Stop Letting a Piece of Paper Define You
We are in the midst of an orthopedic injury epidemic. More people are hurt than ever before, and shockingly, more people are receiving “conclusive” imaging and quick fix surgical interventions than EVER before. It’s time to take a stand.
This is a no holds barred look at the reality of the over prescription of imaging and surgery in this country. This is a call to stop letting an MRI, x-ray or half-assed 2-minute theoretical diagnosis define who you are, or what you are capable of physically achieving.
The medical community is confused on how to use imaging in explaining pain and “dysfunction” to the general population. Here is the reality:
- If you are in your 20s there is a 37% chance that you have “degenerative disc disease” or DDD.
- If you are in your 30s that number jumps to 52%.
- And man, if you are 40 you should absolutely not load up those squats and deadlifts because there is 68% chance that you have the dreaded DDD (Brinjikji, et all 2015).
Here’s the crazy thing, these are percentages of the population that have an image “abnormality” but have zero pain.
Lets reiterate this massively important point:
A high percentage of the population has abnormalities on imaging but does NOT have pain.
This is a phenomenon that is not only isolated to the low back but also exists at most of the other joints of the body. Are there appropriate times for images and surgery? Absolutely! I am not discounting the important role that the medical community plays in keeping people healthy. But this article isn’t for the minority of people who need surgery, this is for the majority who don’t. There are better (and much less expensive) ways to manage pain and dysfunction that do not require a visit to the surgeon.
We are going to look at the 4 most commonly painful and injured regions of the body, and what the best research ACTUALLY says about that piece of paper and how to save yourself from an unnecessary trip under the knife.
The Low Back
I have a question for you: if you saw your grandma, would you tell her that she has “degenerative skin disease”? That is the best way to think about a diagnosis of “degenerative disc disease”. It is a normal part of the aging process.
If you have ever been upright and thrown a few weights around there is a high likelihood you have some sort of “DDD”. The low back is THE most confusing area to get an accurate diagnosis of because even the experts in the medical community cannot agree on how to treat low back pain.
For example, 99/100 spine surgeons at a conference in Bonita Springs, Florida wouldn’t even undergo a lumbar fusion (a surgery that results in the bones of the low back being fused together with screws and plates) even though they perform this exact surgery on a daily basis. Whoa.
Another recent article in Surgical Neurology International looked at patients getting a second opinion for spinal surgery. Only 6% of the second opinion patients were told to have the right surgery from their initial MD! (Epstein, et al 2013). Couple this with lumbar spine surgery rates increasing by 33% and you have a recipe for disaster.
Now before you think that all of these people are your grandma’s age lets take a look at study from the 2016 Rio Olympic Games (Wasserman et al, 2018). Of the 100 athletes who received MRI’s of their spine and 52% had findings of moderate to severe spine disease. It is 100% possible to compete at the highest level of your sport with positive findings of degenerative spine changes and surprisingly, weightlifting was not the sport with the most abnormal findings; diving was.
Unnecessary early imaging for the low back can also negatively affect your confidence and your wallet. People who get early MRI’s absorb $12,948-$13,816 higher medical costs, longer disability and worse outcomes (Webster, et al 2013).
The reality is that only 3-15% of people with back pain shoulder undergo further investigation (Chou, et al 2007). In fact, the mere referral to a spine surgeon resulted in 52% of patients having higher levels of fear (Kidane, et al 2011), causing a phenomenon known as the nocebo effect.
Now for all of these people out there obsessed with their “disc being out”- follow-up MRI at 6-12 months after a disc injury shows that 50% of patients see a 70% decrease in size of the extruded disc! (Fagerlund, 1990, Maigne, 1992, Bush, 1992; Jensen, 1996; Autio, 2006; Monument 2011).
So what does all this show? Your body can actually highly capable of healing on it’s own. Oh yeah, and the larger the extrusion, the MORE likely it is to absorb! (Maigne 1992, Bush 1992, Jensen 1996) So contrary to popular belief, the size of your “slipped disc” does not mean you are “worse”.
