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Sports Medicine Workshop Sports Medicine Workshop.

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Presentation on theme: "Sports Medicine Workshop Sports Medicine Workshop."— Presentation transcript:

1 Sports Medicine Workshop Sports Medicine Workshop

2 Shoulder Problem Evaluation

3 Second most common musculoskeletal complaint Second most common musculoskeletal complaint Difficult joint to examine Difficult joint to examine Multidirectional range of motion- UNIQUE! Multidirectional range of motion- UNIQUE! Shoulder injury can affect nearly every sport and many daily activities Shoulder injury can affect nearly every sport and many daily activities

4 Objectives Review pertinent anatomy Review pertinent anatomy Discuss common pathology Discuss common pathology Discuss historical clues to diagnosis Discuss historical clues to diagnosis Select cases Select cases Physical exam in small group discussions Physical exam in small group discussions

5 Bony Anatomy Anterior

6 Bony Anatomy Anterior and Posterior

7 Radiographic Anatomy

8 Where do things go wrong?? Fractures

9 Where do things go wrong?? Dislocations and Separations Dislocations and separations are protected by both “static” and “dynamic” stabilizers…

10 Where do things go wrong?? Dislocations and Separations Oh, yeah…Arthritis can happen at these joints, too…

11 Glenohumeral Joint Shallow (“golf ball sitting on a tee”) Shallow (“golf ball sitting on a tee”) Inherently unstable (maximizes ROM)Inherently unstable (maximizes ROM) Static stabilizers Static stabilizers glenohumeral ligaments, glenoid labrum and capsuleglenohumeral ligaments, glenoid labrum and capsule Dynamic stabilizers Dynamic stabilizers Predominantly rotator cuff musclesPredominantly rotator cuff muscles Also scapular stabilizersAlso scapular stabilizers Trapezius, leavator scapulae, serratus anterior, rhomboids Trapezius, leavator scapulae, serratus anterior, rhomboids

12 Bony Anatomy “Static Stabilizers”

13 What goes wrong… Besides separations and dislocations?? Instability !!!

14 LABRUM

15 What goes wrong? Tears and tendonopathies

16 The Rotator Cuff Muscles “dynamic stabilizers”

17 The Rotator Cuff Muscles SupraspinatusInfraspinatus Teres minorSupscapularis

18 The Rotator Cuff Muscles: SITS Supraspinatus ABDSupraspinatus ABD Infraspinatus ERInfraspinatus ER Teres minor ER Supscapularis IR Depress humeral head against glenoid to allow full abduction

19 Finally…the subacromial space

20 What can go wrong??? Impingement!!!!! !!

21 Impingement

22 Other Anatomy DeltoidDeltoid Rotator cuffRotator cuff Teres majorTeres major Latissimus dorsi Biceps Pectoralis muscles

23 Shoulder Anatomy

24 Don’t forget the scapular stabilizer muscles

25 So…what causes shoulder pain? Impingement Labrum and biceps pathology A-C joint pathology Rotator Cuff Injury Instability Among other things…

26 Clinical Exam History Pain Pain Acute Acute Chronic Chronic Weakness Weakness Deformity Deformity

27 Clinical Exam History Single event Single event Repetitive overload Repetitive overload Instability Instability Does it feel like it’s going to come out?Does it feel like it’s going to come out? Catching/Locking Catching/Locking

28 Clinical Exam History Sport / Occupation Sport / Occupation Previous injury Previous injury Previous treatment Previous treatment Other joints involved Other joints involved Disability Disability

29 Physical Exam: Big 6 Inspection Inspection Palpation Palpation Range of Motion Range of Motion Strength Strength Neurovascular Neurovascular Special Tests Special Tests

30 Special Tests Impingement Impingement Rotator Cuff Integrity Rotator Cuff Integrity Labrum and Biceps Labrum and Biceps AC (SC) Joints AC (SC) Joints Instability Instability

