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(PBL) Tendinopathy: Tackling Troubled Tendons

Deepak Patel, MD, FAAFP, FACSM

ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

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DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Deepak Patel, MD, FAAFP, FACSMDirector of Sports Medicine, Rush Copley Family Medicine Residency Program, Aurora, Illinois; Assistant Professor, Rush Medical College, Chicago, Illinois

A past FMX presenter, Dr. Patel practices family medicine and sports medicine in Aurora and Yorkville, Illinois, and is medical director for Rush Copley Sports Medicine. His specialty topics include musculoskeletal imaging, concussions, stress fractures, osteoarthritis, joint examinations, pediatric overuse injuries, knee pain, tendonitis/tendonopathy, fractures, and exercise recommendations, as well as evidence-based medicine. He is a fellow of the American College of Sports Medicine. Since Dr. Patel also practices family medicine, he is able to deliver effective presentations to help family physicians address sports medicine and musculoskeletal complaints. He serves as chair for the 2019 AAFP Musculoskeletal and Sports Care course. Dr. Patel has found that staying current with medical advances and evidence-based medicine is the most challenging aspect of family medicine.

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Learning Objectives1. Practice applying new knowledge and skills gained from

Tendinopathy sessions, through collaborative learning with peers and expert faculty.

2. Identify strategies that foster optimal management of tendinopathy within the context of professional practice.

3. Formulate an action plan to implement practice changes, aimed at improving patient care.

Associated Sessions

• Tendinopathy: Tackling Troubled Tendons

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Polling question

Which case to start with?

A. Shoulder pain

B. Elbow pain

C. Lateral hip pain

Shoulder pain

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Chief Complaint

• Shoulder pain

History of Present Illness

• A 55 year old female 

• 2‐3 months of pain with use of shoulder

• No trauma or swelling

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Polling question

• What other history questions do you want to ask?

History of Present Illness‐ Con’t

• A 55 year old female 

• 2‐3 months of pain with use of shoulder

• No trauma or swelling

• Pain with overhead, reaching

• Pain with rolling onto that shoulder

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Polling question

• What examination tests would you perform (tenderness, strength testing, special tests)?

Rotator cuff tests

• + painful arc test best for rotator cuff (SORT: B)

• normal painful arc test helps rule out rotator cuff (SORT: B)

• + drop arm test possibly helpful (SORT: B)

Hermans J, Luime JJ, Meuffels DE, Reijman M, Simel DL, Bierma‐Zeinstra SMA. Does This Patient With Shoulder Pain Have Rotator Cuff Disease?The Rational Clinical Examination Systematic Review. JAMA. 2013;310(8):837‐847. doi:10.1001/jama.2013.276187

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Rotator cuff tests

• Best tests of full thickness tears (SORT: B): 

• + external rotation lag for infraspinatus 

• + internal rotation lag for subscapularis

VERRY, C.; FERNANDO, S.;   Rotator Cuff Disease: Diagnostic Tests Am Fam Physician. 2016 Dec 1;94 (11): 925‐926.

Physical Examination 

• Our case:

• + impingement, painful arc

• Weakness of subscap and supraspinatus

• Mild scapular tilt

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Polling question

Differential diagnosis?

A. Rotator cuff tear

B. Rotator cuff impingement

C. Rotator cuff tendonosis

D. Rotator cuff tendonitis

E. Labrum tear

Polling question

What imaging would you perform?

A. None

B. Xray

C. MRI with IV contrast

D. MRI without IV contrast

E. MRI arthrogram

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Polling question

What percent of asymptomatic patients have a rotator cuff tear on MRI?

A. 10 %

B. 25 %

C. 40 %

D. 60 %

Asymptomatic Abnormal MRI• 40% asymptomatic > 50 y/o have full RTC tear 1,2

• 60% asymptomatic > 60 y/o have partial or full RTC tear 1,3

• Another study: 26‐56% asymptomatic tears age: 63.1  94

• Overhead athletes 40% with partial or full tear in dominant shoulder5

• 55‐72% labrum tears in 45‐60 y/o6

• 52% Occ health patients with worse pathology on asymptomatic side7

1. Moosikasuwan J,Miller T, Burke,B. Rotator Cuff Tears: Clinical, Radiographic, and US Findings. RadioGraphics 2005; 25:1591–16072. Murrell GA, Walton JR. Diagnosis of rotator cuff tears (letter). Lancet 2001;357:769–770. [Published correction appears in Lancet 2001;357:1452.] 3. Worland RL, Lee D, Orozco CG, et al. Correlation of age, acromial morphology, and rotator cuff tear pathology diagnosed by ultrasound in asymptomatic patients. J South Orthop Assoc 2003;12:23–26.4. Mall NA, Kim HM, Keener JD, Steger-May K, Teefey SA, Middleton WD, Stobbs G, Yamaguchi K. Symptomatic progression of asymptomatic rotator cuff tears: a prospective study of clinical and

sonographic variables. J Bone Joint Surg Am. 2010 Nov;92(16):2623-33.5. Connor PM, Banks DM, Tyson AB, Coumas JS, D'Alessandro DF. Am J Sports Med. 2003 Sep-Oct;31(5):724-7. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year

follow-up study.6. Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle‐Aged Patients With Asymptomatic Shoulders. Orthopaedic 

