Evaluation And Management Of Knee And Shoulder Pain

·:{iC0Fp'16ACOFP 53rd Annual Convention & Scientific SeminarsEvaluation and Managementof Knee and Shoulder PainAndrew Ferris, DO

3/17/2016Evaluation andmanagement of Knee andShoulder painAndrew Ferris DOKnee painHistoryChronic vs. AcuteMechanism of injuryEvaluationIntra vs. Extra-articular problemImagingX-rayMRITreatmentHistoryChronic vs. AcuteMechanism of injuryQuality and location of painAggravating activitiesMechanical symptoms1

3/17/2016Acute vs. ChronicAcute Knee PainInjury?YesLigament, patellar subluxation/dislocation, meniscus,fracture, micro-fractureNoInflammatory arthropathies, meniscus, septic arthritis, orOA and PFS, but if these are acute they are usuallyassociated to recent activityAcute vs. ChronicChronic knee painChildren and young adultsPatella-Femoral SyndromeTendonitis/Bursitis/ApophysitisPlica syndromeInflammatory arthritisOsteochondritis dissecansOlder adultsOsteoarthritisPatella-Femoral SyndromeInflammatory arthritisSPONKTendonitis/BursitisMechanism of injuryDirect blowTwistingAcceleration decelerationDid you hear a “pop”Did the knee swell quicklycould you put wait on your knee2

3/17/2016Quality and location ofpainQuality of pain important in differentiating OA ormedical g activitiesPain with weight bearing vs. restPain going up or down stairs or a slopeMorning painStart up paindo you sleep with a pillow between your kneesMechanical symptomsCatchingLockingInstability3

3/17/2016EvaluationInspectionSwelling or scarsPoint tendernessPeripatellar, Joint line, MCL, LCL, Pes Anserine, IT bandRange of motionStabilityVarus and Valgus, Anterior and Posterior drawerApple and McMurrayImagingX-rayFour views of the kneeWeight bearing bilateral AP, Weight bearingbilateral Rosenberg, Lateral, and SunriseAPRosenbergSunriseLateral4

3/17/2016MRIWho needs an MRIPatients with significant mechanical symptomswith exam convincing of meniscal tear withoutsignificant degenerative joint disease on x-ray.Patient with mechanism of injury and examconsistent with ACL, PCL, LCL injuryPatient with x-ray showing osteochondral lesionMRIWho should not get an MRIPatients with advanced degenerative jointdiseaseAcutely injured patient who we can not examthoroughly due to pain and guardingAcute grade 1 and 2 MCL injuriesRoberts et. al. J Bone Joint Surg Am, 2015 May 06Compared MRIs ordered by PCP and Orthopedicsurgeons. Finding showed while each group hadsimilar rates at which MRIs were ordered, thoseordered by the orthopedist resulted in moreappropriate interventions for patients with symptomsand findings amenable to surgical intervention.5

3/17/2016TreatmentVast majority of patients presenting with knee painwill be nonsurgical in natureMost common knee complaint seen in my officeare anterior knee pain and osteoarthritisPatella-Femoral SyndromeMost common knee complaint in the outpatientsettingMainstay of treatment is physical therapy75%-85% improve with conservative treatmentlittle role for NSAIDsReferral to orthopedics with 6-12 months oftreatment without improvement6

3/17/2016OsteoarthritisMulti faceted approachExercise, Weight loss and OTC medsRx NSAIDsPhysical therapyCorticosteroid injectionsHyaluronic acid injectionsOff load bracingSurgeryTendonitis/bursitisActivity ModificationNSAIDsPhysical therapyCorticosteroid injectionsGout vs. Septic arthritisAcute onset of pain with significant effusion andpain on ROMJoint aspiration with cell count with diff. andcrystals, and culturescell count 50,000 without crystals is septicarthritis7

3/17/2016Shoulder painHistoryChronic vs. AcuteMechanism of injuryEvaluationOA, Labrum, Biceps, Rotator Cuff, AC joint or NeckImagingX-rayMRITreatmentHistoryChronic vs. AcuteMechanism of injuryQuality and location of painAggravating activitiesMechanical symptomsAcute vs. ChronicAcute Shoulder PainInjury?YesLabrum, SLAP, Rotator cuffNoSubacromial bursitis, Adhesive capsulitis,Inflammatory arthropathies, Septic arthritis,8

3/17/2016Acute vs. ChronicChronicSubacromial impingementGlenohumeral OsteoarthritisRotator cuff tearAC joint arthritisMultidirection instabilityMechanism of injuryFall on out stretched handForced abductionDislocationSeizureQuality and location ofPainSharp with activityDull at restNight painLocation, Anterior, Mid arm, Scapular9

3/17/2016Aggravating activitiesAbove shoulder level reachingOverhand throwingSleeping on side of affected shoulderReaching behind backMechanical SymptomsLocking or catchingSubluxationCrepitusEvaluationRange of motion, both active and passiveStrength testingImpingement signsPoint tenderness at AC joint, Codman’s point, orBicipital grooveProvocative test; Speed, Yergason, O’Brien,Apprehension relocation, Load shift10

3/17/2016ImagingX-rayAP, Grashey, Axillary, and Acromial outlet viewMRIMRI used to evaluate rotator cuffMRI arthrogram used to evaluate labrum11

3/17/2016TreatmentInjectionssubacromial, biceps, AC joint, GH jointStrengtheningPhysical therapy or home excisesNSAIDSMRIWhen to get an MRIAcute injury in young patient with either profoundweakness not caused by pain or instabilityChronic pain and weakness not responding totreatmentMRI should be used to determine decision forsurgeryThank YouGo Green!12

pain Quality of pain important in differentiating OA or medical origin Location Anterior Jointline Radiating Aggravating activities Pain with weight bearing vs. rest Pain going up or down stairs or a slope Morning pain Start up pain do you sleep with a pillow between yo