SHOULDER Highly mobile, so less stable. Abnormalities cloaked within extensive musculature, dx can be difficult Bony abnormalities less common than li

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Victor Jones
5 years ago
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1 SPORTS MEDICINE CASES A quick tour of some local joints Featuring gco common o and unusual problems

2 SHOULDER Highly mobile, so less stable. Abnormalities cloaked within extensive musculature, dx can be difficult Bony abnormalities less common than ligaments/tendons/cartilage Underlying individual anatomy often contributes to pathology

3 A-C separations SHOULDER A-C JT Repetitive micro-trauma Developmental problems DJD

4 Pain, A-C joint and distal clavicle

5 DISTAL CLAVICLE OSTEOLYSIS Can follow single injury, more commonly repetitive microtrauma Often from weight training- bench press Pain in AC, tender, cross body abduction Subchondral microfractures Rx: ice, NSAIDs, rest/altered exercise Refractory cases resection [ Mumford ]

6 16 y.o. athlete w pain near AC jt

7 16 y.o. athlete w pain near AC jt

8 OS ACROMIALE 8 % of population, often bilateral, most asymptomatic May fuse by age 18, as late as 25 Stress may cause pain, prevent fusion Pain with overhead activity, tender Pain from instability / impingement Rx : NSAIDs, massage, PT; rx injx at site, and into subacromial space; 6 months. Surgical removal /fusion / relief of impingement

9 IMPINGEMENT Common; assoc with overhead lifting, swimming, tennis, throwing Anatomy/activity Painful, often leading to rotator cuff injury Physical exam important, details best seen with MRI

10 IMPINGEMENT

11 ACROMIAL SHAPES

12 IMPINGEMENT

13 IMPINGEMENT

14 CORACOHUMERAL IMP ANTERIOR IMP

15 IMPINGEMENT RX Stretching exercises, avoid overhead activities Weight lifters esp may have imbalanced musculature include RC strengthen to re-balance NSAIDs, or if resistant Rx injx subacromial bursa and/or intra-articular articular Platelet rich plasma gel injx partial tears, tendinosis, adhesive capsulitis High grade tears - surgery

16 ? Early middle aged male, left handed, fell skiing, pain eventually improved Still has pain with overhead motions, some feeling of instability Recently threw football and now has severe pain, increased at night, clicking Possible labral and/or RC tear

17 SUPERIOR LABRUM

18 SUPERIOR LABRUM

19 SUPERIOR LABRUM

20 INFERIOR LABRUM Usually occurs with dislocation/sublux. May have injury to bony glenoid Capsule is often stretched and stripped

21 INFERIOR LABRUM

22 INFERIOR LABRUM

23 UNKNOWN

24 AVASCULAR NECROSIS

25 AVASCULAR NECROSIS

26 ELBOW Repetitive flexion/extension of elbow/wrist often lead to specific syndromes Throwing, racquet sports esp Tendinopathies Osseous injuries Nerve injuries

27 TENNIS ELBOW LATERAL EPICONDYLITIS Majority don t play tennis- any repetitive gripping activity esp w thumb and 2 nd and 3 rd fingers The epicondylitis is 2ndary finding

28 TENNIS ELBOW Lateral epicondyle is common extensor tendon origin Tendinopathy; partial tears; can be complete Clinical: tenderness, pain when gripping, twisting, etc

30 TENNIS ELBOW RX Acute ice, NSAIDs, elbow strap, ROM exercises, PT strengthen/stretch Non responsive: Injx with corticosteroids has been recommended but recently AAOS now says PRP as first line Rx Easily done under US or flouro, not painful Insurance coverage may have to be negotiated

31 LATERAL ELBOW PAIN 11 YEAR OLD GYMNAST

32 LATERAL ELBOW PAIN

33 OSTEOCHONDRITIS DESSICAN [ OCD] OCD occurs in several joints, often in young patients- pain, catching, locking Microtrauma in areas of lesser blood supply;? Genetic factors Rx: MRI to check cartilage integrity, fragmentation; rest!!; ROM exercise If cartilage/bone displaced, disrupted usually require surgical intervention

34 ? 20 y.o. male, recent onset of wrist pain No trauma, plays golf and tennis

35 ? Conservative care, no improvement

36 ?

37 KIENBOCK S DISEASE AVN OF LUNATE Dominant wrist males age Negative ulnar variance often Sports: golf, tennis, martial arts Disruption of delicate blood supply Immobilize in splint or cast for 3 weeks Monitor q 4-5 weeks even if sx resolve

38 ? 50 y.o. male with increasing right hip pain, clicking, mild feeling of instability Has been somewhat athletic, usual injuries

39 ?

40 ?

41 FEMOROACETABULAR IMPINGEMENT [ FAI ] Xray findings suggest femoroacetabular impingement Impingement test + : bring knee up toward chest and rotate it inward toward opposite shoulder

42 FAI

43 FAI

44 FAI

45 FAI TREATMENT Usual early rx of NSAIDs, change activity Football, basketball, hockey etc prone to exacerbate Non-impact sports swimming, cycling better Most conventional nonsurgical rx has had limited success Corticosteroid injx short term relief Your literature has good suggestions, may well work better Surgical rx includes remodeling of the underlying pathologic anatomy, debridement of labrum

46 FAI RX

47 LABRAL TEAR Often seen in young athletes Pain on weight-bearing, flexion and internal rotation; pain persistent painful audible clicking, transient locking, giving way of the hip Runners, jumpers, cross country ski, hockey players, football Very high incidence in professional athletes-2/3s football, 1/3 hockey- many WITHOUT SX!

48 LABRAL TEAR Dx MR arthro ( 91% vs 36%)

49 OTHER HIP PAIN IN ATHLETES Several others common in athletes Some very important to detect early Can preserve athletic career and the hip of course!

50 OTHER HIP PAIN IN ATHLETES Avascular necrosis [AVN] Injury/repetitive; sickle cell; meds inc. steroids; autoimmune; diabetes,etc etc

51 OTHER HIP PAIN IN ATHLETES: AVN Often bilateral; may heal if rx early MRI very sensitive; geographic lesion

52 CORTICAL FRX OSTEOCHONDRAL FRX HIP Jumpers, soccer, basketball, hockey, ski Xray often negative

53 ILIOTIBIAL BAND SYN. [ITBS ] Snapping and pain, lateral aspect of hip at greater trochanter ITB stabilizer of hip and knee Runners, pitchers, kickers, cyclists RX: ice, massage, release rx Occasionally benefits from injx, esp if trochanteric bursa inflamed

54 ITBS

55 ITBS

56 Pain in heel patient has localized pain but xrays are negative Stress fractures are often normal on plain xray Bone scan will be positive but so is MRI and MRI evaluates for other possibilities in the cases where the localized pain is NOT from stress fracture CT scan is very sensitive for usual fractures but very insensitive for stress fractures

57 Stress fracture of heel

58 Stress fracture of heel

59 ? Young female with right hip pain, presents to urgent care on 12/24

60 ? Area of pain

61 ?

62 ?

63 ?

64 ;) Ursus gummiensis

Review shoulder anatomy Review the physical exam of the shoulder Discuss some common causes of acute shoulder pain Discuss some common causes of

Review shoulder anatomy Review the physical exam of the shoulder Discuss some common causes of acute shoulder pain Discuss some common causes of chronic shoulder pain Review with some case questions Bones: