When athletes present to us with orthopedic-related pain, it is our duty to provide them with the most thorough and appropriate explanation of their problem, in order to facilitate the optimal management plan. Part of this involves providing a working diagnosis with which to classify the problem, base our interventions, and effectively communicate with other medical and health professionals.
Older, more biomedical models of pain focused on structural diagnoses, given the best information available at the time. Unfortunately, the science behind many diagnostic labels has been questioned, and in some cases, disproven, however such terms have remained commonplace in clinical practice.
Given the currently adopted biopsychosocial model of pain, where our understanding that the information we provide our patients has a large impact on the way in which they view their problem, their attitudes towards particular interventions, as well as having a direct impact on pain levels, we need to consider if certain diagnostic terms may actually have a negative impact on clinical outcomes.
In this article we discuss 7 commonly used terms that we argue should continue to be phased out of clinical use.
1. “Disc Degeneration”
We understand that changes in disc structure are a normal part of the ageing process, and in most cases aren’t associated with pain or function. A study by Brinjikji et al demonstrated that 70% of asymptomatic individuals in their 40s had signs of disc degeneration (Brinjikji et al., 2014). If patients believe that wearing of their spine is the cause of their pain, it will make them less likely to engage in physical activity, which we know is an important aspect of back pain management. We encourage clinicians to spend time explaining imaging findings to patients in context to normative findings, and focus on the individual factors likely to be related to their condition.
The suffix ~itis causes patients to interpret their problem as a local inflammation that requires rest and/or medication to settle. We understand that the underlying process of tendon pain is not an inflammatory one, and that it is load management that should underpin its management. Labeling tendon pain as tendonitis has been shown to make a person less likely to engage in tendon loading, which is the most important factor in successful recovery (Scott et al., 2020). We encourage the use of the term tendinopathy.
3. “Chondromalacia Patella”
This term implies that structural changes to the articular surface of the patella are causative of anterior knee pain. However, the cartilage of the patella is aneural (Mansour, 2003), and based off of the findings from Dye et al in 1998, we know that the retropatella cartilage is not a pain-producing structure in the knee (Dye et al., 1998). We also know that adolescents, most of whom display pristine cartilage, suffer similar anterior knee symptoms as those with cartilage degeneration. Therefore, attributing pain directly to cartilage damage is not only biomedically incorrect, but, again, is likely to decrease a patient’s engagement in an active management approach. We encourage the use of the term anterior knee pain, or patellofemoral pain.
4. “Adhesive Capsulitis”
Terminology around idiopathic shoulder pain and stiffness has gone through multiple changes over the course of its understanding, since Duplay first described the condition as “peri-arthrite scapulo-humerale” in 1896. The term adhesive capsulitis came out of the work of Codman, who initially attributed the stiffness to adhesions within the glenohumeral joint. Codman eventually revoked the position on his original findings in 1934, opting instead for the term frozen shoulder. Nevasier also advocated for the term adhesive capsulitis in 1945 following a case study where he claimed to observe the humeral head adhering to the axillary fold. However, findings of adhesion within the shoulder have not been observed since, and we now understand that this chronic inflammatory condition is associated with contracture, not adhesion of the capsule. The image of adhesions in the shoulder is likely to lead to fear avoidance and a reliance on passive modalities. We recommend the use of the term “frozen shoulder” (J. Lewis, 2015)
5. Anything ending in “~disease”
In our opinion, the addition of the term “disease” to most musculosketal pain conditions does little to enhance clinical outcomes. Most individuals interpret the term disease to be something chronic, permanent, and in many causes out of their internal locus of control. Adolescent traction apophysitis conditions such as severs and osgood slatters are often discussed with this suffix. For juvenile patients, as well as their parents, discussion of their condition as a disease can drastically raise threat levels, increase fear, and again, foster a sense of helplessness in their management. We recommend that where possible this suffix is dropped from these conditions and replaced with “pain” or “condition”
5. Anything ending in “~syndrome”
Similar to disease, the term syndrome is often associated with something permanent and inherently “wrong” with the patient, and, like all the conditions mentioned above, something that is less likely to be managed successfully conservatively. As with disease, we would recommend that the term be dropped, or replaced with “pain” or “condition”. E.g., instead of “patellofemoral pain syndrome”, simply “patellofemoral pain”, patellofemoral joint pain”, or “anterior knee pain”
6. “Shoulder impingement”
The term shoulder impingement came out of the editorial by Charles Neer in 1972. Neer claimed that the cause of most non-traumatic onset shoulder pain was downward pressure from the acromion causing irritation of the subacromial structures, and that successful resolution of the issue required acromioplasty (Neer, 1972). Neer’s initial description required temporary resolution of symptoms with local anesthetic into the subacromial space as a prognostic indicator. However, this method has not been applied by most orthopedic surgeons, and although acromioplasty has become an extremely common procedure, reported outcomes are inferior to physiotherapy management. If a patient’s understanding is that something is pushing down on the structures in their shoulder from above, then it does not make sense to engage in physiotherapy management. (J. S. Lewis, 2011). The issue is rarely to do with encroachment from the acromion, and more to do with suboptimal biomechanics through the kinetic chain, and inadequate strength and capacity through the rotator cuff. A rehabilitation plan to address these factors has been shown to be the most effective line of treatment. We recommend clinicians use terms such as “subacromial pain” or “rotator cuff related pain”.
An industry-wide change in the usage of orthopedic nomenclature is obviously no easy task. However, in order to strive towards optimal clinical outcomes, there needs to be a collaborative attitude to using language that reflects the current state of our knowledge base and focuses on patient-centered care.
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., & James, K. (2014). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology.
Dye, S. F., Vaupel, G. L., & Dye, C. C. (1998). Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. The American Journal of Sports Medicine, 26(6), 773–777.
Scott, A., Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., de Vos, R.-J., Fu, S. N., Grimaldi, A., & Lewis, J. S. (2020). Icon 2019: International scientific tendinopathy symposium consensus: clinical terminology. British Journal of Sports Medicine, 54(5), 260–262.