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Shoulder Impingement Syndrome: Will Surgery Make a Difference?

Shoulder impingement syndrome (SIS) is one of the most common causes of chronic shoulder pain in adults, and one that is frequently seen in primary care. Typical symptoms include pain with overhead movements, and classic physical exam tests include Neer’s sign, Hawkins-Kennedy sign, and a painful arc.

Pain from shoulder impingement is thought to be secondary to impingement of the rotator cuff tendons due to decreased subacromial space. Subacromial space can be reduced due to multiple reasons:

  • Poor posture creating a protracted shoulder girdle with internally rotated glenohumeral joint, creating a functionally reduced subacromial space
  • Subacromial bursitis, either acute or chronic (although this can also be seen secondary to the former point)
  • Spurring of the inferior surface of the acromion

Treatment of shoulder impingement syndrome typically involves:

  • Physiotherapy to develop pain-free ROM, strengthening of the rotator cuff and periscapular muscles, improved posture, and improved scapular kinetics
  • Oral NSAIDs are commonly prescribed
  • Corticosteroid injection of the subacromial bursa can be considered if pain is severe or the patient has failed a trial of more conservative management

What about surgery?

  • Arthroscopic subacromial decompression is a commonly performed surgery
  • It typically involves shaving down the inferior aspect of the acromion, thereby creating a larger subacromial space
  • A Cochrane review concluded that evidence does not support subacromial decompression surgery as a treatment for shoulder impingement, as it does not provide clinically meaningful benefits in terms of pain relief1
  • The BMJ released a clinical practice guideline strongly recommending against subacromial decompression surgery for the treatment of shoulder pain2
  • More recently, an RCT published in the British Journal of Sports Medicine that involved 5 year follow-up failed to detect any difference in pain between patients who underwent subacromial decompression, patients who underwent diagnostic arthroscopy (placebo surgery), or patients who completed an exercise program3

Bottom line?

Evidence suggests that there is no benefit to subacromial decompression surgery for the treatment of shoulder impingement. Patients with this condition should be reassured that surgery is unlikely to help their symptoms, and that treatment should focus on conservative management.

Janet Barber MD, MSc, BSc

PGY3 Sport and Exercise Medicine, University of Ottawa

Advisor: Dr Taryn-Lise Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

References:

  1. Karjalainen, T. V., Jain, N. B., Page, C. M., Lähdeoja, T. A., Johnston, R. V., Salamh, P., … & Buchbinder, R. (2019). Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews, (1).
  2. Vandvik, P. O., Lähdeoja, T., Ardern, C., Buchbinder, R., Moro, J., Brox, J. I., … & Noorduyn, J. (2019). Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. Bmj364.
  3. Paavola, M., Kanto, K., Ranstam, J., Malmivaara, A., Inkinen, J., Kalske, J., … & Järvinen, T. L. (2020). Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up of a randomised, placebo surgery controlled clinical trial. British journal of sports medicine.

Patellofemoral Pain – A common cause of anterior knee pain

Patellofemoral (PF) pain is a common cause of anterior knee pain in young adults and adolescents. This is described as knee cap pain that is worsened by activities that load onto a flexed knee. These include squatting, stairs, hiking, and running.1,2

The patella acts as a lever which helps extend the knee.1 The patella moves within the trochlear groove of the femur during leg extension and flexion. PF pain is thought to be due to incorrect tracking of the patella.3 More specifically, in PF pain, the patella tracks laterally.

Risk Factors for developing PF pain1

  • Activities including running, squatting, stairs (rapid increase in activities/training)
  • Dynamic valgus (caving in of knees)
  • Female sex (increased Q angle)
  • Foot abnormality (eversion and pes pronatus)
  • Sudden increase in activity level
  • Patellar instability
  • Quadriceps weakness

Diagnosis of this condition is made on a combination of history and physical examination findings. On history, the cardinal feature is that pain around and behind the knee cap is worse during weight-bearing knee flexion activities. Patients may also complain of worsening of their pain after a prolonged period of sitting with the knee flexed (on a plane, in a movie theatre).2

On physical exam, pain with squatting is most sensitive for PF diagnosis.2 Other tests, such as the patellar grind test, apprehension test, and tilt tests, have low diagnostic yields. These do not present with joint swelling, and range of motion is preserved.2

