Nuisance Problems You will Grow to Love - Skin, Bones ... Problems You will Grow to Love Thomas V Gocke, MS, ATC, PA-C, DFAAPA President & Founder Orthopaedic Educational Services,

OrthopaedicEducational Services, Inc.

© 2016 Orthopaedic Educational Services, Inc. all rights reserved.

Nuisance Problems You will Grow to Love

Thomas V Gocke, MS, ATC, PA-C, DFAAPA

President & Founder

Orthopaedic Educational Services, Inc.

Boone, NC

[email protected]

www.orthoedu.com

http://www.orthoedu.com



Faculty Disclosures• Orthopaedic Educational Services, Inc.

Financial

Intellectual Property

No off label product discussions

American Academy of Physician Assistants

Financial

PA Course Director, PA’s Guide to the MSK Galaxy

Urgent Care Association of America

Financial

Intellectual Property

Faculty, MSK Workshops

Ferring Pharmaceuticals

Consultant

2



LEARNING GOALS

At the end of this sessions you will be able to:

• Recognize nuisance conditions in the Upper Extremity

• Recognize nuisance conditions in the Lower Extremity

• Recognize common Pediatric Musculoskeletal nuisance

problems

• Recognize Radiographic changes associates with

common MSK nuisance problems

• Initiate treatment plans for a variety of MSK nuisance

conditions



Inflammatory Response



Inflammatory Response*

When does the Inflammatory response occur:

• occurs when injury/infection triggers a non-specific

immune response

• causes proliferation of leukocytes and increase in blood

flow secondary to trauma

• increased blood flow brings polymorph-nuclear

leukocytes (which facilitate removal of the injured

cells/tissues), macrophages, and plasma proteins to

injured tissues

*Knight KL, Pain and Pain relief during Cryotherapy: Cryotherapy: Theory, Technique and Physiology, 1st edition, Chattanooga

Corporation, Chattanooga, TN 1985, p 127-137



Inflammatory Response*• As a result of the inflammatory process:

– redness occurs at the injury site

– tissue warmth occurs as result of increased cellular

activity

– swelling results from increased fluid

– pain as a result of tissue injury and stretching of nerve

structures

– The accumulation of fluid/edema at the injury site,

• can limit the healing process by reducing joint

range of motion (ROM)

• facilitating the formation of scar tissue. *Knight KL, Pain and Pain relief during Cryotherapy: Cryotherapy: Theory, Technique and Physiology, 1st edition, Chattanooga Corporation,

Chattanooga, TN 1985, p 127-137



UPPER EXREMITY



BURSITIS

• Bursitis:

– Synovial pouch that reduces friction between

adjacent tissue (structures)

– “Nuisance problem”

– Onset: sudden, gradual, traumatic, infection

– 2 types: Septic vs. Non-septic



Bursitis• Septic:

– 2nd to inoculation bursa with bacteria

– Olecranon/Pre-patella most commonly infected bursa

– Local cellulitis precipitates

– Hematogenous spread – rare

– Laborers @ risk for septic bursitis (repetitive motion)

– Immune compromised

• ETOH abuse/DM/Malignancy

• Chronic systemic Glucocorticoid use

• Renal Failure

– Gout/rheumatoid nodules/hx previous sepsis

– Iatrogenic infection due to intra-bursal steroid injection



Bursitis

• Non-Septic:

– Traumatic – Idiopathic – Crystalline-induced

– Olecranon/Pre-patella most commonly infected/affected

bursa

– Inciting event trivial to non-existent

– Laborers @ risk for septic bursitis ( repetitive motion)

– Same population as Septic bursitis

– Crystalline – induced 2nd hx gout

– Rheumatoid arthritis may trigger onset bursitis



Rotator Cuff SyndromeRotator Cuff Tendonitis

Sub-acromial Bursitis

Sub-acromial impingement



Shoulder Anatomy

Musculoskeletal Images are from the University of Washington

"Musculoskeletal Atlas: A Musculoskeletal Atlas of the Human Body"

by Carol Teitz, M.D. and Dan Graney, Ph.D."



Shoulder Anatomy

Musculoskeletal Images are from the University of Washington

"Musculoskeletal Atlas: A Musculoskeletal Atlas of the Human Body"

by Carol Teitz, M.D. and Dan Graney, Ph.D."



