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Nuisance Problems You will Grow to Love
Thomas V Gocke, MS, ATC, PA-C, DFAAPA
President & Founder
Orthopaedic Educational Services, Inc.
Boone, NC
osteojunky@gmail.com
www.orthoedu.com
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Faculty Disclosures• Orthopaedic Educational Services, Inc.
Financial
Intellectual Property
No off label product discussions
American Academy of Physician Assistants
Financial
PA Course Director, PA’s Guide to the MSK Galaxy
Urgent Care Association of America
Financial
Intellectual Property
Faculty, MSK Workshops
Ferring Pharmaceuticals
Consultant
2
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LEARNING GOALS
At the end of this sessions you will be able to:
• Recognize nuisance conditions in the Upper Extremity
• Recognize nuisance conditions in the Lower Extremity
• Recognize common Pediatric Musculoskeletal nuisance
problems
• Recognize Radiographic changes associates with
common MSK nuisance problems
• Initiate treatment plans for a variety of MSK nuisance
conditions
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Inflammatory Response
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Inflammatory Response*
When does the Inflammatory response occur:
• occurs when injury/infection triggers a non-specific
immune response
• causes proliferation of leukocytes and increase in blood
flow secondary to trauma
• increased blood flow brings polymorph-nuclear
leukocytes (which facilitate removal of the injured
cells/tissues), macrophages, and plasma proteins to
injured tissues
*Knight KL, Pain and Pain relief during Cryotherapy: Cryotherapy: Theory, Technique and Physiology, 1st edition, Chattanooga
Corporation, Chattanooga, TN 1985, p 127-137
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Inflammatory Response*• As a result of the inflammatory process:
– redness occurs at the injury site
– tissue warmth occurs as result of increased cellular
activity
– swelling results from increased fluid
– pain as a result of tissue injury and stretching of nerve
structures
– The accumulation of fluid/edema at the injury site,
• can limit the healing process by reducing joint
range of motion (ROM)
• facilitating the formation of scar tissue. *Knight KL, Pain and Pain relief during Cryotherapy: Cryotherapy: Theory, Technique and Physiology, 1st edition, Chattanooga Corporation,
Chattanooga, TN 1985, p 127-137
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UPPER EXREMITY
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BURSITIS
• Bursitis:
– Synovial pouch that reduces friction between
adjacent tissue (structures)
– “Nuisance problem”
– Onset: sudden, gradual, traumatic, infection
– 2 types: Septic vs. Non-septic
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Bursitis• Septic:
– 2nd to inoculation bursa with bacteria
– Olecranon/Pre-patella most commonly infected bursa
– Local cellulitis precipitates
– Hematogenous spread – rare
– Laborers @ risk for septic bursitis (repetitive motion)
– Immune compromised
• ETOH abuse/DM/Malignancy
• Chronic systemic Glucocorticoid use
• Renal Failure
– Gout/rheumatoid nodules/hx previous sepsis
– Iatrogenic infection due to intra-bursal steroid injection
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Bursitis
• Non-Septic:
– Traumatic – Idiopathic – Crystalline-induced
– Olecranon/Pre-patella most commonly infected/affected
bursa
– Inciting event trivial to non-existent
– Laborers @ risk for septic bursitis ( repetitive motion)
– Same population as Septic bursitis
– Crystalline – induced 2nd hx gout
– Rheumatoid arthritis may trigger onset bursitis
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Rotator Cuff SyndromeRotator Cuff Tendonitis
Sub-acromial Bursitis
Sub-acromial impingement
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Shoulder Anatomy
Musculoskeletal Images are from the University of Washington
"Musculoskeletal Atlas: A Musculoskeletal Atlas of the Human Body"
by Carol Teitz, M.D. and Dan Graney, Ph.D."
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Shoulder Anatomy
Musculoskeletal Images are from the University of Washington
"Musculoskeletal Atlas: A Musculoskeletal Atlas of the Human Body"
by Carol Teitz, M.D. and Dan Graney, Ph.D."
