Objective

Adopt methods in diagnostic workup that result in Assessment of the & Next Steps positive patient outcomes and cost‐effective, appropriate interventions. A Practical & Effective Approach for the NP/APN

Pamela Fruechting, PhD, FNP‐BC, ONP‐C

Overview of Today’s Webinar What This Webinar is Not: • Part I: Introduction to Functional Framework for Diagnosis 1. A repetition of grad school musculoskeletal anatomy. • Part II: Diagnostic Errors: How and Why They Occur 2. A primer on basic shoulder exam. • Part III: Functional Framework for Imaging Test Decisions 3. An attempt to make orthopedic specialists out of primary care NPs. • Part IV: Functional Framework for Referral Options • Part V: Review of the Most Common Adult Shoulder Disorders • Part VI: Application of the Functional Framework to Orthopedic Diagnosis • Part VII: Case Studies • Recommended Resources

1 Poll #1

Which best describes your practice area? A. Clinical orthopedics Part I: Introduction to a B. Primary care C. Post‐op general orthopedics Functional Framework for D. Post‐op replacement Orthopedic Diagnosis

Problems with Academic Textbook Approaches What is a Functional Approach to Diagnosis? to Diagnosing Disorders • Function: The action, performance, or purpose of a thing for which it • Typical textbook information for any diagnosis: • Anatomy & pathophysiology is designed • Examination techniques • Disease & disorder characteristics • Treatment • Straightforward emphasis on functional anatomy • Underlying assumption is that the diagnosis is already known. • Unifies the structural and mechanical disorders into one framework • Osteoarthritis • tear • A functional framework can simplify the diagnostic process • Impingement syndrome • Adhesive capsulitis • Knowledge of normal anatomical function is key to detecting pathology • Very few resources focus on practical strategies to efficiently diagnose disorders with the starting point of symptoms and functional disability.

2 Functional Frameworks for Shoulder Types of Functional Impairment Disorders • Structural Disorders • Mechanical Disorders (abnormal • Chronic functional impairment ( > 2 weeks) • Joint/Articular geometry and physics) • Pain • • Injury • Repetitive use • Muscle • Abnormal mechanics • Progressive over time • Tendon/Ligament • Instability • Acute functional impairment ( < 2 weeks) • Vascular • Impingement • Injury • Nerves • Joint limitation • Overuse • Metabolic • Muscle imbalance • No injury (septic arthritis, rheumatoid flare, instability) • Inflammatory • Cervical • Infection • Atrophy, weakness • Neoplasm

Is a specific diagnosis necessary? The Top Three Shoulder Complaints

• Don’t always need a specific, exact diagnosis to guide treatment plan • Which diagnosis best fits? Shoulder Pain • A working diagnosis is valuable when it sufficiently explains the source of pain to the extent of the available information. • Sometimes a specific diagnosis, if wrong, will lead to inappropriate Overhead Pain tests, misdirected treatment, and unnecessary referrals. Loss of Motion

3 Remember… Poll #2

Which patient is the most challenging for you? If you know what’s normal, A. Chronic shoulder pain in a young adult Then you know what’s abnormal – B. Chronic shoulder pain in an older adult C. Shoulder pain without injury D. Patients who insist on MRI Therefore, you know what to correct.

At the PCP NP Clinic…

• 64 year old Mrs. Smith complains of severe right shoulder pain and weakness for the past month after painting two bedrooms. Overhead work and forward reaching at shoulder height exacerbates the pain and radiates to the lateral shoulder. She is worried about a since a month of rest and ibuprofen 800 mg TID hasn’t A Typical Scenario helped. • Unremarkable radiographs • Active = passive motion; no pain until past 90 degrees, passive and actively. Positive impingement sign. • NP Jones is unsure. MRI ordered “just to see what’s going on.”

4 At the Next Clinic Visit a Week Later… Three Weeks Later At the Orthopedic Clinic …

• NP Jones relieved there is pathology on the MRI. • Orthopedic NP: • Patient advised MRI shows partial degenerative rotator cuff tear. • Exam reveals negative drop arm test, negative empty can test, and symmetric supraspinatus strength in addition to previous findings • Advises patient she needs surgery to repair the tear and refers her to • Reviews the outside XR. the orthopedic clinic. • MRI images and report reviewed. NP agrees with radiologist. • Both the patient and NP Jones very happy with today’s appointment • Patient educated and treated for subacromial bursitis. and diagnosis, and now headed for definitive surgical treatment. • Steroid injection given with good relief afterwards. • Physical therapy initiated also. • No surgery necessary. • Patient does not need to see the orthopedic MD.

