nuisance problems you will grow to love...• radial tunnel syndrome confused for tennis elbow. ......
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OrthopaedicEducational Services, Inc.
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Nuisance Problems You will Grow to Love
Thomas V Gocke, MS, ATC, PA-C, DFAAPA
President & Founder
Orthopaedic Educational Services, Inc.
Boone, NC
osteojunky@gmail.com
www.orthoedu.com
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Faculty Disclosures• Orthopaedic Educational Services, Inc.
Financial
Intellectual Property
No off label product discussions
American Academy of Physician Assistants
Financial
PA Course Director, PA’s Guide to the MSK Galaxy
Urgent Care Association of America
Financial
Intellectual Property
Faculty, MSK Workshops
Ferring Pharmaceuticals
Consultant
2
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LEARNING GOALS
At the end of this sessions you will be able to:
• Recognize nuisance conditions in the Upper Extremity
• Recognize nuisance conditions in the Lower Extremity
• Recognize common Pediatric Musculoskeletal nuisance
problems
• Recognize Radiographic changes associates with
common MSK nuisance problems
• Initiate treatment plans for a variety of MSK nuisance
conditions
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Lateral Epicondylitis
Tennis Elbow
Yoon R, Ahmad C:Lateral Epicondylitis (Tennis Elbow) https://www.orthobullets.com/.../lateral-epicondylitis-tennis-elbow
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Lateral EpicondylitisGeneral-
• Overuse injury
• Eccentric overload common extensor tendon (CET)
– Overuse injury Supinator/Extensor muscle groups
• Inflammation at origin of ECRB
• Most common cause lateral elbow pain
• Mechanism
– repetitive extension and supination with elbow in
extension
• Radial tunnel syndrome confused for Tennis Elbow
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• Symptoms
– Pain lateral elbow
– Resistive wrist
ext/supination w/
elbow extended
– pain with torque activities
– grip strength weakness
– grasping difficulties
– localized pain lateral elbow
– no sensory changes
Lateral Epicondylitis
Lateralepicondyle
CommonExtensor tendon
Humerus
Ulna
Extensormuscles
PAIN
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Lateral Epicondylitis
• Physical Exam
– Localized tenderness ECRB
– Weakness with resistive wrist
extension/supination
– Limited ROM/poor flexibility
– No neuro changes
• Diagnostic studies:
– X-ray: articular irregularities
• OCD
• Loose bodies
• Osteophytes
– MRI: best for soft-tissue
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• Treatment:
– Modify Activity
– Conservative Care
• NSAIDS
• ICE
• PT vs. HEP
• Tennis Elbow Straps
• Corticosteroid injection
– Failed response think tear Common Extensor Tendon (CET)
Lateral Epicondylitis
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Medial Epicondylitis
Golfer’s Elbow
Abbassi, Ahmad C:Medial Epicondylitis (Golfer’s Elbow) https://www.orthobullets.com/.../medial-epicondylitis-golfers-elbow
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Medial Epicondylitis
• Medial epicondylitis, or "golfer's elbow
– Similar to the more common lateral epicondylitis ("tennis elbow") in
many respects. Both conditions are
– Overuse tendinopathies that can be associated with racquet sports.
– Other activities associated Medial Epicondylitis:
• golfing and throwing sports, bowlers, archers, and weight lifters.
