Update on Diagnosis and Treatment of Common Soft Tissue Injuries - - PowerPoint PPT Presentation

Update on Diagnosis and Treatment

• f Common Soft Tissue Injuries

Kuwait March 9, 2019

Fadi Badlissi, MD, MSc Director of the Musculoskeletal Medicine Unit The Orthopedic Department & Rheumatology Division HMFP/BIDMC Assistant Professor of Medicine Harvard Medical School

Disclosure

• No conflicts

Case of Shoulder Pain

• 63 year-old female with acute L shoulder pain

for one week

• No trauma
• On exam: limited range of motion (ROM) due

to pain, better passive ROM

• Subacromial tenderness
• Positive impingement, though overall limited

exam due to the pain

Humerus/Greater Tuberosity

Acromion Humerus

Calcific Tendinopathy

• Calcific deposits in the tendon and bursa
• Radiographic prevalence 3-10 %

» Bosworth BM, et al. JAMA 1941

• Painful range of motion (ROM)
• Impingement
• Imaging

– Radiographs – Ultrasound more sensitive – MRI mostly to rule out tear

Calcific Tendinopathy Management

• NSAIDS
• PT
• Subacromial corticosteroid injection
• Extracorporeal Shock Wave Therapy (ESWT)

» Bannuru RR, et al. Ann Int Med 2014 » Arirachakaran A, et al. Eur J Orthop Surg Traumatol 2017

• Barbotage

» Lanza E, et al. Eur Radiol 2015

• Surgery

Predictors Of No Response To Non- Surgical Management Question

• All of these are predictors of no response to

conservative management in calcific tendinitis except:

• 1. Bilateral calcific tendinitis of the shoulder
• 2. Location at the anterior portion of the

acromion

• 3. Fragmented calcifications
• 4. Medial (subacromial) extension
• 5. High volume of the calcific deposit

» Ogon P, et al. Arthritis Rheum 2009

Predictors Of No Response To Non- Surgical Management, Answer

• All of these are predictors of no response to

conservative management in calcific tendinitis except:

• 1. Bilateral calcific tendinitis of the shoulder
• 2. Location at the anterior portion of the

acromion

• 3. Fragmented calcifications
• 4. Medial (subacromial) extension
• 5. High volume of the calcific deposit

» Ogon P, et al. Arthritis Rheum 2009

Another Case of Shoulder Pain

• 58 year-old male, R shoulder pain and limited

range of motion for 3 months

• No improvement with physical therapy
• Exam: limited active abduction 90,

passive 110, severely limited internal rotation, slightly limited external rotation

• Negative impingement sign
• Normal strength

Glenoid Labrum

Frozen Shoulder Diagnosis & Management

• Shoulder pain with progressive limitation in

active and passive range of motion (ROM)

• Limited internal rotation limited differential
• X-ray to rule out dislocation and OA
• MRI to rule out other etiologies of pain
• Primary versus secondary
• More common in diabetics OR 5 (95% CI 3.2-

7.7), prevalence 13.4%

» Zreik NH, et al. Muscles Ligaments Tendons J 2016

Frozen Shoulder Diagnosis & Management

• Intraarticular corticosteroid injection

combined with physical therapy (PT) provided faster pain relief and improvement in function compared to placebo normal saline injection with or without PT

» Carette S, et al. Arthitis Rheum 2003

• Recovery without treatment few months to

years

Rotator Cuff Tear

• It could be difficult to differentiate from

tendinitis clinically

• History of trauma
• Weakness on exam
• Imaging with US, MRI

Humerus Head, Greater Tuberosity

USSONAR.ORG

Humerus Head, Greater Tuberosity

USSONAR.ORG

Rotator Cuff Tear Management

• Conservative versus surgical management depends on:

– Functional level and demand – Age – The width and thickness of the tear, partial vs. full – Acuteness of tear, extent and chronicity of tear – Muscle bulk and retraction

