We often get a phone call or an email from someone who has a digital shoulder MRI file that shows damage. They have been told recently, the “only way” to fix this damage is with surgery, and as we will see from the research below, the surgery may not offer the results the patient is hoping for.
My Shoulder MRI is bad, my doctor says surgery
Sometimes, someone will have a bad shoulder and a bad MRI and surgery may be the best answer. However, shoulder MRIs may present faulty or inaccurate information. In our many years experience, we have found that when MRI is the sole governing tool relied upon by doctors to recommend treatment, a patient will often be sent to a surgery with a shoulder that is not that bad.
It can be very challenging to convince a patient that what is interpreted on MRI is not really there. When someone comes into our office, it is sometimes after they got their “bad MRI” reading and their orthopedists is recommending that they get on the list for surgery. The reason that this person is in our office is for the various reasons that someone contacts us after a surgical recommendation: They can’t take off time from work. They are involved in a sport and are looking to avoid long surgical recovery times. They provide for or are a caregiver to a spouse or aging parent. They just don’t want a surgery. Even so. These people, looking to avoid surgery, STILL, have a hard time believing that the MRI is not that bad, they can probably avoid the shoulder surgery. Then we tell them they probably should not have gotten the MRI in the first place. The response is usually, “What?”
Is an MRI even necessary?
For many people and many different types of shoulder problems, a doctor knowledgeable in treating shoulder problems can often assess the patient’s situation with a good medical history and a physical examination. Occasionally an x-ray may be ordered, especially in situations were injury or accident is the cause of shoulder pain or there is suspected bone spur.
But when someone gets an MRI, a radiologists interprets what he/she sees from the various images presented. The image below is a right shoulder MRI scan.
When radiologists look at panels like these, one problem becomes apparent. They are not seeing the whole shoulder at once. They only see selected images from selected areas of the shoulder. The irony is with all these pictures, the radiologist does not see the whole picture of what is happening in the shoulder. Compounding the challenging of trying to find a possible cause of the shoulder pain is the complexity of the shoulder itself. If an injury is not apparent or obvious. The source of the problem may be obscured and necessitate an arthroscopic surgery.
The radiologist calls them as he/she sees them
It takes a lot of training to be a radiologist. What they are trained in is to be able to as best they can, identify tissue damage. What they see in the image does not tell them what is causing your pain or functional problems. The image only tells them what is damaged and what is not. Often a radiologist will suggest that the doctor doing the physical examination confirm that what the MRI reveals is actually a cause of pain and functional difficulties.
Why would the radiologist recommend this? Because many MRIs are “really bad.” But, a really bad MRI does not mean that the patient has really bad pain.
A study from a group of radiologists cites rising numbers of inappropriately recommended MRIs and surgeries
This study comes straight from a group of radiologists who submitted their paper to the Journal of the American College of Radiology (1) to bring awareness to the inappropriateness of many MRI orders they see. The bullet points are directly from the research:
- “MRI is frequently overused.”
- “We reviewed medical records of 237 consecutive shoulder MRI examinations . . . Of the 237 examinations reviewed:
- 106 (45%) were deemed to be inappropriately ordered, most commonly because of an absent preceding radiograph. (An MRI was ordered because there was no previous MRI).
- Nonorthopedic providers had a higher frequency of inappropriate ordering (44%) relative to orthopedic specialists (17%)
- In the 237 examinations, ultrasound could have been the indicated advanced imaging modality for 157 (66%), and most of these (133/157; 85%) could have had all relevant pathologies characterized when combined with (x-ray).
- While nonorthopedic provider orders were more likely to be inappropriate, inappropriateness persisted among orthopedic providers.”
The less experienced the doctor, the more inappropriate MRIs
A June 2020 paper (2) wrote: “Approximately 23% of (ordered MRIs including those for shoulder pain) claims were classified as inappropriate. Physicians with 10 or less years of experience had significantly higher odds of ordering inappropriate MRIs. Primary care physicians were almost twice as likely to order an inappropriate MRI as orthopedists.”
Does imaging studies truly reflect the patient’s shoulder pain symptoms?
- In the medical journal Shoulder and Elbow, October 10, 2018: (3) Doctors in the United Kingdom made these observations after investigating whether magnetic resonance imaging (MRI) scans can accurately diagnose arthritis of the acromioclavicular joint.
- “MRI is not helpful in making the diagnosis of acromioclavicular joint arthritis. A focused history and clinical examination should remain the mainstay for surgical decision making.
