So, You Want to Become a Doctor? Part Two—History, Physical Examination, Imaging, and Other Tests

You can’t fit a square peg into a round hole.

—Idiomatic expression probably originating with Sydney Smith in a lecture entitled On the Conduct of the Understanding, on moral philosophy delivered at the Royal Institution in 1804: “If you choose to represent the various parts in life by holes upon a table, of different shapes—some circular, some triangular, some square, some oblong—and the person acting these parts by bits of wood of similar shapes, we shall generally find that the triangular person has got into the square hole, the oblong into the triangular, and a square person has squeezed himself into the round hole. The officer and the office, the doer and the thing done, seldom fit so exactly, that we can say they were almost made for each other.”

THE WAY WE WERE (AND WON’T BE IN THE FUTURE; FIGURE 17-1)

Let’s take the perspective of the physician evaluating someone with groin pain. Depending on one’s specialty training, a doctor is ordinarily going to try to wedge the constellation of symptoms and findings into a familiar diagnosis and something that has pertinence to his/her specialty, regardless of how well, or poorly, the history and findings fit that diagnosis.

Figure 17-1.

The General Surgeon’s Approach

When presented with a patient complaining of groin pain, a general surgeon immediately thinks of an inguinal, or other, hernia causing pain by stretching nerves in the inguinal canal. The general surgeon then sets out on a quest to prove the hernia’s presence. He/She deftly maneuvers the tip of his/her finger into the external ring of the patient’s inguinal canal, and perhaps other places, and asks the patient to strain and cough. If no familiar bulge reaches out to meet his/her fingertip, the good general surgeon undauntedly replaces his/her finger with an ultrasound probe on the belly. Thereafter, he/she relies on advanced technology to detect what his/her finger could not. If still no hernia is detected, he/she performs exploratory surgery, using a laparoscope or a direct incision to examine the natural weak points of the abdominal wall in case the hernia was so small that it could not be otherwise detected. Almost always, there is enough circumstantial evidence to justify placing a piece of mesh to reinforce the area of potential weakness. Usually very early after the doctor meets the patient, the focus of care has shifts from identifying the cause of the patient’s pain purely to finding an elusive hernia.

The Orthopedic Surgeon

The orthopedic surgeon might already have been consulted on the same patient, but whether or not that has happened, usually little communication occurs between the orthopod and the general surgeon. The orthopedic surgeon, recognizing that occult groin pain can be due to a fracture, orders a series of X-rays and palpates over the pelvis. Any tenderness or inflammatory changes seen by the imaging are interpreted as consistent with a stress fracture and treated accordingly—with rest, sometimes physical therapy, and anti-inflammatories. Too often, the patients themselves are the only ones keeping track of the lessons learned from one specialist to the next, and they try to figure things out on their own.

Other Specialists
(eg, Urologists, Gynecologists, Colorectal Surgeons, Physiatrists)

Other specialists get consulted, and just like the movie Groundhog Day, occurs over and over again. All specialists do what they do and send the patient home with certain instructions. The instructions often conflict. One of our patients saw 7 different specialists and amassed prescriptions for 7 different anti-inflammatories. The explanations become more and more inconsistent. Frustration intensifies.

THE WAY WE ARE (OR SHOULD BE)

Nomenclature

We have already established that we need to throw out all the terminology related to hernias and talk about the core. We shall apply the language introduced in the previous chapters to clinical practice.

History

We start this conversation by listening and then asking questions that pertain to the 4 parts of the core. As is hopefully obvious by now, suspected core injuries are best diagnosed by someone who is capable and comfortable addressing the entire core. Remember the boundaries of the core and everything within them: the muscles and pelvis bones, the ball-and-socket hip joint, the entire back with the thorax, hollow and solid organs, nerves, blood vessels, and other innards.

If this sounds complicated that is because it can be. The primary focus of evaluating someone with groin pain is to pinpoint the anatomy involved. If it is a core muscle injury, it is not enough to simply say that, we must hold ourselves to the standard of identifying, as exactly as we can, which of the 29 core muscles are involved if we are to have any hope treating folks. Table 17-1 lists the various clinical entities included under the umbrella term core muscle injuries. Pain that occurs only with exertion is likely to represent some degree of muscular injury, while relatively passive or postural pain is more likely from the hip.

TABLE 17-1

SOME DIAGNOSES TO CONSIDER IN THE EVALUATION OF CORE PAIN(S)

The Core Muscles