Common Musculoskeletal Injuries with an Emphasis on the

Primary Care Fall Conference Monday, October 21, 2013

William Vollmar, MDMusculoskeletal Exam

Common Musculoskeletal Injuries with an Emphasis on the Physical Exam

William Vollmar, MD, CAQSMPrimary Care Sports Medicine

Objectives

Organization and approach to the exam for common musculoskeletal injuries.Develop the differential for surgical and non-surgical treatment to common injuries related to the above areas.Counsel your patients appropriately for common musculoskeletal injuries.Identify treatment options for the common injuries by understanding some of the basic principles of rehabilitation.



The Ankle

A complex hinge joint.Minimal mobility with need for overuse and weight bearing.Need for force dispersion to decrease shock to the rest of the body.

Ankle Anatomy



Ankle Sprain

Most common injury of the lower extremity in sports.Eighty five percent of sprains occur to the lateral ligament complex with the ATF being the most commonly sprained ligament.Ten percent are medial sprains.Five percent are high ankle sprains.

Examining the Ankle

Observe for swelling and deformity.Check distal nerve and vascular functions.ROMPalpate anatomic landmarks.Check ligamentous stability.Test muscles and tendons.Thompson’s test for Achilles tear.



Imaging the Ankle

Modified Ottawa Rules- Can patient take 4 steps, tenderness over bony landmarks and ankle instability.Ottawa Rules apply to 18-55 year old patients in their study.The mortise is the key.Plain films- AP, oblique and lateral.

MRI of the Ankle

Never order and orthopedic MRI without plain films first.Good for identifying osteochondral defects and soft tissue pathology.Also becoming the standard for identifying stress fractures of the foot.



Treatment

RICE should be the first response to any ankle injury.Decrease pain and swellingImprove range of motion with dorsiflexion as the most important motion to regainStrengtheningProprioceptionSports specific activity testing

Treatment

• Remember, never let taping or bracing substitute for good rehabilitation with strengthening and proprioception.

• Biomechanical evaluation may be useful in patients with recurrent ankle injuries.



Injecting the Ankle

1 cc steroid and 1-2 cc’s of lidocaine.Good for arthritis of the talo-tibial joint.Occasionally good for sprains that are slow to heal or are causing impingement.Can temporize but rarely cure plantar fasciitis.Never inject in or around the Achilles Tendon.

The Knee

The knee is a hinge joint with a small amount of internal and external rotation as it leaves and enters complete extension.



Knee Anatomy

Acute Injuries

Positive HemarthrosisFracture or bone contusionLigament tearMeniscal tear

Negative HemarthrosisSprainTraumatic synovitisContusionMuscle tear or pull



Overuse Injuries

Patellar femoral painTendonitisBursitisApophysitisIliotibial bandDJDBakers cyst

Acute Injury History

Did the knee swell immediately?Was the knee able to bear weight?Does the knee lock or give way?Did the athlete hear or feel a pop with the injury?Was the range of motion of the knee limited or blocked?



Chronic Injury History

Physical symptoms in overuse injuries:Is the knee stiff in the morning, gets better with activity but hurts with excessive activity?Do jumping or pliometric forces bother the knee more than low level continuous forces?Does the knee develop a true effusion or peri-patellar swelling?

Chronic Injury HistoryPhysical symptoms in overuse injuries:

Does it hurt more to ascend or descend stairs?Does side-to-side/lateral motion bother the knee more than forward motion?Does the patient have night pain?Has the patient grown more than 4 inches in the last year or gained two shoe sizes in the last six months?



Chronic Injury History

Training issues in overuse injuriesHas there been a recent change in duration or intensity of activities?Has there been a change in shoes or a new surface for physical activity?Is the patient doing any type of warm up?Do nutritional habits fit the activities the patient is trying to accomplish?

Examining the Knee

Observe for swelling/effusion and deformity.Check distal nerve and vascular functions.ROMPalpate anatomic landmarks.Check ligamentous stability.Test muscles and tendons.



Imaging the Knee

If needed, simple plain AP and lateral films are the first step. They may be augmented by Sunrise and Notch or Tunnel views as needed.Image overuse injuries only after failure to appropriate treatment for 4 weeks.Not all knee pain comes from the knee. Remember the hip and femur can refer pain.

Advanced Imaging of the Knee

Never get an orthopedic MRI without plain films first!Bone scan is usually only helpful to look for metastatic disease. Stress fractures around the knee are very uncommon.Ultrasound of the posterior fossa can find Baker’s cyst, popliteal aneurysm and DVT.



Injection and Aspiration of the Knee

1 cc steroid and 3-4 cc’s of lidocaine for injection in either flexed or extended position.Aspiration should be done in extended position and local anesthetic should be used to ease the procedure.Good for arthritis and synovitis of the knee. Do not inject septic joint.

Knee Injection



The Shoulder

A ball and socket joint that is more like a ball and saucer joint.High mobility with some need for strength.The rotator cuff muscles should be considered endurance muscles.

