Muscle ‘Strain’ or Tear?
Over the past two decades, the insurance industry has waged a war on their policy holders who have suffered soft tissue injuries in motor vehicle collisions. In the mid 1990’s, they adopted a set of guidelines (called MIST) for the claim adjusting of soft tissue injuries. They have worked hard to produce the myth that soft tissues injuries are something that should resolve with or without treatment in three to six weeks, after which a patient should require no more care. The term “soft tissue” includes tissues such as muscle, tendon, ligament, and cartilage, and the three to six week healing time only applies to muscle (and even that can be disputed), but the insurance industry has mistakenly (and on purpose) applied those parameters to all of the soft tissues, thus minimizing the need for care and for compensation ( Berardinelli DJ. From Good Hands to Boxing Gloves: The Dark Side of Insurance, Trial Guides LLC, Portland OR, 2008). The term “muscle strain” means that muscles fibers have been torn, and there are three grades of muscle strain, with grade I being minimal and grade III being severe. Most muscle strains heal quickly with no residual symptoms. I have personally seen severe muscle strains (i.e. the pulled hamstring which is black and blue from the buttock to half way down the calf) which result in permanent shortening of the muscle due to the invasion of scar tissue during the healing process, but in the grand scheme of things, these are rare, and most muscle strains respond very well to therapy and heal quickly.
Ligaments and tendons have much poorer blood supplies than the muscles, and take much longer to “heal,” if they do so at all. When a ligament is stretched beyond its normal limits and individual collagen fibers tear, this is properly termed a “sprain” injury, and it too has three grades of severity, just like the strain. But when a ligament is stretched, it never regains its original length, and this constitutes a permanent injury. The joint which the ligament is supposed to stabilize becomes unstable, and muscles which overlie the joint are recruited by the central nervous system to stabilize the joint. Consequently, they become over-worked, develop trigger points, and the muscles become permanently short, tight, and tense, and very inefficient- and more easily injured. Eventually the body lays down calcium in the injured ligaments to stabilize them- this is commonly called osteoarthritis. While osteoarthritis is commonly associated with the aging process, and it does worsen with age, the fact is that the development of the bony spurs just takes time, during which the patient may or may not feel pain. But many times, the precipitating event is the motor vehicle collision.
Digital Motion X-ray
I have treated many patients who have been injured in motor vehicle collisions over my twenty-eight years in practice. Prior to November of 2010, I had never heard of digital motion x-ray, so I didn’t know about the diagnostic information it could provide. On almost every occasion, I used the code “847.0” to describe the diagnosis. 847.0 means “cervical strain/sprain,” and if you would have put me on the witness stand and asked me to define cervical sprain, I would have told you that it meant torn ligaments. “And you are treating these ligaments, are you not, Doctor?” The answer would be yes. “And can you tell me just exactly which ligaments are torn and which ones you are treating, Doctor? Be specific, please.” I would have had to sit there like a fool and admit that I didn’t know. And so would most doctors who treat motor vehicle collision victims. The truth is that plain film x-ray (the standard seven view Davis series), MRI, and CT scan do not adequately visualize torn ligaments. Torn ligaments are best visualized with a digital motion x-ray study.
The digital motion x-ray study is a modified Davis series. The parameters of joint motion have been long established by the early pioneers of motion x-ray (they called it cineradiography, cineroentgenography, or videofluoroscopy), and that information has been refined with more recent studies done on live subjects with arthroscopy, digital motion x-ray, and computer modeling, so that when a joint is put into motion, we know what is supposed to happen under normal circumstances. When the spine is put into motion and taken to the extremes of the range of motion, unusual gapping (the medical term for gapping is “diastasis”) between bones occurs when the ligaments are damaged. This is pictorial proof that even someone without training in radiology can see- soft tissue ligament injuries are for real. They are permanent.
