Tiago Villanueva: Taking a renewed look at shoulder injuries

Tiago_VillanuevaI did something very unusual for a GP last weekend, which was to attend a conference on a highly specific topic, namely shoulder injuries. GP’s in Europe usually have a well defined mainstream circuit of national and international conferences, but this event was completely outside my comfort zone. None of the speakers were primary care doctors or worked in a primary care context, rather they were leading Portuguese orthopaedic surgeons, rehabilitation doctors, radiologists, physiotherapists, and exercise and fitness professionals. I was probably the only GP. My motivation to attend was simple. Firstly, most cases of muscular-skeletal injuries that I see in my practice are shoulder injuries rather than hip, knee, or back injuries, which most of the time end up requiring, among other things, sound rehabilitation and physiotherapy. It thus felt right to attend the event in order to gain new knowledge that could potentially help improve my practice and my patient’s care. Secondly, I’ve come to realise that the quality of physiotherapy that my patients get in the community is highly variable, so I felt I needed to start to target my referrals better to the best physiotherapy providers, and for that I needed to network.

After many inspiring presentations my first goal was easily fulfilled. For instance, a common doubt is whether I should refer a patient with a shoulder injury that may require surgical intervention. It’s really not that simple, as António Cartucho explained, we increasingly need to bear in mind the functional expectations of patients before deciding whether to operate or not. For instance, it may make more sense nowadays to operate on an 80 year old patient if he/she is someone who lives alone and independently, and wishes to continue to do so.

Perhaps shoulder injuries caused by surfing are not usually a priority in my inner city practice, but a presentation by surf trainer João Moisés, who trains some of Portugal’s top surfers, opened my eyes to an overlooked issue. He explained that surfers are very prone to shoulder injuries since about 50% of the surfer’s time is spent “rowing” with one’s arms, and most injuries are due to collision with the board. Surfers therefore need focused training in order to stabilise and strengthen their shoulder muscles and subsequently prevent injuries, or even rehabilitate them.

Imaging exams of the shoulder have an important role in the assessment of shoulder injuries and have evolved enormously, but Conceição Pernadas, a radiologist, said that the harvesting of images depends tremendously on the quality of the clinical information provided in the referral, and that was an important reminder and take home message for me.

As for my second goal, I had the chance to introduce myself to and network with some prominent orthopaedic surgeons, and ask them who they refer their patients to for physiotherapy. One prominent orthopaedic surgeon even came back to me at the end of the day with a list he personally wrote of the local physiotherapists he refers his patients to and considers the best. Some of them were actually at the conference. This may be biased of course, but I think this is probably still better than referring patients blindly and allow them to freely choose their physiotherapy provider. At least now I can make a few suggestions should patients wish to know.

I have mentioned in a previous blog the importance of building and managing international networks, but it is equally if not more important to establish good local networks, because they’re usually the most directly relevant to patient care. Learning who the most appropriate colleagues to refer patients to may not only improve care, but also decrease the time lag between referral and  the start of physiotherapy.

Tiago Villanueva is a GP based in Lisbon, Portugal, and is a former BMJ Clegg Scholar and student editor, Student BMJ. He can be followed on Twitter on @TiagoMGF.