Success Stories

You Don’t Treat The X-Ray, You Treat The Patient

It sounds like an Orthopaedic Surgery truism that is obvious to most of us.

But wait, what I learned in residency at the Cleveland Clinic is often ignored by many of my colleagues. Why you ask? Because patients are so fixated on high tech tests, such as an MRI.

I saw Bill recently, a 39 year old landscaper who was experiencing back and right leg pain after moving a heavy pot. His family doctor ordered an MRI of the spine and it showed a bulging disc. Bill was referred to a specialist.

To many spine surgeons this is an opportunity to do another surgery. MRI, bulging disc, back and leg pain = surgery. Right?

What if I told you 80 – 90% of patients like Bill get better with non-surgical treatment? It’s true, they do.

I treated him with Physical Therapy and guess what? What I learned in residency is still true, no matter what the MRI showed.

Bill improved steadily and is very grateful that I chose to treat him conservatively and not resort to surgery solely on the basis of the MRI result.

I knew I had at least an 80% chance of being correct. I liked the odds.

So did Bill.

What If I Told You, You Can Have A Fracture Without An Injury

MaryAnn is a twenty five year old R.N. who had been experiencing pain in the right foot for more than two months.

She did not recall any injury to her foot that could be a cause. I did learn that she liked to walk two or three miles per day. MaryAnn had taken Advil at times if she was especially uncomfortable, but otherwise had not had any treatment. Two previous exams and one set of x-rays had been unremarkable.

What to do?

  • Live with it
  • Take Advil or Tylenol
  • Get arch supports at the drug store
  • Get new athletic shoes
  • Have foot surgery if suggested
I couldn’t tell her to do any of these, because all had been suggested and she wasn’t sure they would help.

So, I decided to re-group.
  • Really careful exam of the foot and ankle
  • More plain x-rays
  • Some lab work for vitamin D levels
  • A bone scan
Many of you already know the diagnosis. A stress fracture of one of the metatarsal bones.

Stress Fractures can be really hard to diagnose. But, persistence is a virtue.

After diagnosis was made she required the daily use of an ultrasound based bone stimulator applied to the foot for twenty minutes for about three months and a special walking boot.

Thankfully the fracture did heal and the pain went away.

Diagnosis can only be made if you can think of it.

There is more. Orthotics are needed to support the foot ideally. Adjustment of the walking program. Vitamin D supplement for chronically low Vitamin D levels.

Moral – if you don’t know what is wrong don’t tell the patient to learn to live with it!

Carpal Tunnel Syndrome Can Be Hard to Diagnose

I see a lot of patients who have carpal tunnel syndrome. Carpal tunnel can present in a number of different ways.

History and physical exam give the most important information.

I often resort to a nerve and muscle test (EMG-NCT) on the affected side to gain even more information.

But sometimes the test comes back marginally positive or even negative. What to do?

If I am convinced that the person has carpal tunnel syndrome, I will go ahead and do a carpal tunnel release.

While tests are very important they don’t always confirm the diagnosis and you have to depend on your clinical skills to make the right diagnosis to help the patient.

I like to think that this is an example of the art of medicine which will remain a very important part of my practice.

Over the years I have successfully treated many carpal tunnel patients whose symptoms were very atypical.

What If I Told You Tests Are Not Always Right?

Sandra is a 47 year old church secretary that had been having neck, shoulder and arm pain for more than a year. MRI had shown some bulging at one disc level on the same side of her pain.

Sandra was diagnosed as having a cervical disc protrusion and underwent neck surgery elsewhere. She really had not improved much when I saw her. I noted on my exam that her shoulder was somewhat stiff and painful. Further testing showed that she did not have a rotator cuff tear. I diagnosed “frozen shoulder” or adhesive capsulitis the pain from which can also be referred to the neck and the arm.

I then did an outpatient procedure I call exam under anesthesia. With Sandra asleep for a few minutes I gently moved her shoulder separating adhesions to relive stiffness and inflammation.

After a little physical therapy following the procedure the neck, shoulder and arm pain went away.

The point is there is no law against having 2 things wrong. Sandra did have “disc trouble” in her neck which the MRI showed, but that was not the cause of her symptoms.

I’m glad to say she is feeling well at this time.

In this case a careful history and an exam of her shoulder on the same side led to the correct diagnosis and treatment. The MRI showed something abnormal, but it was not the cause of her pain.

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