Patient questions · Answered personally
Patients send the questions no one has answered for them. These are my answers: in my own words, including the ones where the honest answer is "I cannot help you, and here is who can."
Why this page exists
Doctors may have told you to give up.
I don't.
And neither should you.
When pain persists, treatments fail, or surgery seems like the only remaining option, it may be time to look at the problem differently. Most people who reach my office have already been told that their imaging is normal, that nothing more can be done, or that they should "learn to live with it." They arrive apologising for taking up time. This page is for them: plain answers to the questions patients actually ask, and an argument, made repeatedly and on purpose, that your symptoms are real, that a cause exists whether or not it has been found yet, and that you are entitled to keep looking for it.
Who answers
Dr. Tortland, personally
Typical reply
Within 2 business days
Cost to ask
None
Published anonymously
Always: no names, ever
Patient advocacy
These are not slogans. They are the working assumptions I bring to every new patient, and they change what happens in the exam room.
01
The specialty on the door matters less than whether the physician will identify the pain generator before proposing a treatment. Ask how they will find the cause, and what they will do if the first answer is wrong.
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02
You are the only person present at every appointment in your case. Come organized, ask for reasoning rather than conclusions, and know that a second opinion is a right, not an insult.
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03
"I've tried everything" almost always means a series of treatments aimed at an unconfirmed diagnosis. A different diagnostic effort is not the same as another round of what failed.
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04
What you describe is clinical evidence. Pain that persists, reproduces with a movement or follows a nerve distribution is a finding, and the losses it causes belong in the chart too.
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05
A normal test does not mean a normal patient. Static imaging misses what only appears under load, and pain refers, so the scan may have been aimed at the wrong structure entirely.
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And if I cannot help
Some problems belong in an operating room, and some tissue is beyond biologic repair. Declining to treat is part of honest practice, but it comes after a real diagnostic effort, never instead of one.
In his own words
Lightly edited for length and anonymised. The substance is unchanged.
It's not all in your head
No. Let me be as direct as I can be: a normal test does not mean a normal patient. It means that particular test, on that particular day, did not capture what is wrong with you.
Most imaging is static. You lie still inside a machine and it photographs your tissue at rest. But a great many musculoskeletal problems only appear under load or motion: a partially torn tendon that gaps only when you contract it, a nerve that stops gliding only when you extend the joint, a ligament that is competent lying down and incompetent standing up. Dynamic ultrasound routinely shows me findings in patients whose MRI reports read as unremarkable.
There is also a simpler explanation that gets overlooked: the wrong structure was examined. Pain refers. Hip pathology presents as knee pain, thoracic problems present as chest pain, a gluteal tendon presents as low back pain. If the imaging was aimed at the site of the symptom rather than the source, it can be perfectly normal and perfectly irrelevant.
Pain has a psychological dimension: chronic pain reliably affects sleep, mood and attention, and I will not pretend otherwise. But that is pain causing distress, not distress inventing pain. The order matters, and it is frequently reversed in a chart.
"It's all in your head" is not a diagnosis. It is what gets said when the workup has run out of ideas.
Paul D. Tortland, DO, FAOASM
Finding the right doctor
Stop looking for a specialty and start looking for a way of thinking. The question is not whether someone is an orthopedist, a physiatrist, a sports medicine physician or an osteopath. The question is whether they will identify your pain generator before proposing a treatment.
Things worth asking on a first visit: Will you examine me physically, with your hands? Do you image dynamically, in the office? What are the possibilities besides the one you have named, and how will you tell them apart? What happens if this treatment does not work? A physician comfortable with those questions is a physician who is reasoning rather than routing.
Watch, too, for how a practice handles uncertainty. Someone who says "I do not yet know, and here is how we will find out" is more useful to you than someone who is immediately certain. Confidence is easy to perform and hard to earn.
And weigh who does the procedure. In regenerative orthopedics especially, the physician's hands, imaging skill and experience matter more than the marketing of the product. Ask how many of these the doctor has personally performed, and whether they will be the one performing yours.
The right doctor is not the one with the most confident answer. It is the one who insists on finding the actual cause first.
Paul D. Tortland, DO, FAOASM
Be your own advocate
Be organized rather than adversarial. The most effective patients I see arrive with a one-page history: when it started, what makes it better and worse, what has been tried and what each thing did, and their actual goal, not "less pain," but "walk the dog for a mile," "return to overhead lifting," "sleep on that shoulder." Specific goals change clinical decisions.
