5/25/16

What part of ortho is the hardest?

¨ Which causes the most difficulty in determining the diagnosis in your practice?

¨ 1.

¨ 2. Hip

¨ 3.

¨ 4. Hand

¨ 5. Foot

¨ 6. Spine What’s new in Sports Medicine in 2016? Brian Feeley, MD UCSF Sports Medicine

Outline GI problems and sports medicine

¨ What’s new in common shoulder problems? ¤ Frozen shoulder ¤ Tears ¤ SLAP tears/Biceps tendonitis ¨ What’s new in common hip problems? ¤ Femoroacetabular impingement/labral tears ¨ What’s new in common knee problems? ¤ Early Arthritis and me niscus te ar s

¨ Focused recent scientific evidence

1 5/25/16

Approach to shoulder problems Approach to shoulder problems

Differential Diagnosis Differential Diagnosis ¤ Rotator Cuff Tears (45%) ¤ Rotator Cuff Tears (45%) ¤ Shoulder arthritis (15%) ¤ Shoulder arthritis (15%) ¤ Frozen shoulder (15%) ¤ Frozen shoulder (15%) SHOULDER ARTHRITIS Pain all the time, loss of ¤ Biceps problems (15%) ¤ Biceps problems (15%) motion ¤ Dislocations (5%) ¤ Dislocations (5%) ¤ Fractures (5%) ¤ Fractures (5%)

¤ Bruise (5%) ¤ Bruise (5%) ¤ Cervical spine problems (25%) ¤ Cervical spine problems (25%)

HISTORY -3 minute office exam

Key questions to ask “VPMCB”

¨ Visual inspection

1. Was there an acute injury? ¨

¨ Motion 2. Are you losing strength? ¨ Cuff-Specific testing 3. Are you losing ? ¨ Biceps Testing

2 5/25/16

Shoulder examination Inspection

¨ Inspection ¨ Presence of infraspinatus atrophy increases ¤ Pat ient in gown likelihood of rotator cuff disease ¨ Palpation ¨ ROM ¨ Positive LR 2.0 ¨ Strength ¤ Supr as pinatus ¨ Negative LR 0.61 ¤ Infr as pinatus & Te r e s minor

¤ Subs c apular is ¤ Bic eps

¨ Other tests http://meded.ucsd.edu/clinicalmed/joints2.htm, permission granted by Dr. Ch a rl e s Go l d b e rg , UCSD SOM

Palpation RANGE OF MOTION

Press where it hurts No problem No arthritis With AROM No cuff tear Location Diagnosis No frozen shoulder Clavicle Clavicle fracture Active Range of Motion AC joint AC joint arthritis “What can you do?” No problem with passive Trapezius/Neck Muscle strain Think CUFF TEAR Front of shoulder Biceps pathology Difficulty with active Back of shoulder Arthritis -check passive Problem with passive Think Shoulder OA or Frozen Shoulder

3 5/25/16

What’s the best way for PCPs to examine the Rotator Cuff Testing shoulder for RCD?

Impingement --Neer’s/Hawkins tests

Muscle Strength We concluded that there is insufficient evidence upon which to base selection of physical tests --Teres Minor for shoulder impingement, and potentially related conditions, in primary care. --Infraspinatus --Supraspinatus --Subscapularis

Rotator cuff disease exam Pain test: Painful arc

¨ Pain provocation tests ¨ Pain and s tr ength tes ts ¨ Often the pain radiates to lateral shoulder/proximal arm (“deltoid”) If painful, positive LR 3.7 for RCD. If not painful, negative LR 0.36 for RCD.

JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

4 5/25/16

Pain & Strength test: Pain/strength test: Drop arm test Subscapularis = internal rotation lag test aka ‘lift off’ Positive LR 3.3, negative LR 0.82 for Positive LR rotator cuff 5.6, negative disease. LR 0.04 for full thickness My favorite test for rotator cuff, pre and post op . JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

Biceps Biceps

¨ O’Brien’s Test (SLAP tears) ¨ Bicipital Tendonitis ¤ Good test for less than 35 years old, shoulder pain, ¤ TTP at biceps groove acute injury n Compare to other side

5 5/25/16

Common Shoulder Problems Case 1

54 year old woman presents with 4 months of shoulder pain that occurred after taking her jacket off. She now has trouble getting things off high shelves and can’t put her belt on.

Case 1—Key points in the history Physical Examination

¤ Was there an acute injury? ¨ Visual inspection Yes, but not really ¨ Palpation ¤ Are you losing strength? ¨ Motion No ¨ Specific testing ¤ Are you losing range of motion? YES, OH YES!

