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Transcript 2-4._Rotator_Cuff

Rotator Cuff Disorders
Glenohumeral Joint
• Shallow (“golf ball sitting on a tee”)
– Inherently unstable (maximizes ROM)
Radiographic Anatomy
GH Joint Stabilizers
• Static stabilizers
– Glenohumeral ligaments, Glenoid labrum and Capsule
• Dynamic stabilizers
– Predominantly Rotator Cuff muscles
– Scapular Stabilizers
• Trapezius, leavator scapulae, serratus anterior,
– Contraction of the long head of the biceps tendon
– Coordinated scapulothoracic rhythm
– Proprioceptive mechanoreceptors in the joint capsule
Static Stabilizers
(glenohumeral ligaments, glenoid labrum and
Glenoid Labrum
Fibrous ring attached to the glenoid articular
surface through a fibrocartilagenous transition
The labrum functions as an anchor point for the
GH ligaments and the biceps tendon
Deepens the glenoid socket and enhances
The superior and antero-superior portions of the
labrum,are less vascular than the posterior and
inferior parts
This decreased vascularity of the superior
labrum may explain the vulnerability of this area
to disruption
GH Capsule
GH Ligaments
• Superior GHL
– Stabilizer of the adducted shoulder.
– limits posterior translation with the
arm in forward flexion, adduction, and
internal rotation,
– Prevents anterosuperior migration of
the humeral head
• Middle GHL
– limit both anterior and posterior
translation of the arm at 45 degrees of
abduction and 45 degrees of external
– provide anterosuperior stability
• Inferior GHL
– The primary restraint to anterior,
posterior, and inferior GH translation
with the arm at 45 to 90 degrees of
abduction and external rotation
Static Stabilizers
(glenohumeral ligaments, glenoid labrum and
Dynamic Stabilizers
• The RTC muscles as well as the scapular
rotators contribute to stabilization by
enhancing the concavity–compression
• Contraction of the long head of the biceps
• Coordinated scapulothoracic rhythm
• Proprioceptive mechanoreceptors in the joint
The Rotator Cuff
Lateral portions of Infraspinatus, Supraspinatus,
Teres minor and Subscapularis muscles and their
conjoint tendon
The main function of the conjoint structure is to
draw the head of the humerus firmly into the
glenoid socket and stabilize it there when the
deltoid muscle contracts and abducts the arm
The musculo tendinous cuff passes beneath the
coracoacromial arch, from which it is separated by
the subacromial bursa
During abduction of the arm the cuff slides
outwards under the arch
The deep surface of the cuff is intimately related
to the joint capsule and the tendon of the long
head of the biceps
Rotator Cuff Disorders
• Supraspinatus impingement syndrome and
• Tears of the rotator cuff
• Acute calcific tendinitis
• Biceps tendinitis and/or rupture
• Rotator cuff pain typically appears over the front
and lateral aspect of the shoulder during
activities with the arm abducted and internally
• It may be present even with the arm at rest
• Tenderness is felt at the anterior edge of the
• Pain and tenderness directly in front along the
delto-pectoral boundary could be associated
with the biceps tendon
• Localized pain over the top of the shoulder is
more likely to be due to acromioclavicular
• Pain at the back along the scapular border may
come from the cervical spine
Supraspinatus Impingement Syndrome and
Tendinitis (leading to cuff tear)
• Painful disorder arises from repetitive
compression or rubbing of the tendons
(mainly supraspinatus) under the
coracoacromial arch
• In the normal shoulder, the
coordinated muscle tension within the
rotator cuff compresses the humeral
head, keeping it centered within the
glenoid fossa
• Any process that interferes with the
rotator cuff's capability to keep the
humeral head centred or that
compromises the normal
coracoacromial arch, including calcium
deposits, thickened bursae, and an
unfused os acromiale, can lead to
impingement of the rotator cuff
• In 1986, Bigliani and Morrison described three
variations of acromial morphology.
• Type I is flat
• type II curved and type III the hooked acromion
• They suggested that the type III variety was most
frequently associated with impingement and
rotator cuff
• The impingement process has
three chronologic stages:
• Stage 1 (Sub-Acute Tendonitis,
Painful Arc Syndrome)
• Stage 2 (Chronic Tendonitis /
Partial Thickness Tear
• Stage 3 (Rotator Cuff
Disruption / Full Thickness
Stage 1 (Sub-Acute Tendonitis, Painful
Arc Syndrome)
• Acute bursitis with
subacromial edema and
• As the irritation
continues, the bursa
loses its capability to
lubricate and protect the
underlying cuff and
tendonitis of the rotator
cuff develops
Patient Presentation
• Insidious pain develops over a period of weeks to months
• The patient's history will usually consist of pain with
overhead activity, reaching, lifting, and throwing.
