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Headed to the ankle doc - input welcome! (Read 120 times)

    Hey fellow runners!

     

    I am headed to the doc (orthopedic with ankle specialty) and wanted to tap the wisdom of the RA community. For those who've seen a doc: what are good questions to ask and treatments to inquire about (xray vs mri and others)?

     

    Background: Ran first half and full in spring and summer 2010 with good results and no injury.  Running regularly at minimum 15mi per week since 2007. 30 yr old female. No other significant health or injury issues.  Started training again July 2012 and injured left ankle in August 2012, most likely TMTS. Reached 14 mile long runs when I started experiencing ankle pain After long runs. Pain was mostly in peroneal area with some achilles involvement. Didn't run the marathon and stopped when weight bearing in AM 2 weeks after onset was significant.  Ran once in October and once in November,  but no real change.  PParadoxically pain seemed to slowly increase in wks off (before I only had it immediately following long runs) so tarted back slowly in January to increase blood flow (3 mi 2x/wk for 2 wks) and couldn't weight bear in AM by end of wk 2 so stopped and went to PT. PT confirmed peroneal and achilles and attributed injury to weak glutes and overall core strength.  No disagreement,  but strengthening and 7 PT sessions and several more months and still no change hence the doc visit to rule out other possibilities.

     

    Welcome your thoughts overall and recommendations specific to seeing a specialist.

     

    Cheers!

    runpsy

      Are you the REAL Psy??

       

      Sorry, I'm not helpful on the ankle question.

      Well at least someone here is making relevance to the subject.

      ShuffleFaster


        Since you asked, I would like to respectfully make the following suggestions/comments:

         

        1.  Good for you for seeing a doc instead of relying on the Internet for your medical care!  Smile

         

        2.  This is going to sound "old school", but for me, 90% of what I need to figure out what a patient has is discovered via a good history.

         

        Therefore, I think the most important thing a patient can do to help themselves is to make it easy for the doc to take a history in an unbiased fashion:.   Specifically:

        • When giving your history, please stick to the facts of the case, presented in an honest, organized, chronological, unembellished fashion. Most diseases declare themselves over time, so a brief timeline can be helpful. 
        • Don't hide relevant information, even if it might make you look a little silly.  (It always amazes me how many folks delay their diagnosis by concealing pertinent facts).
        • Please try to avoid using specific medical terms when describing your symptoms if you're not a medical professional (or even if you are).  Although you wouldn't mean it this way, sometimes patients do this thinking that it somehow enhances their credibility.  This can result in the imprecise use of terms, which can cause them to take you less seriously.  This would be wrong on their part, but it is unfortunately, part of human nature. 
        • Please avoid speculating or giving conclusions to the doc about what this might be until they have a chance to consider the facts.  You are paying them for an unbiased opinion, and you don't want them jumping to easy (but false) conclusions because you've fed it to them.  Ask the doc to tell you what they are thinking (after the H & P) before you start giving them your theories.
        •  Don't be shy about asking questions if the doc reverts to doc-speak or vague answers.  Part of what you are paying him/her for is to communicate effectively with you, so be persistent until you are satisfied with their assessment and plan to help you.  However, don't be disturbed if they say: "I don't know" at first.   That doesn't mean they are hiding something.  On the contrary, I've found that the smartest docs are the ones that will admit they aren't sure what something might be.  It's usually a sign they aren't going to let their ego get in the way of figuring out what you have.  I'd much rather have that than some egomaniac who will say anything to get you out the door.

        3.  The vast majority of times, the diagnosis becomes pretty evident after a thorough history and physical examination.  They'll likely start off with a plain x-ray first, which may be all you need, depending on the results of the H & P.  If they are thinking stress fracture, then a bone scan or MR might be done.  If they find an effusion, they may tap the joint, etc.  (It's hard to know what diagnostic steps might be appropriate without being the one to examine you.)

         

        4.  There are plenty of causes of ankle pain that are not primarily orthopedic in nature.  A good Ortho doc knows this, so don't be dismayed if he suggests that it's something other than running-related.  The downside is that sometimes very specialized docs come back and say: "I've ruled out any Orthopedic cause" and stop there.  That's why it really is optimal to have a smart generalist coordinating your care.  For example, lets say the Ortho doc comes up empty, you might need a referral to see a Rheumatologist, which is something a PCP can most easily arrange.  I've seen lots of patient's who hop from specialist to specialist futilely seeking an answer, whereas a PCP could have helped sort things for them.

