.png)
Joint Effort PAs
We're two orthopedic surgery physician assistants discussing PA school, life as a PA, cases and topics related to orthopedics, and much more!
Joint Effort PAs
Can't Miss Ortho Injuries
Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.
Some injuries you can watch, rehab, and recheck… and then there are the ones you absolutely cannot afford to miss.
This week on Joint Effort PAs, we’re breaking down the big tendon injuries that should immediately be on your radar—because missing them can mean permanent dysfunction, tough recoveries, and unhappy patients 👀
We’re covering:
💥 Distal biceps ruptures
💥 Achilles tendon tears
💥 Pec tendon ruptures (gym injuries you need to recognize fast)
💥 Quad & patellar tendon injuries (don’t ignore that extensor mechanism)
💥 Flexor tendon injuries (small wound, big consequences)
We walk through how they present, what exam findings you can’t ignore, and when to act FAST
If you’ve ever second-guessed a tendon exam or worried about missing something big… this one’s for you.
🎧 Tune in, level up your exam skills, and make sure these are injuries you never miss.
#JointEffortPAs #Ortho #SportsMedicine #TendonInjury #CantMiss #PAlife
Tempo: 120.0
SPEAKER_01Welcome to Joint Effort PAs, where two orthopedic surgery PAs get real about life in medicine. From tips and tricks to professional growth, work-life balance, and everything in between. We're here to share what we've learned and what we're still figuring out. Let's get into it. We're back. Welcome back, everybody. Yeah, we're gonna do something educational to well, I hate when I say that. Yeah, the rest of it is an educational something more clinical. Yeah, yeah. More clinical. All right. On to our weekly recap.
SPEAKER_00Um yeah, we had we had a really good week this week. Um so we um again, my split is clinic three days and then OR two days. The doc I work with is in the OR three days. So at the end of last week, um like the last week before this week, we do our team recap. I'm like, all right, guys, this is what it looks like, blah, blah, blah, blah, blah. And we um recently stopped operating at a rural hospital for a variety of reasons. But this hospital serves a purpose for us for our patients that have insurance they can't go anywhere else, patients that um actually it's mainly just an insurance thing. So anyway, so I I'm I'm like ready to drop the bomb of like, hey, we're going to this rural hospital, even though I was told we can't go there anymore, but like we had to type thing. And so the doc I work with was like, I'm not, I'm not going there. Like, I'm not doing it. But you know, it started with I served up, like, hey, so we're going to the rural hospital. The first patient had pneumonia a month ago. She also sleep on the road on oxygen. She also failed this. Like, I give like 26 weeks. She has one kidney, and I was like, So I'm gonna cancel her. The other patient um is a shoulder. I just looked at his drug test. He literally tested positive for absolutely everything. So I think I'm gonna cancel the day. And then it started this whole conversation. Like, why, why do when I say I don't want to go up there, why are you going up there? So we have these patients that like I don't know about you, but when I look at a patient, I don't really look at their insurance until it's time to schedule surgery. So the doc that I work with never looks at the insurance. So he'll see a patient, win them over, sign him up for surgery, then I'll get the order for surgery. And I was like, wait, we can't see this patient. We now have to go to this rural hospital. Yeah. So I told him, I was like, why do you keep ordering surgery on these people? He goes, I don't discriminate. Why, why would you ask me that? Long story short, so I was like, okay, I guess we have to call the patients, cancel the patients, find time somewhere else, fill the day, blah, blah. Anyway, long story short, we did it, right? Yeah. That's that was midweek. Um, so we we salvaged one of our surgery days, which believe it or not, seems like way more of a win than a loss. It is. Yeah. It's a big win. Yeah, I feel like it was a huge win. So that was that was exciting. Um, we did another washout for a shoulder, uh, which is you know, exciting, not exciting. Um, but that patient ended up doing well. The whole what we talked about a couple weeks of coordinating infectious disease and all that, that actually went very smoothly. Yeah. Yeah. Um, but yeah, other than that, administratively interviewed some candidates, hired a candidate, um, trying to train somebody new in clinic, trying to get ready for a big meeting next week, did a review this week. So uh yeah, Hannah, that was my week.
SPEAKER_01Yeah, normal. It sounds like an average too slightly below even week. No, I think things are sometimes busier than that for you.
SPEAKER_00Yeah, no, it was it was a packed week, but I feel I feel good about it.
SPEAKER_01I love that. Yeah, we um we had a pretty packed early week. Um, went to the conference I was talking about last week, and I was back Monday for clinic. My doc wasn't back Monday yet for clinic. Um, so it was a little bit like less hectic in the sense that there's just not as many. It was just my clinic volume. And then Tuesday when he was back, we uh I was playing the game of going to fourth doing four things in a day.
SPEAKER_02Yeah.
SPEAKER_01We're going to one facility and got a flip room and did a bunch of cases there. And I had it worked out perfectly. I was like, this is only gonna work if everything goes perfect. And I got the flip room with the surgery center facility, which is next door to the hospital, that our other case was gonna start right after. And then we would finish in just enough time to come back to this surgery center and not be late and then have our clinic after it. Yeah. And I was like, oh, this is gonna be amazing. And so we like rolled through the flip room, like I was like just going for it. Yeah. Right. And we everything was on time, maybe even a hair early at the first surgery center. So you're feeling good. I was feeling great until we finished last case, and my doc was like, hey, they delayed us by over an hour at the hospital. I was like, oh my god, no, no, my plans. Yeah. I know that's like it's like melting. Yeah, I wanted to cry. I didn't, but um, yeah, we ended up still like doing it, and we were only an hour-ish behind the rest of the day, which is fine. Like, that's not terrible to be an hour behind um to everything, all things considered. And we ended up doing a washout for a patient that had come in through urgent care like several weeks ago. The PA that was working um ran the MRI by me, and there was all these like lytic lesions in the humeral head. He had a cuff repair outside of the country. I'm like, oh, this looks infected. Get a CT scan, it's definitely infected. All his inflammatory markers were up. Um, so for those, like, and he's older too, so you're not gonna go back and do like a revision cuff repair for a patient like that, even if you do get the infection to clear on the bone to heal, he's gonna be staged for a reverse. So um one of the companies we work with has a really cool like antibiotic cement spacer head. So the plan was to go in and basically like cut the humeral head down like you would for a reverse. Put this um, it it's basically like an anatomic. It looked like a cat.
