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Sports Medicine Workshop

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

1 Sports Medicine Workshop

2 Shoulder Problem Evaluation

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

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

5 Bony Anatomy Anterior

6 Bony Anatomy Anterior and Posterior

7 Radiographic Anatomy 7

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”)
Inherently unstable (maximizes ROM) Static stabilizers glenohumeral ligaments, glenoid labrum and capsule Dynamic stabilizers Predominantly rotator cuff muscles Also scapular stabilizers Trapezius, leavator scapulae, serratus anterior, rhomboids

12 Bony Anatomy “Static Stabilizers”

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


15 What goes wrong? Tears and tendonopathies

16 The Rotator Cuff Muscles “dynamic stabilizers”

17 The Rotator Cuff Muscles
Supraspinatus Infraspinatus Teres minor Supscapularis

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

19 Finally…the subacromial space

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

21 Impingement 21

22 Other Anatomy Deltoid Rotator cuff Latissimus dorsi Biceps Teres major
Pectoralis muscles 17 muscles create the movement of the shoulder

23 Shoulder Anatomy 23

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 Acute Chronic Weakness Deformity

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

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

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

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

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?

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

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

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

37 Acromioclavicular (A-C) Sprain
Damage to A-C joint ligaments Pain and/or deformity over A-C joint Graded I-VI I-III usually treated non-operatively IV-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
Fell onto his shoulder after being pushed Intense pain Hand is tingling and arm feels like it’s hanging X-rays


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

42 Shoulder Dislocation/Anterior Instability
Treatment Reduction of dislocation Protection & rehab, rehab, rehab Most will have future dislocations and/or instability At least 70%!!! (young) May 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 30 10

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

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

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

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

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

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

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

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

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

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

55 Shoulder pain isn’t always the shoulder!! Get more history…
Gall bladder disease Peptic Ulcer Disease Cervical radiculopathy Cardiac ischemia Pulmonary conditions ie 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 Recently shoveled 16” of snow
Can hardly lift left arm due to pain Special Tests? Diagnosis?

58 Biceps Tendonopathy Speed Test Yergason Test Direct palpation

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

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

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

62 Physical Exam Range of Motion
Abduction 0-180o 62

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

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

65 Physical Exam Range of Motion
Internal rotation T5 segment External rotation 80-90o 65

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

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

68 Physical Exam Strength of Subscapularis
Liftoff test Belly press test 68

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

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

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

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

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

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

75 Impingement Signs Hawkins Neer 75

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

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

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

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

80 Crank Test Labral injury
Glenoid labrum tear 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 80

81 Knee Problems

82 Anatomy Review

83 Tibia Fibula Femur Patella Medial & lateral Gerdy’s tubercle
Condyles Gerdy’s tubercle Pes anserine area Tibial tuberosity Tibial plateau Tibial spines Fibula Head Neck Femur Medial & lateral Condyles Epicondyles Trochlear groove Intercondylar notch Patella Superior pole (base) Inferior pole (apex) Medial & lateral facets

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


86 ACL and PCL

87 Iliotibial band (ITB)

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

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

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

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

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

93 Special Tests - ACL Injury
Lachman Test 93

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

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 <18 or >55 All of the above

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

98 Case 1 - Imaging Normal!

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

100 MCL Sprain Diagnosis?

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? RICE Relative Rest
Hinge Brace only if unstable on exam Achieve full ROM Progressive Strengthening Neuromuscular Control (Balance exercises) Functional Exercises (Sport-specific)

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

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

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

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

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

108 What is your diagnosis? Meniscal tear Plica syndrome Osteoarthritis
Bone tumor 10

109 Osteoarthritis Pharmacologic Treatment: Nonpharmacologic Treatment:
Nonpainful aerobic activity Weight loss Physical Therapy Improve ROM, increase strength Bracing 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 Recreational runner
Localizes pain to front of knee No trauma, insidious onset Localizes pain “around kneecap” Worse with stairs Worse after prolonged sitting Knee occasionally “gives out”

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

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 Patellofemoral Joint Exam
Patellar Grind Test

115 Case 3 – Plain Films Lateral AP

116 Case 3 – Plain Films Sunrise Tunnel

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

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

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

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

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 test Noble test

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

124 Iliotibial Band Syndrome
Treatment: Ice massage, pain meds Relative Rest; nonpainful activity Physical Therapy Specific ITB stretches Hip abductor strengthening Core strengthening (Gluteus Medius) Slow return to activity Extrinsic 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 Before we break for hands-on
Questions? Before we break for hands-on

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

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

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

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

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

133 McMurray test for Meniscal injury
Test Med and Lat meniscus separately 3 concurrent maneuvers: Grind it (Rotate tibia AWAY from it) Crunch it (varus or valgus) Pinch it (flex/extend knee) Positive: Painful “pop” Patient supine Heel of patient’s injured leg held while knee fully flexed Fingers of other hand palpate medical joint line while thumb palpates lateral aspect of joint Valgus stress applied Patient’s knee extended with tibia held externally rotated Pain or palpable click over medial joint line indicates medical meniscal tear 133

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

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

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

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

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

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

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