Talking Rehab with Dr. Fred Bagares

The Pathology Pivot

• Fred Bagares • Episode 56

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In today’s episode, I dive into a fascinating case that changed the way I think about diagnosis and treatment. I share the story of a patient with chronic lateral foot pain who everyone thought had a tendon problem—but it turned out to be something completely different. This experience taught me about what I now call the "pathology pivot"—how we tend to assume our diagnosis is correct if the treatment works, even when it might not be.

If you're a clinician, therapist, or even just someone who’s been on a confusing healthcare journey, this one's for you.

Timestamps to Navigate the Episode:

  • [00:00] – Introduction: Who I am and what this podcast is about
  • [00:35] – The case begins: Chronic lateral foot pain without clear trauma
  • [01:40] – The original (incorrect) diagnosis and why it made sense
  • [02:54] – Why the MRI and ultrasound told a different story
  • [03:28] – The real cause: A small overlooked nerve
  • [04:34] – Discussions with surgeons and therapists: Skepticism and resistance
  • [07:00] – Introducing the concept of the "Pathology Pivot"
  • [08:01] – Why getting better doesn’t always confirm your diagnosis
  • [09:30] – Real-world examples of treatment success not meaning diagnostic success
  • [11:02] – How outcome bias affects clinicians and patients alike
  • [13:00] – Final thoughts on mental errors we all make in healthcare

Thank you so much for listening! I hope this episode helps you think a little differently about diagnosis, treatment, and patient care.
 If you enjoyed it, please like, subscribe, and share it with a friend or colleague!

