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Management
of
Musculoskeletal
Injuries:
A
Survey
of
Texas
Family
Physicians
Kyle
J.
Cassas,
M.D.,
Martin
Krepcho,
Ph.D.,
Phillip
Disraeli,
M.D.,
Bradley
Musser,
M.D.
UT
Southwestern
Family
Practice,
Dallas,
Texas
Methodist
Hospitals
of
Dallas
Family
Practice,
Dallas,
Texas |
| |
Introduction
In
the
United
States
and
Canada,
musculoskeletal
complaints
can
often
comprise
up
to
25
percent
of
a
primary
care
physicians’
daily
practice,1-3
while
some
Texas
family
physicians
feel
their
training
in
orthopedics
and
sports
medicine
may
not
have
adequately
prepared
them.
Previous
studies
have
reported
on
the
limited
training
and
lack
of
confidence
in
the
diagnosis
and
management
of
common
“office
orthopedic”
type
problems
by
primary
care
physicians.4,5
Other
studies
have
also
reinforced
the
need
to
strengthen
the
musculoskeletal
training
received
both
in
medical
school
and
residency.1-7
The
purpose
of
this
study
is
to
examine
the
clinical
competency
and
confidence
levels
of
Texas
family
physicians
with
regards
to
musculoskeletal
medicine. |
|
Methods
A
panel
of
three
family
physicians,
two
orthopedic
surgeons,
and
two
primary
care
sports
medicine
physicians
were
consulted
on
the
survey
design,
selection
of
clinical
cases
and
determination
of
the
standard
of
care.
A
56-item
musculoskeletal
survey,
including
three
clinical
case
scenarios
was
then
pilot-tested
by
a
group
of
18
family
physicians
both
in
the
private
practice
and
academic
settings.
The
survey
was
refined
after
the
pilot
and
mailed
to
a
computer-generated,
random
selection
of
1,800
members
of
the
Texas
Academy
of
Family
Physicians.
The
survey
was
then
returned
by
either
standard
mail
or
fax.
Information
obtained
in
the
survey
included:
medical
school
and
residency
graduation
dates,
type
of
residency,
location
and
type
of
current
practice,
completion
of
a
sports
medicine
fellowship
and
prior
experience
as
a
team
physician.
The
survey
also
gathered
information
regarding
the
amount
of
orthopedic
and
sports
medicine
training
during
residency.
The
respondents
were
asked
to
rate
the
quality
and
the
quantity
of
the
orthopedic
and
sports
medicine
training
they
received.
The
final
component
of
this
survey
consisted
of
three
clinical
cases:
lateral
ankle
sprain,
lateral
epicondylitis
(tennis
elbow),
and
knee
meniscal
injury.
Participating
physicians
were
asked
specific
questions
using
a
five-point
Likert
scale
for
each
case
regarding
the
initial
evaluation
and
treatment,
activity
level,
rehabilitation
and
return
to
play
issues.
The
data
was
analyzed
with
Analyse-itTM
(1997-2002
England,
United
Kingdom). |
|
Results
Two
hundred
twelve
Texas
family
physicians
completed
and
returned
this
survey
with
a
response
rate
of
11.55
percent.
The
majority
of
respondents
(86
percent)
graduated
from
residency
over
the
past
20
years.
Most
graduates
were
from
either
a
community-based
(57
percent)
or
university-based
(36
percent)
residency
program.
The
practice
type
consisted
of:
group
practice
(42
percent),
multi-specialty
(24
percent),
solo
(19
percent),
and
academic
(15
percent).
The
practice
location
varied
from
suburban
(44
percent),
urban
(29
percent),
and
rural
(27
percent).
A
total
of
four
respondents
(2
percent)
had
completed
fellowship
training
in
sports
medicine,
and
37
percent
reported
prior
experience
as
a
team
physician.
Only
37.1
percent
of
respondents
agreed
or
strongly
agreed
that
their
orthopedic
training
had
prepared
them
for
their
current
practice.
Many
physicians
(63.2
percent)
felt
that
more
time
was
needed
for
orthopedics
during
their
residency
training.
In
regards
to
sports
medicine,
only
23
percent
of
physicians
felt
that
their
sports
medicine
training
had
prepared
them
for
their
current
practice,
with
many
(63.8
percent)
feeling
that
more
time
during
residency
training
would
have
benefited
them
in
their
future
practice. |
|
|
The
results
of
the
clinical
scenarios
were
as
follows:
Lateral
Ankle
Sprain
Case
Most
physicians
sampled
(98
percent)
recommend
RICE
(rest,
ice,
compression,
and
elevation)
when
dealing
with
an
acute
ankle
sprain
and
96
percent
would
prescribe
a
non-steroidal
anti-inflammatory
(NSAID)
in
the
acute
setting.
More
than
half
(62
percent)
would
order
an
initial
ankle
radiograph,
while
approximately
47
percent
would
consider
referring
this
injury
to
an
orthopedic
surgeon
for
further
evaluation.
Most
(89
percent)
physicians
surveyed
would
allow
these
patients
to
ambulate
with
pain
as
the
limiting
factor
and
many
would
offer
rehabilitation
exercises
to
patients
either
in
the
office
or
outpatient
setting.
Most
(93
percent)
would
allow
return
to
play
when
the
pain
had
resolved
and
the
patient
demonstrated
full
range
of
motion
and
strength.
Lateral
Epicondylitis
(Tennis
Elbow)
During
initial
treatment,
79
percent
of
surveyed
physicians
would
recommend
RICE
for
this
condition.
A
counter-force
brace
was
used
by
80
percent
of
physicians
and
again
a
large
number
(98
percent)
of
physicians
would
prescribe
a
NSAID
in
this
situation.
One
hundred
twenty-three
(58
percent)
physicians
would
offer
a
corticosteroid
injection
of
the
lateral
epicondyle
region
for
this
condition.
In
terms
of
activity
level,
90
percent
of
physicians
would
decrease
overall
level
of
activity
with
pain
as
the
limiting
factor.
Some
physicians
would
review
the
patient’s
tennis
technique,
and
33
percent
would
recommend
alternative
exercises
to
maintain
conditioning.
Over
three-quarters
of
physicians
would
teach
home
exercise
and/or
stretches
in
the
office
and
5
percent
would
refer
to
a
physical
therapist
for
further
management.
Meniscal
Injury
As
initial
treatment,
79
percent
of
physicians
in
this
sample
would
recommend
RICE.
Most
(98
percent)
would
prescribe
a
NSAID,
and
40
percent
report
that
they
would
never
recommend
intra-articular
injection
of
a
corticosteroid.
The
majority
of
physicians
(84
percent)
would
refer
this
condition
to
an
orthopedic
surgeon
for
further
evaluation.
The
use
of
imaging
procedures
consisted
of
plain
radiographs
(82
percent)
and
magnetic
resonance
imaging
(86
percent).
One
hundred
sixty-one
(76
percent)
of
these
physicians
would
reduce
running
distance
with
pain
as
the
limiting
factor
and
92
percent
would
recommend
alternative
exercises
to
maintain
fitness.
Approximately
12
percent
of
these
physicians
would
review
training
techniques
and
biomechanical
factors
with
these
patients.
Nearly
half
would
recommend
some
type
of
rehabilitation
using
a
physical
therapist. |
| |
Discussion
Family
physicians
in
Texas
feel
that
more
needs
to
be
done
both
to
increase
and
strengthen
the
amount
of
musculoskeletal
training
they
receive
during
medical
school
and
residency.
A
recent
study
from
the
University
of
Pennsylvania
School
of
Medicine
reached
similar
conclusions,
reporting
that
despite
the
continued
need
for
musculoskeletal
education,
there
may
be
a
marked
disparity
between
the
amount
of
musculoskeletal
problems
seen
in
practice,
and
the
adequacy
of
preparation
gained
in
medical
school
and
residency.3
This
article
revealed
that
82
percent
of
medical
and
surgical
residents
—
from
37
different
medical
schools
—
failed
to
demonstrate
basic
musculoskeletal
competency
on
a
validated
musculoskeletal
knowledge
exam.3
In
an
earlier
study
of
family
physicians
from
North
Carolina,
51
percent
of
the
respondents
reported
that
their
training
in
orthopedics
had
been
inadequate
for
their
current
practice.8
Several
studies
have
also
identified
deficiencies
in
the
orthopedic
physical
examination
skills
of
medical
students
and
primary
care
physicians.9,10
Despite
the
fact
that
Texas
family
physicians
feel
they
need
more
orthopedic
and
sports
medicine
training,
the
study
sample
performed
well
overall
in
regards
to
managing
three
common
conditions
when
compared
to
the
“expert
panel.”
