Latest / The Driven Athlete / Rationale for Imaging, Root Cause of Shoulder Pain, & Solutions | Ep 67

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Rationale for Imaging, Root Cause of Shoulder Pain, & Solutions | Ep 67 · The Driven Athlete

• 0:00
  Speaker 1: If you're a driven, active person who wants to reach and pursue a higher quality life with some ambition, then guess what this podcast is for you.
• 0:07
  Speaker 1: This is the Driven Athlete Podcast.
• 0:10
  Speaker 1: So I have an interesting topic with this.
• 0:15
  Speaker 1: I don't hate imaging by any means.
• 0:18
  Speaker 1: Mri, x-ray, ct scan like those things are important and they've been revolutionary for healthcare.
• 0:24
  Speaker 1: X-ray, ct scan like those things are important and they've been revolutionary for healthcare.
• 0:27
  Speaker 1: I do believe that they are overly prescribed and overly performed.
• 0:34
  Speaker 1: The reason is for the people that I see right, and here's the reason.
• 0:35
  Speaker 1: Here's one of my rationales on this.
• 0:37
  Speaker 1: Okay, so there's in my from what I've heard, my opinion and people that we see with musculoskeletal issues, some kind of pain that they're coming in like I have back pain, I have shoulder pain, I have neck pain, knee pain, ankle pain, like whatever right, pain in my shin.
• 0:55
  Speaker 1: Questions arise in their head like WTF, like why am I having this pain?
• 1:01
  Speaker 1: I didn't do anything right, but they're like, as an example, there was no mechanism, I didn't get in a car accident, I didn't fall downstairs.
• 1:08
  Speaker 1: This was non-traumatic pain that has now developed in my body somewhere, right, people usually ask what the heck is going on and why do I have this and why is it not going away If it's been a couple of weeks already, right?
• 1:20
  Speaker 1: So questions arise and get nervous, as in like, oh my gosh, there's something wrong with me, I'm battling this pain, right?
• 1:28
  Speaker 1: So what do I do?
• 1:31
  Speaker 1: Usually people go to their primary care doctor first, which makes sense, and then the primary care just to make, hey, doc, I'll make sure everything's okay.
• 1:38
  Speaker 1: What do I do, right?
• 1:39
  Speaker 1: Doc would say, hey, this is out of my scope because it seems like an orthopedic issue.
• 1:44
  Speaker 1: I'm going to refer you to an orthopedic specialist.
• 1:46
  Speaker 1: So then you get a schedule to an orthopedic specialist and you go to see them, and the first thing they're going to do I'm very confident is do an x-ray to rule out fracture and underlying sinister pathology like a bone mass, like a tumor right, A tumor right, a tumor right.
• 2:05
  Speaker 1: So once that's been taken, the next step is to do an MRI.
• 2:11
  Speaker 1: In an MRI or a CT scan, it's to look at the soft tissue structures that are around the joint and the area that's painful, and it's to view and also check out what's going on, not just from the bone standpoint but maybe more detailed view of the surrounding soft tissue structures, soft tissue being like the connective tissue, ligaments, tendons, muscle tissue and labrums as an example, stuff like that.
• 2:40
  Speaker 1: Okay, that Okay.
• 2:40
  Speaker 1: So the question is is like, do I need an MRI?
• 2:44
  Speaker 1: When should I go get one?
• 2:46
  Speaker 1: Like, what's the indicating factors that I should get one?
• 2:52
  Speaker 1: And here's my opinion, cause I've had my own pains and stuff like that.
• 2:54
  Speaker 1: Like I'm a two sport previous athlete in college, I got three kids and I exercise and I'm a very physical, um, uh, job, right, I'd like work with people, do a lot of manual therapy, I show exercises, so things come and go and that's what I've learned with that is like things come in pain, just comes and goes and it's, it's just in pain right now, right, things don't have to last forever, and does it usually mean there gets going to last forever or that something is like severely wrong, right?