- In the medical journal Arthritis care & research, August 2018 (4), doctors in the United Kingdom looked at common shoulder symptoms and the use of imaging to help with management. They were trying to clear up an unclear situation. Here is what they said: “Shoulder symptoms are common, and imaging is being increasingly used to help with management. However, the relationship between imaging and symptoms remains unclear. This review aims to understand the relationship between imaging-detected pathologies, symptoms, and their persistence.”
- What was the answer of this research? “There was no significant association between most imaging features and symptoms among high-quality, cross-sectional studies.”
- What the MRI shows is not always indicative of what the patients pain and range of motion symptoms are, nor can the MRI predict the persistence of these symptoms.
“Shoulder MRI: What Do We Miss?”
Here is a well cited study in the medical journal American Journal of Roentgenology. The title: “Shoulder MRI: What Do We Miss?” (5)
This study looked at the things radiologists missed on MRIs that orthopedic surgeons picked up during an arthroscopic procedure. Since the surgeons are using the imaging report as a road map for preoperative assessment and planning, the discovery of missed problems can help further the understanding of the accuracy of the MRI and the MRI interpretation. This research review examined shoulder abnormalities that either are not well seen or are not seen at all on shoulder MRI and therefore are misinterpreted.
In regard to problems of the shoulder cartilage, the study authors noted: “Cartilage lesions are difficult to diagnose. . . and . . . “Although MRI is an excellent tool for detecting some abnormalities, there are a number of subtler abnormalities of clinical significance that give radiologists greater difficulty.”
In the Journal of the American College of Radiology, (6) researchers looked to “assess the patterns of Appropriate Criteria application among orthopedic specialists and other fields of medicine for use of MRI and radiography and the subsequent necessity for surgical intervention.”
- Of note: People in the study were patients who already had a “bad” shoulder and this MRI was being ordered to see what was the new source of the patient’s shoulder pain was.
- A total of 475 patients who underwent shoulder MRI were included in this study.
- The researchers found significant associations between a patient having had a prior x-ray, being male, and getting subsequently had a shoulder surgery. Orthopedic specialists ordering MRIs had the highest percentage of patients undergo subsequent surgery (33.3%) compared with the second-most, primary care (18.4%), and all other ordering departments.
- The researchers suggest that if you are a man, had a prior x-ray, had an MRI ordered by an orthopedic surgeon, you were most likely to get a surgery.
“Regardless of MR findings, however, physicians should be cautious when recommending surgery in the patient with a vague clinical picture.”
Here is another 2018 study, this time an MRI of the shoulder where SLAP tear is suspected as not really being helpful to many patients with shoulder pain. This one comes from the University of California at Davis.(7)
Here the researchers offer advice on how to make the MRI more successful at really determining what is going on in the shoulder. HOWEVER, even improving the image of the imaging study by variants in the patient’s position during the MRI, may not help the final outcome of the test, should you have a surgery or not. Here is what the researchers said:
“Regardless of MR findings, however, physicians should be cautious when recommending surgery in the patient with a vague clinical picture.”
How about Rotator Cuff tears?
Here is a study that probably assesses the question about MRI accuracy and what is really happening in the shoulder as good an another. It was published in the Journal of magnetic resonance imaging.(8)
“MRI has become an important diagnostic tool in the evaluation of rotator cuff pathology and the technology continues to evolve. . . . Although MRI findings may be diagnostic in some cases, we find that clinical correlation with history and physical examination is critical to differentiate between anatomic variants, incidental findings, and true pathology. We conclude that good communication between the orthopedic surgeon and the radiologist is necessary to optimize diagnostic yield.”
Anatomic variants and incidental findings?
The point of this article is to demonstrate how MRIs can send you to a surgery you may not need because of challenges with the MRI accuracy and interpretation. MRI is not a gold standard of care, as demonstrated by countless studies questioning MRIs validity in certain diagnostic cases. In our years of experience we have found that because it is difficult to determine what the true source of shoulder pain generator is, our approach is to regenerate the entire shoulder with our treatments and not focus on a single problem such as a tear on MRI or a tear in the labrum, or a developing bone-on-bone situation. This is demonstrated in the videos above.
A study from August 2020 (9) wrote: “When evaluating the rotator cuff, it is important to consider some limitations of MR imaging. The appearance of calcium on MR imaging can be bright or dark and can sometimes be misinterpreted as tears or subacromial bone spurs.”
Some people with terrible MRIs have no shoulder pain
A paper in the Journal of bone and joint surgery (10) examined the long-term risks of rotator cuff tear enlargement (the tear is getting worse) and symptom progression associated with degenerative asymptomatic tears. Two-hundred and twenty-four people with shoulder injury were recruited. The patient profile consisted of:
- People with an asymptomatic rotator cuff tear in one shoulder and pain due to rotator cuff disease in the other shoulder enrolled in this study.
