Sport and exercise medicine

Five Things Physicians and Patients Should Question


Released January 26, 2017; Last updated January 26, 2017

1

Don’t order an MRI for suspected degenerative meniscal tears or osteoarthritis (OA).

Degenerate meniscal tears and osteoarthritis (OA) are extremely common in the general population. Early degenerative changes in the meniscus can be found in many subjects under the age of 30. By 50 to 60 years of age, full degenerative meniscal tears are commonly found in 33-50% of subjects. Unless associated with the presence of osteoarthritis (OA), these degenerative meniscal tears are most often asymptomatic. Magnetic resonance imaging (MRI) is not recommended for degenerative meniscal tears unless there are mechanical symptoms (e.g., locking) or lack of improvement with conservative treatment (exercise/therapy, weight loss, bracing, topical or oral analgesia, intra-articular injections). MRI is not recommended for the diagnosis or management of OA. Weight-bearing X-rays should be ordered instead.

2

Don’t prescribe opiates as first line treatment for tendinopathies.

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Although acute inflammatory tendinopathies (i.e., tendinitis) exist, most patients seen in primary care will have chronic symptoms (tendinosis). Multimodality options (e.g., relative rest, activity modifications, physical or athletic therapy, etc.) should be considered as the first line treatment of tendinopathies. Opiates should not be used in the initial phase of treatment.

3

Don’t order orthotics for asymptomatic children with pes planus (flat feet).

Pes planus is common in children. Although it rarely leads to disability, it is still a major concern for parents and is a common cause of clinic visits for pediatric foot problems. Most pediatric pes planus cases are characterized by a normal arch during non-weight bearing, and a flattening of the arch on standing. They are often painless, non-problematic, and resolve by adolescence. The current evidence suggests that it is safe and appropriate to simply observe an asymptomatic child with flexible pes planus.

4

Don’t order an MRI as an initial investigation for suspected rotator cuff tendinopathy.

Initial management of rotator cuff tendinopathy includes relative rest, modification of painful activities, and an exercise program guided by a physical therapist or athletic therapist to regain motion and strength. The addition of subacromial cortisone/local anesthetic injections may be helpful. Should conservative management fail to relieve pain and restore function of the shoulder, consider plain radiographs to rule out bony or joint pathology, and ultrasound to assess for rotator cuff and bursal pathology. MRI or MRA (MR arthrogram) should be considered if symptoms don’t resolve with conservative therapy and there is a concern of labral pathology.

5

Don’t immobilize ankle inversion sprains with no evidence of bony or syndesmotic injury.

Ankle sprains are among the most common injuries seen in the ER or physician clinics. Ankle sprains cause a high incidence of absenteeism in professional and physical activities with important economic consequences. There is good evidence to show that functional bracing of the ankle instead of rigid immobilization is associated with improved and earlier functional improvement and an overall shorter recovery period. For ankle inversion sprains with no associated bony or syndesmotic injury, early mobilization using a functional ankle brace and physiotherapy/athletic therapy should be considered instead of rigid immobilization.


How the list was created

The Canadian Academy of Sport and Exercise Medicine (CASEM) Board approved the development of Choosing Wisely Canada’s recommendations. A small working group was created to review existing Choosing Wisely Canada recommendations. The CASEM Board then created a list of suggested recommendations based on existing research, experience and common practice patterns. A national survey was conducted with CASEM’s membership, soliciting members’ feedback for each recommendation. The five recommendations with near unanimous support were selected to be included in CASEM’s Choosing Wisely Canada’s Top 5 List. Each recommendation was further developed by the small working group, and submitted to CASEM’s publication’s committee for review and feedback. Final edits were made and approved for submission to Choosing Wisely Canada by the CASEM Board.


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1

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2

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3

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4

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5

Cooke MW, Marsh JL, Clark M, et al. Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. The CAST trial. Health Technol Assess. 2009; 13(13): 1-65. PMID: 19232157.

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Prado MP, Mendes AA, Amodio DT, et al. A comparative, prospective, and randomized study of two conservative treatment protocols for first-episode lateral ankle ligament injuries. Foot Ankle Int. 2014; 35: 201-6. PMID: 24419825.