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
