Imaging: A Closer Look

by Constance Taras Karwandyar, PT

When we talk about injuries, we often hear of primary care physicians and orthopedic specialists performing imaging in order to assist patients in treating musculoskeletal pain. Imaging can include, but is not limited to, MRIs, X-rays, or CT scans. Although these tests may help feed our curiosity to “look under the hood,” they may not always be the best place to start.

In a world today looking to decrease healthcare costs, imaging can be a large line item: a study done by Parker et al estimates that musculoskeletal imaging costs are projected to reach $3.6 billion dollars in 2020. While the cost might be worth the peace of mind brought by the imaging results, studies have found that imaging does not actually ease fear and worry about the cause of pain. Once being labeled with “degenerative disc disease” or “knee arthritis,” patients tend to define themselves in terms of these issues. Additionally, abnormal findings are not always directly related to the pain a person is feeling. A patient with severe knee pain may have an MRI that reveals no abnormalities, or a patient with acute but mild back pain will have an MRI showing severe degenerative changes of their discs and two herniated discs.

In particular, non-coordinated findings can be very frustrating for a patient and leave them feeling confused as to the next best step to take. To make matters even more confusing, the literature indicates that positive imaging findings are common and may not be the best guide for future care decisions. A 2020 study performed by Horga et al on 115 asymptomatic (without any pain) adults revealed that 97% showed abnormalities in their knee MRIs. These findings included meniscal tears (30%), cartilage abnormalities of the patellofemoral joint (57%), and moderate tendon lesions (21%). Similar findings are present in low back pain: Brinjikhi et al performed a systematic review gathering information about positive low back imaging findings on asymptomatic adults. Data gathered on over 3,000 people revealed that by age 20, there was a 27% prevalence of degenerative disc findings and by age 50, that number rose to 80%. According to their findings, it is more common to have degenerative changes beginning at age 30 than to not - and this was in an entire population of people without back pain!

Prevalence of abnormal MRI finding in the low back for 3,110 asymptomatic individuals (Brinkikji et al).

It is important to understand that imaging has its place in healthcare and can be very helpful and necessary in certain situations. The American College of Physicians and the American Pain Society published a joint clinic practice guideline regarding the diagnosis and management of low back pain in 2007. According to this guideline, clinicians are recommended to only perform diagnostic imaging if: severe or progressive neurologic deficits are present, serious underlying pathology is suspected or the patient is a potential candidate for surgery or epidural steroid injections. The guidelines also suggest that clinicians should not perform imaging for patients with nonspecific low back pain. 

In summary, imaging can be helpful to rule out serious pathology, be diagnostic when surgical intervention is indicated, or guide a physician when epidural steroid injections are indicated. Routine use of imaging, however may be causing more fear, more confusion, and more cost than necessary. 

If you are confused about your recent imaging findings or have pain but are unsure if you need imaging in the first place, stop by Lakeshore Physical Therapy to discuss it with one of our experienced therapists. We offer complimentary injury screens to decide what is the right next step for you. We want you to feel confident in your healthcare decisions and clear on your road to recovery!

References: 

Brinjikji, P.H. Luetmer, B. Comstock, B.W. Bresnahan, L.E. Chen, R.A. Deyo, S. Halabi, J.A. Turner, A.L. Avins, K. James, J.T. Wald, D.F. Kallmes and J.G. Jarvik, Systematic Liertaure Review of Imaging Features of Spinal Degeneration in Asymptomic Populations. American Journal of Neuroradiology. April 2015,  36 (4) 811-816

Flynn, T.W., Smith, B., Chou, R. Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder That Unnecessary Imaging May Do as Much Harm as Good. Journal of Orthopedic and Sports Medicine. Nov 2011, 41 (11) 838 – 846.

Horga, L.M., Hirschmann, A.C., Henckel, J. et al. Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal Radiol (2020). 

Lewis, J.S., Cook, C.E, Hoffman, T.C., O’Sullivan, P., The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice. Journal of Orthopedic and Sports Medicine. Jan 2020, 50 (1) 1-4.