• 3:18
  Speaker 1: But so I'm a little bit more familiar with just like things getting things getting nicked up right and banged up, um, like tight muscles and joint pain, whatever.
• 3:28
  Speaker 1: Um, on the extreme end of that would be like, imagine, like an MMA athlete, right, uh, or jujitsu or something like that.
• 3:35
  Speaker 1: Those guys and girls are getting their joints torqued and tugged on and twisted the wrong way all the time.
• 3:40
  Speaker 1: Dislocated shoulders, subluxed shoulders, clavicle.
• 3:44
  Speaker 1: Their necks get choked all the time.
• 3:46
  Speaker 1: Hip and ankles get bent the wrong way all the time.
• 3:49
  Speaker 1: So they're always taking their joints to the extreme opposite end range and so they're kind of used to it.
• 3:55
  Speaker 1: You know what I mean.
• 3:55
  Speaker 1: So, like, imagine if someone on the street had never done MMA, never played sports, and they put their ankle in a position that felt the same symptoms that this MMA athlete had.
• 4:03
  Speaker 1: They'd be freaking out.
• 4:04
  Speaker 1: But an MMA athlete, it's a familiarity, they've been already familiar with that type of symptom and that feeling.
• 4:11
  Speaker 1: So that familiarity and exposure therapy makes it a lot less egregious and less freaking out, right?
• 4:18
  Speaker 1: So, anyway, when do I get MRI?
• 4:21
  Speaker 1: All right.
• 4:21
  Speaker 1: So here's my criteria of like.
• 4:25
  Speaker 1: Here's the reason to get an MRI, okay.
• 4:27
  Speaker 1: Number one it's to rule out bad things that we think we're missing as in like, something has been going on and painful.
• 4:35
  Speaker 1: I don't know what I did and it's not going away, okay.
• 4:40
  Speaker 1: Okay, I've tried conservative therapy, stuff like physical therapy and other modalities and stuff.
• 4:47
  Speaker 1: Just try to alter my postures at work and with other activities.
• 4:57
  Speaker 1: I've modified my activity and it seems like it's still not going away.
• 4:59
  Speaker 1: All right.
• 4:59
  Speaker 1: So it's to rule out bad, underlying, sinister pathologies that we think we're missing, that aren't just like you sprained your knee right, like an orthopedic musculoskeletal, neuromusculoskeletal type related pain.
• 5:09
  Speaker 1: So it's to rule out underlying sinister pathologies.
• 5:12
  Speaker 1: Red flags we would call those red flags.
• 5:15
  Speaker 1: It's to justify surgery.
• 5:20
  Speaker 1: So I usually ask people like do you want to get surgery, do you want to pursue that?
• 5:27
  Speaker 1: And you'd be like I don't want surgery, I don't want to do that.
• 5:29
  Speaker 1: Even if it's like a moderately severe problem from a musculoskeletal standpoint, people that we see are still like that seems aggressive.
• 5:39
  Speaker 1: I don't think I'm ready for that 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 course where we've been able to help a lot of people avoid surgery.
• 5:48
  Speaker 1: I don't hate surgery.
• 5:49
  Speaker 1: It doesn't have to be necessary, but it's necessary thing sometimes.
• 5:58
  Speaker 1: But it doesn't always be, it's not always indicated and people can definitely get better without it, even with some severe musculoskeletal derangement and issues going on.
• 6:08
  Speaker 1: Okay, but I don't hate surgery.
• 6:09
  Speaker 1: Surgery is also a revolutionary thing.
• 6:11
  Speaker 1: It's got super advanced.
• 6:13
  Speaker 1: It's amazing.
• 6:14
  Speaker 1: It's just not always necessary.
• 6:15
  Speaker 1: And then the third reason simply is just people want closure, they want to know what's going on.
• 6:20
  Speaker 1: I want to see it.
• 6:21
  Speaker 1: I want to see what's going on.
• 6:22
  Speaker 1: I want to look at it and I want to see it right.
