Table 5.

Examples of Potentially Bias-enhancing Metaphors

Bias	Example Metaphors
Containing extreme or negative connotations	A calcaneal fracture is like an egg crushed flat
	Carpal tunnel syndrome is like “a rock crushing a hose”,or “Ziti being squished to linguini”
Invokes disease modification when only palliation is available	Gel injection for the knee is like getting an oil change for your car
Out-of-date inaccuracies such as overuse or damage	You’re born with an empty bucket and if you only put one drop in it every day, it will overflow eventually (overuse)
	Spontaneous long head of biceps rupture: “Like rubbing a rope on a rock - the rock eventually wins.”
	Lumbar disc herniation: “Treatment is like repair of a flat tire”
Invoking fear	Abdominal aortic aneurysm is like a ticking time bomb
	Distal radius fracture is like a canary in the coal mine signaling fragile bones
Hurt means harm	Just as with a car, the motor gets older (heart) and the bearings start to grind (osteoarthritis)
	Ankle fracture: the ankle joint is like a wheel bearing. If it is too loose it will wear out fast.
Nudging patients towards a specific treatment	A car with 100,000 miles will make noises, does not start on cold mornings, etc. You can either try to tune it up (NSAIDs, injections) or trade it in for a new one (TKA)
	If your car was running as rough as your knee you would take it in for service with the mechanic
Implying vulnerability and progression	A bone with osteoporosis is like a damaged road with many holes in constant maintenance.
Using battle analogies	You will win this battle, because you are a fighter
	Use the weapons at your disposal