Disclosures Disclosures No personal conflicts of interest. Pain - PDF document

6/10/2013 Evaluating Injuries of the Evaluating Injuries of the Evaluating Injuries of the Evaluating Injuries of the Knee and Shoulder Knee and Shoulder Knee and Shoulder Knee and Shoulder Massachusetts Medical Society Massachusetts Medical Society 11 th Annual Men’s Health Symposium 11 th Annual Men’s Health Symposium Eric Berkson, MD Eric Berkson, MD MGH Orthopaedic Sports Medicine MGH Orthopaedic Sports Medicine Director, Mass General Sports Performance Center Director, Mass General Sports Performance Center Instructor, Harvard Medical School Instructor, Harvard Medical School MGH Sports Medicine Team Physician, Boston Red Sox Team Physician, Boston Red Sox Disclosure Disclosure Disclosures Disclosures • No personal conflicts of interest. Pain Swelling • Research supported by: Stiffness – Major League Baseball Locking Instability • Off label use of some products will be discussed MGH Sports Medicine 1

6/10/2013 MGH Sports Medicine MGH Sports Medicine 2

6/10/2013 Sports Medicine Biomechanics Sports Medicine Biomechanics MGH Sports Medicine MGH Sports Medicine 3

6/10/2013 Sports Medicine Biomechanics Sports Medicine Biomechanics MGH Sports Medicine • Rising from Chair 2.5 x bodyweight • Downstairs 3.3 x bodyweight • Walking 3 - 6 x bodyweight 10 pound weight 10 pound weight loss decreases forces loss decreases forces on on knee by 30 to 60 pounds with each step knee by 30 to 60 pounds with each step MGH Sports Medicine 4

6/10/2013  Force of gravity pulling you toward Earth you toward Earth  Sitting in a chair: 1 g  Roller Coaster: 2.5 g’s to 6 g’s Formula Rossa, UAE (149MPM) Kingda Ka, Six Flags NJ (456 ft) Tower of Terror, Gold Coast Australia (6.3g)  Fighter Jet: 9 g’s http://www.youtube.com/watch?v=sNu200WkYZw MGH Sports Medicine Biomechan Shoulder nics of Throwing Shou Elbow ulder Wrist MGH Sports Medicine 5

6/10/2013 • Correlate anatomy, physical examination, and diagnosis • Shoulder Sh ld • Knee • Anterior knee pain • Lateral knee pain • Medial knee pain • When to refer? When to refer? • When is this arthritis? – What arthritis can be fixed? – Cartilage defects vs DJD MGH Sports Medicine History History HISTORY HISTORY 1. Onset 2. 2. Location Location 3. Duration What is the major problem? 4. Quality/Quantity Pain Swelling – Swelling – Mechanical symptoms Stiffness 5. Aggravating Factors Locking 6. Relieving Factors Instability 7. Associated Symptoms 8. Effect on Function ** MGH Sports Medicine 6

6/10/2013 History History • Injury – Torn ligament Torn ligament – Meniscus – Fracture – Patella dislocation – Rotator cuff tear • No Injury – CMP, tendinitis – DJD – Meniscus – Rotator cuff tendinitis Rotator cuff tendinitis – Rotator cuff tear • Non -contact MGH Sports Medicine History: Onset History: Onset • Pain and Instability • Blow to lateral Bl t l t l aspect of knee (valgus force) • Focal tenderness of medial knee along course MCL course MCL Contact Injury - Torn MCL MGH Sports Medicine 7

6/10/2013 History History History: Age Matters History: Age Matters MGH Sports Medicine • Less than 30-35 years of age Less than 30 35 years of age – Dislocations/subluxation common • Falls on outstretched arm, abduction injuries • Throwing or overhead labral injuries – A-C joint injuries with direct fall injuries – Rotator cuff sprains common but tears unusual unusual – Fractures only in high energy injuries MGH Sports Medicine 8

6/10/2013 • Greater than 40 years of age Greater than 40 years of age – Fractures more common – Arthritic conditions of A-C joint and glenohumeral joint – Rotator cuff injuries more common • Strains, partial thickness tears • Full thickness tears MGH Sports Medicine History History Symptoms - Patella • Click / snap • Click / snap • Grind • Pain stairs • “Movie Theatre sign” MGH Sports Medicine 9

6/10/2013 Symptoms - ACL Symptoms - ACL History History – Instability (giving way) – Can run straight ahead but ahead but cannot pivot MGH Sports Medicine History History • Patellar sleeve • ACL fracture fracture • ACL • Joint capsule tear • ACL • PVNS • Patellar • Sickle Cell dislocation • Hemophilia • Osteochondral fracture • Anticoagulant therapy • Peripheral meniscal tear • Ruptured aneurysm • PCL Timing matters… MGH Sports Medicine 10

