Ortho on the go
Ortho on the go
When should I see Ortho
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Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves. Welcome back to the episode. We're going to do something a little bit different today. I wanted to review a topic that I get a lot of questions about, whether it be from friends, family members, um, coworkers, athletes, or even myself, is when should I come to the office and have my aches and pains or injury be evaluated in the orthopedic office? I think in general, a lot of us tend to adopt the watch and wait approach. We tend to say, hey, maybe let's give it some time and get better. Let's do the natural remedies, the ice, anti-inflammatories, elevation, modified activities, and see if things will get better. But the question uh underlying is always when should I go in and get those x-rays? When should I go in and get the evaluation to see if there's something more significant I can do? One of the factors I think that is kind of the leading reason to go in and get it evaluated is when the um level of pain um or level of dysfunction has become dissatisfying uh to you and starts to affect your daily life. Uh, I think one of the main reasons that people come in uh with orthopedic complaints is typically secondary to pain. One of the big things we have to remember about pain is pain is very subjective. Um, this is you know individualized to each person. Each person tolerates pain and different types of pain differently. And pain is often very disconnected from uh a lot of the objective findings we have in orthopedics, uh, such as testing, including x-rays, MRIs, ultrasounds, even the physical examination in the office. A lot of patients come in wanting that MRI, but the MRI won't necessarily treat their pain. And there's a lot of the times that we can have um a negative MRI with still quite significant pain, and we can have a positive MRI with findings that aren't significant and um causing the patient pain. So I think it's important to realize that um with these imagings, um, it's not always that if something shows up on the imaging, this is the source of the pain that the uh individual is having. We all accumulate um wear and tear uh type uh changes uh to our joints over the years with increasing activities. Um, if we do a lot of running activities and maybe lower extremity wear and tear, if we do a lot of upper body activities such as overhead throwing, your dominant arm may have a lot of wear and tear activities, and these changes will show up on the x-rays and even show up on the MRIs, but these could just be normal changes for a lot of different individuals and may not specifically be the source of the pain or the source of the dysfunction. So I talk to patients a lot that sometimes ordering imaging such as MRI is opening up Pandora's box, I can tell them that there's going to be a lot of wear and tear findings, maybe some degenerative uh tearing of the labrum or degenerative tearing of the meniscus, but this may not particularly be the source of the patient's pain. And if we go chasing that and trying to treat that, we may not completely alleviate their symptoms. So again, when do I come in for evaluation? Well, I I think um when it starts to affect your daily activities or when it starts to affect things you like to do, whether that be sports, exercise, hiking, um, or any other type of activity, I think that's when it's time to come in and get it evaluated. We all use sports and other types of activities for multiple reasons. We use it to stay healthy, uh physically fit, but we also use it for mental health, um, just to kind of keep us even keeled uh for all the stresses throughout the day. And sometimes if we're not able to participate in these activities outside of work, sports, walking, hiking, um, you know, whatever it may be, it'll significantly have an effect on our lifestyle. And this will oftentimes um you know cause a significant effect to ourselves, our kids, our family members. I think this is time to go in and get an evaluation to ensure that there's not something underlying that can be corrected and have an easy um correction to it. Now, I also think it's dependent upon the onset of symptoms. Uh so for me, and I teach all the PA students that I work with, the onset of symptoms is very important to me and deciding the underlying possible pathology for patients. So if somebody is at a football game and has an immediate injury secondary to a hit or twisting, um, I think this is something I'd get evaluated quicker within a couple days because the onset of symptoms were abrupt, and this is likely under concerning for more soft tissue or structural damage. But if somebody wakes up, let's say, one morning and says, hey, my shoulder's bothering me, and gives it a few days, and the shoulder pain necessarily is not getting better, um, this could be something you could wait a little bit longer, maybe three to five, five to seven days to allow it to get better. Um, but also, you know, wouldn't wait too long where it starts to affect your daily life. And these patients that have this more insidious onset, these are the ones I like to do more of a functional evaluation in the office, because again, it's not an abrupt onset where you think there could be an injury associated with it and possible underlying structural abnormality. This could be something uh that uh is secondary to a muscle weakness, um a muscle imbalance, uh, a tightness. Um, maybe they're compensating uh and these imbalances are causing uh compensatory pain, and this is causing inflammatory uh changes. So these are the patients like, let's say, for example, somebody comes in complaining of uh a progressive uh lower back pain or a progressive knee pain. Um, I like to do a functional evaluation in the office. I'll have them do a single leg squat, a double leg squat, um, a uh uh Trendellenberg type activities, a glute uh activities. I'll check the range of motion with their hips. And oftentimes you'll see during the squatting activities, they'll have a shift to one side versus the other. They'll have weakness in one glute versus the other, especially with single leg standing and trendellenbergs, you'll see that the glute activation on one side is less. There may be some valgus changes