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Rotator Cuff Syndrome• Pathophysiology
– Anterosuperior Impingement syndrome
• Involves: Acromion, Sub-acromial bursa,
Coracoclavicular ligament & Acromioclavicular
joint
• Supraspinatus tendon inserts greater tuberosity
anterior to Coracoacromial arch
• Biceps tendon passes under Coracoacromial arch
in forward flexion w/ shoulder internally rotated
• Neer (1972) felt RTC tears wear 2nd to
impingement and aided by down sloping acromial
spur
Roy, A: Rotator Cuff Disease; http://emedicine.medscape/article/328253-overview
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Rotator Cuff Syndrome
• Pathophysiology
– Progressive, age-related tendon changes
– Codman (1934) most tears are after age 40 and
significantly increase after age 50
– Articular surfaces tears most at insertion
supraspinatus insertion into greater tuberosity
Roy, A: Rotator Cuff Disease; http://emedicine.medscape/article/328253-overview
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Rotator Cuff Syndrome
• All ages
• Dull achy pain vs. sharp pain
• Gradual onset vs. sudden onset
• “Painful arc” 60-120 degrees ROM
• Night / sleep pain
• Overhead pain & weakness
• Deltoid pain
• Numbness small fingers affected side - relative
• Weakness with daily activity or specific tasks
• Atrophy Shoulder Girdle (Supraspinatus & Infraspinatus)
• Activity level: variable
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Shoulder Physical Exam
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Rotator Cuff SyndromePhysical Examination:
• Inspection: skin, muscle atrophy, deformities
• Palpation: AC, SC, clavicle, coracoid, posterior RTC
• Range-of-Motion: Flex, Ext, IR, ER
• Strength: Flex, Ext, IR, ER
• Neuro/Vascular: C5-T1
• Orthopaedic Tests:
– Speeds: biceps/RTC
– Empty Can: RTC (supraspinatus-infraspinatus)
– Neer/Hawkins: RTC impingement
– Crossover: AC joint
– Apprehension/relocation: Stability
– Obrien’s: Labrial injury
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Don’t Forget Cervical Disease
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Shoulder Examination
• Empty Can Test
– Assess resistive strength
of the Supraspinatus
portion RTC
– Shoulder flex to 90 degrees
& horizontally Abd to
45 degrees
– Positive test indicates pain
and weakness against
resistance
• Empty can test picture
Picture courtesy T Gocke, PA-C
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Shoulder Examination• Speed’s Test
– Assessment Bicep
tendon injury
– Forward flex shoulder
to 90 degrees w/
elbow fully extended
& hand supinated
– apply downward force
to the distal forearm
– Positive test: Pain and
weakness indicating
biceps tendon
pathology (RTC)Photo courtesy TGocke, PA-C
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• Neer & Hawkins RTC Impingement
Tests
– Assess impingement of the
greater tubercle-RTC tendon &
subacromial bursa as humeral
head moves under the Acromion
– Neer: arm max internal rotation
go from ext to fully flex position
over head
– Hawkins: elbow / shoulder flex 90
then passively int / ext rotate
– Positive test indicates pain with
impingement maneuvers
Shoulder Examination
Picture courtesy T Gocke, PA-C
Picture courtesy T Gocke, PA-C Picture courtesy TGocke, PA-C
Picture courtesy TGocke, PA-C
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• Obrien’s Test
– Assess integrity of the
bicep tendon insertion into
the superior glenoid
labrium
– Shoulder flexed to 90,
horizontally ADD to 45
and arm max internal
rotation. Downward force
applied to hand/distal arm
– Positive test indicates
pain and weakness
Shoulder Examination
Picture courtesy T Gocke, PA-C
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• Crossover Test– Assess integrity of the
AC joint for laxity and
degenerative
conditions
– Shoulder flexed to 90 &
patient reaches over
and touches opposite
– Positive test indicates
pain and limited motion
isolated to AC joint
region
Shoulder Examination
Picture courtesy T Gocke, PA-C
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Rotator Cuff SyndromeX-ray studies
• AP/Axillary/Outlet
• Grashy/External Rotation
MRI
• Soft-tissue assessment
• Young adults MRI-arthrogram
CT scan
• Alternative for MRI
• Needs CT arthrogram
Photo courtesy TGocke, PA-C
Photo courtesy TGocke, PA-C
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Don’t Forget Cervical Disease
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Rotator Cuff SyndromeTreatment:
• Identify condition/Manage Pt. expectations
• Modification activities
• NSAIDS: oral vs. topical
– Ibuprofen/Celecoxib/Meloxicam vs. Diclofenac 1 or 2%
• Therapy – strength/ROM
• Injection
• MRI – further diagnostic acute vs. failed therapies
• Surgery
– Arthroscopy Sub-acromial decompression vs. Rotator
repair
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Subacromial Injections
Posterior Approach:
• Posterolateral arthroscopy
portal region
• Sitting position with arm