31 Physical Exam The physical exam will be demonstrated during small group discussions…

32 Which rotator cuff muscle(s) are responsible for external rotation Supraspinatus Infraspinatus Subscapularis Teres Minor Both 2 and 4

33 The apex (bottom) of the scapula is at what level of the spine? C T T T L4

34 Case #1 22-year-old male rugby player falls onto his right shoulder while being tackled 22-year-old male rugby player falls onto his right shoulder while being tackled Severe pain on top of his right shoulder Severe pain on top of his right shoulder

35 Case #1 Notable deformity over superior shoulder Notable deformity over superior shoulder Painful range of motion Painful range of motion Unable to lift right arm above waistUnable to lift right arm above waist Special Tests?? Special Tests?? Diagnosis??? Diagnosis???

36 Acromioclavicular (A-C) Sprain Special Tests Special Tests Shear TestShear Test Cross Arm TestCross Arm Test A-C PalpationA-C Palpation Resisted ExtensionResisted Extension Active compression testActive compression test

37 Acromioclavicular (A-C) Sprain Damage to A-C joint ligaments Damage to A-C joint ligaments Pain and/or deformity over A-C joint Pain and/or deformity over A-C joint Graded I-VI Graded I-VI I-III usually treated non-operativelyI-III usually treated non-operatively IV-VI referred to orthopedic surgeryIV-VI referred to orthopedic surgery

38 AC Joint Sprain Treatment Analgesics, ice prn Sling for as long as needed Physical Therapy ROM restoration Gradual strength exercise Return to sport activity as tolerated

39 Case #2 24-year-old male handball player 24-year-old male handball player Fell onto his shoulder after being pushed Fell onto his shoulder after being pushed Intense pain Intense pain Hand is tingling and arm feels like it’s hanging Hand is tingling and arm feels like it’s hanging X-rays X-rays

40 X RAYS DIAGNOSIS???

41 Shoulder Dislocation/Anterior Instability Humeral head dislocates from glenoid fossa Humeral head dislocates from glenoid fossa Almost always anterior (95%) Almost always anterior (95%) Usually traumatic with injury to capsule-labrum complex Usually traumatic with injury to capsule-labrum complex

42 Shoulder Dislocation/Anterior Instability Treatment Treatment Reduction of dislocationReduction of dislocation Protection & rehab, rehab, rehabProtection & rehab, rehab, rehab Most will have future dislocations and/or instabilityMost will have future dislocations and/or instability At least 70%!!! (young) At least 70%!!! (young) May require surgical tightening/repair of the capsule/labrum complexMay require surgical tightening/repair of the capsule/labrum complex

43 Special Tests Glenoid Labrum and Instability Biceps Load I and II Kim Test Jerk Test Active-Compression Test (O’Brien) Crank Test Apprehension Test Relocation Test Load and Shift Sulcas Sign

44 Which of the following structures can be “impinged”? Biceps tendon Subacromial Bursa Rotator Cuff Tendons All of the above

45 Case #3 35-year-old male tennis player 35-year-old male tennis player Shoulder pain exacerbated by practicing serves Shoulder pain exacerbated by practicing serves Develops dull, aching pain in right shoulder Develops dull, aching pain in right shoulder

46 SHOULDER PAIN Physical Exam Tenderness to palpation anterior shoulder Tenderness to palpation anterior shoulder Pain with abduction starting around 90 degrees Pain with abduction starting around 90 degrees Unable to lift arm past 120 degrees Unable to lift arm past 120 degrees Pain with forward flexion at degrees Pain with forward flexion at degrees Special Tests??? Diagnosis??? Special Tests??? Diagnosis???

47 Shoulder Pain Physical Exam Hawkin’s positive Hawkin’s positive Neer’s positive Neer’s positive IMPINGEMENT??? IMPINGEMENT???

