Shoulders, Knees, and

Ankles –for clinicians who have

other priorities.

Ron Olson, MDDuke Student Health

Shoulder

Green

• Just want to be safe.

• Nothing fancy

• What needs prompt attention

Shoulder

• No diagnosis, no definitive management but recognize what may need urgent care

• Based on – Anatomy– What the patient says

Shoulder --Anatomy

1. head of humerus2. scapula

• acromion• glenoid• spine

3. glenohumeral joint4. clavicle (collar bone)5. acromio-clavicular joint

1. Head of humerus

Palpate acromion and humeral head

1. Head of humerus

1. Head of humerus

2. Scapula -- acromion

2. Scapula -- spine

2. Scapula -- glenoid

• part of the scapula

2. Scapula -- glenoid

3. Glenohumeral Joint

4. Clavicle

5. Acromioclavicular Jt

5. Acromioclavicular Jt

1. Check neuromuscular status

2. Check basic movement internal/ext rotation, abduction

3. Palpate acromioclavicular jt

4. Palpate acromion and humeral head

Shoulder--Assessment

1. Check neuromuscular status

• fingers move

• light touch fingers

Shoulder--assessment

1. Check neurovascular status

• fingers move

• light touch fingers

• pulse/color

Shoulder--assessment

1. Check neurovascular status

• fingers move

• light touch fingers

• light touch deltoid

Shoulder--assessment

Shoulder--assessment1. Check neurovascular status

2. Check basic movement internal/ext rotation, abduction

1. Check neuromuscular status

2. Check basic movement

3.Palpate acromioclavicular jt

Shoulder--assessment

3. Palpate acromioclavicular jt

Shoulder--assessment

1. Check neuromuscular status

2. Check basic movement

3. Palpate acromioclavicular jt

4. Palpate acromion and head of humerus

Shoulder--assessment

Anterior Dislocation

Anterior Dislocation

acromion

humeral head

?

acromion clavicular jt

Anterior Dislocation

1. Check neuromuscular status

2. Check basic movement internal/ext rotation

3. Palpate acromioclavicular joint

4. Palpate acromion and humeral head

If assessment is

fairly normal, If not,

can wait until urgent care

tomorrow needed

Shoulder--Management

Immobilizer for comfort

Shoulder--management

Blue

•Confident in recognizing urgencies

•Recognize a common condition

Rotator Cuff Tendonopathy

Shoulder -- Anatomy

1.Rotator cuff

2. Subacromial arch

3. Impingement

Shoulder -- anatomy

1. Rotator cuff

2.Subacromial arch

3. Impingement

Subacromial Arch

Subacromial Space

Acromion

Greater Tuberosity

Ultrasound

Shoulder -- anatomy

1. Rotator cuff

2. Subacromial arch

3.Impingement

Greater tuberosity

Shoulder--Assessment

1. Painful arc

2. Impingement

3. Apprehension

Shoulder --assessment

1. Painful arc

Shoulder --assessment

1. Painful arc

Shoulder --assessment

2. Impingement

Hawkins Impingement test

Shoulder --assessment

2. Impingement

Hawkins Impingement test

Greater tuberosity

Shoulder --assessment

3. Apprehension ***

Shoulder --assessment

3. Apprehension ***

-Dislocation/subluxation

-Instablity

Instability is a common cause of impingement in young people

Shoulder --Management

rotator cuff tendonosis

Shoulder --management

1. If urgencies ruled outCheck neuromuscular status

Check basic movement

Palpate acromioclavicular joint

Palpate acromion and humeral head

Shoulder --management

1. If urgencies ruled out

2. If not fractured, dislocated

3. If gradual onset

4. If painful arc positive (but other ROM fairly good)

5. If impingement test positive

Probably rotator cuff tendonitis

Shoulder --management

• Rotator cuff is usually the victim, not the culprit

• Instability is a common cause of impingement in young people

• Treatment is usually physical therapy

Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: a two-year randomised controlled trial.S Ketola. JBJS (Br) 2009

