Disclosures

• Founder, RunSafe™ Common Injuries of the • Founder, SportZPeak Inc. and • Sanofi, Investigator initiated grant A n t h o n y L u k e MD, MPH, CAQ (Sport Med) University of California, San Francisco Primary Care Medicine: Update 2017

Overview Acute Hemarthrosis

• Highlight common 1) ACL (almost 50% in children, >70% in presentations adults) • Knee 2) Fracture (, tibial plateau, Femoral • Shoulder supracondylar, Physeal) • Discuss basics of 3) conservative and surgical management • Unlikely meniscal lesions

1 Emergencies Urgent Orthopedic Referral

1. Neurovascular injury •Fracture 2. • Patellar Dislocation – Associated with multiple injuries • “Locked ” - unable to fully extend the (posterolateral) knee (OCD or Meniscal tear) – High risk of popliteal injury • Tumor – Needs arteriogram 3. Fractures (open, unstable) 4. Septic Arthritis

Anterior Cruciate Ligament (ACL) Anterior Cruciate Ligament (ACL) Tear Tear Mechanism Symptoms • Landing from a • Audible pop heard or felt jump, pivoting or • Pain and tense swelling in decelerating minutes after injury suddenly • Feels unstable (bones • fixed, valgus shifting or giving way) stress • “O’Donaghue’s ” = Medial tear, MCL injury, ACL tear • tears Double fist sign more common than medial

2 ACL physical exam Special Tests ACL LOOK • Effusion (if acute) • Lachman's test – test at 20° FEEL Sens 81.8%, Spec 96.8% • “O’Donaghue’s Unhappy Triad” = Medial , MCL • Anterior drawer – test at injury, ACL tear 90° • Lateral meniscus tears more Sens 22 - 41%, Spec 97%* common than medial • Lateral joint line tender - • Pivot shift femoral condyle bone bruise Sens 35 - 98.4%*, Spec 98%*

Malanga GA, Nadler SF. MOVE Musculoskeletal Physical • Maybe limited due to effusion Examination, Mosby, 2006 or other internal derangement * - denotes under anesthesia

X-ray MRI

• Usually non- • Sens 94%, Spec 84% diagnostic for ACL tear ACL tear signs • Can help rule in or • Fibers not seen in out injuries continuity • Edema on T2 films • Segond fracture – • PCL – kinked or avulsion over Question mark sign lateral tibial plateau

3 MRI Initial Treatment

• Sens 94%, Spec 84% • Referral to Orthopaedics/Sports Medicine for ACL tear • Consider bracing, crutches ACL tear signs • Begin early Physical Therapy • Lateral femoral corner bone bruise on T2 • Analgesia usually NSAIDs • May have meniscal tear (Lateral > medial)

ACL Tear Treatment Meniscus Tear

Conservative Surgery Mechanism Symptoms • No reconstruction • Reconstruction • Occurs after twisting •Catching • Physical therapy • Depends on activity injury or deep squat • Medial or lateral knee • Hamstring demands • Patient may not recall pain strengthening  Reconstruction allows • Proprioceptive training better return to sports specific injury • Usually posterior • ACL bracing  Reduce chance of aspects of joint line controversial symptomatic meniscal tear • Swelling • Patient should be  Less giving way asymptomatic with symptoms ADL’s • Recovery ~ 6-9 months

Shea KG, et al. AAOS evidence based reivew, J Bone Joint Surg Am, 2015

4 Special Tests: Meniscus Modified McMurray Testing Fowler PJ, Lubliner JA. 1989; 5(3): 184-186. Test Sensitivity Specificity • Flex to 90

Joint line tender 85.5% 29.4% degrees • Flex knee Hyperflexion 50% 68.2% • Internally or externally Extension block 84.7% 43.75% rotate lower leg with rotation of knee McMurray Classic 28.75% 95.3% (Med Thud) • Fully flex the knee McMurray Classic (Lat 50% 29% with rotations pain) Appley (Comp/Dist) 16% / 5%

Courtesy of Keegan Duchicella MD

X-ray MRI

• May show joint space • MRI for specific exam narrowing and early osteoarthritis changes • Look for fluid (linear bright signal on T2) • Rule out loose bodies into the meniscus

5 Arthroscopy Benefit? Exercise as Good as Arthroscopy?

• An RCT showed that physical therapy vs • RCT found that patients with degenerative arthrosopic partial meniscectomy had meniscus tears but no signs of arthritis on similar outcomes at 6 months imaging treated conservatively with • 30% of the patients who were assigned to supervised exercise therapy had similar physical therapy alone, underwent surgery outcomes to those treated with within 6 months. arthroscopy with 2 year follow up. – Katz JN et al. N Engl J Med. 2013 – Sihvonen R et al; N Engl J Med. 2013 Kise NJ et al., BMJ, 2016

