Posts in imaging
Imaging's Role in Youth Baseball

In our previous blog posts we have written on the limitations of MRI for many injuries and conditions.  In general, these expensive tests have high rates of false positives where patients without pain often have positive results including ligament/labrum tears or tendon changes.  The incidence of false of positives increases in athletes with the majority of major league baseball players, regardless of symptoms, demonstrating rotator cuff tears or labrum injury.   It appears these changes are no different in our little leaguers.  

An article in the Journal of Bone and Joint Surgery examined 10-13 year old little league baseball players.  Each player underwent an MRI on both elbows at the start of the season.   The authors found many of the players with or without pain had imaging findings in their elbow.  Adding to our existing data that many athletes have positive MRI findings without pain or injury.  Two factors were associated with a positive MRI and elbow pain including year round baseball play and working with a private pitching coach.  

Athletes are encouraged to work with a local Physical Therapist to treat their elbow pain and reduce their risk of throwing injuries. 

Mental Health and Its' Impact on Shoulder Function

 "We are what we think. All that we are arises with our thoughts. With our thoughts, we make the world."  - Buddha.

Mental health has a significant impact on recovery from many musculoskeletal diagnoses including low back pain, neck pain, and shoulder pain.  Our thoughts and perceptions about our bodies and their ability to recover from injury and illness strongly influence our course for recovery and healing.  In prior posts we have described the limitations of imaging such as MRI and CT for musculoskeletal diagnoses.  In particular, we can find the same pathology (disc herniation or rotator cuff tears) in people with and without symptoms.  Thus, imaging does not correlate strongly with how patients function and what symptoms they experience due to these imaging findings.  

A recent study in the Journal of Bone and Joint Surgery highlights both the limitations of imaging findings and the importance of mental health on patient function (Wylie et al. 2016).  The authors recruited close to 200 patients with complete rotator cuff tears to determine which clinical and diagnostic factors correlated best with the patients' symptoms of shoulder pain and function.  Interestingly, a patient's mental health had the strongest association with the patient's reporting of pain and shoulder function.  This association was stronger than the correlation between the severity of the shoulder injury on MRI and their reporting of pain and function.  

This study adds evidence to support the assessment of mental health variables in individuals suffering from musculoskeletal pain and may help us understand which patients can or cannot function well given a positive imaging finding.  In our experience, patients with a positive outlook on their recovery have the most optimal outcomes with Physical Therapy.

Evidence Does Not Support Knee Surgery for Meniscal Tears

Tears in the meniscus, cartilage within our knees, can occur due to injury or degeneration attributed to the aging process.  The latter is a much more frequent scenario and often these tears are found on MRIs of patients without knee pain.  These false positive results cast doubt on the direct correlation between a picture of your knee and the symptoms you are experiencing. Thus, meniscal tears are found in patients without pain and those with pain can have a negative image.  Unfortunately, arthroscopic surgery for these age related tears is on the rise with 700,000 procedures performed in the United States each year (Cullen et al. 2009).  Interestingly, a previous randomized controlled trial in the New England Journal of Medicine found no difference in patient outcomes between this meniscal surgery and a sham surgery (Sihvonen et al. 2013).  

In the study, 70 patients were randomized to a partial menisectomy (removal of the meniscus) and 76 were randomized to a sham surgery (Sihvonen et al. 2016).  In the article published in the Annals of Internal Medicine the authors reported close to half of the patients in either group reported mechanical symptoms such as locking or catching prior to surgery.  Surprisingly, no differences were noted between the surgery and sham surgery for relief of pain or mechanical symptoms.  The authors concluded, "resection of a torn meniscus has no added benefit over sham surgery to relieve knee catching or occasional locking".

Patients with meniscal tears are advised to work with a local Physical Therapist on an cost and clinically effective treatment plan before considering any surgical procedure.  

Lateral Hip Pain and Bursitis

Patients with outer hip, lateral, pain have previously been diagnosed with trochanteric bursitis indicating the fluid filled sack between our hip muscle tendons and our thigh bone is to blame for their symptoms.  In addition the -itis ending in the diagnosis leads us to believe there is an inflammatory process taking place in the hip.   Interventions designed to combat inflammation where previously utilized in an attempt to reduce pain and improve function.  Based on the recent research experts have moved toward a more accurate diagnoses for symptoms in the lateral hip which is changing our understanding of the pathology and treatment interventions for this common condition.  

boulder physical therapy lateral hip pain bursitis

Experts are currently moving away from the diagnosis bursitis due to the lack of confirming findings on diagnostic imaging.  Bird et al. reported only 8% of patients with lateral hip pain had bursitis on ultrasound imaging (Arthritis and Rheum. 2001).  A recent study by Long et al. found 80% of close to 800 patients with lateral hip pain did not show any signs of bursitis.  Conversely these imaging studies, including MRI, are finding more chronic, degenerative (scar tissue) changes in the tendons on the gluteus medius and minimus tendons as well as the IT band.  These changes explain the limitations of interventions designed to treat inflammation in these patients.  