140 patients were randomly divided -- supervised exercise program (n =

70)

-- arthroscopic acromioplasty followed by exercise programme (n = 70)

Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: a two-year randomised controlled trial.S Ketola. JBJS (Br) 2009

Self-reported pain at 24 months--improvement in both groups

--no statistically significant difference (p = 0.65)

Shoulder --management

• Rotator cuff tendonosis

• Conservative therapy

• “Calm down” tendonitis

• “Irritate” tendonosis

Black•Confident in recognizing urgencies

•Considered a common condition

•A slightly more complex problem to look for

Scapular Dysfunction

Shoulder -- Anatomy

1. Scapula

2. Serratus anterior

3. Scapular position and movement

1. Scapula

1. Scapula

1. Scapula

2. Serratus anterior

3. Scapular position

Shoulder --assessment

3. Scapular position

3. Scapular movement

3. Scapular movement

Shoulder --Treatment

1. Physical therapy

2. Posture

3. Stretching?? -- Maybe not !!

Shoulder --treatment

1. Physical therapy

Shoulder --treatment

1. Physical therapy

Not just any treatment, the right

treatment

Not just any treatment, the right

treatment

• 102 patients

• over 6 mo persistent subacromial impingement syndrome in whom earlier conservative treatment had failed

• recruited through orthopaedic specialists.

T Holmgren et al. BMJ 2012

• Intervention- eccentric exercises for the rotator cuff- concentric/eccentric exercises for

scapula stabilisers - manual mobilisation.

• Control --unspecific exercises neck & shoulder

• Both

T Holmgren et al. BMJ 2012

CM score=Constant-Murley shoulder assessment (100=maximum function)DASH score=disabilities of arm shoulder and hand (0=maximum function)EQ-5D index 1 to −0.59 (−0.59= lowest health related quality of life)EQ-VAS 0-100 (0=lowest health status);VAS=visual analogue scale 0-100 (0=no pain).

Results:

T Holmgren et al. BMJ 2012

CM score=Constant-Murley shoulder assessment (100=maximum function)DASH score=disabilities of arm shoulder and hand (0=maximum function)EQ-5D index 1 to −0.59 (−0.59= lowest health related quality of life)EQ-VAS 0-100 (0=lowest health status);VAS=visual analogue scale 0-100 (0=no pain).

Results:

T Holmgren et al. BMJ 2012

Results:

95% completed the 12 week study.

Pt assessment of change because of treatment: 69% (35/51) vs 24% (11/46); P<0.001.

Pts subsequently chose to undergo surgery: 20% (10/51) vs 63% (29/46); (P<0.001).

T Holmgren et al. BMJ 2012

3. Posture

Shoulder --treatment

3. Stretching ?

Shoulder --treatment

Knees

Green

•Just want to be safe.

