Knee and shoulder pain are common complaints for patients in the primary care office.
But identifying the source of the pain can be complicated, and an accurate diagnosis of the underlying cause of discomfort is key to appropriate management whether that involves simple home care options of ice and rest or a recommendation for a follow-up with a specialist.
Speaking at the 2022 American College of Physicians Internal Medicine Meeting, Greg Nakamoto, MD, Department of Orthopedics, Virginia Mason Medical Center, Seattle, Washington, discussed common knee and shoulder problems that patients often present with in the primary care setting, and offered tips on diagnosis and appropriate management.
The most common conditions causing knee pain are osteoarthritis and meniscal tears. "The differential for knee pain is broad," Nakamoto said. "You have to have a way to divide it down, such as if it's acute or chronic."
The initial workup has several key components. The first steps: Determine the location of the pain anterior, medial, lateral, posterior and then whether it stems from an injury or is atraumatic.
"If you have to ask one question ask where it hurts," he said. "And is it from an injury or just wear and tear. That helps me when deciding if surgery is needed."
Pain in the knee generally localizes well to the site of pathology, and knee pain of acute traumatic onset requires more scrutiny for problems best treated with early surgery. "This also helps establish whether radiographic findings are due to injury or degeneration," Nakamoto said. "The presence of swelling guides the need for antiinflammatories or cortisone."
Palpating for tenderness along the joint line is important, as is palpating above and below the joint line, Nakamoto said.
"Tenderness limited to the joint line, combined with a meniscal exam maneuver that reproduces joint line pain, is suggestive of pain from meniscal pathology," he said.
Imaging is an important component of evaluating knee symptoms, and the question often arises as to when to order an MRI.
Nakamoto offered the following scenario: If significant osteoarthritis is evident on weightbearing x-ray, treat the patient for the condition. However, if little or no osteoarthritis appears on x-ray, and if the onset of symptoms was traumatic and both patient history and physical examination suggest a meniscal tear, order an MRI.
An early MRI also is needed if the patient has had either atraumatic or traumatic onset of symptoms and their history and physical exams are suspicious for a mechanically locked or locking meniscus. For suspicion of a ruptured quadriceps or patellar tendon or a stress fracture, an MRI is needed urgently.
An MRI would be ordered later if the patient's symptoms have not improved significantly after three months of conservative management.
Nakamoto stressed how common undiagnosed meniscus tears are in the general population.A third of men aged 50-59 years and nearly 20% of women in that age group have a tear, he said. "That number goes up to 56% and 51% in men and women aged 70 to 90 years, and 61% of these tears were in patients who were asymptomatic in the last month."
In the setting of osteoarthritis, 76% of asymptomatic patients had a meniscus tear and 91% of patients with symptomatic osteoarthritis had a meniscus tear, he added.
Treatment will vary depending on the underlying etiology of pain. For a possible meniscus tear, the recommendation is for a conservative intervention with ice, ibuprofen, knee immobilizer, and crutches, with a follow-up appointment in a week.
Three types of injections also can help:
Cortisone for osteoarthritis or meniscus tears, swelling, and inflammation, and prophylaxis against inflammation
Viscosupplementation (intraarticular hyaluronic acid) for chronic, baseline osteoarthritis symptoms
Regenerative therapies (platelet-rich plasma, stem cells, etc) are used primarily for osteoarthritis (these do not regrow cartilage, but some patients report decreased pain)
The data on injections are mixed, Nakamoto said. For example, the results of a 2015 Cochrane review on cortisone injections for osteoarthritis reported that the benefits were small to moderate at 46 weeks, and small to none at 13 weeks.
"There is a lot of controversy for viscosupplementation despite all of the data on it," he said. "But the recommendations from professional organizations are mixed."
He noted that he has been using viscosupplementation since the 1990s, and some patients do benefit from it.
The most common causes of shoulder pain are adhesive capsulitis, rotator cuff tears and tendinopathy, and impingement.
As with knee pain, the same assessment routine largely applies.
First, pinpoint the location: Is the trouble spot the lateral shoulder and upper arm, the trapezial ridge, or shoulder blade?
Next, assess pain on movement: Does the patient experience discomfort reaching overhead or behind the back, or moving at the glenohumeral joint/capsule and engaging the rotator cuff? Check for stiffness, weakness, and decreased range of motion in the rotator cuff.
