Orthopedics for Primary Care Providers

Orthopedics for Primary Care Providers
Jennifer Baker, RN, MSN, FNP-C

Objectives: Identify common presenting musculoskeletal disorders seen in primary care practice Develop a framework for using history and physical exam to aid in diagnosis of these common orthopedic complaints Broaden your differential diagnoses for musculoskeletal complaints Know basic treatment options for disorders that can be appropriately managed in the primary care setting Identify red flags in orthopedic conditions Obtain clinical knowledge in order to identify musculoskeletal conditions that require referral to Orthopedic Surgery

Incidence Over 40 million Americans have musculoskeletal Disorders
Musculoskeletal complaints account for 10-15% of all visits to primary care providers 70% of all new musculoskeletal injuries are treated by PCPs Musculoskeletal issues are the 2nd largest contributor to disability worldwide, with low back pain being the single leading cause of disability Between 1 in 3 and 1 in 5 people live with a painful and debilitating musculoskeletal problem Mk disorders are a huge contribution to the current health system.

Nurse Practitioner Role
Primary Care Providers play an vital role in early recognition and appropriate management of common musculoskeletal problems Nurse Practitioners are often the first contact provider, providing patient triage Appropriate triage requires knowledge of common musculoskeletal disorders, examinations, and treatments The Nurse Practitioner must know how to take a good history, do a thorough exam, know when and how to initiate treatments of these disorders, also when to appropriately refer to orthopedic specialist As NPs and first line providers, MK complaints are likely to be a big part of our practices, no matter the location. We play a very important role in diagnosing, treating, and referring these disorders. It is very important that we have a good knowledge base of these disorders, how to identify them, how to treat them, and when they need to be referred.

Common Presenting Musculoskeletal Complaints
Low Back Pain - lumbago, lumbar radiculopathy, DDD, Spinal Stenosis Shoulder Pain – impingement syndrome, rotator cuff, adhesive capsulitis Elbow Pain – epicondylitis, olecranon bursitis Hand Pain – Carpal Tunnel, CMC arthritis Hip Pain – arthritis, greater trochanteric bursitis Knee Pain – PF syndrome, arthritis, prepatellar bursitis Ankle Pain – ankle sprain, tendonitis, arthritis Foot pain – plantar fasciitis, tendonitis, fractures, arthritis MK issues often present as vague complaints of pain. As we know, a generalized complaint presents a multitude of differential diagnoses, some common, some rare. We as providers have to know both the common and the rare, not to mention the emergency red flags that warrant immediate attention and treatment. This list is not exhaustive, but contains some of what we will be covering with this presentation.

Pediatric MSK Conditions
Osgood Schlatter Sever’s Disease Slipped Capital Femoral Epiphysis (SCFE) Perthes Disease Patellofemoral Syndrome Pes Planovalgus The pediatric population presents its own unique conditions, some of which are emergent and have to be immediately referred. Some examples of pediatric mk conditions are the following

Low Back Pain Lumbosacral strain Herniated Disk
Degenerative Lumbar Spinal Stenosis

Lumbar Spine Strain Herniated Disk DDD/Spinal Stenosis X-rays MRI
Common cause for LBP ages 20-50 May follow acute injury or subacute process with gradually worsening pain Radicular symptoms rare Herniated Disk LBP with radiating pain, numbness and tingling into the buttocks and down the leg DDD/Spinal Stenosis Neurogenic claudication: posture-dependent, radiating buttock and leg pain caused by compression of the lumbosacral nerve roots X-rays MRI Special Test Straight Leg Raise Neurological Exam Muscle testing Sensorium Common presentation of back pain, seen in 3 different conditions. Strain is usually self limiting, improves rapidly, and requires only supportive treatments. (slide) Herniated disc and DDD, stenosis can present with radicular type symptoms, whereas these are rare in simple lumbago and LB strain. (slide) X-rays not always beneficial, especially in low back strain. X-rays can provide good general picture in DDD and can rule out other causes of pain such as compression fractures, tumors. MRI is the best diagnostic study for lumbar stenosis and Herniated disk. Special test includes the SLR – provocative maneuver for nerve compression and radicular symptoms. With the patient lying supine, examiner flexes the hip to approx. 45 degrees with knee extended, dorsiflexion of the ankle. This mechanism leads to reproducible pain and paresthesia to the leg/nerve root, not just isolated low back pain. A positive contralateral SLR is even stronger prognostic indicator of herniated disk. HNP presentation should also include questioning in regards to cauda equina syndrome, which requires emergent intervention.

