Rance McClain, DO, FACOFP, FAOASM Associate Dean, Clinical Sciences Professor, Clinical Sciences William Carey University College of Osteopathic

Transcription

1 Rance McClain, DO, FACOFP, FAOASM Associate Dean, Clinical Sciences Professor, Clinical Sciences William Carey University College of Osteopathic Medicine

2 Identify common orthopedic conditions presenting to primary care offices Apply knowledge of the mechanism of injury for common orthopedic conditions Formulate and conduct a treatment plan to successfully care for common orthopedic conditions

3 10-28% of all primary care visits are orthopedic in nature Over half of primary care physicians surveyed felt comfortable dealing with orthopedic conditions 56% of respondents said medical school was their only formal Musculoskeletal training

4 1998 study 25 question MSK quiz given to 85 incoming residents (all specialties) at the University of Pennsylvania 82% failure rate

5 Commonly associated with physical and emotional stress if trauma is absent Pain and stiffness in neck and upper back May limit ROM and develop trigger points Ipsilateral rotation and contralateral sidebending X-rays, MRI and EMG are usually negative

6 Goal of treatment is to reduce spasm and restore ROM Educate of proper ergonomics Stress reduction Ice or heat packs depending on acute/chronic Meds: NSAIDS and/or muscle relaxants at night Treatments: OMT, tissue massage, ultrasound Trigger point injections or TENS unit for persistent cases

7 Inflammation of supraspinatus and infraspinatus muscles Repetitive overhead work Shoulder pain with overhead activity or with lifting arm

8 Tenderness between greater tubercle of the humerus and the acromion process Bursitis leads to more diffuse lateral pain Provocative testing Hawkins and Neer testing Empty can and drop arm to assess possible tear Plain X-rays Concern if <1cm space between humeral head and undersurface of the acromion process MRI with arthrogram if tendon rupture is suspected

9 Treatment Relative rest from overhead activity Ice and NSAIDs to reduce inflammation Scapular stabilization exercises Subacromial decompression surgery referral Subacromial injection of anesthetic and corticosteroid if experienced

10 Anterior Approach 1-1 ½ needle 21g: 5 ml Seated slight external rotation Horizontal and slightly lateral below acromion process, lateral to tip of the coracoid process, medial to the head of the humerus

11 Posterior Approach 1 ½ -2 needle 21g: 5 ml Seated, neutral or slight internal rotation Posterior tip of the acromion process, medial to head of the humerus aim for the coracoid process

12 Lateral (Subacromial) Approach 1 ½ needle 23g: 5 ml Seated, neutral, distraction (optional) ½ below tip of acromion, angle slightly upwards (posteriorly) At 1 in bursa, deeper to get subacromial space

13 Lateral (tennis) and medial (golf) epicondylitis Associated with activities usually involving tight gripping and repetitive impact Pain centered around the affected epicondyle with weakness of the forearm muscles Resisted extension or flexion of the wrist Diagnosis based on history and location of tenderness

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15 Treatment Limitations on lifting, hammering, wrist motion and fine hand work Ice MASSAGE OMT aimed to release forearm muscle tension Aggressive home stretching exercises Epicondyle splinting with activity NSAIDS may not be of benefit due to the relative avascular tendon site Corticosteroid injection (bath the tendon)

16 Golfer s elbow (flexor tendonitis) 5/8 needle 25g: 1ml Seated, elbow flexed, shoulder internally rotated with dorsum of hand resting on buttock Anterior facet on medial epicondyle, directly over tender spots in fan shape

17 Tennis elbow (extensor tendonitis) 5/8 needle 25g: 1ml Seated, elbow flexed, volar surface of hand resting on flat surface Facet on lateral epicondyle, directly over tender spots in fan shape

18 Superficial bursa susceptible to external pressure and repetitive trauma Is somewhat more susceptible to infection and gout than other bursal sacs Swelling, redness and heat can all occur at the posterior aspect of the elbow overlying the olecranon process Range of motion is rarely affected

19 Treatment of choice is aspiration, drainage and lab analysis Gram stain & culture, uric acid crystals and hematocrit of aspirated fluid Antibiotics if S. aureus infection Compression dressing for hours Avoid direct pressure Education: 10-20% have persistent swelling

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21 Median nerve compression by the transverse carpal ligament at the wrist Symptoms: Numbness of the thumb, index, middle and lateral ring finger Weakness of grip strength Pain through the forearm and wrist

22 Exam: Sensory loss Loss of thumb opposition Phalen and Tinel signs Pronator teres pressure if above are negative Nerve conduction velocity testing

23 Treatment goal = reduce compression of the nerve Reduce repetitive stress Antivibration gloves Address ergonomics in daily activities Wrist splint OMT: forearm flexor release, carpal bone articulation, transverse carpal ligament release Surgical referral if motor symptoms have developed

