The Business of Symmetry

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The idea of symmetry is prevalent in the sciences and is woven into the very laws that govern our universe. Symmetry promotes mobility in living organisms. It makes snowflakes and mathematical equations beautiful.

Do you think about symmetry?

I've obsessed over symmetry for a long time. In gradeschool I taught myself to write and shoot basketball about equally well (or poor) with either hand. Every photo between the ages of about 12 and 20 has my hair parted smack down the center. I still catch myself unconsciously making trivial stabs at symmetry, like putting each contact lens in with the opposite hand. I can hardly clean up toys and sticks in the yard without keeping a running tally of which leg is forward when reaching down.

No baby, baby: Salt N Peppa haircuts irked me...

before their music even had the chance.



So it's little wonder that I grew up to work in physical rehabilitation and sports performance. Much of my time deals in the business of symmetry; identifying and minimizing musculoskeletal asymmetry.

Injuries, habitual postures, repetitive activities, and dominant movement patterns disturb the natural balance of the body, leading to inefficiency, tissue overload, and pain. Beyond human movement, scientists have found associations between structural symmetry and various measures of mental health, attractiveness, social skills, and cognitive ability in old age. But no, I never claimed to treat ugly, mostly because I believe that ugly is a state of mind.

On the other hand, all brains that ponder symmetry have two halves; with hands and brain halves each being quite asymmetrical. While I'd like to be able to make a neat fold between the the two "m"s, even the form of the word "symmetry" hints of an ideal. It's hard to deny the different structures in each half of the body suited to take on different demands.

So maybe we shouldn't get too caught up in symmetry. And I mean that with all my left sided heart, which itself is larger on the left.

Asymmetry often rules the details. Some is explained by this thing we call "dominance." For a number of reasons, the body settles into a preferred or dominant patterns that favors one arm, leg, ear, eye, etc.

Caffeine: beautiful asymmetry

The dominant patterns are often task specific and they may be consistent or mixed. That is, an individual could be right handed with scissors but a lefty stirrer. They could be left footed and right eyed. In terms of muscle size and performance, like jumping, up to 15% difference between the right and left sides is considered normal.

Much of the asymmetry that I deal with in the clinic is simply the result of the body gradually adapting to the demands placed upon it. Sometimes this proves to be unproblematic while in other areas the asymmetry is a warning sign. For example, asymmertry in shoulder flexibility is a fairly good predictor of pitching injuries while an uneven resting posture of the scapula is not. Asymmetry of hip movement has proven to be relevant in the diagnosis and treatment of knee and low back problems, while anywhere from 2 to 6 millimeters is an acceptable difference in leg length.

There’s some evidence that folks can usually fill their left lung easier than their right. The right diaphragm uses the liver for “leverage.” This results in some of the right ribs having a subtle rotation, which in turn affects thoracic and scapula position.

Scientists have found that healthy runners show about the same amount of asymmetry as injured runners. The fact that injured runners have increased joint loading forces as compared to healthy runners suggests that high impact loading is the primary problem, with asymmetry simply influencing the side on which injury first appears.

Some asymmetry is due to trauma and developmental issues. My right pointer- and pinky fingers have been fractured and now turn inward, giving that hand a semblance of the tower of Orthanc. But they don't hurt, at least not yet. Just don't ask me to point out the guilty party in a line of suspected criminals.

Webcam: Wherever I go, I carry

Orthanc with me.

And so it seems that body symmetry is often an ideal with no hard and fast rules. Yet there's something about symmetry.

Despite dominance, structural adaptations, and subtle deviations, it does appear that we're balanced through the integration of whole system imbalances. Yes, symmetrical asymmetry! Plus, a truly amazing ability to adapt.

The torso, for example, is balanced with a liver on the right and a heart on the left. Extremity dominance is balanced through reciprocal function; the left arm moves with right leg and vice versa. Fine coordination on one side of the body often appears with more absolute strength on the other. Dad taught me to throw righty and bat lefty, and now that's just what I do.

Identifying structural or movement asymmetry is a relatively straightforward process. Trained therapists recognize these imbalances and typical patterns. The challenge is determining whether or not an asymmetry is modifiable and worth modifying.

I've found that moving toward symmetry helps. It helps a ton. I witness this reality on a daily basis. I'm often surprised when a patient with right hip bursitis has never noticed how "flat" their left foot is; or fails to relate their right side neck pain to leaning on the left elbow when driving.

It makes sense that if exposure to repeated loading in the same direction does indeed cause microtrauma, movement dysfunction, and eventual pain, why would you not at least try to redistribute the strain? Why shouldn't athletes bring their weakest link up to snuff for both injury prevention and peak performance?

