1. Non-Operative Management of Orthopaedic Issues Reza Omid, M.D. Assistant Professor Orthopaedic Surgery Shoulder & Elbow Reconstruction Sports Medicine Keck School of Medicine of USC

2. Musculoskeletal Injuries Common cause for doctor visists (ER and outpatient). >1 in 4 Americans has a musculoskeletal condition requiring medical attention. Most can be treated non- operatively

3. X-rays Consider x-ray for any patient with injury Fracture/Dislocation/Infection/ Tumor

4. General Orthopaedics Shoulder/Elbow Reconstruction Trauma Pediatrics Hand/Wrist Foot/Ankle Hip/Knee Reconstruction Tumor Sports Medicine Spine

5. Shoulder Pain

6. Differential Dx »Rotator Cuff Disease »Frozen shoulder »Fracture »Calcific Tendonitis »Labral Tears »Biceps Pathology

7. Shoulder Pain –Among the most common sources of pain –Ranks 2 nd to lower back pain as a reason pt. seek medical attention –Approx. 40% of people over 65 yo have rotator cuff tears!

8. Shoulder Pain Rotator Cuff Disorders –17 million individuals in US at risk –600,000 surgeries / year –Most common source WC shoulder pain

9. Rotator Cuff Disease

10. Rotator Cuff Anatomy Supraspinatus Infraspinatus Tere Minor Subscapularis

11. Rotator Cuff Disease Intrinsic Factors –Age related degeneration Extrinsic Factors –Acromial shape –Mechanical pressure on cuff –Activity

12. Conclusions Demographics –Unilateral tear in young –Bilateral tear in older –Tears rare before 50 yo. –>50% in pt over 66 yo.

13. Radiographs Always obtain first AP (scapular plane) Axillary lateral Supraspinatus outlet

14. History –Pain (especially night pain) »Radiates around deltoid »Never below elbow –Weakness –Difficulty reaching overhead or behind –Cannot sleep on affected side

15. Physical Examination –Cervical spine –Shoulder ROM (active/passive) symmetric?

16. Physical Examination Rotator cuff tests –TDA (supraspinatus) –ER at side (infraspinatus) –ER 90° abd (teres minor) –Lift-off (subscapularis)

17. Physical Examination

18. Normal Motion –Elevation – 160 –Abduction ER – 90 –ER @ side -60 –IR/Ext – T7

19. Adjuvant Imaging Modalities MRI Ultrasound CT Arthrogram

20. MRI Reads Labral tears AC arthritis Partial thickness RC tears Full thickness RC tears

21. MRI Results Arthritis: Labral tears AC arthritis Partial thickness tears Tendinosis Rotator Cuff Dz: Full thickness tears High grade partial thickness tears

22. MRI Read No RC Tear Labral tear seen AC joint arthritis seen Dx: Shoulder arthritis

23. Partial Rotator Cuff Tears Can initially treat conservatively If fails conservative treatment then surgery

24. Orthopaedic Referral Full thickness tear in patients <60-65yo Acute (<3month) traumatic full thickness tears in any age Full thickness tear in patients >65 yrs who fail conservative treatment

25. Rotator Cuff Tear Risks - Chronic Changes –retraction with adhesion –tendon morphology –muscle atrophy –fatty degeneration –degenerative changes

26. Conservative Treatment »Rest, Activity modification »NSAIDS »ROM stretching »Cuff/Periscapular strengthening »Corticosteroid Injections

27. Cuff Strengthening

28. Conservative Treatment Injections –Elderly (>65yo) –Partial tears

29. Shoulder Injections “The effect of corticosteroid on collagen expression in injured rotator cuff tendon” Wei A, et al JBJSAm 2006: 1331-8 LIMIT TO 1-2 INJECTION GET MRI PRIOR

30. Proximal Biceps Rupture Suspect RC Tear

31. Shoulder Dislocation If anyone >40 years dislocates get an MRI If full thickness tear seen with healthy muscle bellies then surgery is indicated

32. Frozen Shoulder “Adhesive Capsulitis”

33. Frozen Shoulder –Global and significant loss of both active and passive ROM in gradual fashion –Absence of radiographic findings other than osteopenia

34. Clinical Presentation –Age: late middle age (40-60) –Male < Female –Diabetic and Hypothyroid

35. Clinical Presentation –Significant pain - especially at night! –Insidious onset »No trauma »Minor trauma (“dog pulled me”, “I reached in the back seat of the car”)