6/10/2013 • Cervical radiculitis/radiculopathy • Myofascial pain • Myofascial pain • Viral brachial plexopathy • Thoracic outlet syndrome • Pancoast tumor • Neoplasm of humerus/shoulder girdle (mets) • Thoracic disc herniation • Abdominal problems (gall bladder, pancreatitis, etc.) • Diaphragm irritation MGH Sports Medicine • Hip Pain Hi P i – Child/Adolescent – Arthritis • Lumbar MGH Sports Medicine 11

6/10/2013 Physical Ex Physical Ex • Hip / Lumbar spine exam • Gait Gait xam xam • Alignment • Effusion • ROM • Stability • Palpation • PF Crepitus • Special tests MGH Sports Medicine Radiograph Radiograph • Lateral hy hy • Merchant view(Patella) Not more than 30°! • Standing Bilateral AP • Standing PA view @ 45 Sta d g e @ 5 deg flex MGH Sports Medicine 12

6/10/2013 Radiograph Radiography hy Imaging alone should not dictate treatment MGH Sports Medicine Radiograph Radiography hy For suspected intra-articular abnormalities MGH Sports Medicine 13

6/10/2013 Imaging alone should not dictate treatment MGH Sports Medicine Medial Knee Medial Knee • Medial meniscus • Pes anserinus Pes anserinus e Pain e Pain • OA / DJD bursitis • MCL Sprain • Semimembranosis tendinitis • Osteonecrosis • Stress fracture • Osteochondritis • Physeal Injury • Physeal Injury dessicans (OCD) d i (OCD) • Popliteal cyst • Saphenous Neuritis MGH Sports Medicine 14

6/10/2013 MGH Sports Medicine Medial Knee Medial Knee Pain e Pain MGH Sports Medicine 15

6/10/2013 Medial Knee Medial Knee Pain e Pain MGH Sports Medicine Medial Knee Medial Knee Pain e Pain MGH Sports Medicine 16

6/10/2013 Medial Knee Medial Knee Pain e Pain MGH Sports Medicine Medial Knee Medial Knee Pain e Pain MGH Sports Medicine 17

6/10/2013 Symptoms - Meniscus Symptoms - Meniscus Medial Knee Medial Knee Meniscus DJD DJD e Pain e Pain • Pain Pain • Aching • Aching – medial – medial • Stiffness • Stiffness – – lateral lateral • Pain • Pain • Clicking Clicking • Popping Popping • Locking Locking MGH Sports Medicine Medial Knee Medial Knee • “Popping” sensation • Knee feels painful and p e Pain e Pain tight • Stiffness and swelling • Exam: – Tenderness at joint line – Pain with extension or flexion – Effusion Effusion • Meniscus can loosen drift into joint – Locking or catching of knee – “Pebble in the knee” MGH Sports Medicine 18

6/10/2013 Medial Knee Medial Knee • MRI diagnosed meniscal tears evident in 40% tears evident in 40% e Pain e Pain asymptomatic patient older than 50 years 1 • 56% in 70-90yrs old 2 • Arthritis – 63% : if knee pain, aching stiffness most aching, stiffness most days Eglund NEJM 2008 – 60% without those symptoms 1 Jerosh Archive Orthop Trauma Sug 1996 2. Eglund NEJM 2008 MGH Sports Medicine Medial Knee Medial Knee • Ineffective pain / arthritis alone • Does not alter the natural history of osteoarthritis D t lt th t l hi t f t th iti e Pain e Pain • Mechanical symptoms 1 , loose bodies • Factors to consider – Prior arthroscopy 2 – Correlation of symptoms to pathology – Severity of cartilage loss and bone marrow edema in the same compartment of meniscal tear 3 compartment of meniscal tear – Severity of meniscal extrusion – Meniscal root tear – Age > 70 4 1 Chang Arthritis Rheum 1993 2 Spahn Arthroscopy 2006 – Alignment 3 Kijowski Radiology 2011 4 Wai JBJS 2002 MGH Sports Medicine 19

6/10/2013 Medial Knee Medial Knee • Diagnostic g e Pain e Pain • Therapeutic MGH Sports Medicine • Injections, NSAIDS • Injections NSAIDS • Meniscectomy • Meniscal Repair – Young person – Acute injury – Consider repair C id i – Tear has to be in “red zone” MGH Sports Medicine 20

6/10/2013 Medial Knee Medial Knee Pain e Pain MGH Sports Medicine MGH Sports Medicine 21

6/10/2013 Posterior K Posterior K • Popliteal cyst (?ruptured) • Popliteus rupture P lit t nee Pain nee Pain • Torn meniscus • DVT • Popliteal artery aneurysm • Hamstring strain (?) g ( ) • Referred pain – Swelling in knee – Chondromalacia patella MGH Sports Medicine Anterior Kn Anterior Kn • Osgood Schlatter’s disease nee Pain nee Pain • Patella tendinitis • Patella tendinitis – jumper s knee “jumper’s knee” – Sinding-Larsen-Johannson • Patella instability • Pre-patellar bursitis • Patella or trochlea chondrosis (CMP) • Patellofemoral Syndrome • Patellofemoral Syndrome • Bipartite patella • (Synovial plica) • Referred pain – back/hip/femur/foot MGH Sports Medicine 22