The Role of Second Opinions

Second Opinions

After over 40 years practicing the science and art of podiatry, I fully appreciate the role of second opinions for treatment of injuries. I am fortunate to work at an institution (Saint Francis Memorial Hospital in San Francisco) where second opinions are almost second nature. But, this is not the norm. I believe getting a second opinion for orthopedic/podiatric surgery is really a no-brainer, unless you are stuck in an emergency situation. But for most cases of elective foot and ankle surgery or difficult to treat non-surgical pain syndromes, getting at least two opinions can be helpful. It is ideal that a non-surgeon (podiatrist, therapist, primary care physician, sports medicine physician) helps you decipher the recommendations of two surgeons before you go under the knife. This is the ideal world, but hopefully, you can get this type of ideal treatment. For most patients and doctors, that is way too much work to do. But, you cannot go back and reverse a surgery. Even when the two surgical opinions are identical, you will develop a feel for which surgeon you want to do the surgery. Find out how their surgical approaches are different, and what differences there are in the postoperative treatment. Second opinions for complicated non-surgical problems are less commonly done. But, the approaches of physicians can be so different that they should be done when improvement is stymied. If a doctor/therapist ever implies that you will not get better because of your age, definitely get another opinion. Age can be a factor, but normally only a small part of a slow healing process. Take an active role in your own care; at least you and your family will have fewer surprises in the process. And, never tell one surgeon what the other one says. You want an independent opinion. I tell most of my patients that really we are getting a second opinion on what should be done next. I am surprised when orthopedists and podiatrists that I am using for second opinions recommend another direction in the conservative treatment that I had not thought about. These opinions are worth their weight in gold. 

Golden Rule of Foot: It is best to have a non-surgeon say, “You really need elective foot or ankle surgery,” since surgeons tend to be so selective on who they cut on.

This is an excerpt from my book: Secrets to Keep Moving

Toe Hyper-Extension Injury with Fractures (Including Jones Fifth Metatarsal Fracture): Email Advice

Hi Dr Blake.

     I've been reading your website/blogs for the past 5 months waiting for my right foot injuries and fractures to heal. I'm completely confused about what's going on with my right foot and can't get any straight answers from my doctor. 

    The night I got injured, I guess I lifted my right foot a little higher than usual (I had fallen asleep on the couch) and my toes caught on the decorative and rough transitional tile on our floor causing all of my toes to completely bend under my foot while my body was still in the forward gait movement. I felt pain across the top of my toes (which is weird because the top of my foot shouldn't be on the floor) and when I went to complete the step and put my foot down, the pain was incredible. I fell forward and caught myself on a table before falling to the floor. My foot was in agony and I could not put any weight on my right foot. There was a lump on the side of my foot (base of 5th metatarsal) and cuts across the top of the 4 lesser toes. I guess my toes got crushed under my foot from my weight dragging across the tile floor. 
Dr Blake's comment: All of the tendons that go into the tops of the toes would have been over stretched giving you the pain on the top of the foot and even into the front of your leg. 

    When my husband took me to the doctor and x-rays were taken, he told me I did have a fracture and then said "multiple" fractures. He said I fractured the base of the 5th metatarsal and called it a styloid process fracture.  He didn't say where the other fractures were. He also said I sprained my ankle. He never checked my toes or forefoot. He said I had an easy fracture and I'd be good to go in 6-8 weeks. He gave me a walker boot and said to ice and elevate as much as possible. 
Dr Blake's comment: This is a common problem in medicine. The most obvious injury is recognized, but we all know that the golden rule is "It is better to break a bone, then sprain a ligament." You probably have a lot of soft tissues sprains and strains. This is such an unusual injury, that no specialist will have much experience with it. 

    I had been brought into his office in a wheelchair because I couldn't walk and didn't have crutches, so I was surprised that he thought I could put that boot on and walk out of there. My husband told him again that I could not put any weight on my foot and asked him for crutches and he told us that if we really thought I needed them we could purchase them ourselves at a medical supply store. After 4 weeks, new x-rays, and he said fractures (plural) were healing and to get out of the boot and put a sneaker on. What? By this time my foot was 3 times the normal size and the top of my foot under the skin was blue across all the metatarsal bones. The swelling on the bottom of my foot was horrible - my toes never touched the floor - and I couldn't bend any of my toes. When we pointed this out to him that my foot was getting worse and we were worried about lack of circulation, he told me to wear a post-op shoe instead of a sneaker. He forgot about the ankle sprain and I never was able to wear the post-op shoe because of the pain in my ankle.  Seriously.
Dr Blake's comment: Okay, he/she is clearly treating mentally only one part of the injury. If the metatarsal fracture was the source of all your problems, you would be fully pain free weight bearing by this point. Definitely, you need an MRI to make sense of the soft tissue part of your injury. 