Low Back Pain Treatments Physical Therapy, modalities Medications
Injections Activity Modification Conservative treatment is always a consideration unless patient demonstrates severe or progressively worsening neurological deficits, any red flags suggestive of spinal tumor or infection. PT includes core strengthening, stretching, range of motion exercises. Modalities include transcutaneous electrical nerve stimulation, deep tissue massage, and other treatments. Meds include NSAIDs, analgesics, muscle relaxants, neuromodulators like gabapentin or Lyrica, steroids, narcotics used judiciously. Further treatments include referral to pain mgt and/or surgeon for further treatment options, injections vs surgical intervention.

Shoulder Pain

Rotator Cuff Syndrome/Impingement Syndrome
Mechanism of Injury Rotator Cuff Tendonitis Subacromial Bursitis Impingement Rotator Cuff Tear Repetitive overhead activities Overuse, inflammatory Shape of acromion Falls, acute injury, arm weakness not contributed to simply pain – concern for tear Rotator Cuff Syndrome or Impingement syndrome is more common in patients over 40. Shoulder impingement is part of the spectrum of rotator cuff injury. Generally in the early stages, this involves inflammation, bursitis and rotator cuff tendonitis without actual tearing of the tendons. Partial tears can develop over time and can progress to full thickness. If symptoms do not improve with early conservative treatment, consider MRI for eval of tear.

Rotator Cuff Syndrome/Impingement Syndrome
Repetitive shoulder activities, overhead Pain at night, pain laying on the shoulder Weakness Abnormal or painful ROM Lateral or posterior arm pain Painful arc, pain with AROM approximately degrees Special Tests: Neer’s Impingement Hawkin’s Impingement Drop Arm (massive RC tear) Empty Can (supraspinatus) Lift Off or Belly Press (subscapularis) External rotation (infraspinatus) A complete history is critical in the diagnosis of impingement syndrome, important to identify predisposing factors, such as participation in sports and frequent overhead activities. Pain is the most common symptom. (slide – symptoms) Symptoms can also include localized tenderness, edema, loss of function. Weakness and stiffness sometimes occur, but this is usually secondary to pain, not muscle weakness. If weakness persists, evaluate for tear and/or neurological pathology. Most symptoms of impingement begin gradually and have a chronicity that progresses over several months PE – Slide Special tests are useful in diagnosing impingement, as well as rotator cuff pathology. Special tests can isolate the tendons, and help narrow the differential diagnosis. Impingement tests demonstrate positive results when pain is present. For rotator cuff testing, weakness is noted as a positive result, not simply pain.

Impingement/subacromial bursitis – neers and Hawkins
Impingement/subacromial bursitis – neers and Hawkins. Neers fully passively forward flexing the shoulder. Positive testing indicated by pain. Hawkins is performed by passively forward flexing the shoulder to 90 degrees and internally rotating with the elbow flexed. Pain is positive test. Empty can/jobe’s– arms out, thumbs down. Examiner applies downward force with patient resisting. Weakness is positive result, suggestive of supraspinatus tear. Drop arm – usually indicative of massive rotator cuff tear. Have the patient hold arm at 90 degrees of abduction with thumbs down, inability to hold arm in this position is positive. Infraspinatus – external rotation against resistance Lift off test – subscapularis, IR to the back, push off against resistance. Can do belly test as well if unable to do the lift off due to motion/pain. These are the major special tests for rotator cuff and impingement, although there are more. This gives you a good baseline for RC evaluation.

