In Response to the Recent NY Times Article…”Treat Me, but No Tricks Please”

A recent article written by Gina Kolata titled “Treat Me, but No Tricks Please” focuses on the lack of evidence based medicine that is practiced when it comes to treating certain orthopedic conditions such as hamstring strains and plantar fasciitis. The article starts by discussing a recent email sent by a doctor who was upset about discovering his physical therapy sessions (20) were not covered by his insurer after he sustained a hamstring strain while running on the beach. His anger stemmed from feeling that the physical therapy was “clearly beneficial and cost effective” despite the fact that he had not yet returned to running 8 weeks after the injury. Gina goes on to mention that she also incurred a hamstring strain though her physician did not refer her to physical therapy but rather advised her to undergo platelet rich plasma injections (PRPs) which are still in the experimental phase but showing promising preliminary results despite not being covered by insurance companies. She proceeds to mention that she has also completed physical therapy in the past but found it to be a “waste of time” and that she predominantly received passive treatments such as ice, heat, massage, and ultrasound. Dr. Feinberg of Hospital for Special Surgery (HSS) echoed Gina’s sentiments regarding these particular treatments. The rest of the article goes on to discuss the dearth of literature relating to the best treatments for various musculoskeletal conditions and James Irrgang (University of Pittsburgh and President of the orthopedic section of the American Physical Therapy Association) is interviewed on matters relating to this topic.

As a physical therapist, elite level triathlete, former Division I athlete, researcher, certified triathlon coach, and former patient (I have sustained numerous musculoskeletal injuries and underwent 5 surgeries for orthopedic related conditions) I would like to respond to this article. Specifically, I would like to address what we know about proper treatment of hamstring strains and the art of practicing evidence based medicine. First off, I am sorry to hear about your calamitous experience with physical therapy Gina and I hope that the PRPs have been helpful in facilitating your return to activity. I also feel like you were shortchanged with physical therapy or perhaps did not work with a skilled therapist as your rehab would have been drastically different had you been under my care. It was reassuring, however, to know that you were an informed patient regarding the experimental nature of PRPs.

It is important to understand when discussing hamstring strains (really a nice way to tell a patient there hamstring is torn) that there is a spectrum of injury severity. Grade 1 strains involve a partial disruption of the musculotendinous unit with minimal loss of contractile function. Grade 2 strains also involve a partial disruption with a significant loss of contractile function. Lastly Grade 3 strains involve a complete disruption of the musculotendinous unit, a palpable mass and result in minimal contractile function. The major risk factors for sustaining a muscle strain are as follows: age (Orchard AJSM 2001), previous strain (Orchard AJSM 1997), muscles weakness resulting in an imbalance between agonist and antagonist (Tyler AJSM 2001) and possibly adverse neural tension (Turl JOSPT 1998). The major factor that has not been shown to be a risk factor for muscle strains is FLEXIBILITY. All patients should be educated on the aforementioned characteristics so they understand their relative risk for engaging in certain sports or activities.

Based on the science that has looked at the physiologic processes which take place following muscle strains (discussed in detail in the Textbook of Sports Medicine Chapter 1.3 Skeletal Muscle: Physiology, Training, and Repair After Injury written by Michael Kjaer, Hannu Kalimo, and Bengt Saltin—Leading Authorities on Muscle Physiology) current recommendations have been put forth by the experts for treating muscle strains. DOs are to stay moving, immediate stretching (submaximal) to promote regeneration of myoblasts from satellite cells, apply ice and compression to decrease bleeding and scar formation, and lastly to initiate early submaximal eccentric contractions at the terminal range of motion. DONTs are immobilization, heat, and rest (which is unfortunately the recommended by subpar healthcare professionals)

While the body of literature continues to expand on how to appropriately treat various musculoskeletal conditions, there are still limitations to many of the studies that we base our treatments and interventions on which is why research is critical to advancing medicine. In time, I am confident that more randomized controlled trials (RCTs) will be published that will serve to elucidate any confusion regarding optimal patient care rendered by physical therapists. I assure you that any solid physical therapist understands that each injury is unique especially when considering the musculoskeletal characteristics and profile of the patient and the demands they place on their body. The gold standard for a physical therapist should be an individual who is: familiar with the research, a good listener, an astute observer, effective at integrating their findings and placing them into context of the patient, and a competent educator. I would like to mention to the doctor who wrote the angry email stemming from his lack of coverage for PT that I will make it a point to study the incidence of running injuries among individuals who run on the sand because my clinical experience has suggested that there is an abnormally high rate of injury when running on unsteady surfaces and had you worked with me the hamstring strain may have been avoided all together. To all of the orthopedists out in practice as well as younger physicians who are in fellowship programs, do yourself a favor and PLEASE become familiarized with what constitutes good physical therapy and share this information with ill informed orthopedists. Lastly, to Gina, what I propose to you is the following…a free consultation and plan of care designed to optimize your musculoskeletal well being and reduce your risk of injury in the future so you have a better understanding of physical therapy, an often times under-appreciated profession. I am sure that you will walk away feeling like I did not “waste your time!”

Yours In Health,

Christopher Johnson, MPT MCMT ITCA