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Shoulder and Knee Problems Patricia M. Sohn DNP, APRN-BC

An Orthopedic Review. Shoulder and Knee Problems Patricia M. Sohn DNP, APRN-BC. Objectives. Review anatomy & physiology of the shoulder and the knee Identify common orthopedic shoulder and knee problems encountered in primary care

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Shoulder and Knee Problems Patricia M. Sohn DNP, APRN-BC

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  1. An Orthopedic Review Shoulder and Knee ProblemsPatricia M. Sohn DNP, APRN-BC

  2. Objectives • Review anatomy & physiology of the shoulder and the knee • Identify common orthopedic shoulder and knee problems encountered in primary care • Review assessment, diagnosis & treatment of common shoulder & knee orthopedic conditions

  3. Shoulder Problems • 2nd most common musculoskeletal complaint • Difficult joint to examine • Unique anatomy & range of motion • Problem may reflect bones, soft tissue and/or nerves • Challenging diagnosis

  4. The Shoulder: Bony Anatomy Humerus Clavicle Glenoid fossa Scapula Acromium Coracoid Scapula body Sternum

  5. Shoulder Anatomy: Bones

  6. Shoulder X-Ray

  7. Shoulder Anatomy: Joints • Composed of four joints: • Acromioclavicular • Glenohumeral • Scapulothoracic • Sternoclavicular

  8. Glenohumeral Joint Shallow Gulf ball sitting on tee Unstable Most common dislocated joint Stabilizers GH ligaments Labrum/capsule Scapula Rotator cuff

  9. Shoulder Anatomy: Joints Glenohumeral Scapula-thoracic Acromial-clavicular Sterno-clavicular

  10. Rotator Cuff Muscles: SITS • Four muscle tendons • Stabilize humerus to shoulder socket • Allows for motion • Abduction • Supraspinatus • External rotation • Infraspinatus • External rotation • Teres Minor • Internal rotation • Subscapularis

  11. Rotator Cuff Muscles

  12. Subacromial Space Space between humeral head and inferior acromial border Subacromial bursa Supraspinatus tendon & muscle Long head of bicep muscle

  13. Shoulder Anatomy: Consider nerves & other musculature

  14. Health Assessment • History*** • Patient age • Acute or chronic event • Date of injury • Mechanism of injury (traumatic vs non-traumatic) • Sports, weight lifting, occupational, fall, repetition, etc • History of prior problem/treatment • Duration of symptoms • Pain • Location, character, night pain • Aggravating/alleviating factors • Associated symptoms • Weakness, deformity ,instability, catching, locking, popping, N/T, strength, etc

  15. Clinical Exam • Physical exam-begin with unaffected side • Always compare to normal shoulder*** • Inspection • Palpation • Range of motion • Strength • Neurovascular • Neck & elbow exam

  16. Inspection • Deformities • Humeral head • AC joint • SC joint • Clavicle • Bursa effusion • Bicep bulge • Scapulothoracic motion • Scapular winging • Appearance of skin • Swelling • Ecchymosis • Erythema • Muscle atrophy • Disuse atrophy • Nerve damage

  17. Palpation • Soft tissue • Prox/distal bicep • Subacromial bursa • Shoulder girdle • Scapula • Surrounding muscles • Upper extremity • Include neck palpation • Bony structures • SC joint • Clavicle • AC joint • Acromium • Greater tuberosity • Humerus • Scapula • Surrounding bony structures • Neck, spine, elbow, FA

  18. Range of Motion • Active & passive ROM • Purpose of ROM assessment • Localize abnormality • Obtain accurate diagnosis • Assess ROM impact on ADLs • Primary shoulder movements • Forward flexion • Extension • Abduction • Adduction • Internal & external rotation • Strength***

  19. Range of Motion • Shoulder flexion • 0-180 degrees • Painful arc (70-120 degrees) • Suggests impingement or AC joint DJD • Shoulder extension • 0-60 degrees

  20. Range of Motion • Abduction • 90-180 degrees • Deltoid & supraspinatous • Observe for scapular elevation • Adduction • 0-90 degrees • AC joint • Touch opposite shoulder

  21. Range of Motion Internal Rotation Apley scratch Test (subscapularis) External rotation resisted (infraspinatous/teres minor)

  22. Strength & Impingement Testing • Compare to unaffected side • Differentiate between true weakness vs secondary to pain • Tests help with diagnosis • Empty can test • Lift-off test • Drop-arm test

  23. Strength Testing • Empty can test • 90 degrees abduction • 30 degrees forward flexion • Thumbs pointed down • Patient attempts elevation against resistance • Positive supraspinatous test with pain or decreased strength

  24. Additional Testing Lift-off test Drop arm test Passively abduct pt shoulder If arm drops-positive for rotator cuff tear • Internally rotate shoulder • Pt attempts to push away against resistance • Positive for subscapularis

  25. So What Can Go Wrong? • Tendonitis/bursitis • Rotator Cuff Injury • Adhesive Capsulitis • Labrum & bicep pathology • AC joint pathology • Arthritis • Fractures • Instabilities/Dislocations • Tumors

  26. Red Flag Differential Diagnosis • Neural impingement-cervical spine • Referred pain • Splenic laceration • Ruptured ectopic pregnancy • Hepatic tumors • Myocardial infarction

  27. Tendonitis/Bursitis Findings TREATMENT PLAN Consider differential diagnosis based upon history Tylenol or NSAIDs PT Ice Activity modification Consider lidocaine test or cortisone injection • Adolescents-adults • Tenderness over subacromial bursa space, humeral head, & supraspinatous tendon • Painful flexion, abduction, & external rotation

