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Musculoskeletal Care of the Mature Patient

A patient falls on an outstretched arm and experiences a painful shoulder. The individual seeks assessment from an orthopedic surgeon because of pain in, and limited motion of the shoulder. The X-ray is compatible with minimal arthritic changes in the acromio-clavicular joint and a very normal gleno-humeral joint. There is pain with shoulder elevation so the orthopedic surgeon cannot determine if the limitation is due to a rotator cuff tear or pain. In addition, you have had some recent discomfort in your same upper arm, intermittent for several months. A Magnetic Resonance Image is requested and is interpreted as “a partial tear” of the rotator cuff. How should you be managed?

In an initiative to optimize skeletomuscular care, The American Academy of Orthopedic Surgeons has established work groups to perform systematic reviews of scientific publications on a particular subject and establish clinical guidelines as to the best methods of care. It is part of the evolution in clinical care from opinion alone as to how a patient is treated to scientific evidence based practice. Musculoskeletal care is many different things and practiced in varying settings and geography. In an effort to standardize and optimize quality and efficiency, the guidelines are being created.

In looking at the subject of rotator cuff problems, it was determined that there is inconclusive scientific evidence to support the majority of clinical approaches to treatment in the presence of a partial tear. Based on the clinical practice guideline that was approved by the American Academy of Orthopedic Surgeons for patients with partial rotator cuff tears such as the one described earlier, the following would be the evidence based medical approach:

 1)    non-steroidal anti-inflammatory prescription

2)    physical therapy prescription

3)    reassessment in 10 to 14 days and if no significant improvement, an intra-articular cortisone injection with continuation of physical therapy

4)    repeat assessment at 6 weeks

If the patient is pain free, treatment is complete other than continued strengthening. If the patient still has impairment either from pain or weakness, there is no scientific evidence to support a continuing algorithm of care and the direction from the orthopedic surgeon will be based on experience and opinion including the following with no specific time milestones: 

1)    a second intra-articular cortisone injection and ongoing physical therapy

2)    arthroscopic surgical repair

3)    a single dose visco-supplementation injection

4)    a Platelet Rich Plasma injection

5)    stem cell management

Everything I have described after the six weeks of care based on scientific evidence is anecdotal opinion and individual orthopedic experience. On the other hand, the story of the Yankees’ Bartolo Colon shoulder is very seductive to every patient with shoulder impairment (NYDailyNews.com)



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