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Cindy J. Chang, M.D.
Clinical Professor, Primary Care Sports Medicine
Depts. of Orthopaedics and Family & Community Medicine
Past President, American Medical Society for Sports Medicine
Board of Trustees, American College of Sports Medicine
2019 UCSF Primary Care Medicine
Principles and Practice
Management of Common Problems in Sports
Medicine
Disclosure
▪ I have no conflict of
interest in relation to this
presentation
▪ Ossur Americas:
independent lectures on
osteoarthritis
▪ NeuroSlam: scientific
advisor
▪ Agency for Student
Health Research:
medical advisory board
Cindy J. Chang M.D.2
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Objective
▪ Review common
problems in sports
medicine
▪ Understand basic
anatomy of the
musculoskeletal system
and its clinical correlation
to injuries
Cindy J. Chang M.D.3
History(MS OLDCARTS vs OPQRST)
▪ Mechanism
▪ Symptoms
▪ Onset (O) – date of injury
▪ Location – point to where the pain is
▪ Duration – acute or chronic
▪ Character (Q) – burning, sharp, dull, achy
▪ Aggravating/Alleviating (P) – provokes/palliates
▪ Radiation (R) – come from or go anywhere else
▪ Timing (T) – constant, at night, with activity
▪ Severity (S) – grade pain
https://meded.ucsd.edu/clinicalmed/history.htm
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Case - Elbow Pain
▪ Your patient is a 36 yo female recreational tennis player with
elbow pain radiating down the posterior aspect of her forearm
that has increased over the past two days. She recently
began playing tennis on a USTA team that practices nightly.
▪ She has no medical problems. She takes a combination oral
contraceptive. Family history is noncontributory. She does not
use tobacco, alcohol, or recreational drugs.
▪ She is afebrile with normal vital signs. Examination reveals
tenderness distal to the lateral epicondyle, with pain
increased with wrist extension against resistance. She has
increased pain with resisted supination.
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Cindy J. Chang M.D.
Case - Elbow Pain
Which of the following is most appropriate for this patient?
A. Opioid analgesics
B. Corticosteroid injection
C. Counterforce bracing
D. Extracorporeal shock wave therapy
E. Strength training
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Elbow Anatomy Review
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Elbow XR Review
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Elbow Anatomy Review
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Elbow Anatomy Review
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Elbow Anatomy Review
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Elbow Pain – Dx: Lateral epicondylitis
“tennis elbow”
▪ No single treatment is completely effective
- Counterforce bracing relieves pain
- Strength training, exercise, stretching all decrease pain
▪ RICE: rest, elevation, compression, and elevation
▪ PMM: protection, medication and modalities (physical therapy)
▪ NSAIDs + watchful waiting better than CS injections
▪ CS injection better than PT at 6 wks, worse at 12 wks
▪ PT less pain and better fxn than CS inj or NSAIDs
▪ ECSWT no significant benefit
http://www.aafp.org/afp/2000/0201/p691.html http://emedicine.medscape.com/article/96969-medication#4
http://www.ucdenver.edu/academics/colleges/medicalschool/departments/familymed/education/fellowship/sportsmedf
ellow/Documents/MS%20exam.pdf
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Cindy J. Chang M.D.
Elbow Pain – Diff Dx
▪ If mechanical symptoms
(locking, catching): r/o
intraarticular pathology
▪ If neurological
symptoms (weakness,
paresthesia); r/o nerve
entrapment syndromes
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Cindy J. Chang M.D.
Elbow Pain – Diff Dx
▪ If neurological symptoms (weakness, paresthesia); r/o nerve
entrapment syndromes
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Case – Hand Weakness and Numbness
▪ A 31-year-old female gymnastics
instructor presents to your clinic with a
complaint of right-hand weakness and
numbness.
▪ She also works as a receptionist part-
time and states that her symptoms are
worst at the end of her workday.