Determine if the cause of the pain is traumatic or atraumatic and stems from an acute injury versus degeneration or overuse.
As with the knee, imaging is a major component of the assessment and typically involves the use of x-ray. An MRI may be required for evaluating full- and partial-thickness tears and when contemplating surgery.
MRI also is necessary for evaluating cases of acute, traumatic shoulder injury, and patients exhibiting disability suggestive of a rotator cuff tear in an otherwise healthy tendon.
Some pain can be treated with cortisone injections or regenerative therapies, which generally are given at the acromioclavicular or glenohumeral joints or in the subacromial space. A 2005 meta-analysis found that subacromial injections of corticosteroids are effective for improvement for rotator cuff tendinitis up to a 9month period.
Surgery may be warranted in some cases, Nakamoto said. These include adhesive capsulitis, rotator cuff tear, acute traumatic injury in an otherwise healthy tendon, and chronic (or acute-on-chronic) tears in a degenerative tendon following a trial of conservative therapy.
Office Orthopedics for the Internist: Common Knee and Shoulder Problems. American College of Physicians (ACP-IM) Internal Medicine Meeting 2022. Presented April 29, 2022.
Roxanne Nelson is a registered nurse and an award-winning medical writer who has written for many major news outlets and is a regular contributor to Medscape.
For more news, follow Medscape on Facebook, Twitter, Instagram, YouTube, and LinkedIn.
Originally posted here:
'Where Does It Hurt?': Primary Care Tips for Common Ortho Problems - Medscape
- Stem Cell Therapy Virginia | Stem Cell Treatments [Last Updated On: August 22nd, 2014] [Originally Added On: August 22nd, 2014]
- Virginia Stem Cell Treatments | Stem Cell Treatments [Last Updated On: August 22nd, 2014] [Originally Added On: August 22nd, 2014]
- About Us - StemCell ARTS - Stem Cell Therapy and PRP for ... [Last Updated On: August 22nd, 2014] [Originally Added On: August 22nd, 2014]
- Virginia (Stem Cell) - what-when-how [Last Updated On: August 22nd, 2014] [Originally Added On: August 22nd, 2014]
- Posts Tagged virginia - virginia StemCell Doctors [Last Updated On: August 29th, 2014] [Originally Added On: August 29th, 2014]
- Williamsburg Stem Cell Therapy, Stem Cell Therapy ... [Last Updated On: September 25th, 2014] [Originally Added On: September 25th, 2014]
- Virginia Beach Stem Cell Therapy, Stem Cell Therapy ... [Last Updated On: September 25th, 2014] [Originally Added On: September 25th, 2014]
- Stem Cells Symptoms, Causes, Treatment - Fetal stem cells ... [Last Updated On: September 27th, 2014] [Originally Added On: September 27th, 2014]
- Cell Stem Cell Protocol Review - Medicine School of ... [Last Updated On: September 27th, 2014] [Originally Added On: September 27th, 2014]
- Why Didn't They Win? 10 Huge Discoveries Without a Nobel Prize [Last Updated On: October 9th, 2014] [Originally Added On: October 9th, 2014]
- Misfolded Proteins Clump Together in a Surprising Place [Last Updated On: October 16th, 2014] [Originally Added On: October 16th, 2014]
- Ridiculously tiny stomachs created for disease experiments [Last Updated On: October 30th, 2014] [Originally Added On: October 30th, 2014]
- Billionaire's New Science Institute Plans 'Google Maps' View Of Cells [Last Updated On: December 9th, 2014] [Originally Added On: December 9th, 2014]
- Stem cells and cell adaptations to particular functions [Last Updated On: December 19th, 2014] [Originally Added On: December 19th, 2014]
- The Week That Was: Bear Down [Last Updated On: December 22nd, 2014] [Originally Added On: December 22nd, 2014]
- Most cancers are just bad luck, others from bad genes, environment [Last Updated On: January 20th, 2015] [Originally Added On: January 20th, 2015]
- New ACL Preservation at G2 Orthopedics and Sports Medicine [Last Updated On: February 20th, 2015] [Originally Added On: February 20th, 2015]
