Sports Medicine Workshop Sports Medicine Workshop

Sports Medicine Sports Medicine

WorkshopWorkshop

Shoulder Problem EvaluationShoulder Problem Evaluation

Second most common musculoskeletal Second most common musculoskeletal complaintcomplaint

Difficult joint to examineDifficult joint to examine

Multidirectional range of motion- UNIQUE!Multidirectional range of motion- UNIQUE!

Shoulder injury can affect nearly every Shoulder injury can affect nearly every sport and many daily activitiessport and many daily activities

ObjectivesObjectives

Review pertinent Review pertinent anatomyanatomy

Discuss common Discuss common pathologypathology

Discuss historical Discuss historical clues to diagnosisclues to diagnosis

Select casesSelect cases

Physical exam in small Physical exam in small group discussionsgroup discussions

Bony AnatomyBony AnatomyAnteriorAnterior

Bony AnatomyBony AnatomyAnterior and PosteriorAnterior and Posterior

Radiographic AnatomyRadiographic Anatomy

Where do things go wrong??Fractures

Where do things go wrong??Dislocations and Separations

Dislocations and separations are protected by both “static” and “dynamic” stabilizers…

Where do things go wrong??Dislocations and Separations

Oh, yeah…Arthritis can happen at these joints, too…

Glenohumeral JointGlenohumeral Joint

Shallow (“golf ball sitting on a tee”)Shallow (“golf ball sitting on a tee”)• Inherently unstable (maximizes ROM)Inherently unstable (maximizes ROM)

Static stabilizersStatic stabilizers• glenohumeral ligaments, glenoid labrum and glenohumeral ligaments, glenoid labrum and

capsulecapsule

Dynamic stabilizersDynamic stabilizers• Predominantly rotator cuff musclesPredominantly rotator cuff muscles• Also scapular stabilizersAlso scapular stabilizers

Trapezius, leavator scapulae, serratus anterior, Trapezius, leavator scapulae, serratus anterior, rhomboidsrhomboids

Bony AnatomyBony Anatomy“Static Stabilizers”“Static Stabilizers”

What goes wrong…What goes wrong…Besides separations and dislocations??Besides separations and dislocations??

Instability!!!Instability!!!

LABRUMLABRUM

What goes wrong?Tears and tendonopathies

The Rotator Cuff Muscles“dynamic stabilizers”

The Rotator Cuff Muscles: The Rotator Cuff Muscles: SITSSITS

• SSupraspinatus upraspinatus ABDABD

• IInfraspinatus nfraspinatus ERER

• TTeres minor eres minor ERER• SSupscapularis upscapularis

IRIR

Depress humeral head against glenoid to allow full abduction

Finally…the subacromial space

What can go wrong???

Impingement!!!!!!!

ImpingementImpingement

Other AnatomyOther Anatomy• DeltoidDeltoid• Rotator cuffRotator cuff• Teres majorTeres major

• Latissimus dorsiLatissimus dorsi• BicepsBiceps• Pectoralis musclesPectoralis muscles

Shoulder AnatomyShoulder Anatomy

Don’t forget the scapular stabilizer muscles

So…what causes shoulder pain?

Impingement

Labrum and biceps pathology

A-C joint pathology

Rotator Cuff Injury

InstabilityAmong other

things…

Clinical ExamClinical ExamHistoryHistory

PainPain AcuteAcute ChronicChronic WeaknessWeakness DeformityDeformity


Single eventSingle event

Repetitive overloadRepetitive overload

InstabilityInstability• Does it feel like it’s Does it feel like it’s

going to come out?going to come out?

Catching/LockingCatching/Locking


Sport / OccupationSport / Occupation

Previous injuryPrevious injury

Previous treatmentPrevious treatment

Other joints involvedOther joints involved

DisabilityDisability

Physical Exam: Big 6Physical Exam: Big 6

Inspection Inspection Palpation Palpation Range of MotionRange of Motion StrengthStrength NeurovascularNeurovascular Special TestsSpecial Tests

Special TestsSpecial Tests

ImpingementImpingement

Rotator Cuff Rotator Cuff IntegrityIntegrity

Labrum and BicepsLabrum and Biceps

AC (SC) JointsAC (SC) Joints

InstabilityInstability

Physical Exam

The physical exam will be demonstrated during small group discussions…

Which rotator cuff muscle(s) are responsible for external rotation

1. Supraspinatus

2. Infraspinatus

3. Subscapularis

4. Teres Minor

5. Both 2 and 4

The apex (bottom) of the scapula is at what level of the spine?

