fixated patient

Whilst on an outpatient musculoskeletal placement I followed on treating a patient who had been diagnosed with an MCL sprain to his left knee 6 weeks previously, following a fall playing soccer. At the time I saw him his pain levels were 2-3 and only with very specific movements or after jogging for 15minutes. He also revealed that the pain he experienced post fall had mainly subsided and the pain he was experiencing now he had actually had 3-4 months earlier. With this in mind I did some further tests and found that he had a positive McConnells test and a medial patella glide relieved his pain to zero when squatting. He also had a very tight ITB. I explained what I thought had happened to the patient and that i felt his initial problem had probably healed quite well and this residual pain was probably due to poor patella tracking. He understood this and said it made alot of sense and treatment became focussed on dealing with this.

The next week this patient had an orthopedic review with his surgeon. The surgeon did no tests but told him that he didnt think it was a tracking issue as the pain was too medial. When the patient came in next time, even though he said the taping reduced his pain to nothing during the week, he was very fixated on what the doctor had said and wanted to get an MRI to find the specific source of pain. He also said he had done some research on the internet and he thought it might be cartilage or something, he also had some doctor friends who he was asking for their opinion and they said maybe meniscus tearing. The next week he came in and had pain $250 for and MRI scan to find out what was wrong. The scan revealed that there was a small tear of his posterior medial meniscus and fissuring of the medial patella margins. At this point the patients pain was nil with taping and 1-2 out of 10 without it. He had returned to soccer and was playing for 30 minutes, only feeling slight pain when cooling down. However he continued to remain fixated on his pain and diagnosis and felt that he wasnt improving even though I could show him each week through various objective markers that he was. I had also given him a thorough explanation of how patella tracking involves many factors that may take time to correct.

At our final session he still seemed to feel that his progress was abnormal, even thought he was only complaining of 1-2/10 pain at most and he revealed that another player had suffered the same injury as him at the same game but had not yet returned to sport. He was also questioning wether he should have surgery so the doctor could 'just get in and clean it up'. I found this patient very difficult to deal with as, although he wasnt unpleasant or demanding he was clearly unable to put his condition into perspective and was willing to pay quite alot of money to fix a problem that was causing him 1-2/10 pain 5% of the time and was also improving. I also found it frustrating how my opinion was secondary to his orthopedic surgeon who did a 5 minute assessment, his friend who would have made no assessment and the internet. It was only when imaging backed up my diagnosis that I had any credibility.

What I did learn from treating this patient was that your explanations need to be very clear and confidant as there are so many conflicting information sources for patients. Often to us a diagnosis is not that important if we have found many contributing factors and are treating them successfully, however for some patients they have difficulty letting go of a set diagnosis/cure relationship. It was also difficult to convince this patient that he was getting better, when it was clear to me that he was and had hardly any activity limitations. If I met a patient like this in future I hope I would recognise education as a primary aspect of treatment and establish clear markers to indicate progress and educate the patient on expected/normal recovery.