Why Doctors Misdiagnose Runners | DOC

Why doctors misdiagnose runners

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Today on the Doc On The Run podcast we’re talking about why doctors misdiagnose runners.

Misdiagnosis

All I do is talk to runners who are injured and want to run and ninety nine percent of the time when a runner calls me for advice is because they aren’t getting better and they want a second opinion.

Well much of the time the runner has been misdiagnosed. If you don’t have the right diagnosis, you will be doing the right treatment for the wrong problem and you’re not going to get better.

In this session we’re going to talk about the top six reasons doctors come up with the wrong diagnosis when you’re injured.

The very first reason the doctor seem to come up with the wrong diagnosis when I see somebody who’s been running, training, did a  marathon, did an ultramarathon. They get injured and they go see a doctor. The doctor makes the wrong call and says that you actually have a condition that’s not really a thing that’s bothering you.

1. Your running injury sounds typical

What do I mean about that? Well if you’re running injury sounds typical then it misleads the doctor. Whether you know it or not you think that you come in and you tell the doctor your story and your doctor looks for their problem and that the story that you give, the history, you always think that’s a precursor to the doctor figuring out whether or not you have a specific running injury.

But the truth is the history is the most important component of a runner’s diagnosis. So if you know the whole story behind what happened to you and that story fits closely with something like a metatarsal stress fracture for example if you have pain on the top of your foot and you go in and say “Okay I have this pain on the top my foot. I was running. I was training a lot. I was doing okay then when I did a fifty mile trail race or when I did like my last long run I started getting this aching pain in the top of my foot”, the doctor almost certainly going to start thinking that the number one thing on the list is a stress fracture.

That list is what doctors call the differential diagnosis and that’s just really a term for the list of the things that are probably going to be wrong with you based on your story. So when you tell your story, the doctor comes up for the list of probable causes of your injury and then basically the physical exam that they do and actually start poking and prodding on your foot, well that’s just part of the process of ruling out some of the things on the list.

But the problem is, is that stress fractures are really common and really typical. So if you’re ramping up, your increasing your mileage, you get this aching pain in your foot and it seems to correlate directly with that increase in mileage, most likely something for sure it’s a metatarsal stress fracture. It’s not the only thing, it’s just the most common thing. Then if your doctor examined things too closely, they may just assume you have a stress fracture and tell you to stay off of it. But if it’s mild and it’s just an early form of a stress fracture they may just tell you to slow down, quit running. But that’s just because your condition sounds.

It’s not really stress fracture all the time and of course I see runners who’ve been told they have a stress fracture have completely different and that happens for all different kinds of conditions. You might have been told you have neuroma but you have a plantar plate sprain or you might have been told that you have a plantar plate sprain and it’s a neuroma.

But the reason for that most of the time is because the doctor hears what hat sounds like a convincing story that fits very closely with what we expect for that particular condition.

You have to remember when you go in that if your story sounds typically like a cut and dry that sounds just like a stress fracture, it’s probably stress fracture but that’s not always the case. But that’s reason number one. So you have to go in knowing that there can be a lot of different conditions and if you don’t respond to that treatment of course and you probably been misdiagnosed and maybe it’s because your story just sound so much like the diagnosis you were given.

2. You don’t get a chance to give the full story

The reason number two is that you don’t get a chance to tell the full story. So again when you go in and you start talking to the doctor and the doctor listens to you and thinks it’s probably stress fracture and then says “Okay well I know what’s going on. You’re a runner. You guys are nuts, you run too much. A marathon is crazy. Why would you want to do that anyway? Why don’t you ride a bike instead?” and then they just cut you off and that point of course they have made several conclusions about you.

Number one, they think you’re nuts. Number two, they think you shouldn’t be running. Number three, they think you’re going to want to ride a bicycle and swim as much as you want to run which of course is not true. But they don’t understand you. They don’t understand you’re a runner.

