Physical Therapy and Differential Diagnosis
August 23, 2019
Do you remember your last visit to the ER?
(If you’ve never been to the ER skip this first paragraph and start from the second paragraph).
You were most likely frustrated by the amount of time you spent there, and you were probably surprised by how many tests you went through before you left. From blood tests to imaging studies, to checking if your pupils dilate with light, to listening to your heart and so forth. These tests may not have all been related to the condition you were suffering from – rather, many conditions that you might have been suffering from were eliminated as a result of this process. This is called differential diagnosis.
In the blog post I’ll try to briefly explain differential diagnosis and why it is so important, specifically for physical therapy and sports performance.
A diagnosis is a label for a specific condition that helps to communicate the characteristics of the condition clearly to other health care professionals.
On the other hand, differential diagnosis is a list of possible diagnoses (from the most likely to the less likely) deducted from the examination of the patient.
In physical therapy terms, unlike in other health care professions, the diagnosis is used to understand how the condition affects the individual as it relates to function. This is because therapists work to improve the function of the whole person, as well as the function of the individual system effected by the condition.
The differential diagnosis is built during the initial session. During the initial visit to a physical therapist the client should, in my opinion, be asked as many questions as possible about the symptoms s/he is experiencing (assuming the therapist already has the medical questionnaire and history in his/her hand). This is an extremely important step as the therapist begins creating a list of some possible conditions that may relate to the signs and symptoms the client has.
This differential diagnosis list should be taken into account as the second step of the process, the examination, begins. During the therapist’s examination some of the conditions on the list may be confirmed and some may be eliminated, depending on the results of the examination. This process of differential diagnosis is time consuming, as a lot of data is gathered and analyzed.
As an experienced physical therapist, I have to be aware of the correlation between different conditions and signs and symptoms. This is specifically important because all systems in our bodies may mimic the musculoskeletal conditions that I was taught to treat.
The endocrine, hematological, cardiovascular, pulmonary, immunologic, integumentary, gastrointestinal, renal, hipatic and biliary systems can all mimic orthopedic and musculoskeletal conditions.
Therefore, I know that I may sometimes see a client who doesn’t need any physical therapy at all.
Let’s look at the example of a client with low back pain, perhaps a professional basketball player. It is estimated that some clients who are seen in outpatient physical therapy clinics for low back pain are actually suffering from a non-physical therapy condition. Here is a quick breakdown from a study that was published in the early 2000’s: 4% will have a fracture/s related to osteoporosis, 2% forward displacement of vertebral body or fracture of one portion of the vertebrae, 2% visceral disease, 0.7% cancer and 0.5% infection.
Unfortunately, it’s not uncommon for me as a therapist to refer clients to other health care professionals, as well as to see errors that other physical therapists have made without taking into account the unneeded, unjustified treatment that is being given to their clients.
Differential diagnosis is ongoing and may change over time depending, among other factors, on further evaluation and examination, interventions, checking outcomes and taking into account the results of diagnostic imaging studies, and consulting with other medical professionals. This is not an easy task but it can save lives!
Runner’s knee and jumper’s knee are two common overuse injuries that can affect athletes, especially those who participate in sports that involve a lot of running or jumping. While both conditions can cause knee pain, there are some important differences between the two. Runner’s knee, also known as patellofemoral pain syndrome (PFPS), is a condition that causes pain around the kneecap (patella). It typically occurs when the kneecap doesn’t move properly, causing friction between the patella and the underlying femur bone. This can result in pain, stiffness, and a grinding or popping sensation in the knee. The causes of runner’s knee are not fully understood, but it is thought to be related to overuse and biomechanical issues such as muscle imbalances, poor running form, or weak hip muscles. Runners, as well as individuals who participate in other activities that involve a lot of knee bending, such as cycling or hiking, are at risk of developing runner’s knee. Jumper’s knee, also known as patellar tendinitis, is a condition that causes pain and inflammation in the patellar tendon, which connects the kneecap to the shinbone (tibia). Jumper’s knee is typically caused by repetitive stress on the patellar tendon, such as from jumping or landing from a jump. It is most common in sports that involve a lot of jumping, such as basketball or volleyball. Jumper’s knee can cause pain, tenderness, and swelling in the knee, as well as a feeling of stiffness or weakness in the affected leg. In severe cases, the tendon may even begin to tear or rupture. While both runner’s knee and jumper’s knee can cause knee pain, there are some key differences between the two conditions. Runner’s knee typically causes pain around the kneecap, while jumper’s knee causes pain in the patellar tendon, just below the kneecap. Additionally, runner’s knee is often associated with pain that is worse when going downhill, while jumper’s knee tends to be more painful when jumping or landing. Treatment for runner’s knee and jumper’s knee typically involves a combination of exercises to improve strength, mobility and flexibility in the affected structures. In some cases, bracing or taping may be recommended to support the knee during activity. In rare occasions if conservative treatments are not effective, surgery may be necessary to repair the damaged tissue. In summary, while both runner’s knee and jumper’s knee are knee injuries caused by overuse, they differ in the location of pain and the activities that exacerbate the pain. It’s important to seek medical attention from a skilled physical therapist if you are experiencing knee pain, as early intervention can help prevent the condition from worsening and may even prevent the need for surgery.
