Update on Diagnosis and Treatment of Common Soft Tissue Injuries Kuwait March 9, 2019 Fadi Badlissi, MD, MSc Director of the Musculoskeletal Medicine Unit The Orthopedic Department & Rheumatology Division HMFP/BIDMC Assistant Professor of Medicine Harvard Medical School
Disclosure • No conflicts
Case of Shoulder Pain • 63 year-old female with acute L shoulder pain for one week • No trauma • On exam: limited range of motion (ROM) due to pain, better passive ROM • Subacromial tenderness • Positive impingement, though overall limited exam due to the pain
Humerus/Greater Tuberosity
Acromion Humerus
Calcific Tendinopathy • Calcific deposits in the tendon and bursa • Radiographic prevalence 3-10 % » Bosworth BM, et al. JAMA 1941 • Painful range of motion (ROM) • Impingement • Imaging – Radiographs – Ultrasound more sensitive – MRI mostly to rule out tear
Calcific Tendinopathy Management • NSAIDS • PT • Subacromial corticosteroid injection • Extracorporeal Shock Wave Therapy (ESWT) » Bannuru RR, et al. Ann Int Med 2014 » Arirachakaran A, et al. Eur J Orthop Surg Traumatol 2017 • Barbotage » Lanza E, et al. Eur Radiol 2015 • Surgery
Predictors Of No Response To Non- Surgical Management Question • All of these are predictors of no response to conservative management in calcific tendinitis except : 1. Bilateral calcific tendinitis of the shoulder 2. Location at the anterior portion of the acromion 3. Fragmented calcifications 4. Medial (subacromial) extension 5. High volume of the calcific deposit » Ogon P, et al. Arthritis Rheum 2009
Predictors Of No Response To Non- Surgical Management, Answer • All of these are predictors of no response to conservative management in calcific tendinitis except: 1. Bilateral calcific tendinitis of the shoulder 2. Location at the anterior portion of the acromion 3. Fragmented calcifications 4. Medial (subacromial) extension 5. High volume of the calcific deposit » Ogon P, et al. Arthritis Rheum 2009
Another Case of Shoulder Pain • 58 year-old male, R shoulder pain and limited range of motion for 3 months • No improvement with physical therapy • Exam: limited active abduction 90, passive 110, severely limited internal rotation , slightly limited external rotation • Negative impingement sign • Normal strength
Labrum Glenoid
Frozen Shoulder Diagnosis & Management • Shoulder pain with progressive limitation in active and passive range of motion (ROM) • Limited internal rotation limited differential • X-ray to rule out dislocation and OA • MRI to rule out other etiologies of pain • Primary versus secondary • More common in diabetics OR 5 (95% CI 3.2- 7.7), prevalence 13.4% » Zreik NH, et al. Muscles Ligaments Tendons J 2016
Frozen Shoulder Diagnosis & Management • Intraarticular corticosteroid injection combined with physical therapy (PT) provided faster pain relief and improvement in function compared to placebo normal saline injection with or without PT » Carette S, et al. Arthitis Rheum 2003 • Recovery without treatment few months to years
Rotator Cuff Tear • It could be difficult to differentiate from tendinitis clinically • History of trauma • Weakness on exam • Imaging with US, MRI
Humerus Head, Greater Tuberosity
USSONAR.ORG
Humerus Head, Greater Tuberosity
USSONAR.ORG
Rotator Cuff Tear Management • Conservative versus surgical management depends on: – Functional level and demand – Age – The width and thickness of the tear, partial vs. full – Acuteness of tear, extent and chronicity of tear – Muscle bulk and retraction • Surgery is indicated for acute full thickness tear • Clinical trials showed no advantage for surgical repair in non traumatic and small/medium tears » Kukkonen J, et al. J Bone Joint Surg Am 2015 » Moosmayer S, et al. J Bone Joint Surg Am 2014 • No good quality evidence to favor a specific conservative management approach
Lateral Epicondylitis • Prevalence 1.3% » Shiri R, et al. Am J Epidemiol 2006 • Tenderness over the lateral epicondyle • Mostly mechanical • Pain with resistance to wrist extension and supination • Medial epicondylitis a mirror image of lateral epicondylitis, prevalence 0.4% • Treatment – Occupational therapy – Splints – Iontophoresis with topical naproxen or dexamethasone provides short term relief
