February 19, 2025 • 19 mins
How often do we lean on imaging technologies like MRIs, X-rays, and CT scans as a crutch when faced with mysterious pains? On this episode of the Driven Athlete Podcast, we promise to challenge your perspective on the reliance on medical imaging in diagnosing musculoskeletal issues. We'll discuss the critical role imaging plays while urging caution against its overuse, especially when addressing shoulder pain. Together, we'll unravel the art of differentiating between minor discomfort and serious conditions, ensuring that imaging is reserved for when it's truly needed, not just as a reflexive reassurance tool.
Get ready to uncover the secrets of effective shoulder pain management. Our discussion goes beyond the surface to examine the importance of personalized movement-based diagnoses and the significance of recognizing cardiovascular red flags. We'll guide you through assessing pain patterns and the subtle differences between musculoskeletal problems like rotator cuff pathology and bicep tendonitis. By sharing strategic insights into improving shoulder mechanics and stability through targeted physical therapy, we'll equip you with the knowledge to tackle the root causes of pain head-on. This episode is your roadmap to preventing recurrence and ensuring long-term shoulder health, with imaging as a supportive ally rather than the star of the show.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
If you're a driven, active person who wants to reach
and pursue a higher qualitylife with some ambition, then
guess what this podcast is foryou.
This is the Driven AthletePodcast.
So I have an interesting topicwith this.
I don't hate imaging by anymeans.
Mri, x-ray, ct scan like thosethings are important and they've
(00:22):
been revolutionary forhealthcare.
X-ray, ct scan like thosethings are important and they've
been revolutionary forhealthcare.
I do believe that they areoverly prescribed and overly
performed.
The reason is for the peoplethat I see right, and here's the
reason.
Here's one of my rationales onthis.
Okay, so there's in my from whatI've heard, my opinion and
people that we see withmusculoskeletal issues, some
(00:46):
kind of pain that they're comingin like I have back pain, I
have shoulder pain, I have neckpain, knee pain, ankle pain,
like whatever right, pain in myshin.
Questions arise in their headlike WTF, like why am I having
this pain?
I didn't do anything right, butthey're like, as an example,
there was no mechanism, I didn'tget in a car accident, I didn't
(01:08):
fall downstairs.
This was non-traumatic painthat has now developed in my
body somewhere, right, peopleusually ask what the heck is
going on and why do I have thisand why is it not going away If
it's been a couple of weeksalready, right?
So questions arise and getnervous, as in like, oh my gosh,
there's something wrong with me, I'm battling this pain, right?
(01:28):
So what do I do?
Usually people go to theirprimary care doctor first, which
makes sense, and then theprimary care just to make, hey,
doc, I'll make sure everything'sokay.
What do I do, right?
Doc would say, hey, this is outof my scope because it seems
like an orthopedic issue.
I'm going to refer you to anorthopedic specialist.
So then you get a schedule toan orthopedic specialist and you
(01:49):
go to see them, and the firstthing they're going to do I'm
very confident is do an x-ray torule out fracture and
underlying sinister pathologylike a bone mass, like a tumor
right, A tumor right, a tumorright.
So once that's been taken, thenext step is to do an MRI.
(02:11):
In an MRI or a CT scan, it's tolook at the soft tissue
structures that are around thejoint and the area that's
painful, and it's to view andalso check out what's going on,
not just from the bonestandpoint but maybe more
detailed view of the surroundingsoft tissue structures, soft
(02:31):
tissue being like the connectivetissue, ligaments, tendons,
muscle tissue and labrums as anexample, stuff like that.
Okay, that Okay.
So the question is is like, doI need an MRI?
When should I go get one?
Like, what's the indicatingfactors that I should get one?
(02:52):
And here's my opinion, causeI've had my own pains and stuff
like that.
Like I'm a two sport previousathlete in college, I got three
kids and I exercise and I'm avery physical, um, uh, job,
right, I'd like work with people, do a lot of manual therapy, I
show exercises, so things comeand go and that's what I've
learned with that is like thingscome in pain, just comes and
goes and it's, it's just in painright now, right, things don't
(03:12):
have to last forever, and doesit usually mean there gets going
to last forever or thatsomething is like severely wrong
, right?
But so I'm a little bit morefamiliar with just like things
getting things getting nicked upright and banged up, um, like
tight muscles and joint pain,whatever.
Um, on the extreme end of thatwould be like, imagine, like an
MMA athlete, right, uh, orjujitsu or something like that.
(03:35):
Those guys and girls aregetting their joints torqued and
tugged on and twisted the wrongway all the time.
Dislocated shoulders, subluxedshoulders, clavicle.
Their necks get choked all thetime.
Hip and ankles get bent thewrong way all the time.
So they're always taking theirjoints to the extreme opposite
end range and so they're kind ofused to it.
(03:55):
You know what I mean.
