Treat With Your Head & Not Your Heart
Posted By: Andy Barker
I got caught out this week with a player.
She had sustained a knee injury and it did not look great!
I was actually at the game watching and it was a little unclear to see her exact mechanism of injury.
Possibly a pivot shift, which would be a prime mechanism for an ACL…
Or maybe a fall then a valgus type mechanism that might indicate an MCL injury.
Watching the video footage back after the game, it was still unclear and the player wasn’t quite sure what happened as it occurred so quickly.
To make things even harder, due to pain and apprehension she was almost impossible to assess court-side.
She was braced up and I saw her in the clinic the next day.
Her knee had settled enough to assess better and clinically I diagnosed an MCL injury.
I was happy I could clear her clinically for an ACL injury but she was still very apprehensive and this made MCL valgus testing almost impossible.
I was able to elicit pain, but unable to attain properly if she had any gross instability, as she would just not relax and let me test her!
Mainly for this reason I sent her for an MRI (I also wanted to clear a meniscal injury as she did have some joint line pain, a small joint effusion and either mechanism of injury – valgus or pivot shift, could cause this injury).
Fast-forward 24 hours she had an MRI.
The results were great.
But here was the problem!
The scan came back with a low grade MCL but the rest of the knee looked great.
This was better than expected for sure and clearly the player (and the coach) were overjoyed when I gave them both a call when I received the MRI report.
One thing you always need to remember with imaging of any kind (MRI/US/x-ray) is that a scan gives you an image of anatomy and not function.
In this case the players MRI was good and it showed she had sustained a low level ligament injury to her MCL and that the rest of her knee, including other ligaments ACL, PCL and LCL, menisci and the bony surfaces of the knee were all uninjured.
Her knee was still sore…
And her function was poor.
She was in a brace locked at 30 degrees flexion and using two elbow crutches.
The results of the scan did not change that.
The scan is just part of the puzzle.
After receiving the scan report every part of me wanted to tell her to take the brace off, tell her that there was not too much going on and get cracking with her rehab right away.
But that would be the good news from the MRI clouding my judgement.
It’s me treating with my heart and not with my head.
This is normal.
We all want to be the bearer of good news, right?
But clearly her knee was still sore.
She was struggling to weight-bear, very apprehensive and still in a lot of pain.
Clinically she tested like an MCL.
My head was telling me to then treat her like an MCL.
It was telling me to keep her in the brace, progress her weight-bearing quickly but safely and start to load the knee and lower leg progressively with rehab (firstly in the brace then without).
The head won over the heart and this is what we did.
She is progressing really well and whilst probably won’t make our next game (8 days post injury) I think she will have a great chance of being involved the following weekend (day 13 post injury).
Every part of you wants to help your patients.
That’s why you became a physio…
To help other people and you are in a powerful position to do this, if you get it right.
But you need to state facts and not fiction and always…
Treat with your head and not with your heart.
The New Grad Physio Mentor
PS. These type of scenario’s happen often as a new grad especially when you are receiving referrals or scan results from GP’s or other practitioners.
The key is being able to clinically reason what is going on, taking the referral or scan report and assessing this against your clinical assessment, then making the right call and patient diagnosis.
This can be hard to do if you are seeing injuries that you might not commonly see or have much experience with…
Want to learn how to better clinically reason your patient assessments, treatment technique choice or rehab exercises?