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Determining The Etiology Of Pain And Striving For Non-Surgical Solutions Whenever Possible

In medical school and residency training, we were taught that superficial pain in a muscle, tendon or ligament may be secondary to deeper, more serious problems. Deep edema, compensatory muscle strain and occult fractures are all examples that we may run into in clinical practice. For example, a diagnosis of Achilles tendonitis may lead to months of physical therapy, casts, orthotics, braces and medications. When symptoms do not respond, the patient and you as the practitioner can greatly help the cause by questioning if there is a possible deeper etiology.

Another common scenario actually involves the reverse of this concept and it happens all the time. A patient developed a superficial case of apparent iliotibial band syndrome. The clinician ordered magnetic resonance imaging (MRI), which revealed osteoarthritis in the knee. Without clear proof, the clinician decided that the arthritis must be causing the tendonitis and advised the patient to consider a knee replacement. Wisely, the patient chose, after the presentation of additional opinions, to directly treat the tendonitis first and try to keep the course simple so he could avoid surgery. The pain did go away with stretching, icing, physical therapy and orthotic devices to control overpronation.

I have personally experienced three major injuries in my life and there was a surgical option to consider for all of them. Instead, I chose to try rehabilitation first. So far, I have been successful in avoiding surgery and maintaining full function. We owe it to ourselves as clinicians and potential patients to try rehabilitation first. In the aforementioned patient’s case, her pain actually was superficial and surgery to address her deeper arthritis was unnecessary.

The knee and ankle joints are prime examples of a complex structure in which soreness in one area may be due to deeper problems but perhaps not. One may mistreat deeper injuries when directing care only at the secondary, superficial soreness. Conversely, one may mistreat superficial injuries with concurrent deeper abnormalities when the doctor, physical therapist or patient mistakenly blames the pain on the wrong structure. Common examples include bunion surgery when the pain is from osteoarthritis or surgery for a Morton’s neuroma when the pain is actually coming from the back. Lastly, we might run into this pitfall when unsuccessful Achilles treatment is due to an os trigonum injury or a recalcitrant ankle sprain is also a deeper talar fracture. We should keep this paradigm in mind during initial and subsequent evaluations of our patients.

Dr. Blake is in practice at the Center for Sports Medicine, which is affiliated with St. Francis Memorial Hospital in San Francisco. He is a past president of the American Academy of Podiatric Sports Medicine. He recently published “The Inverted Orthotic Technique: A Process Of Foot Stabilization For Pronated Feet.” One can find the book at

Editor’s note: This blog originally appeared at It is adapted with permission from the author.

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