So, like, imagine if someone onthe street had never done MMA,
never played sports, and theyput their ankle in a position
that felt the same symptoms thatthis MMA athlete had.
They'd be freaking out.
But an MMA athlete, it's afamiliarity, they've been
already familiar with that typeof symptom and that feeling.
So that familiarity andexposure therapy makes it a lot
less egregious and less freakingout, right?
(04:18):
So, anyway, when do I get MRI?
All right.
So here's my criteria of like.
Here's the reason to get an MRI,okay.
Number one it's to rule out badthings that we think we're
missing as in like, somethinghas been going on and painful.
I don't know what I did andit's not going away, okay.
(04:40):
Okay, I've tried conservativetherapy, stuff like physical
therapy and other modalities andstuff.
Just try to alter my posturesat work and with other
activities.
I've modified my activity andit seems like it's still not
going away.
All right.
So it's to rule out bad,underlying, sinister pathologies
(05:01):
that we think we're missing,that aren't just like you
sprained your knee right, likean orthopedic musculoskeletal,
neuromusculoskeletal typerelated pain.
So it's to rule out underlyingsinister pathologies.
Red flags we would call thosered flags.
It's to justify surgery.
So I usually ask people like doyou want to get surgery, do you
(05:27):
want to pursue that?
And you'd be like I don't wantsurgery, I don't want to do that
.
Even if it's like a moderatelysevere problem from a
musculoskeletal standpoint,people that we see are still
like that seems aggressive.
I don't think I'm ready forthat and I would agree I'm
biased, of course where I've had, I'm ready for that and I would
agree I'm biased, of coursewhere we've been able to help a
lot of people avoid surgery.
(05:48):
I don't hate surgery.
It doesn't have to be necessary, but it's necessary thing
sometimes.
But it doesn't always be, it'snot always indicated and people
can definitely get betterwithout it, even with some
severe musculoskeletalderangement and issues going on.
Okay, but I don't hate surgery.
(06:09):
Surgery is also a revolutionarything.
It's got super advanced.
It's amazing.
It's just not always necessary.
And then the third reason simplyis just people want closure,
they want to know what's goingon.
I want to see it.
I want to see what's going on.
I want to look at it and I wantto see it right.
It's just closure is whatthey're looking for for, like a
clear diagnosis that they canvisually look at.
(06:30):
But we can be pretty confidentthat we are most likely what's
probably going to be found right, and there is a cost of
psychological and mental healththat comes with looking at and
consulting with what an MRImight find right, as in like if
somebody has moderate back pain,immediate mild to moderate back
(06:52):
pain.
It's been going on andlingering and it's annoying,
with occasional tightness downtheir glute.
We would probably think thatit's referred nerve pain down
their glute.
All right, that's a very commonthing.
And neural sensitivity right andmost likely on the MRI for a
lumbar spine there's probablygoing to be some kind of
(07:12):
abnormalities, of bulging orherniated discs, narrowing of
the disc space, where thethinning of the disc in the we
call it like more close to boneon bone, where bone on bone is
also a very common term that Ihear a lot but like it doesn't
really paint the picture.
It doesn't and it also doesn'trepresent or indicate a lack of
functionality and a prognosis ofdoom for the rest of your life.
(07:34):
There's plenty of people thathave bone on bone and they
didn't even know it Umenotictype changes, where narrowing of
the foraminal space andosteophytes or bone spurs
developed in there that cancompress the nerve, available
freedom of movement in space.
Ligaments that surround thearea that are inflamed and
(07:56):
hypertrophied, that are growing,that are big because they're
swollen and inflamed and thatcan also limit mobility in the
vertebral joints and the spinalcolumn and then also in the
foraminal space where the nerveroot exits.
So all those are like veryscary sounding things.
Right, and that's a very commonthing where, like over 70% of
(08:16):
people by the age of 45 or 43have some kind of abnormality
found in the spine.
It's actually more uncommon tonot have something going on, so
it doesn't always representfunctionality, prognosis or
severity of symptoms.
There's a disconnect betweenwhat the imaging is finding and
then a person's actual symptoms,their functionality and
(08:36):
prognosis of whether they'regoing to get better.
Right, because plenty of peoplehave good looking imaging but
it's like it's not reallyanything remarkable.
I don't know what's going on,but they're in severe pain and
they have referred pain and it'svery bad.
And then there's people thathave not great looking imaging.
They have a lot ofabnormalities multiple hernia
discs, lots of stenotic changes,osteo bone spurs, um
(08:58):
ligamentous hypertrophy,narrowing of the disc space.
The disc fluidity and umhydration looks poor on multiple
levels, but they feel fine.
They're like I mean, I'm good.
I'm like a little tightoccasionally, but like I'm good,
right, so there's a disconnectbetween what the symptoms are
people are feeling and theactual image that's showing.