Ice versus Heat: A Hot (or Cold) Topic

by Constance Taras, PT

One of the questions we most commonly field when patients have first sustained an injury is “Should I ice it, or would heat be better?” Both heat and ice are conservative, beneficial modalities, but to better understand the benefits of either, let’s first look at the physiological effects of each:
 

Typically, the more traditional approach is to apply ice to musculoskeletal injuries, but the type of musculoskeletal injury is important. For acute injuries that are swollen, warm, and painful (such as ankle sprains), ice can temporarily numb the area and decrease pain signals from the nerves, therefore decreasing pain. Ice also constricts the surrounding blood vessels so that less fluid and fewer cells arrive at the injured area. While this could theoretically slow down healing to the area as it does restrict the flow of healing mediator cells (leukocytes) to the area, it also means that less swelling is present. Less pressure on all the surrounding structures could mean less pain and improved range of motion.

However, what if we are dealing with a more chronic injury? Chronic injuries often suffer from decreased blood flow to the injured area, and as a result have a harder time healing. Application of heat, therefore, is the more beneficial modality, as it increases the rate that blood and repairing cells reach the injured site to improve the overall healing process. We also tend to recommend heat over ice in the case of a muscle in spasm or a tight muscle: the improved tissue extensibility provided by heat helps to relax shortened and tensed muscles in order to decrease spam and ultimately pain. Heat also allows improved stretching and increased range of motion, whereas ice could cause the muscle to tighten further, decreasing range of motion at a joint.

But an equally important factor to consider is how heat or ice makes you feel! If ice makes your pain worse or vice versa then it may not be the best option for you, even if clinically it makes more sense (unless it is contraindicated by other health conditions, such as diabetes, Raynaud’s disease or hypertension). If you are unsure what is the best modality for you and your specific injury, reach out to a Lakeshore physical therapist to help you build a customized plan!

References:

Malanga et. al. Mechanisms and efficacy of heat and cold therapies for musculoskelatal injury. Postgrad Med 2015; Early Online 1-9.

Treating Back Pain: A Spine of the Times

by Jill Jonda, PT

You’re 34 years old with a 9-5 desk job, but you still regularly go to the gym and play a couple pick-up games of basketball a week. One day you wake up and have nagging, gnawing pain just to the right of your spine in the low back. You wait a couple days and it’s not getting any better: in fact it’s traveling into your right buttock. You think, “But I’m just 34 years old! What’s happening to me?”

Unfortunately, this is a pretty common internal dialogue. According to the NIH, about 8 of 10 adults will experience back pain at some point in their lives. Luckily, physical therapists are equally as used to diagnosing and treating back pain, and the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is a well-studied, noninvasive approach for diagnosing and treating pain of a mechanical origin (mechanical pain).  But what is “mechanical pain?” 

Mechanical pain is produced when a stress or force is placed on an anatomic structure and can be aggravated or relieved with greater or less deformation on those tissues. You can demonstrate this easily with just a finger: if you bend your index finger backward to the point of resistance, you’ll experience a strain. Initially, it’s uncomfortable but as you hold it there, pain – the brain’s way of saying to the body, “Stop doing that!” – starts to set in. Once you relieve the stretch on the finger, the pain should subside. The same is true of mechanical pain: many times it completely goes away once the mechanical stress is eliminated.

More often than not, back pain originates from mechanical stress. The spinal column consists of vertebrae and intervertebral discs, which sit between each vertebra. The disc is a very mobile structure consisting of 2 layers – an outer fibrotic layer and an inner gelatinous layer – kind of like a jelly donut. When we flex our spine (bending forward and rounding it), we put greater mechanical stress on the front portion of the disc. The disc becomes displaced backward to the area of least pressure. This generally isn’t a problem, but repeated force on the front portion of the disc can cause the back portion to weaken and start to bulge. The bulge can press on nerve and/or other tissues along the spine, causing pain in areas away from the spine, such as in the buttock or even into the leg (sciatica). Eventually, a bulged disc can lead to a herniation: the jelly center of the disc begins to squish out of the fried dough part, and that’s not ideal for donuts or spines.

As physical therapists, it’s our job to evaluate each of our patients and treat the not only the symptoms but also the cause of their pain, while also preventing similar pain to return in the future. I know my patients think I’m the “posture police,” but for those with pain originating from either the cervical or lumbar spine, I always recommend sitting with good lumbar support in a firm chair to promote a neutral spine. Sitting with slouched posture is bound to produce some sort of mechanical pain, either in the neck or low back, because of the stresses placed on the spine. Also, if sitting is bothersome, stand up and reverse the curvature in your spine by walking around for a few minutes.  Remember, you should see your PT or healthcare provider if your pain isn’t improving. We can help you stand (and sit) corrected!