48 Impingement as a Clinical Sign Repetitive overhead activities Repetitive overhead activities Subacromial bursa and/or rotator cuff impinged between acromion & humerus Subacromial bursa and/or rotator cuff impinged between acromion & humerus Physical therapy, activity modification +/- medications Physical therapy, activity modification +/- medications

49 Diagnoses associated with clinical sign of Rotator Cuff Impingement: Subacromial bone spurs and / or bursal hypertrophy Subacromial bone spurs and / or bursal hypertrophy AC joint arthrosis and /or bone spurs AC joint arthrosis and /or bone spurs Rotator cuff disease Rotator cuff disease Superior labral injury Superior labral injury Glenohumeral instability Glenohumeral instability Scapular dyskinesis Scapular dyskinesis Biceps tendinopathy Biceps tendinopathy A diagnostic injection sometimes helps to clarify the diagnosis

50 Case #4 45-year-old weight lifter 45-year-old weight lifter Caught bar as it was falling off his shoulder Caught bar as it was falling off his shoulder Sudden pain Sudden pain Severe weakness left shoulder Severe weakness left shoulder Worse with overhead activities; while sleeping at night Worse with overhead activities; while sleeping at night Pain in anterior lateral shoulder Pain in anterior lateral shoulder Special tests? Special tests?

51 Case #4 Drop Arm Test Positive Drop Arm Test Positive External Rotation Lag Sign positive External Rotation Lag Sign positive Weakness with Empty Can Sign Weakness with Empty Can Sign Normal bear hug and belly press tests… Normal bear hug and belly press tests… Diagnosis????? Diagnosis?????

52 Rotator Cuff Tear Supraspinatus tendon most common Supraspinatus tendon most common Acute trauma or chronic tendinopathy Acute trauma or chronic tendinopathy Treatment dependent upon age/activity Treatment dependent upon age/activity Young, active usually require operative treatmentYoung, active usually require operative treatment Older, low-activity usually respond to non-operative treatmentOlder, low-activity usually respond to non-operative treatment

53 Case #5 42-year-old female with dull pain right shoulder 42-year-old female with dull pain right shoulder Pain is diffuse in nature Pain is diffuse in nature Sometimes spreads to between shoulder blades Sometimes spreads to between shoulder blades Seems worse at night Seems worse at night

54 Physical Exam Obese, pleasant female Obese, pleasant female Diffuse pain Diffuse pain Normal shoulder exam Normal shoulder exam Not able to reproduce pain during exam Not able to reproduce pain during exam What else do you want to do??? What else do you want to do???

55 Shoulder pain isn’t always the shoulder!! Get more history… Gall bladder disease Gall bladder disease Peptic Ulcer Disease Peptic Ulcer Disease Cervical radiculopathy Cervical radiculopathy Cardiac ischemia Cardiac ischemia Pulmonary conditions Pulmonary conditions ie Pancoast’s tumor, Pneumoniaie Pancoast’s tumor, Pneumonia

56 In the human body, which is the most incredible joint? PIP Knee Ankle Shoulder None of the above

57 Case #6 40-year-old male 40-year-old male Recently shoveled 16” of snow Recently shoveled 16” of snow Can hardly lift left arm due to pain Can hardly lift left arm due to pain Special Tests? Diagnosis? Special Tests? Diagnosis?

58 Biceps Tendonopathy Speed Test Speed Test Yergason Test Yergason Test Direct palpation Direct palpation

59 Biceps Tendonopathies Repetitive overhead activity Repetitive overhead activity Repetitive forearm flexion/supination Repetitive forearm flexion/supination Difficult to discern from rotator cuff tendinopathy or impingement Difficult to discern from rotator cuff tendinopathy or impingement

60 Conclusion Shoulder injuries are common. Shoulder injuries are common. Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis. Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis. Impingement is a clinical sign, not a diagnosis. Impingement is a clinical sign, not a diagnosis. Don’t forget about medical causes. Don’t forget about medical causes.