So I'm not going to hang my haton just what this image is
(09:18):
showing, right?
The example of a way to paintthat picture again would be like
there's a skilled radiologistwhich are extremely
knowledgeable, right, theydeserve a lot of respect, that's
all docs, right and they'relooking at image A and image B,
don't know who it is and don'tknow anything about them.
They wouldn't be able to tellyou who's in pain and who's not,
as in like well, this one looksa lot more effed up on the
(09:43):
image and this one looks a lotbetter.
So most likely, this guy, thegirl that has the more effed up
image, is probably gonna be morepain.
It's not true, that's that youcan't tell that, like there's,
there's a huge disconnectbetween abnormality of imaging
and then people's pain.
It's just very interesting, Idon't.
I, like I said I love it.
Mris are very revolutionary forhealthcare.
(10:06):
Um, but just going back to like,but it doesn't always indicate
symptoms and prognosis and Idon't I wouldn't jump the gun of
um personally for myself and mywife and my kids and stuff like
that of like, oh, we need toget an MRI ASAP, unless we're
thinking and surmising thatthere's something underlying
sinister that we're missing,like, imagine if someone was in
a car accident.
It was pretty severe and nowthey're having a lot of back
(10:27):
pain.
That's a great indication toget imaging Like.
You need x-rays and most likelyan MRI to rule out serious
fracture or other soft tissuedamage that might require
surgery.
Right, but litmus tests for methat I usually suggest to my
patients where I'm like, basedon my professional experience
and my opinion, based on howyou're showing and presenting,
the rationale to get an MRI isto rule out underlying red flags
(10:50):
and sinister diagnoses and lookat the soft tissue that's
surrounding the area.
Okay, that's one.
Number two is to justify surgery.
I don't think you're a surgicalcandidate right now.
Based on what you're presenting, you're able to move your arm
overhead.
It just pinches at the top.
I don't think rotator cuffsurgery right now would bring
more functional ability thanwhat you have right now.
(11:11):
We just got to get it lesspainful right and maybe improve
the scapular upward rotation andstability and all the
surrounding musculature tostabilize it and stability and
all the surrounding musculatureto stabilize it.
Number two the first thing Isaid was the ruling out red
flags.
If we can screen out a couplequestions, then we could be 98%
(11:31):
confident that it's not anunderlying diagnosis that would
require medical attentionimmediately, like a tumor, as an
example, or autonomic issue orsystemic problem.
Right, questions like thatwould be is it unrelenting pain
where you say your arm hurtswhen you do exercise?
Right, when you do physicalexercise?
(11:52):
That sounds scary if it's theleft shoulder, as an example,
because that's a referred painfor cardiovascular events like
heart attack, that type ofmechanisms.
So it's like how do you knowit's not a heart attack?
Well, is it in your chest or inyour shoulder?
Okay, it's in my shoulder?
Okay, just check one for alittle bit.
Better leaning towards shoulderissue versus a cardiovascular
problem, but we're not sure yet.
(12:12):
Number two what kind ofexercise bothers it?
Oh, when I do shoulder press orheavy shoulder raises, I'm like
, oh so not like running right,like cardiovascular exercise
doesn't bring about leftshoulder pain.
No, I haven't ran in a while,okay, so running isn't the thing
that causes pain, it's actualshoulder press and shoulder
movements that are provokingyour shoulder pain.
(12:34):
Correct, okay?
Check one again for leaningmore towards.
It's a musculoskeletal problemof the shoulder, not a
cardiovascular problem in theheart.
Does it make sense, okay?
Next question If you don't doshoulder press for a little bit,
does it feel better?
Yes, okay, so there's amechanism of pain that's causing
(12:54):
this issue.
Right, there's a mechanism ofinjury that's causing more pain
and if we remove that mechanism,things feel better.
Like it's not provoked when youare just walking around or
we're just watching TV.
It hurts when you activelydrive through your shoulder and
push up with the weight.
Yes, okay, the check one againfor probably thinking rotator
cuff pathology of some sort ofbicep tendonitis.
Okay, cool, good.
(13:17):
Next question Is it unrelentingpain where it doesn't get better
at night?
It's waking you up, no matterwhat position changes.
Like if you sleep on it, itgets.
It bothers you.
Yeah, if you roll over andswitch positions as the pain go
away and improve a little bit.
Yes, okay, so positionalchanges make it feel better,
even at night.
Yep, okay, good, check oneagain that we're thinking it's
(13:37):
more musculoskeletal, right,like a neuromusculoskeletal pain
problem versus a cardiovascularproblem.
Next question have you had anyunexplained weight loss where
it's like you really haven'treally been trying to diet,
you're not exercising a ton andyou're just like losing weight,
getting more frail and thin,fatigued and general lethargy,
(13:58):
like lethargic all the time?
