Structure is not Destiny - please don't rush to freaking out about your x-ray, MRI or ultrasound

Audience: Patients Purpose: To highlight the poor link between the bogeymen found on imaging with pain or dysfunction.

Our current technology is amazing when it comes to viewing the insides of our body.  The problem with this fantastic technology is that we can see something (e.g. a tear in a muscle or a joint with some osteoarthritis) and assume that there is something wrong or that this is the source of our pain.  However, the link between tissue "abnormalities" on MRI, x-ray or Ultrasound is often quite poor.  Many, if not most, people have "bad stuff" on their MRIs or x-rays yet have no pain.

A quick anecdote...I was with a patient that had horrible left shoulder pain. Poor movement and worse strength.  His doctor ordered an MRI and my patient reported to me that sure enough the shoulder was a mess.  Torn rotator cuff, bursal thickening, arthritis in many joints, some fluid collecting - an absolute disaster.  BUT, there was a problem.  He wanted to know if the MRI picture could have been "flipped" or "mirrored" because these results were for his Right, painfree shoulder.  The results weren't flipped or mirrored, we got the results for the left later.  They were just as "bad".  Point being, structure is not destiny.  Damage or scary stuff on any imaging report does not equal pain.  This patient ended up pain free in a couple months.  His MRI report would not have changed despite the changes in his strength, mobility and pain.

This is not new

I am not breaking any news here.  We have known this for at least 15 years.  Joint degeneration, disc bulges (even herniations), rotator cuff tears, calcifications in ligaments or joints are all normal variations that can exist without pain.  At certain ages this changes, assumed to be abnormal, are actually normal and more common than a lack of these changes.

Below is a sampling of research highlighting the limitations of structural anomalies and pain.  I was going to provide some insight but instead I will use this post as a catalogue of the research that looks at the relationship between tissue damage/abnormalities and pain.

 

Bottom Line:  Pain is poorly correlated with damage.

One caveat: I hesitate to say this but sometimes these structural changes can be related to pain... it is just not a guarantee or some harbinger of pain doom. What I want to emphasize is that it is just not as cut and dry as many make it seem.  There are many factors that lead to pain but we tend to blame the simplest one (e.g. joint damage) when we actually know better but persist in this fallacy.

Some other links on this topic:

Diane Jacobs: http://humanantigravitysuit.blogspot.ca/2012/04/pain-and-tissue-damage-are-from.html

Bboy Science (Tony Ingram): http://www.bboyscience.com/damage-does-not-cause-pain/

Spine Imaging Abnormalities are really just normalities

Maurer M, Soder RB, Baldisserotto M Spine abnormalities depicted by magnetic resonance imaging in adolescent rowers.Am J Sports Med. 2011 Feb;39(2):392-7. Epub 2010 Oct 2.

Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS N Engl J Med.Magnetic resonance imaging of the lumbar spine in people without back pain. 1994 Jul 14;331(2):69-73. (abstract  here)

Weinreb JC, Wolbarsht LB, Cohen JM, Brown CE, Maravilla KR. Prevalence of lumbosacral intervertebral disk abnormalities on MR images in pregnant and asymptomatic nonpregnant women. Radiology. 1989 Jan;170(1 Pt 1):125-8.  Link here

Takada E, Takahashi M, Shimada K.Natural history of lumbar disc hernia with radicular leg pain: Spontaneous MRI changes of the herniated mass and correlation with clinical outcome.J Orthop Surg (Hong Kong). 2001 Jun;9(1):1-7. Abstract here.

Stadnik TW, Lee RR, Coen HL, Neirynck EC, Buisseret TS, Osteaux MJ.Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology. 1998 Jan;206(1):49-55.

Matsumoto MFujimuraY, Suzuki N, Nishi Y, Nakamura M, Yabe Y, Shiga H.MRI of cervical intervertebral discs in asymptomatic subjects.J Bone Joint Surg Br. 1998 Jan;80(1):19-24. Abstract here.

