How easy is it to misdiagnose an injury?

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?

barking-up-the wrong-tree

 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:

Referred pain


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.

From the 49 findings, not a single one was found on every report. There was disagreement on the spinal level of disc herniations and one didn’t even think there was one. 50% didn’t think nerve root compression was present and overall the misdiagnosis rate for disc herniation was 47.5%.
So next time you think a scan will give you an accurate diagnosis, think again!

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?

The reality is that signs and symptoms overlap constantly and this is seen in the list of the differential diagnoses that you get for a given condition (they are long!). Not to mention that as you age the amounts on concurrent problems, symptomatic or not, grows, so it becomes ‘Eeny, meeny, miny, mo’. The final difficulty is the number of issues on non-symptomatic people on scans and as we saw above the accuracy of the scan or the interpretation of the scan. It’s a giant puzzle of ruling in and ruling out things looking at the whole picture together and nothing in isolation.
Here we can see some research on MRI scans that highlight these points:
In 28% of people who had a disc prolapse diagnosed on an MRI scan were found to not have one when they performed surgery on them. It has also been found that 33% of people that had a normal MRI actually did have one when confirmed by surgery (Weiner et al 2008).
In another study performed by Barreto et al (2019), they MRI scanned people with one-sided shoulder pain and they purposely scanned both sides to compare the results. They found no differences between each side and the only exceptions to this were 10% more severe supraspinatus tendon injuries and glenohumeral osteoarthritis levels on the painful side.

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).

cervical radiculopathy

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!

carpal tunnel- yndrome



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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If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866 195914.


The content in this blog article is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation.

  • Barreto, Rodrigo Py Gonçalves, et al. “Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain.” Journal of shoulder and elbow surgery 28.9 (2019): 1699-1706.
  • Caridi, John M., Matthias Pumberger, and Alexander P. Hughes. “Cervical radiculopathy: a review.” HSS Journal® 7.3 (2011): 265-272.
  • Chow, C. S., et al. “Is symptomatology useful in distinguishing between carpal tunnel syndrome and cervical spondylosis?.” Hand Surgery 10.01 (2005): 1-5.
  • Herzog, Richard, et al. “Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period.” The Spine Journal 17.4 (2017): 554-561.
  • Kassirer JP. Our stubborn quest for diagnostic certainty. A cause of excessive testing. New England Journal of Medicine. 1989;320(22):1489–1491
  • Lee, Aaron Taylor, and Ayse L. Lee-Robinson. “The prevalence of medial epicondylitis among patients with c6 and c7 radiculopathy.” Sports health 2.4 (2010): 334-336.
  • Nakashima, Hiroaki, et al. “Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects.” Spine 40.6 (2015): 392-398.
  • Radanov, B. P., Di Stefano, G., Schnidrig, A., & Ballinari, P. (1991). Role of psychosocial stress in recovery from common whiplash. The Lancet, 338(8769), 712-715.,Smedley, J., Inskip, H., Trevelyan, F., Buckle, P., Cooper, C., & Coggon, D. (2003). Risk factors for incident neck and shoulder pain in hospital nurses. Occupational and environmental medicine, 60(11), 864-869.
  • Rao, Raj D., et al. “Degenerative cervical spondylosis: clinical syndromes, pathogenesis, and management.” JBJS 89.6 (2007): 1360-1378.
  • Rheumatology Network. Evaluating concomitant lateral epicondylitis and cervical radiculopathy. Rheumatology Network. March 7, (2010) Volume: 27
  • Smedley, J., Inskip, H., Trevelyan, F., Buckle, P., Cooper, C., & Coggon, D. (2003). Risk factors for incident neck and shoulder pain in hospital nurses. Occupational and environmental medicine, 60(11), 864-869.
  • Weiner, Bradley K., and Rikin Patel. “The accuracy of MRI in the detection of lumbar disc containment.” Journal of orthopaedic surgery and research 3.1 (2008): 46.

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Online Physiotherapy

Put simply this is Physio done via either telephone or video over the internet. Skype and facetime are examples of this.

Contrary to popular belief online physiotherapy can be very effective and it can help the same injuries that face to face physio can help. I have helped many people with injuries such as disc prolapses, tennis elbow, neck pain and much more).