to their knee when they're doing these types of activities, all of these things, and or uh again, possibly some tightness within the hips, all of these things showing more soft tissue imbalances that if um you know are present and you do repetitive activities, they could cause um noticeable dysfunction and can cause this kind of insidious onset type pain that a lot of people will complain of. Now, with most of these um dysfunctions, we know that they're could be treated either surgically or non-surgically. I think the majority of practitioners, we try to treat this non-surgically. Non-surgical approaches include activity modifications, physical therapy, anti-inflammatory medications. And I make sure to talk to patients about anti-inflammatory medications. How long have you been taking them? How much medication are you taking? We're all who are, andor a lot of patients, myself included, don't particularly like to take medications, but medications can be quite effective if we take them appropriately. You know, with ibuprofen or advil, if we take it just as needed, hey, I come home for a hard workout and I have some pain and I take 400, 600 milligrams of ibuprofen, it'll work mildly as an anti-inflammatory, but it works best if you take it consistently two to three times a day for up to three to five days. And this is when you get the full anti-inflammatory effect of it. So it could be just counseling the patients to possibly take the medication more appropriately, and hopefully this will kind of help them to reduce the inflammation. So if a patient comes in and says, hey, when I take ibuprofen, it definitely helps, but it wears off, I may advise something as simple as taking the ibuprofen four to 600 milligrams, two to three times a day for three to five days, and seeing if this will help to resolve their inflammatory symptoms, including with activity modification. If this doesn't help to resolve it, and or it resolves it while they're on it and then comes back when they're off of it, then we know we have to take the next steps in the conservative treatment regime, maybe injections, um stronger anti-inflammatory medications, physical therapy activities. And then again, if somebody comes in with more of a structural concern, let's say they have an acute injury and they have acute weakness related to it, you may end up getting imaging on this and showing structural concerns, and this would be something we'd probably treat more surgically. But again, not all structural things have to be treated surgically. A lot of chronic rotator cuff tears that have acute onset of symptoms with rotator cuff artropathy, we can often treat these non-surgically. Reassurance is uh a big thing that a lot of patients come in for. We have to understand that there's only a few conditions that we potentially can make worse and or cause long-term damage if we continue to participate in sports and activities. So a lot of patients have these aches and pains that they they just live with and they're able to participate in a lot of their activities with. But in the back of all of our minds is, hey, if I continue to work through this ache and pain, am I going to make things worse? Am I going to have long-term problems? And these long-term problems are going to cause significant dysfunction in the future. Again, there's only a few conditions, such as fractures or other types of acute conditions, that potentially could be made worse by this. So I think a lot of the times we can provide reassurance that you have inflammatory symptoms, you have chronic pain that's been exacerbated by certain activities you're doing. If this is within a tolerable level for you, you can definitely work through this. If it's not within a tolerable level, then I would advise not working through it. Sometimes it's as simple as modifying the activities to allow them to work through it. So maybe if you're playing pickleball, you can play doubles instead of singles. This will require less cutting, pivoting, twisting activities. And potentially this will allow you to rehab this or take anti-inflammatory medications to make the symptoms better. And then a lot of the times they can then participate back into activities. They may also need a short rest and/or discontinuation of the activities to allow them to proceed or participate back in the activities as well. But again, I think reassurance that they can continue to participate in their activities and they're relatively safe to participate in the activities is an important factor that a lot of people come in for. And I think as practitioners and providers, we can provide for these patients. In my personal practice, I like to individualize um the treatment based upon the patient patient's specific needs. So again, we all have aches and pains. We all have pain that we can work through. And uh, but when the pain becomes um limiting and or starts to affect certain things, uh travel commitments, family commitments, uh sports commitments, um, things like that, I think that's when we can individualize the treatment to the patient based upon these multiple factors, and if it's affecting these factors, if somebody does a very labor-intensive job and they have shoulder pain and the shoulder shoulder pain's affecting their job, we have to understand that they have to work and so they have to be able to participate in this. And we may be a little bit more aggressive with their treatment because we know that this is going to affect their way of life and it's gonna affect their income versus somebody that has shoulder pain that does more of a sedentary type job and potentially plays some overhead sports or sporting activities, but they're able to play these without significant um dysfunction or loss of activity. Again, this may be something that we are more conservative with and allow it to potentially get better with time, knowing that it may not cause as significant of a loss of function or effect to the patient as somebody that is relying on this uh for a specific um return back to jobs. Similarly, uh, you know, I get a lot of patients that come into the orthopedic at urgent care, and you know, one of the things that I think is hard for patients to understand is that we can all have these chronic underlying conditions. A lot of patients