Treatment Rest from offending activities, activity modification
Physical Therapy NSAIDs, analgesics Subacromial Injection If suspected tear – refer to ortho and/or imaging Typically, treatment starts conservatively. Activity modification is necessary, then proceed with PT for strengthening of the rotator cuff, restoration of ROM, and improvement in pain. NSAIDs and analgesics are used. Injection is also used in rotator cuff syndrome. Prognosis is good in patients with impingement syndrome. Re-evaluate in 6 weeks to check ROM and strength. If no improvement, consider further imaging at that time.

Injection – Subacromial and Posterior Glenohumeral
Palpate the posterolateral border of the acromion, injection goes approximately 2 cm below. Position needle about 30 degrees and advance up toward the acromion to the bursa This slide demonstrates the location and technique used for subacromial and posterior glenohumeral injections.

Adhesive Capsulitis Mechanism Symptoms and History
Capsular thickening, adhesions, less synovial fluid Pain and sudden loss of ROM of the shoulder, specifically loss of not only ACTIVE but also PASSIVE ROM Exact etiology remains unclear Diagnosis of exclusion May last as long as months Often spontaneous resolution Age >40, slightly more in women There is primary and secondary frozen shoulder. Primary is idiopathic, while secondary is associated with other diagnoses. These include cervical disk disease, central nervous disorders, pulmonary disease, diabetes, ischemia cardiac disease, and thyroid disease. Diabetes has the highest association with frozen shoulder, and the incidence is 2-4 x higher in diabetic population than normal population. It also occurs slightly more often in women, and is rare under the age of 40. Reoccurrence after resolution is rare also. Slide:

Now we will talk about elbow disorders
Now we will talk about elbow disorders. This is a diagram reviewing the anatomy of the elbow to assist in developing differential diagnoses. Elbow Pain

Lateral Epicondylitis
Pain over the lateral epicondyle Pain with repetitive activities, especially involving wrist extension and lifting Tennis Elbow Pain with RESISTED EXTENSION Mechanism usually repetitive elbow activity causing microtears, inflammation

Medial Epicondylitis Same mechanism of injury Repetitive activities
Golfer’s elbow Pain with RESISTED FLEXION

Treatment Rest, ice Activity modification NSAIDs, oral and topical
Counterforce brace, cock up wrist splint to control wrist movement Injection – not first line treatment, conflicting evidence Physical Therapy – mechanics, strengthening First goal for both medial and lateral epicondylitis is to control the pain and inflammation. Activity modification is key. RICE, NSAIDS, both oral and topical can be utilized. Counterforce brace applied to the arm, just distal to the common extensor origin dissipates force across the elbow and distribute the force to take pressure and activity of the inflamed area. Cock up wrist splints can be used and are meant to prevent contraction of the wrist extensors, thereby providing rest to the tendinous origin at the elbow. Once pain relief is experienced, PT becomes a important component to tendon healing. Therapy aims at increasing forearm strength, flexibility and endurance, all while restoring ROM arc. Advance then to resistance based exercises. There is conflicting evidence on the response and indications for steroid injections, most show that they are not usually necessary and do not help the long term course of recovery.

Olecranon Bursitis Inflammation of the bursa, accumulation of fluid and cells within the bursal cavity Swelling and pain over the posterior elbow Caused by repetitive trauma, prolonged pressure, infection, medical conditions, certain occupations Bursa act as cushions between bones and soft tissues. Olecranon bursitis is noted as swelling over the posterior elbow. It can be caused a multitude of things. This can be seen in the presence of Trauma, such as a direct blow to the elbow, repetitive pressure, seen in plumbers or air conditioning technicians, people that crawl around and lean on their elbows. It can also be due to Infection, certain medical conditions such as RA, and gout. If you suspect infection, you much aspirate and send fluid for analysis. If the bursitis is not from an infection, there are several management options. Compression for swelling is first line. Elbow pads. An elbow pad may be used to cushion your elbow. Activity changes. Avoid activities that cause direct pressure to your swollen elbow. Medications. Oral anti-inflammatories may be used to reduce swelling and relieve your symptoms. In fluid analysis, WBC counts >10,000 is considered diagnostic for septic bursitis. Send for cell count with manual differential, crystals, gram stain and cultures. Cultures usually grow staph aureus or staph epidermidis. You must determine whether this is infective or inflammatory. You have to remember anytime you put a needle in something, you run the risk of infecting it and this can be a big deal. If possible, avoid aspiration and treat conservatively. Conservative treatments may take several weeks to be effective.

