Trouble Ron Thompson Tweet

[wfschrec]

Disagree with Cuseregular. Doing a simple physical exam could have determined it was the hip. Anything in the groin region should be considered hip until proven otherwise.

Usually I attribute any groin related issues to marriage but in this case hip would have been my second guess ...

 

[Rocco]

Disagree with Cuseregular. Doing a simple physical exam could have determined it was the hip. Anything in the groin region should be considered hip until proven otherwise.

Not necessarily.

 

[alphaorange]

For Cuseregular...Is it an all or nothing situation with the blood flow? Is it possible that there was inhibited flow that hindered the healing process but did not jeopardize the actual tissue health?

 

[Cuseregular]

For Cuseregular...Is it an all or nothing situation with the blood flow? Is it possible that there was inhibited flow that hindered the healing process but did not jeopardize the actual tissue health?

its so hard to know with certainty, but I'll try and respond. If you don't mind me boring you with some anatomy, there two major arteries that feed the hip joint (medial and lateral femoral circumflex) and some minor ones (such as artery in the ligament of the head of the femur, a branch from the superior gluteal). It was determined with Bo Jacksons injury in and post surgical that he damaged almost all of them which lead to his catastrophic injury situation.

We can hope with Rons that it only involved the minor one(s) or if the major ones that it was minimal and that it followed the minimal damage and maximal healing scenario I outlined elsewhere in this thread. Regardless of which one(s) the hope is the time without supply was minimal because this is what causes the long term damage. Theres cases with just the "minor" one(s) involved that caused severe cases of AVN (avascular necrosis of the hip, which is what his coach seemed to infer he's dealing with.

Theres so many factors like if the persons on certain drugs and/or what their unique structural arterial anatomy is (believe it or not there can be differnces person to person and even within the same person diferrent from their one side vs. the other side, so it makes certainty difficult in terms of diagnosis). The surgical procedures they do now if they caught it quick can minimize damage by boring holes into the bone to recreate blood supply and he might be ok.

Trying to put it all together now with what's been reported in the DO by the coach (artery damage) and with Rons friend is reporting here (he's good to go for 2013 as told by Drs.), then the minimal damage scenario is what we and he obviously hope for. My overriding concern is that at this point it's hard to really know the full extent the situation based on the timeline that blood loss orthopedic related injuries go by and seem to follow. I'll hope for the optomistic reports given here.

 

[Cuseregular]

Disagree with Cuseregular. Doing a simple physical exam could have determined it was the hip. Anything in the groin region should be considered hip until proven otherwise.

not always the case. There is NO way the ortho dr. didn't do a hip eval. at some point soon after the injury complete with orthopedic testing, but it likely was non productive. In my line of work, I treat a ton of disc herniations. Half the time the orthopedic evaluations and tests are also not productive and negative. And if and until we do an MRI it won't be definitively identified. Same with this I'm sure. The difference is with the back issues you go with the Rx treating it as a disc problem based on that knowledge because disc problems are SO common with everyone, but with Rons scenario it's different as its so uncommon.

Again this is the last thing you're thinking in routine injury situations (and we don't know if any injury type incident actually happened as it could have been a Bo Jackson like situation based on what I've heard of his strength); so from the get go you're not thinking this and then the ortho eval. doesn't neccessarily show anything until it progresses further. I've been critical of the med staff up there over the years for certain things, but at this point (or if and until I hear more), I'm not on this one.

 

[JeremyCuse]

So you know the extent of the injury and how long there was no blood flow and whether there was any permanent bone death?

Sent from my DROIDX using Tapatalk 2

As a Cuse fan he should know better, I cant tell you how many times we were told no big deal on an injury and the player was never the same.

 

[anglerman]

Y

Not necessarily.

Y

You do a simple physical exam maneuvers and you can determine if the source of the pain is coming from the hip it's not difficult to diagnose hip pain

If a patient has avascular necrosis it's a very painful condition and they will walk with a limp at the very least. Hip injuries are usually very obvious and usually a big deal.

