Overview

Orthopedics and sports medicine are important topics in family medicine. The curriculum on this page not only covers what you will learn on the individual rotations, but also during your entire residency. The goal is to produce family physicians who can care for the vast array of orthopedic/sports med problems encountered in family medicine. 

During your SM/orthopedic rotations (or R1 sessions for which SM/Ortho attendings are unavailable), each resident should work toward completing the following (See schedule for allotted time for independent learning):

1. Read all assigned readings (posted below) and score a 100% on the associated online quizzes. You may wish to take the quiz first as a pre-test, then complete the readings, the take the quiz again.

   1. Ortho Quiz 1: https://ucfm.wufoo.com/forms/mm92y1205sbvw7/

   2. Ortho Quiz 2: https://ucfm.wufoo.com/forms/m1hagqa918qarn5/

2. View physical examination videos and complete the fracture radiology modules (posted below).

3. Complete the MSK Ultrasound POCUS Module (linked HERE) during your Ortho R1 sessions, or R2-R3 rotation.

4. (OPTIONAL) Complete the practice self-test based upon ITE questions similar to those likely to be encountered on the family medicine boards (provided via email in the first week of your rotation).

5. Meet with the overseeing family medicine faculty, to review key topics and examination skills during the rotation using simulated patient encounters, and answer any questions on assigned readings. This will be scheduled for you and is a low-pressure session intended to provide a framework for approaching common orthopedic concerns and to help identify and address knowledge gaps. Cases include common back, shoulder, elbow, hand/wrist, knee, and ankle complaints. POCUS is integrated into some cases too! (Due to vacations, etc, occasionally, this is not able to be scheduled. If that is the case, you are welcome to email Dr. C to see if we can schedule another time to meet.)

As you work with specialists, it is important you utilize each session in a pro-active way, even if there is more “shadowing” involved than ideal. Key areas to focus on during your learning sessions include the following:

• History: History of the problem/injury, including timing and specific mechanism

• Physical exam:  Approach to the various complaints you see, including special tests (eg, painful arc for supraspinatus, or McMurray for meniscus, etc)

• Management:  How is this problem managed initially?  Chronically?  At the primary care level?  When should it be referred?  What does/should “RICE” really look like? How do you follow up improvement/progress?  Return to play instructions?  Instructions/prescriptions for therapy?  When/how to involve PT/OT/others?  

• Ordering and interpreting tests:  What is the preferred test to order?  How is the test (X-ray, etc) interpreted?

• Procedures:  If you have “seen one” with basic procedures like joint injections, ask if you can “do one” if not otherwise instructed

• Other:  If you have opportunity to join an attending for a community event, such as a sideline event or school preparticipation sports physical screening, even just once, this is a recommended experience!

Here is a checklist of recommended knowledge and skills to help guide you on getting the most out of your sessions with specialists, including a list of suggested questions to ask as time allows. Learners are advised to print this list or keep it on your phone as reference.

Please contact Dr. Rich with questions or concerns. Also please provide us feedback on how to improve the rotation.

Augmenting your learning: 

• Rheumatology: We have tried to find a way to integrate some Rheumatology exposure into one of these rotations, but have not been successful.  For those interested in increasing their Rheumatology exposure, you are encouraged to schedule a 2-week elective in Rheumatology or Pediatric Rheumatology (or CCHMC mix of specialties clinics, if available). Additionally, 3rd Wednesday afternoons, a Rheumatologist sees patients at Good Samaritan Free Clinic, and may be available to shadow.

• Sideline Sports Medicine: If you would like to get exposure to sideline medicine at a football, soccer, or other high school or college sports event, contact Dr. Rish. UC’s Dr Mike Donaworth and CCHMC’s Dr Alissa Conde and Dr Kelsey Logan may have opportunities for shadowing based on time of year.

Schedules

All schedules are subject to change.  Please obtain a detailed and updated schedule by contacting Judy Flick in the residency office prior to the start of your rotation.

