UPPER EXTREMITY PAIN AND MANAGEMENT 117th Missouri Osteopathic Annual Convention May 1,2015 Chateau on the Lake, Branson, Missouri Charles Orth DO,FAOAO Program Director Orthopedics Prime Health Blue Springs MO
I have no financial disclosures
Goals of This Presentation Review common shoulder pathology Rotator Cuff, Labrum, Arthritis Elbow Medial & Lateral Epicondylitis Carpal Tunnel Syndrome Hand Pathology & Treatment Understand exams, treatments, differentials When to test, When to refer
Attrition Cuff tears are due to? A. Extrinsic Impingement B. Intrinsic Impingement C. Shoulder Instability
SHOULDER PATHOLOGY Glenohumeral (GH) Subacromial (SA) Acromioclavicular (AC)
Rotator Cuff Chief complaint Traumatic injury or Atraumatic Prior treatments SYMPTOMS: Pain, Weakness, Instability, Motion Loss, Neurologic Changes
Rotator Cuff Remember an injury can cause a tear The only other reason for tears is? Attritional tear is due to EXTRINSIC impingement
Rotator Cuff Tears Is it torn or not Exam and MRI help diagnose Partial and full tears both can progress Begin with standard x-rays MRI CT Arthrogram US EMG
Physical exam Cervical exam: pain usually constant goes above shoulder Palpate Inspect : atrophy Range of Motion Strength, start below shoulder then go up Neuro: Tinels, etc Special tests Stability tests
Cervical Spine issues Nerve root or central cord issues can refer distally Any prior cervical issues? Need to R/O neck issues If neck symptoms, start with X-ray C3-4, 4-5 level
Cervical Spine Tests Motor Sensory Strength Reflex Lhermitte Sign
Inspection Visual inspection, scars, atrophy, scoliosis, winging Atrophy: which muscles Deltoid, Supraspinatus (SS),Infraspinatus (IS),Teres Minor (TM) Biceps: Rupture long head(popeye) Deltoid= Axillary Nerve SS/IS= Suprascapular Nerve TM=Axillary nerve
Motion Loss Active motion loss:?cuff, AC Impingement, Arthritis, Loose Body Passive motion loss: Adhesive Capsulitis, loose body Prior to any surgery goal is obtain ROM for better results Know motion before surgery for comparison after
Adhesive Capsulitis Frozen Shoulder Pain with loss of motion Fibroblastic proliferation Associated with : Diabetes, autoimmune disorders, prior surgery as lung and breast, prolonged immobilization Mostly External Rotation (ER) motion loss but global loss as well
Adhesive Capsulitis NSAIDS Physical Therapy Intra-Articular injection Heat Within one month considerable relief and better motion MUA Arthroscopic Release only after 3-6 month failed care
GH INJECTION coracoid
Adhesive Capsulitis
Impingement Tests Classical tests for external or bursal pain Primary Compressive Disease from coracoacromial arch Neer vs Hawkins tests Injection test: 10cc 1% lidocaine SA space Crepitance with motion in SA space Pain that recreates patients symptoms
Impingement Tests HAWKINS NEER
Subacromial Injection Post acromion
Treatment Impingement Rest NSAIDS Therapy for Strength Injection Arthroscopy
Internal Shoulder Impingement has loss of which motion? A. External B. Internal C. Flexion D. Extension
Internal Impingement GIRD: Glenohumeral Internal Rotation Deficit Typically Throwers Pain in extreme ER, throw position Limited IR seen Weakness has a Positive empty can sign Posterior tenderness at infraspinatus insertion area ASMI( American Sportsmed Institute): www.asmi.org AOSSM.org STOP program: all sports
GIRD Image
Rehab of Overhead Athletes Dynamic Stabilization Drills Muscle balance Core Program Overall body mechanics Inflammation modalities, cold laser, iontophoresis Incorporate, motion, stretch, strength, throwing phases
Overhead Rehab Decrease irritating sport activity 2-8 weeks Continue with other phases of rehab, motion, stabilize, strengthen, resume activity Follow pitching rules counts and rest days Months of rest during season
