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Sprains and Strains

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Sprains and Strains Bone-Up on Orthopedics Paul D. Giles, DO, MS 7/28/2014 Paul D. Giles, DO, MS Primary Care Sports Medicine Johns Hopkins Community Physicians, Bowie MD Office Medical Director Deaflympics 2013 – USA Team Physician (Bulgaria) To review high volume musculoskeletal injuries seen by family physicians To review the proper diagnostic tests, including physical exam and radiologic test, as well as treatment of these injuries. To discuss information found within question stems and assign meaning found therein. 1 7/28/2014 HPI PE ◦ No injury ◦ Active ROM 180/180 ◦ Intermittent sharp pain lat Pain in all planes and ant shoulder IR L shoulder to T6 Overhead ◦ Pain with resisted ER Sleeping on side ◦ +Empty Can, Work (carpenter) Impingement signs ◦ No numb/ting Neg Crossover, O’Briens, ◦ OTC NSAIDs without relief Speed’s ◦ No h/o prior injury ◦ +TTP ant shoulder Rad-4 view x-ray PMH, PSH, Meds, All, Soc hx, ROS n/c ◦ Normal Diagnosis? Rotator Cuff Tendonosis/Impingement Syn ◦ Can be from chronic microtrauma or acute macrotrauma ◦ c/o pain, weakness and loss of motion Difficulty reaching behind and overhead Painful laying on affected side ◦ Physical Exam + Empty can test, Hawkin’s test, Neer’s Test +Speed’s Test=Biceps Tendonosis +O’Briens Test=SLAP Lesion ◦ Treatment Rest, NSAIDs, PT, Corticosteroid inj Surgery for complete tears Rotator Cuff Interval 2 7/28/2014 HPI PE ◦ Started after raking leaves ◦ No effusion/ecchymosis/ in fall erythema ◦ Constant lat ◦ TTP lat epicondyle forearm/elbow ache ◦ Full, painless PROM at elbow: flex/ext/pro/sup Gripping/lifting ◦ 5/5 mm strength Computer Pain with elbow ext, ◦ No swelling/numb/ting forearm pro, wrist ext, ◦ Ibuprofen with some grip relief ◦ Neg valgus/varus stress ◦ No h/o sig injury ◦ Neg Tinels ulnar groove X-ray 3 view elbow PMH, PSH, Meds, All, ◦ Neg Soc hx, ROS n/c Diagnosis? Lateral Epicondylitis (Tennis Elbow) ◦ Overload of tendon-bone junction ◦ Present with pain and tenderness over lateral epicondyle ◦ Physical exam Tender over lateral epicondyle Pain with resisted wrist extension and extension of middle finger ◦ Treatment PT, bracing (wrist or counterforce), NSAIDs, cort inj Medial Epicondylitis (Golfer’s Elbow) ◦ Pain with resisted wrist flexion 3 7/28/2014 Extensors Lateral Epicondyle Medial Epicondyle Flexors HPI PE ◦ No injury ◦ TTP b/l paraspinals L4-5 Offensive lineman football ◦ Pain with ext ◦ Intermittent ache middle of low back +Stork b/l Wt lifting ◦ 5/5 mm strength b/l LE Playing football ◦ Sensation intact Running ◦ DTRs 2+/4 ◦ No numb/ting ◦ Neg straight leg raise ◦ Chiropractor x6 mos without relief ◦ Normal gait ◦ No meds X-ray 4 view ◦ No prev inj (AP/Lat/Obl) PMH, PSH, Meds, All, Soc ◦ Neg hx, ROS n/c Diagnosis? 