• Little leaguer's elbow
– Traction Apophysitis of the Medial Epicondyle
– Considered a variant of Medial Epicondylitis
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Medial Epicondylitis
• Medial elbow pain w/ or w/o neuro changes
• Occupational hazards
– Grounding golf club (TFCC)
– Power tools/drills
– Gripping
– Throwing
• Pain usually radiates down forearm
• Active & resistive wrist flexion contribute to medial elbow pain
• Prolonged ME 2nd to failure of tendon healing
Medialepicondyle
IncisionSite
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Medial Epicondylitis• Increased stress medial elbow
– Ligament laxity
• Ulnar collateral ligament & capsule
– Ulnar nerve stretched
• Exhibit peripheral neuropathy symptoms
– Muscle weakness CFT
• 2nd to overuse
• Peripheral ulnar neuropathy
• Physical Exam
– General elbow exam
– Ulnar collateral stress test
– Ulnar nerve Tinel – look for associated cubital tunnel symptoms
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• Diagnostic Studies
– X-ray not always indicated
– U/S can look at tendon integrity
– MRI – not necessary to make diagnosis
• Treatment- Conservative Care
• Kids: alter activity PITCH COUNTS - REST DAYS
• RICE
• Support strap CFT region elbow
• NSAIDS
• Physical Therapy
• Corticosteroid Injection - not for kids
NOT every Kid with medial elbow pain needs a “Tommy Johns” surgery
Medial Epicondylitis
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Inflammatory Response
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Inflammatory Response*
When does the Inflammatory response occur:
• occurs when injury/infection triggers a non-specific
immune response
• causes proliferation of leukocytes and increase in blood
flow secondary to trauma
• increased blood flow brings polymorph-nuclear
leukocytes (which facilitate removal of the injured
cells/tissues), macrophages, and plasma proteins to
injured tissues
*Knight KL, Pain and Pain relief during Cryotherapy: Cryotherapy: Theory, Technique and Physiology, 1st edition, Chattanooga
Corporation, Chattanooga, TN 1985, p 127-137
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Inflammatory Response*• As a result of the inflammatory process:
– redness occurs at the injury site
– tissue warmth occurs as result of increased cellular
activity
– swelling results from increased fluid
– pain as a result of tissue injury and stretching of nerve
structures
– The accumulation of fluid/edema at the injury site,
• can limit the healing process by reducing joint
range of motion (ROM)
• facilitating the formation of scar tissue. *Knight KL, Pain and Pain relief during Cryotherapy: Cryotherapy: Theory, Technique and Physiology, 1st edition, Chattanooga Corporation,
Chattanooga, TN 1985, p 127-137
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BURSITIS
• Bursitis:
– Synovial pouch that reduces friction between
adjacent tissue (structures)
– “Nuisance problem”
– Onset: sudden, gradual, traumatic, infection
– 2 types: Septic vs. Non-septic
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Bursitis• Septic:
– 2nd to inoculation bursa with bacteria
– Olecranon/Pre-patella most commonly infected bursa
– Local cellulitis precipitates
– Hematogenous spread – rare
– Laborers @ risk for septic bursitis (repetitive motion)
– Immune compromised
• ETOH abuse/DM/Malignancy
• Chronic systemic Glucocorticoid use
• Renal Failure
– Gout/rheumatoid nodules/hx previous sepsis
– Iatrogenic infection due to intra-bursal steroid injection
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Bursitis
• Non-Septic:
– Traumatic – Idiopathic – Crystalline-induced
– Olecranon/Pre-patella most commonly infected/affected
bursa
– Inciting event trivial to non-existent
– Laborers @ risk for septic bursitis ( repetitive motion)
– Same population as Septic bursitis
– Crystalline – induced 2nd hx gout
– Rheumatoid arthritis may trigger onset bursitis
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Olecranon Bursitis
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Olecranon Bursitis• Olecranon bursa lies between bony Olecranon & skin
• Very superficial bursa and easily traumatized
• Acts to decrease friction between bone and skin
• Inflammation results from overuse, trauma or infection
• Chronic disease states can cause inflammation
– Gout
– Pseudogout
– RA
• Repetitive stress positions can cause inflammation
– Results for constant contact pressure on bursa
– Forward leaning position
• Classic finding: Fluctuant bulge over Olecranon
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• Physical Exam:
– Elbow exam
• ROM loss 2nd to swelling & pain
• Skin inspection very important
– Diagnostic studies
• CBC w/ diff
• ESR
• CRP
• Uric Acid levels