- Two hundred and twenty-four subjects (118 initial full-thickness tears, fifty-six initial partial-thickness tears, and fifty controls) were followed for about five years.
- Tear enlargement was seen in 49% of the shoulders, and the average time to enlargement was 2.8 years. One hundred subjects (46%) developed new pain.
The study showed “the progressive nature of degenerative rotator cuff disease. The risk of tear enlargement and progression of muscle degeneration is greater for shoulders with a full-thickness tear, and tear enlargement is associated with a greater risk of pain development across all tear types.”
- Half the people in this study had an MRI no worse that one taken three years earlier. Half the people had a worse MRI. Half of the people still had no pain. Those with acknowledged full thickness tears had greater risk of pain.
Why you may not need shoulder surgery: Even with a Bad MRI
The simple reason for some is that the tear is not progressing enough to cause new or significant pain. But a tear still exists on MRI. Should it be treated. For appropriate candidates, Stem Cell Therapy is a treatment we use for for musculoskeletal disorders including those causing shoulder pain. Where Do We Get the Stem Cells for Therapy? For each treatment, stem cells are taken from the patient’s iliac crest at the back of the pelvis. These cells are valuable because they are undifferentiated cells, meaning that they do not have a tissue type but can grow to become other, more specialized types of cells. If a joint, cartilage, tendon, ligament, or muscle needs regeneration, stem cells can supply the building material.
How Is the Procedure Done?
Please watch the video below:
The Stem Cell Therapy injection procedure is a simple, in-office procedure with no general anesthesia, as it involves almost no or little pain. Moreover, it takes only about 30 minutes from start to finish. During bone marrow Stem Cell Therapy, a practitioner will inject lidocaine at the top of the buttocks, at or near the posterior superior iliac spine, to numb the area. A tiny incision (which heals quickly after the procedure) is made to allow insertion of a needle to aspirate bone marrow.
No stitches are necessary. The solution obtained is spun in a centrifuge. The stem cells are then harvested and injected into the target area or joint under ultrasound guidance when required.
1 Sheehan SE, Coburn JA, Singh H, Vanness DJ, Sittig DF, Moberg DP, Safdar N, Lee KS, Brunner MC. Reducing unnecessary shoulder MRI examinations within a capitated health care system: a potential role for shoulder ultrasound. Journal of the American College of Radiology. 2016 Jul 1;13(7):780-7.
2 Young GJ, Flaherty S, Zepeda ED, Mortele KJ, Griffith JL. Effects of physician experience, specialty training, and self-referral on inappropriate diagnostic imaging. Journal of general internal medicine. 2020 Jan 23:1-7.
3 Singh B, Gulihar A, Bilagi P, Goyal A, Goyal P, Bawale R, Pillai D. Magnetic resonance imaging scans are not a reliable tool for predicting symptomatic acromioclavicular arthritis. Shoulder & Elbow. 2017 Aug 17:1758573217724080.
4 Tran G, Cowling P, Smith T, Bury J, Lucas A, Barr A, Kingsbury SR, Conaghan PG. What imaging detected pathologies are associated with shoulder symptoms and their persistence? A systematic literature review. Arthritis care & research. 2018 Mar 7.
5 Saqib R, Harris J, Funk L. Comparison of magnetic resonance arthrography with arthroscopy for imaging of shoulder injuries: retrospective study. Annals of The Royal College of Surgeons of England. 2017;99(4):271-274. doi:10.1308/rcsann.2016.0249.
6 Small KM, Rybicki FJ, Miller LR, Daniels SD, Higgins LD. MRI Before Radiography for Patients With New Shoulder Conditions. Journal of the American College of Radiology. 2017 Jun 1;14(6):778-82.
7 Boutin RD, Marder RA. MR Imaging of SLAP Lesions. Open Orthop J. 2018;12:314-323. Published 2018 Jul 31. doi:10.2174/1874325001812010314. 1491
8 Bencardino JT, Beltran LS. Pain related to rotator cuff abnormalities: MRI findings without clinical significance. Journal of Magnetic Resonance Imaging. 2010 Jun;31(6):1286-99.
9 Ashir A, Lombardi A, Jerban S, Ma Y, Du J, Chang EY. Magnetic resonance imaging of the shoulder. Polish Journal of Radiology. 2020;85:e420.
10 Keener JD, Galatz LM, Teefey SA, Middleton WD, Steger-May K, Stobbs-Cucchi G, Patton R, Yamaguchi K. A prospective evaluation of survivorship of asymptomatic degenerative rotator cuff tears. The Journal of bone and joint surgery. American volume. 2015 Jan 21;97(2):89.