- NASA awards UCI $9 million to study underlying mechanisms of 'space brain' [Last Updated On: March 18th, 2015] [Originally Added On: March 18th, 2015]
- Stem Cell Transplantation - Virginia Cancer [Last Updated On: October 30th, 2016] [Originally Added On: October 30th, 2016]
- Regenerative Medicine Research - Virginia-Maryland College ... [Last Updated On: October 30th, 2016] [Originally Added On: October 30th, 2016]
- Home - StemCell ARTS [Last Updated On: October 30th, 2016] [Originally Added On: October 30th, 2016]
- Stem Cell Therapy for Neck & Back Pain - DC Metro Area [Last Updated On: November 23rd, 2016] [Originally Added On: November 23rd, 2016]
- U.Va. Smashes Barrier to Growing Organs from Stem Cells ... [Last Updated On: November 23rd, 2016] [Originally Added On: November 23rd, 2016]
- Tests show no signs of cancer for Danville 2-year-old - GoDanRiver.com [Last Updated On: July 6th, 2017] [Originally Added On: July 6th, 2017]
- Everything's a hustle in Orphan Black episode 5.5 - SYFY WIRE (blog) [Last Updated On: July 9th, 2017] [Originally Added On: July 9th, 2017]
- Grant supports 3D innovation in stem cell-related cancer research at ODU - Southside Daily [Last Updated On: August 5th, 2017] [Originally Added On: August 5th, 2017]
- Roanoke researchers pursue treatments for the type of deadly brain cancer affecting McCain - Richmond.com [Last Updated On: August 5th, 2017] [Originally Added On: August 5th, 2017]
- John Theurer Cancer Center and MedStar Georgetown University Hospital Announce 100 - Business Wire (press release) [Last Updated On: August 5th, 2017] [Originally Added On: August 5th, 2017]
- SpaceX Dragon Delivers Supplies (and Science) to Space Station - Space.com [Last Updated On: August 19th, 2017] [Originally Added On: August 19th, 2017]
- Stem Cell Therapy Hair Growth | McLean | Virginia Surgical ... [Last Updated On: October 15th, 2017] [Originally Added On: October 15th, 2017]
- Stem Cell Therapy - Virginia Spine Institute [Last Updated On: July 11th, 2018] [Originally Added On: July 11th, 2018]
- PRP & Stem Cell Treatment in Richmond VA - Dr. Bill Nordt ... [Last Updated On: July 11th, 2018] [Originally Added On: July 11th, 2018]
- Stem Cells Lynchburg VA | Stem Cell Recovery SW Virginia [Last Updated On: July 24th, 2018] [Originally Added On: July 24th, 2018]
- Stem Cell Transplantation at Virginia Oncology Associates [Last Updated On: November 23rd, 2018] [Originally Added On: November 23rd, 2018]
- Stem Cell Richmond Virginia 23230 [Last Updated On: January 5th, 2019] [Originally Added On: January 5th, 2019]
- Virginia Beach VA 23460 - National Stem Cell Therapy [Last Updated On: February 22nd, 2019] [Originally Added On: February 22nd, 2019]
- Stem Cell Injections Richmond, Virginia | Alternative to ... [Last Updated On: February 24th, 2019] [Originally Added On: February 24th, 2019]
- Stem Cell Therapy in Dallas, TX | National Stem Cell Centers [Last Updated On: March 5th, 2019] [Originally Added On: March 5th, 2019]
- Top 25 Most Haunted Places in Virginia - Colonial Ghosts [Last Updated On: May 13th, 2019] [Originally Added On: May 13th, 2019]
- Dr. Christopher Good | Spinal Surgeon | Virginia Spine [Last Updated On: May 13th, 2019] [Originally Added On: May 13th, 2019]
- Oliver and Elizabeth Hedgepeth column: Human donations are a gift of life - Richmond.com [Last Updated On: November 25th, 2019] [Originally Added On: November 25th, 2019]
- Brown fat warms your body in cold weather | NOVA - NOVA Next [Last Updated On: December 30th, 2019] [Originally Added On: December 30th, 2019]
- Q&A: Cancer Death Rates Are Falling Nationally. Here's What's Happening at UVA - University of Virginia [Last Updated On: January 11th, 2020] [Originally Added On: January 11th, 2020]
- Bent into shape: The rules of tree form - Knowable Magazine [Last Updated On: February 4th, 2020] [Originally Added On: February 4th, 2020]
