knee and shoulder workplace - missouri · 2017-06-01 · x-ray findings response to treatments...
TRANSCRIPT
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Common Knee & Shoulder Injuries in the
Workplace
Jason P Young MD Advanced Orthopedics & Sports Medicine
Factors that Complicate Causation
Most Common Injury + Mechanism
Meniscus Tear – Plant and pivot
MCL Sprain – Valgus load to knee
ACL Sprain – Knee Buckles
PCL Sprain – Direct impact to front of the knee
Chondral Injury – Rapid deceleration or fall onto knee
Fractures – Higher impact fall or direct blow
Quad/Patellar Tendon Tears – Jump/Fall from height
History of the Event
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Careful Consideration
History
Mechanism
Clinical Exam
X-ray Findings
Response to Treatments
History Significant injuries often cause significant pain/discomfort acutely
Witnessed?
Reported in a reasonable time frame Sought treatment elsewhere?
Distracting Injury?
Migrating and Evolving?
Occupational Health Evaluation? Consistent Exam?
Response to treatment?
Distracting Injury
These can certainly occur Underlying injury unnoticed due to severe pain from
significant injury (about 6% in multiple trauma) Crush injuries
Fractures
Burns
Mechanism must make sense
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Normal Knee Anatomy
Cartilage
View with Arthroscopy
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Cellular Level
Arthritis = Loss of Normal Cartilage
How Do We Know?
Important to Get Correct Xrays
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MRI Needed?
What Causes Knee Arthrosis
• Osteoarthritis • Family History
• Inflammatory Arthritis • Rheumatoid – Autoimmune
• Crystalline Arthropathy • Gout/Pseudogout
• Post Traumatic • Prior Fracture • Prior Ligamentous Injury
• Obesity
Exposure…
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How can you tell if work is primary cause of arthritis?
Can Knee Arthritis Be Asymptomatic?
What Causes Symptoms to Develop
New activity that increases forces in the knee
Dietary changes
Can develop spontaneously
Often wax and wane
Everyone’s pain threshold is different
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Recent Case • 60 yo female nurse
• Psych patient scuffle, moved away quickly and and developed pain/swelling
• Has had waxing/waning pain for years, had injections/visco
Recent Case • 48 yo male laborer fell and struck his knee • No reported issues prior but admits he is not
active aside from his job
Chronic Cartilage Injury
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Arthritis Treatments
• Rest, Ice, NSAIDs • Steroid Injection
• Lubricant Injection
• Bracing
• Knee Replacement
Arthroscopy for Arthritis is Futile
Temporary Aggravation of Arthrosis
• Patients with mild to moderate arthritis • MRI can help determine acute component
Acute Cartilage Injury - Patella
Direct Fall Onto Patella – Defect on Patella or Trochlea
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Acute Cartilage Injury Condyle
Usually Deceleration Plant and Pivot Hard to cause cartilage injury to condyle from a fall
Treating Acute Chondral Injury
Meniscus
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Types Of Tears
Mechanism
Determining Acuity • Begins with History - Mechanism Make Sense?
• Exam – Is it Meniscal Pain? Reproducible?
• Radiographs – Is there Arthritis?
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Acute Tears
Treatment
Chronic Degenerative Tears
• Often times they exhibit non specific pain • May have meniscal pain but mechanism vague • Any prior medical is key
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MCL Tear
ACL Tear
History
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Exam
Imaging
Treatment
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Acute?
PCL Tear
Patellar/Quad Tendon Tear
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Treatment
Most Common Shoulder Injuries
Rotator Cuff Anatomy
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Cuff Function
Rotator Cuff Tear Mechanism
Spectrum of disease
Intrinsic Degeneration of Tendon in Watershed Area
Part of the Aging Process
Incidence of Cuff Tear
50-59 y.o – 13%
60-69 y.o. – 20 %
70-79 y.o. – 31% >80 y.o. – 51%
Why Do Some Tears Hurt and Others Not?
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Does Xray Help?
Does MRI Make Sense? There Are Many Asymptomatic
Cuff Tears!
How Do We Tell? Acute Tear Pattern
Muscle Atrophy
Retraction
Acute Progression of Chronic Tear
Fluid/Edema
Objective Data: MRI
Atrophy
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Treatment Be sure no other source of pain!
Judicious Use of Diagnostic Injection
Biceps?
AC Joint?
Get Tendon To Heal
GOAL
Improving Techniques All Arthroscopic
Increase Strength
Increase Contact area
Increase Healing
Partial Thickness Rotator Cuff Tear
Spectrum of Rot Cuff Disease: Tendonopathy Tears
Abundantly common age > 45 years old Mechanism
Overhead/Repetitive
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Partial Thickness Tears Can be pain free then suddenly develop pain at tear increases
in size
Low Grade < 50% High Grade >50%
• My First Line is PT • If Fails Take Down Intact Rotator Cuff and Repair
Impingement Extrinsic Force On Rotator Cuff
Sustained/Repetitive overhead work
Response to Treatment
Repetitive motion or overuse injuries get worse when doing the activity and get better when the inciting activity is removed
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Other Factors?
True Cuff Tendinosis should improve with therapy and/or injection
If it doesn’t improve then likely another reason
Cuff Tendinosis SLAP Tear
SLAP Mechanism
Labral Tear Mechanism
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Treating the biceps Not much difference in Tenotomy (release) vs Tenodesis
Cosmetic Deformity
Possible subtle loss of peak torque (supination)
Age >50 : aggressive with treating biceps if Rotator Cuff Tear
Biceps is often a source of continued pain after cuff repair
AC Joint
By Age 50 AC Joint Becomes Degenerative Is it symptomatic???
Can it be traumatic???
Distal Clavicle Resection
Sometimes too narrow to get scope in the joint