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
Has someone told you you have weak gluteus medius (hip abductor) muscles? The L4, L5, and S1 nerves supply the electricity to this muscle, so there's a GREAT chance the glute med is weak because those nerves are inhibited in your (slouchy) low back. In that case, the solution would simply be to free up those nerves in the low back - and the strength would return immediately! Could save months of strength training, not to mention actually addressing the true cause of the weakness. -- Laura
Last night was a great night! Runner's Depot in Davie hosted my presentation on the spine and how it relates to running injuries. Runners have a reputation for having a lot of injuries and, worse, a lot of recurrent or persistent injuries. The crux of my talk is that a lot of injuries in the lower extremities are misdiagnosed as local injuries and not correctly as injuries originating from the nerves in the lumbar spine. For example, plantar fasciits is commonly misdiagnosed. Yes, it exists, but not as frequently as it is diagnosed. The hallmark sign of plantar fasciitis is extreme foot pain with first steps in the morning. That usually eases throughout the day, but returns each morning since the plantar fascia is on slack all night as you sleep and is then stretched with your first steps out of bed. If that sign is present, I still investigate the spine to rule it out. But when that hallmark sign is absent (for example, the pain is variable throughout the day or week), the diagnosis of a lumbar spine injury is more likely (or another diagnosis). More specifically, a nerve may be being hit or pinched in the lumbar spine and producing pain along the part of that nerve in the foot. IT band issues, patellar tendonitis, hip labral tears, and meniscal damage are a few other pathologies that come to mind when I think about regularly misdiagnosed injuries. Irritated nerves from the spine can produce pain in any area of the lower extremities and must be ruled out in the decision-making process. And remember, just because something is on an x-ray or MRI does not mean it is causing your symptoms. Images are full of problems in people without symptoms so a clinical diagnosis, in which structures and tissues are individually stressed, is needed.
I don't think that spine injuries are more prevalent in runners; nearly everyone will have a spine injury at some point. We just need to be able to diagnose them correctly when they do exist. That way, runners, like everyone else, can get back to doing what they love to do as soon as possible! --Laura
Take a look at this study! 45 volunteers with NO history of hip pain, injury, symptoms, or surgery were given an MRI. (Average age of volunteers: 37.8 years.) MRI's of these asymptomatic participants revealed abnormalities in 73% of hips, with labral tears in 69% of the joints.
I clearly love saying this: just because it's on an image doesn't mean it is causing problems. You need a quality McKenzie mechanical evaluation in the clinic to find out what is actually causing symptoms. --Laura
Check out the short study here: http://ajs.sagepub.com/content/40/12/2720.short
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