61 Physical Exam Inspection Front & back Front & back Height of shoulder and scapulae Height of shoulder and scapulae Muscle atrophy, asymmetry Muscle atrophy, asymmetry

62 Physical Exam Range of Motion Abduction o Abduction o

63 Physical Exam Range of Motion Forward flexion: Forward flexion: 0 o – 180 o0 o – 180 o

64 Physical Exam Range of Motion Extension Extension 0 o – 40 to 60 o0 o – 40 to 60 o

65 Physical Exam Range of Motion Internal rotation Internal rotation T5 segmentT5 segment External rotation External rotation o80-90 o

66 Physical Exam Strength Empty can test Empty can test 30 o angle30 o angle Steady downward pressureSteady downward pressure Tests supraspinatus strength and painTests supraspinatus strength and pain

67 Physical Exam Strength Resisted external rotation Resisted external rotation Tests infraspinatus, teres minor strengthTests infraspinatus, teres minor strength

68 Physical Exam Strength of Subscapularis Liftoff testBelly press test

69 Cross-Arm Adduction Test AC joint pathology AC joint pathology Arm flexed to 90° Arm flexed to 90° Hyperadduct arm across body as far as possible Hyperadduct arm across body as far as possible Pain in AC = (+) test Pain in AC = (+) test

70 A-C Shear Test Interlock fingers with hand on distal clavicle and spine of scapula Interlock fingers with hand on distal clavicle and spine of scapula Pain in A-C joint when hands squeezed together = (+) test Pain in A-C joint when hands squeezed together = (+) test

71 Sulcus Sign Inferior instability Inferior instability Arm relaxed in neutral position, pull downward at elbow Arm relaxed in neutral position, pull downward at elbow (+) test = sulcus at infra-acromial area (+) test = sulcus at infra-acromial area compare to unaffected sidecompare to unaffected side

72 Apprehension Test Anterior instability Anterior instability Shoulder at 90° abducted, slight anterior pressure & External rotation Shoulder at 90° abducted, slight anterior pressure & External rotation (+) test = dislocation apprehension (+) test = dislocation apprehension some false (+)some false (+)

73 Relocation Test Perform after positive apprehension test Perform after positive apprehension test Apply post force over humeral head during external rotation (ER) Apply post force over humeral head during external rotation (ER) (+) test = increased ER tolerance (+) test = increased ER tolerance

74 Load & Shift Test Test for multidirectional instability Test for multidirectional instability Grasp humeral head, slide anteriorly and posteriorly while securing rest of shoulder Grasp humeral head, slide anteriorly and posteriorly while securing rest of shoulder (+) if greater than 50% displacement (graded 1-3) (+) if greater than 50% displacement (graded 1-3)

75 Impingement Signs HawkinsNeer

76 Drop Arm Test Suggestive of Rotator Cuff Tear Passive abduction to 90° Passive abduction to 90° Instruct patient to slowly lower arm Instruct patient to slowly lower arm At 90° abducted arm will suddenly drop, may need to add slight pressure At 90° abducted arm will suddenly drop, may need to add slight pressure (+) drop = (+) test (+) drop = (+) test

77 Speed’s Test Biceps Tendinopathy Long head of biceps tendonitis Long head of biceps tendonitis Fwd flex to 90°, abd 10°, full supination Fwd flex to 90°, abd 10°, full supination Apply downward force to distal arm Apply downward force to distal arm Pain = (+) test Pain = (+) test weakness w/o pain = muscle weakness or ruptureweakness w/o pain = muscle weakness or rupture

78 O’Brien’s Active Compression SLAP lesion (Superior Labrum Antero-Posterior) Labral/AC pathology Labral/AC pathology Arm flexed to 90°, elbow extended, adduct 10-15°, resist downward force Arm flexed to 90°, elbow extended, adduct 10-15°, resist downward force + if AC pain or internal pain/click + if AC pain or internal pain/click

79 O’Brien’s Active Compression SLAP lesion Supination should be pain free (decreased pain) Supination should be pain free (decreased pain)

80 Crank Test Labral injury Glenoid labrum tear Glenoid labrum tear Abduct arm to 160°, pt is supine or upright, elbow secured with one hand axial load at shoulder with other Abduct arm to 160°, pt is supine or upright, elbow secured with one hand axial load at shoulder with other (+) if audible/painful catch/grind is noted (+) if audible/painful catch/grind is noted

