Transcript TITLE OF THE PRESENTATION - Los Angeles Orthopaedic

Non-Operative Management of
Orthopaedic Issues
Reza Omid, M.D.
Assistant Professor Orthopaedic Surgery
Shoulder & Elbow Reconstruction
Sports Medicine
Keck School of Medicine of USC
Musculoskeletal Injuries
• Common cause for doctor visists
(ER and outpatient).
• >1 in 4 Americans has a
musculoskeletal condition
requiring medical attention.
• Most can be treated nonoperatively
X-rays
• Consider x-ray for any patient
with injury
• Fracture/Dislocation/Infection/Tu
mor
General Orthopaedics
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Shoulder/Elbow Reconstruction
Trauma
Pediatrics
Hand/Wrist
Foot/Ankle
Hip/Knee Reconstruction
Tumor
Sports Medicine
Spine
Shoulder Pain
Differential Dx
»Rotator Cuff Disease
»Frozen shoulder
»Fracture
»Calcific Tendonitis
»Labral Tears
»Biceps Pathology
Shoulder Pain
–Among the most common
sources of pain
–Ranks 2nd to lower back
pain as a reason pt. seek
medical attention
–Approx. 40% of people
over 65 yo have rotator cuff
tears!
Shoulder Pain
Rotator Cuff Disorders
–17 million individuals in
US at risk
–600,000 surgeries / year
–Most common source
WC shoulder pain
Rotator Cuff Disease
Rotator Cuff Anatomy
• Supraspinatus
• Infraspinatus
• Tere Minor
• Subscapularis
Rotator Cuff Disease
Intrinsic Factors
–Age related degeneration
Extrinsic Factors
–Acromial shape
–Mechanical pressure on cuff
–Activity
Conclusions
Demographics
–Unilateral tear in young
–Bilateral tear in older
–Tears rare before 50 yo.
–>50% in pt over 66 yo.
Radiographs
Always obtain first
AP (scapular plane)
Axillary lateral
Supraspinatus outlet
History
– Pain (especially night pain)
» Radiates around deltoid
» Never below elbow
– Weakness
– Difficulty reaching overhead or behind
– Cannot sleep on affected side
Physical Examination
–Cervical spine
–Shoulder ROM
(active/passive) symmetric?
Physical Examination
Rotator cuff tests
–TDA (supraspinatus)
–ER at side (infraspinatus)
–ER 90° abd (teres minor)
–Lift-off (subscapularis)
Physical Examination
Physical Examination
Normal Motion
–Elevation – 160
–Abduction ER – 90
–ER @ side -60
–IR/Ext – T7
Adjuvant Imaging Modalities
MRI
Ultrasound
CT Arthrogram
MRI Reads
• Labral tears
• AC arthritis
• Partial thickness
RC tears
• Full thickness RC
tears
MRI Results
Arthritis:
•Labral tears
•AC arthritis
•Partial thickness
tears
•Tendinosis
Rotator Cuff Dz:
•Full thickness tears
•High grade partial
thickness tears
MRI Read
No RC Tear
Labral tear seen
AC joint arthritis seen
Dx: Shoulder arthritis
Partial Rotator Cuff Tears
• Can initially treat conservatively
• If fails conservative treatment
then surgery
Orthopaedic Referral
• Full thickness tear in patients
<60-65yo
• Acute (<3month) traumatic full
thickness tears in any age
• Full thickness tear in patients
>65 yrs who fail conservative
treatment
Rotator Cuff Tear
Risks - Chronic Changes
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retraction with adhesion
tendon morphology
muscle atrophy
fatty degeneration
degenerative changes
Conservative Treatment
»Rest, Activity modification
»NSAIDS
»ROM stretching
»Cuff/Periscapular
strengthening
»Corticosteroid Injections
Cuff Strengthening
Conservative Treatment
Injections
– Elderly (>65yo)
– Partial tears
Shoulder Injections
“The effect of corticosteroid on
collagen expression in injured
rotator cuff tendon”
• Wei A, et al JBJSAm 2006: 1331-8
• LIMIT TO 1-2 INJECTION
• GET MRI PRIOR
Proximal Biceps Rupture
• Suspect RC Tear
Shoulder Dislocation
• If anyone >40 years dislocates
get an MRI
• If full thickness tear seen with
healthy muscle bellies then
surgery is indicated
Frozen Shoulder
“Adhesive Capsulitis”
Frozen Shoulder
–Global and significant loss of both
active and passive ROM in gradual
fashion
–Absence of radiographic findings
other than osteopenia
Clinical Presentation
–Age: late middle age (40-60)
–Male < Female
–Diabetic and Hypothyroid
Clinical Presentation
–Significant pain - especially at night!