Ramifications of PCP NP Inability to Diagnose Financial Cost to Patient

1. Financial cost to patient. Primary Care NP Orthopedic NP 2. Time loss due to delayed treatment. • $150 Established patient, • $225 New patient consultation 3. Financial loss, present and future, for NP. new problem visit • 4. Patient dissatisfaction with NP. • $100 AP & lateral xray $100 New xrays to include axillary view • $1000 MRI shoulder • $175 Steroid injection • $200 Radiologist’s read • TOTAL: $1450 • TOTAL: $500

PTO for 6 hours TOTAL: $180 ($30/hr. x 6 hours) GRAND TOTAL: $2130 [2 hrs NP, 2 hrs. MRI, 2 hrs. ortho]

5 Financial Loss to PCP NP Due to Inability to What if PCP NP Diagnosed & Treated the OA? Diagnose

If PCP NP Treated Mrs. Smith Avoidable Costs for Mrs. Smith Actual Revenue Potential Revenue • Office visit $150 MRI $1000 • $150 Office visit • $150 Office visit • XR $100 MRI read $200 • $100 NWB xrays • $100 NWB xrays • Injection $175 Ortho XR $100 • $250 TOTAL • $175 Steroid injection Ortho eval $225 • $435 TOTAL • PTO 2 hours $ 60 PTO 4 hrs. $120 • TOTAL: $485 TOTAL: $1645 • Future lost revenue because ortho treating patient now

How to Prevent This Scenario • Include axillary view in radiographs • Obtain detailed history, especially about functional symptoms • Replicate patient’s symptoms on exam and compare to contralateral shoulder Part II: Diagnostic Errors: How • Know the drop arm test and empty can test • Loss of external rotation = OA; Inability to abduct shoulder = rotator cuff and Why They Occur • OA is not necessarily related to age • Treat as OA • Steroid injection is a good diagnostic test • No MRI (Defer to ortho) • Avoid referrals based solely on MRI results • Hone your skills and knowledge base

6 Diagnosis: The Artful Detective Game A Tip From Sherlock Holmes

• dia (apart) +’gnosis‘ (recognize, know) “It is of the highest importance in the art of detection to be able to • The art or act of identifying a disease from its signs and symptoms recognize, out of a number of facts, which are incidental and which vital. Otherwise, your energy and attention must be dissipated instead of being concentrated.” –The Reigate Puzzle

Contributing Factors to Diagnostic Errors Results of Diagnostic Errors

• Atypical patient presentation (75% of respondents) • Dissatisifed patient • Failure to consider other diagnoses (50%) • Dissatisfied clinician • Inadequate history (40%) • Failure to account for a symptom (22%) • Unnecessary exposure to radiation • Inadequate physical exam (16%) • Unnecessary monetary costs • Unnecessary functional costs: Increased physical damage, lost work time, prolonged rehab • Higher insurance costs (overuse of resources leads to higher premiums for all clients) Note: N=6394 Source: Physician Perspectives on Preventing Diagnostic Errors (2011). QuantiaResearch. • Loss of patient’s trust

7 Are Diagnostic Errors Preventable? Most respondents answered, “Yes”.

3% Rarely 8% Always 1% Never Three Reasons for Diagnostic 88% Sometimes Errors

Note: N=6394 Source: QuantiaResearch (2011) Respondents were MD/DO (72%), NP (16%), and PA (8%).

Diagnostic Errors Lead to… Three Reasons for Diagnostic Errors

Lack of Basic Orthopedic Imaging Test Errors Knowledge Errors

Treatment Option Errors

Referral Decision Errors Lack of Clinical Social Pressures Competency Diagnostic

8 Reason #1: Lack of Basic Orthopedic Knowledge Reason #2 for Diagnostic Errors: Lack of Clinical Competence • A common cause of needless tests • Master your knowledge of functional anatomy • A major source of insecurity in treating orthopedic patients • Learn and practice basic orthopedic history and exam skills • Leads to missed treatment, unnecessary imaging, late referral, and • Know how to narrow the differential diagnosis list prolonged disability • Remember, “common things occur commonly”. • Worst case scenario: Poor patient outcome leading to malpractice • Understand the rationale for recommended tests and treatments lawsuit • Hone your communication and education techniques…

Tip: Improved Patient Communication How to Build Basic Orthopedic Knowledge & Translates to Better Diagnostic Skills Clinical Competency • Be on time! Wait times = Patient dissatisfaction • Know and understand functional anatomy! • Speak with the patient in a chair next to you • Acquire resources to build your knowledge and skill base • Put down your pen, chart, and computer! • Fine tune your listening and memory skills • Orthopedic conferences • Patients will: • Network with orthopedic colleagues • Talk more • Feel more relaxed • Have more confidence in you • Be more satisfied with care • Empowerment: Educate using a variety of materials. Have handouts ready.

