How to Diagnose, Treat Four Common Conditions

SAN DIEGO — As a family physician trained in sports medicine, Dr. Anthony Beutler encounters many primary care providers who struggle with diagnosis and treatment of musculoskeletal conditions.

“Many times we make the right diagnosis but the patient doesn't get better because we're not addressing the underlying problem,” said Dr. Beutler, chief of the Injury Prevention Research Laboratory at the Uniformed Services University of the Health Sciences, Bethesda, Md.

At the annual meeting of the American Academy of Family Physicians, Dr. Beutler discussed how to diagnose and treat four musculoskeletal conditions.

▸ Plantar fasciitis. This condition is the most common cause of heel pain; it affects about 2 million Americans a year, including 10% of all runners. It is marked by microtears of the plantar fascial aponeurosis, which lead to collagen degeneration and pain, said Dr. Beutler, also of family medicine at the university.

A key diagnostic clue is maximal tenderness at the medial tubercle of the calcaneus. Other clues include heel pain that is worst with the first step in the morning or a dull ache in the heel with activity.

Common causes include muscle weakness, training error, overpronation, improper footwear, and tight heel cords. Dr. Beutler noted that 70% of people with plantar fasciitis have gastrocnemius or soleus inflexibility and cannot passively dorsiflex past 0 degrees.

Heel spurs in this patient population may or may not indicate that plantar fasciitis is causing heel pain. The spurs are not the pain source.

First-line treatments include heel cord and plantar fascia stretching; foot strengthening exercises; orthotics for those with pes planus or overpronation; and ice, compression, and elevation for pain relief.

Second-line treatments include steroid injections for short-term pain relief, night splints, and, for pain that lasts more than 6 months, custom orthotics and surgery. Patients should be referred for surgery only after 6–12 months of treatment failure.

Dr. Beutler emphasized that there are no studies to support or refute the benefit of NSAIDs for pain relief. Ultrasound, laser therapy, and magnetic insoles have been found to be of no benefit.

He advised that patients continue activities at 50% of preinjury level and, when pain begins to improve, that they increase activity no more than 10% per week.

▸ Ankle sprain. This ranks as a chief reason for a visit to the emergency room. The lateral ankle is most commonly affected, usually because of injury to the anterior talofibular ligament. The calcaneofibular ligament and posterior talofibular ligament are less commonly injured.

Recommended treatments include rest, ice, compression, elevation, NSAIDs, and a semirigid brace to improve weight-bearing and reduce the risk of reinjury. “Braces are proven. They will decrease your rate of injury for up to 8 months after you injure your ankle.”

Another key component involves rehabilitation exercises, such as sitting in a chair and “writing” each letter of the alphabet with your toes to improve range of motion, or doing the single-leg balance to help the ankle regain its sense of position or proprioception. Do several repetitions on each foot at least twice daily. Patients should return in 4–6 weeks if they are not better.

▸ Patellofemoral pain. This condition is the most common cause of knee pain in patients aged less than 40 years. It is marked by biomechanical imbalance that causes pain in peripatellar structures. Possible pain generators include the anterior synovium, infrapatellar fat pad, subchondral bone, or retinacula.

The pain is often bilateral and is exacerbated by going up and down stairs. Effusion and erythema are rare.

Common culprits include muscle tightness, weakness of quadriceps and gluteus medius, and bony malalignment.

Consider referral to a physical therapist who focuses on stretching or strengthening exercises, such as single-leg squats and single-leg step downs. If the patient comes back to you having been treated “with ice, heat, fancy gels, and no real stretching or strengthening program, don't waste your time on that therapist any more.”

NSAIDs “are not great for femoral pain” but may provide short-term relief, he said. Orthotics or patellar taping and bracing “work very well for a very few patients.”

▸ Trochanteric bursitis. This condition is the second only to osteoarthritis as a chief cause of hip pain. Tightness in the iliotibial band and weakness in the gluteus medius cause compression of the bursa between the tensor fascia latae and the greater trochanter. Patients who present with trochanteric bursitis describe it as lateral hip pain radiating toward the knee and report that it's painful to get up out of a chair. The feeling ranges from nagging pain to pain so severe they're unable to walk. Most evidence supports a steroid and lidocaine injection into the trochanteric bursa as a first-line treatment. No studies to date compare NSAIDs with steroid injection and other forms of treatment. Single-leg step downs, lateral leg lifts, and hula girl exercises improve strength.

