Competency based clinical shoulder examination training improves physical exam, confidence, and knowledge in common shoulder conditions.

BACKGROUND: Deficiencies in musculoskeletal knowledge are reported at every stage of learning. Medical programs are looking for effective ways to incorporate competency-based training into musculoskeletal education. AIM: To evaluate the impact of bedside feedback on learner's shoulder examination skills, confidence, and knowledge of common shoulder conditions. SETTING: Four-week musculoskeletal clinic rotation. PARTICIPANTS: UCSD third year medical students and internal medicine residents. PROGRAM DESCRIPTION: Learners completed three baseline evaluations: videotaped shoulder examination, attitude survey, and knowledge test. During the 4-week intervention learners received bedside observation and feedback from musculoskeletal experts while evaluating patients with shoulder conditions. Post-intervention learners repeated the three assessments. PROGRAM EVALUATION: Eighty-nine learners participated. In the primary outcome measure evaluating the pre/post videotaped shoulder examination, significant improvement was seen in 21 of 23 shoulder examination maneuvers. Secondary outcomes include changes in learner confidence and knowledge. Greatest gains in learner confidence were seen in performing the shoulder examination (61.5% improvement) and performing injections (97.1% improvement). Knowledge improved significantly in all categories including anatomy/examination interpretation, diagnosis, and procedures. DISCUSSION: Direct observation and feedback during clinical evaluation of patients with shoulder pain improves shoulder examination competency, provider confidence, and knowledge of common shoulder conditions.

Inflammatory characteristics on ultrasound predict poorer longterm response to intraarticular corticosteroid injections in knee osteoarthritis.

OBJECTIVE: To assess whether inflammation on ultrasound is predictive of clinical response to intraarticular (IA) corticosteroid injections in patients with knee osteoarthritis (OA). METHODS: Patients with symptomatic knee OA were randomized to receive either an IA injection of 40 mg triamcinolone acetonide in the treatment group or 1 cc 0.9% saline in the placebo group. Clinical response was assessed by changes in baseline Western Ontario and McMaster Universities (WOMAC) index scores and physician global assessment at 4 and 12 weeks. Ultrasounds were performed at each visit. Patients and assessors were blinded to treatment status. RESULTS: Seventy-nine patients were enrolled into the study. Four-week data were available for 67 patients in the primary analysis comparing change in WOMAC pain score from baseline to 4 weeks. There was almost no change in the WOMAC pain subscale score from baseline to 4 weeks in the control group, but there was a significant improvement in WOMAC pain subscale score from 10.8 (SD +/- 3.2) at baseline to 8.75 (SD +/- 4.0) at 4 weeks in the treatment group (adjusted p = 0.001). Of the 34 patients in the treatment group; 16 (47%) had inflammatory disease and 18 (53%) had noninflammatory disease as determined by ultrasound. There was no difference in the change in WOMAC pain score between the inflammatory and noninflammatory patients in the treatment group at 4 weeks. There was a statistically significant greater improvement in pain subscale scores among noninflammatory patients than among inflammatory patients at 12 weeks. CONCLUSION: Intraarticular corticosteroid injections are an effective short-term treatment for symptomatic knee OA compared to placebo. Patients with noninflammatory characteristics on ultrasound had a more prolonged benefit from IA corticosteroids compared to inflammatory patients.