Aspiration Technique This slide shows the technique used for aspiration of the olecranon bursa. Position patient in 90 degrees flexion with lateral surface of the bursa exposed. Avoid puncture posteriorly because increased risk of fistula formation, avoid ulnar direction to avoid ulnar nerve injury. After aspiration, advise for continuous compression for 7-10 days, leave on for 24 hours and then can remove for bathing but immediately reapply. Consider starting empiric abx if infection is suspected. Send fluid for analysis, including Gram stain, aerobic/anaerobic cultures with sensitivities, cell count with manual differential, crystals.

Hand Pain – Surgical Considerations
Carpal Tunnel CMC Arthritis Next we have hand pain. CT is compression of the median nerve at the wrist. It presents with aching pain in wrist sparing the palm, may radiate to the forearm. Paresthesia in the hand, common in the 1,2, 3, and radial side of the ring finger. Look for thenar atrophy in severe cases. Symptoms are typically worse at night or when driving. Mild cases can at times be managed in primary care, but typically require orthopedics referral for treatment. Wrist splints can help manage symptoms for CT syndrome. EMG/NCS for definitive diagnosis. CMC arthritis can be controlled conservatively with medications, splinting and injections. Typically it presents as hand or wrist pain, pain with gripping and activity, progressively worsening. Can be associated with swelling, decreased motion, and weakness. X-ray is diagnostic for arthritis in the hand and wrist.

Hip Pain This slide is to serve as an overview on the anatomy of the hip, which is imperative in making a diagnosis.

Pain Location Anterior/Groin: Lateral: Posterior/Buttocks:
Hip arthritis Labral tear Avascular Necrosis Hip Flexor Tendonitis Lateral: Trochanteric Bursitis IT Band tendonitis Posterior/Buttocks: Piriformis Syndrome Lumbar Radiculopathy SI joint pain Sciatica History is important. Where is the pain? Location can help narrow the differential, offering faster and more efficient diagnosis.

Hip Arthritis Symptoms: Exam: X-ray - Diagnostic Treatment:
Pain in groin Pain with weight bearing, activity Pain at night, late stage Exam: +FABER X-ray - Diagnostic Treatment: Weight loss NSAIDs PT Injection – fluoroscopy or ultrasound Joint Replacement

Trochanteric Bursitis
Symptoms Point tender over the greater trochanter Painful when lying on affected side Exam Reproducible pain over the greater trochanter Treatment NSAIDs PT – stretching Injection for severe cases Slide - X-rays will sometimes show calcification over the greater trochanter in cases of chronic GTB, severe.

This slide demonstrates the location and technique for trochanteric injections:
Patient in lateral decubitus Find point of maximal tenderness Inject perpendicular, advance to bone, retract 1-2 mm

Hip Special Tests FABER
Patrick's test or FABER test (for Flexion, Abduction, and External Rotation) is performed to evaluate pathology of the hip joint or the sacroiliac joint. The test is performed by having the patient supine, having the tested leg flexed, abducted, and externally rotated. If pain is elicited on the ipsilateral side anteriorly, it is suggestive of a hip joint disorder on the same side. With on hand on the knee, and the other on the ASIS, apply pressure. Increased pain posterior suggests SI dysfunction. FABER

Hip Special Tests Trendelenburg sign – ask the patient to stand and lift the leg (flexing the hip) The flexed side of the pelvis should elevate. Positive testing occurs when the flexed side falls, indicating abductor or gluteal weakness. FAIR test – with the patient supine, hip flex, adducted, internally rotated. If reproduces gluteus pain, suggestive of piriformis syndrome.