dependant
• Identify posterior rim acromion
spine
• Slight cephalad angle
• Aim towards coracoid
• Select analgesic & steroid
preparation
Photo courtesy TGocke, PA-C
Photo courtesy TGocke, PA-C
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Olecranon Bursitis
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Olecranon Bursitis
• Olecranon bursa lies between bony olecranon & skin
• Very superficial bursa and easily traumatized
• Acts to decrease friction between bone and skin
• Inflammation results from overuse, trauma or infection
• Chronic disease states can cause inflammation
– Gout
– Pseudogout
– RA
• Repetitive stress positions can cause inflammation
– Results for constant contact pressure on bursa
– Forward leaning position
• Classic finding: Fluctuant bulge over olecranon
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• Pathophysiology:
– Inflamed synovial cells lead to
increased fluid production
– Increased permeability of capillary
membrane allows fluid to accumulate
– Hemorrhage occurs as a result of
trauma
– Local trauma facilitates inoculation of
overlying skin with bacteria & can
lead to septic bursitis
Olecranon Bursitis
Image courtesy of Tom Gocke PA-C
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Olecranon Bursitis
Physical Examination:
• Inspection: skin changes
• Palpation: Radial head, epicondyles, CFT/CET, Olecranon
• Range-of-Motion: Flex, Ext, pronation/supination
• Strength: Flex, Ext, pronation/supination
• Neuro/Vascular: C5-T1
• Orthopaedic Tests:
– Collateral Ligament stability
– Distal Tricep/Bicep tendon (Hook Sign – Bicep)
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Olecranon Bursitis
Treatment: Non-septic Bursitis• Recognize potential for infection
• Activity modification
• ICE/Heat
• Compression
• NSAIDS: topical vs. oral
• Injection/aspiration vs. Incision & drainage
• Protective Pad/cushion
• Pt. expectations
– Surgical excision chronic/recalcitrant bursitis
• Manage Acute Gouty flares
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Treatment: Septic Bursitis• Diagnostic Studies- +*
– Blood Studies: CBC w/ diff, BMP, ESR, CRP, Uric acid level
– Uric acid level: trending downward
– Glucose: bursal fluid glucose is < 50% serum glucose levels (septic bursitis)
– Aspirated fluid• WBC < 1000/ul normal ( predominantly mononuclear cells)
• WBC 200-1000/ul inflammation ( mononuclear cells)
– WBC >1,500/ul infection (polymorphonuclear cells)
*McAfee JH, Smith DL: Olecranon and Prepatellar Bursitis: Diagnosis and Treatment; Topics in Primary Care, West J Med 1988 Nov; 149:607-610
+ Aaron DL et al: Four Common Types of Bursitis: Diagnosis and management, JAAOS June 2011, 19(6):359-367
Olecranon Bursitis
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Septic Bursitis Non-Septic Bursitis Crystals
Fluid Appearance Purulent Straw-Serous Straw-Serous-Bloody
Leukocytes per uL 1.500 – 300,000
Mean # 75,000
50-11,000
Mean 1,100
1-6,000
Mean 2,900
WBC/Differential >10,000
Polymorphonuclear cells
<1,000
Mononuclear cells
<1,000
Variable
Glucose Ratio < 50% blood glucose >50% blood glucose ?
Gram Stain + > 70% Negative Negative (?)
Crystals None (?) None Monosodium urate crystals- GoutCalcium pyrophosphate or hydroxyapatite crystal- Pseudogout
Culture Staph Auerus &
Epidermiidis (90%)
Streptococcal species
None
McAfee JH, Smith DL: Olecranon and Pre-patellar Bursitis: Diagnosis & Treatment, Western Journal MedicineNov 1988, 149:5;607-610
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• Diagnostic studies*
– Cultures:
• Majority Staphylococcus aureus or epidermidis
• Strep species, gram negatives, H. Flu, anaerobes, mycobacteria
– Crystals
• Monosodium urate crystals- Gout
• Calcium pyrophosphate or hydroxyapatite crystal- Pseudogout
– Radiographs –concern for bone trauma
– AP & Lateral (radial head view)
– McAfee & Smith: No hx trauma – x-ray unnecessary
*McAfee JH, Smith DL: Olecranon and Prepatellar Bursitis: Diagnosis and Treatment; Topics in Primary Care, West J Med 1988 Nov; 149:607-610
Olecranon Bursitis
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Aspiration/Injection or Incision & Drainage
• Suspect infection in most cases
• Plan to aspirate first and inject depending on fluid aspirated
• Aspirate Fluid
– Turbid fluid
– Send fluid for analysis
– Consider I&D and Abx
– Admission?
Olecranon Bursitis
Picture courtesy TGocke PA-C
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LOWER EXREMITY
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Pre-patellar Bursitis
Infra-patellar Bursitis
Pes Anserine Bursitis
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Pre-patella/Infra-patella Bursitis
Illustration demonstrating the anatomy of the prepatellar bursa, which consists of the subcutaneous prepatellar bursa and the superficial infrapatellar bursa. (Adapted with permission from McAfee JH, Smith DL: Olecranon and prepatellar bursitis: Diagnosis and treatment. West J Med 1988;149:607-610.)