Shoulder abnormalities not related to pain

Connor PM, Banks DM, Tyson AB, Coumas JS, D'Alessandro DF. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study.Am J Sports Med. 2003 Sep-Oct;31(5):724-7. Abstract here.

Miniaci A, Mascia AT, Salonen DC, Becker EJ Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. .Am J Sports Med. 2002 Jan-Feb;30(1):66-73. Abstract here

Jost B, Zumstein M, Pfirrmann CW, Zanetti M, Gerber C.MRI findings in throwing shoulders: abnormalities in professional handball players.Clin Orthop Relat Res. 2005 May;(434):130-7. Abstract here

 KNEES

Shellock FG, Hiller WD, Ainge GR, Brown DW, Dierenfield L.Knees of Ironman triathletes: magnetic resonance imaging assessment of older (>35 years old) competitors. J Magn Reson Imaging. 2003 Jan;17(1):122-30. Abstract here

Beattie KA, Boulos P, Pui M, O'Neill J, Inglis D, Webber CE, Adachi JD. Abnormalities identified in the knees of asymptomatic volunteers using peripheral magnetic resonance imaging.Osteoarthritis Cartilage. 2005 Mar;13(3):181-6. Abstract here

Shellock FG, Deutsch AL, Mink JH, Kerr R Do asymptomatic marathon runners have an increased prevalence of meniscal abnormalities? An MR study of the knee in 23 volunteers.

Zanetti M, Pfirrmann CW, Schmid MR, Romero J, Seifert B, Hodler J.  Clinical course of knees with asymptomatic meniscal abnormalities: findings at 2-year follow-up after MR imaging-based diagnosis. Radiology. 2005 Dec;237(3):993-7. Epub 2005 Oct 26.

 

 

More to come.

The mechanical case against foam rolling your IT Band. It can not lengthen and it is NOT tight.

Audience: Patients and therapists Purpose: A brief argument on why attempting to lengthen your IT Band with stretching or foam rolling is a waste of time and not possible.

A note on terminology: This article talks about using a foam roller to "lengthen" the IT Band.  Occasionally, this gets referred to as stretching the ITB.  What is argued is that foam rolling can not "lengthen" or "stretch" this structure more than transiently.  Yes, it will deform a little bit like all viscoelastic biological structures (they all have stress-strain curves with varying degrees of stiffness) but it won't get "longer".

Warning: I recently changed the title on this post (formerly Stop foam rolling your IT Band. It can not lengthen and it is NOT tight.) because a few colleagues have suggested that it is a bit strong.  I agree and also think that such hyperbole will decrease a healthy discussion in the area.  I don't want that.

However, I have not changed the rest of the content and again recognize that some of it is a bit salty.  Much of it is how I talk to myself and entertain myself.  When reading this please just consider the arguments and not HOW they written.  I never expected 40,000 people to read this thing.

Please note, I have always been open to the idea that foam rolling might have an influence on our nervous system and ultimately pain.  My doubts have been around what many people say foam rolling does which I always found biological not possible.  This post explores those ideas.

Original Post -

I am in the minority when I cringe at the rampant unjustified use of the ubiquitous, seemingly harmless but actually evil foam roller for IT Bands.  I've seen their use climb in the past 5 years and I am sure that my success rate at convincing my patients to not roll the crap out of their IT Bands is less than 10%.  Those rollers are WINNING.  Perhaps this post will sway the voters.

Background Reading

My belief has been bolstered by two old anatomy papers by the Fairclough group that showed and proposed that IT Band dysfunction is not a Friction syndrome as the IT band does not "slide around" at the knee.  This perception of sliding is an illusion.  This group also performed a detailed anatomical analysis of the structure.  The papers are here and here.  A more recent study has also lent support to these papers with a biomechanical study looking at the strain placed on the ITB - click here. One of the authors of that paper is Andy Franklin-Miller, whose sports medicine blog you can see here.

