Toughing Out Injuries

An article came out in the March 30th edition of New York Times (which, to me, is yesterday's) called "Sports Injuries: When to Tough It Out."

The link (which may or may not work anymore) is here.

If you can't get that link to work, but still feel like reading the article, I pasted it below in a tiny, tiny font (as large a font as it deserves, reproduced with no permission whatsoever).

My reaction comes after. And then a girl named Cynthia's reaction to mine. And then mine back to Cynthia. And then her submission. And then my victory lap.

All of this coming soon. First, the article:


YOU have been playing a lot of tennis recently, and now you think you have tennis elbow. Or you’re a swimmer with an aching shoulder. A cyclist with sore knees. A runner with pain in your heel. Do you go to a doctor, or tough it out?

Now, before you read on and decide I’m a therapeutic nihilist, I have to tell you that the idea for this column was suggested by a doctor-athlete, Paul D. Thompson, a marathon runner and a cardiologist at Hartford Hospital in Hartford.

And his answer to his own question?

“I think most folks should not go, because most general doctors don’t know a lot about running injuries,” he said, adding, “Most docs, often even the good sports docs, then will just tell you to stop running anyway, so the first thing is to stop running yourself.”

In fact, he said, because you probably will have to make a co-payment if you see a doctor, you will be adding insult — the fee — to your injury. Dr. Volker Musahl, an orthopedist at the University of Pittsburgh Medical Center, had the same sort of response. He competes in marathons and triathlons.

“If you want to continue to run, don’t see a doctor,” Dr. Musahl said. He, like Dr. Thompson, said that if you were one of his patients, coming in with a sports injury like a sore knee or hamstring or heel or hip, he would just tell you to rest.

But Dr. Musahl added a caveat. When he recommends staying away from doctors, he is talking about staying away if you have the usual sort of aches and pains that plague almost everyone who exercises regularly. There are red flags that should prompt you to get medical attention, Dr. Musahl said: pain that gets progressively worse, pain at rest or at night, joint swelling or bruises that do not heal, and knees or elbows or other joints that lock or seem unstable.

Dr. Thomas Best, the president-elect of the American College of Sports Medicine and director of the division of sports medicine at Ohio State University, advises seeing a doctor if you are not recovering in your usual period of time from whatever injury or soreness you typically get. For example, he said, every weekend after his usual 10-mile run, his knees are sore. He is not sure why.

“Lord knows what’s going on in there,” Dr. Best said. But the pain goes away in a day or so, and he has grown used to it. “Know how you typically recover,” he said. “When you are not recovering as you typically do, that’s the first warning that something more is going on.”

The problem with rushing to see a doctor for common injuries, according to Dr. Musahl and others, is that doctors have a limited arsenal. For a typical sports injury — pain or tenderness in a muscle or tendon — they can’t make you recover faster. And some of the treatments doctors dispense, like cortisone shots for injured tendons, can actually slow recovery, albeit providing temporary pain relief.

There are some helpful treatments for run-of-the-mill injuries, but they often do not require a doctor, and doctors often know nothing about them. Rigorous studies have shown that eccentric contractions, in which a muscle lengthens as it works, seem to speed the healing of tennis elbow and of injuries to the Achilles tendon, which attaches the calf muscles to the heel. They involve, for example, doing heel drops for an Achilles tendon injury — standing on a step and dropping your heel, then raising it to the level of the step again.

In one recent study testing an experimental treatment, which turned out not to work, heel drops were used as the standard of care — the presumed-to-be-effective alternative to the treatment being tested. Participants getting the experimental treatment, as well as those who did not get it, did 180 heel drops a day.

Sometimes going to a doctor for a diagnostic workup can be precarious, with scans that can show all sorts of apparent abnormalities and injuries that are not causing any problems.

For example, in a study reported at a recent meeting of the American Orthopedic Society, Dr. Matthew Silvis, an orthopedist in Palmyra, Pa., did M.R.I.’s of the hips of 21 professional hockey players and 21 college players. They showed abnormalities in 70 percent of the athletes, even though these hockey players had no pain or only minimal discomfort that did not affect their playing. More than half had labral tears, rips in the cartilage that stabilizes the hip.

“M.R.I.’s are so sensitive,” Dr. Musahl said. “They frequently show little tears or fraying everywhere. And it is very, very common to have a small labral tear in your hip — it doesn’t mean you have to have the particular symptoms.”

The same is true for rotator-cuff tears, rips in the tendons that help stabilize the shoulder. Studies have found that about half of all middle-age people with no shoulder pain have these tears, although they are unaware of them and have no symptoms.

Dr. Best, though, said that when an athlete has an injury that does not go away in the expected time, skilled doctors could help by finding the cause of the injury in the first place. Knee pain, for example, might actually be caused by a tight iliotibial band, which stabilizes the knee, and weak gluteus muscles. He always watches athletes move to see if he can spot biomechanical problems. And, he said, doctors who do not watch athletes move may never understand the causes of their injuries.