• Gram stain (aspirated fluid or wound culture)
Olecranon Bursitis
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• Treatment
– RICE
– Pad to elbow
– NSAIDS
– Aspiration & injection
• Corticosteroid helps to relieve inflammation
• Steroid can worsen undetected/suspected infection
• Can lead to skin pigment changes
– I&D – for infection
• Culture wound
• Copious irrigation
• Antibiotic coverage
• Resting splint
– Surgical excision ( chronic thickened, inflamed bursa or recurrent infection)
Olecranon Bursitis
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Olecranon Bursitis
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Olecranon Bursitis
• Olecranon bursa lies between bony olecranon & skin
• Very superficial bursa and easily traumatized
• Acts to decrease friction between bone and skin
• Inflammation results from overuse, trauma or infection
• Chronic disease states can cause inflammation
– Gout
– Pseudogout
– RA
• Repetitive stress positions can cause inflammation
– Results for constant contact pressure on bursa
– Forward leaning position
• Classic finding: Fluctuant bulge over olecranon
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• Pathophysiology:
– Inflamed synovial cells lead to
increased fluid production
– Increased permeability of capillary
membrane allows fluid to accumulate
– Hemorrhage occurs as a result of
trauma
– Local trauma facilitates inoculation of
overlying skin with bacteria & can
lead to septic bursitis
Olecranon Bursitis
Image courtesy of Tom Gocke PA-C
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Olecranon Bursitis
Physical Examination:
• Inspection: skin changes
• Palpation: Radial head, epicondyles, CFT/CET, Olecranon
• Range-of-Motion: Flex, Ext, pronation/supination
• Strength: Flex, Ext, pronation/supination
• Neuro/Vascular: C5-T1
• Orthopaedic Tests:
– Collateral Ligament stability
– Distal Tricep/Bicep tendon (Hook Sign – Bicep)
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Olecranon Bursitis
Treatment: Non-septic Bursitis• Recognize potential for infection
• Activity modification
• ICE/Heat
• Compression
• NSAIDS: topical vs. oral
• Injection/aspiration vs. Incision & drainage
• Protective Pad/cushion
• Pt. expectations
– Surgical excision chronic/recalcitrant bursitis
• Manage Acute Gouty flares
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Treatment: Septic Bursitis• Diagnostic Studies- +*
– Blood Studies: CBC w/ diff, BMP, ESR, CRP, Uric acid level
– Uric acid level: trending downward
– Glucose: bursal fluid glucose is < 50% serum glucose levels (septic bursitis)
– Aspirated fluid• WBC < 1000/ul normal ( predominantly mononuclear cells)
• WBC 200-1000/ul inflammation ( mononuclear cells)
– WBC >1,500/ul infection (polymorphonuclear cells)
*McAfee JH, Smith DL: Olecranon and Prepatellar Bursitis: Diagnosis and Treatment; Topics in Primary Care, West J Med 1988 Nov; 149:607-610
+ Aaron DL et al: Four Common Types of Bursitis: Diagnosis and management, JAAOS June 2011, 19(6):359-367
Olecranon Bursitis
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• Diagnostic studies*
– Cultures:
• Majority Staphylococcus aureus or epidermidis
• Strep species, gram negatives, H. Flu, anaerobes, mycobacteria
– Crystals
• Monosodium urate crystals- Gout
• Calcium pyrophosphate or hydroxyapatite crystal- Pseudogout
– Radiographs –concern for bone trauma
– AP & Lateral (radial head view)
– McAfee & Smith: No hx trauma – x-ray unnecessary
*McAfee JH, Smith DL: Olecranon and Prepatellar Bursitis: Diagnosis and Treatment; Topics in Primary Care, West J Med 1988 Nov; 149:607-610
Olecranon Bursitis
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Aspiration/Injection or Incision & Drainage
• Suspect infection in most cases
• Plan to aspirate first and inject depending on fluid aspirated
• Aspirate Fluid
– Turbid fluid
– Send fluid for analysis
– Consider I&D and Abx
– Admission?
Olecranon Bursitis
Picture courtesy TGocke PA-C
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Pre-patellar Bursitis
Infra-patellar Bursitis
Pes Anserine Bursitis
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Pre-patella/Infra-patella Bursitis
Illustration demonstrating the anatomy of the prepatellar bursa, which consists of the subcutaneous prepatellar bursa and the superficial infrapatellar bursa. (Adapted with permission from McAfee JH, Smith DL: Olecranon and prepatellar bursitis: Diagnosis and treatment. West J Med 1988;149:607-610.)
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Symptoms
• Gradual onset to sudden onset
• Localized pain/swelling medial tibial
flare
• Start-up symptoms
– Stiffness better after motion
– Swelling
– Hamstring pain/stiff with knee ext.
