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Introduction

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I messed my left knee up in my freshman year, and my right knee in my sophomore year [both in soccer]. A year and a half after the injuries, I finally couldn’t take it anymore. My doctors originally thought my quads were weak, causing patella subluxation. After four months of therapy and getting worse, my doctors decided to check an MRI, after they decided I had meniscus tears. When the results came in, they realized I had double anterior cruciate ligament tears. The symptoms are very alike, from what they’ve said, so they can’t be blamed for me getting worse. Make sure your doctors are at least 90% sure.

“Guest China” at http://sportsmedicine.about.com

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A regular presentation in sports medicine is that of a patient who has already consulted a number of practitioners for diagnosis and treatment about what appears to be a musculoskeletal problem but whose symptoms remain unresolved.

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Presentations of patients with longstanding symptoms may include:

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  • chronic low back pain or neck pain

  • persistent tendinopathies

  • multiple painful sites

  • a persistent joint problem

  • a non-healing fracture

  • persistent foot pain.

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Longstanding symptoms may be due to a multitude of other conditions that masquerade as sports injuries (Chapter 7), but they may also be true musculoskeletal problems. We also suggest that the reader review Chapter 6, which discusses the perception of pain.

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The purpose of this chapter is to provide a clinical approach to the “difficult” presentation. We do not suggest we have the answers for all, or even most, such presentations. Nevertheless, a systematic approach to this presentation improves the chances of a successful clinical outcome. We use case histories (boxed items) to illustrate our suggestions. Unresolved problems generally present as (i) a diagnostic challenge, or (ii) a therapeutic challenge, so the chapter structure reflects this.

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Diagnosis—is it correct?

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There are several possibilities to consider in a patient who fails to get better. Most importantly, is the diagnosis correct? Patients will only completely respond to management when the proper diagnosis has been reached and the proper treatment has been given (and followed). A careful re-assessment is always indicated in the patient who has failed to improve. This will include reviewing the history and physical examination, as well as personally reviewing the pertinent imaging studies, in consultation with the radiologist if necessary.

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Some conditions that can be easily misdiagnosed are listed in Table 41.1. On some occasions, patients are presumed to have a straightforward case of the condition listed as an “obvious” diagnosis when they actually are suffering from the condition listed in the second column of the table.

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Table 41.1

Some conditions that are not what they appear at first

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