Medial Collateral Ligament (MCL) Meniscal Tear Treatment Injury Conservative Surgery Mechanism Symptoms • Often if degenerative • Operate if internal • Valgus stress to • Pain medially tear in older patient derangement partially flexed knee • May feel unstable • Similar treatment to symptoms • Blow to lateral leg with valgus mild knee osteoarthritis • Meniscal repair if possible • Analgesia • Physical therapy • General Leg Strengthening

6 Medial Collateral Ligament (MCL) MRI Injury Physical Exam • Tender medially over • X-ray non-diagnostic MCL (often (rarely avulsion) proximally) • MRI not usually • May lack ROM necessary “pseudolocking” • Rule out meniscal • tear

Posterior Cruciate Ligament (PCL) MCL Treatment Injury Conservative Surgery Mechanism Symptoms • Analgesia • Rarely needs surgery • Fall directly on knee • Pain with activities • Protected motion with foot plantarflexed • “Disability” > +/- hinged brace • “Dashboard injury” “Instability” +/- crutches • Early physical therapy

7 Posterior Cruciate Ligament (PCL) PCL Treatment Injury Physical Exam Conservative Surgery • Sag sign • Acute: hinged • May require surgery Sens 79%, Spec 100% post-op brace in if complete Grade 3 extension (0-10° tear and symptomatic • Posterior flexion) Sens 90%, Spec 99% • Crutches • Needs urgent surgery Rubenstein et al., Am J Sports Med, 1994; 22: 550-557 • Early physical if lateral side is therapy unstable  postero- X-ray- often non-diagnostic lateral corner injury

MRI is test of choice Early and urgent referral!!

Patellofemoral Pain PFP Syndrome

• Excessive Symptoms • Tender over facets of compressive forces • Anterior patella over articulating • Worse with bending surfaces of PFP joint • Apprehension sign (5x body wt), stairs suggests possible (3x body wt) instability Mechanism • Crepitus under • Too kneecap loose/hypermobile • May sublux if loose • X-rays may show • Too tight – XS lateral deviation or tilt pressure

8 Treatment Options What’s Hip?

Too Loose/Weak Surgical (RARE) • Strengthen quads (Vastus Medialis Obliquus) • Last resort • Correct alignment (+/-orthotics) • Lateral release • Support (McConnell Taping, • Patellar Bracing) realignment Too Tight • Stretch hamstring, quadriceps, hip flexor • Strengthen quads, hip abductors • Correct alignment (+/-orthotics)

Prevalence of Knee Osteoarthritis Cartilage Damage

• As the number of persons over age 65 years, prevalence estimated to double to more than 70 million by 2030. • The incidence of knee OA in the United States is 240 per 100,000 person-years.

Outerbridge Classification, 1961

9 Arthroscopy Arthroscopy

Osteoarthritis What is Osteoarthritis?

• OA is a disease

characterized by Superficial Zone

cartilage Transition Zone degeneration • Cartilage loss and Radial Zone OA symptoms are preceded by damage to the collagen- Tidemark Calcified cartilage

proteoglycan (PG) Subchondral bone plate matrix

Vascular plexus

10 Concepts Diagnosis - History

Arthritis Symptoms • Pain • Irreversible Articular • Mechanical Cartilage Change – Grinding • Cure Not Possible –Catching • Try To Maintain Activity – Locking Level – Giving Way • Swelling

Diagnosis - Radiographs

In FWB Extension XR

11 Treatment Options

• Conservative • Surgical

Try Conservative Management Conservative Treatment First • Lifestyle Unloader Brace • Shoe Wear • Off Load Arthritic • Brace Wear Compartment • Rehabilitation/PT • Pain Relief

Lindenfield, et al Pollo / HSS, AJSM 2002

12 Conservative Treatment Platelet Rich Plasma ?

Medications • Platelet-rich plasma injections contain high concentration of platelet-derived growth factors, which regulate some • NSAID / Tylenol biologic processes in tissue repair. • Analgesics • Glucosamine / Chondroitin • A meta-analysis of 10 studies demonstrated that platelet- rich plasma injections reduced pain in patients with knee • Steroid injections OA more efficiently than placebo and hyaluronic acid • Viscosupplementation injections. However, 9 of the 10 studies had a high risk (Hyaluronic Acid of bias, and the underlying mechanism of biologic injections) healing is unknown. Laudy AB et al. Br J Sports Med. 2015

Surgical Treatment Arthroscopy Arthroscopy for OA • Prospective, Randomized Placebo • Used for Internal Controlled Study Derangement • 165 VA Patients Symptoms • Placebo vs Lavage vs Debridement had similar Knee Specific Pain • Treat Focal Lesions Scores at 1 and 2 years follow up • Remove loose bodies Moseley, New Engl J Med, 2002 • No difference in outcomes: WOMAC, • Temporizing SF-36 Physical component summary score • High Demand Kirkley, New Engl J Med, 2008 • No Malalignment

