You would expect that experienced and expert medical professionals would be extremely accurate on making a diagnosis but how easy is it to misdiagnose an injury?
How often do they bark up the wrong tree?
The body is very good at mimicking other problems with referred pain, which is one of the main reasons that make it easy to misdiagnose an injury. Just because pain is felt in a particular area doesn’t actually mean that this is where the pain is coming from. In fact, we have an article all about this here:
How common is a misdiagnosis?
It was said long ago that to gain diagnostic certainty was impossible and it is not our job to gain certainty but instead it was our job is to minimise diagnostic uncertainty (Kassirer et al 1989). What is amazing about this statement is that it was said at a time when we had much more of a biomedical model focus of the body, which is more the ‘structure equals pain’ type of philosophy with no real focus on psychology, social or environmental factors. Obviously now we have added these other areas to our clinical reasoning in our diagnosis and management but this makes things even more uncertain than in the past because we now realise that damage doesn’t always equal pain.
A great example of a diagnostic challenge is a case study by Herzog et al (2017) where they MRI scanned a 63-year-old lady with chronic lower back pain and L5 radicular pain (Sciatica). She had 10 MRI scans done on her Lumbar spine over a 3 week period at 10 different centres and the overall the finding were many! They found 49 different ‘diagnoses’, examples of these were things such as vertebral alignment issues, disc bulges, disc herniations etc.
As I mentioned earlier not all things are caused by structure and even when they might be that isn’t easy. For example, here is a video showing the biggest risk factor to cause neck pain. (Hint: it’s not structural):
Why do misdiagnoses happen?
I bet this example below will make most clinicians more often than not make the wrong diagnosis:
So it would be easy to assume that if you have a neck problem then you would have neck pain but this isn’t always the case. For example, Caridi et al (2011) stated that Cervical radiculopathy (a trapped nerve in the neck) may or may not be associated with neck pain.
So we could have a patient now with no neck pain but referred pain into their elbow from a C6 or C7 radiculopathy (trapped nerve in the neck).
In a study by Lee & Robinson (2010), they had fifty-five patients that were diagnosed with medial epicondylitis (Golfer’s elbow). Of these, 44 had C6 and C7 radiculopathy whereas, 11 presented with just C6 radiculopathy. What this means is that either the Radiculopathy was mimicking the Golfer’s elbow or it created a neurological weakness thereby causing the Golfer’s elbow to develop.
It’s the same problem with Tennis elbow too. This study indicates that lateral epicondylitis symptoms are present in nearly 70% of patients who have a diagnosis of C6 or C7 radiculopathy or both (Rheumatology network 2010).
It also works the other way too!
For example, somebody could have symptoms of tennis or Golfer’s elbow and you think maybe it’s the neck so you get an MRI of this and you see a disc prolapse, so bingo, that’s it right?
Well maybe not, as this research shows:
87.6% of normal asymptomatic individuals show a disc bulge on Cervical spine MRI scans (Nakashima et al 2015).
So it is very plausible that you assess this patient and you think it could be neck or elbow based on your examination and then the MRI points you to neck problem. So you treat the neck and you are unsuccessful because all along it was the elbow!
Here is another example of how easy is it to misdiagnose an injury:
Carpal Tunnel Syndrome (CTS) is another commonly misdiagnosed condition and in this study, by Chow et al 2005), they highlighted the symptom cross over. They found that hand paraesthesia (abnormal sensation) is common in both Neck and Carpal tunnel issues. In Carpal tunnel syndrome, 84% had nocturnal (night) paraesthesia, 82% had hand paraesthesia that was aggravated by hand activity, and hand pain occurred in 64% of Carpal tunnel sufferers. So these symptoms were in reasonably high incidence with Carpal tunnel syndrome.
However, these symptoms can also present in Cervical spondylosis too but the incidences were lower. Only 10%, 7% and 10%, respectively in Cervical spondylosis cases. Now, as expected the high incidence symptoms for Cervical spondylosis were neck pain in 76% of cases and lower limb symptoms in 44% of cases. Guess what though, these symptoms can also present in Carpal tunnel syndrome too but the incidences were again lower. Only 14% and 9% respectively in Carpal tunnel syndrome.
So let us create this imaginary patient:
This imaginary patient will definitely help you to understand how easy is it to misdiagnose an injury. So they have neck pain, lower limb symptoms, no hand paraesthesia at all and no hand pain. So you think Cervical spondylosis but they aren’t responding to treatment so you get an MRI scan and this shows some Cervical degeneration. So now you are thinking that the diagnosis is correct but you are wrong!
Yes, they have Carpal tunnel syndrome and the likelihood of them having this and presenting with these symptoms are as follows:
Neck pain in CTS: 14% of cases
Lower limb symptoms: 9% of cases
No hand paraesthesia: between 16% and 18% of cases
No hand pain: 36% of cases
Chance of a Cervical spine MRI finding degeneration: 25% of people under 40 have some degree of disc degeneration (Rao et al 2007).
In this instance, it would very difficult to get your diagnosis correct and you will need to somewhat think outside the box!
So overall, going back to the original question, ” how easy is it to misdiagnose an injury?” The answer is very easy! What all this shows is that it is very easy to bark up the wrong tree with your diagnosis and therefore your treatment choices, always think about all the differential diagnoses and never rule something out completely as you could be wrong!
At Hawkes Physiotherapy in Stoke-on-Trent, this is exactly what we do, we assess you to work out the cause of your pain to get an accurate diagnosis because with a misdiagnosis you would be treating the wrong problem, which doesn’t work!
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The content in this blog article is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation.