Sit Up Tall and I’ll Answer You
The patient sits before me with head slumped and shoulders rolled forward, telling the story of his painful neck. A twenty minute physical therapy examination has shown that the details of his body position do indeed effect his symptoms. A simple correction of the slump in his thoracic spine and tilt of the head greatly improves the pain and neck range of motion.
Still, the patient desires a diagnosis, a label that he is familiar with. He asks whether or not he should get an MRI (Magnetic Resonance Image) of the neck.
Muscle spasm. Degenerative joint disease. Sciatica. Rattling off a series of typical and likely scenarios is easy. It is far more challenging to find the aberrant movement that is the root of the problem. It’s even more difficult to help some clients understand why a clear-cut diagnosis is unnecessary and more tricky than you would think. Here I will give it a try.
The Problem is a Verb
Tennis elbow (or lateral epicondylitis).
These diagnoses name an injured part of the body. They are nouns that many people are somewhat familiar with. But it turns out that noun diagnoses are often inaccurate (1,2). For example, it’s nearly impossible to reliably differentiate a shoulder bursitis from tendonitis or a partial rotator cuff tear because they often look and feel similarly.
How you respond to movement matters. Movement is a low cost, highly reliable and relevant diagnostic tool for actually doing something for your aches and pains. At least initially, understanding the noun is less important (3,4). Initial treatment depends on how the symptoms respond to changes in movement and position. Muscle and joint pain almost always has to do with dysfunctional movement. In other words, the real problem is a verb.
The Limits of Diagnostic Imaging
Why, exactly, does your shoulder ache after volleyball practice? Is your Achilles tendon sore because of poor foot structure or hip inflexibility? Will the back and leg pain require surgery or is it likely to respond to more conservative care? You will need some verbs (movement tests) to answer these types of questions.
Although X-rays and MRIs provide a peek into potential causes of pain associated with injury or “wear and tear,” research has proven that looks are deceiving (6, 7, 8, 15). These images show the internal anatomy while the person holds still like a statue. But they do not show how the muscles and joints move, and the exact tissue at fault remains uncertain(5). Over many years, researchers have repeatedly discovered that people in pain and those who report no pain both usually show degenerative changes and tissue injury under MRI.
Orthopedists and physicians have known of the limits of imaging studies for decades.
For example, many people without shoulder problems have partial and full thickness rotator cuff tears(11). Others with severe shoulder pain and weakness have no tear at all. Concerning back pain, the medical community has generously invented a diagnostic label that clearly acknowledges the problem of using diagnostic labels. Nonspecific low back pain has since been diagnosed in over 90% of patients with back pain (9,10). I’m truly not making this up. Search the literature, and you will see countless discussions of nonspecific low back pain.
Experts agree that joint wear and tear is a normal part of aging. Degeneration is not a disease like the diagnosis Degenerative Joint Disease implies. Fifty percent of the MRIs of people in their early twenties show these (13), and the percentage increases each decade! Meniscal tears and osteoarthritis in the knee are almost universal (12), yet not everyone needs a knee replacement.
How much degeneration the body can accommodate varies from person to person. But something other than a structural problem is responsible for causing misery for some people but not others. The difference is in how they move.
The Limits of An Alternative System
So where are we left in our attempts to describe movement related problems with movement-related terminology? Live imaging that allows us to watch internal movement is helpful but very expensive. Some orthopedists and rehabilitation experts have suggested a movement-based classification criteria. It makes sense to healthcare providers who take the time to assess movement quality. But to the rest of the world, these sounds fairly ridiculous.
Lumbar flexion dysfunction.
Scapula upward rotation dyskenesis.
Knee coordination impairment.
In order to be more technically correct in describing movement, we’ve become more vague and silly. Imagine the scenarios.
“Doctor it hurts when I bend forward, like, flexing my spine.”
“Yeah, it seems to me that you have a lumbar flexion dysfunction.”
“Doctor my knee hurts severely and often gives out.”
“Well I’ve determined that you have knee coordination impairment.”
Before laughing, we should recall that we have accepted terms like Restless Legs Syndrome and Halitosis as serious medical terminology. Besides, it’s not so much a label, but a response to movement that we’re after. That’s hard to pin down in just a few words.
The bottom line is that you should never be too intimidated when you hear arthritic this or torn that. Diagnostic imaging is one piece of the puzzle and it really is okay if your doctor didn’t order expensive tests right away. The best thing you can do, at least initially, is to worry less about exactly what’s causing the pain. Instead, seek to find what, if any, movements and positions cause an improvement in pain and function.
I’m willing to admit my biases as a physical therapist. There is absolutely a time and place for surgery and other more invasive procedures. But I would think that sitting with good posture and consistently performing a handful of stretching and strengthening exercise deserves a serious effort.
With the right intervention, changing the details of how your body moves quite often translates into less pain and more verbs.
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2. Saal JS. General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques. Spine. 2002 15;27(22):2538-45.
3. Cook C, Hegedus E, Ramey K. Physical therapy exercise intervention based on classification using the patent response method: a systematic review of the literature. JMPT 2005;13:152-62.
4. Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. Spine. 1997; 22:1115-1122.
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6. Michael J. DeFranco, MD, and Bernard R. Bach, Jr, MD. A Comprehensive Review of Partial Anterior Cruciate Ligament Tears. In The Journal of Bone and Joint Surgery. January 2009. Vol. 91A. No. 1. Pp. 198-208.
7. Videman T, Battie MC, Gibbons LE, Maravilla K, Kaprio J. Association between back pain history and lumbar MRI findings. Spine 2003;28(6):582-8.
8. Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine 2003;3(6):460-5.
9. Koes B. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001;26:2504-2514.
10. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber–Moffett J, Kovacs F. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006;4(2):S192-300.
11. Sher JS, Uribe JW, Posarda A. Abnormal findings on magnetic resonance images of asymptomatic shoulders. Journal of Bone and Joint Surgery 1995;77(A): 10-15.
12. Englund M, Guermazi A, Gale D. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359:1108-1115.
13. Takatalo J, Karppinnen J, Niinimaki J et al. Prevalence of disc degeneration and displacement, annular tears, and modic changes in lumbar MRI scans in young adults. Spine. 2009;34(16):1716-21.
14. Hoangmai H. Pham, Bruce E. Landon, James D. Reschovsky, Beny Wu, & Deborah Schrag. Rapidity and Modality of Imaging for Acute Low Back Pain in Elderly Patients. Archives of Internal Medicine 2009, 169 (10), 972-981
15. Connor PM, Banks DM, Tyson AB, Coumas JS and D’Alessandro DF (2003): Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes. A five-year follow-up study. American Journal of Sports Medicine 31, 5, 724-727.