•Nothing fancy

•What needs prompt attention

1. What looks abnormal

2. Patella

3. Fibular head

Knee -- Anatomy

1. What looks abnormal

Knee -- Anatomy

2. Patella

Knee -- Anatomy

3. Fibular head

Knee -- Anatomy

Knee -- AssessmentWhat needs urgent attentionWhat probably needs an x ray

1. Massive swelling

2. Unable to bear weight

3. Neurovascular compromise

4. Infection

5. Getting Worse

Knee -- Assessmentwhat needs urgent attentionwhat probably needs an x ray

1. Massive swelling

Knee -- Assessmentwhat needs urgent attentionwhat probably needs an x ray

1. Massive swelling

2. Unable to bear weight

Knee -- Assessmentwhat needs urgent attentionwhat probably needs an x ray

1. Massive swelling

2. Unable to bear weight

3. Neurovascular compromise

• Tibialis posterior pulse

Knee -- Assessmentwhat needs urgent attentionwhat probably needs an x ray

Posterior Tibial Pulse

• Massive swelling

• Unable to bear weight

• Neurovascular compromise

• Tibialis posterior pulse

• Dorsalis pedis pulse

Knee -- Assessmentwhat needs urgent attentionwhat probably needs an x ray

• Massive swelling

• Unable to bear weight

• Neurovascular compromise

• Tibialis posterior pulse

• Dorsalis pedis pulse

Knee -- Assessmentwhat needs urgent attentionwhat probably needs an x ray

• Massive swelling

• Unable to bear weight

• Neurovascular compromise

• Tibialis posterior pulse

• Dorsalis pedis pulse

• Wiggle toes

Knee -- Assessmentwhat needs urgent attentionwhat probably needs an x ray

1. Massive swelling

2. Unable to bear weight

3. Neurovascular compromise

4. Infection

swollen and also

red and warm

tender

Knee -- Assessmentwhat needs urgent attentionwhat probably needs an x ray

1. Massive swelling

2. Unable to bear weight

3. Neurovascular compromise

4. Infection

5. Getting Worse

Knee -- Assessmentwhat needs urgent attentionwhat probably needs an x ray

Massive swellingMassive swellingUnable to bear weight Unable to bear weight Neurovascular compromise Neurovascular compromise InfectionInfectionGetting WorseGetting Worse

•If any of these exist, needs prompt attention !!

•does it need an x ray ?

Knee -- Management

Ottawa Knee RulesX-ray required only with acute knee injury and one

or more of the following:

•Age 55 years or older

•Tenderness at head of fibula

• Isolated tenderness of patella

• Inability to flex to 90°

• Inability to bear weight both immediately and in the emergency department (4 steps)

E Ketelslegers et al. Validation of the Ottawa knee rules in an emergency teaching centre. Europ Radiology 2002

• Med students & surgery residents university trauma centre.

• 261 patients with acute knee traumaradiography or follow-up obtained

• Sensitivity and a NPV of 1.00. • Would have reduced radiography by 25%.

•Prospective, suburban, community ED•patients > 17 years with acute knee injuries.•103 patients enrolled; 10 fractures identified

(9.7%).

Acad Emerg Med 2003

Nurses EP

Sens for # 70% 100%

Spec for # 33% 25%

NPV 91 100

PPV 10 13

Ottawa Knee RulesX-ray required only with acute knee injury and one

or more of the following:

•Age 55 years or older

•Tenderness at head of fibula

• Isolated tenderness of patella

• Inability to flex to 90°

• Inability to bear weight both immediately and in the emergency department (4 steps)

Nurses can do it

Blue

•Confident in recognizing urgencies

•Recognize a common condition

Anterior Knee Pain

Knee -- anatomy

1. Patella √

2. Fibular head √

3. Joint line

4. Effusion

Knee -- anatomy3. Joint line

Knee -- anatomy3. Joint line

Knee -- anatomy3. Effusion

Knee -- Assessment

1. Red flags

2. History of "pop"

3. Effusion

4. Inability to fully straighten

5. Inability to bend to 90 degrees

6. Patellar palpation

Knee -- Assessment

1. "Red Flags"Massive swellingMassive swellingUnable to bear weight Unable to bear weight Neurovascular compromise Neurovascular compromise InfectionInfectionGetting WorseGetting Worse

Knee -- assessment

1. "Red Flags"

2. History of "pop"

Knee -- assessment

1. "Red Flags"

2. History of "pop"

3. Effusion

Knee -- assessment

1. "Red Flags"

2. History of "pop"

3. Effusion

4. Inability to fully straighten

Knee -- assessment

1. "Red Flags"

2. History of "pop"

3. Effusion

4. Inability to fully straighten

5. Inability to flex to 90 degrees

Knee -- assessment

1. "Red Flags"

2. History of "pop"

3. Effusion

4. Inability to fully straighten

5. Inability to flex to 90 degrees

6. Patellar palpation

Knee – assessment

•patella itself should not be very tender

•Check "around' the patella

6. Patellar palpation

Knee -- assessment

•Facets – palpate underneath

6. Patellar palpation

Knee -- assessment

•patellar compression

6. Patellar palpation

Knee --Management

Is x ray needed?

