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
Again, it boils down to function vs structure. Most problems are things not functioning well - not structural damage. Think thyroids under or over producing hormones, hearts not pumping blood efficiently, bacterial infections in the gut.
In the musculoskeletal system it’s often nerves misfiring, joints not moving well, muscles not activating. Movement testing reveals these. Structural musculoskeletal issues, though, primarily need imaging to be visualized; they’re hard to see with the naked eye. Those who believe musculoskeletal problems are largely due to structural damage (I do not) therefore usually rely on imaging. A glaring problem with imaging, however, is that people with no complaints will have structural changes upon imaging. That those “changes” become “damage” in the presence of complaints is an unsubstantiated leap.
I use movement to test (and treat) the structure and function of people’s musculoskeletal system. In the event a relevant structural issue that will not respond to therapy is suspected, the individual is referred to the appropriate clinician. -- 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
The technology we have to see what is going on inside our bodies is tremendous. However, it is not always helpful. Just like many of us develop wrinkles and gray hair, orthopedic changes in our body are normal. Since we know that many people have these changes (eg disc bulges or cartilage defects or neuromas) WITHOUT symptoms, we should realize that if a person has complaints we cannot automatically blame these changes. A thorough clinical exam with repeated movement testing is necessary for diagnosis. We find that the bulk of patients just have a joint that's not sitting quite right which can be resolved with movement.
If the patient's complaint is not resolving within several visits using the McKenzie method, then an image may be warranted to see if there is a structural finding that is consistent with the patient's complaint. This is rare, however - the percentage of times I request a patient get an image is under 5%. -- Laura
Mechanical pain isn’t a new concept - it’s the most common kind of pain. Besides pain, tightness, numbness, clicking/locking, and tingling are also possible symptoms. The bad news is usually mechanical problems are diagnosed incorrectly as structural problems (eg torn meniscus). The good news is almost all are fixable - if you find a clinician who can diagnose and treat them, like a McKenzie expert.
Mechanical problems are those that, simply, can be fixed with movement. Examples include pinched nerves, dysfunctional tendons, pulled muscles, and frozen shoulders. However, the biggest subset of mechanical problems is joint derangements. Derangements (misalignments) are when something (somehow!) obstructs the joint, such as a fat pad; a herniated/bulging disc; a bone fragment; or a piece of meniscus, labrum, or cartilage. Treatment for muscles/tendons involves tissue remodeling movement; joint derangements require specific movements to restore proper alignment.
Outside of mechanical problems there are structural, chemical/inflammatory, and nervous system problems, among others. Most healthcare providers and patients conclude that symptoms are from a structural issue because of unreliable orthopedic tests and MRIs. Orthopedic tests are false positives in the presence of mechanical derangements and MRIs consistently show abnormalities that are irrelevant. An expert mechanical exam is needed. -- 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
Tendon issues are unfortunately incorrectly diagnosed all the time. That is, issues that are not tendon problems are diagnosed as tendon problems. “Issues” and “problems” refer to tendinopathy, tendinosis, tendonitis, and tendon tears. We have hundreds of tendons in our bodies; they are pieces of tissue that connect our muscles to our bones. Those that get an unfair share of the blame are the four rotator cuff tendons in the shoulder, the two main tendon groups at the elbow, the Achilles tendon of the ankle, and the patellar tendon at the knee. This frequent misdiagnosis happens for two chief reasons.
One, tendon problems are common on images such as MRI so, in the absence of an expert clinical mechanical exam, the tendon is identified as the culprit simply because of a picture. The concern with this is that tendon problems are common on images such as MRI in people with NO pain or other symptoms. So if Sarah has a large supraspinatus tendon tear on her MRI and no shoulder pain and John has a large supraspinatus tendon tear on his MRI and does have shoulder pain, can you assert that the supraspinatus tendon tear is causing his pain? Not from that information alone, you can’t.
(Say your car starts acting funny. You open up the hood to take a quick look. You see a lot of leaves around the engine. Can you assume that the leaves are causing the problem? Or would your mechanic need to run some diagnostic tests? After all, we know that there are plenty of cars with leaves stuck under the hood that run just fine.)