9 Reason #3 for Diagnostic Errors: Poll #3 Social Pressures • Healthcare is a business model In your own practice, what area is your greatest need for building your • Zero tolerance for lack of a diagnosis expertise? • Insurance and financial constraints A. Anatomy knowledge B. Clinical competency C. Creating a differential diagnosis list D. Effective handling of social pressure for testing or treatment

Functional Anatomy Framework: What are “Diagnostic” Tests? Every Treatment Choice is a Diagnostic “Test”

• “Diagnostic” tests are just a source of information, and not always • Options besides imaging and labs that qualify as diagnostic “tests”: necessarily diagnostic or confirmatory. • Trial of physical therapy • Social pressure for tests: Zero tolerance for lack of a diagnosis. • Joint support with a sling • Restriction of activity • We want the tests to do the diagnosing for us. We hope for a • Joint or bursal injection ‘positive’, so we have something to treat. • Trial of NSAIDS • A negative MRI often halts the diagnostic process. Clinicians give up. • Lifestyle factors (nutrition, sleep hygiene, changes in activity) • A positive MRI can be very misleading and lead to over‐treatment and • Ergonomic changes (position, tool use, handedness) over‐referral.

10 Types of Imaging Test Errors

• Over‐testing leads to diagnostic errors by exposing irrelevant data Part III: Functional Framework that is then given priority. • Under‐testing leads to the exclusion of otherwise relevant diagnoses. for Imaging Test Decisions • Radiologist reports can pressure NPs to pursue further testing. • MRI report: “If there is clinical concern for ____, CT is recommended.”

Imaging Test Error #1: Axillary View of Shoulder

Failure to get an axillary view of the shoulder

11 Imaging Test Error #2: Never Resort to Radiographic Lies

Inability to read shoulder x‐rays. “I can’t interpret your x‐rays because of excessive soft tissue swelling.”

Shoulder X‐Ray of Imaging Test Error #3 Obese Female • Ordering MRI for non‐surgical problems • Types of non‐surgical problems: • Osteoarthritis • Degenerative rotator cuff tear • Overuse syndromes, tendinitis, bursitis • Clinician self‐doubt • Patient pressure

12 Study #1: Diagnostic Validity of Patient‐Reported History for Shoulder Pathology (2017)

Research Question: Are patient‐reported history items predictive of shoulder pathology and appropriate for triaging patients with shoulder Correlation of History, Exam, MRI, pathology to orthopedic outpatient clinics?

& Somerville, L. E., Willits, K., Johnson, A. M., Litchfield, R., LeBel, M.‐E., Moro, J., & Bryant, D. (2017). Diagnostic Validity of Patient‐Reported History for Shoulder A review of two studies Pathology. The Surgery Journal, 3(2), e79–e87. http://doi.org/10.1055/s‐0037‐ 1601878

Diagnostic Validity of Patient‐Reported Diagnostic Validity of Patient‐Reported History for Shoulder Pathology (2017) History for Shoulder Pathology (2017) • Results: • All new patients reporting pain and/or disability of the shoulder joint • The and history agreed in 75% of cases. completed a questionnaire on the history of their pathology. • Of the 25% that did not agree, the physical examination misdirected the diagnosis in about half of the cases. • Next, the surgeon took a thorough history indicating the most likely • In particular, history items were strong predictors of anterior and posterior diagnosis. instability and subscapularis tears. • Then the clinician then performed appropriate physical examination. • Conclusion: • Diagnosis was determined through arthroscopy or MRI . • The patient‐reported history items were effective for diagnosing shoulder pathology and should be considered for use in a triaging instrument.

