Part 2 – Tendon Imaging

When we get the opportunity to see a new patient that presents with a chronic tendon problem, they usually come armed with a trolley full of scans – Xrays, ultrasounds, MRI’s…often multiple scans of each! Any many may be disappointed when we put the scans to the side and barely look at them until we have made our own clinical judgement and decided on a treatment approach. In other words, the scans will rarely influence the treatment or rehabilitation approach we decide to choose. Why is that?

Can Scans Be Used To Diagnose Tendon Problems?

Ease of access to scans (and the constant publicity surrounding AFL players who are seem to get MRI scans for every mild soft tissue problem) has resulted in high pressure (within our own minds, but also from patients) to refer for scans when a problem is not getting better quickly. This has led to an enormous increase in people having scans, but how useful are these scans?

To help answer this question it is interesting to look at a number of studies that have been performed on various body tissues, not just tendons, investigating the link between scan results and actual pain:

  • Between 10 and 30% of elite soccer players investigated in a top Danish soccer league showed signs of tendon pathology on scan, yet had no pain.
  • Of all the rotator cuff tears shown on scans amongst a group of veteran tennis players, 47% of those with pathology shown on scan had no pain. Another study showed that over 50% of people over 60 years of age will show rotator cuff tendon tears on MRI, yet most don’t even know they have a shoulder problem!
  • Tears of the meniscus (main shock absorber of the knee) can be seen on MRI in 30-40% of normal, asymptomatic knees. It appears that just as many middle aged people without knee pain had meniscus tears shown on scan as did those with knee pain.
  • A Systematic Literature Review of the lower back and MRI showed that 30% of asymptomatic 20 years olds showed disc bulges on scan, increasing up to 84% showing disc bulges in 80 year olds.

What this shows is that the correlation between any pathology shown on scan, and the actual pain level of the patient, is poor!

Regarding tendon tears reported on scans, think of it like this: “tendons tears are like wrinkles – they are a normal part of the ageing process”. After a certain age many of us naturally have asymptomatic tendon tears (or knee meniscus tears; or lumbar spine disc bulges), don’t even know it, and definitely aren’t getting any pain or symptoms from it. From these studies it seems that many results seen on scan are more a part of normal ageing and simply don’t have any correlation to our pain.

Can Scans Be Used To Prevent Tendon Problems?

There is a school of thought that scanning tendons may help us prevent the development of tendon problems – for example, if we scan a group of asymptomatic athletes that are vulnerable to tendon problems (runners with high Achilles tendon risk or basketballers with high patella tendon risk), and see some pathology within their tendon, can we implement a loading/exercise program to help prevent the future development of pain? Studies show there is a higher risk of developing achilles or patella tendon problems if you show signs of pathology on scan, however whilst implementing a preventative strategy sounds great, there are inherent risks with this strategy.

Perhaps the greatest risk lies in the potential to create pain in a tendon! One excellent study found that on average, of every 100 athletes that show tendon pathology on scan (but do not have symptoms), only 15-20% will go on to develop symptoms in the future. So by implementing a “preventative” exercise program we are potentially risking causing the development of symptoms in that 80 – 85% of athletes that would have remained symptom free!

Can Scans Be Used To Determine Tendon Healing?

Even this doesn’t get the tick of approval unfortunately – when a tendon problem is rehabilitated fully, is pain free, and the person has returned to full sporting or recreational activity…both the early scans and the return to sport scans look very similar, if not exactly the same! Which is why tendons need ongoing management, long after they have become pain free. Scans should not be used as a true measure of pathology or healing.

Why Get Scanned?

The research is bleak on scanning tendons, however this should be taken in context. Scan results should not be used in isolation to determine a therapy program, a surgical intervention, or be used as a guide for healing or rehabilitation progress. There may well be cases where scanning has its benefits:

Reassurance – tendon problems are so frustrating, and so slow to respond, that sometimes it is nice to get a scan to make sure we haven’t missed an alternative diagnosis. Tendons sit close to so many other structures and tissues, so it might be possible that there is another cause of your pain and in these cases a scan may be nice to check.

Motivation – it’s easy to lose motivation when you’re rehabilitating a tendon, so in some cases it can help to know that there actually is a problem there, and you’re not imagining your pain. Whilst we won’t “hang our hats” on the scan results, we can use them to prove there is some pathology, and that a bit more perseverance is needed! It’s just important to be very careful that minimal emphasis is put on words likes “holes”, or “tears”, or “full thickness”, or “extensive” etc… because these can plant negative emotional seeds that can strongly influence the success of the rehabilitation.

In summary, if you’ve received some scan results that don’t sound too great – don’t despair. Either the results may not be too relevant to your problem, or on the other hand there’s a very good chance, with patience and perseverance and a good therapy program, you can return to full activity despite the ongoing evidence of pathology within the tendon.

Anthony Lance