Peripheral joints: pathology and treatment

PERIPHERAL JOINTS: PATHOLOGY AND TREATMENT Benjamin Bonte, MD Interventional Pain Fellow Hudson Spine & Pain Medicine 11/8/2017 Outline Shoulder

Knee Hip Shoulder pathology Anatomy Physical Exam Specific pathologies Adhesive capsulitis AC joint sprain/arthritis

Rotator cuff pathology Labral pathology Neurogenic thoracic outlet syndrome Shoulder Anatomy Shoulder Anatomy Shoulder Anatomy

Physical Exam Inspection Swelling, deformities, ecchymosis, rash ROM Palpation Sternoclavicular joint, supraclavicular fossa, AC, biceps tendon,

subacromial bursa, supraspinatus/infraspinatus Provocative testing (will discuss with pathologies) Adhesive Capulitis Limited ability to inject fluid (low volume) into GH joint Joint capsule thickening on MRI, loss of

space in axillary recess, thickening of rotator interval Treatment Rehabilitation (ROM) Corticosteroid injection (SA, GH) manipulation under anesthesia Arthroscopic lysis of adhesions usually reserved for IDDM.

AC joint pathology - Acute AC joint sprains are classified from I-VI Physical exam TTP over AC joint scarf test

Widening of coracoclavicular area on shoulder XR AC joint pathology Type I/II conservative tx

Sling for comfort only and not all the time (ROM essential) Return to sport when asymptomatic/full ROM. 2 weeks for type I 6 weeks for type II Type III - controversial Surgery for laborers, athletes

Type IV-VI surgery ORIF or distal clavicular resection with reconstruction of the CC ligament AC joint pathology - chronic Accuracy of blind injection is 60-67%. Ultrasound guidance can be used

AC Joint - Chronic Corticosteroid injection Distal clavicle osteolysis Rotator Cuff Pathology Impingement syndrome most commonly involves supraspinatus tendon. Pain with overhead reaching. Physical exam empty can isolates supraspinatus, neers

and hawkins narrows subacromial space by internally rotating humeral head Acromion morphology can affect risk of RTC pathology Rotator cuff pathology MRI is imaging modality of choice. XR cystic changes at

insertion (greater tuberosity), high riding humerus US is operator dependent Rotator Cuff Pathology Rehabilitation ROM, RTC muscle strengthening, scapular stabilizers (rhomboids, levator scapulae, trapezius, serratus anterior)

Corticosteroid injections Surgical Tears that fail conservative treatment Aids pain relief, may not always lead to functional improvement Surgeries anterior acromioplasty, coracoacromial ligament lysis Excision, repair (if acute athlete,better if repaired within 3 weeks rather than later reconstruction)

OA of shoulder Physical exam: Limited internal rotation of the shoulder XR: cystic changes, joint surface irregularity treatment: NSAIDs, ROM, RTC strengthening, corticosteroid injections accuracy of an anterior approach ranges from 27% to 99%, and

a posterior approach ranges from 50% to 91% Fluoroscopic vs us guided gh injections No statistically significant difference between either

Labral pathology Repetitive overhead sports, trauma, long head biceps pathology, presents as sharp clicking, locking, and instability Seen on MRI Bankart lesion anterior dislocation that causes tear of labrum Hill sachs lesion compression fracture of posterolateral humeral

head due to anterior instability (abutment against anterior glenoid) Surgical treatment may be an option when conservative measures fail. Neurogenic TOS True neurogenic TOS is RARE. Most common cause fibrous band from

a rudimentary cervical rib to the first thoracic rib C8/T1 symptoms (wasting of hand intrinsics) ddx = UNE, radic. Neurogenic TOS EMG to assist with Ddx Abnormal CMAP/SNAP for ulnar,

Abnormal CMAP for median (spared SNAP), fibs in C8/T1 muscles Adsons test (sens 94%-spec 18-84%) Rehabilitation ROM, stretching (scalenes,

pectoralis muscles, trapezius), postural mechanics 1st rib resection Knee pathology Anatomy Physical exam

Specific pathologies Osteoarthritis Meniscus ACL PCL Distal ITB syndrome (burisitis) Patellar dislocation/Patellofemoral pain/Patellar tendinopathy Pes anserine bursitis

Knee Anatomy Modified hinge joint Knee ROM: 0-135 IR/ER of the knee: 10 degrees from neutral Knee Anatomy Knee Anatomy

Knee Anatomy Pes anserinus Sartorius, gracilis, semiTendinosus (SGT) Knee Osteoarthritis Progressive disorder Primary vs secondary Asymmetric joint space

narrowing, most often medial compartment Osteophyte formation, subchondral cysts, sclerosis, joint space narrowing Knee osteoarthritis Conservative treatment, NSAIDs, ice, PT, ice Corticosteroid injections

surgery Knee joint injection Meniscus injury Sharp localized jointline tenderness, may be traumatic or degenerative

Thessaly is most sensitive test (sensitivity high 90s) Mcmurrays may be more practical but much less sensitive (55-85) May present with effusion Injections, PT can generally

be trialed first in most circumstances Surgical resection may be required if injury occurs to inner 2/3 of meniscus (redwhite zone or white-white zone) ACL Injury Most commonly injured ligament in athletics

Typical story: Internally rotated foot, flexed knee, valgus force Co-occurs with meniscal injuries Lachmans is most sensitive test however cannot be used acutely due to swelling also only 90% sensitive Conservative vs surgical treatment based on activity level PCL injury

Impact to tibia with knee flexed Dashboard injury Popliteal tenderness Posterior drawer test Surgical repair of isolated PCL tear is controversial otherwise conservative management is recommended. Hip pathology

Anatomy Physical exam Specific pathologies Femoral Neck Stress fractures (compression vs tension side) Labral pathology FAI (cam and pincer) Osteoarthritis Internal Snapping hip External Snapping hip

GTB syndrome Adductor pathology Hip Anatomy Hip Anatomy Hip Anatomy Intraarticular

Mechanism of injury Axial loading Groin pain C-sign Mechanical

symptoms Locking, catching, buckling, clicking Pain with sitting Extraarticular

Palpable tenderness Clicking, snapping Paresthesias Pain lying on side Patellar dislocation/Patellofemoral pain/Patellar

tendinopathy Pes anserine bursitis Intraarticular hip pain Labral Tear Active young adults Insidious > acute injury 2:1 Degenerative

assoc w/ abnormal joint morphology Groin pain Mechanical symptoms Internal rotation deficit, impingement test FABER, resisted SLR Precursor to OA

Piriformis syndrome Sciatic nerve can be involved Rehabilitation reduce pain and spasm to recover full hip internal rotation Provocative test is FADIR test (flexion, adduction, internal rotation) Corticosteroid injection can be considerd if more

conservative measures fail. Snapping hip syndrome Pain on hip flexion Ice, NSAIDS, PT, stretching, strengthening. Internal snapping hip snapping over iliopectineal eminence (with or without

pain) External snapping hip tight ITB snapping over greater trochanter Greater Trochanteric Bursitis Inflammation of bursa over greater trochanter Inability to lay on affected

side. Recently, thought to be potentially overdiagnosed, with gluteus medius tendinopathy thought to be the more common cause. FAI (cam and pincer)

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