Headed to the ankle doc - input welcome! (Read 124 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

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! 

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!

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.

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.

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