- Dr. Karen Fernandez, PT, DPT
We treat Humans, not MRI's
It is fair to say that the healthcare field has had some great advancements. We can now see the integrity of internal human structures in a variety of ways: magnetic resonance imaging (MRI), radiography (X-Rays), ultrasound (US), computed tomography (CT), among others.
This imaging has been vital to MD's and surgeons in order to find things like fractures after a trauma, cancer that is localized or metastasized, assist in verifying locations of damaged tissue due to strokes, seeing a baby in a mother's womb, and many other uses.
Many patients have multiple images taken of the areas that are causing them pain. When the cause is traumatic, this is extremely useful to make sure there is no fractures that need fixation before allowing weight or movement.
However, a huge misconception is that findings of torn ligaments, ruptured muscles, degeneration, disc herniations or bulges, labral tears, and structural changes like spondylolisthesis are the cause of such pain.
Yes, that is right. This is not to say they can't be. But an "abnormal" finding is not an automatic and definitive cause of the pain you are experiencing. There have been a number of studies demonstrating how healthy, symptom free people also have structural changes like the ones mentioned above. Here are a few:
1. Brinjikji et al. 2015 reviewed 33 articles including 3110 symptom free adults from ages 20-89 that had MRI or CT scans. They discovered that as we age there is an increased prevalence of degeneration in the spine as shown below:
1. Girish et al. 2011 looked at US findings of shoulders in 51 symptom free adults ages 40-70, of which 96% showed at least one "abnormality". Findings included:
Subacromial-subdeltoid bursal thickening in 78% (40/51)
Acromioclavicular joint osteoarthritis in 65% (33/51)
Supraspinatus tendinosis in 39% (20/51)
Subscapularis tendinosis in 25% (13/51)
Partial-thickness tear of the supraspinatus tendon in 22% (11/51)
Posterior glenoid labral abnormality in 14% (7/51)
2. Athletes can also have structural changes in their dominant shoulders with NO PAIN. Connor et al. 2003 did a 5 year follow-up of elite overhead athletes that were symptom free and found:
8/20 (40%) showed partial- or full-thickness tears of a rotator cuff muscle, and no pain
5 years after the study none of the athletes had developed pain or required evaluation/treatment of the dominant shoulder.
1. Guermazi et al. 2012 studied 710 adults aged over 50. Overall this study found "abnormalities" in 89% (631/710) of the adults.
Osteophytes in 74% (524/710)
Cartilage damage in 69% (492/710)
Possibility of at least one abnormality was high in both adults with pain (90-97%) and pain-free (86-88%) knees.
1. Register et al. observed 45 symptom-free people, aged 15-66, that had an MRI of their hip.
Labral tears were identified in 69% of hips scanned
Overall 73% of all people, had at least one abnormality
TLDNR...What These Numbers All Mean
Evidence shows that as we age it is more likely that imaging will show an "abnormality", or structural change. This is normal and can be seen in the spine, shoulder, knee, hip, and I'm sure almost every other joint. The above articles are only a small collection of evidence on this topic. They suggest that these "abnormal" findings are a part of normal aging and unlikely the sole cause of pain in our patients.
Therefore, it is important that clinicians and patients, as consumers of healthcare, do not allow an MRI, US, X-Ray, or CT, to be the deciding factor in the treatment of pain.
A clinician should look at the bigger "picture", the patient as a WHOLE, not just their imaging. Find the impairments and identify what the patient cannot do, what are they being limited to because of their pain, and how can you improve that with the skill set you have.
The technological picture, needs to correlate with the clinical picture.
So as a patient, make sure your Specialist, MD, Physical Therapist, or Chiropractor don't make treatment decisions solely off of your imaging. If there was no trauma and you did not experience a "pop" then it is less likely your clinical test will correlate with imaging. And of course there are exceptions, don’t hesitate to reach out for a free discovery session to talk and ask questions, we are always here to help.
Lastly, if you are a healthcare provider, do not forget to rule out the red flags, and refer out when necessary.
Thanks for reading!