Musculo skeletal problems in the community

1. Musculo skeletal problems in
the community
Dr.A.K.Venkatachalam,
MS, DNB,FRCS,MCH orth
Consultant Orthopaedic surgeon,
Besant nagar,Chennai

2. Atruamatic knee pain
Causes
Patello femoral pain syndrome
Plica
Degenerative meniscal tears
Osteoarthritis of the tibiofemoral
joints( Knee joint)
Pes anserinus bursitis

3. Patello femoral pain syndrome
•Common cause of knee pain, account for
30% of visits to a knee surgeon
•Mechanism of pain is related to
maltracking of patella.
•Common in women
•Main clinical feature is “Pain on walking
upstairs” or rising from the squatting
position which increases the load on the
knees to 7 times that of body weight

4. Patello femoral pain cont’d
•Diagnosis- “Grind test”- done by squeezing patella
against the femur. Sky line views to document mal-
tracking
•Associated with knee osteoarthritis but can also appear
in isolation in patients with mal-tracking of patella
•Treatment- Quadriceps strengthening and patellar
mobilisation.
•If pain not relieved after three months- arthroscopic or
open patellar realignment surgery.
•If no mal alignment then debridement with a shaver

5. Normal and abnormal patellar
alignment seen on sky line views

6. Lateral release for mal alignment of
patella
•Arthroscopic lateral release with LASER

7. Debridement of patella for idiopathic softening of cartilage

8. Plica syndrome
•Plica are embryological remnants in the
synovium of the knee joint
•Medial plica is the commonest cause of knee
pain.
•Plica alone is a rare cause of pain, associated
with patello femoral arthritis and knee OA.
•Clinical diagnosis – clicking on the medial
aspect of the knee when knee is flexed to 90
degrees as the hypertrophied plica rubs against
the medial condyle.

9. Arthroscopic release of medial plica

10. Degenerative meniscal tears
•Mensici transmit 30%- 70% of the load of the
knee, Lateral meniscus > medial meniscus.
•Tears of the menisci are common- 35% on MRI
scans of people > 65 years of age.
• Clinically – cause more pain than pure arthritic
pain-due to displaced tears causing capsular
stretching.
•No effusion seen usually.
•Diagnosis- grinding of the knee in hyper flexion
and circumduction- clicking sound.

11. Degenerative tears of menisci
•Conservative treatment consisting of
quadriceps strengthening.
•Tears producing symptoms mechanical
symptoms like locking, catching need
arthroscopic menisectomy.

12. Cartilage lesions
•Articular cartilage lesions are pre cursors
of osteo-arthritis.
Causes-
•Traumatic knee injury after sports or two
wheeler accidents
•Obesity
•Mal alignment
•Ligament injury like ACL injury.

13. Articular cartilage defect seen at
operation Normal
cartilage
Damag
ed
cartilag
e
Damaged cartilage

14. Reconstructive cartilage surgery

15. Mal alignment of lower limbs
•Common cause of unicompartmental
secondary osteoarthritis
•Patients will require a major surgical
procedure within 10 years
•Corrective osteotomy for active individuals
can postpone a knee replacement by 10
years.
•Costs are lower as no implants are used.

16. Bow legged Dog

18. Unicompartmental osteoarthritis
•Similar to wear of car tyre when wheel
balancing not proper.
•Usually medial compartment arthritis in
genu varum and lateral in Genu valgum.
•Treatment methods- a) Outer heel raise or
float.
•Osteotomy/ Unicompartmental
replacement. Good results for 5 -10 years

19. Deformities of knee are main cause
of secondary unicompartmental
arthritis

20. Shoulder problems in the
community
•Shoulder instability.
•Subacromial impingement
•Adhesive capsulitis.
•Rotator cuff tendonitis & tears

21. Shoulder instability
•The shoulder joint has the maximum
range of movement.
•Anatomy similar to a golf ball perched on a
tee- explains its vulnerability.
•Dislocation or subluxation called
instability.
•98 % of dislocations are anterior.
•Dislocations should be reduced promptly
to maximize function.

22. Instability cont’d
•Clinical features can be remembered by
the mnemonics- TUBS and AMBRI.
•T-Traumatic etiology
•U-Uni directional instability- mainly
anterior
•B-Bankart’s lesion (capsular detachment
of anterior part)
•S-Surgical stabilization is the treatment of
choice- Open or arthroscopic stabilization.

24. Traumatic instability prognosis
•80-90% of persons with an anterior
dislocation will have a recurrent
dislocation.
•First aid is reduction,
•Later rehabilitation and referral

26. Atraumatic Instability
•A-Atraumatic
•M-Multi directional
•B-Bilateral
•R-Rehabilitation by muscular
strengthening
•I-Inferior capsular tightening is the surgical
procedure for failed conservative
treatment.

28. Atraumatic or multi directional
instability (MDI)
•Difficult to manage by
general practitioners.
•Subtle tests are needed
diagnose this multi
directional instability.-
“Sulcus sign”
•Failure to recognize the
multidirectional
component, is the cause
of surgical failures by
many surgeons.