    At 8 weeks, my foot was now 4 times it's normal size, still blue under the skin across the metatarsal bones, bad pitting edema, tension and strain in big toe, 2nd toe and 3rd toe. The 4th and 5th toes seemed dead, still can't bend them, and there was a horribly painful spot between the 4th and 5th toes on the bottom. Doctor took new x-rays and said all the fractures were healed. He said the biggest fracture still needed a little more time but it was basically healed. He said to put a shoe on and walk. Now I'm thinking I'm crazy. Why doesn't he see what my foot looks like and that it's ice cold! He still did not check any of my toes or my forefoot or my entire foot and ankle.  He was basing everything on the x-rays and the "protocol" for the type of fracture he said it was. He went on vacation and my foot got worse so his office had us see another doctor.
Dr Blake's comment: Hooray!!! As patients, we have to be our own ombudsmen. All doctors, including myself, get tunnel vision sometimes. Many times I am shocked when at a followup visit I thought the patient would be perfect, and they were much worse. So, that is when you have to look deeper, and look for something else. Unfortunately, when you look at treatment plans in text books, they mainly talk about one injury at a time. This is difficult when patients present with injuries, like yours, that can have 6 or 7 different injuries at once, some needing different treatments. 

    He said I had a couple fractures at the base of the 5th metatarsal and one was a Jones. He ordered an MRI and told me start non-weight bearing. The MRI said transverse fracture going all the way through the bone was UNHEALED. I was told to stay non-weight bearing and start bone stim. Nothing was done about the pitting edema in my foot or the circulation. The 2nd doctor didn't check or touch my foot either. We asked the doctor what he was going to do about immobilizing my foot to keep it from moving and from me hurting it. He gave me an ankle tubigrip thing. How was that going to protect my foot?  He said I was non-weight bearing so I didn't need anything but that. I didn't understand why they weren't doing anything about the circulation issue and swelling in my foot so my husband took me to a local medical supply place and they recommended a knee high compression stocking to wear. After 3 days, the swelling and pitting edema was a lot better on top of my foot.
Dr Blake's comment: At least you are starting to move in the right direction. Jones fractures may not heal and could require surgery. You need to find a doctor who does that type of surgery that you trust. We know you have a Jones Fracture, but you also have swelling out of control, and other soft tissue injuries. Did the MRI speak on any injury at your toes/tendons/ligaments? Remember, swelling is made worse by removable boots, non weight bearing, pain, improper compression, so there are a lot of normal things that can be making the swelling linger too long. I am always fighting getting the swelling under control. Swelling is our enemy, it definitely slows healing, and makes the pain in an injury last longer. So, perhaps a good physical therapist could review things for you and start a better program of combatting the swelling. 

 The swelling across the metatarsals on the bottom of my foot, the tension and strain through my first 3 toes, can't bend toes, etc. still a problem. And the head of the fifth metatarsal bone is very painful. They haven't checked to see if there are stress fractures in any of my toes or the other metatarsal bones. Every time I bring up the issue of my toes not being able to bend and the stress and tension through my toes, he tells me there's nothing wrong and there's no soft tissue injury because the MRI would have shown it. Of course, he won't physically touch my foot to check for himself.  I've been dealing with this since March 18th and have been non-weight bearing for over 3 months now using the bone stim. 
Dr Blake's comment: I have many patients leave me for various reasons, some I am very sad about. I probably order more second opinions on my own patients than any doctor in my practice. Why are you staying with this group? Why not at least get another opinion? I would have had at least 2 by now. 