Knee Pain Similarly to the hip, knowing your general knee anatomy aids in making a more accurate diagnosis.

Where is the pain? This diagram demonstrates the potential differential diagnoses of knee pain based upon location.

Patellofemoral Chondromalacia
Anterior pain Worse with bending and squatting Worse with uneven ground, stair ascent and descent, running More common in women Younger age Abnormal force generation and distribution during patellar movement Weak quads, hip abductors Known as runners knee, PF chondromalacia is when the cartilage under the patella softens and deteriorates. (slide). These pictures are from knee arthroscopy with the one on the left showing normal cartilage on both the patella and the trochlea of the knee, while the picture on the right shows softening of the cartilage of the patella, and under the label, the trochlea as well.

Chondromalacia Patella
Special Tests: Patellar Grind Test/Clark’s Test Lateral patella tracking – J sign Imbalance between medial and lateral forces Treatment RICE Activity modification NSAIDs PT – Quad strengthening, VMO, hip abductors/adductors Little data for bracing/taping Activity modification. Must avoid what causes pain. Runners must decrease distance and frequency. May have to change activities during rehab period. Patellar grind/Clark’s test involves direct downward pressure to the patella, pain is provocative test. J sign is noted lateral deviation of the patella through the ROM arc. Treatment aims at restoring the imbalance between these medial and lateral forces applied on the patella, with the PT emphasizing quad strengthening, especially the VMO (vastus medialis oblique) which pulls the patella medially, as well as the hip adductor/abductor. PT also uses modalities like Estim, iontophoresis, ultrasound for pain control and inflammation.

Anterior Knee Pain Prepatellar Bursitis
Repetitive kneeling, trauma Swelling to the anterior knee, in front of the patella, no joint effusion Compression first line, continuous, can take weeks to resolve. Other treatments apply. Patellar Tendonitis or Jumper’s Knee Point tender over insertion patella tendon inferior pole of patella Patellar strap, Physical Therapy, NSAIDs Quadriceps tendonitis Point tender superior pole patella Physical Therapy, NSAIDs Pes Anserine Bursitis Tenderness over the pes anserine bursa, medial knee below the joint line Common in runners, can mimic stress fracture Rest, ice, injection, NSAIDs, PT More causes of anterior knee pain consist of prepatellar bursitis, patellar or quad tendonitis, as well as pes anserine bursitis. Pain location, history and exam helps to differentiate these diagnoses. See slide:

First picture is example of severe pes anserine bursitis, helps to see the area affected. Middle is the area of injection for pes anserine bursa injection. Last pic is demonstration of prepatellar bursitis. You can see how the fluid is isolated to only anterior to the patella, no in the joint capsule, extra articular.

Knee Arthritis This picture illustrates the progression of knee arthritis. Initially joint spaces preserved, no obvious osteophytes. Grade I osteophytes and joint space narrowing, 3 showing severe narrowing to the joint space, subchondral sclerosis and more osteophytes, even cysts at times, 4 is bone on bone arthritis

Osteoarthritis Mechanism and History Physical Exam
Insidious knee swelling, pain, stiffness Progressive, worsening pain, frequency, decrease in activity tolerance Most common cause of knee pain in older adults Pain with weight bearing, relieved with rest Periodic flares Night Pain – late sign, severe disease Mechanical symptoms, i.e. locking, catching, popping – loose bodies, cartilage delamination, concurrent degenerative meniscal tears Physical Exam Antalgic gait Genu Varum alignment most common Limited ROM with advanced disease Crepitus +/- effusion

Osteoarthritis Treatment Weight loss Activity modification
NSAIDs/Analgesics Exercise – low impact Bracing Injections Steroid intra-articular Hyaluronic acid viscosupplementation Stem Cells PRP Joint Replacement Typically the treatment for osteoarthritis starts with conservative measures.

