GH Joint Stabilizers Static stabilizers – Glenohumeral ligaments, Glenoid labrum and Capsule Dynamic stabilizers – Predominantly Rotator Cuff muscles – Scapular Stabilizers Trapezius, leavator scapulae, serratus anterior, rhomboids – 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 capsule)
Glenoid Labrum Fibrous ring attached to the glenoid articular surface through a fibrocartilagenous transition zone The labrum functions as an anchor point for the GH ligaments and the biceps tendon Deepens the glenoid socket and enhances stability 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 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 rotation – 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 capsule)
Dynamic Stabilizers The RTC muscles as well as the scapular rotators contribute to stabilization by enhancing the concavity–compression mechanism. Contraction of the long head of the biceps tendon Coordinated scapulothoracic rhythm Proprioceptive mechanoreceptors in the joint capsule
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 tendinitis 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 rotated It may be present even with the arm at rest Tenderness is felt at the anterior edge of the acromion 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 pathology 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 Tear)
Stage 1 (Sub-Acute Tendonitis, Painful Arc Syndrome) Acute bursitis with subacromial edema and hemorrhage 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 impingement. 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 avoided 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 Occasionally This progresses to a rapidly destructive arthropathy Milwaukee shoulder (named after the city where it was first described
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 shoulder 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 examination
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 MRI 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 well- controlled pain, non-operative measures are adequate.
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 process – reducing any bony excrescences at the acromioclavicular joint – Repairing rotator cuff tear if present This can be achieved by open surgery or arthroscopically
Postoperative Management Pendulum exercises are started within 2 days after surgery. This is followed by passive range of motion and active- assisted 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 tendinitis 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
Treatment Conservative first (success in 90%) NSAID Subacromial injection of corticosteroids Physiotherapy 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 tendon A curette is then used to milk out the toothpaste- like calcium deposit. A subacromial decompression is also usually performed
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 below 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 positive
Treatment 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.
Treatment Isolated tears in elderly patients need no treatment 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 muscle) MRI helps to confirm the diagnosis
Treatment 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 – Diabetes – Dupuytren’s disease – Hyperlipidaemia, – Hyperthyroidism, – 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 normal 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’).
Treatment Conservative treatment Aims to relieve pain and prevent further stiffening while recovery is awaited Stretching NSAID 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 first, – Then abduction and flexion – Then cross body adduction Surgical Treatment: – Arthroscopic capsular release
Tennis Elbow (Lateral Epicondylagia) Was wrongly named Lateral Epicondylitis 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 extension
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 extension. 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 origin.
Treatment 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 cases.
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 (FCU) 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 (gout) 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 elbow Painless swelling if not infected
Infected bursitis is seen in gymnasts Painful, errythematous and warm Staff aureus commonest organism In chronic cases bursa is replaced with fibrous tissue Difficult to treat conservatively
Treatment 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 rupture
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
O/E 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.
Imaging 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
Treatment 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 operatively
De Quervain Syndrome Tenosynovitis of the EPB & APL The most common tendinitis of the wrist in athletes Radial-sided wrist pain exacerbated by thumb movements, especially thumb abduction and/or extension Pain may radiate distally or proximally along the course of the APL and EPB tendons
O/E 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
Treatment 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 patients. Complications of corticosteroid injections include depigmentation, fat necrosis, and subcutaneous atrophy. 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 trochanter Related to – Overuse – Wider pelvis seen in women, – A prominent trochanter, – Or in runners who adduct beyond the midline
Treatment 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 activities It is often accompanied by pain Types: Extra-articular – External (by iliotibial band or gluteus maximus over greater trochanter) – Internal (by iliopsoas over AIIS, LT or IPE) Intra-articular (by loose bodies or labral tears)
Causes Extra-articular associated with – Leg length difference (usually the long side is symptomatic), – Tightness in the iliotibial band (ITB) on the longer side – 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 extension. 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 position. Like the internal type, the snapping can be decreased, or eliminated altogether by applying manual pressure over the greater trochanter. Unlike internal snapping, which is typically painless, the external type of snapping is often accompanied by pain secondary to trochanteric bursitis
Imaging X-ray to identify loose bodies MRI Ultrasound
Treatment 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 months.
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 arthroscopically. Postop, these patients will usually undergo extensive physical therapy; regaining full strength may take up to 9–12 months.
Jumper’s Knee (Patellar Tendonitis) Inflammation of the patellar tendon close to the patellar attachment Overuse injury due to explosive jumping 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
Treatment Conservative for Stages 1 & 2 RICE NSAID Strengthening the quadriceps helps to balance the forces across the patella and take pressure off the patellar tendon. 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 (ITBS) 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
O/E 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
Treatment 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 avoided. Proper stretching and warm up as well as periods of rest are encouraged. NSAID 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 is: 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 side.
O/E The joint may be held slightly flexed There is often an effusion In longstanding cases the quadriceps will be wasted. 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 Apley’s Test
Investigations X-ray MRI 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
Treatment 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
ACL The ACL is a two-bundle ligament The cross sectional area of the ACL is approximately 35 mm 2 and the average length is 25 mm. The tension in the two bundles varies with knee flexion; The anteromedial is tight in flexion The posterolateral tight in extension
PCL The PCL is also a two-bundle The two bundles vary in tension with knee flexion The anterolateral is tight in flexion The posteromedial is tight in extension 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 motions 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 point, – Grade 2+ has 5 to 10 mm displacement with no end point, – Grade 3+ has greater than 10 mm displacement
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 extension. 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 leg.
Imaging – X-ray all cases – MRI 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 force. 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 pain Posterior Sag Sign (Gravity Drawer Test) Positive posterior drawer test