Dr. Brian Fullem practices at Elite Sports Podiatry in Clearwater, FL. He ran 14:25 for 5K while at Bucknell University. This is the first in a series of articles by Dr. Fullem, educating us about injury care, injury prevention & other health topics for athletes at all levels of performance.
Dr. George Sheehan, the brilliant author who often captured the essence of running in his writing and was one of the co-founders of the American Academy of Podiatric Sports Medicine stated “Everyone is an athlete. The only difference is that some of us are in training and some are not.”
My simple definition of sports medicine mirrors my idea of the best way to treat every patient, we have a duty to the patient to make a proper diagnosis and treat the cause of the injury and not just the symptoms.
A sports medicine specialist should have the mindset of trying every treatment possible that is medically proven in order to return that athlete to their desired sport and activity level as quickly and safely as possible. The Physician should almost never tell their athletic patients not to work out or in some cases give up their sport of choice without a valid reason or a timetable for future treatments and testing. There should always be several plans laid out, as many times there are multiple potential differential diagnoses at work here.
How do Physicians arrive at that all important diagnosis?
The best start is a thorough history. Patients should leave no stone unturned in relating the course of their injury, since there are always clues that might be a key to putting the puzzle together. It is so important for the Physician to listen to the patient and try not to interrupt. In a study from the University of South Carolina, the medical residents were monitored and on average the Doctor interrupted the patient within 11 seconds and often did not allow the patient to finish their sentences. The average encounter was 11 minutes with patient only speaking for 4 minutes.1
The patient should expect the Doctor to place their hands on the patient to palpate the injured area, check ranges of motion and watch the patient walk and/or run if possible. There is certainly a place for all the testing such as an X-ray, MRI, CT scan, bone scan and Diagnostic Ultrasound. Patient and Doctor alike should be asking themselves this question: Will the new test help make a diagnosis and/or will it change my treatment plan? There are occasions for each type of diagnostic testing but there is not a need to perform diagnostic ultrasounds or even X-rays on every patient that walks in the door. For instance, when it comes to diagnosing an interdigital Neuroma (commonly referred to as a Morton’s Neuroma) the literature strongly supports that clinical diagnosis is equal to Diagnostic Ultrasound and superior to an MRI. A recent paper supported that position and found a squeeze test between forefinger and thumb to be the best test. There is certainly nothing wrong with ordering these tests but they are not always necessary.2
A negative test does not always mean there is nothing wrong. In the past 2 years I have treated 2 runners that had leg pain with negative MRI’s and radiographs from other Doctor’s. They both exhibited stress fracture like symptoms and both tested positive when I ordered a Tri-phasic bone scan, a sometimes forgotten about diagnostic test. Do not be satisfied with a negative X-ray or MRI in the presence of symptoms, very seldom does a problem or injury exist only in the mind of the patient. I can’t recall a single athletic patient that did not want to get better. If the physician has failed to arrive at a diagnosis after several office visits and tests, change your view of the injury, think of what other possible causes exist and never be afraid to ask for another opinion from a different physician.
If one views the advertising for any Podiatrist, Orthopedist, Chiropractor or Physical Therapist, there is a strong possibility that almost every single one states that Sports Medicine is one of their specialties or interests. How many of these medical professionals truly practice sports medicine in a way that has the athletes’ best interests in mind is sometimes another matter. To find a well qualified Sports Medicine Podiatrist go to AAPSM.org, the American Academy of Podiatric Sports Medicine provides training and Podiatrists that demonstrate expertise in sports medicine achieve Fellowship status in the AAPSM.
In my next post we will explore the red flags for the athlete/patient that they might be in the wrong office.
Dr. Fullem serves on the Board of the American Academy of Podiatric Sports Medicine and can be reached at Doctorfullem@gmail.com or at www.DocFullem.com
1 Fam Med. 2001 Jul-Aug;33(7):528-32. Speaking and interruptions during primary care office visits. Rhoades DR1, McFarland KF, Finch WH, Johnson AO.
2 J Foot Ankle Surg. 2014 Nov 26. pii: S1067-2516(14)00450-5. doi: 10.1053/j.jfas.2014.09.021. Diagnostic Accuracy of Clinical Tests for Morton’s Neuroma Compared with Ultrasonography. Mahadevan D1, Venkatesan M2, Bhatt R3, Bhatia M2.