,500/ul infection (polymorphonuclear cells)

• Aspiration/Injection or Incision & Drainage – Suspect infection in most cases – Plan to aspirate first and inject depending on fluid aspirated – Aspirate Fluid • Turbid fluid • Send fluid for analysis • Consider I&D and Abx • Admission? Photo courtesy TGocke, PA-C

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Trochanteric Bursitis • Trochanteric Bursa lies deep to the ITB & superficial to Gluteus medius tendon insertion @ greater trochanter • Gluteus medius/minimus – Attach greater trochanter – ABDuct & Internal rotation • AKA: Greater Trochanteric Pain Syndrome (GTPS) • Trochanteric bursitis = Gluteal tendinosis • Consider pts. with Trochanteric bursitis to have gluteal tendinosis/tear* *Bird PA et al: Prospective evaluation of magnetic resonance imaging findings in patients with greater trochanteric pain syndrome; Arthritis Rheum 2001;44(9): 2138-2145 Musculoskeletal Images are from the University of Washington "Musculoskeletal Atlas: A Musculoskeletal Atlas of the Human Body" by Carol Teitz, M.D. and Orthopaedic Dan Graney, Ph.D." Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Trochanteric Bursitis Clinical Presentation • Mechanism of injury • Repetitive/Change activity • Poor flexibility • Sedentary • Body habitus – Symptoms • Start-up pain • Prolonged sitting • Side sleeping position • Isolated lateral hip pain Groin or Butt pain think something else Musculoskeletal Images are from the University of Washington "Musculoskeletal Atlas: A Musculoskeletal Atlas of the Human Body" by Carol Teitz, M.D. and Orthopaedic Dan Graney, Ph.D." Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Trochanteric Bursitis Physical Examination • Inspection – Have the pt. stand and point to location of their pain • Palpation – tender lateral trochanter/hip • ROM/Strength – ABD pain/passive ADD pain • Neuro/vascular – no changes • Ortho exam – – Stichfield’s Test- hip joint

Illustration demonstrating the location of the trochanteric bursa between the gluteus medius – Patrick/FABER- SI joint dysfunction (2) and the iliotibial band (3) as well as the bursa located between tendon and bone at the gluteus minimus, which is reflected downward (1). (Redrawn with permission from Lequesne M: From "periarthritis" to hip "rotator cuff" tears: Trochanteric tendinobursitis. Joint Bone – Ober Test- positive tight IT band Spine 2006;73[4]:344-348. http://www.sciencedirect.com/science/journal/1297319X.) – Tight Hamstrings/Hip flexors/Quads Four Common Types of Bursitis: Diagnosis and Management. Aaron, Daniel; Patel, Amar; Kayiaros, Stephen; Calfee, Ryan – Consider lumbar spine exam too!!! ournal of the American Academy of Orthopaedic Surgeons. 19(6):359-367, June 2011. Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Hip Ober Test – Pt lateral decubitus position – With the patient lying in the lateral position, support the knee and flex it to 90 degrees. Then extend and abduct the hip. Then release the knee support. – Failure of the knee to Adduct is a positive test.

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Trochanteric Bursitis Injection Treatment • Modify activities • Improve flexibility • NSAIDS – topical vs. oral • Physical Therapy vs. Home Stretching program • Injection • Reassess causes for pain symptoms: – Sacroiliac joint dysfunction – Lumbar Radiculopathy – Femoroacetabular Impingement (FAI) – Hip Dysplasia – Gluteal tendon rupture/tear Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Trochanteric Bursitis • Procedure: Picture courtesy T Gocke, PA-C – Confirm Trochanteric bursitis – Identify point of maximal tenderness – Lateral decubitus position – Sterile prep – Vapo-coolant spray – Injection solution 3ml Bupivacaine, 2 ml Lidocaine & 1-2 ml Triamcinolone 40mg/ml • Spinal needle vs. 1 ½ inch needle Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Retrocalcaneal Bursitis

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Retrocalcaneal Bursitis General • Starts as posterior heel pain • AKA: Pump Bump/Achilles Bursitis • Influencing factors: – Shoe wear/heel counter pressure – Poor hamstring/Achilles flexibility – Activity changes – Structural deformities (calcific tendonitis, Haglund) – Gout/RA/Seronegative Spondyloarthropathies – Mal-aligned sub-talar joint • Alters normal foot mechanics • Transmits more force load to Achilles tendon

Reddy SS: Surgical Treatment for Diseases and Disorders of the Achilles Tendon; JAAOS 17(1):3-14, Jan 2009 Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Retrocalcaneal Bursitis

