Case Manager’s Corner

Mechanism of Injury:

Often results from noncontact, low-velocity, deceleration, and rotational injuries to the knee. Valgus, external rotation or hyperextension forces are the most common.

Subjective Symptoms:

Acutely, most patients hear or feel a pop at the time of injury. Patients may develop a hemarthrosis. Subacute and chronic complaints often consist of knee instability. An isolated ACL tear is rarely painful. Pain may be associated with concomitant meniscal tears, collateral ligament tears, bone bruising, or articular cartilage damage.

Objective Signs:

Ligamentous instability measured clinically with Lachman or pivot shift tests. Objectively, laxity is measured with an arthrometer. MRI is often used to confirm the diagnosis and to detect meniscal pathology present in 60-70% of ACL injuries.

Natural History:

Depends upon patient demands and concomitant injury. Higher demand patients (i.e., athletes, laborers) are often unable to compensate and complain of recurrent instability. Repeat episodes of instability may lead to further meniscal damage, articular cartilage injury and possibly arthritis.

Treatment

Nonsurgical:

Activity modification and physical therapy.

Surgical:

ACL reconstruction using a bone-patellar tendon-bone autograft or allograft, and hamstrings autograft. Preoperative physical therapy to regain extension and quadriceps control, and postoperative physical therapy are usually required.

Mechanism of Injury:

Can be traumatic following a direct impact to the knee or result from a twisting injury. Can also result from developmental problems such as osteochondritis dissecans.

Subjective Symptoms:

Typically, patients complain of localized pain, mechanical symptoms such as catching or locking, and activity-related swelling.

Objective Signs:

Tenderness over the involved area, effusions and crepitus or catching may be present during range of motion. Plain radiographs and MRI may not always detect articular cartilage injury.

Natural History:

Not all focal articular cartilage defects become symptomatic. However, once these lesions produce symptoms, they may progress and lead to degenerative changes in the opposing joint surfaces.

Treatment

Nonsurgical:

Palliative care including NSAIDs and physical therapy.

Surgical:

Depends upon several factors, including defect size, location and depth. Options are grouped by ability to repair the articular surface.

• Palliative: Arthroscopy, debridement and lavage
• Reparative: Microfracture or drilling
• Restorative: Autologous chondrocyte implantation (Carticel), osteochondral grafting

Maximum Medical Improvement Nonsurgical:

Varies based upon extent of symptoms and disease.

Surgical:

• Palliative: 6-8 weeks
• Reparative: 4 to 6 months
• Restorative:
  Osteochondral autograft: 3-4 months
  Osteochondral allograft: 4-6 months
  Carticel™ 8-12 months

Mechanism of Injury:

Direct blow to the lateral side of the knee with the foot planted or in combination with other ligament or cartilage injuries.

Subjective Symptoms:

Painful weight-bearing, medial knee tenderness, and a sense of instability when severe.

Objective Signs:

Medial femoral condyle, joint line or tibial condyle tenderness. Pain with valgus stress testing at 0 to 30 degrees of knee flexion with joint line opening with or without a firm endpoint depending on severity of tear.

Natural History:

Heals with non-operative treatment with minimal to no residual impairment.

Treatment

Nonsurgical:

Depending on severity, may require protected weight-bearing with crutches, a hinged-knee immobilizer, inflammation control, and progressive physical therapy emphasizing range of motion and strength.

Mechanism of Injury:

Most commonly results from a twisting type injury with the foot planted. May also occur with sudden knee hyperflexion. Rarely results from a direct blow to the knee.

Subjective Symptoms:

Acutely, patients complain of joint line pain and delayed knee swelling. Symptoms may diminish over 1-2 weeks, but may recur with squatting, pivoting or cutting activities. Patient may also experience locking, catching or giving-away.

Objective Signs:

Effusion, palpable joint line tenderness, pain with squatting, positive McMurray’s test. MRI may be helpful for confirmation.

