Is Clinical Examination A Lost Art?
- William Fishco DPM FACFAS
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We live in a high-tech world. Medicine and surgery are not exempt. I personally think we are all prone to forget the basic tenets of diagnosis. Think way back to podiatry school when you learned the fundamentals (range of motion, manual muscle testing, gait exam, etc.) of examining the foot and ankle.
Today, it is all about diagnostic ultrasound, MRIs, CTs, bone scans and other “hands-off” testing modalities. Certainly, these tests have their place in working up a difficult diagnosis but let us not forget the most important aspect of examination.
It is not uncommon for me to see patients whom have been previously treated elsewhere. Often these patients say: “The other doctor did not even touch (my) foot.” They note that the physician just looks at X-rays and MRI, and diagnoses a torn ligament.
Another common dilemma is what I call “MRI-TMI.” For example, say you have a patient who has chronic lateral ankle pain. The radiographs do not provide much information so you order a MRI. Inevitably, the MRI is remarkable for a split tear of the peroneus brevis tendon, a chronic tear of the anterior talofibular ligament and an osteochondral defect of the lateral shoulder of the talus.
So what does one do now? Are all these findings significant or is this an example of MRI-TMI? In other words, does the MRI offer too much information?
In my practice, I have a steady flow of the aforementioned patients referred by community DPMs for a second opinion or for surgical consideration. This is when the art of the clinical examination is paramount. Let us face it. Diagnosis of a paronychia or plantar fasciitis takes little clinical acumen. However, when there is pain in the lateral ankle pain where there are two tendons, two ligaments and two joints encompassing the diameter of a quarter, diagnosis is anything but a slam dunk.
The patient with lateral ankle pain is back in your exam room after you have reviewed the MRI. I explain that I do not treat X-rays (or MRIs). Now I tell the patient that I am going to examine his or her ankle again, testing each of the problem areas noted on the MRI.
In these challenging cases, one needs to see the patient back in the office for a more extensive re-evaluation after MRI to try and figure out the true problem. Sometimes the physician does diagnostic anesthetic injections to rule in or rule out a particular pathology such as a talar dome lesion.
What is the bottom line? The more you are able to listen to your patient and examine him or her with your hands, the clearer the clinical condition becomes. This enables you to effectively treat the patient for what he or she needs, and nothing more.