13 Study #2: Low accuracy of interpretation of Low accuracy of interpretation of rotator cuff rotator cuff MRI in patients with osteoarthritis (2013) MRI in patients with osteoarthritis (2013) • Methods: MRI reports of 100 patients who had completed a shoulder Magnetic resonance imaging (MRI) is considered to be a valuable tool for the MRI prior to TSA were reviewed to determine the radiologists’ diagnosis of rotator cuff tears in patients with severe glenohumeral interpretation of the MRI including the diagnosis, presence of a full‐ osteoarthritis who are indicated for total shoulder (TSA). What thickness cuff tear, and the presence of atrophy and/or fatty is the positive predictive value of MRI in diagnosing rotator cuff tears in such patients? infiltration of rotator cuff muscle. • Operative reports were used as a gold standard to determine whether a full‐thickness rotator cuff tear was present.

Sershon, R. A., Mather, R. C., Sherman, S. L., McGill, K. C., Romeo, A. A., & Verma, N. N. (2013). Low accuracy of interpretation of rotator cuff MRI in patients with osteoarthritis. Acta Orthopaedica, 84(5), 479–482. http://doi.org/10.3109/17453674.2013.850012

Low accuracy of interpretation of rotator cuff Rules for Ordering MRI MRI in patients with osteoarthritis (2013) • Preoperative MRI reports: 33/100 patients with full‐thickness rotator cuff • MRI is rarely indicated in the initial diagnostic workup. tear. Only 2/33 patients had full‐thickness tears at surgery. • In general, leave MRI decision to the orthopedic team • Sensitivity 100% (2/33 with full tear at surgery had full tear on MRI) • Obtain MRI only if symptoms are consistent with a specific lesion • Specificity 68% (67/100 negative for tear on MRI and at surgery) • Don’t order any test unless it will change the treatment • Positive predictive value for MRI detection of full‐thickness tears 6% (2/33) • Don’t do “shotgun” testing • False‐positive rate of 32% (MRI positive for tear but no tear at surgery) • Interpretation: The study suggests that although MRI is highly sensitive, it has a low positive predictive value and moderately low specificity and • Exceptions: accuracy in detecting full‐thickness rotator cuff tears in patients with • Acute traumatic joint effusion with negative radiographs. severe glenohumeral osteoarthritis. • Radiographs positive for fracture or tumor.

14 Referral Errors: Timing & Necessity

• Timing • Too soon Part IV: Functional Framework • Not soon enough • Fractures for Referral Options • Mechanical symptoms • Septic arthritis or tumor • Unnecessary • Patient functionally doing well • Wrong diagnosis • Right diagnosis but referral will not change treatment

Prevention of Referral Errors

• Expand your functional orthopedic knowledge • Polish exam skills Part V: Review of the Most • Exhaust conservative treatment for chronic disorders • Consider baseline evaluation by an excellent physical therapist Common Adult Shoulder • Orthopedic practices have own PT depts usually open to outside referrals Disorders • Review cases with orthopedic colleagues before referral

15 Common Chronic Disorders by Region Common Shoulder Disorders by Type

• Global or Deep • Overuse Syndromes • OA, adhesive capsulitis, pathologic fracture,, labral tear • Subacromial bursitis • Anterior • Rotator cuff tendintis • OA, RA, Bicipital tendinitis/rupture, rotator cuff arthropathy • Impingement syndrome • Posterior • Bicipital tendinitis • Labral tear, multi‐directional instability • Adhesive capsulitis • Superior • AC joint OA, subacromial bursitis, osteolysis of the distal clavicle • Degenerative Disorders • Lateral • Osteoarthritis • Rotator cuff tendinitis, rotator cuff tear/arthropathy, calcific tendinitis, adhesive • Degenerative rotator cuff tear capsulitis • Rotator cuff arthropathy (OA + chronic RC tear)

Overuse Syndromes Bicipital Tendinitis

• The “‐itis” syndromes – Bursitis, tendinitis, impingement syndrome • Acute or chronic anterior shoulder pain • Repetitive motion or training errors • Worse with heavy lifting or overhead activity • Localized pain exacerbated by movement, relieved with rest • Tenderness in the bicipital groove • Treatment • Normal radiographs • NSAIDs • Positive Speed’s test • Activity modification • Physical therapy • Steroid injection • MRI only if failure to improve

16 Subacromial Bursitis, Impingement Syndrome, Speed’s Test Rotator Cuff Tendinitis • Acute or chronic, anterior or lateral, shoulder pain • Exacerbated with forward reaching and overhead activity • Usually the dominant hand • No loss of motion • Pain with motion between 90‐120 degrees (RC tendinitis) • Pain with lowering the arm (RC tendinitis) • Tenderness of subacromial bursa and possibly the lateral aspect of the supraspinatus tendon