- First-of-its-Kind Bio-Artificial Pancreas on Track for Type-I Diabetes Cure - Global Trade Magazine [Last Updated On: February 8th, 2020] [Originally Added On: February 8th, 2020]
- Focused Ultrasound Opening Brain to Previously Impossible Treatments - University of Virginia [Last Updated On: May 12th, 2020] [Originally Added On: May 12th, 2020]
- Surrozen reloads with $50M for final dash to the clinic, shines some light on lead Wnt-modulating candidates - Endpoints News [Last Updated On: June 20th, 2020] [Originally Added On: June 20th, 2020]
- Landmark transplant in 1960s Virginia performed with heart stolen from a Black man - Live Science [Last Updated On: August 12th, 2020] [Originally Added On: August 12th, 2020]
- WVU assistant professor receives $3 million to study impacts of air pollution on lungs - The Daily Athenaeum - thedaonline [Last Updated On: August 31st, 2020] [Originally Added On: August 31st, 2020]
- Alleged unwanted hysterectomies and other abuses at ICE facility prompts investigation - USA TODAY [Last Updated On: September 18th, 2020] [Originally Added On: September 18th, 2020]
- Talaris Therapeutics Announces Collaboration With Kentucky Organ Donor Affiliates to Advance Preclinical Study of Tolerance Induction to Organs From... [Last Updated On: September 18th, 2020] [Originally Added On: September 18th, 2020]
- U.S. elections bring wins and losses for research community - Science Magazine [Last Updated On: November 5th, 2020] [Originally Added On: November 5th, 2020]
- Viewpoint: Rightwing packing on Supreme Court means ERA more crucial than ever to protect Women's Rights - Blog - The Island Now [Last Updated On: November 5th, 2020] [Originally Added On: November 5th, 2020]
- Anatomy of a vaccine: What it takes to create a safe, effective COVID shot - University of California [Last Updated On: December 9th, 2020] [Originally Added On: December 9th, 2020]
- Novel Bone Marrow 'Ingredient' To Help Arthritic Horses The Horse - TheHorse.com [Last Updated On: February 7th, 2021] [Originally Added On: February 7th, 2021]
- Study: Israeli-made anti-COVID nasal spray reduced infection at mass gathering - The Times of Israel [Last Updated On: February 23rd, 2021] [Originally Added On: February 23rd, 2021]
- Clint Smith's 'How The Word Is Passed' And Race History - NPR [Last Updated On: June 6th, 2021] [Originally Added On: June 6th, 2021]
- Habitable Earth an anomaly? Awardees of STEM grants study this and more | University of Hawaii System News - UH System Current News [Last Updated On: June 6th, 2021] [Originally Added On: June 6th, 2021]
- Pollution could be sucking the youth out of you, quite literally - ZME Science [Last Updated On: June 23rd, 2021] [Originally Added On: June 23rd, 2021]
- Plug-and-play organ-on-a-chip can be customized to the patient - EurekAlert [Last Updated On: May 2nd, 2022] [Originally Added On: May 2nd, 2022]
- What it's like to compete in the science fair 'Olympics' - Science News for Students [Last Updated On: May 15th, 2022] [Originally Added On: May 15th, 2022]
- PARP Inhibitors Are Under Study as Treatment Options Beyond BRCA-Mutated Breast Cancer - OncLive [Last Updated On: May 15th, 2022] [Originally Added On: May 15th, 2022]
- With Supreme Court Failing California, Is It Time to Go on Our Own? - zocalopublicsquare.org [Last Updated On: July 11th, 2022] [Originally Added On: July 11th, 2022]
- DiPersio receives awards recognizing contributions to cancer care, research Washington University School of Medicine in St. Louis - Washington... [Last Updated On: July 27th, 2022] [Originally Added On: July 27th, 2022]
- Long COVID-19 and other chronic respiratory conditions after viral infections may stem from an overactive immune response in the lungs - Huron Daily... [Last Updated On: August 5th, 2022] [Originally Added On: August 5th, 2022]
- Long COVID-19 May Stem From an Overactive Immune Response in the Lungs - SciTechDaily [Last Updated On: October 13th, 2022] [Originally Added On: October 13th, 2022]