– Variable pain locations: joint
line/medial tibia
– Weakness/giving out
– Catching/lockingImage courtesy TGocke, PA-C
Pes Anserine Bursitis
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Pre-patellar Bursitis Symptoms
• Gradual onset to sudden onset
• Start-up symptoms
– Hx. repetitive kneeling,
squatting, climbing
• Nursemaids knee
• Clergymen’s knee
• Carpet layer’s knee
– Swelling anterior knee
– Redness/warmth
– Pain variable
Picture courtesy Wiki Commons
Picture courtesy TGocke, PA-C
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Pre-patellar Bursitis Physical Examination
• Inspections
– Swelling pre-patellar region
– Skin
• Palpation
– Redness/warmth
– Tender patella region
• ROM/Strength
– Usually no ROM changes
– Normal strength
– Hurts to Kneel/squat/climb
• Neuro/Vascular
• Ortho exam normalPicture courtesy TGocke, PA-C
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Infrapatellar Bursitis
Symptoms
• Less common vs. pre-patella
bursitis
• Gradual onset to sudden onset
• Acts like patellar tendonitis
• Start-up symptoms
– Stiffness getting better after
some motion
– Swelling
– Weakness/giving out
– Catching/pinching sensation
Picture courtesy TGocke, PA-C
Picture courtesy TGocke, PA-C
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Infrapatellar Bursitis Physical Examination
• Inspections
– Swelling patellar tendon region
– No suprapatella swelling
• Palpation
– ? Redness/warmth
– Tender patella tendon region
• ROM/Strength
– Start-up symptoms
– Stiffness
• Neuro/Vascular - normal
• Orthopaedic Tests - normal
Picture courtesy TGocke, PA-C
Picture courtesy TGocke, PA-C
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Pre-patella/Infra-patella Bursitis
• Treatment – Non-Septic Bursitis
– Modify activity
– ICE
– NSAIDS topical vs. oral
– Flexibility
– Physical Therapy
– Protective sleeve vs. pad (pre-patella)
– Injection/aspiration vs. Incision & drainage
• Manage Acute Gouty flares
– Protective Pad/cushion
• High recurrence rate in repetitive activity jobs
*Pes bursitis- treat knee OA usually treats bursitis
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Treatment: Septic Bursitis• Diagnostic Studies- +*
– Blood Studies: CBC w/ diff, BMP, ESR, CRP, Uric acid level
– Uric acid level: trending downward
– Glucose: bursal fluid glucose is < 50% serum glucose levels (septic bursitis)
– Aspirated fluid• WBC < 1000/ul normal ( predominantly mononuclear cells)
• WBC 200-1000/ul inflammation ( mononuclear cells)
– WBC >1,500/ul infection (polymorphonuclear cells)
*McAfee JH, Smith DL: Olecranon and Prepatellar Bursitis: Diagnosis and Treatment; Topics in Primary Care, West J Med 1988 Nov; 149:607-610
+ Aaron DL et al: Four Common Types of Bursitis: Diagnosis and management, JAAOS June 2011, 19(6):359-367
Pre-Patella/Infra-Patella Bursitis
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– Suspect infection in most cases
– Plan to aspirate first and inject depending on fluid aspirated
– Aspirate Fluid• Turbid fluid
• Send fluid for analysis
• Consider I&D and Abx
• Admission?
Pre-patella/Infra-patella Bursitis
• Aspiration/Injection or Incision & Drainage
Photo courtesy TGocke, PA-C
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HIP & PELVIS
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Trochanteric Bursitis• Trochanteric Bursa lies deep to the
ITB & superficial to Gluteus medius
tendon insertion @ greater trochanter
• Gluteus medius/minimus
– Attach greater trochanter
– ABDuct & Internal rotation
• AKA: Greater Trochanteric Pain
Syndrome (GTPS)
• Trochanteric bursitis = Gluteal
tendinosis
• Consider pts. with Trochanteric bursitis
to have gluteal tendinosis/tear**Bird PA et al: Prospective evaluation of magnetic resonance imaging findings in
patients with greater trochanteric pain syndrome; Arthritis Rheum 2001;44(9):
2138-2145Musculoskeletal Images are from the University of Washington "Musculoskeletal
Atlas: A Musculoskeletal Atlas of the Human Body" by Carol Teitz, M.D. and
Dan Graney, Ph.D."
