There is a fairly common phrase in medicine that states: “When you hear hoofbeats, think horses not zebras.” It was used in the 1940’s by Dr. Theodore Woodward of the University of Maryland Medical School while teaching medical interns. To this day, ‘zebra’ is the American medical slang for coming up with an elaborate diagnosis when a more common explanation is more likely. (Gotta love Wikipedia sometimes).
However, I remember a surgeon I worked with about 20 some odd years ago, my first real mentor, telling me once: “Sometimes when you hear hoofbeats, it’s not horses, it IS zebras.” It was then I began to realize the complexity of the human body and the incredible responsibility I was taking on when people entrusted their care to me.
I share this with you in part because I have had an interesting case which ended with a unique diagnosis and it reminded me of the zebras that are lurking all over our patients.
Without going too much into the scenario that I believe most of us who are trained in PRI are familiar with, which is: “I’ve been to a bunch of other people who have evaluated and treated me and no one can really seem to figure out what is wrong with me. Dr. XX sent me to you.” Which fairly quickly turns into: “I can’t believe how much better I have been feeling!”
I do like to clarify with these people that I’m just the messenger :)
Fit, middle aged woman who had a fall off a horse >8 years ago and fractured her sacrum. She had been able to get back to some degree of activity, but was limited with increased walking, any jogging, limitations with her skiing and problems with being in any one position--sitting or standing--for periods of time. MRI to spine and hip ruled out underlying pathology in the spine and hip, for what they were looking for, and one of the cleanest looking pelvis x-rays in terms of position and alignment I have seen.
L AIC and bounced around between a PEC and B BC early on, as she over-abdominalized (my word) everything. Very compliant which helped a lot in her management and she was very aware of her positioning and making appropriate corrective changes.
She progressed very well with her care and she noticed other things which she had been dealing with were clearing up as well (back and shoulder issues). She found her activity level was able to increase commensurately and as a big skier, she really liked the techniques she was given which helped her with her left-footed turns (turns to the right). Neutrality above and below the diaphragm would go back and forth at times, but she consistently presented with HALT scores of at least 3/5.
Her problem was residual discomfort deep in her left lower gluteal / ischial tuberosity region. Technique after technique were introduced to address the pelvic floor, stretch posterior capsule, manual interventions to this area often helped, but sometimes didn’t, and self-soft tissue work (i.e. ball/foam rolling to the area) did not maintain mobility. Palpable thickening of the long head biceps femoris / quadratus femoris region and we just couldn’t get it to “shut off”.
These are the kind of things that keeps me awake at night, saying: “What am I missing?!” (Orthotics and oral appliances were assessed for as well).
Her history and palpation also suggested a sacrococcygeal issue which external techniques did not reduce. I sent her to a gifted osteopath I use for further workup of an anteriorly displaced coccyx. X-rays confirmed this, but it also showed that. . . . her sacrotuberous ligament had calcified--completely! What I had perceived as an area which wouldn’t work right, turned out to be something that was, well, never going to work right.
I am aware that we all have similar stories we could share and it is so easy to get hung up on the desire to try and figure it out and provide a solution. I was chasing pain in some ways, thinking I could provide an answer and solution to make it all go away. But I was also chasing inconsistent findings, which is what I kept trying to attach to her ongoing low-level symptoms.
She is very pleased with where she is at, fully aware of her HEP and self-management and is very grateful with the care she received from, well, all of us reading this. The treatment she was provided “changed her life” in many more ways than just the problem she came to us with. But an important reminder to remember the zebras that we all have and that what we are able to offer our patients is truly a gift, but it is something that we should recognize has its limitations.
Michael J. Mullin