As of recent i’ve been getting myriad questions about these various tissue presentations and although there is tremendous amounts of information on this topic, people still don’t seem to have the right perspective, unfortunately.
As we get older, rotator cuff tears, meniscus tears of the knees, and degenerative disc disease of the spine (hint it’s not really a disease), show up more often. Most people assume that these are directly related to pain. That assumption is categorically wrong and i’m going to spend this entire article trying to convince you of that.
Tissue tears and degeneration, what does it really mean?
If you are 50+ the chance that you have an asymptomatic rotator cuff tear is quite high. In the general population approximately 22% of people have a rotator cuff tear of varying degrees and among those aged 50, half who have rotator cuff tears, have no symptoms.
Among those that are 60 and 70+ the numbers become even more muddied as 66% or 2/3rds of individuals have tears but no symptoms.
These numbers are very similar for meniscus tears.
The numbers for spinal degeneration are even more enlightening. If you are 50 years old, 80% of the population, 8/10 people, have some amount of spinal degeneration yet no pain.
60% of people 50 years old also have disc bulges and don’t even know it.
And no, this doesn’t put you at higher risk for pain. That’s another question people also ask. “If I have degeneration or a disc bulge does that place me at higher risk??” Nope. No evidence for that and I don’t see that happening in my practice, either.
Does the meniscus, rotator cuff, ACL, and discs need to heal to have no pain? What does healing even mean?
This gets to the crux of this issue. If there is tissue that is “abnormal,” or different from when we were in our teens and twenties, and now we have pain, doesn’t the tissue that is abnormal need to heal in order for us to improve? Doesn’t that healing mean that the tissue is physically growing back together or sewing itself back up?
No, it’s not that simple.
You can “heal,” i.e. have less or no symptoms, even if the tear, degeneration, etc, never “heals” in our traditional sense of reattachment.
To illustrate this, I want to tell you a short story of a client I worked with during my last internship during PT school.
I was working at a small PT clinic at the time and they had invested a few years ago in building out an aquatic therapy room with this cool piece of technology, an underwater treadmill. The treadmill was encased in a tank, approximately 4-5 feet wide and 7-8 feet in length.
I was working with a gentleman for the first time who was recovering from a hip injury at the time. He took his shirt off, got into the tank, the water filled up, and he started walking on the treadmill.
As he was walking, I noticed something peculiar about his right collar bone where it attaches to the shoulder blade. This is known as the acromioclavicular joint or AC joint. It was completely detached.
Every time he took a step and swung his arm, the tip of his collar bone would poke up into his skin as if floating inside of his body with no attachment point. I couldn’t stop staring.
After I had gotten over the initial shock, I asked him, “doesn’t that hurt?” He said what, my hip? I laughed and said “no, your shoulder… what happened?”
“Oh,” he replied, “I had an accident about 20 years ago, fell off my mountain bike and separated my AC joint.” “At that time they said I could either have surgery or just let it be, and I decided to let it be. It hurt for a while but now it’s fine and I can pretty much do anything I want.”
This guy who had a completely separated AC joint, the end of his collar bone literally poking into his skin, moving up and down with every arm swing, had no pain in shoulder, and hadn’t for a very long time.
This moment proved to me that the body, and pain, is much more complex that just, “this tear is the cause of your pain.”
When people say “it’s my meniscus,” it needs to heal, I now view this whole interaction as cavemen pointing to a rock and describing it as a rock, and not going any further. This is unfortunately what we still do in the musculoskeletal healthcare establishment.
Practitioners and the general public alike, see a tear, say “oh that’s a tear, tear, bad,” and then go on to use our archaic tools to try and “solve” such tear. I had hoped that we would have evolved past this simplistic reasoning, however, we’ve still got a long way to go, as it’s easier to be a caveman than to live in the gray of endless complexity.
I suppose my call to action for anyone reading this is to be curious. Ask “is that actually true, or am I just accepting this on blind faith because it matches up with what I already believe?”
It’s interesting… I didn’t expect this to become a dialogue on curiosity and truth however this is at the crux of how we understand pain, injury, and how we choose to live our lives.
Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. J Orthop. 2013;10(1):8-12.