• They may have a job or recreational activity that involves
repetitive overhead movement (painting, tennis)
• A long day of overhead activity may increase symptoms to
the point where the patient seeks medical attention
• The pain usually occurs over the anterolateral aspect of the
shoulder, and the patient may point to this specific area
• It may radiate down to the deltoid insertion
• Very often the patient may report pain at night,
exacerbated by lying on the involved shoulder or sleeping
with the arm overhead.
Physical Exam
• Careful evaluation of the cervical spine to rule out a neurologic
problem such as a herniated cervical disc that can mimic
shoulder pathology. This is especially true if a patient presents
with bilateral symptoms
• Feel For Supraspinatous tenderness
• Point tenderness is most easily elicited by palpating this spot
with the arm held in extension, thus placing the supraspinatus
tendon in an exposed position anterior to the acromion process
• With the arm held in flexion the tenderness disappears
Impingment Tests
1- Painful Arc test
2- Neer Impingement Sign
3- Hawkin’s Impingement Sign
Individually, neer and hawkins tests have been shown
to be sensitive but not very specific for diagnosing
When combined, these two tests have a negative
predictive value greater than 90%
Painful Arc Test
• On active abduction scapulohumeral rhythm is
disturbed and pain is aggravated as the arm
traverses an arc between 60 and 120 degrees.
• Repeating the movement with the arm in full
external rotation may be much easier for the
patient and relatively painless
• Neer sign: stabilize the patient's scapula and
internally rotate while raising the arm passively in
forward flexion
• This decreases room available in the subacromial
space, thus causing the rotator cuff and overlying
bursae to be compressed under the
coracoacromial arch.
• Hawkins sign the
patient's arm is passively
flexed to 90 degrees.
• The elbow is also bent to
90 degrees and the arm is
forcibly internally rotated
• This brings the greater
tuberosity under the
acromion, compressing
the cuff and bursae
Stage 2 (Chronic Tendonitis / Partial
Thickness Tear
• Subacute tendinitis is
often reversible, settling
down gradually once the
initiating activity is
• If ignored, inflammation
and possible partial
thickness tears of the
rotator cuff
• The patient, usually aged between 40 and 50
• History of recurrent attacks of subacute tendinitis
• The pain settling down with rest or anti-inflammatory
treatment, only to recur when more demanding activities
are resumed
• Pain is worse at night
• The patient cannot lie on the affected side and often finds
it more comfortable to sit up out of bed.
• Pain and slight stiffness of the shoulder may restrict even
simple activities such as hair grooming or dressing.
• Impingement, Neer and Hawkins signs are positive
• In addition there may be signs of bicipital tendinitis:
tenderness along the bicipital groove and crepitus on
moving the biceps tendon
• Small, unsuspected tears are quite often found during
arthroscopy or operation
Stage 3 (Rotator Cuff Disruption / Full
Thickness Tear)
• As the process continues
the wear on the tendon
results in a full thickness
tear stage III
• The tendon of the long
head of biceps, lying
adjacent to the
supraspinatus, also may be
involved and is torn
• Large tears of the cuff eventually
lead to serious disturbance of
shoulder mechanics
• The humeral head migrates
upwards, abutting against the
acromion process, and passive
abduction is severely restricted
• Abnormal movement
predisposes to osteoarthritis of
the gleno-humeral joint
• This progresses to a rapidly
destructive arthropathy
Milwaukee shoulder (named
after the city where it was first
• A full thickness tear may follow a long
period of chronic tendinitis, but
occasionally it occurs spontaneously
after a sprain or jerking injury of the
• There is sudden pain and the patient is
unable to abduct the arm.
• Passive abduction also may, in the early
stages, be limited or prevented by pain
• If the diagnosis is in doubt, pain can be
eliminated by injecting a local
anaesthetic into the subacromial space.
• If active abduction is now possible the
tear must be only partial
• If active abduction remains impossible,
then a complete tear is likely.
Imaging For Impingement
• X-rays are usually normal in the early stages of the cuff
dysfunction, but with chronic tendinitis there may be
erosion, sclerosis or cyst formation at the site of cuff
insertion on the greater tuberosity
• In chronic cases thinning of the acromion process and
upward displacement of the humeral head.
