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RTC tear - when to see the orthopedist
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RTC tear - when to see the orthopedist - March 13, 2008 9:00:46 PM
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Kaden
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Scenario - patient comes in with MRI showing several cuff tears (partial thickness) in supraspinatus and infraspinatus along with a downsloping acromion. Referred to me for shoulder impingment.
I am not saying I shouldn't be seeing this guy and suspect he will do well but it got me thinking.
At what point should someone like this be seeing an orthopod before coming to therapy for conservative care to at least discuss the severity of the tear, treatment options, etc.
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RE: RTC tear - when to see the orthopedist - March 13, 2008 9:39:08 PM
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TexasOrtho
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This is a good question to think about both in the context of our current referral-based system and eventually direct access. I get a load of PCP referrals with shoulder pain. The idea is that if they fail conservative care (or my assessment is that they don't have a good rehab prognosis) they are eventually sent to the orthopedist for the assessment.
I think the value of MRI for shoulder pathology is pretty limited unless there is a high suspicion of a large rotator cuff tear. Most of us in the 30+ age range, symptomatic or not, are likely to show signs of acromial changes, rotator cuff tears, labral tears etc... I'll need to find the studies on this, but I seem to recall an investigation that concluded only large to massive rotator cuff tears on MRI correlated well with clnical presentation.
Assuming this is the case (big assumption) it would be an interesting investigation to see how many of those who respond favorably to physical therapy demonstrate true histological changes in the tissue or "discover" alternative motor plans to the structual changes in their shoulder. I've seen some folks with pretty nasty looking MRI do quite well with physical therapy.
I heard a good discussion on ReachMD the other day from UPenn orthopedic surgeon. He was suggesting that older adults with higher retear rates following their RC repairs would have done better had they had the repair at earlier stages of the disease when the tissue had better healing potential. It seems like the jury is still out.
Even in the context of pure direct access, I would refer the patient to a trusted orthopedist to verify the patient wasn't a surgical candidate. Then you've got the green light. If they are, then you are likely to see the patient following the surgery.
Ramble complete...I'm not sure if that even answered your question Kaden. I think I stroked off there in the middle of that post.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: RTC tear - when to see the orthopedist - March 13, 2008 9:46:48 PM
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PTupdate.com
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Kaden: If you are a member of PTupdate.com, you can go to Archive 11, and choose Dec 17, 2006 article review on partial thickness cuff tears, and determining factors as to shape/size/location/side that determines outcomes. Always considered it a good guide when wondering how a particular case may turn out
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: RTC tear - when to see the orthopedist - March 13, 2008 10:15:49 PM
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kamryn
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Hi John - would you mind sharing the reference? Thanks.
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RE: RTC tear - when to see the orthopedist - March 13, 2008 10:32:48 PM
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SJBird55
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I don't let MRI results be the determining factor for the requirement of a surgeon's knife. I currently have 2 patients with (+) MRI for definite rotator cuff tears. Reading the report does create the thought of, "what the heck am I going to do for these two patients?" But as with anything, that information just gets pieced in my brain as a "nice to know" kind of thing and I take a step back and decide if there is a clinical correlation. I don't have any research to support this, but the biggest objective finding that indicates to me that physical therapy will have a greater probability to be beneficial is to observe active range of motion of flexion and abduction. If the patient is able to achieve 160 degrees or so of active elevation without that upper trapezius substantially elevating the scapula, I feel pretty confident that there's a chance for a positive outcome. If I observe for example 20-45 degrees of active range of motion with elevation (with definite upper trapezius recruitment) and the patient is in obvious pain... and then passively 1) painfree and normal range - I assume there is a tear, I can't prognose how the patient will tolerate graded activity (probably poorly if the upper trap/scapula isn't controled because the humerus is going to mitigate superiorly) or 2) significant guarding and pain - I know the person needs some type of additional pain control to do what needs to be done.
Unlike the lumbar spine, which has an nicely evolving classification system, the shoulder doesn't really have an agreed upon classification system for physical therapists. Without an agreed upon classification system for the shoulder joint it is difficult to respond to the results of conservative outcomes with interventions provided by physical therapists.
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RE: RTC tear - when to see the orthopedist - March 14, 2008 1:15:36 AM
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Kaden
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Thanks Folks,
Duffy I am a member and will check it out. SJ and Rod, I agree with your take on folks with definite tears on MRI but do well with PT. I think many patients treated successfully for impingment probably had a small tear in many cases.