If these facts done drive home the point that we have all been looking at treatment and diagnosis of low back pain completely ass backwards, then I don’t know what will.
If DDD is the standard diagnosis of the low back, then a degenerative rotator cuff tear, bone spurs, bursitis is the equivalent of the shoulder (aka glenohumeral joint). The low back is defiantly the low hanging fruit here as it has the best support for non-operative management with positive findings on images. But other joints, such as the shoulder are catching up.
Additional diagnoses of the shoulder include labral tears, dislocations and cartilage defects each with multiple sub-types. Before we delve into the research on imaging of the shoulder, the outlook of patient and client management would be purely incomplete without the mention of anecdotal case studies that I myself as a clinician have stacked up over the years treating and managing patients with “functional death sentence” imaging on the shoulder.
Many of my patients from a diverse demographic ranging from geriatrics to professional baseball players were categorized or recommended surgery before a physical or functional diagnostic evaluation. Many of them, upon recommendation did go under the knife, and of this sub-group, those who responded positively to surgery were in the clear minority.
Many patients who were recommended surgical intervention had a greater amount of long term success rehabilitating conservatively. The best evidence will show us that even in the shoulder, conservative measures can be equal if not superior to surgical intervention.
You don’t have to take my word for it, just ask one of the best and most well known orthopedic surgeons in the country, Dr. James Andrews, “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I”(NY Times Oct 28, 2011).
To prove his point, Dr. Andrews examined 31 non-painful professional pitchers. MRIs showed abnormal cartilage in 90% of them and abnormal rotator cuff tendons in 87% of them (NY Times Oct 28, 2011). Wow. Almost every single player “had something wrong” but was playing at a high level without pain. Now think about this, these are athletes who are abusing the crap out of their shoulders but none had issues performing. So next time you do a push up or bench press and your shoulder hurts, maybe you should worry about finding someone who can help you fix your crappy form first.
How about ‘the normal person” (i.e. non-professional athlete). Grish et al in 2011 looked at 51 men aged 40-70 who were asymptomatic.
- 96% had abnormalities.
- 78% had bursal thickening and 22% had a rotator cuff tear.
How about another study in 2014 by Kukkonen, et al in the The Bone and Joint Journal? This study followed patients with a non-traumatic supraspinatus (a rotator cuff muscle) tear out to 1 year. Guess what?! At one-year follow-up operative treatment was no better than conservative treatment and “conservative treatment should be considered as the primary method of treatment for this condition”. Some realities here, the average age of the person studied here was 62.6 years but they included people as young as 31.
Another review of the literature in the International Journal of Sports Physical Therapy concluded that exercise rehabilitation should be the first line in patients with partial or full thickness tears. However, this same study also concluded that younger patients with acute tears more than 1cm will typically respond well to surgical intervention (Edwards, et al 2016). I have personally seen this clinically. I am not “anti-surgery”. I am anti jumping right into images and surgical intervention when it is not warranted.
How about labral tears (specifically, superior labral or SLAP tears), which tend to happen in younger, more active populations? Well, guess what?! Conservative care is again the winner as is shown in this study in the Journal of Arthroscopic and Related Surgery (Blaine, et al 2007) “the present study validates the non-operative treatment of superior labral tears, with improved pain relief and functional outcomes comparable to those seen with operative treatment. Based on these findings, an initial trial of non-operative treatment may be considered in patients with the diagnosis of isolated superior labral tear”.
Just so people don’t think that I am a cherry picker of the science, I will present a recent study in the Journal of Shoulder and Elbow Surgery (Piper et, al 2018) that concluded that operative treatment for rotator cuff tears was superior to non-operative treatment. Here is the catch (and the thing that really irritates me about research)- the “superior outcome” of surgery did not even meet the minimal clinically important difference in the outcome. Meaning, the change in the outcome (pain, which is really bad choice for an outcome) wasn’t significantly improved to say it was actually an improvement (versus happening by chance). AND the surgery and types of rotator cuff tears that the participants had were not even the SAME. In high level medical research, you cannot compare apples to oranges.