• Osteoarthritis of the acromioclavicular joint is common
• In older patients and in late cases the glenohumeral joint
also may show features of osteoarthritis.
• Magnetic resonance imaging MRI effectively demonstrates
the structures around the shoulder and gives valuable
information (regarding lesions of the glenoid labrum, joint
capsule or surrounding muscle or bone).
• However, it should be remembered that up to a third of
asymptomatic individuals have abnormalities of the rotator
cuff on MRI
• Changes on MRI need to be correlated with the clinical
• Ultrasonography has comparable accuracy
with MRI for identifying and measuring the
size of full thickness and partial thickness
rotator cuff tears
• It has the disadvantage that it cannot identify
the quality of the remaining muscle as well as
• And cannot always be accurate in predicting
the reparability of the tendons.
Treatment of Supraspinatus Impingement
• Uncomplicated impingement syndrome (or tendinitis) is
often self-limiting and symptoms settle down once the
aggravating activity is eliminated
• The majority of patients with impingement syndrome can
be managed conservatively.
• The treatment program consists of physiotherapy, activity
modification, NSAID, and steroid injections into the
subacromial space.
• The majority of patients should have a satisfactory result
and not require surgery.
• The physical therapy program includes soft tissue stretching
and strengthening of the humeral head depressors. These
are the internal and external rotators.
• Strengthening these muscles helps to depress the humeral
head and decrease impingement
• As range of motion increases, pain levels should decrease.
• The scapular stabilizers should also be strengthened. These
include the upper and lower trapezius, serratus anterior,
and rhomboids.
• These muscles contribute to optimal positioning of the
scapula during overhead activities. If these muscles fatigue,
the scapula is no longer able to keep up with the humerus .
The humeral head continues to translate anteriorly and
superiorly worsening impingement symptoms.
• Strengthening of the deltoid muscle is counterproductive
as its action promotes elevation of the humeral head.
• Patients with a Type I acromion had a 91% successful result.
Patients with Types II and III had less success with 68% and
64%, respectively.
Surgical treatment
• The indications for surgical treatment are
essentially clinical;
• The presence of a cuff tear does not
necessarily call for an operation.
• Provided the patient has a useful range of
movement, adequate strength and wellcontrolled pain, non-operative measures are
Indications for surgery
• If symptoms do not subside after 3 months of
conservative treatment, or if they recur
persistently after each period of treatment
• Younger patients
• Large rotator cuff tears
• The operation is subacromial decompression
which consists of:
– excising the coracoacromial ligament,
– undercutting the anterior part of the acromion
– reducing any bony excrescences at the
acromioclavicular joint
– Repairing rotator cuff tear if present
• This can be achieved by open surgery or
Postoperative Management
• Pendulum exercises are started within 2 days after
• This is followed by passive range of motion and activeassisted motion.
• Full active range of motion can usually be achieved by
3 to 4 weeks.
• Light weights and strengthening can begin at 6 weeks.
• The overhead athlete should avoid these sports until at
least 3 months.
• It takes 6 months for complete recovery
Rotator Cuff Disorders
• Supraspinatus impingement syndrome and
• Tears of the rotator cuff
• Acute calcific tendinitis
• Biceps tendinitis and/or rupture
Acute Calcific Tendonitis
• Acute shoulder pain may follow
deposition of calcium
hydroxyapatite crystals, usually in
the ‘critical zone’ of the
supraspinatus tendon slightly
medial to its insertion
• Cause is unknown
Clinical Features
• Affects 30–50 year-olds.
• Aching, sometimes following overuse develops
and increases in severity within hours, rising to an
agonizing pain
• After a few days, pain subsides and the shoulder
gradually returns to normal.
• During the acute stage the arm is held immobile
• The shoulder is usually too tender to permit
palpation or movement
Conservative first (success in 90%)
Subacromial injection of corticosteroids
Extracorporeal shockwave therapy
Needle aspiration and irrigation (acute cases)
Surgical Treatment
• Severe disabling symptoms which have persisted
for more than 6 months and are resistant to
conservative treatment
• Gleno-humeral arthroscopy
• Once the calcium deposit is identified, the
capsule is carefully incised from the bursal side
with a knife in line with fibre orientation of the
• A curette is then used to milk out the toothpastelike calcium deposit.
• A subacromial decompression is also usually
Biceps Tendinitis
• Primary tendinitis involves inflammation of
the tendon within the bicipital groove.
