1. Rotator Cuff Disorders

2. Glenohumeral Joint Shallow (“golf ball sitting on a tee”)
Inherently unstable (maximizes ROM)

3. Radiographic Anatomy 3

4. GH Joint Stabilizers Static stabilizers Dynamic 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

5. Static Stabilizers (glenohumeral ligaments, glenoid labrum and capsule)

6. 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

7. GH Capsule

8. GH Ligaments Superior GHL Middle GHL Inferior 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

9. Static Stabilizers (glenohumeral ligaments, glenoid labrum and capsule)

10. 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

11. 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

12. Rotator Cuff Disorders
Supraspinatus impingement syndrome and tendinitis
Tears of the rotator cuff
Acute calcific tendinitis
Biceps tendinitis and/or rupture

13. 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

14. 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

15. 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

16. 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)

17. 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

18. 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.

19. 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

20. 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%

21. 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

22. 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.

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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.

31. 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.

32. 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

33. 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.

34. 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

35. 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.

36. 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.

37. 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

38. 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

39. Rotator Cuff Disorders
Supraspinatus impingement syndrome and tendinitis
Tears of the rotator cuff
Acute calcific tendinitis
Biceps tendinitis and/or rupture

40. 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

41. 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

42. Treatment Conservative first (success in 90%) NSAID
Subacromial injection of corticosteroids
Physiotherapy
Extracorporeal shockwave therapy
Needle aspiration and irrigation (acute cases)

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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.

51. 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.

52. 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

53. 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.

54. 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

55. 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

56. 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’).

57. 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

59. 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

60. 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

61. 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

62. 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.

63. 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

64. 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.

65. 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

66. 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

67. 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

68. 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

69. 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.

70. 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

71. 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

72. 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

73. 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.

74. 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

75. 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

76. 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

77. 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

78. 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

79. Bursitis most commonly is seen about the greater trochanter
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

80. 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

81. 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)

82. 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)

83. 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

84. 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

85. Imaging
X-ray to identify loose bodies
MRI
Ultrasound

86. 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.

87. 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.

88. 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

89. 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

90. 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

91. 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

92. 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

93. 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

94. 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.

95. 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

96. 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

97. 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

98. 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.

99. 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

100. Meniscal Tests
McMurrays’s Test Thessaly’s Test
Apley’s Test

101. 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

102. 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

103. 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

104. ACL The ACL is a two-bundle ligament
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 flexion;
The anteromedial is tight in flexion
The posterolateral tight in extension

105. 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

106. 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

107. 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

108. 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

109. 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

110. 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.

111. Definitive treatment:
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)

112. 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

113. Clinical features Unstable knee Posterior lateral knee pain
Posterior Sag Sign (Gravity Drawer Test)
Positive posterior drawer test