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Greater Trochanteric Pain Syndrome

Trochanteric bursitis has mistakenly been the diagnosis of choice in the past years to describe any pain over the greater trochanter. Surgical, histological and imaging studies have shown that most patients who receive a diagnosis of bursitis actually have “greater trochanteric pain syndrome” (GTPS) attributable to medius and/or minimus gluteal tendinopathy or tears, thickened ilio-tibial bands (ITBs) or external coxa saltans (i.e. snapping hip) with little to no evidence of actual bursitis. Two or more of these diagnoses are often seen concomitantly. In a recent study from the American Journal of Roentgenology, in 877 sonograms of patients presenting with greater trochanteric pain, 50% had gluteal tendinosis, 28,5% had thickening of the ITB, 0,5% had a gluteal tear and 20% had trochanteric bursitis.

A proposed cause of GTPS is repetitive friction between the greater trochanter and ITB associated with overuse, trauma, and altered gait patterns. GTPS affects patients between 40 and 60 years old, and predominantly females. Likely risk factors include elevated body mass index (BMI), overuse, and abnormal hip biomechanics.

On history, patients commonly present with lateral hip pain, localized to greater trochanter, which is worse with weight-bearing activities, lying on the affected side at night, side-bending and prolonged sitting. Hip and back pain commonly coexist. Pain can worsen with time and be exacerbated by falls, sporting overuse such as long-distance running or unaccustomed exercise. The ability to “put on shoes” can help distinguish between osteoarthritis (unable) and GTPS (no pain or difficulty).

On physical examination, the clinician should look for a standing posture with slightly flexed hip and ipsilateral knee or listing to the contralateral side on sitting. Examination of the gait should be done to identify an antalgic or Trendelenburg gait. Direct palpation of the greater trochanter has a positive predictive value of 83% (for positive MRI findings). Provocative tests that aim to increase the tensile load on the gluteus tendons used for diagnosis are FABER, FADER (flexion, adduction & external rotation) and passive adduction. Other tests that aid diagnosis and rule out other pathologies are the dial test (for capsular laxity), Ober test, log rolling, the impingement test, the internal snapping of the iliopsoas tendon and the straight leg raise. A combination of these tests should be used to increase diagnostic accuracy.

The differential diagnosis includes hip osteoarthritis, femoroacetabular impingement (FAI), lumbar spine referred pain and pelvic pathology.

GTPS is a clinical diagnosis however in recalcitrant cases or those with unclear history or clinical findings, imaging can be used to exclude other pathologies and confirm the diagnosis. Hip X-ray is useful as first-line investigation to exclude osteoarthritis of the hip, femoroacetabular impingement (FAI) and fractures. Ultrasound or MRI of the hip is the second-line imaging of choice as it has a high positive predictive value for diagnosis of GTPS.

Conservative treatment results in 90% improvement for patients with GTPS. The main goals are to manage load and reduce compressive forces across greater trochanter, strengthen gluteal muscles and treat comorbidities. This includes weight loss, NSAID, physiotherapy, load modification and biomechanics optimization. Referral to a Sport Medicine physician might be necessary for cases that do not respond to conservative treatment. Adjunct treatments include modalities such as shock wave therapy and the positive results usually persist for 12 months post-treatment. Corticosteroid injections can be helpful in some refractory cases. Interestingly, platelet-rich plasma (PRP) injections showed clinically and statistically significant improvement in recalcitrant patients in a patient reported-outcomes study. However, more studies are needed to ascertain the impact of this treatment.

Surgical interventions are extremely rare and only for advanced refractory cases, failing optimal conservative treatments. Surgery can include minimally invasive endoscopic bursectomy, ITB and fascia lata release or lengthening, trochanteric reduction osteotomy or gluteal tendon repair. Often surgery incorporates a combination of these interventions. The functional outcomes of surgery are usually favourable.

 

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 :

 

  1. Speers CJBhogal GS, Greater trochanteric pain syndrome: a review of diagnosis and management in general practice, Br J Gen Pract.2017 Oct;67(663):479-480

 

  1. Reid D., The management of greater trochanteric pain syndrome: A systematic literature review, Journal of Orthopaedics 13 (2016) 15-26

 

  1. Redmond JM, Chen AW, Domb BG, Greater trochanteric pain syndrome, J Am Acad Orthop Surg 2016;24:231-240

 

  1. Walker-Santiago RWojnowski NMLall ACMaldonado DRRabe SMDomb BG. Platelet-Rich Plasma Versus Surgery for the Managaement of Recalcitrant Greater Trochanteric Pain Syndrome : A systematic Review. 2019 Dec 24.

