Ultrasound imaging (USI) may be one of the newer forms of imaging, but newer doesn't mean better. USI for abdominal organs and the uterus is valuable, but its value when it comes to musculoskeletal problems is not convincing. A new study in Physical Therapy in Sport entitled “Ultrasound imaging features of the Achilles tendon in dancers. Is there a correlation between the imaging and clinical findings? A cross-sectional study” does not find a correlation.
The study looked at the Achilles tendons of 29 dancers with no pain nor functional problems - 58 tendons total. With USI, 62% of the young women had at least one abnormal tendon. Of the 58 tendons, 26 were abnormal when examined using USI. This study also points to others that do not find a relationship between what USI shows and pain.
How is this applicable? Say one of these dancers with an abnormal tendon starts having pain in her Achilles after the study. It’s easy to assume that the tendon - which was abnormal on USI - is the problem. However, given that it was abnormal without pain, it makes sense that something else could be causing pain - perhaps something that cannot be visualized. For that reason, we should test a person’s musculoskeletal system by moving her musculoskeletal system. Versus imaging, that gives us improved chances to find the true source of the problem. --Laura
There is absolutely a time and place for joint replacements. While it’s every patient’s decision, I believe it’s best to explore conservative measures first - if for no other reason than risk alone. An individual’s determination should be based on a collection of facts and viewpoints.
It’s typically true that, when compared to replacement, therapy 1. poses less health risk 2. mandates less time off work 3. costs less 4. instills more self-efficacy 5. hurts less. Of course in the right patient group, it also provides superior outcomes. Within 5 visits I can usually arrive at a prognosis. With a poor prognosis (ie there’s too much structural compromise to improve), presenting the option of a surgical consult makes sense. If a patient explores therapy and a replacement is indicated, little time or money is lost in that endeavor if the therapist is skilled at arriving at a prognosis early.
“How can a person with a given diagnosis of OA who’s been recommended a new knee do well with therapy?” I treat a patient with joint complaints just like everyone else. I diagnose the patient based on a history and movement exam and treat accordingly. Most diagnoses do well with therapy, but in some cases it becomes clear that surgery is needed. -- Laura
Imaging can show plenty of things that are not related to people’s complaints. You need to move people to understand their problem. I am not against imaging when used under the appropriate circumstances. But imaging people’s spines (who have no red flags) before moving them to arrive at a diagnosis is plain wrong. Stenosis is quite normal with aging and is present on images of people with zero pain. Therefore, we know stenosis is not an automatic pain generator. If you have complaints and imaging shows stenosis, it holds that something else could be causing your pain. We don’t know until we move you. In my experience, the large majority of patients who have come to me saying another clinician diagnosed them with stenosis have done very well with therapy. In most of those cases, therefore, something else was causing their symptoms and their initial diagnosis was incorrect.
Scenario one. Your image shows stenosis. We move your spine and, despite the bony stenosis your image shows, you respond well to movement(s) and your symptoms resolve. [majority of cases in my experience]
Scenario two. Your image shows stenosis and, after we move you for several visits, it becomes clear that the stenosis is related to your symptoms. We discuss how we need just a couple weeks of specific movement to see if we can change any correlated soft tissue stenosis and impact your symptoms. We know that there is bony stenosis on the image but we still don’t know if bone or soft tissue is the real issue. Soft tissue we can usually change with movement, bones we cannot. After a few weeks your symptoms decrease or resolve so that no further intervention is desired/needed. [fewer cases]
Scenario three. Same as number two except, after the couple weeks of specific movement, your symptoms are unchanged. At this point we can integrate different strategies in therapy with goals of minimal to moderate overall improvement of symptoms - or you can have a surgical consult with the goal of more significant improvement. [fewer cases]
The point is we don't know which scenario applies to you until we move you. -- Laura
Osteoarthritis (OA) is prevalent with aging. So is gray hair. And wrinkles. OA is a form of joint degeneration, just like gray hair and wrinkles represent types of degeneration. But we think of hair and skin changes kindlier, accepting them as normal, harmless parts of getting older.
OA, on the other hand, gets a bad rap – a painful rap – when in fact it can also be normal and harmless. An association between OA and pain is unfortunately widely believed. If someone’s knee hurts and a knee MRI shows osteoarthritis, we quickly blame the osteoarthritis for the pain and tell ourselves that it can’t be fixed (unless we have surgery). When our head or skin hurts, do we automatically blame our grays or our wrinkles?
It is clear OA doesn’t necessarily cause pain because we find plenty of OA in people without pain. In fact, a person over 60 undeniably has OA somewhere in her body. Pain in a joint may be from OA, but it may also be from an irritated nerve, a dysfunctional tendon, or a misalignment in the joint – which are all typically very fixable! Expert McKenzie clinicians identify (and then treat) the true cause of someone’s pain. -- Laura
Alignment is important! When you move forward, you should be rolling over, and pushing off of, your big toe. This is the way the body was meant to move, step after step, year after year. If your movement pattern is off-kilter, your muscles, joints, etc. will likely break down at some point. (Just like misaligned tires on a car will usually lead to problems.)
When it comes to fixing an incorrect movement pattern, you first need to identify WHY you're not moving properly, of course. Your leg or legs may be moving incorrectly because of misalignment in one of your joints such as your spine, hip, knee, ankle, or any of the multiple joints in your foot. Or perhaps a muscle is weak or tight, not allowing you to move in a straight line. Considering how repetitive this movement is in our lives, it really is vital to have it functioning optimally to prevent injuries such as joint dysfunction (arthritis, meniscal and ligament problems) and muscle/tendon dysfunction (strains, tendinitis, tendinopathy). -- Laura
I realize I sound like a broken record, but I can't stress this enough: just because something is identified on an x-ray, MRI, or CT scan, does not mean it is causing a problem! Because so many people WITHOUT symptoms have abnormalities, it's clear we can't use imaging to diagnose orthopedic pathology. Instead, patients need a clinical exam in which the structures of the body are stressed in order to determine what the root of the pain/numbness/tingling/etc. is. This chart has some great statistics! Say you're over 40, for example: there's a 68% chance some of your disks are degenerated, a 45% chance some disks have shrunk in height, a 50% chance some disks are bulging, and a 33% chance some disks are protruded. These spinal changes are therefore quite normal as we age and are not necessarily correlated with symptoms. -- Laura
"It should be remembered that radiographic signs of degeneration are almost universal after 55, but that symptoms are present in only about 50% of those with such changes."
Huskisson EC, Hart FD (1987). Joint Diseases: All the arthropathies (4th ed.). Wrght, Bristol.
-- This means that abnormalities on imaging do not necessarily correlate with symptoms. Plenty of people are walking around with torn rotator cuffs, meniscal tears, arthritis and the like without any actual symptoms. More importantly, plenty of people incorrectly think that their symptoms can't be fixed because imaging shows something is irreversibly wrong. Via a thorough clinical examination, I aim to find and address the true cause of a patient's symptoms. Don't overlook expert physical therapy just because something is on an x-ray or MRI.
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