• To be considered primary, no other
pathological findings (such as impingement,
bony abnormalities within the groove, or
biceps subluxation) should be present
• Secondary tendinitis caused by the same
causes of impingement syndrome
• Anterior shoulder pain (particularly in the
region of the bicipital groove) is the hallmark
of biceps tendonitis
• With biceps tendinitis the pain is usually
described as a chronic aching pain, which is
worsened by lifting and overhead activities
• The pain frequently radiates distally to
approximately the mid arm level but rarely
radiates proximally.
• Inciting events include repetitive activities
involving lifting and overhead activities.
• There is such a close association between
subacromial impingement and biceps
tendonitis that the two conditions have closely
overlapping symptoms.
• They can be very difficult to distinguish
Physical Findings
• The hallmark of biceps tendon related pathology is
point tenderness in the bicipital groove
• The bicipital groove is three inches
the acromion with the arm
in 10 degrees of internal rotation
• As the arm is internally and
externally rotated, the pain should
move with the arm
• This is distinct from subacromial
bursitis where the pain location remains relatively
constant despite the position of the arm
Provocative Tests
Speed's test
With the elbow in extension, the patient flexes the
shoulder against resistance from the examiner. Pain in
the bicipital groove is considered positive
Yergason test —The patient attempts to supinate the
wrist against resistance (with the elbow flexed at the
side). Pain in the bicipital groove is considered
• Rest, ice, and NSAID
• As symptoms improve, range of motion
exercises and strengthening can be added
• Subacromial steroid injections or bicipital
sheath steroid injections may also be utilized
• If conservative fails, surgery
– Debridement of the LHB,
– Biceps tenotomy (for elderly)
– or biceps tenodesis
Rupture of LHB
• The patient is usually aged over 50
• While lifting he or she feels
something snap in the shoulder
and the upper arm becomes
painful and bruised.
• Ask the patient to flex the elbow:
the detached belly of the biceps
forms a prominent lump in the
lower part of the arm.
• Isolated tears in elderly patients need no
• If the rupture is part of a rotator cuff lesion or
if the patient is young and active
– This is an indication for anterior acromioplasty; at
the same time the distal tendon stump can be
sutured to the bicipital groove (biceps tenodesis
– Postoperatively the arm is splinted with the elbow
flexed for 4 weeks.
Distal Biceps Rupture
• 45 years old
• Feels sudden pain and weakness
at the front of the elbow after
strenuous effort
• Normally the biceps tendon stands
out as a taut cord across the
elbow crease
• Loss of supination power with the
elbow flexed (negating supinator
• MRI helps to confirm the diagnosis
• Surgery not always necessary
• Some manage with slightly
reduced elbow flexion: in
time, the other elbow flexors
will compensate
(brachioradialis, brachialis)
• There will be a very obvious
cosmetic defect and greatly
reduced power of supination
• The best results are achieved
by operation within 2 weeks,
before the tendon retracts
and the interosseous tunnel
becomes occluded.
Adhesive Capsulitis (Frozen Shoulder)
• Progressive pain and stiffness of the
shoulder which usually resolves
spontaneously after about 18 months
• Due to adhesions of the capsule of GH joint
• Cause remains unknown
• Associated with
Dupuytren’s disease
It occasionally appears after
recovery from neurosurgery
Clinical features
• The patient aged 40–60, has 3 stages:
• Stage 1 Pain (0-6 months):
– May give a history of trauma, often trivial, followed by
aching in the arm and shoulder
– Pain gradually increases in severity and often prevents
sleeping on the affected side.
• Stage 2 Freezing (6-12 months):
– Pain begins to subside but as it does so stiffness
becomes an increasing problem
• Stage 3 Thawing (12-18 months):
– Gradually movement is regained, but it may not return
to normal and some pain may persist
• Apart from slight wasting, the shoulder looks quite
• The cardinal feature is lack of active and passive
movement in all directions.
• X-rays are normal
Differential Diagnosis
• Septic Arthritis
• Post traumatic stiffness
• Reflex sympathetic dystrophy
– Shoulder pain and stiffness may follow myocardial
infarction or a stroke.
– The features are similar to those of a frozen shoulder
– In severe cases the whole upper limb is involved, with
trophic and vasomotor changes in the hand (the
‘shoulder–hand syndrome’).