Shrug Sign Pt will abduct shoulder as the rotator cuffs goal is to hold down the humeral head Shrug caused by torn cuff, weak, or absent cuff Deltoid normally then can elevate the shoulder Reliable for cuff pathology Clin Orthop Relat Res 2008;466:2813-19
Rotator Cuff Strength Testing It takes 20% deficit of strength to detect weakness Always compare opposite side Hand dominance
LIFT OFF TEST SUBSCAP EXAM Subscapularis Testing Belly Press Test Bone Joint Surg Am 1996:78:1015-23
SUPRASPINATUS TESTING
INFRASPINATUS TESTING STRONGEST EXTERNAL ROTATOR SEATED EXT. ROTATION ELBOW AT 90 DEGREE
Biceps Tendon Pain Generator Speeds Test Yeargason s Test
Radiologic testing for pathology With MRI evaluate muscle atrophy Atrophy determines age of tear Retraction of tear Impingement Labral injury Loose body Remember arthrogram or Ultrasound if cannot do MRI
Typical MRI of Cuff Tear
Partial Rotator Cuff Tears May occur over time Can progress More common on articular side, MRI PASTA= partial articular side tendon avulsion Delamination process Usually under 45 age Tear 50% or greater repair to bone Smaller 20%. Larger 51%, Full tear 29% Yamanaka etal. Clinical Ortho 1994
Partial Cuff Tear PASTA
Full Cuff Tears To repair or not Is Physical Therapy Relevant
Full Cuff Tears to repair or not Evidence Based Orthopedics 2012: Ch 89: 763-769 Ch 88; 752-759 Bursectomy equal to acromioplasty Home exercises preferred to PT US as effective as MRI for detecting full cuff tears Weakness, loss of function, acute injuries are reasons to repair
Shoulder Instability Means an abnormal excessive motion in one or more directions Instability is pathologic Multidirection (MDI) instability infers an inferior direction Bidirectional instability seen in throwers Laxity is different is not pathologic, Neuromuscular
Understanding Instability Frequency, acute, fixed Direction: ANT,POST,INF,MDI Cause: Traumatic Atraumatic Degree: Subluxation Dislocation Congenital Neuromuscular
Understanding Instability Congenital: usually multi-directional Ehlers-Danlos, Marfans Traumatic: 90% or more anterior dislocation
Anterior Shoulder Laxity Test Done in the plane of scapula Feel degree of motion Apprehension
Relocation Test
Sulcus test 0= no translation 1= 1cm or less 2= 2 cm or less 3> 2cm 3cm or > = MDI
Which is the best x-ray to detect a Bony Bankart Lesion? A. Y-View B. Westpoint C. Internal Rotation External Rotation
Instability X-Rays Standard x-rays Y view Axillary view Westpoint view: Bony Bankart Lesion
Dislocation X-ray AP VIEW Y VIEW
WestPoint X-Ray
MRI for Instability Labral tear Labral Tear
Plain xrays Look for simple OA
Osteoarthritis Shoulder Increases with age Global motion loss Pain Crepitance NSAIDS, Physical Therapy, Intra-articular Injection Surgery: Total Shoulder vs Reverse Shoulder
Shoulder Clinical Exams Neer Hawkins Obrien Lift off Belly Press Speed Yeargason Hornblower Impingement Cuff pathology SLAP/Labrum SubScap Subscap Bicep Bicep Infraspinatus/Teres Minor
Useful Websites/Apps www.asmi.org: pitching, and medical info page www.shoulderdoc.co.uk www.orthobullets.com CORE Clinical Orthopedic Exam: app Procedures Consult: app CME: OAKSTONE PUBLISHING Orthopedic Sports Medicine/A comprehensive review
Which exercises are best for lateral epicondylitis? A. Concentric B. Isometric C. Eccentric
Lateral Epicondylitis Tennis Elbow Most Common elbow disorder diagnosed for pain 1-3% of adults each year Usually dominant arm 50% of all tennis players
Elbow Anatomy ECRB** Extensor Carpi Radialis Brevis Extensor Digitorum Communis (EDC) Microtears Histology shows angiofibroblastic tendinosis
History Onset 40-50 s Lateral elbow pain Wrist extension and grip pain Difficult opening things, jars, lids, driving
Eccentric Tyler Twist Exercise
