Posts tagged imaging
What Can I Do To Reduce The Progression Of Knee Arthritis

Knee arthritis is a common condition among older adults and remains one of the greatest causes of disability in our country. Consistent with many musculoskeletal conditions there remains a disconnect between imaging findings and a patient’s clinical presentation. Studies have shown many patients without knee pain can have signs of arthritis on their x rays. In addition, many older adults with knee pain can have negative x rays for arthritis. This lack of association is likely due to many patient factors including activity level, functional demands, strength, flexibility, and overall health. For example, a stronger patient is less likely to experience pain during a given activity compared to their weaker peers. Strength training as part of an individually tailored Physical Therapy program remains the gold standard for conservative treatment of this condition. A new research article highlights other modifiable factors which may influence the progression of knee arthritis.

A longitudinal, observational study was conducted to determine the factors associated with knee arthritis progression in older adults (Halilaj et al. Osteoarthritis and Cartilage. 2018). Authors recruited subjects based on presence (N = 3285) of the condition. Patient history, demongraphic, functional outcomes and x findings were taken upon the first visit. Patient’s were then categorized by risk of progression of arthritis. High risk patients included histories of knee pain, aching or stiffness, previous total knee replacement, family history of arthritis, high body mass index, or previous knee injury. Patient disease progression was based on follow up x rays at 1 and 2 year follow up. In addition, patient’s completed functional outcomes at these time points.

Authors then calculated predictive variables which may have contributed to the radiographic findings. Consistent with previous research, x ray findings of arthritis including joint space narrowing did not predict patient symptoms. Authors prediction models found a slower gait speed, poor sleep, and higher meat intake were associated with knee arthritis disease progression. This supports previous research on the importance of a patient’s overall health in managing their knee arthritis. Smoking history, body mass intake, sleep, diet, and exercise remain some of the most powerful modifiable factors to reduce the progression and symptoms associated with knee arthritis.

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Should I Be Concerned About The Noises In My Knee?

Many healthy joints in the body, most commonly in the knee, present with joint noise called crepitus during range of motion testing. Crepitus can be an auditory cracking or popping sound or a sensation of grating in a joint. More concerning than joint noise is an associated sharp pain in the joint or associated locking, catching, or clicking of the joint. These signs and symptoms should be evaluated for potential injury to the joint surfaces and cartilage. If sharp pain or these mechanical symptoms are not present, joint noise or crepitus likely does not indicate an underlying injury to the joint. We often find crepitus in otherwise healthy knees. A recent research study reinforces our clinical understanding of joint crepitus in the knee joint.

Pazzinatto and colleagues examined 584 participants with crepitus and similar radiographic findings of knee arthritis in both knees (Braz J Phys Ther. 2018). These individuals were matched to peers of similar sex, body mass index, and presence of knee arthritis except these individuals did not have crepitus in either knee. Researchers had both groups, crepitus and absence of crepitus, perform both subjective measurements of pain and function, as well as, objective tests of strength, endurance, gait speed, and function. Authors reported lower subjective reports of pain, function, and quality of life in the group of participants with crepitus. Interestingly, they reported no difference in objective measurements or function. Authors concluded the presence of knee crepitus was not associated with objective function or strength measurements.

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Physical Therapy First Reduces Opioid use, ER visits, and Healthcare Costs in patients with low back pain

The evidence and momentum continue to build for seeing a Physical Therapist first for patients with low back pain.  Physical Therapists have continually been shown to be clinically and cost effective providers for low back pain conditions.  This approach, direct access to Physical Therapy, has been utilized by large hospital systems and Fortune 500 companies to both accelerate a patient's recovery and reduce health costs.  Studies report up to $1500 in cost savings when using this approach secondary to decreased utilization of health care services include office visits, medications, imaging, and surgery.


A recent study followed patients with a recent onset of low back pain over a one year period (Frogner et al. Health Services Research. 2018).  Participants healthcare utilization was calculated based on whether they saw a Physical Therapist first, a Physical Therapy later, or were not prescribed Physical Therapy.  Consistent with the existing literature, patients who were seen by a Physical Therapist first had a 90% lower probability of being prescribed an opioid, as well as, lower rates of emergency department and imaging services.  The lower utilization of healthcare services were reflected in the significant cost savings found in the PT first group.

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Will my neck pain and MRI findings worsen with age?

Aging occurs in all of our body systems including the spine.  Similar to wrinkles and grey hair, the spine will demonstrate age related changes including disk bulges, herniations, facet and ligament changes, as well as, degeneration around age 30.  Interestingly, we find a high percentage of these changes in people with and without neck pain.  Thus, we need to be careful when interpreting MRI findings in the cervical spine to ensure the pathology in question matches a patient's clinical presentation.  An interesting study was just performed and questioned how changes on a patient's MRI correlated with their current symptoms.