SPEAKER_00Like it looked like a normal humoral head.
SPEAKER_01Yeah, it's like a CTA head, but it's like a cement antibiotic construction thing. Um, put that in there and we will work on getting this infection to clear, ID SOM, pickline, all the things. And then if it does, and um, yeah, we may do a reverse on him down the road. Yeah. So that's awesome. Yeah, so that was good. Wrist fracture, night clinic, typical long Tuesday, another total on a Thursday, and regular week after that. Did some PRP on Friday.
SPEAKER_00It was a good week. We had um just real quick, I had um, again, on one of our days, so we had three cases at one facility, and then there was a little gap because we finished early, not because we were delayed, where we had to go to another facility. So I had like 40 minutes that I had to mess around with. So right when I scrub out of the case, I get something from our urgent care, and it was like, hey, you know, I have this lady who fell on her hip a month ago. She's here, she's got a tremendous amount of soft tissue swelling. So, you know, can you see this? And I was like, Can I see this right now? Or like, can I see it later? So I said, Well, I'll just swing by. So the lady fell on the outside of her hip a month ago. So first I'm like, okay, did she break her hip? And then they missed it, right? So re-x-ray, she looks fine. She doesn't have any pain with weight bearing. She's like, it's just so swollen. So um the I walk in the room and the lady's laying on her, you know, contralateral hip. So the effective hip is in the air. It looks like a camel hump. It's massive, massive. So I was like, oh my god, it's like that's a hematoma, seroma something. So I grabbed the ultrasound, throw the ultrasound on it, hypo, hypochoic lesion. You can't even see the end of it. Yeah. So just like four seconds ago. So I said, Yeah, it's it's fluctuant. Let's um let's drain it, right? So in the back of my head, I'm like, okay, this might be infected. It's an older lady, but like, let's see. Numb it up. 285 CC's of bloody fluid came out of this. Um ended up being, I mean, it sounds like a Morel Laval lesion, right? Like, yeah, like basically, yeah, yeah. So it was still satisfying. That is so satisfying. So satisfying. I love those. Yeah. So it was it was a good teaching moment just for the the provider in Injury Express because I think otherwise they would have sent that out, got a test, I would have seen it in clinic. Um, but it was it was really cool. That is really cool. Yeah. So that that was um that was awesome. And I'll see I'll see her back this week. Um I hope it didn't fill back up. It might have.
SPEAKER_01Well, and will you do it again if it did? Um, she's older, like she's 70 something.
SPEAKER_00I can't imagine doing a surgery for like an actual IND on this lady would be effective. I think if I made it smaller and tell her, hey, give it time, I think we'll be okay. Yeah. Yeah.
SPEAKER_01Oh, we brushed over our uh our race yesterday. Oh yeah.
SPEAKER_00We did. We can talk about that.
SPEAKER_01Yeah.
SPEAKER_00Yeah.
SPEAKER_02Yeah.
SPEAKER_00Hannah and I uh did a uh a 5k and a 10k yesterday. So we were we were just talking about our you know leveling up this year. We're also going to potentially mention that we sponsor one. Yes. Yeah, we were talking about the answer.
SPEAKER_01I think that needs to be um in the works.
SPEAKER_00I think as an orthopa, you should want to do that. Is that like like be active? You you're saying or yeah, well, yeah. I I don't wanna I don't wanna like our well so here's a backstory. Our company um has a wellness committee, right? So the wellness committee was like, hey, for you know, Q2, we're we're gonna um sign people up for this 5k, 10k, half marathon, uh, you know, something we can build camaraderie, we're getting out in our our community. And it was a little underwhelming as far as the participation.
SPEAKER_01So and the location had to do with that too. It was a lot of people.
SPEAKER_00But you have ortho PAs, you have orthopedic surgeons, you have physical therapists, you have people who are promoting health and wellness in the community. Like, I just want to see you walk it. Yeah.
SPEAKER_01I'm supposed to walk it, right?
SPEAKER_00So I'm gonna I'm gonna say some things on that.
SPEAKER_01Yeah, yeah, we like need some competitions.
SPEAKER_00Yes, yeah. So if we were to host a 5K, yeah, right, just a 5K, um, I would expect majority of our staff to show up, uh-huh, right? We'd have to like stake it somehow. Like winner gets this, loser gets that. Yeah, but not loser, sorry, excuse me. The loser. No, but like I don't know. Last to finish. Last to finish. No, I think uh I think some healthy competition. We need a bench press competition. Okay, well, everybody in here is that we could heaviest deadlift. Um, but we were you happy with your time yesterday?
SPEAKER_01Yeah, I mean, well, like it wasn't my best time by any means, but it's so interesting, like just your perception of how hard things feel based on the conditions. Yeah. And like it was really, really windy, I feel like it was pushing against me, and my pace was like not super fast for a 5k, but it felt really hard. And I went back and looked at my heart rate afterwards, and I was like, I like I was like zone two, three the whole time. Like, why'd it feel so hard? It could have been because I took three shots of tequila two nights before and then um didn't sleep well the night after.
SPEAKER_00So no, I think it definitely was that, and I will second that. Um, I think sometimes though, if you've done enough races for whatever reason, some days you're just feeling it, and some days it feels like a chore. Yeah, like the hardest part about yesterday for me was I assumed that I was gonna convince you to do the 10K and the person you did the 5k with. So I in my head, all four of us were gonna do it. So I didn't bring my headphones. Yeah, and then when I got there and everyone was like, No, we're all on our own. I was like, I'm listening to myself breathe. This is ridiculous. Like then it got in my butt and I'm like, Are you are you are you gonna make it? Yeah, you're gonna make it maybe.
SPEAKER_01In retrospect, I should have, yeah, I should have done the 10K because I feel like a 5K, I make myself come out really fast, and I'm really pushing it to like it's it's a speed game. There's like no pacing in it. Yeah. Um, and and that's not really like what I'm what I excel in. Yeah. And then we watch some horses run and we watch them run really fast. We did. Do horses have Achilles tendons? Can they rupture it? I wonder.
SPEAKER_00I they must. I mean, if you look at a horse sideways, like they're so defined. Yeah, it's like dogs too. Like I feel like that would be a very vulnerable area, but I don't think they rupture them.
