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TENDINITIS and BURSITIS of the KNEE

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TENDINITIS and BURSITIS of the KNEE Musculoskeletal Disorders and Conditions of Adults Frank Caruso DMSc, PA-C, EMT-P Skin, Bones, Hearts & Private Parts 2019 2 Goals : • Review MSK pearls - briefly • Review common musculoskeletal disorders of the adults – diagnosis and treatment • Review common Rheumatologic conditions • Review common fractures/dislocations/soft tissue injuries of the MSK • Review Benign and Malignant Soft Tissue Tumors Seven Part : • Part I: Physical Exam • Part VI: Common Key Points/General Fractures – Basics of Principles Fracture Care • Part II: Conditions of the Adult/Child Adult MSK - Treatments • Part VII: Benign and • Part III: Pregnancy Malignant Bone and • Part IV: Older Adults Soft Tissue Tumors • Part V: Rheumatologic Conditions – Common, overview 4 Part I Examination Key Points 5 Examination Key Points • Area needs to be well exposed – gown your patients!!! • Understand normal functional anatomy • Observe normal activity • Palpation • Range of Motion • Strength/neuro-vascular assessment • Specific provocative assessment Where Do Patients Go that have Pain? YOUR OFFICE!! 8 Musculoskeletal System • The musculoskeletal system provides the stability and mobility necessary for physical activity. • Physical performance requires bones, muscles, and joints that function smoothly and effortlessly. General Principles • Musculoskeletal exam performed if symptoms (i.e. injury, pain, decreased function) – different from a “screening exam” • Focused on the symptomatic area • Musculoskeletal complaints common 10 Historical Clues • What’s the functional limitation? • Symptoms in single vs multiple joints? • Acute vs slowly progressive? • If injury – mechanism? • Prior problems with this area? • Systemic symptoms? 11 Terminology • Anatomic Position and planes of the body • Flexion: – moving forward out of the frontal plane of the body – except knee and foot) • Extension – Movement in the direction opposite to flexion • Abduction – Movement that brings a structure away from the body • Adduction – Movement that brings a structure towards the body 12 13 14 History 15 MUSCULOSKELETAL PROBLEMS QUESTIONS TO ASK • Any trauma? • Medical history? • Location of pain? – Systemic diseases? • Any radiation? • What makes it better? • Occupation? • What makes it worse? • Hobbies/Daily • Have you had this before? Activities? • Any surgery? • Any medication/treatments? • Any functional problems – Loss of motion, weakness, numbness? 16 Examination Keys to Evaluating Any Joint • Have area well exposed • Inspect joint(s) in question, any signs of inflammation, injury (swelling, redness or warmth) Any deformity – compare to opposite side • Understand normal functional anatomy • Observe normal activity – what can’t they do? Any specific limitations? 17 Examination Keys • Palpate joint – any warmth? Point tenderness? What structures are involved? • Range of motion – active(patient moves) and passive (you move it) • Strength, neuro-vascular assessment • Specific provocative maneuvers • If acute injury and pain – may be difficult to assess as the patient attempts to “protect” the area injured – Attempt to examine the unaffected side first (gain confidence, develop sense of their normal) 18 General Exam Musculoskeletal Overview End Feel • The sensation the examiner feels in the joint as it reaches the end of the range of motion of each passive movement • Bone to bone: This is hard, unyielding – normal would be elbow extension. • Soft–tissue approximation: yielding compression that stops further movement – elbow and knee flexion. End Feel • Tissue stretch: hard – springy type of movement with a slight give – toward the end of range of motion – most common type of normal end feel : knee and metacarpophalangeal joint extension. Abnormal End Feel • Muscle spasm: invoked by movement with a sudden dramatic arrest of movement often accompanied by pain - sudden hard – “vibrant twang” • Capsular: Similar to tissue stretch but it does not occur where one would expect – range of motion usually reduced. Abnormal End Feel • Bone to bone: similar to normal bone – to bone but the restriction or sensation of restriction occurs before the normal end of range of movement • Empty: detected when considerable pain is produced by movement - - no real mechanical resistance – acute bursitis - Abnormal End Feel • Springy block: similar to a tissue stretch – occurs where one would not expect it to occur – usually found in joints with menisci. There is a rebound effect – example: would feel a springy block end feel with a torn meniscus of a knee when it is locked or unable to go into full extension. 