No, I've been fine, like Ihaven't lost a lot of weight.
I'm trying to lose weight withworking out.
That's why I'm going to the gymand doing more stuff.
Oh, I see, okay, so you're nothaving those red flags, signs
and symptoms.
Cool, Then that tells me 98%confident.
Last question have you ever hadany previous history of
cardiovascular events myocardialinfarction, transient ischemic
(14:21):
attack in brain or othercardiovascular things that's
been going on?
No, okay, so then we're again,again, very confident 98% that
it's not a heart issue.
Do you have any heart issues inyour immediate family?
So, yeah, well, my dad had thata while when he was like in his
seventies and eighties.
Okay, and right now you're inyour forties?
Yeah, but you haven't had anyin your own previous history.
(14:42):
No, okay, so very well thatright there is like an example
of the screen of like we're 98%confident that it's probably not
a cardiovascular related issuecausing left shoulder pain but
rather something in the shoulderlike the rotator cuff, biceps
tendonitis I'm not going to saylabrum because that's more of a
passive structure.
It's not the pain generatingissue, it's underlying
(15:05):
instability of the shoulderwhich we could still we wouldn't
work on that right, likesurrounding muscular strength
and stability.
So that means that's within ourscope.
So we're going to take actionand intervene with appropriate
sports, physio, musculoskeletalinterventions and to make things
feel better, right To getbetter.
And that's when we go toobjective screening and we'll
(15:26):
watch them and their shouldermove and see if we can reproduce
and provoke the symptoms andget a better clear diagnosis of
why this shoulder pain began inthe first place and that's when
we start intervening with theright stuff.
Hopefully that makes sense, asin like, we're not just going to
do a protocol of shoulderexercises, because everyone's
unique and things come about.
(15:47):
They don't hurt for no reason.
Things come about for differentreasons for different people
and we have to be very clear andpurposeful and diagnosing.
What was the cause of the cause?
Right, the cause of yourshoulder pain is your rotator
cuff or supraspinatus tendonthat's lit up.
Infraspinatus biceps tendon, um, the labrum is involved if it's
(16:08):
.
But see, like I said, it'slabrum represents underlying
instability of the shoulder,which still is going to be a
scapular problem, and theninternal stability of the
shoulder, which is we're goingto crush stability stuff in a
non-painful way If crush was anaggressive word just non-painful
, in a non-painful way.
We're going to really work onshoulder stability stuff, um.
So, that being said, like we'regonna, we're gonna really work
(16:31):
on, um improving the cause ofthe cause.
And the cause of the pain isyour rotator cuff, structures,
biceps tendon, um, anteriorcapsule, superior capsule, um,
that's the cause of the pain.
But what caused that to get alllit up and involved in the
first place?
That cause of the cause is whatwe have.
That to get all lit up andinvolved in the first place,
that cause of the cause is whatwe have to tackle.
(16:51):
That's what we have to focus on.
Otherwise she's going to keepcoming back.
And that's something we ask ourclinicians, that we mentor in
our fellowship program and ouradvanced fellowship postdoctoral
fellowship training programthat we do.
We teach this stuff because weask them.
You've been managing thispatient and they're doing better
.
Three months down the road,let's say they're like yo full
go, like I haven't seen you in amonth, do your thing, full go.
(17:16):
What's the likelihood of thepain not coming back?
If it comes back, then thatmeans we didn't solve the actual
underlying cause of the causeand if it doesn't come back,
then that means we did a goodjob right.
We actually had a clear,accurate, movement-based
diagnosis and we were able tosolve the underlying cause of
the cause problem and prevent itfrom coming back again.
I hope that all makes sense.
(17:36):
And if you have any questionsabout MRI and imaging and stuff
like that, I guess I don't hateMRI.
Ct scan it's to look at theunderlying soft tissue and rule
out bad things and underlyingsensory diagnosis and justify
surgery and the last thing, tobring closure.
Those are the three realreasons to get an MRI.
It might not always benecessary and we can always ride
the train of conservativetreatment and therapy first.
(17:58):
And if things get better, likeI asked my patients, like what
if we work on stuff for a monthand things get better, then what
?
We continue to ride that trainof momentum, right, and we know
that we're accurate, perfect,high five, right, and that
people would still say like, andit's understandable, I'm not
making fun of anybody, it'd justbe like I would still want an
(18:19):
MRI to look at it.
It's like okay, so what you'relooking for is closure, which is
like a very expensive closurestatement is what you're looking
for and that's understandable.
You want to see it.
I don't think you're going toget the answers you want and
it's not going to changeanything we're going to do.
That's a big, that's a bigstatement, as in like, that's a.
That's a very clear, um, bigpoint that I wanted to make.
It's like, even if we get anMRI, it's not going to change
(18:41):
anything that we do, becauseyou're still, your scappula
still isn't moving, what yourshoulder blade is still not
moving upwards and rotatingenough.