Uneven structure can often be accommodated or improved with specific corrective exercises, if not "fixed" to be perfectly even. Even partial reversal of habitual postures and ingrained movement strategies is often enough to allow healing of weakened or overworked tissues.

Reversing mechanical forces. Modifying movement patterns. Lengthening restricted joints and strengthening/stabilizing weak tissues. Do you understand why lasting relief for your painful spine or unstable knee is rarely a matter of simply cracking that baby back "in?"

In conclusion, instead of aiming for symmetrical movement, we should technically be aiming for more symmetrical movement. And a PT guy is fulfilled when he attempts to unite truth with beauty, and in doing so, helping someone along their way.


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Mental Reps - Patriot News

If you're interested, here's a link to the Patriot News (slightly edited) versions of some of the work that I've done here.

http://topics.pennlive.com/tag/bob%20gorinski/posts.html

There will be one column per month for the next 6 or so months. Then we take it from there, I guess.

I've submitted You Should Probably Wear Shoes as my next entry for August.

I enjoy my time here thinking and typing. If anyone has

suggestions or pressing fitness/rehab comments or questions, certainly let me know.

bg

Baseball Advice

[Some seriously good stuff by Kyle Wagner. Plenty more at gowagsbaseball.com]


Post Season Analysis

As a coach, you should always sit down after a season and discuss with your players what you see as their strengths and weaknesses. This way they have some direction with which to work.

Here are some post season general thoughts to whom it may concern.

1- Why do coaches constantly tell catchers to block everything? Nobody on base and the ball gets past the catcher and I hear coaches yell " block it." Why? To practice? Obviously those coaches never caught before. It's hard work catching all those potential dirt balls when you NEED to block let alone when your coach would like to see you practice.
Coaches, please let your catcher relax a little when he can.

2- I believe one of the most overlooked aspects to coaching is instructing the outfielders on where to throw the ball in crucial late inning situations.

Example: 5-3 game. Last inning. Runner on 1st base. Single up the middle. Center fielder throws to 3B to try and throw out the 4th run allowing the 5th run to move into scoring position. Ugh! How about an "all throws to 2nd base defense" coach!

3- The changeup is not a 2 strike pitch. Unless you've got yourself a Cole Hamels changeup, don't throw it when the batter is looking to protect. The changeup needs to be thrown in "hitter advantage" counts when the fastball is expected. Think 1-0, 2-0, 2-1. And if you're really, really good 3-1.

4- Who started all the cheers in the dugout stuff? It's baseball. Seriously, when did this happen?

5- Please, please, please stop telling your kids to not look at the ball when they run. Good baseball players hit the ball and take a peak at the ball so the position of the ball guides their decision making. The 1B coach should not be the only person to see it go through the shortstops legs.

Furthermore, I witnessed two separate ocassions where a baserunner was hit with a ground ball because he wasn't looking at the ball. Please!

6- Don't be afraid or embarrassed to say "I'm sorry." We've all been in a competitve situation where we've acted inappropriately. You're not alone. And as long as you didn't go Billy Martin on the umpire it goes a long way to apologize.

Awesome To You

My 33rd lap around the sun is nearly complete. It's a pretty unremarkable birthday, hopefully. I'll be having cake and ice cream with Amy and my 4 little friends and likely some neighbor kids.

It's time to reflect on leaving the court, weight room, field, etc., gracefully, and getting my 30 minutes of semi-vigorous activity like a good middle aged man.

Wince.

Golf slays me. Since when are marathons and triathlons the measure of an adult athlete? I imagine that in a few days, at 34, I still won't want to do those things unless I have to.

Don't get me wrong. I can appreciate why bajillions of people love golf. I absolutely applaud anyone interested in pushing their bodies through the sweat and discipline and discomfort of new heights, whatever they may be.

Well, some exceptions are noted.

[editors note: don't do a Google search of the words "shake weight"]

But on the whole, I'm pretty sure that long drawn out cardio is overrated. Not that anyone should stop jogging or recumbent biking or Tony Little Gazelling IF they love to run or recumbent bike or Gazelle. I'm definitely still of the age where I'd like my fitness and leisure activities to pass the Awesome Test.

Most of the things you see people do for exercise don't pass the test. If The Bachelor and every other show involving long drawn out rose ceremonies can utterly butcher the word "amazing", then I'm allowed to stretch "awesome" into an 800 word blog.

I recently saw a dude at Planet Fitness plodding away on the treadmill. Sure, there is a lot worse he could be doing with his time, but I didn't think that was very awesome.

