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Thank you for joining our uh CME presentation today. Uh I'm Doctor David Bene E VP of Clinical Value Based Care for Health Care Outcomes Performance Company, also known as HCO. Our topic uh for today is initial management of atraumatic uh rotator cuff uh syndrome. Before we get started on the topic of the day. Uh As we do for all CM E events, I want to assure the audience that I have no financial or nonfinancial relationships to disclose as it relates to this topic and subsequent um presentation as a reminder uh of those of you, uh those of you who have attended other CME topics we prevented uh presented in this series. Our objective is to improve the continuum of care and outcomes for musculoskeletal patients by defining the role of primary care providers in musculoskeletal value based care. Uh We also aim to provide diagnostic and management to pearls to PCPs and other providers referring uh to M SK specialists so that uh providers who manage the initial presentation of common M SK issues can be uh can more accurately diagnose and treat those conditions. Uh In addition, we aim to help providers identify red flags and other clinical factors. Uh Necessitating urgent imaging or specialist referral at the end of today's session. Uh We hope the audience will be uh better uh able to diagnose rota rotator cuff pathology. Initiate non surgical treatment for patients with rotator cuff symptoms and determine which patients would be most likely to benefit from subacromial uh injections, diagnostic imaging, um and skilled outpatient therapy in order to achieve these objectives. Uh We will briefly review the hop o specialty care network tip sheet. Uh Then we'll do a brief run through uh multiple important topics and the initial management of atraumatic rotator cuff syndrome. Uh starting with a uh a brief background and then uh moving to an evaluation of the shoulder for rotator cuff issues and then moving on to tips for conservative treatment uh testing. And finally, we will touch on uh when a specialist referral may be uh warranted. It's important to recognize why HCO and HCO Specialty Care Network also abbreviated as uh HS CN. Uh believes that information uh is important to distribute to our referral network including pcps and all other upstream uh providers. Uh Some of you may be more familiar than others um uh in the movement in healthcare towards uh value based care, uh by definition, value based care programs incentivize um healthcare providers to provide improved quality of care while reducing unnecessary costs. HCO Specialty Care Network is a clinically integrated network which is a type of value based care program. And in Arizona, HS CN um has a full population health program for a Medicare Advantage Population. Uh HCN was recently recognized by a top accreditation organization UAC for its commitment to clinical integration and high quality care. And HSN is actually the first specialty network in the country for which the clinically um clinical integration designation was awarded. Uh The HSC A network comprised of almost all of the orthopedic surgeons uh and many pain providers in Arizona uh who have all come together to join forces to follow standardized evidence based clinical pathways. HSC N also collaborates with other providers uh including yourselves who encounter MSK conditions with the goal of improving patient outcome uh and experience. Uh Before we dive into the topic of the day, uh I must also provide some background to this talk into the barriers. This information has in day to day clinical care. Uh The information today uh shared in this talk today is evidence based and consensus driven uh with recommended reco recommended practices designed to be implemented for patients with uh MSK conditions. Uh But as should be said, for all clinical programs, clinical discretion should be used uh with this guide with these guidelines for patients, especially if they're concomitant, clinical factors or comorbid conditions that may alter uh the clinically appropriate uh treatment path. We uh we start uh thi this um uh this talk with uh it, the HSEN tip sheet for which um uh which we're gonna start a and mention all of these uh uh talks as well. Um If you don't have a copy of this tip sheet, we did send it uh to all the pcps um uh who would be viewing this uh CM E event uh via snail mail. Um But if you need a copy, please feel free to email us and we're happy to send another copy to you if you email HSEN at HCO dot com. Um This tip sheet is uh more specifically older uh Medicare Medicare advantage population. Um But many tips here are also relevant to a younger population as well. Um Today, we're focusing on shoulder pain due to atraumatic rotator cuff syndrome. That's the second line uh on this tip sheet. Um We'll go through each column in a little bit more detail. Um But it is a good way to see the overall suggestions of the specialists uh for initial management of MSK conditions. Um As you can see on the tip sheet uh for shoulder pain uh including ro rotator cuff pain, but also for arthritis of the shoulder. Initial management comprises of conservative care, which may include therapy which we'll discuss more uh later in this talk. Uh but also importantly advanced um uh imaging uh and DMI are not part of the initial treatment recommendations as you see by the uh red logo there. Uh As a review, the rotator cuff comprises four tendons. Um that assist with movement of the arm and shoulder including supraspinatus, infraspinatus, subscapularis, and the teres minor uh rotator cuff pain. Uh is quite common with a prevalence of 16 to 34% of the general population. Um The condition is most common in middle aged elderly patients uh due to degeneration. Uh there's some uh impingement or overhead activities uh may cause a rotator cuff pain uh especially uh when done with poor form or posture. Uh In addition to the risk factor of age, this condition is more common uh in patients who have elevated BMIs uh hypertension and who smoke when evaluating uh a patient uh with shoulder pain. In order to determine um if the rotator cuff may be the culprit. Uh First, it's best to perform a general shoulder evaluation which includes a measurement of the shoulder range of motion including flexion abduction and internal external rotation. It's also uh useful to do upper extremity strength testing. Um uh And we'll also then highlight some specific tests, tests for a rotator cuff um pain as well in the next few slides. A couple of the um specific tests um that uh are that may be useful in diagnosing rotator cuff pain is the drop arm uh test uh and the painful arc test um for the um uh a painful arc test. After the patient actively a uh abducts, the arm lifts it to its side. Uh The painful arc test is positive if the patient has pain in the shoulder with active range of motion over uh 90 degrees which is when the shoulder is straight