Bring your imaging on disc or via portal, not just the report. Bring a list of your questions and keep it visible. And ask for reasoning, not just conclusions: "What made you rule that out?" is a collaborative question, and a good clinician will welcome it.
If you are dismissed, you are permitted to say so plainly and move on. Requesting your records, seeking a second opinion, or declining a proposed surgery are all normal exercises of your rights, not acts of defiance. You are the only person present at every appointment in your case. That makes you the continuity of care.
You are the only one who attends every appointment. That makes you the most informed member of your own care team.
Paul D. Tortland, DO, FAOASM
Your symptoms are valid
What you are describing is one of the harder parts of chronic pain: the invisibility of it. There is no cast, no scan everyone can point at, and the fatigue of managing it looks, from outside, like withdrawal or reluctance.
Your symptoms are data. Pain that has persisted, that reproduces with a specific movement, that follows a nerve distribution, that wakes you at a particular hour: these are clinical findings, and I treat them as such. I have built a diagnosis on a patient's description more than once when the imaging offered nothing.
It also helps to name the cost out loud, to family and to your clinicians. Not the pain score: the losses. The hobby you stopped. The stairs you avoid. The work you are doing at sixty percent. That is the part that actually needs treating, and it is the part most likely to be left out of a chart.
Your description of your own pain is clinical evidence. Not a complaint to be managed around.
Paul D. Tortland, DO, FAOASM
Don't give up on yourself
"Everything" is almost never everything. When I take a careful history from a patient who says this, what I usually find is a series of treatments aimed at a diagnosis that was never confirmed: injections into the joint when the problem was the tendon beside it, therapy for a rotator cuff when the pain came from the nerve, surgery on a structure that was degenerated but painless.
So the honest answer has a condition attached. It is reasonable to keep going if the next step is different in kind from what has failed: a fresh diagnostic effort rather than another round of the same treatment. Repeating a failed approach with more determination is not persistence.
I will also tell you when I do not think I can help. Some tissue is too far gone for biology to repair, and some problems genuinely belong in an operating room. Saying so is part of the job. But that conversation should come after a real diagnostic effort, not instead of one.
In more than 30 years of this work, the patients who eventually got better were rarely the ones with the least damage. They were the ones who kept insisting the cause be found.
Hope is not a treatment plan. But neither is resignation, and only one of them leads to a diagnosis.
Paul D. Tortland, DO, FAOASM
The question I am asked most
Not which is "better." They buy different things at different prices, and the honest comparison includes where surgery wins.
The short version
Surgery is mechanical: it removes, repairs or replaces structure, and it is decisive when structure is the problem. PRP is biologic: it stimulates repair in tissue that still has the capacity to heal, and it changes nothing mechanical. The real trade-off is certainty versus reversibility. Surgery offers a more predictable outcome and a permanent alteration of your anatomy. PRP offers a slower, less certain result that costs you nothing you cannot get back, and leaves surgery fully available if it fails.
Choose surgery first
Try biology first
The part rarely said out loud
A great deal of orthopedic surgery is performed on findings that were never the source of the pain. Degenerative changes are extremely common on imaging in people with no symptoms at all, so seeing a tear on a scan does not establish that it is your tear. That is the reason I put so much weight on a dynamic diagnostic examination before recommending anything, biologic or surgical. The wrong operation, done well, still leaves you in pain.
Treatment questions
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Include what hurts, how long it has been going on, and what has already been tried. If your question would help other patients, it may be published here: anonymously, always.
Written question
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Questions answered on this page are general patient education and do not constitute medical advice, a diagnosis, or a physician-patient relationship. I cannot give individual medical direction by email or telephone without an examination. If your symptoms are worsening rapidly, you have new weakness, numbness or loss of bowel or bladder control, or you have signs of infection, seek urgent care now rather than waiting for a reply.
Sources
01
Brinjikji W, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology.
02
Girish G, et al. Ultrasound of the shoulder: asymptomatic findings in men. American Journal of Roentgenology.
03
Beard DJ, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet.
04
Kise NJ, et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial. BMJ.
05
Mulvaney SW, Tortland PD, Shiple B, Curtis K. Regenerative medicine options for chronic musculoskeletal conditions: a review of the literature. Endurance and Sports Medicine. 2018.
Browse
Every patient question Dr. Tortland has answered about PRP, BMAC, MFAT and non-surgical orthopedic care, in one place.
A dynamic ultrasound evaluation looks at your tissue moving under load, which is where a great many "normal" imaging results turn out to have missed something.