SPEAKER_01Yeah, they rub they tear their ACLs. They sure do. Yeah. Those get fixed.
SPEAKER_00But anyway, yeah, we'll have to we'll have to start some buzz about sponsoring a 5K. I think we should do that. I think we have to. I I don't think there's another option.
SPEAKER_01Yeah. So I agree with that. Okay. Well, kind of back on that idea, we wanted to go over some can't miss injuries. We can make this a whole series of things because we're going to specifically just um more touch on tendon injuries today.
SPEAKER_00Yeah. I think in orthopedics, at least in our practice, um, when you have newer providers, and again, let's focus on APPs, APPs in the ER, APPs in clinic, APPs in in urgent care, there's certain things that you will see that you really can't miss, right? And again, like Hannah said, we will pare it down to tendon injuries. But in our world, when you have a tendon injury and it's a full thickness rupture, there's certain areas that if you delay treatment significantly affects the outcome. Yeah. Yeah. Um, so let's let's talk about those.
SPEAKER_01Yeah. And these more so happen because of typically the issue with why these you don't want to be delayed is retraction.
SPEAKER_00Yeah. Um which surgically harder, right? Harder to get the structure unretracted and then reattached. Um, but depending on the age of the patient, depending on how old the injury was, um, the repair is not, you know, it's it's harder to do that. The tissue's not as good. Tissue's not as good.
SPEAKER_01So um, yeah, yeah. And these lead to these ones specifically lead to, well, we can talk about that and get into the dysfunction that each of them may lead to. Um, so we we're specifically going over more of these load-bearing tendon injuries. So we wanted to kind of touch on the fact that there are some tendon injuries that yes are sometimes surgical, but don't need to be as um rushed. Yeah. Um, so for example, we were just talking about, you know, somebody comes in and falls on their shoulder and you suspect a rotator cuff injury. Um, yeah, and an acute injury like that, you might be more inclined to get an MRI more quickly, but not necessarily stat and think that it is gonna be surgical, but those are not like detrimental if you see someone and you're like, uh, is it a cuff tear or not? If you hold off on getting the MRI and delay things by several weeks or months, even like it's it's not gonna go from fixable to not fixable that quickly, typically.
SPEAKER_00Yeah, I would say with a rotator cuff tear, like, you know, let's say it's the perfect heat-up patient. It's a 55-year-old male, otherwise healthy, fell on his shoulder, now can't raise his arm.
SPEAKER_01All of a sudden, like had full motion before, and now he can't, like, yeah.
SPEAKER_00So that that I would see that and say, you know what? Even if he says something like, yeah, I've had impingement in the past, that's that's a rotator cuff too, no matter which way you cut it. I would probably get the MRI as long as the insurance wouldn't tell me that I couldn't, right? Um, but the communication to the patient is not like, we need to get it. Yeah, we have to fix this because your window's about 12 weeks. Like you can fix an acute tear in that period of time and they're still gonna have a good outcome. Now get into six months, get into an older patient with crappy tissue, you're talking about retraction and atrophy and humor head elevation, that's a whole different conversation. But that doesn't happen. It's not like in the two weeks that you know we're gonna talk about other endurance.
SPEAKER_01And that also um is important for like setting expectations too, because as somebody who worked energetic care and now outside of it, um, you know, people worry about that. They're like, oh my gosh, I I fell and now I can't raise my arm. And I they come in on a Sunday afternoon and they're like, I need a stat MRI done today and my rotator cuff fixed next week.
SPEAKER_00So that's that's interesting. So what do you tell the patients, like, if that were me, okay? Like we were talking about this with somebody yesterday, yeah, who one of our coworkers recently returned to adult sports, and she's like, I mean, if I fell and had a distal radius fracture, like I don't know what I would do. So, like, if our coworker fell and did that, I would ex expedite treatment.
SPEAKER_01Oh, totally. You know what I mean?
SPEAKER_00So I don't want to hear from a provider when I come in and I'm like, oh my God, this is tragic. I can't raise my arm. And the provider would be like, you're okay. Yeah, you know. So it's hard, how do you like, how do you deliver that?
SPEAKER_01Like a lot of the, yes, you're trying to expedite it. So, right, in the right patient that you're like, okay, this is definitely an acute tear and and we are probably gonna want to fix it. Like, yeah, you're gonna expedite it to the best ability that you can. Like, you guys are probably gonna try to work that patient in on your schedule within a couple of weeks if you can. Um, but I think just educating them that, like, yes, we are gonna get this done as quickly as we're able to get everything coordinated, but just the reassurance that it's not gonna change their surgical outcome, the delay of one to three weeks, that it's not as, you know, it's not like one of these other things where they are gonna have a worse outcome if they get it fixed in two days versus two weeks, two weeks, or you know, even a little bit beyond that. Yeah. So I think just like reassuring them by that. But yeah, like there are instances that you are gonna expedite those things, obviously.
SPEAKER_02Yeah.
SPEAKER_01Um, but you know, if somebody comes in, not really super clear exam, like, oh, I don't know, I was lifting something and my shoulder started hurting, and I was progressively hurting over a couple weeks, and it hurts them to lift it, and they've got some weakness, but you're not sure if it's more guarding. Um, like maybe you just don't get the MRI on that one. Like you can you can inject it maybe and see how they do, and then get the MRI down the road. So um, rotator cuff tendon injuries, not as emergent.
SPEAKER_00We will and we'll see the same thing with ACLs, right? So, someone, you know, I saw this kid on my son's soccer team literally Friday night, a non-contact um twist. He felt a pop. We all heard a pop, and he's money. And then, you know, it was Friday night at nine o'clock. So his parents were like, maybe go to the ER. And I was like, You don't, you don't. Like this is something that unfortunately, yeah, what just happened happened. Yeah, you're gonna feel like absolute garbage tomorrow. But, you know, this is not something that we need to, you don't need to go to the ER right now. In fact, if you did, they're not gonna be getting to do anything. They're gonna put you in a stupid knee mobilizer that's gonna be on your ankle when I see you on Monday. Yeah, yes, it will be on the ankle. But no, so ACLs, uh again, it it it's it's you know, it's traumatic for the person and the family, whatever. But for that patient, honestly, MRI probably Monday, Tuesday. Uh quad's gonna be garbage, so a little bit of rehab before we end up fixing that patient. And let's say there's an MCL injury, might want to delay it purposely so that the MCL heals so that we can fix the ACL. So those I feel like are misconstrued immediacy injuries. Yes, yeah.
