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PLANNING ON GETTING AN MRI? HERE'S WHAT YOU NEED TO KNOW FIRST.

Jun 28, 2022

So first , let me start off with if your provider (or you) have legit reasons to think cancerous tumors are present, then absolutely, get that image!! Same goes for a trauma like a major car accident or falling off a high surface - there are certain times where imaging is warranted and necessary to make sure something truly major isn’t going on.

Outside of that, chances are this can save you LOTS of money and time (because imaging isn’t cheap and often can take awhile to get authorized/scheduled)…

Let me start by saying pain is super complex. There are a number of tissues in the body that can get irritated or inflamed and set up an alarm signal in your brain that then translates to pain in a region. And that pain may actually not even show up in the same area as where the signal originated from. There are all sorts of referral patterns or crazy ways that pain show up. Hell, just last week I saw someone with wrist pain that was coming from the shoulder and another with knee pain that was coming from the low back, and another with a headache coming from the neck. Past that, there’s also so many other psychosocial and environmental factors that go into pain - How are you sleeping? What’s your diet like? Are you managing stress effectively? Even FEAR of pain can even cause physical pain! The very act of thinking “I can’t deadlift anymore because I have degenerative disc disease and it is always going to hurt” can actually bring on pain before you even perform the lift! So while MRIs and other diagnostic imaging has it’s place, it’s often unnecessary and not really giving us any legit information about where your pain is coming from anyways. When it comes to musculoskeletal pain, the vast majority of the time we can get better and more accurate info on what’s going on and how to best treat it through a thorough history and physical examination versus any image.

Let’s go through a few studies that drive this home…

I wanna start with this big study on low back findings because one of the more common things I hear is “oh, I had a disc bulge years ago, so I can’t do XYZ and it’s why I have so much pain.” Honestly, someone (or society) along the way did you a disservice by leading you to believe that. And then our beliefs and expectations drive our outcomes, so it’s no wonder you’re still dealing with pain. I’m not saying it’s in your head, but at the same time…it is your brain that’s allowing the pain to continue at that point.

Did you know that EVERY clinical guidelines for physicians for the treatment of nonspecific low back pain (LBP) IN THE WORLD explicitly says that imaging is NOT recommended and SHOULD NOT be done unless there’s cause to believe a space-occupying-lesion (MRI or CT scan) or major fracture (xray) may be present?!?! Now as to why physicians aren’t following their own clinical guidelines….it’s either because they haven’t kept up with the research and seen their own updated guidelines OR it’s because insurance companies still reimburse for these at high rates.

There are several reasons why imaging isn’t recommended/warranted except in the case of major red flags. The biggest one is because at this point, research has solidly proven that no matter what tissue damage we find on imaging, we CANNOT correlate it to that persons symptoms. One of the research studies that determined this is one done by Brinjikji, wt al in 2014 where they took hundreds of people in all decades of life with NO PAIN and had them get imaging. So what did they find?! All kinds of things!!!! I’ll post the graph of the results below, but the gist is that it would highly abnormal for your image to show nothing regardless of what symptoms you may or may not be having. And if all of the people in this study can have all kinds of “terrible” findings on their image, yet have no pain, why can’t anyone else also not have any pain?! The answer is they can. You can have multiple disc bulges, labral tears, etc and have absolutely NO PAIN and function just fine. Hell, think of these things as normal signs of aging, kind of like wrinkles.

(asymptomatic = ZERO symptoms/pain/functional limitation)

Another study on “abnormal” knee findings using MRI in asymptomatic patients in their 50’s to 70’s found similar findings. The list of things they found include damage to the cartilage lining of the femur, underlying bone damage, meniscus injury, and more. Yet these were again all people with NO pain or dysfunction. And as before, the prevalence of the findings increased with age in the study participants. This once again demonstrates that there appears to be a normal amount of wear that occurs to the knees over a lifetime, yet it doesn’t necessarily correlate with the patient experiencing pain.

What about the shoulder? Minagawa et al did a study where they did imaging on both shoulders of 664 participants and found full thickness rotator cuff tears in 147 of those people. But how many were experiencing symptoms? Only 34.7%. The other 65.3% had zero symptoms! So again, a solid number of the ones experiencing pain could go through conservative care to get out of pain and get stronger.

