No pain, no gain! When everything is not as it seems.

A couple of interesting journal articles caught my eye this last week. Both are very relevant to my practice and highlight why things are not always as they seem. Both articles were published in the British Journal Of Sports Medicine. The first article included in it’s title “When Abnormal is normal” and the second “Pain or Injury? Why differentiation Matters”. As with many things in medicine, the devil is often in the details, and context always matters; diagnoses, examination findings and treatment options are not always black and white. I often have discussions with my patients about these nuances.

In the first paper, the authors highlight the high prevalence of imaging abnormalities on MRI scans. MRI technology has improved immensely over the course of my career, and is frequently utilized by sport medicine and other doctors to help in the diagnosis and staging of a whole variety of conditions, but it’s important to realize that our scans have become so detailed, that we often pick up structural ‘abnormalities’ that are really just a part of normal aging. An abnormal finding on an MRI is not always a problem. We often call these findings ‘incidentalomas’

I was part of a study a few years ago that involved detailed MRI scanning of the hearts of active people. The target population involved professional athletes - not me - and active fit individuals - I guess I fit the bill here! I lay in the MRI machine for 40 minutes as a very detailed scan of my heart was taken.I talked to the radiologist after my scan, where I learnt that by definition, almost everyone they had scanned that day was ‘abnormal’ by current definitions! We all had small visible scars in our cardiac muscle and conducting tissues - and yet as far as we all knew, we didn’t have any heart health issues. In fact we were all very fit! It turns out that these small scars are in fact quite normal findings in active people, and negative, or ‘normal’ scans tend to occur in a much less active, more sedentary population; these are the very folks who tend to have more heart health problems!

Similar MRI findings were discussed in the recent BJSM paper. We know that cartilage lesions in the knee, hip and shoulder labral abnormalities and disc abnormalities in the spine of healthy, asymptomatic 40 year olds are incredibly common. If you’re over 40 and have a lumbar spinal (low back) MRI, 80% of you will have disc degeneration, whether or not your back is sore. In British premier league soccer professionals, abnormal hamstring findings were just as likely to occur in those who had a strain and those who didn’t. Similarly if your knee is scanned, over half of all individuals will have cartilage abnormalities, yet no symptoms. It’s almost like getting wrinkles and grey hairs, of which I have many! Patient’s tend to worry about these ‘abnormal’ imaging findings, and this leads to avoidance of activities, increased doctor’s office visits, the unnecessary use of medications and in some cases even surgery, for supposed problems. These scans can certainly have value, but your physician needs to put your complaints and the imaging findings into context, to determine what is in fact relevant to your complaints.

The second paper that caught my attention, from the same journal, was of a similar ilk, in that all is not always at it seems. It was in reference to pain. I think it’s important to state from the outset that pain is a complex condition. I am by no means a pain expert but I see a lot of people in clinic who are suffering with painful knees,hips, ankles and shoulders!

Pain has been defined as an unpleasant sensory or emotional experience that is associated with actual or potential tissue damage. That last bit is important, and I have a lot of discussions with my patients about their pain experience. Sometimes pain is associated with actual tissue damage. If you break a bone, tear a muscle, strain a ligament or tendon it will invariably be a painful event, but not all pain equates to tissue damage; in many of the conditions I see, some degree of pain is in fact quite normal, and it’s important not to become fearful of all pain. When rehabilitating a painful achilles tendinitis, for example, the exercises we might prescribe, heel drops off the edge of a stair, will often be uncomfortable to perform. This pain is not to be feared, and does not mean that further damage is being done in the achilles; in fact, Dr Hakan Alfredson, who developed and popularized these exercises felt that if there was no pain, weight should be added to make them painful, as they are more effective that way!

In a similar manner, if you wake up with a headache one morning, which can occur for a variety of non-serious reasons, do you think that a brain scan would show a structural abnormality? Most likely not, and yet the pain is real. The authors of the paper made an attempt to define and describe the different features of pain that may or may not indicate injury. They described the differences between ‘Sports related Injury’ and ‘Sports Related Pain’, the latter being pain that occurs independently of a specific tissue injury. Importantly, patient expectations and beliefs, have a big impact on this latter type of pain. Your mood and sense of control are just as important as the actual cause of the pain.

I won’t go into all the nitty gritty details here, suffice to say that all pain is not bad, just as all MRI findings are not serious. Your physician or treating therapist should be able to give you some parameters that will help you determine if you are on the right track in your recovery from injury, or if you are experiencing pain. So remember to ask when you are in! How much pain is acceptable? How do I know if I’m causing damage? Is this a good pain or a bad pain? Is that tear on the scan a problem? No pain, no gain, may in fact not be the best mantra to live by, or it may! As I said at the beginning, context matters, and everyone is different.