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Trochanteric BursitisClinical Presentation
• Mechanism of injury
• Repetitive/Change activity
• Poor flexibility
• Sedentary
• Body habitus
– Symptoms
• Start-up pain
• Prolonged sitting
• Side sleeping position
• Isolated lateral hip pain
Groin or Butt pain think something elseMusculoskeletal Images are from the University of Washington "Musculoskeletal
Atlas: A Musculoskeletal Atlas of the Human Body" by Carol Teitz, M.D. and
Dan Graney, Ph.D."
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Trochanteric BursitisPhysical Examination
• Inspection
– Have the pt. stand and point to location of their
pain
• Palpation – tender lateral trochanter/hip
• ROM/Strength – ABD pain/passive ADD
pain
• Neuro/vascular – no changes
• Ortho exam –
– Stichfield’s Test- hip joint
– Patrick/FABER- SI joint dysfunction
– Ober Test- positive tight IT band
– Tight Hamstrings/Hip flexors/Quads
– Consider lumbar spine exam too!!!
Illustration demonstrating the location of the trochanteric bursa between the gluteus medius (2) and the iliotibial band (3) as well as the bursa located between tendon and bone at the gluteus minimus, which is reflected downward (1). (Redrawn with permission from LequesneM: From "periarthritis" to hip "rotator cuff" tears: Trochanteric tendinobursitis. Joint Bone Spine 2006;73[4]:344-348. http://www.sciencedirect.com/science/journal/1297319X.)
Four Common Types of Bursitis: Diagnosis and Management.Aaron, Daniel; Patel, Amar; Kayiaros, Stephen; Calfee, Ryanournal of the American Academy of Orthopaedic Surgeons. 19(6):359-367, June 2011.
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HipOber Test
– Pt lateral decubitus
position
– With the patient lying in
the lateral position,
support the knee and flex
it to 90 degrees. Then
extend and abduct the
hip. Then release the
knee support.
– Failure of the knee to
Adduct is a positive test.
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Trochanteric Bursitis InjectionTreatment
• Modify activities
• Improve flexibility
• NSAIDS – topical vs. oral
• Physical Therapy vs. Home Stretching program
• Injection
• Reassess causes for pain symptoms:
– Sacroiliac joint dysfunction
– Lumbar Radiculopathy
– Femoroacetabular Impingement (FAI)
– Hip Dysplasia
– Gluteal tendon rupture/tear
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Trochanteric Bursitis• Procedure:
– Confirm Trochanteric bursitis
– Identify point of maximal
tenderness
– Lateral decubitus position
– Sterile prep
– Vapo-coolant spray
– Injection solution
3ml Bupivacaine, 2 ml Lidocaine &
1-2 ml Triamcinolone 40mg/ml
• Spinal needle vs. 1 ½ inch
needle
Picture courtesy T Gocke, PA-C
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Retrocalcaneal Bursitis
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Retrocalcaneal BursitisGeneral
• Starts as posterior heel pain
• AKA: Pump Bump/Achilles Bursitis
• Influencing factors:
– Shoe wear/heel counter pressure
– Poor hamstring/Achilles flexibility
– Activity changes
– Structural deformities (calcific tendonitis, Haglund)
– Gout/RA/Seronegative Spondyloarthropathies
– Mal-aligned sub-talar joint
• Alters normal foot mechanics
• Transmits more force load to Achilles tendonReddy SS: Surgical Treatment for Diseases and Disorders of the Achilles Tendon; JAAOS 17(1):3-14, Jan 2009
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Retrocalcaneal Bursitis
Four Common Types of Bursitis: Diagnosis and Management.Aaron, Daniel; Patel, Amar; Kayiaros, Stephen; Calfee, RyanJournal of the American Academy of Orthopaedic Surgeons. 19(6):359-367, June 2011.
Illustration demonstrating the anatomy of the hindfoot. The posterior calcaneal tuberosity is covered with fibrocartilage just proximal to the insertion of the Achilles tendon. This tuberosity apposes the anterior wall of the retrocalcaneal bursa. (Reproduced with permission from Stephens MM: Haglund's deformity and retrocalcanealbursitis. Orthop Clin North Am 1994;25[1]:41-46.)
