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The Physical Exam Can Be Pretty Important

I just learned a valuable lesson.

A friend of mine described some fluid build up in her knee, made worse by exercise. She said she had seen an orthopedist who recommended surgery… and she wondered what I thought. Based on her description, I assumed that she had an acute knee effusion – potentially from some recent exercise-induced ligament or meniscal damage.

My friend said that she was concerned about having surgery, and that she was planning to have an MRI first. I must admit that I was a little bit confused as to why surgery was recommended so quickly, without having the MRI results to confirm the cause of the effusion (and that surgical correction was warranted). My knee jerk response was to question the clinical judgment of the orthopedist, and to wonder if he was too “surgery happy” and was leading my friend away from conservative measures (of which I am a great fan).

Several weeks passed, and I finally met my friend in person for a quick look at her knee (she was still waiting for the MRI). Guess what? She did NOT have a knee joint effusion at all. What she had was an almond-sized ganglion cyst on the side of her knee.

I felt pretty silly. Of course the orthopedist recommended surgery (a tiny procedure under local anesthetic) without the MRI. He was indeed offering the appropriate treatment.

Sometimes a picture’s worth 1000 words. And sometimes the physical exam can make the diagnosis – no other studies needed.This post originally appeared on Dr. Val’s blog at

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3 Responses to “The Physical Exam Can Be Pretty Important”

  1. DermDoc says:

    I had to laugh when I read this; I cannot tell you how many times I try to diagnose a rash on one of my family members by phone. I would add that a camera phone picture is worth only about 450 words.

  2. Number One Dinosaur says:

    Similar case (in principle): Mentally challenged woman complained of pain “down there” over the weekend, via phone. I recommended sitz baths, only to find on physical exam that what she actually had was a hernia.

    OTOH, I would still fault the ortho for not explaining the diagnosis to the patient well enough for her to convey it accurately to you. Or…should I fault you for recommending (or agreeing with the need for) an MRI without an exam?

  3. ValJonesMD says:

    Dear Dino,

    Guilty as charged! The orthopedist didn’t explain things too well, and I was complicit in approving of an unnecessary and expensive test. One can often diagnose a problem by history alone, but not always. Great example – hernia. In this case a camera phone would have helped immensely, DermDoc.

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