SPEAKER_01And I think there is immediacy on the patient's behalf more. So like I need to get this done so that I can get back quicker, which is not untrue. Like, I totally get that, but we're talking about more so from a provider's perspective, like easing the fear of like, okay, if I saw this person and they had an ACL and I didn't get the MRI immediately, or if I missed it, something detrimental outcome-wise is going to happen. And that's not the case with those types of injuries. Um, I think a lot of this is like educating the patient too, not to make it sound like, oh, we don't want you to get help quickly. Right. More so like, let me save you money and time from unnecessary things like going to the ER for them to do nothing. And um, yeah. So let's get into the ones that we don't want to miss. Yes. The ones that are a little bit more uh urgent.
SPEAKER_00Yes. So number one, first contestant is distal biceps tendon rupture. Yes. So both of us see these. Um the doc I work with now less so because in his uh, and I'm putting words in his mouth, but that's fine. Uh, he will not see a distal biceps tendon rupture that's more than nine days old. Yeah, yeah. Like that is his time frame, yeah. That is this time frame because um when these uh when these injuries happen, yeah, they never happen on a small skinny dude. They just don't. They don't happen on females unless you can tell me you've done one on a female.
SPEAKER_01We've not done one on a female, but I did look up there there's case reports of them being on females.
SPEAKER_00Far less, I think safe to say, far less common in females. Yeah. But it's usually the jacked dude that works out and you know did some type of eccentric load, felt a pop. And if you see that, if you if you see that demographic walk into clinic or injury express, that should be on your differential right away. Yeah, felt a pop in my elbow. Fel to pop in my elbow. Um, if you see them like a couple days after bruising, right, they can usually move their elbow.
SPEAKER_01And sometimes not terribly painful. Oftentimes it's not really painful at all.
SPEAKER_00Yeah. Um, but when we see these, um, these are stat MRIs to confirm diagnosis and then stat treatment. Okay. Uh, so what is your what is your clinical threshold? Like when you see these, do you like an MRI? Do you like an ultrasound? Do you like verbal communication from, you know, the referring provider?
SPEAKER_01Always verbal communication with anything that's suspected. And I'm talking like these injuries that we're talking about, or like anything suspected to be surgical. So we can start making around with the schedule, making room, making, making things work and planning ahead. Um, but yes, direct communication. We generally always get a stat MRI for these. Um, I love using ultrasound. Um, and I have been trying to get better at ultrasounding distal biceps, they're really challenging. They are very for a while. I was ultrasounding it and I was like, oh, I think I see it every time, and it wasn't the same. But it like but it like dives down. You have to I've gotten better. You have to subinate so much. You do, but you have to see toe in. Is that yeah? You have to subinate so much and toe in. Yeah. And I don't know. I just don't like at this point, I don't trust enough my diagnostic skill with the ultrasound to go purely based. Off that. Now there was one a couple of weeks ago, but the MRI had already been ordered. It hadn't been done yet. I ultrasounded it and just like exam and history and everything. I was like, okay, this is torn. Like, I don't really need if the old if the MRI doesn't come back, we're still going to proceed with surgery kind of thing. But it ended up coming back. Um, those are the ones though that like, if we don't get the MRI before, and I'm like really certain I'm like sweating as we're opening, and I'm like, oh it's better be torn. It better be torn. Yeah, like I will be we don't get in there and it looks totally intact. We're like, what the fuck? Yeah. Um, but yeah, yeah. Uh stat imaging um MRI that'll help us determine retraction. Um we we don't have quite as strict of a nine-day time frame. We've fixed some that are three to four weeks out, even. Um, we've even done some that are chronic that we've grafted with an Achilles graft. Um that one was interesting. But yeah, so we'll we'll uh we'll do those several weeks out, but definitely not as easy. Um, so those that's a big one. So your things on exam to look for are like you were talking about, the bruising, the hook test, that's your clinical exam finding for it. Basically, if you take your index finger and try to hook it around the biceps tendon, um, I feel like sometimes you can get people get misled with uh palpating like their lacertis with that. Um so I always just say, like, if the history matches up and like visually you're concerned, just get the MRI because it could also be like a high grade partial, and then you can have the conversation of do you fix it now? Do you wait to fix it? Um, so yeah.
SPEAKER_00Yeah. And you will see, I mean, ideally, you will see that reverse pop eye. And Hanna and I were talking before we were doing this about newer providers that see this in Indry Express for a patient that comes in. Sometimes with the same mechanism, they feel a pop. And you really have to roll the sleeve up, take the shirt off, look at the other side, because if the biceps contour is abnormal, sometimes for newer eyes, it's hard to determine if that is a proximal rupture or a distal rupture. And I will tell you what, proximal ruptures don't care. Yeah, I mean those I don't think I can go into a whole episode of why we leave those alone, but unless it's both. And then you're ever seen that one time in my life.
SPEAKER_01Have you ever seen that belt? I don't think so. Yes, you have. Have I? I'm having a moment right now. Oh, okay.
SPEAKER_00Oh, yeah. So we have both seen it once. Oh my god, sorry, yes. I just take my turn my clinical brain on for a second. Um, but no, the proximal biceps ruptures, those ones completed, totally different than distal. So, really, really important that you get a sense of where that ruptured from because you will have that deformity bilateral. Now, if you're seeing the patient like the second it happened and they come over from the gym or whatever it was, you're not really gonna get that great exam. You're not really gonna see the pop eye, you're not really gonna appreciate the bruising, but you will get probably the positive hook test and you will have that weakness in supination. Um, some of these, most of these, I don't think, have any weakness in flexion.
SPEAKER_01I mean, it's one test you can use. And this is a conversation too that, and I wouldn't have this from an urgent care perspective with the patient, let the surgical team have this, but distal biceps ruptures aren't necessarily something that has to be fixed. Um, most of the time we do fix it for cosmetic reasons and strength reasons, because most of the people in the demographic who are rupturing this are younger, younger males who need it to work and like do rely on that uh that function that they would miss from it. So that's why we do fix the majority of them. But like an older patient, non-dominant hand, somebody who really like doesn't need that, yeah, like they're not gonna miss that loss of um supination strength, um a little bit of flexion, but very minimal with that. It's not really gonna affect their grip too much at all. So you can go without it. Um, if I ruptured mine, which again, very rare for females, yeah, but if I did, would I fix it? I don't know. Would I look like I had a cooler bicep if I left it alone? Maybe. Maybe. Yeah.
