knowing when things are right

Monday, March 11, 2013

The problem with technology in medicine is that it gives patients the false sense of security that if a test is normal, all is well. Never mind that the test may have limitations and that history and physical examination may more accurately reflect the clinical situation. Such is the case with the Chicago Bull’s Derreck Rose and the LA Dodgers’ Zack Greinke. While the tests on their knee and elbow respectively, have come back clean, that does not necessarily mean that all is well in the world.

Let’s start with Mr. Rose and his ACL tear. After successful surgery, he has spent months in physical therapy and rehab to the point where his doctor has decided that he is cleared to play. Still, Mr. Rose is not quite confident in the knee and this is where the athlete and the patient can trump the doctor. While the medical staff can say that the knee has full range of motion and the muscles that support the knee, the quad and hamstring, have return to full strength, they cannot know the exact time when the player trusts the knee to perform. While there can be some hesitancy, the other issue has to do with proprioception, the perception of space where the knee is in relation to the rest of the body and the amount of strength required to keep it there. Trust is an emotion that the player can willfully address, but proprioception is an unconscious reflex. The combination of the two allows the player to perform without hesitancy.

While Bulls’ fans wonder why Adrian Peterson can play football 6 months after ACL surgery and Derrick Rose is still working hard in practice, they need to be reminded that every patient recovers in their own time. Rehabilitation guidelines that take a patient from one step to the next on the road to recovery are just guidelines. Physical therapists are trained to gauge recovery and pushing the patient to the next level until they are ready. However, athletes participating in contact sports are a special case. While a construction worker can control their work environment, Mr. Rose has a constantly evolving workspace, where other players can force unexpected body movement and landing zones. Proprioception needs to be functioning to prevent another injury.

Mr. Greinke’s elbow is another story.  With $147 million dollar contract at stake, the Dodger management wants to make certain that there are no structural issues within and surrounding his elbow joint. For anybody else, a physical examination may be perfectly adequate to sort out minor injury from major disaster, but pitchers are not normal people. They place enough torque on their muscles and joints that a small twinge may be the early signal of a mechanical and anatomic flaw. However, it is once again a problem of proprioception. Greinke’s elbow doesn’t feel right and that sensation of twinge may cause changes in his pitching motion. Or was a subtle change of his pitching motion enough to cause a twinge of pain. The MRI may be normal, but the pain is still there.

Too often, patients demand blood tests and x-rays because having a tangible result is more satisfying than the doctor’s proclamation that he thinks all is well. The word “think” gets in the way of the message. Patients would much prefer the word “know”. Most medical people have enough experience not to be 100% sure of anything. The body has a way of reminding us that it can be devious in how it can disguise injury and illness. The same can be said for testing. Occult fractures, those that are not initially seen on an x-ray, plague physicians and patients who are subsequently found to have a broken bone. Normal white blood cell counts in the face of major infection are a reminder that it is how the patient looks in person that matters, not how they appear on paper.

Rose and Greinke may appear well on paper but that doesn’t mean that they are ready to perform at their accustomed level of athletic prowess. As with eve3rything else in medicine, if you listen hard enough, the patient will tell you what’s wrong…and what’s right.

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