Rotator Cuff Syndrome• Pathophysiology

– Anterosuperior Impingement syndrome

• Involves: Acromion, Sub-acromial bursa,

Coracoclavicular ligament & Acromioclavicular

joint

• Supraspinatus tendon inserts greater tuberosity

anterior to Coracoacromial arch

• Biceps tendon passes under Coracoacromial arch

in forward flexion w/ shoulder internally rotated

• Neer (1972) felt RTC tears wear 2nd to

impingement and aided by down sloping acromial

spur

Roy, A: Rotator Cuff Disease; http://emedicine.medscape/article/328253-overview



Rotator Cuff Syndrome

• Pathophysiology

– Progressive, age-related tendon changes

– Codman (1934) most tears are after age 40 and

significantly increase after age 50

– Articular surfaces tears most at insertion

supraspinatus insertion into greater tuberosity

Roy, A: Rotator Cuff Disease; http://emedicine.medscape/article/328253-overview



Rotator Cuff Syndrome

• All ages

• Dull achy pain vs. sharp pain

• Gradual onset vs. sudden onset

• “Painful arc” 60-120 degrees ROM

• Night / sleep pain

• Overhead pain & weakness

• Deltoid pain

• Numbness small fingers affected side - relative

• Weakness with daily activity or specific tasks

• Atrophy Shoulder Girdle (Supraspinatus & Infraspinatus)

• Activity level: variable



Shoulder Physical Exam



Rotator Cuff SyndromePhysical Examination:

• Inspection: skin, muscle atrophy, deformities

• Palpation: AC, SC, clavicle, coracoid, posterior RTC

• Range-of-Motion: Flex, Ext, IR, ER

• Strength: Flex, Ext, IR, ER

• Neuro/Vascular: C5-T1

• Orthopaedic Tests:

– Speeds: biceps/RTC

– Empty Can: RTC (supraspinatus-infraspinatus)

– Neer/Hawkins: RTC impingement

– Crossover: AC joint

– Apprehension/relocation: Stability

– Obrien’s: Labrial injury



Don’t Forget Cervical Disease



Shoulder Examination

• Empty Can Test

– Assess resistive strength

of the Supraspinatus

portion RTC

– Shoulder flex to 90 degrees

& horizontally Abd to

45 degrees

– Positive test indicates pain

and weakness against

resistance

• Empty can test picture

Picture courtesy T Gocke, PA-C



Shoulder Examination• Speed’s Test

– Assessment Bicep

tendon injury

– Forward flex shoulder

to 90 degrees w/

elbow fully extended

& hand supinated

– apply downward force

to the distal forearm

– Positive test: Pain and

weakness indicating

biceps tendon

pathology (RTC)Photo courtesy TGocke, PA-C



• Neer & Hawkins RTC Impingement

Tests

– Assess impingement of the

greater tubercle-RTC tendon &

subacromial bursa as humeral

head moves under the Acromion

– Neer: arm max internal rotation

go from ext to fully flex position

over head

– Hawkins: elbow / shoulder flex 90

then passively int / ext rotate

– Positive test indicates pain with

impingement maneuvers



Picture courtesy T Gocke, PA-C Picture courtesy TGocke, PA-C

Picture courtesy TGocke, PA-C



• Obrien’s Test

– Assess integrity of the

bicep tendon insertion into

the superior glenoid

labrium

– Shoulder flexed to 90,

horizontally ADD to 45

and arm max internal

rotation. Downward force

applied to hand/distal arm

– Positive test indicates

pain and weakness





• Crossover Test– Assess integrity of the

AC joint for laxity and

degenerative

conditions

– Shoulder flexed to 90 &

patient reaches over

and touches opposite

– Positive test indicates

pain and limited motion

isolated to AC joint

region





Rotator Cuff SyndromeX-ray studies

• AP/Axillary/Outlet

• Grashy/External Rotation

MRI

• Soft-tissue assessment

• Young adults MRI-arthrogram

CT scan

• Alternative for MRI

• Needs CT arthrogram

Photo courtesy TGocke, PA-C




Don’t Forget Cervical Disease



Rotator Cuff SyndromeTreatment:

• Identify condition/Manage Pt. expectations

• Modification activities

• NSAIDS: oral vs. topical

– Ibuprofen/Celecoxib/Meloxicam vs. Diclofenac 1 or 2%

• Therapy – strength/ROM

• Injection

• MRI – further diagnostic acute vs. failed therapies

• Surgery

– Arthroscopy Sub-acromial decompression vs. Rotator

repair



Subacromial Injections

Posterior Approach:

• Posterolateral arthroscopy

portal region

• Sitting position with arm

dependant

• Identify posterior rim acromion

spine

• Slight cephalad angle

• Aim towards coracoid

• Select analgesic & steroid

preparation





Olecranon Bursitis



Olecranon Bursitis

• Olecranon bursa lies between bony olecranon & skin

• Very superficial bursa and easily traumatized

• Acts to decrease friction between bone and skin

• Inflammation results from overuse, trauma or infection

• Chronic disease states can cause inflammation

– Gout

– Pseudogout

– RA

• Repetitive stress positions can cause inflammation

– Results for constant contact pressure on bursa

– Forward leaning position

• Classic finding: Fluctuant bulge over olecranon



• Pathophysiology:

– Inflamed synovial cells lead to

increased fluid production

– Increased permeability of capillary

membrane allows fluid to accumulate

– Hemorrhage occurs as a result of

trauma

– Local trauma facilitates inoculation of

overlying skin with bacteria & can

lead to septic bursitis

Olecranon Bursitis

Image courtesy of Tom Gocke PA-C



Olecranon Bursitis

Physical Examination:

• Inspection: skin changes

• Palpation: Radial head, epicondyles, CFT/CET, Olecranon

• Range-of-Motion: Flex, Ext, pronation/supination

• Strength: Flex, Ext, pronation/supination

• Neuro/Vascular: C5-T1

• Orthopaedic Tests:

– Collateral Ligament stability

– Distal Tricep/Bicep tendon (Hook Sign – Bicep)



Olecranon Bursitis

Treatment: Non-septic Bursitis• Recognize potential for infection

• Activity modification

• ICE/Heat

• Compression

• NSAIDS: topical vs. oral

• Injection/aspiration vs. Incision & drainage

• Protective Pad/cushion

• Pt. expectations

– Surgical excision chronic/recalcitrant bursitis

• Manage Acute Gouty flares



Treatment: Septic Bursitis• Diagnostic Studies- +*

– Blood Studies: CBC w/ diff, BMP, ESR, CRP, Uric acid level

– Uric acid level: trending downward

– Glucose: bursal fluid glucose is < 50% serum glucose levels (septic bursitis)

– Aspirated fluid• WBC < 1000/ul normal ( predominantly mononuclear cells)

• WBC 200-1000/ul inflammation ( mononuclear cells)

– WBC >1,500/ul infection (polymorphonuclear cells)

*McAfee JH, Smith DL: Olecranon and Prepatellar Bursitis: Diagnosis and Treatment; Topics in Primary Care, West J Med 1988 Nov; 149:607-610

+ Aaron DL et al: Four Common Types of Bursitis: Diagnosis and management, JAAOS June 2011, 19(6):359-367

Olecranon Bursitis



Septic Bursitis Non-Septic Bursitis Crystals

Fluid Appearance Purulent Straw-Serous Straw-Serous-Bloody

Leukocytes per uL 1.500 – 300,000

Mean # 75,000

50-11,000

Mean 1,100

1-6,000

Mean 2,900

WBC/Differential >10,000

Polymorphonuclear cells

<1,000

Mononuclear cells

<1,000

Variable

Glucose Ratio < 50% blood glucose >50% blood glucose ?

Gram Stain + > 70% Negative Negative (?)

Crystals None (?) None Monosodium urate crystals- GoutCalcium pyrophosphate or hydroxyapatite crystal- Pseudogout

Culture Staph Auerus &

Epidermiidis (90%)

Streptococcal species

None

McAfee JH, Smith DL: Olecranon and Pre-patellar Bursitis: Diagnosis & Treatment, Western Journal MedicineNov 1988, 149:5;607-610



• Diagnostic studies*

– Cultures:

• Majority Staphylococcus aureus or epidermidis

• Strep species, gram negatives, H. Flu, anaerobes, mycobacteria

– Crystals

• Monosodium urate crystals- Gout

• Calcium pyrophosphate or hydroxyapatite crystal- Pseudogout

– Radiographs –concern for bone trauma

– AP & Lateral (radial head view)

– McAfee & Smith: No hx trauma – x-ray unnecessary


Olecranon Bursitis



Aspiration/Injection or Incision & Drainage

• Suspect infection in most cases

• Plan to aspirate first and inject depending on fluid aspirated

• Aspirate Fluid

– Turbid fluid

– Send fluid for analysis

– Consider I&D and Abx

– Admission?

Olecranon Bursitis

Picture courtesy TGocke PA-C



LOWER EXREMITY



Pre-patellar Bursitis

Infra-patellar Bursitis

Pes Anserine Bursitis



Pre-patella/Infra-patella Bursitis

Illustration demonstrating the anatomy of the prepatellar bursa, which consists of the subcutaneous prepatellar bursa and the superficial infrapatellar bursa. (Adapted with permission from McAfee JH, Smith DL: Olecranon and prepatellar bursitis: Diagnosis and treatment. West J Med 1988;149:607-610.)