Anatomy• Achilles tendon inserts into
Calcaneous
• Calcaneous usually down
sloping
– Haglund deformity
increases contact pressure
of Achilles on calcaneous
Dorsiflexion
• Bursa
– Retrocalcaneal: between
bone and tendon
– Superficial: between skin
and tendon
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Retrocalcaneal BursitisPhysical Examination
• Inspection
– Assess gait
– Rear-foot alignment
• Neutral-Varus-Valgus
• Pes Planus – Cavus
• “Too many toes sign”
• Palpation – tender Achilles insertion
calcaneous
• ROM/Strength
– Decreased KBDF/KEDF
– Hind foot varus & Rigid 1st ray
predisposed ?
• Neuro/vascular – no changes
• Ortho exam – Look @ mortise & sub-
talar stability
Morhopedics – Creative Common Attribution-Share Alike 3.0
Photo courtesy TGocke, PA-C
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Retrocalcaneal Bursitis
• Radiographic views
– Ankle: AP, Lateral,
Mortise (standing)
– Foot: AP, Lateral,
Oblique (standing)
Photo courtesy TGocke, PA-C
Photo courtesy TGocke, PA-C
Haglund Deformity
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Retrocalcaneal BursitisTreatment:
• Modify activity
• Modify shoe wear/types – padding/orthotics
• Improve flexibility Gastroc-Achilles complex
• NSAIDS: topical vs. oral
• Physical Therapy
– Iontophoresis/Phonophoresis
• Phonophoresis: Steroid driven into tissue by ultrasound
• Iontophoresis: Electrical charge draws steroid into tissues
– Acetic Acid: change in calcium ions reduces inflammation
and reduces chance of scar tissue formation
• Surgery- excise Haglund deformity
DO NOT INJECT ACHILLES REGION WITH STEROIDS
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Foot Pain
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Plantar Fasciitis
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Plantar Foot
From Wikimedia Commons
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Plantar Fasciitis• Definition: inflammation of the fascia
• “Heel spur pain”
• Primary function is for support longitudinal arches (med/lat)
• Affects women > men
• Average onset 45 yrs
• Obesity worse
• Extreme changes in activity
• Poor foot wear choices
• Poor Flexibility
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Symptoms:
• Pain with ambulation
• Worse in AM or after prolonged rest/sitting– “start-up pain”
– Better after warming up
• Pain localized to heel region– Central Heel pad
– Medial arch or heel pain
• Body size contributes
• Gait changes
• Pathophysiology:
– Micro tears in plantar fascia tendon insertion
– 50% develop plantar grade heel spurs
Plantar Fasciitis
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Examination– Observe Gait
– Observe foot posture
• Planus – Hind foot valgus – plantar callosities
– Assess flexibility Achilles and toe flex/ext groups
– Palpate plantar fascia
– Assess Posterior Tibial tendon integrity (strength)
– Neuro/Vascular (Tarsal Tunnel vs. Baxter’s neuropathy)
Plantar Fasciitis
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Plantar Fasciitis
• X-ray: Standing lateral
– Traction spur considered
a normal finding (arrow)
– High suspicion for
Calcaneal stress fracture
or tumor
– Consider CT, MRI or
bone scan if failed
treatment
4-6 weeks
Photo courtesy TGocke, PA-C
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Plantar Fasciitis• Treatment
– Conservative care cures most cases
– Achilles and plantar fascia flexibility - KEY
– NSAIDS
– ICE (“frozen plastic bottle foot massage”)
– Heel pad vs. rigid arch support
LAST RESORTS– Immobilization (cast vs. ankle boot)
– Night splint
– Injection
– Surgery –failed after 6 months tx
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Plantar Fasciitis
• Calf/Gastroc Stretch • Toe Flexor stretch
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Pediatric MSK Problems
Calcaneal Apophysitis: American Academy of Foot and Ankle Surgeons
http://www.acfas.org/Content.aspx?id=1483
Patellofemoral Pain Syndrome: American Academy of Orthopaedic Surgeons,
http://orthoinfo.aaos.org/topic.cfm?topic=A00680
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Medial Epicondylitis
aka: Little Leaguer’s Elbow
Young CC: Medial Epicondylitis; https://www.physio-pedia.com/Medial_Epicondylitis, October 23, 2017
Abbasi D, Ahmad C: Little Leaguer’s Elbow: https://www.orthobullets.com/sports/3086/little-league-elbow
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Medial Epicondylitis
• Medial epicondylitis, or "golfer's elbow
– Similar to the more common lateral epicondylitis ("tennis elbow") in
many respects. Both conditions are
– Overuse tendinopathies that can be associated with racquet sports.