Many times the right diagnosis is made, but the patient doesn't get better because of unaddressed underlying issues. DR. BEUTLER

Musculoskeletal Coding Dos and Don'ts

Dr. Beutler shared the following tips for getting paid:

▸ Do capture the time you spend. Brace fitting and care coordination can be included in the patient education or complexity sections of your E&M code. Crutch training can be coded as CPT 97116 or included in your E&M code. Fifteen minutes of exercise teaching can be coded as CPT 97110; smaller amounts of time can be included in your E&M code.

▸ Don't forget to code injections. Use CPT 20610 for most injections. Finger joints are 20600.

▸ Do use a 29 modifier. “If you diagnose subacromial shoulder pain and do a subacromial joint injection at the same visit, use a 29 modifier with your CPT code of 20610,” he said. “This tells the insurance company that you both diagnosed the subacromial pain and did the injection at the same visit.”

▸ Don't forget to bill for durable medical goods. If you provide the braces or the crutches, make sure that shows up on your billing.

▸ Do phone a friend. Phone your orthopedic office or referral center and ask them who does their orthopedic billing and coding. Find that person and take them out to lunch to talk coding, Dr. Beutler advised. “It will be well worth your time.”

SAN DIEGO — As a family physician trained in sports medicine, Dr. Anthony Beutler encounters many primary care providers who struggle with diagnosis and treatment of musculoskeletal conditions.

“Many times we make the right diagnosis but the patient doesn't get better because we're not addressing the underlying problem,” said Dr. Beutler, chief of the Injury Prevention Research Laboratory at the Uniformed Services University of the Health Sciences, Bethesda, Md.

At the annual meeting of the American Academy of Family Physicians, Dr. Beutler discussed how to diagnose and treat four musculoskeletal conditions.

▸ Plantar fasciitis. This condition is the most common cause of heel pain; it affects about 2 million Americans a year, including 10% of all runners. It is marked by microtears of the plantar fascial aponeurosis, which lead to collagen degeneration and pain, said Dr. Beutler, also of family medicine at the university.

A key diagnostic clue is maximal tenderness at the medial tubercle of the calcaneus. Other clues include heel pain that is worst with the first step in the morning or a dull ache in the heel with activity.

Common causes include muscle weakness, training error, overpronation, improper footwear, and tight heel cords. Dr. Beutler noted that 70% of people with plantar fasciitis have gastrocnemius or soleus inflexibility and cannot passively dorsiflex past 0 degrees.

Heel spurs in this patient population may or may not indicate that plantar fasciitis is causing heel pain. The spurs are not the pain source.

First-line treatments include heel cord and plantar fascia stretching; foot strengthening exercises; orthotics for those with pes planus or overpronation; and ice, compression, and elevation for pain relief.

Second-line treatments include steroid injections for short-term pain relief, night splints, and, for pain that lasts more than 6 months, custom orthotics and surgery. Patients should be referred for surgery only after 6–12 months of treatment failure.

Dr. Beutler emphasized that there are no studies to support or refute the benefit of NSAIDs for pain relief. Ultrasound, laser therapy, and magnetic insoles have been found to be of no benefit.

He advised that patients continue activities at 50% of preinjury level and, when pain begins to improve, that they increase activity no more than 10% per week.

▸ Ankle sprain. This ranks as a chief reason for a visit to the emergency room. The lateral ankle is most commonly affected, usually because of injury to the anterior talofibular ligament. The calcaneofibular ligament and posterior talofibular ligament are less commonly injured.

Recommended treatments include rest, ice, compression, elevation, NSAIDs, and a semirigid brace to improve weight-bearing and reduce the risk of reinjury. “Braces are proven. They will decrease your rate of injury for up to 8 months after you injure your ankle.”

Another key component involves rehabilitation exercises, such as sitting in a chair and “writing” each letter of the alphabet with your toes to improve range of motion, or doing the single-leg balance to help the ankle regain its sense of position or proprioception. Do several repetitions on each foot at least twice daily. Patients should return in 4–6 weeks if they are not better.