29 Range of Motion • Active ROM and passive ROM for each joint and related muscle group • Note – Pain – Limited or spastic movement – Joint instability – Deformity – Contracture Range of Motion • Passive ROM may exceed active ROM by 5 degrees. • Active ROM and passive ROM should be equal in contralateral joints. • Discrepancies may indicate muscle weakness or disorder. • Use goniometer where there is increased or limited ROM. NEUROLOGICAL EXAM 35 Let's Put It All Together!! Common Conditions Musculoskeletal System Part II Conditions of the Adult Musculoskeletal System 37 Most Common Outpatient Orthopedic Conditions 1. Common presenting symptoms 2. Physical exam findings 3. Diagnosis 4. Treatment Cervical Cervical Strain- ICD9 847.0, ICD10 S13.4 “Oh my aching, stiff, Special tests: x-rays, painful neck” MRI, EMG/PNCV PE: Trigger points, Treatment: Reduce reduced motion, muscle irritability normal neurologic, no and spasm and re- bony tenderness establish the normal cervical lordosis Greater Occipital Neuralgia ICD 9 723.8/10M79.2 • Headaches • Piercing throbbing, electrical shock pain • Starts in neck spreads to ear, frontal area • Reproduction of pain upon compression of the greater occipital nerve against the edge of the occiput. – Treat trigger point Cervical Spondylosis • Also known as degenerative cervical disc disease • Common radiographic finding after age 50, frequently asymptomatic • Complaints of neck stiffness/pain, loss of motion • Treat symptomatically, rarely needs surgery – involve physical therapy early on in the course of symptoms 44 45 Cervical Radiculopathy “My hand and fingers feel numb” Special tests: x-rays, MRI, “I think I have a pinched EMG/PNCV nerve” Treatment: Reduce pressure PE: Abnormal upper extremity over the nerve, improve neurologic exam, loss of neurologic function, motion, +spurling sign, vertical traction may not help, improve neck flexibility, paracervical tenderness. Look neurosurgical consultation for muscle atropy – change in reflexes Myofascial Pain • Chronic disorder • Pressure or sensitive points in muscles (trigger points) causes pain in the muscle • Treatment: Physical therapy, trigger point, work station analysis 48 Shoulder ICD-9 ICD 10 • Shoulder pain – 719.41 • Shoulder pain – M25.51 • Rotator cuff sprain - • Rotator cuff sprain - 840.4 S43.4 • Rotator cuff tendonitis • Rotator cuff tendonitis – 726.10 – M75.1 50 51 52 Supraspinatus 53 54 Infraspinatus 55 Teres Minor 56 Subscapularis 57 Shoulder: Impingement Syndrome “It’s too painful to raise Special tests: X-Ray, MRI my arm up”, I can’t Treatment: Increase the sleep on my shoulder at subacromial space, night” physical therapy, PE: +FAR, AC tenderness, steroid injection, rotator cuff strength subacromial should be normal decompression Shoulder: Rotator Cuff Tendinitis “I can’t reach up or back Special tests: x-rays, MRI anymore” Treatment: Reduce cuff PE: Subacromial inflammation, physical tenderness, FAR therapy, prevent present, painful arc, rotator cuff tear rotator cuff strength can be diminished Shoulder: Rotator Cuff Tear “I have no strength in my arm”, Special testing: x-ray, MRI I have loss motion” Treatment: Recover and PE: Loss of motion, weakness improve lost strength, in rotator cuff testing, high return of range of motion, riding humeral head on x- therapy, surgery, rehab ray, atrophy of infra/supraspinatis over scapula Biceps Tenosynovitis • CPT code: 20550 – Injection of single tendon sheath • ICD-9 Code: 726.12 • ICD-10 Code: M75.2 Biceps Tendinitis “ The front of my Special tests: x-rays, MRI shoulder hurts every Treatment: Reduce time I lift my brief case, inflammation, I have this lump in my strengthen the biceps muscle” muscle and tendon, PE: Local tenderness in surgical debridement the bicipital groove, pain aggravated by flexion of the elbow, a bulge in the arm. Glenohumeral Joint ICD-9 ICD-10 • Shoulder pain: 719.41 • Shoulder pain: M25.51 • Shoulder adhesive • Shoulder adhesive capsulitis: 726.0 capsulitis: M75.0 • GH joint arthritis, • GH joint arthritis, unspecified: 716.91 unspecified: M 13.91 • GH joint arthrosis, post- • GH joint arthrosis, post- traumatic: 715.11 traumatic: M19.01 • GH joint arthrosis , • GH joint arthroisis , secondary: 715.21 secondary: M19.21 Glenohumeral Osteoarthritis “My shoulder makes a terrible Special tests: x-ray, MRI to clunking noise, my shoulder evaluate rotation cuff is stiff” Treatment: combine exercises PE: Crepitation with to improve ROM, circumduction or clunking injections, Surgery sensation, restricted abduction and external rotation Shoulder: Adhesive Capsulitis “My shoulder is stiff; I can’t Special tests: x-ray, MRI reach back to my wallet or Treatment: Gradually stretch get to my bra” out the glenohumeral joint PE: Loss of ROM glenohumeral lining, return of normal joint, especially abduction ROM/strength, and external rotation, no manipulation, debridement evidence DJD on x-ray Scapulothoracic Syndrome ICD-9 ICD10 • Bursitis of
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