The doctor cut you off, doesn’t hear whole story, they’ve already decided also that based on the little part of your story that you gave them that you have a stress fracture or plantar fasciitis or some other problem. The deal is that you have to tell your full story then it’s not really that probable that it would just be a stress fracture unless something happened. But then you start telling them “Okay well I actually landed on a shard rock when I was running downhill”, well then it’s probably going to be something difference. It’s probably not going to be the same conclusion the doctor we come to.

You have to finish your story and if you’re doctor doesn’t hear your whole story sometimes they’ll come to the wrong conclusion just based on these little bits of your story that they think or the most relevant. You got to have a chance to tell the whole story.

3. Your foot hurts too much the day of your doctor visit

The reason number three is actually a little confusing to the patient sometimes. The reason number three is that your foot actually hurts too much the day you go and see the doctor. So if your foot hurts too much the day of your doctor visit you can confuse the doctor believe it or not.

An ankle sprain is probably the best example of this. You’re running down a trail and you just hit a rock or slipped or something and you roll your ankle. You roll your ankle, it hurts, you limp through the rest of your run and you get home it swells up like a balloon later that day and you can barely run on it.

So you go to the doctor and your doctor looks at it and pushes on it. Well the first thing to do is try to figure out whether or not you broke anything because it does happen. You can break your ankle if you roll it too hard and if you do that then obviously the treatment is different than if you just sprained your ankle.

The first thing a doctor’s going to do is try to check and see whether you might have a broken bone. There’s a specific set of rules that we all follow to determine whether or not you might need X-rays when you sprained your ankle. They’re called “The Ottawa Ankle Rules” but the details are not important. The important part is that one of the components of the rule for example is if you push on the fibula or the outside ankle bone on the side of your foot and it causes pain then you should have ankle X-rays to see whether or not there’s a broken bone.

But here’s the point of this is that if it hurts so much that your whole ankle is swollen, well the truth is because you have so much swelling in the soft tissue around those ligaments on the outside of your ankle that it all hurts and just because you push on that bone and it’s swollen in the soft tissue over the bone hurts, it doesn’t mean you need X-rays. It just means you have soft tissue swelling that really is distended, you’re stretching the nerve fibers in the skin and then when you’re pushing on it, it hurts.

In this circumstance you may have ripped one ligament in your ankle and sprained it really badly. But you haven’t broken your fibula. You haven’t broken the lateral process of the talus. You haven’t broken your heel bone. You haven’t broken the neck of your talus. If you push on each of those structures individually, it’s still going to hurt because the doctor’s pushing through the soft tissue to the bone and when you squeeze the distended swollen tissue, the soft tissue in between the skin and the bone, it hurts. So if you have a lot of pain and you can get misdiagnosed.

The most memorable cases for me was I saw a gut one time. He was an ultramarathoner and he actually just won an ultramarathon. He had gone to the UCS clinic which is like one of the most prestigious medical institutions in the world. He went to the running institute there, the run clinic at the university to get an assessment. It’s a whole team of people where they’ve got all different kinds of practitioners who look at patients and try to figure out from the standpoint of a podiatrist and a physical therapist and all these different specialists like what they really think might be going on with you.

Well deal is he went in and when they evaluated to him it was right after his race and he hurt himself. He had an issue. The problem is after race like that you have so much swelling and that it can hurt when you on push everything and there’s so much inflammation in the soft tissues on the MRI that they basically looked at it. They kind of poked and prodded. But everything was sore and then based on the MRI, they diagnosed him with one problem that was not his problem at all.

He just have lots of inflammation everywhere in the soft tissues and in the bones and everything else because he just won a trail race along with that. If you run fifty miles and you run hard, you’re going to have swelling. You’re going to have inflammation within the bones. You’re going to have inflammations around the soft tissues. If you get MRI it’s completely misleading.