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What is rehab or rehabilitation? My name is Fred Begaris, a board-certified sports and spine medicine physician in Virginia Beach, Virginia. After 10 years of practice, I still find musculoskeletal medicine both fascinating and challenging. This podcast is about the lingering thoughts and questions I've had after residency and fellowship. My hope is to spark discussion, challenge dogma, and share my experiences in musculoskeletal medicine. Welcome to the Talking Rehab Podcast. A couple years ago, I had a pretty interesting case of lateral foot pain. I was asked by one of my colleagues to see a personal friend of theirs where this particular person had a two-year history of chronic lateral foot pain. And this person had symptoms after a kind of non-traumatic event. It was interesting because the only thing they could attribute was before the onset of symptoms, they were putting things away on a ladder for a long period of time, kind of on their tippy toes. And about a day and a half later, they started noticing that they're getting this ankle pain or foot pain, and things just got progressively worse from there. So they ended up going through the typical channels. They saw orthopedic surgery. They saw podiatry. They ended up going into physical therapy. And essentially, they just didn't really get any better. And so I was asked by my colleague to take a look at them. And the presumed diagnosis at that particular time was a perineal insertional tendinopathy. So right at the base of the fifth metatarsal of the foot. And when I saw them, very tender to palpation on the lateral foot. And anyone that's treated perineal tendinopathy in that particular part, they have very typical symptoms, point tenderness, a lot of pain with eversion of the foot. And so any activity, standing, walking, running, eversion is a big part of that type of motion. So resistance to that motion provokes symptoms. And there was a little bit of a numb sensation, but it was predominantly pain. Prior to this, no history of surgeries, no nothing. Very healthy athlete. Actually played collegiate sports. It was a racket sport, I believe. But aside from that, very healthy. And upon talking with them, I was, they had MRIs of the foot, which didn't show any evidence of tendinopathy. I thought that was interesting. That was the presumed diagnosis. That was a tendonitis, tendinopathy. But that happens a lot in medicine. I have ultrasound in my practice. And I looked at the tendon very closely. And I could see clear as day that the tendon was super healthy. Even for a former collegiate athlete that's still physically active, no evidence of tendinopathy, like nothing at all. And so I ended up finding that there was actually a very small nerve right around the insertion of the perineal tendon, which was the dorsal cutaneous lateral branch of the foot. And as I'm talking with the patient, I'm essentially pushing on this particular nerve. And I can see it on the screen flipping back and forth. And they're saying, that's the pain. That's the pain. Whatever you're doing right there, that's the pain. And so I had them do the typical perineal tendon testing, and they were getting reproduction of their symptoms. So I can see how basically everybody before me thought that this was a perineal tendinopathy or tendinitis because it acted exactly the way we would expect it to. However, I found that the tendon was fine, the MRI of the foot showed that the tendon was fine, but I did find this one small nerve. Now, MRIs, for those of you who don't know, do not typically show very small cutaneous branches, and particularly pathologic ones. So I gave my findings to the patient. They were very happy about it. And I decided to go back to my friend and say, hey, this is the actual problem. And so they're a surgeon. So I asked them, I said, what would you do with this particular nerve? And have you ever seen this as an actual problem? And they basically said that they had never seen this as a problem. But they also looked very skeptical at my conclusion. And I showed them the images and everything. And this is a chronic issue. So I threw out a theoretical. What if this was the actual problem? What would you do? And they just threw out a lot, probably just remove it. And that seemed like just pretty typical surgeon answer. I thought it would be best if I asked other people, what else do they think? So I actually was able to talk with a physical therapist that they had worked with the most. And I gave them my findings. And I said, thank you for working with this patient. I wanted to get your thoughts because I actually don't think that this is a perineal tendinitis or tendinopathy. There's a very small nerve in this particular area. And I proceeded to tell the whole story. And essentially, I wanted to know from their standpoint, if this is a nerve problem, how does that change your approach from a therapy standpoint? Because presumably, I'm not a physical therapist. But I would assume that if someone has a nerve problem versus a tendin problem, the approach may be different. So that's what I was hoping to get out of the conversation. That was the whole point. I started to talk to them about it. And very quickly, the therapist said, well, you know, I've never heard of that before. I'd have to do my own research. I'd have to see the images because this acts like a tendinopathy. And I said, I agree with how it presents. But is it possible that assuming there's a nerve in this area, how would you treat it? And they were very resistant to the idea that this might be a different diagnosis. And I understand. I understand why they would be a little bit defensive of their position. They were saying, I would have to do my own research. And I'd have to look this up and see the images myself. And I was like, what other information do you need? The MRI clearly says there's no tendinopathy. I'm telling you the ultrasound does not show any tendinopathy. And I'm also pinpointing the nerve and reproducing the exact pain while they're on the table. As a matter of fact, when you do the tendon testing that is positive in tendinopathy or tendinitis, I can actually see the nerve is flipping back and forth over the tendon. So it's hurting where the tendon attaches, but it's not the actual tendon. And I thought I was actually going to have a very constructive discussion. And I can tell that it was not received well. Well, this is pretty much the story that led me to the idea of what I'll call the pathology pivot. And the pathology pivot is really based on the assumption that the treating person is correct as long as the treatment works. And what I mean by that is let's say that you have a basic knee problem. All right. No trauma, no nothing. We do. We assume that this is a, let's say, a patellofemoral syndrome, something relatively non-surgical and very benign. We do physical therapy. They're doing better. And we're happy with it. And then we say, I'll just follow up with me in a couple of weeks. And then all of a sudden, they come back in a couple of weeks and the pain is not only back, but it's actually worse. And all of a sudden, the thought is maybe it's not patellofemoral syndrome. Maybe it's something else. And the reality is that it could have been something else from the beginning. It's just that the person was responding to the initial treatment. And so your assumption is that the problem is what you thought it was. And so in the setting of the treatment not working, all of a sudden, you draw the conclusion that it couldn't be my previous diagnosis. It must be something else, when in reality, you could have just misdiagnosed them in the beginning, and they just happened to get better. And this is not necessarily exclusive to clinicians making this type of mental, I don't want to say mental error, but it is a kind of a bias. We have a tendency to associate success with confirmation of diagnosis. And that's not always the case. Another great example is when people take an anti-inflammatory for a pain problem. The fact that they respond to the treatment or the fact that they respond to an anti-inflammatory does not confirm that this is an inflammatory problem. Sometimes the pain just gets better. Because I've had patients where they'll take an anti-inflammatory for knee pain and say, oh, the knee must be really inflamed. And then they take a Tylenol, which is not an anti-inflammatory, and they get the same pain relief. And they don't draw the conclusion that this is a non-inflammatory issue. I think that this is a really important kind of bias that we all need to pay attention to because it's very easy to fall into the trap of success. Essentially, it's almost outcome bias, where just because people are responding the way that you hope they would doesn't mean that your theory is always correct. And it's an interesting clinical scenario where people can be getting better, but not necessarily because you're correct. I think that's actually important because at the end of the day, humans, for the most part, are just happy to feel better. As long as they're not missing something huge, they're okay, as long as they're getting better. But especially in this new age of social media, there's a lot of information out there. And a lot of people get better with kind of general recommendations, which is great. But then when you tie it to a particular diagnosis, it doesn't necessarily confirm your suspicion all the time. There are such things as diagnostic tests. But in this particular example that I started with, this particular person looked and acted like a tendon-related problem. That was the presumed diagnosis across the orthopedic surgeon, across the podiatrist, across the radiologist, across the physical therapist. They all said that this acted like a perineal tendinopathy, perineal tendinitis. Now, in this particular example, everyone called this a tendinitis, which is on the spectrum of disease. It's a mild course or form of disease. But prior to ordering the MRI, the language that was used by the clinicians was that this was a mild disease. But as they were not responding to treatment, they described this as a tendinopathy or a severe tendinopathy, unresponsive to treatment, which is what justified the ordering of the MRI. However, the MRI did not demonstrate that. My ultrasound evaluation didn't represent that. And I gave them the actual diagnosis, and they still didn't necessarily believe me, even though myself and the patient could clearly see that the nerve was bouncing back and forth, and she was saying, ow. This case was several years ago, and I couldn't really wrap my head around it at the time, but now with more experience, I've now coined the term the pathology pivot. And the pivot isn't always necessarily a correct one. That's the other piece of it, is that even in the face of successful treatment that stops working, we automatically assume that it must be something else that's going wrong, which is why my treatment is not working. But in reality, sometimes your treatment, despite being a good diagnosis, just doesn't work. So, again, it almost is like a mental, it's mentally healthy for us to believe that our treatments always work because we're always right, but the reality is that sometimes they work even though we're wrong. But I thought that this was kind of an interesting case to bring this up because the more experience I've been getting over the years and the more I talk with physicians and physical therapists, I can see that mental error that we all make sometimes. And again, I'm not in the business of correcting people right then and there. I'm just throwing this idea out into the universe, wondering if someone is going to hear this and realize that they are making the same mental error. Because I do it, we all do it. This is a human error of cognition. So, anyway, thought I would share this one, just an interesting case. Talk to you guys soon. Thanks again for listening. Thank you for listening to the Talking Rehab podcast. I hope that this podcast stimulates you to question your own practice and how you approach rehabilitation. I truly appreciate your time and attention. If you enjoyed listening, make sure to like and subscribe to the podcast. I wish you a movement-filled day. Take care.