13 High Tibial Osteotomy High Tibial Osteotomy Technique Opening Wedge Results Good To Excellent

• 73% - 95% @ 5 yrs • 45% - 80% @ 10 yrs • 30% – 46% @ 20 yrs • Jevsevar DS. Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. J Am Acad Orthop Surg. 2013

Unicondylar Arthroplasty Total Knee Arthroplasty

Results 5-year survival rate was 87.8% Replace All Joint Surfaces (95% CI, 87.3% to 88.3%) • Significant negative influence Excellent, Reliable Pain Relief of , depression, and complicated diabetes Fails due to: • Excessive Poly Wear • Progression of OA into Other Compartment Jeschke E et al. J Bone Joint Surg Am., 2016

14 Total Knee Arthroplasty Shoulder Impingement Syndrome • Survivorship 90 – 95% will last more than 10 Mechanism Symptoms • 80-85% that it will last 20 • Impingement under • Pain with years acromion with flexion – Overhead activities American Association of Hip and Knee Surgeons, http://www.aahks.org/, 2016 and internal rotation – Sleep (Internal Meta Analysis – 11 Series of the shoulder rotation) • Rotator cuff, – Putting on a jacket • 3 – 18 yr f/u of 682 subacromial bursa • 93% Good – Excellent and biceps tendon • 11% Complications • 4% Revision • 21% Radiolucent Lines

Shoulder Pain Differential Shoulder Impingement Syndrome Diagnosis • Rotator cuff tendinopathy LOOK • Rotator cuff tears • May have posterior shoulder atrophy if • SLAP Lesion chronic or RC tear • Calcific tendinopathy • Poor posture • “Frozen” shoulder (adhesive capsulitis) FEEL • Tender over anterolateral • Acromioclavicular joint problems shoulder structures • Scapular weakness MOVE • Cervical radiculopathy • May lack full active ROM

15 Shoulder Impingement Syndrome MOVE

LOOK • May have posterior shoulder atrophy if chronic or RC tear • Poor posture FEEL • Tender over anterolateral shoulder structures MOVE • May lack full active ROM Painful Arc 60 - 120° Flexion and External rotation

Rotator Cuff strength testing Rotator Cuff strength testing Supraspinatus 30° Infraspinatus/teres minor - •Empty can External rotation • Thumbs down abducted • Keep at 90º to 30º • Patte’s test at 90º • Horizontally adduct to 30º shoulder abduction For tendonitis, For tendonitis Sens = 57 % Sens = 77 % Spec = 71 % Spec = 38 % For tears, For tears, Sens = 36 % Sens = 19 % Naredo et al. Ann Rheum Dis, 2002; Spec = 95 % Spec = 100 % 61: 132‐136. Naredo et al. Ann Rheum Dis, 2002; 61: 132-136.

16 Rotator Cuff strength testing Impingement Signs

Subscapularis – Internal Neer rotation / Lift-off test • Passive full flexion • Positive is For lesions, reproduction of Sens = 50 % shoulder pain Spec = 84 % For tears, Sens = 83 % Sens = 50 % Spec = 51 % Spec = 95 % PPV = 40 % NPV = 89 %

MacDonald et al. J Shoulder Surg, 2000; 9: 299-301. Naredo et al. Ann Rheum Dis, 2002; 61: 132-136.

Impingement Signs Impingement Signs

Hawkin’s test • Spurling’s test for • Flex shoulder to 90º cervical radiculopathy • Flex elbow to 90º Sens = 64% • Internally rotate Spec = 95% • Positive - reproduce PPV = 58% shoulder pain NPV = 96% Sens = 88 % Spec = 43 % PPV = 38 %

NPV = 90 % MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301.

17 X-ray AP Scapula X-ray AC Joint view

• Avulsion • Osteoarthritis • Calcific tendinosis • Osteolysis • Enthesopathy (traction spurs) • Alignment

X-ray Lateral Scapula X-ray Lateral Scapula

• Mercedes sign – humeral head should be centered in glenoid

• Can check for “hooked” acromion

Normal Large acromial spur

18 X-ray Axillary View

• Position • Dynamic test • Posterior • Operator dependent dislocation • Areas of tendinosis hypoechoic • Tears

MRI Rotator Cuff Tears

• MRI not needed for conservative treatment • Use it to rule out significant pathology How good for full thickness tears? • 69 to 100 percent sensitive • 88 to 100 percent Tear specific

