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Tears

This topic contains 4 replies, has 2 voices, and was last updated by   Christopher Stepien September 29, 2018 at 6:32 am.

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  • #4989

    Brandon Cohen DC, CSCS
    Participant

      I’m getting relatively proficient at clinically diagnosing labral tears and rotator cuff tears. Getting the imaging is always helpful for communication, but I’m unsure what tears need to be evaluated as a candidate for surgery.

      I imagine the answer is, when conservative care won’t help, but what I’m looking for is information on what size tears, or maybe what location might have the best outcomes for surgeries.

      I’ve spent some time searching for answers, and have come to the following two conclusions:

      1) There isn’t a good black/white answer for this.

      2) I generally suck at looking for information in medical journals.

      Thanks,

      #4991

      Adam Holen D.C.

        You already sort of answered the question. When conservative care won’t help (full or nearly full ROM, minimal adhesion, etc) then it’s our job to get the diagnosis right. Once you know the diagnosis and just need to confirm it via imaging, it’s on to the next step (knowing you won’t be able to do much). The orthopedic consult will want to see images anyway, so you did your job by figuring it out. As for which tears and how big, that’s not something I’d lose any sleep over because that’s not our expertise (it doesn’t change our approach). What you can offer (the orthopedic consult) is the information they don’t have such as load, capacity, symptoms, and dysfunction. This may better help them determine what exactly makes for a surgical candidate. I’m sure others may have better input, but as far as the specificity of these cases, I’m mainly concerned with getting it right (diagnosis) and then getting them to the next best expert for their professional opinion on what to do, vs. me trying to figure out how bad or where exactly this or that may be. If you can’t fix it, it’s not your problem to bear in terms of treatment. But you do provide tremendous value in getting the diagnosis correct and saving patients from a litany of unnecessary interventions.

        #4992

        Brandon Cohen DC, CSCS
        Participant

          Adam, I agree. My concerns more lie in what other providers might do. I know I can’t control that, but I would feel more comfortable referring someone to an orthopedist who I am somewhat confident will be a surgical candidate, versus sending someone with a tear who is clearly not surgical and then gets a cortisone injection and sent to 6 weeks of PT to give them something to do.

          #4993

          Adam Holen D.C.

            Ahhh okay, that makes sense I understand. That’s a good question, not sure what exactly justifies a surgical candidate. Other than labral tears being in the red zone, partial tendon tears/tendinosis, non-neuro compressive discs, or mild cartilage damage it seems like most everything else would require some sort of surgical intervention. But I agree, it would be nice to have an idea of what’s worth it because patients can very easily get run through the mill with injections and passed off to PT for “rehab.” How frequent are cases that are the ‘gray area’ which you can improve ROM (say maybe 80% function or better), strengthen, and hope they don’t screw it up? For me that’s a weird spot when you know what’s there, you just don’t know how bad. Is that more of a response to treatment group then? Front loading the diagnosis and potential for MRI if things don’t respond well. I don’t want to be relying too heavily on response to treatment, but I’m also never going to look at a shoulder MRI and go “Yup, that’s surgical” unless it’s blatantly obvious which would be picked up on exam anyway.

            #4994

            Christopher Stepien
            Participant

              This is interesting for me to read because I’ve had the same problem as you Brandon. I want to be an “expert” at knowing what solutions are available – like a musculoskeletal concierge.

              But I can hear Bill in my head saying, “Your job isn’t to be an expert in all the options. Just to fix people with conservative musculoskeletal care.”

              My current approach is to “be curious” about options and what seems to be working/vs. not working. This frame seems to have taken away my recovering perfectionist’s attachment towards getting everything right and knowing all of the answers.

              I also like the 50% of the circumference rule for rotator cuff tears. Not sure if that’s valid or helpful. But I like it.

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