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Symptoms
• Gradual onset to sudden onset
• Localized pain/swelling medial tibial
flare
• Start-up symptoms
– Stiffness better after motion
– Swelling
– Hamstring pain/stiff with knee ext.
– Variable pain locations: joint
line/medial tibia
– Weakness/giving out
– Catching/lockingImage courtesy TGocke, PA-C
Pes Anserine Bursitis
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Pre-patellar Bursitis Symptoms
• Gradual onset to sudden onset
• Start-up symptoms
– Hx. repetitive kneeling,
squatting, climbing
• Nursemaids knee
• Clergymen’s knee
• Carpet layer’s knee
– Swelling anterior knee
– Redness/warmth
– Pain variable
Picture courtesy Wiki Commons
Picture courtesy TGocke, PA-C
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Pre-patellar Bursitis Physical Examination
• Inspections
– Swelling pre-patellar region
– Skin
• Palpation
– Redness/warmth
– Tender patella region
• ROM/Strength
– Usually no ROM changes
– Normal strength
– Hurts to Kneel/squat/climb
• Neuro/Vascular
• Ortho exam normalPicture courtesy TGocke, PA-C
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Infrapatellar Bursitis
Symptoms
• Less common vs. pre-patella
bursitis
• Gradual onset to sudden onset
• Acts like patellar tendonitis
• Start-up symptoms
– Stiffness getting better after
some motion
– Swelling
– Weakness/giving out
– Catching/pinching sensation
Picture courtesy TGocke, PA-C
Picture courtesy TGocke, PA-C
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Infrapatellar Bursitis Physical Examination
• Inspections
– Swelling patellar tendon region
– No suprapatella swelling
• Palpation
– ? Redness/warmth
– Tender patella tendon region
• ROM/Strength
– Start-up symptoms
– Stiffness
• Neuro/Vascular - normal
• Orthopaedic Tests - normal
Picture courtesy TGocke, PA-C
Picture courtesy TGocke, PA-C
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Pre-patella/Infra-patella Bursitis
• Treatment – Non-Septic Bursitis
– Modify activity
– ICE
– NSAIDS topical vs. oral
– Flexibility
– Physical Therapy
– Protective sleeve vs. pad (pre-patella)
– Injection/aspiration vs. Incision & drainage
• Manage Acute Gouty flares
– Protective Pad/cushion
• High recurrence rate in repetitive activity jobs
*Pes bursitis- treat knee OA usually treats bursitis
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Treatment: Septic Bursitis• Diagnostic Studies- +*
– Blood Studies: CBC w/ diff, BMP, ESR, CRP, Uric acid level
– Uric acid level: trending downward
– Glucose: bursal fluid glucose is < 50% serum glucose levels (septic bursitis)
– Aspirated fluid• WBC < 1000/ul normal ( predominantly mononuclear cells)
• WBC 200-1000/ul inflammation ( mononuclear cells)
– WBC >1,500/ul infection (polymorphonuclear cells)
*McAfee JH, Smith DL: Olecranon and Prepatellar Bursitis: Diagnosis and Treatment; Topics in Primary Care, West J Med 1988 Nov; 149:607-610
+ Aaron DL et al: Four Common Types of Bursitis: Diagnosis and management, JAAOS June 2011, 19(6):359-367
Pre-Patella/Infra-Patella Bursitis
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– Suspect infection in most cases
– Plan to aspirate first and inject depending on fluid aspirated
– Aspirate Fluid• Turbid fluid
• Send fluid for analysis
• Consider I&D and Abx
• Admission?
Pre-patella/Infra-patella Bursitis
• Aspiration/Injection or Incision & Drainage
Photo courtesy TGocke, PA-C
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HIP & PELVIS
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Trochanteric Bursitis• Trochanteric Bursa lies deep to the
ITB & superficial to Gluteus medius
tendon insertion @ greater trochanter
• Gluteus medius/minimus
– Attach greater trochanter
– ABDuct & Internal rotation
• AKA: Greater Trochanteric Pain
Syndrome (GTPS)
• Trochanteric bursitis = Gluteal
tendinosis
• Consider pts. with Trochanteric bursitis
to have gluteal tendinosis/tear**Bird PA et al: Prospective evaluation of magnetic resonance imaging findings in
patients with greater trochanteric pain syndrome; Arthritis Rheum 2001;44(9):
2138-2145Musculoskeletal Images are from the University of Washington "Musculoskeletal
Atlas: A Musculoskeletal Atlas of the Human Body" by Carol Teitz, M.D. and
Dan Graney, Ph.D."