This should have been an obvious diagnosis

 

[anglerman]

Once again I completely disagree with cuseregular. Disc herniations are almost always very obvious and easy diagnoses. If your in orthopedics and can't diagnosis a herniated disc then you shouldn't be in practice.

I would say that disc herniations is garden variety medicine and any competent health care provider should easily be able to diagnose and manage them

A good sports medicine doctor should NEVER miss a diagnosis as major as a avascular necrosis.

 

[alphaorange]

Once again I completely disagree with cuseregular. Disc herniations are almost always very obvious and easy diagnoses. If your in orthopedics and can't diagnosis a herniated disc then you shouldn't be in practice.

I would say that disc herniations is garden variety medicine and any competent health care provider should easily be able to diagnose and manage them

A good sports medicine doctor should NEVER miss a diagnosis as major as a avascular necrosis.

Avascular necrosis is the result of the lack of blood flow for a given period of time. As far as I have read, there is not an indication of that condition at this time. I know if I were a medical professional, I would be insulted by your tone. Perhaps you are also a medical professional, and if so, kudos to you. If not, I might be inclined to listen to people that are. Not even the "easy" diagnosis are always easy.

 

[Rocco]

YY

You do a simple physical exam maneuvers and you can determine if the source of the pain is coming from the hip it's not difficult to diagnose hip pain

If a patient has avascular necrosis it's a very painful condition and they will walk with a limp at the very least. Hip injuries are usually very obvious and usually a big deal.

This should have been an obvious diagnosis

No it is not. This condition is often misdiagnosed due to the masked symptoms. At least that is according to someone I spoke with last night.

 

[JD]

He went out before contact began if I remember correctly, I am going to say it should be correctable given the more traumatc AVN generally s a result of traumatc injury , think Bo's hip dislocation during that tackle. Fingers crossed a simple vascular procedure restored the blood flow.

 

[anglerman]

No it is not. This condition is often misdiagnosed due to the masked symptoms. At least that is according to someone I spoke with last night.

No it's not difficult. Hip pain is hip pain. You make your diagnosis based on physical exam and subjective symptoms.

 

[TexanMark]

Once again I completely disagree with cuseregular. Disc herniations are almost always very obvious and easy diagnoses. If your in orthopedics and can't diagnosis a herniated disc then you shouldn't be in practice.

I would say that disc herniations is garden variety medicine and any competent health care provider should easily be able to diagnose and manage them

A good sports medicine doctor should NEVER miss a diagnosis as major as a avascular necrosis.

anglerman are you a Ortho MD or do you have direct inside info? Just want to figure out why you are so certain cuseregular is wrong...he is one of the best at what he does...of course most of this is speculation from way too little info. Personally I'm hoping for the best and he makes a full recovery and plays in '13 on a bowl team.

 

[Cuseregular]

Once again I completely disagree with cuseregular. Disc herniations are almost always very obvious and easy diagnoses. If your in orthopedics and can't diagnosis a herniated disc then you shouldn't be in practice.

I would say that disc herniations is garden variety medicine and any competent health care provider should easily be able to diagnose and manage them

A good sports medicine doctor should NEVER miss a diagnosis as major as a avascular necrosis.

dude sorry for the tone of this response as I'm mirroring you, but you're completely clueless on disc herniation related issues and the clincial nuances associated with them. How do I know this with certainty? Oh where to start?

First I guess I'll make mention that I personally have an L5 disc herniation I've been dealing with for 15 years following a hoops game (the final straw) at age 35. Been dealing with recurrent LBP episodes since age 22 and with every episode the orthopedic testing evaluation was completely unproductive short of reduced motion issues and spasms found with any generic low back pain syndrome. And there was no consistent radicular leg symptoms and when there was it was infrequent. So now without any certainty with respect to disc concerns (negative ortho findings, no leg Sciatica symptoms characteristic of disc displacments), so what do you do?

