In Part 1 of our series, we discussed the common scans performed in a musculoskeletal setting and what you might/might not see in the results.

All of these scans are used to scan anomalies in structures – breaks, tears, increased water as a result of inflammation, decreased joint space between bones etc. Similar to blood tests, they don’t always paint a complete picture on their own, they are a snapshot in time, or “diagnostic tools” to help form a diagnosis.

For example, an ultrasound can detect an inflamed bursa –known as bursitis, it does not tell you why there is a bursitis. Did you get hit? Did you sprain your joint nearby? Did you overload the surrounding structures? A decreased joint space between bones can mean different things as well. Is it osteoarthritis (joint wearing, causing reduced joint space)? Are you carrying more weight, hence compressing a weight bearing joint more? Some also suggest muscular tension across the joint would compress the joint as well, giving a decreased joint space scan.

Generally (not always), pain is felt when a structure is loaded beyond its capacity (e.g. an overloaded weak tendon, a strained ligament in stretch), but if we can shift that load to other structures, that pain may be reduced, even if the structural integrity is only 50% - for example the hips are doing more propulsion instead of the Achilles tendon. This means, if a scan detects a structural defect (e.g. tear), it may not be painful, and it may not be the cause of the pain. The structural defect is there, but it may be clinically irrelevant and it may not be related to your complaint/injury. Vice versa, the scan may show nothing wrong, but the structure that appears to be 100% intact on a scan may be overloaded and cause pain. This is the reason why scans are diagnostic tools – they aid the diagnosis, they are NOT the diagnosis. This is also likely the reason why some people may have pain but have perfectly normal scans, while others may have no pain but have terribly damaged structures as shown on images.

Hence, scans are useful diagnostic tools. Diagnostic tools imply that they are tools to aid the diagnosis, they are NOT the diagnosis on their own. So, the next time you get a scan done. Take your time to discuss it with a clinician – it may not be as bad as it looks, literally.

Addressing these causes are where clinicians come in with their various techniques; medical, surgical, therapy, exercise, nutrition. A change in diet may decrease weight and hence puts less compression onto the joints. Stretches may reduce muscular tension over the joint and reduce compression. Strengthening/activation of other surrounding structures/muscles would reduce the overloading of a tendon by shifting that load to other structures. Improving balance and core control would put less stress on the ligaments on your ankle to keep balance on their own. These are things that the scans cannot and will not detect: non-structural issues.

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A poor muscular length/tension/strength/control around the hip would affect balance – potentially causing or aggravating ankle sprains; it would affect the position the knee is in below the hip when it stands/walks/runs, potentially causing irritation and inflammation of the joint; it would be unable to produce efficient propulsion/loading as your run or jump, potentially putting more load onto your Achilles tendon and irritating it. All these aggravation/irritation/overload can happen over a longer period of time causing small damages and recurrent healing and inflammation processes giving you all the -itis problems (bursitis, tendinitis), or they can happen acutely over a very short time giving you more of a structural defect (e.g. tears and ruptures of ligaments, tendons, muscles). However, until a structural defect happens, compensations, asymmetry, overloading can still happen and cause pain – and this is not detected by scans.

A physical structure gets damaged the same way regardless if its biological or not. Every structure/material will deform elastically when it receives stress until its yield point. Elastic deformation means the structure/material will return to its original length/shape/configuration once the stress is removed – no damage is done, no healing required of biological structures. If the structure/material receives stress beyond its yield point it will start to deform elastically. Plastic deformation means the structure/material will NOT return to its original length/shape/configuration even after the stress is removed – damage is done, and luckily for some biological structures, they can heal – usually accompanied by inflammation and pain.

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The way it can heal/recover is simple: reduce the load onto the damaged structure, let it heal. There are 2 ways to do this: reduce the overall load, or shift/distribute the load onto other structures. Reducing the overall load by resting, using lighter weights, doing less volume/distance will allow healing. Shifting/distributing load onto other structures such as hips for propulsion in gait, core for balance will also reduce the load onto an injured structure and allow healing. For example, an injured Achilles tendon may be less irritated if the propulsion in gait is done more by the hips. A sprained ankle ligament may need to do less balancing if the hips and core can maintain balance on their own.

What happens after the healing is done? Let’s assume for argument’s sake that the structure managed to heal to its previous 100% capacity prior to the injury – you’re fully healed. However, if your return to the same activities/sports with the same intensity, load and technique as before, what would happen? At 100%,before you got injured, you were doing the same activities/sports with the same intensity, load and technique – and you got injured. So even if you get back to 100%, the same thing is likely to happen again.

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This is where prehab-rehab enters, it brings you “above” the 100% -depending on what you need it may be strength, mobility, control of surrounding structures, not just the injured structure. This would allow the load that was initially taken on by the injured structure to be distributed to other structures (e.g. muscles, larger joints) that now has improved strength/mobility/control. It may also include improved technique in the movement (e.g. technique of lifting This would reduce the load on the injured structure and reduce the likelihood of re-injury or pain.

As you may have noticed, if it is simply about rehab-prehab of other structures, this can be applied even when the structures don’t heal 100%, say at 70%. That would be correct. The principles stay the same and it involves improving strength, mobility, control of movement in the relevant structures(not just the injured structure). This may mean: For an Achilles tendon injury, improve running/propulsion technique, improved hip extension mobility and strength for propulsion. For recurrent ankle sprains, improved core stability, improved hip stability which contributes to improved balance. In both of these cases, the principles apply regardless if the structural integrity is at 10% or90%.

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At the end of the day, we need to stop labeling our clients by their diagnosis. They are first and foremost people and we need to treat each individual on a case by case basis, taking into account other factors, be it lifestyle, stress, nutrition and consider them accordingly.

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