Here’s a photo that shows a good overview of what “abnormal” findings may actually be normal or at least can be treated conservatively to get you out of pain and back to doing all the things:

And if these studies doesn’t convince you, I’ve got personal experience. I still have multiple disc bulges throughout my neck and back as well as some tearing in my rotator cuff and right labrum - possibly the left, too, but it’s never been imaged - and I still do all the things in CrossFit, weightlifting, and outdoor sports. And the only reason I ever got those images to know those results is because of major traumatic falls and car accidents that warranted imaging to check for fractures, etc, or they were back when I still had corporate health insurance and it required an image (a rant for another time). But I’d assume all of those things had already been there (except for the labrum which showed up after a really bad snowboarding fall - and yes, I treated that without surgery) and there is absolutely no way to know when they showed up. Hell, the disc bulges in my neck were found after 2 separate car accidents years apart with zero change in how they showed up on image…yet I had neck pain the first time I got the imaging (from something else entirely, though that didn’t stop medical providers from trying to blame them *eye roll*) and ZERO pain the second time. Hmmm….doesn’t sound like those had anything to do with my pain, right? If any provider ever tells you something like “oh this disc bulge here is from X incident…” Unless you legit had imaging the week prior to X and it wasn’t there, they are making an assumption at best. And even so, you cannot create a causative link between any musculoskeletal image finding and a person’s pain like we saw in that study above. For that matter, if you ever have a provider say that any specific musculoskeletal tissue is the cause of your pain, they are lying. Now don’t mishear me - I bet they mean well. And it might be a very educated guess they are making, but it’s just that - a guess. There is no way for us to know if any specific tissue is “at fault”…but what we CAN say based on our assessment is what general area is causing the pain and based on how an individual is presenting, we can come up with a really solid plan of care to get them out of pain and back to doing everything they need/want to.

Here’s another fun thing to consider:

If you don’t like your image results, go down the road and get another! It’ll likely be different!

Yes, I am aware of how grossly a generalized statement that is, but research has proven to show that results can and will be biased by whoever is reading it. Herzog at al is a research study where they took one 63 year old woman with LBP, including radicular symptoms (meaning she had symptoms down one leg) and had her get imaging at 10 different MRI centers within a 3 week period and looked at whether or not the reports were similar between the 10. Findings: little to NO consistency between them!!! In fact, there were 49 distinct findings across the 10 reports and about 33% of those findings were only in 1/10. I don’t wanna bog y’all down with the research (though feel free to email me with any questions if you do want to discuss it!), but yea, basically your imaging legit isn’t telling me much.

This variability is concerning since a lot of times our imaging is what’s referenced as to why a treatment is done or what’s covered by insurance, etc. But I think the big takeaway is to stop putting so much stock in an image especially when it comes to musculoskeletal pain. Again, tumors and such are a vastly different story here, but if we know that things like disc bulges or rotator cuff tears are relatively “normal” and are in plenty of people without any pain…AND we know that the results on our image reports differ based on who’s reading them…then what’s the point?? Honestly, I think there isn’t one. And most of the time, the “findings” on it are relatively normal. Hell, if you’re over the age of 20, I can pretty much guarantee that there will be “aBnOrMaL findings” found that are actually completely normal and don’t mean anything about your symptoms. The only times I suggest people get one is if there are major red flags present (things that point towards tumors or spinal cord issues or a traumatic event where the patient fits the criteria for imaging first) OR if we’ve really tried everything that should work for awhile without the expected results.

Ok, I’m gonna stop rambling and spouting research now. I think you get the point - you probably don’t need that image. And if a provider says you do, ask why. Use this blog and it’s info as a resource to advocate for yourself against unnecessary imaging and medical charges. And I would absolutely LOVE to discuss this further with anyone, so please - I’m looking forward to any and all questions.

Much love y’all,

Megan

P.S. Did you know that you could use membership sessions with me to really discuss any musculoskeletal thing you have questions about?! Think of it like consulting Google expect you get personalized results and advice that aren’t given based on SEO or ad costs. I already have a few people that we started out addressing a specific injury concern or made sure they could get back into X activity without issue and then transitioned into a mix of addressing anything that came up in the last month and then coaching/consulting on things like this! Check out memberships here

"Your knees are shot and if you keep up all the activity you're doing, you won't walk at 30"- what I was told by medical professionals at age 18 after my 3rd knee surgery. Fast forward to today, and I'm 32 and not only do I Crossfit 4-5 days a week, but my off days are usually spent trail running and/or hiking. And the only time I have knee pain is when I take 4 or more days off from activity. You see, the stronger the muscles around a joint are, the more they can unload the joint - i.e. the ligaments, meniscus, and cartilage in the knee don’t have to absorb quite as much force as they would otherwise. And less pressure = less risk of damage or pain.

