Eric M. Kutz, D.O. Arlington Orthopedics Harrisburg, PA

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1 Eric M. Kutz, D.O. Arlington Orthopedics Harrisburg, PA

2 2 offices 805 Sir Thomas Court Harrisburg 3 Walnut Street Lemoyne

3 Mechanism of injury Repetitive overhead activities Falls to the ground Falls with a catch Trying to catch something that has fallen Pulling injuries Injury types Subacromial bursitis/rotator cuff strain/sprain Rotator cuff tears AC separation Labral injuries

4 Pain with motion Overhead activity worst as well as reaching Strength maintained ROM limited by pain only Treatment NSAIDS/activity modification/csi Limit activity briefly +/- PT (rot. cuff strain) Minimal limitations Persistent pain = MRI

5 Pain/weakness/decrease d ROM Difficulty raising arm/performing ADL s/pain at night Initial trial of PT/NSAIDS/light duty reasonable Rarely non-surgical by the time they reach us

6 Outpatient surgery Arthroscopic vs open procedures no difference in recovery time or rehab protocols Usually significant pain postop; regional block performed pre-op for pain control Most require narcotic pain medications weeks after surgery, commonly taken as PT starts as well Size of tear and quality of repair dictate progression of rehab and activity

7 Sling with abduction pillow post-op Constant x 2 weeks, remove pillow and wear sling for next 1-2 weeks Out of sling usually in 3-4 weeks as PT begins 0-4 weeks: PROM/pendulum exercises 4 weeks begin formal PT: PROM/AAROM x 4weeks 8-10 weeks add gentle strengthening with progression as tolerated

8 Recovery can take 3-6 months Return to work One arm work/must wear 4 weeks What do they do? Pain meds? What s their motion like? Formal PT 3x/week At 4 weeks sling is d/c d, can do work at waist level- no lifting At 8 weeks can progress activity, strengthening started May lift all restrictions by 3 months but may take up to 6 in certain cases

9 Tennis elbow Pain about the lateral aspect of the elbow Exacerbated by repetitive gripping or grasping Sharp pain can significantly limit activities You don t have to play tennis to get tennis elbow

10 Diagnosis Tender to palpation at the lateral epicondyle May have tenderness into extensor musculature Pain with resisted wrist extension, pain with resisted supination Typically does not require MRI for diagnosis

11 Conservative treatment Most cases can be resolved conservatively Can take months, may have flare ups NSAIDS, activity modifications, tennis elbow brace- must wear properly, corticosteroid injections, physical therapy

12 Surgical management Consider after a good 4-6 months of conservative treatment Outpatient surgery Lateral incision Degenerated tendon debrided Bone spur/osteophyte removed (painful) Tendon then repaired Splinted post-operatively Maintained 5-7 days

13 Recovery MUST REST Once splint removed, still limited- no lifting >5lbs, gripping, grasping 4-6 weeks post-op May require physical therapy, typically will 4 weeks- can be initiated at 4-6 week mark post-op Return full duty usually 6-8 weeks

14 Commonly called golfer s elbow Less common Repetitive pulling, gripping, grasping Pain about the medial aspect of the elbow Treated very similarly- NSAIDS, activity modification, bracing, injections Rarely surgical Commonly resolves over 6 weeks, may have recurrences

15 De Quervain s tenosynovitis 1 st dorsal compartment of the wrist includes: abductor pollicis longus (APL) and extensor pollicis brevis (EPB) Inflammation of the tendon sheaths within the compartment due to repetitive activities Gripping, grasping, lifting, twisting,etc. Can significantly limit activities

16 Diagnosis Clinical exam: TTP over radial aspect of wrist, painful grip, (+) Finkelstein s test, pain only (typically no sensory changes) Treatment NSAIDS, activity modification, corticosteroid injection, thumb spica splint

17 Surgical management Outpatient procedure Splint 3-5 days post-op, splint removed, motion encouraged Sutures removed at 10 days, advance activities PT rarely needed, usual return to full duty by 4 weeks

18 Compression of the median nerve at the wrist Can be related to repetitive use activities Typing, gripping, grasping, etc. Pain, numbness, and tingling into the thumb, index, and long fingersmedian nerve distribution Begins intermittently, often bothers at night

19 Diagnosis Clinical exam may show diminished sensation within the median nerve distribution and pain, (+) Tinel s test and Phalen s test, weakness, and muscle atrophy in more severe cases EMG/NCV positive

20 Treatment Activity modification, bracing, injections(?) Surgical management Outpatient procedure Open vs endoscopic Higher incidence of incomplete release with endoscopic procedure Splint for 5 days- protect wound, allow early healing, sutures out at 10 days

21 Recovery Typically seen in the office at 10 days post-op 6 weeks Grip and pinch strength typically normal by 6 weeks Numbness/tingling improved/resolved very quickly Severe cases take longer to recover Occasionally require hand therapy Return to work Office work 7-10 days Limitations for 2-4 weekssoreness around incision, stiffness Heavy laborer Can take up to 6 weeks to return to full duty

22 Mechanism of injury Twist/awkward turn/variety of falls/trip over cord, hose, etc. Direct blow, struck by something (from the front or side) Repetitive pivoting or twisting

23 Meniscal/ligamentous Medial or lateral meniscus ACL, PCL, MCL, LCL Bony contusion/bone bruise Fractures Tibial plateau/proximal fibula

24 Symptoms Pain with pivoting or twisting, squatting, crouching Catching, locking, giving way Pain with change of direction Usually have pain in a specific area MRI- test of choice

25 Types of tears Radial, horizontal cleavage, buckethandle, degenerative Conservative Treatment Activity modification, NSAIDS, corticosteroid injection Limited success in this environment

26 Surgical treatment = Arthroscopy Outpatient surgery Menisectomy vs repair Menisectomy allows weight bearing immediately Repair requires 4-6 weeks of NWB on crutches Menisectomy much more common/repair in younger patients

27 Menisectomy 2-6 weeks Low demand/sitting jobs patients can return 5-10 days post-op Higher demand patients (heavy labor, plant workers, warehouse, construction, etc.) will often require light duty or other modifications for 4-6 weeks Checked in the 10 days post-op (sutures out, activities advanced, etc.), final check 4 weeks later +/- physical therapy Meniscus repair 4-10 weeks NWB on crutches for 1 st 4-6 weeks (must avoid shear forces on repair) Bracing Low demand patients can still RTW during those first two weeks on crutches Higher demand/heavy laborers will require sitting work or off work during their time of NWB These patients typically require physical therapy

28 Caused by a direct blow or fall Can sometimes accompany other injuries Recovery typically 2-6 weeks Non-surgical Will occasionally require a corticosteroid injection

29 Questions?

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