4 7/28/2014 Spondylolysis-defect in pars interarticularis ◦ Caused by repeated hyperextension of the lumbar spine ◦ History-Adolescents Strenuous athletic participation LBP often without radiation Insidious onset, progresses to chronic, dull, midline L/S pain PE ◦ Tenderness to palpation over defect Can have step-off with spondylolisthesis ◦ ROM ◦ Stork test-key PE test for diagnosis Dx ◦ X-rays-oblique view will show chronic defect ◦ Bone Scan vs CT Scan vs MRI TX ◦ Rest vs Brace spondyloLISTHESIS 5 7/28/2014 HPI PE ◦ Heard pop in knee landing ◦ Large effusion from jump in basketball Immediate swelling ◦ TTP med/lat jt line ER-x-rays neg ◦ Ext to 10/flex to 90 Knee immobilizer. NSAIDs ◦ Sig guarding ◦ Constant pain ?laxity on ant Any WB drawer/Lachman’s test Using crutches (?giving out) Neg valgus/varus stress ◦ +swelling Unable to do McMurray’s -ecchymosis/erythema ◦ Antalgic gait ◦ No prev inj X-ray 4 view wt PMH, PSH, Meds, All, Soc hx, ROS n/c bearing (AP/Lat/Tunnel/ Sunrise)-neg Diagnosis? ACL injury ◦ Primary stabilizer of knee ◦ Prevents anterior translation of tibia on femur ◦ Can be contact or noncontact ◦ Increased incidence in adolescent females ◦ Will often hear pop followed by immediate effusion ◦ + Lachman test, Pivot Shift and Anterior Drawer Tests ◦ Surgery based on associated injuries and patient preference 6 7/28/2014 HPI PE ◦ Rolled ankle playing soccer ◦ +swelling ◦ Immediate swell/bruise ◦ Ecchymosis lat ankle Unable to cont playing ◦ TTP ATFL,CFL Urg care-x-rays neg No medial TTP Stirrup brace/crutches ◦ Dec ROM due to ◦ Inter sharp pain lat ankle stiffness/pain Worse walking ◦ Weak IR/ER with pain + limp ◦ -ant drawer, +Talar tilt, ◦ + swell/bruise -ER/Eversion test, ◦ NSAIDs with some relief -syndesmosis squeeze, ◦ h/o 3 ankle sprains-no tx -Thompson’s test X-ray 3 view wt bearing PMH, PSH, Meds, All, Soc hx, ROS n/c (AP/Obl/Lat) ◦ Neg Diagnosis? Lateral ankle sprain ◦ 80-85% of all ankle sprains ◦ Inversion + plantarflexion of ankle ◦ 3 ligaments stabilize the lateral ankle Injured in order based on severity: ATFLCFLPTFL ◦ Present with swelling, ecchymosis and variable weight- bearing tolerance Anterior Drawer Test for ATF/Talar Tilt Test for CF ◦ Ottawa ankle rules guide need for x-ray ◦ Treatment #1 rule is control swelling: RICE Crutches if limping Aggressive PT to regain strength and stability Bracing can be used as an adjunct to rehab and to prevent future injury ◦ Associated Injury ◦ Fracture to the base of the 5th Metatarsal 7 7/28/2014 Dislocation ◦ Complete dissociation of humeral head from glenoid fossa Subluxation is a transient displacement without complete dissociation ◦ 95% are anterior dislocations ◦ Treatment Stabilize arm, multiple relocation techniques Surgery vs Nonsurgical management 90% of young athletes will re-dislocate ◦ Associated injuries Joint capsule Labrum tear-Bankart Lesion Humeral fracture-Hill Sachs Deformity Axillary nerve or artery AC joint separation (separated shoulder) ◦ Multiple ligaments and mm stabilize joint ◦ Fall on top of shoulder ◦ Graded I-VI (I-III most common) ◦ Evaluation Tender over AC Joint + Crossover Test ◦ Treatment Grades I-III: Ice, sling for comfort, PT to regain ROM Grades IV-VI: Refer for surgery I II IV V VI Sprain/Strain vs Radiculopathy ◦ Presentation of pain/stiffness limited to neck and upper back most likely sprain/strain ◦ Radicular symptoms include pain, numbness/tingling and weakness into shoulder and arm to the hand ◦ + Spurlings sign = radiculopathy ◦ Imaging X-ray, MRI, EMG ◦ Tx NSAIDs, muscle relaxers and PT