Daimon and colleagues in this year's Journal of Bone and Joint Surgery followed pain free individuals over a 20 year period.  At the time of the initial MRI all 193 subjects were pain free and physicians documented the degree of cervical degeneration.  The authors reported these age related changes progressed in 95% of subjects and affected all spinal levels over the 20 year period.  As expected, the rates of spinal changes correlated directly with a patient's age.  Surprisingly, the authors reported no relationship between the progression of this degeneration and the onset of clinical symptoms.  One exception was narrowing of the canals (foramen) in the neck.  Narrowing of these canals correlated with upper extremity symptoms due to compression of the nerve root.  

This study adds to the vast amounts of data documenting the high rates of false positive spinal MRI testing.  The lack of specificity of these tests limits their utility unless they can be interpreted with the patient's current symptoms.  Most of these abnormal findings were there before you had neck pain and will be there after successful treatment by a Physical Therapist.  

What imaging pathologies are associated with shoulder pain?

MRI testing of the shoulder is no different than testing in other body regions.  Pathologies such as bursa changes, tendinopathies, labral and rotator cuff tears are very common in asymptomatic populations and tend to increase with an individual's age.  Many of these MRI findings do not contribute to a patient's current symptoms and may be reflective instead of the natural aging process in the shoulder.  Conversely, some pathologies such as rotator cuff tears may explain a patient's symptoms especially when these findings match the patient's subjective history or clinical examination.

Tran and colleagues sought to answer this question by reviewing the available evidence on shoulder MRI findings and a patient's symptoms and prognosis (Arthritis Care Res. 2018).  Authors reviewed 56 papers and found no significant association between most imaging findings and current symptoms.  One exception was enlarging rotator cuff tears which were shown to be associated with an increased incidence of symptoms.  In general, the majority of these studies were low in quality and authors called for high quality studies on this topic.  

How Important is Imaging for Tendon Pain and Injury?

Our prior posts on tendon injuries have described the structural changes that take place with chronic symptomatic tendinopathies.  The disorganization of tendon fibers and the body's attempts to heal the injured tendon are best viewed on ultrasound or MRI imaging.  MRI is a very sensitive tool, but lacks specificity meaning a positive finding may or may not be contributing to a patient's presentation and symptoms.  Further, we often see positive findings in asymptomatic individuals.  Rio et al. described the presence of positive findings (tendinosis) in asymptomatic and active individuals and also the lack of impact of some findings on a patient's presentation (Sports Med. 2014).  The MRI and ultrasound images document both normal and abnormal imaging findings.  Images courtesy of Docking et al. JOSPT. 2015.

achilles tendon, ultrasound, boulder physical therapy
abnormal achilles tendon, MRI, boulder physical therapy

In the pictures above, we can observe healthy tendon alignment primarily in parallel to resist and absorb tensile forces across the ankle joint, as well as, a high water and protein content reducing friction through the tendon.  Conversely, a tendon with features of tendinosis demonstrates a disorganized tendon structure where tendon cells (tenocytes) are in higher numbers and have a more rounded appearance.  This appearance makes the tendon less resisted to traditional tensile forces since the tendon is not arranged in a parallel alignment.  Finally, there is an ingrowth of nerve fibers and blood vessels which likely contribute to the increased pain and symptoms noted in the achilles as well as in other structures within the body (central sensitization).  If a tendinosis progresses in nature, partial tears in the tendon can also be noted on MRI.  The accuracy of these changes on MRI explaining a patient's symptoms is described as diagnostic utility.  

MRI and ultrasounds greatest limitation on accuracy may be the lack of agreed upon gold standard in the literature.  In a review of the literature Docking et al. reports the specificity for diagnosis with MRI (.68-.70) and ultrasound (.63-.83) for tendinopathies.  Up to 59% of asymptomatic individuals will document some change within the tendon on imaging.  These numbers show a degree of false positives making the clinical examination an essential part of any clinical diagnosis.   This is consistent with the majority of musculoskeletal problems.  If we rely solely on the MRI findings we run the risk of being incorrect in both our diagnosis and treatment.  This will lead to higher healthcare costs and a longer duration of care for the patient.

In short, imaging can be a helpful component of our clinical diagnosis but only if we can use our subjective and objective examination to distinguish between asymptomatic tendinosis or symptomatic tendinopathy.  In addition, an image rarely is helpful in determining how to use manual therapy and exercise to appropriately treat the patient.