Adhesive Capsulitis Rotator Cuff • Also known as ”frozen shoulder” Arthropathy • Active and passive motion are the same • Decreased motion when compared to contralateral shoulder • Normal radiographs • PT treatment of choice –“No pain, no gain” • Steroid injection helpful adjunct to PT Degenerative Osteoarthritis Rotator Cuff Tear

17 Osteoarthritis

• “Wear and tear”, age‐related, genetics • Noninflammatory, asymmetric, deterioration of articular cartilage • Increased pain with activity, stiffness • Radiographs show joint space narrowing, subchondral sclerosis, Osteoarthritis and Rotator Cuff osteophytes • Treatment: Tears • Exercise/PT • Activity modification • NSAIDS • Steroid injection •

Osteoarthritis OA vs. Degenerative Rotator Cuff Tear

• Similar symptoms of pain, stiffness • Motion loss: • OA –external rotation • RC tear – abduction and forward flexion • Joint line pain • OA – glenohumeral pain • RC tear –lateral pain • No MRI needed initially • Similar treatment: • Analgesics • Physical therapy • Steroid injection (GH joint for OA vs. subacromial for RCT)

18 Degenerative Rotator Cuff Tear Rotator Cuff Arthropathy (Rotator cuff pathology + Joint pathology)

• Long‐standing RC tear • Glenohumeral degeneration • Hallmark: Superior migration of humeral head

Degenerative Rotator Cuff Osteoarthritis Tear Part VI: Application of the Functional Framework to Orthopedic Diagnosis

Rotator Cuff Arthropathy

19 Foundation: Know the Shoulder Anatomy! Muscle Action, Function, and Posture

• Basic shoulder anatomy • Neck, back, core, shoulder, arm, forearm, hand • Understand what is normal –Your knowledge is your GPS • Learn on your own body • Know where you are anatomically during the exam • Shadow an orthopedic MD, NP, or PA • Explain why certain exam findings are indicative of specific pathologies • Shadow a top‐notch physical therapist at an orthopedic clinic • Forces across shoulder • Be able to describe to patients how the shoulder functions • Planes of motion • Extension –Flexion • Abudction ‐ Adduction • Rotation (External and Internal)

Correspondence of Symptoms to Anatomy Differential Diagnosis by Location of Pain

• Weakness • Pain Location • Nerve entrapment or cervical radiculopathy • Superior shoulder pain: AC joint OA, osteolysis of distal clavicle • Rotator cuff pathology • Lateral shoulder pain: Subacromial bursitis, RC pathology • Bicipital tendinitis • Anterior shoulder pain: Bicipital tendinitis/rupture, OA, labral tear • Posterior shoulder pain: OA, labral tear • Rupture of long head of biceps • Distal to : Cervical radiculopathy • Loss of Motion • Adhesive capsulitis • Glenohumeral OA

20 Functional Anatomy Framework: Functional Anatomy Framework for Non‐Injuries: The Five Diagnostic Categories Acute vs. Chronic 1. Mechanical (catch, pop, lock) Acute ( < 2 weeks) Chronic ( >2 weeks) • Labral tear, bicipital tendon tear 1. Inflammatory/infection 1. Mechanical (catch, pop, lock) 2. Inflammatory/infection • RA flare, septic arthritis • Labral tear, impingement • RA flare, septic arthritis 2. Overuse (the “‐itis” family) 3. Overuse (the “‐itis” family) • Bursitis, tendinitis, impingement, • Bursitis, tendinitis osteolysis distal clavicle 4. Degenerative 3. Degenerative • Osteoarthritis, post‐traumatic OA • Osteoarthritis, post‐traumatic OA 4. Lesion 5. Lesion • AVN, tumor • Avascular necrosis, pathologic fracture, tumor

First Things First: 1. Focus on the Functional Disability Do You Know What Your Patient Knows? • Patients explore the internet before they see you • Functional disability statements: • Many patients already have a good idea of their diagnosis and treatment options • “I can’t do ______because of my shoulder pain.” • Start the diagnostic process by inquiring what patients know • “I can’t tuck in my shirt in back.” • Include this information in your diagnostic process • Critique web sites so you can recommend reputable sites • ”This is different for me because ______”.

