Office Orthopedics for the Primary Care Physician: Evaluation of the Knee and Shoulder

1
Office Orthopedics for the Primary Care
Physician Evaluation of the Knee and Shoulder

• John Michelotti, MD
• Helena Orthopedic Clinic

2
Shoulder

• Stiffness
• Weakness
• Stability
• Smoothness

3
Knee

• Swelling
• Stability
• Locking
• Patellofemoral

4
Shoulder

• DONT MISS THE BIG STUFF!!!!

5
Shoulder - Tumors

• Night pain
• Metastatic Disease
• Atypical Pain

6
Shoulder - Infection

• Fevers
• Chills
• Erythema
• Range of Motion

7
Calcific Tendinitis

• Mimic Infection
• Severe pain
• Loss of ROM
• Diagnosis
• Radiographs
• Treatment
• Medications
• NSAIDS
• Narcotics
• Aspiration
• Physical therapy
• Arthroscopy

8
Shoulder Stiffness Adhesive Capsulitis

• History
• Diabetic
• Cardiac Cripple
• Female age 40-60

9
Shoulder StiffnessAdhesive Capsulitis

• Physical Exam
• Range of Motion
• Forward Elevation
• External Rotation
• Internal Rotation
• First to get bad, last to get better
• Strength normal

10
Shoulder StiffnessAdhesive Capsulitis

• Studies
• Radiographs
• AP
• Axillary Lateral
• Outlet

11
Shoulder StiffnessAdhesive Capsulitis

• Treatment
• PT, PT, PT
• 18 months?
• Manipulation Under Anesthesia
• Arthroscopy Lysis of Adhesions

12
Shoulder WeaknessRotator Cuff Tear

• History
• Age
• Degenerative gt 50
• Injury
• Age gt 30
• Dislocation
• Age gt 35

13
Shoulder WeaknessRotator Cuff Tear

• Physical Exam
• Strength
• External Rotation
• Resisted Deltoid
• OBriens test
• Range of Motion
• Normal?
• Loss small tear

14
Shoulder WeaknessRotator Cuff Tear

• Studies
• Radiographs
• AP, Ax. Lat, Outlet, AC
• MRI
• Sagittal oblique
• Coronal oblique
• Ultrasound

15
Shoulder WeaknessRotator Cuff Tear

• Treatment
• Physical Therapy
• Injections?
• Repair
• Arthroscopic
• Open

16
Shoulder StabilityDislocations

• History
• Age
• Male - 15-30
• Female teens
• Mechanism
• Traumatic
• Unilateral
• Atraumatic
• Multidrectional

17
Shoulder StabilityDislocations

• Physical Exam
• Apprehension
• Relocation test
• Load and Shift
• Anterior
• Posterior
• Inferior

18
Shoulder StabilityDislocations

• Studies
• Radiographs
• Axillary Lateral!!!
• MRI
• With contrast

19
Shoulder StabilityDislocations

• Treatment
• Traumatic
• Rehabilitation
• Bracing
• Stabilize - Bankart
• Open
• Arthroscopic

20
Shoulder StabilityDislocations

• Treatment
• Atraumatic
• Rehab, Rehab, Rehab
• Stabilize
• Inferior Capsular shift
• Interval Closure

21
Shoulder StabilityDislocations

• TUBS
• Traumatic
• Unilateral
• Bankart
• Surgery

• AMBRI
• Atraumatic
• Multidirectional
• Bilateral
• Rehabilitation
• Inferior capsular shift

22
Shoulder SmoothnessOsteoarthritis

• History
• Age gt 50
• Duration
• Stiffness
• Cuff tear arthropathy
• lt4
• Dislocation arthropathy
• age at first dislocation
• Surgery

• Physical Exam
• Stiffness
• Loss of ER
• Crepitance

23
Shoulder SmoothnessOsteoarthritis

• Studies
• Radiographs
• True AP
• Goats Beard
• Axillary Lateral
• Posterior erosion

24
Shoulder SmoothnessOsteoarthritis

• Treatment
• Physical Therapy
• Injections
• Subacromial
• Glenohumeral
• Arthroplasty
• Hemiarthroplasty
• Total Shoulder

25
What Else?

• THE I WORD
• (Impingement)

26
Impingement

• Bursitis
• Tendonitis
• Spur
• What really is it?

