Shoulder and Knee
Injury: Treatment
and Prevention
Samir Sharma MD
Board Certified
Fellowship Trained
Sports Medicine
Head Team Physician
San Jose Sabercats
Shoulder Injuries
Anatomy
 The shoulder has the
greatest degree of
movement of any joint in
the body
 It is a multiaxial ball
and socket joint
Anatomy
 The Rotator Cuff is a set
of four muscles that
surround the humeral
head.
 They function to help
abduct and rotate the
arm and also function
as dynamic stabilizers
of the joint.
Instability, Impingement & DJD
Think of all soft tissue shoulder disorders to
fall in three broad categories:
1) Instability
2) Impingement
3) DJD
The Age of the patient generally places them
in each of these categories
Shoulder Instability
 Mostly cccurs in younger patients <30 years of age
 The extreme form of this is a shoulder dislocation
 Can cause secondary tendonitis and labrum and
cartilage tears
 Anterior instability is the most common 95 %
 Usually occurs when the patient raises their arm
overhead in a throwing position
 Subluxation vs Dislocation
 Dislocation has to be reduced
Shoulder Instability
 History, the patient is “apprehensive” about putting
their arm overhead
 History of previous anterior dislocations
 Physical Exam positive apprehension test improved
when posterior pressure is applied over the anterior
aspect of the shoulder
Apprehension Sign
Shoulder Dislocation
Shoulder Instability < 20 Years
For dislocators < 20 years old there is a 90%
chance of redislocation. As one ages the
chance of redislocation lessens
In this high risk group, surgical repair and
capsular tightening is recommended
Arthroscopic techniques have advanced
significantly over the past several years
Shoulder Instability > 30 Years
Anterior Dislocations for first time dislocators
over the age of 30, a trial of physical therapy
followed by reevaluation
After a course of PT, On PE if the pt still has a
positive apprehension sign this is an indicator
that the capsule is stretched and the IGHL
complex is not functioning properly
Shoulder Instability > 50 Years
 In patients older than 50 who have a dislocation,
concomitant rotator cuff tear at the time of injury needs
to be ruled out
 If there is a small tear, a trial of therapy can still be
initiated to regain motion and strengthen the
periscapular muscles
 In older patients >65 with a dislocation surgery is
usually not necessary and the treatment is physical
therapy with rehab
Impingement
 Overuse type injuries which occur in the middle aged
40-60 individual
 As the arm is abducted the rotator cuff tendons and
biceps tendon abut (impinge) against the acromion
causing inflammation in the bursa and wear of the
RTC tendon
 As this happens thousands of times the rotator cuff
starts to fray and tear
Impingement
Rotator Cuff Tendonitis
 Gradual onset of pain along anterolateral shoulder
 Difficulty sleeping on the affected side
 May be preceded by an antecedent trauma
 Patients complain of difficulty with overhead lifting
Rotator Cuff Tendonitis
 Physical exam may include a painful arc from
60-120 degrees of abduction
 Weakness on supraspinatus muscle strength
testing
 Positive impingement tests
Painful Arc Associated with Impingement
Rotator Cuff Tendonitis
 Treatment: NSAIDS,
subacromial cortisone
injections and physical
therapy
 After 3-4 months of
conservative therapy
with no improvement
consideration could be
given to an arthroscopic
subacromial
decompression
Rotator Cuff Tendonitis
 Arthroscopic Subacromial Decompression
involves removal of any subacromial bone
spurs, inflamed subacromial bursa, and direct
assessment of the status of the rotator cuff and
glenohumeral joint
 Open subacromial decompression achieves the
same purpose however the deltoid muscle is
detached and reattached and a larger incision is
involved
Rotator Cuff Tear
 History is similar to RTC tendonitis
 Physical exam may show increased
supraspinatus weakness and atrophy of the
supraspinatus fossa
 MRI is the study of choice
 Arthrogram is also a good study to just look at
whether there is a tear in the rotator cuff
Rotator Cuff Tear
Treatment- In a patient who is <50 years of age
immediate referral to an orthopedist
Key point is that degenerative rotator cuff tears
occur in patients greater than 50 years
A tear in a patient less than 50 years of age is a
traumatic tear unless proven otherwise
Rotator Cuff Tear
 Traumatic rotator cuff tears require operative
fixation
 Degenerative Rotator Cuff Tears treatment is
controversial
 May initiate physical therapy, NSAIDs and 1-2
cortisone injections
 If no improvement consider surgical repair
Rotator Cuff Tear
Rotator Cuff Repair
DJD
 Degenerative Joint Disease of the shoulder
(Osteoarthritis)
 Commonly occurs in older patients >60 years
of age
 History of stiffness and pain
 Radiologic Diagnosis
Degenerative Shoulder Disease
 History Pain and Stiffness
 May be preceded by antecedent trauma
 Physical Exam
 Marked loss of motion
 Diffuse muscle atrophy
 Crepitus on ROM
Degenerative Shoulder Disease
 Xray: Grashey Xray true AP xray of the
shoulder shows loss of joint space and humeral
osteophytes
 Treatment
 Gentle ROM and Strengthening
 NSAIDS
 Intrarticular cortisone injection
Degenerative Shoulder Disease
Degenerative Shoulder Disease
Surgery is indicated when pain is not
amenable to conservative management
Surgery include a hemiarthroplasty vs a
Total Shoulder Replacement
Surgery can predictably relieve pain.
