1

A n t h o n y L u k e MD, MPH, CAQ (Sport Med)

Associate Professor, Director Primary Care Sports Medicine

University of California, San Francisco

Advances in Internal Medicine 2008

Primary Care Sports Medicine

Unlocking the Mysteries of the Knee and Shoulder

Overview

• Anatomy and injury biomechanics

• Highlight common presentations

• Discuss high yield physical exam tips

• Discuss basics of conservative and surgical management

Take Home Messages

• History is Key

• Confirm the

diagnosis with PE

• Think

– Age

– Traumatic or

Atraumatic

History is Key

• Numbness

• Fever

Instability Dysfunction

Pain

Who?

What?

2

History is Key

When?

• Acute vs Chronic (2 weeks? 6 weeks?)

Where?

• Think anatomy

• One finger test

How?

• Mechanism of injury

Physical Exam

LOOK – Observation

• Swelling, Erythema, Atrophy,

Deformity, Surgical Scars

(SEADS)

FEEL – Palpate important

structures

MOVE – Assess Range of

Motion

SPECIAL TESTS

Provocative tests • Reproduce patient’s pain

Stress tests • Stress structures for instability

(i.e. ligaments)

Functional tests • Assess functional movements

(i.e. weight bearing activity)

Treatment Options

Conservative

• MICE (Modified activity,

Ice, Compression,

Elevation)

• Medications/Analgesia

• Rehabilitation therapy

• Casting/ Braces /

Orthoses

• Crutches

Surgery

• Reconstruction

• Repair

• Re-align

• Remove internal derangement

Case - Knee Swelling

22 year old girl comes has twisting injury in her knee skiing. Develops immediate swelling after injury and has to be brought down by ski patrol

LOOK - effusion

FEEL • Lateral joint line tender -

femoral condyle bone bruise

MOVE

• Maybe limited due to effusion or other internal derangement

3

Q1: The first step for the

diagnosis in this case is: 1) Lachman test

2) Anterior Drawer test

3) X-ray

4) MRI

5) McMurray test

Physical Exam = MRI • Physical exam is as sensitive as MRI

• Full agreement Clinical vs MRI 61%,

Clinical vs Arthroscopy 39%, MRI vs

Arthroscopy 50% Clinical and MRI examination correlation (percentage) with

Arthroscopic findings n = 109 patients

Test Meniscus ACL

Sensitivity 38 / 59 100 / 54

Specificity 93 / 50 97 / 92

Positive predictive

value

93 / 76 85 / 43

Negative

predictive value

35 / 32 97 / 95

Madhusudhan,

Journal Orthop Surg Research,

2008

Special Tests ACL

• Lachman's test – test at 20°

• Anterior drawer – test at 90°

• Pivot shift

Malanga GA, Nadler SF. Musculoskeletal Physical

Examination, Mosby, 2006

* - denotes under anesthesia

Sens 81.8%, Spec 96.8%

Sens 35 - 98.4%*, Spec 98%*

Sens 22 - 41%, Spec 97%*

Anterior Cruciate Ligament (ACL)

Tear

Mechanism

• Landing from a

jump, pivoting or

decelerating

suddenly

• Foot fixed, valgus

stress

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L i g a m e n t Anatomy and Biomechanics

Ultimate Ligament Tension

Failure

• ACL: 2200 N (Anterior)

• PCL: 2500 N (Posterior)

• MCL: 4000N (Valgus)

• LCL: 750N (Varus)

• Posteromedial Corner

• Posterolateral Corner

Biomechanical Studies

Forces on the ACL/Graft

• Level Walking = 169 N

• Ascending Stairs = 67 N

• Descending Stairs = 445 N Morrison, Biomech, 1970

Morrison, Bio Eng,1968,1969

• Normal Walking = 400 N

• Sharp Cutting = 1700 N Butler, Clin Orthop, 1985

• Sports = 2000+ N

Anterior Cruciate Ligament (ACL)

Tear

Symptoms

• Audible pop heard or felt

• Pain and tense swelling in minutes after injury

• Feels unstable (bones shifting or giving way)

• “O’Donaghue’s Unhappy Triad” = Medial meniscus tear, MCL injury, ACL tear

• Lateral meniscus tears more common than medial

Double fist sign

X-ray

• Usually non-

diagnostic

• Can help rule in or

out injuries

• Segond fracture –

avulsion over

lateral tibial plateau

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MRI

ACL tear signs

• Fibers not seen in

continuity

• Edema on T2 films

• PCL – kinked or

Question mark sign

MRI

ACL tear signs

• Lateral femoral corner

bone bruise on T2

• May have meniscal

tear (Lateral > medial)

Sens = 64%

Spec = 95%

PPV = 58%

NPV = 96%

Thomas et al. Knee Surg Sports Traumatol Arthrosc, 2007; 15: 533-536.