The reason it’s memorable to me is I listened to his story, I looked at his video clips that he had of him running to show his gait style, where he pronates, when he pronates and based on all of that stuff I could tell for sure. I said “Look this is your problem. This is all that’s wrong with you that other thing is not the problem at all and this is what you need to do to fix it” and he actually got a little bit upset and he was really kind of mad that they had made the wrong call when he went to this clinic where they’re supposedly all these experts and said look man a fairness.

So if you if you have an injury and you’re thinking about going to see a doctor but you push on your foot and it hurts in all kinds of different places, then you’re going to mislead you doctor too. If you want to simplify that, you can basically just do something like soaking your foot in ice water, doing a contrast bath routine, just applying some ice, elevating, using compression socks, do something to reduce the inflammation before you go in to the doctor for that visit. Because if you have tons of inflammation, tons of swelling and tons of pain, your doctor going to have a hard time figuring out what the one problem is that is really bothering you. And we most runners, one problem. It’s one thing. It’s one injured structure. It’s not everything in your foot or ankle and you don’t need to treat it like it’s everything in your foot and ankle.

So try to get some of the inflammation in so you won’t have that problem that will lead to a misdiagnosis.

4. Your foot doesn’t hurt enough the day of your doctor visit

Now the next problem is that your foot doesn’t actually hurt enough when you go in to the doctor.

When I was graduating from medical school I actually bought a Nissan Xterra. I love that car. I always wanted one of those and I was actually really excited to have it. My bike would fit in it and I can take my climbing gear in it. It is comfortable. It was an awesome car for me at the time and I’ll tell you they drove me bananas.

Every time I drive on a bumpy road out there and there is this ticking noise because the seal in the window which sort of like squeak right by my head and it drove me bananas. I took it into the shop like half a dozen times. Could not find a noise, could not reproduce the noise. One of mechanics actually drove it himself like he took it home and stuff for several days to drive it all the time to see if it’s like the temperature change that did it. They could never figure it out. And when I sold that car I actually remember the guy that drove away with it, the first thought was I’ll never have to hear that noise again.

So the point here is that sometimes it’s hard to diagnose subtle things. If you’ve had an injury that’s kind of been nagging and it kind of comes and goes and it really pops up when you do races or it really kind of pops up again we’re doing your speed workout or long run. But then it subsides and you can continue to train. Those subtle injuries are sometimes difficult to diagnose.

The reason for that is that the main thing is a doctor listens to your story and tries to figure out what’s going on. Once they hear your story they kind of come up with this list of things that might be which we call the differential diagnosis and then after we have our differential or our list, we start poking and prodding on your foot, checking for muscle strength, checking tendons, checking to see what hurts when we mess with your foot. And then we try to make a conclusion about was really wrong with you.

So if we push on a structure and it doesn’t hurt, we assume there’s nothing wrong with it. So that’s the problem is if you really have a subtle injury and it’s not really bothering you the doctor might push around and then they say “I don’t really know. I don’t see anything wrong”. The same is how the mechanic couldn’t figure out was wrong with the door ceiling of my car.

If that’s the case, if you have this really subtle thing if you can push on your foot and you know where it’s sore, well that’s not a problem. That’s going to be easy but if it’s been several days since you’ve been running and your pain is really gone away and you pushed around your foot and you yourself can’t push on that spot and find something that really reproduces your symptoms and causes the same kind of pain when you run then it may be difficult for the doctor.

In that case what you can do is you can go out maybe before you see the doctor and do a short run. Do it the day before or the morning of the appointment or something. But if you know that running just like two or three miles will make it a little bit sore and you do that the day before or the day of your appointment then it may make that subtle injury kind of flare up just a tiny bit. Not enough to do some damage but maybe to make it flare it just enough that the doctor will have an easier time finding the one structure that’s really messing with you and causing your pain because you’ve got to get the right diagnosis.