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25 Inflammation of the flexor tendons as they cross the MCP joint Associated with repetitive gripping or pressure in the palm of the hand Nodules or swelling causes the tendon to catch as it passes under the A1 pulley Symptoms Pain or loss of motion with flexion/extension of finger Clicking or locking in active flexion

26 Examination Localized tenderness to palpation at distal palm Pain aggravation with extension of affected finger Clicking or locking of motion is possible Nodule may be palpable along the flexor tendon

27 Treatment Restrict gripping or padded glove with activity Splint or buddy tape to remove stress Ice massage Corticosteroid injection at A1 pulley Can be repeated in 6 weeks if symptoms not 50% better OMT = Myofascial release is the mainstay of osteopathic treatment, home stretches Surgery if failure of above measures

28 25 gauge 5/8 needle ½-¾ total anesthetic and corticosteroid volume Inject at 30⁰ angle Have patient flex/extend the finger prior to injecting

29 Irritation and spasm of the supporting musculature of the lumbar spine Poor posture, scoliosis, spondylolisthesis, osteoarthritis, etc. Strain occurs as a protective mechanism Symptoms Localized lower back pain and stiffness

30 Examination Paraspinal muscle tension and spasm Loss of lumbar lordotic curvature Decreased lumbosacral flexion and lateral bending Usually a negative neurological examination Specialized testing Lumbar x-rays with oblique views for spondy

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32 Treatment Avoid stressful movement Teach proper ergonomics and mechanics/lifting Lumbar support for the chair and vehicle Gentle stretching initially Rehab and strengthening after acute phase Gradual return to activity as tolerated

33 Treatment Modalities Ice initially, then alternate heat and ice Therapeutic ultrasound for deep heating TENS unit OMT Soft Tissue techniques initially Progress to gentle articulatory in subacute phase Muscle energy and HVLA if progresses to chronic

34 Tension in the piriformis muscle causing pressure on the sciatic nerve Usual anatomy is sciatic nerve exits under muscle belly Rarely the sciatic nerve runs through two heads Symptoms Tender point in mid belly of piriformis muscle Paresthesia in distribution of sciatic nerve

35 Examination Tenderpoint palpation Limit to internal rotation of the femur Treatment OMT: Myofascial release and counterstrain to piriformis muscle Aggressive home stretching and range of motion

36 Poor tracking of the patella in the femoral groove Can progress to chronic damage of the cartilage on the undersurface of the patella (chondromalacia) Symptoms Knee pain in the front of the knee, especially with unlevel surface of going up and down stairs Crepitance Occasional swelling Knee gives out on activity

37 Examination Crepitance with passive subluxation in the femoral groove Apprehension sign Q angle evaluation Ballotable patella X-rays Sunrise view of the patella

38 Treatment Ice if there is an effusion Avoiding stressful activity on the knee joint Vastus medialis strengthening NSAID therapy for 3-4 weeks at onset of rehab Patellar restraining brace with activity Orthopedic referral if Q angle > 20⁰

39 Most common ligamentous injury Anterior talofibular ligament damage Inversion ankle injury is usual mechanism Symptoms Pain, swelling and ecchymosis Instability, especially with recurrent injury

40 Examination Tenderness anterior and inferior to the lateral malleolus Ottawa Ankle Rules (and Ottawa Foot Rules) Guidelines for assessing need to order X-rays for ankle (and foot) injuries

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42 Treatment Allow soft tissue injury to heal Limit activity but encourage early mobilization Allows healing to occur along lines of stress Provide support from inversion/eversion while allowing flexion and extension Gradual return to activity OMT: Lymphatics early, then articulatory treatments as the healing progresses

43 Inflammation at the origin of the plantar fascia Associated with pes planus, pes cavus, pronation and shortened achilles tendon Obesity, poorly fitted shoes and prolonged standing on hard surfaces Symptoms Pain at anterior medial aspect of calcaneous

44 Examination Pain at insertion of plantar fascia Full structural assessment of foot and ankle Make sure to assess patient barefoot and standing X-rays Only indicated if suspect calcaneal stress fracture Commonly note calcaneal calcification (heel spur)

45 Treatment Correct for underlying biomechanical issues Limit activity Aggressive stretching NSAID therapy Occasional orthotics Rarely night splint Surgery

46 Nonoperative fractures Stress fractures Nondisplaced extra-articular fractures Small avulsion fractures *Nondisplaced, single fragment, intra-articular fractures Still get orthopedic assessment as second opinion on stability of the fracture

47 Describing fracture to orthopedist Location Proximal, middle, distal, intra-articular Displaced/non-displaced 25%, 50%, 75%, complete Do NOT use terms dislocated or subluxed as these could confuse the surgeon that a fracture/dislocation occurred Fracture pattern Transverse, oblique, spiral, impacted, comminuted Angulation Describe the apex of the angulation (ie: dorsal angulation) Unusual features Open vs. closed, associated joint injury, neurovascular injury

48 Questions?