 

Some quick points about the IT Band

- the IT Band is not really a strap that runs from the hip to the knee.  It is not a discrete entity.  Rather it is just the thickest part of the fascia lata.  The fascia lata being the sock that wraps around the entire thigh.  The IT Band is just the lateral thickening of this sock

- the IT Band is some dense connective tissue and probably can't be permanently deformed.  While it may be stretched in the short term this is due to its viscoelastic properties (i.e. adding a bit of grease or shaking out the cobwebs) rather than any means where it is actually permanently lengthened.  Actual lengthening would require you to damage your IT Band to get it into a lengthened state.  5 minutes on a foam roller or 10 minutes of daily stretching would not be able to do it.

- you might be able to stretch the muscles that attach to the IT Band.  However, muscle stretching is also very difficult.  The changes in muscle stiffness we see with stretching and warm up are again due to the viscoelastic properties of tissue.  Muscles don't become looser they just have increased tolerance to stretch. Update Nov 2015: some research has even challenged this idea! This is most likely an adaptation of the nervous system rather than any change in muscle tissue properties. See my post here on muscle stretching.

- the IT Band can't be lengthened because it is tethered to the entire length of the femur.  Got that?  It is tied to the leg bone.  It ain't going no where.

- it is supposed to be tight.  Therapist will tell you it is tight because they were told to look for it to be tight.  They don't have a proper method to determine this.  The test that  looks at ITB tightness (OBER's test) is really just an assessment of hip adduction range.  So many other factors influence this range that to blame it on the IT Band is just bullying (IT Bullying!).

-what if you could lengthen it? Then what? Could you over do it and have some jigglying IT Band that just wobbles when you run? No! This does not happen.  It does not stretch.

- the ITB may be similar to tendons.  Meaning it stores and releases elastic energy.  We definitely don't want to length it or change its properties.  There is little evidence that tendon stiffness can be changed through stretching so perhaps the ITB is similar.

 

Some thoughts and questions on Foam Rolling the IT Band

- I know this is popular.  I know people swear by it. But that does not make it right.  I don't doubt that after beating the crap out of your IT Band you feel something different in that IT Band.  That is your nervous system adapting to some huge painful stress you just placed on it.  It does not mean that your ITB got longer or you dug out some adhesions.

- How can a foam roller stretch an IT Band?  A roller compresses the band it does not tension it. Without tension there is no stretch. Don't tell me it bowstrings it.  This is negligible.

- How can a roller dig out adhesions?  This is a massive question because you can even question the existence of adhesions.  But assuming that adhesions exist between the sliding to two different layers of tissue how would a roller that just compresses tissue create some form of interlayer gliding.  If you think you are causing the IT Band to slide better in its interface with the biceps femoris than you are completely wrong because the IT Band does abut or interface with that hamstring.  If you think that the roller is freeing up the sliding between the IT Band and the Vastus Lateralis how would compression do this?  I can't fillet a chicken breast with a rolling pin.  I need some instrument to put between the two halves I want to separate.  Same with the theory between interlayer sliding.

 

- The foam roller improves tissue health.  Maybe.  You are certainly stressing the shit out of the IT Band, neural structures, skin, bone and everything.  You are probably even creating an inflammatory response.  This might have some merit.  But I would bet you could get a similar stress with some other movement or exercise that would have other performance or therapeutic benefit.  Why not take the thumper and thump away on your leg (I actually do this for kicks)

 

-Last, no real research on any of the beliefs about foam rolling.  I recognize that a lack of research is not proof but you would think something would come along by now. Update (November 2015: there is some research on foam rolling.  Feel free to wade through the mess of it. I would only ask "is foam rolling the best use of your time?")

-Super last, I am open to being convinced that it is worthwhile.  Perhaps, rolling your IT Band has some other benefit.

-when discussing foam rolling we also need to discuss fascia.  I have a related post here.