Ottawa Knee RulesX-ray required only with acute knee injury and one

or more of the following:

•Age 55 years or older

•Tenderness at head of fibula

• Isolated tenderness of patella

• Inability to flex to 90°

• Inability to bear weight both immediately and in the emergency department (4 steps)

Knee -- management

Massive swellingUnable to bear weight Neuromuscular compromise InfectionGetting Worse

If no red flags

Knee -- Assessment

1.If no Red flags2. If no history of "pop“

3. If no effusion

4. If no inability to fully straighten

5. If no inability to bend to 90 degrees

6. If no direct patellar tenderness

Consider“anterior knee

pain”

Knee -- assessment

If patellar palpation reveals

•No direct exquisite tenderness

•Tenderness of facets

•Pain with patellar compression

•If symptoms worse with stair and sitting

It is even more likely to be anterior knee pain

Anterior Knee Pain

Caused by ??

Patellar pressure

Improper tracking

Plica

Fat pad

Anterior Knee Pain

Caused by ??

Patellar pressure Q angle

Improper tracking Pronation

Plica Chondromalacia

Fat pad Osteoarthritis

Pain threshold

Knee --Management

anterior knee pain

•physical therapy

Knee --management

anterior knee pain

•listen

S Piva. Arch Phys Med Rehabil 2009

S Piva. Arch Phys Med Rehabil 2009

S Piva. Arch Phys Med Rehabil 2009

Beck Anxiety IndexFear Avoidance Belief Questionaire – physical activity

Fear Avoidance Belief Questionaire --work

S Piva. Arch Phys Med Rehabil 2009

Correlation with Function

Correlation with Pain

Beck Anxiety Index -0.45 * 0.34 *Fear Avoidance Belief Questionaire --Physical Activity

-0.32 * 0.31 *

Fear Avoidance Belief Questionaire -- work

-0.34 * 0.37 *

* p = < 0.05

Knee --management

anterior knee pain

Black

•Confident in recognizing urgencies

•Considered a common condition

•A slightly more complex problem to look for

Peripatellar tendonopathies

Knee –peripatellar tendonopathies

1. Quadriceps tendonopathy

2. Patellar tendonopathy

3. Osgood schlatters

4. Iliotibial band syndrome

5. Pes anserine bursitis/tendonopathy

1. Quadriceps tendonopathy

2. Patellar tendonopathy

3. Osgood Schlatter’s

4(a). Iliotibial Band Syndrome

4 (b)Iliotibial Band Syndrome

– at hip

4(c) Biceps Femoris Tendonopathy

5. Pes Anserine Bursitis/Tendonopathy medial

hamstrings

Iliotibial Band Syndrome

Stretching tight hamstrings

Ankle

Green

• Just want to be safe.

• Nothing fancy

• What needs prompt attention

• What needs attention today– open wounds

Ankle – Anatomy, Assessment, and Management

• What needs attention today– open wounds– strange shapes

Ankle – Anatomy, Assessment, and Management

• What needs attention today– open wounds– strange shapes– massive swelling

Ankle – Anatomy, Assessment, and Management

• What needs attention today– open wounds– strange shapes– massive swelling

Ankle – Anatomy, Assessment, and Management

• What needs attention today– open wounds– strange shapes– massive swelling– red and warm

Ankle – Anatomy, Assessment, and Management

• What needs attention today– open wounds– strange shapes– massive swelling– red and warm– beware of mid foot

Ankle – Anatomy, Assessment, and Management

Blue

•Confident in recognizing urgencies

•Recognize a common condition

Sprain of anterior talofibular ligament (ATFL)

Ankle -- Anatomy

1. Anterior talofibular ligament (ATFL)2. Lateral malleolus3. Medial malleolus4. Navicular5. Base of fifth metatarsal

Ankle -- Anatomy

1. Anterior talofibular ligament (ATFL)

Ankle -- Anatomy

2. Lateral malleolus3. Medial malleolus

Ankle -- Anatomy

4. Navicular

Ankle -- Anatomy

4. Navicular

Ankle -- Anatomy

4. Navicular

Ankle -- Anatomy

4. Navicular

Ankle -- Anatomy

5. Base of fifth metatarsal

Ankle -- Anatomy

5. Base of fifth metatarsal

Ankle -- Assessment

What Needs an X ray ?

