412 | The Lies That Linger: Harmful Diagnoses Medicine Won’t Let Die

[00:00:05] Welcome to the Optimal Body Podcast. I'm Dr. Jen and I'm Dr. Dom and we are doctors of physical therapy bringing you the body tips and physical therapy pearls of wisdom to help you begin to understand your body, relieve your pains and restrictions and answer your questions. Along with expert guests, our goal of the Optimal Body Podcast is really to help you discover what optimal means within your own body. Let's dive in.

[00:00:28] I'm so excited because we just started Pelvic Floor Foundations moving as a community yesterday and there is still an opportunity to get into our private group chat. This is exclusive access to me over the two weeks of the course where you can ask me anything. You can send videos, you'll be in a community all moving and doing it together. But don't worry because you have lifetime access to this course. And for being a podcast listener, although our huge discount is over, you can use code OPTIMAL10 at checkout.

[00:00:58] So just go to Jen.health.com and use code OPTIMAL10 at checkout and get into this course, move with us because it is so much better to go through with a community where you actually have accountability to show up. This is our way of developing integrated pelvic floor awareness through assessment, education and movement over the next 16 days. You'll identify tension, weakness, disconnection to your pelvic floor. You'll understand why Kegels alone aren't

[00:01:28] the solution and what to do.

[00:01:29] Instead, we're going to address your breath. We're going to address your breath, your posture, movement and your entire core and how that plays a role in your pelvic health. Now we're going to address if you're leaking with sneezing, jumping, laughing, back pain or hip pain, pain during intimacy, a weak core, no matter how much you exercise. These are really the tools to help you reconnect and rebuild your foundation without spending hours in the gym. It is 10 minutes a day, including a workbook, including a recorded Q&A.

[00:01:59] with a pelvic floor physical therapist and so much information. I promise you don't want to miss out on this. Use code OPTIMAL10 and get into the private chat where you can join the community moving together and ask me anything along the way to help support your journey. I hope I see you there. It's Jen.health backslash pelvic floor.

[00:02:20] I'm actually really glad we're doing this podcast now. Hopefully you've listened to a lot of our other podcasts on specific diagnoses and don't feel as terrified to hear that diagnosis potentially. However, I think just talking about this broadly and we're going to just talk about a few common diagnoses that we think don't really need to be addressed or put in people's minds as often.

[00:02:45] The diagnosis is overused and the use of imaging to get someone to the diagnosis is actually more harmful. And we're going to talk about why. Yeah, because there's so many research and we've talked about this many times on the podcast before how there's so much more research in showing that people who have pain and people who don't have pain often have similar imaging results.

[00:03:08] Whether we're looking at the knee, the back, the shoulder, there are so many times where we have normal age-related changes and degeneration of a joint, which the word degenerate, we're going to talk about degenerative disc disease. That phrase in itself sounds bad. Oh, my body's degenerating. Right.

[00:03:28] And rather than taking an image of someone who's already in pain and is already wondering why they're in pain, rather than taking an image to then get a result on an MRI to say, oh, yep, we're seeing this and this and this around your joint. So you have this diagnosis. It only hurts the process more. Just start treating the pain. Just start treating the function rather than needing to give them a diagnosis that then puts something else in their mind that they're broken. Right.

[00:03:57] And so I think this is a really important conversation and I hope not only listen, but maybe pass it along to other people because getting the word out that we're not so fragile. Yeah. And that we do age and just like we see changes on the outside, we're going to see changes on the inside and that's okay. And it might not be the reason you're in pain and be open to explore other reasons why you might be in pain.

[00:04:21] And I don't want anyone to take this as us telling you like, because people get so attached to those diagnoses and people come in to a PT or two. Oh, well, I have this diagnosis and I have this diagnosis and I have this diagnosis and it becomes a part of your story. And we don't want you to think that we're saying like, oh, no, your image didn't show that. Oh, no. Yeah. Your image did show that, that there's normal age related degeneration in your back or there's some tissue changes in your knee. That is true.