• 6:25
  Speaker 1: It's just closure is what they're looking for for, like a clear diagnosis that they can visually look at.
• 6:30
  Speaker 1: But we can be pretty confident that we are most likely what's probably going to be found right, and there is a cost of psychological and mental health that comes with looking at and consulting with what an MRI might find right, as in like if somebody has moderate back pain, immediate mild to moderate back pain.
• 6:52
  Speaker 1: It's been going on and lingering and it's annoying, with occasional tightness down their glute.
• 6:57
  Speaker 1: We would probably think that it's referred nerve pain down their glute.
• 7:01
  Speaker 1: All right, that's a very common thing.
• 7:05
  Speaker 1: And neural sensitivity right and most likely on the MRI for a lumbar spine there's probably going to be some kind of abnormalities, of bulging or herniated discs, narrowing of the disc space, where the thinning of the disc in the we call it like more close to bone on bone, where bone on bone is also a very common term that I hear a lot but like it doesn't really paint the picture.
• 7:27
  Speaker 1: It doesn't and it also doesn't represent or indicate a lack of functionality and a prognosis of doom for the rest of your life.
• 7:34
  Speaker 1: There's plenty of people that have bone on bone and they didn't even know it Umenotic type changes, where narrowing of the foraminal space and osteophytes or bone spurs developed in there that can compress the nerve, available freedom of movement in space.
• 7:50
  Speaker 1: Ligaments that surround the area that are inflamed and hypertrophied, that are growing, that are big because they're swollen and inflamed and that can also limit mobility in the vertebral joints and the spinal column and then also in the foraminal space where the nerve root exits.
• 8:06
  Speaker 1: So all those are like very scary sounding things.
• 8:10
  Speaker 1: Right, and that's a very common thing where, like over 70% of people by the age of 45 or 43 have some kind of abnormality found in the spine.
• 8:22
  Speaker 1: It's actually more uncommon to not have something going on, so it doesn't always represent functionality, prognosis or severity of symptoms.
• 8:30
  Speaker 1: There's a disconnect between what the imaging is finding and then a person's actual symptoms, their functionality and prognosis of whether they're going to get better.
• 8:38
  Speaker 1: Right, because plenty of people have good looking imaging but it's like it's not really anything remarkable.
• 8:44
  Speaker 1: I don't know what's going on, but they're in severe pain and they have referred pain and it's very bad.
• 8:48
  Speaker 1: And then there's people that have not great looking imaging.
• 8:51
  Speaker 1: They have a lot of abnormalities multiple hernia discs, lots of stenotic changes, osteo bone spurs, um ligamentous hypertrophy, narrowing of the disc space.
• 9:04
  Speaker 1: The disc fluidity and um hydration looks poor on multiple levels, but they feel fine.
• 9:07
  Speaker 1: They're like I mean, I'm good.
• 9:08
  Speaker 1: I'm like a little tight occasionally, but like I'm good, right, so there's a disconnect between what the symptoms are people are feeling and the actual image that's showing.
• 9:15
  Speaker 1: So I'm not going to hang my hat on just what this image is showing, right?
• 9:20
  Speaker 1: The example of a way to paint that picture again would be like there's a skilled radiologist which are extremely knowledgeable, right, they deserve a lot of respect, that's all docs, right and they're looking at image A and image B, don't know who it is and don't know anything about them.
• 9:34
  Speaker 1: They wouldn't be able to tell you who's in pain and who's not, as in like well, this one looks a lot more effed up on the image and this one looks a lot better.
• 9:44
  Speaker 1: So most likely, this guy, the girl that has the more effed up image, is probably gonna be more pain.
• 9:46
  Speaker 1: It's not true, that's that you can't tell that, like there's, there's a huge disconnect between abnormality of imaging and then people's pain.
• 9:55
  Speaker 1: It's just very interesting, I don't.
• 9:57
  Speaker 1: I, like I said I love it.
• 9:57
  Speaker 1: Mris are very revolutionary for healthcare.