▪ On physical examination, there is a loss
of sensation along the palmar aspect of
her thumb and first two digits. You note
atrophy of her thenar eminence as well.
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Cindy J. Chang M.D.
Case – Hand Weakness and Numbness
The nerve implicated in her symptoms innervates which of the
following muscles?
A. Flexor digitorum superficialis
B. Adductor pollicis
C. Extensor digitorum
D. Abductor pollicis longus
E. Flexor carpi ulnaris
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Wrist/Hand Anatomy Review
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Wrist/Hand Anatomy Review
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Wrist/Hand Anatomy Review
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Wrist/Hand Anatomy Review
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Case – Hand Weakness and Numbness
The nerve implicated in her symptoms innervates which of the
following muscles?
A. Flexor digitorum superficialis
B. Adductor pollicis
C. Extensor digitorum
D. Abductor pollicis longus
E. Flexor carpi ulnaris
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Cindy J. Chang M.D.
Hand Weakness and Numbness –Dx: Carpal Tunnel Syndrome
▪ Your patient is presenting with carpal
tunnel syndrome, which affects the
median nerve. It is caused by
compression of the nerve by the flexor
retinaculum at the palmar surface of
the hand.
▪ Symptoms of carpal tunnel syndrome
are explained by the distal innervation
of the nerve. It supplies sensation to
the palmar aspect of the thumb and
adjacent 2 radial digits.Moore, KL, et. Al; Clinically Oriented Anatomy. Lippincott,
Williams, and Wilkins (2014). Philadelphia, PA.
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Hand Weakness and Numbness –Dx: Carpal Tunnel Syndrome
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Cindy J. Chang M.D.
Case – Wrist Pain after a Fall
▪ A 15-year-old boy presents to the emergency room for wrist
pain and swelling after a skateboarding accident. He broke
his fall by landing on his wrist while the hand was in an
outstretched or hyperextended position (FOOSH).
▪ On physical exam, his wrist is swollen more on the radial
side, and there is point tenderness on palpation of the
anatomical snuffbox. He also hurts over the distal radius.
▪ The following x-ray image depicts which of the following
injuries resulting from this fall?
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Case – Wrist Pain after a Fall
A. Scapholunate ligament injury
B. Scaphoid fracture
C. Triquetrum fracture
D. TFCC tear
E. Salter-Harris Type 1 fracture
distal radius
F. Radial head fracture
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Case – Wrist Pain after a Fall
Scapholunate ligament sprain
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Case – Wrist Pain after a FallScaphoid fracture
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Case – Wrist Pain after a FallTriquetrum fracture
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Case – Wrist Pain after a FallTriangular FibroCartilage Complex tear
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Case – Wrist Pain after a FallSalter-Harris Type 1 fracture distal radius
▪ I – S = Straight across. Fracture of the cartilage of the physis (growth plate)
▪ II – A = Away from joint. The fracture is through and into the metaphysis, or Away from the joint.
▪ III – L = Leading to joint. The fracture is through and into the epiphysis, Leading to the joint.
▪ IV – TE = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.
▪ V – R = Rammed (crushed). The physis has been crushed.
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Case – Wrist Pain after a Fall…check other joints!
Radial head fracture
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Cindy J. Chang M.D.
Case – Shoulder Dislocation
▪ A 20-year-old right-hand-dominant man
presented to the Emergency Department
following a traumatic dislocation of his
right shoulder that was self-reduced when
surfing. Physical exam revealed an intact
axillary nerve with intact neurovascular
status distally.
▪ Prior to presenting to your office, he had
dislocated two more times. A family friend
was able to get him an MRI and he brings
in the CD but you are still waiting for the
faxed report. He comes to you for advice
as his family physician.
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Case – Shoulder Dislocation
▪ What do you think will be the next best step in management?