Natural History:

Not all meniscal tears will require surgical intervention. Natural history depends on patient activity level, tear location, size and type. Large unstable tears tend to become symptomatic while small degenerative tears may be associated with minimal symptoms. Small degenerative tears are often found as incidental findings on MRI and must be correlated to clinical findings.

Treatment

Nonsurgical:

Physical therapy may be appropriate for small tears that become asymptomatic through relative rest and protection.

Surgical:

Arthroscopic meniscectomy or meniscal repair.

Mechanism of Injury:

Results from trauma to the anterior aspect of the knee, postoperative or generalized muscle deconditioning, or from repetitive activities on incline surfaces.

Subjective Symptoms:

Anterior knee pain especially while walking on stairs and inclines. Patients may also complain of “giving way,” crepitus, locking and swelling. Often, symptoms are bilateral. Patients complain of stiffness and a poorly localized dull ache with prolonged sitting ("movie sign").

Objective Signs:

Abnormal quadriceps muscle contraction with weakness of the vastus medialis obliquus. Often associated with tightness of the hamstrings and lateral soft tissue restraints of the knee. May have underlying patellofemoral instability and abnormal extensor mechanism alignment (i.e., increased quadriceps or ‘Q’ angle).

Natural History:

Without intervention, symptoms often persist or progress leading to further limitations in activity.

Treatment

Nonsurgical:

Nonsurgical treatment is nearly always the mainstay of treatment. Emphasis is on a formal patellofemoral program with reduction of inflammation, improved flexibility and strengthening of the muscle groups responsible for patellar tracking. McConnell taping and bracing may be useful in some instances.

Surgical:

Rarely, with long standing patellar tilt or subluxation, arthroscopy and lateral release can be curative. Patellar femoral instability and localized arthritis may require a formal extensor mechanism realignment procedure that includes a tibial tubercle osteotomy (i.e., Fulkerson procedure).

Mechanism of Injury:

Blunt trauma to the acromioclavicular (AC) joint may result in post-traumatic arthritis. Alternatively, repetitive overhead activities such as those associated with impingement syndrome may lead to degenerative changes within the AC joint.

Subjective Symptoms:

Dorsal shoulder pain often made worse with bringing the arm across the chest and with overhead activities.

Objective Signs:

AC joint tenderness to direct palpation, elicitation of pain with cross-arm adduction, elimination of pain with injection of local anesthetic into the AC joint, confirmation of joint space narrowing with radiographs or increased uptake with a bone scan.

Natural History:

In most instances, once the pain is initiated, it will persist or increase especially if the inciting event is not eliminated.

Treatment

Nonsurgical:

NSAIDs, cortisone injection into the AC joint, limited physical therapy.

Surgical:

Arthroscopic (or open) distal clavicle excision (i.e., Mumford procedure).

Mechanism of Injury:

May be due to minor trauma to the shoulder, but often there is no identifiable cause. Associated with diabetes, thyroid disease, and following chest or breast surgery.

Subjective Symptoms:

Pain and restricted range of active and passive glenohumeral motion.

Objective Signs:

Initially, patients complain of pain with range of motion (Stage 1). Patients then progress through a stiffening phase with limited range of motion (Stage 2). Eventually, patients may demonstrate gradual returns in motion (Stage 3).

Natural History:

Usually self-limiting and passes through three distinct stages:

Stage 1: Painful phase
Stage 2: Stiffening phase
Stage 3: Thawing phase

The time for recovery varies, but most patients experience improvements in motion within 12 to 18 months.

Treatment

Nonsurgical:

Treatment options include local steroid injections, physical therapy and modalities. Emphasis is on passive stretching with a dedicated home exercise program.

Surgical:

If conservative treatment fails, especially if motion is limited to < 90 degrees of forward elevation or 0 degrees of external rotation despite 3 to 6 months of physical therapy, arthroscopic debridement and manipulation under anesthesia may be required.