6 5/25/16

Frozen Shoulder=Adhesive Capsulitis Causes

nd ¨ Key points in the history and physical ¨ 2 most common cause of shoulder pain in US ¤ No ‘real’ trauma in patients 40-60

¤ Pain all the time ¨ Mostly unknown

¤ Limited ROM ¤ Associated with Diabetes, Thyroid Problems

Frozen Shoulder Mimics All Other Processes!

Natural History

Thickening of capsule with Inflammatory cells and fibrosis

7 5/25/16

JSES 2012 Treatment Options

¨ 100 patients, 5 year follow up (no treatment) ¤ Average duration of symptoms-1.6 years ¤ 91% return to full/near full function

Do Nothing Treatment

¨ Injections done blindly vs. injections done under ultrasound

¤ Patients with less pain at the time of injection ¤ More likely to get better after UTZ injection

8 5/25/16

Am J Sports Med 2016 Surgery for Adhesive Capsulitis

¨ Only for people who fail non-operative ¨ 74patients randomized to steroid (low or high dose) vs NSAIDS ¤ 6 months PT, injections

¨ Steroid injection groups got better faster than placebo group

¨ Long term both did well

Considerable State of the Art: Frozen Shoulder Loss of motion Surgery vs. pain, limited PT/Injection ADL

¨ 1976: May be auto-immune Xrays: OA ¨ 2010-2016: Mild limitations PT/Injection ¤ Everyone will get better in daily Surgery only if Loss of passive activities fail non-op ¤ Injections may quicken improvement range of motion n UTZ injections are more effective Less than 3 6 months Xrays: no OA mo nths : PT/ROM ¤ Surgery only for those that fail all other treatment =Fr o ze n PT for ROM program Surgery only if Shoulder fail non op More than 3 6 months mo nths : PT/ROM Injection program

9 5/25/16

Case 2 Case 3—Key points in the history

¨ 56 year old male, 3 months of shoulder pain and weakness after an awkward fall while hiking. ¤ Was there an acute injury? Hasn’t been able to return to the gym. He has Yes

pain at night and lifting things is difficult. ¤ Are you losing strength? Yes

¤ Are you losing range of motion? No

Rotator Cuff Tears What is a rotator cuff tear?

Common condition over age of 60 ¤ As high as 40% of patients over 60 will have a tear n Increasingly older population….who wants to stay active Full Loss of attachment of the tendon to Thickness Partial Cuff Tear ¤ Can be traumatic or without trauma Tear Usually (but not always) causes shoulder pain Impingement and weakness

10 5/25/16

Natural history of Imaging of Rotator Cuff Tears Full thickness rotator cuff tears

Keener et al (JBJS 2014) ¨ Risk factors for progression: Tear Progression

smaller Age >60 unchanged Fatty infiltration on MRI 2-5mm >5mm Larger tear Waldt et al. Radiology 2008 95% accurate at SS tears

Natural History: Non Operative Exercise for Rotator Cuff Tears

¨ Rest, activity modification ¨ Many Case Reports in Literature

¨ NSAIDS ¨ MOON Data Largest Series N=450 patients ¨ Physical therapy ¤ Symptomatic Atraumatic Full Thickness Rotator Cuff Tears ¨ Injections ¤ Evidence Based Rehabilitation Program ¤ Prospective Cohort Study

11 5/25/16

Patient Outcome Measures After Nonoperative Treatment

METHODS Baseline Scores 6 Weeks p -values 12 Weeks p -values ¨ 452 subjects were enrolled and given an EBM based SF-12 MCS 40.3 40.6 0.29 40.9 0.79 physical therapy program SF-12 PCS 35.3 35.6 <0.0001 36.0 <0.0001 ¨ Work with therapist until ready for Home Program ASES 54.4 69.1 <0.0001 75.3 <0.0001 WORC 47.0 62.5 <0.0001 69.4 <0.0001 ¨ Assess patients at 6, 12 weeks, 1, 2 years (now 5 years) SANE 46.6 62.7 <0.0001 70.0 <0.0001 Marx Activity Scale 9.9 10.1 0.095 10.0 0.44 ¤ Are you cured? ¤ Are you better and want to continue with therapy? ¤ Are you no better and want to have it repaired?