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Trochanteric BursitisClinical Presentation
• Mechanism of injury
• Repetitive/Change activity
• Poor flexibility
• Sedentary
• Body habitus
– Symptoms
• Start-up pain
• Prolonged sitting
• Side sleeping position
• Isolated lateral hip pain
Groin or Butt pain think something elseMusculoskeletal Images are from the University of Washington "Musculoskeletal
Atlas: A Musculoskeletal Atlas of the Human Body" by Carol Teitz, M.D. and
Dan Graney, Ph.D."
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Trochanteric BursitisPhysical Examination
• Inspection
– Have the pt. stand and point to location of their
pain
• Palpation – tender lateral trochanter/hip
• ROM/Strength – ABD pain/passive ADD
pain
• Neuro/vascular – no changes
• Ortho exam –
– Stichfield’s Test- hip joint
– Patrick/FABER- SI joint dysfunction
– Ober Test- positive tight IT band
– Tight Hamstrings/Hip flexors/Quads
– Consider lumbar spine exam too!!!
Illustration demonstrating the location of the trochanteric bursa between the gluteus medius (2) and the iliotibial band (3) as well as the bursa located between tendon and bone at the gluteus minimus, which is reflected downward (1). (Redrawn with permission from LequesneM: From "periarthritis" to hip "rotator cuff" tears: Trochanteric tendinobursitis. Joint Bone Spine 2006;73[4]:344-348. http://www.sciencedirect.com/science/journal/1297319X.)
Four Common Types of Bursitis: Diagnosis and Management.Aaron, Daniel; Patel, Amar; Kayiaros, Stephen; Calfee, Ryanournal of the American Academy of Orthopaedic Surgeons. 19(6):359-367, June 2011.
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HipOber Test
– Pt lateral decubitus
position
– With the patient lying in
the lateral position,
support the knee and flex
it to 90 degrees. Then
extend and abduct the
hip. Then release the
knee support.
– Failure of the knee to
Adduct is a positive test.
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Trochanteric Bursitis InjectionTreatment
• Modify activities
• Improve flexibility
• NSAIDS – topical vs. oral
• Physical Therapy vs. Home Stretching program
• Injection
• Reassess causes for pain symptoms:
– Sacroiliac joint dysfunction
– Lumbar Radiculopathy
– Femoroacetabular Impingement (FAI)
– Hip Dysplasia
– Gluteal tendon rupture/tear
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Trochanteric Bursitis• Procedure:
– Confirm Trochanteric bursitis
– Identify point of maximal
tenderness
– Lateral decubitus position
– Sterile prep
– Vapo-coolant spray
– Injection solution
3ml Bupivacaine, 2 ml Lidocaine &
1-2 ml Triamcinolone 40mg/ml
• Spinal needle vs. 1 ½ inch
needle
Picture courtesy T Gocke, PA-C
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Retrocalcaneal Bursitis
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Retrocalcaneal BursitisGeneral
• Starts as posterior heel pain
• AKA: Pump Bump/Achilles Bursitis
• Influencing factors:
– Shoe wear/heel counter pressure
– Poor hamstring/Achilles flexibility
– Activity changes
– Structural deformities (calcific tendonitis, Haglund)
– Gout/RA/Seronegative Spondyloarthropathies
– Mal-aligned sub-talar joint
• Alters normal foot mechanics
• Transmits more force load to Achilles tendonReddy SS: Surgical Treatment for Diseases and Disorders of the Achilles Tendon; JAAOS 17(1):3-14, Jan 2009
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Retrocalcaneal Bursitis
Four Common Types of Bursitis: Diagnosis and Management.Aaron, Daniel; Patel, Amar; Kayiaros, Stephen; Calfee, RyanJournal of the American Academy of Orthopaedic Surgeons. 19(6):359-367, June 2011.
Illustration demonstrating the anatomy of the hindfoot. The posterior calcaneal tuberosity is covered with fibrocartilage just proximal to the insertion of the Achilles tendon. This tuberosity apposes the anterior wall of the retrocalcaneal bursa. (Reproduced with permission from Stephens MM: Haglund's deformity and retrocalcanealbursitis. Orthop Clin North Am 1994;25[1]:41-46.)
Anatomy• Achilles tendon inserts into
Calcaneous
• Calcaneous usually down
sloping
– Haglund deformity
increases contact pressure
of Achilles on calcaneous
Dorsiflexion
• Bursa
– Retrocalcaneal: between
bone and tendon
– Superficial: between skin
and tendon
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Retrocalcaneal BursitisPhysical Examination
• Inspection
– Assess gait
– Rear-foot alignment
• Neutral-Varus-Valgus
• Pes Planus – Cavus
• “Too many toes sign”
• Palpation – tender Achilles insertion
calcaneous
• ROM/Strength
– Decreased KBDF/KEDF
– Hind foot varus & Rigid 1st ray
predisposed ?
