Delayed Response After Injury

By Brian "Steve" Keen D.C.
I have heard many times throughout my career that a delayed response to treatment after a personal injury can be very difficult to prove.  One must do some further investigation to give the particular injury its due credibility.  The provider must look at:

  1. THE MECHANISM OF INJURY,
  2. CONSIDER THE EXACT SUBJECTIVE COMPLAINTS,
  3. LIST THE OBJECTIVE FINDINGS
  4. COME UP WITH A PLAUSIBLE DIAGNOSIS,
  5. ASSESS THE PROGNOSIS AND CONSIDER THE CLINICAL PICTURE IS VALID,
  6. PROVIDE A TREATMENT PLAN BASED ON EXAMINATION.

I have had two personal experiences of delayed responses after injuries in my own life I would like to share.

During the Spring of 1996 when I was in my last year of Chiropractic School, I suffered a delayed injury after a motor vehicle accident.  I was sitting at a red light stopped, and a cab driver decided to make a left turn on an amber light right in front of me, but at the same time a large pickup truck decided to run the amber light going straight.  This subsequently led to a t-bone collision between the two and the cab ended up sliding into the front of my car and crushed it.  Both of my knees smashed into the dashboard.  Immediately I jumped out of my car rubbing my knees to see if the other people involved in the accident were ok.  After a few days, I had the claims adjuster for the cab company’s insurance come out to assess the damage to my car and he cut me a check and totaled out my vehicle.  My knees no longer hurt by then.  A month went by and then I started developing right hip pain. 

When Spring semester ended, I came to visit my wife who was living in Maryland and working as a Doctor of Chiropractic for Multi-Specialty Healthcare alongside of Dr. Charles Thorne.  I was hobbling around barely able to make it up and down steps.  Getting in and out of a car was problematic.  The hip pain was really interfering with my lifestyle.  My wife suggested that I go to get checked out by Dr. Thorne.  I finally did and he performed an examination and treated my hip for several visits using therapeutic modalities along with manual therapies and manipulation.  He diagnosed me with bursitis of the hip.  This seemed to help tremendously but the pain still continued to nag me.  He then referred me to an M.D. within his group who injected cortisone into my hip.  This helped so much that I felt like I could sprint within an hour after the injection, but two days later I was back to square one.  The pain lasted for months and I was back in school in Georgia starting Fall semester.  Back then, I used to hunt on my grandfather’s farmland in North Georgia with a group of friends from school.  It was archery season and our group decided to go up one morning to hunt.  I had a tree climbing stand where the stand comes in two pieces, where the top piece helps you hoist yourself up, and the lower piece allows you to pull up with your legs and lock it onto the tree, basically shimmying yourself up a tree using alternating actions.  While doing this on that particular morning, I felt something in my hip “pop.”  Immediately I felt relief and my hip pain was essentially gone.  It just took that axial distraction type of passive manipulation to make it normal again.

My second delayed reaction after an injury occurred about nine years ago.  I was walking on a sidewalk and thought I was walking through a stream of water, but it turned out to be ice.  I slipped and fell onto my extended right wrist and onto my right knee.  This caused a nasty abrasion to my knee and my wrist felt sprained for about two weeks before the pain vanished.  About six weeks later, the pain came back in my right wrist with a vengeance and I developed a lump on the dorsal aspect of my wrist.  This is called a ganglion cyst.  It is a cyst formed from a build-up of mucopolysaccharides which can form in a joint.  Jamming of the joint can predispose a person to developing one of these ganglion cysts.  I was having a hard time adjusting my patients with this condition because many chiropractic manipulation techniques require an extended wrist and extension was the action that was causing pain.  I had learned in school that an old-school treatment for a ganglion cyst is to hit it with a book.  This is why a ganglion cyst is sometimes referred to as a Bible Cyst.  Although I would never recommend for any of my patients to smash his or her wrist with a book because of the chance of another injury, this is exactly what I decided to do to myself.  I was at work one day and found the largest book I could find and smash the cyst with it.  I grabbed a giant book called the Physicians Desk Reference, then placed my hand flat on the desk and smashed the cyst and wrist.  Did it hurt?  Yes, but it worked.  The cyst was gone and so was the pain on wrist extension.

What can we conclude from these examples of delayed reaction after injury?  The first example is easy to conclude if you look closely at the mechanism of injury.  My knees had slammed into the dashboard and caused bruising to my knees, which only lasted a couple of days.  What I didn’t realize at the time is that my hip was also jammed at the same time and it took close to a month for the bursa in my hip to flare up, whereupon I became symptomatic.  It finally took a mirror image cure for the condition.  What I mean by this is that the injury was caused by compression of the joint.  It was the axial distraction of the joint while using a climbing tree stand that ultimately seemed to fix the problem.  The second example is much like the first.  The mechanism of injury was falling onto an extended wrist and spraining it.  Several weeks later a ganglion cyst formed on the same wrist and by smashing it with a book, I was able to redistribute the mucopolysaccharides out from a build-up within a cyst.  It is very important for the doctors who treat patients with delayed response to injuries to consider the entire clinical picture in cases such as these.  The documentation and specificity of the mechanism of injury can help to prove causation.  Finally, although sometimes it might seem quite hard to prove that a delayed symptom could be caused from an old injury, the truth could be right in front of your face.