Lateral Epicondyle
Lateral Epicondylitis Radius Lat Epicondyle
Corticosteroid Injections for Lateral Epicondylitis • Compared to physical therapy, they provide short term benefits • No long term benefit, possibly harmful • Tenotomy might be of additional benefit » Coombes BK, et al. JAMA 2013 » Coombes BK, et al. Lancet 2010 » Smidt N, et al. Lancet 2002
Lateral Epicondyle Injection
Lateral Epicondylitis, Other Options • Prolotherapy, injection of irritant solution and anesthetic, small numbers » Scarpone M, et al. Clin J Sport Med 2008 • Botulinum toxin injection, improvement in pain but not function » Placzek R, et al. J Bone Joint Surg Am 2007 » Espandar R, et al. CMAJ 2010
Lateral Epicondylitis, Platelet Rich Plasma & Autologous Blood Injection • Metaanalyses and larger randomized control studies showed lack of effectiveness » de Vos RJ, et al. Br J Sports Med 2014 » Ahmad Z, et al. Arthroscopy 2013 • Smaller studies showed some effectiveness but potential bias and no control group » Peerbooms JC, et al. Am J Sports Med 2010 » Gosens T, et al. Am J Sports Med 2011
Bursitis • Acute versus chronic • Is the joint involved? Is is septic? • With olecranon bursitis it could be challenging – Extension – Supination pronation • Prepatellar bursitis sympathetic knee effusion could be challenging to differentiate from septic knee, extension usually preserved in bursitis
Elbow Anatomy
Bursitis Question • All of these could be associated with acute bursitis Except: 1. Gout 2. Pseudogout 3. Lupus 4. Trauma 5. Infection
Bursitis Answer • All of these could be associated with acute bursitis Except: 1. Gout 2. Pseudogout 3. Lupus 4. Trauma 5. Infection
Bursitis Diagnosis • Establish the diagnosis Joint versus bursa • Exam: effusion, tenderness, erythema • Imaging most of the times not necessary • Aspirate, synovial fluid analysis – Cell count – Crystals – Stains and cultures
Infrapatellar Bursitis • 53 year-old male with crystal proven history of gout • Acute onset left knee anterior pain • No trauma • Exam: No effusion, normal extension, and flexion but painful • Warmth, swelling and tenderness over the anterior proximal tibia
Patella
Tibia
Bursitis Management • Aspiration • Corticosteroid injection If infection is ruled out, risk of skin atrophy and fistulae in superficial bursa • Treat the underlying etiology
Indications For Bursectomy • Inadequate drainage & response to treatment • Debridement of wound or soft tissue infection • Chronic bursitis • Surgery for reluctant recurrent bursitis, might be helpful especially in non inflammatory olecranon bursitis based on small series » Stewart NJ, et al. J Shoulder Elbow Surg 1997
Case Hip Pain • 71 year-old female with left hip pain for 2 months • No trauma • Pain localized over the lateral aspect radiating to the knee but not below it • Exam: normal ROM, pain with Patrick’s test laterally • Resistance to abduction painful but normal strength
Gluteus Max Gluteus Medius Greater Trochanter
Trochanteric Bursitis, Question • What percentage of patients with a clinical diagnosis of trochanteric bursitis have fluid in the bursa? 1. > 90% 2. 60-80% 3. 30-60% 4. 20% or less
Trochanteric Bursitis, Answer • What percentage of patients with a clinical diagnosis of trochanteric bursitis have fluid in the bursa? 1. > 90% 2. 60-80% 3. 30-60% 4. 20% or less
Trochanteric Bursitis • Mostly gluteus medius and minimus tendinosis • Ultrasound study of subjects with lateral hip pain, half had evidence of tendinosis, only 20% fluid in the greater trochanteric bursa » Long SS, et al. AJR Am J Roentgenol 2013 » Bird PA, et al. Arthritis Rheum 2001
Greater Trochanteric Bursitis Management • Corticosteroid injections provide faster relief but similar long term outcome compared to physical therapy » Mellor R,et al. BMJ 2018 • Surgery occasionally needed for persistent pain > 1 year with a documented gluteus medius tear • Similar results with open vs. arthroscopic surgery • Outcomes less favorable with fatty degeneration of the muscles » Chandrasekaran S, et al. Arthroscopy 2015 » Thaunat M, et al. Arthroscopy 2018
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