The second reason for this misdiagnosing conundrum? Lack of expert clinical “mechanics.” When I first began as a physical therapist, if a patient came to me with shoulder pain (with or without an MRI report), I performed the orthopedic shoulder tests I learned in school. While there are several tests aimed at diagnosing a rotator cuff tendon problem, these tests are actually not very good. They can regularly be positive when something other than the tendon is at fault. If physical therapists, orthopedists, general practitioners, surgeons, chiropractors, athletic trainers, etc. are still basing their diagnoses (and subsequent treatment) on these tests, they are missing a lot of crucial information.
Once I learned during my post-doctoral coursework that other problems can mimic tendon problems, I began looking for these in the clinic. And, lo and behold, most of the time it is something else causing the patient’s problem. The top two problems that mimic tendon problems are misalignment in the spine joints whose nerves send signals to the area of the tendon (eg the neck) and misalignment in the extremity joint closest the tendon (eg the shoulder).
How do I diagnose a tendon problem then? These are my top two criteria:
In closing, don’t jump to conclusions based on an image or the location of pain. A lot of shoulder pain is coming from the neck or from a shoulder joint that is not sitting properly – not a rotator cuff tendon. Likewise, a lot of pain on the outside of the hip is coming from the low back or from a hip joint that is not sitting properly – not the gluteal tendon. Our bodies are beautiful in their intricacy and nuance, making my job as a mechanical therapist exciting. It is the ability to understand this nuance that makes a clinician effective at diagnosing and treating. --Laura
Joel Laing, a McKenzie specialist in Australia, gives a great demonstration of a rapidly resolvable shoulder issue - specifically, shoulder pain and loss of motion. The wonderful thing about the McKenzie method is that we are trained to actually LOOK for these problems. I was not trained to look for these problems during my physical therapy doctoral program. Now that I know how to diagnose these issues, most patients get better in a handful of visits or less versus weeks/months of PT.
In his case he needs to repeatedly move his shoulder backwards with his palm down. Typically when we find the healing movement the patient needs, the patient does a few sets per day. As Joel also points out, there are often certain movements that make the problem worse as well. While the shoulder heals, we usually ask the patient to avoid those motions for a few days if possible.
When it comes to shoulder pain, the top two diagnoses I see are:
1. The pain is actually coming from the neck or upper mid-back, so we treat the spine with movement and the shoulder pain goes away.
2. The pain is quickly resolvable with targeted shoulder movement (like in Joel's case).
Don't let shoulder pain affect your life; in the large majority of cases we can get it better fast. And don't get a diagnosis based on an MRI. Most people over 30 will have problems in the shoulder on an MRI. Since problems on an image (a torn labrum, degenerated tendons, a torn rotator cuff, bone spurs) are so prevalent in people without pain, what you see doesn't necessarily correlate with your pain. You instead need a quality McKenzie clinical exam. -- Laura
I recently treated a patient who is emblematic of a slew of patients, especially baby boomers. She came to me with an MRI showing severe spinal stenosis - and several other spinal irregularities. She had been referred to a surgeon, but, luckily, as the idea of surgery at age 83 did not appeal to her, ended up coming to me instead. As we talked during the evaluation, it was clear that she already had two strong impressions. One, the stenosis was the cause of her symptoms. And, two, her stenosis was an irreversible disorder that would possibly get worse without surgical intervention. She had met a former patient of mine and had called me on the off chance physical therapy could help.
Stenosis refers to the narrowing of an opening. In the spine, stenosis commonly refers to narrowing of the opening through which nerves pass secondary to either bony overgrowth (eg osteophytes) or disc height loss. These changes in the spine are quite prevalent. Can stenosis be symptomatic? Yes. Irreversible without surgery? Yes.
But ... can stenosis (true, bony stenosis) be apparent on imaging and not be the cause of the patient's symptoms? An even louder yes. Very commonly.
In this patient's case, other spinal irregularities were observed on imaging as well. However, she had left her doctor's office believing that the stenosis was producing her symptoms. How was that determined? Diagnosing stenosis on imaging alone is not enough. A patient deserves a thorough physical examination to determine the cause of her symptoms, and then deserves a treatment plan specifically targeting that cause. Upon moving my patient's spine in different directions during her physical evaluation - I use the McKenzie method of mechanical diagnosis and therapy - I noted a favorable response to spine extension. In her case, over the course of four visits, she responded very well to sustained extension in prone. -- Laura
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