[00:04:49] And that is just a small part of the story. And the message we want to get out is that there are people who are not in pain who have that same thing on their image. So how can we get you into the group that is not in pain? And maybe still has that. That has, likely will still have that on your image. Taking a quick pause from the interview to talk about an aspect of health that not many of us pay attention to, but we have complete control over and that's our hydration. Now, I'm not just talking about drinking enough water.

[00:05:18] I'm talking about getting in and replacing the electrolytes that we lose every day without even knowing it. That's why Jen and I take Element to make sure we're replacing the sodium, potassium, and magnesium that we lose, especially on these hot, hot summer days in Southern California. Making sure your electrolytes are optimized can help with so many things like brain fog, fatigue, muscle crampings, sleep, even regular bowel movements. That's why we make sure we use Element every day.

[00:05:45] And it not only helps us make sure our electrolytes are in check, it tastes absolutely delicious. And you get a free sample pack with every single order so that you know which one you're going to like the most when you come back and inevitably order more. So head down to the link in the show notes. That's just drinkelement.com backslash optimal. DrinkElement, spelled out L-M-N-T, dot com backslash optimal. Let's get back into the episode.

[00:06:10] And this was spurred by a comment someone left on YouTube about our chondromalacia patellae video, essentially saying like, hey, they've made recommendations that we don't even use this term anymore. Because the term chondromalacia patellae essentially means that there's degenerative or abnormal changes of the cartilage around the patella. And they actually sourced in their comments some research on structural findings.

[00:06:39] And we did a little more research. And so I'll just go into a cross-sectional study that compared people who have patellofemoral pain compared to healthy controls, essentially showed no statistically significant difference in patellar cartilage defects, bone marrow lesions, and high signal intensity of the Haffa fat pad, which is this fat pad that's under your patella.

[00:07:06] So those were present in both groups, but there was no statistically significant association between those structural abnormalities seen on the image and patellofemoral pain. Furthermore, we go down the line and a lot of people like to say, oh, my provider told me that my patella are squinting or my patella are misaligned, or I have this misalignment in my knee and my hips.

[00:07:33] So there's a research study that did a comparison of people who have pain versus people who don't have pain that found that certain alignment measurements, such as higher instil-salvio ratio, whatever, which means your patella is higher, patellar tilt angle and greater lateral displacement were associated with morphological abnormalities on MRI. That essentially means that it was associated with changes on your MRI.

[00:08:02] However, these alignment measures showed minimal association with reported symptoms or function, meaning that having those changes had very minimal to no relationship with pain or functional deficits. Which we've talked about patellar tracking before, and I've shown how I have squinting patella, where the patella come in toward each other and I have no knee pain.

[00:08:26] So I'm a walking example of how my patella are laterally tilted and squinting. And, you know, you can come up with all the reasons why I should have knee pain and I don't. Yeah. And just to kind of wrap up this whole discussion on chondromalacia patellae, the consensus statement from the 4th International Patellofemoral Pain Research Retreat. Yes, there are professionals out there that go on retreats just to talk about patellofemoral pain.

[00:08:55] Advised against using the term chondromalacia patellae for patellofemoral pain. This term implies cartilage damage, which may not be present, potentially leading to misdiagnosis or unnecessary interventions. The last thing, the Journal of Orthopedic and Sports Physical Therapy, which is a highly regarded journal in physical therapy consensus, also recommends retiring the term chondromalacia patellae in favor of patellofemoral pain.