Knee Injection Preferred Superolateral
Supine, leg extended Locate the superior aspect of the patella Locate the lateral edge of the patella Inject at the intersection of those Topical ethyl chloride for comfort Inferomedial/Inferolateral Sitting, leg flexed at 90 degrees Locate patellar tendon At midpoint of the tendon, move about 1 cm medially or laterally Usually a depression noted Direct at 45 degree angle to the center of the knee This slide shows several approaches used for knee joint injections. Superolateral approach has been shown as having the highest accuracy based on anatomic location.

Surgical Knee Pathology
Meniscus Tear ACL/PCL MCL/LCL Patellar Fracture Loose body Referral considerations for knee pain include :

I think that it helps to be able to see abnormal findings in context so that you can apply this to your practice. We all learn the appropriate maneuvers, but not often do we get to see these positive findings. He demonstrates several different tests, the Lachman, pivot shift, and finally the anterior drawer, all of which are notably positive.

This demonstrates a grossly positive anterior drawer present in acute ACL rupture.

Foot and Ankle Now for the ankle. Again, where is the pain. Knowing anatomy is a necessary component in determining appropriate differentials and ultimately definitive dx.

Ankle joint bony anatomy

Foot and Ankle Slide shows the ligaments of the ankle. The Lateral ligament complex are commonly injured ligaments with inversion ankle sprains, which is the most common injury. High ankle sprain less common, occurs with an external force through the syndesmosis, injury to the anterior tibiofibular ligaments

Ankle Sprain Mechanism Presentation Exam
Inversion injury in plantar flexed position Injury to lateral ligament complex (ATFL, PTFL, CFL) Presentation Pain, swelling, bruising, inability to bear full weight, loss of functional ability Exam Pain, bruising, edema lateral and anterolateral ankle Pain weight bearing Decreased and painful ROM Instability, laxity with drawer testing Lateral ligament ankle sprains are the most common MSK injuries in the US. Goals of treatment include reduction in pain and edema, prevention of further injury. Inadequate treatment can lead to chronic ankle instability, pain, loss of ROM. Most commonly the mechanism of injury is inversion.

This chart shows differentiating between inversion sprains affecting the lateral ligaments, ATFL, PTFL, CFL, eversion injuries affecting the deltoid ligament, and high ankle sprains, which involve the anterior tibiofibular ligament. In the common ankle sprain, Grade I injury, ATFL stretched, no frank ligament tear, no laxity on exam, minimal swelling or bruising noted, no significant limitation in motion. Grade 2, moderate injury to ligament complex, complete tear ATFL, +/- CFL, may have ankle laxity, moderate swelling and bruising, and usually decreased and painful ROM, impaired gait. Grade 3, complete tear ATFL, CFL, capsule, significant instability, severe swelling and bruising, decreased ROM, painful.

We are all familiar with the Ottawa ankle rules
We are all familiar with the Ottawa ankle rules. This slide does a good job showing these. X-rays are indicated in ankle injuries if bone tenderness along distal 6 cm of the posterior tibia or medial malleolus, bone tenderness over the distal 6 cm of the fibula or lateral malleolus. Inability to weight bear for 4 steps immediately or in the ED. Foot x-rays are indicated per these rules if tenderness over the base of the 5th metatarsal or the navicular bone.

First pictured is the squeeze test, special test for high ankle sprain
First pictured is the squeeze test, special test for high ankle sprain. Video demonstrates positive ankle drawer, indicating severe ankle instability

Ankle Sprain Treatment
First treatment steps RICE Immobilization – brace or boot for more serious injury Weight bearing as tolerated unless severe pain, then crutches Referral if concern for fracture, dislocation, subluxation, tendon rupture, locking of the joint, syndesmotic injury Nonoperative Most recover well, typically not surgical issue unless recurrent instability Functional rehabilitation superior to prolonged immobilization PT 2-3 weeks post injury MRI if continued symptoms after 6 weeks conservative treatment