Well since my friend runs a local MRI facility what you do is do an MRI and lo and behold there it is, a large L5 disc herniation (Protruding and mostly contained). Not exactly straight forward now is it in that scenario now is it?

How else do I know? Well being a college prof some 22 years now teaching orthopedics, neuro/spinal anatomy/neurophysiology you get a lot of exposure to related issues. For example with being exposed to and sometimes a part of clinical trials and studies; it's a well known fact that over 50% of the population over the age of 35 who are asymptomatic showing no pain symptoms, it's a fact that some 50-55% of them show up as having lumbar disc herniations. According to your logic of how "garden variety" disc hernations are well then all of them should have positive orthopedic findings for disc herniations. Anyone can google this fact and see the multiple studies and we at the college on a smaller scale have confirmed it in our unpublished look at this issue.

Well guess what, they don't. Why? Well this is where nuance comes in with associated factors and variable involved that do not allow for much in orthopedics to be cut and dry and 'garden variety'. Everyones anatomy is different to a certain exent and in the case of spinal issues and discs some people have larger spinal canals than others allowing them to accomodate a disc problem better such that they may never be symptomatic. Worse yet was the fact that until 15-20 years ago drs. used these MRI finding for an automatic reason to do surgery where as in point of fact that particular finding may frequently be coincidental.

This is why they call our professions "practices" because that's exactly what they are in that it is an art and a science. Even if someome is not showing traditional disc signs a competent practioner still has it in the back of their mind, especially so with advancing age and each recurrent back pain episode. Being in a health care practice environment some 21 years now you treat a lot of these cases and learn these facts after thousands of cases.

Furthermore, most textbooks on back pain and orthopedics associated with it will say that of all back pain somewhere around 14-18% of it are related to "disc herniation". These are the people with characteristic signs and symptoms of sciatic radiculitis, reduced lumbar flexion, productive (+) SLR with associated qualifiers (Braggard, Bonnets, Etc), or using your terms these are the "garden variety" cases of disc displacements.

So the astute practioner understands that the generally accepted number of 14-18% of LBP being related to disc herniation is actually ridiculously low and much higher due to nuance of individual circumstances (spinal canal size, type of herniation protrusion vs. prolapse, and the differing vaiable of each patients unique pain tolerance profile). This is how missed diagnosis occur. So very common.

Now with AVN the same nuance is true as well. It takes a while for the major symptoms to show up until sufficient damage is done to allow the diagnosis to finally occur. The pain is subtle at first and not particularly intense at first so it can evade detection do to it's rarity. It's not garden variety this issue and not the first thing that one thinks of with a limping patient who likely hasnt sustained a particular trauma. And when early on the orthopedic evaluaton is still non productive you still don't think about this. However, a few weeks into it (3-5) weeks if the patient is still having issues then it gets into your mind as a possible concern.

Nuance. If you're in health care in your early years you'll start to see it with patients. And if you are in it a while and you're not seeing it it's time to open your eyes.

 

[anglerman]

Look you are providing incorrect information. I don't care what you teach. It's not difficult to diagnose degenerative disc disease my friend I've diagnosed thousands of them and I consider it very simple basic medicine. And by the way I have 3 herniations in my lumbar and cervical spine

You diagnose them very easily based on subjective symptoms and physical exam. It's also relatively easy to diagnose the exact discs involved

I will say again a good orthopedic surgeaon should be able to differentiate avascular necrosis from from a groin strain

That's my clinical opinion and it also fact. This isn't difficult.

 

[Millhouse]

dude sorry for the tone of this response, but you're completely clueless on disc herniation related issues and the clincial nuances associated with them. How do I know this with certainty? Oh where to start?

First I guess I'll make mention that I personally have an L5 disc herniation I've been dealing with for 15 years following a hoops game (the final straw) at age 35. Been dealing with recurrent LBP episodes since age 22 and with every episode the orthopedic testing evaluation was completely unproductive short of reduced motion issues and spasms found with any generic low back pain syndrome. And there was no consistent radicular leg symptoms and when there was it was infrequent. So now without any certainty with respect to disc concerns (negative ortho findings, no leg Sciatica symptoms characteristic of disc displacments), so what do you do?