5. The doctor doesn’t examine you closely enough

This one to me is the only one, the only reason on the list that is really totally one hundred percent inexcusable. I just don’t get it. I do second opinion with people all the time where I will see the patient, the patient will say they saw someone. I know who the person is, I know they’re reputable. I know that they’re qualified and everything else and they will say to me “The doctor never looked at my foot. I actually never even took my shoes off”.

They don’t even look at you so that is really a problem and I think it’s inexcusable. So you’re going to the doctor to get expertise. You’re going to get somebody you can listen your story and come up with the most probable thing based on your story and you’re getting someone who has a lot of knowledgeable experience and training at looking at your foot, pushing around, testing things, trying to figure out what the real problem is based on the physical exam.

That is one reason that I think when you go to the doctor, if you’re there and you have a problem with your foot and your doctor doesn’t look at your foot, you should stop the doctor and tell them “Are you going to look at my foot to make sure, absolutely sure that it’s not something else?” and even when I do consultations with runners on the web, we have a web camera where we meet virtually through a virtual doctor visit. I’ll have them turn the camera to look at their foot and if lighting’s terrible or their camera is terrible for something that I basically have them push around, I ask them tons of questions and them start pushing on things individually and when we find the thing that hurts I say “Okay I want you to put your finger on it, I want you to push on it and hold your finger there and take a picture with your phone and send it to me so I can see exactly where that is”.

So it’s inexcusable when you’re in the same room with a doctor and they don’t even bother. That’s one of the worst ones I think but you need to be aware that does happen sometimes and even if your doctor seems confident don’t take that is an okay thing.

6. Your doctor is in a rush

I’m sure that every single person listening to this is having an experience when they went in to see a doctor, the doctor was in a rush and they got the wrong diagnosis.

I’ll tell you my personal horror story with that and this is about as bad as it gets. I used to race motorcycles professionally and toward the end of that I was actually in college. My intention was to go to medical school and I was very busy. It was doing two degrees. I was doing independent research on organic chemistry. I was also working. I have always taken an overload of classes.

I had this injury where I completely ripped my knee apart. I needed a reconstruction because I tore my ACL, PCL and my medial collateral ligament. A lot of damage, they had to rebuild it. The problem is that my ACL actually perforated impartially but my PCL was completely torn. That’s unusual but I had an unusual injury.

Again this comes back to this thing about what’s common and doctors make a misdiagnosis. So I went to see a guy, a great surgeon, taught at the University. He was nice. He was qualified. All the right stuff, had all the right credentials. I go and see him and he looks at me and he heard the story, looked at my knees. He examined me and he said “Yes you tire your PCL and we’re going to have to fix that. We’re going to take a graft. We will take it out of your patellar tendon. We’ll make a new graft for that. We will drill some holes through your fibula or through your femur and through your tibula and we will anchor it in there. We will recreate that ligament for you. But Tim’s going to come and explain it to you”.  I said “Okay great! No Problem” and he left the room and Tim the physician’s assistant came in and said “Okay we need to schedule you for surgery”.

I said “I got class now but semester’s almost done. What’s recovery like?” Tim says, “Well it’s really not that bad. We do this all the time. Basically with these surgeries, we’ll put in a graft and you will be in a knee brace and we will unlock it in a day or two and you should be on crutches for a day and then you’ll have a knee brace but you will be able on it so you will be able to get around and it shouldn’t be too bad. Then take some time to recover before doing sports and stuff. But it’s a fairly quick return to activity” and said “Okay well my last final is on like Wednesday or something so I guess I could do it like that Thursday or Friday and then that’ll give me like four days before I have to go back to class on Monday before the summer session starts”.

So we scheduled it. Everything’s good right? So I go to the operating room and they do surgery. I wake up and the doctor looks at me and he says, “Okay everything went great” We’re able to do this and that and so on and gives me details of the procedure. He says “You’ll need to be off of your feet completely on crutches for six to eight weeks. You will need to be immobilized for two weeks at the outset

After two weeks we will take your stitches out and then we’ll start moving your knee. To make things worse he said, “You basically need to be in bed for the next one to two weeks to let it heal” and I said “What do you talking about? Tim told me this would be like two days. I have a class on Monday and I have to go to work next week and I’m going to be standing the entire day at work after I’m in class” and he said “Well you won’t be able to do that. You just have to not go to work and you’ll have to have somebody help you out around the house” and I was just like “You’re confused like I’m working my way through school and that’s not possible”.