Functional improvement is not as
predictable
Case Study # 1
Pt. is a 57 yr old male seen for consultation in regards to rt. shoulder.
Pt. injured rt. shoulder at work climbing in and out of truck using
steering wheel to pull himself up & diagnosed w/rt. shoulder
impingement syndrome with AC joint arthritis. Initial treatment
of PT and NSAIDS, improving slower than expected. MRI
conducted, showed moderate supraspinatus and infraspinatus
tendinosis with a small-to-moderate sized interstitial tear and
detachment of the tendons.
Treatment: Pt. underwent shoulder arthroscopy and debridement
with distal clavicle resection. Pt. went back to full duty and was
made MMI with 0% impairment. Future medical provided to
include antiinflammatory medications and cortisone injectsion as
needed for flare ups.
Case Study # 2
Pt. is a 53 yr old male who injured rt shoulder by a compactor
smashing rt shoulder. Had severe rt shoulder pain and difficulty
with use of arm. Started on ibuprofin 600 mg & Soma. MRI was
performed and showed a supraspinatus complete tear with
retraction & AC joint arthritis. Conservative treatment of PT and
cortisone injection failed.
Treatment: Pt. underwent rt shoulder arthroscopy, rotator cuff
tendon repair and resection. Patient returned to full duty., made
MMI with no permanent restrictions and 0% impairment rating.
Future medical to include antiinflammatory medications and
cortisone injection as needed for flare ups.
Case Study #3
Pt. is a 42 yr old female injured lt shoulder while picking up towels.
Also undergoing treatment for RMI for hand/wrist/forearm. Pt
had difficulty with overhead use, use of her arm and difficulty
sleeping at night. MRI was performed and showed anterior
superior labrum signal with mild arthrosis of AC joint.
Treatment: Pt underwent lt shoulder cortisone injection and
improved with ROM. Still has some residual lt shoulder pain.
Made MMI with no permanent restrictions, 0 % whole body
impairment and future medical to include follow up visits,
antiinflammatory medications, and cortisone injections as needed
for flare ups.
Case Study # 4
Pt. is 46 yr old plumber who injured rt shoulder by using too much
force while using cordless drill. Complains of pain, reduced
strength and ROM. STAT MRI requested which showed rotator
cuff tear.
Treatment: right shoulder arthroscopy with subacromial
decompression, debridement of labrum, and repair of the partial
thickness articular surface tear. Pt fell 1 week after surgery,
aggravated injury and delayed recovery. WCE completed which
showed Pt will benefit from work hardening program. After
completion, Pt was able to return to work full duty, range of
motion increased significantly, and pain factors decreased to point
where medication no longer needed. Pt extremely happy with
outcome.
Shoulder Injury Prevention
 Lift items close to the body
 Only lift items below shoulder level
 When using a mouse keep in front of you at fingertip
level so you do not have to reach with your arm
outstretched
 Take posture breaks when repetitively using the arm
and shoulder
Shoulder Injury Prevention
If performing a job which requires repetitive
lifting, conditioning with rotator cuff
strengthening exercises maybe beneficial
Stretch before performing lifting tasks
Take breaks to prevent muscle fatigue
Knee Injuries
Anatomy
Think of the knee source of pain in 4 basic
areas.