21 2. What KIND of Function is Impaired? 3. What Kind of Function is NOT Impaired?

• Specific activity interference • Clinicians and patients focus on disability, missing pertinent positive • Positional pain information. • Instability • This is critical for the diagnostic process. • Loss of motion • What can your patient do that does not cause pain, popping, etc.? • “I can sleep all night.” • Weakness • “I can still pick up boxes at work, but not heavy ones like before.” • Rest pain • “I’m alright as long as I don’t do overhead work.” • Interferes with sleep

Key Terms: Mechanical Symptoms If Any Mechanical Symptoms, Always Ask… • Grinding (crepitus): A scraping sensation perceived with motion • Ask: “Do you feel a grating or grinding sensation in your shoulder?” • Where in the shoulder the patient perceives it • Extra‐articular • Catching: During motion, something snags and delays motion. • Intra‐articular • Ask: “Do you feel like something snags in the shoulder during certain • What activity provokes it motions?” • How often it happens • Popping: Something is immediately in the way of the joint and a pop • If patient can recreate the symptoms can be felt and/or heard as it quickly releases. • If it is bothersome enough to avoid it and how • Ask: “Does you shoulder pop like something is in the way?” • If mechanical symptom is associated with pain, ask: • Instability: The shoulder subluxes or dislocates intentionally or • How severe? unintentionally. • How long does the pain last? • Ask: “Does your shoulder slip partially out or dislocate?” • Can they continue their activity? • Ask: “How do you put it back in?” • What relieves it?

22 Know What To Look For & How to Find It

• Location of the pain • Nature of the pain • Timing of pain and relationship to activity • Decreased • Swelling • Catch, pop, lock –Can patient recreate it? Shoulder Examination Tips • Instability • Unilateral vs. bilateral • Crepitus • Deformity – superior migration humeral head • Atrophy

Four Components of the Shoulder Exam Forward Flexion 1. Look (observe the function): • Posturing of shoulder, muscle mass, alignment 2. Move (test the function): • MOST IMPORTANT: Compare active & passive ROM • Strength • Stability 3. Feel (palpate the functional structures): 4. Recreate the functional complaint • Note also what does not recreate the functional complaint

ALWAYS DO A BILATERAL EXAM

23 Abduction Adduction

External Rotation Externtal Rotation at 90 Degrees Abduction in Neutral (ER + 90)

24 Internal Rotation Internal Rotation at 90 Degrees Abduction in Neutral (IR + 90)

Neer’s Test for Impingement Hawkin’s Test for Impingement

25 Empty Can Test for Recreate the Patient’s Complaint: Rotator Cuff Tear General Tips • Know shoulder anatomy and physiology • Note the alignment of bilateral • Always compare both lower extremities • Note any atrophy • Observe active motion • Note the point at which the shoulder hurts • Place hand on patient's shoulder while they recreate mechanical symptoms • Carefully isolate source(s) of pain • Equally important: Discover what does NOT recreate their complaint!

Diagnostic Clues Related to Motion Exam Pathology Active = Passive > Less Pain on Notes Passive Active Passive Rotator Cuff XX Loss of active elevation 60‐ 120. Possibly full overhead if assisted. Positive drop‐arm test. Positive impingement sign. Osteoarthritis X Loss of external rotation with elbow at side and Imaging Decisions forearm supinated. Adhesive Capsulitis X Restricted in all planes Subacromial Bursitis X Positive impingement sign Long head biceps X “Popeye” deformity. tendinitis or rupture Possible positive impingement sign.

26 Functional Anatomy Framework: Initial Imaging Functional Anatomy Framework: MRI Only Two Indications for MRI • KEY: Get orthogonal views –“One view is no view” • Radiograph series for the shoulder: 1. Lesion of bone, cartilage, or muscle • AP This is the only absolute indication for MRI • 15 degree AP 2. Mechanical disorder that does not respond to conservative • Axillary lateral treatment

Note that overuse disorders, degenerative disorders, and inflammatory/infection disorders do not initially need MRI.

