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It is not unusual to be misdiagnosed when pain is due to another cause

By Dr. Jordan Duncan
For West Sound SportsPlus

As the weather continues to improve, people will start getting out and doing things they haven’t done in months, for example running, playing softball, biking, gardening, or some other unaccustomed activity. Some will present to their doctor with aches and pains, and it is not uncommon to leave the office with a diagnosis of tendonitis. This makes sense to most people, and is therefore not second guessed, since tendonitis seems so common.

Tendonitis is often diagnosed in the medical community if someone has pain in the region of a tendon, whether around the knee, ankle, hip, shoulder, elbow, or wrist, especially if that pain is increased with contraction or stretch of the affected muscle/tendon unit. 

Not so fast.

In recent years we have discovered that what we used to think were tendon problems actually may not be. It is not unusual for people to have the previously mentioned diagnostic criteria when their pain is due to another cause. Of course, people still develop tendon pain, it just may not be as common as once thought.

Now this diagnostic confusion isn’t a problem if people who truly don’t have a tendon issue still get better despite treatment directed at their tendon. The natural history of most conditions is favorable regardless of the treatment applied, which is one of the marvelous features of the human body.

This diagnostic confusion is a problem, however, if the diagnosis is made in someone who doesn’t have a true tendon problem, and after treatment directed at their tendon they are no better.

Many people are walking, or perhaps limping, around with pain they were told is due to tendonitis – when in fact it is not. They have often been through several courses of care and their condition is not improving. More invasive treatments may have even been proposed. 

If this is you or someone you know, read on. This could be you or someone you know in the near future, however, in which case I would still read on. 

There are specific criteria for true tendon problems. I will list six of the more common features. 

1) Pain provocation is very consistent. Tendon problems are provoked by specific movements or activities that tend to hurt every time someone performs it. You generally won’t hear someone say “Sometimes it hurts when I do this (e.g. a pushup) and other times it doesn’t.” 

2) The pain is very localized. You should be able to cover the pain with one or two fingertips. Therefore, the area of pain in a tendon problem is usually no larger than a quarter. 

The pain is not felt in a broad area like the whole knee or shoulder, and it shouldn’t change location from day to day. For example, if you sometimes feel pain on the inside of your elbow and other times you feel pain on the outside of your elbow, it likely isn’t a tendon problem.

3) The pain gets worse when more load is applied to the tendon. Someone with a patellar tendon problem at the knee would say that squatting 250 pounds hurts worse than squatting 100 pounds. Someone with an Achilles tendon problem would say that their pain is worse with quick changes of direction than it is with slow jogging. If more load makes your pain better, it is highly unlikely that it is a tendon problem.

4) There is no passive motion loss at the affected joint. Restricted motion is highly unlikely in a tendon problem. If your tendon is irritable it may be difficult to actively move the affected joint through its full range of motion, particularly against gravity or resistance. Someone else, however, should be able to passively move your joint through its full range of motion without restriction or obstruction. 

5) There is no pain at rest. Unless the affected tendon is loaded beyond its physiological capacity, you won’t experience pain. Therefore, tendon problems don’t hurt at rest when they’re unloaded. There is one exception to this particular rule, and that is if you overdid a provocative activity the day prior. It takes about 24 hours for inflammatory cells to accumulate in tendon problems, which could leave someone feeling achy the day after too much activity.

6) The pain doesn’t tend to get better with more activity. A true tendon problem generally would not get better the more you ran (e.g. in the case of an Achilles tendon problem) or the more throwing you did (e.g. in the case of a shoulder tendon problem). In most cases the pain would stay the same or perhaps get worse with more activity.

Now there are exceptions to these rules, however they are just that, exceptions.  

Most true tendon problems behave in the manner described above, containing all six features. These criteria are far more specific to tendon problems than simply pain in the general region of a tendon that is worsened with contraction or stretch, and allow us to be far more accurate in our diagnosis.

It should be noted that I am not talking about an acutely ruptured or torn tendon. The presentation I am generally describing here is someone who developed non-traumatic pain that either came on slowly or all at once. They may have been playing basketball for the first time in a while or lifting heavier weight that they are used to. Tendons generally become symptomatic with excessive loads on a normal tendon or normal loads on a weak tendon.

If you have been diagnosed with a tendon problem, you aren’t getting better despite treatment, and your pain doesn’t fit the behavior of tendon pain listed above, a second opinion is warranted. There are excellent evidence-based guidelines for the rehabilitation of true tendon problems, however they don’t work well when the source of pain is not actually a tendon.

There are many conditions which mimic tendonitis, which is why proper diagnosis is absolutely crucial for effective treatment.

If you have any questions or would like more information, you can contact Dr. Duncan at jordanduncandc@gmail.com


Dr. Jordan Duncan is the owner of Silverdale Sport & Spine, a sports medicine clinic located in Silverdale, WA. 

Dr. Duncan is one of a small handful of chiropractors in the state of Washington to be certified in the McKenzie Method® of Mechanical Diagnosis and Therapy, a reliable evidenced based method of assessment and treatment for musculoskeletal conditions of the spine and extremity joints. 

In addition to treating a diverse patient population, Dr. Duncan enjoys treating athletes and has worked with numerous high school, collegiate, and professional athletes. He has served as an expert opinion for a wide variety of healthcare and fitness articles. 

As a competitive athlete growing up in Kitsap County and a current runner, Dr. Duncan understands the importance of quickly returning to your sport, whether you are a long distance bike rider, high school soccer player, recreational golfer, avid CrossFitter, or enjoy another activity. 

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