• Conservative treatment
• Aims to relieve pain and prevent further stiffening while
recovery is awaited
• Stretching
• Pendulum exercises
• Reassure the patient that recovery is certain
• MUA + intra-articular methylprednisolone and lignocaine
– MUA the scapula is stabilized with one hand
– The GHJ is moved gently but firmly into External rotation
– Then abduction and flexion
– Then cross body adduction
• Surgical Treatment:
– Arthroscopic capsular release
Tennis Elbow (Lateral Epicondylagia)
• Was wrongly named Lateral
• Chronic Non-inflammatory pain
and tenderness over the lateral
epicondyle of the elbow (the
bony insertion of the common
extensor tendons, ECRB &ECRL)
• Considered and overuse injury
• Common among tennis players
• More common in non-players
who perform similar activities
involving forceful repetitive wrist
• Tends to occur in inexperienced tennis
players 35 to 50 years of age
• Who are inadequately conditioned and
often use poor technique
• Several factors are associated with tennis
elbow: heavier, stiffer, more tightly strung
rackets; incorrect grip size; metal rackets;
inexperienced players; and bad backhand
technique as increased racquet vibration,
typically initiated by off-centre hitting
• High-level tennis players who warm up, use
good technique, and are well conditioned
rarely develop tennis elbow
• Individuals who use a one-handed
backhand technique are at higher risk of
developing tennis elbow when compared
with those who use two hands
Clinical features
• Pain comes on gradually, often after
a period of unaccustomed activity
involving forceful gripping and wrist
• It is usually localized to the lateral
epicondyle, but in severe cases it
may radiate widely.
• It is aggravated by movements such
as pouring out tea, turning a stiff
door handle, shaking hands or lifting
with the forearm pronated
• The elbow looks normal, and flexion
and extension are full and painless
• localized tenderness at or just
below the lateral epicondyle;
• Pain can be reproduced by
passively stretching the wrist
extensors (by the examiner
acutely flexing the patient’s
wrist with the forearm
pronated) or actively by having
the patient extend the wrist
with the elbow straight.
• X-ray is usually normal, but
occasionally shows
calcification at the tendons
• 90% tennis elbows will resolve
spontaneously within 6–12 months.
• The first step is to identify, and then
restrict, those activities which cause pain.
• Modification of sporting style may solve
the problem.
• A tennis elbow clasp is helpful.
• The role of physiotherapy and
manipulation is uncertain.
• Injection of the tender area with
corticosteroid and local anaesthetic
relieves pain but does not cure it
Surgical treatment
• For Persistent or recurrent cases
• The origin of the common extensor muscle
is detached from the lateral epicondyle
• Surgery is successful in about 85 per cent of
Golfer’s Elbow (Medial Epicondylagia)
• Similar to tennis elbow but affects
the medial epicodyle
• Primarily involves the tendons of
the pronator teres and flexor carpi
radialis (FCR) muscles, and
occasionally the flexor carpi ulnaris
• Three times less common than
tennis elbow
• Same c/f as tennis elbow but on
medial side
• Same treatment
Olecranon Bursitis
• Inflammation of the superficial
olecranon bursa
• Traumatic or non-traumatic
• Used to be called student’s or
miner’s elbow due to friction
• Common in contact sports due
to direct fall on a partially flexed
• Painless swelling if not infected
• Infected bursitis is seen in
• Painful, errythematous and
• Staff aureus commonest
• In chronic cases bursa is
replaced with fibrous tissue
• Difficult to treat conservatively
• Compression & cryotherapy in acute
traumatic bursitis
• Aspiration in severe bursa distention
or suspicion of infection + c&s
• Surgery in resistant cases
• Septic bursitis treated first with
aspiration & antibiotics
• Surgery if doesn’t respond
• Longitudinal incision slightly lateral
to olecranon to avoid ulnar nerve
• Carefully dissect the whole bursa
• Meticulous skin handling
• Compressive dressing and splinting
for 10 days
Gamekeeper’s Thumb
• Injury to the ulnar collateral
ligament (UCL) of thumb MPJ
• UCL is an important stabilizer of
the thumb
• Acute & chronic
• Acute injury known as skier’s
thumb occurs due to a fall
on outstretched hand with
thumb forced into abduction
• Often associated with an
avulsion fracture of the
proximal base.
• Grade 1: pain only felt on
stressing the ligament (no laxity)
• Grade 2 pain and limited degree
of laxity
• Grade 3 Marked laxity with no
pain on the stressed ligament
indicates possible complete
• In 80% cases of a complete tear, the aponeurosis
of the adductor pollicis muscle is interposed
between the bones of the MCP joint and the
torn ligament. When this condition (referred to
as a Stener lesion) occurs
• Pain, swelling and bruising over MCP joint,
acutely this is accompanied with haematoma
and inflammation.