Similar to clinical exam !!

Initial Treatment

• Referral to Orthopaedics/Sports Medicine

• MICE = Modified activity, Ice,

Compression, Elevation

• Consider bracing, crutches

• Begin early Physical Therapy

• Analgesia usually NSAIDs

ACL Tear Treatment

Conservative

• No reconstruction

• Physical therapy • Hamstring

strengthening

• Proprioceptive training

• ACL bracing controversial

• Patient should be asymptomatic with ADL’s

Surgery

• Reconstruction

• Depends on activity demands

• Reconstruction allows better return to sports

• Reduce chance of symptomatic meniscal tear

• Less giving way symptoms

• Recovery ~ 6 months

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Acute Hemarthrosis

1) ACL (almost 50% in children, >70% in adults)

2) Fracture (Patella, tibial plateau, Femoral supracondylar, Physeal)

3) Patellar dislocation

• Unlikely meniscal lesions

Medial Collateral Ligament (MCL)

Injury

Mechanism

• Valgus stress to

partially flexed knee

• Blow to lateral leg

Symptoms

• Pain medially

• May feel unstable

with valgus

Medial Collateral Ligament (MCL)

Injury

Physical Exam

• Tender medially over

MCL (often proximally)

• May lack ROM

“pseudolocking”

• Valgus stress test – test

at 20°

Malanga GA, Nadler SF.

Musculoskeletal Physical

Examination, Mosby, 2006

Sens = 86 - 96 %

MCL Treatment

Conservative

• Analgesia

• Protected motion

+/- hinged brace

+/- crutches

• Early physical therapy

Imaging

• X-ray non-diagnostic

(rarely avulsion)

• MRI not usually

necessary

Surgery

• Rarely needs surgery

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Q2. The most common sign of

meniscal tear is:

1) Joint line tenderness

2) Effusion

3) Positive McMurray Test

4) Loss of range of motion

5) Limp

Special Tests: Meniscus Fowler PJ, Lubliner JA. Arthroscopy 1989; 5(3): 184-186; Yelland, Evidence Based Medicine, 2007.

Test Sensitivity Specificity

Joint line tender 67 to 92% 29 to 97%

Hyperflexion 50% 68.2%

McMurray Classic

(Med Thud)

16 to 67% 69 to 98%

Thessaly 66 to 92% 91 to 97%

Appley (Comp/Dist) 16 to 41% 80 to 93%

MRI 40 to 100% 66 to 100%

Meniscus Tears

Mechanism

• Occurs after twisting

injury or deep squat

• Patient may not recall

specific injury

Symptoms

• Catching

• Medial or lateral knee

pain

• Usually posterior

aspects of joint line

• Swelling

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Meniscus Tears

Traumatic tears

• Younger patients

• Frequently associated with ACL tear

• Vertical longitudinal common

Degenerative tears

• Older patients

• Frequently no trauma

• Frequently horizontal cleavage, flap, or complex tears

• Reduced healing potential

Modified McMurray Testing

• Flex hip to 90

degrees

• Flex knee

• Internally or externally

rotate lower leg with

rotation of knee

• Fully flex the knee

with rotations

Courtesy of Keegan Duchicella MD

Thessaly Test

• Hold patient’s hands for

support

• Patient bends knee to 5°

while he/she twists on knee

• Twisting movement will

reproduce pain from meniscal injury

• Repeat with 20° knee

flexion

Medial side: Sens 89%, Spec 97%

Lateral side: Sens. 92%; Spec 96%

Karachalios et al. J Bone Joint Surg Am, 2005; 87: 955-962

Courtesy of Keegan Duchicella MD

MRI

• Look for fluid (linear

bright signal on T2) into

the meniscus

Fox M, Radiol Clin N Am,

2007; 1033-1053

Sens = 88 - 90 %

Spec = 87 - 90 %

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• Medial meniscus: 10-30 % of width

