Athletes with difficult or longstanding neuromusculoskeletal symptoms

Original Editor - Wanda van Niekerk

Top Contributors - Wanda van Niekerk and Kim Jackson  


At some stage in their careers most sports medicine clinicians will be confronted with patients with difficult and longstanding musculoskeletal symptoms. These patients will often report that they have been assessed and treated by other clinicians with limited success and that their symptoms are still present.[1]

Patients with difficult or longstanding musculoskeletal symptoms may present with:[2]

These persistent symptoms may be due to conditions masquerading as sports injuries, but chances are that they may be true musculoskeletal problems.[2] The question is then, how do clinicians approach these “difficult” and persisting presentations?

Clinical approach to difficult and longstanding musculoskeletal problems[1][2]

Determining the diagnosis[2]

Give yourself enough time to assess the patient with a long history of persistent problems. Also explain to the patient the necessity to revisit the entire history, previous examinations and other investigations used.[1][2]

Start at the very beginning

  • Get the details of the patients' earliest symptoms in his or her own words, rather than from a referral letter.[2]
  • Assess the presenting complaint, the time course and the response to previous therapy.[2]
  • Remember to investigate the past medical history as well as family history.[1][2]
  • Be specific with questioning - associated musculoskeletal symptoms may provide clues to an alternative diagnosis.[2]
  • Assess the patients’ demands of his or her work as symptoms might arise from this, rather than from their sport.[2]
  • Investigate the patients' history of non-musculoskeletal symptoms as well.[1][2]

Physical Examination

  • Be thorough and meticulous with your assessment.[2]
  • Always examine the spine (referred pain commonly goes undiagnosed)[2]
  • Continue the examination even if an abnormality has been found, there may be a combination of contributing factors involved.[2]
  • Routine physical examinations are not always sensitive enough to test for pain in the athletic population and therefore functional assessments need to be a part of the physical examination.[1][2]

Previous investigations

  • Reassess the results of previous investigations, false negatives and incorrect interpretation of results may lead to a prolonged diagnosis.[2]
  • Consider other suitable tests that have not yet been performed.[2]
  • Collaboration between the clinician and radiologist is useful to optimise the outcome for the patient.[2]


In certain cases of patients with difficult or longstanding problems, the patient may not respond to treatment, although the diagnosis seems straightforward. In such cases it is worth to:[1][2]

  • Establish that the diagnosis is in fact correct[1][2]
  • Review the details of past treatment techniques[1][2]
  • Aim to elicit the underlying cause of the problem[2]
  • Contemplate various treatment options[1][2]
  • Surgical intervention is the last resort and only when the indications for surgery are met[2]

Correct diagnosis?

  • Some conditions can be easily misdiagnosed. Some patients present with a presumably straightforward condition when in fact they are suffering from a different condition.
  • Common misdiagnosed conditions:[1][2]
Obvious diagnosis True or alternate diagnosis
Tennis elbow Cervical disc abnormality
Persistent hamstring strain Neural mechanosensitivity
Achilles tendinopathy Posterior impingement

Retrocalcaneal bursitis

Patellafemoral pain/ Knee OA Referred pain from the hip
Bucket handle tear of the meniscus Referred pain form ruptured L4-5 disc
  • Biomechanical problems are often the reasons for persisting longstanding symptoms. Assess all relevant biomechanical factors.[1][2]
  • Suggested biomechanical issues related to persistent symptoms in athletes[2]
Persistent Symptom Biomechanical issue possibly present
Shoulder pain in swimmer Poor scapulae stability

Limited trunk rotation

Elbow pain in throwing athlete letting the elbow hang because of trunk and lower limb weakness

Decreased glenohumeral external rotation

Lumbar pain in tennis player Poor control of lumbar hyperextension
Anterior knee pain in runner Weakness of vastus medialis and poor gluteal control of pelvis
  • Investigate training regimes and possible training errors.[1]
  • Always gather full and specific details of treatment received.[1][2]
  • Make use of the multidisciplinary team approach.[2]
  • Refer to appropriate professionals and experts in their specific field of interest.[2]


Dealing with difficult and long standing musculoskeletal problems can be frustrating for both the patient and the clinician.Taking time to assess and perform .detailed examinations is worthwhile and may discover the missing piece of the puzzle in the diagnosis or treatment. Critical review of all previous investigations is important and functional and biomechanical assessments is especially necessary with athletes.[2]


  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 The patient who every other health professional can't fix...2012 (last accessed 26 September 2018)
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 2.29 2.30 2.31 2.32 2.33 2.34 2.35 2.36 2.37 Brukner P. Khan K. Clinical Sports Medicine. 3rd edition. Sydney: McGraw-Hill 2006.