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7/23/2015
1
Office Orthopaedics: MSK or not MSK? That is the Question
Anthony Luke MD, MPH
Essentials of Primary Care 2015
UCSF OrthopedicsPrimary Care Sports Medicine
Disclosures
• Founder, RunSafe™
• Founder & CEO, SportZPeak Inc.
• Sanofi, Investigator initiated grant
• Intel, Industry grant
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Outline
• Approach to MSK complaints
• How do you use symptoms?
• Discussion = Differential Diagnosis & Approach
• Neck
• Nerve
• Scapular dyskinesis
• Vascular -TOS
• Mobility
History: Demographics
Who?
• Age
• Occupation
• Recreation / Sports
• Hand Dominance
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History is Key
• Numbness
• Fever
Instability Dysfunction
Pain
History is Key
When?
• Acute vs Chronic (2 weeks? 6 weeks?)
Where?
• Think anatomy
How?
• Mechanism of injury
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Red Flag Symptoms
• Severe disability
• Numbness and tingling
• Night pain
• Constitutional symptoms (fever, wt loss)
• Swelling with no injury
• Systemic illness
• Multiple joint injury
Case 1
• Who? 15 year old male football player
• When? Last season
• What? Had a right arm “stinger” last year after getting hit; sometimes gets some neck pain with contact but not everytime
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Spurling’s test - Cervical radiculopathy
Sens = 64%Spec = 95%PPV = 58%NPV = 96%
Burners / Stingers
• Axial loading, hyperflexion, hyperextension or sudden rotation can cause injury to cervical spine and surrounding soft tissues
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C e r v i c a l S p i n e
• Atlantoaxial instability
• Multiple level fusion
• Significant cervical stenosis
• Consider risk of spinal cord injury during sports participation
• Select low risk sport
• Discuss with specialistTorg Ratio = y/z = 0.8
Posture
• Lines: ear lobe-acromion-iliac crest
• Lordosis, kyphosis
• Pelvic inclination -ASIS lower than PSIS
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LOOK“SEADS”
• Swelling
• Erythema
• Atrophy
• Deformity
• Surgical Scars
Suprascapular Nerve
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Ulnar nerve – Cubital tunnel syndrome
• Elbow Flexion test
• Tinel sign
• Ulnar nerve subluxation
TIPS Peripheral Neuropathy
• Look for occult onset of pain, weakness, numbness
• Might follow acute trauma
• Think compression or traction
• Look for specific muscle atrophy
• Check for dermatomal numbness or focal weakness
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Case 2
• Who? 48 year old female, looks exhausted
• What? Has had severe 12/10 pain
• When? 2 nights
• Where? Diffuse shoulder pain, will NOT let you move it
• How? No trauma, woke with the pain
WHAT DO YOU DO?
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Impingement/Rotator Cuff Tears
Impingement
Partial Cuff Tear
Full Thickness Tear
Calcific tendinosis
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Calcific Tendinosis
• Severe acute pain in shoulder
• Patient unwilling to move shoulder
• X-ray may show calcium deposits
• Ultrasound more sensitive than MRI
• Can consider subacromial steroid injection
Tendon Pain
• May be present at the start of an activity then “warm-up”
• Sore when the muscle is used
• May occur in “compensation” for other structural problems near by
• Check for underlying spondyloarthropathy: Psoriasis, GI symptoms, STD
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3 Basic P/E findings for tendinopathy
1. Tenderness on direct palpation
2. Reproduction of pain with resisted contraction (eccentric loading)
3. Reproduction of pain with passive stretch
Elbow Tendinopathies
Lateral epicondylosis
• Tender lateral epicondyle
• Resisted third digit extension
• Resisted wrist extension
Medial epicondylosis
• Resisted pronation/wrist flexion
Distal biceps
• Resisted supination
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Bone Pain
• Constant
• Sharp
• Greater load = greater pain (i.e. weightbearing)
• May have pressure features
Greater tuberosity fractures
• Indications for Greater tuberosity fractures > 2 mm
• Isolated axillary nerve injury
• Subacromial impingement (common)- due to displacement of fragment or even scar tissue formation, especially extension and external rotation
Green A, Norris TR. Skeletal Trauma: Basic science, management, and reconstruction (3rd edition). Elsevier Science, 2003, p. 1558.
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Other problems in the area
• Acromioclavicular joint osteoarthritis
• Sternoclavicular joint injuries
• Osteolysis of the distal clavicle
Take Home Points - Symptoms
• Ask More About Function (as well as Pain)
• How does this problem affect your day to day function?
• What can’t you do that makes this a problem?
• If you could take this problem away immediately (magic), how would your life be?
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Case 3
• Who? 40 year old male with R anterior shoulder and scapular pain and winging scapular dyskinesis
• What? Pain with overhead activities and sleeping
• When? He has had pain progressively worsening over 6 months
• How? Had an injury skiing around 6 months ago but only vague history; Works as auto mechanic
• Where? Shoulder radiating to lateral arm
Winging• Long Thoracic
Nerve– Serratus Anterior
• Less common– Spinal Accessory
Nerve (trapezius)
– Dorsal Scapular Nerve (rhomboids)
• Scapular Dyskinesis – MOST COMMON
– Pain may alter mechanics or vice versa
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Scapular – Dynamic Stabilizers
• Levator scapulae
• Trapezius muscle
• Serratus anterior
• Rhomboids
• Latissimus dorsi
• Pectoralis minor
Scapulohumeral Rhythm
• Ratio of Scapular to Humeral movement
• Occurs via coupled movement of the scapular muscles
• Through elevation, scapula upwardly rotates, posteriorly tilts and externally rotates
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Observation
• Rest
• Range of Motion
• Function!!