Anyway, you're still slamminginto anterior translation of a
lack of shoulders.
Internal stability we stillhave to work on that right.
The lat is still dominant andpec minor is still all guarded.
All that stuff's messing up andeffing up your mechanics in
(19:02):
your shoulder and contributingover time like the straw that
broke the camel's back, leadingto shoulder pain, and an MRI
isn't going to fix that and it'salso not going to change what
we do.
Anyway, those are my thoughtson that.
I'm always open to questionsand discussion and if you have
any questions, don't hesitate toreach out.
If you're a driven, active person who wants to reach
and pursue a higher qualitylife with some ambition, then
guess what this podcast is foryou.
This is the Driven AthletePodcast.
So I have an interesting topicwith this.
I don't hate imaging by anymeans.
Mri, x-ray, ct scan like thosethings are important and they've
(00:22):
been revolutionary forhealthcare.
X-ray, ct scan like thosethings are important and they've
been revolutionary forhealthcare.
I do believe that they areoverly prescribed and overly
performed.
The reason is for the peoplethat I see right, and here's the
reason.
Here's one of my rationales onthis.
Okay, so there's in my from whatI've heard, my opinion and
people that we see withmusculoskeletal issues, some
(00:46):
kind of pain that they're comingin like I have back pain, I
have shoulder pain, I have neckpain, knee pain, ankle pain,
like whatever right, pain in myshin.
Questions arise in their headlike WTF, like why am I having
this pain?
I didn't do anything right, butthey're like, as an example,
there was no mechanism, I didn'tget in a car accident, I didn't
(01:08):
fall downstairs.
This was non-traumatic painthat has now developed in my
body somewhere, right, peopleusually ask what the heck is
going on and why do I have thisand why is it not going away If
it's been a couple of weeksalready, right?
So questions arise and getnervous, as in like, oh my gosh,
there's something wrong with me, I'm battling this pain, right?
(01:28):
So what do I do?
Usually people go to theirprimary care doctor first, which
makes sense, and then theprimary care just to make, hey,
doc, I'll make sure everything'sokay.
What do I do, right?
Doc would say, hey, this is outof my scope because it seems
like an orthopedic issue.
I'm going to refer you to anorthopedic specialist.
So then you get a schedule toan orthopedic specialist and you
(01:49):
go to see them, and the firstthing they're going to do I'm
very confident is do an x-ray torule out fracture and
underlying sinister pathologylike a bone mass, like a tumor
right, A tumor right, a tumorright.
So once that's been taken, thenext step is to do an MRI.
(02:11):
In an MRI or a CT scan, it's tolook at the soft tissue
structures that are around thejoint and the area that's
painful, and it's to view andalso check out what's going on,
not just from the bonestandpoint but maybe more
detailed view of the surroundingsoft tissue structures, soft
(02:31):
tissue being like the connectivetissue, ligaments, tendons,
muscle tissue and labrums as anexample, stuff like that.
Okay, that Okay.
So the question is is like, doI need an MRI?
When should I go get one?
Like, what's the indicatingfactors that I should get one?
(02:52):
And here's my opinion, causeI've had my own pains and stuff
like that.
Like I'm a two sport previousathlete in college, I got three
kids and I exercise and I'm avery physical, um, uh, job,
right, I'd like work with people, do a lot of manual therapy, I
show exercises, so things comeand go and that's what I've
learned with that is like thingscome in pain, just comes and
goes and it's, it's just in painright now, right, things don't
(03:12):
have to last forever, and doesit usually mean there gets going
to last forever or thatsomething is like severely wrong
, right?
But so I'm a little bit morefamiliar with just like things
getting things getting nicked upright and banged up, um, like
tight muscles and joint pain,whatever.
Um, on the extreme end of thatwould be like, imagine, like an
MMA athlete, right, uh, orjujitsu or something like that.
(03:35):
Those guys and girls aregetting their joints torqued and
tugged on and twisted the wrongway all the time.
Dislocated shoulders, subluxedshoulders, clavicle.
Their necks get choked all thetime.
Hip and ankles get bent thewrong way all the time.
So they're always taking theirjoints to the extreme opposite
end range and so they're kind ofused to it.
(03:55):
You know what I mean.
So, like, imagine if someone onthe street had never done MMA,
never played sports, and theyput their ankle in a position
that felt the same symptoms thatthis MMA athlete had.
They'd be freaking out.
But an MMA athlete, it's afamiliarity, they've been
already familiar with that typeof symptom and that feeling.
So that familiarity andexposure therapy makes it a lot
less egregious and less freakingout, right?
(04:18):
So, anyway, when do I get MRI?
All right.
So here's my criteria of like.
Here's the reason to get an MRI,okay.
Number one it's to rule out badthings that we think we're
missing as in like, somethinghas been going on and painful.