Anatomy • Achilles tendon inserts into Calcaneous • Calcaneous usually down sloping – Haglund deformity increases contact pressure of Achilles on calcaneous Dorsiflexion • Bursa Illustration demonstrating the anatomy of the hindfoot. The posterior calcaneal tuberosity is covered with fibrocartilage just proximal to the insertion of the Achilles tendon. This tuberosity apposes the anterior wall of the – Retrocalcaneal: between retrocalcaneal bursa. (Reproduced with permission from Stephens MM: Haglund's deformity and retrocalcaneal bone and tendon bursitis. Orthop Clin North Am 1994;25[1]:41-46.) – Superficial: between skin Four Common Types of Bursitis: Diagnosis and Management. and tendon Aaron, Daniel; Patel, Amar; Kayiaros, Stephen; Calfee, Ryan Journal of the American Academy of Orthopaedic Surgeons. 19(6):359-367, June 2011. Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Retrocalcaneal Bursitis Physical Examination • Inspection – Assess gait – Rear-foot alignment • Neutral-Varus-Valgus • Pes Planus – Cavus Morhopedics – Creative Common Attribution-Share Alike 3.0 • “Too many toes sign” • Palpation – tender Achilles insertion calcaneous • ROM/Strength – Decreased KBDF/KEDF – Hind foot varus & Rigid 1st ray predisposed ? • Neuro/vascular – no changes • Ortho exam – Look @ mortise & sub- talar stability Photo courtesy TGocke, PA-C Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Retrocalcaneal Bursitis Photo courtesy TGocke, PA-C

• Radiographic views Haglund Deformity – Ankle: AP, Lateral, Mortise (standing) – Foot: AP, Lateral, Oblique (standing)

Photo courtesy TGocke, PA-C

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Retrocalcaneal Bursitis Treatment: • Modify activity • Modify shoe wear/types – padding/orthotics • Improve flexibility Gastroc-Achilles complex • NSAIDS: topical vs. oral • Physical Therapy – Iontophoresis/Phonophoresis • Phonophoresis: Steroid driven into tissue by ultrasound • Iontophoresis: Electrical charge draws steroid into tissues – Acetic Acid: change in calcium ions reduces inflammation and reduces chance of scar tissue formation • Surgery- excise Haglund deformity DO NOT INJECT ACHILLES REGION WITH STEROIDS Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Plantar Fasciitis

From Wikimedia Commons Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Plantar Fasciitis • Definition: inflammation of the fascia • “Heel spur pain” • Plantar fascia has 3 slips. – Medial – Central – Lateral – Central slip arises from medial Calcaneal tuberosity – Inserts to 5 digits Flexor Tendons • Primary function is for support longitudinal arches (med/lat) • Affects women > men • Average onset 45 yrs • Obesity worse • Extreme changes in activity • Poor foot wear choices • Poor Flexibility Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Plantar Fasciitis

Symptoms: • Pain with ambulation • Worse in AM or after prolonged rest/sitting – “start-up pain” – Better after warming up • Pain localized to heel region – Central Heel pad – Medial arch or heel pain • Body size contributes • Gait changes • Pathophysiology: – Micro tears in plantar fascia tendon insertion – 50% develop plantar grade heel spurs Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Plantar Fasciitis

Examination – Observe Gait – Observe foot posture • Planus – Hind foot valgus – plantar callosities – Assess flexibility Achilles and toe flex/ext groups – Palpate plantar fascia – Assess Posterior Tibial tendon integrity (strength) – Neuro/Vascular (Tarsal Tunnel vs. Baxter’s neuropathy) Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Plantar Fasciitis

• X-ray: Standing lateral – Traction spur considered a normal finding (arrow) – Not cause for Plantar Photo courtesy TGocke, PA-C Fasciitis – High suspicion for Calcaneal stress fracture or tumor – Prior to corticosteroid injection – Consider CT, MRI or bone scan if failed treatment 4-6 weeks Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Plantar Fasciitis

• Associated Conditions – Tarsal Tunnel syndrome – Calcaneal stress fx – Calcaneal bone tumor – Rupture of the Plantar Fascia – Referred pain from lumbar region – Posterior Tibial nerve entrapment (Baxter’s nerve)

• Treatment – Conservative care cures most cases – Achilles and plantar fascia flexibility - KEY – NSAIDS – ICE (“frozen plastic bottle foot massage”) – Heel pad vs. rigid arch support – Immobilization (cast vs. ankle boot) – Night splint – Injection – Surgery – last resort - failed after 6 months

• Calf/Gastroc Stretch • Toe Flexor stretch

Calcaneal Apophysitis: American Academy of Foot and Ankle Surgeons http://www.acfas.org/Content.aspx?id=1483 Patellofemoral Pain Syndrome: American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=A00680