However,
there
were
a
few
findings
that
deserve
mention.
A
large
number
of
physicians
prescribe
anti-inflammatory
medication
in
the
acute
setting
to
help
control
pain
associated
with
injury.
These
medications
may
lead
to
increased
acute
swelling
within
the
injured
tissues.
A
consideration
should
be
made
to
use
a
medication
such
as
acetaminophen
during
the
first
24-48
hours
after
injury
to
help
control
pain
without
the
associated
risks
of
increasing
swelling.
Anti-inflammatory
medications
may
also
inhibit
the
initial
healing
response
by
limiting
“healthy”
inflammation
and
the
influx
of
inflammatory
mediators
that
are
needed
for
tissue
repair
and
remodeling
(level
3
evidence).11
Anti-inflammatory
medications
also
carry
some
risk
of
adverse
effects
(gastrointestinal
bleeding
and
renal
damage)
and
associated
costs
if
used
on
a
chronic
basis
by
our
patients.
This
study
sample
also
was
very
likely
to
refer
many
of
these
conditions
for
further
evaluation
by
specialists
but
it
is
unclear
from
the
study
the
reasons
for
these
referrals.
Many
physicians
refer
when
the
patient
is
not
responding
to
the
initial
treatment
as
expected
or
because
the
injury
is
more
severe
than
usual.
Others
may
refer
due
to
a
lack
of
confidence
in
proper
diagnosis
and
management
of
some
musculoskeletal
conditions
or
because
of
liability
concerns.
There
are
also
times
when
patients
or
their
families
request
specialty
evaluation
when
it
may
not
be
necessary.
It
is
possible
that
as
musculoskeletal
knowledge
and
confidence
increase
over
time
that
primary
care
physicians
may
be
able
to
care
for
many
of
the
non-operative
musculoskeletal
conditions
encountered
in
their
daily
practices,
avoiding
unnecessary
testing
and
referrals. |
|
Many
physicians
in
this
study
sample
were
reluctant
to
or
did
not
educate
their
patients
about
proper
rehabilitative
exercises
when
injured.
Similarly,
they
did
not
offer
ways
to
maintain
cardiovascular
conditioning
while
attempting
to
recover
from
injury.
When
dealing
with
the
injured
athlete
or
‘weekend
warrior’
it
is
preferable,
when
possible,
to
allow
the
athletes
to
modify
the
activity
to
allow
recovery
or
develop
other
ways
to
maintain
conditioning.
Lower
impact
activities
such
as
swimming
pool
therapy,
elliptical
trainer
or
stationary
bicycle
can
often
accomplish
these
goals
while
still
allowing
the
patient
to
stay
active.
A
similar
study
by
Glazier
et
al4
has
determined
that
Ontario
primary
care
physicians
managed
three
clinical
case
scenarios
fairly
well
but
were
more
likely
to
prescribe
NSAIDs
inappropriately,
order
unnecessary
tests
and
inappropriate
referrals,
as
well
as
not
prescribing
exercises
frequently
enough.
They
concluded
that
primary
care
physicians
need
further
exposure
to
musculoskeletal
problems,
both
during
medical
school
and
in
residency
training.
Increasing
the
amount
of
training
and
exposure
at
the
medical
school
level
is
the
first
step
in
improving
knowledge
in
musculoskeletal
medicine.
Creating
a
foundation
of
knowledge
that
can
be
built
upon
and
refined
during
post-graduate
training
are
key
components.
Courses
like
gross
anatomy
should
emphasize
functional
and
surface
anatomy
as
well
as
the
biomechanics
of
joints
and
how
these
areas
relate
to
patient
diseases
or
injuries.
Schnirring
et
al
summarized
in
1999
that
only
12
percent
of
Canadian
medical
schools
require
clinical
exposure
to
musculoskeletal
medicine,
and
even
less
time
is
devoted
during
the
preclinical
years.1
Clinical
training
should
be
shifted
from
the
inpatient
orthopedic
setting
to
a
more
clinically-oriented
office
approach
when
possible.