1. C72. T33. T74. T125. L4

Case #1Case #1

22-year-old male 22-year-old male rugby player falls rugby player falls onto his right onto his right shoulder while shoulder while being tackledbeing tackled

Severe pain on top Severe pain on top of his right of his right shouldershoulder

Case #1Case #1

Notable deformity Notable deformity over superior over superior shouldershoulder

Painful range of Painful range of motionmotion• Unable to lift right Unable to lift right

arm above waistarm above waist

Special Tests??Special Tests?? Diagnosis???Diagnosis???

Acromioclavicular (A-C) SprainAcromioclavicular (A-C) Sprain


• Shear TestShear Test

• Cross Arm TestCross Arm Test

• A-C PalpationA-C Palpation

• Resisted ExtensionResisted Extension

• Active compression testActive compression test

Acromioclavicular (A-C) SprainAcromioclavicular (A-C) Sprain

Damage to A-C joint Damage to A-C joint ligamentsligaments

Pain and/or Pain and/or deformity over A-C deformity over A-C jointjoint

Graded I-VIGraded I-VI• I-III usually treated I-III usually treated

non-operativelynon-operatively• IV-VI referred to IV-VI referred to

orthopedic surgeryorthopedic surgery

AC Joint Sprain Treatment

Analgesics, ice prn Sling for as long as needed Physical Therapy

• ROM restoration• Gradual strength exercise• Return to sport activity as

tolerated

Case #2Case #2

24-year-old male 24-year-old male handball playerhandball player

Fell onto his shoulder Fell onto his shoulder after being pushedafter being pushed

Intense painIntense pain Hand is tingling and Hand is tingling and

arm feels like it’s arm feels like it’s hanginghanging

X-raysX-rays

X RAYSX RAYS

DIAGNOSIS???

Shoulder Dislocation/Anterior Shoulder Dislocation/Anterior InstabilityInstability

Humeral head Humeral head dislocates from dislocates from glenoid fossaglenoid fossa

Almost always Almost always anterior (95%)anterior (95%)

Usually traumatic Usually traumatic with injury to with injury to capsule-labrum capsule-labrum complexcomplex

Shoulder Dislocation/Anterior Shoulder Dislocation/Anterior InstabilityInstability

TreatmentTreatment• Reduction of dislocationReduction of dislocation• Protection & rehab, rehab, rehabProtection & rehab, rehab, rehab• Most will have future dislocations Most will have future dislocations

and/or instabilityand/or instability At least 70%!!! (young)At least 70%!!! (young)

• May require surgical May require surgical tightening/repair of the tightening/repair of the capsule/labrum complexcapsule/labrum complex

Special TestsGlenoid Labrum and Instability

Biceps Load I and II Kim Test Jerk Test Active-Compression Test (O’Brien) Crank Test Apprehension Test Relocation Test Load and Shift Sulcas Sign

Which of the following structures can be “impinged”?

1 2 3 4

25% 25%25%25%

10

1. Biceps tendon2. Subacromial

Bursa3. Rotator Cuff

Tendons4. All of the above

0

0

30

Case #3Case #3

35-year-old male 35-year-old male tennis playertennis player

Shoulder pain Shoulder pain exacerbated by exacerbated by practicing servespracticing serves

Develops dull, Develops dull, aching pain in right aching pain in right shouldershoulder

SHOULDER PAINSHOULDER PAINPhysical ExamPhysical Exam

Tenderness to palpation anterior Tenderness to palpation anterior shouldershoulder

Pain with abduction starting around Pain with abduction starting around 90 degrees 90 degrees

Unable to lift arm past 120 degreesUnable to lift arm past 120 degrees Pain with forward flexion at 90-120 Pain with forward flexion at 90-120

degreesdegrees Special Tests??? Diagnosis???Special Tests??? Diagnosis???

Shoulder PainShoulder PainPhysical ExamPhysical Exam

Hawkin’s positiveHawkin’s positive

Neer’s positiveNeer’s positive

IMPINGEMENT???IMPINGEMENT???

