7/5/2009. Tendonitis (tendonosis) Sprains and ligament tears Nerve impingemnts

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Patricia Wilkerson
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1 Common Clinical Adult Orthopedic Problems General Processes Tendonitis (tendonosis) Sprains and ligament tears Nerve impingemnts Tendonitis Over use phenomenon Natural reaction to stress increased fluid and lubrication Increased blood supply and inflammatory cells prostaglandin mediated inflammation Rest, Ice, Gentle active motions and some mild stretching OT/PT modalities NSAIDS and activity modifications Sprains, Strains Soft tissue injury heals with scar and remodeling R I C E and then early functional mobilization NSAIDS for symptomatic treatment Early return to non stressed ROM Collagen takes 6-12 weeks to regain strength and remodeling up to one year AC JOINT Shoulder SUBACROMIAL REGION GLENOHUMERAL PROBLEMS AC JOINT PROBLEMS AC joint arthrosis - young as well as old AC joint separation- traumatic ,2,3rd degree 1

AC Joint Arthrosis Weight lifter traumatic presents as bursitis

DIAGNOSIS AND TREATMENT NSAIDS MRI to R/O other associated R/C

Separation traumatic in origin 1-2-3 degree of separation Not a

of ligaments and distal clavicular resection Impingement and

shoulder Night pain Cannot reach overhead Cannot throw without

2 AC Joint Arthrosis Weight lifter traumatic presents as bursitis mass effect over shoulder impinges on rotator cuff INJECTION FOR DIAGNOSIS AND TREATMENT NSAIDS MRI to R/O other associated R/C pathology Surgical excision of the distal clavicle AC joint Separation traumatic in origin degree of separation Not a functional problem usually No hurry on definitive treatment Pain meds and symptomatic tx. initially Careful of skin overlying area May need surgical repair of ligaments and distal clavicular resection Impingement and Bursitis Compression of the bursa and cuff Weak or unstable shoulder Night pain Cannot reach overhead Cannot throw without pain Impingement and Bursitis Positive impingement sign MRI to look for rotator cuff pathology X-rays for spur or arthritis 2

Gleno-Humeral Instability Usually anterior dislocation or subluxation with labral pathology hl Usually

Dislocated Shoulder Anterior most common Reduce under some anesthesia if required Abduction and traction

recurrence MRI to look for other pathology Adhesive Capsulitis Usually female,40 s PAIN, Restriction of

3 NSAIDS, heat, ROM Physical tx. strengthen rotator cuff Steroid injection into bursa Arthroscopic bursectomy and removal of impingement Gleno-Humeral Instability Usually anterior dislocation or subluxation with labral pathology hl Usually traumatic Arm externally rotated and abducted Tears ant. capsule etc. Dislocated Shoulder Anterior most common Reduce under some anesthesia if required Abduction and traction with gentle terminal internal rotation Kocher maneuver Dependent on age older patient = decreased chance of recurrence MRI to look for other pathology Adhesive Capsulitis Usually female,40 s PAIN, Restriction of motion over time Can hide underlying other pathology such as tumor or shoulder disease PAIN -PAIN -PAIN Physical therapy stellate blocks sometimes Closed /arthroscopic manipulation Investigation for underlying disease (lung and breast CA) 3

All types and all causes May present as impingement or bursitis Need MRI/arthrogram to evaluate

Discontinuity of the supraspinatus Rotator Cuff Tears Cubital Tunnel Syndrome Compression of

hyperflexion Splint, elbow pad, activity evaluation NSAIDS Injection EMG/NCV s Release sub

the elbow usually ECRB/L Tennis elbow, carpenters elbow etc Can be incapacitating because of

4 All types and all causes May present as impingement or bursitis Need MRI/arthrogram to evaluate Physical exam pain on resisted RC muscles Rotator Cuff Tears Cephalad humeral head Discontinuity of the supraspinatus Rotator Cuff Tears Cubital Tunnel Syndrome Compression of the ulnar nerve at the elbow Tingling in ulnar nerve distribution Happens at night and during hyperflexion Splint, elbow pad, activity evaluation NSAIDS Injection EMG/NCV s Release sub muscular, sub fascial, epicondylectomy Lateral Epicondylits Tendonitis of the extensor wad at the elbow usually ECRB/L Tennis elbow, carpenters elbow etc Can be incapacitating because of the pain Counterforce brace Ice, NSAIDS, ultrasound Injection, Iontophoresis STRETCH!!!!!!!! Counseling SURGERY IS LAST! 4