81 Knee Problems

82 Anatomy Review

83 Femur Femur Medial & lateralMedial & lateral Condyles Condyles Epicondyles Epicondyles Trochlear grooveTrochlear groove Intercondylar notchIntercondylar notch Patella Patella Superior pole (base)Superior pole (base) Inferior pole (apex)Inferior pole (apex) Medial & lateral facetsMedial & lateral facets Tibia Tibia Medial & lateralMedial & lateral Condyles Condyles Gerdy’s tubercleGerdy’s tubercle Pes anserine areaPes anserine area Tibial tuberosityTibial tuberosity Tibial plateauTibial plateau Tibial spinesTibial spines Fibula Fibula HeadHead NeckNeck

84 Anatomy – Major Ligaments & Tendons Quadriceps tendon Quadriceps tendon Patellar tendon Patellar tendon Medial & lateral patellar retinaculua Medial & lateral patellar retinaculua

85 MCLLCL MCLLCL

86 ACL and PCL

87 Iliotibial band (ITB)

88 Anatomy – Menisci of the Knee Medial meniscus Medial meniscus Lateral meniscus Lateral meniscus Meniscal ligamentsMeniscal ligaments Functions of the menisciFunctions of the menisci Meniscal zones Meniscal zones White-whiteWhite-white Red-whiteRed-white Red-redRed-red

89 Knee Exam Overview Inspection Inspection Palpation Palpation Range of Motion Range of Motion Strength Strength Neurovascular Neurovascular Special Tests Special Tests

90 Case 1 – Medial Right Knee Pain 16yo HS soccer player, previously healthy 16yo HS soccer player, previously healthy Tackled from right side while running Tackled from right side while running Immediate onset of medial jt line pain Immediate onset of medial jt line pain Delayed onset local medial edema, stiffness Delayed onset local medial edema, stiffness Able to bear weight Able to bear weight

91 Key Questions in the History Mechanism of Injury? Mechanism of Injury? Acute or Chronic? Acute or Chronic? Location and level of pain? Location and level of pain? Able to walk? Able to walk? Mechanical Symptoms? (Locking, popping, catching?) Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Associated instability? Swelling? Swelling? Previous injuries or surgeries? Previous injuries or surgeries?

92 Case 1 - Exam Inspection: Mild medial knee edema Inspection: Mild medial knee edema Palpation: + ttp medial knee Palpation: + ttp medial knee ROM: can’t bend >80d ROM: can’t bend >80d Strength: mildly decreased Strength: mildly decreased Neurovascular: normal Neurovascular: normal Special tests: Special tests: Neg Lachman, Anterior Drawer, McMurray, varus stressNeg Lachman, Anterior Drawer, McMurray, varus stress + mild increased gap on valgus stress (compared to left) with good endpoint + mild increased gap on valgus stress (compared to left) with good endpoint

93 Special Tests - ACL Injury Lachman Test Lachman Test

94 Special Tests - PCL Injury Posterior Drawer Test Posterior Drawer Test Sag Sign Sag Sign Quad-Active Test Quad-Active Test

95 Varus/Valgus stress for LCL and MCL Injury

96 Features that should prompt an xray after acute knee injury include: Unable to bear weight Can’t flex >90d Patella TTP Fibular head TTP Age All of the above

97 5 Ottawa Knee Rules i.e. When to order a knee xray after acute injury Age > 55 or 55 or < 18 Unable to walk Unable to walk TTP on PATELLA TTP on PATELLA TTP on FIBULAR HEAD TTP on FIBULAR HEAD Unable to flex 90 deg Unable to flex 90 deg

98 Case 1 - Imaging

99 Case 1 – Differential Diagnosis More Likely Less Likely Meniscal Tear Meniscal Tear Ligamentous Injury Ligamentous Injury Which ligament?Which ligament? ACL ACL PCL PCL MCL MCL LCL LCL Muscle Strain Muscle Strain Fracture Fracture Patellofemoral Pain Patellofemoral Pain Plica Plica

100 MCL Sprain

101 What grade of sprain is likely present of the MCL? Grade 1: no laxity, but hurts Grade 2: mild laxity, still intact Grade 3: complete tear Grade 4: hurts like *^%*

102 MCL Sprain Treatment? Treatment? RICERICE Relative RestRelative Rest Hinge Brace only if unstable on examHinge Brace only if unstable on exam Achieve full ROMAchieve full ROM Progressive StrengtheningProgressive Strengthening Neuromuscular Control (Balance exercises)Neuromuscular Control (Balance exercises) Functional Exercises (Sport-specific)Functional Exercises (Sport-specific)

103 Case 2 56 yo retired Army LTC 56 yo retired Army LTC 15 years worsening L>R knee pain 15 years worsening L>R knee pain Former parachutist, no specific trauma Former parachutist, no specific trauma No previous knee surgeries No previous knee surgeries Stiffness worse in morning Stiffness worse in morning Pain is worse with activity, better with rest Pain is worse with activity, better with rest

104 Case 2 – Key Questions Mechanism of Injury? Mechanism of Injury? Acute or Chronic? Acute or Chronic? Where/how bad is pain? Where/how bad is pain? Mechanical Symptoms? (Locking, popping, catching?) Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Associated instability? Swelling? Swelling? Previous injuries or surgeries? Previous injuries or surgeries? What makes it worse? What makes it worse? What makes it better? What makes it better? Insidious Onset Insidious Onset Chronic Chronic Difficult to localize; mild Difficult to localize; mild No No None None Occasional Occasional Lots of “Bad Landings” No surgery Lots of “Bad Landings” No surgery Activity Activity Rest Rest

105 Case 2 – Physical Exam Inspection: Inspection: Genu varusGenu varus Bony enlargement at Med/Lat joint linesBony enlargement at Med/Lat joint lines Palp: Posterior medial joint line ttp Palp: Posterior medial joint line ttp ROM: Decreased flexion, 110 deg, mild crepitus ROM: Decreased flexion, 110 deg, mild crepitus Strength: normal Strength: normal Neurovascular: normal Neurovascular: normal Special Tests: no ligamentous laxity, neg meniscal tests Special Tests: no ligamentous laxity, neg meniscal tests

106 Special Tests - Meniscal Injuries Joint line tenderness Joint line tenderness McMurray Tests McMurray Tests Thessaly test Thessaly test Bounce-home test Bounce-home test Full Squat Full Squat

107 Case 2 – Plain Films Joint space narrowing Subchondral Sclerosis Osteophytes Subchondral Cysts

108 What is your diagnosis? 1. Meniscal tear 2. Plica syndrome 3. Osteoarthritis 4. Bone tumor

109 Osteoarthritis Nonpharmacologic Treatment: Nonpharmacologic Treatment: Nonpainful aerobic activityNonpainful aerobic activity Weight lossWeight loss Physical TherapyPhysical Therapy Improve ROM, increase strength Improve ROM, increase strength BracingBracing Pharmacologic Treatment: Pharmacologic Treatment: APAP Supplements Glucosamine and Chondroitin NSAIDs, COX-2’s Tramadol Viscosupplementation Intrarticular Steroids

110 Case 3 31 year old female, L knee pain 31 year old female, L knee pain Recreational runner Recreational runner Localizes pain to front of knee Localizes pain to front of knee No trauma, insidious onset No trauma, insidious onset Localizes pain “around kneecap” Localizes pain “around kneecap” Worse with stairs Worse with stairs Worse after prolonged sitting Worse after prolonged sitting Knee occasionally “gives out” Knee occasionally “gives out”

111 Case 3 – Key Questions Mechanism of Injury? Mechanism of Injury? Acute or Chronic? Acute or Chronic? Where is the pain? Where is the pain? Mechanical Symptoms? (Locking, popping, catching?) Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Associated instability? Swelling? Swelling? Previous injuries or surgeries? Previous injuries or surgeries? What makes it worse? What makes it worse? What makes it better? What makes it better? Insidious Onset Insidious Onset Chronic Chronic Anterior knee Anterior knee No, but sometimes gives out No, but sometimes gives out None None Running, Stairs Running, Stairs Multiple days of rest Multiple days of rest

