Adapting Vision Foundation Models (VFMs) to medical imaging via LoRA has become standard practice, yet model selection is guided almost entirely by downstream task metrics, treating backbones with similar performance as interchangeable. We investigate whether equal performance implies equal internal representational shift. We analyse four ViT-B/16 backbones, DINOv3, SigLIP2, MerMED-FM, and BiomedCLIP, pre-trained with different objectives (self-distillation vs. contrastive vision-language) and on different data domains (natural vs. medical images). We adapt each to brain tumour segmentation and evaluate on six datasets covering both segmentation and Alzheimer's disease classification. Using attention divergence, weight-change analysis, and activation patching, we find that the four models converge to similar segmentation performance (mean Dice 78-81%) through markedly different internal dynamics, yet diverge in cross-task transfer: segmentation adaptation improves Alzheimer's disease classification for DINOv3 but degrades it for the other three backbones. We reveal a dissociation between modification magnitude and causal importance: the most heavily modified layers are not the causally relevant ones, with early-to-mid layers identified as sufficient for segmentation recovery. Restricting LoRA to these layers matches or approaches full-layer segmentation while reducing classification degradation in the three affected backbones, providing a mechanistically grounded strategy that is more parameter-efficient and more robust than standard full-layer adaptation.

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