SPEAKER_00So so uh those that are delayed diagnosed, right? If you do that exam delayed, you will see the deformity, and sometimes it scars in so much that you kind of miss that hook test. Yeah. If you've seen any of those, but those ones are a little tricky. Um, so let's say it is the 42-year-old, you know, weightlifter who cares tremendously about what his arms look like. Um now the discussion to fix that is you know, we make an incision on the forearm. We have, when we make that incision, cannot access the biceps. So we turn that into a little hockey stick and go fishing for it. Yeah. Right. So that's harder. You've got to take the tendon that is retracted, now pull it back down, attach it to the radial um uh tuberosity, right? Yeah. Now, why we don't do that, well, we don't like to do that, one, anatomically, that's a very keyhole spot on a someone who's got a jacked form, and two, that radial nerve. That radial nerve wraps right around that, that um that proximal radius. So that's not fun. Um and then progression of activity afterwards, if that's retracted, you've got to keep them immobilized longer to get that full extension without putting excessive stress on that. So it's a longer, yeah, it's a longer recovery. Sometimes there's chronic weakness. Um, sometimes the reconstruction's harder, incision-wise, it looks all jacked up. So distal biceps tendon ruptures. I would say notify surgical team, stat MRI. Do you splint? We don't splint.
SPEAKER_01Like immediate immediate.
SPEAKER_00I would just sling them um to help prevent retraction, basically. Yeah. So then check that radial nerve, make sure there's no wrist drop for whatever reason. Um, but yeah, distal biceps tendon ruptures. Elbow MRI, it's not an upper arm MRI. That's also something to differentiate.
SPEAKER_01Not a not a humorous MRI. Um, okay. Anything else to add with the distal bicep? No. Okay. I think that's it.
SPEAKER_00Pec tendons. Number two. Contestant number two, pec tendon tear.
SPEAKER_01Yeah, I've I've never, we were just talking about this. I've never seen one, which means that I've either missed them or that it just they're not as common and it's not come across my clinic.
SPEAKER_00These ones are tricky. So this uh this one is usually bench press mechanism. It's again, it's not the skinny dude. Yeah, it's not, it's not a female, right? It's going to be your male weightlifter, history of weightlifting. Maybe now they're 50 and they, you know, just do a little uh physical job. Um, bench press, fell to pop, her to pop, they come in and exam-wise, I like to put them in that goalpost position and you can see. I mean, you can see the tension of the peck on one side and you lose it on the other side. Yeah, right here. Like in the axle. So it's asymmetry. If you have them kind of pull across your body or try to do that that bench pest maneuver, you will see the the muscle, the tendon retract, um, and you can stick your hand right in that defect. So that's loss of x loss of the anterior axillary fold, axillary asymmetry. Um, but if you don't, if you don't have them take their shirt off and look at both sides, you're gonna miss it. Um in our injury express, it's hard, right? Like, is it your rotator cuff? Is it your peck? Like if it's if it's super, super cute, like again, they came in you know from the gym right to right to clinic, you may not have those telltale signs, but the history sells it, right? Yeah, it was bench pressing and it felt well. Um now these ones, at least in our clinic, stat MRI of the chest with the pec protocol. Now, can you get the shoulder? Sure. Will you sometimes not get medial enough? Yeah. So now you have the patient who got the MRI of the shoulder. I need more images of the pec. So why does it matter, right? Like if, and less so with the distal biceps, but if the pec major tears off of the bone and there is tendon on the torn part, right? That is fixable. We should do that within seven days. Okay. Okay. If it is torn at the myotendinous junction and there's little tendon on the residual piece, that's very hard.
SPEAKER_01Yeah, you can't really fix tendon to muscle.
SPEAKER_00Yeah, or muscle to muscle, right? So some of these tears are intramuscular. Yeah. So we leave that alone. Some of them are so close to the tendon, but like I've seen these, and we did one of these recently where there's 95% tendon left on the bone, and what's torn off is muscle with like a little fleck of tendon. And those are hard. I mean, those are hard.
SPEAKER_01Do you still try to fix those? Or like I did.
SPEAKER_00We just did one that was about eight weeks old.
SPEAKER_01And I um, you know, so like you're doing basically tendon to tendon.
SPEAKER_00Well, no, you you essentially disregard tendon attached to bone. You're doing muscle with a little bit of tendon and pulling that all the way over to the bone. So it's the same uh so you're trying to.
SPEAKER_01Oh my gosh. Okay, so like there's a little bit of tendon left on the muscles, so you're repairing that back, you're pulling that over. And like they're having to hold keep their arm like this. So I will tell you. So added, yeah.
SPEAKER_00It's the same. Um, you probably use the um, I don't even know what it's called, but you drop the implant through the bone and then countertension. It's the same thing, but you do it. From the biceps. Okay. So it's the same mechanism. But when we fix these, they are in full internal rotation and we leave them there.
SPEAKER_01Like I will um like do you like wrap and spike them to themselves basically?
SPEAKER_00Or sling them so no abduction pillow. I will go with the cheapo sling so they're as tight down abducted as next to them. But when I um I try to close the skin, I've got like my tech doing this because then the skin all folds together. Yeah.
SPEAKER_01Um those are hard, like closing the closing the biceps that you had to like keep them so flexed to keep it tight and like it's in the crease. Yeah.
SPEAKER_00Yeah, I know. It's the same thing with a peck, and especially like where the peck is, the bottom of that incision is always next to the armpit, so it always gets like a little yucky.
SPEAKER_01Yeah, and then like you're dressing, trying to put a dressing in the armpit. I feel that with my totals, like my tegaderm, it's like oh, the hair. Yeah, like oh my god. So shave everybody's armpit before totals. I'm gonna start telling them to do that. I don't know why I just thought of that.
