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Non-Operative Management of
Orthopaedic IssuesReza Omid, M.D.
Assistant Professor Orthopaedic Surgery
Shoulder & Elbow Reconstruction
Sports Medicine
Keck School of Medicine of USC
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Musculoskeletal Injuries
•Common cause for doctor visists (ER and outpatient).
•>1 in 4 Americans has a musculoskeletal condition requiring medical attention.
•Most can be treated non-operatively
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X-rays
•Consider x-ray for any patient with injury
•Fracture/Dislocation/Infection/Tumor
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General Orthopaedics
• Shoulder/Elbow Reconstruction• Trauma• Pediatrics• Hand/Wrist• Foot/Ankle• Hip/Knee Reconstruction• Tumor• Sports Medicine• Spine
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Shoulder Pain
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Differential Dx
»Rotator Cuff Disease»Frozen shoulder»Fracture»Calcific Tendonitis»Labral Tears»Biceps Pathology
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Shoulder Pain–Among the most common sources of pain
–Ranks 2nd to lower back pain as a reason pt. seek medical attention
–Approx. 40% of people over 65 yo have rotator cuff tears!
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Shoulder PainRotator Cuff Disorders
–17 million individuals in US at risk
–600,000 surgeries / year
–Most common source WC shoulder pain
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Rotator Cuff Disease
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Rotator Cuff Anatomy
•Supraspinatus• Infraspinatus•Tere Minor•Subscapularis
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Rotator Cuff DiseaseIntrinsic Factors
–Age related degeneration
Extrinsic Factors–Acromial shape–Mechanical pressure on cuff–Activity
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ConclusionsDemographics
–Unilateral tear in young–Bilateral tear in older–Tears rare before 50 yo.–>50% in pt over 66 yo.
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Radiographs
Always obtain first
AP (scapular plane)
Axillary lateral
Supraspinatus outlet
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History–Pain (especially night pain)
»Radiates around deltoid»Never below elbow
–Weakness–Difficulty reaching overhead or behind–Cannot sleep on affected side
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Physical Examination
–Cervical spine–Shoulder ROM (active/passive) symmetric?
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Physical Examination
Rotator cuff tests–TDA (supraspinatus)–ER at side (infraspinatus)–ER 90° abd (teres minor)–Lift-off (subscapularis)
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Physical Examination
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Physical Examination
Normal Motion–Elevation – 160–Abduction ER – 90
–ER @ side -60–IR/Ext – T7
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Adjuvant Imaging Modalities
MRI
Ultrasound
CT Arthrogram
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MRI Reads
• Labral tears• AC arthritis• Partial
thickness RC tears
• Full thickness RC tears
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MRI Results
Arthritis: •Labral tears•AC arthritis•Partial thickness tears•Tendinosis
Rotator Cuff Dz:•Full thickness tears•High grade partial thickness tears
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MRI Read
No RC Tear
Labral tear seen
AC joint arthritis seen
Dx: Shoulder arthritis
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Partial Rotator Cuff Tears
• Can initially treat conservatively
• If fails conservative treatment then surgery
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Orthopaedic Referral
• Full thickness tear in patients <60-65yo
• Acute (<3month) traumatic full thickness tears in any age
• Full thickness tear in patients >65 yrs who fail conservative treatment
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Rotator Cuff TearRisks - Chronic Changes
– retraction with adhesion– tendon morphology– muscle atrophy– fatty degeneration– degenerative changes
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Conservative Treatment
»Rest, Activity modification
»NSAIDS»ROM stretching»Cuff/Periscapular strengthening
»Corticosteroid Injections
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Cuff Strengthening
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Conservative TreatmentInjections
–Elderly (>65yo)–Partial tears
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Shoulder Injections
“The effect of corticosteroid on collagen expression in injured rotator cuff tendon”
• Wei A, et al JBJSAm 2006: 1331-8
•LIMIT TO 1-2 INJECTION•GET MRI PRIOR
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Proximal Biceps Rupture
• Suspect RC Tear
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Shoulder Dislocation
• If anyone >40 years dislocates get an MRI
• If full thickness tear seen with healthy muscle bellies then surgery is indicated
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Frozen Shoulder“Adhesive Capsulitis”
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Frozen Shoulder–Global and significant loss of both active and passive ROM in gradual fashion
–Absence of radiographic findings other than osteopenia
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Clinical Presentation
–Age: late middle age (40-60)
–Male < Female
–Diabetic and Hypothyroid
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Clinical Presentation
–Significant pain - especially at night!