Qoute from Rod
"I heard a good discussion on ReachMD the other day from UPenn orthopedic surgeon. He was suggesting that older adults with higher retear rates following their RC repairs would have done better had they had the repair at earlier stages of the disease when the tissue had better healing potential. It seems like the jury is still out. "
It is thoughts like this above that prompted my question initially. More of a timing thing. If I choose not to refer out and end up having a poor outcome with therapy are we risking creating a poor surgical outcome? Which makes one think it would be nice to have the orthopedist for a second opinion.
Even in the context of pure direct access, I would refer the patient to a trusted orthopedist to verify the patient wasn't a surgical candidate. Then you've got the green light. If they are, then you are likely to see the patient following the surgery.
Rod are you saying you would refer them out in this case or in a direct access case. For me it is tricky since the referring physician decided not to make that referral.
To be honest, after evaluating him he looked more like the patient you are unsure about impingment versus small tear and definitely not a large tear. I typically wouldn't refer this person for a second opinion. This case was just intersting to me b/c he came into the scenario with the MRI showing multiple tear.
Worth noting, he did have superior labral tear, infraspinatus tear and supraspinatus tear. Clinically it was the suprapinatus that seemed most problematic.
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RE: RTC tear - when to see the orthopedist - March 14, 2008 7:13:34 AM
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SJBird55
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So, if you are unsure about impingement or small tear (and you have no MRI) - do your clinical tactics change?
Will putting a surgeon in the mix do anything for the patient (besides increase cost) when you are unsure of whether impingement or small tear?
Does it matter if the involved extremity is the dominant or non-dominant extremity?
What about when you do have a referral for services and you also have the MRI with the results of tears, bursitis, AC arthritis and possible labral involvement - how do you handle ALL the patient questions? (Blank is torn... will it heal? will I be able to do Blank? why am I not having surgery? shouldn't I have surgery? what will this shoulder be like in 5 years?)
I think that initially, it is better to let clinical presentation and common sense prevail before any high cost diagnostic tests are performed. (IF the patient is responding, do I really care the exact diagnosis? Do we ever know the exact diagnosis anyways? Does giving the situation an exact diagnosis add anything to my clinical decisions?) We are the neuromusculoskeletal experts. When I recommend a referal for an ortho consult, there is always a definite roll for the consult: 1) the patient needs pain control or 2) I'm very sure there is a tear, the patient isn't responding as anticipated after a few sessions and I firmly believe my services will waste the patient's (and my) time and money because the outcome with my services alone isn't going to achieve the desired outcomes. 1-6 visits to determine a consult is necessary doesn't seem unreasonable to me. Risking a poorer outcome by not beeing seen by ortho soon enough... hmmm... I highly doubt that. I'm horrible at keeping everything completely straight in my mind, but I believe 8-12 months after injury is when there is a greater probability of poorer surgical outcomes for tears (although it does depend on why the tear occurred and age of the patient...). I tend to look at it this way - if conservative treatment with physical therapy has good outcomes, then the patient won't have to undergo an invasive procedure, risk infection, have life on hold for a chunk of time, miss as many work days, or have substantially increased financial costs.
The guy I'm treating at the moment was referred from ortho - almost same issues as above except completely ruptured infraspinatus tear, mild supraspinatus tear, bicipital rupture, AC degeneration, labral tear/degeneration. He has a pacemaker so no MRI but instead ultrasound. He's going to do just fine. He's a retired builder - if he's able to hold a drill just above shoulder height and get enough strength to allow him to fly-fish, he's gonna be a happy camper. I would have never suggested an ortho consult, but he was in an auto accident so he's had quite the work up. I was laughing as I was going over his particular situation... "What makes it better?" Fishing "What makes in worse?" Not Fishing. I told him I had someone in my family I'd have him meet. Our son (12 year old) came into the clinic after school. I introduced the patient and our son. I told our son the gentleman had shoulder problems. I asked our son, "what do you think makes his shoulder feel better?" Our son looks at me, looks at the guy, gives a slight shrug and says, "Fishing." I asked our son, "so what do you think makes his shoulder feel worse?" Our son gives me a curious look and pauses a bit and says, "Not fishing." LOL Hopefully in a couple of weeks the weather will be a bit warmer - I plan on bringing a couple of poles in the clinic and there will be some ground casting going on. LOL And no... I'm not going to use some Wii fishing... a real pole with real line with a real reel with a little weight.
