Discussion: Don't believe that

I dont' believe all this "trendy" new stuff about a lot of injuries being more psychological. Look at the state your calf was in after the Northerns.

I had a physio tell me that my brain was amplifying the "out of all proportion" pain in my damaged finger back in May, and he started doing frictions, then (as things got worse & worse) i decided to pay £300 for a proper scan which showed I had a partial rupture of one, possibly two, pulley ligaments. In other words, a potentially show stopping injury. I could even see on the screen my tendon bow stringing, it was that bad.

On an illness level, a lot of people with ME/CFS are told they must be more "confident" that they can do more (not be "fearful"), as their brain is telling them they can't. Conveniently ignoring the fact that if they follow this advice, many will get worse & worse until their symptoms cripple them. In the case of my ex landady, that eventually killed her.

It's all well & good new theories emerging about what causes injury , what pain's telling us etc., but I don't therefore automatically subscribe to all of it.

Phil - I have minimal experience of ME/CFS but I did read all of your blog a few months ago when you posted the old pictures of SPOOK I found it very interesting and enlightening - and the SPOOK profiles had RashRouteRicky in stitches.

With your finger you were clearly given poor advice and poor assessment skills from the Physio. If you would like to talk through any of my advice to Charlie especially in relation to what happened to you earlier this year my number is 07930 867 829.

I’d like to take this opportunity to explain a bit about the diagnostic process. Charlie’s description did not use the words I used but is broadly accurate. However the phrase “in my head” is rather general and emotive to many. Almost all pain is “in your head” but it doesn’t mean you don’t have a broken leg.

Accurately diagnosing injury is quite difficult. If someone has an obvious structural issue that’s fine. If your ankle is swollen and discoloured it’s pretty obvious something is wrong. A serious muscle tear will often present with bruising - again, clearly something is wrong. When there is no visible evidence of structural damage things become harder.

One significant issue is that many medical professionals misunderstand the results of the tools available to them. Some examples are described here: http://www.bbc.co.uk/news/magazine-28166019

In the case of US & MRI scans of muscle/tendon/ligament injuries scans can miss things. That isn’t too surprising given the complexity of the structures in say, the knee. What is less well understood is that there is little correlation between the results of scans and pain experienced by the people and/or subsequent development of injuries i.e. if you do an MRI scan of the lower back in a group of pain-free individuals 90% of scans will show degenerative discs, and 30-40% will show tears of the disc, bulges of the disc and facet joint wear and tear. These findings do not then correlate with people going on to experience back problems. Similar studies have been done on the Achilles and knee and show similar results. As yet I'm not aware of any studies into the relevance of US scan results with respect to calf injury. In the correct situation scans are wonderful tool in identifying pathology (Phil's finger), however if they are used for everybody experiencing pain then people can be diagnosed with a pathology that bears no relation to there pain and may have preexisted their pain for years.

Obviously if someone can barely walk due to a calf injury and the US scan shows a muscle tear in a calf then it’s reasonable to associate the two. However if someone has an injury in a more complex structure e.g. the knee, and an MRI scan shows a tear, then far more care is needed in interpreting that result.

However, and it is a big caveat, if you, as a medical professional, think that there is a possibility of something more serious then ethically you need to have that investigated if only to rule it out. Your own experience may make you very sure there is no real problem but you still need consider carefully performing the investigation. In that sense I very much agree with what Phil says.

Now, let’s consider the case of Patient Four-X, a man in his fifties, slightly peculiar but not so peculiar that it affects diagnosis. He has presented with repeated calf and Achilles problems over several years, with a similar pattern of building up strength then reinjuring after high intensity races.

For several months Patient 4X has been building strength in his calves and avoiding the kinds of loading that have caused injuries in the past. He has successfully competed in several races without apparently aggravating the injury. The patient reports recent pain but no external events that would normally lead to this kind of pain.

What are the possibilities?

Well, yes, something very serious could be wrong. However on balance this seems unlikely. If you start sending such patients for scans you might as well start dragging random people off the street and scanning them. All indicators suggest the level of loading that the calves have been subjected to is unlikely to cause significant issues.

So is there a possibility there is a mechanism where body can create/transmit pain when there is no current structural cause for the level pain?

Well, turns out that (relatively) recent research based on both muscle biopsy studies (mainly in rats!) and studies scanning the brain and measuring its response to stimuli suggests there are such pathways. It seems that when an area has been traumatized in the past the pain system can become over-sensitized and report pain anomalously. There is also the possibility of pain memory, which is a different mechanism but is being shown by research to be a real thing, although I personally don’t that is what is happening in the case of Mr 4X.

Diagnosis is difficult. The body is complex. Research results leads to theories, many of which don’t stand the test of time. The scientific basis of much medicine that is practiced, including physiotherapy, is pretty shaky. Much of the medical intervention being given to the top athletes in the world is not backed by scientific research - or more accurately extensive scientific research has repeatedly failed to find any evidence that the interventions undertaken are beneficial. But then research can often be, at best, a blunt tool, and at worst seriously flawed or cynically manipulated. We have to do what we can within that framework.

Thanks to Mr 4X for giving me permission to discuss his case.