• Asymmetry
• Four point palpation
MOVE
Flexion, External rotation, and Internal rotation
Painful Arc 60 - 120°
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Rotator Cuff Tear vsImpingement?• Difficulty lifting
– Pain vs weakness ?
• Drop arm sign
• Fail conservative Tx
• Tears uncommon < 40 y.o.
Sens = 10 %PPV = 100 %
Bryant et al. J Shoulder Elbow Surg, 2002; 11: 219-224.
Take Home Points
• Scapular dyskinesis is common as a pattern of dysfunction, more than neurogenic winging
• Use impingement signs to rule in shoulder problems
• Rotator cuff strength tests help diagnose shoulder issues
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Case 4
• Who? 38 year old female secretary
• What? Neck pain with radiating pain to the right elbow and right arm numbness and some ulnar nerve symptoms
• When? She has had worsening pain over 3 months
• How? Talking on her phone is painful, sleeping is sore
• Where? Numbness to 4th and 5th fingers
Case 4• LOOK 5’ 5”, 130
pounds– Rolled forward
shoulder posture, head forward posture
• FEEL– Tender over cervical
spine near R C7 facet joint
• MOVE– C-spine - ROM 45°
flexion 40° extension painful; right rotation 50° left rotation 70°
– ROM shoulder 180 flexion bilaterally
• SPECIAL TESTS– Rotator cuff strength
5/5
– Neer and Hawkin’snegative test
– Spurling’s test positive
– Roos’ test positive, Adson’s positive on right
– Elbow flexion test positive
– Tinel’s sign negative
– U/E 5/5, Reflexes normal, sensation intact to light touch
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Sudden Death RoundThoracic Outlet syndrome
• Repetitive upper extremity use– shoulder, elbow, hand
• assembly line
• computer with mouse and phone
• Poor posture
• Reaching
• Stress
• Apical breathing
Thoracic Outlet Syndrome tests• Possible
compression of the subclavian artery between the scalenes and any cervical rib
• Compression of neurovascular symptoms in the upper extremity by the pectoralisminor
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Adson’s Test• Seated patient extends and
turns head toward the tested shoulder
• Shoulder is abducted and extended.
• Subject inhales while the examiner palpates the ipsilateral radial pulse.
• Positive findings: Diminution or elimination of the pulse and reproduction of the paresthesias
• Studies show poor to good specificity and good sensitivity.
Wright’s Hyperabduction Test
• With patient seated, the clinician hyperabducts and externally rotates the patient’s arm while assessing the ipsilateral radial pulse
• Positive findings: Diminution or elimination of the radial pulse and reproduction of the paresthesias
• No studies have examined validity
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Roos Stress Test
• Patient holds shoulders in abduction and external rotation at 90 degrees with elbows flexed at 90 degrees and repeatedly open and close their hands for three minutes.
• Positive findings: Reproduction of their symptoms or a sensation of heaviness and fatigue.
• No studies have examined validity of the Roos stress test as it pertains to thoracic outlet syndrome.
Case 4
• Who? 38 year old female secretary
• What? Neck pain with radiating pain to the right elbow and right arm numbness and some ulnar nerve symptoms
• When? She has had worsening pain over 3 months
• How? Talking on her phone is painful, sleeping is sore
• Where? Numbness to 4th and 5th fingers
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What is “Normal” Flexibility?
• Flexibility is the range of motion available at a joint or series of joints
• Hypermobility vs. Hypomobility
• Spectrum like hypertension
Modified Marshall Test
Micheli Score
• Look at passive thumb abduction of the right hand
• Grade 1 = 0°
• Grade 2 = 45°
• Grade 3 = 90°
• Grade 4 = 135°
• Grade 5 = thumb touches forearm
• Can use + or – for in between grades
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Common Pictures
Hyperlaxity
• OVERUSE & Postural problems
• Associations with subluxation of the hip, patella, shoulder, and proximal cervical spine, osteoarthritis, chondrocalcinosis,
• Bad sprains
Tight
• Patellofemoralsyndrome, hamstring and quad strains
• Tendinopathies
• Osgood-Schlatter’sdisease, Sever’sdisease and peripelvicapophyseal avulsion fractures
Multidirectional instability
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Stability Tests
Sulcus sign (MDI)No Sens / Spec Data
Subtalar Tilt test
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Posture
• Lines: ear lobe-acromion-iliac crest
• Lordosis, kyphosis
• Pelvic inclination - ASIS lower than PSIS
Rehab, rehab, rehab
Strengthening
• Core stability
• Postural exercises
– Upper Back
• Proprioception exercises
• Endurance / conditioning
• Ergonomic assessment at work
? Chronic pain
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Take Home Points
• Always think about Posture
• Check for flexibility
• Consider hypermobility syndrome
• Use physical therapy
You may not have seen it, but it has seen you.
• Problem with Look, Feel, Move ?
• Worry especially if problems greater than 6 months
• No relief or worse with physiotherapy
• Internal derangement symptoms
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