7/23/2015

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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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