Did you feel a pop?
It is a simple question that we rattle off to complete our musculoskeletal history. The answer may or may not give higher suspicion for a diagnosis of tear over sprains.
But have you — the provider — ever felt a pop?
Like any good physiatrist, I try to fill my extracurricular time with physical activity. This inevitably led to the formation of a residency street hockey team.
Ten minutes into our semifinal game, the score was tied.
After a multi-month hiatus due to a plantar fasciitis flare, I was back on the rink and streaking towards the goalie on a breakaway. As I ran, I planned my “celly” (aka what I would do to celebrate after I danced around the goalie and scored a top shelf shot.
Call, injuries, and holiday obligations had left us with minimal substitutions, and as the team’s creator and captain, I was feeling the pressure of performance.
Then — pop!
A jolt of pain shot from the sole of my foot as my body collapsed to the ground.
Not my best “celly.”
A plantar fascia rupture was confirmed on ultrasound the following morning, as my classmate/teammates hovered in the dark around the screen signifying the end of my season.
Given our field, as I crutched about clinic garnering sympathy from both patients and providers alike, I was also peppered with medical advice.
“No weight-bearing for two weeks.”
“Actually, studies suggest up to three.”
“Those crutches need to be raised up a bit.”
“Maybe, if you want an Erb’s palsy.”
“Did you get an X-ray?”
More than half of the physicians I encountered suggested I obtain further imaging, despite the textbook mechanism of my injury.
If “acute plantar fasciitis that returns to play too quickly without stretching and feels a pop at the insertion” isn’t enough of a home run, then how about pain over calcaneal insertion? What about coupled with fiber discontinuity on ultrasound and surrounding edema?
History and physical, the importance of which we hammer into every medical student who comes through our hallowed halls, often falls by the wayside in modern medicine.
Ultrasound, X-ray, MRI is where we hang our hats.
Office time is limited and precious. We are over-encumbered by inefficient electronic medical records, pressured by RVUs and terrified of missing a Lisfranc fracture. Subsequently, histories are brief and physical exams focused.
Sometimes, further testing may not be warranted, and the diagnosis will pop out at you.
Lindsey Migliore is a physiatrist and can be reached on Twitter @DrMigliore.
Image credit: Shutterstock.com