Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello and thank you for joining our CME presentation today. I'm Doctor David, be E VP of uh Clinical Value Based Care for health care uh outcomes Performance company, also known as HCO. Our topic for today is the initial management of uh meniscal tears of the knee. Uh Before we get started on the topic of the day as we do for all CM E events, I want to assure the audience I have no financial or nonfinancial relationships to disclose uh as it relates to this topic and subsequent presentation as a reminder to those of you who have attended other c topics we prevented. Uh I'm sorry, presented in this series. Our objective is to improve the continuum of care for muscle skeletal patients. Um by defining the role of primary care providers in musculoskeletal value based care. Uh We also aim to uh provide diagnostic and management pearls to pcps and other providers uh referring to M SK specialists so that providers who manage the initial presentation of many common M SK issues can um better accurately diagnose and treat these conditions. In addition, we uh aim to um help providers identify red flags and other clinical factors, uh necessitating urgent imaging or specialist uh referral at the end of today's session, uh we hope the audience will be able to more accurately diagnose me meniscal pathology from symptomatology and physical examination. We also hope the audience is able to initiate uh the management of patients with meniscal tears uh which includes determining which patients are most likely to benefit from therapy and diagnostic testing. And furthermore which patients with meniscal pathology would benefit from a specialist referral in order to achieve these objectives. Uh We'll briefly review uh the HCO specialty care uh network tip sheet that we do in uh all uh lectures in this series. Uh Then we'll do a brief run through of multiple important topics on the initial management of meniscal tears. Uh starting with a background and then moving to evaluation of the knee for meniscal uh pathology. Um then moving on to tips for conservative uh management uh testing. And finally, we'll touch on when a specialist referral may be clinically uh warranted. HCO and HCO Specialty Care Network also abbreviated as HS CN uh believes in this information. It is important to distribute to our referral network including pcps and all other upstream providers to improve the continuum of, of muscle skeletal uh uh care and support value based uh patient care. Some of you may be more familiar than others with um uh the movement in healthcare towards value based care. Um just as a, a background value based care programs are are made to incentivize healthcare providers to provide improved quality of care while reducing unnecessary cost. HCO Specialty care network is a clinically integrated network at C in that's a type of value based care program and in Arizona, uh HSEN is a full population health program for a Medicare advantage population. Uh HSEN was recently recognized by a top national accreditation organization U A uh for its commitment to clinical integration and high quality care. HSN is actually the first specialty network in the country for which the clinical integration designation was awarded. The HSC A network uh comprises orthopedic surgeons and and many other muscle skeletal provides providers in Arizona who have joined forces to follow standardized evidence based clinical pathways. HSN also collaborates with other providers uh including yourselves uh who encounter MSK conditions uh with a goal of improving patient outcomes and experience as uh you are all uh well aware, a lot of the initial management of M SK care uh doesn't occur in a specialist level. Um But upstream, uh in the PCP Clinic, um A and other uh initial responders uh in saying this, it is a, it's clear the Population Health Program clearly relies on PCPs to help reduce unnecessary M SK cost. Um as they are the most uncom most common gatekeeper for M SK care. Uh Before we get into the topic of the day, um It's important to mention the information shared in this talk is evidence based and consensus driven with recommended practice designed to be implemented for patients with muscle skeletal conditions. Um But like all clinical programs, um clinical discretion should be used when using um guidelines or, or these um the information in this uh in this talk, especially if there's concomitant clinical factors or comorbid conditions that may alter the clinically appropriate uh treatment path. Let's start uh with a review of the HSEN uh tip sheet as we have for all uh talks within the series. Uh We sent out this tip sheet. Um and I've, I mentioned some other talks as well, but if you don't have a copy and you would like one for your office, please feel free to email us at HSC N at HCO uh dot com and we're happy uh to get one to you. Uh This tip sheet uh is obviously more specific to the older Medicare or Medicare advantage population, but there are many tips, tips here that are relevant to a younger population uh as well. Uh Today, we're focusing on knee pain due to uh meniscal tears. Um That's actually the uh sixth row down on this tip sheet uh or