07. Musculoskeletal Medicine Dr. Chris Smith Vietnam Sept. 2012

Harvard Medical SchoolMusculoskeletal Care for the General Doctor: Shoulder and Knee Pain C.. Harvard Medical SchoolThe Painful Shoulder and Knee Recognize, diagnose and treat the most

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Musculoskeletal Care for the General Doctor: Shoulder and Knee Pain

C Christopher Smith, MD, FACP

Associate Professor of Medicine,

Harvard Medical School

Beth Israel Deaconess Medical Center

Disclosure of Financial Relationships

C Christopher Smith, MD

Have no relationships with any entity producing,

marketing, reselling or distributing health care goods

or services consumed by, or used on patients.

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The Painful Shoulder and Knee

Recognize, diagnose and treat the most common causes of shoulder and knee pain in the primary care setting

Know how to differentiate among other common causes of shoulder and knee pain

The Painful Shoulder and Knee

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Shoulder Pain

A 65-year-old woman with a history of type II DM

presents for evaluation of new left shoulder pain The pain is in her anterior and lateral shoulder and has

gradually worsened over the last three weeks It is

dull and constant and keeps her up at night She also notices marked discomfort when she combs her hair and cannot get clothes from a high shelf due to pain and weakness She denies any trauma or prior

injuries She works as a shop keeper

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Anatomy of the Shoulder

UpToDate, 2006

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The Rotator Cuff Muscles

UpToDate, 2006

Causes of Shoulder Pain

Referred Pain Diaphragmatic, Subdiaphragmatic and Intrathoracic Causes

-Harvard Medical School

In the primary care setting, what is the most common cause of

nontraumatic shoulder pain?

A Bicipital Tendonitis

B Impingement Syndrome

C Adhesive Capsulitis (Frozen Shoulder)

D Osteoarthritis of the Glenohumeral Joint

E Acromioclavicular Joint Osteoarthritis

In the primary care setting, what is the most common cause of

nontraumatic shoulder pain?

A Bicipital Tendonitis

B Impingement Syndrome

C Adhesive Capsulitis (Frozen Shoulder)

D Osteoarthritis of the Glenohumeral Joint

E Acromioclavicular Joint Osteoarthritis

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Causes of Shoulder Pain in the Primary Care Setting:

So what is impingement syndrome?

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Impingement Syndrome

UpToDate, 2006

Typical History of Impingement

Syndrome

Any age, but risk increases with age

Anterior or lateral shoulder pain

Pain exacerbated by abduction and forward

flexion

Night pain common

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Age and Shoulder Pain

Physical Exam

Inspection

Palpation

• Difference between passive and active

 Pain active > passive ROM likely soft tissue disorder

 Pain equal with active and passive ROM likely articular process

intra-Strength and Sensation

Specific Maneuvers to Confirm Diagnosis

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Maneuvers to Verify Impingement Syndrome

Empty Can Test

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Maneuvers to Verify Impingement Syndrome

Neer’s Test

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NSAIDs or Subacromial injection

• Each is better than placebo

• Little long term difference

• No benefit in combination treatment

White, J Rheumatol 1986 Petri Arthritis Rheum 1987

Supraspinatus Tendon Tear

• Positive “Drop-Arm” Test

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Diagnosing Rotator Cuff Tear

# Positive signs* Age Probability of

rotator cuff tear

A 55-year-old male with IDDM, HTN and GERD presents with three months of worsening left lateral shoulder pain, which is worse at night

He reports pain with most any movement

Range of motion testing reveals pain and

restricted movement in most directions

Symptoms are present with both passive and active movement.

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Adhesive Capsulitis or Frozen Shoulder

• Thickening and contraction of the capsule

surrounding the glenohumeral joint

• Insidious onset of pain

• Night pain

• Pain in deltoid, but no tenderness to palpation

• Pain and limited active and passive ROM

• Need AP X-ray of glenohumeral joint to rule out glenohumeral arthritis

• Treatment: Physical Therapy

Adhesive Capsulitis or Frozen Shoulder

• Immobility is the most important risk factor

• 10% of patients with impingement develop frozen shoulder due to immobility

• Other risk factors:

• Diabetes

• Hypothyroidism

• AVN of glenohumeral head

• Chronic Regional Pain Syndrome

• Treatment: Physical Therapy

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Summary

Impingement syndrome most common cause of shoulder pain in the primary care setting

Systematic approach to physical exam

Range of Motion: pain with abduction, forward

flexion; active > passive

Empty can and Neer, tests to confirm

Drop arm indicates a complete tear - especially in patients > 60 years old

 Adhesive Capsulitis

• DM or Immobile shoulder

• Limited ROM in most planes

• Pain with both active passive ROM

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The Painful Knee

A 23-year-old male with no prior orthopedic injuries presents to your clinic one day after injuring his right knee during a game of football He recounts that the injury occurred when another

player fell onto the lateral aspect of his right knee He was able

to continue playing, but with a slight limp

He did not notice a “pop,” or immediate swelling There is no laxity or “catching.” The pain is on the medial aspect of his right knee, just above the joint line

Exam reveals slight medial swelling, but no ecchymosis There

is tenderness to palpation just superior to the medial joint line and pain with valgus stress, but a solid end point and no laxity.

