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.