actually second from the bottom, it's probably easier to uh say it that way. And the overall recommendations for meniscal tears um is similar to other conditions of the hip and knee, including arthritis and labral tears of the hip for uh initial management. Uh This includes conservative uh management but uh does not include as a first line treatment, formal outpatient therapy, DM E or advanced diagnostic imaging uh as a review um uh of the anatomy um where the tibia and femur meet, there are two we shaped or, or crescent shaped pieces of cartilage that provide cushion and stability. Uh when weight is transferred between uh the bone of the leg um with uh weight bearing, uh meniscal tears are common individuals over the age of 40 especially in tho those who are involved in high impact activity like sports that involve cutting pivoting sudden stops or starts. Um like for a lot of us now, pickleball um but could happen uh without any obvious trauma as well. And actually, from personal experience, I could tell you it could happen just from taking a short job. Uh jog and uh worn out sneakers. Um A mile care can be atraumatic uh completely require or require less trauma than expected. Uh in the setting of ongoing degenerative process. Um Overall, the incidence is quite high, an estimated 61 per 100,000 people per year have a meniscal tear. The the prevalence is higher in men than women, but uh women certainly have their fair share of meniscus uh pathology as well. And although it's not too relevant with regard to a difference in initial management, meniscal tears are more common, medial tears, tears are more common than lateral tears of the meniscus in order to uh determine um if knee pathology uh is possibly stemming from me, meniscus tear. Uh you first wanna perform a thorough history and physical um history of mechanical symptoms like catching or locking or instability um can happen, but they're not universal and some patients may feel a pop in the knee with an injury. But again, this is not, uh does not happen all the time. Uh Most of the time, uh injured patients can continue to walk or play sports uh for a certain amount of time, but they'll start to notice an increase in swelling over a few days after their injury with the knee becoming increasingly uh stiff inspection of the knee for signs of swelling and tenderness along the joint line. Um uh I is a useful way of, of seeing if there might be a meniscal pathology. Um but the swelling could also be a little bit more diffuse around the entire knee. Uh range of motion can be normal or limited somewhat, uh mostly due to pain. Um But there shouldn't be any significant laxity if the concurrent injury. Um if there's no concurrent injury to the stabilizing ligaments of the knee, like the ACL and the PCL, uh one test, uh that is uh more specific for the pathology is uh the mcmurray's uh test uh to perform the MM mcmurray's test. Uh standing to the side of your patient who's lying some pine on an exam table, uh with one hand, holding the knee and palpating the joint line. Put your other hand on the sole of the patient's uh foot. Uh Then with the knee maximally maximally flexed, extend the knee along with moving uh the foot to put pressure on both the inside of the knee. A valgus stress and the outside of the knee of various uh stress. Uh The test is positive there's pain along the joint line or if the knee snaps, clicks or locks. Uh Another test uh for a meniscus tear is the Ales compression test or ales groin test. Uh for this test. Um Have your patient life prone with their affected knee flexed to 90 degrees, uh then apply downward pressure to the knee as you rotate the tibia and lower leg as we're looking for in the mcmurray's test. This test is positive with joint line pain, clicking, popping or uh locking of the knee. If you have a patient with a suspected meniscal tear base and history and physical examination, uh before a referral to a specialist or diagnostic testing, you should start imagining the condition with uh relative rest, ice and compression. You could add nsaids as well that might decrease uh some of the pain uh and inflammation. I in order for uh the patient um uh to improve uh activity modification is an important first step. This involves avoiding activities, exercises or sports that exacerbate the symptoms. Uh and actually, that may be the most difficult step for some of the, some of your patients. Um In addition, it'd be beneficial um for the patient to have a home exercise program. Uh Even in the absence of formal outpatient physical therapy, uh outpatient physical therapy treatments should be reserved for patients um who cannot tolerate or fail home exercises. Um Even for those uh patients who appear, they may benefit from a formal therapy. Uh Multitherapy, um multivisit therapy is uh not uh generally necessary. Many patients could use 1 to 3 sessions of therapy uh to learn some exercises that they can then uh go on and do at home. Um In saying that it would be helpful if you make a prescription uh for therapy, more specific meaning instead of writing uh for PT eval and treat uh for a meniscal tear, you may write PT eval and treat 1 to 3 sessions with a quick, quick transition