will have underlying osteoarthritis within the knee, osteoarthritis within the hip, um, chronic rotator cuff insufficiency that will happen and accumulate over time, but a lot of this is tolerable and we'll it we're able to modify and or compensate enough where we can live our daily lives without dysfunction regarding this, but we may do some activity or for some reason it may push us over the level of being able to modify around these dysfunctions and it may then become symptomatic. It's frequent that patients will come into the clinic and I'll say, Wow, you have significant arthritis in your knee, and they'll say, My knee has never bothered me before. The arthritis didn't happen recently. That's been going on for years, but it was within a tolerable level for each patient, which again, that pain tolerance is individualized. And whether it's some activity they did, it pushes them over that tolerable level and turns it into a pain that is noticeable for them and a pain that is restrictive for them that we potentially will have to treat. These patients always have some kind of trip or activity coming up, a once-in-a-lifetime vacation that they're leaving for. And so I always discuss with them that I can give you short-term relief. I can give them a cortisone injection in the knee, a cortisone injection in the hip, you know, anti-inflammatory medications, maybe a medroll dose pack to provide short-term relief to potentially get them through these trips or activities, but they may not provide long-term relief unless we correct the underlying problem, which could be some soft tissue dysfunction, um, ambulatory dysfunction compensation that they're doing. So I think it's again important to educate and counsel the patients that we can provide short-term relief to some of these activities, but more long-term relief may require more counseling and more treatment. Again, this is where I think patient education comes in. Um, I think it's very important to sit down and have a conversation with the patients regarding your thought process and philosophy for their particular injury. Again, you know, if somebody comes in and kind of says, Hey, I woke up Monday morning and I have significant pain within my shoulder, I don't remember any onsetting or inciting incident. I don't remember a fall, a trauma, an injury. I discuss that this is probably more of an inflammatory condition than it is a structural condition. Yes, you may have some underlying structural concerns, some degenerative matering and your menistius, but you've acutely inflamed this, and this is likely what's causing your pain. And so if we can calm this inflammatory symptoms down, ideally it will make your symptoms and your pain better, and you can continue to tolerate your underlying structural concerns or long-term degenerative concerns. Again, if we rush into the MRI and the MRI shows these degenerative concerns, you know, they may not get better with acute treatments like arthroscopies and debreedments of the knee because they've been living with that for a long period of time and it never caused them some concern. When you rush in there and do an arthroscopy and debreedment, it could be a long run for a short slide, a slight bit of improvement in their daily life, and we can potentially make them worse. So I think educating them on the onset of symptoms, the severity of symptoms, the limitations in their symptoms, your thought process regarding what you're seeing on the x-rays, the onset of symptoms and how that plays a role into an acute versus structural type andor inflammatory type concern. So they can potentially even make the diagnosis and/or make the decision without you in the room. I like to educate patients enough where they can go home and say, hey, you know, he he told me this, this, and this, and that allowed me to potentially make this decision. And again, I think giving patients options is important, saying, you know, we can be conservative or aggressive with this, we can get an MRI regarding this condition, but there's a 90 plus percent chance the MRI won't change what we're gonna do. It'll just define the diagnosis. And some patients will want that and some patients won't want it, especially if it's not gonna change what we're gonna do. If their symptoms are more inflammatory in nature, and we know conservative treatments with medications, injections, and physical therapy is gonna be the answer, independent of what the MRI shows. Some patients are willing to hold off on the MRI until they potentially fail these conservative treatments. And if they fail the conservative treatments, then getting the MRI, but at that point, maybe it's more a pre-surgical, pre-procedural test, like for low back pain that has ridicular symptoms. We know that, you know, a majority of these will get better with physical therapy time and treatments. But if they have some neural impingement that is refractory to this, we may have to go to an injection, we may have to go to dissectomy. So educating the patients that, again, a lot of the times these objective tests that we do won't necessarily confirm the cause of their pain and sometimes will show chronic things that may not necessarily be the source of their pain. So I thought this would be an interesting topic to talk about, to discuss with patients, to have that discussion of when I should come in and get evaluated and my thought process regarding when I'm uh talking to patients about the onset of symptoms and the symptomology itself. Again, thanks for listening to the podcast. I've enjoyed the conversation today. I hope in the upcoming episodes I'll have some interviews with some of my uh friends, coworkers, and different people throughout the um orthopedic profession, kind of discussing more about functional evaluations, discussing more about um different types of sports injuries. Um and again, uh please follow us on social media. Uh I have started a the YouTube uh page, and so hopefully I'll be able to put imaging and x rays up on the YouTube page as well as on Instagram and uh Facebook. Uh please don't hesitate to add any comments on there uh about you know what you like, what you don't like about the podcast, and what you'd like to see in the future. Uh I hope you uh guys have a good rest of your day. Thank you.