         

        5.  Lastly, if you can stand one more bit of unsolicited advice please:   It has become de rigueur these days to tell people to become "medical consumers" and aggressively challenge docs to make sure they are taking care of you correctly.  That's fine as far as it goes, but unfortunately, some patients take this to extremes and adopt "I already don't trust you" attitude.  Nobody likes it when one party assumes the other is dumb/dishonest/incompetent/uncaring even before the interaction has taken place.   Ironically, it's the attitude of these self-same people that leads to the very outcome they were trying so hard to avoid.

         

        So, I'd suggest:  trust, but verify.  Don't make weird assumptions about the motives of the doc.   Most likely, they are going to do their best to help you, and they want to work with you to get you back to doing what you love.  There are always exceptions, of course, so if you get one of those, move on to someone else you can trust.  Again, this is where a PCP can be very helpful since they generally know the people they refer to).

         

        I realize the above may not have been exactly the suggestions you were looking for, but this is really my best advice to increase your chances of getting an accurate, timely diagnosis.

         

        Good luck to you!

          ^^^

          It would be nice to have a generalized version of the above post stickied at the top of this forum, like a "Preparing for a visit to the doctor due to a running-related injury."  It seems like so many people are afraid to visit a doctor because the result will be, have surgery and stop running forever.  Thanks ShuffleFaster.

          2013 H1:  7 hours/week base.  Q3: Train for goal race.  Q4:  Goal Race.


          Interval Junkie --Nobby

            Since you asked, I would like to respectfully make the following suggestions/comments:

             

            Bookmarked for a wonderful and comprehensive response.  Wish I had read this before going to my doc.  Not that I muffed it.  But it would have helped me lay out a plan of how to explain the history of my issue.

             

            I always thought there should be a class in high school called, "how to talk to a doctor about what ails you."  Therein you'd learn a common language that you and your doc could use to communicate.  I'm always at a loss on the vocabulary of pain.  "What kind of pain is it?" Hmm, I don't know, it just kinda hurts.  "Do you feel pain when I do this?" No, but it feels different than when you touch there; but I wouldn't call it "pain".  I feel like every doctor visit is about establishing a vocabulary.  Most of the time I wish they could just hook me up to a machine just to answer my questions regarding pain and feelings -- because I have no idea.

             

            And there's always the problem of self-editing: is this relevant, or not?

             

            The triage nurse once asked me on a 1-10 scale how bad my felt for a broken foot, and another for viral meningitis.  Both times I think I said 4.  I have a pretty good imagination of much greater pains.  Of course I got triaged behind the guy who stubbed his toe and declared it a 9.  I waited 7hrs.  But I guess that is exactly how that triaging question is supposed to work - based on perceived pain, not objective pain.

            2014 Goals:  sub-3 Marathon 

            Current Status 06/19: Pelvic stress-fracture = 6-weeks of no running.

              ShuffleFaster thanks so much for the wonderfully comprehensive reply that will likely be helpful to so many others!!  Much appreciated!

               

              One element that hasn't entered the conversation yet is insurance coverage and cost.  I was informed by the staff at the doc's office where I'm going that x-rays will be done before I see the doc.  Since my insurance doesn't cover that I asked to see the doc first to see if it was indicated.  Without committing one of the issues you listed, ShuffleFaster, such as coming in with theories, etc. how would you navigate this?  I suppose it's true I do have a theory that my ankle is not brokenWink but I don't obviously have the expertise to know whether xrays are truly indicated versus a matter of procedure.  Unfortunately cost prohibitiveness makes this an issue when deciding which recommendations to follow.

               

              Anyways, I think seeing the doctor first will hopefully address this and lead to a differential diagnosis specific to my situation.  Appreciative of the feedback.

               

              Hope to join you all on the trails/roads again soon!

              RunPsy

               

              ps: LedLincoln - I s'pose I could answer that if I knew who the "REAL Psy" is and so I guess that would be a "no!"  I do happen to be a shrink thoughWink


              Boston Strong in 2014!

