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How to get a diagnosis: A 4 step guide by Jonathan Bell

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I follow a number of fascinating blogs and I’m drawn to those that relate to my passion for skiing. Of course I can’t resist looking at and contributing to medical blogs. One of the things I’ve learned is there are many people out there who are convinced that medical practice is some sort of dark art!

A popular post on blog sites is a plea for help in sorting out an injury or unexplained pain. Many of the responses are well-meaning but not always that helpful. Some responses are rather more bizarre.

It would appear that fellow bloggers have frequently tried treatment with limited information about their diagnosis. You may not be surprised to learn that I’m not a fan of this approach and I’ll explain why. I thought I’d then try and unravel the problem of how to arrive at a diagnosis. I will introduce another important term “assessment of severity”. I’ll explain the important difference between the diagnosis and assessment.  We will then cover how a treatment plan is arrived at. You’ll notice I haven’t mentioned scans yet but rest assured I’ll cover that too.

In my experience injured sportsmen and women just want treatment that will allow them to return to sport as soon as possible. They can be tempted to jump straight into a treatment before a clear diagnosis has been arrived at. It is not helped that there are whole specialties that practice in this way with their fixing, manipulating and adjusting methods. Many of these treatments require numerous visits that are time consuming and without a clear plan on how they will cure the problem. Frequently problems will “cure” themselves as many muscle/joint and ligament problems are self limiting they can settle with passage of time. The patient then goes away none the wiser that it wasn’t the 10 treatments that cured them just natural healing. In addition there are specialties that very much focus on trying treatments, seeing if they work and if not trying a different treatment. Not surprisingly sometimes luck means that the treatment is  highly successful. If the wrong treatment has been tried the frustrated individual ends up with numerous visits to the practitioner but without any recovery.

Treatments are expensive, can be painful and where they require a visit are time consuming so I believe it is therefore essential to try and get the treatment right from the outset and minimize the number of sessions. For me that means getting to the bottom of what is wrong and then planning the treatment accordingly. That means getting a diagnosis. A diagnosis is a clear label for your condition. Once you have a clear diagnosis a well trained physiotherapist or doctor will understand what treatment will and won’t work.

A diagnosis consists of a History (a description of your problem) and an Examination (a physical examination of the painful part). I’ll cover history and examination in more detail in a later post. Collating this information leads to a clinical diagnosis which in reality is usually a short list of possible labels for your problem. This list is called a differential diagnosis. Scans and other tests are then used to investigate the list of possibilities until we whittle the list down to one diagnosis

Let’s look at an example. Imagine someone turns up with pain on the inner side of the knee. After the history and examination we might have a differential diagnosis of:-

  1. A ligament injury
  2. Meniscus tear
  3. Referred pain from the kneecap (more on referred pain later)

An MRI scan can then be used to investigate which of these three is the correct diagnosis. As MRI’s are very sensitive you get huge amounts of information including the possibility that there may be two or three possible diagnoses present on the same scan (again I’ll cover how to use MRI later) . Scans without a clinical diagnosis are frequently a waste of money.

Let’s assume that the scan suggest a ligament injury. All we need now is to assess the severity of the problem.

The importance of assessing the severity can be illustrated by considering a diagnosis of medial ligament injury of the knee. A minor teak may get better in 4 weeks with physiotherapy.  It is also possible to have a medial ligament injury that has completely ruptured it. This is a more severe version of the same diagnosis. A severe medial collateral ligament injury may require surgery and months of rehabilitation.

We can now plan a treatment based on the diagnosis and the severity of the problem. We could of course start with the premise that all pains on the inner side of the knee are likely to be due to ligament injuries. Given that minor medial ligament injuries are very common if we treated all pains on the inner side of the knee as minor ligament injuries we would be giving the correct treatment for a very sizable proportion of patients. However that is not a very considered approach and the people who don’t have minor ligament injuries might be getting an ineffective treatment that could actually be making them worse.

So what works best? When we have the diagnosis and severity we use our years of experience and knowledge of the science to write a treatment plan. We can usually give a clear idea of what that will involve and the time to recovery. There is often the option to have different treatments. At Wimbledon Clinics we are not just a surgical clinic and think it is important that you are offered non operative treatment. You will be able to discuss the pros and cons of different treatments. That helps you to understand your problem and get an idea of how you want it treated. You will be then able to make a decision as to whether you want surgery or try and manage without. But all of this discussion and useful information can only be available to you if you have had a clear diagnosis made and an assessment of the severity of the problem.

Seeing you, asking about your problem, examining you and arranging investigation involves both your time and the doctor’s. A lot of people worry that it will be expensive. As most diagnoses around the knee are not particularly severe and most likely to settle with a program of physiotherapy we wondered whether we could try and come up with a fixed price for arriving at not only a diagnosis but a clear assessment of the severity and then a treatment plan. So we have come up with The Game Ready package for a fixed price that would include an assessment with an experienced sport and exercise physician, an MRI scan and a follow-up call. If, as is likely, you only need physiotherapy we can recommend one near your home or place of work. Before you know it you are on the path to recovery.  If you do need surgery you can decide whether to continue with us or ask to be referred on the NHS by your GP. Again at Wimbledon Clinics we offer surgery at a fixed price.

So the next time you have a pain that is preventing you from remaining active or participating in your sport you could see a practitioner who will just start treating you on the basis that they might luckily apply the correct treatment.  The alternative is that you can take a more considered approach of finding out exactly what is wrong with you and hearing a clear plan on how best to treat the problem. You can then plan your treatment based on an understanding of what treatment is required and how much it will cost.

Please visit Jonathan’s blog on Snowheads.

If you want to learn more call 0208 944 0665 and speak to one of our Treatment Coordinators.