R1 Schedules: Rotation Goal: "R1s will establish a foundation for the diagnosis and management of a breadth of common sports medicine and orthopedic conditions through observation, interview, and hands-on exam opportunities under the guidance of a master Orthopedic/SM clinician." R1s are paired up with an orthopedist or sports medicine specialist for a “weekly” longitudinal experience throughout the year (once-a-week during your 2-week FMC block, all year, minus attending or learner vacation/conference time, and exceptional rotations such as global health). Mentors include: Drs Mike Donaworth and Jon Divine (both UC FM Sports Medicine), Dr Stephen Dailey (UC Ortho), and Dr George Matic (Beacon Orthopedics). If sessions are cancelled, R1s should use their session for independent learning, including working on: 1) Ortho Quizzes 1 & 2 and their associated readings; 2) Additional readings and videos below, including in the Ortho Toolbox; 3) MSK Ultrasound POCUS Module; and 4) Common Orthopedic Radiology, Fractures, and Management Part 1 (Upper Extremity) module (If you have completed part 1 and would like to help us build part 2, let us know!).

R2+ Block Schedules: The general schedule, complete with times, locations, and contact information,  is provided by Judy. An overview of the schedule is here, but exceptions may apply:

• Mon AM - Steve Sallada & Jennifer Ripley (JSC, PT) / OFF*

• Mon PM - SM/Modules/Cases/Other**

• Mon EVE - Erin Meece, NP, Sports Med (Acute Walk-in Clinic, JSC, 6-9pm)

• Tue AM - SM/Modules/Cases/Other** / Faculty-led Ortho/MSK POCUS Cases (FMC)

• Tue PM - OFF

• Tue EVE - Erin Meece, NP, Sports Med (Acute Walk-in Clinic, JSC, 6-9pm)

• Wed AM - Dr Divine (Sports Med)

• Wed PM - Dr Monir Tabbosha, Neurosurg/Spine

• Wed EVE - Dr Sean Boyle, OMM (FMC)

• Thu AM - Dr Noah Shaftel, Ortho Hand

• Thu PM - Residency Conferences

• Fri AM - Dr Doug Schuckmann, Podiatry (JSC)

• Fri PM - Dr Jennifer Chung, PM&R

*PT is one session only; **SM/Modules include: 1) Rotation readings/videos, ITE questions, Quizzes x2 (8hrs); 2) MSK POCUS (2hrs); 3) MSK Radiology (2hrs)

Required Readings & Video Learning Assignments

At the beginning of your rotation, please read the chapters from Steinberg, Gerald G et al.  Orthopaedics in Primary Care ( The chapter links are below ). During your rotations, also utilize/familiarize yourself with Sarwark/AAOS/AAP, Essentials of Musculoskeletal Care 4, and The Sports Medicine Patient Advisor, located in the FMC Precepting Office (Please do not remove from FMC - sorry!).  Selections from the first two books above, along with a few key articles (linked below), comprise your required reading assignments each rotation.  The Sports Medicine Patient Advisor has excellent one-pagers for patients on almost every orthopedic condition.  Don't forget to complete the online quiz based on your readings (See links above)!

Please read or watch the following during your rotation blocks (two 2-week blocks):

• Exercise is Medicine

  • Please read this provider guide and review links as time allows to learn important principles on prescribing exercise using a motivational interviewing approach.

• Back

  • Steinberg, Chapter 5, Back, pp139-170 (This reading is optional; pp 139-146 is a succinct summary of anatomy that is clinically applicable; this reading is strongly advised.)

  • Classic article: http://www.aafp.org/afp/1999/1115/p2299.html

  • Acute Low Back Pain (Click here)

  • Chronic Low Back Pain (Click here)

  • Video (Exam): http://www.youtube.com/watch?v=by3cBYXxXew

  • Video (Review): http://www.youtube.com/watch?v=YcivUFHpKo4&feature=relmfu

• Knee

  • Steinberg, Chapter 7, Knee, pp204-240 (This reading is optional; pp 204-214 is a succinct summary of anatomy that is clinically applicable; this reading is advised.)

