SHoulder pain management in General Practice : Do what I say not what I do…

IMG_0783

 

SHoulder pain presentations to GPs are very common. What do you do for them?

Clinical assessment? empiric treatment? Investigations?

It depends but this latest survey of Australian GPs and rheumatologists sheds some interesting light on the matter.

General Practitioner Management of Shoulder Pain in Comparison with Rheumatologist Expectation of Care and Best Evidence: An Australian National Survey

Using clinical vignettes, the authors sent out surveys to 3500 Australian GPs and 270 Rheumatologists, randomly selected from a mailing list. They asked how each respondent would manage each vignette.

The Vignettes were of : rotator cuff tendinopathy, acute rotator cuff tear, acute and late adhesive capsulitis presentation.

The authors then did a literature review of the available evidence for management of each condition and produced a best clinical practice summary for each.

They then make claims that surveyed doctors displayed a mismatch between real world practice and the best evidenced approach they produced.

What did they find?

We order too many imaging tests for common shoulder pain presentations.

We also order ultrasound guided steroid injections which evidently have no proven superiority over anatomical injections.

We refer these conditions  too often to specialists despite lack of evidence of benefit of surgical Rx or specialist care by a rheumatologist.

The paper makes some good points but misses a few things from my GP viewpoint.

the issue of overreliance on imaging and using USS guided injections is something I agree with. A good exam and history will suffice most of the time. I think referring for imaging should be in minority of cases, say where there are red flag concerns i.e past history of cancer and concern of metastases. I dont understand why USS guided injections are popular..have we stopped learning how to do anatomical ones? Why dont we as GPs learn to do USS guided injections ourselves and invest in a clinic USS machine? Even better we learn to do shoulder USS ourselves and can add it as part of our shoulder exam. Its not a difficult exam as the structures are all superficial. Early on in my training I committed to being skilled at musculoskeletal medicine and injection techniques. I later did a post graduate degree in medical acupuncture via Monash University. Anatomical injection techniques work well with long record of efficacy and safety in competent hands.

I do understand how many GP colleagues can seem to overrely on imaging. I dont think this is fair of the paper to suggest that there is no good reason for GPs to order shoulder imaging. Many of these cases are work related with possible significant insurance issues and imaging is not unreasonable to document pathology and the baseline shoulder state. Many patients are keen for imaging to be done , to find something that can be “fixed” and as GPs its in our nature to please our patients ( mostly ;-))..or at least be seen to be active in our management plan.

But here is the thing. You order a test it should be to confirm your clinical diagnosis, or exclude serious ones. A test should rarely if ever be used to go fishing for a diagnosis we have not made. That rotator cuff tendon tear you find on USS..who knows if it was there before the pain or not? And now its something you and the patient can get perhaps overly fixated on..maybe even lead to surgery that may or may not be superior to conservative management in the long run.

This is somewhat like acute back pain in GP medicine. Imaging rarely  helps initially..no more than clinical exam..unless there are red flags . Treat the pain, treat the person, treat their functioning. Dont worry about something on an xray that may or may not be the cause of the pain and certainly be wary of suggestions that surgery may help back pain cause there is some mild disc pathology.

I have never referred a shoulder pain patient to a rheumatologist. As GPs we should be able to manage common shoulder presentations. I do refer to shoulder surgeons for acute tendon tears and in cases where earlier return to activity is highly valued by the patient. I inject shoulders anatomically. I have learnt shoulder USS and do this regularly as part of my examination. I dont use USS to inject shoulders..its just not necessary and makes a simple procedure more complex than it need be.

What do you do ?

 

Advertisements

2 thoughts on “SHoulder pain management in General Practice : Do what I say not what I do…

  1. Pingback: Where Disorders Meet Healthy

  2. An interesting discussion, Minh!

    I must admit I probably do “over-image” for shoulder pain but that’s partly because of patient demand and also partly because of my own lack of confidence in my musculoskeletal diagnostic skills. Mind you, I think I’m probably as good as most young GPs in this area – ie, somewhere between hopeless and pretty good. Musculoskeletal is an area of medicine that is not taught well at the student level and is constantly identified by registrars as an area of weakness.

    I agree with your advice about history and examination being the cornerstone of diagnosis and interpreting imaging with caution! I followed up a patient recently who had been seen by another doctor with shoulder pain and had an USS guided subacromial steroid injection because there had been an ultrasound report demonstrating “very minor bursal thickening.” He had had very little response to the steroid injection and now, 6/52 later, wanted another one. But his history didn’t support the diagnosis of bursitis and nor did his examination, which was more suggestive of early capsulitis. It just demonstrates how people can be fooled into latching onto one minor abnormality on the USS and ascribing all the symptoms to it even if it doesn’t match the clinical picture at all.

    In any case, I DO like to do my own anatomical injections because I enjoy doing procedures, it’s cheaper and more convenient for the patient and also I feel like it’s one of the basic skills a well rounded GP should have. But again, it’s not something that’s well taught so I’m having to rely on a combination of online / FOAM resources and ad-hoc advice from a good friend of mine who is both an excellent physio and now musculoskeletal GP who helps me out in exchange for womens health tutorials! The other barrier is that patients often demand the USS guided injections because they want “the best care” and perceive it to be so.

    I rarely refer shoulder pain to specialists. Occasionally ortho but never rheum. I think the far more underutilised specialist for shoulder pain is the physio. And for some reason patients seem to think that you are fobbing them off if you insist they see a physio… and unfortunately for some the cost of a good course of physio treatments is cost prohibitive.

    I would definitely love to see more musculoskeletal FOAM to help me buff up this area of my practice. Do you know of any good resources already out there?

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s