By Anthony J. Lombardi, DC
The conventional assessment of musculoskeletal injuries has traditionally been performed in a vacuum. A chiropractor treating a patient with elbow pain typically performs elbow orthopedic testing, while a patient with low-back pain undergoes an exam that focuses on straight-leg raise and sacroiliac joint tests. Patients with non-traumatic knee pain undergo every knee orthopedic test imaginable, until the chiropractor draws his or her own conclusion. Conventional assessment approaches often lead to incorrect interpretations of diagnostic imaging and conventional orthopedic testing (Jensen, 1994, Cadogan, 2011, Contant, 2003). When injuries are assessed in a vacuum, there are often discrepancies among the different diagnoses.
As clinicians, we are presented with injuries and different clinical presentations that challenge the way we assess our patients. Several landmark studies have shown that tissue tears revealed on imaging are very common in patients who are completely asymptomatic (Jensen, 1994, Worland, 2003, Oschman, 2007, Cadogan, 2011, Simpson, 2006, Contant, 2003). There is a lack of a causal relationship between diagnostic imaging results orthopedic testing, and symptoms. Thus, we must look further into what is happening on a musculoskeletal level when patients are experiencing pain and dysfunction.
A New England Journal of Medicine study (Jensen, 1994) revealed that in a MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions. Given the high prevalence of these findings and of back pain sufferers, the discovery of bulges or protrusions by MRI in people with low back pain may frequently be just coincidental. A study focusing on rotator cuff tears (Worland, 2003) determined that approximately 40 percent of asymptomatic patients over the age of 50 have full-thickness rotator cuff tears. In a research paper (Oschman, 2007), it was reported that the high incidence of asymptomatic tears in the study group indicate rotator cuff tears can be regarded as a natural correlate of aging and that bilateral tears are common. There is an over-reliance on single orthopedic tests, which is unreliable (Contant, 2003) in clinical environments when assessing musculoskeletal dysfunction, and there is a lack of research to support conventional orthopedic testing (Cadogan, 2011)
With the advancement of manual therapy, we have learned and developed a multitude of standardized treatments – yet almost every chiropractor assesses their patients differently. In light of the research, it may be time that we re-evaluate how we approach assessment to provide more consistent clinical outcomes.