So to make a long story short I found out what happened was Tim thought it was an ACL reconstruction which is very common. I had a PCL reconstruction which is completely and totally different and not very common at all. So through that very small miscommunication I ended up with a really difficult situation because I had to go to class, I’m on crutches like two miles across campus to the classes I had to go to from the parking lot and then on top of that because I was on crutches and had such early activity, I got a blood clot in my leg and wind up with a huge complication and was back in the hospital.

This is not a good thing and it happened all because the doctor and his assistant were both in a rush. So when you have something like what seems like plantar fasciitis and the doctors in a rush, the doctor gave you the information for plantar fasciitis and then the assistant came and explained what to do about it. And even doing all that stuff religiously and you’re not improving and you’re confused. Well that’s because you have the misdiagnosis based on the fact that the doctor was in rush. The doctor’s in a hurry. He didn’t really figured out was wrong with you. It sounded like something common and then he sent you on the way with the wrong instructions because they got the wrong diagnosis.

So that’s the thing. You need to make sure that these things happen. You need to understand that they happen and you make sure that it doesn’t happen to you above all else. So whenever you’re going to the doctor make sure that you give them the full story. Make sure that you slow him down and give them the rest of the story. Even if it seems like they’ve already switched on to that whole like I’ve already made a decision process and make sure they look at you, examine you and they know where it really hurts on your foot so that you don’t get a misdiagnosis. That’s a crucial part.

Just remember when you go into the doctor you need to get your questions answered. You need to not let them rush you along and you need to make sure you get the right diagnosis. So if you go in and you get the right treatment for the right problem, you’re going to get better. If you’ve been misdiagnosed, you’re not going to get better. So if you’ve been diagnosed and you like the doctor, you trust the doctor but you’re not getting better you only have a couple of options either you see somebody else, get a second opinion or go back to the doctor, call the doctor’s office and just say “Look I’m doing all this stuff. I’m really doing it and I’m concerned that I don’t have the right diagnosis because I’m not getting better at all. I’m not improving.”

It’s totally fair to do that. So you have to make sure you stay on track. Remember if you get a misdiagnosis, you’re not going to get back to running because you’re just not going to get better when you’re doing the wrong treatment because you have a completely different problem.

If you have a question that you would like answered as a future addition of the Doc On The Run Podcast, send it to me PodcastQuestion@docontherun.com. And then make sure you join me for the next edition of the Doc On The Run Podcast!

Dr. Christopher Segler is a podiatrist and ankle surgeon who has won an award for his research on diagnosing subtle fractures involving the ankle that are often initially thought to be only ankle sprains. He believes that it is important to see the very best ankle sprain doctor in San Francisco that you can find. Fortunately, San Francisco has many of the best ankle sprain specialists in the United States practicing right here in the Bay Area. He offers house calls for those with ankle injuries who have a tough time getting to a podiatry office. You can reach him directly at (415) 308-0833.

But if you are still confused and think you need the help of an expert, a “Virtual Doctor Visit” is the solution. He has been “meeting” with runners all over the world and providing just that sort of clarity through online consultations for years. He can discuss your injury, get the answers you need and explain what you REALLY need to do to keep running and heal as fast as possible.

You can arrange a Virtual Doctor Visit with a true expert on running injuries. Right from the comfort of your own home you can meet online with the doctor, discuss your running history, talk about your running injury and figure out a customized recovery plan that will help you heal the running injury so you can get back to running as quickly as possible.

Book your Virtual Doctor Visit with Doc On The Run now!