#274 MSK Triple Distilled: Shoulder, Elbow, Hip, Knee

May 17, 2021 | By Molly Heublein

Dominate MSK complaints in primary care! A packed recap from our past musculoskeletal episodes, triple distilled to what you need to know.  Learn some buckets to consider when addressing knee pain, just how simple hip complaints are, when to urgently refer shoulder problems, and easy exam maneuvers to differentiate elbow pain.  Use our simple framework to help with the top diagnoses walking into your primary care clinic. 

Credits

• Written and Produced by: Molly Heublein, MD
• Show Notes by: Molly Heublein, MD
• Cover Art and Infographics: Matthew Watto
• Hosts: Stuart Brigham MD; Molly Heublein, MD Matthew Watto MD, FACP; Paul Williams MD, FACP  
• Editor: Emi Okamoto MD, FACP; Clair Morgan of nodderly.com (audio)

Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME!

Sponsor: GeriPal GeriPal.org

Subscribe on Apple Podcasts, Spotify, or wherever you consume podcasts.

Sponsor: Birch by Helix birchliving.com/curb

Birch is giving $200 dollars off ALL mattresses and 2 free eco-rest pillows at birchliving.com/curb

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

Show Segments

• Intro, disclaimer
• Case from Kashlak- general orthopedic complaints
• Yellow flags
• Case from Kashlak Knee
• 4 buckets of knee pain
• Ligamentous injury
• Meniscus
• Patellofemoral
• Knee exam
• Knee Imaging
• Osteoarthritis treatment
• Case from Kashlak: hip
• Three steps to hip diagnosis
• Case from Kashlak: Shoulder
• Case from kashlak: elbow
• Take-home points

Musculoskeletal Pearls

1. In assessing non-traumatic joint pain in patients, focus on age, gender and risk factors, differentiate between centralized vs. peripheral pain and look out for yellow flags. 
2. Use the 4 buckets to evaluate non-traumatic knee cases: osteoarthritis, patellofemoral pain, meniscus tears and ligamentous injuries.  
3. Order three plain view radiographs if you decide to get knee xrays for OA: (sunrise/merchant view (most helpful for PF OA), standing WB AP views, standing at 30 degree flexion (good for posterior OA). 
4. When evaluating for hip pain, first consider the windshield wiper test to rule out hip osteoarthritis, second lateral for greater trochanteric bursitis and third rule out back pain 
5. Age and comorbidities are keys to differentiating shoulder pain, adhesive capsulitis and rotator cuff tears are most common in middle-aged women, tendonitis in younger patients and shoulder osteoarthritis in older patients.

MSK Notes 

Osteoarthritis: #177 with Dr Neogi

The History

Focus on age, gender, and risk factors/comorbidities to help narrow your differential rather than the super detailed history we typically take in internal medicine.  

Osteoarthritis is total joint failure.(Katz JAMA 2021)

Think about the whole person- try not to miss centralized pain disorders. Be aware of Yellow Flags which were traditionally applied to back pain, but when present suggest a patient might not respond as well to traditional therapy.  These include a belief that the pain is harmful/catastrophizing, fear avoidance, a belief that passive treatment is better, and/or an underlying mood disorder.

Knee: #98 with Dr Parks

Rule out emergency things like a septic joint.

4 buckets of knee: 

Ligamentous Injury:  The ACL is about the thickness of your pinky finger, so tears tend to be high impact traumas.  Without a history of significant injury or findings of laxity on exam by checking anterior/posterior drawer or Lachman’s test, ligamentous tears are unlikely.   

Meniscal Injury: On exam, patients present with focal pain with full knee flexion, tenderness along joint line, a positive McMurray test, and/or positive Thessaly test.  Many patients will improve with time/physical therapy, so no need to address emergently.  Younger patients may benefit from arthroscopy if not improving with conservative treatment; in older patients meniscal tears are part of osteoarthritis, so arthroscopy is less helpful (Mordecai WJO 2014).  

Osteoarthritis: tends to be chronic, bilateral, but symptoms may flare after a small injury. 

Patellofemoral Joint Issues:  Patellofemoral syndrome or patellofemoral OA.  Anterior diffuse knee pain, worse with sitting for too long or walking downstairs.  On exam, you may palpate crepitus under their patella while they flex and extend their knee, full range of motion (ROM) can elicit worse pain on side of condition. 

None of the above: Bursitis (localized tenderness and external joint swelling) or iliotibial band injuries

Knee Exam:

Check out Dr. Park’s 30 sec knee exam

Crepitis is unfortunately an insensitive marker for OA.  Bony enlargement on exam has very high positive likelihood ratio of 11 for OA (though is probably a late finding). (Katz JAMA 2021)

Knee Imaging: 

If you are going to get xrays, order a sunrise/merchant/sub-patellar view (most helpful for PF OA), standing Weight Bearing AP, and standing at 30 degree flexion (good for posterior OA).  Don’t order the knee series 3+ views without specifying.

General Osteoarthritis Treatment:

Patient education is important (slow progression of disease, importance of exercise, weight loss).  Osteoarthritis is “total joint failure” and lifestyle measures may reduce inflammation or reduce central pain beyond just the mechanical benefits of weight loss.  Physical therapy can help significantly improve arthritis pain. 

Pharmacological therapy: acetaminophen has low evidence of benefit.  Topical diclofenac is a safe option to try. Duloxetine can be an option for select patients. Steroid injections: trial data does not show significant benefit (physical therapy was superior), but for select patients it may help. In advanced cases, referral to orthopedics to consider joint replacement. (Deyle NEJM 2020, Katz JAMA 2021)

Hip: #149 with Dr Parks

Three Steps to approach hip pain:

Step 1- Look for OA: primary symptom is pain localizing to the groin, check for ROM with the windshield wiper test– if limited indicative of hip OA.  Treat like knee osteoarthritis, physical therapy, consider replacement in older patients.

