COMMON KNEE AND SHOULDER PROBLEMS

1. COMMON KNEE AND SHOULDER PROBLEMS CLINICAL ASSESSMENT MRI IMAGING

2. MRI PANACEA ? PANDORA’S BOX ?

3. MRI • INCEPTION 1980’S • REVOLUTIONIZED EVALUATION OF STI • SUPERB ST CONTRAST cf OTHER DI • MULTIPLE PLANES

4. MRI 101 • PROTONS ALIGN WITH MAGNETIC FIELD • RFW DISTURB ALIGNMENT. • ENERGY RELEASED DURING REALIGNMENT MEASURED AND USED TO GENERATE IMAGE • RF SEQUENCES MANIPULATED TO HIGHLIGHT DIFFERENT TISSUES IN DIFFERENT WAYS

5. MRI 101 (continued) temptation reality • SOPHISTICATED, ELEGANT TECHNOLOGY • ANATOMY TEXT-LIKE IMAGES • TEMPTING TO VIEW AS THE DEFINITIVE Ix • DEPENDING ON TISSUE, SENSITIVITY 80 – 95% • SPECIFICITY LESS • THUS POTENTIALLY SIGNIFICANT FALSE + AND FALSE -

6. MRI 101 (cont) • EXPENSIVE • LONG WAITS -> CAN LEAD TO UNNECESSARY DELAY IN RX • PATIENT INTOLERANCE • PRESSURES TO ORDER FROM PTS, PT, DC, LAWYER, ETC (might be easier to say “can’t order” than to spend time explaining why inappropriate) • TIME TO PROPERLY COMPLETE REQUISITION OTHER PROBLEMS

8. ACUTE KNEE INJURIES HISTORY: MECHANISM OF INJURY SWELLING MECHANICAL SYMPTOMS PAIN

9. MENISCAL TEAR • MECHANISM: Compression usually necessary, rotation, valgus • MEDIAL > LATERAL • SWELLING: Gradual • MECHANICAL SX: Clunking, locking • PAIN: Not necessarily localized

10. MENISCAL TEAR CLINICAL ASSESSMENT: SQUAT

11. MENISCAL TEAR CLLINICAL ASSESSMENT: THESSALY TEST

12. MENISCAL TEAR CLINICAL ASSESSMENT: JOINT LINE TENDERNESS

13. MENISCAL TEAR CLINICAL ASSESSMENT: McMURRAY

14. ACUTE KNEE INJURY: ? XRAY • AGE > 55 • ISOLATED TENDERNESS OF PATELLA (NO OTHER BONY TENDERNESS) • TENDERNESS OF HEAD OF FIBULA • INABILITY TO FLEX KNEE TO 90 DEGREES • INABILITY TO BEAR WEIGHT IMMEDIATELY AND IN ER • (MASSIVE SWELLING) OTTAWA KNEE RULES

15. MENISCAL TEAR: ?MRI YES NO • EQUIVOCAL CLINICAL PRESENTATION AND NO IMPROVEMENT WITH PT • HIGH SUSPICION OF OTHER INJURY (ACL, PCL, SUBCHONDRAL) • CLASSICAL PRESENTATION • DEGENERATIVE CHANGES

16. MEDIAL MENISCAL TEAR

17. MCL SPRAIN • MECHANISM: VALGUS STRESS • IF SIGNIFICANT SWELLING SUSPECT ASSOCIATED INJURY • IF SENSE OF INSTABILITY AND LITTLE PAIN SUSPECT HIGH-GRADE INJURY

18. MCL SPRAIN • CLINICAL ASSESSMENT: VALGUS STRESS AT 30 DEGREES AND FULL EXTENSION (if gap at full extension, suspect MCL + ACL) • Gr 1: 1-5 mm, firm EF • Gr 2: 6-10 mm, firm • Gr 3: >10 mm, soft

19. MCL SPRAIN: ?MRI YES NO • HIGH SUSPICION OF ACL OR PCL • ISOLATED MCL

20. MCL - MRI NORMAL

21. MCL SPRAIN - MRI GR 2 GR 3

22. ACL SPRAIN • MECHANISM: ROTATION, VALGUS, HYPEREXTENSION • SWELLING: IMMEDIATE, MASSIVE • MECHANICAL SX: INSTABILITY • PAIN: DIFFUSE

23. DO NOT MISS THIS

24. ACL SPRAIN • CLINICAL ASSESSMENT: LACHMAN TEST • Gr 1: 1-5mm > contralat • Gr 2: 6-10mm • Gr 3: >10mm • A=firm • B=soft

25. ACL SPRAIN • CLINICAL ASSESSMENT: ANTERIOR DRAWER

26. ACL SPRAIN • CLINICAL ASSESSMENT: PIVOT SHIFT • Knee relaxed, full ext. Valgus stress to tibia with axial load and int rot. Knee flexed. Lat tibia subluxes, reduces with flex. • Gr 0: no detectable shift • Gr 1: glide • Gr 2: abrupt reduction • Gr 3: temporary lock then reduction