• Surgery is indicated for acute full thickness tear
• Clinical trials showed no advantage for surgical repair in

non traumatic and small/medium tears

» Kukkonen J, et al. J Bone Joint Surg Am 2015 » Moosmayer S, et al. J Bone Joint Surg Am 2014

• No good quality evidence to favor a specific conservative

management approach

Lateral Epicondylitis

• Prevalence 1.3%

» Shiri R, et al. Am J Epidemiol 2006

• Tenderness over the lateral epicondyle
• Mostly mechanical
• Pain with resistance to wrist extension and supination
• Medial epicondylitis a mirror image of lateral

epicondylitis, prevalence 0.4%

• Treatment

– Occupational therapy – Splints – Iontophoresis with topical naproxen or dexamethasone provides short term relief

Lateral Epicondyle

Lateral Epicondylitis

Lat Epicondyle Radius

Corticosteroid Injections for Lateral Epicondylitis

• Compared to physical therapy, they provide

short term benefits

• No long term benefit, possibly harmful
• Tenotomy might be of additional benefit

» Coombes BK, et al. JAMA 2013 » Coombes BK, et al. Lancet 2010 » Smidt N, et al. Lancet 2002

Lateral Epicondyle Injection

Lateral Epicondylitis, Other Options

• Prolotherapy, injection of irritant solution and

anesthetic, small numbers

» Scarpone M, et al. Clin J Sport Med 2008

• Botulinum toxin injection, improvement in

pain but not function

» Placzek R, et al. J Bone Joint Surg Am 2007 » Espandar R, et al. CMAJ 2010

Lateral Epicondylitis, Platelet Rich Plasma & Autologous Blood Injection

• Metaanalyses and larger randomized control

studies showed lack of effectiveness

» de Vos RJ, et al. Br J Sports Med 2014 » Ahmad Z, et al. Arthroscopy 2013

• Smaller studies showed some effectiveness

but potential bias and no control group

» Peerbooms JC, et al. Am J Sports Med 2010 » Gosens T, et al. Am J Sports Med 2011

Bursitis

• Acute versus chronic
• Is the joint involved? Is is septic?
• With olecranon bursitis it could be challenging

– Extension – Supination pronation

• Prepatellar bursitis sympathetic knee effusion could

be challenging to differentiate from septic knee, extension usually preserved in bursitis

Elbow Anatomy

Bursitis Question

• All of these could be associated with acute

bursitis Except:

• 1. Gout
• 2. Pseudogout
• 3. Lupus
• 4. Trauma
• 5. Infection

Bursitis Answer

• All of these could be associated with acute

bursitis Except:

• 1. Gout
• 2. Pseudogout

3. Lupus

• 4. Trauma
• 5. Infection

Bursitis Diagnosis

• Establish the diagnosis Joint versus bursa
• Exam: effusion, tenderness, erythema
• Imaging most of the times not necessary
• Aspirate, synovial fluid analysis

– Cell count – Crystals – Stains and cultures

Infrapatellar Bursitis

• 53 year-old male with crystal proven history of

gout

• Acute onset left knee anterior pain
• No trauma
• Exam: No effusion, normal extension, and

flexion but painful

• Warmth, swelling and tenderness over the

anterior proximal tibia

Patella

Tibia

Bursitis Management

• Aspiration
• Corticosteroid injection If infection is ruled
• ut, risk of skin atrophy and fistulae in

superficial bursa

• Treat the underlying etiology

Indications For Bursectomy

• Inadequate drainage & response to treatment
• Debridement of wound or soft tissue infection
• Chronic bursitis
• Surgery for reluctant recurrent bursitis, might

be helpful especially in non inflammatory

• lecranon bursitis based on small series

» Stewart NJ, et al. J Shoulder Elbow Surg 1997

Case Hip Pain

• 71 year-old female with left hip pain for 2

months

• No trauma
• Pain localized over the lateral aspect radiating

to the knee but not below it

• Exam: normal ROM, pain with Patrick’s test

laterally

• Resistance to abduction painful but normal

strength

Greater Trochanter Gluteus Medius Gluteus Max

Trochanteric Bursitis, Question

• What percentage of patients with a clinical

diagnosis of trochanteric bursitis have fluid in the bursa?