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RE: RTC tear - when to see the orthopedist - March 14, 2008 7:37:56 AM
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cottonra
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Kaden,
Great question, which is one many PTs should have when treating this pt. I had the same question few years ago, so part of my dissertation addressed this question. One portion of my disseration, which directly addresses this question was just presented at CSM 08, the full abstract is in the JOSPT Jan 08 review of CSM presentation (OPO 138: CottonRA, et al).
Your pt is at risk of poor outcome if they have a combo of:
After 4 weeks of PT,
If their functional score (I use ASES and SANE) remain low (below 55)
If their pain level remains high (high VAS, pain at rest/night)
If your clinical exam leans toward the presence of abnormal anatomy (RCT, SLAP, etc)
High # of comorbidities
On the other hand, if your pt (even with RCT, SLAP) is progressing well by 4 weeks (pain is minimizing, function is improving) they have a good shot at good outcome of conservative treatment
To answer the original question, How long do I treat before referral? 4 weeks, if pain is controlled and function is improving, continue with conservative tx; if by 4 weeks, continued high pain levels and low functional score, refer
Ryan Cotton, PT, DHS, OCS
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RE: RTC tear - when to see the orthopedist - March 14, 2008 11:08:23 AM
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PHS
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I think a big component in this population is the patients occupation and ultimately functional needs in order to return to their desired activity
I work in a setting w/ some direct access capabilities and able to refer to an orthopedist at any time, as Im also my institution's orthopedic surgeon triager.
If a patient with high levels of function (eg athlete, pitcher, QB, etc) comes to me with the above large RCT findings, theres nothing in the world P.T can do that will allow this individual to return back to the needed high levels of rotatory/throwing speeds needed for their sport.This individual would more likely be a surgical candidate.
On the other hand if a sedentary individual comes to me, w goals of returning back to function, Id treat.
Prior to treat though, A GOOD accurate Dx is inminent as failure to doing so CAN potentially cause further injury. Cleland has done a fantastic job at compiling some of the most Sn and Sp tests (remember the acronyms SNout and SPin). The high statistical levels of some of the tests out there, can give a therapist the degree of confidence needed to arrive at a clinical Dx as well as an optimal POC.
While I agree the MRI does tend to have some loose bolts in terms of accuracy (Sn 80's and Sp 80's ...cant recall exact % )
they do provide a high level of suspicion for RCT's and when correlated w MOI, and clinical findings will guide the train of thought of any surgeon and P.T.
Large RCT in sedentary non-athlete populations can do well w conservative physical therapy, and most surgeons will exhaust conservative measures prior to surgery.
A few things to remember in this RCT pop: is acromium shape type 1-3 can adversely impact the outcome of any therapy as well as further re-injury, like our case above. grade of RCT tears and their appropriate advancement in the POC.
So in a nutshell: refer if athlete w suspected large RCT and Tx all others w/ an accurate Dx (as this will dictate your POC)Id refer only if conservative Tx fails and, or pt's Sx's worsened.
I would request MRI only if suspect a large RCT.
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RE: RTC tear - when to see the orthopedist - March 14, 2008 12:12:11 PM
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Shill
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Ryan,
Very nice post. Short, sweet, objective. 3 of my favorite qualities.
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Steve Hill PT
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RE: RTC tear - when to see the orthopedist - March 14, 2008 12:31:37 PM
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buckeye
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kaden -
The liability risk here can be problematic. The U.S. is a litigious society. If the PT does not refer to a surgeon in a timely manner, the patient ends up with surgery, and the result is sub-optimal - then the PT is in line to be blamed for the results. We all understand this is not an exact science but it does not stop juries and judges from rewarding people with sums of money if they think the professional is not performing at a reasonable standard of care. I am not suggesting we practice defensive physical therapy, but your question brings up the point that some level of evidence to support our decisions can be a good thing.
Some of the responses have suggested a conservative amount of physical therapy trial is reasonable - I agree. I have seen patients with rotator cuff tears that could not be repaired (the surgeon opened the shoulder, did some clean up, and closed the shoulder) who were able to reach overhead five or more repetitions actively, lift two or three pounds overhead, and sustain overhead reach for greater than 10 seconds with good form. So if your patient is not planning high level overhead activities, convservative care (no surgery) may be successful. Maybe a discussion with the patient along the lines of informed consent would be wise - explain proposed treatment, risks, potential benefit, time frame, cost, and reasonable alternatives to treatment.
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RE: RTC tear - when to see the orthopedist - March 14, 2008 2:37:09 PM
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Kaden
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Thanks for the replies folks.