• Lateral meniscus: 10-25 % of width

• From geniculate arteries

• Posterior horns have increased vascularity

Vascular Penetration

Lat

Med

Courtesy of Steve Arnocsky

Meniscus can heal

Red zone tears:

• Blood supply promotes healing

• Heals with cellular fibrovascular scar

• Mechanical strength may never return to normal

White zone tears: • Minimal reparative

response

Fibrocartilage present at 6

months

Courtesy of Steve Arnocsky

Meniscal Tear Treatment

Conservative

• Often if degenerative tear in older patient

• Similar treatment to mild knee osteoarthritis

• Analgesia

• Physical therapy • General Leg

Strengthening

Surgery

• Operate if internal

derangement

symptoms

• Meniscal repair if

possible

Meniscectomy

• Partial meniscectomy preserves some function

• Partial meniscectomy of 15-34% of meniscus increases contact pressures about 350%

• Arthritis proportional to amount of meniscus removed

• 50 % or greater reduction in contact area

• Increased load/area = degeneration

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Knee Emergencies

1. Neurovascular injury

2. Knee Dislocation

– Associated with

multiple ligament

injuries (posterolateral)

– High risk of popliteal

artery injury

– Needs arteriogram

3. Fractures (open,

unstable)

4. Septic Arthritis

Urgent Orthopedic Referral

• Fracture

• Patellar Dislocation

• “Locked Joint” - unable to fully extend the

knee (OCD or Meniscal tear)

• Tumor

Q2. The most common cause of

acute hemarthrosis is:

1) Patellar fracture

2) Bucket handle meniscal tear

3) Anterior cruciate ligament tear

4) Tibial plateau fracture

5) Hemophilia

Cartilage Damage

Outerbridge Classification, 1961

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Osteoarthritis Patellofemoral Pain

• Excessive compressive forces over articulating surfaces of PFP joint

Mechanism

• Too loose/hypermobile

• Too tight – XS pressure

Symptoms

• Anterior knee pain

• Worse with bending (5x body wt), stairs (3x body wt)

• Crepitus under kneecap

• May sublux if loose

PFP Syndrome

• Tender over facets of

patella

• Apprehension sign

suggests possible

instability

• Merchant view

• X-rays may show lateral subluxation or tilt

• Average sulcus angle 142º

Too Loose?

Hypermobility

• Associated with subluxation of the patellae

• Medial facet more commonly affected

• Medial patellar ligament – Tight in extension and lax

in flexion

– Mean tensile strength of 208 N

– Reconstruction controversial?

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Too Tight?

Popliteal Angle

(Hamstrings)

Thomas

Test (Hip

Flexor) Ely’s

Test (Quads)

Ober’s

Test (ITB)

Lateral hyperpressure

syndrome

Patellar Tendon

• 90% type 1 collagen

• Tendon blends into medial and lateral retinacula

• Thicker distally than proximally

• Insertion strain is 3-4 times greater than in the midsubstance

Woo et al, Injury and repair of the MSK soft tissues, AAOS, 1988.

Iliotibial band friction syndrome

• 10-21% of running overuse injuries

• ITB crosses the lateral femoral epicondyle at 30°

• Not a discrete structure, but a thickened part of the fascia lata

• Associated with “varus” moment at the knee

Treatment Options

Too Loose/Weak

• Strengthen quads (Vastus Medialis Obliquus)

• Correct alignment (+/-orthotics)

• Support (McConnell Taping, Bracing)

Too Tight

• Stretch hamstring, quadriceps, hip flexor

• Strengthen quads, hip abductors

• Correct alignment (+/-orthotics)

Surgical (RARE)

• Last resort

• Lateral release

• Patellar

realignment

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Weak Hip Abductors

(Gluteus Medius)