• Neuro/vascular – no changes
• Ortho exam – Look @ mortise & sub-
talar stability
Morhopedics – Creative Common Attribution-Share Alike 3.0
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Retrocalcaneal Bursitis
• Radiographic views
– Ankle: AP, Lateral,
Mortise (standing)
– Foot: AP, Lateral,
Oblique (standing)
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Haglund Deformity
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Retrocalcaneal BursitisTreatment:
• Modify activity
• Modify shoe wear/types – padding/orthotics
• Improve flexibility Gastroc-Achilles complex
• NSAIDS: topical vs. oral
• Physical Therapy
– Iontophoresis/Phonophoresis
• Phonophoresis: Steroid driven into tissue by ultrasound
• Iontophoresis: Electrical charge draws steroid into tissues
– Acetic Acid: change in calcium ions reduces inflammation
and reduces chance of scar tissue formation
• Surgery- excise Haglund deformity
DO NOT INJECT ACHILLES REGION WITH STEROIDS
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Plantar Fasciitis
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Plantar Foot
From Wikimedia Commons
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Plantar Fasciitis• Definition: inflammation of the fascia
• “Heel spur pain”
• Plantar fascia has 3 slips.
– Medial – Central – Lateral
– Central slip arises from medial Calcaneal tuberosity
– Inserts to 5 digits Flexor Tendons
• Primary function is for support longitudinal arches (med/lat)
• Affects women > men
• Average onset 45 yrs
• Obesity worse
• Extreme changes in activity
• Poor foot wear choices
• Poor Flexibility
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Symptoms:
• Pain with ambulation
• Worse in AM or after prolonged rest/sitting– “start-up pain”
– Better after warming up
• Pain localized to heel region– Central Heel pad
– Medial arch or heel pain
• Body size contributes
• Gait changes
• Pathophysiology:
– Micro tears in plantar fascia tendon insertion
– 50% develop plantar grade heel spurs
Plantar Fasciitis
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Examination
– Observe Gait
– Observe foot posture• Planus – Hind foot valgus – plantar callosities
– Assess flexibility Achilles and toe flex/ext groups
– Palpate plantar fascia
– Assess Posterior Tibial tendon integrity (strength)
– Neuro/Vascular (Tarsal Tunnel vs. Baxter’s neuropathy)
Plantar Fasciitis
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Plantar Fasciitis
• X-ray: Standing lateral
– Traction spur considered
a normal finding (arrow)
– Not cause for Plantar
Fasciitis
– High suspicion for Calcaneal
stress fracture or tumor
– Prior to corticosteroid
injection
– Consider CT, MRI or bone
scan if failed treatment
4-6 weeks
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Plantar Fasciitis
• Associated Conditions
– Tarsal Tunnel syndrome
– Calcaneal stress fx
– Calcaneal bone tumor
– Rupture of the Plantar Fascia
– Referred pain from lumbar region
– Posterior Tibial nerve entrapment (Baxter’s nerve)
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Plantar Fasciitis
• Treatment
– Conservative care cures most cases
– Achilles and plantar fascia flexibility - KEY
– NSAIDS
– ICE (“frozen plastic bottle foot massage”)
– Heel pad vs. rigid arch support
– Immobilization (cast vs. ankle boot)
– Night splint
– Injection
– Surgery – last resort- failed after 6 months
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Plantar Fasciitis
• Calf/Gastroc Stretch • Toe Flexor stretch
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Pediatric MSK Problems
Calcaneal Apophysitis: American Academy of Foot and Ankle Surgeons
http://www.acfas.org/Content.aspx?id=1483
Patellofemoral Pain Syndrome: American Academy of Orthopaedic Surgeons,
http://orthoinfo.aaos.org/topic.cfm?topic=A00680
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Calcaneal Apophysitis
• Sever’s Disease
• Ages 8-14
• Results from repetitive stress activity
• Stressors cause inflammation @ Calcaneal Physis
• Pain worse with activity better with rest
• Causes:
– Tight Achilles
– Obesity
– Foot biomechanics
• Pes Planus w/ rear-foot valgus vs. Cavus foot
– Running sports
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Calcaneal Apophysitis
• Symptoms
