Why a diagnosIs CAN BE unhelpful

  Revised 2024.

 I was walking past the tennis court on my way to lose yet another match a few  nights ago  when I overheard a teenager tell his friend that he couldn’t play pennant because his knee cartilage had ‘worn thin’. I nearly vaulted  over the massive fence to tell him he  had been given a harmful pathoanatomical radiological diagnosis and that whoever had said that  was not using   evidence based  science and  either  had not read  or  didn’t believe the Australian peak medical/ scientific body’s recommendations on the diagnoses of musculoskeletal pain. But I didn’t. Instead, I decided to update my neglected blog.

Joint, spine and  muscle pain is  treated and diagnosed  by a range of practitioners  usually based on joint and muscle tests, patient history, stretches, radiology and prodding.  A diagnosis depends on what the patient remembers or reveals about their pain and the symptoms/tenderness on the day, which can change a week or two later.  

Unlike all other areas of medical science, diagnoses for joint and spine pain are not standardised. That means three different practitioners in the same practice could diagnose the same problem three different ways. Twenty years ago, respected American medical researcher, Richard Deyo pointed out (Deyo 1993) that  most diagnoses are fad theories rather than hard science. Nothing has changed. This situation creates confusion, despair and helplessness in patients and diagnositic uncertainty in practitioners.

Unless a fracture or dislocation has been missed, radiology findings are unhelpful. Narrowed joints, spondylosis, thinning cartilage, torn menisci,  bone ‘ impinging’ on bone, or bone impinging on tendon, osteoarthritis,  bulging discs,   worn or thin looking bones, frayed and calcified tendons, split and worn knee cartilage, narrow discs,  pinched nerves, cartilage tears,   gluteal tendon tears, injuries, spondylosis, and spondylolisthesis, osteoarthritis and impingement   ‘damage’ and ‘faults’, ‘impinged’ hip or shoulder joints have not been proven to cause pain.  Really. Certainly they can coincide with pain, but there is no evidence that they are the cause of it. 80 % of us have pain and all of us have x-rays that show wear and tear, damage and faults. This is not evidence that one caused the other.

Many diagnoses  are Greek Latin names/suffixes  that describe where the pain is felt or what structure is inflamed. A diagnosis of arthritis,  plantar fasciitis, bursitis, tendinitis, tenosynovitis,  capsulitis and discitis describes inflammation in and around joints, tendons, fascia and discs.   The question is WHY do joints/muscles/ tendons become inflamed/swollen?

Exactly the same symptoms of shoulder pain/ stiffness can be  diagnosed  as  capsulitis, a frozen shoulder, supraspinatus tendinitis, tendon impingement, rotator cuff syndrome, bursitis, scapular instability or cervical referred pain.

The same hip symptoms can be blamed on  impingement, psoas syndrome, osteoarthritis, a torn gluteal tendon, bursitis, referred (L45) pain, pelvic instability, a leg length discrepancy or  a foot/limb bio-mechanical problem.

Knees: pain in younger patients can be diagnosed as  growing pain, ilio tibial tract syndrome,  patella femoral pain, inflamed or torn ligaments or tendons, bio mechanical fault,   meniscus tear, ligament damage, tendinitis, Osgood Schlatters and/or inflamed fat pads. The same set of symptoms are more likely to be diagnosed (described) as arthritis once over 50.

Back pain can be diagnosed as a sacroiliac sprain, sciatica, a pinched nerve, a bulging disc, a facet joint problem, instability, poor alignment. Or due to uneven leg length. There is no evidence that any of these diagnoses help or guide treatment.

Try getting a standard diagnosis/explanation when both the right shoulder and right hip are equally bothersome.  That opens another can of diagnostic worms: fibromyalgia, polymyalgia, polyarthralgia, ME, central sensitization syndrome, complex regional pain syndrome, an unfortunate co-incidence or ‘arthritis’ ? Or the old, unproven chestnut : an injury 'threw things out.'

