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OES Site Color Scheme 1 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 Ferring Pharmaceuticals Consultant Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. 2 LEARNING GOALS 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 Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Inflammatory Response Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Inflammatory Response* 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 Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. BURSITIS • 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 Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Rotator Cuff Syndrome Rotator Cuff Tendonitis Sub-acromial Bursitis Sub-acromial impingement Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Shoulder Anatomy 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. Shoulder Anatomy 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. Shoulder Physical Exam 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 Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Shoulder Examination • 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
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