27
Why Are We Here?
28
Impingement

• History
• Insidious onset
• ? Trauma
• Pain
• Lateral Arm
• Cant sleep on it
• Overhead activity

29
Impingement

• Physical Exam
• Neers Test
• Hawkins Test
• Pain with resisted
• Deltoid
• External Rotation
• Radiographs
• Normal

30
Impingement

• Treatment
• Physical Therapy
• NSAIDS
• Subacromial Injection
• Diagnostic
• Therapeutic
• Prognostic
• Arthroscopy
• Subacromial Decompression

31
Biceps Tendonitis

• History
• Insidious onset
• ?Trauma
• Thrower
• SLAP tear
• Pain
• Burning
• Anterior shoulder
• Biceps groove

32
Biceps Tendonitis

• Physical Exam
• Pain at biceps groove
• Speeds test
• Yergasons test
• Radiographs
• Normal

33
Biceps Tendonitis

• Treatment
• NSAIDS
• Physical Therapy
• Modalities
• Arthroscopy
• Tenotomy
• Tenodesis

34
Knee

• DONT MISS THE BIG STUFF!!!!

35
Knee - Tumors

• Night Pain
• Metastatic Disease
• Atypical Pain

36
Knee - Infection

• Fevers
• Chills
• Range of Motion
• Gout
• Pseudogout

37
Knee Fractures

• Always get radiographs
• Pediatrics (physis open)
• AP, lateral, sunrise
• Adult
• Standing AP, PA, lateral, sunrise

38
Knee - History

• Age
• lt50 ligaments, meniscus, patellofemoral
• gt50 meniscus, osteoarthritis, patellofemoral
• Mechanism
• Traumatic
• Pop, Drop, Cant walk, Immediate swelling
• ACL until proven otherwise
• Injury , Sore, OK to walk, swelling later
• Meniscus vs chondral injury

39
Knee - History

• Atraumatic
• Multiple injuries (Over the years)
• Insidious onset
• True Locking
• Stair and Hill pain (especially down)
• Location of the pain
• Anterior, posterior, medial, lateral
• Other injuries
• Ankle sprain

40
Knee Physical Exam

• Examine the other side first
• Effusion / Swelling
• Relax, lie down, hands on stomach not on head!!
• Milk the pouch
• Look above patella
• If swelling Think like a mechanic!!
• Meniscus, ligaments, chondral injury,
  osteoarthritis
• Dont forget inflammatory
• Gout, pseudogout

41
Knee Physical ExamSwelling/Effusion
42
Knee Stability
43
Knee - Stability

• Anterior Cruciate Ligament
• Lachman, Pivot shift, Anterior drawer
• Posterior Cruciate Ligament
• Sag, Posterior drawer, Quadriceps active test
• Medial Collateral Ligament
• Valgus stress at 0 and 20 degrees, tenderness
• Lateral Collateral Ligament
• Varus stress at 0 and 20 degrees, tenderness

44
Knee Ligament Exam

• Lachman
• Endpoint
• Varus
• LCL
• Palpate cord
• Valgus
• MCL
• PCL
• Posterior Drawer 90

45
Knee Physical Exam

• Location of the pain Tendonitis
• Inferior, Superior pole of patella
• Patellar / Quadriceps tendonitis
• Medial retinaculum
• Patellar tendonitis
• Iliotibial band at lateral epicondyle
• Pes anserine insertion of medial hamstrings
• Sartorius, gracilis, semitendinosus

46
Knee - Studies

• Radiographs
• Standing AP and PA
• Lateral
• Sunrise
• MRI
• Overused!!!

47
Knee - Treatment

• Nonoperative
• Medications
• NSAIDS
• Glucosamine, Chondroitin
• Braces
• Ligaments
• Off the shelf, Custom fit
• Patellofemoral

48
Knee - Treatment

• Physical Therapy
• Stretching, Strengthening, Taping, Modalities
• Modify Activities
• Swimming, Biking
• All Works well for patellofemoral,
  tendonopathies, mild osteoarthritis, MCL and PCL
  tears (isolated), small meniscus tears

49
Knee - Treatment

• Operative
• Arthroscopy
• Works well for meniscus pathology, loose bodies,
  small chondral flaps
• Questionable efficacy for advanced
  osteoarthritis, patellofemoral pathology, plica
• Reconstruction Ligament
• ACL, PCL, LCL, and combined instabilities
• Patellar instability
• Reconstruction Advanced cartilage pathology
• Osteotomies
• Arthroplasty

50
Shoulder and Knee

• DONT MISS THE BIG STUFF!!!!

51
September 13, 2004