Plantar Fasciitis History Exam Treatment
Most common cause of heel pain Plantar heel pain at the distal plantar fascia (medial calcaneal tuberosity) and may extend into the mid-substance Start up pain characteristic Exam Tenderness with palpation over the plantar fascia, most pronounced at insertion on plantar medial calcaneus Tight Gastrocnemius and/or Achilles tendon Presence of calcaneal enthesophyte has no clinic relevance to PF Treatment Stretching Orthotics, heel cups NSAIDS Night Splint Physical Therapy Boot immobilization for severe cases PF is self limiting process with 80-90% resolution within 10 months. However, this is a common presenting problem and can be debilitating in severe cases. It is difficult to treat and patients become frustrated with prolonged symptoms. Rarely is surgical intervention used in orthopedic practice for this problem. (slide) Provider specific treatments include injections. Risks of this include fascial rupture and fat pad atrophy. Improvement with injections typically lasts less than 3 months, but can vary. Weight loss can help as well. Stretching is very important to the treatment of this.

Foot/Ankle Referral Considerations
Ankle Arthritis These x-rays depict severe arthritis to the ankle. Conservative measures for treatment of this include AFO bracing, injections, medications. Surgical treatment includes ankle fusion vs ankle replacement.

Jones Fracture 5TH metatarsal fractures according to zones. Unless simple tuberosity fracture, zone I, recommend referral.

Morton’s Neuroma Compression neuropathy of common digital nerve, most common is 3rd intermetatarsal space. Females > Males. Burning or radiating pain, tingling, numbness, usually plantar aspect of webspace, but can radiate to toes. Symptoms improve when barefoot. Mulder’s sign – squeeze forefoot medial to lateral and apply dorsal pressure over affected webspace. Positive test is audible or palpable click that causes pain. Can attempt conservative measures, shoe modification with wider toe box, metatarsal pads. Consider ortho referral for surgical excision.

Hallux Valgus Hallux Rigidus First x-ray shows severe bunion, hallux valgus. Second x-ray shows severe hallux rigidus, arthritis of the first MTP joint. The inset is normal joint.

Pediatric Musculoskeletal Disorders
Sever’s Disease Osgood Schlatter Pes Planovalgus Slipped Capital Femoral Epiphysis Legg-Calve-Perthes Disease The pediatric population has specific musculoskeletal issues that can present. This list is not all-inclusive, but certainly has some common problems and then of course a couple of surgical issues that require immediate referral that you do not want to miss.

Sever’s Disease/Calcaneal Apophysitis
One of the most common causes of heel pain in children Inflammation of the growth plate of the heel Repetitive stress – running and jumping Growth Spurts This is a common problem, presents in ages 8-14; this growth plate typically fuses between years of age. Treatment aims at decreasing pain and inflammation. Activity modification and limitation of activity if severe pain. Heel cups, stretching utilized. Note the sclerosis on the x-ray above.

Osgood Schlatter Pain at the attachment of the patellar tendon on the anterior shin Point tenderness over the tibial tubercle Worse with running and jumping sports, athletes In periods of rapid growth Treatment includes activity modification until pain resolves, can take months. Stretching of the quads and hamstrings is helpful. In rare cases you can avulse or fracture the tubercle. Can also end up with large anterior nodules in severe cases, especially if activity modification is not utilized.

Pes Planovalgus Loss of medial foot arch
Commonly presents as painless flexible deformity in early childhood Arch develops around 5-6 years If arch is restored with patient standing on tiptoe, deformity is flexible Rigid flatfoot is always pathological Otherwise called flexible flatfoot. Often parents are concerned by appearance or shoe wear, concerned for long term issues. Typically if symptomatic, first intervention is arch support orthotics. This demonstrates flexible flatfoot, arch restored with tiptoe, or if arch returns while not weight bearing . Rigid flatfoot has no arch on or off the ground.