The next day I stood by an athlete repeatedly pulling 135 pounds right off the floor with perfect form. That was definitely awesome.

I saw a lady biking down past the Yellow Breeches. She looked like she was benefitting from the ride, getting from A to B in the fresh air, but I wouldn't say it was awesome.

I caught a neighbor kid jumping his bike off the side of a ramp in our yard. He fell in the grass and that was awesome.

118 mph controlled tennis serves? Lifting 95 pounds from floor to over head fifty times in less than 10 minutes? Rapid fire flips and backward somersaults on a narrow balance beam? Fade away jump shots in the eye of lanky behemoths? Awesome, awesome, awesome.

Nine iron from 30 yards for an eagle? Swimming for more than, like, 15 minutes? Driving around other guys driving? That...thing people do on an elliptical machine? These are either difficult or physically challenging, but not both. And not awesome.

I don't even try to be awesome at everything that's awesome. I think advanced yoga and extreme cheer leading are pretty awesome. You don't have to be formally trained to know awesome when you see it. In fact, ask anyone less than 18 if a certain activity is awesome, and they're probably right.

Of course, what passes the awesome test for an adult is far from hard science. The problem is that the common denominators for my preferences are not words you think of with aging. Speed, skill, strength, intensity and risk. Not exactly "take the stairs instead of the elevator" type of activities.

Ain't Too Proud to TENS

"Now tell me again. What's this supposed to do?"

Patients often pose this question in the clinic, right after I've slapped electrodes on a sore spot.

The rationale for electric stimulation can get pretty technical, of course. But to keep it simple, I usually just tell patients that it helps with swelling, muscle spasms, inflammation, and temporarily masks the pain.

"Oh. Okay then."

And it's true.

How a little voltage accomplishes these things is really less mysterious than you would think. Neuromuscular stimulation (NMES) is a strong electrical current that's proven to help with recruitment of weak or injured muscles. We use that in the clinic too, but for now we're only talking about using transcutaneous electrical neuromuscular stimulation (TENS) for pain relief.

The TENS current causes the spinal cord to release a natural endorphin called encephalin, which reduces the reactivity of pain pathways. TENS also provides sensory overload at or around the painful area, effectively bum-rushing the nervous system so you notice relatively less pain. Lastly, the electricity causes constriction and dilation of small arteries by way of a few mechanisms. The increased blood flow leads to decreased swelling and increased metabolism of toxic and inflammatory substances.

So yeah, it's not just a distraction. Well, sorta. But nobody can bill for an empirically proven, much needed, and highly demanded therapeutic nap.

But looking past glorified naps, inflammatory substrates, and decreased sensory perception, TENS is not exactly an evidence-based procedure when you try to put numbers on functional outcomes like lifting at work or jumping on the court. More than that, TENS doesn't give rehab people anything to brag about. It's not technical or highly skilled. There are no costly continuing educations tracts where medical professionals get to show off lots of letters for their E-stim certification.

I've never seen a fellow PT "market" the use of E-stim as a strong point in their treatment programs. I mean, could you imagine...?

"My clinic is unsurpassed when it comes to turning this dial and pushing that button."

You could prop any monkey or reader of People Magazine into a rehab setting, teach them a few contraindications, and they could slap electrodes around painful body parts. Oh, and turn the unit on. Yeah, uh...nobody has ever had to remind me to turn the thing on.

PTs do have other good reasons for the backlash against E-stim and other passive modalities like ultrasound. I've learned that the 80's and 90's sometimes had PTs charging insurance companies for 24-plus visits of "treatment" consisting of E-stim and a hot pack for 30 or 60 minutes. Again, therapeutic nap not withstanding, this practice over that many visits is lazy at best and deceptive at worst.

Working on your feet is...work.


One of my past writings was published as a guest editorial in Advance Magazine for PTs. It was a tongue-in-cheek call for PTs to quit acting like they have all the answers and with that, experience the freedom that comes from embracing the limits of our profession. I wrote a sarcastic "about the author" blurb that said I was certified in Ultrasound and E-stim.

Most PTs (and only PTs) would get the joke; the idea of specializing in something that no therapist takes great pride in. To say the least, I found that the editors at Advance are not PTs.