36. Late Frozen Shoulder –Significant loss of ROM »active and passive

37. Physical Exam –Passive ROM restricted »ER early »global late –ER < 50% unaffected side (pathognomic) –Pain with extremes of ER

38. Treatment Conservative –NSAID’s –Physical Therapy Fluoro-Guided Intraarticular Steroid Injection!

39. Accuracy of glenohumeral joint injections: comparing approach and experience of provider. Tobola JSES 2011:1147 Posterior: 50% Anterior: 42%

40. Arthroscopic Release –Surgical release of contractures –Remove scar tissue –Complete motion

41. Elbow Pain

42. Differential Dx Lateral Epicondylitis Instability Biceps Pathology Medial Epicondylitis Olecranon Bursitis Fracture

43. Lateral Epicondylitis “Tennis Elbow”

44. Presentation Lateral elbow pain with grip Especially in extension TTP at lateral epicondyle

45. Conservative Treatment NSAIDs Activity modification Physical therapy Counterforce brace Iontophoresis Injections

46. Conservative Treatment

47. Iontophoresis

48. Injections Corticosteroids Platelet Rich Plasma Botulinum Toxin A

49. ONLY 1 INJECTION!

50. POSTEROLATERAL ROTATORY INSTABILITY OF THE ELBOW IN ASSOCIATION WITH LATERAL EPICONDYLITIS. A REPORT OF THREE CASES. Kalainov JBJSAm 2005: 1120

51. Physical Therapy Modalities Eccentric exercises

52. Medial Epicondylitis “Golfers Elbow” -Medial elbow pain with grip -Much less common -TTP at FP mass -Similar treatment

53. Olecranon Bursitis Most resolve with symptomatic treatment Avoid aspiration unless you suspect infection Surgery has high complication rate!

54. Distal Biceps Tears Anterior elbow pain with associated “pop” Treated surgically as opposed to proximal biceps ruptures

56. Hand/Wrist Pain

57. Carpal Tunnel

58. Treament Brace NSAIDs Vit B6 (50 mg PO tid) may help some of patients Injections (nerve can be injured!)

59. DeQuervain’s Tenosynovitis

60. Other Causes of Radial Sided Wrist Pain Scaphoid fracture Wrist arthrits Radial sensory nerve injury “Crossover syndrome” (another sheath of tendons)

61. Treatment Brace with thumb spica NSAIDs Corticosteroid injection into sheath

62. Hip Pain

63. Differential Fracture Stress Fracture FAI Arthritis

64. Stress Fracture Runners Female Rest MRI (If Femoral neck fracture seen refer)

65. Stress Fractures

66. Femoroacetabular Impingement (FAI)

67. Treatment of FAI RICE, NSAIDs Physical Therapy If MRI ordered get MR Arthrogram of Affected Hip NOT Pelvis

68. Knee Pain

69. Differential Dx Meniscus tear Arthritis/OCD Ligament Injury Fracture

70. Knee Effusion Ligament tear Meniscus tear Osteochondral fracture Synovitis Consider MRI

71. Anterior Knee Pain

72. Treatment RICE Weight loss (every pound lost is 7 pounds off the knee) Bracing Physical Therapy

73. Meniscus Tears

74. Treatment RICE Weight loss (every pound lost is 7 pounds off the knee) Bracing Physical Therapy Corticosteroid injection Surgery is last option

75. Baker’s Cysts

76. ACL Injuries

77. Treatment of ACL If active and only mild arthritis orthopaedic referral. If degenerative and non-active treat non-operatively Age is irrelevant

78. Arthritis RICE Glucosamine/Chondroitin “Viscosupplement” Injections Corticosteroid Injections Unloader Bracing PT

79. Physical Therapy for Hip/Knee Injuries ROM Quadriceps Strength Hamstring Strength Hip Abductor Strength IT Band Stretching Iliopsoas Stretching

80. Foot/Ankle Pain

81. Ankle Sprain Get x-rays!! Most can be treated with CAM walker 5 th MT Fracture

82. Ottawa Ankle?

83. Achilles Tendon Injury If torn refer If intact treat with RICE, NSAIDs, CAM boot, PT for eccentric exercises

84. Achilles Tendon Injury Tendinopathy vs insertional tendonitis Heel lift NSAIDS PT (eccentric exercises)

85. Plantar Fascitis Inflammation of the plantar fascia Achilles stretching RICE Boot

86. Questions???

87. www.dromid.com omid@usc.edu Reza Omid, M.D. Assistant Professor Orthopaedic Surgery Shoulder & Elbow Reconstruction Sports Medicine Keck School of Medicine of USC