Step 2 – Check for Greater Trochanteric Pain Syndrome: Lateral pain over the greater trochanter indicative of greater trochanteric pain syndrome/bursitis.

Step 3 – Rule out Low Back Pain: this is more buttock/posterior pain (Parks 2017)

Hip Exam:

Check out Dr Parks’ 8 Second Hip Exam.  

Imaging for Hip OA: 

Radiographs are not required for OA diagnosis, but can help confirm OA/rule out less common things like avascular necrosis.  If imaging, order an AP pelvis, which gives you both hips- allowing a nice comparison between the symptomatic side and the patient’s contralateral which Dr Parks likes to use as a “control”.  Dr Neogi highlighted her study showing that between patients severity of OA symptoms does not correlate with xray findings, but within a single patient severity between joints does correlate (Neogi BMJ 2009).  

Shoulder: #124 with Dr Senter

Narrow down by age and comorbidities:

Younger patients (under 40) commonly get tendonitis.

Middle age patients commonly get frozen shoulders (women and patients with type 2 diabetes are higher risk) and rotator cuff tears (atraumatic).

Older patients (80-90 years) often present with glenohumeral osteoarthritis.

Shoulder Exam:

Rule out radicular neck pain which will get better when the patient places their hand on their head, whereas shoulder pain is often worse with shoulder rotation to raise the hand.

Check out our Shoulder Exam with Dr Senter.

Limited passive ROM vs. normal ROM are bucket defining: 

Limited passive ROM is consistent with osteoarthritis vs adhesive capsulitis.  An xray can help differentiate since it will be normal in adhesive capsulitis but may show osteoarthritis changes in OA.

One challenge is that when a patient is in significant pain, it can be difficult to fully assess range of motion, so you may be tricked early on- reassess after better pain control. 

The natural history of adhesive capsulitis is that it resolves on its own, so treatment is focused on symptom relief (treatments do not seem to speed recovery).  Expect 6-9 months of pain, 6-9 months of stiffness and 6-9 months of “thawing” to get back to baseline (Risk 1982). 

If the patient has full range of motion you are dealing with rotator cuff disease.  Goal here is to rule out a full-thickness rotator cuff tear.  On exam, check for weakness (which suggests full rotator cuff tears)- these patients should be referred for surgery (Mukovozov 2013).  If there is no weakness and normal ROM, most likely diagnosis is partial rotator cuff tear or impingement syndrome, which respond well to conservative therapies. 

Elbow: #240 with Dr Parks

Epicondylitis: 

On exam, you will find tenderness focally over the affected epicondyle. A resisted maneuver can help you confirm- hold arms out in full extension, palms down and resist dorsiflexion/extension- this will trigger lateral epicondyle pain; hold arms out in full extension palms up and resist wrist flexion- this will trigger medial epicondyle pain. Here is Dr Parks demonstrating the exam and some stretches.   None of our treatments clearly impact long term recovery, this is a self-limited condition.  Treatment is aimed at pain relief- topical nsaids, ice, physical therapy, bracing. 

Olecranon bursitis:  Easy to diagnose with swollen bursa visible on exam.

Radial Head fracture: after a fall on an outstretched arm.

Easy to differentiate septic elbow joint from inflamed bursitis.  Both will cause pain on flexion of the elbow, but in inflamed olecranon bursitis there will not be pain with elbow supination/pronation while a septic elbow will be extremely painful to supinate/pronate.

Closing Points 

• Primary care can treat many orthopedic complaints, but if a patient is not improving as expected, ortho consult is suggested. 

Goal

Listeners develop an approach to the diagnosis and management of common MSK complaints relating to the knee, hip, shoulder, and elbow.

Learning objectives

After listening to this episode listeners will…  

1. Identify patients with focal joint pains who may have a more central pain condition
2. Describe the pathophysiology of osteoarthritis
3. Diagnose and treat a patient with knee osteoarthritis
4. Differentiate hip arthritis from trochanteric bursitis and referred hip pain.
5. Identify patients who need urgent surgical consultation for shoulder pain
6. Describe the expected course for epicondylitis

Disclosures

Drs. Brigham, Heublein, Watto, and Williams report no relevant financial disclosures. 

Citation

Heublein MR, Watto MF, Williams PN, Brigham SK. “#274 MSK Triple Distilled”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date May 17, 2021.

Recommended References

1. #98: Knee Pain: History, exam, bracing, x-rays, and injectables with Ted Parks, MD.  The Curbsiders Podcast, June 4, 2018.
2. #124 The Shoulder – Simplify Your Approach with Carlin Senter, MD.  The Curbsiders Podcast, November 12, 2018.
3. #149: Hip Pain for Primary Care with Ted Parks, MD.  The Curbsiders Podcast, May 6, 2019.
4. #177 Osteoarthritis Master Class with Tuhina Neogi MD, PhD.  The Curbsiders Podcast, October 14, 2019.
5. #240 Elbow Pain: Straighten it out with Ted Parks, MD.  The Curbsiders Podcast, November 2, 2020.
6. Dr. Park’s 30 sec knee exam
7.  Dr Parks’ 8 Second Hip Exam
8. Shoulder Exam with Dr Senter
9. Dr Parks demonstrating the elbow anatomy,  exam and some epicondylitis stretches
10. 2019 ACR Osteoarthritis Guidelines
11. Katz JN, Arant KR, Loeser RF. Diagnosis and Treatment of Hip and Knee Osteoarthritis: A Review. JAMA. 2021;325(6):568–578. doi:10.1001/jama.2020.22171