Physical Exam Pain over lateral epicondyle slightly anterior Pain with resisted wrist dorsiflexion: COZEN test Differential Dx: Cervical Radiculopathy, Radial Tunnel, Intra-articular pain, elbow instability X-rays usually normal, may show calcific tendonitis MRI will show changes 80% or > improve over 1 year
COZEN TEST
Tennis Elbow Evidence Evidence Based Orthopedics 2012: CH:92, 787-795 MRI/US useful to aid clinical diagnosis Initial corticosteroids useful in short term NSAIDS may be no more effective than placebo for long term relief
Medial Epicondylitis Golfers Elbow Dominant arm 75% of time Much less common than lateral Seen in golfers, pitchers, carpenters, racquet players MC: FCR and PT Ulnar nerve symptoms Approx. 50% 40 s-50 s Grip affected, worse in pronation motions X-rays usually normal
Treatment Similar to Lateral Epicondylitis treatment Be careful of ulnar nerve with injections Iontophoresis Topical Pain Lotions Conservative care works 80% of time Surgery: 85% success
Carpal Tunnel Syndrome MC compressive neuropathy Risks: Female, Pregnancy, Hypothyroid, RA, Smoker,ETOH Assoc. conditions: DM,Hypothyroid,RA,Pregnancy,Amyloid Repetitive motion/vibration jobs
Symptoms Numbness median nerve fingers Nocturnal pain Hand Diagram
Carpal Tunnel Exam Atrophy thenar Durkins Compression Test: Most sensitive exam, 30sec Phalens test Tinels test Sensory exam 2ppt Semmes-Weinstein: more sensitive EMG
EMG Increase in Latencies Distal sensory > 3.2ms Motor >4.3ms Decrease conduction velocity <52 m/sec abnormal
Carpal Tunnel Treatment NSAIDS Nite Splints Exercise Activity modification Steroid injection, 80% transient improvement Failure to improve with injection poor prognosis Carpal Release Revision Carpal Tunnel Release: 75% have some relief
Carpal Tunnel Injection
References Nerve glide exercises Steroid Injections Splinting Evidence Based Orthopedics 2012: CH 119: 1012=1019
Which nervous system is involved in Minor Causalgia? A. Autonomic B. Sympathetic C. Parasympathetic
CAUSALGIA THE DREADED RSD WHEN PHYSICAL EXAM DOES NOT MATCH NORMAL EXAM Pain is way out of the normal Even light touch, painful Skin changes even hyperhidrosis Skin color changes
Causalgia the Dreaded RSD Start aggressive pain management Use all modalities Narcotic, NSAIDS, Neurontin type, Topical compounds add ketamine Physical Therapy May need Pain management for sympathetic blocks
Dequervains Syndrome Stenosing tenosynovitis 1 st Dorsal wrist compartment F>M, age 30-50 Causes: Idiopathic, Pregnancy, Overuse, Traumatic
Dequervains Test Finkelstein Test: positive
Dequervains Treatment NSAIDS Thumb spica splint Steroid injection Surgical release
Dequervains Release
Trigger Finger Stenosing tenosynovitis of flexor tendon sheath A1 pulley is area of entrapment DM more common, RA, amyloidosis Ring finger most common Can have pain, locking, or locked finger Feel crepitance, or bump, or click at A1 pulley Thumb does not respond well to injections
Trigger Finger Treatment NSAIDS Nite splint Activity modification Injection: Steroid 1-3 injections common Injections in DM does not work as well Surgery if all fails
Trigger Finger
Paronychia Infection MC hand infection( 1/3 of all ) Adults usually Staph aureus DM usually mixed infection Chronic look for candida albicans Nail bitters, suckers, manicures, trauma
Paronychia Infection Treatment Warm soaks Antibiotics Possible nail removal I&D, separate incision if needed
Paronychia Infection Incision
Attrition Cuff tears are due to? A. Extrinsic Impingement B. Intrinsic Impingement C. Shoulder Instability
Internal Shoulder Impingement has loss of which motion? A. External B. Internal C. Flexion D. Extension
Which is the best x-ray to detect a Bony Bankart Lesion? A. Y-View B. Westpoint C. Internal Rotation D. External Rotation
Which exercises are best for lateral epicondylitis? A. Concentric B. Isometric C. Eccentric
Which nervous system is involved in Minor Causalgia? A. Autonomic B. Sympathetic C. Parasympathetic
THE END