[00:09:22] Because patellofemoral pain essentially just means you're having pain around your patella and the femur, which is the thigh leg in your bone. So, again, if you go in and get an image and someone says, oh, you've got chondromalacia patellae, remember this. Remember this moment and say like, nope, I've heard that that term should be retired. And I essentially just have knee pain because those image results are pretty common on people of my age

[00:09:49] or are pretty common in people who don't have pain. Exactly. And this also reminded me of a comment that I was in a, or not comment, but I was in a discussion in a DM with someone who was reaching out and freaking out, by the way, she was already in PT. So, she was seeing a physical therapist for, I believe, her back issues. Maybe a little bit more that was going on, but she was getting frustrated because she's like,

[00:10:15] you know, I should be getting better, which a lot of us feel in that sense. Like, why am I not getting better? And so, it was asking about our gen health plans and what more she could be doing. But her physical therapist also wanted to assure her, like, just stay the course. Stay the course and it will get better. Yep. Go to the doctor, get some imaging just to prove that you are okay. And that if you stay the course, this will improve.

[00:10:46] That was a mistake because she, the reason she was reaching out to me, she was freaking out because of her image results. And what the doctor ended up telling her was that, oh my gosh, look at this image. You have degenerative disc disease. You're in your thirties. You have like, this should not be happening. This is abnormal. You are going to need, we'll start with injections. Then we'll see if we need surgery.

[00:11:10] And I feel like neglecting the information that she's already in physical therapy. She has seen improvements. And if she just stayed the course, maybe she would see more improvements. Yeah. Right? Or maybe if she did get into a gen health plan to help supplement, it would, you know, help along the way as well. Now instead. Now instead, she's freaking out. It has more anxiety. I've got degenerative disc disease. I'm only 30. Right. And I can be the example of this.

[00:11:40] I can almost promise that if you took an image of my spine, I would have some significant going on, on my image, um, that I don't even want to know. Yes. I don't even want to know. I feel like we've talked about this before on the podcast, probably several times. And what we see from the studies is that degenerative disc disease is common, even among people without back pain.

[00:12:04] And there was a study that found that 81.4% of asymptomatic individuals. So people who don't have pain will show a disc herniation. 76.1% had an actual fissure. So, you know, something happening within their disc and 75.8 had nucleus, had nucleus degeneration. So degeneration of the disc. Yeah.

[00:12:31] 75.8% who do not have back pain. And notably, even in 20 to 29 years age, nearly 45% had disc bulging at L5S1 area, which is the most common area that people come in with. Oh, I have a disc bulge at this area. Well, maybe, maybe it is quite common. Yeah. Maybe you had that before you even had the onset of pain.

[00:13:01] Maybe it increased when you had your onset of pain. Maybe it, maybe it's a part of the story. It's a part of the story. It's a part of your body story for sure. Right. But it doesn't have to be one-to-one associated with your pain. Right. And so sometimes labeling people with DDD based solely on imaging can lead to unnecessary interventions and it may prompt further tests. specialists, specialist referrals.

[00:13:27] I mean, we all know how much money this can start to add up into and even surgeries that may not benefit the patient because we have also both worked with patients who've had back surgery based on imaging and findings and have still been in pain. Speaking of our YouTube comments, there was one yesterday where someone's like, yep, I just had my 10th back surgery in the last seven years, blah, blah, blah.

[00:13:54] But again, like more interventions tends to be get more interventions. It generally doesn't mean this one surgery is going to be the fix and, you know, resolution of all of my pain symptoms. And that's what people think. That doesn't tend to be the reality in research. And these aren't our opinions. Yes, there are opinions, but it's backed by research that we shouldn't be using chondromyloatia patella. We shouldn't be just throwing degenerative disc disease in people's face.

[00:14:23] This is put out by groups of people who get together and put together these clinical guidelines for professionals. So professionals really need to get on board with these clinical guidelines and stop using scary sounds. Yeah, freaking people out. And just focusing on pain and function. How can we get you back to feeling better and functioning better? Yes. Another one, again, we've talked about before is rotator cuff tears. It's such a broad term. Yeah, because there's four rotator cuff muscles.

[00:14:52] They can tear in many different places. And again, when you have shoulder pain or if someone's seeing certain clinical signs, they're like, oh, let's get an image. Let's see what this shows on the image. But a study found that the prevalence of rotator cuff tears in general population, so this is just anyone, was 22%, with asymptomatic tears being twice as common as symptomatic ones. So let that sink in.