Impingement as a Clinical SignImpingement as a Clinical Sign

Repetitive overhead Repetitive overhead activitiesactivities

Subacromial bursa Subacromial bursa and/or rotator cuff and/or rotator cuff impinged between impinged between acromion & humerusacromion & humerus

Physical therapy, Physical therapy, activity modification activity modification +/- medications+/- medications

Diagnoses associated with clinical Diagnoses associated with clinical sign of Rotator Cuff Impingement:sign of Rotator Cuff Impingement:

Subacromial bone spurs and / or bursal Subacromial bone spurs and / or bursal hypertrophyhypertrophy

AC joint arthrosis and /or bone spursAC joint arthrosis and /or bone spurs Rotator cuff diseaseRotator cuff disease Superior labral injurySuperior labral injury Glenohumeral instabilityGlenohumeral instability Scapular dyskinesisScapular dyskinesis Biceps tendinopathyBiceps tendinopathy

A diagnostic injection sometimes helps to A diagnostic injection sometimes helps to clarify the diagnosisclarify the diagnosis

Case #4Case #4

45-year-old weight 45-year-old weight lifter lifter

Caught bar as it was Caught bar as it was falling off his shoulderfalling off his shoulder

Sudden painSudden pain Severe weakness left Severe weakness left

shouldershoulder Worse with overhead Worse with overhead

activities; while activities; while sleeping at nightsleeping at night

Pain in anterior lateral Pain in anterior lateral shouldershoulder

Special tests?Special tests?

Case #4Case #4

Drop Arm Test PositiveDrop Arm Test Positive

External Rotation Lag External Rotation Lag Sign positiveSign positive

Weakness with Empty Weakness with Empty Can SignCan Sign

Normal bear hug and Normal bear hug and belly press tests…belly press tests…

Diagnosis?????Diagnosis?????

Rotator Cuff TearRotator Cuff Tear

Supraspinatus tendon most commonSupraspinatus tendon most common

Acute trauma or chronic tendinopathyAcute trauma or chronic tendinopathy

Treatment dependent upon Treatment dependent upon age/activityage/activity• Young, active usually require operative Young, active usually require operative

treatmenttreatment• Older, low-activity usually respond to non-Older, low-activity usually respond to non-

operative treatmentoperative treatment

Case #5Case #5

42-year-old female with dull pain 42-year-old female with dull pain right shoulderright shoulder

Pain is diffuse in naturePain is diffuse in nature Sometimes spreads to between Sometimes spreads to between

shoulder bladesshoulder blades Seems worse at night Seems worse at night

Physical ExamPhysical Exam

Obese, pleasant femaleObese, pleasant female

Diffuse painDiffuse pain

Normal shoulder examNormal shoulder exam

Not able to reproduce pain during examNot able to reproduce pain during exam

What else do you want to do???What else do you want to do???

Shoulder pain isn’t always the Shoulder pain isn’t always the shoulder!!shoulder!!

Get more history…Get more history…

Gall bladder diseaseGall bladder disease Peptic Ulcer DiseasePeptic Ulcer Disease Cervical radiculopathyCervical radiculopathy Cardiac ischemiaCardiac ischemia Pulmonary conditionsPulmonary conditions

• ie Pancoast’s tumor, Pneumoniaie Pancoast’s tumor, Pneumonia

In the human body, which is the most incredible joint?

1 2 3 4 5

20% 20% 20%20%20%1. PIP2. Knee3. Ankle4. Shoulder5. None of the

above

Case #6Case #6

40-year-old male40-year-old male

Recently shoveled Recently shoveled 16” of snow16” of snow

Can hardly lift left Can hardly lift left arm due to painarm due to pain

Special Tests? Special Tests? Diagnosis?Diagnosis?

Biceps TendonopathyBiceps Tendonopathy

Speed TestSpeed Test

Yergason TestYergason Test Direct palpationDirect palpation

Biceps TendonopathiesBiceps Tendonopathies

Repetitive overhead Repetitive overhead activity activity

Repetitive forearm Repetitive forearm flexion/supinationflexion/supination

Difficult to discern from Difficult to discern from rotator cuff tendinopathy rotator cuff tendinopathy or impingementor impingement

ConclusionConclusion

Shoulder injuries are common.Shoulder injuries are common.

Knowledge of the anatomy is crucial Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis.to correct patho-anatomic diagnosis.

Impingement is a clinical sign, not a Impingement is a clinical sign, not a diagnosis.diagnosis.

Don’t forget about medical causes.Don’t forget about medical causes.

Physical ExamPhysical ExamInspectionInspection

Front & backFront & back Height of Height of

shoulder and shoulder and scapulaescapulae

Muscle atrophy, Muscle atrophy, asymmetryasymmetry

Physical ExamPhysical Exam Range of MotionRange of Motion

Abduction 0-180Abduction 0-180oo


Forward flexion: Forward flexion: • 00oo – 180 – 180oo


ExtensionExtension• 00oo – 40 to 60 – 40 to 60oo


Internal rotationInternal rotation• T5 segmentT5 segment

External rotationExternal rotation• 80-9080-90oo

Physical ExamPhysical Exam StrengthStrength

Empty can testEmpty can test• 3030oo angle angle• Steady downward pressureSteady downward pressure• Tests supraspinatus strength and painTests supraspinatus strength and pain