The bottom line is that I use E-stim in the clinic, always as a component of a comprehensive treatment program. Most people love it. Patients often comment, sometimes with creative expressions, on how it works. I do feel it's good practice for PTs to give full disclosure on the matter. Mine usually sounds something like:

"E-stim is not essential in your treatment if you don't prefer it. It doesn't address the root cause of mechanical pain; the poor strength, flexibility, or movement patters. Problems that are mechanical in nature really do require a mechanical change to fix. Manual mobilization of the joints, flexibility work, and ugh, conditioning exercise, are a lot more effort for the patient and the therapist, but they ultimately treat the problem instead of temporarily helping the symptoms.

...and who can deny the power of the therapeutic nap?"

There. Was that so bad? So now lets zap away if it makes you feel good.

Extreme forward head posture with severe kyphosis. And blue. E-stim will definitely fix this dude.

E-stim won't likely be proven alone to be effective for functional outcomes. I don't care. There is an extensive research base of TENS for pain relief (not necessarily functional outcomes) in both the clinical and laboratory settings. If it helps with pain, albeit temporarily, what's the harm in that? You go ahead and try living in pain 24/7 and see if a few hours of nonfunctional, temporary pain relief is worth it.

There's an exciting area of study regarding the use of a slightly different type of electrical current that, rather than stimulating the muscles and nerves to "fire," acts as a specific electrical signal to all tissues in the body. The signal causes those tissues to inhibit or accelerate what they do, which may be a promising way to circumvent the side effects often see with medications.

Until then, if aches and pains cause you to seek a PT, I would probably try to zap you, and would definitely try to get you to move differently.

It's Mental REPS, not Mental Laying Around on TENS.

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[Here's the bio that was actually published in the Advance editorial.]

Robert Gorinski is a physical therapist in private practice in Harrisburg, PA. He specializes in ultrasound and the use of other passive modalities. He is creator and founder of the Common Sense Method of Recuperative Rehabilitation Therapy.

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Abs Are Not the Core

Rehab and fitness professionals get loads of questions about abs, especially if they have 'em. And of course, there are as many opinions about abs as there are fitness people. Since some are asking, here's my own fitness-person-mandatory-abs-write-up.

I'm going to give it all away, right off the bat. Yes here it is, up front and free of charge! Herein lies THE secret to abs, and you don't even have to read the entire writing!


First and foremost, above everything else, you should know that the secret of definition is you.



All of you. Yes, you must get all holistic about it. That's why the "just" plans are always a lie.

Just seven minutes of exercise per day...
Just two pills before major meals...
Just wear these toning shoes while at home or work...
You're eating the wrong yogurt. It's definitely the yogurt.





Okay already. We see them. Your abs.

The truth is that You are so far beyond PTs and trainers and nutritionists and the ripped guys and gals in Facebook ads. Sure, some of us are able to guide and assist in some areas, but please understand that getting any one area "spot on" will not help if you're lacking in other areas.

I'd like to think that abs are a side effect of a generally healthy person who, with much intention, makes an effort to be atypical.

Don't worry. I'm not going to try to go all fitness guru. "Check out my abs, and you should believe everything I, with abs, say." Yechht. I'm not eager to try and impress anyone; at least not with abs. Ask my wife and close friends.

But what's it like to have abs? Well, when you have a firm midsection you always leap out of bed in the morning feeling awesome and you always feel awesome about yourself. You shoot at least 98% from the field in pick-up basketball and you never envy anyone. Everything you cook on the grill comes out roasted to savory perfection, and you never step in dog poo.

Your wife always wants to have sex, like, whenever, and you're way awesome at it and stuff. Your children always make wise decisions and you never snap at them because they obey you like Rodd and Todd Flanders. You're always patient with stressed out, workaholic desk jockeys who ask how many crunches you should be doing and insists that you're lucky.

I have had fairly defined abs since I was about 15. How is it that I'm almost 34 and still have abs? Some of my condition is [1] genetic and [2] environmental. Just some of it. I'm a male built from relatively lean and athletic parents who raised me in a physically active environment.



I don't think anyone should pull the "poor genetics" card as an excuse to give up. I truly believe that just about everyone can get fairly lean. But please, ladies, don't think "lean," "fit," or "healthy" means fashion model scrawny.











Some of my own condition is due to [3] training and nutrition know-how. Since it's my life's work to know something about this stuff and be able to help folks and answer questions, I should probably practice what I preach. Along those lines, keeping fit and pushing to achieve physical performance goals are sort of a [4] hobby of mine, and the aesthetics are a side effect.

Much of it is related to my [5] general temperament and [6] general activity level, having a serious case of ants in the pants. Like, I enjoy pulling my kids all over the place in their wagons and I'll practice bike tricks until my hands are bleeding where time permits. The key is that I'm truly, naturally doing all this activity for fun, not for exercise. This means lots of burnt calories without my mind registering "hey, you're being good and burning lots of calories."