– Localized heel pain (pressure)
– Gait change
• Limping
• Toe walking
– Pain after running/jumping
– Swelling/redness variable
– Avoidance of activities
– Growth spurts – shoes and pants
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Calcaneal Apophysitis• Physical Exam
– Inspection:
• Variable swelling/redness
• Gait changes based on acuity of symptoms
– Palpation:
• Lateral calcaneal pain/Achilles tenderness
• Tenderness based on acuity of symptoms
– Range-of-Motion (ROM):
• limited by pain
• Knee bent Dorsiflexion vs. Knee Extended Dorsiflexion
– Strength: usually normal
– Neuro/Vascular: no changes
– Ortho Tests
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Calcaneal Apophysitis
Radiographs
• AP- Lateral
• Harris Heel
– Radiographs helpful in
refuting other bone
injuries
– Typically see fissuring of
Calcaneal epiphysis
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Calcaneal Apophysitis
• Treatment– Recognition of complaints
– Conservative care
• RICE
• NSAIDS
• Flexibility (Hamstring/Quad/Gastroc-Achilles)
• Heel Cushion
• Good Shoes
– Modification of Activities
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Patella-Femoral pain
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Patella-Femoral pain• Occurs for many reasons
– Overuse
– Poor strength
– Poor flexibility
– Anatomy
– Obesity
• Affects all ages
– Adolescent
– Mid-Lifers vs. “Old Teenagers”
• Anterior Knee Pain
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Patella-Femoral pain• Anatomy Review
– Femur/Tibia/Patella
• Patella rides in Femoral Groove
• Articular cartilage cushions Patellofemoral
articulation
• Synovial membrane lubricates Patellofemoral glide
– Muscles/Tendons/Ligaments
• Quads – motor function knee
• Extra-articular ligaments/Retinaculum – hold
patella in place allow for normal glide
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Patella-Femoral pain
• Characteristics
– Stairs/Stand/Sit/Squat Kneel & Crawl
– Ache
• Pain comes 2nd to soft-tissue inflammation & bone
• Articular cartilage wears down -Chondromalacia
– Swollen/Stiff
– Vague symptoms
• Overuse
– Repetitive activity
– Increased frequency vs. intensity vs. duration
– Flexibility/strength
– Improper foot wear or training techniques
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Patella-Femoral painMalalignment
• Patella –Femoral trochlea mismatch
– Abnormal contact pressure patella-trochlea
– Leads to Chondromalacia & soft tissue inflammation
– Abnormal tracking Patella
• Contributing Factors
– Patella Aligns lateral : lateral tethering
– Patella Aligns medial : “squinting patella”
– Patella too High – Alta (Baha to low)
– Soft-tissue Imbalance
• Weak Quads
• Tight retinaculum
• Hamstrings/Patella tendon
– Improper foot wear or training techniques
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Patella-Femoral Pain• Physical Exam
– Inspection:
• Patella alignment
• Gait changes based on acuity of symptoms
– Palpation:
• Lateral retinaculum tenderness
• Tenderness Medial & Lateral facets
– Range-of-Motion (ROM):
• limited by pain/crepitation
• J move
• Lateral tracking
– Strength: weak quads/poor flexibility
– Neuro/Vascular: no changes
– Ortho Tests
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Patella-Femoral pain
Radiographs
• AP- Lateral- Sunrise
– Radiographs helpful in
defining bone injuries
– Typically see:
• Compression
• Mal-tracking
• Alta/Baja
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Photo courtesy TGocke, PA-CPhoto courtesy TGocke, PA-C
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Radiographs
• Sunrise View
• Merchant View
• Tangential View
– All look at articular
surface of patella
– Position of patella
– Compression points
patella
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Radiographs• Patella Height: (Blumensaat's Method)
– Knee flexed to 30 degrees
– Draw a line thru the roof of the
Intercondylar notch
– Line should touch the inferior pole of
the patella
• Normal height - inferior pole patella
touches Blumensaat’s line
• Patella Alta – inferior pole patella above
line
• Patella Baja – Inferior pole patella below
line
Blumensaat's C: Die Lageabweichugen und Verrekugen der Kniescheibe;
Ergenbnisse der Chirurgie und Ortho 228(31):149-223.