Resources: 

Treat Your Own Back by Robin McKenzie

Plantar Fasciitis: More Than Just a Footnote

by James Bansberg, DPT

Feet: so far away and often overlooked…until you wake up one morning and realize it’s impossible to place any weight through your foot. Feet are our foundation - our body’s connection with the earth - yet we place them in tight, uncomfortably angled, or worn down shoes, and refuse to maintain them the way we do other body parts.  Considering that plantar fasciitis is the leading cause of heel pain, and affects more than 2 million people in the US, it may be time to give this hard-working appendage a little more love.  

The plantar fascia is made up of thick fibrous bands of connective tissue that act like a cable between the heel and toes. These bands work hard, acting as shock absorbers, foot stabilizers, and arch supporters. Since we can be so unforgiving to our feet, there are multiple impairments that can lead to aggravation of the tissue. So what kind of risk factors should you be looking for in order to get to the root of the cause?

• Poor ankle and toe mobility
• Ramping up activity too quickly (marathon training!)
• Obesity
• Age (typically 40+)
• High or low arches
• Stiff/cramping calf muscles
• Prolonged daily standing on hard surface
• Improper footwear (worn, poor fitting, high heels, low support)

The presence of any of these risk factors can lead to plantar fasciitis, and many of us have more than one. Fortunately, there are just as many options to reduce risk: stretching and strengthening muscles that may be cramping or that don’t get much opportunity to be fully stretched often helps, as does rest. Proper shoe fitting (as well as replacing stressful footwear with more supportive options) can dramatically reduce risk, and if obesity is a factor, weight loss may help as well. Depending on the severity of pain, your doctor may recommend other options, such as night splinting.

If you have foot pain, however,evidence suggests that physical therapy will help you recover faster and cost you less than if you do not receive treatment. Experienced therapists at Lakeshore Physical Therapy will administer a comprehensive evaluation to determine impairments and utilize current evidence and proper treatment to help lower pain and improve function.  

Resources:

“Utilization of Physical Therapy Intervention Among Patients With Plantar Fasciitis in the United States” (J Orthop Sports Phys Ther 2017;47(2):49–55. doi:10.2519/jospt.2017.6999).

Swimmer's Shoulder: What You Should Know

by Stephanie Korso, PT

Swimming is a phenomenal way to improve cardiovascular fitness, burn lots of calories, strengthen muscles and prevent disease. As a non-contact sport, there is little risk for acute and catastrophic injuries, but there is still risk for injury. Prevention, early recognition and early treatment are key to managing swimming injuries and remaining active.

The most common swimming injury is swimmer's shoulder, which refers to any shoulder pain related to swimming. Up to 90% of swimming injuries involve the shoulder, and as many as 73% of swimmers may report shoulder pain during their career. The repetitive nature of swimming contributes to overuse and predisposes swimmers to shoulder injury.

Although swimmer's shoulder can involve any shoulder dysfunction, such as tendinosis or impingement syndrome, shoulder instability is the most common. This is because the same factors that improve swimming performance also contribute to shoulder instability:

Increased Shoulder Range of Motion
Increased shoulder range of motion helps reduce drag and allows for greater stroke length, both of which contribute to increased swimming speed. However, increased range of motion also contributes to increased ligament laxity and increased strain on rotator cuff muscles, which contributes to decreased stability.

Increased Shoulder Adduction and Internal Rotation Strength
Up to 90% of forward propulsion in swimming comes from the upper body. The pectoralis major and latissimus dorsi muscles, responsible for shoulder adduction and internal rotation, are the primary muscles that create the propulsive force needed in swimming. Increased strength in these muscles contributes to increased swimming speed, but it also leads to muscle imbalance and further instability.

Prolonged, Fatiguing Shoulder-Intensive Training
An experienced swimmer knows that swimming involves both shoulder strength and endurance. Training involves long work-outs that fatigue muscles. As rotator cuff and scapular muscles fatigue, shoulder instability increases.