Removal of damaged tendon and repair Venting the

Surgical Repair De Quervains disease Radial long

Finklestein s test ICE NSAIDS-- SPLINTAGE

compression and loss of blood supply Splints

Traumatic, arthritic Gold Standard Needs workup

Dependable results with the right group of

Arthroplasty Pain at base of thumb Goes along

5 Removal of damaged tendon and repair Venting the EVIL HUMORS! Surgical Repair De Quervains disease Radial long thumb extensors multiple Tendonitis Positive Finklestein s test ICE NSAIDS-- SPLINTAGE Injection Carpal Tunnel Syndrome Nerve compression and loss of blood supply Splints NSAIDS activity evaluation Systemic causes Traumatic, arthritic Gold Standard Needs workup with EMG/NCV's Failure of conservative treatment Dependable results with the right group of patients Open Release CMC Arthritis CMC Arthroplasty Pain at base of thumb Goes along with other arthritic conditions Positive grind test and positive x rays Female, older NSAIDs, splintage, restriction of activity 5

Scaphoid Fracture Poorly vascularised bone High rates

usually May need ORIF if displaced Operative trends

bands, MP,PIP Involves nerves and vessels Operate

Disease Thumb, ring Stenosing tenosynovitis NSAIDs

Common in Diabetics Trigger Digit Traumatic usually

Can pin closed and can operate to repair if too much

Arthritis and Radiculopathy Facet joint arthrosis

6 Scaphoid Fracture Poorly vascularised bone High rates of nonunion Typical history of neglected trauma Cast usually May need ORIF if displaced Operative trends Cellular change amongst the fibroblasts Contractile bands, MP,PIP Involves nerves and vessels Operate when unable to passively extend PIP joint Dupuytren s Disease Thumb, ring Stenosing tenosynovitis NSAIDs splintage injections Release, open or percutaneous Common in Diabetics Trigger Digit Traumatic usually Needs x-ray Splint for weeks! Can pin closed and can operate to repair if too much articular surface is displaced Mallet Finger Cervical Arthritis and Radiculopathy Facet joint arthrosis Protruding disc material Cx pain with radiculopathy and DTR changes Disc Rupture 6

Pattern of discomfort Epidural Can be radicular

shoulder pathology Relieved by traction or

Collar Physical therapy Injections Surgery OK TO

watching them Fluid field and changing guidelines!

7 Pattern of discomfort Epidural Can be radicular Can be posterior shoulder and masquerade as shoulder pathology Relieved by traction or distraction Not first order of TX Traction NSAIDs Collar Physical therapy Injections Surgery OK TO WATCH DEPENDING ON AGE AND SEVERITY OF CURVE! Risser sign Idiopathic vs. leg length inequality etc Scoliosis Can correct anything!!! Timing is key as well as guidelines for watching them Fluid field and changing guidelines!! Greater Trochanteric Bursa Impinges on Iliotibial band Mimics sciatica Point tender + Ober test Injection test/treatment Hip Bursitis 7

8 Avascular Necrosis Hip and Humerus End bone circulation Stages for treatment Crutches to total joint NSAIDs crutches synovitis Drilling,grafting, replacements Fractured Hip Intertroch, Neck,Subtroch Pelvis sup/inf rami Need ORIF or replacement depending on pattern Metabolic state of patient Hip prostheses Knee arthritis NSAIDS Injections steroid Injections visco- elastic? Hyalgan, Synvisc Bracing for varus knees Valgus and Varus Knees Patello femoral conditions Adolescent Females Valgus knees Q-angle Track laterally 8

9 Torn Meniscus Mechanical symptoms or locked knee MRI Arthroscopic TX Osteochondritis Dissecans Usually growing children Can see in adult as result of AVN Make the knee mechanically sound Grades of OCD Mechanically sound and get it to heal Or remove it Ankle Sprain X-rays intact mortise damage to articular surface Anterior drawer ATFL Air cast elevation get them moving!!! Stretch heel cord SHOEWEAR PROBLEMS Bunions Natural change to the adult foot accelerated by some footwear Shoe wear modification Operate only if painful in bare feet Gout? 9

10 Plantar Fasciitis Stretching Stretch plantar fascia Post tibial nerve calcaneal branch Tarsal tunnel Lithotripsy?? Injection?? Stretch stretch stretch!! Mortons Neuroma Shoe wear mods Inject Metatarsal Pad Surgery Ingrown Toenail Cut nails too short on lateral folds Nail tries to grow thru lateral fold creates infection SOAKS --pushing nail fold away until nail grows out Shoe wear and cleanliness Surgical Solutions Gout Hyperuricemia Podagra usually 1st metatarsal- phalangeal joint VERY TENDER past what you would expect clinically 10

11 Xray and Clinical of Gout Any other conditions that you want us to talk about? 11

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