Sunday, June 1, 2008

Imaging and Shoulder Pain: Why we don't treat MRIs....

How many of us have heard patients tell us they'll be relieved if they could just get an MRI to "tell them what's wrong."? I'll be the first to admit I too jumped on this bandwagon early in my career. I was very eager to see an individuals MRI report to correlate their clinical symptoms. You've heard me quote a wise old PT friend of mine who said "We don't treat MRIs". Well RV, this one goes out to you. ;)

This fascination with "seeing" what's wrong has lost a bit of its luster as I've read some very interesting reports on the lack of agreement between MR and clinical presentations. We've seen this phenomenon in low back and shoulder pain where imaging studies don't necessarily correlate with the patients clinical presentation.

It'd been a while since I've seen a good study on this topic so I figured I'd look up what the American Journal of Roentgenology had to say on the issue. The article takes a whopping 1079 consecutive patients referred for shoulder MRI. The subjects were asked to complete validated shoulder questionnaires regarding pain and disability. These were correlated with the radiologists' MR findings.

What did the authors conclude?
  • MRI is highly accurate at detecting the presence of a partial or full-thickness rotator cuff lesion.

  • There was no relationship between pain or disability with the size or location of the rotator cuff tear.

  • Rotator cuff lesions may be thought of as a natural correlate of aging

  • It is not clearly identified why some rotator cuff lesions are symptomatic while others are "silent"

  • Factors such as bursitis, capsuloligamentous lesions, or cartilage lesions may confound the findings of MRI as they pertain to the rotator cuff

  • There may be "no relationship between rotator cuff tear size and the inflammatory reaction responsible for the pain and disability, like low back pain is unrelated to the size of disc herniations."

What are the author's recommendations?

  • "Despite the absence of correlation between the size of the rotator cuff tears and the level of disability,MRI provides important data that may affect the management of rotator cuff lesions and should be performed before rehabilitation or surgery."

Really AJR? Let me make sure I understand. There is little to no correlation between imaging and symptoms, yet folks should go ahead and get the MRI anyway? Even before rehab? That's a hard one to swallow. In his defense of the study's author, the investigation took place in France within a socialized health care system where utilization would doubtless be far different from ours.

Regardless of the author's curious conclusion, the study is an honest representation of how limited the value of MRI can be for common musculoskeletal complaints. It also underscores the importance for physical therapists not to get too caught up in hounding the referring physician for the MRI report.

Treat the patient, not the report!

Krief, O.P. (2006). Shoulder Pain and Disability: Comparison with MR Findings. American Journal of Roentgenology, 186(5), 1234-1239. DOI: 10.2214/AJR.04.1766


  1. The problem comes up because surgeons often base decision to operate on that radiologic finding. Forget correlating with a clinical exam.

    Example: Had a gentleman recently that is wheelchair bound, having shoulder pain with decreased ability to reach overhead. Goes to Ortho, gets MRI, and lo and behold a rotator cuff tear was found. PT was ordered b/c insurance required evidence of conservative care first.

    Exam found 5/5 strength in shoulder and nearly equally restricted AROM and PROM. Oh, and pt was diabetic.

    Treated for ROM issues related to likely AC and his ROM increased, pain decreased and DASH score was cut by greater than half from his initial visit. All at a cost likely less than the MRI itself.

  2. Sorry for changing the subject Rod, but this post sort of struck a nerve.

    Coming from a student's perspective, one who is in the midst of deciding between graduating with an MPT or staying in school to receive a DPT, seeing how rather blatant data is construed so to maintain the physician as the initial step in a patient's rehabilitation doesn't convince me that direct access is right around the corner. Not to say that direct access is the only reason for me to stay in school for the DPT. In my opinion, the invaluable experience of working in the field currently precedes staying in school to receive a degree whose expanded scope of practice isn't likely to be fulfilled in the near future.

    This is a personal opinion of course, coming from someone is more than ready to begin working and stop driving his '97 Accord. Once the landscape does begin to change, I will be more than happy to achieve the highest standard of clinical preparation offered.

    On another note, tell any "Justin" Towles fans in Crosby to work some magic and get him hitting again.

