Musculoskeletal Aging

1. Musculoskeletal Aging Dorothy D. Sherwood, MD, FACP 4/19/2012

2. Overview • Pathobiology • Clinical Presentation and Treatment of: • Cervical Spine • Lumbar Spine • Hip • Knee

3. Degeneration of Cartilage Chondrocyte: Normal function to create and break down matrix Proinflammatory cytokines ( IL 1, 6,7,8 and TNF alpha) cause chondrocytes to stop making healthy matrix and increase the breakdown of cartilage Thickening of subchondral bone,osteophyte formation, hypertrophy, ligamental injuries. Pathobiology of DJD

4. Risk Factors • AGE! 50 to 80% of people over 60 have symptomatic DJD • Obesity • Genetics • Injuries • Crystal arthopathies • Vitamin D deficiency

5. Cervical Spine Disease • Anatomy: • 8 cervical nerves with ventral and dorsal roots • Spinal nerve spits into the dorsal ramus and the ventral ramus • Dorsal ramus – posterior neck pain • Ventral ramus – Brachial plexus as well as paraverterbral neck pain • Myotome- group of muscles innervated by a spinal nerve • Dermatome- sensory innervation.

7. Cervical • 80 to 90 % of non-traumatic cervical pain is due to DJD – but DD included • Rheumatoid Arthritis • Spondyloarthritis • Polymyagia Rheumatica • Bone Mets/Cord Tumor • Infection • Multiple Sclerosis

9. Cervical DJD • Stiff neck/cervical strain: c/o neck pain, restricted ROM, para-spinal muscle tenderness – may or may not have trigger points; no weakness, no sensory symptoms, will have LROM of the neck on exam. Neurological exam normal. • Management: NSAID if tolerated in elderly; low dose hydrocodone if needed for further relief of pain ( sleep interuption ) ; avoid muscle relaxers – don’t work and are very anticholinergic.

10. Cervical DJD • Cervical Spondylosis – DJD • Cervical Spondylitic myelopathy: weakness, impaired coordination, gait impairment, bowel or bladder incontinece, babinsky • Due to cord compression by arthritic changes. Think of it as squeezing the cord • Cervical Radiculopathy: pain, weakness, sensory changes and reflex changes due to pinching the nerve at the cervical foramen

11. Cervical DJD • Physical Exam: • Cervical ROM • Muscle palpation • Strength, reflexes, sensory, gait, upper motor neuron signs • Maneuvers: Spurling, Elvey, Upward Traction • Imaging: • X ray Cervical spine: shows curvature, shows position of vertebra, shows arthritic changes that can be causing pain, metastatic lesion, osteomylitis • MRI Cervical Spine: age >50, immunocompromised, h/o cancer, neurological findings, fever – non-contrast if just looking for DJD changes. Gadolinium in patietns with GFR < 30 causes Nephrogenic Systemic Fibrosis • CT Cervical Spine: looking more for boney problems

13. Cervical DJD • Treatment: • Motor findings: refer to Neurosurgeon of choice • Sensory findings: respond well to time… • Steroid taper • TCA • Gabapentin • Narcotics • If safe, NSAID is always indicated ( but not if you are using a steroid taper )

14. NSAID and Elderly • Renal Toxicity • Age is major risk factor after known CKD • CHF • Hypertension with chronic meds • Volume Depletion • GI Toxicity • Age • H. pylori • Steroid use • Anticoagulant use • Prior h/o bleeding ulcer • Choice: lowest dose, shortest duration, monitor every 3 months for GI and or Renal Toxicity • Use PPI in all patients over age 70

15. Lumbar Spine Disease • Pathophysiology • Loss of Interverterbral disc with degeneration • Loat on the Facets • Facet hypertrophy • Ligament hypertrophy

16. Lumbar DJD • Terminology: • Spondylosis: arthritis • Spondylolisthesis: slippage – Grade 1 to 4 • Sondylolysis: fracture of the pars interarticularis • Spinal Stenosis; squeezing the cord • Radiculopathy: nerve root compression

18. Lumbar • Clinical Presentation: • Pain • Sensory Loss • Weakness • Neruogenic Claudication • Bowel, Bladder incontinece, Erectile Dysfunction – Cauda Equina or Conus Medullaris Syndrome ( compression at T11)

19. Lumbar DJD • DD: • Vascular • Distal polyneuropathy • DJD hip and knee • SI Joint pain • Inflammatory conditions • Arachnoiditis • Chronic Demylinating Polyneuropathy • Sarcoidosis • Carcinomatous meiningitis • Lymes, HSV, HZV< EBV, mycoplasma, TB

20. Lumbar DJD • Exam: • Palpate back • Observe movment • Neurological Exam

22. Lumbar DJD • Evaluation: • Back pain alone of recent onset: NSAID, opiate, follow up in 4 weeks – if still present X ray and ESR – if abnormal MRI • Back pain with neruo findings in patient >50: pain relief – opiate, NSAID not as helpful: if pain only – treat and if not better in 4 weeks – MRI: If weakness – MRI and refer. • Bowel, bladder, ED, sensory level – MRI • H/O fever, cancer, weight loss - MRI

23. Lumbar • Treatment modalities • Physical Therapy : No proven benefit, no standard treatment protocol, but everyone does it and patients like it • Injections: may give short term benefit • Surgery: depends on the problem – helps in a young back, dicy at best in an old back

24. Hip DJD • DD: Trochanteric Bursitis, Gluteusmedius Bursitis, DJD, fracture • There are 18 bursas in the hip joint and they can all hurt • Take Home: Hip Joint Pain is anterior groin pain • Trochanteric Bursitis is lateral thigh pain • Lateral Cutaneous Femoral Nerve Pain – not influenced by movement • Anterior hip or groin pain – usually DJD but r/o osteonecrosis, abdominal pathology such as hernia, or L2-3 nerve root • Posterior pain is almost never the hip – lumbar, SI Joint or Leriche’s syndrome (vascular disease causing buttock, hip, thigh claudication)

25. Hip DJD • Exam: • FABERE Test • Flex • Abduct • Externally Rotate • Extend • Internal and External Rotation • Palpation

26. Hip DJD • Treatment: • Injections can be your best friend

29. Knee Pain • Medial: meniscal, medial ligament, Anserine bursitis • Lateral: meniscal, lateral ligament, iliotibial band syndrome • Anterior: Patellofemoral syndrome, Patellar bursitis, Patellar tendonopathy ( jumpers leg ) Osgood Schlutter – tibial pain • Posterior:Arthritis, Bakers Cyst,

30. Valgus Movement testing Medial Collateral Ligament

31. Varus movement, testing lateral collateral ligament