Symptoms

• Gradual onset to sudden onset

• Localized pain/swelling medial tibial

flare

• Start-up symptoms

– Stiffness better after motion

– Swelling

– Hamstring pain/stiff with knee ext.

– Variable pain locations: joint

line/medial tibia

– Weakness/giving out

– Catching/lockingImage courtesy TGocke, PA-C

Pes Anserine Bursitis



Pre-patellar Bursitis Symptoms



– Hx. repetitive kneeling,

squatting, climbing

• Nursemaids knee

• Clergymen’s knee

• Carpet layer’s knee

– Swelling anterior knee

– Redness/warmth

– Pain variable

Picture courtesy Wiki Commons




Pre-patellar Bursitis Physical Examination

• Inspections

– Swelling pre-patellar region

– Skin

• Palpation

– Redness/warmth

– Tender patella region

• ROM/Strength

– Usually no ROM changes

– Normal strength

– Hurts to Kneel/squat/climb

• Neuro/Vascular

• Ortho exam normalPicture courtesy TGocke, PA-C



Infrapatellar Bursitis

Symptoms

• Less common vs. pre-patella

bursitis


• Acts like patellar tendonitis


– Stiffness getting better after

some motion

– Swelling

– Weakness/giving out

– Catching/pinching sensation





Infrapatellar Bursitis Physical Examination

• Inspections

– Swelling patellar tendon region

– No suprapatella swelling

• Palpation

– ? Redness/warmth

– Tender patella tendon region

• ROM/Strength

– Start-up symptoms

– Stiffness

• Neuro/Vascular - normal

• Orthopaedic Tests - normal






• Treatment – Non-Septic Bursitis

– Modify activity

– ICE

– NSAIDS topical vs. oral

– Flexibility

– Physical Therapy

– Protective sleeve vs. pad (pre-patella)

– Injection/aspiration vs. Incision & drainage

• Manage Acute Gouty flares

– Protective Pad/cushion

• High recurrence rate in repetitive activity jobs

*Pes bursitis- treat knee OA usually treats bursitis



Treatment: Septic Bursitis• Diagnostic Studies- +*

– Blood Studies: CBC w/ diff, BMP, ESR, CRP, Uric acid level

– Uric acid level: trending downward

– Glucose: bursal fluid glucose is < 50% serum glucose levels (septic bursitis)

– Aspirated fluid• WBC < 1000/ul normal ( predominantly mononuclear cells)

• WBC 200-1000/ul inflammation ( mononuclear cells)

– WBC >1,500/ul infection (polymorphonuclear cells)


+ Aaron DL et al: Four Common Types of Bursitis: Diagnosis and management, JAAOS June 2011, 19(6):359-367

Pre-Patella/Infra-Patella Bursitis



– Suspect infection in most cases

– Plan to aspirate first and inject depending on fluid aspirated

– Aspirate Fluid• Turbid fluid

• Send fluid for analysis

• Consider I&D and Abx

• Admission?


• Aspiration/Injection or Incision & Drainage




HIP & PELVIS



Trochanteric Bursitis• Trochanteric Bursa lies deep to the

ITB & superficial to Gluteus medius

tendon insertion @ greater trochanter

• Gluteus medius/minimus

– Attach greater trochanter

– ABDuct & Internal rotation

• AKA: Greater Trochanteric Pain

Syndrome (GTPS)

• Trochanteric bursitis = Gluteal

tendinosis

• Consider pts. with Trochanteric bursitis

to have gluteal tendinosis/tear**Bird PA et al: Prospective evaluation of magnetic resonance imaging findings in

patients with greater trochanteric pain syndrome; Arthritis Rheum 2001;44(9):

2138-2145Musculoskeletal Images are from the University of Washington "Musculoskeletal

Atlas: A Musculoskeletal Atlas of the Human Body" by Carol Teitz, M.D. and

Dan Graney, Ph.D."



Trochanteric BursitisClinical Presentation

• Mechanism of injury

• Repetitive/Change activity

• Poor flexibility

• Sedentary

• Body habitus

– Symptoms

• Start-up pain

• Prolonged sitting

• Side sleeping position

• Isolated lateral hip pain

Groin or Butt pain think something elseMusculoskeletal Images are from the University of Washington "Musculoskeletal

Atlas: A Musculoskeletal Atlas of the Human Body" by Carol Teitz, M.D. and

Dan Graney, Ph.D."