I have no idea if the fracture(s) is healing and no idea how much longer he plans on keeping me non-weight bearing. If he has a "plan" he's not sharing it with me. Like the 1st doctor in his office, they have tunnel vision about the base of the 5th metatarsal fracture and are blind to what else is going on with my foot and ankle. I'm a prisoner in my house because I can't walk or drive. I can't be up using the crutches more than 5 minutes because my left hip now gives out on me.  This seems really crazy and not normal.  I would truly appreciate any suggestions you might have. I have the digital x-rays that were taken and would be happy to e-mail them to you if you would like to take a look.  Again, any help would be greatly appreciated to stop this insanity.  Thank you. 
Dr Blake's comment: I would look at the AAPSM website, go under membership, and find someone in your area. I will be happy to look at the MRI, but you need someone local. This is not normal. You need several opinions. The doctor patient trust is broken. Once broken, it can not be fixed easily. So, start a new. The new person can get ahold of old x rays and MRIs. You need a new foot person, a physical therapist, a pain management specialist, and, in California, a sports psychologist. If you want to send me the MRI, send to Dr Rich Blake, 900 Hyde Street, San Francisco, CA, 94109. I hope this helps some. Rich

Ganglion Cyst Mimicking Sesamoid Injury: The Positive Role of an MRI

This young lady emailed me back in Dec 2012 to let me know that she fractured her sesamoid bone and was scheduled for surgery and should she seek another opinion. Her original email is at the bottom of this post. I encouraged her to get a second opinion. She cancelled the upcoming surgery and followed her gut. What was so different from other cases of sesamoid injuries was her feeling she was stepping on a golf ball. She was able to get another opinion and a MRI documenting the ganglion cyst with no fracture to the sesamoid. 

Dr. Blake,

 I am so sorry that is has taken so long to get back to you but I had an MRI yesterday and I am attaching 2 images. The Dr. suspected and the MRI confirmed that I don't have a sesamoid fracture but a very large ganglion cyst in my foot. I have been scheduled for surgery the end of May to remove the cyst and start the recovery process. Thank you so much for your encouragement to seek a third opinion, I consider you my second opinion,  I truly believe you have saved me a lifetime of suffering. 

Sincerly,

Large Ganglion Cyst is seen next to a totally normal sesamoid

Large  Ganglion Cyst noted on MRI under the first metatarsal near the sesamoids

Dr. Blake,

I was diagnosed with a fibula sesamoid fracture on my left foot. I feel like I am walking on a golf ball and that is what I call it now. I walk on the side of my foot to keep the pressure off of the ball of my foot but that is causing knee pain and hip pain.  The podiatrist that I saw took one set of x-rays sold me cushions for my shoes and arch supports to wear. I tried those for 2 weeks and no relief. When I returned to the podiatrist he suggested since the arch supports provided no relief that I try a cortisone shot. The shot took the inflammation out of my foot, for about a week,  so it felt like the golf ball went away but the pain was more severe since there was not any extra padding on the ball of my foot. I returned to the Dr. 2 weeks later and he said there is nothing else he can do surgery is my only option and sent me home. I feel after reading your blog that I really need a second opinion before I let anyone do surgery on my foot. My question is do I get that second opinion from another podiatrist or do I try to see an orthopedic doctor? I am scheduled for surgery on December 28, 2012. Any help or advice is very much appreciated. I have cried with my husband over this whole situation and how frustrated I am please help. 

Sincerely,

Second Opinions

Second Opinions: Musings from a Footstool #1

After over 30 years practicing the science and art of podiatry, I fully appreciate the role of 2nd opinions for treatment of injuries. I am fortunate to work at an institution that 2nd opinions are almost 2nd nature. But, it is not the norm. I believe getting a second opinion for orthopedic/podiatric surgery is really a no-brainer, unless you are stuck in an emergency situation. But for most cases of elective foot and ankle surgery, getting at least 2 opinions can be helpful. It is ideal that a non-surgeon (podiatrist, therapist, primary care physician, sports medicine physician) helps you decipher the recommendations of two surgeons before you go under the knife. This is the ideal world, but hopefully, you can get this type of ideal treatment. For most, that is way too much work to do. But, you can not go back and reverse surgery. Even, when the two surgical opinions are identical, you will develop a feel for which surgeon you want to do the surgery. Find out how the surgical approaches are different, and what differences are in the post operative treatment.
Second opinions for complicated non-surgical problems are less commonly done. But, the approaches of physicians can be so different that they should be done when improvement is stymied. If a doctor/therapist ever implies that you will not get better because of your age, definitely get another opinion. Age can be a factor, but normally only a small part of a slow healing process. Take an active role in your own care, at least you and your family will have less surprises in the process.