19 Adhesive Capsulitis SIS Treatment “Frozen Shoulder” Conservative Surgery • Women greater than • Education • If patient fails men (70%) • Modify Activities conservative treatment • Age > 40 years for > 6-12 months • Alter Biomechanics / • Affects 2-5 % of Decrease tendon load • If > 1 cm population • Ice/NSAIDs (no evidence) • Eccentric exercise • Subacromial • 20-30% develop programs decompression symptoms in opposite • Steroid injection +/- bursectomy shoulder – slightly better than placebo +/- rotator cuff repair (Cochrane Database, 2004

Frozen Shoulder Diagnosis

• Gradual loss of range of • Limited range of motion motion (usually lose • May have had initial trauma external rotation, • Pain at the extremes of abduction and flexion) motion • Investigations (X-ray, • May have history of Ultrasound) usually diabetes, hypothyroidism, negative rheumatoid arthritis, now Breast Cancer Tx

20 Natural History Treatment

• 0-3 months “gradual onset” - painful • Pain management (+/- sling) • 2-9 months “ freezing” • Education and reassurance • Active home stretching program • 4-12 months “ frozen” • 5-26 months “thawing” • Physiotherapy • Oral NSAIDs (or steroids) • Usually self-limited • Glenohumeral injection capsular distension • Rarely needs surgery (examination under Hannafin & Chiaia, Clin Orthop Rel Res, 2000 anesthesia or Arthroscopic release)

Steroid injection Treatment

• RCT showed intraarticular steroid injection • Pain management (+/- sling) provided better pain relief in the first 8 • Education and reassurance • Active home stretching weeks than NSAIDs. program • However, no difference was seen in range • Physiotherapy of motion or pain after 12 weeks • Oral NSAIDs (or steroids) • Results similar to other non-controlled • Glenohumeral injection studies capsular distension • Rarely needs surgery Ranalletta M at al., Am J Sports Med, 2016 (examination under anesthesia or Arthroscopic release)

21 Shoulder Dislocation Shoulder Dislocation

Mechanism Mechanism Anterior (>95%) Anterior (>95%) • Force applied with • Force applied with shoulder in external shoulder in external rotation/ abduction rotation/ abduction Posterior (<5%) • Posterior force with shoulder in internal rotation/ adduction •EtOH (alcohol), Electrocution, Epilepsy

Shoulder “Dislocation” Diagnosis

History Symptoms Physical Exam • Fall on outstretched • “Dead ” (due to • Tender anterior hand traction on brachial shoulder • Hit with arm in plexus) • May have decreased abduction • Pain anteriorly sensation to army • Shoulder “came out” • Limited motion patch (axillary nerve) • Reduced • Apprehension test spontaneously or in • Sulcus sign (MDI) the ER

22 X-ray and MRI Complications after Dislocation

Acute rotator cuff tear • 40 to 60% incidence of in patients > 40 years old Frozen shoulder • Older the patient the stiffer they get mobilize early within 2-3 weeks Recurrent dislocation • >90% recurrence < 20 years; 14% > 40 yrs Rowe CR. Prognosis in dislocation of the shoulder. J Bone Joint Surg Am, 1956. • Early surgical stabilization still controversial

Hill Sachs Lesion – compression – Avulsion of fracture of posterior humerus capsular attachment to the glenoid

Initial Treatment Treatment for Shoulder Instability

• Sling x 2-4 weeks •T– Traumatic •A– Atraumatic with pendulum •U– Unilateral •M– Multidirectional exercises • Early physical therapy •B– Bankart lesion •B– Bilateral • Modification of •S– Surgical •R– Rehabilitation activities treatment •I– Inferior capsular (refer for consultation) shift

23 Acromioclavicular Joint Diagnosis “Separation” Mechanism Symptoms Physical Exam • Direct fall on the • Pain directly over AC • Swelling, tenderness +/- step deformity • Common biking, • Difficulty lifting over AC joint contact sports (hockey, weights • Early limited motion football etc.) • Difficulty reaching actively due to pain • May tear #1 overhead and across • Cross over sign + acromioclavicular body ligament; #2 coracoclavicular ligament

Investigations Classifying AC Separations

•AC joint views Type affected Exam • Weighted views rarely 1 Acromioclavicular (AC) lig Tender over AC ordered ; joint, no step Coracoclavicular (CC) lig OK 2 AC lig torn Mild step < width CC lig partially torn of clavicle

3 AC and CC ligs torn Obvious step => width of clavicle

24 Treatment Return to Sports

Conservative • Grade 1 – as symptoms allow, typically up to 2 weeks • Sling as good as figure eight • Grade 2 – typically 4 to 6 weeks • Physiotherapy – taping, restore ROM, • Grade 3 – up to 12 weeks maintain strength • Modify activities

Refer to Surgery

• Type 4 – Posterior dislocation • Type 5 – High riding distal clavicle (tenting the skin) • Type 6 – Posterior-inferior dislocation

25 AVOID STRESS

12th UCSF Primary Care Sports Medicine Conference San Francisco, Dec 1-3, 2017 Hotel Intercontinental

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