You are NOT your MRI:

How imaging studies don’t always tell you the whole story

 

By Dr. Justin Cronk, DC

 

Many patients walk into the clinic armed with imaging studies showing some pretty nasty things: disk bulges, cartilage tears, labrum injuries, rotator cuff tears, disk degeneration, etc. More often than not, these people are in a lot of pain (and have been for some time) and they are also having some difficulty wrapping their heads around the fact that these things are happening to their bodies. There is confusion, desperation, and quite often, depression.

This seems to be especially difficult in athletes because these types of findings often come with the doctor urging them to stop whatever it is they are doing and do something less demanding and more “low impact” like swimming, or chess. But here’s the thing. Sometimes these abnormal findings are actually NOT causing the pain they are experiencing. Sometimes they are simply the most guilty looking suspect in the line-up, so they ending up taking the blame for it.

Just take a look at the stats on this image below. This infographic was created by Lee Higginbotham, a physiotherapist on the International Olympic Committee. Lee compiled information from several different studies demonstrating abnormalities seen on the MRIs of ASYMPTOMATIC people – meaning, people without any symptoms at all. No pain. No external indication of injury nor any history of injuries to the regions being studied. Nothing.

Yet look what they found.

 

Whoa. Sorta makes you think, right?

Lets put a more personal touch on this. Let’s say you have been experiencing low back pain for quite some time. Maybe you injured yourself lifting an object, or tying your shoe, or attempting some stupid human trick (generally prefaced by you saying something to the effect of, “hey, watch this!”). Or maybe your low back pain just gradually snuck up on you over time and you haven’t the slightest clue about how or why it began. Eventually, you will have reached a critical point where your spouse has gotten sick of your incessant whining and forces you to go to the doctor.

After an evaluation, your doctor believes your particular issue is bad enough to warrant an MRI, and off you go. Then the doctor sits you down and tells you the bad news. You have degenerative disk disease, maybe even a bulge or two. Not cool. Not cool at all.

The general course of action after that is something like this: the doctor prescribes some PT and maybe a medication or two. They generally want you to wait a while before intervening with anything too invasive so if PT or meds don’t work, the next step is often injections, and if that doesn’t work it goes on to uglier, more invasive procedures and sometimes people get stuck in a vicious cycle of this sort for YEARS. Don’t get me wrong. I am not anti-surgery, anti-medication, or anti-injection, and I think PTs are awesome.

But…

What if that degenerative disk disease has already been there for a while? After all, it’s not like it happens overnight. And what if those bulges have been there for years? Unchanged? What if you are somewhere in the 37% to 96% of people who already have asymptomatic degenerative disc disease?

What if that nasty stuff you are seeing on your MRI is not actually the thing that’s causing your pain? What if all that “stuff” has already been there for years and your pain is actually being caused by something else? Why aren’t you feeling better yet? Okay, enough of the questions. You see where I am going with this. The truth is, maybe the reasons why your current treatment plan isn’t working is because you and your doctor are focusing on the wrong things, maybe it’s being caused by something else?

Here’s a very recent case of mine.

A patient came into my clinic with some pretty terrible low back pain the came on as a result of deadlifts gone wrong in a group fitness class. They had numbness and pain radiating down their leg, back spasms, pain bending over, pain getting out of a chair and off the toilet, pain when trying to sleep at night – the whole shebang. It was not pretty. To add insult to injury, they could no longer exercise and began putting on weight which caused an onslaught of depression. If you’ve ever suffered from chronic pain, you can relate. Sometimes the only thing that makes you feel better is eating a half gallon of chocolate ice cream at night (their words, not mine).

They came armed with an MRI and here is what the report said: L5/S1 disk herniation; a large bulge at L4/L5; and degenerative disk disease. Sound familiar? (Lee Higginbotham might have something to say about this). After that, they went through the wringer – multiple injections, medications, PT, chiropractic, massage. All with no relief, what-so-ever. So after spending a small fortune and wasting a lot of time, they were no better. In fact, they were getting worse.

I once started a podcast. One of my first guests on this podcast was Dr. Ritchie Shoemaker, M.D., author of a great book called, Surviving Mold. In this book, he had a chapter called “Ass² (ass-squared) Medicine”. Which essentially translates to “assuming an assumption is correct”.

Ass² goes like this: One doctor makes a diagnosis that seems to make sense based on the information at hand and personal bias (that’s Ass¹). Henceforth, every doctor and health care practitioner the patient sees from there on assumes that the current diagnosis made by the first Ass¹ is correct, even if it’s actually incorrect (hence another Ass¹ enters the mix). Ass¹ + Ass¹ = Ass².  That is Ass Squared Medicine in a nuttshell.  Dr. Shoemaker said this is a pervasive and tragic problem in our health care system and we are all guilty of it. (okay for you math nerds out there, I know Ass¹ + Ass¹ technically equals 2Ass¹, but you get the point.)

I digress. Back to my patient.

During my exam, it quickly became clear that many of their symptoms simply did not jive with their MRI diagnosis. As a rule, I try to eliminate any bias (as much as possible) when conducting an exam so as not to get caught up in Ass² medicine. Yes, the herniation and the bulge was there, and technically they had DDD, but their symptoms just did not correlate with injuries to an L4/L5 or L5/S1 disc (radiating pain generally follows very specific and predictable pathways based on the spinal level and the disk involved).

It was Verbal the whole time. Who knew?

To make a long story short, by the end of the exam we found a whole host of structural and biomechanical problems but determined that the majority of their pain and symptoms were most likely coming from a different area altogether. The main suspect looked VERY guilty, but as it turns out, it was the unsuspecting, ambiguous guy down the line  that was causing all of the problems (with a few accomplices). So OF COURSE the injections weren’t working, they weren’t even injecting the right area!

We did some myofascial release, ischemic compression, and IASTM on this area, worked on hip mobility, and began introducing some basic movements focusing on spinal stability, glute strength, and hip hinging and told them to come back later on that week.

Three days later, they walked back into the clinic and told me the numbness and pain down their leg was gone. It went away the evening after the initial treatment and had stayed gone since. Granted, they still had some pain and we still had some work to do, but clearly, we were on the right track.

Does this happen all the time? Heck no. But it happens A LOT. Much of the time the findings on an MRI or CT are absolutely the cause of the patient’s pain and injections and/or medication is 100 % appropriate.  But, you might be surprised at how often it’s unnecessary – especially when it’s spinal related pain being blamed on degenerative disc disease or disk bulges.

Remember, you are not (always) your MRI. Same goes for x-rays too – probably even more so. But that’s another story. Just don’t be an Ass².

 

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