It’s time we all face three facts: the first, if you are an athlete you should consider twice whether to use your insurance healthcare benefits to receive physical therapy at your neighborhood’s so-called “sports physical therapy” clinic. Second, we must face the reality that not all sports clinics can provide efficient and effective specialized care to athletes, whether amateur or professional. And third, we must accept that effective, efficient specialized care deserves to be recognized, paid for, and used on a regular basis in the sports performance world. Each player within our complex healthcare system in the United States, which includes insurance companies and big businesses among others, makes up the powerful and politically active special interest groups represented before lawmakers by high-priced lobbyists (14). Each player has a different economic interest, including physicians and physical therapists seeking to increase their reimbursement for services provided while insurance companies continue their effort to decrease their payment for providers, which inevitably leads to a major cost containment problem (6). This together with a system that is focused on acute care, uncoordinated, high cost, technology driven and offers unequal access and mixed outcomes (3,6,14). It is also not governed by one central agency and as a result is a very complex system to understand and change. While some athletes are covered for physical therapy services used directly through their team or organization, to a larger degree athletes pay a specific premium (financing) through their employer or self-pay based insurance plan to cover their healthcare services each year (6). These services include physical therapy services that are in most cases capped for a certain amount of time, sessions and treatment provided, chosen by the payer (insurance), in addition to additional continued increased costs via copayment per visit and/or yearly deductible (6). Some athletes will find themselves being treated in an outpatient physical therapy clinic (24). Currently there are about 18,000 outpatient physical therapy clinics (and increasing) in the United States, most of them are in-network (get reimbursed directly through the health insurance company), which are increasingly operated and owned by the big players in the market as they try to consolidate with other physical therapy businesses to increase overall financial revenue (17). This is no surprise as physical therapy has become more accessible and is used now more than ever before, to some extent due to the enactment of the Affordable Care Act and greater public awareness (3, 6, 7). This has resulted in physical therapy services being reimbursed with lower pay to meet the high demand, which on the flip side results in a more work for less money scenario for business owners. This in turn leads to increased patient caseload per therapist in the outpatient clinic setting and high turnover rates (5, 16, 18, 20). Nowadays, the standard in-network clinics hire physical therapy assistants, physical therapy aids and trainers to meet the high demand for services so as to share patient care and withstand the higher caseload per day. These same outpatient clinics largely operate on a uniform basis, in that all physical therapists treat any patient that comes in through their door, from an elder after a traumatic brain injury to a wheelchair bound adult after a spinal cord injury sustained in a motor vehicle accident, to an elite athlete recovering from an ACL reconstructive procedure. The newly graduated doctors of physical therapy who are hired to work in these clinics are undoubtedly highly educated and motivated professionals that underwent extensive studies to treat a wide variety of conditions including musculoskeletal, cardiopulmonary, neuromuscular, integumentary and developmental, and as well as the aforementioned conditions I mentioned, but with two big caveats: lacking advanced practical knowledge and advanced theoretical knowledge (9, 25). And it is here that one may raise the question on whether the current physical therapy educational program was solely designed for the therapist to seamlessly integrate with the healthcare system and meet the demands of the big players in this system. The ongoing increase in sought for treatment by people who suffer from sports, musculoskeletal and orthopedic conditions as they relate to movement dysfunction, pain and disabilities brought clinics to an understanding that specifically naming and marketing their practices as “sports physical therapy” will lead them to an increased patient caseload. From a business perspective this is clearly a good marketing strategy, but from the physical therapist’s perspective this could be viewed as an ethical and professional issue that may lead to healthcare fraud and abuse. According to the Code of Ethics for the Physical Therapist (1) therapists “shall demonstrate independent and objective professional judgment in the patient’s or client’s best interest”, while the Standards of Practice for Physical