A. Shoulder immobilizer and serial radiographs
B. Bankart repair for surgical stabilization
C. Surgical repair of a rotator cuff tear
D. Physical therapy
E. Learn how to become left handed
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Review of Shoulder Anatomy
▪ Layers
- Bony articulations (4)
- Static stabilizers
▪ Bones, ligaments, capsule,
labrum
- Dynamic stabilizers
▪ Scapular
stabilizers/rotators
▪ Rotator cuff muscles
- Bursa
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Shoulder Anatomy ReviewBony Articulations
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Shoulder Anatomy ReviewBony Articulations
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Shoulder Anatomy ReviewStatic Stabilizers
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Shoulder Anatomy ReviewStatic Stabilizers
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Shoulder Anatomy ReviewDynamic Stabilizers
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Shoulder Anatomy ReviewDynamic Stabilizers
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Shoulder Anatomy ReviewScapular Motion
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Shoulder Anatomy ReviewDynamic Stabilizers
▪ Rotator Cuff
- Supraspinatus
- Infraspinatus
- Teres minor
- Subscapularis
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Shoulder Anatomy ReviewDynamic Stabilizers
▪ Rotator Cuff
- Supraspinatus
- Infraspinatus
- Teres minor
- Subscapularis
- Subscapularis
- Supraspinatus
- Infraspinatus
- Teres minor
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Shoulder Anatomy ReviewBursa
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Case – Shoulder Dislocation
B. Bankart repair
▪ Your 20 yo patient likely has a Bankart lesion in the setting of
a first time traumatic dislocation and now resultant instability
of the glenohumeral joint due to the Bankart lesion.
▪ This requires surgical stabilization.
▪ A Bankart lesion may involve only the labrum or the labrum
plus a bony portion of the glenoid (bony Bankart).
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Possible Xray Findings
Hill Sachs Lesion –
compression fracture of
posterior humerus
Bony Bankart Lesion – Avulsion
fracture of glenoid
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Case – Shoulder Dislocation
▪ Labral-only lesions are most commonly repaired via an
arthroscopic stabilization procedure where the labrum is fixed
back to the glenoid. Bony Bankart lesions may be addressed
with open reduction and internal fixation with concomitant
labral stabilization.
▪ <1% of RC tears occur in those < 20 yo
▪ There is a 40 to 60% incidence in patients > 40 years old
▪ Physical therapy will help strengthen the dynamic stabilizers.
However, there is a >90% recurrence if < 20 years old; only
14% recurrence if > 40 yrs old
Minagawa et al J Orthop 2013, Familiari et al ICJR 2014
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Case – Shoulder Pain
▪ 55 yo RHD female with onset of right shoulder
pain one year ago when playing tennis
▪ Had been “getting along” with it and
controlling symptoms but began to notice
gradual loss of motion despite ice and
NSAIDs
▪ Now presenting with pain all the time,
including night pain, with inability to sleep on
shoulder due to pain
▪ She has had to buy new bras that clasp in
front
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Case – Shoulder Pain
What is your next step with your patient?
A. Refer to PT if her ROM doesn’t improve with an aggressive
HEP at 1 mo F/U
B. Control other comorbid conditions like HTN and
hyperlipidemia that predispose her to this problem
A. Refer her to ortho for surgical manipulation under anesthesia
B. Cortisone injection
C. None of the above
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Case: Shoulder PainAdhesive Capsulitis
▪ Spontaneous, gradual onset of
shoulder stiffness and pain caused
by tightening of joint capsule
▪ 70% female, 40-60 yoa
▪ Comorbid conditions include
diabetes, hypothyroid dz, RA
▪ Can occur after shoulder
immobilized or subconscious
restricted motion after minor injury
or ???
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Case: Shoulder PainAdhesive Capsulitis
▪ IR/ADDuction first to go
and last to come back
▪ Scapular substitution
▪ End range pain
▪ Disuse atrophy
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Natural History of Adhesive Capsulitis
▪ 0-3 months “gradual onset” - painful
▪ 2-9 months “ freezing”
▪ 4-12 months “ frozen”
▪ 5-26 months “thawing”
▪ Usually self-limited
“The art of
medicine
consists of
amusing the
patient while
nature
cures the
disease.”
