The Questions, The Diagnosis, The Solution

I have been receiving emails for a few years from people around the world who read an article I wrote in 2007. It is so strange for me to see people responding to an article from so far away, but it is even stranger to me that they are responding to that particular article. The article was written to clarify the differences between tendinosis and tendonitis. There are some important distinctions to make when talking about these diagnoses and that was the focus of my article. And I believe the article has been so popular because the description of how each condition manifests physically is detailed and this has helped people to figure out the differences in what they were diagnosed with and what they likely had instead. My mentor once said, “Clinicians make a diagnosis when they are tired of asking questions.” I spend a lot of my time disproving a diagnosis. This is because in the past I have treated a diagnosis instead of a patient. In other words I knew, let’s say, how to treat a herniated disc, so I used the treatment strategies for that, but the patients symptoms clearly were not consistent with that diagnosis. So I have learned and for the most part been consistent in my practice with continuing to question what I am doing to make sure I am not missing something. The most common mistake people, this means medical practitioners as well as the patient’s themselves, make is coming to a conclusion about the particular condition while ignoring the symptom or symptoms that disproves the diagnosis. The other most common mistake is to forget the possibility that more than one thing may be going on simultaneously and what you or a patient really has is multiple diagnoses. My favorite example that I have seen in the past is “spinal stenosis” of the lumbar spine. Stenosis is defined as an abnormal narrowing of the spinal canal that may occur in any of the regions of the spine. There are two main ways to make this diagnosis. One is an X-ray or MRI and the other is the clinical presentation, in other words, the symptoms a patient presents with. The clinical presentation is what I would like to highlight right now. The main characteristics patients present with are difficulty standing and walking. Often the patient will describe bending over or sitting as ways to alleviate their pain, as in walking while leaning over a grocery cart. Leaning over the cart allows them to walk longer with less pain. I have had patients with a diagnosis of stenosis that report standing and walking are when they feel at their best, and sitting and bending are what hurts them the worst. Clearly the opposite of what I would expect them to say. But when I look at their X-ray or MRI it is clear that they do not have a lot of space in their spinal canal and it sure looks like it is stenotic to me. So what gives? Well for me I would say this is a case where a patient has stenosis but it is not the main source of their current pain. This often happens with patients with degenerative disc disease too. Often the X-ray shows one thing and their symptoms another. But for me this is why it is so important to stay open to the possibility that there is more going on than a diagnosis can tell us. I also am writing this because I am certain in my practice this particular issue leads to a lot of frustration and false expectations by me and my patients. I treat the patients based on what they present with and I even do my best to remember to do that each visit so that I am not tempted to just follow a path I have set for myself after the initial visit. I am in no way suggesting that as medical practitioners we ignore or overlook pieces of the puzzle, in fact the behind the scenes experience in medical related offices is often very different than most patients know. As practitioners we use our experience and training to offer our patients the best we have to offer and in some cases this means trying one thing to see what happens, not knowing for sure what to expect. And another is sending a patient to another medical practitioner. So starting with a best “guess” is often needed when there are so many things going on that things are simply too muddy to tell what is what. I am also writing this to make sure that we all remember, in particular that I remember, that when things don’t work out as anticipated, it is not a sign of failure. It can be used to help create clarity. Things become clearer when we zero in on what is going on and specifically what didn’t work. In fact when I try to disprove the diagnosis but “can’t,” it often means the diagnosis is accurate. My most common response to those people who email about tendonitis and tendinosis is to ask questions to make sure we are really talking about the same thing. I don’t assume that what I said is what they really have. I need the time frames to match the diagnoses, I need the symptoms responses, (i.e. what makes you better and what makes you worse) and I need everyone I treat to know that one of my possible answers to what is going on with them is “I don’t know.” So if given a chance, I ask more questions and continue to look for solutions and possible pieces that don’t fit the diagnosis. I have enjoyed my new office in Saratoga Springs because I have blocked off time to make sure I have time to ask and answer these questions. If you are ever in need of an opinion I gladly offer mine—through email or in person. Matthew Goodemote MPT, Diplomate, McKenzie Institute International Owner of Goodemote Physical Therapy This email address is being protected from spambots. You need JavaScript enabled to view it. 518-306-6894