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Causes of Knee Pain

Acute Knee Pain

Calmbach, Am Fam Phys 2003

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Mechanism of Injury

Right Knee

Calmbach, Am Fam Phys 2003

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Calmbach, Am Fam Phys 2003

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Valgus Stress

Varus Stress

A 23-year-old male with no prior orthopedic injuries presents to

your clinic one day after injuring his right knee during a game of touch football He recounts that the injury occurred when

another player fell onto the lateral aspect of his right knee He was able to continue playing, but with a slight limp

He did not notice a “pop,” or immediate swelling There is no laxity or “catching.” The pain is on the medial aspect of his right

knee, just above the joint line

Exam reveals slight medial swelling, but no ecchymosis There

is tenderness to palpation just superior to the medial joint line

There is pain with valgus stress, but a solid end point and no

laxity.

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Medial Collateral Ligament Sprain

 “Sprained” Knee

 Direct trauma to the side opposite the

location of pain (valgus stress)

 If mild, can continue with activity

 Most commonly involves proximal MCL

 Pain with valgus stress

 Most common cause of acute knee “injury”

in primary care setting (50%)

Valgus Stress and MCL Strain

 First Degree Sprain

• Tenderness along MCL

• <5mm laxity but solid end point

 Second Degree Sprain

• Laxity at 30° flexion, not in full extension

• Solid end point

 Third Degree Sprain

• Significant laxity at 30°; laxity in full extension

• No solid end point

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Treatment of MCL Strain

Grade I and II managed conservatively

Rest, Ice, Compression, Elevation and NSAIDs

Physical Therapy to restore ROM and to regain muscle strength

Brace to protect knee from further injury

Grade III can also be treated conservatively but

would need to rule out other ligamentous injury

• MRI

• Refer to orthopedics

A 39-year-old male presents to your office on

a wheelchair pushed by his 14-year-old son This morning while playing football with his son, he stopped suddenly and planted his

right knee to turn; his knee gave out and he fell to the ground He noted a “pop” and

immediate pain and swelling in his knee He had to be helped off the field and reports that his leg feels “unstable.”

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Anterior Cruciate Ligament Injury

History of forced hyperextension (clipping),

noncontact deceleration or “cutting” or twisting

movement—especially with planted foot and

valgus stress

Spindler, NEJM 2008

Harvard

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Anterior Cruciate Ligament Injury

History of forced hyperextension (clipping),

noncontact deceleration or “cutting” or twisting

movement—especially with planted foot and

Anterior Drawer Test

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Lachman Maneuver

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Treatment of ACL Injuries

Treatment depends on severity of injury and level of patient activities.

Most can perform straight line activities

Consider surgery in patients with complete tear and

• <40 years of age

• High function level for recreation, work, sports

• Associated damage to menisci or collateral ligaments

• Ongoing knee pain, swelling or episodes of laxity

• Able to commit and comply with intensive rehab (6-12 months)

Acute management: improve hemarthrosis and ROM

Without surgery up to 50% develop OA

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Meniscal Injuries

Common (35% of all patients)—especially with

osteoarthritis (up to 80% of patients with OA)

• In OA less likely to have mechanical symptoms

Either Acute or Chronic Pain

Twisting or cutting while weight bearing

Often initially able to continue activity

Clicking, catching, locking— esp if tear extends anteriorly

beyond the MCL (“bucket-handle tear”)

Intermittent pain—usually with rotational

movements

Delayed effusion Englund, NEJM 2008

Meniscal Injury

Joint line tenderness

McMurray’s test

Duck Walk

Lachman—one third also have ACL injury

Poehling, Clin Sports Med 1990

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Management of Meniscal Injuries

 Treatment depends on degree of symptoms and patient’s functional status

• Anti-inflammatory medications

• PT—straight leg raises to restore strength

• Consider orthopedic referral if pain and disability persist for 2-4 weeks

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Power of Physical Examination

 Given prevalence in primary care setting,

likelihood of ligamentous or meniscal tear is

<1.5% if exam is negative

 If exam is positive, post test probability is 50%

 MRI is slightly more sensitive, but less

specific

Jackson, Ann Intern Med 2003 Scholten, J Fam Pract 2001 Solomon, JAMA 2001

Liu, J Bone Joint Surg 1995 Rose, Arthroscopy 1996

Other Causes of Acute Pain

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A careful, systematic physical examination is

essential to confirm the etiology of knee pain

Most causes of knee pain can be accurately

diagnosed and treated by PCPs

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Questions?