The Art of Diagnosis

For some patients, Dr. Edwards would play 'Diagnosis Charades'.

Full confession, I really do not like the word diagnosis. It is a little too limited, definitive, and stodgy for my tastes. I believe that we would be better served just identifying dysfunctional body parts than knowing fancy words that typically just describe symptoms. That saying, understanding symptoms and how they relate to dysfunctional body parts is extremely beneficial when coming up with treatment options. Understanding anatomy, biomechanics,  and physiology can make diagnosing musculo-skeletal injuries so easy it is a wonder why most doctors get it wrong most of the time.

It is important to understand location and type of symptoms to make a proper diagnosis. Location of symptoms does not necessarily indicate location of dysfunction. Many dysfunctional body parts refer symptoms to other parts of the body. Luckily, there are patterns which come is handy for those clever enough to recognize those patterns. The type of symptoms tell a good doctor what kind of structure is dysfunctional.

Embryologically speaking, there are three types of structures: bone, consisting of bones, joints, ligaments, discs, and cartilage; muscle, consisting of muscles, tendons, and organs; and nerve, which encompasses tissues of the brain, spinal cord, cranial nerves, autonomic nerves, nerve roots, and peripheral nerves. Bone symptoms are typically described as a deep dull ache and can refer to other bone-like structures. Muscle is also an ache but feels more like fatigue and soreness. Muscle is more superficial and usually stays within the same structure. Nerve symptoms are more electrical in nature; numbness and tingling, just numbness, burning, shooting, etc. Nerves stay in the network of nerves. Knowing this will get you pretty far.

Consultation is the first step. I ask for location and have the patient describe the symptoms. I also look for the mechanism of injury knowing that some structures are more likely to fail, depending on the stress placed on them, than others. With a good consultation, I have a fairly solid idea of what the problem is.

The second step is to do an exam. Bone structures cannot move themselves. For these tests, I do the movement on the patient checking for instability, pain, and altered movement. When I isolate joint movements, I can narrow down the location of dysfunction. Instability tests will suggest ligament issues (assuming we are not dumb enough to do a stability test on a complete fracture). X-ray is helpful to see fractures and degenerative changes. MRI is helpful to see disc bulges, ligament tears, and pathology. Repetitive movement works great for determining how to reform a bulged disc.

Muscles and tendons move bones. To test a muscle or tendon, resisting the muscle’s movement is an easy way to determine which muscle is injured. Why most doctors do not do this is baffling. Pain with resistance at the end of the muscle is usually tendon related and anywhere else is usually the muscle itself. If the type of pain is described as muscular but cannot be recreated with resisted movement, it could be an organ referring pain. Here again, repetitively resisting movement can really help determine how to help treat the injured structure.

Nerve symptoms require some specialized tests in the form of reflexes and sensation testing. True neurological injuries are very difficult to diagnose and to treat. In addition, any of the above can cause secondary and tertiary issues in other parts of the body, like muscles spasms or nerve pain due to encroachment with a disc herniation, for example.

Finally, one of the best ways to diagnose an issue is to treat the issue and see if it helps. Obviously you cannot do this with everything, but as a chiropractor, I can do this for most injuries. Even a surgeon will tell you that nothing is definitive until they open you up and see it in real life. The point being do not get too caught up with figuring out what something is before trying to treat it. Ruling out conditions is still valuable.

There you have it. Instead of plugging symptoms into WebMD to discover that you have a rare, incurable, terminal illness, just step back and look at the anatomy, physiology, and biomechanics of the body and go from there. Or, see your local chiropractor and let them help you through your issues or point you in the right direction. We spend a tremendous amount of time learning about all aspects of the human body.

 

Tennis Elbow? I Do Not Even Play Tennis!

tennis-elbow-pictureIn a world where we have so much access to information, I find that when it comes to diagnoses, there are some overly-simplified patterns. If there is pain in the foot, it is plantar fascitis, pain down the leg is labeled sciatica, and elbow pain is tennis elbow. Not that these conditions are not common; just not that common. Tennis elbow is particularly over-diagnosed. Pain in the elbow is common. Tennis elbow, however, is specifically pain resulting from injury to the extensor tendons which insert at the lateral epicondyle causing inflammation and dysfunction. Simply put, to be tennis elbow, the pain must be right around the little knob on the outside of the elbow and get worse when trying to extend the wrist with resistance. It is called tennis elbow presumably because repetitive backhand swings in tennis will cause such a condition. Incidentally, pain on the inner knob is known as golfers elbow.

