Question
Hi Dr. Leatherman,
I will give you a quick history of my back problem and you can give me your advice. When I was 12 yrs old I jumped off a trampoline and felt something snap in my lower back, within 5 minutes I couldn't walk. Mom gave me Advil and was better in a few days. when I was 16, got hit hard playing football, same thing. when I was 22 while at work,same thing happened, went to my DR, said it was a back sprain, was better in a few weeks, it has happened a few more times over the last 20 yrs or so but nothing to bad until this past Saturday. While putting Christmas decorations away I felt the pain come back a little, took some advil felt ok. I was in a bowling tournament so I bowled that night, and needless to say, didn't feel to good after that, but bowled good enough to qualify to bowl in the next round the next day. Well when I got up the next morning I felt somewhat sore, but not to bad. Well during bowling my back really gave out, could barely get the ball out. Well that night the pain was so bad I couldn't move. Nothing I took worked at all. Went to the dr's and he said back strain. The thing is nothing he gave me is working either. He gave me muscle relaxers and pain killers, but nothing is working and today is Wednesday. Could there be something else wrong? There is no pain shooting down my leg, no numbness or anything like that. The only time there is no pain is when I am laying down, then I have a hard time getting up. Whats your thoughts on this??

Answer
Dear Rob,

The problem with what you have told me is that I have no idea what type of examination your doctor performed.  A strain injury is really a cop out diagnosis because it really tells me nothing about the involved anatomy.  The word strain implies a muscular injury however it is often utilized incorrectly.  Is the injury to the muscle, the ligaments, the joint capsules, the fascial slings, the joint space, the outter fibers of the disk, or what???  Not to mention if the muscle is injured which muscle is involved?  This is important to identify because each muscle has different attachment points and mechanisms of action, not to mention the injured tissue will help to determine the treatment plan.

Did your doctor actually perform any diagnostic testing on you?  Or did he just ask you to bend forward, backward, and ask you a few questions about the pain?  In my experience most general practitioners perform very little musculoskeletal examination if any.  They sometimes even stand across the room and never put their hands on the body, which is unfortunate.  However, unfortunate, recent clinical research corroborates that medical schools do a poor job in musculoskeletal medicine.  (**See below research**)

You need to get an examination from a chiropractic physician as we specialize in musculoskeletal and soft tissue injuries.  It is very difficult for me to opine on your exact situation without knowing certain diagnostic facts that would be obtained upon clinical examination, however, I believe you probably have multiple areas of concern not just the musculature.  The fact that you do not have pain down the leg is a good sign though...it indicates that the nerve roots are not involved, however it tells me nothing about the status of the disk, joint capsules, or support tissue, and this should be evaluated functionally with orthopedic testing.  My best advice to you in this case is, ice the area for pain 20 minutes at a time, every 2 hours - perform gentle range of motion stretching (increasing soreness is okay, but not sharp pain) - and schedule an appointment for examination with a local chiropractic physician.

Hope this helps Rob.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net

**Educational Deficiencies in Musculoskeletal Medicine**
The Journal of Bone and Joint Surgery (Am) 84: 604-608 (April 2002)

Kevin B. Freedman, MD, and Joseph Bernstein, MD
Investigation performed at the University of Pennsylvania School of Medicine

FROM ABSTRACT
Background:  We previously reported the results of a study in which a basic competency examination in musculoskeletal medicine was administered to a group of recent medicine school graduates.  This examination was validated by 124 orthopedic program directors, and a passing grade of 73.1% was established.

According to that criterion, 82% of the examinees failed to demonstrate basic competency in musculoskeletal medicine.  It was suggested that perhaps a different passing grade would have been set by program directors of internal medicine departments.

To test that hypothesis, and to determine whether the importance of the individual questions would be rated similarly, the validation process was repeated with program directors of internal medicine residency departments as subjects.

Methods:  Our basic competency examination was sent to all 417 program directors of internal medicine departments in the United States.  Each recipient was mailed a letter of introduction explaining the purpose of the study, a copy of the examination, and our answer key and scoring guide.  There was no mention of the results of the first study.

The subjects were requested to rate the importance of each question on the same visual analog scale, ranging from 憂ot important?to 憊ery important,?as had been used by the orthopedic program directors.  These ratings were converted into numerical scores.

The program directors were also asked to suggest a passing score for the examination, and this score was used to assess the examinees?performance on the examination.  The results on the basis of the internal medicine program directors?responses and those according to the orthopedic program directors?responses were compared.

Results:  Two hundred and forty (58%) of the 417 program directors of internal medicine residency departments responded.  They suggested a mean passing score (and standard deviation) of 70.0% ?9.9%.  As reported previously, the mean test score of the eighty-five examinees was 59.6%.

Sixty-six (78%) of them failed to demonstrate basic competency on the examination according to the criterion set by the internal medicine program directors.  The internal medicine program directors assigned a mean importance score of 7.4 (of 10) to the questions on the examination compared with a mean score of 7.0 assigned by the orthopaedic program directors.