  • Evaluation of Knee Pain, Pt 1 (Click here)

  • Evaluation of Knee Pain, Pt 2 (Click here)

  • Video (Exam): http://www.youtube.com/watch?v=eRPvoNe9Aho

• Ankle

  • Ankle Injuries: http://www.aafp.org/afp/1998/0201/p474.html

  • Acute Ankle Sprain (pdf): Click here

  • Video (Exam): http://www.youtube.com/watch?v=3uEQVhx4mu8&feature=related

• Foot/Podiatry

  • Top 10 Podiatry Pearls (Click here)

  • Physical & Occupational Therapy

    • Sarwak, Rehabilitation & Therapy, pp175-224 (In FMC; skim only)

    • Readings from TCH OT/PT Outpatient Experience

• C-Spine:

  • Steinberg, Chapter 1, Cervical Spine, pp1-29

• Shoulder

  • Sarwak, Shoulder, pp263-268, pp291-300, pp311-316 (In FMC)

  • The Painful Shoulder, Evaluation: http://www.aafp.org/afp/2000/0515/p3079.html

  • The Painful Shoulder, Acute & Chronic Conditions: http://www.aafp.org/afp/2000/0601/p3291.html

  • Video (Exam): http://www.youtube.com/watch?v=VSrLbzZzJU8

• Elbow

  • Sarwak, Elbow, pp370-376, pp384-388 (In FMC)

  • Evaluation of Elbow Pain in Adults: http://www.aafp.org/afp/2014/0415/p649.html

• Hand & Wrist

  • Hand & Wrist, Pt 1 (Click here)

  • Hand & Wrist, Pt 2 (Click here)

• Pediatric Ortho

  • Steinberg, Chapter 16, Pediatric Ortho, pp381-411

• Concussion Management

  • Evaluation and Management of Concussion, 2012 AFP (Click here) - Pay attention to second impact syndrome, return to play, and guidelines for head imaging. Additional references and resources are below, including an Evernote on concussion and head imaging decision making.

• Preparticipation Sports Physical

  • Preparticipation Physical (AFP 2015) (See Sports Medicine Elective site for more resources)

  • Preparticipation Physical Evaluation (AFP 2021) (This article includes helpful sections on care for Transgender athletes and athletes with disabilities)

• Radiology in Orthopedics

  • Common Orthopedic Fractures, Radiology & Management, Part 1 (Upper Extremity): Learning Module

  • Common Orthopedic Fractures, Radiology & Management, Part 2 (Lower Extremity): Learning Module (NOT YET AVAILABLE)

• POCUS Module 10: MSK Ultrasound (Linked HERE), also noted above in Overview

Ortho Rotation Toolbox (extras that may be helpful to you):

PHYSICAL EXAM REVIEW: Click here for UCSD’s excellent review of various musculoskeletal physical exam areas

RADIOLOGY REVIEW:  At the start of your rotations, you may wish to review radiology tutorials on musculoskeletal xray interpretation found here:  http://radiologymasterclass.co.uk/tutorials/tutorials.html.

SHOULDER & KNEE EXAM GUIDE:  Many residents also find this Shoulder and Knee Exam Guide a helpful reference:  One-pager on Shoulder & Knee Exams. 

MOST BANG FOR BUCK ON SHOULDER EXAM:  See this great little video from JAMA on most important shoulder exam tests for evaluating rotator cuff:  http://jama.jamanetwork.com/multimediaPlayer.aspx?mediaid=5975016# (For full PDF article from JAMA:  The Rational Shoulder Exam, JAMA 2013)

INJECTIONS GUIDE:  From Dr. Holliday's Effective At Every Visit website:  Injections Cheat Sheet

INJECTIONS VIDEOS FROM AAFP (2015):  Contact Dr Collins to borrow this set of videos including shoulder, elbow, hand, knee, foot, and tender point injection teaching.  (Dr Spata's injection book in the FMC is another great resource, if interested.)

