Shoulder and Knee Injury: Treatment and Prevention

1. Shoulder and Knee Injury: Treatment and Prevention Samir Sharma MD Board Certified Fellowship Trained Sports Medicine Head Team Physician San Jose Sabercats

2. Shoulder Injuries

3. Anatomy • The shoulder has the greatest degree of movement of any joint in the body • It is a multiaxial ball and socket joint

4. Anatomy • The Rotator Cuff is a set of four muscles that surround the humeral head. • They function to help abduct and rotate the arm and also function as dynamic stabilizers of the joint.

5. Instability, Impingement & DJD • Think of all soft tissue shoulder disorders to • fall in three broad categories: • Instability • Impingement • DJD • The Age of the patient generally places them • in each of these categories

6. Shoulder Instability • Mostly cccurs in younger patients <30 years of age • The extreme form of this is a shoulder dislocation • Can cause secondary tendonitis and labrum and cartilage tears • Anterior instability is the most common 95 % • Usually occurs when the patient raises their arm overhead in a throwing position • Subluxation vs Dislocation • Dislocation has to be reduced

7. Shoulder Instability • History, the patient is “apprehensive” about putting their arm overhead • History of previous anterior dislocations • Physical Exam positive apprehension test improved when posterior pressure is applied over the anterior aspect of the shoulder

8. Apprehension Sign

9. Shoulder Dislocation

10. Shoulder Instability < 20 Years • For dislocators < 20 years old there is a 90% chance of redislocation. As one ages the chance of redislocation lessens • In this high risk group, surgical repair and capsular tightening is recommended • Arthroscopic techniques have advanced significantly over the past several years

11. Shoulder Instability > 30 Years • Anterior Dislocations for first time dislocators over the age of 30, a trial of physical therapy followed by reevaluation • After a course of PT, On PE if the pt still has a positive apprehension sign this is an indicator that the capsule is stretched and the IGHL complex is not functioning properly

12. Shoulder Instability > 50 Years In patients older than 50 who have a dislocation, concomitant rotator cuff tear at the time of injury needs to be ruled out If there is a small tear, a trial of therapy can still be initiated to regain motion and strengthen the periscapular muscles In older patients >65 with a dislocation surgery is usually not necessary and the treatment is physical therapy with rehab

13. Impingement Overuse type injuries which occur in the middle aged 40-60 individual As the arm is abducted the rotator cuff tendons and biceps tendon abut (impinge) against the acromion causing inflammation in the bursa and wear of the RTC tendon As this happens thousands of times the rotator cuff starts to fray and tear

14. Impingement

15. Rotator Cuff Tendonitis Gradual onset of pain along anterolateral shoulder Difficulty sleeping on the affected side May be preceded by an antecedent trauma Patients complain of difficulty with overhead lifting

16. Rotator Cuff Tendonitis Physical exam may include a painful arc from 60-120 degrees of abduction Weakness on supraspinatus muscle strength testing Positive impingement tests

17. Painful Arc Associated with Impingement

18. Rotator Cuff Tendonitis Treatment: NSAIDS, subacromial cortisone injections and physical therapy After 3-4 months of conservative therapy with no improvement consideration could be given to an arthroscopic subacromial decompression

19. Rotator Cuff Tendonitis Arthroscopic Subacromial Decompression involves removal of any subacromial bone spurs, inflamed subacromial bursa, and direct assessment of the status of the rotator cuff and glenohumeral joint Open subacromial decompression achieves the same purpose however the deltoid muscle is detached and reattached and a larger incision is involved

20. Rotator Cuff Tear History is similar to RTC tendonitis Physical exam may show increased supraspinatus weakness and atrophy of the supraspinatus fossa MRI is the study of choice Arthrogram is also a good study to just look at whether there is a tear in the rotator cuff

21. Rotator Cuff Tear Treatment- In a patient who is <50 years of age immediate referral to an orthopedist Key point is that degenerative rotator cuff tears occur in patients greater than 50 years A tear in a patient less than 50 years of age is a traumatic tear unless proven otherwise

22. Rotator Cuff Tear Traumatic rotator cuff tears require operative fixation Degenerative Rotator Cuff Tears treatment is controversial May initiate physical therapy, NSAIDs and 1-2 cortisone injections If no improvement consider surgical repair

23. Rotator Cuff Tear

24. Rotator Cuff Repair

25. DJD Degenerative Joint Disease of the shoulder (Osteoarthritis) Commonly occurs in older patients >60 years of age History of stiffness and pain Radiologic Diagnosis

26. Degenerative Shoulder Disease History Pain and Stiffness May be preceded by antecedent trauma Physical Exam Marked loss of motion Diffuse muscle atrophy Crepitus on ROM

27. Degenerative Shoulder Disease Xray: Grashey Xray true AP xray of the shoulder shows loss of joint space and humeral osteophytes Treatment Gentle ROM and Strengthening NSAIDS Intrarticular cortisone injection

28. Degenerative Shoulder Disease

29. Degenerative Shoulder Disease Surgery is indicated when pain is not amenable to conservative management Surgery include a hemiarthroplasty vs a Total Shoulder Replacement Surgery can predictably relieve pain. Functional improvement is not as predictable

30. Case Study # 1 Pt. is a 57 yr old male seen for consultation in regards to rt. shoulder. Pt. injured rt. shoulder at work climbing in and out of truck using steering wheel to pull himself up & diagnosed w/rt. shoulder impingement syndrome with AC joint arthritis. Initial treatment of PT and NSAIDS, improving slower than expected. MRI conducted, showed moderate supraspinatus and infraspinatus tendinosis with a small-to-moderate sized interstitial tear and detachment of the tendons. Treatment: Pt. underwent shoulder arthroscopyand debridement with distal clavicle resection. Pt. went back to full duty and was made MMI with 0% impairment. Future medical provided to include antiinflammatory medications and cortisone injectsion as needed for flare ups.

