Need help with joints/tendons in Ontario
July 9, 2015 10:54 AM   Subscribe

What can I do to get appropriate, up-to-date care for joints and tendons in Ontario?

I have a lot of MSK problems. Some of them are chronic, others recur, and I have a new one right now. Some of them are interfering with aspects of my life (lifting things weighing over ~1 lb with my dominant hand; exercising beyond very limited movements). I had an amazing physiotherapist, who did diagnose and mostly successfully treat some of these issues, but he moved.

One thing is that I don't really even know what's going on, for everything. E.g. I may or may not have osteoarthritis in my knees, depending on which radiologist's report you read. (2013: narrowed joint space; GP: "you have OA". This year: report says "normal" - same GP: "your knees are fine, what about an antidepressant" (on the possibility that it might be a "pain syndrome", a hypothesis for which I had to prompt after the treatment suggestion.) I asked about the discrepancy in the X-rays. GP didn't have anything to say about that ("sometimes they're just different"), and took the latest report as authoritative.

Saw a sports med about my longstanding wrist/forearm problem (which had been ok for some time thanks to good physio, but came back after I walked around carrying some extra heavy groceries for a longer period than usual). It's apparently "tennis elbow", now (though the pain is further down, where the old pain was; could be referred I suppose but it's the same pain) and sports med suggested bracing, shock wave, and cortisone shots if none of that works. Some of which would make sense, according to what I've read, if I could be sure it was tennis elbow (it might be, but don't think so, because of the history), and if it was acute (which it's not).

I am not at all keen on cortisone shots, as I've read that they damage tendons over time. Also because they don't actually heal anything, they just temporarily take care of pain. Also because I've read that the consensus now is that with tendinopathy, the problem is not inflammation, but degeneration, and that a different approach is required. Except almost no one I have seen (barring my old physio) seems to be on board with this consensus.

So I want to heal my tendons (have not described all the issues here), if that is possible, using current evidence-based approaches. And discover what's up with my knees. I am at the point, however, where I wouldn't trust a radiologist as far as I could throw them*. I can get the *reports* from the hospital, but the private labs I've been to, however, won't release anything except for through the doctor, and I am not getting much communication out of any doctor.

And I don't know how I'd even get a second opinion, in Ontario. Do I get new X-rays/ultrasounds somewhere else or ask to have the older ones read again? By whom? How do I get my images (not just the reports) back from a private lab? How do I find a sports clinic that is up on the latest knowledge, other than luck? People I know can't recommend anyone.

I'm also seriously afraid of looking like a "problem patient" because of my thick, discordant file. I think this would incline doctors to see me as someone needing psychological vs orthopaedic care. (And although yes there is sensitization and pain has a neurological component, I know that what is happening in my body is mostly not about my head.) How do I advocate for myself as a patient in a way that will avoid that possibility?

*Because I have learned that there is often just a lot of grey area in interpretation. What I don't get is, since that's pretty much known to be the case, why isn't it required that two pairs of eyes evaluate an image before an opinion is provided? And I know it's a specialism, but why do non-radiologist doctors take the report 100% for granted, and not at least look at the image itself, or listen to patients?
posted by anonymous to Health & Fitness (2 answers total) 1 user marked this as a favorite
 
May I recommend the website painscience.com. He delves at great depth into many of the issues you mention. He's a massage therapist who does extensive reviews of the scientific literature.

To get a second opinion from a GP, just go to another GP who's taking patients. To get another opinion from a different specialist, ask your GP for another referral. Getting a second opinion is pretty accepted.

Having someone else read radiology images is less likely to happen. Your question about why aren't all images aren't evaluated by 2 radiologists is a good one, especially given recent 'scandals' in Canada where one radiologist or another seemed to be particularly prone to missing things. The simple answer is cost. Why aren't all patients seem by 2 GPs simultaneously to see if they agree? Probably most of the time one is good enough and it would double the cost. I guess one way to go about it is to write a letter to the head of the radiology department stating as you understand it your knee had arthritis one year and none the next, and could they either comment on whether they are planning to publish a case report on disappearing osteoarthritis, hitherto unknown to medical science, or have someone re-read both xrays and get their story straight? But to be fair, every test has a false negative and a false negative rate, and have to be taken with a grain of salt. Furthermore, radiology simply has an inescapable subjective component to interpretation, like almost everything in medicine.

But in any case, if you search for "structuralism" on that website, you'll get more insight into how little radiologic findings often correlate with the clinical picture. They don't necessarily give you "the answer". They give you another clue, that must be tied together with the history and physical examination. And in many cases, it doesn't really matter, because their is no specific proven treatment regardless, or clinically there are multiple coexisting conditions, etc., so you end up trying this and that until it either goes away or the problem becomes clearer.

Orthopedic docs always look at the xrays themselves, and sometimes disagree with the radiologist. But most other non-radiology docs have not spent many many years in training to read films, and rightly don't feel competent to do so.

Of course your question as to why docs don't listen to patients is rhetorical, as all should.

If your GP or sports medicine doc can't find you a good physio, then your options are trial and error, word of mouth, online review sites. Like finding a good nanny or a good car mechanic.

I don't know that delving down into whether or not you have a touch of what everyone gets with age (signs of degeneration in the knee) on the xray is super crucial at this stage. If you do, the approach would include meds, exercise/physio. If you don't, well, pretty much the same. Very few knee conditions these days go direct to surgery, so that means everything goes to physio.

And physio ain't exactly an exact science either.

We can put a man on the moon but generally have only vague ideas of what causes human aches and pains, so come in with low expectations about the exactitude of labels put on them and directness of cures.
posted by kevinsp8 at 8:53 PM on July 9, 2015


Rheumatologists are joint experts. They may be more helpful to you than a sports medicine/ortho person.
posted by hydropsyche at 3:24 AM on July 10, 2015


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