SPEAKER_00I know they get razor burn, it's like a whole thing. And then have you ever had someone who's gotten like a yeast infection in their armpit? No. Yeah, we have. It's disgusting. Oh my god. Anyway, okay. But things to think about. But the for the pect tendon tears, cosmesis, again, if you've got your heavy weightlifter who now looks, you know, different one side to the other, they're gonna care. Yeah. Um, do you have to fix all pect tendon tears? No, right? But what are you looking at? You're looking at a strength deficit, you're looking at, you know, cosmetically, they're gonna look a little bit, a little bit off. Yeah. Um, but if these are missed, they retract tremendously. And then you have to go fish it out, pull it over. Um, so what's the latest you'll do then? Uh we've done one in about eight weeks. Yeah. Uh we've done one before, actually a couple before where we have to use a graft. So that's the other reason for the stat MRI. Like, where's the tendon torn? How much tendon is left on the fixable um muscle? And then do you need graft augmentation? So those ones that we will do a graft with, they still cosmetically look a little different. Yeah, they just do.
SPEAKER_01The biceps we did the graft with does too.
SPEAKER_00Yeah, so cosmesis if you wait. Um, but again, I think for patient satisfaction, uh, getting those in for stat MRIs and making sure you're ordering the right MRI, so it's the the chest, at least it is in our practice, but that still gets all jacked up about 50% of the time. Yeah, you can do everything right. But but here's the other thing. So say, you know, we run into this sometimes. Say you have a new provider, and then we're like, don't miss this, right? Yeah. So they see someone and you know, they don't have all the telltale signs, but they order the stat chest MRI, and you see a little bit on the chest that's like, hey, super spinatus, looks like it's retracted. Now you gotta get the shoulder MRI.
SPEAKER_01Like I said, I've had that too, and I'm like, ugh. Yeah, because they get like over concerned, like, oh my god, I don't want to miss pec tendon ruptures. Like, yes, you don't want to mix those miss those, but like keep in mind, very rare. Yeah, yes.
SPEAKER_00Typically, yeah, well, it's a certain demographic, right? So if we look at you know, occurrence, it's far more likely that someone's gonna tear the rotator cuff than it is their pec, but it's it's it is harder for someone to tear their rotator cuff on a bench press than their peck, right? Um, and I will not ultrasound uh the pec. I haven't really, I mean guess, found it necessary, but I will for a rotator cuff. Yeah.
SPEAKER_01Will you diagnose a tear on your ultrasound?
SPEAKER_00I would still get the MRI because you've got the partial thickness tears that you're not really if it's a full thickness tear, you'll see it on the ultrasound. Yeah, yeah. Definitely. But the the pec, I I haven't done those. I guess I'm not confident with those. Yeah. Um, but anyway, so the pec, the pec repairs, if you diagnose them well, those go well. I would say you gotta fix it within the two-week time frame. Um, and those patients end up being being pretty happy. But if it requires a graft or if it's uh if it's delayed, it's it's rougher. Yeah. So that should be on the list. Red flags. Red flags.
SPEAKER_01All right, on to contestant number three. Maybe we'll brush more over this and neither of us really. I mean, like I've I've done these before and assisted in a couple of cases, but um, in our current practice, not seeing these as much, Achilles tendon tears. Yeah, um, this is a a big one. Um, and probably like one of the more common acute tendon injuries you think of working in orthopedics. So um again, more common in men. Yeah.
SPEAKER_00They're all male injuries. Fun fact, my college roommate, um, she played club soccer uh in college, and then right after college, she, you know, moved back home or whatever, and she was playing rec indoor soccer, was treated with cipro for some upper respiratory whatever, and ruptured her Achilles fluoroquinolines. I know, yeah. So those um that's you know, anecdotally, that is actually true. And I don't know anyone who would prescribe cipro. Yeah, like UTS backter. Yeah, yeah. Um, but it's the it's the push-off mechanism. You hear a loud as hell pop. Gunshot, that's what they'll call it.
SPEAKER_01Yeah, the gunshot. Yeah. This is actually a common board question one that like you'll get on um on your PA boards. Um your weekend warrior athlete playing basketball, goes up for a layup, here's a gunshot pop. Yeah, was just on the Cipro. Yeah. Yeah.
SPEAKER_00The dad playing Red Rover at their kids' school went to go sprint, pops it. Yeah, pickleball. Yeah. Went to go sprint for a ball, hear a pop. Um, but you see these uh in let's say clinic, Indre Express, ER, whatever. They can't walk. Yeah. Right. So they're usually coming in a wheelchair. Yeah. I throw them on their stomach, get the foot up in the air, do a Thompson's test. Um, and again, full ruptures, that heel is not moving at all. Yep.
SPEAKER_01Yeah, yeah. Um, and again, I think where the this is a satisfying clinical exam finding. It's one of the few ones that, like, I'm like, wow, this is actually pretty textbook and easy, and it responds just like the textbook tells you it will.
SPEAKER_00Uh, and then you will feel a gap. Like if you if you put that patient in the prone position and bend their knee and their foot just kind of flops there, you will feel that that gap. Um now, if you see that patient, uh, you can boot them with some heel cups, you can splint them. Um, you know, I, you know, I can go on about weight bearing, non-weight bearing, but that I will ultrasound that. I ultrasound them. Yeah, you can't. Yeah, those are easy to see on ultrasound. And some of our physicians here don't require an MRI scan. Some of them are like, boom, with the history of ultrasound, I'm good to go. Some want the MRI scan just for surgical planning. Again, is it more myotendinous? You know, where is that rupture? Um, but a a differential for that is your calf, your calf rupture. So your your physical exam has got to be spot on. And anytime I see a calf rupture, it's metal gastroc way higher than the Achilles. So those ones, um, you you just got to do a good physical exam. And again, the patient comes in in a wheelchair. Yeah, I'm still getting them up on the table. Yeah. It's gonna take a minute. Yeah, yeah.
SPEAKER_01But you just have to do it. And you know, if you're not comfortable with ultrasound, this is a a good one to like get yourself comfortable with it. Yeah. Um, because it's it's pretty easy to see.
SPEAKER_00So now these ones, again, less uh an issue if it is missed, because at least in clinical practice and even you know, anecdotally with some friends that I play soccer with, you cannot fix these and they do okay. Yeah. So I would maybe not put this in the category of like you have 10 days and that's it. But I think you need to know when it's Achilles versus calf and give the patient the option. Uh, older patients, we're not fixing those. Yeah, you you know, boot them in a heel wedge and then progressively lower the heel wedge, lower demand, maybe, and they're not playing sports or something. They end up doing fine. But if you've got your collegiate soccer player, like you're you're gonna fix that. Yeah. Um, so those ones, uh again, caveat because I'll see this on the back end. These patients can get blood clots. If you see them and you immobilize them, you gotta put them on a blood thinner.