out. Um And the arm is straight out from the body. Um W when lowering the arm down from an abducted position, the patient should also be able to lower uh the arm smoothly. Uh with rotator cuff um pathology, this becomes more difficult uh and painful. Um And the arm sometimes will just drop down. Uh There'll be a, a pa a positive drop arm uh test. Another test uh looking at rotator cuff pathology is job's test also known as the empty can uh test uh with the arm fully extended and the thumb uh pointed down. Um If there's pain in the shoulder with resistance to elevation, uh that's typically positive with a rotator cuff uh pathology and one additional test uh specific to certain muscles of the rotator cuff. Uh They're the most commonly impacted is a test which looks for external rotator um weakness uh to perform this test. You can ask the patient to flex the arm uh to 90 degrees uh as you see here uh and attempt to move the forearm laterally uh against resistance. Once uh rotator cuff pain appears to be the most likely uh issue contributing uh to shoulder pain. Uh according to your history and examination, now, we can focus on the initial treatment uh for atraumatic uh rotator um Cuff syndrome, non surgical treatment. Um should be, um, for at least, uh, eight weeks in duration. Uh This includes a course of antiinflammatory medications and a home exercise program that's aimed at decreasing pain and gradually increasing strength of the rotator cuff. There are many ways to get a home exercise program started for your patients. Uh And there are many online resources to get them started with pretty simple, straightforward exercises that you could find online. Uh This is a good first step for many patients. Uh since rotator cuff pain and improved motion um will very often subside without any formal outpatient therapy. I if the patient doesn't appear to be improving uh with a home exercise program, a more formal uh therapy prescription can be written, but multiple therapy sessions is typically not necessary when you're writing a therapy prescription instead of just writing for eval and treat for shoulder pain. Sometimes it's, it's useful and, and we do recommend that you write uh for only a few sessions uh for the patient to get started. Um like for four visits or 1 to 2 visits over a two to week, 2 to 3 week uh time frame that usually suffices to get the patient started. Um any more uh therapy than this uh right off the bat may not be uh clinically necessary. Um And also uh maybe um they wait for the patient to come to therapy more often, then they need to get better. Uh If you're able to perform suboral uh injections in your office. That could be a good way to gr decrease severe uh inflammation. Uh but it's usually not necessary as a first line course. And typically it's not a good reason um by itself to refer to a specialist. Um, steroids should also be limited as much as possible uh due to the potential for side effects, um particularly in population sensitive to steroid medications, uh like diabetics. It's notable that even with um no comorbidities, uh patients should have no more than two steroid injections per year. Uh and they should be spread out uh three months, uh at least. Um And that's the case if you have an injection in the spine uh in the past or somewhere else in the body, it still should be limited uh to new to no more than two steroid injections uh per year, spread out over 33 months apart, at least. Uh Another um um option uh for treatment uh could be Toradol. It's not great for people sensitive to nsaids, but it may be good if there's severe pain uh on initial uh evaluation. Um but opioids and other injections, uh such as uh platelet rich plasma injections are not recommended for pain control um in this population, especially as part of initial treatment. Uh for most pa patients with atraumatic shoulder pain and more specifically rotator cuff uh pain. No imaging is typically uh necessary. Well, imaging is recommended for traumatic uh shoulder pain, including those with a suspected fracture or dislocation. Uh and also for those with a suspected malignancy uh in this clinical scenario of a traumatic rotator cuff pain, um which is the most common presentation. Uh it's typically best to defer imaging, uh especially advanced imaging uh to a specialist uh to a specialist who can to let it guide further treatment. Um and of note, uh shoulder pain due to arthritis, it's usually um um not unreasonable to start conservative care first. Also before getting an X ray to confirm a diagnosis uh of arthritis, um especially if the pain is not, um, not very significant or, or worsening. Uh And importantly, MRI s uh are not necessary conservative treatment um uh of an atraumatic rotator cuff tear and when the patient gets to the point of needing an MRI, usually that should be done, uh almost always by a specialist. Um That's true for CT S and ultrasounds. Uh they should be ordered by specialists as a way of guiding further treatment for those who failed conservative care. And when should you refer to an orthopedic shoulder specialist? Um, if the symptoms of pain and functional deficit do not improve despite a minimum of eight weeks and more more commonly, a few months of conservative care, a referral uh can then be clinically appropriate even in that setting if the patient uh is not or will not consider a procedure or a surgery, a surgical referral is typically not necessary. Um Clearly a referral to a specialist has to be taken in a case by case basis and should always be considered in the context of the patient's medical uh condition, uh work situation and other factors that may impact their health. Uh and outcome. I'd like to end each see me talk by highlighting some um important take home points. Uh First, conservative treatment prior to specialist referral and diagnostic imaging is almost always uh the most appropriate treatment. The conservative treatment should be exhaustive. Um As many times conservative care is all that's needed for patients to recover. And the conservative treatment should last no less than eight weeks but can span many months. A physical therapy should be used sparingly and often a home exercise program will suffice especially as an initial treatment for a shoulder pain, presenting to your office when therapy is ordered, ordering just a few sessions is completely clinically appropriate to see how the patient is doing. Uh As usually um if the patient gets to the point of needing uh formal outpatient therapy, only uh having just a few sessions uh will likely get them better without need for further uh treatment. And in almost all clinical scenarios, advanced imaging including Mr Isc Ts and ultrasounds um should be ordered by a specialist. Uh Thank you for joining us uh today uh for this presentation. Uh We hope you enjoyed uh the talk and hope you join us again as we explore other topics in MSK care. Thank you and have a good day.