▸ Patellofemoral pain. This condition is the most common cause of knee pain in patients aged less than 40 years. It is marked by biomechanical imbalance that causes pain in peripatellar structures. Possible pain generators include the anterior synovium, infrapatellar fat pad, subchondral bone, or retinacula.

The pain is often bilateral and is exacerbated by going up and down stairs. Effusion and erythema are rare.

Common culprits include muscle tightness, weakness of quadriceps and gluteus medius, and bony malalignment.

Consider referral to a physical therapist who focuses on stretching or strengthening exercises, such as single-leg squats and single-leg step downs. If the patient comes back to you having been treated “with ice, heat, fancy gels, and no real stretching or strengthening program, don't waste your time on that therapist any more.”

NSAIDs “are not great for femoral pain” but may provide short-term relief, he said. Orthotics or patellar taping and bracing “work very well for a very few patients.”

▸ Trochanteric bursitis. This condition is the second only to osteoarthritis as a chief cause of hip pain. Tightness in the iliotibial band and weakness in the gluteus medius cause compression of the bursa between the tensor fascia latae and the greater trochanter. Patients who present with trochanteric bursitis describe it as lateral hip pain radiating toward the knee and report that it's painful to get up out of a chair. The feeling ranges from nagging pain to pain so severe they're unable to walk. Most evidence supports a steroid and lidocaine injection into the trochanteric bursa as a first-line treatment. No studies to date compare NSAIDs with steroid injection and other forms of treatment. Single-leg step downs, lateral leg lifts, and hula girl exercises improve strength.

Many times the right diagnosis is made, but the patient doesn't get better because of unaddressed underlying issues. DR. BEUTLER

Musculoskeletal Coding Dos and Don'ts

Dr. Beutler shared the following tips for getting paid:

▸ Do capture the time you spend. Brace fitting and care coordination can be included in the patient education or complexity sections of your E&M code. Crutch training can be coded as CPT 97116 or included in your E&M code. Fifteen minutes of exercise teaching can be coded as CPT 97110; smaller amounts of time can be included in your E&M code.

▸ Don't forget to code injections. Use CPT 20610 for most injections. Finger joints are 20600.

▸ Do use a 29 modifier. “If you diagnose subacromial shoulder pain and do a subacromial joint injection at the same visit, use a 29 modifier with your CPT code of 20610,” he said. “This tells the insurance company that you both diagnosed the subacromial pain and did the injection at the same visit.”

▸ Don't forget to bill for durable medical goods. If you provide the braces or the crutches, make sure that shows up on your billing.

▸ Do phone a friend. Phone your orthopedic office or referral center and ask them who does their orthopedic billing and coding. Find that person and take them out to lunch to talk coding, Dr. Beutler advised. “It will be well worth your time.”

SAN DIEGO — As a family physician trained in sports medicine, Dr. Anthony Beutler encounters many primary care providers who struggle with diagnosis and treatment of musculoskeletal conditions.

“Many times we make the right diagnosis but the patient doesn't get better because we're not addressing the underlying problem,” said Dr. Beutler, chief of the Injury Prevention Research Laboratory at the Uniformed Services University of the Health Sciences, Bethesda, Md.

At the annual meeting of the American Academy of Family Physicians, Dr. Beutler discussed how to diagnose and treat four musculoskeletal conditions.

▸ Plantar fasciitis. This condition is the most common cause of heel pain; it affects about 2 million Americans a year, including 10% of all runners. It is marked by microtears of the plantar fascial aponeurosis, which lead to collagen degeneration and pain, said Dr. Beutler, also of family medicine at the university.

A key diagnostic clue is maximal tenderness at the medial tubercle of the calcaneus. Other clues include heel pain that is worst with the first step in the morning or a dull ache in the heel with activity.

Common causes include muscle weakness, training error, overpronation, improper footwear, and tight heel cords. Dr. Beutler noted that 70% of people with plantar fasciitis have gastrocnemius or soleus inflexibility and cannot passively dorsiflex past 0 degrees.

Heel spurs in this patient population may or may not indicate that plantar fasciitis is causing heel pain. The spurs are not the pain source.