Imaging is not required for the diagnosis of PF pain.1 Radiographs should be obtained in cases where the diagnosis is not clear, or when the patient does not respond to first-line treatment options.2

The treatment of PF pain includes rest, activity modification, and physical therapy. The key is to work on and correct the underlying causes of the pain. This may include avoiding repetitive activities, assessing footwear, and most importantly addressing hip and knee muscular imbalances that cause the knee cap to track incorrectly. Patients should begin with a structured physiotherapy program to help correct imbalances.2 In some cases, foot orthotics can be considered to help with leg alignment and reduce pain in the short term.4 Bracing and taping techniques, while not fully supported by evidence, can help patients during periods of activity by stabilizing the patella.3

Sonam Maghera, MD, BMSc

Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn-Lise Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

1.    Gaitonde DY, Ericksen A, Robbins RC. Patellofemoral Pain Syndrome. Am Fam Physician. 2019;99(2):88-94.

2.    Crossley KM, Callaghan MJ, Linschoten R van. Patellofemoral pain. Br J Sports Med. 2016;50(4):247-250.

3.    Jin J, Jones E. Patellofemoral Pain. JAMA. 2018;319(4):418-418.4.         Collins NJ, Barton CJ, Middelkoop M van, et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med. 2018;52(18):1170-1178.

Calcific Tendinosis: There are calcium deposits on a shoulder ultrasound, now what?

Calcific tendinosis is a condition that results in calcific depositions in the rotator cuff tendons of the shoulder. Many terms encompass this definition, these include calcific tendinopathy, calcific tendinitis, calcific shoulder periarthritis, calcific tendonitis, or rotator cuff calcification disease.

Contrary to popular belief, calcific tendinosis is not caused by trauma or overuse. While the exact etiology is unknown, there is evidence leading to an association with diabetes and thyroid disorders.1,2 Furthermore, there is some evidence to say those with occupations that promote internal rotation and slight abduction (impingement position) are at higher risk for this condition: desk workers, cashiers, and production line workers.3

The formation of calcium deposits is thought to be due to incorrect healing of the tendon. There are 4 distinct phases of this condition4

  1. Formative phase – formation of calcium deposits in the tissue
  2. Resting phase – deposits remain stable
  3. Resorptive phase – inflammatory reaction occurs, deposits are resorbed, this can cause extreme pain
  4. Post-calcific phase – calcium deposits resorbed, tendon returns back to normal

Presentation and Exam

The onset of pain can be chronic or acute (during the resorptive phase). There is no trauma preceding this pain. On occasion, patients may complain of night pain and decreased range of motion. On exam, patients can present with positive impingement test (Neer’s or Hawkings), painful abduction, and decreased ROM.5

Imaging

Ultrasound is the best and most cost-effective modality to assess calcifications of the rotator cuff. Ultrasound also allows one to assess for tears and dynamic rotator cuff impingement. Calcifications can also be seen on plain radiographs. In those patients whom you are suspicious of a bony pathology, a standard set of shoulder radiographs should be completed (AP, axillary, outlet view).3 MRI is not recommended.

Treatment

Currently, there is no gold standard treatment for calcific tendinosis.

First-line treatment includes conservative measures. These include NSAIDs, physiotherapy, manual therapy, and corticosteroid injections into the subacromial bursa (for those with an acute attack). In those with no improvement in 6 months, further treatment can be considered.3

Second-line options include shockwave therapy and ultrasound-guided needling (barbotage). These treatments are performed by specialized providers. Shockwave therapy attempts to break down calcium deposits and stimulate healing. Ultrasound-guided needling involves attempting to break up and aspirating the calcium deposits. This is complemented with a bursal injection to prevent subsequent bursitis.3 For those who respond to the treatments above, surgery can be considered to remove the calcium deposits.3

In terms of prognosis, 50% of symptomatic patients become pain-free with conservative treatments in 3 months, 20% more pain-free in 1 year. Of the remaining 30%, 20% will improve with barbotage and shockwave therapy. The remaining 10% will likely require surgery.6

Bottom line, most patients will improve with conservative treatment, in those that don’t respond you can consider referral to a provider for shockwave therapy or ultrasound-guided needling (barbotage).

Sonam Maghera, MD, BMSc

Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (SEM), Dip Sport Med

References

1.    Harvie P, Pollard TCB, Carr AJ. Calcific tendinitis: natural history and association with endocrine disorders. J Shoulder Elbow Surg. 2007;16(2):169-173.