–Insidious onset
»No trauma
»Minor trauma (“dog pulled me”, “I
reached in the back seat of the car”)
Late Frozen Shoulder
–Significant loss of
ROM
»active and passive
Physical Exam
–Passive ROM restricted
»ER early
»global late
–ER < 50% unaffected side
(pathognomic)
–Pain with extremes of ER
Treatment
Conservative
–NSAID’s
–Physical Therapy
Fluoro-Guided Intraarticular
Steroid Injection!
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Accuracy of glenohumeral joint
injections: comparing approach
and experience of provider.
Tobola JSES 2011:1147
Posterior: 50%
Anterior: 42%
Arthroscopic Release
–Surgical release of contractures
–Remove scar tissue
–Complete motion
Elbow Pain
Differential Dx
Lateral Epicondylitis
Instability
Biceps Pathology
Medial Epicondylitis
Olecranon Bursitis
Fracture
Lateral Epicondylitis
“Tennis Elbow”
Presentation
• Lateral elbow pain with grip
• Especially in extension
• TTP at lateral epicondyle
Conservative Treatment
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NSAIDs
Activity modification
Physical therapy
Counterforce brace
Iontophoresis
Injections
Conservative Treatment
Iontophoresis
Injections
Corticosteroids
Platelet Rich Plasma
Botulinum Toxin A
ONLY 1 INJECTION!
POSTEROLATERAL ROTATORY
INSTABILITY OF THE ELBOW IN
ASSOCIATION WITH LATERAL
EPICONDYLITIS. A REPORT OF
THREE CASES.
Kalainov JBJSAm 2005: 1120
Physical Therapy
• Modalities
• Eccentric exercises
Medial Epicondylitis
“Golfers Elbow”
-Medial elbow pain with grip
-Much less common
-TTP at FP mass
-Similar treatment
Olecranon Bursitis
• Most resolve with symptomatic
treatment
• Avoid aspiration unless you
suspect infection
• Surgery has high complication
rate!
Distal Biceps Tears
• Anterior elbow pain with
associated “pop”
• Treated surgically as opposed to
proximal biceps ruptures
Hand/Wrist Pain
Carpal Tunnel
Treament
• Brace
• NSAIDs
• Vit B6 (50 mg PO tid) may help
some of patients
• Injections (nerve can be injured!)
DeQuervain’s Tenosynovitis
Other Causes of Radial Sided
Wrist Pain
Scaphoid fracture
Wrist arthrits
Radial sensory nerve injury
“Crossover syndrome” (another
sheath of tendons)
Treatment
• Brace with thumb spica
• NSAIDs
• Corticosteroid injection into
sheath
Hip Pain
Differential
Fracture
Stress Fracture
FAI
Arthritis
Stress Fracture
• Runners
• Female
• Rest
• MRI (If Femoral neck fracture
seen refer)
Stress Fractures
Femoroacetabular
Impingement (FAI)
Treatment of FAI
RICE, NSAIDs
Physical Therapy
If MRI ordered get MR
Arthrogram of Affected
Hip NOT Pelvis
Knee Pain
Differential Dx
Meniscus tear
Arthritis/OCD
Ligament Injury
Fracture
Knee Effusion
Ligament tear
Meniscus tear
Osteochondral fracture
Synovitis
Consider MRI
Anterior Knee Pain
Treatment
RICE
Weight loss (every pound lost is 7
pounds off the knee)
Bracing
Physical Therapy
Meniscus Tears
Treatment
• RICE
• Weight loss (every pound lost is 7
pounds off the knee)
• Bracing
• Physical Therapy
• Corticosteroid injection
• Surgery is last option
Baker’s Cysts
ACL Injuries
Treatment of ACL
• If active and only mild arthritis
orthopaedic referral.
• If degenerative and non-active
treat non-operatively
• Age is irrelevant
Arthritis
• RICE
• Glucosamine/Chondroitin
• “Viscosupplement” Injections
• Corticosteroid Injections
• Unloader Bracing
• PT
Physical Therapy for Hip/Knee
Injuries
• ROM
• Quadriceps Strength
• Hamstring Strength
• Hip Abductor Strength
• IT Band Stretching
• Iliopsoas Stretching
Foot/Ankle Pain
Ankle Sprain
• Get x-rays!!
• Most can be treated with CAM
walker
• 5th MT Fracture
Ottawa Ankle?
Achilles Tendon Injury
• If torn refer
• If intact treat with RICE,
NSAIDs, CAM boot, PT for
eccentric exercises
Achilles Tendon Injury
• Tendinopathy vs insertional
tendonitis
• Heel lift
• NSAIDS
• PT (eccentric exercises)
Plantar Fascitis
• Inflammation of the plantar
fascia
• Achilles stretching
• RICE
• Boot
Questions???
www.dromid.com
[email protected]
Reza Omid, M.D.
Assistant Professor Orthopaedic Surgery
Shoulder & Elbow Reconstruction
Sports Medicine
Keck School of Medicine of USC