Well since my friend runs a local MRI facility what you do is do an MRI and lo and behold there it is, a large L5 disc herniation (Protruding and mostly contained). Not exactly straight forward now is it in that scenario now is it?

How else do I know? Well being a college prof some 22 years now teaching orthopedics, neuro/spinal anatomy/neurophysiology you get a lot of exposure to related issues. For example with being exposed to and sometimes a part of clinical trials and studies; it's a well known fact that over 50% of the population over the age of 35 who are asymptomatic showing no pain symptoms, it's a fact that some 50-55% of them show up as having lumbar disc herniations. According to your logic of how "garden variety" disc hernations are well then all of them should have positive orthopedic findings for disc herniations. Anyone can google this fact and see the multiple studies and we at the college on a smaller scale have confirmed it in our unpublished look at this issue.

Well guess what, they don't. Why? Well this is where nuance comes in with associated factors and variable involved that do not allow for much in orthopedics to be cut and dry and 'garden variety'. Everyones anatomy is different to a certain exent and in the case of spinal issues and discs some people have larger spinal canals than others allowing them to accomodate a disc problem better such that they may never be symptomatic.

This is why they call our professions "practices" because that's exactly what they are in that it is an art and a science. Even if someome is not showing traditional disc signs a competent practioner still has it in the back of their mind, especially so with advancing age and each recurrent back pain episode. Being in a health care practice environment some 21 years now you treat a lot of these cases and learn these facts after thousands of cases.

Furthermore, most textbooks on back pain and orthopedics associated with it will say that of all back pain somewhere around 14-18% of it are related to "disc herniation". These are the people with characteristic signs and symptoms of sciatic radiculitis, reduced lumbar flexion, productive (+) SLR with associated qualifiers (Braggard, Bonnets, Etc), or using your terms these are the "garden variety" cases of disc displacements.

So the astute practioner understands that the generally accepted number of 14-18% of LBP being related to disc herniation is actually ridiculously low and much higher due to nuance of individual circumstances (spinal canal size, type of herniation protrusion vs. prolapse, and the differing vaiable of each patients unique pain tolerance profile). This is how missed diagnosis occur. So very common.

Now with AVN the same nuance is true as well. It takes a while for the major symptoms to show up until sufficient damage is done to allow the diagnosis to finally occur. The pain is subtle at first and not particularly intense at first so it can evade detection do to it's rarity. It's not garden variety this issue and not the first thing that one thinks of with a limping patient who likely hasnt sustained a particular trauma. And when early on the orthopedic evaluaton is still non productive you still don't think about this. However, a few weeks into it (3-5) weeks if the patient is still having issues then it gets into your mind as a possible concern.

Nuance. If you're in health care in your early years you'll start to see it with patients. And if you are in it a while and you're not seeing it it's time to open your eyes.

Quack

Sent from my DROID RAZR using Tapatalk 2

 

[Cuseregular]

Look you are providing incorrect information. I don't care what you teach. It's not difficult to diagnose degenerative disc disease my friend I've diagnosed thousands of them and I consider it very simple basic medicine. And by the way I have 3 herniations in my lumbar and cervical spine

You diagnose them very easily based on subjective symptoms and physical exam. It's also relatively easy to diagnose the exact discs involved

I will say again a good orthopedic surgeaon should be able to differentiate avascular necrosis from from a groin strain

That's my clinical opinion and it also fact. This isn't difficult.

So I'm providing incorrect information on my own back experience? Umm, ok.
And are you saying that from day one of injury the ortho dr. up there well regarded and highly experience should have picked this up? From day one?

