When it sees you but you don’t see it

Do Not Miss!!!

All of us who practice clinical care — who actively treat athletes and other patients — are keenly aware of the perils of a medical missed diagnosis.  The issues of concern can range from the relatively obvious — an Achilles tendon rupture for instance — to the more subtle.  In the case of an Achilles tendon rupture [or a scaphoid fracture or slipped capital femoral epiphysis (SCFE)], the outcomes from a medical misdiagnosis can be severe for both the patient and clinician:  significant morbidity for the former, and a possible medical malpractice suit (most especially in our litigious United States) for the latter.

Early in my training it was hammered home to me that if I let a patient with an Achilles tendon rupture walk out of my room with some bland assurance that one should give his or her acute posterior ankle pain a couple of weeks of rest and ice, and a message of ‘come back and see me if you’re not feeling better in a few weeks,” well….I could say hello to a suit which I would most certainly have to settle out of court.

Don’t want to be ‘that guy’ who doesn’t see the Achilles tendon rupture when it sees me.

Cassidy Foley, D.O., lead author

But what of some relatively common issues that may have more benign consequences, even if not initially ‘seen?’  What of the issues where missed or delayed diagnosis can result in weeks to months to years of frustration and, perhaps, unnecessary workup and/or misguided and ineffective treatments?

With those thoughts in mind, I was delighted to read an excellent study on the “Diagnosis and Treatment of Slipping Rib Syndrome” in the January 2019 CJSM.  This is both a piece of original research and an excellent primer/overview of the condition.  Lead author Cassidy Foley, D.O. was among a group of regular contributors to the pages of CJSM, including Dai Sugimoto, William Meehan, and Andrea Stracciolini. The group performed a 15 year single center retrospective chart review and found 362 athletes with rib pain, nearly 15% (N = 54) of whom were diagnosed with the condition.  Women were more likely to have slipping rib syndrome (70%), the mean age at presentation was 19.1 years (range 4 – 40 years), and the condition is almost always unilateral.  Most significantly, I think, the mean time from symptom onset to diagnosis was 15.4 months!

In their discussion, the authors emphasize the importance of having a high index of suspicion for this condition, most especially in the active young female who may have hypermobility and prolonged unilateral rib pain that is resistant to conservative measures.  Among the many take home points I walked away with were

  1. the importance of the physical exam maneuver known as the hooking maneuver
  2. unfortunately, many of these athletes (to repeat: most of whom are women) are dismissed and diagnosed with ‘psychiatric diagnoses,’ which leads me to wonder if in this area sports medicine clinicians are guilty of an observed pattern in the wider medical world, where women with chronic painful conditions are more apt to be labeled as having ‘psychosomatic’ pain.
  3. the most successful treatment options included: osteopathic manipulative treatment, surgical resection, and diclofenac gel.

After reading this study, I will have a higher index of suspicion for slipping rib syndrome in my clinic, and perhaps soon I will ‘see’ a slipping rib syndrome.  I have considered this diagnosis before, but now I wonder: on how many occasions in the last 25+ years has it seen me without my recognizing its face?

What are some of your diagnoses of similar concern? What do you think has seen you when you have not seen it?

Another one that jumps to mind for me is ‘cuboid syndrome’, a diagnosis I began to consider a couple of decades ago only when a fellow doctor interested in running, as I was, made me aware of this condition. Recognition of it is of great importance, as the treatment is rather straightforward and can be very satisfying.

Hint: may be a good topic for a CJSM submission?!

Bravo Drs. Foley et al. for publishing this piece.  Hope you’ll be sending us more.

 

About sportingjim
I work at Nationwide Children's Hospital in Columbus, Ohio USA, where I am a specialist in pediatric sports medicine. My academic appointment as an Associate Professor of Pediatrics is through Ohio State University. I am a public health advocate for kids' health and safety. I am also the Deputy Editor for the Clinical Journal of Sport Medicine.

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