  3. Believe me. We are sacrificing chickens around the clock to get JR on track. He's a good guy and we want to see him do well.

    I understand your frustration and think you make a good point. I won't be holding my breath for direct access either. I need all the oxygen to my brain I can get.

    This study did have a distinct 'cha-ching' factor to it. Imagine if the conclusion had been "There was no correlation between MRI findings and disability. As such we recommend the more judicious applicaton of expensive diagnostic testing." I'm sure there would be more than a few unhappy radiologists in the audience.

    I think time is on our side. We are relatively inexpensive and effective source of conservative care for musculoskeletal complaints. I had a patient come in the other day who's insurance would NOT pay for an MRI until conservative management failed. There are some good things out there. We have to just keep plugging away.

    Great to hear from you by the way Ryan. Feel free to stop by anytime.

  4. Dear Rod:

    I came across your blatantly sexist comments about the blog I write about my chronic pain condition, (Scroll down to jog your memory.) There is no place for people like you in the field of physical therapy. I'm not sure what, if any, action can be taken against you. But, for my own peace of mind, I am sending letters about your comments to both the American Physical Therapy Association (I assume you are a member) and Dr. Phillip Sizer, head of the doctoral program at Texas Tech. Your lack of empathy astounds me. I hope that your mother, sister or significant other never join the ranks of the tens of millions of chronic pelvic pain sufferers. For that matter, I hope that you never experience chronic pelvic pain yourself as men are also sufferers. I would not wish it on my worst enemy. Glad you had such a "blast" at my expense. -Bonnie Bauman

    "Reminds me of something my pappie used to tell me: "Remember. Dyspareunia is better than NO-pareunia." Seriously, theres no way I'm getting up in any of my patients' vajayjay. More power to those who can, but I will most certainly pass on this um...treatment.

    Disclaimer: This is my Y chromosome talking out of turn.

    I had a blast with it and didn't have a drop of alcohol in me at the time. I shudder to imagine what the alternative to thinking "outside" the box would be."

  5. Dear Rod, I read your post or actually your "Y" chromosome's post. These are my "XX" chromosomes responding. As an athlete my entire life- competitive skier, horsewoman, dog trainer, runner, RN I was struck by your lack of professional sensitivity regarding women with pelvic pain. I guess you should know, that pelvic pain strikes men on a very frequent basis. In all likelihood, you have probably misdiagnosed male pelvic pain as a simple muscle strain. I am no wimp. And I can tell you that this kind of pain is debilitating. It stopped my life dead in it's tracks. I am a very strong and optimistic person. I am also lucky to have had good doctors diagnose me right away. I was more fortunate to have doctors refer me to compassionate and skilled pelvic pain therapists. I hope you will educate yourself and others on how to diagnose possible pelvic pain and appropriately refer. I am stunned at your arrogance and lack of professionalism. This only contributes more to the isolation and misunderstanding of pelvic pain in both men and women. Did you know that many competitive cyclists develop this condition- i.e. testosterone filled men who are in such pain and ashamed to seek out care for pain and numbness in their testicles, inability to achieve erections, orgasm, sit comfortably? Anyone who is active and who sits or gives childbirth, or has even one urogenital infection is at risk for this. As an RN, an ex-athlete, a patient with pelvic pain for 18 months, I just could not allow myself to ignore your post. I hope you will take this email as encouragement to reevaluate your sense of professionalism and realize that physical therapy involves the entire musculoskeletal system and organs involved- not just knee strain and such. I hope you give your specific area of specialty the sensitivity and expertise it deserves and appropriately refer pelvic pain patients. I am certain you have missed a few. You can read my blog in the pelvic pain matters archive entitled "Explain the Pain" I urge all your PT students and professionals to read about "cyclists syndrome", rehab of the short pelvic floor etc. So many muscles around the hips and SI joint contribute to pelvic pain and I know it is not part of the standard PT curricula. I am so proud of Bonnie Bauman who "outed" herself as a pelvic pain patient to educate the general public and professionals as well.
    p.s. Rod and I have already had a thoughtful exchange about this and I just posted this to give others a chance to think about some of the more uncomfortable specialties in PT/OT such as musculoskeletal problems that cause pelvic pain in both men and women.