For years, I avoided squatting below parallel, catching heavy weight in a squat such as full cleans and snatches, and had a crazy wide squat stance. I also avoiding running and would get nervous hiking downhill. Why? Because I let the nocebo (negative thoughts) given to me medical professionals dictate my movement. You see, I've had three knee surgeries, with the 1st one being in 5th grade and the last being a cartilage graft during college. Most of my knee injuries have been due to Osteochondritis Dissecans (Rare condition. Lack of blood flow to bone causing cracks to form in the cartilage and underlying bone. Cause unknown). Though one surgery was an ACL reconstruction where they took out part of my patellar tendon and put it where the ACL should be.

With each of these instances (a few others didn't require surgery), I was told yet again that I should stop doing any high impact activity, never run on hard ground, that I should never do heavy squats, and definitely don't go below parallel even without weight. This is devastating news to a very active and athletic fifth grader. And let's be real, still devastating to an active college student. Thankfully, I'm stubborn. I agreed to quit all hard court sports like basketball (though to be fair, as soon as everyone else hit their growth spurt, I probably wouldn't have lasted) and gymnastics. But I refused to give up soccer. And with that came weight training once I got to high school.

I still lift and do Crossfit 4 days a week and trail run or hike in the off days. I honestly LOVE heavy squats and deadlifts, and I am constantly challenge myself! And you know what I realized once I left soccer but was still in the gym doing weightlifting? My knees only bothered me when I did one of 2 things: wayyyyy overdid it or skipped the gym and hiking several days in a row.

Two main takeaways from this bit:

1. Don't let a doctor's opinion dictate your own opinion or your life.

Every profession has it's bad and good apples. And a certain degree does not make one infallible.

2. Heavy squats fix everything (read: your body wants to be loaded. Strength training has countless benefits and should definitely be a part of your life)

So I bet you’re like “Sweet, so strength is important. Got it. But what are some ways to build up strength?” Here ya go:

First, I should explain that it’s not always as simple as “get stronger.” Mobility and technique also need to be considered when figuring out the cause of knee pain. And it’s almost never directly the knee. Typically, if a mobility issue is at play, it is either from the hips or ankles, though it could be from further up as well. This will be it’s own blog (or maybe Eboko!) soon

As far as technique goes, it really kind of depends on when you’re having pain. For example, if it’s just with running, maybe you’re not keeping enough bend in your knee throughout the gait cycle, causing increased stress on the knee. If it’s just at the transition point at the bottom of a squat, maybe you’re only going to parallel, which is actually the knee angle with the highest amount of pressure on the knees. Or maybe you’re letting your knees come inward even just slightly with squats or sumo deadlifts and causing undue stress. If you are having pain with a certain lift/movement and want it assessed, or just want to dial in technique, I do offer movement assessments. Ok, gonna get nerdy and dive a bit deeper to include some research on technique for the next few paragraphs...(if you don’t care about research and just want the takeaways…skip to the next bolded line)

Research by Bloomquist et al showed that deep squats improved strength throughout the range of motion while shallow squats did improve strength a little more at shallow depth, but minimal strength increase at deeper positions. In other words, if you constantly squat above parallel, you;ll get stronger in that position, but not really improve strength for things like getting up and down from the floor, squatting down to pick up heavy items off the ground, catching nd standing a clean or snatch at full depth. Squat jump strength also improved only with full depth squats, not quarter squats according to research by Hartmann et al.

Hartmann et al also found that the compressive forces in the knee are highest at 90 degrees and have little quad tendon support, yet when you squat deeper, there is actually a protective wrapping effect around the knees! My mom can attest to that. One of my biggest recent “wins” is finally getting my mother to listen to me (seriously, it’s like pay back for not listening as a child) about squats. She does not have ACLs in either knee and then retore an MCL about 10 years ago while waterskiing. She has at least listened to me for awhile that the best thing she can do for her knees is keep up strength to create the extra support needed in lieu of those ligaments. About a month ago, I finally got her to start doing a few exercises I wrote including some goblet squats with increased weight. However, she’s been scared to squat below parallel. So she called me up and told me her knees were achy. I explained the above research and told her to just give going below parallel a shot for a few days and call me back. Guess what?! Her knee pain was GONE!

The other major lie that we’ve all heard is that your knees can’t past your toes. Absolute BS. In fact, I can personally say that the first time I really felt my quads fire during a squat was when I finally let my knees go past my toes. It’s also the first time I didn’t end of having soreness in my low back after a bunch of squats. Here’s why: Fry et al did some research looking at joint forces at the hips and knees when knee movement is restricted to avoid going past the toes or allowed to do so. They found that if it is restricted, there’s a 1000% increase in hip forces. One thousand y’all! It also caused your torso to come more forward since the hips had to stay back. This then places more pressure on your back. Between those factors, it’s no wonder my back was getting sore with back squats! Some of whether or not your knees need to come forward and the degree to which they do is definitely dependent on your specific anatomy.