2.    Mavrikakis ME, Drimis S, Kontoyannis DA, Rasidakis A, Moulopoulou ES, Kontoyannis S. Calcific shoulder periarthritis (tendinitis) in adult onset diabetes mellitus: a controlled study. Ann Rheum Dis. 1989;48(3):211-214.

3.    Sansone V, Maiorano E, Galluzzo A, Pascale V. Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment. Orthop Res Rev. 2018;10:63-72.

4.    Uhthoff  null, Loehr  null. Calcific Tendinopathy of the Rotator Cuff: Pathogenesis, Diagnosis, and Management. J Am Acad Orthop Surg. 1997;5(4):183-191.

5.    Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980;8(3):151-158.

6.    Noël E. Treatment of calcific tendinitis and adhesive capsulitis of the shoulder. Rev Rhum Engl Ed. 1997;64(11):619-628.

https://www.uptodate.com/contents/calcific-tendinopathy-of-the-shoulder?search=calcific%20tendinosis&source=search_result&selectedTitle=1~26&usage_type=default&display_rank=1

URL for picture above – Up-To-Date

Osteochondritis Dissecans (OCD) of the Knee – Take Home Points for Primary Care Physicians

Osteochondritis dissecans (OCD) is a focal abnormality of subchondral bone that can lead to detachment of a bone fragment and overlying cartilage (See Figure). It typically affects children and adolescents. Most patients are athletes, and risk of OCD is higher in boys than girls.

The most common location for OCD is at the knee, but it can also occur at the elbow (capitellum) or ankle (talus). At the knee, most cases involve the medial femoral condyle, and less often involve the lateral femoral condyle, and the patella.

The pathophysiology is not well understood, but repetitive microtrauma and local vascular insufficiencies are contributing factors.

Why is it important to recognize this condition?

OCD of the knee can be an uncommon cause of knee pain in the pediatric population. If left untreated, it can lead to degeneration of the cartilage and early osteoarthritis.

How does OCD present? And how do you diagnose it?

OCD has 3 main presentations:

  1. Incidental discovery on imaging, patient is asymptomatic
  2. Pain during sports and activities
  3. Continuous pain (this may be insidious onset), swelling, and/or locking of the joint

On exam, joint effusion may be present, and there may be tenderness at the site of OCD (e.g. medial femoral condyle). The Wilson test helps to detect medial condyle lesions – The test is positive if there is pain with internal rotation of tibia during extension of knee between 90 and 30 degrees, and relief of pain when the tibia is rotated laterally.

Differential diagnoses include meniscal tears, symptomatic discoid meniscus, osteochondral fracture, ACL injury, and patellofemoral syndrome.

Plain radiograph is the first step of investigations. AP, lateral, and tunnel views of the knee should be obtained. Findings can range from focal lucency to visibly detached fragment. MRI can be ordered to further characterize the lesion.

What is the prognosis of OCD?

OCD can heal over time or get worse. Factors that are associated with better prognosis include younger age (presence of open physes), smaller size of lesion, and location at the medial femoral condyle. Unhealed lesions, especially those that lead to loose fragments, can progress to osteoarthritis. 

How do you treat OCD?

  1. Asymptomatic patients should be monitored until radiographs are normal.
  2. In general, initially treatment is usually 3-6 months of sports restriction. When adherence to restrictions is poor, a long-leg cast can be used for immobilization in the short term (e.g. 6 weeks).
  3. MRI should be obtained for any patient with persistent pain after initial treatment, in older children (boys > 13, girls > 11) at initial presentation, or atypical location of lesion (i.e. not medial femoral condyle) to further characterize the lesion
  4. Unstable appearing lesions on imaging or persistent pain after 3-6 months of conservative treatment are indications for surgical referral

In summary, OCD is an abnormality of subchondral bone that most commonly affect the medial femoral condyle of the knee. It is an important diagnosis to consider in an active pediatric/adolescent patient presenting with knee pain with or without mechanical symptoms. Diagnosis can be made with plain radiography, and the lesion can be further characterized by MRI. Mainstay of treatment is cessation of sports activities for 3-6 months, and refractive cases require surgery.