Slipped Capital Femoral Epiphysis
Displacement of the proximal femur relative to the capital femoral epiphysis Most commonly in boys 13-15, girls 11-13 Most over 95th percentile in weight Bilateral involvement 25-60% Incidence 1/100,000, increasing due to childhood obesity Consider possibly endocrinopathy if atypical patient presentation Early diagnosis is essential. Referred pain is one cause of delayed diagnosis. Patients can present with pain in the groin, but pain can also be referred to the thigh or the knee commonly. The pain is dull in character, worsens with activity, and is progressive. Most have externally rotated gait, out toeing. This is a surgical problem, and outcomes depend on degree of displacement at the time of stabilization and whether or not avascular necrosis occurs. On x-ray look at Klein’s line, a line drawn along the superior femoral neck on the AP intersects the lateral epiphysis normally intersects a small portion of the lateral capital epiphysis

Slipped Capital Femoral Epiphysis

Legg-Calves-Perthes Idiopathic osteonecrosis of the femoral head in children Most common in boys 4-8 years old Bilateral 10-12% of cases Short stature in 90% of cases Insidious onset of a limp, pain to the groin, thigh or knee Worse with activity, relieved with rest Perthes disease, otherwise known as idiopathic osteonecrosis of the femoral head in children. Condition has been associated with exposure to secondhand smoke, and collagen defect. Positive family hx I 1-20%, but direct causation or correlation is largely unknown. It is thought to be related to a temporary interruption in the blood supply to the capital femoral epiphysis. PE shows decrease in abduction and IR. Atrophy of gluteal muscles common finding. + Trendelenburg test. X-ray is diagnostic, showing decreased size of the capital femoral epiphysis, can progress to ultimate collapse. Treatment for this is a controversial topic in orthopedics, can be both nonoperative and surgical depending on the patient and the provider.

Red Flags!! Fever Bone pain in patient with history of Cancer
Pain at night, pain that wakes from sleep Weight Loss Inability to weight bear Pain at rest Rash

In conclusion, I hope that this presentation has helped to identify some of the common presenting mK problems you may see in primary practice. With this knowledge, hopefully you will be equipped to establish differential diagnoses, feel comfortable with conservative treatments, and know when to appropriately refer to orthopedic specialist.

References Anterior Drawer in Ankle Instability [Video file]. (2013, June 30). Retrieved March 1, 2019, from Anderson, B. C. (2006). Office Orthopedics for Primary Care: Diagnosis (1st ed.). Philadelphia, PA: Elsevier Saunders. Anderson, B. C. (2006). Office Orthopedics for Primary Care: Treatment (3rd ed.). Philadelphia, PA: Elsevier Saunders. Bracey, J. E., MD. (2016, June 30). Common Musculoskeletal Problems [Powerpoint Presentation]. Retrieved February 28, 2019, from commonmskproblems.pdf Cleland, J. A., Koppenhave, S., & Su, J. (2016). Netter's Orthopaedic Clinical Examination: An Evidence-Based Approach (3rd ed.). Philadelphia, PA: Elsevier. Douglas, R. J., MD. (2014). Aspiration and Injection of the Knee Joint: Approach Portal. Knee Surgery & Related Research, 26(1), 1-6. doi: Kalb, R. L., MD. (n.d.). Primary Care Orthopedics. Lecture presented at Office Orthopedics CME in New Mexico, Santa Fe. Lachman Test [Video file]. (2013, October 23). Retrieved March 1, 2019, from

References Lotke, P. A., Abboud, J. A., & Ende, J. (2014). Lippincott's Primary Care Orthopedics (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. McNabb, J. W. (2015). A Practical Guide to Joint & Soft Tissue Injection (3rd ed.). Philadelphia, PA: Lippincott Williams &Wilkins. Musculoskeletal Conditions. (2018, February). Retrieved March, 2019, from Our knowledge of Orthopaedics. Your best health. (2019). Retrieved March 1, 2019, from Positive Anterior Drawer Sign of Knee [Video file]. (2018, December 14). Retrieved March 1, 2019, from Rynders, S. D., & Hart, J. A. (2013). Orthopaedics for Physician Assistants. Philadelphia, PA: Elsevier Saunders.

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