 

Updated Last, I was given some links to some posts by Paul Ingraham. I haven't read these yet but have read Paul's other work so wanted to post these here.

http://saveyourself.ca/tutorials/iliotibial-band-syndrome-stretch.php http://saveyourself.ca/tutorials/iliotibial-band-syndrome-tendinitis.php http://saveyourself.ca/blog/0039.php

 

Caveat of Ignorance

For those that really disagree with me and really love foam rolling try to get past my obviously hyperbolic title.  I agree it is a little strongly worded.  Again, I write from a place of ignorance (as should everyone on this topic) so I am open to any information

 

UPDATE: Below are a few links that further discuss foam rolling

1. Mike Boyle disagrees with even my hesitant conclusion and does provides a rationale for foam rolling.  Basically, he believes that foam rolling prepares and individual to participate in activity as foam rolling a stress placed upon a tissue and we should expect tissues to respond positively to stress. I have mentioned that this might be something going for foam rolling I just am unsure how this would really work in practice.  He provides  No specific mechanism  just the advice that it works so we should do it.  Interestingly, he refers to me as a "muscular therapist".  I am flattered, I always thought I was quite skinny.

http://strengthcoachblog.com/2012/04/12/is-foam-rolling-bad-for-you/

2. Mike Nelson provides an argument against foam rolling:

http://miketnelson.blogspot.ca/2008/01/get-off-foam-roller.html

3. Carl Valle provides a very interesting piece that addresses what Mike Boyle said about foam rolling. I found this blog really very informative.  I've read Carl's stuff before and consistently find it interesting.

http://www.elitetrack.com/blogs/details/6897/

4.  An interesting case study looking at foam rolling and tensiomyography by Jose Fernandez.  I would be interested in learning more about the measurement properties of this technique.

http://ideasforbasketball.com/2012/04/18/myofascial-release-foam-rolling-contractile-muscle-properties/

5. An abstract that looks at the use of foam rolling as a warm up tool.  I have not read the full masters so can't fully comment.  They suggest that foam rolling decreases jump performance in the short term.

http://digitalcommons.sacredheart.edu/masterstheses/2/

6. Here is a post by Dean Somerset providing a different rationale for why individuals might benefit from foam rolling.  This stuff is a good start.

 

Thanks,

 

Greg

 

 

Patellofemoral Pain Syndrome - 2 day exercise program

Audience: Patients Contents: Attached is a pdf of a two day (6 day a week) basic exercise program for someone with patellofemoral pain syndrome.

For therapists, this would obviously be modified for the specific needs of your patients/clients.

 

Program One here: pfps bodymechanic sheet

Program Two Here - hip and knee dysfunction two day program for le dysfunction

Have fun,

Greg Lehman

Your Toronto Physiotherapist

Patellofemoral pain syndrome exercise sheet

Attached is a basic exercise protocol as part of a large physiotherapy regime I might use for someone with some lower extremity dysfunction.  Many of these exercises would be used for non specific knee pain (PFPS, ITB syndrome).  The nordic hamstring exercise could be skipped but should certainly be used for anyone with posterior chain weakness/dysfunction.  I use that ol' nebulous word 'dysfunction' when something is wrong (e.g. pain) but I'm not willing to commit to some BS therapist jargon about the cause of the problem.  You could put in the same room 5 great therapists (physiotherapists, chiropractors, massage therapists, sport med docs) who could all get someone better but they would each explain the problem completely different and often contradict each other.  So, I use the general word dysfunction. Attached is a two page pdf for primarily knee problems that might have a proximal component.

Does everyone love my beautiful fitness model.  I spend way too much time with her.

Click below for a pdf version of the exercise sheet.

hip and knee dysfunction two day program for le dysfunction

Adios,

Greg Lehman, Physiotherapist & Chiropractor

Neuromuscular knee control exercise series

Audience:  Patients Format:  Patient Handouts

Topic:  Trunk, hip and knee motor control exercises to improve control of knee position

This post is  a handout that I give to patients.  As with all exercises they should be done under some supervision (physiotherapist, personal trainer, chiropractor) and always with a health professionals guidance.  In no way are these exercises stand alone.  They should be tailored to each patient's needs and progressed or modified accordingly.

Gregthebodymechanic poser neuromuscular retraining for hip stability