Yuhao Shi, MD, Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

References1,2

1.           Accadbled, F., Vial, J. & Sales de Gauzy, J. Osteochondritis dissecans of the knee. Orthopaedics and Traumatology: Surgery and Research vol. 104 S97–S105 (2018).

2.           Masquijo, J. & Kothari, A. Juvenile osteochondritis dissecans (JOCD) of the knee: Current concepts review. EFORT Open Reviews vol. 4 201–212 (2019).

Steroid Injections in the COVID-19 Era

Does an intra-articular corticosteroid injection lead to systemic steroid absorption? Yes.

There is ample evidence that intra-articular injections of corticosteroids lead to numerous systemic effects. Most common steroids injectates can result in adrenal suppression for over a month. Accordingly, should a patient contract COVID-19 in the month following the injection, the steroid may continue to have a systemic effect.

The evidence for the use of corticosteroids in COVID-19 illness is limited and mixed. At the time of this publication, many societies in Canada and globally, including WHO, recommend against the routine use of steroids for the treatment of viral pneumonias.

The translation of this recommendation to intra-articular injections remains ambiguous. Whether or not the systemic effect of an intra-articular cortisone injection is sufficient to have an impact on the course of illness is completely unclear. Yet, given the uncertainty, prudence would suggest against their use.

If still unconvinced, another consideration could be the impact on the care your patient would receive should he/she suffer from severe illness. Currently, many novel treatment modalities are limited to clinical trials, and a recent corticosteroid injection may impact eligibility for enrolment.

 

What can you do instead?

Go back to basics! An evidence-based physical therapy program for arthritis is a great place to start, even during a pandemic. While many GLA:D programs are closed, information about their exercises can be found at: https://gladcanada.ca/index.php/what-is-glad-canada-2/. Many insurance providers are also moving to cover virtual visits with physiotherapists, allowing patients to receive customized treatment programs.

Alternative pain management modalities include ice, heat, self-massage, and acetaminophen. Of course, reminding patients that while a pandemic does not make it easier, weight management is the cornerstone of happy joints and a healthy body. A reminder that every kilogram of weight loss results in 4 kg off their knee never hurts!

 

Nitai Gelber, MD, CFPC

PGY-3 Sport and Exercise Medicine, University of Ottawa

Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

BCCDC. “Unproven Therapies for COVID-19.” 30 Mar. 2020, http://www.bccdc.ca/Health-Professionals-Site/Documents/Guidelines_Unproven_Therapies_COVID-19.pdf.

Fascia, Daniel, et al. “The Safety of Corticosteroid Injections during the COVID-19 Global Pandemic.” AMSIG, 30 Mar. 2020, http://www.amsig.org/recommendations-from-bssr-the-safety-of-corticosteroid-injections-during-the-covid-19-global-pandemic/.

Messier, Stephen P., et al. “Weight Loss Reduces Knee-Joint Loads in Overweight and Obese Older Adults with Knee Osteoarthritis.” Arthritis & Rheumatism, vol. 52, no. 7, 2005, pp. 2026–2032., doi:10.1002/art.21139.

Russell, Beth, et al. “COVID-19 and Treatment with NSAIDs and Corticosteroids: Should We Be Limiting Their Use in the Clinical Setting?” Ecancermedicalscience, vol. 14, 2020, doi:10.3332/ecancer.2020.1023.

WHO. “Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease Is Suspected.” 13 Mar. 2020, http://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf.

Lower limb stress fractures in sport: Optimizing management and outcome

Stress fractures are common injuries in athletes and account for 10% of all sport injuries.  Ninety percent of stress fractures are located in the lower extremities. The risk factors related to stress fractures consist of the following: a history of past stress fractures, female sex, training regimen, footwear, training surface, and type of sport with repetitive loading (such as running and jumping). Non-steroidal anti-inflammatory drugs should be avoided in all fractures as they may inhibit callus formation and slow down the initial healing process.

In the management of stress fractures, 7 aspects should be considered:

  • Is the fracture low or high risk?
  • What is the optimal imaging modality?
  • Conservative versus surgical treatment?
  • What technique is chosen if surgical?
  • What optimal rehabilitation schedule if conservative treatment?
  • How fast can sport be resumed?
  • What preventive program is available for this type of fracture?