Predictors of Failure of Effectiveness of Therapy Nonoperative Treatment? Strongest Association 5 year outcomes ¨ LOW PATIENT EXPECTATIONS 28 9 Su rgery 9 REGARDING SUCCESS WITH THERAPY Cured

Deceased (p<0.0001) Dropped Out ¨ If a patient thought PT would not be 191 Lo st effective-it generally wasn’t

¨ If a patient thought PT would be N= 433 (> 95% Follow up) effective-It was <80% of Patients Had Surgery Patients Chose to Have Surgery in First 12 Weeks

12 5/25/16

Randomized Trials So who should have surgery? Surgery vs. Conservative Indications for surgery: ¨ Degenerative Tears with 5 Acute injuries Loss of function year f/u 6.5 Smaller tears do better ¤ Surgery outcomes better Better muscle quality (no n Constant score, ASES, VAS atrophy, no fatty infiltration) pain and satisfaction Lower rate or rerupture Easier rehab ¤ Clinical benefit debated (did not 9.0 Easier for me to do reach MCID)

¤ 24% of PT group crossed over

¤ Nonop patients, 37% tear enlargement: assoc with inferior outcome Moosmayer et al JBJS 2015

Algorithm for full thickness tears Case 3

MRI: tear Consider Weak on exam Surgery Eval ¨ 37 year old computer Acute engineer has 4 months of

MRI: tear PT/Injection, anterior shoulder pain. No we akne s s surgery if fails Suspect He cannot complete his Cuff Tear workouts. He is markedly PT/Injection tender along his anterior MRI: tear Surgery if Weak on exam shoulder. He has an MRI Chronic failed PT that shows a superior PT/Injection MRI: tear: labral tear. Surgery only if No we akne s s adamant

13 5/25/16

Case 5—Key points in the history The biceps shoulder complex

¤ Was there an acute injury? Differential for Anterior Shoulder Pain No Biceps tendonitis ¤ Are you losing strength? Subscapularis Tear No SLAP tear (usually posterior) AC joint arthritis ¤ Are you losing range of motion? No

Biceps vs. SLAP tear? Treatment for SLAP tears

SLAP TEAR BICEPS ¨ If younger than 35, PT, then consider surgery for repair in non-operative management fails ¨ Throwing/Acute injury ¨ Overuse/activity related (change

¨ Pain with O’Briens test in activity) ¨ ¨ If OLDER than 35—OFTEN NORMAL FINDING ON ¤ Pain is often deep and Pain with O’Briens test posterior ¤ Pain is often anterior MRI.

¨ No Pain in biceps groove ¨ TTP in biceps groove ¤ NON OP (PT/NSAIDS)

¤ No improvement with injection ¤ Improvement with injection ¤ higher rate of failure with SLAP repair (3x higher failure rate). Biceps tenodesis

14 5/25/16

PT, Surgery for Treatment for SLAP tears SLAP/BICEPS <35, acute SLAP repair if injury PT fails

¨ Provencher et al, AJSM 2014 SLAP ONLY ¤ 179 patients who underwent SLAP repair PT/Injection >35, no acute n 36% failed, 30% had revision surgery Surgery only if injury fail non-op n #1 risk factor for failure was age >36 (RR=3.5) SLAP/BICEPS

Less than 3 90% improve ¤ Summary: SLAP repair not recommend for people mo nths : and return to BICEPS PT for ROM sports over 36 (consider non-operative (PT, injection) or TENDONITIS Biceps te no de s is biceps tenodesis). More than 3 70% improve mo nths : and return to PT vs Injection sports

Part II: The hip LOTS OF CAUSES OF HIP PAIN

¨ 45 year old male arrives with 3-4 months of increasing hip pain and clicking. Pain with some 5 COMMON CAUSES OF HIP PAIN sitting and running. Hasn’t tried anything. His chiropractor got an MRI and shows a labral tear. Arthritis FAI/Labral tears ¨ What would you do? Trochanteric Bursitis Muscle Strains Stress Fractures

15 5/25/16

Localization of the pain Hip – a 1 minute exam

¨ Posterior Pain • Low back/sciatic nerve ¨ Range of Motion • SI joint • Flexion • Hamstring ¨ Lateral pain • Abduction • Trochanteric bursitis (COMMON) • Internal rotation • Gluteus tears (Rare) • ¨ Groin Pain External rotation • FAI (Femoroacetabular Impingement) ( U nder 50) • OA (over 50) • Adduc tor Str ains • Joint pain (FAI, labral tear, OA)=pain with FLEXION and INTERNAL ROTATION

Labral Tears/Impingement Labral tears/impingement

¨ What is the labrum? ¨ What causes a labral tear? • Isolated trauma • Abnormal bony anatomy (FAI)

16 5/25/16

Femoroacetabular impingement (FAI) Labral Tears/Impingement

¨ What are the symptoms of a labral tear? • Similar to a meniscal tear • Limitation of daily activities n Poor sports performance

• Catching/locking/popping (can be extraarticular) • Pain—usually positional in nature • Flexion activities Cam Impingement Pincer Impingement

“Classic” labral patients have groin pain Hip Imaging

¨ Start with Xrays!