to home exercise or uh 1 to 2 sessions per week for two weeks with a quick transition to home exercise uh program. Uh with regard to uh bracing, uh very few patients would benefit from bracing for meniscal tears. Uh in the absence of ligamentous injury, meniscal tears are not associated with laxity or joint instability. So, bracing uh can provide warmth and support but generally, it doesn't do anything to add a mechanical advantage uh for the knee on the flip side, providing a brace does um uh disinhibit. Um uh it does in, I'm sorry, does inhibit um the muscles of the knee from activating there attributing um to weakness of the knee over time, especially for patients who are wearing a brace or knee sleeve for long periods of time, uh daily. Uh if bracing is uh trialed. Um uh I in a case where conservative uh measures, uh other conservative measures have failed an over the counter uh hinge Neopine, uh neo, sorry, neoprene, uh knee uh brace can be um used temporarily. Uh and these can be found at drugstore. And the and the price usually the drugstore is cheaper uh than when the prescription uh runs through insurance. Custom bracing is not indicated. Um If there's need for custom bracing that should be ordered by a specialist. But even um ee even uh this is only done in rare circumstances. Um and usually only with uh another uh a concomitant knee injury. Uh just a quick note on injections. Um evidence is mixed on the effectiveness of corticosteroid injections for treating meniscus tears. So it should be avoided in patients who have well preserved cartilage on X ray and uh possibly require surgery. Also remembers that, remember that injections should be done sparingly to avoid medical complications associated with steroids like in diabetic patients and should only be done a couple of times a year uh total uh at least three months apart um and referring to a specialist, um it shouldn't be done for patients just needing an injection alone for meniscus um uh pain with regard to testing in the absence of trauma. Uh diagnostic testing is not necessary uh before starting uh treatment uh with trauma like um any concern for a fracture. Um an X ray is a good test to start with. Um this uh would be in the case of a patient with a knee uh falling or due to a car accident. Uh Additionally, a patient with atraumatic knee pain, but there's suspicion for malignancy. An X ray is a, a good first study to get. Um of note, meniscus tears are common in individuals with arthritis, which does not change the overall uh treatment plan. Um arthritis can be a red herring in this situation and lead you down a path uh that does not solve the underlying cause of the patient's uh knee pain, uh testing including blood work, CT scans and ultrasounds. Also, n nerve conduction studies are not indicated in initial management unless there's suspicion for other underlying conditions or complications. Uh Additionally, MRI should be used judiciously and only for patients presenting with a lock knee or uh um and uh usually, MRI should be done by orthopedic surgeon if the patient has a lock knee and you're sending the orthopedic uh surgery as well. It's best for the orthopedic surgeon to order that MRI. So you could skip that step. Um biologics such as uh P RP should be avoided um with meniscal tears, speaking of uh specialist referrals. Uh So I want you to refer to a specialist with suspected or known uh meniscus tears. If the patient does have locking of the knee or an inability to fully extend the knee, a referral may be appropriate, uh, or if the patient has persistent pain, uh worsening pain or, or mechanical uh, symptoms that have failed to improve, uh, with a full trial of conservative treatment. Um Again, a referral may be uh clinically appropriate. And as I've mentioned in other talks in this series, if a patient is not willing to consider an injection or surgery, uh sending the patient to a surgeon may not be necessary. As I do with all the talks in the series, I like to end the talk uh with some take home points. Um first conservative treatment prior to specialist referral and diagnostic imaging is typically the most appropriate initial treatment. A home exercise regimen is reasonable as initial treatment. Um uh whereas uh a formal outpatient uh physical therapy is usually not necessary as an initial treatment, consider a trial should last uh six weeks or more to avoid unnecessary referrals uh and testing. And additionally, patients who require D MDM E should research the cost of attaining um noncustom DM E at a drug store instead of through insurance. And again over the counter, uh DM E is uh completely uh appropriate as opposed to a custom uh DM E for meniscal pathology. Uh MRI CT scans should not uh typically be ordered by uh PCP. Uh This um can be done um for tears uh uh associated with a locked knee. Uh But again, that should um be done by a specialist. Um So spending sending the patient to a specialist first before that MRI is done is usually the right path. Uh Thank you for uh joining uh me here today for uh this uh this uh talk. Uh We hope you enjoyed the talk and I look forward to having you join us for other um CME events in the near future. Thank you. Have a good day.