– Other activities associated Medial Epicondylitis:
• golfing and throwing sports, bowlers, archers, and weight lifters.
• Little Leaguer's elbow
– Traction Apophysitis of the Medial Epicondyle
– Considered a variant of Medial Epicondylitis
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Little Leaguer’s Elbow
Medialepicondyle
Medial Elbow pain in Adolescent
• Medial Elbow injuries:•Medial Epicondyle stress fractures
•Ulnar collateral ligament (UCL) injuries
•MSK Injuries
•flexor-pronator mass strains
•Traction Apophysitis
•avulsion injuries, rather than UCL
sprains
•Flexor/Pronator mass•Wrist/Finger flexor muscles
•Pronation
•Occurs @ Wrist & Elbow
•Pronator Teres
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Little Leaguer’s Elbow•Pathophysiology
•Repetitive valgus loading - throwing motion
•Resulting in micro-trauma to the immature skeleton
•Causing tension overload of the medial structures
•Risk factors:
•(Pitching most common injury Mechanism)
•Greater than 80 pitches per game
•More than 8 months of competitive pitching per year
•Fastball speed > 85mph
•Continued pitching despite arm fatigue/pain
•Multiple games in short duration time
•Skeletal Muscle Weakness
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Little League Elbow
Radiology• X-ray view Elbow
– AP & Lateral (Oblique optional)
– Findings:
• Widening Physis (asymmetric to contralateral
side)
• Fissure/Fracture Medial Epicondyle (avulsion)
• MRI
– Better assessment of soft-tissue injury and edema @
Physis
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Little League Elbow
Treatment• Recognize potential injury
• Restrict activity
• ICE
• NSAIDS
• Strengthening
• Failure to improve - MRI
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Pediatric Knee Problems
Patellofemoral Pain Syndrome: American Academy of Orthopaedic Surgeons,
http://orthoinfo.aaos.org/topic.cfm?topic=A00680
Gregory JR: Osgood Schlatter Disease, emedicine.medscape.com/article/1993268-overview,
February 13, 2017
Woon C: Osgood Schaltter’s Disease, https://www.orthobullets.com/.../osgood-schlatters-
disease-tibial-tubercle-apophysitis
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Osgood Schlatter's Disease
Tibial Tubercle Apophysitis
http://radiopaedia.org/articles/osgood-schlatter-disease
http://www.eorthopod.com/content/osgood-schlatter-disease
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Osgood-Schlatter’s Disease• General
– Occurs 8-15 age group (boys 12-15/girls 8-12)
– Boys > Girls
– Overuse problem – increased demand on immature skeleton
– Caused by tight hamstrings limit knee extension and
increasing pull of quad/patellar tendon on tibial tubercle
– Small area heterotopic ossification seen 2nd to microtrauma
a the Tibial Apophysis
• Clinical Symptoms
– Swelling tibial tubercle area
– Pain with ambulation, stair-climbing, jumping & running
– Pain with palpation
– Limited ROM knee 2nd to tight hamstrings
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Osgood-Schlatter’s Disease• Physical Examination
– General Knee exam
– Pay specific attention to age group, flexibility and
location pain
– Tender palpate tibial tubercle
– Pain with AROM & resistive AROM knee extension
• Differential Diagnosis
– Jumper’s Knee
– Avulsion fracture tibial physis
– Synding-Larsen-Johansen Disease – connective
tissue disorderhttp://radiopaedia.org/articles/osgood-schlatter-disease
http://www.eorthopod.com/content/osgood-schlatter-disease
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Osgood-Schlatter’s Disease• Radiographs:
– AP, Lateral, Sunrise
– AP - Normal
– Lateral
• Bony changes noted at
tibial tubercle
• May need comparison
view contralateral knee
– Sunrise – check patella
position in trochlea
http://radiopaedia.org/articles/osgood-schlatter-disease
http://www.eorthopod.com/content/osgood-schlatter-disease
Picture courtesy TGocke, PA-C