Functional Anatomy Framework: MRI‐A

• MRI arthrogram • Indications: Labral tear, recurrent rotator cuff tear • The contrast is injected into the shoulder joint • If it leaks out of the joint anteriorly or posteriorly, likely due to labral tear • If it leaks out of the joint superiorly, this indicates rotator cuff tear Treatment Options

27 Four Functional Treatment Domains Four Functional Treatment Goals

Pain Reduce Pain

Improve Patient Daily Meet Patient Daily Expectations Function Expectations Function Achieve Quality of Life Acceptable Quality of Life

Functional Anatomy Framework: Functional Anatomy Framework: Treatment Options for Acute Inflammatory Treatment Options for Chronic Disorders Disorders 1. Mechanical (catch, pop, lock) • Bursitis, tendinitis • NSAIDs, activity modification, PT. • MRI if conservative treatment fails. Defer MRI to ortho – may need arthrogram. • NSAIDS 2. Overuse (the “‐itis” family) • Physical therapy • NSAIDs, activity modification, PT. • Activity modification • No MRI. • Steroid injection subacromial bursa 3. Degenerative • NSAIDs, aspiration/steroid injection, activity modification • No MRI • No MRI. • RA 4. Lesion of bone, cartilage, or muscle • Aspiration and steroid injection of glenohumeral joint • MRI with and without contrast • NSAIDS or prednisone taper • No MRI

28 Functional Anatomy Framework: Remember… Treatment Options for Acute Inflammatory Every Treatment Choice is a Diagnostic “Test” Disorders • Everything you do is a “test” that will narrow the differential diagnosis • Trial of physical therapy • Restriction of activity • Septic arthritis • Joint or bursal injection • Aspiration and culture/sensitivity • Topical or oral NSAIDS • NO STEROID INJECTION or MRI • Lifestyle factors (nutrition, sleep hygiene, changes in activity) • Refer to orthopedic MD immediately (within 24 hrs.) • If any concern about evolving sepsis, send immediately to ER

Functional Anatomy Framework: Referral Recommendations Emergent Urgent Delay

Lesion/Tumor OA, RA Referral Recommendations Septic Bursitis Fracture Arthritis Tendinitis Impingement Acute Rotator Cuff Tear Chronic RCT

29 Septic Arthritis Tumors

Red Flag –Septic Arthritis Red Flag ‐ Septic Arthritis

• Septic arthritis • Aspirate joint for cell count, gram stain/culture/sensitivity, crystals • Suspect this in patient with: • No MRI • Total • No steroid injections • Rheumatoid arthritis • Diabetes, arterial disease, chronic kidney disease • Call orthopedist for antibiotic recommendation until definitive treatment • Recent oral or injected steroids within the last month • Oral antibiotics will never cure the infection. • Usually acute onset • REFER IMMEDIATELY • Substantial joint effusion • Prompt surgical irrigation and debridement & 6 weeks of IV antibiotics • Severely painful motion • Early treatment minimizes destruction of joint and soft tissue and • Night pain decreases risk of sepsis

30 Septic Arthritis: Red Flag ‐ Tumors Evaluation of Synovial Fluid • Tumors Septic Arthritis • May present as shoulder or chest pain Onset Acute • Night pain if malignant Effusion 2‐3+ • Usually identified on radiographs, often an incidental finding when benign Disability Severe pain

Cell Count >50,000 PMNs >90% Crystals Negative Bacterial Culture Positive

Imaging Studies in Tumor Evaluation

• Plain radiographs

• MRI with/without contrast • Visualize soft tissue and bone marrow edema • CT with/without contrast • Visualize bone detail (cortical continuity, erosion, endosteal scalloping) Case Studies • Technetium Tc‐99m bone scan • Sensitive for infection, trauma, and tumor but not specific • Useful to determine if cancer patient has metastasis

31 Case Study #1 Functional Anatomy Framework: History The Five Diagnostic Categories 62 year old Mr. Allen complains of worsening pain right shoulder and 1. Mechanical (catch, pop, lock) stiffness that began about eight months ago with no known inciting • Labral tear, bicipital tendon tear event. It is described as “deep” and hurts with activity. 2. Inflammatory/infection • OTC topical and oral analgesics and NSAIDS provide minimal relief • RA flare, septic arthritis • Activity modification and rest of little benefit over the months 3. Overuse (the “‐itis” family) • Bursitis, tendinitis, impingement syndrome 4. Degenerative • Osteoarthritis, post‐traumatic OA 5. Lesion • AVN, tumor, pathologic fracture

Case Study #1 Case Study #1 Exam Radiographs • Abduction 60 degrees • AP, 15 degree AP, and axillary view are normal. • Forward flexion 70 degrees • External rotation 20 degrees • Extension to lateral buttock • Active motion = passive motion • Anterior, posterior, lateral tenderness • Positive impingement sign • Negative drop arm test • Contralateral shoulder has full motion • Mild shoulder girdle atrophy