Baker’s Cysts

The highlights:

  • A Baker’s cyst is a common swelling in the medial posterior fossa.
  • Commonly, it is secondary to an extension of the synovial space posteriorly, and accordingly will worsen with activities that will worsen a knee effusion
  • Given its prevalence and ease of diagnosis, imaging is rarely indicated
  • Treatment mainstay is addressing the primary knee pathology (ex: osteoarthritis treatment)

Popliteal synovial cysts are a common sighting in the primary care setting. Commonly known as Baker’s cysts, they refer to a swelling in the medial popliteal fossa.

While many patients are often distressed by their appearance, these swellings are benign. Simplistically, Baker’s cysts can be explained to the patient as an extension of their knee effusion. As the joint swelling worsens, a posterior extension into the popliteal cyst acts as a reservoir for the effusion.

The diagnosis of a Baker’s cyst is typically done clinically. It is typified by a medial popliteal cystic mass that increases in prominence with the knee in full extension and reduces with partial knee flexion.

The differential diagnosis for Baker’s cysts includes DVT, tumours (including sarcomas and lymphoma), and popliteal artery aneurysm. These diagnoses should be suspected if the location is atypical (ex: lateral popliteal fossa), the mass is firm or pulsatile, or if there is surrounding erythema, warmth, or tenderness.

Imaging, including X-rays and ultrasound, is only necessary if the diagnosis is uncertain or if another condition is suspected.

The treatment of Baker’s cysts typically relies on the treatment of the underlying joint disorder. For osteoarthritis, this involves activity modification, physiotherapy, and bracing when appropriate. When symptomatic, an intraarticular glucocorticoid injection may be indicated with or without prior drainage. As the cyst typically communicates with the joint, there is no need to target the cyst directly. Should this approach fail, an ultrasound-guided direct aspiration and injection of the cyst may be attempted.

Patients should be reminded that the Baker’s cyst is likely to recur as their primary joint disorder worsens and the effusion reforms. Accordingly, invasive interventions should be reserved for symptomatic cysts (i.e. pain and stiffness).

Should you or your patient continue to have questions or concerns, a referral to your local sports medicine specialist may be appropriate. A referral to orthopedic surgery may be appropriate following failed interventions for consideration of a cyst resection or joint replacement.

 

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

Acebes JC, Sánchez-Pernaute O, Díaz-Oca A, Herrero-Beaumont G. Ultrasonographic assessment of Baker’s cysts after intra-articular corticosteroid injection in knee osteoarthritis. J Clin Ultrasound 2006; 34:113.

Bandinelli F, Fedi R, Generini S, et al. Longitudinal ultrasound and clinical follow-up of Baker’s cysts injection with steroids in knee osteoarthritis. Clin Rheumatol 2012; 31:727.

Chen Y, Lee PY, Ku MC, et al. Extra-articular endoscopic excision of symptomatic popliteal cyst with failed initial conservative treatment: A novel technique. Orthop Traumatol Surg Res 2019; 105:125.

Fritschy D, Fasel J, Imbert JC, et al. The popliteal cyst. Knee Surg Sports Traumatol Arthrosc 2006; 14:623.

Han JH, Bae JH, Nha KW, et al. Arthroscopic Treatment of Popliteal Cysts with and without Cystectomy: A Systematic Review and Meta-Analysis. Knee Surg Relat Res 2019; 31:103.

Handy JR. Popliteal cysts in adults: a review. Semin Arthritis Rheum 2001; 31:108.

Marra MD, Crema MD, Chung M, et al. MRI features of cystic lesions around the knee. Knee 2008; 15:423.

Torreggiani WC, Al-Ismail K, Munk PL, et al. The imaging spectrum of Baker’s (Popliteal) cysts. Clin Radiol 2002; 57:681.

Ontario Bariatric Network Offering New ECHO Training Series starting in January

Do you know how to work with your patients living with obesity who have received specialty care from the Bariatric Centre of Excellence at The Ottawa Hospital? 

A new series of 6 sessions focused on obesity management and post-bariatric care will be offered at no cost to primary care providers interested in building clinical expertise.  The sessions start on January 15, 2019, and are held bi-weekly from 12 – 1:30 pm.

Click to learn more: 2020 Curriculum ECHO Flyer The Ottawa Hospital

Project ECHO OBN is an innovative technology-enabled collaborative learning program where primary care providers and an interdisciplinary team of clinicians from the BCoE work together to discover new ways of providing care more effectively to patients with obesity.

Build clinical expertise by joining our six-week series to discuss patient cases from your practice and learn about leading surgical and medical treatment options for patients with obesity, strategies to identify and prevent potential post-operative complications after bariatric surgery as well as tools and resources to assist you to manage obesity-related issues seen in primary care.

CME Opportunity for Primary Care Providers: Cancer Update 2019

The Champlain Regional Cancer Program is pleased to invite you to Cancer Update 2019.

This annual event takes place on Friday,  December 6, 2019.

For details, please see the Cancer Update 2019 and feel free to share with others in your organization. 