Mechanism of Injury:

Rotator cuff compression between the humeral head and the coracoacromial arch during repetitive overhead activities initially leading to bursitis within the subacromial space. May be posttraumatic and related to rotator cuff tendonitis or tearing.

Subjective Symptoms:

Painful forward elevation of the arm above the shoulder level. The pain is usually anterior or lateral over the deltoid. Often associated with difficulty sleeping on the affected side. May be associated with weakness and motion loss.

Objective Signs:

Painful arc of motion between 70-120 degrees of forward elevation, positive impingement findings with reproduction of pain with the arm passively elevated above the shoulder level (Neer’s and Hawkin’s signs). Positive impingement test (pain relief after a Lidocaine injection into the subacromial space). May be associated with rotator cuff weakness and motion loss. XR may show congenital or acquired spur formation of the acromion or distal clavicle.

Natural History:

Untreated without interruption of the precipitating cause, impingement syndrome can progress through 3 stages, ranging from simple and reversible inflammation to irreversible rotator cuff tendonitis and tearing.

Treatment

Nonsurgical:

Temporary elimination of the precipitating cause, NSAIDs, physical therapy emphasizing glenohumeral and scapulothoracic strengthening and posterior capsular stretching, possibly a cortisone injection directly into the subacromial space.

Surgical:

Shoulder arthroscopy and subacromial decompression followed by short-term physical therapy.

Mechanism of Injury:

Results from a single traumatic event or due to repetitive microtrauma possibly in association with chronic impingement syndrome (i.e., stage III).

Subjective Symptoms:

May present with similar complaints as impingement syndrome with pain predominating, especially with overhead activities. Tears with inadequate compensation from surrounding intact musculature may be associated with weakness and greater passive than active motion.

Objective Signs:

Weakness against resistance in the plane of motion controlled by the torn tendon (muscle). Often accompanied by positive impingement findings (i.e., Neer’s and Hawkin’s signs). MRI helpful to determine extent and chronicity, but not always required for confirmation.

Natural History:

Depends upon patient factors and biologic factors related to the muscle-tendon unit. Smaller, partial-thickness tears in lower-demand patients may do well with nonsurgical management. Tears of any size in higher-demand patients may lead to chronic pain and weakness if left untreated. The extent of irreversible muscle atrophy depends upon chronicity, tear size, patient age and comorbidities.

Treatment

Nonsurgical:

Physical therapy emphasizing glenohumeral and scapulothoracic strengthening and NSAIDs. Judicious use of cortisone injections primarily when surgical repair not anticipated.

Surgical:

Technique depends upon surgeon experience, tear size, location and chronicity:

• Arthroscopic rotator cuff repair
• Arthroscopically-assisted rotator cuff repair
• Open rotator cuff repair

Mechanism of Injury:

Anterior shoulder dislocation resulting from trauma to the abducted and externally rotated arm.

Subjective Symptoms:

Acutely, patients complain of significant pain with the inability to internally rotate the arm. Often requires a manual reduction by a physician. In between episodes of subluxation or dislocation, patients may complain of persistent pain and a sense that the shoulder will dislocate again with the arm abducted and externally rotated.

Objective Signs:

Positive apprehension test recreating the sense of instability with the arm abducted and externally rotated with a decrease in the patient’s symptoms with a posteriorly directed force on the proximal humerus (i.e., the relocation maneuver). May be associated with a rotator cuff tear in older individuals and axillary nerve injury.

Natural History:

Younger patients engaged in high risk activities (overhead athletes, collision athletes, and laborers) with a high incidence of recurrent instability. Older patients have a significantly lower risk of recurrent instability, but may complain of symptoms due to rotator cuff pathology.

Treatment

Nonsurgical:

Following closed reduction, short-term immobilization followed by physical therapy. Treatment of chronic instability requires strengthening of the rotator cuff and scapular stabilizers.

Surgical:

• Arthroscopic Bankart repair
• Arthroscopic Bankart repair with heat shrinking capsullorhaphy
• Open Bankart repair with capsular shift