In all stress fractures, radiographs are the first-line modality and may reveal linear sclerosis and periosteal reaction prior to the development of a frank fracture. In most stress fractures, the radiographs are negative although clinical symptoms are present. When a high-risk stress fracture is considered and radiographs are negative, a bone scan, CT scan or MRI is recommended. MRI is highly sensitive with findings ranging from periosteal edema of bone marrow to intracortical signal abnormality.

Conservative management ranging from non-weightbearing with a cast or Aircast with crutches to limited weightbearing crutch-assisted without pain is usually the optimal treatment when possible, even in high risk fractures.

High risk stress fractures;

A stress fracture is considered high risk because it is located either on the tension side of the bone or in an area of limited vascularity. Therefore, they are at increased risk of fracture propagation, displacement, non-union or delayed union. High risk stress fractures should be referred to orthopedic surgery with immediate cessation of activity as they might need surgical treatment. Those include distal anterior tibial diaphysis, fifth metatarsal base, medial malleolus, lateral femoral neck, tarsal navicular and great toe sesamoid. These fractures require specialized imaging to define and quantify the injury. The location of injury and response to initial conservative treatment will determine whether surgical management is needed.

High risk sport related stress fractures include the following:

 Anterior tibial diaphysis:

In 85% of cases, the radiographs are negative although clinical symptoms are present which should accelerate the request for a bone scan, CT or MRI. Treatment protocols consist of conservative management for 3 to 6 months with crutch-assisted weightbearing until resolution of pain in lower grade injuries and of casting in higher grades of injuries. In case of failure of conservative treatment, then a surgical intervention is recommended. The return times to sports for such injury is usually 7 months for both conservative and surgical management. However, the return to sports rates differed with 71% for conservative management and 96% for surgical management.

An exception is made when a complete fracture line is seen with both cortices involved. In this case, the stress fracture should be managed as an acute fracture. If the fracture is undisplaced, conservative management is recommended. If the fracture is displaced, a surgical intervention with an intra-medullary nail is required. The return times for these injuries then increases to 11.5 months for conservative management and 7 months for surgical management. The return rates remain similar with 67% for conservative and 100% for surgical management. For conservative management, recommended rehabilitation techniques consist of activity cessation, with avoidance of heavy loading of the tibia, limited weightbearing with crutches for 3 to 6 months. For surgical management, rehabilitation involves a progressive weight-bearing program supervised by a physiotherapist starting the first week following surgery with return to full loading activities between 6 and 8 weeks after surgery.

Fifth metatarsal base:

These stress fractures present on radiographs as a sclerotic or radiolucent line at the proximal aspect of the fifth metatarsal. These changes can be absent on radiographs in up to 69% of patients for this type of fracture. Again, MRI is the second line imaging. CT can be used to assess if there is fracture union after conservative treatment. Treatment of these fractures depends on the radiologic “Torg” classification. Conservative treatment is now often favored except in high level athletes and in high repetitive loading sports (running, jumping) where surgery is considered first line. If there is delayed union (Torg 2) or non-union (Torg 3), surgery is also recommended.

Medial malleolus:

Radiographs can be negative in 55% of cases. For undisplaced fractures, they can be treated conservatively in low level athletes although a good evaluation has to be done as these fractures tend to contribute to long term ankle instability. These injuries must be followed by strengthening, range of motion and proprioception training with a physiotherapist to prevent ankle instability.

Lateral (tension side) femoral neck:

Theses stress fractures occur most commonly in marathon and long distance runners. They are not seen on radiographs in up to 80% of cases. This stress fracture is treated with urgent surgical fixation to prevent fracture displacement and associated risk of avascular necrosis (AVN) of the femoral head. A minimum of 2 years clinical and radiographic follow-up should be done to ensure that delayed post-treatment AVN does not occur.

Navicular:

These stress fractures present most commonly in sprint runners. In high level athletes, surgical management may result in faster return to sport time but some randomized control studies are still needed to confirm this.

Sesamoids (great toe):

These stress fractures occur most commonly in sports such as dancing, gymnastics and sprinting; all involving forced dorsiflexion of the great toe. Medial sesamoid fracture is more common than lateral sesamoid as load occurs on the medial aspect of the toe with gait. Conservative treatment is the first line approach. However, if the patient remains symptomatic after 3 to 6 months, surgery should be considered because of a high rate of delayed union, non-union and fragmentation.

