Gut feeling in clinical practice?

She explained that she went over on (rolled) her ankle nearly 11 weeks before; she stepped off a curb and felt a crack or snap in her ankle. She developed severe pain, swelling and bruising. She attended A&E and had an X-ray, following which, she was advised that ‘there was no fracture’ but the consultant was not 100% sure. No further diagnostics or assessments were recommended.

Clinicians’ intuition and gut feeling are often talked about in healthcare but are largely mysterious. Clinicians describe just knowing that there was something wrong with a patient but not exactly how they came to that conclusion.

How many times did you have a gut feeling about a patient you have just assessed in your clinic? How many times did you think: 'This isn't right' or 'There must be something else going on'?

I certainly get this often. But the question is: is there really a place for gut feeling in our clinical practice? Shouldn’t we be relying on evidence-based practice only leaving the gut feeling for other, non-clinical things? I certainly think that gut feeling is equally as important as our clinical knowledge, so let me share this clinical study with you.

A 44-year-old female was contacted telephonically via the PhIL service requesting advice and rehab for her ankle complaint.

During the PhIL consult, she reported she was unable to weight-bear through her foot due to severe pain. She was only able to weight-bear through her toes and she had to mobilise with crutches. Due to persisting symptoms, she had visited the minor injuries clinic again, where she was discharged as there was ‘no evidence of a fracture’ on her recent X-rays. She was told that she sprained her ankle badly and that it would heal with time.

The patient was growing increasingly concerned about her condition, feeling that her ankle was unstable. She was experiencing clicking and popping with each movement, and she was in severe pain, up to 8/10 on the Numeric Pain Rating scale (NPR) where 0 is no pain and 10 is the worst possible pain. She was unable to tolerate any direct pressure over her ankle, even when lying in bed.

Following subjective assessment, I was reasonably confident there was something more sinister going on rather than a sprain. I suspected she had a type of fracture that was impossible to be picked up by a standard X-ray and a possible, severe ligamentous tear. I advised the client to contact her GP urgently for an assessment and to also ask for a referral to her local MSK Team. I advised her that she needed further investigations and that the sooner she could obtain them, the better.

During a follow-up call 2 weeks later, the patient reported she had undergone another X-ray, which again, showed no fractures. No other diagnostics were completed.

I again encouraged her to insist on further imaging. I somehow ‘knew’ the injury was missed and this client was facing a long recovery or potentially, life-long functional restrictions. She understood I was unable to guide her through a rehabilitation plan until sinister pathology was formerly excluded, as differentiation was difficult at this stage. More damage could have been provoked if I prescribed an exercise plan. I felt this patient trusted me and I was hoping that my gut feeling would not let me down.

After 4 months the client emailed me advising that she funded private consultation following which she was referred for an urgent MRI due to suspicion of potentially 2 breaks. The client was diagnosed with 2 badly torn ligaments in her ankle and was placed in a moon boot for 6 weeks. She was starting to be able to place her foot on the floor and expressed an understanding that she had a 50/50% chance of needing surgery to relocate the tendon to support the healing.