                This really isn't advice since you have already selected a physician, but in my experience, I think it could be important to find out what kind of experience a doctor has in treating running related injuries. When I had to see a doctor regarding a groin muscle injury, he made lame jokes about my running -- "What are you running from?" -- and seemed to find it funny/silly that I would want to run long distances. I only needed him to refer me to a physical therapist so I only saw him once, but I wondered how committed he would be to helping me achieve my running goals. A few years later, I went back to the practice for a broken collarbone (again, not a running injury and the practice was local and took my insurance) and I got a similar reaction. The second doctor assumed that the only thing I would be interested in doing for exercise would be playing tennis since I was a 50-something woman living in the suburbs. Although he monitored the healing of my collarbone, he had little practical advice on when I could resume running or cycling. I would definitely not go back there for a running-related injury.

                2014 goals

                2000 miles; 5k < 24:30; HM < 1:56Century Bike Ride

                 

                Upcoming:

                NYC Half Marathon 3/16Boston Marathon 4/21

                ShuffleFaster


                  ShuffleFaster thanks so much for the wonderfully comprehensive reply that will likely be helpful to so many others!!  Much appreciated!

                   

                  One element that hasn't entered the conversation yet is insurance coverage and cost.  I was informed by the staff at the doc's office where I'm going that x-rays will be done before I see the doc.  Since my insurance doesn't cover that I asked to see the doc first to see if it was indicated.  Without committing one of the issues you listed, ShuffleFaster, such as coming in with theories, etc. how would you navigate this?  I suppose it's true I do have a theory that my ankle is not brokenWink but I don't obviously have the expertise to know whether xrays are truly indicated versus a matter of procedure.  Unfortunately cost prohibitiveness makes this an issue when deciding which recommendations to follow.

                   

                  Anyways, I think seeing the doctor first will hopefully address this and lead to a differential diagnosis specific to my situation.  Appreciative of the feedback.

                   

                  Hope to join you all on the trails/roads again soon!

                  RunPsy

                   

                  ps: LedLincoln - I s'pose I could answer that if I knew who the "REAL Psy" is and so I guess that would be a "no!"  I do happen to be a shrink thoughWink

                  I think it's perfectly reasonable to request an exam before x-rays.

                   

                  The reason why x-rays are generally done first is for efficiency's sake.  That way, the doc can examine you while having the x-rays all in one single encounter instead of examining you, then getting an x-ray, then coming back to give you his/her opinion.

                   

                  Personally, while understandable, I think that's suboptimal.  If you don't examine the patient first, how do you know what particular x-ray to order?  For example, if a patient has wrist pain, many times, we will order a special view (i.e. scaphoid view)  ONLY if a particular region of the wrist is tender to exam.   Depending on where your ankle/foot hurts, you may need stress views, etc.  No way of telling until you get examined.

                   

                  I'm of the philosophy that a physician should interview and examine the patient and only suggest ordering what is necessary instead of the shotgun approach.  IMHO, a doc should also discuss whatever tests they want to do with the patient to get their take on the proposed plan before carrying it out.

                   

                  The potential downside of declining pre-appointment x-rays is that it may cost you some time, since your appointment is going to be interrupted (most likely) by some sort of x-ray.  Worst case scenario is that they will make you come back for a second appointment, but that seems unlikely since every private practice Ortho doc I'm familiar with does x-rays right on site.

                   

                  Bottom line, IMHO.  YOU are the patient, and it's YOUR body and YOUR money.  If you want an exam first, I would respectfully suggest making that known to the office in a collegial fashion and tell 'em since you gotta pay for it out of pocket, you'd like an exam first so that you be sure to get only the exact x-rays you need.

                   

                  If they balk at that very reasonable request, then I'd ask them to run the request past the doc (or talk to the doc yourself).  If they absolutely refuse, then I'd find another doc.

                   

                  Hope that helps a little.

                   

                  PS:  I agree with jerseyrunner--sports medicine guys, especially those that run themselves can be very useful in these situations.

                    Thanks ShuffleFaster and others for their input!  Glad to have the support.

                     

                    I had a good experience at the doc, not pressured to take x-rays, which turns out weren't appropriate at this point.  My doctor ended up recommending a CAM (controlled ankle movement, I think) boot to treat achilles and/or peroneal tendonitis since it's been going on 9 months now.  I have some questions about that, for another post, but want to reiterate my appreciation for the tips going in.  I brought in a factual history timeline of my symptoms, typed up, which the doc seemed to appreciate and made the history taking smooth and thorough.

                     

                    cheers,

                    runpsy