Eric M. Kutz, D.O. Arlington Orthopedics

Harrisburg, PA

2 offices 805 Sir Thomas Court

Harrisburg 3 Walnut Street

Lemoyne

Mechanism of injury Repetitive overhead

activities Falls to the ground Falls with a catch Trying to catch something

that has fallen Pulling injuries

Injury types Subacromial

bursitis/rotator cuff strain/sprain

Rotator cuff tears AC separation Labral injuries

Pain with motion Overhead activity worst as

well as reaching Strength maintained ROM limited by pain only

Treatment NSAIDS/activity

modification/CSI Limit activity briefly +/- PT (rot. cuff strain) Minimal limitations Persistent pain = MRI

Pain/weakness/decreased ROM

Difficulty raising arm/performing ADL’s/pain at night

Initial trial of PT/NSAIDS/light duty reasonable

Rarely non-surgical by the time they reach us

Outpatient surgery Arthroscopic vs open

procedures – no difference in recovery time or rehab protocols

Usually significant pain post-op; regional block performed pre-op for pain control

Most require narcotic pain medications weeks after surgery, commonly taken as PT starts as well

Size of tear and quality of repair dictate progression of rehab and activity

Sling with abduction pillow post-op Constant x 2 weeks, remove

pillow and wear sling for next 1-2 weeks

Out of sling usually in 3-4 weeks as PT begins

0-4 weeks: PROM/pendulum exercises

At @ 4 weeks begin formal PT: PROM/AAROM x 4weeks

At @ 8-10 weeks add gentle strengthening with progression as tolerated

Recovery can take 3-6 months Return to work

One arm work/must wear sling @ 4 weeks

What do they do? Pain meds? What’s their motion like? Formal PT 3x/week

At 4 weeks sling is d/c’d, can do work at waist level- no lifting

At 8 weeks can progress activity, strengthening started

May lift all restrictions by 3 months but may take up to 6 in certain cases

“Tennis elbow” Pain about the lateral

aspect of the elbow Exacerbated by repetitive

gripping or grasping Sharp pain can

significantly limit activities “You don’t have to play

tennis to get tennis elbow”

Diagnosis Tender to palpation at the

lateral epicondyle May have tenderness into

extensor musculature Pain with resisted wrist

extension, pain with resisted supination

Typically does not require MRI for diagnosis

Conservative treatment Most cases can be

resolved conservatively Can take months, may

have flare ups NSAIDS, activity

modifications, tennis elbow brace- must wear properly, corticosteroid injections, physical therapy

Surgical management Consider after a good 4-6

months of conservative treatment

Outpatient surgery Lateral incision

Degenerated tendon debrided

Bone spur/osteophyte removed (painful)

Tendon then repaired Splinted post-operatively

Maintained 5-7 days

Recovery MUST REST Once splint removed, still

limited- no lifting >5lbs, gripping, grasping 4-6 weeks post-op

May require physical therapy, typically will last @ 4 weeks- can be initiated at 4-6 week mark post-op

Return full duty usually 6-8 weeks

Commonly called ”golfer’s elbow”

Less common Repetitive pulling, gripping,

grasping Pain about the medial aspect

of the elbow Treated very similarly-

NSAIDS, activity modification, bracing, injections

Rarely surgical Commonly resolves over 6

weeks, may have recurrences

De Quervain’s tenosynovitis 1st dorsal compartment of the

wrist includes: abductor pollicis longus (APL) and extensor pollicis brevis (EPB)

Inflammation of the tendon sheaths within the compartment due to repetitive activities Gripping, grasping, lifting,

twisting,etc. Can significantly limit

activities

Diagnosis Clinical exam: TTP over

radial aspect of wrist, painful grip, (+) Finkelstein’s test, pain only (typically no sensory changes)

Treatment NSAIDS, activity

modification, corticosteroid injection, thumb spica splint

Surgical management Outpatient procedure Splint for @ 3-5 days

post-op, splint removed, motion encouraged

Sutures removed at 10 days, advance activities

PT rarely needed, usual return to full duty by 4 weeks

Compression of the median nerve at the wrist

Can be related to repetitive use activities Typing, gripping, grasping,

etc. Pain, numbness, and

tingling into the thumb, index, and long fingers- median nerve distribution

Begins intermittently, often bothers at night

Diagnosis Clinical exam may show

diminished sensation within the median nerve distribution and pain, (+) Tinel’s test and Phalen’s test, weakness, and muscle atrophy in more severe cases

EMG/NCV positive

Treatment Activity modification,

bracing, injections(?) Surgical management

Outpatient procedure Open vs endoscopic

Higher incidence of incomplete release with endoscopic procedure

Splint for 5 days- protect wound, allow early healing, sutures out at 10 days

Recovery Typically seen in the office at 10

days post-op then @ 6 weeks Grip and pinch strength typically

normal by 6 weeks Numbness/tingling

improved/resolved very quickly Severe cases take longer to recover Occasionally require hand therapy

Return to work Office work 7-10 days

Limitations for 2-4 weeks- soreness around incision, stiffness

Heavy laborer Can take up to 6 weeks to return to

full duty

Mechanism of injury Twist/awkward

turn/variety of falls/trip over cord, hose, etc.

Direct blow, struck by something (from the front or side)

Repetitive pivoting or twisting

Meniscal/ligamentous Medial or lateral

meniscus ACL, PCL, MCL, LCL

Bony contusion/bone bruise

Fractures Tibial plateau/proximal

fibula

Symptoms Pain with pivoting or

twisting, squatting, crouching

Catching, locking, giving way

Pain with change of direction

Usually have pain in a specific area

MRI- test of choice

Types of tears Radial, horizontal

cleavage, bucket-handle, degenerative

Conservative Treatment Activity modification,

NSAIDS, corticosteroid injection

Limited success in this environment

Surgical treatment = Arthroscopy

Outpatient surgery Menisectomy vs repair

Menisectomy allows weight bearing immediately

Repair requires 4-6 weeks of NWB on crutches

Menisectomy much more common/repair in younger patients

Menisectomy 2-6 weeks Low demand/sitting jobs

patients can return 5-10 days post-op

Higher demand patients (heavy labor, plant workers, warehouse, construction, etc.) will often require light duty or other modifications for 4-6 weeks

Checked in the office @ 10 days post-op (sutures out, activities advanced, etc.), final check 4 weeks later

+/- physical therapy

Meniscus repair 4-10 weeks NWB on crutches for 1st 4-6

weeks (must avoid shear forces on repair)

Bracing Low demand patients can

still RTW during those first two weeks on crutches

Higher demand/heavy laborers will require sitting work or off work during their time of NWB

These patients typically require physical therapy

Caused by a direct blow or fall

Can sometimes accompany other injuries

Recovery typically 2-6 weeks

Non-surgical Will occasionally require

a corticosteroid injection

Questions?