SJ - I agree up to six or so sessions of PT is warranted in this case to see how he progresses. The only thing I found interesting in this case is this is not a 2 week history of shoulder pain. He has had these complaints since June of last year and now they have worsened to the point he seeks services. I just found it peculiar that the family MD would request MRI and with these results send to PT with ortho referral.
I did bring up some of the points discussed above to the patient and the nice thing for me is he doesn't in any circumstances want surgical intervention so easy choice in this case not to immediately refer to ortho. It just raised the question in my mind.
Ryan - thanks for the post. With regards to the 4 week time frame, you reference this from the time they start therapy. Is there any consideration for how long they have had shoulder complaints.
Ulitimately I think he will absolutely be able to avoid surgical intervention - just a gut feel after my eval. However, he would like to return to weight training activities and I will just have to be honest with him that this may or may not happen to the level he would like. But, after a RTC repair the answer would probably be the same.
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RE: RTC tear - when to see the orthopedist - March 14, 2008 2:41:16 PM
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Kaden
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SJ,
To answer your other question about tactics chaning when usnure of small tear or imingingement the answer is no they would not change. That did help me in this case decide to continue to see the patient without referring on. If I did not have the MRI I would have continued conservative treatment as I would not have suspected a large tear in his case.
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RE: RTC tear - when to see the orthopedist - March 14, 2008 3:27:37 PM
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SJBird55
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I read a recent article on physicians and their ability to diagnose. Physicians fail in their diagnostic abilities. With it becoming a greater norm to rely on high tech diagnostic testing, diagnostic problems arise. When does one become concerned about any diagnostic findings? This article mentioned how radiologists tend to suggest that the diagnostic findings should correlate with clinical assessment in their reports. In other words, more and more abnormalities are being found but the relevance of those findings is questionable. The problem is, generally speaking, physicians really aren't clinically assessing - physicians are basing a higher percentage of their clinical decision-making on the diagnostic test results. Our system sucks... lack of time, poor listening ability, not manually assessing (might go with lack of time), lack of common sense, concern about potential litigation and dependence on high cost technology/diagnostic testing are issues that are affecting the overall efficiency and effectiveness in the neuromusculoskeletal world.
Diagnostic tests have a time and a place. As a whole, they are overutilized.
Interesting, Cotton - Boissonnault found that the number of comorbidities did not affect shoulder function after a rotator cuff repair surgery. The comorbidities affected health, but not shoulder function. What comorbidities did you factor in that did have an affect on shoulder function? (Diabetes is the only one that initially comes to my mind, but for the specific situation of adhesive capsulitis.)
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RE: RTC tear - when to see the orthopedist - March 14, 2008 4:25:12 PM
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Kaden
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Good point SJ. One has to wonder what would have happened if a patient like I am treating now ended up at the orthopedist first. If as you say, MDs highly basing things on diagnostics, this guy may have been on the table without a chance to rehab.
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RE: RTC tear - when to see the orthopedist - March 14, 2008 4:38:37 PM
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jma
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Cotton, great abstract. Do you know which journal your article will be published?
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RE: RTC tear - when to see the orthopedist - March 17, 2008 9:20:58 AM
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cottonra
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Kaden,
The 4 weeks was from onset of PT. We put chronicity of sxs in our regression model, but it was found to have no impact on outcome measures at DC. Good news for us, if we dx and treat appropriately then chronicity should not have an impact.
SJ,
I agree with Boissonault. Remember, his pts were post-op, my study cited was of non-op, and I think that makes all the difference. Although, in my whole dissertation, I looked at post-op also, and co-morbidities were not predictive.
JMA,
First attempt at submission will be J Shoulder ELbow Surg, if they do not accept, we will move onto our professional journals (Phys Ther or JOSPT)
Ryan Cotton, PT, DHS, OCS
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RE: RTC tear - when to see the orthopedist - March 17, 2008 12:10:56 PM
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SJBird55
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Cotton, yes, I know his were post-op. He didn't include diabetes as a comorbidity though.
The only comorbidities that I might consider affecting function with conservative RTC would be diabetes, fear and depression.
Apparently McKee & Yoo (2000) found the same finding with regard to chronicity and surgical outcomes.
Good luck with submission.
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RE: RTC tear - when to see the orthopedist - March 17, 2008 2:37:16 PM
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Kaden
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Ryan, thanks for the input and I look forward to seeing the published results.
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