Review of Common Orthopedic Conditions

Educational Objectives

The goal of this program is to improve treatment of common orthopedic conditions. After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose de Quervain tenosynovitis in patients with thumb pain.
2. Manage gluteal tendinopathy in patients with lateral hip pain.

Summary

Bursitis and tendinopathy (rotator cuff pathology): cause pain in the subacromial space, aggravated by overhead activities; pain may occur while lying on the side; commonly affects abduction; painful range of motion (ROM) but strength remains intact; a positive Neer test and Hawkins-Kennedy test; a painful arc can help in diagnosis; physical examination helps; X-ray can help rule out osteoarthritis (OA), show pathognomonic changes, and help identify calcific tendinopathy; ultrasonography may help identify tendinopathy or partial tears; treatment — physical therapy (PT) is the mainstay; avoid aggravating activities; cortisone injections can help (reserved for patients who cannot start PT because of pain or plateau)

Tears: partial tears are typically chronic changes; show positive tests similar to tendinopathy; a full tear is usually an acute injury that can vary based on the age of the patient; in presence of underlying degenerative rotator cuff pathology, a small injury can result in a rotator cuff tear; a positive Neer test and Hawkins-Kennedy test; a positive drop arm test and weakness with strength testing can help diagnose; magnetic resonance imaging (MRI) can help evaluate a massive rotator cuff tear; ultrasonography does not help much; obtain an X-ray for limited ROM and inability to do it actively or passively; glenohumeral joint OA and frozen shoulder have active and passive limited ROM; PT is not helpful; adhesive capsulitis presents similarly but shows less arthritis on X-rays; treatment — recovery typically takes 18 mo to 3 yr; can consider intra articular glenohumeral injection (distend them with saline) followed by a cortisone injection, and then PT

Elbow epicondylitis: a chronic condition caused by overuse; affects golfer’s elbow (medial epicondyle, flexor tendon, and muscles), causing tenderness and palpation; pain occur with resisted wrist flexion; tennis elbow (or lateral epicondylitis) is more common, involving extensor muscles; exhibits resisted third finger extension (extensor carpi radialis moving up into lateral epicondyle); treatment — no imaging is indicated; counterforce braces (Cho-Pat strap) can be helpful; cortisone injections are rarely indicated; may need Tenex or surgery if the injury is recalcitrant

Olecranon bursitis: an inflammation of the bursa; caused by trauma, inflammatory conditions, or infection; can cause tenderness to palpation, and swelling; ROM is normal; can affect the knee; like gluteal tendinopathy and trochanteric bursitis; treatment — consider aspiration if there is systemic symptom or infection; conservative; include icing, compression, and avoiding trauma; cortisone injections are not recommended; can consider surgery for refractory cases

Fall onto an outstretched hand (FOOSH): a high index for suspicion for scaphoid fractures is associated; cause tenderness and palpation; scaphoid bone (navicular of the wrist or the foot) is kidney bean-shaped and can be on both sides; get wrist X-rays with a scaphoid view; immobilizing the affected area with a thumb spica splint may help and repeat X-ray within 7 to 14 days

De Quervain tenosynovitis: pain at the thumb or distal base with repetitive movements; can do Finkelstein test; characterized by pain along the radial styloid; often seen in mothers (can occur in anybody); treatment — rest and avoidance; thumb spica splint and cortisone injections can help; can consider occupational therapy (eg, iontophoresis)

Carpal tunnel syndrome: the median nerve compression in the carpal tunnel; have different symptoms; patient may experience pain up into their forearm; worsening of pain at night; more common in people with diabetes mellitus and thyroid disorder; severe muscle atrophy is a concern; Phalen test, Tinel test, and compressions do not help much; patients may show weakness with thumb abduction; treatment — include a splint, avoidance of activities, and a cortisone injection (no motor involvement or significant nerve damage with thenar muscles wasting); otherwise electromyography (EMG) and decompression surgery may help

Ulnar nerve entrapment: less common; usually occur at the elbow level; cause pain with flexion and tingling of the fourth and fifth fingers; a positive Froment sign; treatment includes splinting and avoiding activities

Differential of hip and back pain: anterior or anterolateral hip pain are primarily OA; lateral or posterolateral hip pain are primarily gluteal tendinopathy or greater trochanteric pain syndrome; posterior or back pain is more likely the sacroiliac (SI) joint and lumbosacral radiculopathy; hip OA — mostly hip pain radiates to the groin that worsen with weight bearing; decreased and painful active and passive flexion of the hip and internal rotation; a positive test for anterior impingement help; X-rays reveal joint space narrowing, subchondral sclerosis, and cystic changes; oral analgesics and aqua therapy are effective; activity modification or a surgical evaluation can help; cortisone injection is not recommended; multiple injections increase the risk for avascular necrosis (AVN; a disruption of blood supply to the hip); AVN can be traumatic or atraumatic and occur more in people with a history of trauma, steroids, alcohol use, and smoking; sickle cell, radiation, and rheumatologic conditions increases the risk; MRI can detect the changes if there is a high suspicion

Labral pathology: often seen in athletes; difficult to diagnose; anterior hip pain with mechanical symptoms of clicking and catching; positive flexion, adduction, internal rotation (FADIR) test; X-ray may show femoroacetabular impingement (which may or may not cause symptoms)

Gluteal tendinopathy: an aching sensation over the posterior lateral hip, which worsens with pressure applied on the affected side; cause tenderness over the gluteal muscles in the greater trochanteric bursa and pain with abduction; consider FADER test; treatment — include PT and analgesics; cortisone injection used (if the injury is recalcitrant); it is a chronic overuse injury