Okay, now for the fun stuff. Strength. Note that this is specific for the person dealing with knee pain with squatting…

As I mentioned earlier, if you have strength surrounding the joint, it will unload it and you won’t deal with pain that comes from pressure on the internal structures (for example, osteoarthritis bone changes won’t cause pain) But…how do you build strength if you’re dealing with knee pain already?? The following exercises will be a great start!!

Even better if you mix in things to spike your heart rate like a 30” arm only bike sprint…gets your heart rate going, thereby increasing fluid circulation to the legs/knees which will drastically help “flush out” any inflammatory chemicals. Therefore, decreased swelling and pain!

There are plenty of great drills not listed here, but this is a great start:

-Knee Gapping.

Ok this one is for you if you just feel a lot of pressure in your knee when you squat and feel like it limits you. You know that feeling when your knee is even a little swollen and it won’t quite bend all the way back into full flexion? Yea, this helps with that. A ton. You can use a small ball, like a lacrosse ball, or a tightly rolled up towel like I am here. This helps glide the tibia (the lower leg bone) forward as you go into end range motion, which is what’s needed, and increase the joint space so it doesn’t get as much of that pressure feeling. Help yourself into end range flexion by grabbing your lower leg and pull it in, as shown. Make sure to get some calf motion in by moving your ankle around as the gastroc does cross up over the knee and assist in this motion. (side note: please ignore the squeeky ball in the background from the pups)

- Spanish squats.

Easily my favorite exercise to not only get a quick solid quad burn, but to unload the knee and allow better movement. I’ve used this countless times with acute knee pain, chronic arthritis, post surgical, and a whole host of other people (and myself) to be able to squat sooner and build/maintain strength. The band is placed directly behind the knees. You want to make sure there is solid tension in the band throughout the movement - as you can see in this video, the band can hold my weight. Unlike a normal squat, you keep your shins perpendicular to the ground. The kettlebell is mostly to counterbalance and help me keep my chest upright. Shoutout to Zach Long, PT, DPT (aka @thebarbellphysio) for introducing me to these several years ago while we were at a course together.

- Copenhagen Planks.

So it may not be readily obvious how these help your squat, but the truth is the inner thigh muscles play a HUGE role in full depth squats, and if their capacity isn’t adequate, it can cause knee pain, particularly on the inside of the knee. Now, this exercise is MUCH harder than it looks, so I highly recommend starting it where you have the top knee supported on the bench (or couch or whatever you’re using). If that’s still too much, you can leave the bottom leg on the ground and allow it to help support as much as needed, but as little as possible (don’t cheat yourself!)

- Bulgarian Split Squats.

Not just for lifters. This is a fantastic exercises for hikers and trail runners as it not only works on the muscles you use in your sport, but it also challenges single leg and trunk/core stability which are very important. Get into a lunge position with the back leg up on a box/bench/couch/whatever and then drop your trunk straight down while both knees bend. I’m using a kettlebell in a goblet hold here, but you can also do a barbell in the front/back/Zercher position

- Hip Thrusters

Yes, I know, this is a butt exercise. But without strong glutes, your knees will be trying to compensate for lack of stability. No bueno. Besides, lets be real, is there a downside to having a nice ass? No.

In this video, my fiancé is demonstrating with both legs, but going single leg is a great option as well! Please note, he’s also going absurdly light with the weight here. You want to go HEAVY on this exercise. You’ll probably surprise yourself with how heavy you can go…I have multiple patients over 65 that do this one well over 100, if not 200 pounds for reps. Just make sure you can actually hit full extension at the top (meaning your hips finish in line with your knees and shoulders)

No barbell? That’s fine! Use a super heavy dumbbell or kettlebell…just know you’ll be limited by getting the weight on/off your lap and will need to up the reps to have any benefit.

Ok, hopefully these exercises are helpful!

One last quick note that I’d be remiss if I didn’t mention: When discussing knee pain, you have to consider lifestyle factors. All too often, knee pain is due to any increase in the body’s inflammatory response. And I’m not just taking about the injury response. If our diet, our sleep, and/or our stress is trash, it affects our entire system. So while I don’t wanna vilify the occasional cup of ice cream (that would make me a hypocrite), I do want to point out that if you’re crushing a whole pizza, McDonalds, and M&Ms every day, then it’s not entirely surprising that you feel lie you have “bad knees”…but if you take away the inflammatory-inducing foods, get 8 hrs of sleep, and move your body regularly, I bet you would find that you actually have good knees! They were just mad at you and letting you know they were mad…