I have patient’s walk into the clinic armed with imaging studies and MRI reports showing some scary words such as disc bulge, degenerative disc, labral tears and cartilage tearing. What follows is typically concern, depression or the feeling of desperation, especially if they were told you might need surgery. Here’s the thing though…even if you have no pain and no history of injuries, you will likely have an abnormal MRI.
Check out this infographic made by Lee Higginbotham, a sports physiotherapist on the Olympic International Committee. Just take a look at the first box. 87% of people with no back pain have a disc bulge.
It gets worse when you’re an athlete. Dr. James Andrews, one of the leading orthopedic surgeons in the world who has operated on athletes like Tom Brady, Albert Pujols and Michael Jordan, once said “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI.”
Dr. Andrews took a shoulder MRI on 31 healthy professional baseball pitchers and found that 90% had abnormal articular cartilage and 87% had abnormal rotator cuff tendons.
So what gives?
I’ll give you an example of a patient I had recently.
This patient golfs 3-4 times per week and is darn good at it. Over the past few months, he has had off-and-on back pain that he treated with Icy Hot and some stretches he found on Google. Eventually the pain began to affect his ability to walk up and down the hills on the golf course and he found himself turning down invitations to play with friends. This was the tipping point. He went to see his doctor who thought the pain was significant enough to warrant an MRI.
A week later, the patient returns to see his doctor who reveals the bad news; the MRI shows degenerative disc disease and two herniated discs. The doctor discussed the typical progression of treatment. The patient was to start taking 2 medications and see a physical therapist. If those didn’t work, he would get injections. If there was still no relief, then they would progress into more invasive procedures.
Now is a good time for me to say that I am not anti-medication, anti-surgery or anti-imaging. These can be incredible diagnostic and treatment tools when used for the right patient at the right time. MRI’s are also important in the diagnosis of things like spinal cord compression and tumors.
Back to our golfer. How do we know that this patient hasn’t had degenerative disc disease and a bulging disc for several years and gone about his life with no issues? After all, degenerative disc disease doesn’t happen overnight. So how do we know that these things are causing his pain and not something else?
During my examination, I observed how the patient was moving in different planes and evaluated the movement of his kinetic chain. I watched him walk on an incline on the treadmill. I watched him bend and extend. I watched him swing the golf club. What I found was structural and biomechanical issues at the hip that was affecting what was happening at the lowback. Yes, he technically still has a disc bulge and degenerative discs, but this wasn’t what was causing his pain.
I performed some manual stretching and some instrument assisted soft tissue mobilization and followed it up with mobility and strengthening exercises. We worked on improving his hip hinge and glute strength.
He came back a week later and had significant improvements in his ability to go up and down hills. We still had some work to do, but we were clearly on the right path.
No injections in this guy’s future!
The MRI is an amazing tool, but we have to remember that it provides a snapshot. Imagine you asked me how the Hornets played last night, and I show you a single photo from the game and nothing else. You need more information. While I appreciate the benefit of these diagnostic tools, we must perform a complete history and functional examination before recommending treatments. In fact a thorough history taking and functional exam may negate the need for more sophisticated and expensive testing. This could save a TON of healthcare dollars.
So the next time you have some musculoskeletal discomfort, don’t run to the doctor and ask for an MRI. Find someone who looks at YOU and not an MRI report.
Dr. Garrett Foland PT, DPT
August 2020
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