Before we move on from the shoulder, lets end where we began with high level athletes and people who beat the crap out of their bodies on a daily basis. It was shown that high level, asymptomatic Division-1 athletes demonstrated MRI changes at the shoulder and wrist similar to those “associated with abnormalities for which medical treatment and sometimes surgery are advised”(Fredericson, et al 2009, Lee, et al 2017). If you exercise and bang your body around, expect to see some changes on images. And yes, and there is high quality evidence to support that claim.
As we continue our journey to yet another poorly diagnosed area, we arrive at the hip joint. This is the area where the pelvis and the femur articulate. There are two BIG diagnoses’ that occur here:
- Hip arthritis.
- Femoral acetabular impingement (the more sexy name for FAI).
Lets jump into hip arthritis first.
I hate this diagnosis, man do I hate it. Why? Because arthritis is very poor predictor of pain. If you have ever stood upright against gravity and moved somewhere, you will most likely have some level of arthritis. Period. The way arthritis is diagnosed is by comparing the joint space between two bones. God forbid if its narrow because boom, you will be told you have the dreaded arthritis. Once again, high quality evidence does not support this connection between arthritis findings and pain.
Example- there is a weak association between joint space narrowing seen on a hip x-ray and actual hip symptoms (Chu, et al, 2011). It is not abnormal for people to have joint space narrowing (S.Jacobsen et, al 2004).
How about FAI, a condition diagnosed by identifying excess bony growth on either the femur (known as a CAM impingement) or the pelvis (known as a pincer impingement) that results in an abnormal shape of either (or both) structures. Theoretically, this causes poor bone alignment as the bones move on each other and can cause pinching and tearing of the labrum (a ring of fibrocartilage that sits between ball and socket that promotes stability of the joint) and ultimately pain most notably in the groin.
One of the biggest sports with incidences of FAI is hockey. Guess what? 77% of healthy hockey players who had no pain had hip and groin abnormalities on MRI (Silvis, et all 2011). This finding is also supported by a study in Arthroscopy by Gallo, et al in 2014.
Even up 85% of asymptomatic soccer players have imaging findings of FAI (Yepez, et al 2017). What we see in this population is the body’s ability to adapt to the stressed placed on it. Not some abnormality that needs to always be addressed surgically to restore the body back to where it should be. Oh and by the way, this study in the Journal of Hip Preservation Surgery from 2016 found that only 64% of patients were satisfied after undergoing arthroscopic surgery for FAI. Man, I wish I could survive a 64% satisfaction rate and still stay in business!
This is an area that hits a little close to home as I have had the pleasure of working with some of the TOP hip surgeons who are on the forefront of the FAI/Labral tear research and treatment. There are people who do really well after this surgery but it takes a long time (up to 2 years). However, this is not the majority.
Most of the people who do well were properly diagnosed and had gone through appropriate rehabilitation and a differential diagnosis process (i.e. rule out other causes of symptoms) before they went under the knife. A reality about FAI. If you have played sports especially for a long period of time, there is high chance your body has FAI as an adaptation and not as some disease process. Some people are just born with it (pick your parents wisely) just like they were born with certain hair color, eye color, etc. We need to stop using the term “abnormal” because in fact many “abnormalities” are, in fact, NORMAL!
Did you know that when given an x-ray, up to 85% of adults with no knee pain have knee arthritis? (Bedson, et al 2008). An even more interesting number is that only 19-30% of people between the ages of 40-80 who HAD knee pain had radiographic osteoarthritis (OA). So basically, you have a higher chance of having radiographic OA and NO pain then pain.
Another interesting point- if you look at Bedson’s study, the medical world does not even agree on what constitutes OA on an image. You really want to take someone’s word about the arthritis in your knee when they don’t even have a consistent reference standard?
Another structure that is commonly blamed for knee pain is the meniscus. Given that knee arthroscopy is the most commonly performed orthopedic procedure performed, this a HUGE area for us to look at. Think of the meniscus as the pillow of the knee. It is responsible for accepting and distributing load across the knee joint and it secondarily provides knee joint stability. There have been some keynote studies in the past few years on degenerative meniscus tears and exercise vs surgery via meniscectomy (where they take out the torn tissue and round the edges of what is left).