-Voltaire 52
Hannafin & Chiaia, Clin Orthop Rel Res, 2000
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Treatment of Adhesive Capsulitis
▪ Pain management (+/- sling)
▪ Education and reassurance
▪ Active home stretching program
▪ Physical Therapy
▪ Oral NSAIDs (or steroids)
▪ Glenohumeral injection-capsular distension
▪ Rarely needs surgery (examination/manipulation under anesthesia or arthroscopic lysis of adhesions)
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Steroid injection?
▪ RCT showed intraarticular steroid injection provided
better pain relief in the first 8 weeks than NSAIDs.
▪ However, no difference seen in range of motion or
pain after 12 weeks
▪ Results similar to other non-controlled studies
Ranalletta M at al., Am J Sports Med, 2016 54Cindy J. Chang M.D.
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Case – Ankle injury
▪ 16 yo female playing in basketball game
and turned her ankle inwards after a
rebound when she came down on
another foot
▪ Felt a pop; was unable to bear weight
▪ Immediate swelling on the outside and
front of ankle
▪ Able to limp into your exam room the next
day; points to her lateral ankle as the
area of most pain
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Case – Ankle injury
Which is the following is an indication to order X-Rays?
A. Feeling or hearing a pop
B. Inability to walk for 4 steps immediately after the injury
C. Any bruising along the lateral and/or medial malleolus
D. Tenderness on palpation along posterior edge of
medial malleolus
E. Numbness around the area of swelling
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Case – Ankle injury
Which is the following is an indication to order X-Rays?
A. Feeling or hearing a pop
B. Inability to walk for 4 steps immediately after the injury
C. Any bruising along the lateral and/or medial malleolus
D. Tenderness on palpation along posterior edge of
medial malleolus
E. Numbness around the area of swelling
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Ankle and Foot Anatomy- Bones
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Ankle and Foot Anatomy- Ligaments
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Ankle and Foot Anatomy- Anterior
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Ankle and Foot Anatomy-Lateral
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Ankle and Foot Anatomy-Medial
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Ankle and Foot Anatomy-Posterior
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Case – Ankle injury
Ottawa Ankle and Foot Rules
▪ Inability to weight bear immediately and in the emergency / office (4 steps)
▪ Bone tenderness at the posterior edge of the medial or lateral malleolus (Obtain Ankle Series)
▪ Bone tenderness over the navicular or base of the fifth metatarsal (Obtain Foot Series)
Sens 97%, Spec 31-63%, NPV 99%, PPV <20%
Bachmann LM et al BMJ 2003
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Ottawa Ankle and Foot Rules
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Case – Foot Injury
▪ 45 yo female at the climbing gym, slipped
and lost her footing and landed awkwardly
from ~4 feet
▪ Could bear weight but painful to push off.
R foot became more swollen than L
▪ Went to urgent care and told x-rays
normal, stay off feet for weekend, given
crutches
▪ Comes to see you on Monday as still hurts
to walk
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Case – Foot Injury
Of the following, what is the most important question to ask?
A. How many times a day have you been icing?
B. Were you lying down or standing for your X-rays?
C. Have you been keeping it wrapped in a compression type of
bandage?
D. Would you feel more comfortable in a walking boot?
E. Are you having pain when driving?
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Case #2 – Foot InjuryLisfranc ligament sprain
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Case – Ankle injury
▪ A 24-year-old professional athlete
presents to you with acute-onset
right ankle pain and an inability to
bear weight. You note significant
edema and ecchymosis of the
affected ankle.
▪ She states she had a similar
injury to her left years ago. Xrays
were already obtained, with left
ankle for comparison since she
reported the prior injury. You
decide to take a look at the xrays
first before examining her.
