Should We MRI All Patients With Joint Pain?

You wake up one morning and your shoulder hurts. You’re not sure why and blame it on your sleeping position.  Or perhaps you bent down to pick something up and when you stand up your knee hurts. These are very common stories heard from patients in the office of an Orthopedic Surgeon.

The onset of joint pain without significant trauma is very common over the age of 40. Wait, What? 

It’s true… joint pain will affect everyone.  Humans love to assign blame.  The pain must be because of “X” and it’s the “Y” that’s hurting me.  Well… you don’t have to sustain an injury to have joint pain, and more often than not, the findings on your MRI may not be the cause of pain.  Keep this post in mind as you read through this… you cannot unsee your MRI report. 

Perhaps you wait a week before seeing a doctor.  Worse yet, you run off to your primary care doctor immediately.  Surely pain means that something is wrong… right?  That seems intuitive.  We’ve always been taught that pain is bad… or that pain means that something is wrong.   Well, not so fast.  Sure, some of you might have horrible pain that requires attention… but most don’t. 

Many of you will have shoulder, elbow, or knee pain for no apparent reason as we age. 

Our tendons and joints hate vacations and surprises.  Meaning, they don’t like periods of inactivity or an activity level 2-3x what they are used to.  

Sedentary behavior is not tolerated well by our joints.  Our tendons and muscles like to exercise.  That ‘s why we tell people with mild-moderate arthritis to keep exercising.  Our muscles, tendons, and joints like the force or stress that resistive exercises provide. 

A joint supported by weak muscles is a joint at risk for pain. That being said, even if you do exercise, you are still at risk of developing joint pain.  Part of being an aging athlete is dealing with these occasional setbacks.  This post dove into managing the mature athlete… and rest is rarely the right answer. 

 So back to your aching knee or shoulder.  What’s your next step?

Should I insist on an MRI? 

Let’s say you do go to your primary care doctor or Orthopedist. Many of you expect your doctor to order an MRI. Some of you will actually insist on it. 

I am asking you to think twice before demanding an MRI study. Why? Because almost no one over the age of 40 is going to have a normal knee or shoulder MRI. A good radiologist will be able to find “changes” with almost any study. See this graphic… then let’s consider what it means.

As we mature, various “age-appropriate” changes are going to take place. If you are referred for a shoulder MRI there is a very high probability that the scan will show a labral tear… and there is a nearly 100% chance that the “labral tear” was there long before your pain started. There’s a good chance your rotator cuff will show a “partial tear”… it’s not really a tear. It’s more like the front of your blue jeans where the knee portion wears out.  And turning over in bed or sleeping wrong didn’t cause it.  

There is also an 80+% chance of having a disc abnormality on a spine MRI in “normal’ people.  You don’t want to have spine surgery unless absolutely necessary.  Don’t chase a spine MRI unless there’s a good reason to do so. 

Meniscus tears in your knee are very common in folks who have no knee pain. Yes… many people in the 50s and beyond who are walking, running, playing golf, tennis and cycling have a meniscus tear and don’t know it. 

I know very active runners with meniscus tears treated without operations and they have no ongoing issues. I have treated hundreds of patients with meniscus tears without surgery. Most returned to an active lifestyle. Very few worsened over the years. And it is very unlikely that an operation or earlier imaging would have influenced their ultimate clinical outcome. That’s the key take home. 

The bottom line is that imaging someone after the age of 40 is rarely going to result in an impression that says “normal”.  And the changes seen on the MRI might not even be the cause of the pain or correlate with the severity of your pain. 

More importantly, most of the current research into small degenerative rotator cuff tears or tears of the medial meniscus shows that the results of surgery are often no better than placebo.  That means that they took a group of people with a certain tear. They operated on half of them, and the other half just had anesthesia and two cuts were placed on their skin.  The tear wasn’t treated in the placebo group.  Guess what?  Both groups had improved pain.  

Many studies show that physical therapy is as effective as surgery for many of these age-appropriate findings.

In the majority of circumstances, we do not have to rush into ordering an MRI unless there is a  history of a traumatic injury. Immediate severe pain after a fall from a ladder, a twisting injury to the knee while playing soccer, or a fall off your bike might result in the need for an MRI. 

Most mild to moderate atraumatic joint pains can be observed clinically for signs of improvement.  Assuming your examination and x-rays do not reveal anything that strongly suggests that advanced imaging would change the treatment recommendations — then observation, benign neglect and physical therapy will ultimately return most of you back to the level of function you had before your shoulder or knee started bothering you.

Ok.. so you want the MRI anyway.  And your physician obliges you.  What’s the harm, right? Wrong. 

After an MRI you might find out that you have a meniscus tear or a rotator cuff tear. Many of you will be able to take that information in stride and move on.  Many of you may not.  You cannot unsee your MRI report. Every serve or overhead in your tennis game will be affected… every time your shoulder aches or clicks you will think your tear became larger.  You will stop kneeling or squatting down in fear of making your meniscus “tear” worse. You could be very afraid that you will not be able to go on that vacation you have scheduled in two months. 

All these “what if…” questions start to swirl around your mind.  I’ve seen this in my clinical practice more times than I care to remember.

Over-imaging can lead to over-treatment.  

We haven’t even touched on the issue of potential over-treatment yet. While it’s true that most degenerative cuff tears and meniscus tears feel better over time ( a few months, not a few weeks) with physical therapy, there are still some patients who will receive treatment recommendations based on their MRI findings. You must always ask a doctor who recommends knee or shoulder surgery the following: ” What will happen to me if I don’t have the surgery?”

The truth is that most of you will get better. Some won’t and may need to have an operation.  There is a ton of scientific literature to support these claims.  

We as physicians should strive to treat patients and not imaging study impressions, but that can be a challenge for some docs.  There are most certainly a number of people undergoing surgery for an age-appropriate change before giving non-surgical management a chance to work. 

When considering surgery, now the potential risks becomes real.  Anti-coagulation for AFib is stopped, a DVT might occur, your arthritis might worsen from the loss of meniscal tissue. The risks of arthroscopy are very real.  These are risks that many are willing to assume in the proper context and if surgery is truly in your best interest.  But people should not be exposed to risk unless surgery is clearly clinically indicated.  This also assumes that other less risky options have failed to improve your quality of life. The only surgery without risk is surgery on someone else.

When managing knee, back, elbow, and shoulder pain in the middle age adult and beyond less is often more.  Sure, there are times to image these patients. Yes, some may ultimately benefit from imaging and surgery. But the numbers of people who would qualify as appropriate candidates for imaging and/or surgery are far lower than they are today.