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Posts Tagged ‘new york times’

There was an article in the New York Times recently entitled Sports Injuries: When to tough it out.

The part of the article that stood out involved diagnostic testing. Here is a quote from the article:

“Sometimes going to a doctor for a diagnostic workup can be precarious, with scans that can show all sorts of apparent abnormalities and injuries that are not causing any problems.

For example, in a study reported at a recent meeting of the American Orthopedic Society, Dr. Matthew Silvis, an orthopedist in Palmyra, Pa., did M.R.I.’s of the hips of 21 professional hockey players and 21 college players. They showed abnormalities in 70 percent of the athletes, even though these hockey players had no pain or only minimal discomfort that did not affect their playing. More than half had labral tears, rips in the cartilage that stabilizes the hip.”

“M.R.I.’s are so sensitive,” Dr. Musahl said. “They frequently show little tears or fraying everywhere. And it is very, very common to have a small labral tear in your hip — it doesn’t mean you have to have the particular symptoms.”

The same is true for rotator-cuff tears, rips in the tendons that help stabilize the shoulder. Studies have found that about half of all middle-age people with no shoulder pain have these tears, although they are unaware of them and have no symptoms.

Testing certainly has it’s place but it is important to understand that testing is only one piece of the puzzle. The assessment, symptomatology, mechanism of injury, and experience also play a critical role because:

  • Hockey players are going to have hip labral tears
  • Baseball players are going to have labral fraying
  • Middle aged people are going to have degenerative changes
  • Assembly line workers are going to have tests positive for carpal tunnel and rotator cuff tears
  • Individuals over the ages of 50-60 are going to present with lumbar spine pathology
  • And so on…

And all of these test results could appear in someone who is completely asymptomatic.

It gets interesting when the individual reaches threshold – when symptomatology now presents itself.

Here are a couple of examples to consider from several years ago – both involved individuals diagnosed with carpal tunnel syndrome.

  • One individual fell on their wrist and aggravated their wrist. Within about a week of developing symptoms, an EMG was done and the test came back positive for CTS. So…in 1-2 weeks someone is going to go from not having CTS to now having it???
  • A individual was having significant wrist and shoulder pain – a recent flare-up. They were previously diagnosed with CTS via EMG (chronic case). With the latest flare-up in symptoms, another EMG was ordered since it had been awhile from the previous EMG.  Here this individual was in pretty severe pain and the new EMG results were…EMG results were improved from previous testing and were now within the “normal” range. A person who is in pretty severe pain now is being told that they no longer have CTS???
  • Add your own story or example here.

Everything is fine when 2 and 2 equal 4. It starts to get dicey when things don’t add up as easily. Again, the assessment – the symptoms- mechanism of injury – and your experience as a clinician play a significant role in bringing together the full picture.

As a young athletic trainer, I was under the impression that MRI and other diagnostic testing were the final determinant regarding someone’s injury status. Years of experience, research, professional discussion, and lots of “huh??? This doesn’t make sense” moments have changed that thought process over the years.

Diagnostic testing does have it’s place but it is important to keep testing in the proper perspective. It is a piece of the puzzle and requires putting the other pieces together as well. Diagnostic testing does not slam the door on the case necessarily – plenty of detective work needs to be done so that the entire case can be properly evaluated.

What are your thoughts? Have you had similar experiences when diagnostic testing and reality weren’t quite meshing?

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Over the last week or so, there has been some controversy regarding the article written in the New York Times on January 6th that was entitled Treat Me, but No Tricks Please. For those of us who work in the field of injury rehabilitation, the article wasn’t particularly flattering. (I use injury rehabilitation instead of physical therapy in this instance because you are fooling yourself if you think this was an indictment on just physical therapists. Anyone who works in the field of injury care and rehabilitation- athletic trainers, physicians, phsyical therapists, etc. is included.)

At the beginning, the author builds into the article by writing:

“I also tore my hamstring running, but my doctor never mentioned physical therapy. Instead he referred me for platelet-rich plasma, an experimental treatment that involves having my own blood platelets injected into the torn tendon. The cost, including the radiologist’s fee, an ultrasound and the plasma injection, was $2,200.

My insurer would not pay, which made sense to me because the plasma treatment is considered experimental. It might work; then again, it might not.

But the letter the angry doctor had received from his insurer made me wonder whether physical therapy was different from the plasma treatment. Is there rigorous evidence showing it works?”

And so from there, the author went on to address the efficacy of physical therapy. Again, not very flattering. And yet, if there was any positive to come – (the positive comments in support of physical therapy not to be denied) was the fact that we as professionals need to continually reassess our strategies and protocols to make sure that we are delivering the best care possible.

So fast forward a few days and it is ironic that a study discussing the Platelet Rich Plasma injections referenced in the article was released in the January 13th edition of the Journal of the American Medical Association. The study was entitled: Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy.

The conclusion of the study:

“Among patients with chronic Achilles tendinopathy who were treated with eccentric exercises, a PRP injection compared with a saline injection did not result in greater improvement in pain and activity.”

So while the author of the article clearly stated that the PRP treatment may or may not work, it is ironic that the very example that was used to introduce the  thought provoking article has been shown to be (in this particular study) an ineffective treatment option.

The point of this revelation is not  “ah-hah, now who is the one who looks foolish” because the author was simply asking the question – which if we all asked ourselves similar questions about the methods we use, may come to realize they are ineffective as well. This will ultimately lead us to find better options and strategies and ultimately, better care for our patients.



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