112 Physical Exam Inspection: mild genu valgus Palpation: TTP lateral > medial patellar facets ROM: full w/o pain Strength: normal Neurovascular: normal Special Tests: + patellar grind Decreased patellar glide Inflexible hamstrings (Popliteal angle)

113 Patellofemoral Joint Exam

114 Patellar Grind Test Patellar Grind Test

115 Case 3 – Plain Films AP Lateral

116 Case 3 – Plain Films Tunnel Sunrise

117 What’s your diagnosis? Patellar tendinopathy Patellar instability Patellofemoral syndrome Plica syndrome

118 Patellofemoral Syndrome Treatment: Treatment: Relative rest; non-painful aerobicsRelative rest; non-painful aerobics Physical TherapyPhysical Therapy Improve Quad/Hamstring flexibility Improve Quad/Hamstring flexibility Quad, Hip abductor strengthening Quad, Hip abductor strengthening Core strengthening Core strengthening Patellar stabilization brace/tapingPatellar stabilization brace/taping Foot orthoticsFoot orthotics Surgery (last-ditch effort)Surgery (last-ditch effort)

119 Case 4 34 yo Army MAJ training for 1 st marathon 34 yo Army MAJ training for 1 st marathon Atraumatic onset of R lateral knee pain 1 week ago after 10 mile run Atraumatic onset of R lateral knee pain 1 week ago after 10 mile run Sharp burning pain Sharp burning pain Better with rest, returns with running Better with rest, returns with running

120 Case 4 – Key Questions Mechanism of Injury? Mechanism of Injury? Acute or Chronic? Acute or Chronic? Where is the pain? Where is the pain? Mechanical Symptoms? (Locking, popping, catching?) Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Associated instability? Swelling? Swelling? Previous injuries or surgeries? Previous injuries or surgeries? What makes it worse? What makes it worse? What makes it better? What makes it better? Insidious Onset Insidious Onset Acute Acute Lateral knee Lateral knee No, but sometimes gives out No, but sometimes gives out None None Running Running Multiple days of rest Multiple days of rest

121 Physical Exam Inspection: normal Palpation: TTP over lateral femoral condyle ROM: full Strength: normal Neurovascular: normal Special tests: + Noble test Tight on Ober test

122 Ober testNoble test

123 What’s your diagnosis? Osteoarthritis Meniscal tear Iliotibial band syndrome LCL sprain

124 Iliotibial Band Syndrome Treatment: Treatment: Ice massage, pain medsIce massage, pain meds Relative Rest; nonpainful activityRelative Rest; nonpainful activity Physical TherapyPhysical Therapy Specific ITB stretches Specific ITB stretches Hip abductor strengthening Hip abductor strengthening Core strengthening (Gluteus Medius) Core strengthening (Gluteus Medius) Slow return to activitySlow return to activity Extrinsic factors: shoes, running surface, training errorsExtrinsic factors: shoes, running surface, training errors

125 What the heck is a Plica? Congenital thickening of joint capsule Redundant meniscus Loose piece of intra- articular cartilage Figment of my imagination

126 Plica Syndrome?

127

128 Special Tests - ACL Injury Lachman Test Lachman Test Knee flexed to degreesKnee flexed to degrees Stabilize distal femurStabilize distal femur Anteriorly translate tibia on femurAnteriorly translate tibia on femur Watch & feel for amount of translation & end pointWatch & feel for amount of translation & end point Pivot Shift Pivot Shift

