Tendon issues are unfortunately incorrectly diagnosed all the time. That is, issues that are not tendon problems are diagnosed as tendon problems. “Issues” and “problems” refer to tendinopathy, tendinosis, tendonitis, and tendon tears. We have hundreds of tendons in our bodies; they are pieces of tissue that connect our muscles to our bones. Those that get an unfair share of the blame are the four rotator cuff tendons in the shoulder, the two main tendon groups at the elbow, the Achilles tendon of the ankle, and the patellar tendon at the knee. This frequent misdiagnosis happens for two chief reasons.
One, tendon problems are common on images such as MRI so, in the absence of an expert clinical mechanical exam, the tendon is identified as the culprit simply because of a picture. The concern with this is that tendon problems are common on images such as MRI in people with NO pain or other symptoms. So if Sarah has a large supraspinatus tendon tear on her MRI and no shoulder pain and John has a large supraspinatus tendon tear on his MRI and does have shoulder pain, can you assert that the supraspinatus tendon tear is causing his pain? Not from that information alone, you can’t.
(Say your car starts acting funny. You open up the hood to take a quick look. You see a lot of leaves around the engine. Can you assume that the leaves are causing the problem? Or would your mechanic need to run some diagnostic tests? After all, we know that there are plenty of cars with leaves stuck under the hood that run just fine.)
The second reason for this misdiagnosing conundrum? Lack of expert clinical “mechanics.” When I first began as a physical therapist, if a patient came to me with shoulder pain (with or without an MRI report), I performed the orthopedic shoulder tests I learned in school. While there are several tests aimed at diagnosing a rotator cuff tendon problem, these tests are actually not very good. They can regularly be positive when something other than the tendon is at fault. If physical therapists, orthopedists, general practitioners, surgeons, chiropractors, athletic trainers, etc. are still basing their diagnoses (and subsequent treatment) on these tests, they are missing a lot of crucial information.
Once I learned during my post-doctoral coursework that other problems can mimic tendon problems, I began looking for these in the clinic. And, lo and behold, most of the time it is something else causing the patient’s problem. The top two problems that mimic tendon problems are misalignment in the spine joints whose nerves send signals to the area of the tendon (eg the neck) and misalignment in the extremity joint closest the tendon (eg the shoulder).
How do I diagnose a tendon problem then? These are my top two criteria:
In closing, don’t jump to conclusions based on an image or the location of pain. A lot of shoulder pain is coming from the neck or from a shoulder joint that is not sitting properly – not a rotator cuff tendon. Likewise, a lot of pain on the outside of the hip is coming from the low back or from a hip joint that is not sitting properly – not the gluteal tendon. Our bodies are beautiful in their intricacy and nuance, making my job as a mechanical therapist exciting. It is the ability to understand this nuance that makes a clinician effective at diagnosing and treating. --Laura
In late January I met a patient who had fallen in September, suffering the “terrible triad” at the elbow (coronoid and radial head fractures and a dislocation). After two surgeries to repair the damage, she contracted a staph infection which led to a third surgery and then a fourth when the wound didn’t close. Later she had physical therapy elsewhere which at times was extremely painful and at times disillusioning due to lack of attention.
At our first visit her elbow was stuck at a 90-degree angle, with a lack of forearm supination. Her shoulder on that side also demonstrated mild/moderate losses of motion in several planes consistent with adhesive capsulitis/frozen shoulder. Lastly, her neck was lacking motion in several planes. Subjectively, she did not report pain, but that it felt like a vice was around her elbow. Her ability to use her extremity for almost all tasks was obviously severely limited.
During our evaluation, I determined her homework would be pushing her elbow into extension and pushing her shoulder into flexion over the next few weeks, repeatedly. I asked her to push her elbow 10 times every 2 hours and her shoulder 10 times every 2 hours. The only equipment required was a surface like a table, and it would only take 2 minutes. A key ingredient to this exercise prescription was that it SHOULD produce pain when it was performed, but that the pain SHOULD NOT last outside of a mild aggravation up to about 15 minutes. An important piece of our encounter was also setting expectations. I explained that restoring motion in her extremity would take many months of her diligent work and that I was only needed very intermittently - mostly to steer the home program in the right direction.
This approach to physical therapy treatment was vastly different from what I had employed earlier as a clinician. Before, I would have prescribed a home exercise routine to be performed once or twice per day, including several motions at each joint. I would have recommended clinic visits 2-3 times per week. I likely would have used heat and then, after causing the patient pain, used ice. Now, instead, I was teaching the patient how to treat herself using one simple, quick exercise for each problem repeatedly throughout the day. I called a mentor to ask if this would really do the trick. Didn’t the patient need me? Soft tissue work? Mobilization? She advised me to give this approach time; if things didn’t improve then I would explore other options.
Our second visit was 6 weeks later. Due to having to take care of her mother, my patient related she had only done the exercises about once a day. However, the elbow had gained about 15 degrees; the shoulder was the same. I didn’t change her homework. At our third visit (in June) her elbow had opened an additional 30 degrees and gained a significant amount of supination. Her shoulder now lacked only about 5% of its total motion. She reported that the discomfort was decreasing and that she was gaining more use of her extremity, most notably with typing. During visits 4 and 5 this month I focused more on restoring neck and upper back mobility, giving her an additional exercise for homework. While I did some manual stretching of her elbow during our sessions, she was making herself better by doing a specific exercise repeatedly throughout the day.
The goal is to continue to improve motion at the elbow and spine and then reestablish strength. We’ll need to make sure there is no residual nerve tension as well. Despite the four surgeries and internal hardware, I am aiming for full restoration of motion and strength as I have learned the body has an amazing way of healing if it is consistently given the correct stimulus. This treatment approach (outlined by the McKenzie method of mechanical diagnosis and therapy) doesn’t just promote patient empowerment through self-treatment. It’s also safe, allows the patient to avoid unnecessary pain, and requires little to no bells and whistles. It’s a treatment model I wholeheartedly support. --Laura
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