• 10:06
  Speaker 1: Um, but just going back to like, but it doesn't always indicate symptoms and prognosis and I don't I wouldn't jump the gun of um personally for myself and my wife and my kids and stuff like that of like, oh, we need to get an MRI ASAP, unless we're thinking and surmising that there's something underlying sinister that we're missing, like, imagine if someone was in a car accident.
• 10:26
  Speaker 1: It was pretty severe and now they're having a lot of back pain.
• 10:27
  Speaker 1: That's a great indication to get imaging Like.
• 10:28
  Speaker 1: You need x-rays and most likely an MRI to rule out serious fracture or other soft tissue damage that might require surgery.
• 10:34
  Speaker 1: Right, but litmus tests for me that I usually suggest to my patients where I'm like, based on my professional experience and my opinion, based on how you're showing and presenting, the rationale to get an MRI is to rule out underlying red flags and sinister diagnoses and look at the soft tissue that's surrounding the area.
• 10:54
  Speaker 1: Okay, that's one.
• 10:56
  Speaker 1: Number two is to justify surgery.
• 10:58
  Speaker 1: I don't think you're a surgical candidate right now.
• 11:00
  Speaker 1: Based on what you're presenting, you're able to move your arm overhead.
• 11:02
  Speaker 1: It just pinches at the top.
• 11:04
  Speaker 1: I don't think rotator cuff surgery right now would bring more functional ability than what you have right now.
• 11:11
  Speaker 1: We just got to get it less painful right and maybe improve the scapular upward rotation and stability and all the surrounding musculature to stabilize it and stability and all the surrounding musculature to stabilize it.
• 11:22
  Speaker 1: Number two the first thing I said was the ruling out red flags.
• 11:26
  Speaker 1: If we can screen out a couple questions, then we could be 98% confident that it's not an underlying diagnosis that would require medical attention immediately, like a tumor, as an example, or autonomic issue or systemic problem.
• 11:39
  Speaker 1: Right, questions like that would be is it unrelenting pain where you say your arm hurts when you do exercise?
• 11:49
  Speaker 1: Right, when you do physical exercise?
• 11:52
  Speaker 1: That sounds scary if it's the left shoulder, as an example, because that's a referred pain for cardiovascular events like heart attack, that type of mechanisms.
• 12:01
  Speaker 1: So it's like how do you know it's not a heart attack?
• 12:02
  Speaker 1: Well, is it in your chest or in your shoulder?
• 12:05
  Speaker 1: Okay, it's in my shoulder?
• 12:06
  Speaker 1: Okay, just check one for a little bit.
• 12:08
  Speaker 1: Better leaning towards shoulder issue versus a cardiovascular problem, but we're not sure yet.
• 12:12
  Speaker 1: Number two what kind of exercise bothers it?
• 12:16
  Speaker 1: Oh, when I do shoulder press or heavy shoulder raises, I'm like, oh so not like running right, like cardiovascular exercise doesn't bring about left shoulder pain.
• 12:25
  Speaker 1: No, I haven't ran in a while, okay, so running isn't the thing that causes pain, it's actual shoulder press and shoulder movements that are provoking your shoulder pain.
• 12:34
  Speaker 1: Correct, okay?
• 12:36
  Speaker 1: Check one again for leaning more towards.
• 12:38
  Speaker 1: It's a musculoskeletal problem of the shoulder, not a cardiovascular problem in the heart.
• 12:43
  Speaker 1: Does it make sense, okay?
• 12:45
  Speaker 1: Next question If you don't do shoulder press for a little bit, does it feel better?
• 12:50
  Speaker 1: Yes, okay, so there's a mechanism of pain that's causing this issue.
• 12:55
  Speaker 1: Right, there's a mechanism of injury that's causing more pain and if we remove that mechanism, things feel better.
• 13:00
  Speaker 1: Like it's not provoked when you are just walking around or we're just watching TV.
• 13:05
  Speaker 1: It hurts when you actively drive through your shoulder and push up with the weight.
