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Order Wisely: Hip and Shoulder Pain

Hip pain and shoulder pain are two of the eight priority clinical areas designated by the Protecting Access to Medicare ACT (PAMA), which require emergency medicine and ambulatory care providers to consult appropriate use criteria (AUC) delivered by a Centers for Medicare and Medicaid Services (CMS) approved clinical decision support mechanism (CDSM) in the electronic medical record (EMR) when ordering advanced imaging (CT, MRI, nuclear medicine).

The aim of Johns Hopkins-created AUC is to facilitate best practices and work toward reducing the prior authorization burden for ordering providers by leveraging the CDSM to guide both patient selection and ordering of the appropriate advanced imaging test.

These AUC focus on common indications in the ambulatory setting:

They were created through collaboration of orthopaedic surgery specialists, radiologists and informationists from a large academic center and multiple literature reviews from 1990 to the present.

icon of a painful hip

Hip Pain and Suspected Labral Tear, FAI or Ischiofemoral Impingement

Diagnostic Test Appropriate Use Rules

  1. Hip radiographs should be performed before MRI (ideally with modified Dunn)
  2. MRI is highly effective for diagnosing ischiofemoral impingement
  3. MRA is highly effective for diagnosing labral pathology and cartilage lesion
  4. Imaging with 3T MR is better than 1.5T MR for evaluating labral and chondral pathology
  5. Consider diagnostic injection for suspected FAI, especially for low sensitivity, low prevalence situations
  6. Diagnostic arthroscopy may still have a role in the absence of MRI diagnosis for hip pathology 

MRI Medical Necessity Rules

In addition to having groin or buttock pain, patients must be <50 years of age and have two of the following indicators:

Radiographic indicators
  1. Absence of joint space narrowing
  2. Cam or pincer
  3. Crossover sign or ischial spine sign
  4. Os acetabulae
Clinical indicators
  1. Pain at the end of hip range of motion
  2. Reproducible groin pain on hip flexion/adduction/internal rotation
  3. “Positive” response to intra-articular injection
  4. Prior hip arthroscopy or open hip procedure

MRI Appropriate Use Criteria for Labral Tear

 
Recent X-ray and at least two of the following:
  • Hip or groin pain
  • Giving way by history
  • Clicking
  • Pain with ROM
  • Limited ROM

If above criteria are met, order: MRI WO Contrast (Left versus Right versus Bilateral)

MRI Appropriate Use Criteria for Femoroacetabular Impingement

 
Nondiagnostic x-ray and at least two of the following:
  • Hip or groin pain
  • Giving way by history
  • Clicking
  • Pain with ROM
  • Limited ROM
  • Positive impingement test

If above criteria are met, order: MRI WO Contrast (Left versus Right versus Bilateral)

hip pain icon

Shoulder Pain & Suspected Rotator Cuff Tear or SLAP Lesion

Diagnostic Test Appropriate Use Rules

  1. Radiographs should be performed as the initial imaging test for shoulder pain. A range of conditions can be identified and subsequently treated (e.g., calcific tendinosis).

  2. For suspected rotator cuff tears, US and MRI are equivalent. Although US is less expensive, it is highly operator dependent.

  3. MRI is superior for looking at intra-articular pathology, such as labral tears.

  4. MRI and MRA are similar in efficacy, but a few studies suggest higher sensitivity and specificity in identifying intra-articular pathology with MRA, such as labral tear.

MRI Medical Necessity Rules

In addition to pain, patients must have two of the following clinical indicators:

  1. Traumatic event by history or overuse syndrome (e.g., pitcher)
  2. History of limited function or described weakness
  3. Physical exam finding of shoulder tenderness
  4. Painful or limited motion
  5. Weakness on muscle testing
  6. Clicking or popping perceived by patient or on physical exam during rotation or shoulder elevation
  7. Pain with manual shoulder elevation
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