[00:15:22] They found rotator cuff tears twice as often in people without shoulder pain than people who did have shoulder pain. The prevalence increased with age, reaching 51% of people over 80 years old. Another study reported that 48% of full thickness tears, that means one of your rotator cuff muscles was completely torn through, were asymptomatic. So nearly 50% of people that had full thickness tears had no symptoms.

[00:15:52] No pain, no symptoms. So this just, again, highlights that there are so many people not in pain who have these rotator cuff tears. The takeaways from this and the guidelines based on what the research says advise against routine imaging for shoulder pain without specific indications as incidental findings, like you image someone's shoulder, oh, you have a rotator cuff tear, can lead to overdiagnosis and overtreatment.

[00:16:22] Imaging should be reserved for cases where it will directly influence management decisions. And some of those indications are massive reduction in function, locking of the joint, severe pain beyond the ability to do anything functionally, no improvement since the onset or the injury or the onset of the pain. And that's what, again, your professional should be tuned in to like, okay, we're seeing some severe indications here.

[00:16:52] Maybe we do get the image rather than, oh, I've got this shoulder pain that started three weeks ago. It's kind of getting better. I can't quite get my arm full overhead. Right. Those are not indications to immediately run and get an image. Right. Those are indications like the guidelines now recommend to start with conservative treatment and see if we can regain that function and get the pain to go down so we don't freak someone out and tell them their rotator cuff is torn. And I just want to also highlight... I have a torn rotator cuff.

[00:17:21] Another one. I was throwing a rock. My arm went dead. I did end up going and getting an image because I was supposed to start playing football in a few weeks. And they said, oh, yeah, it shows that you have a little... And on these images, again, it shows it as interference. You don't just see a perfect muscle that is like has a tear in it. Like people go to school to interpret these results. And they're like, oh, there's some interference here, which probably means you have a tear in your rotator cuff. I did nothing. I just waited.

[00:17:50] I started some rehab on myself. This was before I even knew I wanted to be a physical therapist. And then I was playing football a couple months, maybe a month later. I mean, and it's incredible to be able to hear that kind of story and the empowerment of what, you know, give your body time and an opportunity and hopefully a professional physical therapist to be able to help guide you or a gen health plan. But the other thing I do want to mention is that we're not against surgery.

[00:18:19] There is a time and place when surgery is going to be beneficial for any part of the body. That is, there is a reason that these exist, right? But there should be more care as to when they are intended for use and why. And so this is where we just want to continue to highlight that the image doesn't say the full picture.

[00:18:43] It's part of your story, but it's not the full picture and really trying something different with movement, with, with what else could be going on in your body is so important. And I just want to, we want to wrap with shoulder impingement because this is such an, also a common diagnosis that goes back kind of to our chondromalacia point where we, we should be throwing out the term chondromalacia because it's telling you in your brain that you have

[00:19:11] some structural damage and that's the reason that you have pain where that might not be what's actually happening. And that is the same with shoulder impingement. What we now know, because shoulder impingement, you're thinking, oh, my, the space in my shoulder has now gotten compressed and it's pushing on some tendons and ligaments and causing pain when I move in a certain way. So I'm impinging on some structures and that's causing pain.

