Ortho/Sports Med

Ortho/Sports Med #

Home Exercise Handouts #

Area Default Theraband No Theraband
Foot Default English, Spanish -
Knee Default English, Spanish English, Spanish
Lumbar/hip Default English, Spanish English, Spanish
Thoracic/cervical Default English, Spanish -
Shoulder Default English, Spanish -
UE ROM English, Spanish - -
Wrist/elbow Default English, Spanish -
Shin Splints English, Spanish - -

Low Back/Hip #

  • FADIR
    • hip joint (same as Hawkin’s for shoulder)
    • internal rotation puts pressure on the labrum
  • FABER
    • SI vs hip, need to specify site of pain
  • SLR => radiculopathies
    • Can do “slump” test: slump down and extend leg, get’s to same place

SI Joint Pain #

  • Can be referred from low back
  • Treatment
    • PT, low back strengthening
    • Injections are helpful
      • usually want a low back MRI before to make sure it’s not the low back

Anatomy/Landmarks #

From ASIS to pubic tubercle:

  • ASIS: sartorius insertion
  • AIIS (1/3 of way to pubic tubercle): rectic femoris insertion
  • Psoas (2/3 of way to pubic tubercle) covers hip joint
  • Pubic tubercle

Shoulder #

  1. Neer’s
    • To ears
    • AC impingement
  2. Hawkin’s
    • Cross to 45deg
    • AC impingement
  3. Cross arm
    • “Tricep stretch” position
    • +/- load AC
  4. O’Brien’s
    • Positive if hurts with thumb down and better with thumb up
    • Tests labrum
  5. Bicipital groove
    • Speed’s
    • Yergason’s
  6. Thoracic outlet
    • Roo’s
    • Adson’s

AC Separation #

  • Type I
    • Pain only, no AC, no CC involvement on XR
    • RICE
    • Sling: prn
    • ROM exercises immediately as tolerated
    • Usually back to normal in a few days to up to two weeks.
    • Full clearance after 6 weeks
  • Type II
    • AC involvemend, no CC involvement on XR
    • RICE
    • Sling: 3-7 days
    • ROM exercises as tolerated
    • usually return to normal at 2-4 weeks
    • Full clearance after 6 weeks
  • Type III
    • AC and CC inolvement (CC difference >50% between sides)
    • RICE
    • Sling: for 2-3 weeks
      • PT once out of sling
    • No lifting more than a coffee for 2-3 weeks
    • Full activity at ~6 weeks
  • Type IV, V, and VI
    • Need surgery

Joint Injections #

Structure Needle Size (gauge) Needle Length 1% Lidocaine (cc) 40 mg/ml Triamcinolone (cc)
Large Joints/Bursa
IA Knee 22 1.5" 4 2
IA Glenohumeral 22 1.5" 4 2
Subacromial Bursa 22 1.5" 4 2
Greater Trochanteric Bursa 22 1.5", spinal if obese 4 2
Small/Medium
AC Joint 22 1" 1 0.5
Ankle joint 22 1.5" 2 1
Biceps Tendon 22 1.5" 2 1
Carpal Tunnel 22 1" 1 1
De Quervain Tendon 22 1" 1 0.5
Elbow Epicondyle 22 1.5" 1 0.5
Finger/Toe Joint 22 1" 0.25 0.25
Ganglion Wrist 18 1.5" 0.5 0.5
Lumbar Facet Spinal Spinal 2 2
Meralgia Paresthetica 22 1" 2 1
Morton’s Neuroma 22 1" 1 0.5
Prepatellar/Olecranon bursa 22 1" 2 1
Pes Anserine Bursa 22 1.5" 2 1
Plantar Fascia 22 1.5" 2 1
Sacroilliac Joint 22 1.5" 2 2
Trigger Finger 25 1" 0.5 0.5
Trigger Point (1-2 ml per TP) 22 1" 2 8
Wrist Joint 22 1" 1 1
Injection Position Landmark Needle Direction
Subacromial Sitting 2cm medial to posterior-lateral corner of acromion, Feel for soft spot just inferior to spine of scapula. Parallel to Floor towards AC joint. Bury needle.
Glenohumeral Sitting 2cm medial to posterior-lateral corner of acromion, Feel for soft spot just inferior to spine of scapula. Parallel to Floor towards Coracoid. Bury needle.
Knee Superior Lateral Supine 1 cm posterior and superior to superior lateral corner of patella (posterior to quad tendon in soft spot) Parallel to Floor, perpendicular to long axis of femur from lateral to medial. Bury needle.
Knee Lateral Sitting, cross Feet with leg to be injected on top “soft spot” lateral to patella tendon, superior to tibia, inferior to femur Parallel to floor directed 45 degree medially towards middle of joint. Bury needle.
Pes Anserine Bursa Supine Most tender point over proximal anterior medial tibia Perpendicular to bone. Tap bone and pull back 1-2 mm and inject.
Greater Trochanter Supine on side opposite injection Most tender bony spot over Greater Trochanter Towards Greater Trochanter, Tap Bone, pull back 1-2 mm and inject
Carpal Tunnel Supine Ulnar to Palmaris Longus Tendon if they have one (Bring pinky and thumb together and flex wrist) and 1/2 cm proximal to distal palmar crease. If they don’t have one in line with 4th finger radial to ulnar artery. 45 degrees degree distally toward tip of index finger to depth of 0.5 inches
De Quervain Tendon Supine or sitting, karate chop position (5th Metacarpal down) In-between Extensor Pollicis Brevis and Abductor Pollicis Longus Tendon 1cm proximal to distal aspect of Radial Styloid 45 degrees Proximal to Distal towards radial styloid, parallel to tendons until pierce tendon (1/4 inch). If unable to inject you are in tendon. With pressure on syringe slowly retract needle until medicine flows freely.
Lateral Epicondylitis Supine, arm at side with elbow flexed 45 degrees and wrist supinated Most tender point over Common Flexor or Extensor tendon just distal lateral epicondyle. Find flexor tendon by flexing wrist against resistance. Find extensor tendon by extending middle finger against resistance. Directly perpendicular and into tendon (appx 1/2 to 3/4 inch).
Medial Epicondylitis Supine, arm abducted with elbow flexed 45 degrees and wrist pronated Most tender point over Common Flexor or Extensor tendon just distal medial epicondyle. Find flexor tendon by flexing wrist against resistance. Find extensor tendon by extending middle finger against resistance. Directly perpendicular and into tendon (appx 1/2 to 3/4 inch)
Trapezius Trigger Point Sitting Painful and palpable trigger point Directly perpendicular into muscle until the needle recreates their pain (appx ½ to 1 inch). Inject 1-2 ml per TP.
Trigger Finger Sitting with palm up Midline and Midshaft of volar proximal phalanx directly perpendicular to long axis of flexor tendon, tap bone and inject

Risks #

  • 1 in 4,000 (0.025%) risk of infection
    • If injecting intraarticularly, infection is an emergency
    • Usually show up in 24-48 hours following an injection.
  • Steroid Flare
    • Increased pain first 24 hours after injection due to reaction with steroid
      • lower chance with triamcinolone or Depo-Medrol
  • Nerve and Blood Vessel Damage (know your anatomy and aspirate if needed prior to injection)
  • Fat atrophy for superficial injections
    • Dexamethasone has lower chance of fat atrophy

MSK Ultrasound (European Society of MSK Ultrasound) #

Resources #