The Problem is a Verb

When it comes to muscle and joint aches and pain, patients and health care providers find it challenging to conceive of the problem as anything but a noun.

Herniated disc.
Tennis elbow (or lateral epicondylitis).
Torn meniscus.
Shoulder bursitis.

These are the type of labels we're familiar with. Everyone likes the idea of trying to deal with nouns. But it turns out that the noun is often inaccurate (1,2). At least initially, it's really not that important (3,4). Muscle and joint pain almost always has to do with dysfunctional movement. In other words, the problem is a verb.

Almost all-seeing, but not all-knowing.

Why, exactly, does your shoulder ache after volleyball practice? Is your Achilles tendon on fire because of poor foot structure or hip inflexibility? Will the headache and radiating pain down your arm require surgery or is it likely to respond to more conservative care?

It's more important to answer those kinds of questions than it is to identify exactly what hurts. And you'll need some verbs to find good answers.

Although X-rays and MRIs will give you an inside peek into potential causes of pain associated with injury or "wear and tear," the exact tissue at fault is often uncertain(5). Pictures of anatomical nouns in a rested state show how things look but not how they function. Form and function are obviously linked, but research has proven that looks are deceiving (6, 7, 8, 15).

You better take into account how they function.

The problem with noun diagnosis is that people who are in pain and those who have absolutely no pain often have disastrous looking structure. For example, the top dogs of orthopedic medicine and rehabilitating have knowingly skirted that mystery for decades by using the term"nonspecific low back pain," and have since given that diagnostic label to over 90% of patients with back pain (9,10).

I swear I'm not making this up.

It turns out that identifying the cause of pain is also tricky business elsewhere in the body. Is your partially torn rotator cuff tendon the reason why it hurts to buckle your seat belt? Maybe not. Many people without shoulder issues have partial and full thickness tears(11). I've treated people with full tears who are able to reach and lift overhead just fine after improving the mobility of their scapula and thoracic spine.

Experts agree that joint degeneration is a normal part of aging. Meniscal tears and osteoarthritis in the knee are almost universal (12), yet not everyone needs a knee replacement. Your MRI shows degenerative disc disease and herniations? Well, so do fifty percent of the MRIs of people in their early twenties (13)!

How much degeneration the body can accommodate varies from person to person. But something other than just a structural problem is responsible for causing misery for some people but not others.

The difference is in how they move.

So where are we left in our attempts to describe movement related problems with movement-related terminology? What do patients get when clinicians simply try to be honest about the limits of anatomical (noun) diagnoses?

Lumbar flexion dysfunction.
Scapula upward rotation dyskenesis.
Knee coordination impairment.

We get unsatisfactory professor words. Ugh. In order to be more technically correct, we've become more vague and silly. I've noun-diagnosed this phenomenon in healthcare providers as Well Duh Syndrome.

Imagine the scenarios at the office.

"Doctor it hurts when I bend forward, like, flexing my spine."
"Yeah, it seems to me that you have a pronounced case of lumbar flexion dysfunction."

"Doctor my knee hurts pretty bad. It often just gives out."
"Well I've determined that you have knee coordination impairment."

Before you laugh, remember that you've accepted terms like Restless Legs Syndrome and Halitosis as serious medical terminology. Besides, it's not so much a label, but a response to movement that we're after. That's hard to pin down in just a few words.

These poor (Ravens) fans have been
diagnosed with NFL Cheering Impairment.

The bottom line is that you should never be too intimidated when you hear arthritic this or torn that. Diagnostic imaging is one piece of the puzzle and it really is okay if your doctor didn't order expensive tests right off the bat.

The best thing you can do, at least initially, is to worry less about exactly what's causing the pain. I know that's asking a lot. Instead, seek to find out what, if any, movements and positions cause a change in pain and function.

A case for diagnostic imaging.


Nobody can "fix" arthritis. And I won't try to tell you that MRI and CT Scans are useless and that nobody should ever have surgery. But with the right intervention, changing the details of how your body does it's verbs quite often translates into less pain and more verbs.

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1. Borenstein DG, O'Mara JW, Boden SD, Lauerman WC, Jacobson A, Platenberg C, Schellinger D, Wiesel SW. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven-year follow-up study. J Bone Joint Surg Am. 2001 Sep;83(9):1306-11.

2. Saal JS. General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques. Spine. 2002 15;27(22):2538-45.

3. Cook C, Hegedus E, Ramey K. Physical therapy exercise intervention based on classification using the patent response method: a systematic review of the literature. JMPT 2005;13:152-62.

4. Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. Spine. 1997; 22:1115-1122.

5. Chou R, Rongwei F, Carrino J, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet. 2009;373 (9662): 463-472.

6. Michael J. DeFranco, MD, and Bernard R. Bach, Jr, MD. A Comprehensive Review of Partial Anterior Cruciate Ligament Tears. In The Journal of Bone and Joint Surgery. January 2009. Vol. 91A. No. 1. Pp. 198-208.

7. Videman T, Battie MC, Gibbons LE, Maravilla K, Kaprio J. Association between back pain history and lumbar MRI findings. Spine 2003;28(6):582-8.

8. Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine 2003;3(6):460-5.

9. Koes B. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001;26:2504-2514.

10. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006;4(2):S192-300.

11. Sher JS, Uribe JW, Posarda A. Abnormal findings on magnetic resonance images of asymptomatic shoulders. Journal of Bone and Joint Surgery 1995;77(A): 10-15.

12. Englund M, Guermazi A, Gale D. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359:1108-1115.

13. Takatalo J, Karppinnen J, Niinimaki J et al. Prevalence of disc degeneration and displacement, annular tears, and modic changes in lumbar MRI scans in young adults. Spine. 2009;34(16):1716-21.

14. Hoangmai H. Pham, Bruce E. Landon, James D. Reschovsky, Beny Wu, & Deborah Schrag. Rapidity and Modality of Imaging for Acute Low Back Pain in Elderly Patients. Archives of Internal Medicine 2009, 169 (10), 972-981

15. Connor PM, Banks DM, Tyson AB, Coumas JS and D’Alessandro DF (2003): Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes. A five-year follow-up study. American Journal of Sports Medicine 31, 5, 724-727.