Trochanteric BursitisPhysical Examination

• Inspection

– Have the pt. stand and point to location of their

pain

• Palpation – tender lateral trochanter/hip

• ROM/Strength – ABD pain/passive ADD

pain

• Neuro/vascular – no changes

• Ortho exam –

– Stichfield’s Test- hip joint

– Patrick/FABER- SI joint dysfunction

– Ober Test- positive tight IT band

– Tight Hamstrings/Hip flexors/Quads

– Consider lumbar spine exam too!!!

Illustration demonstrating the location of the trochanteric bursa between the gluteus medius (2) and the iliotibial band (3) as well as the bursa located between tendon and bone at the gluteus minimus, which is reflected downward (1). (Redrawn with permission from LequesneM: From "periarthritis" to hip "rotator cuff" tears: Trochanteric tendinobursitis. Joint Bone Spine 2006;73[4]:344-348. http://www.sciencedirect.com/science/journal/1297319X.)

Four Common Types of Bursitis: Diagnosis and Management.Aaron, Daniel; Patel, Amar; Kayiaros, Stephen; Calfee, Ryanournal of the American Academy of Orthopaedic Surgeons. 19(6):359-367, June 2011.



HipOber Test

– Pt lateral decubitus

position

– With the patient lying in

the lateral position,

support the knee and flex

it to 90 degrees. Then

extend and abduct the

hip. Then release the

knee support.

– Failure of the knee to

Adduct is a positive test.



Trochanteric Bursitis InjectionTreatment

• Modify activities

• Improve flexibility

• NSAIDS – topical vs. oral

• Physical Therapy vs. Home Stretching program

• Injection

• Reassess causes for pain symptoms:

– Sacroiliac joint dysfunction

– Lumbar Radiculopathy

– Femoroacetabular Impingement (FAI)

– Hip Dysplasia

– Gluteal tendon rupture/tear



Trochanteric Bursitis• Procedure:

– Confirm Trochanteric bursitis

– Identify point of maximal

tenderness

– Lateral decubitus position

– Sterile prep

– Vapo-coolant spray

– Injection solution

3ml Bupivacaine, 2 ml Lidocaine &

1-2 ml Triamcinolone 40mg/ml

• Spinal needle vs. 1 ½ inch

needle




Retrocalcaneal Bursitis



Retrocalcaneal BursitisGeneral

• Starts as posterior heel pain

• AKA: Pump Bump/Achilles Bursitis

• Influencing factors:

– Shoe wear/heel counter pressure

– Poor hamstring/Achilles flexibility

– Activity changes

– Structural deformities (calcific tendonitis, Haglund)

– Gout/RA/Seronegative Spondyloarthropathies

– Mal-aligned sub-talar joint

• Alters normal foot mechanics

• Transmits more force load to Achilles tendonReddy SS: Surgical Treatment for Diseases and Disorders of the Achilles Tendon; JAAOS 17(1):3-14, Jan 2009




Four Common Types of Bursitis: Diagnosis and Management.Aaron, Daniel; Patel, Amar; Kayiaros, Stephen; Calfee, RyanJournal of the American Academy of Orthopaedic Surgeons. 19(6):359-367, June 2011.

Illustration demonstrating the anatomy of the hindfoot. The posterior calcaneal tuberosity is covered with fibrocartilage just proximal to the insertion of the Achilles tendon. This tuberosity apposes the anterior wall of the retrocalcaneal bursa. (Reproduced with permission from Stephens MM: Haglund's deformity and retrocalcanealbursitis. Orthop Clin North Am 1994;25[1]:41-46.)

Anatomy• Achilles tendon inserts into

Calcaneous

• Calcaneous usually down

sloping

– Haglund deformity

increases contact pressure

of Achilles on calcaneous

Dorsiflexion

• Bursa

– Retrocalcaneal: between

bone and tendon

– Superficial: between skin

and tendon



Retrocalcaneal BursitisPhysical Examination

• Inspection

– Assess gait

– Rear-foot alignment

• Neutral-Varus-Valgus

• Pes Planus – Cavus

• “Too many toes sign”

• Palpation – tender Achilles insertion

calcaneous

• ROM/Strength

– Decreased KBDF/KEDF

– Hind foot varus & Rigid 1st ray

predisposed ?

