nuisance problems you will grow to love...• radial tunnel syndrome confused for tennis elbow. ......

OrthopaedicEducational Services, Inc.

© 2016 Orthopaedic Educational Services, Inc. all rights reserved.

Nuisance Problems You will Grow to Love

Thomas V Gocke, MS, ATC, PA-C, DFAAPA

President & Founder

Orthopaedic Educational Services, Inc.

Boone, NC

[email protected]

www.orthoedu.com

http://www.orthoedu.com



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



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



Lateral Epicondylitis

Tennis Elbow

Yoon R, Ahmad C:Lateral Epicondylitis (Tennis Elbow) https://www.orthobullets.com/.../lateral-epicondylitis-tennis-elbow



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



• 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


Lateralepicondyle

CommonExtensor tendon

Humerus

Ulna

Extensormuscles

PAIN




• 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



• Treatment:

– Modify Activity

– Conservative Care

• NSAIDS

• ICE

• PT vs. HEP

• Tennis Elbow Straps

• Corticosteroid injection

– Failed response think tear Common Extensor Tendon (CET)




Medial Epicondylitis

Golfer’s Elbow

Abbassi, Ahmad C:Medial Epicondylitis (Golfer’s Elbow) https://www.orthobullets.com/.../medial-epicondylitis-golfers-elbow




• 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




• 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



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



• 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




Inflammatory Response



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



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



BURSITIS

• Bursitis:

– Synovial pouch that reduces friction between

adjacent tissue (structures)

– “Nuisance problem”

– Onset: sudden, gradual, traumatic, infection

– 2 types: Septic vs. Non-septic



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



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



Olecranon Bursitis



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



• 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



• 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



Olecranon Bursitis



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



• 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



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)



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



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



• 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


Olecranon Bursitis



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



Pre-patellar Bursitis

Infra-patellar Bursitis

Pes Anserine Bursitis



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.)



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



Pre-patellar Bursitis 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



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



Infrapatellar Bursitis

Symptoms

• Less common vs. pre-patella

bursitis


• Acts like patellar tendonitis


– Stiffness getting better after

some motion

– Swelling

– Weakness/giving out

– Catching/pinching sensation





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






• 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



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)


+ Aaron DL et al: Four Common Types of Bursitis: Diagnosis and management, JAAOS June 2011, 19(6):359-367

Pre-Patella/Infra-Patella Bursitis



– 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?


• Aspiration/Injection or Incision & Drainage

Photo courtesy TGocke, PA-C



HIP & PELVIS



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."



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."



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.



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.



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



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



Retrocalcaneal Bursitis



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




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



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





• Radiographic views

– Ankle: AP, Lateral,

Mortise (standing)

– Foot: AP, Lateral,

Oblique (standing)



Haglund Deformity



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



Foot Pain



Plantar Fasciitis



Plantar Foot

From Wikimedia Commons



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



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



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



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




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



Plantar Fasciitis

• Calf/Gastroc Stretch • Toe Flexor stretch



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






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

https://www.physio-pedia.com/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



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

http://www.orthobullets.com/sports/3086/little-league-elbow?expandLeftMenu=true#2942




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







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



Little League Elbow

Treatment• Recognize potential injury

• Restrict activity

• ICE

• NSAIDS

• Strengthening

• Failure to improve - MRI



Pediatric Knee Problems

Patellofemoral Pain Syndrome: American Academy of Orthopaedic Surgeons,


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




Osgood Schlatter's Disease

Tibial Tubercle Apophysitis

http://radiopaedia.org/articles/osgood-schlatter-disease

http://www.eorthopod.com/content/osgood-schlatter-disease





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



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






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








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






Pediatric Foot Problems



Iselins Disease: https://www.orthobullets.com/pediatrics/4073/iselins




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



– sports




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



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



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






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




Apophysitis 5th Metatarsal Base



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



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


Normal Apophysis



Strayer SM: Fractures of the Proximal 5th Metatarsal; Am Fam Physician. 1999 May 1;59(9):2516-2522



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www.orthoedu.com Thunder Hill Overlook, Blue Ridge Pkwy

Blowing Rock NC

Photo Courtesy TGocke, PA-C

nuisance problems you will grow to love...• radial tunnel syndrome confused for tennis elbow. ......

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