Aaron Perez

The irony I find myself returning to is that MRI technology has not made us better diagnosticians. It has, in many cases, made us worse ones, because the image is so concrete and the language of the report so authoritative that it takes deliberate effort to resist anchoring to it. When the MRI arrives before the history is fully taken, the finding shapes what questions get asked and which ones don't. Bias abounds throughout the encounter. The encounter organizes itself around what the scanner found rather than what the patient experienced, and that is very difficult to undo once it has happened. Don't look at the scans first... the basics matter. Take a history... confirm it with an exam, then see if the MRI findings make sense in the same context.

We've been told for decades that osteoarthritis is "wear and tear." But.... it's mostly wrong. If mechanical wear were the primary driver, runners would all need knee replacements. They don't. In fact, recreational runners have lower rates of knee OA than sedentary people. Most research shows that running can be protective. Go figure! We've been told to rest. No... that's makes things worse. People who are active and strong keep their joints longer. No matter what the crays hsows. One thing that's changed is metabolic health. Elevated blood sugar, insulin resistance, chronic low-grade inflammation — these degrade cartilage at a cellular level. Inflammatory mediators circulate through our bodies and affect joint tissue from the inside. I see this every day in my office… people (with solid metabolic health) with horrible-looking X-rays and very little pain, and people with mild arthritis on imaging who are miserable. The difference isn't the X-ray. It's the inflammation. I put out an entire book on knee osteoarthritis on my substack lat summer. So to answer the question… it hasn't always been like this. But our metabolic health hasn't always been like this either. And far too many people are not being given proper guidance on how to manage their OA.

Here is the foundation of a message I have been repeating for decades: you are not broken. Aging tissues adapt and remodel. They accumulate structural changes that look dramatic on a screen or report but often function remarkably well in real life. When we frame every structural variation as pathology, we risk overdiagnosis and overtreatment. When we instead recognize that many imaging findings are common, or age-related phenomena, we can shift the focus back to capacity, strength, load tolerance, and resilience. open.substack.com/pub/howard…