[00:19:36] Where what we now know is that the test that kind of, that we use to, to create this diagnosis, which usually has to do with reaching across your body and turning your thumb down towards the ground impingement positions that we learned in physical therapy. It cannot distinguish between various shoulder pathologies leading to potential mixed misdiagnoses

[00:20:00] and imaging findings like acromium spurs or reducing reduced subacromial space. So this is the space in the shoulder joint where your rotator cuff muscle goes through essentially one of them are frequently observed in asymptomatic individuals. So people who have no pain can be shown on an image to have this reduced space as well, indicating

[00:20:27] that these structural changes may not directly cause pain. And the diagnosis of impingement syndrome may not accurately be, you know, kind of identifying the pathology. And that's why this kind of starts to become an overuse diagnosis that's not necessarily getting to the root cause of why you're in shoulder pain or really help anything except create a little bit more anxiety and fear because maybe I don't want to lift my arm in a certain

[00:20:56] way because I'm afraid that it's going to cause this impingement or make damage worse. Yeah. Not to mention that surgical procedures like subacromial decompression, which started to become very common or very popular for people who had shoulder impingement or impingement like symptoms, um, have not consistently demonstrated superior outcomes compared to conservative treatments. Randomized controlled trials indicate that many patients experience similar improvements with physical

[00:21:24] therapy alone, questioning the necessity of surgery based solely on an impingement diagnosis. And I use quotes every time I say impingement because like Jen said, we should be throwing that out. Right. It's just that you have shoulder pain. Yes. All right. Let's figure out what the root cause is because it's likely not that you have reduced subacromial space. Which is something that we had used for years. You just have some irritation at the shoulder, some overuse probably, and we need to figure out

[00:21:50] what else we can get moving better so that you start to feel something different and feel better and get back into the movement that you want to be doing. So again, like just to reiterate, seeing an image is a part of your story. We're not trying to negate what's on the image. We're trying to help people understand that we will see changes on our images throughout our lifetime, whether they are contributing to what we're feeling in our body or feeling symptoms

[00:22:15] or reduction of function or not, because so many studies are coming out that show asymptomatic individuals have similar changes on their images to people who are having pain. And we just went through a few examples of diagnoses that are becoming outdated or diagnoses that we think are generally used in a way that put more fear in people's heads, that put more

[00:22:40] fear in people's desire to move or ability to move rather than help them. Well, and I just want to add in just real quick, we have interviewed Andrew De... How do you say his last name? Dietelbach. Yeah, thank you. Yes, Andrew Dietelbach, a shirtless dude. Who had a 10 millimeter, right? Disc herniation. Yep. Which is quite the disc herniation. Yeah, that's a centimeter.

[00:23:06] And he talks into his experience of not having surgery, avoiding surgery and taking a year. Oh, the magic of time to really get back to rehab basics and, you know, reduce the pain himself. And I just want to point that out, you know, maybe go back and listen to that episode.

[00:23:31] But this is where also when the doctor tells you this is the worst I've ever seen, this is horrible. You should be in so much pain. I don't know how you're walking in here, whatever it may be. Oh, try not to take that on. Yeah. Because the image might be worse for someone else and they didn't even have surgery. At that point, ask for a different doctor. Because I do, I promise you that there's someone out there who has an image that has looked worse in history and they're probably not in pain or they probably rehabbed that conservatively.

[00:24:01] I would confidently say that with how many people are in this, who are in this world. Like there are people out there not in pain that have images that look the same as yours or worse. And how can we get you into that bucket rather than, you know, clinging on, oh, my image looks like this. I'm never going to be, I'm never going to be out of pain. Right. Thanks for listening. And this is clearly something that Jen and I are super passionate about because we believe

[00:24:27] people should be educated and given information about their body in a way that empowers them, not tears them down or puts more fear in them about getting back to a pain-free life. Please consider passing this along to somebody, especially if you know somebody who has gotten multiple diagnoses and that's what they cling to. That's what they tell you. We think that this could be really helpful for people who are in that boat. We just started going through the Pelvic Floor Foundations course with a big group of people.

[00:24:55] Jen is still in her postpartum recovery one year out. So she is really working back to fully integrating that pelvic floor and we want to do it with a massive community. So you can come join with us. That link is down in the show notes. It's just Jen.health backslash pelvic floor. You can use code optimal 10 and you'll actually get the discount that just went away. So you can still get in at the discounted price and go through that course with us. And of course, we will see you next time on the Optimal Body Podcast.