Epidural inj Surgery 8 7/28/2014 Fall on outstretched arm Limited flex/ext and pronation/supination ◦ Tenderness over lateral elbow ◦ Swelling may or may not be present Often missed on initial x-ray ◦ Important to re-xray after 2-3 wks Treatment ◦ Sling for 3-7 days ◦ Early ROM ◦ Surgery rarely necessary Little leaguer’s elbow ◦ Spectrum of injuries to elbow ◦ Also overuse and poor mechanics ◦ Caused by medial stress or lateral compression ◦ Pitch counts ◦ Treatment is rest followed by strength exercises Focus on correcting mechanics Progressive throwing program Distal radius fracture ◦ Very common-17% of all fractures in ER ◦ Treatment based on multiple anatomical factors ◦ Cast up to 6wks Scaphoid fracture ◦ 70% of true wrist fractures ◦ Risk of nonunion or AVN ◦ Pain in anatomical snuff box ◦ May not be seen on initial x-rays ◦ Long arm vs short arm cast ◦ Can take up to 4 months to heal 9 7/28/2014 Carpal Tunnel Syndrome ◦ numb/ting and pain in radial 3 digits ◦ (+) Tinel and Phalen tests ◦ Confirmed by EMG with NCV ◦ Treatment Cock-up Splint, NSAIDS, PT Surgery >3 mos conservative care or worsening neurological symptoms DeQuervain’s Tenosynovitis ◦ APL & EPB-1st dorsal compartment ◦ Tenderness and swelling over radial styloid ◦ (+) Finkelstein’s Test ◦ Treatment Thumb spica splint, NSAIDs, PT, Corticosteroid inj Surgical release of 1st dorsal compartment Sprain/Strain vs Radiculopathy ◦ Presentation of pain/stiffness limited to neck and upper back of sprain/strain ◦ Radicular symptoms include pain, numbness/tingling and weakness into buttock and leg to the foot ◦ + Straight Leg Raise = radiculopathy ◦ Imaging X-ray, MRI, EMG ◦ Tx NSAIDs, muscle relaxers and PT Epidural inj Surgery Meniscus ◦ Traumatic or degenerative ◦ Caused by weight-bearing + rotational forces ◦ c/o knee pain, delayed swelling, locking and catching Effusion and joint line tenderness on exam +McMurray and Thessaly (“Twist & Shout”) tests ◦ Treatment RICE, NSAIDs Functional symptoms require surgical evaluation 10 7/28/2014 Osgood-Schlatter Disease ◦ Osteochondritis of the tibial tuberosity ◦ Most commonly seen in ◦ 13-14 y/o boys 11-12 y/o girls ◦ Most common in jumping sports ◦ History Recent growth spurt Anterior knee pain ◦ Physical Exam Tender over prominent tibial tuberosity ◦ Tx Ice, NSAIDs, Stretch/Strengthen quads and hams OK to play to pain tolerance ◦ Self-limited condition Legg-Calve-Perthes Disease ◦ Interruption of blood supply to femoral epiphysis ◦ Average age is 4-9 y/o ◦ Present with deep hip, groin or thigh pain May radiate to knee ◦ Walk with limp, dec IR of hip ◦ Dx with x-ray MRI/Bone scan if early ◦ Tx-Refer to ortho Slipped Capital Femoral Epiphysis L-C-P ◦ Due to shearing forces during growth spurts ◦ Avg age 8-15 y/o ◦ Early dx is key-insidious onset of hip/groin/thigh/knee pain SCFE Dec IR on PE X-rays-ice cream scoop slipping off cone ◦ Refer to Ortho OA ◦ GROIN PAIN = HIP JOINT ◦ Pain can radiate to knee or low back, so make sure to check hip ◦ Tx with NSAIDs, PT, Cort inj, Surgery Trochanteric Bursitis ◦ Pain/tenderness over greater trochanter ◦ Worse with hip flex/ext ◦ Multiple underlying factors ◦ Tx with
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