Physical ExamPhysical Exam StrengthStrength

Resisted external Resisted external rotationrotation• Tests infraspinatus, Tests infraspinatus,

teres minor teres minor strengthstrength

Physical ExamPhysical Exam Strength of SubscapularisStrength of Subscapularis

Liftoff testLiftoff test Belly press Belly press testtest

Cross-Arm Adduction TestCross-Arm Adduction Test

AC joint pathologyAC joint pathology Arm flexed to 90Arm flexed to 90°° Hyperadduct arm Hyperadduct arm

across body as far across body as far as possibleas possible

Pain in AC = (+) Pain in AC = (+) testtest

A-C Shear TestA-C Shear Test

Interlock fingers Interlock fingers with hand on distal with hand on distal clavicle and spine clavicle and spine of scapulaof scapula

Pain in A-C joint Pain in A-C joint when hands when hands squeezed together squeezed together = (+) test= (+) test

Sulcus SignSulcus Sign

Inferior instabilityInferior instability Arm relaxed in Arm relaxed in

neutral position, neutral position, pull downward at pull downward at elbowelbow

(+) test = sulcus at (+) test = sulcus at infra-acromial area infra-acromial area • compare to compare to

unaffected sideunaffected side

Apprehension TestApprehension Test

Anterior instabilityAnterior instability Shoulder at 90Shoulder at 90°°

abducted, slight abducted, slight anterior pressure & anterior pressure & External rotationExternal rotation

(+) test = (+) test = dislocation dislocation apprehensionapprehension• some false (+)some false (+)

Relocation TestRelocation Test

Perform after Perform after positive positive apprehension testapprehension test

Apply post force Apply post force over humeral head over humeral head during external during external rotation (ER)rotation (ER)

(+) test = (+) test = increased ER increased ER tolerancetolerance

Load & Shift TestLoad & Shift Test

Test for multidirectional instabilityTest for multidirectional instability Grasp humeral head, slide anteriorly and Grasp humeral head, slide anteriorly and

posteriorly while securing rest of shoulderposteriorly while securing rest of shoulder (+) if greater than 50% displacement (graded (+) if greater than 50% displacement (graded

1-3)1-3)

Impingement SignsImpingement Signs

Hawkins Neer

Drop Arm TestDrop Arm TestSuggestive of Rotator Cuff TearSuggestive of Rotator Cuff Tear

Passive abduction Passive abduction to 90to 90°°

Instruct patient to Instruct patient to slowly lower armslowly lower arm

At 90At 90°° abducted abducted arm will suddenly arm will suddenly drop, may need to drop, may need to add slight pressureadd slight pressure

(+) drop = (+) test(+) drop = (+) test

Speed’s TestSpeed’s TestBiceps TendinopathyBiceps Tendinopathy

Long head of biceps Long head of biceps tendonitistendonitis

Fwd flex to 90Fwd flex to 90°°, abd , abd 1010°°, full supination, full supination

Apply downward Apply downward force to distal armforce to distal arm

Pain = (+) testPain = (+) test• weakness w/o weakness w/o

pain = muscle pain = muscle weakness or weakness or rupturerupture

O’Brien’s Active CompressionO’Brien’s Active CompressionSLAP lesion (Superior Labrum Antero-Posterior)SLAP lesion (Superior Labrum Antero-Posterior)

Labral/AC Labral/AC pathologypathology

Arm flexed to 90Arm flexed to 90°°, , elbow extended, elbow extended, adduct 10-15adduct 10-15°°, , resist downward resist downward forceforce

+ if AC pain or + if AC pain or internal pain/clickinternal pain/click

O’Brien’s Active CompressionO’Brien’s Active CompressionSLAP lesionSLAP lesion

Supination should Supination should be pain free be pain free (decreased pain)(decreased pain)

Crank TestCrank TestLabral injuryLabral injury

Glenoid labrum tearGlenoid labrum tear Abduct arm to 160Abduct arm to 160°,°,

pt is supine or pt is supine or upright, elbow upright, elbow secured with one secured with one hand axial load at hand axial load at shoulder with othershoulder with other

(+) if audible/painful (+) if audible/painful catch/grind is notedcatch/grind is noted

Knee ProblemsKnee Problems

Anatomy ReviewAnatomy Review

FemurFemur• Medial & lateralMedial & lateral

CondylesCondyles EpicondylesEpicondyles

• Trochlear grooveTrochlear groove• Intercondylar notchIntercondylar notch

PatellaPatella• Superior pole (base)Superior pole (base)• Inferior pole (apex)Inferior pole (apex)• Medial & lateral facetsMedial & lateral facets