The diagnosis Greater Trochanteric Pain Syndrome (GTPS) is now being utilized to more accurately describe these chronic changes among patients with lateral hip pain.  GTPS accounts for a small amount of sports injuries but has its' highest incidence among individuals aged 40-60 years old (Mulligan et al. 2014).  In our Physical Therapy practice we commonly see this condition among individuals with a prior history of low back pain and IT band pain.  These patients often demonstrate weakness in their hip musculature leading to muscle imbalances across the lower quarter.  The degenerative changes in the tendon represent a decrease in the tendon's ability to tolerate loading in movement and athletic events.  Interventions should focus on correcting hip muscle imbalances and poor movement patterns which perpetuate this condition.   When appropriate, progressive resistance exercises should be implemented to improve these tissues' ability to tolerate stress and help remodel the tendon.

To learn more about how to accurately diagnose and treat your lateral hip pain contact your local Boulder Physical Therapists at Mend.

Hip Pain and the Role of Diagnostic Imaging

Often in Physical Therapy we are asked if an image would help in our diagnosis or treatment of a patient's symptoms.  The answer is very dependent on the individual patient's case but in most cases imaging has not been shown to improve outcomes.  In prior posts we have discussed the strengths and limitations of diagnostic imaging such as MRI or x rays for musculoskeletal pain.  One of the main limitations of these tests is the presence of both false negatives, the absence of pathology in those who have symptoms, or the more risky false positives, the presence of pathology in those who do not have symptoms.  As our technology has improved we are able to view body structures in greater detail leading to "positive" findings even in asymptomatic people.  These false positives may lead to unnecessary tests, medications, or procedures if they are not balanced by thorough clinical exam.  

Recently researchers in the British Medical Journal published a study on the relationship between hip pain and x ray evidence of hip arthritis (OA) (Kim et al. 2015).  The authors performed x rays on subjects and then interviewed these individuals for the presence of pain in the hip, groin, or low back.  In one cohort of the study of >900 participants only 16% of painful hips showed evidence of OA (false negative) and only 21% of hips with the presence of OA were painful (false positive).  Similarly, in a second cohort of >4300 patients the authors found only 9% of frequently painful hips showed signs of OA and 24% of hips with OA were painful.  

The authors concluded that hip pain was not present in many hips with OA and many hips with pain did not not show signs of hip OA.  The authors recommend utilization of a strong clinical examination prior to diagnosis based on diagnostic imaging alone.  Visit your local Physical Therapist to assist in your evaluation and treatment of hip pain.

Return to Sport and Back Surgery

We have previously written on low back pain and the dramatic rise in surgeries with this patient population, despite evidence of superior outcomes over conservative treatment and Physical Therapy.  Prior research has documented the dramatic rise in the number of lumbar MRI imaging for the low back and a corresponding increase in the number of lumbar surgeries (figure 1 below).  One of the main predictors of spinal surgery over age or degree of injury in the spine remains how many MRI machines are in your area.  These images are highly sensitive and find even the smallest pathology, but often lack the specificity (high false positives) to correctly diagnosis every patient without an appropriate clinical examination.  The high false positives, finding pathology in asymptomatic people, is noted on the 2nd figure below in a study of 3,000 people.  As we age there is a higher probability of finding pathology making a negative image less likely past age 30.   Interestingly, many of these severe injuries on our spine heal and improve if given time (3rd figure). 

louisville physical therapy, low back pain
boulder physical therapy, low back pain, MRI results
low back pain, MRI, healing, louisville physical therapy

Tiger Woods has experienced a difficult recent history of injury with missed tournaments due to injuries including back pain.  He recently underwent a discectomy to remove disc material from his spine, but has yet to return to prior levels of play.  His upcoming return highlights a key question, what is the likelihood an athlete return to the same level of play following a lumbar surgery.  A recent review article in the British Journal of Sports Medicine reviewed the recent literature to answer this question (Reiman et al. 2015).  The authors reviewed 14 articles on the return to sport rate after either conservative (including physical therapy) or surgical treatment for lumbar disc herniations.   The authors reported no difference in the return to sport rate between surgical and conservative treatments.  Only 59% of the athletes undergoing surgery return to the same level of play after this procedure.   

This study highlights the limitations of focusing on only pathology/MRI scan in the treatments of patients with low back pain and injury.  Given the equivalent outcomes between Physical Therapy and surgery patients should consider conservative treatments prior to surgical interventions for disc injury.