Shoulder Anatomy

from orthoinfo.aaos.org

from orthoinfo.aaos.org

The shoulder joint is a complicated joint.

It is made up of three bones: the scapula (shoulder blade), the clavicle (collarbone) and the humerus (upper arm bone). The true shoulder joint is where the shoulder blade meets the upper arm bone.

A second joint exists where the collarbone meets the shoulder blade on the top and front of the shoulder and is called the AC or acromioclavicular joint. When people refer to a shoulder separation, it is really the AC joint that has been injured, not the true ball and socket (glenohumeral) joint of the shoulder. A third joint exists where the shoulder blade sits on the back of the ribcage called the scapulothoracic joint.

The shoulder joint is unique in that it can move in almost every direction, unlike the knee that just straightens and bends. The large ball on the relatively flat socket is what allows the shoulder such unrestricted motion.

What keeps the humeral head (the ball) on the flat surface of the glenoid (socket) is the muscles, tendons, and ligaments that surround the head plus a lip of cartilage (labrum) that surrounds and extends the socket to help contain the head.

The rotator cuff is a group of 4 muscles that converge on the outside of the shoulder to help elevate and rotate the arm. The tendinous attachment of these tendons to the upper arm bone is called the rotator cuff. The long head of the biceps tendon also runs over the top of the shoulder and attaches to the upper part of the socket through the upper labrum.

Between the top of the shoulder blade (the acromion) and the rotator cuff and biceps tendons is a large fluid filled sack called the bursa. It is normally quite thin and helps allow these tissues to slide under the acromion without rubbing or abrading.

Arthritis of the Knee

arthritisknee1-300x164What is arthritis of the knee?
Arthritis of any joint is when there is inflammation and damage to the normal joint surface. The normal articular cartilage is smooth and firm. With arthritis, the surface of the joint becomes pitted, eroded, and irregular causing swelling and pain. There are many types of arthritis.

The most common type of arthritis is osteoarthritis, or wear and tear that is seen in older individuals. Another form of arthritis is rheumatoid arthritis. It is commonly involves multiple joints, especially in the hands and wrists.

It can occur at any age. One more common form of arthritis is post-traumatic arthritis. It follows an injury to the surfaces, the meniscus, or the ligaments, which makes the joint susceptible to arthritis often many years after the injury.

Symptoms
Patients with arthritis typically describe pain and stiffness, especially with the first few steps after getting up from a chair or first thing in the morning. In the early stages of arthritis, the knee is often swollen, and even warm to the touch. After years of having arthritis, the knee rarely swells, but it becomes more difficult to fully straighten or bend the knee. Arthritic knees are painful with activity.

Diagnosis
kneearthritis2-300x140The physician’s work-up will start with a careful history and exam. A history of prior injury, pain, stiffness and swelling may suggest arthritis. The exam often shows some swelling and decreased range of motion. Sometimes, patients develop deformities if one side of the knee wears out more than the other side.

The legs can then appear “knock-kneed” or “bow-legged.” X-rays are usually the key in determining the extent of the arthritis. Arthritic knees show loss of normal joint space, cysts and bone spurs on x-ray.

Treatment
Early treatment of arthritis may involve non-steroidal anti-inflammatories, ice, rest, injections and activity modification. If these methods are not satisfactory in keeping a patient from becoming sedentary, surgery is often discussed. Ideally for surgery, patients should be in their mid-60s (current knee replacements last about 20 years or more so are not ideal for those in their 40s or 50s), able to walk only a block or two (considered sedentary), and experience pain at night (effecting quality of life).

However, as techniques and materials become better, physicians are considering knee replacements in younger and younger patients.

Surgical options for arthritis range from arthroscopic debridement (cleaning out the loose pieces and smoothing the surfaces), osteotomies (cutting a wedge out of the bone above or below the knee to try to throw more of the weight onto the better half of the knee), cartilage replacement (transferring plugs of bone and cartilage to the involved areas), to partial or total knee replacements in which the arthritic surfaces are removed and replaced with metal and plastic surfaces.

Your orthopedist will have a thorough discussion with you about which surgical option is best for you, and discuss the risks and benefits of the surgery with you.

Osgood-Schlatter Disease

What is Osgood-Schlatter Disease?
Osgood-Schlatter Disease is a condition that occurs in adolescents that involves pain and inflammation that occurs where the patellar tendon attaches to the lower let bone (tibia). It is commonly seen during a sports season that involves running and jumping (basketball, soccer, track).

osgood-300x252Diagnosis
The diagnosis is usually made by identifying swelling and tenderness at the attachment of the patellar tendon to the front of the tibia. Often a bump is present at that location. Occasionally x-rays will reveal a bony prominence or sometimes an extra piece of bone where the patellar tendon attaches to the tibia.

MRI scans are not usually necessary to help make the diagnosis in these patients.

Treatment
Surgery is almost never needed, as most cases of Osgood-Schlatter Disease will resolve as one reaches the end of adolescence. Often, activity restrictions are necessary to help resolve the symptoms. Warming up and stretching before activities and icing after can be helpful. Non-steroidal anti-inflammatories are sometimes necessary to help with the discomfort.

Patellofemoral Pain and Instability

patellar1-300x300Anatomy
The kneecap (or patella) is a small bone that sits in front of the knee and provides mechanical advantage for our extensor mechanism (quadriceps muscles) in helping one straighten out there knee. The quadriceps tendon attaches to the upper pole of the kneecap and the patellar tendon attaches to the lower pole of the kneecap.