SI joint dysfunction: pain worsens in the morning with prolonged inactivity and activities that increase instability or twisting of the body; affects runners, skiers, people who do single rotations in the line; pain radiates to back and buttocks; causes tenderness and palpation at the SI joint; a positive FABER test and weak core stability and balance help diagnose; ask where the pain is located; hip OA is likely if the pain is in the anterior groin; X-rays are not indicated (consider if systemic or inflammatory processes are suspected); PT, nonsteroidal anti-inflammatory drugs (NSAIDs), and activity avoidance can help

Lumbar radiculopathy: pain at the affected site; can cause numbness, tingling, and burning sensation; motor weakness, foot drop, and difficulty to raise heel; can consider straight leg raise test (L5/S1); diminished reflexes or weakness (similar to carpal tunnel syndrome); obtain X-rays (to rule out arthritis or other causes) and MRI (if symptoms are severe); EMG is not diagnostic until 4 to 6 wk after symptoms; treatment — PT and possible referral for injections (for pain); consider decompression (for significant weakness or acute injury)

Knee OA: variable presentation with pain, swelling, and dysfunction; antalgic gait and decreased ROM of knee; patients are unable to walk without knee extension; cause tenderness and palpation over any joint lines; a positive McMurray test; X-rays can help diagnose OA; treatment — weight loss, analgesics, and PT; cortisone injections can help; viscosupplementation can be used for mild to moderate conditions; knee replacement (if severe)

Meniscus tears: a shear stress with knee flexion and compression and femoral rotation; acute or chronic; can cause joint line tenderness; a positive McMurray test; Thessaly test is helpful to diagnose meniscus tears; check the location of pain; patellar fracture or patellofemoral pain syndrome can cause pain in the anterior knee and patella; imaging is not always indicated but X-rays are needed for OA; can obtain MRI; treatment include relative rest, icing, PT, unloader knee brace, cortisone injections, or surgery (unresponsive or younger patients)

Ligament tears: anterior cruciate ligament tear — common; caused by contact or non-contact mechanisms; popping, swelling, significant pain, dysfunction with effusion may occur; a positive Lachman test; MRI is preferred; X-ray can reveal tibial spine avulsion fractures; immobilization is recommended; refer orthopedic (if necessary); medial collateral ligament tear — valgus stress tests; cause pain; X-ray can show avulsion fracture; treatment involves bracing and PT

Patellar tendinopathy: stop running and start PT; patellar subluxation then refers sports medicine; PT for patellofemoral pain syndrome and a cortisone injection for infrapatellar fat pad syndrome; patellar subluxation can be observed in X-rays; PT, activity modification, and working on strength can help

Ankle sprains: usually inversion injuries leading to the lateral ligaments; presentation varies depending on the severity; grade 2 or 3 sprains involve bruising, pain, swelling, and dysfunction; individuals with grade 1 or 2 sprains can walk or may not show up for examination; Ottawa Ankle Rules outline when to perform tests to exclude fractures; pain occurs primarily on bony prominences; check standing anteroposterior, lateral, and mortise views; treatment — protection, rest, ice, compression, and elevation (PRICE), NSAIDs, and PT (rather than a boot and ankle stabilizing orthosis); boots are helpful for ankle injuries with dysfunction

Plantar fasciitis: sharp pain which occurs in the first few steps in the morning or after inactivity; pain at the medial calcaneal tuberosity with dorsiflexion of the calf or toes; imaging is not recommended; treatment — stretching, shoes, avoidance of aggravating activities, and possibly a night splint; cortisone injections are avoided (do not help and can cause fat pad atrophy)

Readings

Cloutier D, Sasek CA, Eggers-Knight JT, et al. General orthopaedic roundtable: management of olecranon bursitis. JBJS Journal of Orthopaedics for Physician Assistants. 2018;6(3):pe25. doi: 10.2106/JBJS.JOPA.17.00044; Dancy ME, Alexander AS, Clark CJ, et al. Gluteal tendinopathy: critical analysis review of current nonoperative treatments. JBJS Reviews. 2023;11(10). doi: 10.2106/JBJS.RVW.23.00101; Karachalios T, Hantes M, Zibis AH, et al. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. Journal of Bone and Joint Surgery. 2005;87(5):p955–962. doi: 10.2106/JBJS.D.02338; Larsen CG, Fitzgerald MJ, Nellans KW, et al. Management of de Quervain Tenosynovitis: a critical analysis review. JBJS Reviews. 2021;9(9). doi: 10.2106/JBJS.RVW.21.00069; Tseng WC, Chen YC, Lee TM, et al. Plantar fasciitis: an updated review. Journal of Medical Ultrasound. 2023;31(4):p268–274. doi: 10.4103/jmu.jmu_2_23; Wipperman J, Penny ML. Carpal tunnel syndrome: rapid evidence review. American Family Physician. 2024;110(1):p52–57; Wolf JM. Lateral epicondylitis. New England Journal of Medicine. 2023;388(25):p2371–2377. doi: 10.1056/NEJMcp2216734.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Northway was recorded at the 10th Annual Internal Medicine Fall Review, held October 4-5, 2024, in Ann Arbor, MI, and presented by the University of Michigan Medical School. For information on upcoming CME activities from this presenter, please visit medschool.umich.edu/offices/cme. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

FP731502

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.