Now with respect to disc issues you've very subtlely changed the subject. We were talking about disc herniaton and not "disc degeneration" that you changed to. You're absolutely right that disc degenation is very easily diagnosed. A basic exam and eval. with a simple x-ray will show this no doubt. And with that in mind though, many people with this condition similarly are not symptomatic even though they have it...

http://www.folsomphysicaltherapy.com/imaging_of_lumbar_degenerative_disc_disease.pdf

go right to the conclusion on page 23

Furthermore, these degenerative disc cases are also concommitant with disc hernations which complicates the clinical picture greatly. And no doubt you know that xrays are pretty much useless to show this part of the story (the internal aspect of the disc). So this is where MRI comes in to give us a definitive diagnosis that will help with treatment.

I"d like to do them in all suspected cases of LBP due to disc displacements but as I'm sure you're aware, insurance issues make this a non starter and thus experience and, again, the nuance art/science and experience aspect of practice must lead us in Rx.

This because of what you say is only sometimes true. At the risk of repeating myself not all disc herniation patients show characteristic symptome. For example, if they did show traditional symptoms, as you know, the herniated disc would be accompanied by certain characteristic and consistent physical findings as well as productive orthopedic testing.

For example, a L5 herniation would be associated with an S1 reduced myotome (weak gastrocs, foot everters), dermatome changes (reduced or even loss of feeling over the side of the foot, dorso/lat calf), and reflex changes (loss of the ankle jerk). Similar circumstances with different anatomy for other disc levels in the spine.

Problem is of course that often times all of this together isn't the case as I outlined in the post above. So we send them when we can for MRI and we still find some version of disc herniation but not to the point always of causing characteristic symptoms. This again to the unique variables and nuance involved.

I'm certainly not providing innaccurate information rather just providing what is commonly known now among modern providers/clinicians and research professionals. Are all the following providing innaccurate information too?

http://home.comcast.net/~jasoncillo/Lumbar.pdf

http://www.acr.org/~/media/889E0EC394D642B6B2AF7379357B4E57.pdf

http://www.ncbi.nlm.nih.gov/pubmed/8208267

http://ukpmc.ac.uk/articles/PMC2465278//reload=0;jsessionid=uxwX4TagEcmfjoVpSMM7.6

http://www.alignthespinechicago.com/herniated-discssciatica/

http://longbeach.patch.com/groups/d...ck-pain-its-probably-not-your-herniated-discs

http://www.rebuildyourback.com/herniated-disc/pain.php

A couple on AVN and how hard it is to diagnose:

http://www.ncbi.nlm.nih.gov/pubmed/912968

http://emedicine.medscape.com/article/333364-clinical#showall

http://orthodoc.aaos.org/MarkKatzMD/AVNStrikesYoung.htm

 

[MaxwellCuse]

^^Not to make light of things but this is one reason why Marrone usually refers to them as LBIs and UBIs.

 

[Cuseregular]

Quack

Sent from my DROID RAZR using Tapatalk 2

enema and colonoscopy....

 

[qdawgg]

enema and colonoscopy....

Everyday for a week.

 

[bothsocksup]

I want my 4 minutes back

 

[Cuseregular]

I want my 4 minutes back

your "4" minutes? I want my hour and 4 minutes back it took to put all that together!

 

[Chip]

enema and colonoscopy....

It was awkward when the doctor finally said "sir, this is not a nightclub."

 

[bevosu]

"each patients unique pain tolerance profile"-an interesting variable.

As a layman with a high tolerance for pain I think anybody who thinks they can easily diagnose spinal (disc) injury is a practitioner that I'd want to stay away from.

Everybody is unique. Lots of people don't feel the same level of pain as others. It's easy and understandable why a practitioner would and will overlook various possibilities, given that the patient may not feel the same level of discomfort another patent would (with the same condition).

 

[Shenexon]

This has been a fascinating thread. Judging solely from the demeanor of the posts by the two medical practitioners trading posts, I'd prefer to have Dr. Cuseregular evaluating my issues. I've never found any medical condition to be "simple" and orthopedics seem more complex than most. My main concern would be the enema and colonoscopy treatment, but I hope that's a "special" treatment for "special" patients.