In the British Journal of Sports Medicine in 2016, exercise vs meniscectomy was compared for degenerative meniscus tears without radiographic OA. Those involved in the study were followed for 2 years. There was NO DIFFERNCE between surgical group and non-operative group. In fact, the non-op group gained significantly more quad strength at 3 months. So basically, skip the surgery, exercise and get stronger! You will be ahead of everyone given the false promise of going under the knife.
The BJSM took these findings a step farther and in 2017 came out with clinical guidelines that made a “STRONG recommendation AGAINST the use of arthroscopy in nearly all patients with degenerative knee disease, based on systematic reviews…further research is unlikely to alter this recommendation”.
Even more “this recommendation applies to patients with or without imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptom onset”. Holy shit! First off, these recommendations basically state that even if your knee pain started yesterday and an image found some degeneration, you are still better off exercising! Second, whenever you read anything in clinical guidelines that has words like “strong” and suggests that more research won’t budge findings you can be pretty damn confident.
Good things come in threes so lets look at one more BJSM study from Stensrud et al in 2014. Here, they looked at 82 patients with degenerative meniscal tears who had knee pain. Guess what they found? The participants had impaired quad strength! In short, they were WEAK!!! And here we all were thinking that oh my god, if I do squats I am going to need a knee replacement. false! Maybe squats and leg strength is exactly what you need.
Lets finish this section by looking at some more high level athletes. In an article in the Journal of Knee Surgery from 2008 14 asymptomatic NBA players knees (28 knees) were evaluated. Three knees (10%) were considered “normal”. Yes, here we go again. A significant percentage of these individuals had something “wrong” including articular cartilage lesions, effusion (almost 30%), bone marrow edema, tendonosis, loose, bodies and even an osteochondral fracture! I will repeat, all of these players were playing WITHOUT PAIN!!! (Walczak, et al 2008).
Studies similar to this in college basketball (Pappas, et al 2016), NBA (Major et al 2002, Kaplan, et al 2005), adolescent soccer players (Soder, et al 2011) and even amateur ice hockey players (Change, et al 2018). By now, I hope you’re appreciating this trend.
How To Intelligent Act on Imaging
Imagine this, you have an episode of back/shoulder/hip/knee pain, you go to your doctor who gives you an x-ray and tells you that you have degeneration. You are referred to a surgeon who wants to get an MRI just to see “what’s going on”. The MRI comes back with “something wrong” (which based on statistics, everyone’s basically will) and that you will need surgery but wants you to try some rehab first.
Your MD also tells you to stop doing your normal workout routine (why? Who the hell knows?!). You go to rehab with the mindset that it will not obviously not work because “there is something wrong with me”. Concurrently, your activity level is decreasing, your time spent in pain is increasing because you are less active and more depressed, more fearful of “hurting yourself more”. Can you see where I am going with this?
This process costs you in every realm- mentally, physically, emotionally, financially. Now compare….
You have pain. You seek out a rehab pro who is a musculoskeletal expert who relies on evidence and a good clinical exam to diagnose your movement faults/weak links. You have a thorough assessment, your weak links are addressed, you are educated on how to tweak you exercise routine and how to self manage without narcotics or pain pills.
You are able to exercise within the first week of when your pain started and are back on your way to health immediately. Oh, and the financial cost is thousands of dollars less. The unfortunate thing is that former happens more often than the latter.
Clinically, I see this on a DAILY basis. I typically spend almost all of my assessment undoing the verbal and mental damage that has already been done to patients. And we wonder why we have an opioid epidemic in this country.
The real truth is this… If you have pain you are not damaged, your most likely just weak. So stop letting a fucking piece of paper define who you are, and what your body is capable of achieving, period.
About The Author
Dr. Justin Farnsworth is a sports performance physical therapist currently practicing in Rochester, New York. As an ex-collegiate and professional soccer player, Justin has utilized his unique skill set as a coach and practitioner to create a hybrid performance therapy management of his clientele consisting of elite level athletes, military and tactical operators and the general fitness population.
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