We read with interest the case study by Ungaro et al.,1 which was published in the latest edition of the IJOM.The authors' highlight important issues with regard to the consideration of alternative and potentially serious diagnoses should a patient fail to respond in a timely manner to osteopathic treatment. This serves as a reminder to us all to be on guard continually during our encounters with patients, and to be prepared to re-evaluate a diagnosis when a patient is not improving or worsening. In particular, it is not infrequent in the emergency department to see elderly women who have had pain after apparently innocuous injuries (or indeed there may be no history of antecedent trauma at all), who turn out to have insufficiency fractures.
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