• Neuro/vascular – no changes

• Ortho exam – Look @ mortise & sub-

talar stability

Morhopedics – Creative Common Attribution-Share Alike 3.0





• Radiographic views

– Ankle: AP, Lateral,

Mortise (standing)

– Foot: AP, Lateral,

Oblique (standing)



Haglund Deformity



Retrocalcaneal BursitisTreatment:

• Modify activity

• Modify shoe wear/types – padding/orthotics

• Improve flexibility Gastroc-Achilles complex

• NSAIDS: topical vs. oral

• Physical Therapy

– Iontophoresis/Phonophoresis

• Phonophoresis: Steroid driven into tissue by ultrasound

• Iontophoresis: Electrical charge draws steroid into tissues

– Acetic Acid: change in calcium ions reduces inflammation

and reduces chance of scar tissue formation

• Surgery- excise Haglund deformity

DO NOT INJECT ACHILLES REGION WITH STEROIDS



Plantar Fasciitis



Plantar Foot

From Wikimedia Commons



Plantar Fasciitis• Definition: inflammation of the fascia

• “Heel spur pain”

• Plantar fascia has 3 slips.

– Medial – Central – Lateral

– Central slip arises from medial Calcaneal tuberosity

– Inserts to 5 digits Flexor Tendons

• Primary function is for support longitudinal arches (med/lat)

• Affects women > men

• Average onset 45 yrs

• Obesity worse

• Extreme changes in activity

• Poor foot wear choices

• Poor Flexibility



Symptoms:

• Pain with ambulation

• Worse in AM or after prolonged rest/sitting– “start-up pain”

– Better after warming up

• Pain localized to heel region– Central Heel pad

– Medial arch or heel pain

• Body size contributes

• Gait changes

• Pathophysiology:

– Micro tears in plantar fascia tendon insertion

– 50% develop plantar grade heel spurs

Plantar Fasciitis



Examination

– Observe Gait

– Observe foot posture• Planus – Hind foot valgus – plantar callosities

– Assess flexibility Achilles and toe flex/ext groups

– Palpate plantar fascia

– Assess Posterior Tibial tendon integrity (strength)

– Neuro/Vascular (Tarsal Tunnel vs. Baxter’s neuropathy)

Plantar Fasciitis



Plantar Fasciitis

• X-ray: Standing lateral

– Traction spur considered

a normal finding (arrow)

– Not cause for Plantar

Fasciitis

– High suspicion for Calcaneal

stress fracture or tumor

– Prior to corticosteroid

injection

– Consider CT, MRI or bone

scan if failed treatment

4-6 weeks




Plantar Fasciitis

• Associated Conditions

– Tarsal Tunnel syndrome

– Calcaneal stress fx

– Calcaneal bone tumor

– Rupture of the Plantar Fascia

– Referred pain from lumbar region

– Posterior Tibial nerve entrapment (Baxter’s nerve)



Plantar Fasciitis

• Treatment

– Conservative care cures most cases

– Achilles and plantar fascia flexibility - KEY

– NSAIDS

– ICE (“frozen plastic bottle foot massage”)

– Heel pad vs. rigid arch support

– Immobilization (cast vs. ankle boot)

– Night splint

– Injection

– Surgery – last resort- failed after 6 months



Plantar Fasciitis

• Calf/Gastroc Stretch • Toe Flexor stretch



Pediatric MSK Problems

Calcaneal Apophysitis: American Academy of Foot and Ankle Surgeons

http://www.acfas.org/Content.aspx?id=1483

Patellofemoral Pain Syndrome: American Academy of Orthopaedic Surgeons,

http://orthoinfo.aaos.org/topic.cfm?topic=A00680

http://www.acfas.org/Content.aspx?id=1483

http://orthoinfo.aaos.org/topic.cfm?topic=A00680



Calcaneal Apophysitis

• Sever’s Disease

• Ages 8-14

• Results from repetitive stress activity

• Stressors cause inflammation @ Calcaneal Physis

• Pain worse with activity better with rest

• Causes:

– Tight Achilles

– Obesity

– Foot biomechanics

• Pes Planus w/ rear-foot valgus vs. Cavus foot

– Running sports




• Symptoms

– Localized heel pain (pressure)

– Gait change

• Limping

• Toe walking

– Pain after running/jumping

– Swelling/redness variable

– Avoidance of activities

– Growth spurts – shoes and pants



Calcaneal Apophysitis• Physical Exam

– Inspection:

• Variable swelling/redness

• Gait changes based on acuity of symptoms

– Palpation:

• Lateral calcaneal pain/Achilles tenderness

• Tenderness based on acuity of symptoms

– Range-of-Motion (ROM):