The internal medicine program directors gave twenty-four of the twenty-five questions an importance score of at least 5 and seventeen of the twenty-five questions an importance score of at least 6.6.

Conclusions:  According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination.

It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate. [WOW]

THESE AUTHORS ALSO NOTE:
揗usculoskeletal care is provided by a variety of practitioners, including internists, family practitioners, rheumatologists, emergency physicians, pediatricians, and orthopedic surgeons.?br>
揗astery of the basics of musculoskeletal medicine is therefore essential for many, if not all, medical students.? 揑deally, a solid knowledge base would be acquired in medical school and refined during postgraduate training.?br>
The authors previously evaluated the quality of musculoskeletal knowledge among a cohort of 85 recent medical school graduates in residency, and found that 82% 揻ailed to demonstrate basic competency in musculoskeletal medicine.?[Freedman KB, Bernstein J.  The adequacy of medical school education in musculoskeletal medicine.  J Bone Joint Surg Am, 1998; 80:  1421-7.] [WOW]

揙n the basis of these data, we suggested that medical school training in musculoskeletal medicine is inadequate.?br>
METHODS
The previous study抯 questions and scoring were validated by having the questions, answers, and scoring procedures assessed by 124 (out of 157) orthopedic residency program directors.

In this current study, the same questions, answers, and scoring procedures were evaluated by 244 (out of 417) internal medicine residency program directors.

An open-response format was used to eliminate the possibility of scoring points by guessing. 25 questions were used.  There was no time limit for completion of the examination.

The responses of the internal medicine program directors and those of the orthopedic program directors were compared and serve as the basis of this report.  All 25 questions used in the study are in the article along with correct answers and the percent of correct answers given.

THE THREE QUESTIONS PERTAINING TO THE SPINE:
1.  A patient comes to the office complaining of low-back pain that wakes him up from sleep.  What two diagnoses are you concerned about?

ANSWER:  Tumor and infection      PERCENT OF CORRECT ANSWERS:  33%

2.  A patient has a disk herniation pressing on the 5th lumbar nerve root.  How is motor function of the 5th lumbar nerve root tested?

ANSWER:  Dorsiflexion of the great toe (toe extensors also accepted).
PERCENT OF CORRECT ANSWERS:  20%

3.  A patient presents with new-onset low-back pain.  Under what conditions are plain radiographs indicated?  Please name 5

ANSWER:  Age>50; neurological deficit; bowel or bladder changes; history of cancer, pregnancy, drug use or steroid use; systemic symptoms (night pain, fever); pediatric population.
PERCENT OF CORRECT ANSWERS:  50%

[IMPORTANT:  These testers and reviewers in both orthopedics and internal medicine consider a new-onset of low back pain in a pediatric or pregnant population to be an indicator of exposing radiography].

DISCUSSION
揂ccording to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine.?br>
揑t is reasonable, therefore, to conclude that medical school preparation in musculoskeletal medicine is inadequate.?br>
揟he average amount of time spent in courses or rotations dedicated to orthopedics was only 2.1 weeks for all examinees, and 33% of them graduated from medical school with no such exposure.?br>
This represents <2% of the entire typical medical school curriculum.

The authors suggest that the standard rotation in orthopedic surgery probably emphasizes too many particulars of surgical practice, and does not emphasize conditions that are more clinically important.?br>
揟he ideal course in musculoskeletal medicine should concentrate on common outpatient orthopedic problems, orthopedic emergencies, and the musculoskeletal physical examination.?br> 揗edical school curricula must place a greater emphasis on musculoskeletal medicine.  Because of the aging of the population, the prevalence of bone and joint diseases in the United States, already the primary reason people seek medical care梚s sure to rise.  Thus, the demands will soon be even greater.  Students must master the topic of musculoskeletal medicine.  The results of these studies suggest that they have not.?br>
KEY POINTS FROM SUNCOAST HEALTHCARE PROFESSIONALS
(1)   On this musculoskeletal medicine test, orthopedic residency directors considered a passing score to be 73.1%, and 82% of the examinee抯 residents failed to demonstrate basic competency.
(2)   On this musculoskeletal medicine test, internal medicine residency directors lowered the passing score to 70%, and 78% of the examinee抯 residents still failed to demonstrate basic competency.
(3)   The lowest percent of correct answers pertained to questions relating to the spine, indicating that these residents are least competent in musculoskeletal spine issues.
(4)   These experts in both orthopedics and internal medicine consider new-onset of low back pain in a pediatric and pregnant population to be an indicator for exposing radiographs.
(5)   The average amount of time spent in medical education on orthopedics was only 2.1 weeks.
(6)   33% of medical school graduates had no exposure to orthopedics.
(7)   The orthopedics emphasized in medical school emphasizes surgery, and not common daily clinical problems.
(8)   Musculoskeletal problems will increase in the future because of the aging population.
(9)   Medical school preparation in musculoskeletal problems is inadequate.