“You as a runner, coming into my office and lying down on a table — that’s a pretty nonfunctional exam,” Dr. Best said.

It is worth pointing out that doctors who advise you to avoid doctors do follow their own advice.

Dr. Thompson went to an orthopedist about five years ago for knee pain that plagued him whenever he ran. He said he knew the doctor well because they mountain-biked together. He had an M.R.I. that showed that his iliotibial band was inflamed. Dr. Thompson stretched it, and the pain eventually went away.

The visit before that one was 25 years ago when Dr. Thompson had plantar fascitis — heel pain caused by an inflamed tendon at the bottom of the foot. He went to a podiatrist, who gave him expensive orthotics and cortisone injections, but they did not help.

Then a podiatrist for the Celtics basketball team told him to tape his foot, and the problem went away. While a review by the Orthopedic Section of the American Physical Therapy Association classified the evidence for taping as “weak,” Dr. Thompson swears by it.

“The fact that experts think the taping evidence is weak means they are not seeing enough runners and is the best argument for not seeing them,” he said. “If I stop taping,” he added, the problem “comes back in a month.”

As for Dr. Musahl, he says he never sees a doctor for his sports injuries. When he feels pain, he cross-trains awhile until the pain goes away. And that is how most experienced athletes behave, Dr. Musahl said. They know their injuries and know that the injuries will heal with or without a doctor visit.

“Athletes who are older usually have had that problem before,” he said. “They are smart about it, they know it is self-limiting.”

“Younger people come in immediately,” Dr. Musahl said.

Then, if they continue with their sport, they learn about the limits of medicine.

By GINA KOLATA



Okay, my reaction to this depends on who's actually reading the Times... but my hunch is it's a very dangerous suggestion (i.e. "don't see a doctor for your sports injuries").

And the continuation of my hunch is that anyone who thinks otherwise has spent too much time in the company of kinesiological (or similarly educated) colleagues.

Though I'm certainly open to criticism on that.

But I'm not open to criticism about this: people - as a rule - are idiots. And while Times readers may be marginally less brain dead on average, the difference can't be that profound.

If I wanted to say that with any real certainty, I'd obviously look up real demographic data.... But my low-energy version of that is this: http://websiteoutlook.com/www.nytimes.com says the Times website gets an average of 11,827,956 daily views, 69% in the U.S.

http://www.webtrafficagents.com/WebSitevalue/SiteValuation.aspx?s=nytimes.com (another site that just measures traffic) says it gets 14,908,365.

Both of those equate to between 4-5 million unique viewers per day, every day.

And Wikipedia lists their December 08 unique viewer traffic as more than 18 million people with over 146 million unique viewers that year (which seems believable if there are 4.5 million unique people visiting the site every day, some of them daily, some weekly, some monthly, etc).

Given that level of viewership, I have a really hard time believing that millions and millions and millions of people would draw the appropriate conclusion from an article like this.

I have a hard enough time believing a hundred people would draw the right conclusion (based on the rule that people are idiots).

The majority of these readers aren't going to know the difference between "the usual aches and pains" and "the red flags." And in the part where he's talking about a tight IT band as a possible cause of knee pain, Times readers aren't even going to know what an IT band is.

So expecting them to heal themselves (coming up with all their own therapeutic modalities) seems crazy to me.

The guy making the suggestion (the one who can't be bothered to see doctors) is a doctor himself. He's not just some guy who also reads the Times when he's supposed to be working. So while I would trust him to make the right decisions, I wouldn't trust any of his readers to do anything remotely reasonable.

If they don't have someone holding their hand throughout the whole recovery process, they're going to find themselves battling a worsening, increasingly-chronic condition.

Granted, I agree about the "most docs don’t know..." part. I took someone to the doctor about six months ago because her foot was trampled by a horse and it was all black and swelling. I wanted to make sure she didn't break any bones.

"Nope. No broken bones. Just keep a heat pad on it for a few days and you should be okay." Six months ago, treating inflammation with heat was the doctor's best advice.

So I'm not too keen on MD advice for musculoskeletal problems either. But on average, I'm pretty sure brain dead tennis enthusiasts are better off getting a medical eval than swinging around a different racket while taking chondroitin.

I guess my ideal solution would be to create an acute-session physical therapy clinic. A little pop-in ER-style set-up where athletic trainers play the role of nurses.

But since that's hardly feasible, I would definitely settle with fewer "fix-it-yourself" publications.


I could be wrong about the whole thing. Maybe it's a really helpful article.


Okay..........


RESPONSE FROM A READER:

First of all I have to say I agree with you, but I also agree with the article.