  28. Rotator Cuff Injury findings Treatment plan Consider differential dx Consider x-ray NSAIDs or Tylenol PT Consider cortisone injection Persistent problems will require MRI for accurate dx Consider ortho referral May require surgery to repair rotator cuff injury • RC tears are rare < 45 yrs • Spontaneous RC tears can occur >50 yrs • Trauma hx? • Tender shoulder • Increased pain with activity, sleeping • Decreased ROM, strength • Positive empty can, drop arm • External rotation weakness

  29. Adhesive Capsulitis findings Treatment plan Aggressive PT (>6 months) Ice, heat NSAIDS Cortisone injections Time Consider x-ray Surgical manipulation Surgical arthroscopic manipulation • Stiffened GH joint with loss of motion • Age > 50 yrs: trauma? • Frequently reversible • Pain with motion • Decreased abduction, flexion & rotation (passive & active) • Hiking of scapula • Nocturnal pain • Usually no TTP • Functional limitations

  30. Thinking About Additional Testing?

  31. Additional Plan of Care • Based upon history and clinical exam*** • Consider x-ray • Trauma, obvious deformity, immobility, arthritis, persistent pain despite conservative treatment • Consider MRI, CT • Rotator cuff injury, AC separation, dislocations, infection, bicep rupture persistent shoulder pain despite conservative treatment • Consider referral to orthopedic provider

  32. Butt….we’re halfway done 

  33. Knee Overview • Common site of injury and pain • 33% of Musculoskeletal complaints in PC • Pediatric & adults • Synovial hinged knee joint • Largest joint in the body • Synovial cavity filled with fluid • Articular capsule • Articular cartilage • Tendons, menisci, bursa

  34. The Knee: Bony Structures • Femur • Tibia femoral joint is largest in the body • Patella • Largest sesamoid bone • Protects joint, increases leverage of quad • Tibia • Bears brunt of forces • Forms ankle at distal end • Fibula

  35. Knee X-Ray

  36. The Knee Joint • Patella-femoral joint • Lined with synovial cartilage • Meniscus • Fibrocartilage • Medial & lateral • Two half moon shapes • Medial is torn more often • Ligaments (provide stability) • Collateral ligaments • Medial & lateral • Cruciate ligaments • Anterior & posterior

  37. The Knee Joint • Bursae • Prepatella • Suprapatella • Pes • Muscles & Tendons • Rectus femoris • Vastus muscles • Patella tendon • Ilitotibial band

  38. Health Assessment • May vary by age group • Thorough & complete history • Prior problems/treatment • Acute or chronic event • Date of injury/length of problem • Mechanism of injury(traumatic vs non-traumatic (sports, occupational, fall, rapid or insidious onset, etc) • Duration of symptoms • Pain • Location, character, weight bearing, • Alleviating/aggravating factors • Associated symptoms • Catching, locking, popping, instability, swelling, N/T

  39. Clinical Exam • Physical exam • Have patient point to the pain • Always compare to normal knee*** • Inspection • Palpation • Range of motion • Strength • Assess joints above & below

  40. Inspection • Visualize both knees • Examine non-affected knee first • Obvious traumatic deformity? • Anatomic deformity • Varus/valgus • Gait abnormality • Atrophy • Erythema • Effusion (type) • Bruising

  41. Palpation Flex to 90 degrees Knee joint line • Integrity of distal femur • Superior, inferior, medial & lateral patella facets • Patella mobility • Patella apprehension & compression test • Crepitus • Medial & lateral joint lines • Medial & lateral knee • IT tract • Tibia tubercle • Pes bursa

  42. Range of Motion • Consider trauma hx • Normal ROM • 0 degrees extension • 130 degrees flexion • 20-30 degrees int/ext • Assess passive ROM

  43. Strength • Meniscus • McMurray • Ligament stability • ACL • Lachman’s (30 degrees flexion) • Anterior drawer (90 degrees flexion) • PCL • Posterior drawer (90 degrees flexion) • Cruciates • Valgus/varus stress (0-30 degrees)

  44. Almost Done 

  45. So What Could Go Wrong? • Consider patient age & activity level • < 20 yrs • Patella femoral syndrome (PFS), tendonitis, Osgood schlatter, osteochondritis dissecan • 20-50 yrs • PFS, meniscus tear, ligament tear, bursitis, tendonitis, gout, ITB • > 50 yrs • Meniscus tear, bursitis, osteoarthritis, gout,

  46. Knee Pain Red Flags • Fracture • Acute ACL tear • Patella dislocation • Septic arthritis • DVT • Neurovascular damage • Compartment syndrome • Quad/patella tendon rupture • Tumor

  47. Patellofemoral Syndrome • Vague, retro patella knee pain • Results from physical/biomechanical changes in knee joint • Insidious onset • Common in females • Point to anterior knee • Worse with stair climbing, prolonged sitting • No meniscus/ligament symptoms

  48. Patellofemoral Syndrome Findings Treatment plan Tylenol/NSAIDs RICE HEP/PT Patella strap/taping Shoe orthotics as needed Consider x-ray for persistent problems Consider ortho referral for persistent problems • Positive compression test • Patella crepitus • Mild effusion possible • Patella facet tenderness • Check hamstring tightness • Check foot arch • Check heel cord flexibility • Check IT band tightness

  49. Meniscus Tear: Tear of Fibrocartilage findings Treatment plan X-ray if contact type injury Tylenol/NSAIDs RICE HEP/PT Activity modification Consider referral or MRI if pain persists beyond 8 weeks May consider cortisone injection • May have hx of twisting type knee injury • Medial or lateral joint line pain • Positive McMurray • Catching and/or locking • May resist full flexion • May have swelling • Squatting or twisting activities increase pain

  50. Just Five More Slides!

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