The primary goals in management of swimmer's shoulder are to reduce inflammation, increase stability and return the athlete to full activity as soon as possible. Initially, the athlete will need to modify activity so that no pain is experienced. During this time, the athlete will implement exercises to decrease muscle imbalances, improve rotator cuff and scapular strength, and improve muscle endurance. The athlete may then gradually increase activity as pain decreases. Physical therapy is often helpful not only to guide progressions of strength exercises, but to also improve spine mobility and help release overworked pectoralis major and latissimus dorsi muscles.

As the saying goes, prevention is better than the cure. Therefore, incorporating exercises to strengthen the rotator cuff and scapular muscles into training regimens prior to onset of pain is optimal.

References:
Weldon EJ III, Richardson AB. Upper extremity overuse injuries in swimming. Clinical Sports Med. 2001; 20(3), 423-438.

Weiss Kelly A. Non-contact sports: Running, swimming, and dance - identifying common injuries. Pediatric Annals. 2010; 39(5), 279-285.

Khodaee M, Edelman GT, Spittler J, et al. Medical care for swimmers. Sports Med. 2016; 2(27).

The Harm of Overtraining in Adolescents

by Stephanie Korso, PT

This is part two in our two-part series on overtraining.

If you have been following our blog, then you are probably already familiar with overtraining and ways to prevent overtraining, especially with regard to endurance running and weightlifting. In case you are tuning in for the first time, however, here is a brief summary of what you need to know:

• When we train, we stress our system and then allow it to recover. This then allows our system to adapt so it can tolerate greater stress in the future. With any training program, there is a risk of overtraining.
• Overtraining involves a loss of balance between stress and recovery. Not only does this contribute to overuse injuries, pain syndromes, and decreased performance, but overtraining can also have negative physiological effects. It can contribute to altered hormone levels, systemic inflammation, immune system suppression, excessive fatigue, poor concentration, sleep disorders, and even depression.

While it is possible for anyone to be affected by overtraining, some people are at higher risk than others. Adolescents are at high risk for overtraining because there is pressure for early sport specialization and there are increased opportunities to play on multiple sports teams (school, park district, travel, etc.). Overtraining in adolescents is especially concerning because it can affect puberty, contribute to poor academic performance, and limit socialization. Furthermore, injuries sustained during adolescence, especially if not appropriately managed, can limit sport participation throughout high school, college, and even adult life.

The best treatment for overtraining is prevention. For adolescents, the following formula is recommended to avoid overtraining: hours trained per week < years old. That means, if Kevin is 12 years old, he should avoid playing more than 12 hours of baseball each week to help prevent overtraining and its potential negative consequences.

If overtraining syndrome is present in adolescents, relative rest for 6-12 weeks is recommended. Then, as young athletes begin returning to sport, they should gradually increase activity volume before increasing intensity. If signs of overtraining reappear, then activity levels should be again be modified to allow proper recovery. 

TLC for the ACL

by Amy Goldstein, PT

No matter what sport you follow, there's a good chance you've heard of athletes suffering from an ACL tear. The anterior cruciate ligament (ACL) is a knee ligament that attaches the front top portion of the shin bone (tibia) to the back bottom portion of the thigh bone (femur). One of four ligaments in the knee, the ACL prevents the tibia from sliding forward and medially from the femur. ACL tears are one of the most common knee injuries, with over 100,000 occurring annually in the US.

While it may not be surprising that contact sports such as football and soccer are a common source of ACL injuries, it is possible to tear the ACL without any direct contact at all. Changing direction rapidly, stopping suddenly, landing from a jump incorrectly or landing with a hyperextended knee can also cause injury to the ACL. Females are 3.5 times more likely to tear their ACL than males, and ACL injuries are most prevalent among 15-19 year-olds.

So what can be done to prevent injury? Evidence has suggested that strengthening the muscles of the leg and core, as well as working on neuromuscular control and balance of the leg, can help prevent a tear of the ACL. Strengthening the hamstrings, gluteal muscles and external hip rotators can help to prevent the inward collapse that occurs during an ACL injury, while working on neuromuscular control and balance helps to improve the timing of the muscles in the leg. Athletes can also work on jumping mechanics to improve landing form and to prevent excess strain on the ACL. Typically, a strengthening program of 3 times a week for at least 6 weeks is required to notice a change.

Amy can be reached at amy@lakeshore-pt.com.