Analysis of Appropriate Initial Shoulder Imaging by Referring Physicians in Patients Referred to an Orthopaedic Surgeon for Shoulder Pain
BACKGROUND: Shoulder complaints are one of the twenty principal reasons for outpatient physicians visits in the United States each year. Shoulder symptoms are one of the top four reasons individuals are seen by Orthopaedic surgeons each year. Appropriate initial evaluation of these complaints includes history, physical examination and appropriate radiographs, including an axillary lateral. In our study, we wished to evaluate that rate at which patients referred to Orthopaedic surgeons for shoulder symptoms had appropriate initial radiographic evaluation. We hypothesized, given our own antidotal observation, that there would be a high rate of inappropriate or incomplete radiographic work-up prior to referral. METHODS: We performed a retrospective chart review of all consecutive new patients referred to a single surgeon’s outpatient office from July 2016 – December 2016 for shoulder complaints. A total of 51 patients were identified and met inclusion criteria. We identified whether the patients were referred to the Orthopaedic office with an appropriate initial radiographic work-up, incomplete initial radiographic work-up and which view was missing, and no appropriate initial radiographic work-up. We also identified whether the referring provider was a primary care physician, primary care sports medicine physician, Orthopaedic surgeon, or other type of physician. Rates of appropriate initial radiographic evaluation were calculated between the different groups. RESULTS: The rate of appropriate initial radiographic evaluation was 27.5% overall, 20.0 % for primary care providers, 63.6% for Orthopaedic surgeons, 33.3% for sports medicine primary care providers, and 0% for other providers. Rates of incomplete initial radiographic work-up was 43.1% overall, 40.0% among primary care providers, 36.3% for Orthopaedic surgeons, 33.3% among sports medicine primary care providers, and 86.0% for other providers. In all cases the radiographic series had omitted an axillary lateral. Percentage of patients with no initial radiographic evaluation was 27.5% overall, 40.0% for primary care providers, 0% for Orthopaedic surgeons, 33.3% for sports medicine primary care providers, and 14.2% for other providers. DISCUSSION: These findings are important for many reasons. Most importantly, it demonstrates a gap between what is seen as appropriate work-up for shoulder complaints and what is actually occurring in clinical practice for both Orthopaedic surgeons and non-Orthopaedic surgeons. This would be an area of interest for further research in order to determine the root cause and why the axillary lateral is often omitted. CONCLUSION: A majority of patients being referred to an Orthopaedic surgeon for shoulder symptoms are not being referred with appropriate initial radiographic evaluation.