1. Medial (inner)
2. Lateral (outer)
3. Anterior (front)
4. Posterior (back)
Medial Aspect of Knee
Important Structures
1. MCL
2. Medial Meniscus
3. Pes Anserine
tendons
4. Medial Condyle /
Medial Tibial
Plateau
Lateral Aspect of Knee
1)
2)
3)
4)
Lateral meniscus
ACL
Lateral Condyle/
Lateral Plateau
Iliotibial Band
Anterior & Posterior Aspects of Knee
Anterior Knee Pain
 Patellar Chondromalacia
 Essentially softening and wear of the patellar
cartilage due to overuse or maltracking
 Patients complain of pain while climbing
stairs
 MRI shows mild thinning of the cartilage
 Treatment is NSAIDS/ Cortisone injection
Anterior Knee Pain
 Patellofemoral Arthritis
 Diagnosed by decreased ROM with crepitus on PE
 Lateral Xray shows diffuse narrowing of the
patellofemoral compartment with osteophytes
 Treatment - Cortisone Injection/
Viscosupplementation Injections
 Newer Trials of Isolated Patellofemoral Replacement
Patellofemoral Arthiritis
Medial Compartment Pain
1. Degenerative meniscal tear
2. Osteoarthritis
3. Pes Anserine tendonitis
4. MCL
Degenerative Meniscal Tears
Patients c/o of catching and locking
Degenerative tears can occur with minimal
trauma
Complaints of knee giving way
Distinguish from bucket handle tear of the
meniscus
Mcmurray Exam
 Pt is supine with the knee
flexed
 The examiner internally
and externally rotates the
leg
 A positive test is a snap or
click felt along the joint
line that is accompanied
by pain
Types of Meniscus Tears
Bucket Handle Meniscus Tear
 Pt cannot achieve full extension
 Moderate to large effusion in knee
 There is a block to extension when passively
trying to extend knee
 Urgent referral
Degenerative Joint Disease
 Weight Bearing x-rays are crucial!
 They show the functional space in the knee
 Always specify on the prescription to obtain
weight bearing x-rays
 Radiographically joint space narrowing with
osteophytes are classic
 Otherwise known as osteoarthritis
Degenerative Joint Disease
Degenerative Joint Disease
Patients c/o of catching and locking of the knee
due to the friction caused by the rough surfaces
rubbing against each other
History of stiffness
PE: May have effusion, decreased ROM and
crepitus
Treatment
 Depends on amount of cartilage wear
 If there is joint space narrowing on xray (greater than 1
cm) this correlates with a large amount of
osteochondral wear
 Consideration should be given for intrarticular
cortisone injection
 Also viscosupplementation is an option
Medial Collateral Ligament Tear
History of trauma
Valgus force to knee
Medial Joint tenderness
Reproduction of pain with valgus load to
knee
 Test against opposite knee




Valgus Stress Test (MCL)
Radiologic Findings of MCL Tear
Medial Collateral Ligament Tear
 Treat with crutches and bracing for
4-6 weeks depending on severity of
tear
 Usually PT will help regain Post
injury muscle strength and ROM
ACL Tear
 Usually occurs with pivoting and
twisting
 Patients describe a “Pop” when injury
occurs
 Marked swelling with an effusion
 Positive Lachman exam
Lachman Test (ACL test)
 With the patient supine
and the knee flexed
approximately 30 degrees
 Stabilize the proximal
thigh and apply an
anterior directed force on
the tibia
ACL Tear
Initial treatment goal is to regain ROM of knee
and decrease swelling
Knee is initially swollen
PT sessions to teach ROM and strengthening
exercises is helpful
ACL Treatment
Surgery reserved for active individuals or
those with functional instability
Arthroscopic procedure
Different types of graft options
Case Study # 1
Pt. is 68 year old male, injured left knee when he slipped and twisted
his knee at work. Diagnosed with Arthrofibrosis, maceration of
the meniscus, and left knee marked articular cartilage along
weight bearing surface of medical compartment. Returned to
work full duty, PT prescribed. Improving slower than expected.
MRI ordered revealed medial meniscus maceration and tearing.
Ortho consult requested.
Treatment: Left knee cortisone injection relieved pain. No permanent
work restrictions, 0% impairment. Made MMI with future medical
(antiinflammatory medications and cortisone injections) for flare
ups.
Case Study # 2
Pt. is 53 yr old male, injured rt. knee when he tripped over some tied
wire. Had increased rt. knee pain, swelling, catching & locking.
MRI performed which showed full thickness chondral defect
along latereral patellar face ad intrasubstance degeneration of
anterior and posterior horn of medical meniscus. Pt had continued
rt. knee pain, difficulty weightbearing & use of rt. knee.
Treatment: Pt. underwent antiinflammatory medications and activity
restriction. Reached maximum medical improvement and made
MMI with no permanent work restrictions and 0% impairment.
Given future medical to include antiinflammatory medication and
cortisone injection as needed for future flare ups of knee.
Knee Injury Prevention
 Every pound of weight is 4-6 pounds of force
on the knee
 Avoid activities in which the employee is
bending or squatting for prolonged periods of
time
 Design the space so that the employee can
work from a seated position instead of a
kneeling one
Knee Injury Prevention
 If you have to kneel for prolonged periods
wear well designed knee pads
 Well designed breaks to allow employees to
relieve pressure on the knees and stretch
 Important to prevent deconditioning with
good quadriceps and hamstring strengthening
exercises
Questions?
Thank you!
Dr. Samir Sharma
Alliance Occupational Medicine
2737 Walsh Ave. Santa Clara, CA.
315 S. Abbott Ave. Milpitas, CA.
1901 Monterey Rd. Ste 10 San Jose, CA.