• Maximal tenderness on palpation over UCL
• Decreased range-of-movement
• Pinch grip and power are lost, thumb may
deviate radially
• Test for sensation and observe for
neurovascular compromise
• Local anaesthetic or ring block
can assist to fully test laxity.
• Apply valgus force with the
thumb in 30° of flexion. If there is
more than 30° laxity or more than
15° more laxity than on the
uninjured side, rupture of the UCL
is likely.
• Then examine the thumb in full
extension with a valgus stress to
assess the accessory collateral
ligament. If less than 30° valgus
laxity, or 15° or less than on the
uninjured side, the accessory
ligament is intact.
• Plain X-rays to rule out avulsion fractures
• Ultrasound and MRI if diagnosis is in doubt
• Ultrasound shows a sensitivity
and specificity of around 80% and
• MRI has around 100% specificity and
sensitivity detecting UCL injury
Assess for other injuries
Analgesia, ice, splint, elevate
X-ray to exclude fracture
Immobilise thumb in a plaster or Paris
thumb spica cast for 1 week, then patient
can be changed to a thermoplastic thumb
spica cast for 2-6 weeks
• Arrange for early plastic surgery review for
operative Vs conservative
management. Currently a very contentious
issue and debate continues regarding
which UCL injuries require surgical repair.
• As a rule incomplete tears are managed
conservatively, while complete tears and
avulsion fractures do better managed
De Quervain Syndrome
• Tenosynovitis of the EPB &
• The most common tendinitis
of the wrist in athletes
• Radial-sided wrist pain
exacerbated by thumb
movements, especially
thumb abduction and/or
• Pain may radiate distally or
proximally along the course
of the APL and EPB tendons
• Tenderness over the first
dorsal compartment
• Positive Finkelstein test
• This test is performed by
flexing the thumb into the
palm and passively deviating
the wrist ulnarly, thus causing
maximum stretch to the APL
and EPB tendons
• Splinting for acute symptomatic relief.
• Single CS injections into the first dorsal compartment
sheath are successful in alleviating symptoms in 62% of
patients and two injections are successful in 80% of
• Complications of corticosteroid injections include
depigmentation, fat necrosis, and subcutaneous
• Corticosteroid injections in diabetic patients may be
less desirable and less successful.
• 90% of patients can be expected to have satisfactory
outcomes following surgical release of the first dorsal
compartment for DeQuervain syndrome
• Risk of injury to superficial radial nerve
Hip Bursitis
• Bursitis most commonly is
seen about the greater
• Related to
– Overuse
– Wider pelvis seen in women,
– A prominent trochanter,
– Or in runners who adduct
beyond the midline
• The treatment of most bursitis includes rest,
stretching of the involved tendons, and NSAIDs.
• In refractory cases, corticosteroid injection
• The delivery of corticosteroid in the case of psoas
bursitis, must be made with the use of
radiographic guidance
• In refractory cases, surgical excision of the either
the trochanteric bursa or the iliopsoas bursa
The Snapping Hip
• Audible snapping, usually with
flexion and extension of the hip
during exercise or with normal
• It is often accompanied by pain
• Types:
• Extra-articular
– External (by iliotibial band or
gluteus maximus over greater
– Internal (by iliopsoas over AIIS, LT
or IPE)
• Intra-articular (by loose bodies
or labral tears)
• Extra-articular associated with
– Leg length difference (usually the long side is
– Tightness in the iliotibial band (ITB) on the longer
– Weakness in hip abductors and external rotators
– Poor lumbo-pelvic stability
– Abnormal foot mechanics (over-pronation)
• The physical examination of patients
with suspected internal snapping (IP)
should include examining the patient
in a supine position and having him or
her demonstrate the snapping with
active leg motion
• Flexion and extension of the hip can
reproduce the symptoms.
• In order to make the symptoms more
prominent, the hip should be abducted
with flexion and adducted with
• The snapping can often be eliminated
or significantly lessened by applying
pressure over the iliopsoas tendon
• The external type is reproduced
with hip flexion and extension,
although the patient typically can
reproduce the snap more
effectively while in a standing
• Like the internal type, the
snapping can be decreased, or
eliminated altogether by applying
manual pressure over the greater
• Unlike internal snapping, which is
typically painless, the external
type of snapping is often
accompanied by pain secondary
to trochanteric bursitis
• X-ray to identify loose
• Ultrasound
• Identification of the underlying cause
• Correcting any contributing biomechanical
abnormalities such as over-pronation
• Stretching tightened muscles, such as the
iliopsoas muscle, piriformis or iliotibial band
• HI-RICE(Hydration, Ibuprofen, Rest, Ice,
Compression, Elevation) regimen lasting for at
least 48 to 72 hours after the onset of pain
• Corticosteroid injections to the iliopsoas bursa
temporary relief usually only last weeks to
• Surgical treatment is rarely
necessary unless intra-articular
pathology is present or,
• In patients with persistently
painful iliopsoas symptoms
surgical release of the
contracted iliopsoas tendon has
been used since 1984.
