"I Need an MRI, so I know What is Wrong with Me, and I Can Get it Fixed!"

Hey Team,

I enjoy the clinical setting of physical therapy and particularly the outpatient arena. The joy of meeting new people daily, helping my long-time patients, or joking with my colleagues truly makes the job enjoyable. My favorite part of the job is the daily unknown. I will see a patient with a dysfunction in the neck, knee, shoulder, ankle, hip, back, or vertigo during the day. One can never predict what type of disorder a patient will have… but this is the fun part. In my little way… I am a detective. I get to test my theories of why a patient has a problem with specific tests, interventions, or at a minimum, trial, and error. But overall, I like the unpredictability and the ability to create order from the madness. I want to take the unknown or irrational understanding of their pain and bring light to the dysfunction's biomechanical and logical reason.

I also like to write the health column for the Statesman-Examiner or other weekly newsletters to address my patients' concerns. At times, I use these forums to manage an unconfirmed belief. I have done this in past columns concerning arthritis. ("You have arthritis, and you have to live with it!" Seven reasons this statement is FALSE!)

A pattern will emerge from this unconfirmed belief in the clinic and is understandable from a patient perspective. We have been programmed with our relationship to the medical field to hold these beliefs due to our previous medical interactions, media, or confirmation bias. 

THE MRI FRUSTRATION

I have found frustration from my patients with the increased frequency of getting an MRI for their specific dysfunction. These patients inform me they were not approved for an MRI due to their insurance company restrictions. You see, many insurance companies are not covering an MRI if it does not meet a threshold of justification. This leads to frustration for the patient and creates a transfixed obsession with what they "need" to get "fixed." Unfortunately, this hurts our care overall. 

Let me explain. Insurance companies have become stricter on approving an MRI due to the expense ($2500-$4000 per scan) and the imaging studies' previous prevalence. The MRI demonstrates images of the muscle, bone, or connective tissue; however, the clinical exam finds much of the scan's information. As a result, specific patterns exist, combined with the disorder's presentation, allowing the provider to understand the condition confidently. In most patients I treat, I can determine the shoulder, knee, back, or hip disorder without needing an imaging study. 

3 EXAMPLES OF WHY AN MRI IS NOT NEEDED

#1: In 2019, researchers used 230 asymptomatic individuals and performed a knee MRI on each knee. The results demonstrated 97% of individuals had knee abnormalities. WOW, 97%!!!! 30% of these were meniscal tears. But wait, if they had a tear and damaged tissue, why did they not have any pain? I hear this from my patients often. "I have a tear to the meniscus, and surgery is the only way to make it better." This study pokes a big hole in this MRI bias! All of the individuals in this study had no pain in the knee. How can this be? This study is one example allowing us to question the effectiveness of using an MRI as the primary determinant of a dysfunction.

#2: In 2015, researchers created a Meta-Analysis of 33 randomized controlled studies determining the prevalence of back dysfunction in people who have no back pain. They found similar results as the knee study determining 37% of 20-year-olds had some back dysfunction and increased to 96% of 80-year-olds. What does this mean? How is this possible! How can people have an MRI demonstrating a disc bulge, degeneration, or spinal stenosis but not have any symptoms or pain?

#3: But what about needing an MRI for surgery? Take a look at this study on rotator cuff tears from 2019. They took all patients suspected of a rotator cuff tear and performed an MRI to determine the severity. From this study of 51 individuals, 96% (46/51) did not have surgery on the rotator cuff but continued with conservative care. So… the vast majority of people who received an MRI never even had surgery? So, what was the point of the MRI? 

THE MRI IS OVERRATED!

Let's unravel this a bit. From these articles, we can see an MRI can find dysfunction in the knee, back, shoulder, but this is not a predictor of pain or a successful outcome. If we can have an apparent dysfunction but no pain, we must question using an MRI when we have pain. If we need an MRI to get "fixed," why do we NOT have more people receiving surgery after a positive MRI result?

Plus, I have not even touched on the results of research articles demonstrating the false positive of an MRI. An MRI requires interpretation, and many times the understanding of the image is not consistent with the reality of the person's situation. For example, the radiologist reading the original report and the patient's orthopedic surgeon does not always agree on their "interpretation" of the image. A presurgical diagnosis and a post-surgical diagnosis do not always align when a patient has a surgical procedure. Once a surgeon begins to repair a suspected tissue… the reality of the situation does not always match the "interpretation" of the report. What does this mean? THE MRI IS OVERRATED!

Don't get me wrong, an MRI is necessary and has its purpose but is a roadblock for the patient receiving the care they need. Patients will become fixated on the need for an MRI, believe it is the only way to "find out what is wrong with them," and become obsessive regarding the image's results. After the MRI report, many patients become fixated on the MRI report's degenerative joint disease, arthritis, or a tear. But what do these research articles explain? IT DOESN'T MATTER! You may have all these dysfunctions, have no pain, and not need surgery. How comforting is that! You can have a "tear" or "arthritis" and still be just fine or better…be pain-free with full function. 

WHEN TO GET AN MRI

An MRI has a purpose, but the goal needs to be assisting in clinical decision-making. For example, suppose a patient has a non-functioning shoulder, a recent fall, and a suspected detached biceps tendon rupture. In that case, an MRI is used to confirm a rupture to expedite surgery. An MRI is also excellent for a patient's differential diagnosis who does not respond correctly to conservative care. A patient not responding correctly or has improper clinical findings will necessitate an MRI referral. 

WHY IT MATTERS

As I explained at the beginning of this column, I love working with my patients and assisting on their road to recovery. Obsession or a bias towards an MRI has led patients to delay their care or not make the most of their conservative care treatments. The MRI does not assist in the healing process and is not an intervention. It is a picture. It cannot explain how the patient feels, moves, interacts at work, or how their dysfunction limits their lives. 

My goal is to help people improve their lives and get the most of each day. Looking for an MRI to fix the pain, movement, or limitations in life only delays our treatment and wastes an opportunity to improve… today! Overall, Team, if you feel you need an MRI to get better, you should discuss it with your provider. A rationale will conclude your specific dysfunction with imaging studies to guide an effective plan of care. Sometimes an MRI is needed to help guide care, but it is often not. Thank you for reading today, and feel free to reach out to meet if you have questions on this information or any other topics I have already covered. Keep Moving!

•      The author, Rob Sumner, is a Doctor of Physical Therapy and owner of Sumner Specialized Physical Therapy. He's happy to answer any questions about this article, wellness, fitness, or physical therapy overall by phone at (509) 684-5621 or by email at Rob@SumnerPT.com