I don't know what I did andit's not going away, okay.
(04:40):
Okay, I've tried conservativetherapy, stuff like physical
therapy and other modalities andstuff.
Just try to alter my posturesat work and with other
activities.
I've modified my activity andit seems like it's still not
going away.
All right.
So it's to rule out bad,underlying, sinister pathologies
(05:01):
that we think we're missing,that aren't just like you
sprained your knee right, likean orthopedic musculoskeletal,
neuromusculoskeletal typerelated pain.
So it's to rule out underlyingsinister pathologies.
Red flags we would call thosered flags.
It's to justify surgery.
So I usually ask people like doyou want to get surgery, do you
(05:27):
want to pursue that?
And you'd be like I don't wantsurgery, I don't want to do that
.
Even if it's like a moderatelysevere problem from a
musculoskeletal standpoint,people that we see are still
like that seems aggressive.
I don't think I'm ready forthat and I would agree I'm
biased, of course where I've had, I'm ready for that and I would
agree I'm biased, of coursewhere we've been able to help a
lot of people avoid surgery.
(05:48):
I don't hate surgery.
It doesn't have to be necessary, but it's necessary thing
sometimes.
But it doesn't always be, it'snot always indicated and people
can definitely get betterwithout it, even with some
severe musculoskeletalderangement and issues going on.
Okay, but I don't hate surgery.
(06:09):
Surgery is also a revolutionarything.
It's got super advanced.
It's amazing.
It's just not always necessary.
And then the third reason simplyis just people want closure,
they want to know what's goingon.
I want to see it.
I want to see what's going on.
I want to look at it and I wantto see it right.
It's just closure is whatthey're looking for for, like a
clear diagnosis that they canvisually look at.
(06:30):
But we can be pretty confidentthat we are most likely what's
probably going to be found right, and there is a cost of
psychological and mental healththat comes with looking at and
consulting with what an MRImight find right, as in like if
somebody has moderate back pain,immediate mild to moderate back
(06:52):
pain.
It's been going on andlingering and it's annoying,
with occasional tightness downtheir glute.
We would probably think thatit's referred nerve pain down
their glute.
All right, that's a very commonthing.
And neural sensitivity right andmost likely on the MRI for a
lumbar spine there's probablygoing to be some kind of
(07:12):
abnormalities, of bulging orherniated discs, narrowing of
the disc space, where thethinning of the disc in the we
call it like more close to boneon bone, where bone on bone is
also a very common term that Ihear a lot but like it doesn't
really paint the picture.
It doesn't and it also doesn'trepresent or indicate a lack of
functionality and a prognosis ofdoom for the rest of your life.
(07:34):
There's plenty of people thathave bone on bone and they
didn't even know it Umenotictype changes, where narrowing of
the foraminal space andosteophytes or bone spurs
developed in there that cancompress the nerve, available
freedom of movement in space.
Ligaments that surround thearea that are inflamed and
(07:56):
hypertrophied, that are growing,that are big because they're
swollen and inflamed and thatcan also limit mobility in the
vertebral joints and the spinalcolumn and then also in the
foraminal space where the nerveroot exits.
So all those are like veryscary sounding things.
Right, and that's a very commonthing where, like over 70% of
(08:16):
people by the age of 45 or 43have some kind of abnormality
found in the spine.
It's actually more uncommon tonot have something going on, so
it doesn't always representfunctionality, prognosis or
severity of symptoms.
There's a disconnect betweenwhat the imaging is finding and
then a person's actual symptoms,their functionality and
(08:36):
prognosis of whether they'regoing to get better.
Right, because plenty of peoplehave good looking imaging but
it's like it's not reallyanything remarkable.
I don't know what's going on,but they're in severe pain and
they have referred pain and it'svery bad.
And then there's people thathave not great looking imaging.
They have a lot ofabnormalities multiple hernia
discs, lots of stenotic changes,osteo bone spurs, um
(08:58):
ligamentous hypertrophy,narrowing of the disc space.
The disc fluidity and umhydration looks poor on multiple
levels, but they feel fine.
They're like I mean, I'm good.
I'm like a little tightoccasionally, but like I'm good,
right, so there's a disconnectbetween what the symptoms are
people are feeling and theactual image that's showing.
So I'm not going to hang my haton just what this image is
(09:18):
showing, right?
The example of a way to paintthat picture again would be like
there's a skilled radiologistwhich are extremely
knowledgeable, right, theydeserve a lot of respect, that's
all docs, right and they'relooking at image A and image B,
don't know who it is and don'tknow anything about them.
They wouldn't be able to tellyou who's in pain and who's not,
as in like well, this one looksa lot more effed up on the
(09:43):
image and this one looks a lotbetter.
So most likely, this guy, thegirl that has the more effed up
image, is probably gonna be morepain.
