A 52 year old male patient was referred by his chiropractor to an orthopedic group for assessment for back and right shoulder pain. He injured his shoulder while lifting weights using tonal. He was seen by a PA for his back on February 15, 2022. The PA declined to assess the right shoulder because of billing reasons. The patient scheduled an appointment with one of the group's upper extremity specialists who evaluated the patient two days later, February 17th.
The surgeon ordered an x-ray of the right shoulder, diagnosed the patient with impingement syndrome with biceps tendinitis. He performed a subacromial corticosteroid injection the same day and sent the patient to physical therapy. He did not order a MRI of the right shoulder as requested by the patient. He did indicate that he might order the MRI based upon the results of physical therapy.
During the first physical therapy assessment appointment on March 2nd the physical therapist ruptured the right bicep muscle while doing a Speed’s test. The physical therapist apparently fainted after the event.
The STAT MRI performed the same day revealed a complete tear of both the long and short heads of the distal biceps from the radial tuberosity with retraction.
The patient went to a second surgeon who noted that the tear occurred when the therapist applied resisted downward force on the patient's supinated extended arm. The second surgeon performed a bicep tendon repair on March 10, 2022. and is scheduling the patient for a shoulder repair as well as the right shoulder imaging that he ordered demonstrated a high-grade partial tearing of the rotator cuff tendon and tearing of the biceps labral anchor. This surgery will need to be delayed until after the patient's bicep tendon is healed.
The questions are whether the first surgeon deviated from the standard of care by failing to order the MRI that the patient requested and whether he likely performed an insufficient evaluation given that the patient's right bicep tore during a basic physical therapy evaluation.
Files:
No questions yet!
Do you believe there might have been medical error?
An MRI was not indicated on the first visit, with no PT done. Patient had no elbow pain or suggestion of damage to distal biceps. MRI of shoulder would not have predicted this. Speed test will not tear an intact tendon.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
MRI of shoulder would not have predicted distal biceps rupture. Rupture must be due to some pre-existing tendinopathy that sounds like it was asymptomatic.
What makes you a good expert for this case?
Extensive court experience. Experience in managing shoulder and elbow injuries.
How often do you encounter cases similar to this one in your practice?
5 times per week. I fix shoulder problems 1-2/week.
Do you believe there might have been medical error?
MRI is NOT indicated as a first or second line study for shoulder pain. XR, physical exam and PT are standard and appropriate responses. Only were PT to fail would an MRI be indicated. The fact that the patient requests the MRI is utterly irrelevant - the patient does not establish the standard of care. Most private insurers wouldn't even approve an MRI without pre-authorization documenting 6 weeks of physical therapy. Distal biceps rupture has nothing to do with the shoulder and only underscores that the patient has underlying degenerative tendinosis. Distal biceps ruptures are "straw the broke the camels back" injuries that occur spontaneously, usually with eccentric stress. It has nothing to do with the physical exam of the shoulder, nor does it in any way imply a deficient physical exam, as no physical exam maneuvers would be likely to cause a distal biceps rupture.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
see above. There is no medical error, so there is no injury related to this supposed claim, unless there are significant details in the history that have not been provided.
What makes you a good expert for this case?
I treat these injuries on a daily basis, have assisted in creating and vetting all of the AAOS Clinical Practice Guidelines and Appropriate Use Criteria, for rotator cuff injuries among other topics.
How often do you encounter cases similar to this one in your practice?
Frequently. I perform distal biceps repairs and shoulder arthroscopy and rotator repairs routinely and treat patients with similar presentations on a daily basis.
Do you believe there might have been medical error?
It is not the standard of care to order an MRI at the preliminary assessment for shoulder pain that began without trauma (fall fron height, motor vehicle accident, etc). XR and physical examination are the standard investigations for this. Additionally, physical examination of the elbow (distal biceps) while it can be helpful, is not mandatory is the patient does not have elbow related complaints (this patient did not seem to, according to the provided data). The biceps rupture could have occurred at any time and likely would have ruptured during shoulder surgery rehab had the patient been rushed urgently toward shoulder MRI and shoulder. surgery.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient probably had a high grade partial tear or weakening of the distal biceps tendon that would have ruptured regardless of what the surgeon did or did not do, if it indeed ruptured during a physical examination. This was going to happen anyway. It would not have been detected with standard or care investigations in this case because the patient did not have elbow related symptoms. It also would not have been prevented because the treatment for such an injury, of symptomatic, is already the same surgery that he eventually had to undergo - distal biceps repair. The shoulder will still be equally repairable - outcomes of partial thickness rotator cuff repairs or biceps labral anchor repairs (the fix for which would have been a biceps tenodesis likely rather than a true repair) are not any worse if delayed even a few months.
What makes you a good expert for this case?
I am a board certified orthopedic surgeon with fellowship training in upper extremity surgery. I have performed expert witness review for the state Attorney General office.
How often do you encounter cases similar to this one in your practice?
Approximately once or twice per month, regarding each the shoulder and the elbow injuries.
Do you believe there might have been medical error?
The PA appeared to perform enough of an examination to determine the patient did have impingement which does incorporate tendinosis and even partial thickness tearing. Appropriate nonop treatment was begun after a steroid injection. The SOC does not mandate an MRI at the initial visit, and it would appropriately have been denied by insurance as there was no determination of an actual full thickness tear at that first visit. The SOC is to document a suspicion of injury, begin standard nonoperative treatment modalities, such as rest, NSAIDs, and therapy, reassess as a subsequent visit, and potentially obtain an MRI based upon therapy outcome. The fact that the patient sustained a tear of the distal biceps tendon during therapy is terrible, bad luck, and a coincidence (the "straw that broke the camel's back"). The acute/stat MRI at the subsequent examination was warranted and appropriate as the scope of the injury changed dramatically.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
same as above. No one can know when the final fibers of a partially torn cuff or distal biceps insertion site will fail/rupture.
What makes you a good expert for this case?
I perform an extremely high volume of rotator cuff related surgery- up to 6-8 repairs per week throughout the year and treat at least that many patients every day in clinic. I teach colleagues around the US and world on the latest state-of-the-art techniques to manage rotator cuff pathology
How often do you encounter cases similar to this one in your practice?
This is a red swan type of incident. In hindsight, I am certain pathology would have been visualized had an MRI somehow been obtained, but, as I said, that IS NOT the standard of care based upon our own peer reviewed literature.
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