• Sever’s Disease • Ages 8-14 • Results from repetitive stress activity • Stressors cause inflammation @ Calcaneal Physis • Pain worse with activity better with rest • Causes: – Tight Achilles – Obesity – Foot biomechanics • Pes Planus w/ rear-foot valgus vs. Cavus foot – Running sports Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Calcaneal Apophysitis

• Symptoms – Localized heel pain (pressure) – Gait change • Limping • Toe walking – Pain after running/jumping – Swelling/redness variable – Avoidance of activities – Growth spurts – shoes and pants

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Calcaneal Apophysitis • Physical Exam – Inspection: • Variable swelling/redness • Gait changes based on acuity of symptoms – Palpation: • Lateral calcaneal pain/Achilles tenderness • Tenderness based on acuity of symptoms – Range-of-Motion (ROM): • limited by pain • Knee bent Dorsiflexion vs. Knee Extended Dorsiflexion – Strength: usually normal – Neuro/Vascular: no changes – Ortho Tests Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Calcaneal Apophysitis

Radiographs • AP- Lateral • Harris Heel – Radiographs helpful in refuting other bone injuries – Typically see fissuring of Calcaneal epiphysis

• Treatment – Recognition of complaints – Conservative care • RICE • NSAIDS • Flexibility (Hamstring/Quad/Gastroc-Achilles) • Heel Cushion • Good Shoes – Modification of Activities

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Patella-Femoral pain • Occurs for many reasons – Overuse – Poor strength – Poor flexibility – Anatomy – Obesity • Affects all ages – Adolescent – Mid-Lifers vs. “Old Teenagers” • Anterior Knee Pain

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Patella-Femoral pain • Anatomy Review – Femur/Tibia/Patella • Patella rides in Femoral Groove • Articular cartilage cushions Patellofemoral articulation • Synovial membrane lubricates Patellofemoral glide – Muscles/Tendons/Ligaments • Quads – motor function knee • Extra-articular ligaments/Retinaculum – hold patella in place allow for normal glide

• Characteristics – Stairs/Stand/Sit/Squat Kneel & Crawl – Ache • Pain comes 2nd to soft-tissue inflammation & bone • Articular cartilage wears down -Chondromalacia – Swollen/Stiff – Vague symptoms • Overuse – Repetitive activity – Increased frequency vs. intensity vs. duration – Flexibility/strength – Improper foot wear or training techniques Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Patella-Femoral pain Malalignment • Patella –Femoral trochlea mismatch – Abnormal contact pressure patella-trochlea – Leads to Chondromalacia & soft tissue inflammation – Abnormal tracking Patella • Contributing Factors – Patella Aligns lateral : lateral tethering – Patella Aligns medial : “squinting patella” – Patella too High – Alta (Baha to low) – Soft-tissue Imbalance • Weak Quads • Tight retinaculum • Hamstrings/Patella tendon – Improper foot wear or training techniques Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Patella-Femoral Pain • Physical Exam – Inspection: • Patella alignment • Gait changes based on acuity of symptoms – Palpation: • Lateral retinaculum tenderness • Tenderness Medial & Lateral facets – Range-of-Motion (ROM): • limited by pain/crepitation • J move • Lateral tracking – Strength: weak quads/poor flexibility – Neuro/Vascular: no changes – Ortho Tests Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Patella-Femoral pain Radiographs • AP- Lateral- Sunrise – Radiographs helpful in defining bone injuries – Typically see: Photo courtesy TGocke, PA-C • Compression • Mal-tracking • Alta/Baja

• Sunrise View Picture courtesy TGocke, PA-C • Merchant View • Tangential View – All look at articular surface of patella – Position of patella – Compression points patella

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Radiographs • Patella Height: (Blumensaat's Method) – Knee flexed to 30 degrees Blumensaat’s Line – Draw a line thru the roof of the Intercondylar notch – Line should touch the inferior pole of the patella • Normal height - inferior pole patella touches Blumensaat’s line • Patella Alta – inferior pole patella above line • Patella Baja – Inferior pole patella below line

Blumensaat's C: Die Lageabweichugen und Verrekugen der Kniescheibe; Ergenbnisse der Chirurgie und Ortho 228(31):149-223. Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Radiographs Patella Height: (Insall Method)* – Relationship of patella length to length of patellar tendon • Length of patellar tendon: – Measured inferior pole patella to insertion tibial tuberosity • Length patella: – Longest lateral length patella • Normal Ratio: – Patellar / Tendon = 1 – <0.8 : patella alta or tendon rupture

* Insall J, Salvatie E: Patella Position in normal knees joints, Radiology 1971, p101-104 Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Radiographs

Patella Alta: Patella Baja:

