Lessons from a second opinion: Part I
A client of mine, I’ll call him Chris, had been experiencing some pain on the outside of his left ankle for a couple of months. Based on our conversations and his abilities, his pain level seemed to be at about a 3 or 4 out of 10 most days. He was still walking, occasionally running, and strength training with caution. Over time, it didn’t get worse but it wasn’t getting better, so he decided to get it checked out.
A little background here. Chris is semi-retired and absolutely loves physical activity. He is always committed and enthusiastic to move, and whether it be our sessions, pilates, or classes with The MOB, his mental and physical health depend heavily on his ability to be physically engaged on a daily basis. He also travels internationally a couple times a year on vacation which requires a degree of stamina and fitness for someone of his age.
So, Chris goes to the orthopedist and gets an MRI which shows a tear in one of the tendons around his ankle. Chris updated me via text with news from the appointment: he was in a boot for six weeks, only upper body exercise allowed with no running and limited walking (or an exercise bike). Physical therapy would only possibly be introduced after the boot came off, and surgery would be necessary if the tendon didn’t heal in the boot. I tried calling Chris to better understand the situation, but he was so upset and in shock he didn’t want to speak.
Chris thankfully decided to get a second opinion. Orthopedist #2 (surgeon actually) took him out of the boot, said he can walk and exercise as long as he doesn’t jump or twist the ankle, and he should start physical therapy as soon as possible. Chris was enormously relieved. He’s been continuing his physical activity with caution, has begun physical therapy, and is hopeful.
So what happened here? How could the prognosis be so wildly different for the same issue? Here are my thoughts:
Failure to treat a whole person: Doc #1 failed to weigh the costs of his planned protocol. Science gives us a certain amount of information, never enough. And the health care professional has a duty to provide options as well as an opportunity-cost analysis for each option. The opportunity-cost is largely dependent on the individual. Did the orthopedist ask Chris what his daily activity is like? Did he ask him about the functionality of his foot? Did he assess his pain levels? Did he allow space for Chris to share that he’s traveling in two months and wants to be fit for the journey? I don’t know what conversation they had, but I can assure you, doc #1 was assessing Chris’s foot independently of Chris the person. The opportunity of putting Chris in a boot was that maybe it would have time to do some healing with complete rest for 6 weeks. Two mega costs that were not considered: Chris is in his late 70’s which means muscle mass is lost at an alarming rate when the body is not consistently loaded. The subsequent atrophy in the leg from 6 weeks in a boot and other musculature affected by lack of exercise would be remarkably difficult to re-gain. This is a massive cost when considering the prevalence of falls, disability, and deaths resulting from frailty and sarcopenia in older adults. The second biggest cost is Chris’s mental health. Chris was devastated with the news of the boot. One of Chris’s biggest joys, hobbies, and sources of energy in his life was taken from him without second thought, with no real alternatives and no uplifting prognosis. Which leads to the second point.
Little hope: There is always hope with musculoskeletal injuries. There is always healing potential, there is always adaptation happening, and there is always room for a resilient mindset. While I wasn’t there in the room where the conversation took place, Chris’s despondence was palpable and a direct result of the information he’d been give and how it was presented to him.
Outdated clinical practice:
Assessing pain levels: the orthopedist’s decision to place Chris in a boot for 6 weeks was actually shocking to me. Chris’s pain level was never excruciating, not even excessively painful. Often we would have a session and his symptoms did not change during or even after running on his foot. When pain levels are low and consistent, it’s not only safe to move the affected area, but highly encouraged for healing. Immobilization is generally reserved for acute injuries, aggressive tears, high pain levels, or excessive inflammation. While Chris’s affected foot is slightly swollen and may benefit from some immobilization, it probably doesn’t warrant a 6 week boot with counterproductive consequences of muscular atrophy in the long term.
Loading for healing: Soft tissue and bone respond to loading — placing weight on the affected area promotes healing by “teaching” the cells in the affected area how to repair and reconstruct the area based on the demands that are being placed on it. Immobilization may reduce inflammation, but it will not rehab the injury in a way that restores its functional capabilities before the injury.
PT: Physical Therapy is considered the standard first-line-of-treatment clinical practice guideline for soft tissue injury. Maybe doc #1 interpreted a very large tear on the MRI which would render immediate PT unsafe? A tear of that degree would be called a massive tear or a rupture. Neither of those were the diagnosis. Especially with Chris’s moderate pain levels, physical therapy is a prevalent and well supported guideline for initial treatment options.
Doc #1 was not ill meaning and is practicing based on years of experience. However that doesn’t negate that his way of practicing healthcare has potential detrimental consequences. Considering we have updated information on how to work with people in pain, both on the psychological and the physical front, I’m sharing this story to arm you with the ability to make the best decisions for yourself in a similar situation.
But wait, how are you supposed to know who to trust? You don’t know what the clinical guidelines are, you’re not spending hours reading up to date tendon rehab protocols — and you shouldn’t have to. I recommend asking yourself some questions to help you assess:
Does the gravity of the treatment option seem comparable to how you’re feeling about your injury?
Are you more scared and nervous leaving the doctor’s office than you are comforted?
Are you more nervous about the outcome of the treatment than the injury itself?
Were you given options?
Were you educated about your situation in a way that reduced your fear and elevated your confidence rather than the reverse?
You deserve to be given options, you deserve to be seen and treated as a whole person, and you deserve to have space in the conversation to discuss the concerns about how the treatment will impact your quality of life. My guess is that these questions were ruminating in Chris’s mind subconsciously (or maybe consciously), leading him to seek out a second opinion. You can also let the answers to the above questions guide you in seeking out another opinion, or even another practitioner with the same opinion but who may yield you some comfort and confidence rather than doom and gloom. More on that in another story. Stay tuned for part II.
Keep moving.