When will I get back to normal is a hard question to answer, even for a good do

[Guest guest]

Tuesday, Nov. 14, 2006

It's All About the Timing

When will I get back to normal " is a hard question to answer, even

for a good doctor

By DR. SCOTT HAIG

" How long is this going to lay me up, doc? "

In the office for something elective or in the ER for something

urgent, this is usually the first question I get after explaining

what's wrong and how we're going to fix it.

Break your wrist? Six weeks in a cast then six weeks of exercises.

Carpal tunnel? Ten days with the surgical bandage-if you have a desk

job, you can be back to work that afternoon but you can't hold a

racquet for three more weeks. I try not to sound like a waitress

rattling off tonight's specials but after 22 years, sometimes I

can't help it.

" But when will I be back to normal-out of pain? " This is a far more

difficult question.

Like most orthopedic surgeons, I primarily treat pain. Pain is

never " normal " and it's almost never gone on schedule; medical

judgments about how long it will take to go away are hard to make—

and often wrong.

is pretty, very thin, 13 and loves to dance. She has been

en pointe for a year. Hers is the collected smile, extended neck and

slightly out-toeing gait of a serious ballerina. I can guess why

she's in my office: her foot hurts. She walks without pain, goes to

school, even gets through gym class pretty comfortably—but she can't

dance. A big dance recital is coming up—dancers from the famous

ballet company in the city will be there to watch her—and she wants

to be " back to normal " by then. She and her Mom want to know when

this pain will go away.

When I touch her long, skinny foot, it hurts at one particular spot.

This is where it hurts when she tries to dance. The X-ray at first

glance is normal, but if you look very carefully there's a little

disruption of the lace-like pattern of the bone's spongy internal

architecture at exactly the spot where it hurts. (This X-ray, by the

way, was read as " normal " by the radiologist. Only an MRI or bone

scan will reliably show the fracture to someone who has not had the

opportunity to examine the patient and focus on the one tiny spot.)

has a stress fracture of the cuboid-the squarish bone on

the outside of the hindfoot. These fractures are not common but I've

seen a few in dancers and gymnasts. Stress fractures are tiny cracks

in bone that seem to occur simply because the substance of the bone

itself can't take the stress that's being applied—pretty much the

way a paper clip you keep bending back and forth will weaken and

turn whitish at the bend before it breaks in two. That white spot is

a stress fracture of the metal. Bend it a few more times and the

paper clip breaks in half—a completed fracture.

There's a lot of confusion in the lay world about

fractures. " Broken " and " fractured " mean the same thing. And a

stress fracture is not something about which most folks have any

intuitive feeling. So I have this dialogue whenever someone has one:

" It's starting to break-like the paper clip, " I say.

" But its not really broken? "

" A tiny bit-yes it is. "

" But it hurts so much "

" Well it's your bone, it's alive and has nerves. Ever get kicked in

the shin? "

" But if it's alive why doesn't it get strong enough to deal with the

stress and not fracture? "

" We don't know. All we do know is that the stress you gave it was

too much, too soon. "

" So when's it going to get better? How long is this going to lay me

up? "

It would be great if the timing issue were as straightforward as the

treatment. Treatment of stress fractures is pretty easy.

Immobilization or rest—basically avoiding the stress that caused the

fracture— usually gets them to heal within six weeks. In a child it

might be faster, in an older person probably a bit longer.

But how long does a foot take to stop hurting? Particularly in a

time-stressed little girl from a high-power suburban school, drawn

to the difficult world of classical dance? There are many reasons,

both physical and mental, for this thing to hurt for a long time. I

put into a big, bulky but very secure foot and ankle brace.

At three weeks she was a little less tender but definitely not

better-so back in she goes and I'm now the bad guy-no recital. Her

mother is sharp, though; I don't have to threaten with crutches and

operations to get her on board with me on this.

And comforts me when I say I'm sorry about keeping her out

of dance for another three weeks: " It's ok-It's nice to be home in

the afternoon. I read and play games, I have a life. " This is a

little embarrassing for both adults in the room; my kids are

overworked too. Another timing issue. Broken feet often hurt regular

people for months after the bones are healed. Our saying is " Foot

pain is low back pain of the extremities, " meaning many patients

with foot pain, like chronic back patients, never get better, no

matter what you do. So we treat it with respect. I have seen a

stress fracture of the foot keep a middle-aged woman hobbling in

pain for over a year. Every doc in my field has experience with

schoolgirls whose mysterious foot and leg pains are relieved only by

a doctor's note that gets them out of gym.

On the other end of the unrelieved spectrum are the non-compliant

adolescent patients who sneak the forbidden activities and never let

the fracture heal. But seems pretty together, I get the

strong impression that she wants to dance and the X-ray, which I

have now examined with a magnifying glass, definitely shows the

fracture. " How long will it take? " I suggest " 40 days and 40

nights " —that's the basic six weeks, less two days for her youth-and

it has a kind of prophetic ring. " Are you sure? " " We'll see " . A good

sense of timing is the primary mark of a good doctor. How long can

the fever stay this high before we hospitalize? Should we use a few

more days of antibiotics? When do you tell the woman in labor to

come in to the hospital? Tell the aging man it's time for his knee

replacement? The family it's time for a hospice?

Scarcely any time is spent on questions like these in a medical

education and if I were to say, " ok, I'll fix that " I don't know

where I would begin, how I would teach it, especially to young

people who just haven't felt as many months trickle though them as I

have. I wish I could because there is a deep and enchanting thing,

sometimes beautiful, about people as they step skillfully with time.

It's some kind of dance, maybe a lot like 's.