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Wednesday, May 19, 2010
Injury Rehabilitation: When Pain is Superficial, think Deep
In medical school and residency training you are taught that superficial pain in a muscle/tendon/ligament may to secondary to deeper, more serious problems. The superficial structures may be sore for many reasons including deep swelling that has surfaced (like after an ankle sprain), or muscle soreness from strain as they compensate to protect the deeper tissues. Hundreds of examples abound including the diagnosis of achilles tendinitis only to later find out that there was a chip fracture in the back of the ankle requiring surgery. The diagnosis of achilles tendinitis may have been followed with months of physical therapy, casts, orthotics, braces, and medications. A sports medicine practitioner works hard when superficial structures are identified as the cause of pain to at least consider deeper evaluation if the symptoms do not respond. This is where the patient can greatly help their own cause by asking questions about possible deeper structures involved.
Golden Rule of Foot: Treat the Patient not the Test (xray, MRI, bone scan, etc) Another common scenario happens all the time, and I will use Judy's story to describe it. In this case, Judy actually developed a superficial tendinitis on the outside of her knee called: Iliotibial Band Syndrome. The smart clinician looked deeper with an MRI and found arthritis in the knee. The decision was made, without proof, and not following our KISS principle (see post covering), that the arthritis must be causing the tendinitis, and the knee required a knee replacement. The patient wisely choose the KISS principle and treated the tendinitis first (on advice from other physicians) to see if the pain would go away and it did. I have had 3 major injuries in my life and all 3 had a surgical option. Good people recommended good surgeries for me. But I choose to try rehabilitation first, and so far, I am fully functional and have avoided surgery. We owe it to ourselves to try rehabilitation first. In Judy's case, her pain was superficial, and surgery on her deeper arthritis was unnecessary.
The photo above shows the complexity of the knee joint and how soreness in one area may be caused by deeper problems, but may be not. So, deep injuries can be mistreated when the care is only directed at the secondary more superficial soreness. And, superficial injuries with concurrent deeper non-painful abnormalities can be mistreated when the doctor, therapist, and/or patient mistakenly blames the pain on the wrong structure. Please review one of my earlier posts on Second Opinions. Golden Rule of Foot: Allow time for Rehabilitation to succeed or fail, so that you can possibly avoid unnecessary surgery.