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 an Orthopedic Surgeons office. The onset of joint pain without significant trauma is very common over the age of 40.

Perhaps you wait a week, or worse, you run off to your primary care doctor immediately.  Surely pain means that something is wrong… right?  Well, not so fast. Many of us will have shoulder, elbow, or knee pain for no apparent reason as we age.  Sedentary behavior is not tolerated well by our joints.  Our tendons and muscles like to be exercised. They like the force or stress that resistive exercises provide.  A joint supported by weakened muscle is a joint at risk for pain. That being said, even if you do exercise, you are still at risk for developing joint pain.  So back to your aching knee or shoulder.  What’s your next step?

Let’s say you do go to your primary care doctor or Orthopedist. Many of you expect an MRI to be ordered. Some 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.

shoulder MRI findings in people with no pain

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 “tear” was there long before your pain started. There is also an 80+% chance of a disc abnormality on a spine MRI in “normal’ people. Meniscus tears are very common in folks who have no knee pain. I know very successful runners with meniscus tears managed without operations and 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.

MRI changes in knees

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.  These studies show that physical therapy is as effective as surgery for these age appropriate findings.

In the majority of circumstances we do not have to rush into ordering an MRI   Unless there is history of a traumatic injury. Say a fall from a ladder, a twisting injury to knee while playing soccer or you fell off your bike most joint pains can be observed clinically for signs of improvement.  Assuming your examination and x-rays do not reveal anything that strongly suggests that 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 will 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.  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.

We haven’t even touched on the issue of potential over-treatment. 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.  We as physicians should strive to treat patients and not imaging study impressions, but that can be a challenge for some.  There are most certainly a number of people undergoing surgery for an age appropriate change before giving non-surgical management a chance to work.  Now the 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 an arthroscopy are very real.  These are risks that many are willing to assume in the proper context. But they should not be exposed to them unless clinically indicated, and other less risky options have failed to improve their quality of life. The only surgery without risk is a 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.

Disclaimer:  this information is for your education and should not be considered medical advice regarding diagnosis or treatment recommendations. Some links on this page may be affiliate links. Read the full disclaimer.

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About the author:

Howard J. Luks, MD

Howard J. Luks, MD

A Board Certified Orthopedic Surgeon in Hawthorne, NY. Dr. Howard Luks specializes in the treatment of the shoulder, knee, elbow, and ankle. He has a very "social" patient centric approach and believes that the more you understand about your issue, the more informed your decisions will be. Ultimately your treatments and his recommendations will be based on proper communications, proper understanding, and shared decision-making principles – all geared to improve your quality of life.

2 comments on “Should We MRI All Patients With Joint Pain?

  • Hi Dr.
    I am a 52 year old Male 6 feet 172 lbs about 18% body fat. I was training for the Marathon and it was going well until I began to develop some knee pain after certain runs (Yasso 800 not long slow runs) that eventually worsened.
    I went to my Orthopedic Surgeon in Chicago (city) and he suspected a menisucs tear and went in for xray and MRI.
    I just got back the MRI and am experiencing some of the psychology you mention
    It appears that there is a medial meniscus tear due that is degenerative on one of the menisci and at that point the cartilage is worn thin and damaged and at that point some bone bruising and what he called mild arthritis albeit at that one point..
    I am now experiencing low level burning pain but no sharp pain – knee feels weak.
    He advised that I “rest” for 6 weeks and then evaluate but that my running marathons is probably over – ok I can deal with the following
    – what cardio is safe (starimaster?) during this 6 week “rest” period
    – can I continue to so lower leg weight lifiting? during the “rest” period
    Given the information I have shared does the meniscus/cartilage/bone issue sound reversible to you and will it only get worse?
    I will follow whatever diet/exercise regimen is necessary to overcome this…
    I feel like my doctor rushed me (I have cadillac insurance btw) and did not give me a thorough pan even during the 6 “rest” weeks
    Any advice is appreciated – yes I love to run but dont want any to jeopardize myself with arthritis either
    Thanks for your you tube videos
    Best
    Ted

    • Hi Ted … Thanks for your kind praise.
      Osteoarthritis is a common issue today. It appears to be more common than in the past. Modern medicine can not reverse arthritic changes, but there is some early research showing that PRP and/or certain stem cells injections might, repeat, might slow the progression of osteoarthritis. This area is still the wild west in Ortho, but it might be worth talking to some experts in your area about it.

      Rest is a relative term in Orthopedic Surgery. Rest rarely implies sitting on a couch. Everyone who is able to should pursue resistive exercises and non impact forms of aerobics. It would be a shame to lose all your aerobic fitness waiting a few weeks to a few months for your knee to calm down. Non impact aerobics and body weight resistive exercise will not worsen the progression of the arthritis above its typical baseline progression. Swimming, cycling … perhaps an elliptical, can help maintain your aerobic fitness. All runners should perform some form of resistive exercises such as squats, wall sits, lunges, calf raises, bridges, etc. You may want to work with a PT too for some structured guidance as you start out.
      You may or may not be able to return to distance running. Tough to say and I haven’t seen you or your studies so I can not comment on that. Try to find a Sports doc who is also a runner. They tend to know the research better… and certainly understand a runner’s mindset.

      Good luck.

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