I think the article was speaking to the chronic athlete who is usually more educated to start, secondly the new york times does know its readers and as you said a high percentage are educated and can take this article for what it is. Not fact, but conversation. Information you might not talk about with a friend because he isint a runner or isint a doctor.

I am lucky enough to talk to doctors all day long. Ranging from primary care to endos, cardiologist, rheumatologist, ob/gyn ect. From personal experience I would not ask any of my doctors for injury advice- they have absolutly no training in this area unless it is a passion of their own. Most of the doctors I see ask for my advice for their own muscle/ skeletal issues. Again as you mentioned they still are not versed in inflammation treatment, which we think of as main stream at this point.

So overall the people we would worry about taking this advice the wrong way aren't even going to read this article. They are probably to busy watching tv, drinking a beer and smoking a cig.

PTs should not need a refferal.

I have a question for you about something that really bothers me about lack of attention to kinesiology.

Why when we are children are we evaluated for allergies ect, but there is never an evaluation for muscle/skeletal issues? If we diagnosed and treated dysfunction from the start we would have a lot less injuries and a lot more people who could be active.

Cynthia


ME BACK:

I just want to respond to a couple sentences. I see where you were going, and largely agree, but there are a couple parts on which I'm feeling compelled to comment.

(All the parts I'm not commenting on, I agree with, so don't regard this as me being combative... though that's clearly what it is).

First, this:

"I think the article was speaking to the chronic athlete who is usually more educated to start."

I don't disagree that athletes are more in touch with their bodies than the proverbial couch potato, but this is not a passable level of expertise.

All I ever hear from athletes at every level, from little league to pro (excluding those with an academic background in athletic training/ physiology/kinesiology/physical therapy/etc), is "you've got tendinitis." And then they take a bunch of ibuprofen.

But if you look at painful tendons - even in chronic overuse injuries - you aren't going to find a bunch of macrophages and lymphocytes and neutrophils. So when you treat with NSAIDS, what is it that you're actually doing? Other than immediately blocking cox-2 and suppressing protein synthesis and eventually inducing a nice gastrointestinal bleeding, not much.

Now the argument can be made that the Times readers know better, and thus wouldn't subscribe to this therapy. i.e. this argument (the other sentence I wanted to respond to):

"So overall the people we would worry about taking this advice the wrong way aren't even going to read this article. They are probably to busy watching tv, drinking a beer and smoking a cig."

I just don't think this is true. First, I don't think Times readers know any better than their half-illiterate counterparts when it comes to physiology. Geopolitics, probably. But geopolitical participation doesn't cause and/or heal and/or worsen injuries.

And neither does "watching TV, drinking a beer and smoking a cig."

So I'm not really worried about how that demographic would interpret this article. I worry about the people who read it that actually are highly active.

Probably ten million people were exposed to the title of the article while it was highly visible on the website. On average, each visitor to the Times website views just over two full articles (in addition to the main page) every time they visit.

Now I have no idea how many people actually read this specific article. It depends on how interesting and relevant its competition was. But I would expect it to be no less than (very conservatively) several hundred thousand people.

And it seems unreasonable to assume that the majority of these people would know enough about the human body to say something other than "it's tendinitis."

Again, people are idiots. And when it comes to things like golf or commercial mortgage lending, I become the idiot.

And if an article was published that told me I shouldn't pay to talk to a finance guy before I signed the papers contracting me into a huge mortgage, it would be dangerous for me to read it.

All it would do is mislead me into thinking I'm capable of solving everything on my own when the reality is I'm not.

So that's my problem with the Times article. It encourages people in a way they shouldn't be encouraged. And that's what I find dangerous.


And again, I'm open to criticism.



CYNTHIA RESPONDING AGAIN:

Courtney,

I cant wait to meet you someday soon! You have a very good argument and I think you are right about the comments of mine you picked out. So who is qualified to read this article? Or should it never have been written? Would it be suitable for Runners world magazine?

Cynthia



LAST ONE... ME TO CYNTHIA

Hi Cynthia.... Thank you. Um.... Yes. I think Runners World would be fair.

But I still don't think it should be published as is. To me, all the article did is offer no diagnostic tools whatsoever, and then encourage people to trust their judgment.

So instead of telling people that an IT band exists and then moving on, it should explain how to recognize if the IT band is causing the problem and whether or not that's a serious issue or something people can remedy on their own....

"If the onset of your pain happened in this pattern, and you feel it here, and this worsens it, and this relieves it, etc, it might be a.... whatever..... don't bother seeing the doctor for this. He'll just tell you to stop running when in reality, you could stretch it like this......"

Or, more interestingly, they should have written the article you suggested about why there is never an evaluation for muscle/skeletal issues in children. I would read that with no diatribe to follow.


-courtney




Feel free to send me your thoughts, everyone else: courtney.jensen@huskymail.uconn.edu

Cheers!







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