29. Subacromial impingement
•Rubbing of the of the rotator cuff on the
undersurface of the acromial arch.
•Causes are extrinsic and intrinsic.
•Extrinsic or primary causes are abnormal
shape of the acromion, bony spurs from
the acromio clavicular joint, displaced
fractures of the greater tuberosity.

30. Clinical features
Pain on elevation of arm through the painful arc 30 – 110.

31. Intrinsic impingement
Definition- Impingement of the rotator cuff
on the undersurface of the acromion on
elevation due to superior migration of
humerus
Causes-
•Weak rotator cuff tendons.
•Can result from instability- disappears
after correction of instability.

32. Adhesive capsulitis
Syn- Frozen shoulder
Periarthritis

33. Adhesive capsulitis( frozen
shoulder or Peri-arthritis
•Multitude of causes-
•Diabetes, Parkinsonism, depression,
hypothyroidism, cervical spondylosis are
the chief extrinsic causes.
•Primary frozen shoulder occurs as a
separate entity.

34. Adhesive capsulitis
Diabetes is the chief cause of frozen
shoulder in the community.
3 phases in a protracted course
Pain
Progressive stiffness
Resolution
Earlier thought to be a self limiting disease

35. Adhesive capsulitis cont’d
•Even with appropriate treatment, it may
take 6- 12 months to resolve.
•Earlier thought that 90% of patients
recover spontaneously, however studies
have shown that 50% of patients can be
left with a motion deficit.
•No single treatment is available-
frustrating to the patient as no rapid cure
is available.

36. Adhesive capsulitis
•Painful phase can be treated with
NSAID’S failing which, intra articular
steroid injection after checking glucose
levels.
•Stiff phase- physical therapy
•MUA if no progress after self
physiotherapy.
•Failing which arthroscopic release of tight
capsular structures, followed by CPM.

37. Rotator cuff tendonitis & tears
•Commonest cause of chronic shoulder
pain in middle age and elderly.
•As common as grey hair.
•Not all tears need surgical treatment, tears
in younger patients need surgery.
MRI scans are the best diagnostic modality
in the absence of reliable Ultra sound
radiologists.

38. Treatment
Physical therapy is a waste as torn tissues
cannot heal.
If pain continues after 6 months of
conservative treatment & steroid
injections, surgical treatment is necessary.
Steroid injections are a useful mode of
therapy, but learning when and how much
and where are important considerations.

39. ANKLE AND FOOT PROBLEMS
•Ankle sprains
•Sinus tarsi syndrome
•Talar dome fracture
•Plantar fascitis
•Tendonitis of Tendo achilles and Tibialis
posterior

40. •Ankle sprains are the commonest cause of sprain- injury to the
components of the lateral ligament of the ankle occurs.
•Always rule out a fracture by x rays.
•Rule out fracture of the base of the fifth meta tarsal (Jones
fracture)
•Diagnose medial sprains early- Tibialis posterior tears – lead to
commonest cause of acquired flat foot.

41. Treatment of ankle sprains
•No POP casts.
•R- Rest
•Icing,

42. Treatment of ankle sprains
•C- compression strapping
•Elevation was the previous method.
• Ankle stretching on the night of injury,.
Cold treatment no longer preferred for
ligament sprains as it decreases blood
supply

43. Treatment of ankle sprains
•M-movement
•E-exercise
•A- analgesics ( Not Brufen, but Chymoral
to reduce inflammation and break
adhesions
•T- Treatment
•Stationary bike cycling on day 2 – 3.

44. Achilles tendonitis
•Pain 4- 6 cm above
its insertion of the
tendon.
•Degeneration is the
main etiology.
•Steroid injection is
contra indicated as it
can lead to rupture of
the tendon.

45. Plantar fascitis
•Very common cause of heel pain.
•Inflammation of the origin of the plantar fascia
from the antero medial part of the calcaneus.
•Tight Achilles tendon predisposes- patients lack
dorsi flexion beyond 90 degrees.
•Injection of steroid into the tender area followed
by stretching of the heel cord to 15 degrees
beyond neutral.
•No bare feet.

46. Resistant causes of foot pain
•Commonly seen after an ankle sprain. Consider
if pain & effusion persists 6- 8 weeks after an
ankle sprain.
Causes-
•Osteochondral fracures of the talus ( talar dome
fractures)
•Sinus tarsi syndrome
•X rays are inconclusive for talar dome fracture.
CT scans or MRI scans are useful.

47. Talar dome fractures
•Initial treatment-
walking casts
•Surgery if pain
persists.
•Cartilage surgery
regeneration of fibro
cartilage by surgical
means or by transfer
of osteo-chondral
plugs harvested from
the knee.

48. Sinus tarsi syndrome
•Sinus tarsi syndrome
– Important cause of
chronic ankle pain
after an ankle sprain.
May be due to subtle
instability of the ankle.
Pronated feet are
predisposed-

49. Treatment of sinus tarsi syndrome
•Try insoles at first
•Steroid injection into the tender area after
a trial of anti inflammatory drugs & foot
wear (Arch support) modification.

50. Chronic foot and ankle conditions
•Need early intervention as they can lead
to biomechanical failure, chronic pain and
disability.