Journal of Sports Medicine. 2016;4(1):2325967115623212. doi:10.1177/2325967115623212.7. Liu, T., et. Al.  Patients Older Than 40 Years With Unilateral Occupational Claims for New Shoulder and Knee Symptoms Have Bilateral MRI Changes.  Clinical Orthopaedics & Related Research. 475(10):2360‐

2365, October 2017. 

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Polling question

Treatment options/plan?

A. Physical therapy

B. Nsaids

C. Corticosteroid injection

D. Corticosteroid injection + Physical therapy

Plan

• Activity modification (SORT: C)

• P.T. (scapular and cuff) (SORT: B)

• Analgesics (SORT: C)

Dejaco, B., Habets, B., van Loon, C. et al. Eccentric versus conventional exercise therapy in patients with rotator cuff tendinopathy: a randomized, single blinded, clinical trial. Knee Surg Sports Traumatol Arthrosc (2016). Jun 28. [Epubahead of print]  doi:10.1007/s00167‐016‐4223‐xReijneveld EAE, Noten S, Michener LA, et al Clinical outcomes of a scapular‐focused treatment in patients with subacromial pain syndrome: a systematic review Br J Sports Med 2017;51:436‐441

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Plan

• Steroid injection only for severe, refractory, temporary benefit (SORT: B)

• Imaging if failed above for 6‐8 wks and considering surgery (SORT: B)

W Dong, H Goost, XB Lin, et al. Treatments for shoulder impingement syndrome a PRISMA systematic review and network meta‐analysis. Medicine (Baltimore) 2015;94:1–17.

Subacromial Impingement/Rotator cuff

• Corticosteroid: minimal benefit and = placebo, <4 wks

• BJSM Sys. Rev.: Steroid vs anesthetic limited benefit <8wks 

• Injection + PT > PT at 6 wks, not after

• Ketorolac > triamcinolone

• Cochrane: Injection= ultrasound =acupuncture =NSAIDS

• Ultrasound guided=landmark injection

Foster ZJ, Voss TT, Hatch J, Frimodig A. Corticosteroid Injections for Common Musculoskeletal Conditions. Am Fam Physician. 2015 Oct 15;92(8):694-9.Cook T, Minns Lowe C, Maybury M, et al Are corticosteroid injections more beneficial than anaesthetic injections alone in the management of rotator cuff-related shoulder pain? A systematic review Br J Sports Med 2018;52:497-504. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev. 2003;(1):CD004016.

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Rotator Cuff‐ injection

• Minimal limited pain benefit

• May accelerate tendon degeneration

• “wide use may be attributable to habit, underappreciation of the placebo effect, incentive to satisfy rather than discuss a patient’s drive toward physical intervention, or for remuneration, rather than their utility.”

Mohamadi, A., Chan, J.J., Claessen, F.M.A.P. et al. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis Clin Orthop Relat Res (2017) 475: 232. doi:10.1007/s11999-016-5002-1

Elbow 

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Chief Complaint

• Elbow pain

History of Present Illness

• A 35 year old male with use of elbow. Lateral side. No trauma or swelling. He has full range of motion

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Polling question

• What examination tests would you perform (tenderness, strength testing, special tests)?

Physical Examination 

• Tender lateral epicondyle

• Preserved strength of elbow. 

• Weakness of wrist extensors, supinators

• 3rd Digit extension test +

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Polling questionLaboratory/Radiology

Indications for imaging is?

Polling question‐Treatment options

• What treatment options would you advise?

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Treatment

• Analgesics 

• Avoid gripping, twisting or pronated lifting

• Ok to lift with open palm

Lateral Epicondylitis

• Limited benefit in pain or function (SORT: A): • Bracing 

• Physical Therapy 

• Eccentric helps but not superior to other treatment (SORT: B)

• ESWT

Sims SEG, Miller K, Elfar JC, Hammert WC. Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand (New York, NY). 2014;9(4):419-446. doi:10.1007/s11552-014-9642-x.Heijnders ILC, Lin CC. The effect of eccentric exercise in improving function or reducing pain in lateral epicondylitis is unclear Br J Sports Med 2015;49:1087‐1088. Ortega‐Castillo, Miguel, and Ivan Medina‐Porqueres. "Effectiveness of the eccentric exercise therapy in physically active adults with symptomatic shoulder impingement or lateral epicondylar tendinopathy: A systematic review." Journal of Science and Medicine in Sport 19.6 (2016): 438‐453.