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Osgood-Schlatter’s Disease
• Treatment:
– Symptomatic care
– ICE
– NSAIDS
– Knee pad or sleeve: decrease pain from contact pressure
– Immobilize for recalcitrant symptoms or poor patient
compliance
– Change activity up to 2-3 months
• May need longer for more severe cases
– Surgery to correction for rupture/bony fracture - rare
http://radiopaedia.org/articles/osgood-schlatter-disease
http://www.eorthopod.com/content/osgood-schlatter-disease
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Pediatric Foot Problems
Calcaneal Apophysitis: American Academy of Foot and Ankle Surgeons
http://www.acfas.org/Content.aspx?id=1483
Iselins Disease: https://www.orthobullets.com/pediatrics/4073/iselins
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Calcaneal Apophysitis• AKA: Sever’s Disease
• Ages 8-14
• Results from repetitive stress activity
• Stressors cause inflammation @ Calcaneal Physis
• Pain worse with activity better with rest
• Causes:
– Tight Achilles
– Obesity
– Foot biomechanics
• Pes Planus w/ rear-foot valgus vs. Cavus foot
Calcaneal Apophysitis: American Academy of Foot and Ankle Surgeons
http://www.acfas.org/Content.aspx?id=1483
– sports
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Calcaneal Apophysitis
• Symptoms
– Localized heel pain (pressure)
– Gait change
• Limping
• Toe walking - NOT assoc with Sever’s dz
– Pain after running/jumping
– Swelling/redness variable
– Avoidance of activities
– Growth spurts – shoes and pants
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Calcaneal Apophysitis• Physical Exam
– Inspection:
• Variable swelling/redness
• Gait changes based on acuity of symptoms
– Palpation:
• Lateral calcaneal pain/Achilles tenderness
• Tenderness based on acuity of symptoms
– Range-of-Motion (ROM):
• limited by pain
• Knee bent Dorsiflexion vs. Knee Extended Dorsiflexion
– Strength: usually normal
– Neuro/Vascular: no changes
– Ortho Tests
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Calcaneal Apophysitis
Radiographs
• AP- Lateral
• Harris Heel
– Radiographs helpful in
refuting other bone
injuries
Typically see fissuring
of Calcaneal epiphysis
Calcaneal Apophysitis: American Academy of Foot and
Ankle Surgeons
http://www.acfas.org/Content.aspx?id=1483
Photo courtesy TGocke, PA-C
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Calcaneal ApophysitisTreatment• Recognition of complaints
• Modification Activity
• Conservative care
– RICE
– NSAIDS
– Flexibility (Hamstring/Quad/Gastroc-Achilles)
– Heel Cushion
– Good Shoes
– Immobilization - failed conservative tx & activity modification
Calcaneal Apophysitis: American Academy of Foot and Ankle Surgeons http://www.acfas.org/Content.aspx?id=1483
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Apophysitis 5th Metatarsal Base
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Apophysitis 5th Metatarsal
• AKA: Iselin’s disease
• Traction Apophysitis at base 5th Metatarsal
• Repetitive activity pull Peroneus Brevis base 5th Metatarsal
• Peak ages 8-13 yrs M = F
• Activity specific - Soccer, Basketball, Dancers
• Worse with activity - better Rest
• Physical Exam
– Base 5th Metatarsal tenderness
– Isolated swelling base 5th Metatarsal
https://www.orthobullets.com/pediatrics/4073/iselins
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Apophysitis 5th Metatarsal
• Radiographs
– Wt bearing AP, LAT,
Oblique
– Apophysis runs parallel
to shaft 5th MT
– Lateral-Inferior margin of
5th MT tubercle
• Treatment
– Recognition
– Rest/activity modification
– Immobilize -
symptomatic
www.orthobullets.com/pediatrics/4073/iselins
Photo courtesy TGocke, PA-C
Normal Apophysis
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Strayer SM: Fractures of the Proximal 5th Metatarsal; Am Fam Physician. 1999 May 1;59(9):2516-2522
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