Anderson, an internist, has incorporated his twenty years of experience in clinical practice into this book on the treatment of common outpatient orthopaedic problems that are seen by primary-care physicians.
The book is divided into four sections. The first section describes the most common outpatient orthopaedic conditions; the second is on fractures; the third consists of exercise-instruction sheets to be given to patients; and the fourth discusses supports, braces, and casts.
The chapters on problems related to the neck discuss two conditions: cervical strain and cervical radiculopathy. The chapter on cervical strain begins with an illustration and some text informing the reader on how to give a trigger-point injection. This is followed by a brief description of what cervical strain consists of and a list of symptoms that patients usually report. There is a short section on physical examination, with eye-catching "summary" sections emphasizing the chief features of examination. Radiography, special testing, and diagnosis are covered briefly. Treatment, including physical therapy, then is described. Again, there is a highlighted box that lists the main features of physical therapy. This is followed by a discussion of the injection technique and aftercare.
A similar format is used to describe other conditions. The section on the shoulder covers impingement syndrome, rotator cuff tears and tendinitis, frozen shoulder, strains of the acromioclavicular joint in osteoarthritis, biceps tendinitis, subscapular bursitis, arthritis, and multidirectional instability. In the section on multidirectional instability, which is sometimes difficult even for trained orthopaedic surgeons to recognize easily, the author gives a very simplistic presentation of the condition and states that it can be treated by the primary-care physician for several weeks, if not for three to four months, and that only if the symptoms persist after this length of time should the patient be referred to a specialist. In light of the many modern medical advancements that have taken place, this recommendation seems inappropriate, and it illustrates the cursory nature of some of the sections. It also raises questions as to which conditions are appropriate to discuss under the rubric of primary care.
I have similar concerns about other sections of this book, as well as questions about the specific recommendations made by this author and about the validity of this type of book, which is aimed at the primary-care physician. Books such as this, which feature easy-to-read formats and boxes of highlighted text, are growing in popularity despite the fact that they often oversimplify complex medical problems.
Other areas of the text also should be read with caution. Although the data on cervical strain are fairly accurate, the use of traction for patients who have cervical radiculopathy has not proved to be useful for the treatment of foraminal encroachment due to spondylosis. No references are cited to support this treatment or other suggested modalities.
The clinical information on symptoms and findings is also accurate, for the most part. However, some of the comments and recommendations are of questionable validity and relevance. For example, in the discussion of rotator cuff injuries in the chapter on the shoulder, Anderson notes that as many as one-third of patients with persistent symptoms who are at least seventy years old have either a partial or a full-thickness rupture of a rotator cuff tendon. The inference is that this is an acute problem; however, there is no mention of the fact that 60 to 70 percent of asymptomatic individuals have evidence of full-thickness rotator cuff tears on magnetic resonance imaging. Anderson goes on to suggest that, if the symptoms persist, arthrography or diagnostic ultrasonography should be performed and referral to an orthopaedic surgeon should be considered. However, it would be more appropriate to refer the patient before making the arthrogram.
In the section on fractures, Anderson states that nondisplaced fractures can be treated with a cast by the primary-care physician; however, this should not be attempted unless the physician has a great deal of experience in the application of different types of casts and is trained in the art of treating fractures. The recommendations for the treatment of other types of fractures in this section are appropriate.
The section on commonly used supports, braces, and casts also raises concerns. The use of an expensive knee brace without appropriate consultation is certainly not ideal in this day and age. The application of an above-the-knee cast, which can be fraught with problems, is another questionable recommendation.
In summary, although this book provides some useful guidelines for the primary-care physician, the recommended timing of referral to an orthopaedist often appears to be delayed or referral is not emphasized. Initially, the book appears to be informative; however, careful perusal reveals that some of the recommendations and assumptions concerning the extent of musculoskeletal care that should be provided by the primary-care physician need to be reconsidered. This book does not do justice to the advances in our knowledge base in the field of musculoskeletal problems.
Leela Rangaswamy, M.D.
Deputy Editor
The Journal of Bone and Joint Surgery
Needham, Massachusetts