The patient who every other health professional can’t fix…

Have you ever had a patient present to your clinic with longstanding musculoskeletal symptoms? Did they tell you that they have seen a number of other health professionals who ‘couldn’t help them’ or ‘didn’t know what they were doing’? After receiving your world-class treatment did their symptoms remain relatively unchanged or even slightly worse?

Chapter 41 in Clinical Sports Medicine (CSM4ed) tackles this patient presentation head on. Management strategies, case scenarios and clinical pearls are presented in a unique format. The chapter aims to guide the clinician towards the best course of assessment and management in a systematic and focused manner. The chapter is co-authored by Dr Jim Macintyre from the Centre of Orthopaedic and Rehabilitation Excellence in West Jordan, Utah and Jonas Kwiatkowski from the Centre for Hip Health and Mobility, Vancouver, Canada who both provide valuable insights and clinical experience. Diagnosis and management plans are discussed separately. The format provides an opportunity for both novice and experienced clinicians to reflect on their assessment and management of these types of patients.

Were previous diagnoses correct?

For patients who present to the clinic with a long or complicated history, additional time should be scheduled to allow the clinician to determine the most accurate working diagnosis. If this need only becomes apparent once the patient is behind closed doors and extra time is not available, an explanation that more assessment will be required will acknowledge the complexity of the presentation.

The table titled ‘Some conditions that are not what they appear at first’ within Chapter 41 provides examples of commonly misdiagnosed conditions. Examples include tennis elbow symptoms that originate in a cervical disc, persistent hamstring strains that are secondary to abnormal neural mechanosensitivity, and chronic compartment syndrome that may be misdiagnosed as shin splints. Considering these examples it can be seen how easily a patient can receive inadequate treatment and not improve. If a patient is not improving, careful re-examination of key objective findings and a review of their management plan is essential. Referred pain and pain of systemic origin are other commonly missed causes of seemingly straight forward musculoskeletal pain and can be made apparent with a detailed re-examination.

Patients with longstanding symptoms often present with a number of previous investigations and results. Chapter 41 discusses the role and issues related to functional imaging and interpretation of results. For example, were the correct investigations and tests ordered in the first place and were existing scans and test results interpreted correctly? Reviewing previous investigations without relying on reported results can uncover previously missed pathologies, without the need for further investigations. Developing a close working relationship with a radiologist can provide the clinician with a valuable second opinion.

Were previous management plans appropriate?

It is important to review past treatments critically. What treatment does the patient perceive as being helpful? Do any outcome measures support your patient’s perception? Some presentations may respond well to treatment in terms of short-term clinical outcomes but re-occur or prevent the patient from returning to sport. Often biomechanical issues or training errors can be a part of the cause of persistent symptoms. Chapter 41 features a table that highlights such biomechanical issues. For example, persistent shoulder pain in a swimmer could be the result of a lack of trunk rotation. Ongoing patellofemoral symptoms could be related to more proximal issues such as hip weakness. It is therefore important to keep biomechanical and extrinsic risk factors in mind as not to miss any important primary causes for the presenting complaint.

Common features of management plans for musculoskeletal pain are exercise programs. It is important to review these exercise programs and how they are being performed. Is the patient performing the exercises correctly (or at all)? Are the exercises appropriate for the current stage of their condition (e.g. acute versus subacute, irritable versus non-irritable). This is an opportunity to evaluate the patients understanding of the purpose and method of their exercise program. It is an opportunity for the clinician to assess whether the exercises are being performed with the correct technique and with an appropriate dosage. Collectively, the patient and clinician can then determine whether the exercise program is effective or whether it is directly or indirectly aggravating the symptoms.

If the information in Chapter 41 isn’t enough, remember that each regional chapter of the textbook provides a list of differential diagnoses which will aid lateral thinking into the often difficult presentation of the patient with longstanding symptoms.

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