#491 Pathologic vs. abnormal x-ray and MRI findings in runners - DOC

#491 Pathologic vs. abnormal x-ray and MRI findings in runners

Today on the Doc On The Run Podcast, we’re talking about the difference between pathologic versus abnormal findings on x-rays and MRIs in runners.


I do second opinions all day for runners and every Monday and Wednesday and Friday, I actually talk with some people who have signed up to discuss their problems, discuss their advancement in their activities and their training activities as they try to move faster through the recovery process after over training injuries. I get lots of interesting questions from those discussions.

The other day I was talking to one of these runners who had some abnormal findings on the x-rays, specifically it was calcification in the Achilles tendon, and she wanted to know if she should have surgery to remove the calcification or little bony chips that were in the Achilles tendon. That’s a great question.

Now, the interesting thing is that that was discovered from an x-ray where she had a stress fracture in one of the metatarsals. This didn’t even come from an Achilles tendon problem. This brings up a great point that oftentimes we, as physicians, order tests to confirm what we think or rule out what we suspect.

I recently gave a talk in Hawaii that was called Clinical Acumen versus Medical Imaging: When to make the call in returning athletes to activity, and I was lecturing to physicians who were getting their continuing medical education credits. The entire point of that talk was that we know that when we, as doctors, have a gut instinct about something, most of the time, that’s usually right.

But because we’re scientists and because we want objective evidence that actually can prove what we think and make sure that we’re doing the right thing for the patient, we often order tests like blood tests, x-rays, or MRIs. What’s really interesting? There’ve been some studies that actually show that doctors will actually believe these tests even if the tests are known to have problems and show false results, and they’ll often take those false results and act on those, even if their gut instinct says something different.

What you really have to understand as a runner is that when you get an x-ray or an MRI, you can have things that are abnormal, that don’t look normal, and that look like a problem. But if they’re not causing pain and they’re not interfering with your activity, they’re not what I would call pathologic. Pathologic means it’s a disease process. It’s an injury. It’s a thing that’s called trouble. It’s causing pain, and it’s preventing you from doing the activities that you actually enjoy like running.

Achilles tendon calcification

If you have calcification in the Achilles tendon and you have a little bone spur that’s sort of growing from the heel bone into the Achilles tendon, and your doctor says, “Well, you have a bone spur there. That’s not normal. Maybe that’s contributing to your problems. Maybe it’s not pliable enough. Let’s go in there and take it out,” well, I’ve done that multiple times. Sometimes when you go in there, it looks like the bone spur is separate from the Achilles tendon, but then you actually get in there and it’s in the middle of the Achilles tendon.

You have to detach the Achilles tendon, cut the Achilles tendon open and scrape the bone spur out of there. Then reattach the Achilles tendon with some bone anchors, sew it back down, and then the patient wakes up in an above the knee cast that’s bent at 45 degrees. You wind up with a long recovery that can be seriously detrimental to your running fitness.

Metatarsus Adductus

This also happens with lots of other simple conditions that really look bad on x-rays. One of them is called metatarsus adductus. And that means that the metatarsal bones are just tilted at a weird angle and that can be pathologic. You can have pain. You can get stress fractures in the foot, particularly the fourth and fifth metatarsals when you have this condition.

But if you’ve been running for many, many years and then you have planter fasciitis and the doctor gets an x-ray of your foot and says, “You have metatarsus adductus. We need to do surgery and cut all those metatarsals and tilt them back over where they belong and put little screws in them to hold them in place,” well, that’s crazy, but that does happen.


Bunions are also another thing that are very, very common, but are not necessarily pathologic. I mean, they are abnormal. The bone is in an abnormal position. The big toe is in an abnormal position. But if you can run, if you can train and do all of your activities without any pain, I don’t know why you’d want to do bunion surgery. But if you have bunions and you walk into a podiatrist office and you just say, “I have pain. What do you think?” They’re going to look at your feet and think, “I think you have bunions and let’s do surgery.”

You have to really think about whether or not the condition that you have, in particular, the finding that shows up on your MRI or your x-ray that’s not even in the neighborhood of where the discomfort is, you have to think about whether or not it’s just something that is a little weird and abnormal, but it’s not contributing to your problems. If not, you definitely should not consider something like surgery to try to address it. If that ever happens, get a second opinion first.