Shoulder Anatomy



Biomechanics

The rotator cuff must secure the humeral head into the glenoid fossa for any meaningful work to be accomplished across the shoulder.The first sign of a shoulder going toward cuff failure is the loss of internal rotation.

History Considerations

Acute vs. chronicMechanism of injuryDifferentiate neurological and cervical spine sources for painNight time pain



Impact to the Top of the Shoulder

AC separationClavicle fracture

Impact with Arm Abducted and Externally Rotated

Dislocation of the glenohumeral jointSubluxationCapsular laxity



Gleno-humeral Dislocation

If you identify an anterior and/or inferior dislocation first check distal nerve and vascular functions.If they are intact, reduce the dislocation as soon as possible.Ninety five percent of gleno-humeral dislocations are anterior or inferior.The other 5% are posterior and are caused by major trauma.

Acute Rotator Cuff Tears From Trauma

Less commonOccurs when forces beyond the control of the shoulder, end their journey at the shoulder.Not usually athletic injuries but injuries of major trauma.



Acute Rotator Cuff Tears From Chronic Overuse

More commonOver 35 years oldDominant armOveruse history with work or athletics

Examining the ShoulderObserve for swelling and deformity.Check distal nerve and vascular function.ROMStrength testingImpingement testingStability testing



Examining the Shoulder

AC joint testingProvocative rotator cuff testingLabrum testing

Imaging the Shoulder

Rule number 1: Never order an orthopedic MRI without getting plain films first.Rule number 2: Never break rule number 1.



Imaging the Shoulder

AP view“Y” view (Sometimes called trauma view)Axillary viewOutlet view

MRI of the Shoulder

Plain MRI of the shoulder is great for rotator cuff and other soft tissue pathology.MR Arthrogram of the shoulder will improve the ability to find a labral tear about 10-15% over plain MRI.



Where do you put Thoracic Outlet Syndrome in a shoulder lecture?

This is something to always keep in mind when all else seems normal.Eighty five percent of TOS is treated by physical therapy.The most common surgical cause for TOS is a cervical rib.

Injection of the Shoulder

1-2 cc’s steroid and 3-8 cc’s of lidocaine.Posterior approach is most favorable for almost all diagnoses.Good for impingement and tendinopathy. Occasionally useful in partial cuff tears. Can mask full thickness tears.



Shoulder Injection

The Hand and Wrist

Complex multi-articular joint.Designed for fine dexterity and repetitive use.“C” shaped cartilage on ulnar aspect known as TFCC.No cartilage on radial aspect.



Finger Anatomy

Wrist Anatomy



History Considerations

FOOSH- fell on out-stretched hand.Repetitive work environment.Snuff box tenderness.Caught a jersey while playing sports.Arthritis or tendonitis pain patterns.

Examining the Hand and Wrist

Observe for swelling and deformity.Check distal nerve and vascular functions.ROMPalpate anatomic landmarks.Check ligamentous stability.Test muscles and tendons.



Imaging the Hand and Wrist

Plain films of the wrist usually include an AP, oblique and lateral views.Augment plain films with a scaphoid view to cone down on fracture of this bone.Augment plain films with an AP clenched fist view for scapho-lunate dissociation.

MRI of the Hand and Wrist

Never order an orthopedic MRI without plain films first.Plain MRI of the wrist is now standard of care for imaging scaphoid fractures.Tri-compartmental MR Arthrogram of the wrist is good for TFCC tears and ligamentous pathology.



Injections around the Hand and Wrist

Carpal tunnel injection.DeQuerveins injection.Trigger finger injection.

The Elbow

A complex hinge joint with distal rotation.Designed to get our hands and wrists into places where they can get injured.Flexion, Extension, Pronation and Supination.



Anatomy of the Elbow

Historical Considerations

Swinging a 2 year old around by the hands.Tennis elbow should be renamed industrial elbow.Baseball player- Child, adolescent or adult.FOOSH injury.



Examining the Elbow

Observe for swelling/effusion and deformity.Check distal nerve and vascular functions.ROMPalpate anatomic landmarks.Check ligamentous stability.Test muscles and tendons.

Imaging the Elbow

Plain films usually include AP, lateral and oblique views.Sail sign is key for unseen supracondylar fracture.Rule of 3’s for treating radial head fractures. Greater than 30 degrees of angulation, proximal fragment greater than 30% of joint surface and fragment displaced more than 3 mm should be referred to orthopedics.



MRI of the Elbow

Never order an orthopedic MRI without plain films first.Good for collateral ligamentous pathology.Good for loose bodies and osteochondral lesions.

Injection of Lateral Epicondylitis

1 cc steroid and 1 cc lidocaine.After two failures with steroid, consider PRP injection.



Platelet Rich Plasma (PRP)• Potential healing properties on tendons and

ligament injuries through the recruitment, proliferation, and differentiation of cells.

• PRP is a concentrate of platelets and associated growth factors obtained through withdrawal and centrifugation of a sample of patient's own blood.

• Evidence shows improvement in elbow tendonosis primarily. Lack of evidence in other sites.

Platelet Rich Plasma



Corticosteroid Injections• Corticosteroid injections into articular,

periarticular, or soft tissue structures relieve pain, reduce inflammation, and improve mobility.

• Can be helpful for temporary relief and sometimes definitive treatment of tendonopathies.

• Most commonly used for osteoarthritic or rheumatoid conditions.

• There is little systematic evidence to guide medication selection for therapeutic injections.

The Low Back

• Injury to the low back can be a frustrating evaluation for any physician.

• Most common musculoskeletal complaint for PCP.

• Most injuries due to muscular or ligament strain.

• Discogenic or neurologic injuries.• Spondyloarthropathies



Spine Anatomy

Muscle Testing

You need to watch the whole body move to often see what is happening to the back.Muscle testing of the low back is done by group. Pain with testing the paraspinal muscles in extension usually indicates muscular injury or spasm. Flexion pain, which does not test the paraspinal muscles directly, is more associated with ligamentous or disc injury.



Neurological and Disc Disease

Pain with back flexionStraight leg raisePain with coughing or sneezingDeep tendon reflexesStrength testingSensory testingPain with neck flexion while the patient is standing

Musculo-skeletal Disease

Pain with back extensionPain with extension combined with rotationPain with lateral flexionSI joint testingGluteus medius testing



Spondyloarthropathies

Pain with back flexionPain with back extension (worst)Stork testingIn young athletes, stress fracture of the pars is probably the most overlooked low back injury.

ImagingX-rays of the back should not be conducted unless more than simple muscle strain or sciatica is indicated by history and exam. If x-rays are ordered, obtain five view LS spine films first. These allow evaluation of the bones and disc spaces. They also allow visualization of the neural foramina and the pars.MRI of the lumbar spine should be ordered only after plain films have been obtained and there is strong indication for neurological or disc pathology.



Treatment

Treating simple low back strain should involve NSAIDS, ice and relative rest so as to avoid the onset of stiffness. Occasionally the use of muscle relaxants for sleep can be helpful. Heat may be useful in treating morning stiffness, especially in arthritics, but will often relax all of the back musculature and inhibit support from surrounding structures.

Treatment

From a therapy stand point, lumbar stabilization and/or core strengthening are helpful in the treatment and prevention of further simple low back pain.Treatment of any type of neurological or non-surgical disc pathology should involve organized physical therapy as well as NSAIDS and relative rest.



References:

1.Griffin, L. Y. et al. Essentials of Musculoskeletal Care 3rd Edition. American Academy of Orthopedic Surgeons, 2005.2.Bachman, L.M. et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003 February 22; 326(7386): 4173.Ivins, D. Acute Ankle Sprain: An Update. Am Fam Physician. 2006 Nov 15;74(10):1714-1720.4.Kinkade, S. Evaluation and Treatment of Acute Low Back Pain. Am Fam Physician. 2007 Apr 15;75(8):1181-1188.5.Calmbach, W. and Kutchens, M, Evaluation of Patients Presenting with Knee Pain: Part I. History, Physical Examination, Radiographs, and Laboratory Tests. Am Fam Physician. 2003 Sep 1;68(5):907-912.6.Calmbach, W. and Kutchens, M, Evaluation of Patients Presenting with Knee Pain: Part II Differetial Diagnosis. Am Fam Physician. 2003 Sep 1;68(5):917-922.7.Stephens, M. et al. Musculoskeletal Injections: A Review of the Evidence. Am Fam Physician. 2008 Oct 15;78(8):971-976.

References:

1.Johnson, G. et al. Treatment of Lateral Epicondylitis. Am Fam Physician. 2007 Sep 15;76(6):843-848.2.Woodward, T. The Painful Shoulder Part I. Clinical Evaluation. Am Fam Physician. 2000 May 15;61(10):3079-3088.3.Woodward, T. The Painful Shoulder: Part II. Acute and Chronic Disorders. Am Fam Physician. 2000 Jun 1;61(11):3291-3300.4.Leggit, J. et al. Acute Finger Injuries: Part I. Tendons and Ligaments. Am Fam Physician. 2006 Mar 1;73(5):810-816.5.Leggit, J. et al. Acute Finger Injuries: Part II. Fractures, Dislocations, and Thumb Injuries. Am Fam Physician. 2006 Mar 1;73(5):827-834.6.Forman, T. et al. A Clinical Approach to Diagnosing Wrist Pain. Am Fam Physician. 2005 Nov 1;72(9):1753-1758.7.Taylor, D. et al. A Systematic Review of the Use of Platelet-Rich Plasma in Sports Medicine as a New Treatment for Tendon and Ligament Injuries. Clinical Journal of Sport Medicine: July 2011 - Volume 21 - Issue 4 - pp 344-352.



Common Musculoskeletal Injuries with an Emphasis on the Physical Exam

William Vollmar, MD, CAQSMPrimary Care Sports Medicine

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Common Musculoskeletal Injuries with an Emphasis on the