Therapy (2) call for therapists to “ensure that the level of expertise within the service is appropriate to the needs of the patients and clients served”. Both of these statements are undermined in reality as professional judgment and level of expertise is clearly lacking in these clinics. Caring for the athlete through on-going physical therapy, regardless of injury status, will help in mitigating injury risk both in the short and long-term, promote physical and mental wellbeing, as well as maintain and/or increase performance during both the in-season and off-season (11, 19, 22). Moreover, caring for the professional athlete becomes highlighted in the case of injury as the financial tolls, as well as mental to some degree, are high to all people surrounding the athlete, including the athlete’s family, medical and support staff, and other stakeholders including investors (15, 21, 23). This individualized specialized care is time consuming and requires a therapist to be sufficiently educated and experienced, collaborate with the athlete and other healthcare providers, as well as to be highly motivated and willing to invest to maintain continued professional development and standards (8, 10, 12). An in-network clinic will simply not be able to provide this level of care to an athlete because of time restrictions, insurance limitations, equipment and space restrictions, lack of incentives to provide high quality care and high caseloads of patients per therapist. While some benefit from this standard care, simply put, the specific subgroup of athletes who are treated in an in-network outpatient clinic are likely to withstand increased costs and poor outcomes due to ineffective and wasteful care that can also impact athletes safety (4, 13). The good news for athletes is that more and more specialized privately owned sports performance practices have been opening their doors to offer high quality care. These practices are unique, customizing their comprehensive quality services to fit athletes’ needs individually, and are run by highly specialized therapists (and not big corporations) who, needless to say, do not base their treatment and care decisions solely on insurance companies’ decisions on plan of care, and reimbursement revenue. Some of the most brilliant minds in the sports performance world in physical therapy work in these practices. Their dedication to the profession is uncanny, spending most of their time, money and effort to make this possible. The athletes among us should start making these same informed decisions relating to their minds and bodies rather than the insurance companies and big “sports physical therapy” mills, and embrace these advantageous high quality services while investing their money doing so, understanding they are closer now than ever before to reaching their performance goals. References American Physical Therapy Association. (2020, August 12). Code of ethics for the physical therapist. https://www.apta.org/siteassets/pdfs/policies/codeofethicshods06-20-28-25.pdf American Physical Therapy Association. (2020, August 12). Standards of practice for physical therapy. https://www.apta.org/apta-and-you/leadership-and governance/policies/standards-of-practice-pt American Physical Therapy Association (2021, February 26). 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The ever expanding scientific research in the field provides athletes and their coaches with the best available principles and concepts to use to maximize sports performance, and of course – to win – something that can be worth billions of dollars in professional sports. Cutting-edge equipment and technology is continually studied and iterated upon, with the aim of improving practice and performance in sports. Currently in the sports performance world, the main topic that is being discussed, studied and implemented is monitoring technologies that provide a wide array of data regarding a player’s fitness, workloads and fatigue status, to inform decisions regarding training and recovery options for minimizing injury risk and optimizing performance. Workload monitoring tools like microtechnology, including microsensors and accelerometers, have become popular and measure the physical demands placed on athletes during training and competition, such as accelerations and decelerations. Fatigue monitoring tools, such as testing devices that measure workload and monitor physiological responses to competition demands (such as blood lactate and heart rate), provide coaches, medical staff, sports performance staff and scientists with a better understanding of how the athlete is responding to training load, competition demands and non-training stressors. Fatigue and workload monitoring tools are already changing the sports world – and will likely continue to change it – for example, by perhaps reducing the number of games in a professional basketball season, to help athletes avoid fatigue and enable them to perform at the highest level with low risk of injury, to the benefit – socially and financially – of all of the sports industry.