–Insidious onset»No trauma »Minor trauma (“dog pulled me”, “I reached in the back seat of the car”)
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Late Frozen Shoulder
–Significant loss of ROM»active and passive
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Physical Exam–Passive ROM restricted
»ER early»global late
–ER < 50% unaffected side (pathognomic)
–Pain with extremes of ER
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Treatment
Conservative–NSAID’s–Physical Therapy
Fluoro-Guided Intraarticular Fluoro-Guided Intraarticular Steroid Injection!Steroid Injection!
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Accuracy of glenohumeral joint
injections: comparing approach and
experience of provider.Tobola JSES 2011:1147
• Posterior: 50%• Anterior: 42%
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Arthroscopic Release
–Surgical release of contractures–Remove scar tissue–Complete motion
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Elbow Pain
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Differential Dx
Lateral Epicondylitis
Instability
Biceps Pathology
Medial Epicondylitis
Olecranon Bursitis
Fracture
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Lateral Epicondylitis“Tennis Elbow”
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Presentation
• Lateral elbow pain with grip
• Especially in extension• TTP at lateral
epicondyle
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Conservative Treatment
• NSAIDs• Activity modification• Physical therapy• Counterforce brace• Iontophoresis• Injections
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Conservative Treatment
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Iontophoresis
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Injections
Corticosteroids
Platelet Rich Plasma
Botulinum Toxin A
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ONLY 1 INJECTION!
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POSTEROLATERAL ROTATORY INSTABILITY OF THE ELBOW
IN ASSOCIATION WITH LATERAL EPICONDYLITIS. A REPORT OF THREE CASES.
Kalainov JBJSAm 2005: 1120
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Physical Therapy
•Modalities•Eccentric exercises
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Medial Epicondylitis“Golfers Elbow”
-Medial elbow pain with grip
-Much less common
-TTP at FP mass
-Similar treatment
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Olecranon Bursitis
• Most resolve with symptomatic treatment
• Avoid aspiration unless you suspect infection
• Surgery has high complication rate!
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Distal Biceps Tears
• Anterior elbow pain with associated “pop”
• Treated surgically as opposed to proximal biceps ruptures
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Hand/Wrist Pain
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Carpal Tunnel
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Treament
•Brace•NSAIDs•Vit B6 (50 mg PO tid) may help some of patients
•Injections (nerve can be injured!)
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DeQuervain’s Tenosynovitis
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Other Causes of Radial Sided Wrist Pain
Scaphoid fracture
Wrist arthrits
Radial sensory nerve injury
“Crossover syndrome” (another sheath of
tendons)
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Treatment
•Brace with thumb spica•NSAIDs•Corticosteroid injection into sheath
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Hip Pain
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Differential
Fracture
Stress Fracture
FAI
Arthritis
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Stress Fracture
•Runners•Female•Rest•MRI (If Femoral neck fracture seen refer)
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Stress Fractures
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Femoroacetabular Impingement (FAI)
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Treatment of FAI
RICE, NSAIDs
Physical Therapy
If MRI ordered get MR Arthrogram of
Affected Hip NOT Pelvis
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Knee Pain
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Differential Dx
Meniscus tear
Arthritis/OCD
Ligament Injury
Fracture
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Knee Effusion
Ligament tear
Meniscus tear
Osteochondral fracture
Synovitis
Consider MRI
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Anterior Knee Pain
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Treatment
RICE
Weight loss (every pound lost is 7 pounds off the
knee)
Bracing
Physical Therapy
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Meniscus Tears
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Treatment
•RICE•Weight loss (every pound lost is 7 pounds off the knee)
•Bracing•Physical Therapy •Corticosteroid injection•Surgery is last option
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ACL Injuries
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Treatment of ACL
•If active and only mild arthritis orthopaedic referral.
•If degenerative and non-active treat non-operatively
•Age is irrelevant
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Arthritis
•RICE•Glucosamine/Chondroitin•“Viscosupplement” Injections
•Corticosteroid Injections•Unloader Bracing•PT
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Physical Therapy for Hip/Knee Injuries
•ROM•Quadriceps Strength•Hamstring Strength•Hip Abductor Strength•IT Band Stretching•Iliopsoas Stretching
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Foot/Ankle Pain
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Ankle Sprain
•Get x-rays!!•Most can be treated with CAM walker
•5th MT Fracture
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Ottawa Ankle?
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Achilles Tendon Injury
•If torn refer•If intact treat with RICE, NSAIDs, CAM boot, PT for eccentric exercises
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Achilles Tendon Injury
• Tendinopathy vs insertional tendonitis
• Heel lift• NSAIDS
• PT (eccentric exercises)
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Plantar Fascitis
•Inflammation of the plantar fascia
•Achilles stretching•RICE•Boot
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Questions???
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www.dromid.com
Reza Omid, M.D.Assistant Professor Orthopaedic SurgeryShoulder & Elbow ReconstructionSports MedicineKeck School of Medicine of USC