• limited by pain

• Knee bent Dorsiflexion vs. Knee Extended Dorsiflexion

– Strength: usually normal

– Neuro/Vascular: no changes

– Ortho Tests




Radiographs

• AP- Lateral

• Harris Heel

– Radiographs helpful in

refuting other bone

injuries

– Typically see fissuring of

Calcaneal epiphysis





• Treatment– Recognition of complaints

– Conservative care

• RICE

• NSAIDS

• Flexibility (Hamstring/Quad/Gastroc-Achilles)

• Heel Cushion

• Good Shoes

– Modification of Activities



Patella-Femoral pain



Patella-Femoral pain• Occurs for many reasons

– Overuse

– Poor strength

– Poor flexibility

– Anatomy

– Obesity

• Affects all ages

– Adolescent

– Mid-Lifers vs. “Old Teenagers”

• Anterior Knee Pain



Patella-Femoral pain• Anatomy Review

– Femur/Tibia/Patella

• Patella rides in Femoral Groove

• Articular cartilage cushions Patellofemoral

articulation

• Synovial membrane lubricates Patellofemoral glide

– Muscles/Tendons/Ligaments

• Quads – motor function knee

• Extra-articular ligaments/Retinaculum – hold

patella in place allow for normal glide




• Characteristics

– Stairs/Stand/Sit/Squat Kneel & Crawl

– Ache

• Pain comes 2nd to soft-tissue inflammation & bone

• Articular cartilage wears down -Chondromalacia

– Swollen/Stiff

– Vague symptoms

• Overuse

– Repetitive activity

– Increased frequency vs. intensity vs. duration

– Flexibility/strength

– Improper foot wear or training techniques



Patella-Femoral painMalalignment

• Patella –Femoral trochlea mismatch

– Abnormal contact pressure patella-trochlea

– Leads to Chondromalacia & soft tissue inflammation

– Abnormal tracking Patella

• Contributing Factors

– Patella Aligns lateral : lateral tethering

– Patella Aligns medial : “squinting patella”

– Patella too High – Alta (Baha to low)

– Soft-tissue Imbalance

• Weak Quads

• Tight retinaculum

• Hamstrings/Patella tendon

– Improper foot wear or training techniques



Patella-Femoral Pain• Physical Exam

– Inspection:

• Patella alignment

• Gait changes based on acuity of symptoms

– Palpation:

• Lateral retinaculum tenderness

• Tenderness Medial & Lateral facets

– Range-of-Motion (ROM):

• limited by pain/crepitation

• J move

• Lateral tracking

– Strength: weak quads/poor flexibility

– Neuro/Vascular: no changes

– Ortho Tests




Radiographs

• AP- Lateral- Sunrise

– Radiographs helpful in

defining bone injuries

– Typically see:

• Compression

• Mal-tracking

• Alta/Baja


Photo courtesy TGocke, PA-CPhoto courtesy TGocke, PA-C



Radiographs

• Sunrise View

• Merchant View

• Tangential View

– All look at articular

surface of patella

– Position of patella

– Compression points

patella




Radiographs• Patella Height: (Blumensaat's Method)

– Knee flexed to 30 degrees

– Draw a line thru the roof of the

Intercondylar notch

– Line should touch the inferior pole of

the patella

• Normal height - inferior pole patella

touches Blumensaat’s line

• Patella Alta – inferior pole patella above

line

• Patella Baja – Inferior pole patella below

line

Blumensaat's C: Die Lageabweichugen und Verrekugen der Kniescheibe;

Ergenbnisse der Chirurgie und Ortho 228(31):149-223.

Blumensaat’s Line



RadiographsPatella Height: (Insall Method)*

– Relationship of patella length

to length of patellar tendon

• Length of patellar tendon:

– Measured inferior pole patella

to insertion tibial tuberosity

• Length patella:

– Longest lateral length patella

• Normal Ratio:

– Patellar / Tendon = 1

– <0.8 : patella alta or tendon

rupture

* Insall J, Salvatie E: Patella Position in normal knees joints,

Radiology 1971, p101-104



RadiographsPatella Alta:

Patella Baja:



Patella-Femoral painTreatment

• Recognize condition

• Assess flexibility and strength

• Modify activities

• Improper foot wear or training techniques

• ICE/Heat

• NSAIDS: Oral – Topical – Injectable

• Surgical

– Arthroscopy

• Chondroplasty

• Lateral Release

– Tibial Tubercle Transfer

• Realign patella tendon with bone repositioning



Osgood Schlatter's Diseasehttp://radiopaedia.org/articles/osgood-schlatter-disease

http://www.eorthopod.com/content/osgood-schlatter-disease

http://radiopaedia.org/articles/osgood-schlatter-disease

http://www.eorthopod.com/content/osgood-schlatter-disease



Osgood-Schlatter’s Disease• General

– Occurs 11-15 age group ( rapid growth)