TibiaTibia• Medial & lateralMedial & lateral

CondylesCondyles• Gerdy’s tubercleGerdy’s tubercle• Pes anserine areaPes anserine area• Tibial tuberosityTibial tuberosity• Tibial plateauTibial plateau• Tibial spinesTibial spines

FibulaFibula• HeadHead• NeckNeck

Anatomy – Major Ligaments & TendonsAnatomy – Major Ligaments & Tendons Quadriceps tendonQuadriceps tendon

Patellar tendonPatellar tendon

Medial & lateral patellar Medial & lateral patellar retinaculuaretinaculua

MCLMCL LCLLCL

ACL and PCLACL and PCL

Iliotibial band (ITB)Iliotibial band (ITB)

Anatomy – Menisci of the KneeAnatomy – Menisci of the Knee

Medial meniscusMedial meniscus Lateral meniscusLateral meniscus

• Meniscal ligamentsMeniscal ligaments• Functions of the Functions of the

meniscimenisci

Meniscal zonesMeniscal zones• White-whiteWhite-white• Red-whiteRed-white• Red-redRed-red

Knee Exam OverviewKnee Exam Overview

InspectionInspection PalpationPalpation Range of MotionRange of Motion StrengthStrength NeurovascularNeurovascular Special TestsSpecial Tests

Case 1 – Medial Right Knee PainCase 1 – Medial Right Knee Pain

16yo HS soccer 16yo HS soccer player, previously player, previously healthyhealthy

Tackled from right Tackled from right side while runningside while running

Immediate onset of Immediate onset of medial jt line painmedial jt line pain

Delayed onset local Delayed onset local medial edema, medial edema, stiffnessstiffness

Able to bear weight Able to bear weight

Key Questions in the HistoryKey Questions in the History

Mechanism of Injury?Mechanism of Injury? Acute or Chronic?Acute or Chronic? Location and level of pain?Location and level of pain? Able to walk?Able to walk? Mechanical Symptoms? (Locking, Mechanical Symptoms? (Locking,

popping, catching?)popping, catching?) Associated instability?Associated instability? Swelling?Swelling? Previous injuries or surgeries?Previous injuries or surgeries?

Case 1 - ExamCase 1 - Exam

Inspection: Mild medial knee edemaInspection: Mild medial knee edema Palpation: + ttp medial kneePalpation: + ttp medial knee ROM: can’t bend >80dROM: can’t bend >80d Strength: mildly decreasedStrength: mildly decreased Neurovascular: normalNeurovascular: normal Special tests:Special tests:

• Neg Lachman, Anterior Drawer, McMurray, Neg Lachman, Anterior Drawer, McMurray, varus stressvarus stress

+ mild increased gap on valgus stress + mild increased gap on valgus stress (compared to left) with good endpoint(compared to left) with good endpoint

Special Tests - ACL InjurySpecial Tests - ACL Injury Lachman TestLachman Test

Special Tests - PCL InjurySpecial Tests - PCL Injury Posterior Drawer TestPosterior Drawer Test

Sag SignSag Sign

Quad-Active TestQuad-Active Test

Varus/Valgus stress for Varus/Valgus stress for LCL and MCL InjuryLCL and MCL Injury

Features that should prompt an xray after acute knee injury include:

Unable to

bear weight

Can’t flex >

90d

Patella

TTP

Fibular h

ead TTP

Age <18 or >55

All of t

he above

17% 17% 17%17%17%17%1. Unable to bear

weight2. Can’t flex >90d3. Patella TTP4. Fibular head

TTP5. Age <18 or >556. All of the above

5 Ottawa Knee Rules5 Ottawa Knee Rulesi.e. When to order a knee xray after acute injuryi.e. When to order a knee xray after acute injury

Age > 55 or < 18Age > 55 or < 18 Unable to walkUnable to walk TTP on PATELLATTP on PATELLA TTP on FIBULAR HEADTTP on FIBULAR HEAD Unable to flex 90 degUnable to flex 90 deg

Case 1 - ImagingCase 1 - Imaging

Case 1 – Differential DiagnosisCase 1 – Differential DiagnosisMore LikelyMore Likely Less LikelyLess Likely

Meniscal TearMeniscal Tear Ligamentous InjuryLigamentous Injury

• Which ligament?Which ligament? ACLACL PCLPCL MCLMCL LCLLCL

Muscle StrainMuscle Strain

FractureFracture Patellofemoral PainPatellofemoral Pain PlicaPlica

MCL SprainMCL Sprain

What grade of sprain is likely present of the MCL?