Ottawa Ankle RulesIs X ray indicated ?

Ottawa Ankle RulesFoot X ray is indicated if there is any of

1. inability to bear weight both

at time of injury

and

at time of exam

Ottawa Ankle RulesFoot X ray is indicated if there is any of

1. inability to bear weight at injury and exam

2.tenderness of navicular

Ottawa Ankle Rules

Foot X ray is indicated if there is any of

1.inability to bear weight at injury and exam

2.tenderness of navicular

3.tenderness of base of fifth metatarsal

Ottawa Ankle RulesAnkle X ray is indicated if there is any of

1. inability to bear weight both

at time of injury

and

at time of exam

Ottawa Ankle RulesAnkle X ray is indicated if there is any of

1. inability to bear at injury and exam

2. tenderness of posterior edge of distal 6 cm of lateral malleolus or tip of lateral malleolus

Ottawa Ankle RulesAnkle X ray is indicated if there is any of

1.inability to bear at injury and exam

2.tenderness lateral malleolus

3.tenderness of posterior distal 6 cm of medial malleolus or tip

Ankle – Assessment

Sprain anterior talofibular ligament

Ankle – Assessment

Sprain anterior talofibular ligamenttenderness here (and nowhere else) is

actually "good"

Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. LM Bachmann et al. BMJ. 2003.

• Meta-analysis of 27 studies reporting on 15,581 patients

• Sensitivity of almost 100% • Modest specificity

1. AcuteRestIceElevationCompression

Ankle – ManagementATFL Sprain

2. RecoveryRange of MotionStrengthNo limp

Ankle – ManagementATFL Sprain

3. Full RehabilitionProprioception

Ankle – ManagementATFL Sprain

Ankle•Confident in recognizing urgencies

•Considered a common condition (ATFL sprain)

•A slightly more complex problem to look for

High Ankle Spraintibiofibular ligament sprain

High Ankle Sprains areslow to heal

Ankle -- Anatomy

• High ankle sprain• Tibio fibular

ligaments

Ankle -- Anatomy

• High ankle sprain

Ankle -- Assessment

• Squeeze test

Pain is here

Ankle -- Assessment

• dorsiflexion & external rotation

Ankle -- Management

• Same as ATFL, but longer

Ankle -- Management

• 522 athletes, aged 12-70

lateral ankle sprain up to two months before

256 (120 female, 136 male) intervention

266 (128 female, 138 male) control

• Both groups received usual care.

• intervention 8 week home based proprioceptive training program

2009

• During the one year follow-up, 145 athletes reported recurrent ankle

sprain: 56 (22%) in the intervention group 89 (33%) in the control group.

NNT = 9 35% reduction in risk of

recurrence.

2009

• There were 116 male and female volleyball teams followed prospectively during the 2001-2002 season.

• intervention group (66 teams, 641 players) balance board training program

• control group (50 teams, 486 players) followed their normal training routine.

• .

E Verhagen, Am J Sports Med 2004

E Verhagen, Am J Sports Med 2004

Summary

Shoulder

• Expected anatomy, shape, and function

• Rotator cuff tendonitis

victim of instability

• Scapular function

Summary

Knee

• Expected shape and function

• Don’t miss

• Anatomy

• Anterior Knee Pain

• Peripatellar tendonopathies

Summary

Ankle

• Ottawa ankle rules

• ATFL, high ankle sprains

• Proprioception

Summary

• tendonopathy vs tendonitis

• stretching

The End

Ankle -- Anatomy

• Peroneal tendons