• 13:09
  Speaker 1: Yes, okay, the check one again for probably thinking rotator cuff pathology of some sort of bicep tendonitis.
• 13:14
  Speaker 1: Okay, cool, good.
• 13:17
  Speaker 1: Next question Is it unrelenting pain where it doesn't get better at night?
• 13:20
  Speaker 1: It's waking you up, no matter what position changes.
• 13:24
  Speaker 1: Like if you sleep on it, it gets.
• 13:25
  Speaker 1: It bothers you.
• 13:25
  Speaker 1: Yeah, if you roll over and switch positions as the pain go away and improve a little bit.
• 13:30
  Speaker 1: Yes, okay, so positional changes make it feel better, even at night.
• 13:34
  Speaker 1: Yep, okay, good, check one again that we're thinking it's more musculoskeletal, right, like a neuromusculoskeletal pain problem versus a cardiovascular problem.
• 13:43
  Speaker 1: Next question have you had any unexplained weight loss where it's like you really haven't really been trying to diet, you're not exercising a ton and you're just like losing weight, getting more frail and thin, fatigued and general lethargy, like lethargic all the time?
• 13:59
  Speaker 1: No, I've been fine, like I haven't lost a lot of weight.
• 14:02
  Speaker 1: I'm trying to lose weight with working out.
• 14:03
  Speaker 1: That's why I'm going to the gym and doing more stuff.
• 14:05
  Speaker 1: Oh, I see, okay, so you're not having those red flags, signs and symptoms.
• 14:09
  Speaker 1: Cool, Then that tells me 98% confident.
• 14:14
  Speaker 1: Last question have you ever had any previous history of cardiovascular events myocardial infarction, transient ischemic attack in brain or other cardiovascular things that's been going on?
• 14:25
  Speaker 1: No, okay, so then we're again, again, very confident 98% that it's not a heart issue.
• 14:31
  Speaker 1: Do you have any heart issues in your immediate family?
• 14:33
  Speaker 1: So, yeah, well, my dad had that a while when he was like in his seventies and eighties.
• 14:37
  Speaker 1: Okay, and right now you're in your forties?
• 14:39
  Speaker 1: Yeah, but you haven't had any in your own previous history.
• 14:42
  Speaker 1: No, okay, so very well that right there is like an example of the screen of like we're 98% confident that it's probably not a cardiovascular related issue causing left shoulder pain but rather something in the shoulder like the rotator cuff, biceps tendonitis I'm not going to say labrum because that's more of a passive structure.
• 15:02
  Speaker 1: It's not the pain generating issue, it's underlying instability of the shoulder which we could still we wouldn't work on that right, like surrounding muscular strength and stability.
• 15:11
  Speaker 1: So that means that's within our scope.
• 15:14
  Speaker 1: So we're going to take action and intervene with appropriate sports, physio, musculoskeletal interventions and to make things feel better, right To get better.
• 15:24
  Speaker 1: And that's when we go to objective screening and we'll watch them and their shoulder move and see if we can reproduce and provoke the symptoms and get a better clear diagnosis of why this shoulder pain began in the first place and that's when we start intervening with the right stuff.
• 15:38
  Speaker 1: Hopefully that makes sense, as in like, we're not just going to do a protocol of shoulder exercises, because everyone's unique and things come about.
• 15:47
  Speaker 1: They don't hurt for no reason.
• 15:48
  Speaker 1: Things come about for different reasons for different people and we have to be very clear and purposeful and diagnosing.
• 15:55
  Speaker 1: What was the cause of the cause?
• 15:57
  Speaker 1: Right, the cause of your shoulder pain is your rotator cuff or supraspinatus tendon that's lit up.
• 16:03
  Speaker 1: Infraspinatus biceps tendon, um, the labrum is involved if it's.
• 16:08
  Speaker 1: But see, like I said, it's labrum represents underlying instability of the shoulder, which still is going to be a scapular problem, and then internal stability of the shoulder, which is we're going to crush stability stuff in a non-painful way If crush was an aggressive word just non-painful, in a non-painful way.
