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Monday, January 6, 2020

When the Pain is Superficial, Think Deep

When the Pain is Superficial, Think Deep

In medical school and residency training we are taught that superficial pain in a muscle/tendon/ligament may be 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: When the treatment is not progressing, think about deeper structures as the cause of the pain.

Another common scenario (of the reverse) 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 Ilio-Tibial 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 KISS principles, that the arthritis must be causing the tendinitis, and that the knee required a knee replacement. The patient wisely chose 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 three major injuries in my life, and all three had a surgical option. Good people recommended good surgeries for me. But I chose 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 perhaps 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.

Golden Rule of Foot: Allow time for rehabilitation to succeed or fail, so that you can possibly avoid unnecessary surgery or have the surgery you need with a firm conviction. 

The above has been an excerpt from my book: Secrets to Keep Moving

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.