– Boys > Girls

– Overuse problem – increased demand on immature skeleton

– Caused by tight hamstrings limit knee extension and increasing

pull of quad/patellar tendon on tibial tubercle

– Small area heterotopic ossification seen 2nd to microtrauma a the

tibial apophysis

• Clinical Symptoms

– Swelling tibial tubercle area

– Pain with ambulation, stair-climbing, jumping & running

– Pain with palpation

– Limited ROM knee 2nd to tight hamstrings



Osgood-Schlatter’s Disease• Physical Examination

– General Knee exam

– Pay specific attention to age group, flexibility and

location pain

– Tender palpate tibial tubercle

– Pain with AROM & resistive AROM knee extension

• Differential Diagnosis

– Jumper’s Knee

– Avulsion fracture tibial physis

– Synding-Larsen-Johansen Disease – connective

tissue disorder



Osgood-Schlatter’s Disease• Radiographs:

– AP, Lateral, Sunrise

– AP - Normal

– Lateral

• Bony changes noted at

tibial tubercle

• May need comparison

view contralateral knee

– Sunrise – check

patella position in

trochlea



Osgood-Schlatter’s Disease• Treatment:

– Symptomatic care

– ICE

– NSAIDS

– Knee pad or sleeve: decrease pain from contact

pressure

– Immobilize for recalcitrant symptoms or poor patient

compliance

– Change activity up to 2-3 months

• May need longer for more severe cases

– Surgery to correction for rupture/bony fracture - rare



Take Home Points• Manage patient expectations

• Conservative measures usually make things better

• Modification of activities

• Shoulder & Hip – think outside the box (Neck & Back)

• Bursitis – always be suspicious of infection/gout

• Improve Strength & Flexibility:

• Patellofemoral problems

• Trochanteric Syndrome

• Plantar Fasciitis/Achilles Tendonitis/Bursitis

• Choose PT over HEP

• Foot position can affect upstream problems

Never inject RetroCalcaneal bursitis



THANK YOU

www.orthoedu.com

www.orthoedu.com Thunder Hill Overlook, Blue Ridge Pkwy

Blowing Rock NC

Photo Courtesy TGocke, PA-C



References• McAfee JH, Smith DL: Olecranon and Prepatellar

Bursitis: Diagnosis and Treatment; Topics in Primary Care, West J Med 1988 Nov; 149:607-610

• Aaron DL et al: Four Common Types of Bursitis: Diagnosis and management, JAAOS June 2011, 19(6):359-367

• Gocke TV: Injection & Aspiration of Common

Musculoskeletal Conditions 1 & 2, Orthopaedic

Educational Services, Inc., www.orthoedu.com 2014

• Gocke TV: Shoulder Examination, Orthopaedic


• Foye PM: Retrocalcaneal Bursitis,

emedicine.medscape.com, updated November 26, 2014





References• Gocke TV: Foot Soft tissue 1 &2, Orthopaedic


• Gocke TV: Knee Injuries-Extra-articular 2, Orthopaedic


• Roy A: Rotator Cuff Disease, eMedicine – Medscape;

updated Sept 14, 2014

• Brox JI, Staff PH, Ljunggren AE, Brevik JI. Arthroscopic

surgery compared with supervised exercises in patients

with rotator cuff disease (stage II impingement

syndrome). BMJ. Oct 9 1993;307(6909):899-903.

• Reddy SS: Surgical Treatment for Diseases and

Disorders of the Achilles Tendon; JAAOS 17(1):3-14,

Jan 2009





References• Kilfoil RL: Acetic acid iontophoresis for the treatment of

insertional Achilles tendonitis; BMJ Case Reports 2014,

casereports.bmj.com

• Costa IA, Dyson A: The integration of acetic acid

iontophoresis, orthotic therapy and physical rehabilitation

for chronic plantar fasciitis: a case study; J Can Chiropr

Assoc. 2007 Jul-Sep; 51(3): 166–174

• Gocke TV: An Urgent Care Approach to Joint and Soft-

tissue Injection/Aspiration, Part 1; JUCM Sept 2014; 8-

19

• Gocke TV: An Urgent Care Approach to Joint and Soft-

tissue Injection/Aspiration, Part 2 ; JUCM Oct 2014; 9-22

Documents

Nuisance Problems You will Grow to Love - Skin, Bones ... Problems You will Grow to Love Thomas V Gocke, MS, ATC, PA-C, DFAAPA President & Founder Orthopaedic Educational Services,