• Iliopsoas and iliotibial band
lengthening can be done
• Postop, these patients will
usually undergo extensive
physical therapy; regaining full
strength may take up to 9–12
Jumper’s Knee (Patellar Tendonitis)
• Inflammation of the patellar tendon
close to the patellar attachment
• Overuse injury due to explosive
• Damage occures during landing
• Stage I: Pain after activity
• Stage II: Pain during and after activity
• Stage III: Same as in phase II, but with
diminished performance
• Stage IV: Complete rupture of the
tendon, acute loss of extension
accompanied by a painful noisy snap
Conservative for Stages 1 & 2
Strengthening the quadriceps helps to balance the forces
across the patella and take pressure off the patellar
Also, hamstring stretching is extremely important to take
pressure off the anterior structures of the knee
Neoprene sleeves or braces can help decrease or disperse
the forces on the patella
Surgery is reserved for patients who experience
debilitating pain for 6 to 12 months
The overall goal of surgery is to remove the damaged
tissue from the tendon and stimulate blood flow to
promote healing.
Patients with stage 4 disease who have suffered a
complete tendon rupture also need surgery
Iliotibial Band Friction Syndrome
• Inflammation of the iliotibial band
as it rubs against the lateral
epicondyle of the femur
• It is most symptomatic when
running downhill
• Predisposing factors:
– ITB tightness
– Musculotendinous imbalances
around the knee
– Excessive foot pronation
– Genu varus
– Overtraining
• local swelling and tenderness
over the iliotibial band anterior to
the epicondylar origin of the
lateral collateral ligament
• The tenderness can be variable in
different degrees of knee flexion.
• Ober Test:
• While the patient is on the lateral
position, the patient is asked to
abduct the hip then flex the knee
flexed. Keep the knee flexed
• When asked to adduct the hip,
patients with tight iliotibial band
are not able to touch the
examining table with the medial
side of their affected extremities
• The patient may start ice massage and stretching
exercises over the lateral structures of the thigh
• Physical activities without pain are allowed.
• Running downhill or on very hard surfaces should be
• Proper stretching and warm up as well as periods of
rest are encouraged.
• In refractory cases steroid injections around the lateral
epicondylar bursae can be useful but direct injection
over the tendon should be avoided.
• If there is any lower limb mal-alignment, orthotics may
be prescribed
Meniscal Lisions
• The menisci have an
important role in:
• (1) Improving articular
congruency and increasing
the stability of the knee,
• (2) Controlling the
complex rolling and gliding
actions of the joint and
• (3) Distributing load
during movement
• During standing, at least 50%
of the contact stresses are
taken by the menisci when
the knee is loaded in
extension, rising to almost
90% with the knee in flexion.
• If the menisci are removed,
articular stresses are
markedly increased;
• Even a partial meniscectomy
of one-third of the width of
the meniscus will produce a
threefold increase in contact
stress in that area.
• The medial meniscus is much less mobile than
the lateral, and it cannot as easily accommodate
to abnormal stresses.
• This may be why meniscal lesions are more
common on the medial side than on the lateral
• There is gradual stiffening and degeneration of
the menisci with age, so splits and tears are more
likely in later life
• In young people, meniscal tears are usually the
result of trauma
• The meniscus consists mainly
of circumferential fibres held
by a few radial strands.
• It is, therefore, more likely to
tear along its length than
across its width
• The split is usually initiated
by a rotational grinding force,
which occurs when the knee
• Semi-Flexed and Pivoting
while Taking weight
Most of the meniscus is avascular and
spontaneous repair does not occur unless the
tear is in the outer third, which is vascularized
from the attached synovium and capsule
Clinical features
• Pain
• Swelling appears hours later, or next day
• With rest the initial symptoms subside, only to
recur after trivial twists or strains
• Sometimes the knee gives way spontaneously
and this is again followed by pain and swelling
• Locking (the sudden inability to extend the knee
fully) suggests a bucket-handle tear
• The patient sometimes learns to unlock the knee
by bending it fully or by twisting it from side to
• The joint may be held slightly flexed
• There is often an effusion
• In longstanding cases the quadriceps will be
• Tenderness is localized to the joint line, in the
vast majority of cases on the medial side
• Flexion is usually full but extension is often
slightly limited
Meniscal Tests
McMurrays’s Test
Thessaly’s Test
• X-ray
• Differential diagnosis:
• Partial tear of MCL
• Loose bodies
– Insidious history
– presentation variable in character and intensity.