• 16:24
  Speaker 1: We're going to really work on shoulder stability stuff, um.
• 16:27
  Speaker 1: So, that being said, like we're gonna, we're gonna really work on, um improving the cause of the cause.
• 16:34
  Speaker 1: And the cause of the pain is your rotator cuff, structures, biceps tendon, um, anterior capsule, superior capsule, um, that's the cause of the pain.
• 16:44
  Speaker 1: But what caused that to get all lit up and involved in the first place?
• 16:46
  Speaker 1: That cause of the cause is what we have.
• 16:46
  Speaker 1: That to get all lit up and involved in the first place, that cause of the cause is what we have to tackle.
• 16:51
  Speaker 1: That's what we have to focus on.
• 16:52
  Speaker 1: Otherwise she's going to keep coming back.
• 16:54
  Speaker 1: And that's something we ask our clinicians, that we mentor in our fellowship program and our advanced fellowship postdoctoral fellowship training program that we do.
• 17:01
  Speaker 1: We teach this stuff because we ask them.
• 17:05
  Speaker 1: You've been managing this patient and they're doing better.
• 17:07
  Speaker 1: Three months down the road, let's say they're like yo full go, like I haven't seen you in a month, do your thing, full go.
• 17:16
  Speaker 1: What's the likelihood of the pain not coming back?
• 17:18
  Speaker 1: If it comes back, then that means we didn't solve the actual underlying cause of the cause and if it doesn't come back, then that means we did a good job right.
• 17:26
  Speaker 1: We actually had a clear, accurate, movement-based diagnosis and we were able to solve the underlying cause of the cause problem and prevent it from coming back again.
• 17:34
  Speaker 1: I hope that all makes sense.
• 17:36
  Speaker 1: And if you have any questions about MRI and imaging and stuff like that, I guess I don't hate MRI.
• 17:42
  Speaker 1: Ct scan it's to look at the underlying soft tissue and rule out bad things and underlying sensory diagnosis and justify surgery and the last thing, to bring closure.
• 17:50
  Speaker 1: Those are the three real reasons to get an MRI.
• 17:52
  Speaker 1: It might not always be necessary and we can always ride the train of conservative treatment and therapy first.
• 17:58
  Speaker 1: And if things get better, like I asked my patients, like what if we work on stuff for a month and things get better, then what?
• 18:06
  Speaker 1: We continue to ride that train of momentum, right, and we know that we're accurate, perfect, high five, right, and that people would still say like, and it's understandable, I'm not making fun of anybody, it'd just be like I would still want an MRI to look at it.
• 18:20
  Speaker 1: It's like okay, so what you're looking for is closure, which is like a very expensive closure statement is what you're looking for and that's understandable.
• 18:26
  Speaker 1: You want to see it.
• 18:28
  Speaker 1: I don't think you're going to get the answers you want and it's not going to change anything we're going to do.
• 18:31
  Speaker 1: That's a big, that's a big statement, as in like, that's a.
• 18:35
  Speaker 1: That's a very clear, um, big point that I wanted to make.
• 18:38
  Speaker 1: It's like, even if we get an MRI, it's not going to change anything that we do, because you're still, your scappula still isn't moving, what your shoulder blade is still not moving upwards and rotating enough.
• 18:48
  Speaker 1: Anyway, you're still slamming into anterior translation of a lack of shoulders.
• 18:53
  Speaker 1: Internal stability we still have to work on that right.
• 18:56
  Speaker 1: The lat is still dominant and pec minor is still all guarded.
• 18:59
  Speaker 1: All that stuff's messing up and effing up your mechanics in your shoulder and contributing over time like the straw that broke the camel's back, leading to shoulder pain, and an MRI isn't going to fix that and it's also not going to change what we do.
• 19:10
  Speaker 1: Anyway, those are my thoughts on that.
• 19:12
  Speaker 1: I'm always open to questions and discussion and if you have any questions, don't hesitate to reach out.