• Increased varus moment and internal rotation at the knee

Osteoarthritis

Symptoms

• Pain

• Mechanical – Grinding

– Catching

– Locking

– Giving Way

• Swelling

Diagnosis - Radiographs

In

Extensi

on

FWB

XR

Surgical Treatment

Arthroscopy for OA

• Prospective, Randomized Placebo Controlled Study

• 180 Patients

• 165 VA Patients

• Placebo vs Lavage vs

Debridement had similar Knee

Specific Pain Scores at 1 and 2

years follow up

Moseley, New Engl J Med, 2002

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Surgical Treatment

• Prospective, Randomized

Controlled Study

• N = 86 vs 86 controls

• Patients randomly assigned to

surgical lavage and arthroscopic

débridement + optimized

physical and medical therapy

versus physical and medical

therapy alone Kirkley, New Engl J Med, 2008

RCT 2008 Arthroscopy for OA

• No difference in outcomes: WOMAC, SF-36 Physical component

summary score

Kirkley, New Engl J Med, 2008

Total Knee Arthroplasty

Meta Analysis – 11 Series

• 3 – 18 yr f/u of 682 Knees

• 93% Good – Excellent

• 11% Complications

• 4% Revision

• 21% Radiolucent Lines

• Survivorship 90 – 95% @ > 10 – 15 yrs

Total Knee Arthroplasty

159 pts (2//08 knees)

• 65% Played Sports Pre-Op, RTS

• Lower Impact Level – Bowling 91%

– Golf 57%

– Tennis 20%

– Bradbury, AJSM 1998

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Q3. Which of the following can

cause shoulder impingement:

1) AC joint osteoarthritis

2) Rotator cuff tear partial tear

3) Rotator cuff full-thickness tear

4) Shoulder instability

5) Bicipital tendinopathy

Shoulder Pain Differential

Diagnosis

• Rotator cuff tendinopathy

• Rotator cuff tears

• SLAP Lesion

• Calcific tendinopathy

• “Frozen” shoulder (adhesive capsulitis)

• Acromioclavicular joint problems

• Scapular weakness

• Cervical radiculopathy

Mechanism

• Impingement under

acromion with flexion

and internal rotation of

the shoulder

• Rotator cuff,

subacromial bursa and

biceps tendon

Shoulder Impingement Syndrome Impingement Symptoms Problems with:

• Overhead activities?

• Sleep?

• Putting on a jacket?

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MOVE

Flexion and External

rotation

Painful Arc 60 - 120°

Impingement Signs

Neer

• Passive full flexion

• Positive is

reproduction of

shoulder pain

Sens = 83 %

Spec = 51 %

PPV = 40 %

NPV = 89 %

MacDonald et al. J Shoulder

Elbow Surg, 2000; 9: 299-301.

Impingement Signs

Hawkin’s test

• Flex shoulder to 90º

• Flex elbow to 90º

• Internally rotate

• Positive - reproduce

shoulder pain

Sens = 88 %

Spec = 43 %

PPV = 38 %

NPV = 90 % MacDonald et al. J Shoulder

Elbow Surg, 2000; 9: 299-301.

Impingement Signs

• Spurling’s test for

cervical radiculopathy

Sens = 64%

Spec = 95%

PPV = 58%

NPV = 96%

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Rotator Cuff Tear vs Tendinosis?

• Difficulty lifting

– Pain vs weakness ?

• Drop arm sign

• Fail conservative Tx

• Tears uncommon < 40

y.o.

Sens = 10 %

PPV = 100 % Bryant et al. J Shoulder Elbow

Surg, 2002; 11: 219-224.

Rotator Cuff strength testing

Supraspinatus

• Empty can

• Thumbs down abducted

to 90º

• Horizontally adduct to 30º

For tendonitis

Sens = 77 %

Spec = 38 % For tears,

Sens = 19 %

Spec = 100 % Naredo et al. Ann Rheum Dis,

2002; 61: 132-136.

Rotator Cuff strength testing

Infraspinatus/teres minor -

External rotation

• Keep elbows at 90º

• Patte’s test at 90º

shoulder abduction

For tendonitis,

Sens = 57 %

Spec = 71 % For tears,

Sens = 36 %

Spec = 95 %

Naredo et al. Ann Rheum Dis,

2002; 61: 132-136.

X-ray AP Scapula

• Avulsion

• Calcific tendinosis

• Enthesopathy

(traction spurs)

• Alignment

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Ultrasound

• Dynamic test

• Operator dependent

• Areas of tendinosis

hypoechoic

• Tears

MRI

Tear

How good for full thickness tears?