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Case – Ankle injury
What is your diagnosis?
A. grade 1 ankle sprain
B. grade 2 ankle sprain
C. grade 3 ankle sprain
D. bimalleolar ankle fracture
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Normal Ankle X-Ray
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Evaluate entire fibula
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Case – Ankle injuryGrade 3 ankle sprain
▪ Grade 1 injury involves ligamentous
stretching without grossly evident
tearing or joint instability.
▪ Grade 2 injury involves a partial tear of
a ligament with moderate joint
instability; it is often accompanied by
significant localized swelling and pain.
▪ Grade 3 injury involves a complete
tear of a ligament with marked joint
instability and severe edema and
ecchymosis.
Rose NG, Green TJ. Ankle and foot. In: Walls R, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical
Practice. 9th ed., 2018:634-658.e3.
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Case – Ankle/Foot Injury
▪ 34 yo male, enjoys walking and hiking,
recently joined his work softball league
▪ First game of the season and hit a grounder;
while sprinting to first base, he felt a rock hit
the back of his lower leg and he stumbled
and fell. His teammates heard a pop. Needed
assistance to get to the bench
▪ Iced, elevated, ACE wrap and NSAID
▪ He could walk as long as he kept the ankle
stiff; wore his hiking boots to come see you
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Case – Ankle Injury
What is the most likely injury based on his history?
A. Anterior cruciate ligament (ACL) tear
B. Achilles tendon tear
C. Posterior tibialis tendon tear
D. Calf tear
E. Plantar fasciitis tear
F. B and C
G. B and D
H. B and E
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Case – Ankle Injury
Achilles tendon tear and Calf tear
Thompson test
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Case – Ankle Injury
Posterior tibialis tendon tear
Too
Too many toes sign
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Case – Knee Injury
▪ 40 yo female joined a gym in January with her competitive
sister-in-law
▪ Began working with a personal trainer and they started a
program of Olympic lifting (squatting, cleans) and
plyometrics (box jumps)
▪ After 2 weeks began having left knee pain after workouts
but continued training
▪ Now seeing you 2 weeks later because now it hurts during
training and even with walking, especially on the stairs
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Case – Knee Injury
What is the Least likely diagnosis?
A. Patellofemoral syndrome
B. Patellar tendinitis
C. Pes anserine bursitis
D. MCL sprain
E. ITB syndrome
F. Hamstring strain
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Patellofemoral Pain
▪ Will point to kneecap
region
▪ Pain associated with
- running, lunging, squats
- sitting for prolonged period
- going down stairs (may be
worse than up stairs)
▪ Soft tissue swelling often
described as puffiness
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Patellofemoral Pain
▪ Thomas test to evaluate tight hip
flexors, quads, ITB
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Patellofemoral Pain
▪ Positive patellar
compression test
▪ Pain on palp of medial facet
of patella
▪ Increased patellar mobility
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Patellofemoral Pain
▪ Double and Single Leg Squat to
evaluate for weak quads, gluts
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Patellar Tendinitis
▪ Pain with
- resisted knee extension
- resisted straight leg raise
- single leg squat
▪ May have swelling at
inferior pole of the patella
▪ Tenderness at prox patellar
tendon
▪ Osgood Schlatters
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Pes Anserine Bursitis
▪ Primary flexors of the knee
▪ Protects knee against rotatory
and valgus stress
▪ Pain often acute
▪ Can occur with sports and
exercise
▪ Can also occur in sedentary
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Iliotibial Band Syndrome
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Hamstring Strain
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Case – Knee Pain
▪ 65 yo male with h/o medial meniscectomy R knee 20 yrs ago
▪ Reports moderate pain medial knee and general swelling
since hiking last weekend
▪ Denies locking and instability, no AM stiffness
▪ On your exam, he has moderate effusion, but no warmth. There
is crepitus with range of motion. He is tender at the medial joint line
and above/below medial joint line on the medial femoral condyle
and medial tibial plateau. McMurrays testing is negative, but knee
feels tight with squatting. You don’t find any ligamentous laxity
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Case – Knee Pain
What do you recommend at this time?