129 Special Tests - PCL Injury Posterior Drawer Test Posterior Drawer Test Knee flexed to 90 degreesKnee flexed to 90 degrees Posteriorly translate tibia on femurPosteriorly translate tibia on femur Watch & feel for amount of translation & end pointWatch & feel for amount of translation & end point Sag Sign Sag Sign Knees flexed, quads relaxedKnees flexed, quads relaxed  compare both sides Look for tibial posterior “sag” relative to femurLook for tibial posterior “sag” relative to femur Quad-Active Test Quad-Active Test Knee flexed; hamstrings fully relaxedKnee flexed; hamstrings fully relaxed Slide foot along table (quad active)Slide foot along table (quad active) Observe for anterior relocationObserve for anterior relocation

130 Special Tests - MCL Injury Valgus Stress Testing Valgus Stress Testing Knee flexed to 30 degreesKnee flexed to 30 degrees Relax ACL/PCL & joint capsule Relax ACL/PCL & joint capsule Valgus stress applied to kneeValgus stress applied to knee Look and feel for translation and endpointLook and feel for translation and endpoint Compare to uninjured sideCompare to uninjured side May repeat with knee in full extensionMay repeat with knee in full extension

131 Special Tests - LCL Injury Varus Stress Testing Varus Stress Testing Same test as valgus stress testingSame test as valgus stress testing Except applying a varus stress insteadExcept applying a varus stress instead LCL, IT band, & PLC are testedLCL, IT band, & PLC are tested

132 Special Tests - Meniscal Injuries Joint line tenderness Joint line tenderness Full Squat Full Squat McMurray Tests McMurray Tests Thessaly test Thessaly test Bounce-home test Bounce-home test

133 McMurray test for Meniscal injury Test Med and Lat meniscus separately Test Med and Lat meniscus separately 3 concurrent maneuvers: 3 concurrent maneuvers: Grind it (Rotate tibia AWAY from it)Grind it (Rotate tibia AWAY from it) Crunch it (varus or valgus)Crunch it (varus or valgus) Pinch it (flex/extend knee)Pinch it (flex/extend knee) Positive: Painful “pop” Positive: Painful “pop”

134 Special Tests - Meniscal Injuries Thessaly Test Thessaly Test Pt stands on affected legPt stands on affected leg Knee bent at 20 degreesKnee bent at 20 degrees Examiner holds pt’s hands and rotates pt to both sidesExaminer holds pt’s hands and rotates pt to both sides Meniscal grind Meniscal grind Positive test: pain, painful click.Positive test: pain, painful click.

135 Anterior Knee Exam Palpation of patellar facets Glide and lift patella medially & laterally Glide and lift patella medially & laterally Palpate undersurface of patella for tenderness Palpate undersurface of patella for tenderness

136 Patellar Exam Patellar GlidePatellar Glide Knee in extension, relaxed Knee in extension, relaxed Medial & lateral patellar displacement Medial & lateral patellar displacement Measured in quadrantsMeasured in quadrants Normal: 1-2 quadrants Normal: 1-2 quadrants Patellar Apprehension Patellar Apprehension Lateral patellar displacement Lateral patellar displacement  patient apprehension or guarding or guarding

137 Anterior Knee Exam Patellar Grind Test Patellar Grind Test Knee 10 deg flexion Knee 10 deg flexion Glide patella distally, and firmly compress patella against trochlear groove Glide patella distally, and firmly compress patella against trochlear groove Active quadriceps contraction  pain Active quadriceps contraction  pain

138 Special Tests – Ober’s Test Lateral decubitus with testing side up, testing knee flexed Lateral decubitus with testing side up, testing knee flexed Adduct and fully flex hip  Abduct, externally rotate, & extend hip Adduct and fully flex hip  Abduct, externally rotate, & extend hip Slowly release support against gravity from leg, allowing gravity to take leg towards table Slowly release support against gravity from leg, allowing gravity to take leg towards table Positive test: leg remains abducted despite examiner releasing leg Positive test: leg remains abducted despite examiner releasing leg

139 Special Tests Noble’s test Noble’s test Palpate lateral femoral condylePalpate lateral femoral condyle Flex and Extend KneeFlex and Extend Knee + Test is pain at site of palpation+ Test is pain at site of palpation


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