17 5/25/16

FAI—MRI Imaging Labral tears are common as we get older

¨ 88-95% sensitive and ¨ Silvis, et al AJSM 2011 specific (MR ¤ Evaluated healthy athletes with no hip pain ) n 64% had evidence of labral tear/FAI on MRI/XR exam

¨ Swiss axial views to evaluate cam lesion ¨ Silvis et al AJSM 2014 ¤ Follow up study of same patients ¨ Lidocaine injection test n Only 1 had progressed with their symptoms • Diagnostic/therapeutic

Treatment of FAI/labral tears

Labral tear s w er e id en tif ied in 6 9 % o f h ip s, ch o n d ral “Magnetic resonance images of 1. Physical Therapy defects in 24%, lig amen tu m ter es tear s in 2 .2 %, asymptomatic participants revealed lab r al/paralabral cy sts in 1 3 %, Participants older than 35 abnormalities in 73% of hips, with 1. Core Exercises years were 13.7 times (95% CI, 2.4-80 times) more likely labral tears being identified in 69% of to h av e a ch o n d ral defect an d 1 6 .7 times (9 5 % CI, 1 .8 -158 2. Activity modification the . A strong correlation was times) mo r e lik ely to h av e a subchondralcy st co mp ared 3. Hip muscle strengthening with participants 35 or younger. Male subjects were 8.5 seen between participant age and times ( 9 5 % CI , 1 .2 -56 times) more likely to have an early markers of osseous bump than female subjects degeneration such as cartilage defects 2. Corticosteroid injection and subchondral cysts.” 1. Diagnostic and therapeutic

18 5/25/16

Groin pain/suspected Surgery for FAI labral tear

Limiting activities? ¨ Indications for surgery (FAI) PT-focus on Fluoroscopic injection • Pain with flexion/internal rotation strength/core exercises PT-focus on strength/core exercises • Labral tear on MRI • Relief of pain with injection test yes Symptomatic improvement? • Failed physical therapy Home exercise program Consider arthroscopic Return to sports debridement

Outcomes of hip When not to recommend surgery

Works well for FAI (Bedi JBJS 2013) Works well with younger patients (Larson AJSM 2012) “Arthroscopic labral debridement in patients forty-five years of age or older was associated with a relatively high reoperation rate and minimal overall improvement in joint- specific and quality-of-life outcome measures. Although differences in some outcome measures were statistically significant, most did not reach the level of the minimum clinically important difference. Arthroscopic debridement of labral tears in this patient population must be approached with caution as the overall clinical benefit was small.” JBJS 2014

19 5/25/16

When not to recommend surgery Finally…the knee

¨ 56 year old male presents with 3 months of medial sided knee pain, worse with flexion and “Overall, 45 % of the hips failed for squatting. It limits his activities including martial repeat surgery (20 %) or rating for hip function as abnormal or severely abnormal arts and running. He thinks he has a (25 %). Twelve hips (20 %) required subsequent surgical intervention at a mean tear. 23 (range 6-60) months (7 total hip arthroplasties, 2 open revisions, 3 arthroscopic revisions).” KSSTA2014

Physical Exam for meniscus tears MRI

¨ Joint Line Tenderness

¨ ¨ MRI for specific exam

¨ Thessaly Test

¨ Look for fluid (linear bright signal on T2) into the meniscus

20 5/25/16

Doc…should I have surgery? Partial Menisectomy for Degenerative Tears

RCT: 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative Summary: medial and no knee osteoarthritis. 12 month follow up No mechanical symptoms RESU L TS: Gradual onset, mild pain-no In the intention-to-treat analysis, there were no surgery significant between-group differences in the change from baseline to 12 months in any primary outcome. CON CL U SION S: Mechanical symptoms, In this trial involving patients without knee recent change osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after Acute worsening-consider arthroscopic partial meniscectomy were no better surgery than those after a sham surgical procedure

Does taking part of the meniscus out hurt my knee?

Souza, et al KSSTA 2014

Volume of tear correlates with The rate of medial meniscus lesions (tear or degeneration) was not signal change on MRI post op significantly higher in those who developed incident OA (85%) compared with the control patients (68%; P = .07). However, medial meniscus extrusion, Changes occur near area of complex tears, and tears with large radial involvement were more common at removed meniscus baseline in cases compared with controls. CONCL USI ON: ->Having tear likely increases with meniscus tears with greater radial involvement and extrusion are risk of arthritis (a little bit), at greater risk for later development of radiographic OA having surgery may or may not change history

21 5/25/16

Thank you Meniscus tears Xrays: no OA Surgery vs. MRI: tear PT/Injection Questions: [email protected] Acute Xrays: [email protected] PT/Injection mild/ mo de r ate Surgery only if OA fail non-op Suspect MRI: tear Meniscus Tear PT/Injection Xrays: no OA Surgery only if MRI: tear Chronic fail non-op

Xrays: PT/Injection mild/ mo de r ate Surgery only if OA adamant MRI: tear

22