[Dhinu Jayaseelan]

Hmm – that’s a bit strange. I have been involved in a few cases where there wasn’t a specific MOI suggestive of a full-thickness tear, but clinical exam made sense, and no improvement was had after a few weeks. In that case, imaging has been helpful in guiding what ended up being successful surgical intervention. It’s not as common for what sounds like a unilateral (?) decision guided by the surgeon based on imaging – despite the positive outcome.

It makes me wonder what goes on in the MD’s head when looking at imaging. This is also a great example of what seems like ‘experience’ holding up the stool of evidence-based practice. Research is useful, obviously, but past experiences can be equally important. In that way, while I’m not glad you had a negative experience, I’m glad you can bring a different perspective to your patient interactions to allow for informed decision making.

Thanks

Dhinu

[Dhinu Jayaseelan]

Hi Dave –

Thanks for your post. I think you raise some important questions when it comes to surgical v. non-surgical management of individuals with shoulder problems. One of those questions is the utility of imaging in guiding management. I offered some references regarding asymptomatic individuals with cuff tears in my recent response to Sarah’s post. You brought up the important process of CLUSTERING findings to possibly include imaging, but also physical testing and subjective questioning in the decision making process. Regardless of how Sn or Sp a test is, when we consider the development and measurement properties of tests, we always should incorporate multiple data points.

When it comes to the patient, I’ve learned that they’re completely correct in thinking they should get a repair. If something is broken or torn, it should be fixed. I have a patient now who is a biomedical engineer, shoulder pain x 30 years – he very much thinks pathoanatomically, and it can be tough at times to help him understand the context. Besides evidence – which may be hit or miss in terms of how much patients care about it – what strategies have you used to help people understand ‘normal abnormality’? What additional strategies could you incorporate to improve the understanding of patients who justifiably are skeptical of conservative management in the presence of pathology identified by imaging?

Similarly, what are your thoughts on tear progression? Sure, we can get similar outcomes to surgical management in many comparative studies, but even the long term follow up in those studies is rarely > 5 years. How do you answer the question if a patient says ‘well if it doesn’t get fixed, will it get worse?’. These articles came to mind, but again, don’t necessarily answer the question for everyone (Kim, 2017; Tashjian, 2012; Hsu, 2015). When we say something is safer and cheaper though, often times we consider more of a narrow view of short term. That person who did/didn’t have shoulder surgery isn’t being tracked for a 10, 20, 50 year follow up. I wonder, did that person who had an equivalent or superior outcome with conservative treatment at 1 year go on to develop altered pain processing, or reduced tensile capacity of the cuff leading to subsequent functional limitation, etc etc etc. I don’t have the answers to these questions, but thinking about this stuff helps me to try and understand the patient and surgeon’s perspective, rather than being biased by my own.

thanks – looking forward to following up with this topic.

Dhinu

References:
– Hsu J, Keener JD. Natural History of Rotator Cuff Disease and Implications on Management. Oper Tech Orthop. 2015;25(1):2-9. doi:10.1053/j.oto.2014.11.006
– Kim YS, Kim SE, Bae SH, Lee HJ, Jee WH, Park CK. Tear progression of symptomatic full-thickness and partial-thickness rotator cuff tears as measured by repeated MRI. Knee Surg Sports Traumatol Arthrosc. 2017;25(7):2073-2080. doi:10.1007/s00167-016-4388-3
– Tashjian RZ. Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clin Sports Med. 2012;31(4):589-604. doi:10.1016/j.csm.2012.07.001

[Dhinu Jayaseelan]

Hi Sarah –

Thanks for your post. You offered some examples that resonated with my own clinical practice. In the case of your 60 y/o patient – it’s good that the outcome was positive. I’m wondering – what were some variables you remember that seemed to be associated with this poor outcome with initial management? Limited motion? Severe weakness? Did he have a trauma? Why do you think that the image led so quickly to surgery, when there are a number of studies suggesting cuff abnormalities on imaging are normal in older asymptomatic individuals (Teunis, JSES 2014; Tempelhof, JSES 1999; Minagawa, J Orthop 2013; Yamamoto, JSES 2011). Was this surgeon more aggressive or conservative? Looking back, do you think there was anything you could have detected clinically to say – you know this guy probably would do better with surgery, as compared to someone else with a similar age/activity level?

If some patients, like your boating guy, get better based on management directed by imaging, why do you think there is a hesitancy to use it more regularly to guide management? I’d like to hear more about your perception on why your experience has been more negative in regards to imaging. What are some specific components of the imaging process that can be harmful, do you think? Why do you think you have these negative perceptions? Is it because you’ve seen patients whose outcomes worsened after imaging? Did your professors have a bias that led away from imaging? I’m wondering if you can drill down a bit into why you had that initial bias regarding imaging. These studies specifically come to mind for me – Brady, Insights Imaging 2017; Bedell, JAMA 2004.

We can always argue every patient is an n of 1, but identifying how imaging can be useful is important, since like you and many others, we’ve potentially become biased against its use for a number of valid reasons.

Thanks for your thoughts – looking forward to hearing more about this.

Dhinu

References:
– Bedell SE, Graboys TB, Bedell E, Lown B. Words that harm, words that heal. Arch Intern Med. 2004;164(13):1365-1368. doi:10.1001/archinte.164.13.1365
– Brady AP. Error and discrepancy in radiology: inevitable or avoidable?. Insights Imaging. 2017;8(1):171-182. doi:10.1007/s13244-016-0534-1
– Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. J Orthop. 2013;10(1):8-12. Published 2013 Feb 26. doi:10.1016/j.jor.2013.01.008
– Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8(4):296-299. doi:10.1016/s1058-2746(99)90148-9
– Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014;23(12):1913-1921. doi:10.1016/j.jse.2014.08.001
– Yamamoto A, Takagishi K, Kobayashi T, Shitara H, Osawa T. Factors involved in the presence of symptoms associated with rotator cuff tears: a comparison of asymptomatic and symptomatic rotator cuff tears in the general population. J Shoulder Elbow Surg. 2011;20(7):1133-1137. doi:10.1016/j.jse.2011.01.011

[Dhinu Jayaseelan]

Interesting discussion on an important topic. Here’s an additional article that may be relevant. It goes into the neurobiology of placebo a bit, and provides a number of decent representations of the interplay of various factors and treatment outcome.

I like the examples you’re providing of when ‘words went wrong’ – it’s important we reflect on bad or negative experiences and identify how we don’t bias outcomes negatively based on our delivery.

Are there factors listed in this article that you are not, but could be, taking advantage of?

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