Register online Now!

www.cancerprimarycare.eventbrite.ca

For more information contact Champlain Primary Care at 613-798-5555 x 15811 or cancerprimarycare@toh.on.ca

Post Bariatric Care and Obesity Management

Project ECHO® OBN
Update Your Knowledge on Post Bariatric Care and Obesity Management

The Ontario Bariatric Network (OBN) is launching an exciting new initiative Project ECHO™ OBN that partners primary care providers with a multi-disciplinary team of specialists from the Bariatric Centres of Excellence (BCOE) to share best practices on bariatric care and obesity management.

This series of 6 sessions hosted by The Ottawa Hospital begin on October 2, 2019 and is open to physicians, residents and medical students, nurse practitioners and allied health professionals working in primary care.  There is no cost to attend.

Learn about:

  • Changing practices in the surgical and medical management of patients with obesity
  • BCOE and primary care collaboration to implement the Shared Care Model
  • Obesity-related co-morbidities and treatment options
  • Evidence-based approaches to effectively manage patient complications

Managing the care of post-bariatric surgery patients can be complex.  Register soon to take advantage of this no-cost learning opportunity!

For more information on session dates, curriculum details and to register, please visit https://obn.echoontario.ca

Click to view PDF with details: ECHO Flyer with curriculum Aug 2019

 

 

New Event: OntarioMD Every Step Conference

Register to attend the OntarioMD EMR: Every Step Conference on September 26, 2019 in Toronto.

If you register before Friday, July 5, you can take advantage of the Super Early Bird Rate of just $160 for a full day of learning, networking and CME credits!

Register now at https://lnkd.in/eRVcQbm

 

The EMR: Every Step Conference is for physicians, nurse practitioners, allied health professionals and administrative staff.

This conference will be accredited for CME pending approval from the Ontario College of Family Physicians.

learn more

FIT Implementation – Are you ready?

In preparation for the June 2019 roll-out of Fecal Immunochemical Testing in June 2019, the Champlain Regional Cancer Program invites you to attend: “FIT Implementation – Are you ready?” part of the Continuing Professional Development Series.

When: Wednesday, May 29, 2019
5:30pm – 8:00pm

You can attend in person or by webcast or OTN.

In person at:
The Ottawa Hospital, General Campus, Critical Care Wing
Room CCW 5225
501 Smyth Road
Ottawa

For webcast or OTN, details are available at www.cancerprimarycare.eventbrite.ca

Registration for this event can be made directly on our event registration site: www.cancerprimarycare.eventbrite.ca

Please feel free to forward this email and information to your colleagues.

This Group Learning program has been certified by the College of Family Physicians of Canada and the Ontario Chapter for up to 2 Mainpro+ credits.

Health Report Manager & EMR Practice Enhancement Program

Health Report Manager – Health Report Manager (HRM) is a digital health solution that enables clinicians using an OntarioMD-certified EMR to securely receive patient reports electronically from over 250 participating hospitals and specialty clinics, including over 30 in Champlain LHIN.

HRM electronically delivers text-based Medical Record reports, (e.g. Discharge Summary), and transcribed Diagnostic Imaging (excluding image) reports from sending facilities directly into patients’ chart, within your EMR. Once you are connected to HRM, you will also receive eNotifications, a useful digital health tool that lets you know sooner than the arrival of the discharge summaries that your patients were in the hospital.

Learn more about HRM. To sign up, please contact your local OntarioMD Practice Advisor or support@ontariomd.com.

 

EMR Practice Enhancement Program – The EMR Practice Enhancement Program (EPEP) is a complimentary provincial service designed to take an in-depth look at how you use your EMR to help you enhance your EMR skills and efficiency.

EPEP offers a current analysis of your EMR use, practice workflow and data quality to help you move beyond data capture and use information to improve patient care and practice efficiency. It provides hands-on support from Practice Advisors and Peer Leaders, who are expert EMR users, to create an enhancement plan that reflects your unique practice priorities, leading to improved workflow, efficiency and patient care.

 

Get started with EPEP today, or contact support@ontariomd.com to connect with a Practice Advisor.

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

Follow on Twitter:    @ECHOWound

Important Concussion Resources

In Ontario, over 150,000 people are diagnosed annually with concussion in emergency departments and by primary care physicians. In 2016 there were 15,736 concussions diagnosed in the Champlain LHIN. It remains evident that both healthcare providers and patients feel ill-prepared to effectively navigate the healthcare system with respect to concussion care and management of persistent concussion symptoms.

The Ontario Neurotrauma Foundation,ONF has been working to provide clarity and evidence-informed direction with respect to post-concussion care for healthcare providers and patients by releasing the Standards of Post-Concussion Care and the  3rd Edition Guideline for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms for Adults over 18 Years of Age. Providers can use the resources to learn about up-to-date evidence-informed practices and recommendations. ONF’s goal is to streamline visits with healthcare providers and provide direction to patients and families to increase confidence about how, what and when care should be provided.