It's not true, that's that youcan't tell that, like there's,
there's a huge disconnectbetween abnormality of imaging
and then people's pain.
It's just very interesting, Idon't.
I, like I said I love it.
Mris are very revolutionary forhealthcare.
(10:06):
Um, but just going back to like,but it doesn't always indicate
symptoms and prognosis and Idon't I wouldn't jump the gun of
um personally for myself and mywife and my kids and stuff like
that of like, oh, we need toget an MRI ASAP, unless we're
thinking and surmising thatthere's something underlying
sinister that we're missing,like, imagine if someone was in
a car accident.
It was pretty severe and nowthey're having a lot of back
(10:27):
pain.
That's a great indication toget imaging Like.
You need x-rays and most likelyan MRI to rule out serious
fracture or other soft tissuedamage that might require
surgery.
Right, but litmus tests for methat I usually suggest to my
patients where I'm like, basedon my professional experience
and my opinion, based on howyou're showing and presenting,
the rationale to get an MRI isto rule out underlying red flags
(10:50):
and sinister diagnoses and lookat the soft tissue that's
surrounding the area.
Okay, that's one.
Number two is to justify surgery.
I don't think you're a surgicalcandidate right now.
Based on what you're presenting, you're able to move your arm
overhead.
It just pinches at the top.
I don't think rotator cuffsurgery right now would bring
more functional ability thanwhat you have right now.
(11:11):
We just got to get it lesspainful right and maybe improve
the scapular upward rotation andstability and all the
surrounding musculature tostabilize it and stability and
all the surrounding musculatureto stabilize it.
Number two the first thing Isaid was the ruling out red
flags.
If we can screen out a couplequestions, then we could be 98%
(11:31):
confident that it's not anunderlying diagnosis that would
require medical attentionimmediately, like a tumor, as an
example, or autonomic issue orsystemic problem.
Right, questions like thatwould be is it unrelenting pain
where you say your arm hurtswhen you do exercise?
Right, when you do physicalexercise?
(11:52):
That sounds scary if it's theleft shoulder, as an example,
because that's a referred painfor cardiovascular events like
heart attack, that type ofmechanisms.
So it's like how do you knowit's not a heart attack?
Well, is it in your chest or inyour shoulder?
Okay, it's in my shoulder?
Okay, just check one for alittle bit.
Better leaning towards shoulderissue versus a cardiovascular
problem, but we're not sure yet.
(12:12):
Number two what kind ofexercise bothers it?
Oh, when I do shoulder press orheavy shoulder raises, I'm like
, oh so not like running right,like cardiovascular exercise
doesn't bring about leftshoulder pain.
No, I haven't ran in a while,okay, so running isn't the thing
that causes pain, it's actualshoulder press and shoulder
movements that are provokingyour shoulder pain.
(12:34):
Correct, okay?
Check one again for leaningmore towards.
It's a musculoskeletal problemof the shoulder, not a
cardiovascular problem in theheart.
Does it make sense, okay?
Next question If you don't doshoulder press for a little bit,
does it feel better?
Yes, okay, so there's amechanism of pain that's causing
(12:54):
this issue.
Right, there's a mechanism ofinjury that's causing more pain
and if we remove that mechanism,things feel better.
Like it's not provoked when youare just walking around or
we're just watching TV.
It hurts when you activelydrive through your shoulder and
push up with the weight.
Yes, okay, the check one againfor probably thinking rotator
cuff pathology of some sort ofbicep tendonitis.
Okay, cool, good.
(13:17):
Next question Is it unrelentingpain where it doesn't get better
at night?
It's waking you up, no matterwhat position changes.
Like if you sleep on it, itgets.
It bothers you.
Yeah, if you roll over andswitch positions as the pain go
away and improve a little bit.
Yes, okay, so positionalchanges make it feel better,
even at night.
Yep, okay, good, check oneagain that we're thinking it's
(13:37):
more musculoskeletal, right,like a neuromusculoskeletal pain
problem versus a cardiovascularproblem.
Next question have you had anyunexplained weight loss where
it's like you really haven'treally been trying to diet,
you're not exercising a ton andyou're just like losing weight,
getting more frail and thin,fatigued and general lethargy,
(13:58):
like lethargic all the time?
No, I've been fine, like Ihaven't lost a lot of weight.
I'm trying to lose weight withworking out.
That's why I'm going to the gymand doing more stuff.
Oh, I see, okay, so you're nothaving those red flags, signs
and symptoms.
Cool, Then that tells me 98%confident.
Last question have you ever hadany previous history of
cardiovascular events myocardialinfarction, transient ischemic
(14:21):
attack in brain or othercardiovascular things that's
been going on?
No, okay, so then we're again,again, very confident 98% that
it's not a heart issue.
Do you have any heart issues inyour immediate family?