First-line treatments include heel cord and plantar fascia stretching; foot strengthening exercises; orthotics for those with pes planus or overpronation; and ice, compression, and elevation for pain relief.

Second-line treatments include steroid injections for short-term pain relief, night splints, and, for pain that lasts more than 6 months, custom orthotics and surgery. Patients should be referred for surgery only after 6–12 months of treatment failure.

Dr. Beutler emphasized that there are no studies to support or refute the benefit of NSAIDs for pain relief. Ultrasound, laser therapy, and magnetic insoles have been found to be of no benefit.

He advised that patients continue activities at 50% of preinjury level and, when pain begins to improve, that they increase activity no more than 10% per week.

▸ Ankle sprain. This ranks as a chief reason for a visit to the emergency room. The lateral ankle is most commonly affected, usually because of injury to the anterior talofibular ligament. The calcaneofibular ligament and posterior talofibular ligament are less commonly injured.

Recommended treatments include rest, ice, compression, elevation, NSAIDs, and a semirigid brace to improve weight-bearing and reduce the risk of reinjury. “Braces are proven. They will decrease your rate of injury for up to 8 months after you injure your ankle.”

Another key component involves rehabilitation exercises, such as sitting in a chair and “writing” each letter of the alphabet with your toes to improve range of motion, or doing the single-leg balance to help the ankle regain its sense of position or proprioception. Do several repetitions on each foot at least twice daily. Patients should return in 4–6 weeks if they are not better.

▸ Patellofemoral pain. This condition is the most common cause of knee pain in patients aged less than 40 years. It is marked by biomechanical imbalance that causes pain in peripatellar structures. Possible pain generators include the anterior synovium, infrapatellar fat pad, subchondral bone, or retinacula.

The pain is often bilateral and is exacerbated by going up and down stairs. Effusion and erythema are rare.

Common culprits include muscle tightness, weakness of quadriceps and gluteus medius, and bony malalignment.

Consider referral to a physical therapist who focuses on stretching or strengthening exercises, such as single-leg squats and single-leg step downs. If the patient comes back to you having been treated “with ice, heat, fancy gels, and no real stretching or strengthening program, don't waste your time on that therapist any more.”

NSAIDs “are not great for femoral pain” but may provide short-term relief, he said. Orthotics or patellar taping and bracing “work very well for a very few patients.”

▸ Trochanteric bursitis. This condition is the second only to osteoarthritis as a chief cause of hip pain. Tightness in the iliotibial band and weakness in the gluteus medius cause compression of the bursa between the tensor fascia latae and the greater trochanter. Patients who present with trochanteric bursitis describe it as lateral hip pain radiating toward the knee and report that it's painful to get up out of a chair. The feeling ranges from nagging pain to pain so severe they're unable to walk. Most evidence supports a steroid and lidocaine injection into the trochanteric bursa as a first-line treatment. No studies to date compare NSAIDs with steroid injection and other forms of treatment. Single-leg step downs, lateral leg lifts, and hula girl exercises improve strength.

Many times the right diagnosis is made, but the patient doesn't get better because of unaddressed underlying issues. DR. BEUTLER

Musculoskeletal Coding Dos and Don'ts

Dr. Beutler shared the following tips for getting paid:

▸ Do capture the time you spend. Brace fitting and care coordination can be included in the patient education or complexity sections of your E&M code. Crutch training can be coded as CPT 97116 or included in your E&M code. Fifteen minutes of exercise teaching can be coded as CPT 97110; smaller amounts of time can be included in your E&M code.

▸ Don't forget to code injections. Use CPT 20610 for most injections. Finger joints are 20600.

▸ Do use a 29 modifier. “If you diagnose subacromial shoulder pain and do a subacromial joint injection at the same visit, use a 29 modifier with your CPT code of 20610,” he said. “This tells the insurance company that you both diagnosed the subacromial pain and did the injection at the same visit.”

▸ Don't forget to bill for durable medical goods. If you provide the braces or the crutches, make sure that shows up on your billing.

▸ Do phone a friend. Phone your orthopedic office or referral center and ask them who does their orthopedic billing and coding. Find that person and take them out to lunch to talk coding, Dr. Beutler advised. “It will be well worth your time.”