Blumensaat’s Line
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RadiographsPatella Height: (Insall Method)*
– Relationship of patella length
to length of patellar tendon
• Length of patellar tendon:
– Measured inferior pole patella
to insertion tibial tuberosity
• Length patella:
– Longest lateral length patella
• Normal Ratio:
– Patellar / Tendon = 1
– <0.8 : patella alta or tendon
rupture
* Insall J, Salvatie E: Patella Position in normal knees joints,
Radiology 1971, p101-104
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RadiographsPatella Alta:
Patella Baja:
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Patella-Femoral painTreatment
• Recognize condition
• Assess flexibility and strength
• Modify activities
• Improper foot wear or training techniques
• ICE/Heat
• NSAIDS: Oral – Topical – Injectable
• Surgical
– Arthroscopy
• Chondroplasty
• Lateral Release
– Tibial Tubercle Transfer
• Realign patella tendon with bone repositioning
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Osgood Schlatter's Diseasehttp://radiopaedia.org/articles/osgood-schlatter-disease
http://www.eorthopod.com/content/osgood-schlatter-disease
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Osgood-Schlatter’s Disease• General
– Occurs 11-15 age group ( rapid growth)
– Boys > Girls
– Overuse problem – increased demand on immature skeleton
– Caused by tight hamstrings limit knee extension and increasing
pull of quad/patellar tendon on tibial tubercle
– Small area heterotopic ossification seen 2nd to microtrauma a the
tibial apophysis
• Clinical Symptoms
– Swelling tibial tubercle area
– Pain with ambulation, stair-climbing, jumping & running
– Pain with palpation
– Limited ROM knee 2nd to tight hamstrings
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Osgood-Schlatter’s Disease• Physical Examination
– General Knee exam
– Pay specific attention to age group, flexibility and
location pain
– Tender palpate tibial tubercle
– Pain with AROM & resistive AROM knee extension
• Differential Diagnosis
– Jumper’s Knee
– Avulsion fracture tibial physis
– Synding-Larsen-Johansen Disease – connective
tissue disorder
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Osgood-Schlatter’s Disease• Radiographs:
– AP, Lateral, Sunrise
– AP - Normal
– Lateral
• Bony changes noted at
tibial tubercle
• May need comparison
view contralateral knee
– Sunrise – check
patella position in
trochlea
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Osgood-Schlatter’s Disease• Treatment:
– Symptomatic care
– ICE
– NSAIDS
– Knee pad or sleeve: decrease pain from contact
pressure
– Immobilize for recalcitrant symptoms or poor patient
compliance
– Change activity up to 2-3 months
• May need longer for more severe cases
– Surgery to correction for rupture/bony fracture - rare
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Take Home Points• Manage patient expectations
• Conservative measures usually make things better
• Modification of activities
• Shoulder & Hip – think outside the box (Neck & Back)
• Bursitis – always be suspicious of infection/gout
• Improve Strength & Flexibility:
• Patellofemoral problems
• Trochanteric Syndrome
• Plantar Fasciitis/Achilles Tendonitis/Bursitis
• Choose PT over HEP
• Foot position can affect upstream problems
Never inject RetroCalcaneal bursitis
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THANK YOU
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References• McAfee JH, Smith DL: Olecranon and Prepatellar
Bursitis: Diagnosis and Treatment; Topics in Primary Care, West J Med 1988 Nov; 149:607-610
• Aaron DL et al: Four Common Types of Bursitis: Diagnosis and management, JAAOS June 2011, 19(6):359-367
• Gocke TV: Injection & Aspiration of Common
Musculoskeletal Conditions 1 & 2, Orthopaedic
Educational Services, Inc., www.orthoedu.com 2014
• Gocke TV: Shoulder Examination, Orthopaedic
Educational Services, Inc., www.orthoedu.com 2014
• Foye PM: Retrocalcaneal Bursitis,
emedicine.medscape.com, updated November 26, 2014
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References• Gocke TV: Foot Soft tissue 1 &2, Orthopaedic
Educational Services, Inc., www.orthoedu.com 2014
• Gocke TV: Knee Injuries-Extra-articular 2, Orthopaedic
Educational Services, Inc., www.orthoedu.com 2014
• Roy A: Rotator Cuff Disease, eMedicine – Medscape;
updated Sept 14, 2014
• Brox JI, Staff PH, Ljunggren AE, Brevik JI. Arthroscopic
surgery compared with supervised exercises in patients
with rotator cuff disease (stage II impingement
syndrome). BMJ. Oct 9 1993;307(6909):899-903.
• Reddy SS: Surgical Treatment for Diseases and
Disorders of the Achilles Tendon; JAAOS 17(1):3-14,
Jan 2009
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References• Kilfoil RL: Acetic acid iontophoresis for the treatment of
insertional Achilles tendonitis; BMJ Case Reports 2014,
casereports.bmj.com
• Costa IA, Dyson A: The integration of acetic acid
iontophoresis, orthotic therapy and physical rehabilitation
for chronic plantar fasciitis: a case study; J Can Chiropr
Assoc. 2007 Jul-Sep; 51(3): 166–174
• Gocke TV: An Urgent Care Approach to Joint and Soft-
tissue Injection/Aspiration, Part 1; JUCM Sept 2014; 8-
19
• Gocke TV: An Urgent Care Approach to Joint and Soft-
tissue Injection/Aspiration, Part 2 ; JUCM Oct 2014; 9-22