Low risk stress fractures:

Low risk fractures are treated with rest and exercise limitation because of the low risk of fracture propagation, non-union or delayed union. These include posteromedial tibial diaphysis, metatarsal shafts, distal fibula, medial femoral neck, femoral shaft and calcaneus.

In the majority of low risk stress fractures, a bone scan or radiographs are sufficient and the x-ray can be repeated instead of ordering a CT scan or MRI. In the case of medial femoral neck, femoral shaft or calcaneus fracture suspicion, an MRI should be requested because of the possibility of surgical management or to exclude other diagnoses.

Medial femoral neck:

If a fracture line is more than 50% of the femoral neck width or is displaced, a surgery is required to stabilize the fracture.

Femoral shaft:

Displaced fractures, delayed union and non-union require surgical consultation.

Calcaneus:

MRI can help to eliminate differential diagnoses such as plantar fasciitis, Achilles tendinosis and retrocalcaneal bursitis. These stress fractures are also difficult to detect on radiographs and may require surgical intervention if there is subtle displacement.

Metatarsal shafts fractures:

Among metatarsals, the second is the most common affected, followed by the third and fourth metatarsals. These fractures are usually treated conservatively with activity limitation for 6 to 8 weeks with an Aircast boot, short leg cast or fore-foot offloading shoe. Progressive return to exercise as pain allows can then be started.

In conclusion, it is important to remember that negative plain radiographic findings should not be considered alone but in conjunction with clinical findings. In the case of negative imaging with positive clinical findings, if there is a suspicion of high-risk stress fracture, additional imaging (bone scan, CT, or MRI) must be requested and conservative treatment implemented immediately for optimal treatment. If a low risk stress fracture is suspected, additional bone scan and serial plain radiographs are sufficient with conservative treatment, except in the case of femoral fractures suspicion.

In all stress fractures, independent of whether management is conservative or surgical, full level sport should not be started until there is clear evidence of clinical and radiological union and pain free ambulation.

Marie-Ève Roy, MD, CCFP
Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKin, MSC, MD, CCFP (SEM), Dip Sport Med

 

References:

Robertson GA, Wood AM. Lower limb stress fractures in sport: Optimising their management and outcome. World J Orthop. 2017 Mar 18;8(3):242-255.

Saunier J, Chapurlat R. Stress fracture in athletes. Joint Bone Spine. 2018

May;85(3):307-310.

Matcuk GR Jr, Mahanty SR, Skalski MR, Patel DB, White EA, Gottsegen CJ. Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol. 2016 Aug;23(4):365-75

 

Choose Wisely – The Knee Ultrasound

Quick & Simple: Knee ultrasounds rarely have any use in the diagnosis of acute knee injuries.

Acute knee injuries are a common presentation in the family practice office. Depending on the suspected injury, the most common imaging modalities ordered are X-ray, ultrasound, and MRI. While the exact total cost of imaging is not widely accessible, the cost of each scan includes the technician’s time, radiologist’s report, and machine use. Thankfully, many acute knee injuries can often be diagnosed clinically without need for further imaging.

Knee ultrasounds can most reliably identify injuries to the external tendons and ligaments of the knee due to the limitation of the ultrasound waves from penetrating bones and thereby assessing deeper structures. This fact may appear confusing, as the radiology reports may comment on the meniscus and even the ACL but with very limited accuracy.

This is where an understanding of the literature becomes important. While some studies may report surprisingly high specificities and sensitivities for evaluation of deep knee structures, they often do not reflect true values for imaging done in the community. From our perspective as clinicians, ultrasound offers a partial and often unreliable evaluation of deep knee structures.

In conclusion:

  • Knee ultrasounds are most reliable for evaluations of quadriceps and patellar tendons, MCL, LCL, and bursitis.
  • While reliable, these diagnoses should be made clinically and immediate imaging is often not indicated.
  • While tempting, at this point, ultrasound does not offer reliable assessments of the meniscus and ACL and should not be ordered routinely for these suspected injuries.
  • Given our LHIN resources, knee ultrasounds should rarely be ordered given the cost and minimal impact on prognosis or treatment.

As always, if in doubt, consider contacting your local sport medicine physician for advice regarding which imaging modality is most appropriate.