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Eccentric exercise

Polling question

• Indication for corticosteroid injections?

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Lateral Epicondylitis ‐ Steroid Injection

• Without injection resolves in 6‐24 months 

• Corticosteroid 4‐6 wks benefit• At 1 yr, no difference

• Recurrence rate: injection 35‐50% vs PT 8‐29%

• Muscle energy = injection at 1 yr

Foster ZJ, Voss TT, Hatch J, Frimodig A. Corticosteroid Injections for Common Musculoskeletal Conditions. Am Fam Physician. 2015 Oct 15;92(8):694-9.

Lateral Epicondylitis ‐ Injection

• Corticosteroid injection: standard = peppered = via iontophoresis (SORT: B)

• Corticosteroid injection NOT recommended (SORT: A) 

• Botulinum toxin A injection, prolotherapy, PRP, or autologous blood some pain benefit (SORT: B)

• Hyaluronate injection, prolotherapy, autologous blood need further study (SORT: B)

Sims SEG, Miller K, Elfar JC, Hammert WC. Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand (New York, NY). 2014;9(4):419-446. Dong W, Goost H, Lin X, et al  Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta‐analysis Br J Sports Med 2016;50:900‐908. Branson R., et al.,  Comparison of corticosteroid, autologous blood or sclerosant injections for chronic tennis elbow.  J Sci Med Sport. 2017 Jun;20(6):528‐533. doi: 10.1016/j.jsams.2016.10.010. Epub 2016 Oct 29.

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Lateral Hip Pain

Chief Complaint

• Lateral hip pain

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History of Present Illness

• A 55 year old female with lateral pain

• Increased with position changes

• No trauma or swelling. 

• Pain with rolling onto that hip

Polling question

• What other history questions do you want to ask?

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Polling question

Differential diagnosis?

A. Trochanteric bursitis

B. Gluteal tendinopathy

C. Iliotibial band tendinopathy

D. Hip osteoarthritis

• Trochanteric bursitis (acute, rare)

• Gluteus medius tendinopathy

• Gluteus minimus tendinopathy

Greater Trochanteric pain Syndrome (GTPS)

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Polling question

• What examination tests would you perform (tenderness, strength testing, special tests)?

GTPS Exam‐ Piriformis palpation

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GTPS Exam‐special tests

Grimaldi A, et. Al. Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. Br J Sports Med. 2016 Sep 15. pii: bjsports-2016-096175. doi: 10.1136/bjsports-2016-096175. [Epub ahead of print]Grimaldi A., et. Al . Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management. Sports Med. 2015 Aug;45(8):1107-19. doi: 10.1007/s40279-015-0336-5

Test Sensitivity Specificity

FABER 82.9% 90%

Single leg stance 30 sec 100% 93%

Trendelenburg 72.7% 76.9%

Isometric hip abduction 80% 71%

Hip abduction 90deg hip flexion 88% 97.3%

Ober 23% 95%

• Flexion of hip,

• ABduction of hip

• External Rotation

• Push the opposite ASIS and same knee posteriorly

• Pain in groin=hip pathology

• Pain in Back=SI joint

FABER test

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Single leg stance

Modified Trendelenburg Test

• Stand, Hands on hips, feet together

• Lift 1 leg

• Watch for hip/pelvis drop/tilt

• Weakness of contralateral hip abductors

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hip abduction

Isometric W/ 90 deg hip flexion

Ober’s Test

• Patient lateral recumbent position

• Place 1 hand on hip to prevent trunk rotation

• Hold patient’s ankle & extend thigh

• At maximal extension, allow knee to adduct toward table

• Compare to other leg

• + if significant tightness (knee suspend above the table)

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GTPS treatment• Eliminate/reduced Iliotibial band/Gluteal tension (SORT: C)

• Analgesics (SORT: C)

• Stretching, strengthening (SORT: B)

• Flouroscopic guided injection= landmark (SORT: B)

• Short term (<3 month) benefit

Barratt, P. et. Al. Conservative treatments for greater trochanteric pain syndrome: a systematic review Br J Sports Med bjsports-2015-095858Published Online First: 10 November 2016 doi:10.1136/bjsports-2015-095858

Questions

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Thanks!

Deepak.patel@rushcopley.com

www.rushcopley.com/dpatel