This
would
allow
students
and
residents
to
focus
on
refining
history
taking,
physical
exam
skills,
reviewing
surface
anatomy,
as
well
as
outpatient
skills
such
as
splinting,
casting,
injection
techniques
and
patient
education. |
| At
the
resident
level,
those
interested
in
gaining
more
experience
in
casting,
splinting,
joint
injections
and
musculoskeletal
examinations
can
look
for
further
training
during
elective
time
or
during
an
orthopedic
and
sports
medicine
elective
rotation.
Some
programs
in
Texas
offer
elective
time
in
sports
medicine
to
those
residents
interested
in
furthering
their
skills
or
who
may
be
interested
in
a
one-year
sports
medicine
fellowship
after
residency.
Residency
program
directors
should
investigate
the
possible
benefits
of
adding
a
sports
medicine
clinic
to
the
residency
program.
Residents
should
also
be
encouraged
to
look
for
opportunities
to
become
team
physicians
for
local
athletic
programs,
to
attend
sports
medicine
clinics,
and
to
become
involved
with
the
youth
athletic
community.
This
type
of
exposure
can
provide
valuable
hands-on
opportunities
and
experiences
that
will
enhance
and
build
confidence
in
managing
musculoskeletal
injuries.
Upon
completion
of
training,
primary
care
physicians
can
seek
out
continuing
medical
education
opportunities
to
address
the
musculoskeletal
deficiencies
of
their
training.
Prior
reports
have
emphasized
that
CME
is
one
of
the
best
ways
to
improve
knowledge
and
confidence
in
managing
musculoskeletal
disorders.5
Organizations
like
the
American
Academy
of
Family
Physicians
provide
yearly
comprehensive
review
courses
dealing
with
the
primary
care
management
of
musculoskeletal
injuries
that
can
enhance
knowledge
and
improve
the
quality
of
patient
care.
Primary
care
physicians,
residents
and
medical
students
can
also
become
involved
in
organizations
like
the
Texas
Chapter
of
the
American
College
of
Sports
Medicine,
which
offers
an
annual
meeting
and
opportunities
to
further
enhance
their
musculoskeletal
knowledge
or
even
present
sports
medicine
research
or
clinical
cases.
For
more
information
visit
www.tacsm.org.
The
goal
of
Texas
family
physicians
should
be
to
strengthen
their
diagnostic
accuracy
through
proper
history
and
physical
exam
skills,
decreasing
unnecessary
medication
use
and
the
inappropriate
use
of
testing/radiological
studies.
Often
expensive
MRI
and
other
diagnostic
tests
are
unnecessary
and
are
used
in
place
of
a
good
history
and
physical
examination.
Physicians
dealing
with
musculoskeletal
problems
should
be
competent
to
know
both
when
and
when
not
to
refer
to
specialists
in
orthopedics
and
sports
medicine. |
|
| |
Some
areas
of
limitations
of
this
study
include
a
poor
response
rate,
which
could
have
been
improved
by
follow-up
mail
to
non-respondents,
or
the
use
of
a
Web-based
or
e-mail
type
survey.
There
may
have
also
been
some
response
bias
in
physicians
not
comfortable
in
managing
these
musculoskeletal
conditions
and
therefore
not
returning
the
survey.
The
respondents
were
also
not
able
to
explain
some
of
their
answers,
which
may
have
provided
some
useful
information
regarding
patient
care.
Also
those
surveyed
may
have
answered
the
clinical
cases
differently
from
how
they
actually
practice
because
of
the
Hawthorne
effect
(knowing
they
were
participating
in
a
research
project).
In
summary,
the
findings
of
this
study
reveal
that
Texas
family
physicians
would
like
further
training
in
musculoskeletal
medicine
to
help
prepare
them
for
the
types
of
patients
they
encounter
on
a
daily
basis.
Similar
to
previous
studies,
this
study
sample
may
have
over
prescribed
anti-inflammatory
medication,
underutilizing
cross-training
activities
to
maintain
cardiovascular
fitness
and
may
have
ordered
unnecessary
radiological
procedures
and
referrals
to
specialist.
Further
research
is
needed
to
help
shape
the
education
and
curriculum
of
our
medical
students
and
residents
in
musculoskeletal
medicine.
Acknowledgments:
The
authors
would
like
to
thank
the
Texas
Academy
of
Family
Physicians
Foundation
and
UT
Southwestern
Family
Practice
Program
for
funding
related
to
this
project. |
|
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Freedman
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RH,
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