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Patella-Femoral pain Treatment • Recognize condition • Assess flexibility and strength • Modify activities • Improper foot wear or training techniques • ICE/Heat • NSAIDS: Oral – Topical – Injectable • Surgical – Arthroscopy • Chondroplasty • Lateral Release – Tibial Tubercle Transfer • Realign patella tendon with bone repositioning Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Osgood Schlatter's Disease http://radiopaedia.org/articles/osgood-schlatter-disease http://www.eorthopod.com/content/osgood-schlatter-disease

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Osgood-Schlatter’s Disease • General – Occurs 11-15 age group ( rapid growth) – Boys > Girls – Overuse problem – increased demand on immature skeleton – Caused by tight hamstrings limit knee extension and increasing pull of quad/patellar tendon on tibial tubercle – Small area heterotopic ossification seen 2nd to microtrauma a the tibial apophysis • Clinical Symptoms – Swelling tibial tubercle area – Pain with ambulation, stair-climbing, jumping & running – Pain with palpation – Limited ROM knee 2nd to tight hamstrings

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Osgood-Schlatter’s Disease • Physical Examination – General Knee exam – Pay specific attention to age group, flexibility and location pain – Tender palpate tibial tubercle – Pain with AROM & resistive AROM knee extension • Differential Diagnosis – Jumper’s Knee – Avulsion fracture tibial physis – Synding-Larsen-Johansen Disease – connective tissue disorder

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Osgood-Schlatter’s Disease • Radiographs: – AP, Lateral, Sunrise – AP - Normal – Lateral • Bony changes noted at tibial tubercle • May need comparison view contralateral knee – Sunrise – check patella position in trochlea

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Osgood-Schlatter’s Disease • Treatment: – Symptomatic care – ICE – NSAIDS – Knee pad or sleeve: decrease pain from contact pressure – Immobilize for recalcitrant symptoms or poor patient compliance – Change activity up to 2-3 months • May need longer for more severe cases – Surgery to correction for rupture/bony fracture - rare

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Take Home Points • Manage patient expectations • Conservative measures usually make things better • Modification of activities • Shoulder & Hip – think outside the box (Neck & Back) • Bursitis – always be suspicious of infection/gout • Improve Strength & Flexibility: • Patellofemoral problems • Trochanteric Syndrome • Plantar Fasciitis/Achilles Tendonitis/Bursitis • Choose PT over HEP • Foot position can affect upstream problems

Never inject RetroCalcaneal bursitis

www.orthoedu.com Thunder Hill Overlook, Blue Ridge Pkwy Blowing Rock NC Photo Courtesy TGocke, PA-C

Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. References • McAfee JH, Smith DL: Olecranon and Prepatellar Bursitis: Diagnosis and Treatment; Topics in Primary Care, West J Med 1988 Nov; 149:607-610 • Aaron DL et al: Four Common Types of Bursitis: Diagnosis and management, JAAOS June 2011, 19(6):359-367 • Gocke TV: Injection & Aspiration of Common Musculoskeletal Conditions 1 & 2, Orthopaedic Educational Services, Inc., www.orthoedu.com 2014 • Gocke TV: Shoulder Examination, Orthopaedic Educational Services, Inc., www.orthoedu.com 2014 • Foye PM: Retrocalcaneal Bursitis, emedicine.medscape.com, updated November 26, 2014 Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. References • Gocke TV: Foot Soft tissue 1 &2, Orthopaedic Educational Services, Inc., www.orthoedu.com 2014 • Gocke TV: Knee Injuries-Extra-articular 2, Orthopaedic Educational Services, Inc., www.orthoedu.com 2014 • Roy A: Rotator Cuff Disease, eMedicine – Medscape; updated Sept 14, 2014 • Brox JI, Staff PH, Ljunggren AE, Brevik JI. Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome). BMJ. Oct 9 1993;307(6909):899-903. • Reddy SS: Surgical Treatment for Diseases and Disorders of the Achilles Tendon; JAAOS 17(1):3-14, Jan 2009 Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. References • Kilfoil RL: Acetic acid iontophoresis for the treatment of insertional Achilles tendonitis; BMJ Case Reports 2014, casereports.bmj.com • Costa IA, Dyson A: The integration of acetic acid iontophoresis, orthotic therapy and physical rehabilitation for chronic plantar fasciitis: a case study; J Can Chiropr Assoc. 2007 Jul-Sep; 51(3): 166–174 • Gocke TV: An Urgent Care Approach to Joint and Soft- tissue Injection/Aspiration, Part 1; JUCM Sept 2014; 8- 19 • Gocke TV: An Urgent Care Approach to Joint and Soft- tissue Injection/Aspiration, Part 2 ; JUCM Oct 2014; 9-22