 

Nitai Gelber, MD, CFPC
PGY-3 Sports and Exercise Medicine, University of Ottawa

Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

 

References

“AIUM Practice Guideline for the Performance of a Musculoskeletal Ultrasound Examination.” Journal of Ultrasound in Medicine, vol. 31, no. 9, 2012, pp. 1473–1488., doi:10.7863/jum.2012.31.9.1473.

Alves, Timothy I., et al. “US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions.” RadioGraphics, vol. 36, no. 6, 2016, pp. 1759–1775., doi:10.1148/rg.2016160019.

Cova, Maria, and Emilio Quaia. “Faculty of 1000 Evaluation for Clinical Indications for Musculoskeletal Ultrasound: A Delphi-Based Consensus Paper of the European Society of Musculoskeletal Radiology.” F1000 – Post-Publication Peer Review of the Biomedical Literature, 2012, doi:10.3410/f.715297848.790852873.

Project ECHO Ontario Skin and Wound

ECHO stands for Extensions for Community Healthcare Outcomes.

The ECHO model™ links specialist/ resource team (Hub) with primary care community-based partners (Spokes) to form the Hub and Spokesmodel.  It uses a combination of live online sessions and in-person skills training to build health care capacity. The online sessions are live 2 hours weekly and include a short educational lecture, followed by case-based learning from the participants’ own patients.

The resource team (Hub) puts together the content of the ECHO educational lectures. Participants present de-identified cases of their own patients during the live online sessions. Participants also contribute to case discussions and evaluation surveys. They also receive continuing education/ continuous professional development credits (CE/ CPD).

Through the ECHO model™, community providers and specialists learn from each other, acquire knowledge, skills, increase competency and build a strong community of practice. Participants become part of a supportive community of practice and an inter-professional team.

See: Q&A’s – ECHO Ontario Wound and Skin

We’re launching in May. Sign up below if you’re interested in no cost interprofessional skin and wound care learning surveymonkey.com/r/FM6T99B #onhealth #wounds #dermatology

What Is It?

  • FREE case-based learning on: wound bed preparation, pressure injuries (ulcers), diabetic foot ulcers, venous leg ulcers, interprofessional team building and other topics
  • No cost mentorship on skin and wound care best practices
  • Access to physicians, nurses and allied health providers who will offer you guidance on your patients with complex skin and wound care needs.

Who Should Join?

  • Health care providers based in Ontario who have an interest in skin and wound care, including nurses, physicians, and allied health providers.

Benefits for Participants

  • Enhanced care for patients with skin and wound care issues
  • Certificate of Attendance, if a regular participant
  • Continuing Medical Education (CME) Credits awarded by Queen’s University
    • Being part of an interprofessional community of practice

Details

  • Weekly 2-hour sessions: 15-minute didactic lecture, based on International Interprofessional Wound Care Course (IIWCC) curriculum, followed by a discussion of real clinical cases submitted by participants
  • Topics discussed: diabetic foot ulcers, leg ulcers, pressure injuries, wound bed prep, infection, malignant, post-surgical wounds, traumatic injuries, peristomal, lymphedema, acute infection and other wound and skin care issues
  • Hands-on learning at semi-annual boot camp sessions held across Ontario

Interested? Here’s What You’ll Need

  1. Internet connection and webcam-enabled device like a laptop or smartphone
  2. Minimum two hours per week of committed time
  3. Willingness to present your patient cases for group discussion

To Express Interest in Joining

Email:       info@echowoundskin.com

For More Information:

Visit:        https://www.echoontario.ca/Echo-Clinic/Wound.aspx

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Pain Management Resources for Ontario Providers

Helping patients manage their pain is complex. To support primary care providers as they navigate this challenging landscape, partners across Ontario have come together to provide a one-stop spot for family physicians, nurse practitioners and other primary care clinicians to find resources to help manage their patients’ pain.

A range of supports – from guidelines on appropriate opioid use to CME-accredited webinars on topics like chronic pain – are included. Plus, access direct links to medical mentors who can provide timely advice and guidance on challenging care issues.

Resources are updated regularly and can be found at: http://www.hqontario.ca/Quality-Improvement/Guides-Tools-and-Practice-Reports/Primary-Care/Partnered-Supports-for-Helping-Patients-Manage-Pain

For more information about this coordinated approach to provide clinicians in Ontario with pain management resources contact:  http://www.hqontario.ca/