SPEAKER_01Yeah. What do you usually use? Just regular aspirin?
SPEAKER_00Yeah, aspirin 81 twice a day or 325 once a day, but just they gotta be on something. Yeah. So Achilles tendon ruptures, those ones, those are technically.
SPEAKER_01Yeah, yeah. Middle of the road as far as urgency, then we'll call it. But um still, yeah, still one you should recognize. Yeah. Um contestant four, something that you're a little bit more familiar with. Yes. Um, and have some recent. I've got great stories with these. Yeah.
SPEAKER_00So contestant number four, quad tendon rupture, and we'll we'll loop in its its relative, the patellotendon rupture. Um, so these ones are generally eccentric load or a fall, right? So uh, for example, and again, these are all anecdotal. Patients pumping gas trips over the um whatever, the what is that called?
SPEAKER_01The like the cord.
SPEAKER_00The cord.
SPEAKER_01It's a cord. Like the the hose, the hose. Yeah. Why was that so hard?
SPEAKER_00Patient trips over the hose, slams her knee down on the concrete. Yeah, that wouldn't happen. Patients on the um patients in the community pool on their 40th birthday goes to do a massive cannonball when they're trying to jump, ruptures their patellar tendon. Did you I feel like you that's a specific story? Oh, it was a very specific story. Yeah. I mean, how embarrassing though, seriously. Yeah, yeah. They had to like fish him out of the pool. Oh my god. Somebody videoed it. Oh my god.
SPEAKER_02It's like a whole thing, right?
SPEAKER_00Um, jump, jump for the layup and then fill the pop in the knee, right? Uh going down the stairs, fell down the stairs, you know, that happens. So um, anyway, these ones, uh, when you see it again, it's not the females. Like, it's just not. So I will get these texts over the weekend of like, oh, 76-year-old fell underneath, can't straighten her leg. I'm gonna get a stat MRI for a quad. And I'm like, it's not a quad. Yeah, it's not a quad. Like it's a female, it's not. Um, get the x-ray, you get the x-ray. You will see for the quad tendon, you'll see that patella sitting low. So patella baja for the patellar tendon ruptures, you'll see the tendon high.
SPEAKER_01So um well, when it's not a tendon, I guess in a female, you and they fall directly on their knee, think more. Yeah, yeah, yeah. Your kneecap's split in half.
SPEAKER_00And yeah, uh, these ones, uh, patients sitting with their knee in a bent position, cannot straighten their leg. And again, there is a difference between I can't versus it hurts too bad, right? So you can either have the patient sit at 90 degrees flexion and try to straighten or hold them an extension and see what happens.
SPEAKER_01See if they have to drop it immediately. Yeah.
SPEAKER_00So um loss of extensor mechanism, uh, x-ray findings. What I will tell patients, especially the older guys that end up rupturing their quad, is healthy quads don't rupture, right? So these ones generally have a little bit of um enthesophytes at their distal quad. Like it's a sick tendon that ruptures. Yeah. Um now for uh diagnostics, I love ultrasounding these.
SPEAKER_01Yeah, I was gonna say these are probably pretty good easy.
SPEAKER_00These are I will put them on the same uh caliber as Achilles tendon, but again, I've had a couple of these where I will ultrasound, and I'm I'm like a hundred percent sure I will I will say that. Yeah, but then I say to myself, what if I did as we make the decision? Like I said, what if I know this is not ruptured, like to kill myself? I hate that feeling. Like I'm so confident, and then like when the patient rolls back, you're like, wait, wait, wait, did I actually like somebody go grab me an ultrasound right now? Yeah, so uh so those ones, ultrasound, I love that. MRI, absolutely fine. Uh I've seen these ones more delayed than anything else. Yeah. And I the one recently that we saw was patient went to the ER knee immobilizer and he regained some extensor function, but he lacked his final 20 degrees. Like he never could fully extend. So when this patient was seen in urgent care, they were like, yeah, yeah, you got straining whatever. So by the time we saw him, it was eight weeks later. Yeah. There's a quad tendon rupture.
SPEAKER_01So had it just like, I guess, because they had him in a mobilizer, like filled in with pseudotendon and kind of like.
SPEAKER_00So the exam, you didn't really feel the defect. Um, he was walking, so it didn't look like it was such an issue. But the MRI scans, full thickness, retracted. We actually ended up fixing him with a graft. Um, I saw another lady who, you know, lived in Jamaica high school, whatever. Um, she's in her 20s, and she said, Yeah, like I fell, I fell going up the stairs however long ago. Um, I think it was seven years, and I went to see Ortho. They said I needed surgery, and I got scared, so I didn't want to. Now I have kids, I can't run in the backyard. So I go to examine her. She tore her quad tendon seven years prior. Seven years like there was a defect, she couldn't straighten her leg and this. Lady again, she she grew up in Jamaica, she was a a track athlete. So sick tendons don't rupture. This lady had, you know, probably quad tendinitis or tendinosis and um ruptured quad. So we fixed that. Uh, and when you know, when we talked about the pec or the biceps, when you use a graft and you fix this in extension, she could get zero to 20 after we fixed that. So for this lady to get zero to 90, 0 to 120, like this is gonna be year recovery. Yeah, like that's so different than what it could have been had it been fixed a human. Immediately, yeah. Um, so missed, you know, missed diagnosis, delayed treatment, complex surgery, use of the graft. I don't know that this lady will ever run or jump again because that is just not, it's not like her native tissue. Will she be able to walk in the backyard? Yes, she will. But anyway, the quad, the quad tendon rupture, epitellar tendon rupture, those ones are, those ones should be right on your forefront.
SPEAKER_01Yeah. Yeah.
SPEAKER_00Um, yeah.