I have found that neither tennis elbow or golfers elbow are more common than just a regular subluxated elbow. As a hinge that rotates and pivots and is made up of three bones and two joints, dysfunction is easy to come by. Often, the radial head will get stuck farther back than it should be. This will cause a strain on the muscles that insert in that area and mimic or create tennis elbow. The good news is that with an adjustment or a few, the condition typically responds quickly. If it is, indeed, tennis elbow, the best thing to do is to make sure the elbow is adjusted and functioning properly, then focus on the tendons with ice, stretching, and myofascial massage or active release. So, the next time somebody complains of tennis elbow, tell them to see their local friendly chiropractor.

 

Your Chiropractor As Your Primary Care Doctor?

The concept of having a primary care physician is to control the cost of patients seeing a specialist directly. Under the primary care model, patients see their family doctor who treats or refers to a specialist. This frees up more expensive specialists from seeing patients directly who may or may not be a candidate for the specialist. All said, even though it does cut costs for insurance and patients, the concept can also help direct a patient to proper and appropriate care. In this way, managed care has it right in theory if maybe not exactly for the right reasons. 
Proper care is predicated upon a primary care doctor being a competent differential diagnostician who can manage the overall case especially if multiple specialists are involved. Unfortunately, the way it stands, most primary care physicians are either not very good at differential diagnosis or they just don’t have the time to do it right. Part of the problem, whether they like it or not, is that they are inundated with too many patients. Too many patients creates an environment of hasty visits and poor communication. In addition, there is pressure from the insurance companies to be more efficient and to save costs often at the expense of proper diagnostic protocols. 
Here is where chiropractors can come in. Chiropractors have learned the art of differential diagnosis, pathology, etc. just as much as our medical colleagues. In addition, chiropractors have more training in musculoskeletal diagnosis, radiology, and nutrition. In my practice, I spend a good amount of time during the initial visit discovering any and all health concerns and what is functioning well with a holistic outlook. In short, most chiropractors if they were interested would make excellent primary care doctors. 
There are some major advantages to using some chiropractors as primary care doctors (not all chiros are interested and some see diagnosing as a dirty word). First, we have a shortage of primary care doctors which really limits access to care (I wonder how much worse it will get if go to socialized medicine). Opening it up to chiropractors could significantly ease the burden. 
Second, chiropractors tend to build stronger relationships with their patients. Chiropractors tend to see patients much more than just when their patients are sick enough to go in. In addition, we put an emphasis on building relationships because we have to in order to grow our practices
Third, chiropractors are actually concerned about patients’ health and not just their sickness. Sure most people come in because of a problem but what is the underlying cause and what else can be prevented? You don’t know unless you ask and in my office, at least, we make it a point to comb through your entire history and do a full exam. 
Fourth, although we cannot prescribe medication, our ability to conservatively treat patients in a cost effective manner is second to no other health profession.  
Just like in anything cooperation is the key. There are still specialized MD’s who will not accept a referral from a chiropractor and, there are chiropractors who act like diagnosing is an evil art form invented by the medical community. Both are part of the reason that chiropractic still struggles with a legitimate identity (another post, altogether). 
I think my patients who know me well use me as their primary care doctor. Usually, the switch happens when they have something come up and they go to their MD. They then casually bring it up to me. I take the time to diagnose and educate and then point them in the right direction for proper care. Sounds like a win win to me. What do you think? 

Does This Frustrate You?

I was talking to a patient the other day about the problems she was having with her feet. The symptoms didn’t seem to be consitent with any musculoskeletal trauma and the presentation was a little vague (generalized pain but in the joint line, kind of achy, hurt at random times, etc.) At the same time, she has also been complaning  that her psoriais is acting up. This sparked a thought in my brain that she may be suffering from psoriatic arthritis. 

I told her to look up some information and also to talk to her MD about it to see if he woul do any follow up testing. She reported back later that when she mentioned it to him he said, without even examining the foot, “I dont’ think it’s that.” To which the patient replied, “What do think it is then?” The doctor said, “I have no idea.” 

WHAT? How can you say it is not something but also say you have no idea what it is? Does this make sense? If it were completely out of the range of possibilites like, “Hey doc my ankle hurts do you think I may have been bitten by a cobra while in bed last night (assuming you don’t live in India)?,” then I could see answering the way he did. But please, give the patient a break! At least tell her why you don’t think it is psoriatic arthritis. Better yet, try diagnosing for real before you rule out something. Frustrating!