non-operative management of orthopaedic issues reza omid, m.d. assistant professor orthopaedic...

Non-Operative Management of

Orthopaedic IssuesReza Omid, M.D.

Assistant Professor Orthopaedic Surgery

Shoulder & Elbow Reconstruction

Sports Medicine

Keck School of Medicine of USC

Musculoskeletal Injuries

•Common cause for doctor visists (ER and outpatient).

•>1 in 4 Americans has a musculoskeletal condition requiring medical attention.

•Most can be treated non-operatively

X-rays

•Consider x-ray for any patient with injury

•Fracture/Dislocation/Infection/Tumor

General Orthopaedics

• Shoulder/Elbow Reconstruction• Trauma• Pediatrics• Hand/Wrist• Foot/Ankle• Hip/Knee Reconstruction• Tumor• Sports Medicine• Spine

Shoulder Pain

Differential Dx

»Rotator Cuff Disease»Frozen shoulder»Fracture»Calcific Tendonitis»Labral Tears»Biceps Pathology

Shoulder Pain–Among the most common sources of pain

–Ranks 2nd to lower back pain as a reason pt. seek medical attention

–Approx. 40% of people over 65 yo have rotator cuff tears!

Shoulder PainRotator Cuff Disorders

–17 million individuals in US at risk

–600,000 surgeries / year

–Most common source WC shoulder pain

Rotator Cuff Disease

Rotator Cuff Anatomy

•Supraspinatus• Infraspinatus•Tere Minor•Subscapularis

Rotator Cuff DiseaseIntrinsic Factors

–Age related degeneration

Extrinsic Factors–Acromial shape–Mechanical pressure on cuff–Activity

ConclusionsDemographics

–Unilateral tear in young–Bilateral tear in older–Tears rare before 50 yo.–>50% in pt over 66 yo.

Radiographs

Always obtain first

AP (scapular plane)

Axillary lateral

Supraspinatus outlet

History–Pain (especially night pain)

»Radiates around deltoid»Never below elbow

–Weakness–Difficulty reaching overhead or behind–Cannot sleep on affected side

Physical Examination

–Cervical spine–Shoulder ROM (active/passive) symmetric?

Physical Examination

Rotator cuff tests–TDA (supraspinatus)–ER at side (infraspinatus)–ER 90° abd (teres minor)–Lift-off (subscapularis)

Physical Examination

Physical Examination

Normal Motion–Elevation – 160–Abduction ER – 90

–ER @ side -60–IR/Ext – T7

Adjuvant Imaging Modalities

MRI

Ultrasound

CT Arthrogram

MRI Reads

• Labral tears• AC arthritis• Partial

thickness RC tears

• Full thickness RC tears

MRI Results

Arthritis: •Labral tears•AC arthritis•Partial thickness tears•Tendinosis

Rotator Cuff Dz:•Full thickness tears•High grade partial thickness tears

MRI Read

No RC Tear

Labral tear seen

AC joint arthritis seen

Dx: Shoulder arthritis

Partial Rotator Cuff Tears

• Can initially treat conservatively

• If fails conservative treatment then surgery

Orthopaedic Referral

• Full thickness tear in patients <60-65yo

• Acute (<3month) traumatic full thickness tears in any age

• Full thickness tear in patients >65 yrs who fail conservative treatment

Rotator Cuff TearRisks - Chronic Changes

– retraction with adhesion– tendon morphology– muscle atrophy– fatty degeneration– degenerative changes

Conservative Treatment

»Rest, Activity modification

»NSAIDS»ROM stretching»Cuff/Periscapular strengthening

»Corticosteroid Injections

Cuff Strengthening

Conservative TreatmentInjections

–Elderly (>65yo)–Partial tears

Shoulder Injections

“The effect of corticosteroid on collagen expression in injured rotator cuff tendon”

• Wei A, et al JBJSAm 2006: 1331-8

•LIMIT TO 1-2 INJECTION•GET MRI PRIOR

Proximal Biceps Rupture

• Suspect RC Tear

Shoulder Dislocation

• If anyone >40 years dislocates get an MRI

• If full thickness tear seen with healthy muscle bellies then surgery is indicated

Frozen Shoulder“Adhesive Capsulitis”

Frozen Shoulder–Global and significant loss of both active and passive ROM in gradual fashion

–Absence of radiographic findings other than osteopenia

Clinical Presentation

–Age: late middle age (40-60)

–Male < Female

–Diabetic and Hypothyroid

Clinical Presentation

–Significant pain - especially at night!