Some of it is due to me [7] being hardheaded and maybe a little spiteful toward people who gripe about being out of shape and guarantee that a few more years will put me in the same place. More than of few of such folks are younger than me, fueling the fire to prove them wrong.



Lastly, some of it comes from me having an [8]everyday midlife crisis, seeing what years of bad decisions looks like. Even scarier is the fallout of freak accidents and unexplained and unearned disease processes. Each day in a PT clinic is a reminder that any given day is only about four weeks away from not having abs.

Okay already. And [9] selfishness, okay? I honestly feel edgy and generally not mentally right if I go more than 3 or 4 days without doing something strenuous. It's a priority to me. I'm healthier physically and especially mentally. I'm a better husband and dad and PT when I get my fix.

Lastly, I include a few core strengthening exercises because weak abs have repeatedly been implicated in low back, knee, and hip injuries.

Surely there are others, but those are ten primary reasons for abs.



Now, far more importantly, are the things not responsible for having abs.

[1] Dieting hard. I don't really eat that clean. Now don't get me wrong, I may eat very clean by some standards, rarely touching anything deep fried. I do attempt to avoid trans fats. But moderate amounts of scrambled eggs and pizza and burgers are absolutely fair game. Sure, that may change as I get older, but it works for now because I (usually) don't overeat for my size and activity level.

I never was an emotional eater. It's nothing that reflects me. That's the point: I never had to deal with that complex issue. If it's an issue for you, don't be misled into thinking that exercise or B complex vitamins are a solution to that problem.

The primary "active" ingredients in my diet are heavy squats, overhead presses, and chin-ups. No, seriously, carrying muscle on your frame is absolutely the best thing that allows you to stay lean without eating like a frail mouse.



Learning what normal portions sizes look like is definitely beneficial. But if you're chronically measuring out 3/4ths cup of brown rice, 1/2 cup of steamed broccoli, and adding it to 1 plain jane chicken breast and a dash of lemon, you're holding on WAY too tightly. If you feel the need to routinely do this, something is drastically wrong elsewhere. It may be hormonal issues from stress and lack of sleep. It may be weekend food or drink binges. It may be too much sedentary work and leisure. Only you know your situation, but if you follow a hyper anal diet and aren't lean enough, you should seriously think of addressing something other than diet.

[2] Supplements are no reason for abs. Acacia Berry is not the cornerstone of rippedness. Neither is cinnamon or Ripped Fuel or any other temporary stimulant. Are you kidding me? The big picture of abs is a fairly complex, long-term process that you can't buy for $39.99. Caffeine has been proven to help the body burn a higher proportion of fat for fuel during exercise and has some other benefits aside from this. Of course it's going to be bad for you if you overdo it.

[3] Exercise selection. The secret to abs is no specific, cutting edge core exercise. The issue is not muscle recruitment. Your abs are probably contracting just fine when you do most of the zillions of exercises you can easily look up on youtube.

How about 5 minute abs? I do only one or two ab exercises, each for about 25 to 50 reps, per week. But I consistently do lots of big heavy leg exercises and farmer walk and sprint and throw my kids and mountain bike around.

Now it's true that core exercises can be done incorrectly. Like all exercises, some ab exercises are unnecessary or just not worth the risk. Abdominal weakness often greatly contributes to lumbar spine dysfunction. But please don't imagine that there's some particular, proprietary movement that will suddenly sharpen your abs and melt the overlying fat away.

[4] Long drawn out cardio (LDOC). I hate LDOC. I think too much of it ultimately eats away muscle and therefore sets your abs up for failure in the long run. I train hard and play hard. I could probably run 8 miles or bike 100 if I had to. I mean, it wouldn't be fun or super fast, but I could do it if I had to.

Sure - you can and should run or bike or cardio twist the night away if you enjoy LDOC. But it's certainly not an essential part of abs. How many ripped distance runners to you know?



Lastly, if abs are not a priority, good for you. Abs are just part of the covering of who we really are; the shell, effected by who we are nonetheless. A self-absorbed fitness freak is no fun for anyone. While abs are overrated and they don't make people happy, nobody should misprioritize their health and wellness.

I personally don't believe that a person can will themselves into transforming who they are. Sooner or later, the body tells the truth. The well balanced person is the core of what others are attracted to. And it's what we have been after all along.

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One of my favorite images of all time. But what can we learn from this? Their bodies told the truth, and they both died early due to drastically different issues.


Live well and don't take it for granted - abs or no abs.

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.