25%

25%

25%

25% 1. Grade 1: no laxity, but hurts

2. Grade 2: mild laxity, still intact

3. Grade 3: complete tear

4. Grade 4: hurts like *^%*

MCL Sprain

Treatment?Treatment?• RICERICE• Relative RestRelative Rest• Hinge Brace only if unstable on examHinge Brace only if unstable on exam• Achieve full ROMAchieve full ROM• Progressive StrengtheningProgressive Strengthening• Neuromuscular Control (Balance Neuromuscular Control (Balance

exercises)exercises)• Functional Exercises (Sport-specific)Functional Exercises (Sport-specific)

Case 2Case 2

56 yo retired Army LTC56 yo retired Army LTC 15 years worsening L>R knee pain15 years worsening L>R knee pain Former parachutist, no specific Former parachutist, no specific

traumatrauma No previous knee surgeriesNo previous knee surgeries Stiffness worse in morningStiffness worse in morning Pain is worse with activity, better Pain is worse with activity, better

with restwith rest

Case 2 – Key QuestionsCase 2 – Key Questions

Mechanism of Injury?Mechanism of Injury? Acute or Chronic?Acute or Chronic? Where/how bad is pain?Where/how bad is pain? Mechanical Symptoms? Mechanical Symptoms?

(Locking, popping, (Locking, popping, catching?)catching?)

Associated instability?Associated instability? Swelling?Swelling? Previous injuries or Previous injuries or

surgeries?surgeries? What makes it worse?What makes it worse? What makes it better?What makes it better?

Insidious OnsetInsidious Onset ChronicChronic Difficult to localize; mildDifficult to localize; mild NoNo

NoneNone OccasionalOccasional Lots of “Bad Landings” No Lots of “Bad Landings” No

surgerysurgery ActivityActivity RestRest

Case 2 – Physical ExamCase 2 – Physical Exam

Inspection: Inspection: • Genu varusGenu varus• Bony enlargement at Med/Lat joint linesBony enlargement at Med/Lat joint lines

Palp: Posterior medial joint line ttpPalp: Posterior medial joint line ttp ROM: Decreased flexion, 110 deg, mild ROM: Decreased flexion, 110 deg, mild

crepituscrepitus Strength: normalStrength: normal Neurovascular: normalNeurovascular: normal Special Tests: no ligamentous laxity, neg Special Tests: no ligamentous laxity, neg

meniscal testsmeniscal tests

Special Tests - Meniscal InjuriesSpecial Tests - Meniscal Injuries Joint line tendernessJoint line tenderness

McMurray TestsMcMurray Tests

Thessaly testThessaly test

Bounce-home testBounce-home test

Full SquatFull Squat

Case 2 – Plain FilmsCase 2 – Plain Films

Joint space narrowing

Subchondral Sclerosis

Osteophytes

Subchondral Cysts

What is your diagnosis?What is your diagnosis?

Menisc

al tear

Plica sy

ndrome

Oste

oarthriti

s

Bone tumor

25% 25%25%25%1.1. Meniscal tearMeniscal tear

2.2. Plica syndromePlica syndrome

3.3. OsteoarthritisOsteoarthritis

4.4. Bone tumorBone tumor

OsteoarthritisOsteoarthritis

Nonpharmacologic Nonpharmacologic Treatment:Treatment:• Nonpainful aerobic Nonpainful aerobic

activityactivity• Weight lossWeight loss• Physical TherapyPhysical Therapy

Improve ROM, increase Improve ROM, increase strengthstrength

• BracingBracing

Pharmacologic Pharmacologic Treatment:Treatment:• APAPAPAP• SupplementsSupplements

Glucosamine and Glucosamine and ChondroitinChondroitin

• NSAIDs, COX-2’sNSAIDs, COX-2’s• TramadolTramadol• ViscosupplementationViscosupplementation• Intrarticular SteroidsIntrarticular Steroids

Case 3Case 3

31 year old female, L knee pain31 year old female, L knee pain Recreational runnerRecreational runner Localizes pain to front of kneeLocalizes pain to front of knee No trauma, insidious onsetNo trauma, insidious onset Localizes pain “around kneecap”Localizes pain “around kneecap” Worse with stairsWorse with stairs Worse after prolonged sittingWorse after prolonged sitting Knee occasionally “gives out”Knee occasionally “gives out”


Mechanism of Injury?Mechanism of Injury? Acute or Chronic?Acute or Chronic? Where is the pain?Where is the pain? Mechanical Mechanical

Symptoms? (Locking, Symptoms? (Locking, popping, catching?)popping, catching?)