27. ACL SPRAIN • CLINICAL ASSESSMENT: PIVOT SHIFT

28. ACL SPRAIN: ?MRI YES NO • HIGH LIKELIHOOD OF ASSOCIATED STI, SUBCHONDRAL INJURY, BONE BRUISING • “OLDER” PATIENT WHO IS BETTER MANAGED WITH PT, ACTIVITY MODIFICATION, BRACING

29. ACL TEAR

30. PCL SPRAIN • MECHANISM: DIRECT BLOW TO TIBIA WITH KNEE FLEXED, HYPEREXTENSION, VARUS/VALGUS STRESS IF FIRST LINE OF DEFENCE TORN • SWELLING: OVER 24 HR • MECHANICAL SX: +/- INSTABILITY • PAIN: DIFFUSE, POSTERIOR • (RARELY SEEN AS ISOLATED INJURY)

31. PCL SPRAIN • CLINICAL ASSESSMENT: POSTERIOR SAG

32. PCL SPRAIN • CLINICAL ASSESSMENT: POSTERIOR DRAWER

33. PCL SPRAIN: ?MRI YES: • HIGH LIKELIHOOD OF ASSOCIATED INJURY

34. PATELLAR DISLOCATION/SUBLUXATION • MECHANISM: VALGUS, ROTATION • SWELLING: IMMEDIATE, MASSIVE • MECHANICAL SX: NO UNLESS # (SUBCHONDRAL #), ASSOC INJURY • PAIN: DIFFUSE

35. PATELLAR DISLOCATION/SUBLUXATION CLINICAL ASSESSMENT • PATELLAR TENDERNESS • MEDIAL SOFT TISSUE TENDERNESS • PATELLAR APPREHENSION TEST • PATELLA ALTA, “J” SIGN

36. PATELLAR DISLOCATION/SUBLUXATION XRAY? MRI? • YES: R/O # • NO, UNLESS SUSPICION OF SUBCHONDRAL #, ASSOCIATED STI

37. PATELLAR DISLOCATION/SUBLUXATION

38. ACUTE SHOULDER PROBLEMS: GLENOHUMERAL DISLOCATION TUBS AMBRI

39. TUBS • MECHANISM: ABD/ER • XR TO R/O # • SHOULDER IMMOBILIZER FOR COMFORT; D/C ASAP (CONSIDER ER BRACE) • EARLY PT • NO MRI

40. TUBS: RECURRENT • ANTERIOR APPREHENSION TEST/FOWLER’S RELOCATION SIGN • XR: AP, Y VIEW, AXILLARY, WEST POINT (BANKART), STRYKER NOTCH (HILL-SACHS) • REFER • NO MRI

41. ANTERIOR APPREHENSION SIGN FOWLER’S RELOCATION SIGN

42. AMBRI • GENERALIZED JOINT LAXITY • LOAD AND SHIFT TEST, INFERIOR SULCUS SIGN • PT • NO XR, MRI

43. LOAD AND SHIFT INFERIOR SULCUS

44. LABRAL TEAR • MECHANISM: DIRECT BLOW, DISLOCATION/SUBLUXATION, REPETITIVE OVERHEAD STRESS (MOST COMMON) • USUALLY ACCOMPANIES OTHER PATHOLOGY WHICH IS MAIN FOCUS OF RX: INSTABILITY, RC TENDINOPATHY/IMPINGEMENT

45. SLAP/BICEPS TENDINOPATHY • MECHANISM: FALL, LOAD IN FLEX/EXT, OVERHEAD OVERUSE • SX: PAIN, CATCHING WITH LOAD IN FLEX; CLICK; IMPINGEMENT; SENSE OF INSTABILITY

46. TEST • BICEPS TENDINOPATHY: SPEED’S

47. TESTS • SLAP: O’BRIEN’S, CRANK, PAIN PROVOCATIVE, COMPRESSION ROTATION, BICEPS LOAD

48. O’BRIEN’S

49. MRI? LABRAL TEAR/SLAP BICEPS TENDINOPATHY • NO – NEED MRA • NO – EASY CLINICAL DX, WON’T CHANGE RX, WORST CASE OUTCOME IS A COSMETIC PROBLEM

50. ROTATOR CUFF TENDINOPATHY, TEAR, IMPINGEMENT MECHANISM SYMPTOMS • TRAUMA • USUALLY OVERHEAD OVERLOAD • PAIN: DIFFUSE, OFTEN SUPERIOR REFERRED TO DELTOID INSERTION • +/- CLICK • IMPINGEMENT: SEVERE PAIN WITH ELEVATION/IR • WEAKNESS: ?PAIN-INHIBITION