So, yeah, well, my dad had thata while when he was like in his
seventies and eighties.
Okay, and right now you're inyour forties?
Yeah, but you haven't had anyin your own previous history.
(14:42):
No, okay, so very well thatright there is like an example
of the screen of like we're 98%confident that it's probably not
a cardiovascular related issuecausing left shoulder pain but
rather something in the shoulderlike the rotator cuff, biceps
tendonitis I'm not going to saylabrum because that's more of a
passive structure.
It's not the pain generatingissue, it's underlying
(15:05):
instability of the shoulderwhich we could still we wouldn't
work on that right, likesurrounding muscular strength
and stability.
So that means that's within ourscope.
So we're going to take actionand intervene with appropriate
sports, physio, musculoskeletalinterventions and to make things
feel better, right To getbetter.
And that's when we go toobjective screening and we'll
(15:26):
watch them and their shouldermove and see if we can reproduce
and provoke the symptoms andget a better clear diagnosis of
why this shoulder pain began inthe first place and that's when
we start intervening with theright stuff.
Hopefully that makes sense, asin like, we're not just going to
do a protocol of shoulderexercises, because everyone's
unique and things come about.
(15:47):
They don't hurt for no reason.
Things come about for differentreasons for different people
and we have to be very clear andpurposeful and diagnosing.
What was the cause of the cause?
Right, the cause of yourshoulder pain is your rotator
cuff or supraspinatus tendonthat's lit up.
Infraspinatus biceps tendon, um, the labrum is involved if it's
(16:08):
.
But see, like I said, it'slabrum represents underlying
instability of the shoulder,which still is going to be a
scapular problem, and theninternal stability of the
shoulder, which is we're goingto crush stability stuff in a
non-painful way If crush was anaggressive word just non-painful
, in a non-painful way.
We're going to really work onshoulder stability stuff, um.
So, that being said, like we'regonna, we're gonna really work
(16:31):
on, um improving the cause ofthe cause.
And the cause of the pain isyour rotator cuff, structures,
biceps tendon, um, anteriorcapsule, superior capsule, um,
that's the cause of the pain.
But what caused that to get alllit up and involved in the
first place?
That cause of the cause is whatwe have.
That to get all lit up andinvolved in the first place,
that cause of the cause is whatwe have to tackle.
(16:51):
That's what we have to focus on.
Otherwise she's going to keepcoming back.
And that's something we ask ourclinicians, that we mentor in
our fellowship program and ouradvanced fellowship postdoctoral
fellowship training programthat we do.
We teach this stuff because weask them.
You've been managing thispatient and they're doing better
.
Three months down the road,let's say they're like yo full
go, like I haven't seen you in amonth, do your thing, full go.
(17:16):
What's the likelihood of thepain not coming back?
If it comes back, then thatmeans we didn't solve the actual
underlying cause of the causeand if it doesn't come back,
then that means we did a goodjob right.
We actually had a clear,accurate, movement-based
diagnosis and we were able tosolve the underlying cause of
the cause problem and prevent itfrom coming back again.
I hope that all makes sense.
(17:36):
And if you have any questionsabout MRI and imaging and stuff
like that, I guess I don't hateMRI.
Ct scan it's to look at theunderlying soft tissue and rule
out bad things and underlyingsensory diagnosis and justify
surgery and the last thing, tobring closure.
Those are the three realreasons to get an MRI.
It might not always benecessary and we can always ride
the train of conservativetreatment and therapy first.
(17:58):
And if things get better, likeI asked my patients, like what
if we work on stuff for a monthand things get better, then what
?
We continue to ride that trainof momentum, right, and we know
that we're accurate, perfect,high five, right, and that
people would still say like, andit's understandable, I'm not
making fun of anybody, it'd justbe like I would still want an
(18:19):
MRI to look at it.
It's like okay, so what you'relooking for is closure, which is
like a very expensive closurestatement is what you're looking
for and that's understandable.
You want to see it.
I don't think you're going toget the answers you want and
it's not going to changeanything we're going to do.
That's a big, that's a bigstatement, as in like, that's a.
That's a very clear, um, bigpoint that I wanted to make.
It's like, even if we get anMRI, it's not going to change
(18:41):
anything that we do, becauseyou're still, your scappula
still isn't moving, what yourshoulder blade is still not
moving upwards and rotatingenough.
Anyway, you're still slamminginto anterior translation of a
lack of shoulders.
Internal stability we stillhave to work on that right.
The lat is still dominant andpec minor is still all guarded.
All that stuff's messing up andeffing up your mechanics in
(19:02):
your shoulder and contributingover time like the straw that
broke the camel's back, leadingto shoulder pain, and an MRI
isn't going to fix that and it'salso not going to change what
we do.
Anyway, those are my thoughtson that.
I'm always open to questionsand discussion and if you have
any questions, don't hesitate toreach out.
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