Insidious OnsetInsidious Onset ChronicChronic Anterior kneeAnterior knee No, but sometimes No, but sometimes

gives outgives out

NoneNone NoneNone NoneNone Running, StairsRunning, Stairs Multiple days of restMultiple days of rest

Physical Exam

Inspection: mild genu valgus Palpation: TTP lateral > medial patellar

facets ROM: full w/o pain Strength: normal Neurovascular: normal Special Tests:

• + patellar grind• Decreased patellar glide• Inflexible hamstrings (Popliteal angle)

Patellofemoral Joint ExamPatellofemoral Joint Exam

Patellofemoral Joint ExamPatellofemoral Joint Exam

Patellar Grind TestPatellar Grind Test


AP

Lateral


Tunnel

Sunrise

What’s your diagnosis?

Patella

r tendinopath

y

Patella

r insta

bility

Patello

femoral sy

ndrome

Plica sy

ndrome

25% 25%25%25%1. Patellar tendinopathy

2. Patellar instability3. Patellofemoral

syndrome4. Plica syndrome

Patellofemoral SyndromePatellofemoral Syndrome

Treatment:Treatment:• Relative rest; non-painful aerobicsRelative rest; non-painful aerobics• Physical TherapyPhysical Therapy

Improve Quad/Hamstring flexibilityImprove Quad/Hamstring flexibility Quad, Hip abductor strengtheningQuad, Hip abductor strengthening Core strengtheningCore strengthening

• Patellar stabilization brace/tapingPatellar stabilization brace/taping• Foot orthoticsFoot orthotics• Surgery (last-ditch effort)Surgery (last-ditch effort)

Case 4Case 4

34 yo Army MAJ training for 34 yo Army MAJ training for 11stst marathon marathon

Atraumatic onset of R Atraumatic onset of R lateral knee pain 1 week lateral knee pain 1 week ago after 10 mile runago after 10 mile run

Sharp burning painSharp burning pain Better with rest, returns Better with rest, returns

with runningwith running


Mechanism of Injury?Mechanism of Injury? Acute or Chronic?Acute or Chronic? Where is the pain?Where is the pain? Mechanical Mechanical

Symptoms? (Locking, Symptoms? (Locking, popping, catching?)popping, catching?)



Insidious OnsetInsidious Onset AcuteAcute Lateral kneeLateral knee No, but sometimes No, but sometimes

gives outgives out

NoneNone NoneNone NoneNone RunningRunning Multiple days of restMultiple days of rest

Physical Exam

Inspection: normal Palpation: TTP over lateral femoral condyle ROM: full Strength: normal Neurovascular: normal Special tests:

• + Noble test• Tight on Ober test

Ober testOber test Noble testNoble test

What’s your diagnosis?

Oste

oarthriti

s

Menisc

al tear

Iliotibial b

and syndro

me

LCL s

prain

25% 25%25%25%1. Osteoarthritis2. Meniscal tear3. Iliotibial band

syndrome4. LCL sprain

Iliotibial Band SyndromeIliotibial Band Syndrome

Treatment:Treatment:• Ice massage, pain medsIce massage, pain meds• Relative Rest; nonpainful activityRelative Rest; nonpainful activity• Physical TherapyPhysical Therapy

Specific ITB stretchesSpecific ITB stretches Hip abductor strengtheningHip abductor strengthening Core strengthening (Gluteus Medius)Core strengthening (Gluteus Medius)

• Slow return to activitySlow return to activity• Extrinsic factors: shoes, running surface, Extrinsic factors: shoes, running surface,

training errorstraining errors

What the heck is a Plica?

Congenital th

ickening of...

Redundant menisc

us

Loose

piece of in

tra-arti

...

Figm

ent of m

y imagin

ation

25% 25%25%25%1. Congenital thickening of joint capsule

2. Redundant meniscus3. Loose piece of intra-

articular cartilage4. Figment of my

imagination

Plica Syndrome?

Special Tests - ACL InjurySpecial Tests - ACL Injury Lachman TestLachman Test

• Knee flexed to 15-30 degreesKnee flexed to 15-30 degrees• Stabilize distal femurStabilize distal femur• Anteriorly translate tibia on Anteriorly translate tibia on

femurfemur• Watch & feel for amount of Watch & feel for amount of

translation & end pointtranslation & end point

Pivot ShiftPivot Shift

Special Tests - PCL InjurySpecial Tests - PCL Injury Posterior Drawer TestPosterior Drawer Test