32 Case Study #1 Case Study #1 Differential Diagnosis What Next? • Adhesive capsulitis • Asymmetric global loss of motion Focus on adhesive capsulitis as the diagnosis: • Relatively recent onset with quick progression of disability • XR normal • • Glenohumeral OA Steroid injection + prolonged PT (“No pain, no gain”) • Asymmetric loss of external rotation • No MRI needed for either diagnosis. • Chronic progression • XR would show decreased joint space +‐ osteophytes • If referral to ortho, they will also treat conservatively before getting • Tumor MRI‐A. • Constitutional symptoms • Expect no improvement with steroid injection

Converge symptoms, anatomical function, and exam findings

Case Study #2 Case Study #2 History Exam • 74 year old female with chronic right shoulder pain with activity and • Abduction 80 active, 140 passive at night, worsening over the last year. Pain is worse with overhead • External rotation 20 vs.70 contralateral activity and putting on a jacket. Previous PCP treated her unsuccessfully with physical therapy and NSAIDS. History of proximal • Forward flexion 80 active vs. 150 passive humerus fracture twelve years ago. • Positive impingement sign • Positive drop arm test • Positive crepitus

33 Case Study #2 Functional Anatomy Framework: Radiograph The Five Diagnostic Categories 1. Mechanical (catch, pop, lock) 2. Inflammatory/infection 3. Overuse (the “‐itis” family) 4. Degenerative 5. Lesion

Case Study #2 Case Study #2 Differential Diagnosis Treatment Options • Rotator cuff tear • MRI? • Glenohumeral osteoarthritis • Physical therapy? • Adhesive capsulitis • Steroid injection to alleviate pain? • Impingement syndrome • Subacromial? • Intra‐articular?

34 Case Study #2 Recap: A Functional Framework for Diagnosis Actual Diagnosis • Remember, chronic RC tears are rarely surgical –MRI not indicated. • Function: The action, performance, or purpose of a thing for which it • Rotator Cuff Arthropathy is designed • Chronic loss of function and motion • Substantiated with radiograph • Straightforward emphasis on functional anatomy • Treat as OA • Unifies structural and mechanical elements into one framework • Steroid injection • A functional framework simplifies the diagnostic process • Physical therapy can strengthen remainder of RC, but will not do anything for the OA component • Knowledge of normal anatomical function is key to detecting pathology • Reproduction of the patient’s pain is key to differential diagnosis

Essentials of Musculoskeletal Care (5th ed.) (2016) April D. Armstrong & Mark C. Hubbard (Eds.)

My Top Resource Picks

35 Physical Examination of the Spine and Extremities (1976) Anatomy: A Regional Atlas of the Human Body (2010) Stanley Hoppenfeld Carmine D. Clemente

Atlas of Human Anatomy (2014) InnerBody – Interactive Anatomy Web Site Frank H. Netter InnerBody.com

36 American Academy of Orthopaedic Surgeons Clinical Practice Guidelines www.aaos.org

National Association of Orthopaedic Nurses American Academy of Family Physicians www.orthonurse.org www.aafp.org

37 Wheeless’ Textbook of Orthopaedics Nutrition in Clinical Practice (2015) www.wheelessonline.com David L. Katz

References

• Armstrong, A. D. & Hubbard, M. C. (2016). Essentials of Musculoskeletal Care. Fifth Ed. Rosemont, IL: American Academy of Orthopaedic Surgeons. • MacDonald, O. W. (September 2011). Physician Perspectives on Preventing Diagnostic Errors. Waltham, MA: QuantiaMD. • Sershon, R. A., Mather, R. C., Sherman, S. L., McGill, K. C., Romeo, A. A., & Verma, N. N. (2013). Low accuracy of interpretation of rotator cuff MRI in patients with osteoarthritis. Acta Orthopaedica, 84(5), 479–482. http://doi.org/10.3109/17453674.2013.850012 THANK YOU! • Somerville, L. E., Willits, K., Johnson, A. M., Litchfield, R., LeBel, M.‐E., Moro, J., & Bryant, D. (2017). Diagnostic Validity of Patient‐Reported History for Shoulder Pathology. The Surgery Journal, 3(2), e79–e87. http://doi.org/10.1055/s‐0037‐1601878

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