A. Refer to an ortho surgeon to consult on knee replacement surgery
B. Order an MRI of the knee to evaluate need for surgical intervention
A. Refer to an orthopedic surgeon for surgical debridement and lavage
(“clean it up”)
A. Perform a cortisone injection to help with the pain and swelling
B. Refer to physical therapy and encourage weight loss
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What is OA? What parts of the knee joint are affected?
Disease of the entire synovial joint and multifactorial, including joint degeneration,
intermittent inflammation, and peripheral neuropathy
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How do you classify severity of Knee OA?
▪ Kellgren and Lawrence System for classification of knee OA
Kellgren and Lawrence, Ann Rheum Dis 1957
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How do you classify severity of Knee OA?
▪ Kellgren and Lawrence System for classification of knee OA
- Grade 0 -- None
- Grade 1 -- Minor – usually no pain or discomfort
- Grade 2 -- Mild – pain after long day of running/walking, some
stiffness after immobile, sore when kneeling or bending
- Grade 3 -- Moderate – frequent pain, joint stiffness, some swelling
- Grade 4 -- Severe – great pain when walking or moving the knee
Kellgren and Lawrence, Ann Rheum Dis 1957
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What about an MRI to diagnose OA?
▪ MRI in the setting of OA will ALWAYS show a meniscus tear
- Patients will get fixated on the meniscus tear
- Likely will want to undergo surgery
- Unclear how much benefit
▪ Indications for ordering an MRI
- Obvious and significant injury (especially in younger patients)
- Associated severe effusion
- Locking of the knee (can’t straighten or bend)
- Non-operative treatments have failed
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Interventions
Kirkley et al, NEJM 2008; Juni et al, Cochrane Library 2015; McAlindon et al, JAMA 2017
▪ AKS (irrigation with saline and “clean-up”)
- Compared to Control group (PT/medical therapy)
- Significant improvement at 3 months with surgery (~ past
studies involving sham surgery), but thereafter, no difference
in WOMAC scores
▪ Intraarticular cortisone injection vs. placebo injection
- Low quality evidence with inconclusive results re: pain relief,
improved function, and duration of steroid effect
- Q3 month RCT--IA TAC vs saline inj under US
- Signif more cartilage loss in TAC group; no signif diff in pain
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PT, Exercise and Strength Training
▪ Almost everyone will have some weakness and/or
functional limitations or imbalances that can be corrected
▪ The most effective PT interventions are exercise:
aerobic, aquatic, strengthening, and proprioception
- Evaluation of strength and gait
- Closed chain exercises
- Low to Non-impact aerobic exercise
▪ bike, elliptical, swimming, H2O rehab/exercises
- Joint capsule and muscle stretches
- Modalities as needed
- Daily home exercise and rehab self-management programs
Wang, AIM 2015; https://www.aaos.org/research/guidelines/oaksummaryofrecommendations.pdf
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Weight Management- For every 1 lb weight loss, 4-6 lb in force on the knee per step
- Pain reduction with even minimal weight loss
- Exercise alone without dietary changes not as effective
- Markers of cartilage turnover and breakdown are decreased
after bariatric surgery
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14th Annual UCSF
Primary Care Sports Medicine Conference
December 12- 14, 2019
Intercontinental San Francisco
Join us in December
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Join us on Saturday, January 11th
@ Cal Memorial Stadium
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UCSF Musculoskeletal Exam Tutor App
▪7 musculoskeletal cases
▪> 60 high quality exam videos
performed by UCSF experts
▪Apple app store
-Search UCSF
Musculoskeletal Exam App
▪$20
▪iOs (Apple) devices only
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Check out our sports rehab guide for patients! https://sportsrehab.ucsf.edu/
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Questions?
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