SPEAKER_01And those are the big ones. Oh, I did want to, I wanted to throw in um uh flexor tendon injuries of the hand, another don't miss one. Yeah. Um I feel like these are that one's tough too. It's tough. Um, and you always need to have a higher index of suspicion than you think. These are the ones that will unfortunately get delayed from the ER. Yes. Um, because they cut, like they accidentally were cutting vegetables and the knife slipped and sliced their finger, right? And they go into the ER. They're like, oh, look, it's like it's a laceration, and they're like, oh, let's just they throw a couple stitches in it, follow up, you know, to get the stitches taken out in a couple of weeks. And they do, and they come see us and they're like, hey, I'm here to get my stitches out from the ER, but I can't bend my finger. Yeah. And you're like, oh shit. Yeah. Yeah. Yeah. Um, I mean, there's not a lot of tissue between your skin and your flexor tendon, your finger. Um, so I, you know, always obviously if they have an open laceration, you clean it out really good. Inspection, a lot of the times you can see the torn end of the tendon, but it can be tough if you don't know exactly what you're looking for. So I just say, like, have a really high index of suspicion and tell them they should follow up with a hand surgeon very quickly if there's any issue with lack of function. So you definitely want to, and this exam part can be hard if it's acute because their hand hurts because it cut open, it's bleeding everywhere, you're putting stitches in it. Um, getting them to bend their finger. Most people don't want to bend their finger. They're like, you can't bend it, but they can't bend it because it's so painful and swollen, or because their flexor tendon is lacerated. Um, but that's so you're gonna numb them up anyway to to fix the laceration. So you numb them up and see if they can, you know, bend a little bit. You want to check both FDP and FDS, depending on where the laceration is, it's more likely to be one or the other. Um, but yeah, these are these are quick fixes. If you do not get to these quickly, bad outcomes. Bad bad thing, bad, bad, bad things. We're having a sad, sad day. We've we've done a couple delayed, it's not fun at all. These retract very, very quickly. Yeah. Um it sucks. Yeah.
SPEAKER_00Yeah. Well, uh, they will say the most missed, you know, whatever fracture is generally the term, but the most missed fracture is the second one, right? So you see the last ration, it's bleeding. Hey, I get to close this today, but if you don't check for tendon function, you're missing it because it's the other thing, right? Yeah, yeah. So that's that's a tough one.
SPEAKER_01Um you've got Jersey finger too. I'll throw that in there really quickly. Um, and you know, depending on surgeon preference, actually, and age of the patient demographic. Yeah, this one does get missed, but like I would argue depending on the age of the patient and their functional demands, not as detrimental because a lot of these we're not maybe necessarily fixing. Um, they might just, you know, decide to leave it and have uh extended fingertip. It's fine. It's fine.
SPEAKER_00Um, so why do we care about these things? I think um, you know, if you've been on the diagnostic end of thinking it's a knee contusion, and then you know the surgeon comes back and is like, hey, this was a quad tendon rupture, you missed this, like that hurts. That hurts in a deep level.
SPEAKER_01Yeah, you feel it in your soul and it, yeah.
SPEAKER_00It's one of those things you never miss again, right? But um I think if you you have these things on the forefront, like, you know, we just went over four or five clinical entities. That should be if I see this, I should move forward with this. So I think for new providers, uh, that's everything, right? I mean, I don't want to miss this, I don't want to miss that, whatever. So I think it's more likely for newer providers, experienced providers. Again, I will get these phone calls on the weekend of like, oh, 76-year-old female fell on her knee. I'm gonna order the MRI, and I'm like, it's not a quad. It's just not. It's female 76, not a quad. So you will see patterns and you see if these recognizable patterns, you can kind of move forward better. But that history, man, that history is usually everything.
SPEAKER_01A history is in most things gonna lead you to your diagnosis.
SPEAKER_00Did you feel a pop, right? If it's the the guy at the gym weightlifting and his pec hurts, but he didn't feel a pop, that's probably not a pec ten. And so um, it's really important that you you kind of systematically go through these. Um, but again, w if you miss these things, it affects the patient's ability to trust you, right? So um this And PAs in general.
SPEAKER_01PAs in general, yeah. Yeah, they're like, I don't ever want to see a PA again because they missdiagnosed.
SPEAKER_00Yeah, yeah. Um, but don't let, you know, don't let imaging replace your physical exam. Physical exam, look at the other side. That's so telling. Um, definitely. Um so again, takeaways, test the function. Don't just, you know, if it hurts so bad, it doesn't mean it must be a rupture. It's loss of function. Um, big tendon injuries and loss of strength, you've got to act fast, except if it's a rotator cuff. Except if it's a rotator cuff. Um, and not every tear is an emergency, right? So if it's you know, patellar dislocation, I don't, I don't really care about those, right? I mean, I do, but not in a stat fashion.
SPEAKER_01You're saying like MPFL ruptures and stuff like that. Yeah.
SPEAKER_00ACLs, those are not really stat. Um, and then those are meniscus tears.
SPEAKER_01Oh, people think they're those are like really stat. Are those really urgent? Yes, and yeah.
SPEAKER_00Yeah, I mean, if they're locked knees, those are those are tough to live with, right? Um, but anyway, so that uh I wish somebody went over this with me before I started. And they probably did. Yeah. Right. Maybe. I don't know.
SPEAKER_01You probably want to. Yeah, no, I wish I I wish I had this podcast to tell me what to do when I first started.
SPEAKER_00I know, I know. And I think I think as a new provider though, like I would rather I would rather have the conversation with you to correct and order less MRIs than go over the stuff you missed.
unknownYes.
SPEAKER_01You see what I'm saying? Yeah. So I'd rather be an error provider. I would rather over-order MRIs to an extent. To an extent. Than underorder them. Yeah. Right. You don't want to be that person who's like, this is everything is really bad. And then the person's like anticipating the worst, and they see the surgeon for follow-up and they're like, everything's fine, it's nothing. And then yeah.
SPEAKER_00Yeah, fine. So you don't want to be that person either. But as um, you know, as you become more experienced, it becomes a little bit a little bit easier. But um, those those should live, the ones we went over today, those should live in a very special part in your brain if you're an ortho PA.
SPEAKER_01All right. Well, until next time.
SPEAKER_00Till next time. Everybody have a good week.
SPEAKER_01Bye.
SPEAKER_00Thanks for tuning in to Joint Effort PAs. If you enjoyed this episode, be sure to subscribe, leave a review, and share it with a fellow PA or med-minded friend. You can also follow us on Instagram at Joint Effort PA's for updates and extra content.