Pathology is “something abnormal: the structural and functional deviations from the normal that constitute disease or characterize a particular disease.” (Merriam-Webster) Many times it is obvious when something isn’t working correctly, but to be able to identify less noticeable pathology in the musculoskeletal system, one needs to know what normal is. There are exceptions, but norms exist. Muscles have a certain strength and flexibility, joints have a specific amount of motion and feel at their end ranges, nerves have a normal amount of excursion, and movements like walking have certain biomechanical patterns. So, if a person has identified orthopedic pathology such as an achy shoulder, nerve pain down the leg, a stuck knee, numb fingers, a weak quad, what is one to do?
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One can change one’s habits, take something, purchase a device ranging from the normal to the fringe, or seek out the help of a professional. If consulting with a professional, numerous factors contribute to this decision, such as insurance coverage, one’s knowledge regarding different professions, cost, prior experience, and personal recommendations. When it comes to consumers’ knowledge, to close the knowledge gap, a crucial point is worth highlighting: in order to get the optimal care, you should see someone who does not just identify your pathology (eg a weak arm), but who has expertise in diagnosing the cause of your pathology (eg supraspinatus tendinopathy). How can you fix a problem if you can’t recognize the true cause? (And furthermore, how can you restore someone to normal if you don’t know what normal is?)

Commonly utilized in this country are doctors of medicine specializing in orthopedics, doctors of osteopathy, doctors of physical therapy, and doctors of chiropractic. While an education in diagnosis and musculoskeletal norms is fundamental among them, scholastic instruction among these fields is not consistent. (My post-doctoral training in orthopedics even diverges significantly from what I learned in school with respect to diagnosing and treating.) General practitioners, primary care physicians, and internists, by the way, receive, on the whole, little education in this field of orthopedic diagnosis.

People with issues also consult with professionals such as personal trainers, Pilates and yoga instructors, sports and conditioning specialists, massage therapists, and running coaches. These professionals are not trained in diagnosing pathology. Most of them specialize instead in performance - taking a normal (non-pathological) body and making it better. There is absolutely a role for this. Unfortunately, though, pathology is often being addressed in this arena. Will the “treatment” succeed sometimes? Of course. Time alone heals a lot of pathology, even if typically just temporarily and not fully. But this is not in the best interest of the person with the problem.

To use an example, let’s take a semi-professional sprinter whose primary complaint is that her left calf doesn’t have the same strength as her right. When she stands on just her left foot, she can’t push up very high on her toes. This, though it does not seem to be major pathology, is pathology - a muscle is not performing normally. It’s not just a matter of performance. The question is (the question always is): Why? What is causing this pathology of weakness? What is the diagnosis? Possible diagnoses include Achilles tendinopathy, calf muscle strain or tear, ankle or knee derangement/malalignment, stress fracture, S1-S2 nerve root impingement at the spine, and peripheral nerve entrapment in the lower extremity. There are less likely orthopedic and non-orthopedic diagnoses to consider as well, such as neurological diagnoses.

In all scenarios – just like with the example above - possible diagnoses should be churning in the competent professional’s mind and the correct one should be deduced through a verbal history and physical examination. (Imaging is rarely needed.) Arriving at the diagnosis will then dictate the proper treatment. When looking for professional assistance, consider who has the appropriate education to diagnose your problem. It may take a few tries, but your health is worth it. -- Laura

​Among the many successful patient encounters I had in Peru, an especially memorable case was a male patient around 60 years old who presented with complaints of left knee pain with walking on hills and with squatting. He demonstrated a minimal loss of left knee extension, pain with left knee flexion overpressure and extension overpressure, weakness in the left hip flexor, and movement loss in his lumbar spine. We used squatting as his primary baseline test - it was indeed very painful for his left knee, which also buckled at the bottom of the squat, forcing him to push on a table with his hands to return to standing. Repeated movements in the sagittal plane for the spine had no effect on squatting; nor did repeated movements of the left knee (sagittal and transverse planes). I did not enjoy continually asking him to retest squatting, but that information was crucial, especially considering I would never see him again. I could sense he was growing frustrated as well since, after movement upon movement, squatting remained very painful. It wasn’t until we performed supine rotation in flexion that squatting proved better. With repetition, his squatting ability continued to improve. His knee now had no movement loss and no pain with overpressure and his hip flexor was strong. You could see the excitement on his face; the translator conveyed that the patient was happy and appreciative. I taught him how to perform the maneuver at home and am optimistic that he will be walking and squatting better in the future. -- Laura