Managing Uncertainty

Thanks for all the feedback from last month's newsletter about the difficulties of being evidence-based. It seems many of you have the same issues I do here. 

Another common issue I think we all have working in musculoskeletal healthcare is getting comfortable with and managing uncertainty. 

Not because uncertainty is rare. Quite the opposite.

Uncertainty in healthcare is everywhere. Its in our assessments, our diagnostic labels, our imaging findings, our prognosis estimates, and in the very human habit of wanting every painful body part to come with a neat little explanation and a clear culprit. 

Patients often want to know exactly what's causing their pain. 

And if we’re being honest, we often want that too. 

We want to be able to say with confidence, “It’s this tendon,” “It’s that muscle,” or “This specific tissue is the problem.” 

It feels more reassuring. More professional. More skilled. More like we’ve done our job. 

But the uncomfortable truth is that, in many cases, we cannot diagnose the exact tissue or structure causing someone’s pain with any real certainty or reliability. 

And this is not incompetence or a lack of trying.

It's just reality. 

The Myth of Diagnostic Certainty

In musculoskeletal practice, pain is rarely as clean and precise as we’d like it to be.

When a patient comes in with shoulder pain, is it the supraspinatus tendon, is it irritated or torn, is it the long head of biceps, or the bursa as well? 

In back pain, is it a facet joint, a disc, a muscle, or even the dehydrated fucking fascia that seems to be the go-to specific diagnosis these days 

Same with neck pain, knee pain, hip pain, elbow pain, and most other regions we spend our days prodding, poking, and naming. 

Clinical symptoms, signs and tests often overlap. 

Pain patterns are messy. 

Imaging findings are frequently non-specific. 

And many so-called “special tests” are far less special than their names suggest. 

But this doesn’t mean our assessments are useless, or that we shouldn’t fully and thoroughly examine people in pain.

Far from it. 

It simply means our assessments are often better at identifying patterns, irritability, functional limitations, likely contributing factors, and ruling out serious pathology than they are at pinpointing one exact tissue with surgical precision. 

That distinction matters. 

Because too many clinicians still think their value lies in naming the exact damaged bit. 

It doesn’t. 

We Dont Treat Pathology

Our physiology is already getting on with that.

Inflammation regulation, tissue remodelling, sensitisation settling, strength changes, confidence rebuilding, and movement tolerance improving.

The body is handling a lot of the ‘getting better’ whether our specialist therapist egos like it or not.

What we do is help manage the consequences of the pathology.

We help reduce pain sensitivity.

We help improve tolerance to movement and load.

We help maintain function.

We help people sleep, cope, move, exercise, work, train, and live better while things settle or adapt.

We help people understand what is happening.

We help them avoid making things worse through fear, avoidance, overload, confusion, or panic.

In other words, we don’t “fix” tissues. We manage people and their problems.

Patients Often Don’t Need a Precise Diagnosis

Many clinicians worry that if they don’t give a precise structural diagnosis, patients will lose confidence in them.

That fear is understandable. Humans love certainty, and healthcare has trained people to expect answers dressed up as facts even when they’re closer to educated guesses.

But most patients don't need a pathoanatomical tissue-level diagnosis.

They need three things:

• A clear and honest explanation.
• A realistic and optimistic prognosis.
• And that you understand their problems and actually give a shit about them.

That’s it.

Patients are usually far less concerned with whether you can identify the exact irritated fibre in a tendon and more concerned with questions like:

• What is this?
• Is it serious?
• What can I do about it?
• How long will it take?
• Can I still work, train, sleep, or function? 

Those are the questions that matter most. 

And the good news is we can answer those well, even when we cannot be certain about the exact tissue involved. 

Wording Matters

This is where many clinicians accidentally blow their own foot off. 

They either overstate certainty and pretend to know exactly what is causing pain when they don’t. 

Or they swing too far the other way and say, “I don’t know what’s causing your pain,” which may be honest, but often lands like, “I have no fucking idea what I’m doing, and you’ve paid good money for this confusing little chat.” 

There is a better way. 

Instead of framing uncertainty as ignorance, frame it as clinical reasoning. 

Instead of saying: 

“I don’t know what’s causing your pain.” 

Try saying: 

“There are several possible structures in this area that could be contributing to your pain, but it’s often difficult to be completely certain which one it is because these conditions overlap a lot, and our tests are not that accurate” 

That's more accurate, more confident, and more useful. 

Then follow it with: 

“But the good news is that the treatment and management for all these possibilities is very similar, and so is the overall prognosis.” 

That sentence does a lot of heavy lifting. 

It tells the patient:

• You still know your shit
• You’re not trying to bullshit them
• You’re honest and humble 
• The uncertainty is normal
• The uncertainty is not dangerous
• The plan is still clear 

That is what good, honest reassurance sounds like. 

Not fake certainty. 

Not vague waffle. 

Clear, calm, honest direction. 

How to Explain to Patients without Losing Trust 

Patients lose trust in clinicians when uncertainty sounds like a lack of knowledge. 

They do not lose trust when uncertainty is explained clearly, calmly, and professionally. 

Our job is not to hide uncertainty. It’s to manage it confidently. 

I often find myself saying things like: 

“There are several structures in this area that can produce very similar symptoms, and the tests and imaging we have are not always good at separating them out perfectly.” 

Or: 

“We can narrow this down to a small group of likely possibilities, but being 100% certain about the exact tissue is often not possible, and in most cases it doesn’t actually change what we do.” 

Or: 

“What matters most right now is that nothing here suggests anything serious, your symptoms are very common, and the approach to helping this improve is usually very straightforward.” 

This builds trust because it shows honesty and perspective. 

Be Specific About Uncertainty, But Confident About the Plan 

A useful rule is this: 

• Be humble about the diagnosis.
• Be confident about its prognosis and management.  

Not arrogant. Not performative. Just clear and confident. 

You might say: 

“I can’t tell you with complete certainty whether this is primarily coming from the tendon, or another nearby structure, because they often behave very similarly. But I can say with confidence that this is often a very manageable musculoskeletal problem, and the outlook is good, and the treatment approach is going to focus on settling symptoms, restoring movement, and building your tolerance back up.” 

That doesn’t sound unclear, unsure, or weak 

It sounds competent. 

And competence is not pretending to know everything. 

Certainty is Overrated. Clarity is Not

Patients don’t need us to be perfect. They need us to be useful. 

They need knowledge without bluff, bluster, and bullshit.

They need honesty and humility. 

They need to know that even if we cannot identify the exact tissue causing pain, we can still understand the problem well enough to help. 

That is great physiotherapy. 

Final Thoughts

Many clinicians get stuck chasing the exact pathology as if naming the tissue is the same as solving the problem. 

It isn’t. 

In many cases, the body is already handling the tissue side of things as best it can. 

Our role is often to guide, support, modify, coach, reassure, load, and adapt around that. 

So the next time you feel uncomfortable not being able to name the exact structure, remember this: 

You DO NOT need absolute diagnostic certainty to provide excellent care. 

But you DO need great communication and excellent assessment skills, sound evidence-based clinical reasoning, and a solid plan. 

And for most patients, that is far more valuable than a confident-sounding Latin label. 

Now, if you want more help at navigating uncertainty and improving your communication, reassuring, and motivation skills then be sure to check out my Rehab Essentials mentorship program that covers all of this and more. 

And as a special offer for subscribing and reading my newsletters, you can get 25% off both the 12-month and lifetime access options by using the code NEWS at checkout.

Until next month 

Take care and stay strong 

Adam