3/31/17. MUSCULOSKELETAL CARE: PITFALLS IN THE PRIMARY CARE OFFICE Luke Stephens MD, MSPH April 7 th, 2017 Family Medicine Update DISCLOSURES

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1 3/31/17 MUSCULOSKELETAL CARE: PITFALLS IN THE PRIMARY CARE OFFICE Luke Stephens MD, MSPH April 7 th, 2017 Family Medicine Update DISCLOSURES None BACKGROUND Family Medicine Residency, 2011 Academic Fellowship and Assistant Professor, University of Missouri, Primary Care Sports Medicine Fellowship, Primary Care Sports Medicine Practice (90%), Team Physician University of Illinois-Chicago Team Physician Maine West High School 1

2 3/31/17 PITFALLS IN PRIMARY CARE MSK Common themes in referrals Common questions to common problems Common frustrations from referring physicians, physical therapists and patients COMMON PITFALLS History and Examination Imaging Treatment Physical Therapy Referrals When to involve specialists (and who) Pearls HISTORY PITFALLS History is still the top priority for diagnosis and treatment Trauma or onset Length of symptoms Prior episodes, prior injuries Joint above, joint below Referred pain, radicular pain Mechanical symptoms Prior diagnosis 2

3 EXAMINATION PITFALLS Anatomy ROM, passive vs active Symmetry Paper shorts (Inspection) Erythema, scars, effusion, true ROM Cheap IMAGING PITFALLS Over-reliance on MRI Under-reliance on XR Incorrect XR Incorrect MRI EMG/NCS timing, technique Communication with radiologists OVER-RELIANCE ON MRI, UNDER-RELIANCE ON XR Jed Kuhn MD, AMSSM 2014 Most MSK MRI reports should start with no one over 40 will have a normal MRI- Howard Lusk MD, twitter 1/31/2017 Know your population Osteoarthritis, Degeneration of Cartilage Mechanism of Injury or Onset of Symptoms Necessity of Urgent Intervention Goals for Treatment!

fairly quick The key is getting the correct views (weight bearing, joint specific) and considering

4 PROS XR Osteoarthritis is common in Primary Care XR are fairly easy to read, OA is easy to assess, even patients can do it XR is ubiquitous, no prior authorization, cheap Visualize multiple joints, fairly quick The key is getting the correct views (weight bearing, joint specific) and considering contralateral images ASSESSING KNEE OA, #1 (60 yo F) ASSESSING KNEE OA, #1 '()*+,*-./)(01)2.3,045 &

5 ASSESSING KNEE OA, #1 (76 yo F) ',((,*-.'7*1,50.3,045 ASSESSING KNEE OA, #2 ASSESSING KNEE OA, #2 (87 yo M) 6

$Prognostic tool +/- To catch atypical, but obvious processes Osteoporotic fracture Malignancy Segond s fracture Implications for advanced imaging CONS XR Radiation Wide variation in Radiologist s$

6 ASSESSING KNEE OA, #3 (60 yo F) PROS XR Value for patient s to see their own joints Less paternalistic, more of a joint decision Increase compliance? Prognostic tool +/- To catch atypical, but obvious processes Osteoporotic fracture Malignancy Segond s fracture Implications for advanced imaging CONS XR Radiation Wide variation in Radiologist s interpretation for severity of OA Does it change management? Repeat imaging with the specialists Have pt bring CD 8

7 3/31/17 PROS MRI No radiation More definitive imaging for complex pathology (soft tissues) Reassurance for both patient and provider +/- CONS MRI False positives Asymptomatic pathology Confounded by soft tissue edema False negatives Adhesive capsulitis Loose bodies <3 mm Non arthrogram studies Poor quality magnets, open MRI Variation in Radiologist s skill and reporting Chronic vs. Acute injuries OTHER DIAGNOSTIC PITFALLS Timing and technique of EMG/NCS Ultrasound for diagnosis (achilles, morton s neuroma, etc) Peer to peer discussions Look at your own XR Respect osteoporosis Prior films for comparison Communication with Radiologist Repeat Radiographs at 2 weeks w/ trauma Too much swelling 7

KNEE IMAGING (XR) Standing AP and Lateral, sitting sunrise Weight bearing is paramount with OA Sunrise view for patellofemoral assessment Bilateral films SHOULDER IMAGING