31. Case Study # 2 Pt. is a 53 yr old male who injured rt shoulder by a compactor smashing rt shoulder. Had severe rt shoulder pain and difficulty with use of arm. Started on ibuprofin 600 mg & Soma. MRI was performed and showed a supraspinatus complete tear with retraction & AC joint arthritis. Conservative treatment of PT and cortisone injection failed. Treatment: Pt. underwent rt shoulder arthroscopy, rotator cuff tendon repair and resection. Patient returned to full duty., made MMI with no permanent restrictions and 0% impairment rating. Future medical to include antiinflammatory medications and cortisone injection as needed for flare ups.

32. Case Study #3 Pt. is a 42 yr old female injured lt shoulder while picking up towels. Also undergoing treatment for RMI for hand/wrist/forearm. Pt had difficulty with overhead use, use of her arm and difficulty sleeping at night. MRI was performed and showed anterior superior labrum signal with mild arthrosis of AC joint. Treatment: Pt underwent lt shoulder cortisone injection and improved with ROM. Still has some residual lt shoulder pain. Made MMI with no permanent restrictions, 0 % whole body impairment and future medical to include follow up visits, antiinflammatory medications, and cortisone injections as needed for flare ups.

33. Case Study # 4 Pt. is 46 yr old plumber who injured rt shoulder by using too much force while using cordless drill. Complains of pain, reduced strength and ROM. STAT MRI requested which showed rotator cuff tear. Treatment: right shoulder arthroscopy with subacromial decompression, debridement of labrum, and repair of the partial thickness articular surface tear. Pt fell 1 week after surgery, aggravated injury and delayed recovery. WCE completed which showed Pt will benefit from work hardening program. After completion, Pt was able to return to work full duty, range of motion increased significantly, and pain factors decreased to point where medication no longer needed. Pt extremely happy with outcome.

34. Shoulder Injury Prevention Lift items close to the body Only lift items below shoulder level When using a mouse keep in front of you at fingertip level so you do not have to reach with your arm outstretched Take posture breaks when repetitively using the arm and shoulder

35. Shoulder Injury Prevention If performing a job which requires repetitive lifting, conditioning with rotator cuff strengthening exercises maybe beneficial Stretch before performing lifting tasks Take breaks to prevent muscle fatigue

36. Knee Injuries

37. Anatomy Think of the knee source of pain in 4 basic areas. 1. Medial (inner) 2. Lateral (outer) 3. Anterior (front) 4. Posterior (back)

38. Medial Aspect of Knee Important Structures 1. MCL 2. Medial Meniscus 3. Pes Anserine tendons 4. Medial Condyle / Medial Tibial Plateau

39. Lateral Aspect of Knee Lateral meniscus ACL Lateral Condyle/ Lateral Plateau Iliotibial Band

40. Anterior & Posterior Aspects of Knee

41. Anterior Knee Pain Patellar Chondromalacia Essentially softening and wear of the patellar cartilage due to overuse or maltracking Patients complain of pain while climbing stairs MRI shows mild thinning of the cartilage Treatment is NSAIDS/ Cortisone injection

42. Anterior Knee Pain Patellofemoral Arthritis Diagnosed by decreased ROM with crepitus on PE Lateral Xray shows diffuse narrowing of the patellofemoral compartment with osteophytes Treatment - Cortisone Injection/ Viscosupplementation Injections Newer Trials of Isolated Patellofemoral Replacement

43. Patellofemoral Arthiritis

44. Medial Compartment Pain 1. Degenerative meniscal tear 2. Osteoarthritis 3. Pes Anserine tendonitis 4. MCL

45. Degenerative Meniscal Tears Patients c/o of catching and locking Degenerative tears can occur with minimal trauma Complaints of knee giving way Distinguish from bucket handle tear of the meniscus

46. Mcmurray Exam Pt is supine with the knee flexed The examiner internally and externally rotates the leg A positive test is a snap or click felt along the joint line that is accompanied by pain

47. Types of Meniscus Tears

48. Bucket Handle Meniscus Tear Pt cannot achieve full extension Moderate to large effusion in knee There is a block to extension when passively trying to extend knee Urgent referral

49. Degenerative Joint Disease Weight Bearing x-rays are crucial! They show the functional space in the knee Always specify on the prescription to obtain weight bearing x-rays Radiographically joint space narrowing with osteophytes are classic Otherwise known as osteoarthritis

50. Degenerative Joint Disease