• 1. > 90%
• 2. 60-80%
• 3. 30-60%
• 4. 20% or less

Trochanteric Bursitis, Answer

• What percentage of patients with a clinical

diagnosis of trochanteric bursitis have fluid in the bursa?

• 1. > 90%
• 2. 60-80%
• 3. 30-60%
• 4. 20% or less

Trochanteric Bursitis

• Mostly gluteus medius and minimus

tendinosis

• Ultrasound study of subjects with lateral hip

pain, half had evidence of tendinosis, only 20% fluid in the greater trochanteric bursa

» Long SS, et al. AJR Am J Roentgenol 2013 » Bird PA, et al. Arthritis Rheum 2001

Greater Trochanteric Bursitis Management

• Corticosteroid injections provide faster relief but

similar long term outcome compared to physical therapy

» Mellor R,et al. BMJ 2018

• Surgery occasionally needed for persistent pain >

1 year with a documented gluteus medius tear

• Similar results with open vs. arthroscopic surgery
• Outcomes less favorable with fatty degeneration
• f the muscles

» Chandrasekaran S, et al. Arthroscopy 2015 » Thaunat M, et al. Arthroscopy 2018

Popliteal (Baker) Cyst

All of these are correct EXCEPT:

• 1. It can spontaneously ruptures
• 2. When it ruptures, it is difficult to differentiate

it from a deep venous thrombosis

• 3. Once aspirated it does not recur
• 4. A one way valve between the medial

gastrocnemius head and the semimembranosus tendon helps create the cyst

Popliteal (Baker) Cyst, Answer

All of these are correct EXCEPT:

• 1. It can spontaneously ruptures
• 2. When it ruptures, it is difficult to differentiate

it from a deep venous thrombosis

• 3. Once aspirated it does not recur
• 4. A valve between the medial gastrocnemius

head and the semimembranosus tendon helps create the cyst

Baker Cyst, Trans

Med Head of Gastroc

Baker Cyst, Long

Baker Cyst, Aspiration

Arthroscopic Excision

• Rarely indicated
• In persistent symptomatic popliteal cysts
• Modified arthroscopy in small series was

successful in half of the patients

» Ahn JH, et al. Arthroscopy 2010

• High risk of recurrence even with surgery

Case Achilles Enthesitis/Tendinitis

• 52 year-old with ulcerative colitis with

progressive R heel pain over the past few months

• Exam: tenderness and soft tissue swelling over

the posterior right heel

Calcaneus

Question

• Thompson test is negative in all of these

EXCEPT:

• 1. Achilles tendinitis
• 2. Achilles tendon rupture
• 3. Plantar fasciitis
• 4. Podagra
• 5. Ankle lateral collateral ligament injury

Answer

• Thompson test is negative in all of these

EXCEPT:

• 1. Achilles tendinitis
• 2. Achilles tendon rupture
• 3. Plantar fasciitis
• 4. Podagra
• 5. Ankle lateral collateral ligament injury

Achilles Enthesitis/Tendinitis & Tear

• Soft tissue swelling & tenderness
• Thompson’s test
• Trauma
• Imaging if necessary
• Surgery decision will need to be made

urgently

Case Ankle Pain & Swelling

• 53 yo female woke up with a sudden onset of

pain in her L ankle

• Saw her internist a week later, on exam

redness, swelling and warmth

• Attempt to aspirate fluid did not yield any
• Treated with naproxen without improvement
• Prednisone 40 mg for presumed gout, no

improvement

Case Ankle, Cont.

• Nine days later saw her PCP with no

improvement

• X-rays negative
• Treated empirically for ? Gout with colchicine

Labs

• CRP 3.2
• ESR 2
• U acid 5.8 mg/dl
• CBC normal

Rheum Consult

• 4 weeks after the onset of her pain
• No improvement in her pain
• Significant tenderness over the lateral aspect
• Soft tissue swelling
• No effusion

Tibia Talus

Talus