Guides to Permanent Impairment
The AMA’s Guide to Evaluation of Permanent Impairment, 6th Ed., recognizes the torn ligaments as significant injuries because they cause joint instability. The authors term this AOSMI, or Alteration of Spinal Motion Integrity, and they require a demonstration of at least 3.5 mm. or 20% translation (linear slippage) of one segment upon another to qualify for instability. Each unstable segment is assigned a 4-8% whole person impairment rating, and multiple unstable segments are assigned a starting point of 19% permanent whole person impairment, before the modifiers are applied. But according to Daffner, RH et al. (A New Classification for Cervical Vertebral Injuries: Influence of CT. Skeletal Radiology 2000; 29: 125-32), who did a study based on their analysis of 1,052 separate cervical spine injuries, a spinal injury should be classified as “major” if any of a long list of radiographic/CT findings was present, the first of which was “more than 2 mm of displacement of a vertebrae in any plane,” which is a very common finding on cervical motion studies. And, in the real world, it isn’t the amount of displacement which is important- it’s the fact that the ligament has been torn, and that it will never be the same again. The standards established are far above the baseline necessary to cause symptoms. In 1975, White and Panjabi () established that the upper limit of normal for displacement of one vertebra on another was 3.5 mm., and the medical profession adopted that as its standard, and they have never changed it. Since then, more sophisticated methods of measurement and evaluation have evolved, and we now know that the threshold for ligament injury is much less than that. (Lin, et al.).
What does all this mean? It means that based on plain film studies done in individual doctor’s offices or by the local diagnostic centers, your clients have been grossly under-diagnosed. Other than the really lame cervical sprain codes, no mention is made of any specific ligamentous injury. If specific ligaments are mentioned, then solid objective proof has to be available, and the appropriate diagnosis codes for describing ligament injury have to be used. Contrary to popular opinion, cervical spine MRI is not very good for identifying ligament injuries. A picture is worth a thousand words, and when the moving pictures show a bone that is way out of place, and anyone can see it, it has impact- major impact. The jury no longer listens to a defense attorney making the case that the soft tissue injuries are being faked, because they aren’t being faked. No one could fake the lateral mass of the atlas sliding off the lateral mass of the axis when tipping the head to the left or right! And these injuries are ridiculously common. Just take a look at the link to the article about the alar ligaments which establishes that the alar ligaments are naturally more brittle due to a low percentage of elastin fibers, so they are easily torn (Saldinger, et al. Histology of the Alar and Transverse Ligaments, Spine, Vol. 15, No. 4, 1990, p. 257-261)).
The cases you have been handling all along have all had these injuries involved. The DMX technology has been around for almost 25 years, but my machine is the only one in the Tucson area. After a proper physical examination, the only way to evaluate the full extent of your client’s for instability secondary to ligamentous injuries is with a digital motion x-ray exam. The 5th Edition of the AMA Guides to the Evaluation of Permanent Impairment puts it like this on page 379: “Motion of the individual spine segments cannot be determined by a physical examination but is evaluated with flexion and extension roentgenograms.”
Will you get resistance from the insurance companies when you ask them for fair compensation for your client’s injuries? Absolutely! But you’re getting that anyway right now! I know I’m preaching to the choir when I tell you that the insurance companies don’t want to pay anything to anybody- if they could, they would keep every bit of premium money for themselves. Will they send your clients with extensive ligamentous injuries to IME doctors who are on their payroll who will write reports which will discount the importance of the motion studies? You’d better believe it! But notice that I said “discount,” not “refute,” as at this point, I am unaware of any local radiologists, neurologists, neurosurgeons, orthopedists, or physiatrists who have ever had any training in interpretation of digital motion x-ray, so their opinions are easily refuted. At the same time, I have the privilege of being able to send all of my studies out to Avery Knapp, MD, a neuroradiologist who really “gets it” when it comes to DMX studies, advanced MRI studies, and the proper diagnosis of ligament injury. If you have any clients who have had MRI studies which were read as mostly negative, and continue to have radical symptoms, it is worth your time and money to send the studies to Dr. Knapp for his opinion. He works for EliteRad Radiology Services, of Winter Springs, Florida, but is licensed in Arizona, and locally EliteRad is contracted with SimonMed to read the films associated with personal injury cases.
Please don’t get the idea that digital motion x-ray studies are only for the “really difficult cases.” Everyone who is whiplashed is a “really difficult case,” as every one of them will tear ligaments, which will cause permanent consequences. Naturally, some will respond better or differently than others, and one thing that has been very apparent since I began doing this work is that chiropractic care for motor vehicle collision victims is very effective in creating a favorable outcome.