•69 to 100 percent sensitive

•88 to 100 percent specific

Tendoninopathy Treatment

Conservative

• Education

• Initial – Sling, Pain control, Actvity modification

• Physical Therapy or home exercise program for 6 – 12 weeks

• If need significant pain relief, consider MRI or steroid injection – slightly better than placebo

(Cochrane Database, 2004)

Surgery

• If full thickness rotator cuff tear suspected, send within 2 weeks

• If rotator cuff tear > 1 cm

• If patient fails conservative treatment for > 6-12 months

• Depends on different factors including age, demand and size of tear

• Subacromial decompression

+/- bursectomy

+/- rotator cuff repair

Rotator Cuff Tear Treatment

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Q4. The best test to identify a

frozen shoulder is:

1) Passive internal rotation

2) Passive external rotation

3) O’Brien’s test (labral test)

4) Pain with resisted supraspinatus testing

5) Decreased sensation in all fingers on the

affected side

6) An axillary temperature

Adhesive Capsulitis

“Frozen Shoulder”

• Women greater than

men (70%)

• Age > 40 years

• Affects 2-5 % of

population

• 20-30% develop

symptoms in opposite

shoulder

Frozen Shoulder

• Gradual loss of range of

motion

• May have had initial trauma

• Pain at the extremes of

motion

• May have history of

diabetes, hypothyroidism,

rheumatoid arthritis

Diagnosis

• Limited range of

motion (usually lose

external rotation,

abduction and flexion)

• Investigations (X-ray,

Ultrasound) usually

negative

20

MOVE

Flexion and External

rotation

Painful Arc 60 - 120°

MOVE

External rotation Internal rotation

Natural History

• 0-3 months “typically gradual onset” - painful

• 2-9 months “ freezing”

• 4-12 months “ frozen”

• 5-26 months “thawing”

• Usually self-limited Hannafin & Chiaia, Clin Orthop Rel Res, 2000

Adhesive Capsulitis Treatment

Conservative

• Education and reassurance

• May take 24 months to

unthaw

• Physical therapy

• Oral NSAIDs (or steroids)

• Glenohumeral injection +/-

capsular distension

Surgery

• Exam and

manipulation under

anesthesia

• Arthroscopic release

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Stability Tests

Apprehension test - caution if acute dislocation

• Abduct shoulder to 90°

• Externally rotate arm

Sens = 69 %

Spec = 50 %

For labral tear Rowe CR, Zarins B. J

Bone Joint surg Am,

1981; 63: 863-872.

Stability Tests

Sulcus sign (MDI)

No Sens / Spec

Data

Labral Test (O’Brien Test) Step 2: Palm Up Step 1: Palm Down

For AC joint pathology, +

pain over AC joint

Sens = 100 % Spec = 97 %

For labral tear, + pain

deep in shoulder

Sens = 67-69 % Spec = 41-50 %

Shoulder “Dislocation”

History

• Hit or fall with arm

in abduction

• Shoulder “came

out”

• Still dislocated or

spontaneously

reduced

• How long has it

been dislocated?

Symptoms

• “Dead arm” (due to traction on brachial plexus)

• Pain anteriorly

• Limited motion

• May have decreased sensation to army patch (axillary nerve)

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X-ray and MRI

Hill Sachs Lesion – compression

fracture of posterior humerus

Bankart Lesion – Avulsion of

capsular attachment to the glenoid

Complications after Dislocation

Acute rotator cuff tear

• 40 to 60% incidence of in patients > 40 years old

Frozen shoulder

• Older the patient the stiffer they get mobilize early within 2-3 weeks

Recurrent dislocation

• >90% recurrence < 20 years; 14% > 40 yrs Rowe CR. Prognosis in dislocation of the shoulder. J Bone Joint

Surg Am, 1956.

• Early surgical stabilization still controversial

Initial Treatment

• Sling x 2-4 weeks

with pendulum

exercises

• Early physical therapy

• Modification of

activities

Treatment for Shoulder Instability

• T – Traumatic

• U – Unilateral

• B – Bankart lesion

• S – Surgical

treatment (refer for consultation)

• A – Atraumatic

• M – Multidirectional

• B – Bilateral

• R – Rehabilitation

• I – Inferior capsular

shift

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You may not have seen it, but it

has seen you. • Problem with Look,

Feel, Move ?

• Worry especially if problems greater than 6 months

• No relief or worse with physiotherapy

• Internal derangement symptoms

Everyone will get OA in the knees and rotator cuff problems in the shoulder – Eventually !!!

3rd UCSF Primary Care Sports Medicine

conference

November 21-22, 2008 in San Francisco

St. Francis Hotel