Normally the kneecap glides smoothly in a groove on the front of the femur (thigh bone). The Back of the kneecap and the front of the femoral groove are coated with smooth cartilage that allows the kneecap to glide smoothly.

What is patellofemoral pain?
Patellofemoral pain is a generic term for pain that occurs in the front of the knee. It can result from wearing or arthritis of the joint surface on the back of the kneecap, overuse, malalignment, muscle imbalance, flat feet (pronation) or trauma to the kneecap.

Symptoms
Most patients with patellofemoral pain complain of discomfort in the front of the knee that is worsened with stairs, inclines, sitting for long periods of time, squatting or kneeling, or even with prolonged standing. Occasionally patients report swelling, especially after rigorous activity or episodes in which the patellar has dislocated. Often patients describe grinding (crepitation) when they straighten the knee against resistance.

Diagnosis
The physician’s work-up will start with a careful history and exam. When pain is worse with squatting, kneeling, stairs, and prolonged sitting without a specific injury patellofemoral pain is suspected. The examination often reveals grinding under the kneecap, lateral tracking or malalignment of the kneecap, and often tenderness along either side of the kneecap. X-rays can help determine if the kneecap is tracking properly and if there is any wear starting behind the kneecap. MRI scans are usually not as helpful for patellofemoral pain, except to look for other pathology within the knee.

Treatment
Non-surgical treatment is helpful in the majority of patients with patellofemoral pain. Non-surgical treatment may involve formal physical therapy, cross-training and activity modification, weight loss and general fitness, braces. modification in training schedules and form, non-steroidal anti-inflammatories, taping of the kneecap, inserts for shoes, and other modalities. When non-surgical treatment fails, especially with abnormal anatomy (tight lateral restraints or poor alignment), surgery can be helpful.

Sometimes the tight lateral restraints that are tethering the kneecap on one side can be released through the arthroscope (lateral release). In more severe cases in which the kneecap is dislocating or wearing unevenly, more drastic steps are needed to help get the kneecap to track centrally, such as reconstructing the ligament on the inside of the knee or actually cutting the bony attachment of the patellar tendon and moving it to a more central position under the kneecap.

What to expect after surgery
On the rare occasions that surgery is performed for patellofemoral problems, the post-operative treatment depends on the extent of the surgical procedure. If a lateral release is all that is needed, the patient is usually placed in a straight let knee immobilizer for one week while weight bearing fully without crutches. After a week, the brace is removed and therapy is begun to regain motion and strength. It is often 6 to 8 weeks before returning to most normal activities.

If more extensive surgery is needed to re-align the patellar tracking by reconstructing a ligament or moving the bony insertion of the patellar tendon, crutches and bracing may be used initially and the return to full activities may be delayed until complete healing has occurred.

Quadriceps Tendon Tears

patellar1-300x300Anatomy
The quadriceps tendon attaches the main group of muscles in the front of the thigh (quadriceps) to the upper pole of the kneecap (patella).

The quadriceps muscle attaches to the upper pole of the kneecap through the quadriceps tendon to allow one to straighten out their leg or to support ones weight while squatting. When the quadriceps tendon is torn, one cannot support their weight when the knee is bent, such as getting up from a chair or going down the stairs.

Injury Mechanism
The quadriceps tendon is usually injured with a sudden high force across the tendon, such as landing from a jump. The quadriceps tendon can be injured by a direct blow or a sharp laceration across the tendon. Often, the quadriceps tendon is weak prior to the injury due to chronic illness or a period of inactivity.

Symptoms
Quadriceps tendon injuries present as significant pain across the front of the knee, just above the kneecap, and immediate weakness in supporting ones weight while squatting. There is often cramping of the thigh muscles. Patients usually cannot straighten their knee out fully with a complete tear of the quadriceps tendon. Rapid swelling occurs. Often, one can feel a gap above their kneecap at the site of the rupture.

Diagnosis
patellar2-300x235The physician’s work-up will start with a careful history and exam. The physician can often feel the defect in the quadriceps tendon and can appreciate the weakness on trying to straighten out the knee against resistance.

With a complete tear, x-rays reveal a low position of the patella, since the pull of the quadriceps is no longer pulling up on the patella.

An MRI scan is often obtained to confirm the diagnosis, especially if the physician is concerned that the injury may be just a partial tear that may be able to heal without surgical repair. Plain x-rays show the bones of the knee, while MRI scans reveal the soft tissues around the knee including the ligaments, menisci, muscles and tendons.

Treatment
Your physician will discuss treatment options with you. Treatment decisions are based on whether the injury is a complete tear or a partial tear. Partial tears are usually treated with a brace. The brace is initially locked out completely straight to take all of the pressure off of the injured tendon. As healing occurs, the hinges are unlocked and motion and strengthening are initiated. With complete tears, surgery is usually recommended.

Surgery involves sewing the two ends of the tendon together with strong suture material. If the tendon has pulled directly off of the kneecap, drill holes are made into the bone to repair the tendon directly to the bone. Risks and benefits of surgery are discussed thoroughly with the patient.

What to expect after surgery
Quadriceps tendon surgery is usually performed as an outpatient procedure. Patients are sent home with crutches and a knee brace with the knee fully straightened to protect the repair. Depending on the strength of the repair, patients start gentle range of motion and progressive weight bearing over 6-8 weeks.

Patients are using a stationary bike by 2 months, and an elliptical or stair climber shortly thereafter. Jogging is restricted until 4 months following surgery and full sports activities are not resumed until 6 months after surgery. Most patients can return to full activities, with no restrictions and no bracing at the 6th month point.