Have you ever had a painful area that no one could diagnose? Are you still suffering with this? If so, then this blog article may help you understand it a bit better.
The injury or lack thereof…
Often an area on your body can become painful without any real injury. Sometimes this happens suddenly, other times more gradually. These particular types of injuries can be a challenge to diagnose because determining cause and effect becomes more difficult. It’s not like you fell, twisted your knee and then developed pain. That would rule in one or two particular structures. However, without a mechanism of injury there can often be multiple factors that are at play.
A fairly common area where I will see pain without a mechanism of injury is the shoulder. The typical pattern goes as follows:
Initially, you start to notice a gradual onset of pain in your left shoulder. It doesn’t seem too bad at first but then, over a period of months it starts to slowly increase in its intensity. Then, it starts to restrict your arm movement. This is followed by an inability to start to do some basic things such as reaching behind your back, combing your hair, or even brushing your teeth.
By this stage a few months have went by and you finally decide to see your doctor. They prescribe an x-ray and give you some anti-inflammatory medication. The x-ray comes back negative. They then refer you for an ultrasound. You wait 2 more months and finally get your ultrasound. It comes back relatively normal too.
By this point anywhere from 3-5 months have typically elapsed, all the while your pain in your shoulder has not improved much. Your doctor then suggests a referral to an orthopaedic surgeon. You wait another 3 months for this appointment… When you finally see the orthopaedic surgeon he orders a MRI. This takes another 3 months until your appointment.
Finally you get your MRI and are eagerly anticipating the results as you are sure that something is going to turn up. I mean, it’s been almost A FULL YEAR since your pain has persisted. However, to your shock and horror the MRI shows only a bit of mild swelling around one of the rotator cuff tendons. Your surgeon then tells you that you are NOT a candidate for surgery and suggests you try some physiotherapy.
You book in for your first assessment with a physiotherapist. After a thorough conversation with the physiotherapist, they assess you and review your medical imaging. They then explain their diagnosis of your condition. They talk about something called shoulder impingement, and how the structure that is getting impinged is your supraspinatus tendon, one of the rotator cuff muscles. They explain that it’s likely getting continually pinched because some of the other muscles around the shoulder are too tight, whereas other ones are too weak.
They further explain that addressing these muscles imbalances through a combination of approaches should likely be able to bring your symptoms under control within 2-3 months. At this point you wonder, “why didn’t I see a physiotherapist earlier?”.
Their are a few important lessons to be learned from the above fictional, but all too common scenario. Firstly,
- Our medical system moves slow but there are reasons for this. If a doctor were simply to refer every patient that presented with shoulder pain for a MRI right off the bat then our system would end up being over-burdened. As it stands now, our system is nearing its capacity. The reason why doctors refer for x-rays first for most orthopaedic injuries, is because they are cheap and relatively quick to get. Yes, they are limited to mostly show the state of bones and don’t really provide any information on specific soft tissue injuries. However, if something does pop up then you have saved some time and money.
- Ruling things out does provide valuable information. It’s easy to feel defeated after getting a negative result on a MRI. However, this actually tells us a lot! In the example above, it tells us you’re not a candidate for surgery.
- Conservative treatment can and usually should begin early on. Usually, the physiotherapy treatment that would be provided in the first 2 or 3 months would not change even if an injury ended up requiring surgery. What will change is the long term treatment, and by the time you get to that stage, you should already start to be getting some of your imaging and specialists consults.
My first primary goal with any patient I see is to rule out 2 possible scenarios:
- That the injury is non-musculoskeletal and may actually require another form of treatment or referral back to the patient’s family physician., OR
- That the the injury requires immediate surgery and/or additional imaging.
If I can rule out those 2 scenarios, which is usually not too hard to do, then it means that the patient is a candidate for conservative treatment with physiotherapy. I call this PLAN A. We get started with a trial of 2-3 sessions of treatment over 2-3 weeks and see if we can make a difference.
FOR ALL INJURIES, if I am not seeing progress within 2-3 sessions then I WILL refer you back to your family doctor for more investigations. I call this PLAN B.
After several sessions of improvement, we may find that we hit a plateau with treatment where no further gains are being made. At this point then I would also refer you back to your family doctor for further imaging or consults. Once again, you can think of this as PLAN B.
All physiotherapists at our clinic are trained to properly assess you and determine if the injury is appropriate for conservative treatment. If it isn’t, or if you stop responding to treatment then we will refer you back to your family physician for the appropriate imaging and/or consults. This is our promise to you and it is the foundation of our “7 step guarantee to ensure you recover faster“, which can be seen here. So, why wait for a year to get started on dealing with an injury conservatively?
MScPT, CGIMS, CAFCI, CSCS
Co-Owner of South Cowichan Physiotherapy
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