–Insidious onset»No trauma »Minor trauma (“dog pulled me”, “I reached in the back seat of the car”)

Late Frozen Shoulder

–Significant loss of ROM»active and passive

Physical Exam–Passive ROM restricted

»ER early»global late

–ER < 50% unaffected side (pathognomic)

–Pain with extremes of ER

Treatment

Conservative–NSAID’s–Physical Therapy

Fluoro-Guided Intraarticular Fluoro-Guided Intraarticular Steroid Injection!Steroid Injection!

Accuracy of glenohumeral joint

injections: comparing approach and

experience of provider.Tobola JSES 2011:1147

• Posterior: 50%• Anterior: 42%

Arthroscopic Release

–Surgical release of contractures–Remove scar tissue–Complete motion

Elbow Pain

Differential Dx

Lateral Epicondylitis

Instability

Biceps Pathology

Medial Epicondylitis

Olecranon Bursitis

Fracture

Lateral Epicondylitis“Tennis Elbow”

Presentation

• Lateral elbow pain with grip

• Especially in extension• TTP at lateral

epicondyle

Conservative Treatment

• NSAIDs• Activity modification• Physical therapy• Counterforce brace• Iontophoresis• Injections

Conservative Treatment

Iontophoresis

Injections

Corticosteroids

Platelet Rich Plasma

Botulinum Toxin A

ONLY 1 INJECTION!

POSTEROLATERAL ROTATORY INSTABILITY OF THE ELBOW

IN ASSOCIATION WITH LATERAL EPICONDYLITIS. A REPORT OF THREE CASES.

Kalainov JBJSAm 2005: 1120

Physical Therapy

•Modalities•Eccentric exercises

Medial Epicondylitis“Golfers Elbow”

-Medial elbow pain with grip

-Much less common

-TTP at FP mass

-Similar treatment

Olecranon Bursitis

• Most resolve with symptomatic treatment

• Avoid aspiration unless you suspect infection

• Surgery has high complication rate!

Distal Biceps Tears

• Anterior elbow pain with associated “pop”

• Treated surgically as opposed to proximal biceps ruptures

Hand/Wrist Pain

Carpal Tunnel

Treament

•Brace•NSAIDs•Vit B6 (50 mg PO tid) may help some of patients

•Injections (nerve can be injured!)

DeQuervain’s Tenosynovitis

Other Causes of Radial Sided Wrist Pain

Scaphoid fracture

Wrist arthrits

Radial sensory nerve injury

“Crossover syndrome” (another sheath of

tendons)

Treatment

•Brace with thumb spica•NSAIDs•Corticosteroid injection into sheath

Hip Pain

Differential

Fracture

Stress Fracture

FAI

Arthritis

Stress Fracture

•Runners•Female•Rest•MRI (If Femoral neck fracture seen refer)

Stress Fractures

Femoroacetabular Impingement (FAI)

Treatment of FAI

RICE, NSAIDs

Physical Therapy

If MRI ordered get MR Arthrogram of

Affected Hip NOT Pelvis

Knee Pain

Differential Dx

Meniscus tear

Arthritis/OCD

Ligament Injury

Fracture

Knee Effusion

Ligament tear

Meniscus tear

Osteochondral fracture

Synovitis

Consider MRI

Anterior Knee Pain

Treatment

RICE

Weight loss (every pound lost is 7 pounds off the

knee)

Bracing

Physical Therapy

Meniscus Tears

Treatment

•RICE•Weight loss (every pound lost is 7 pounds off the knee)

•Bracing•Physical Therapy •Corticosteroid injection•Surgery is last option

Baker’s Cysts

ACL Injuries

Treatment of ACL

•If active and only mild arthritis orthopaedic referral.

•If degenerative and non-active treat non-operatively

•Age is irrelevant

Arthritis

•RICE•Glucosamine/Chondroitin•“Viscosupplement” Injections

•Corticosteroid Injections•Unloader Bracing•PT

Physical Therapy for Hip/Knee Injuries

•ROM•Quadriceps Strength•Hamstring Strength•Hip Abductor Strength•IT Band Stretching•Iliopsoas Stretching

Foot/Ankle Pain

Ankle Sprain

•Get x-rays!!•Most can be treated with CAM walker

•5th MT Fracture

Ottawa Ankle?

Achilles Tendon Injury

•If torn refer•If intact treat with RICE, NSAIDs, CAM boot, PT for eccentric exercises

Achilles Tendon Injury

• Tendinopathy vs insertional tendonitis

• Heel lift• NSAIDS

• PT (eccentric exercises)

Plantar Fascitis

•Inflammation of the plantar fascia

•Achilles stretching•RICE•Boot

Questions???

www.dromid.com

omid@usc.edu

Reza Omid, M.D.Assistant Professor Orthopaedic SurgeryShoulder & Elbow ReconstructionSports MedicineKeck School of Medicine of USC