8 KNEE IMAGING (XR) Standing AP and Lateral, sitting sunrise Weight bearing is paramount with OA Sunrise view for patellofemoral assessment Bilateral films SHOULDER IMAGING AP, true AP, axillary, Scapular Y view ROM is key when considering MRI of shoulder MRI-arthrogram with labral concerns Must consider age/function of patient SHOULDER XR VIEWS 9

9 SHOULDER XR VIEWS REFERRAL PITFALLS Physical Therapy Specialist Physicians Return to Work Return to School PHYSICAL THERAPY REFERRALS What are you treating What imaging has been done Open communication with your PT s Limit the number of joints per session, per referral :

10 3/31/17 PT REFERRAL KEY TERMS Eval and Treat Modalities per PT Frequency and duration Return to run program Gait analysis, Running analysis Evaluate and Treat for orthotics, posting per PT Occupational Therapy SPECIALIST REFERRALS (WHEN) Radiographs Advanced imaging Trial of Physical therapy Severity of symptoms Length of symptoms Impact on ADLs, job Prior episodes and treatment Age of Patient COMMON OA TREATMENTS Ice APAP, NSAIDS (topical and oral) Know you NSAIDS ($, CV and GI profile, ½ life) Ibuprofen, naproxen, meloxicam, voltaren Glucosamine/Chondroitin Physical Therapy Injections Corticosteroids Viscosupplementation Prolotherapy Platelet rich products Stem Cells 10

11 3/31/17 ADDITIONAL TREATMENT Surgery Advanced imaging Acupuncture Manipulation Naturalist (herbals, supplements) Orthotics Braces Tenex SPECIALIST REFERRALS (WHO) Orthopaedics Sports Medicine Joint Replacement Shoulder, elbow Knee, hip Spine (Ortho/Neuro) Primary Care Sport Medicine (non-operative) Physical Medicine and Rehabilitation Neurology Podiatry Chiropractor/ Acupuncturist/Massage Therapist SCHOOL/WORK RESTRICTIONS School Please allow additional time between classes student to leave class early (to avoid hallway congestion) use of elevator, crutches, ice, brace, boot/shoe access to ATCs at HS Student is to complete physical therapy exercises during PE/Gym class for the following 4/6/8 weeks (bring printed handouts from PT) Length of time out of sports/pe/gym Work Spine involvement Certainty of diagnosis, Additional evaluation Anticipated length of restriction 11

$COMMON TRAPS Baker s cyst/ganglion cysts Negative XR fractures Growth plates Scaphoid fractures (wrist) Radial head fractures (elbow) Splint/Casting/Booting Too long Too much Too$

12 COMMON TRAPS Baker s cyst/ganglion cysts Negative XR fractures Growth plates Scaphoid fractures (wrist) Radial head fractures (elbow) Splint/Casting/Booting Too long Too much Too little BAKER S CYST GROWTH PLATE INJURIES <((=>""?1(<?,*@?A))?5A?1-"(?=,BAB@CD(?=,BEF;;;&; #%

SCAPHOID FRACTURES FOOSH Injury Snuff Box pain Negative initial xrays Repeat xrays (2 weeks from injury) Splinting vs Casting 17 yo RH M, 5 months from football wrist sprain Radial Head

13 SCAPHOID FRACTURES FOOSH Injury Snuff Box pain Negative initial xrays Repeat xrays (2 weeks from injury) Splinting vs Casting 17 yo RH M, 5 months from football wrist sprain Radial Head Fractures Mechanism-Fall Loss of ROM Flexion/extension Pronation/supination Initial imaging Negative sail s sign, anterior fat pad Repeat imaging/examination Splinting, Sling Length of immobilization #!

14 3/31/17 FINAL PEARLS Toe Fractures Crutches at office Splinting materials at office Good resources at the office Fracture book/resource Sports Med Advisor THANK 14

Evaluation and Management of Knee Pain. Michael Cassat, MD University of Arkansas for Medical Sciences

Evaluation and Management of Knee Pain Michael Cassat, MD University of Arkansas for Medical Sciences Disclosure I have no actual or potential conflict of interest in relation to this program/presentation.