Notwithstanding  water cooler stories of miraculous cures, no one type of treatment has been proven to reduce pain whether it be for back, foot, big toe, knee, hip, tennis elbow or sciatic  pain. Long term outcomes for pain are poor. Diagnoses that focus on a faulty or damaged structure are not helping and have been shown, ultimately, to make the problem worse.  

In the 1990s,  the tendency to blame pain on damaged structures and advice to rest/have surgery contributed to an epidemic of back pain. As a result most Western countries advised doctors to:

1)Order radiology ONLY  to rule out a fracture or a medical concern such as a tumour

2) NOT diagnose pain as a pathology/damage (I.e.  to avoid diagnosing back pain as ‘osteoarthritis’ or a disc ‘bulge’ or a ‘pinched nerve’)

3) To treat pain with exercise not rest or surgery.

4) Account for a patient’s individual psychosocial issues.

The Australian work protection authorities launched a multi media advertising campaign to promote this approach which was shown to reduce work insurance claims. In other words, it helped get people back to work and avoid surgery.

SADLY: 25 years on, patients are again routinely sent for scans or x-rays. Diagnoses of  ‘injuries,’ tendon,  cartilage and muscle  micro tears, disc bulges and surgical options are back. 

Pain is complex, real and serious. It is not ‘all in the brain’. However, few health and medical practitioners(including surgeons and  specialists ) are  trained to understand it, let alone explain it or what to put on medical certificates.  Consequently, researchers have found that health professionals in Australia and England fall back on unproven pathology diagnoses even when they know it is wrong to do so(Slade, Molloy et al. 2012, French, McKenzie et al. 2013) (Simmonds, Derghazarian, & Vlaeyen, 2012). What else can they say or write on reports?

 In summary

A diagnosis is bad for patients and the science because

1) It is not based on hard evidence. Instead it is either guess  work, a fad theory or a brush off. There are no standardized, proven, replicable diagnoses, (shared by medical and health practitioners)   for common everyday joint, muscle  and spine  muscle pain.

2)Many feel helpless if pain is explained as a fault/damage in their body over which they have no control. This is a risk factor for disability

3) It does not guide an evidence based  treatment regime nor offer a useful prognosis.

4)  Researchers and  practitioners cannot share  findings  if they call the same thing different names. This  does not help pain science.

5) A diagnosis  can make patients fearful, depressed and helpless. They erode confidence in exercise  rehabilitation and the ability to self manage pain.

6) It puts people off the one treatment known to help: exercise. Why would anyone exercise or walk  if told bones were ‘grinding’ on bones?

7)  Diagnoses based on radiology  lead to surgery which has not been proven to help pain or instability any more than a carefully graduated exercise program.

8) A diagnosis is more likley to be a description of symptoms than a helpful explanation of the cause of the problem.

Questions to ask a practitioner offering a diagnosis include:

What is the science behind it?

Is the diagnosis standardised: i.e. do all doctors/health practitioners explain these symptoms exactly the same way?

How exactly does this explanation help me recover?

It might be awkard to ask this: but why they are ignoring medical guidelines?

REFERENCES  

NHMRC (2003). "Evidence based management of acute musculoskeletal pain."

Koes, B.W., et al., An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. European Spine Journal: Official Publication Of The European Spine Society, The European Spinal Deformity Society, And The European Section Of The Cervical Spine Research Society, 2010. 19(12): p. 2075-2094.

ABC RN Thinking about knee surgery? Exercise might be a better bet. 
http://ab.co/2airKwj

Wagemakers, Luijsterburg et al. 2010, El Barzouhi, Vleggeert-Lankamp et al. 2013, Heales, Broadhurst et al. 2014, Skou, Thomsen et al. 2014, Larson, Moreau-Gaudry et al. 2014. 

Anne Brennan Williamstown South Physiotherapy