– A loose body may be palpable and is often visible on x-ray.
• Recurrent dislocation of the patella
– Knee giving way (the pt collapses to the ground
– Tenderness is localized to the medial edge of the patella
– The apprehension test is positive
• Fracture of the tibial spine
– Follows an acute injury and may cause a block to full extension.
– Swelling is immediate and the fluid is blood-stained.
– X-ray may show the fracture
• Conservative treatment
• If the knee is not locked, the tear is peripheral
and can therefore heal spontaneously
• After an acute episode, the joint is held
straight in a plaster backslab for 3–4 weeks
• Crutches and quadriceps exercises
• MRI check if the meniscus has healed
• Surgery indications
• (1) If the joint cannot be unlocked
• (2) If symptoms are recurrent
• Suturing or Excision
• At diagnostic arthroscopy tears close to the periphery, can be sutured; at
least one edge of the tear should be in red zone (vascularized)
• Tears other than those in the peripheral third are dealt with by excising
the torn portion
• Total meniscectomy must be avoided
– instability
– Secondary osteoarthritis
• Arthroscopic meniscectomy faster rehabilitation
• The ACL is a two-bundle
• The cross sectional area of
the ACL is approximately 35
mm2 and the average length
is 25 mm.
• The tension in the two
bundles varies with knee
• The anteromedial is tight in
• The posterolateral tight in
• The PCL is also a two-bundle
• The two bundles vary in
tension with knee flexion
• The anterolateral is tight in
• The posteromedial is tight in
• The insertion of the PCL on
the tibia is slightly lateral,
and 1 to 2 cm below the
joint line
ACL Injuries
• Pivoting on a semi-flexed
weight bearing knee
• Feel a pop, followed by pain
and swelling
• Unable to continue playing
• In chronic cases there is
knee instability with
pivoting, jumping, or lateral
• The patients complain that
the knee gives way, and it
feels like the bones are
coming apart
Lachman Test
• The knee flexed at 30 degrees,
and the hamstrings relaxed.
• The examiner assesses the
amount of anterior translation
and the presence or absence of
an endpoint compared to the
opposite knee
• The Lachman test can be graded
as follows:
– Grade 1+ has up to 5 mm
displacement with a firm end
– Grade 2+ has 5 to 10 mm
displacement with no end point,
– Grade 3+ has greater than 10 mm
The dropped leg Lachman test
• In the acute situation, the
dropped leg Lachman test
is performed by letting
the thigh rest on the edge
of the bed
• The leg is dropped over
the side with 30 degrees
of knee flexion
• The hamstring muscles
are relaxed in this position
Pivot Shift Test
• This test is performed by
the examiner supporting
the patient's leg in
• One hand then applies
an axial load, and valgus
force as the knee is
slowly flexed
Anterior Drawer Test
• It is performed with the
patient's knee flexed 90
degrees and stabilized by
the examiner sitting on the
foot, while applying an
anterior directed
force to the proximal tibia
• The amount of anterior
translation of the tibia
under the femur is
compared to the opposite
• Imaging
– X-ray all cases
• Treatment:
• The initial treatment of all ACL
injuries includes splinting, crutches,
and early physiotherapy
• Definitive treatment:
– Conservative: avoid pivoting sports
then resume modified activities with a
knee brace
– Surgical: ACL reconstruction
(arthroscopic or open)
PCL Injury
• Isolated PCL tears most likely result
from a direct blow to the proximal
tibia, causing a posteriorly directed
• This occurs with the so-called
dashboard knee in motor vehicle
accidents, or when the proximal tibia
contacts an immovable object.
• A fall on a flexed knee with the foot in
plantar flexion may also induce an
isolated PCL tear
• Forced flexion plus internal rotation
has also been reported to cause
isolated PCL tears
Clinical features
• Unstable knee
• Posterior lateral knee
• Posterior Sag Sign
(Gravity Drawer Test)
• Positive posterior drawer