Some years ago, I hurt my right shoulder diving into a pool.  It did not improve with time, so I went to see an orthopedic surgeon who did a careful exam, diagnosed a muscle strain in the rotator cuff, and told me to stay away from activity that caused pain.

As I did not improve, he tried an injection with indifferent results and prescribed physical therapy.  I did this very conscientiously, but still had very limited range of motion.  It was time for an MRI.  

The MRI did not show a tear in the shoulder joint, so surgery was not recommended.  A “strain” is supposed to get better with PT, and I kept doing the prescribed exercises.  I continued to be unable to perform certain motions (such as throwing), however, so the doctor said it was time for surgery.

At surgery, the surgeon found a complete tear in one of the rotator cuff muscles.  He later told me that, while generally very accurate, MRIs occasionally missed important pathology.  He repaired the offending muscle, and I was throwing batting practice for my youth baseball team six months later.

Knee Pain: Garden Variety Arthritis or Something Else?

About four years ago, I developed pain in my right knee.  I was a bit of a runner (“loper” is a better term), and I thought, at my age of 71, arthritis was a good bet.  I tried to ignore it, using anti-inflammatory drugs as needed.  Pain persisted, however, so I consulted an orthopedic surgeon who specialized in knees.

From his exam, he felt my diagnosis was correct, did not do an X-ray, and said I could keep running while managing pain as I had been doing.  I was to return in three weeks if symptoms got worse.  Which they did.  He ordered an X-ray, which revealed the expected findings consistent with a joint that could be a good candidate for arthritis.  There was nothing else of note on the film.

I stopped running, but the pain persisted, so the doctor ordered an MRI, even though he felt it would not show anything more than what we already knew. Wrong. I had a stress fracture of the tibia (the bigger of two bones between the knee and ankle).  The prescription was to lay off high impact activity (i.e., running) until I got better,  Which I did with therapeutic success.

Another Diagnostic Dilemma 

Last year, I hurt my left wrist while breaking a fall after tripping on an uneven sidewalk.  I ignored the pain as long as I thought reasonable, then visited a hand surgeon.  He did a careful exam, and obtained X-Rays that revealed no fracture.  Based on minimal swelling and mild symptoms, he thought I had a mere strain, and gave me a brace, telling me to lay off any activity that caused pain.

I followed this advice without improvement, so the doctor ordered an MRI.  This revealed the fracture that the conventional X-Ray missed. He immobilized the wrist, predicted I would be better in a few weeks, and prescribed physical therapy to insure complete recovery of strength and motion.  Today, I have a hard time remembering which wrist I broke.

Thoughtful, Cost-effective Medicine

In each of the above described situations, some friends felt that my physicians were a trifle glib when evaluating my initial presentation.  They felt they should have been much more aggressive in getting to the diagnoses.  I, on the other hand, thought (and think), they practiced exemplary expectant management.  In each instance, they felt I would get better without the expensive diagnostic tests that only later proved to be necessary.  Critically, they persisted in follow-up until my situation was resolved.  Part of their decision making process was based on their belief that any delay in diagnosis would not compromise the eventual good outcome.  

Head CT Scans in Clinical Practice

Headache is one of the most common complaints in primary care outpatient medicine.  Too often, evaluating doctors order a CT scan of the head upon a patient’s initial visit for this complaint.  There are good reasons to obtain a scan quickly: for instance, patients who state their headache is by far the worst they ever had may have an intracranial bleed that requires immediate intervention.  But CT scans are expensive and expose patients to radiation that may not be necessary.  And most headaches can be characterized safely and accurately with a good history and physical exam.  Follow-up is critical and a scan may be justified if symptoms persist.  This is expectant management, and it is good, cost-effective medicine. 

*NOTE: The diagnostic restraint I am advocating in this post is only appropriate in selected situations.  Physicians must continually weigh a policy of embarking on a diagnostic adventure versus waiting in the expectation that a complaint will improve on its own.

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