CONCUSSION MANAGEMENT:  Overview (AFP 2012); PPT (2017 R3 Presentation); AAN Concussion Guidelines; Evernote on Concussion Management; AAP Concussion Guidelines 2018 (Sports Related)

PREPARTICIPATION SPORTS PHYSICAL:  Preparticipation Physical (AFP 2015)  (See Sports Medicine Elective site for more resources)

AMSSM SIDELINE SPORTS MEDICINE GUIDELINE: AMSSM Sideline Preparation Guide

PEDIATRIC SPORTS MEDICINE POTPORRI:  Medscape Slideshow

OSTEOPATHIC MANIPULATIVE MEDICINE: (Pending)

See the Sports Medicine Elective page for additional resources.

Topic Areas

Each resident will review the topic areas listed above in the readings list during their rotations.  Overall, the curriculum is designed to cover the following major areas per ACGME requirements and ACSM recommendations:

1. Spine:  Cervical Spine, Lower Spine/Back & Hip

2. Lower extremity: Knee, Ankle, Foot

3. Upper extremity: Shoulder, Elbow, Wrist & Hand

4. Pediatric orthopedic problems

5. Sports concussion management

6. Preparticipation sports physical

7. Radiology of Common Upper & Lower Extremity Fractures (also through Radiology rotation)

8. Splinting and Casting (featured in R1 Procedures workshop)

9. Joint Injections (FMC Procedure Clinic and R1 and R2+ block rotations)

10. Pediatric Orthopedics (Intoeing, Limping, Enthesites/Growing Pains) (Annual Thursday Conference didactic)

11. Musculoskeletal ultrasound (POCUS Module 10)

Ortho/Sports Med - Topics to Know Part 1:

1. Evaluation of Ankle Pain

   1. Charcot's Joint

   2. Fractures

   3. Sprains

   4. Osteroarthritis

2. Knee

   1. Complete Exam

   2. Evaluation of knee pain

      1. Osteoarthritis

      2. Menisucs Injury

      3. Anterior knee pain (Chondromalacia patellae)

      4. Ligamentous Injuries/Tears (Anterior and Posterior Cruciate Ligaments)

      5. Bursitis (Pre-patellar and superficial infrapatellar (housemaid knee), anserine bursitis

      6. Tendonitis (patellar, iliotibial band)

      7. Bakers Cyst

   3. Pediatric Knee Pain

      1. Osgood Schlatter

   4. Knee Injection and Aspiration

3. Shoulder

   1. Complete Exam

   2. Evaluation of Shoulder Pain

      1. Osteoarthritis

      2. Impingement Syndromes

      3. Rotator Cuff Syndromes

      4. Rotator Cuff Tears

      5. Bicep Tendonitis and Tears

      6. Acromioclavicular ligamentous injuries (sprains, subluxation, dislocation)

      7. Dislocation of the shoulder

      8. Frozen Shoulder (Adhesive Capsulitis)

   3. Injections

4. Fractures

   1. Initial management

   2. Salter Harris fractures

   3. Buckle fractures

   4. Ottowa rules

   5. Jones fracture

   6. Vertebral Fractures

   7. Clavicular Fractures

5. Leg

   1. Complete Exam

   2. Evaluation of leg pain

      1. Shin Splints

      2. Stress Fracture of the tibia and fibular

      3. Tenosynovitis of the anterior long tendons of the foot

      4. Compartment syndrome

6. In-Toeing Alignment Problems

   1. Gait Evaluation and Alignment Exam

   2. Following conditions:

      1. Metatarsus adductus

      2. Femoral Anteversion

      3. Tibial Torsion