We do a lot of research in our clinic, one topic we frequently research is shoulder osteoarthritis. One of the subtopics we research is the question, “why did someone get a shoulder surgery?” Often times the answer is: “because my shoulder MRI was bad.”

My Shoulder MRI is bad, my doctor says it is time to think about 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.

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.”

Stem cell therapy in the shoulder

 

Does imaging studies truly reflect the patient’s shoulder pain symptoms?

  • In the medical journal Shoulder and Elbow, October 10, 2018: (2) 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. 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.” (3)
    • 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?” (4)

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, 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. (5)

 

“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.(6)

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.(7)

“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.

 

 

References:

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 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.
3 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.
4 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.
5 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.
6 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