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Wrinkles on the Inside

"Wrinkles on the Inside" is the title of a booklet written by 3 physical therapists: Tim Flynn, PT, PhD, Jared Hall, PT, DPT and Jim Heafner, PT, DPT. I really like the title of the book and the concepts and imagery used to describe what's happening to our bodies as we age.

We're all familiar with the lines that develop on our faces as we age. We call them wrinkles. If you smile a lot, you'll have laugh lines, if you frown more, well, you'll deepen those lines. Do wrinkles hurt? No (well, maybe just our ego!) Not surprisingly, the inside our our bodies function in a similar way. As we age, we develop wear and tear in certain patterns depending on our use. You may have heard the term "degenerative joint disease" which is really just another term for osteoarthritis. Which, in this context, is just another phrase to describe wrinkles on the inside. Over time, the cartilage that lines the articulating surfaces of the joints becomes frayed and worn simply by the tasks involved with daily living and exercise. This can lead to arthritis or disc degeneration that may be seen on imaging.

In modern medicine, it is not uncommon to get imaging such as an X-ray or MRI. But is it helpful? That depends. It is likely that if you're lucky enough to live into your seventies, you will have 7 decades of wear and tear on your body. We would expect to see those wear patterns on bone and other soft tissues. Is that the cause of the pain you're coming in to see your therapist? That depends. That's where physical therapists come in: to correlate your physical symptoms with the presentation on imaging. The other question I like to ask patients: will getting imaging change what we do in therapy? The answer is often "no." Patients are not likely to jump to surgery right off the bat (and honestly, most physicians and insurances would make you go through a course of physical therapy to see if the problem could be solved conservatively.) Physical therapists are taught in school to look for impairments and treat those rather than treating pathophysiology seen on imaging.

There's an oft-quoted study by Brinjikji et al in 2014 that looked at the MRI findings of age- and gender-matched people who had low back pain (symptomatic) vs those who did NOT have low back pain (asymptomatic). The some interesting findings in this systematic review are that, for example, disc degeneration is observed in imaging in 52% of ASYMPTOMATIC 30 year olds and 88% of ASYMPTOMATIC 60 year-olds examined in the study in which a total of over 3,000 asymptomatic individuals. Similarly, disc bulges are found on MRI in 50% of 40 year-olds and 77% of 70 year olds who are ASYMPTOMATIC.

This is all to say: if you have pain or functional deficits, come in to see your physical therapist. Together, we will make a joint decision about how we will proceed with your care in therapy and if and when it is appropriate or necessary to refer you on to imaging or a specialized physician.


Flynn, Heafner, Hall. Wrinkles on the Inside: A Look Into How We Age. 2019

Brinjikji W, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. PMID: 25430861; PMCID: PMC4464797.

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