• Knee flexed to 90 degreesKnee flexed to 90 degrees• Posteriorly translate tibia on Posteriorly translate tibia on

femurfemur• Watch & feel for amount of Watch & feel for amount of

translation & end pointtranslation & end point

Sag SignSag Sign• Knees flexed, quads relaxedKnees flexed, quads relaxed

compare both sidescompare both sides• Look for tibial posterior “sag” Look for tibial posterior “sag”

relative to femurrelative to femur

Quad-Active TestQuad-Active Test• Knee flexed; hamstrings Knee flexed; hamstrings fullyfully

relaxedrelaxed• Slide foot along table (quad Slide foot along table (quad

active)active)• Observe for anterior relocationObserve for anterior relocation

Special Tests - MCL InjurySpecial Tests - MCL Injury

Valgus Stress TestingValgus Stress Testing• Knee flexed to 30 degreesKnee flexed to 30 degrees

Relax ACL/PCL & joint Relax ACL/PCL & joint capsulecapsule

• Valgus stress applied to kneeValgus stress applied to knee

• Look and feel for translation Look and feel for translation and endpointand endpoint

• Compare to uninjured sideCompare to uninjured side

• May repeat with knee in full May repeat with knee in full extensionextension

Special Tests - LCL InjurySpecial Tests - LCL Injury

Varus Stress Varus Stress TestingTesting• Same test as Same test as

valgus stress valgus stress testingtesting

• Except applying Except applying a varus stress a varus stress insteadinstead

• LCL, IT band, & LCL, IT band, & PLC are testedPLC are tested

Special Tests - Meniscal InjuriesSpecial Tests - Meniscal Injuries Joint line tendernessJoint line tenderness

Full SquatFull Squat

McMurray TestsMcMurray Tests

Thessaly testThessaly test

Bounce-home testBounce-home test

McMurray test for McMurray test for Meniscal injuryMeniscal injury

Test Med and Lat meniscus Test Med and Lat meniscus separatelyseparately

3 concurrent maneuvers:3 concurrent maneuvers:• GrindGrind it (Rotate tibia it (Rotate tibia

AWAY from it)AWAY from it)• CrunchCrunch it (varus or it (varus or

valgus)valgus)• PinchPinch it (flex/extend knee) it (flex/extend knee)

Positive: Painful “pop”Positive: Painful “pop”

Special Tests - Meniscal InjuriesSpecial Tests - Meniscal Injuries

Thessaly TestThessaly Test• Pt stands on Pt stands on

affected legaffected leg• Knee bent at 20 Knee bent at 20

degreesdegrees• Examiner holds pt’s Examiner holds pt’s

hands and rotates hands and rotates pt to both sidespt to both sides

Meniscal grindMeniscal grind

• Positive test: pain, Positive test: pain, painful click.painful click.

Anterior Knee ExamAnterior Knee Exam

Palpation of patellar Palpation of patellar facetsfacets

Glide and lift patella Glide and lift patella medially & laterallymedially & laterally

Palpate undersurface Palpate undersurface of patella for of patella for tendernesstenderness

Patellar ExamPatellar Exam

• Patellar GlidePatellar Glide Knee in extension, relaxedKnee in extension, relaxed Medial & lateral patellar Medial & lateral patellar

displacementdisplacement• Measured in quadrantsMeasured in quadrants

Normal: 1-2 quadrantsNormal: 1-2 quadrants Patellar ApprehensionPatellar Apprehension

Lateral patellar displacementLateral patellar displacement

patient apprehensionpatient apprehension

or guardingor guarding

Anterior Knee ExamAnterior Knee Exam

Patellar Grind TestPatellar Grind Test

Knee 10 deg flexionKnee 10 deg flexion Glide patella distally, Glide patella distally,

and firmly compress and firmly compress patella against patella against trochlear groovetrochlear groove

Active quadriceps Active quadriceps contraction contraction pain pain

Special Tests – Ober’s TestSpecial Tests – Ober’s Test

Lateral decubitus with Lateral decubitus with testing side up, testing testing side up, testing knee flexedknee flexed

Adduct and fully flex hip Adduct and fully flex hip Abduct, externally rotate, Abduct, externally rotate, & extend hip& extend hip

Slowly release support Slowly release support against gravity from leg, against gravity from leg, allowing gravity to take leg allowing gravity to take leg towards tabletowards table

Positive test: leg remains Positive test: leg remains abducted despite abducted despite examiner releasing legexaminer releasing leg


Noble’s testNoble’s test• Palpate lateral Palpate lateral

femoral condylefemoral condyle• Flex and Extend Flex and Extend

KneeKnee• + Test is pain at + Test is pain at

site of palpationsite of palpation

Documents

Sports Medicine Workshop Sports Medicine Workshop