MRI Findings: Pathology or interesting anatomy?
If it's often times more normal to be abnormal then shouldn't abnormal findings be called normal and does it suggest being "normal" is now abnormal? Wait...what? If that was confusing, imagine being a patient and getting a 30-second review of your most recent MRI results!
If we look at the literature, and we're seeing this consistently across the board in various amounts, it is becoming more and more clear that a host of "injuries" are seen in asymptomatic patients. If someone can have the exact same MRI results as your "bone-on-bone" knee or "disc herniations" but have little to no pain, then it would seem we have to appreciate that something else is likely contributing to your individual experience. This isn't a post about chronic pain or pain science in general, but the goal of this post was really to channel my inner Tyler Durden from Fight Club: "The things you own end up owning you." Or in other words, do not become your MRI. Let's run through a few statistics to give this some context:
We're seeing disc bulges, protrusions or herniations, and extrusion in asymptomatic patients and these aren't low numbers but Jensen et al. (1994) found >80% of participants with no back pain had positive MRI findings. More recently, as broken down by my good friends at TheLogicofRehab.com, Brinjiki et al. (2014) reported disc degeneration in asymptomatic participants from 37% in 20 year-olds to 96% of 80 year-olds, disc bulges in 30% of 20 year-olds to 84% of 80 year-olds, etc. Derek Miles, PT and Mike Ray, DC break this down on their blog far better than I could so I highly encourage the read.
How about the shoulder? Schwartzberg et al. found 72% of their participants had a SLAP (labral) tear, 53 of them had no symptoms. Dr. James Andrews, one of the top orthopedic surgeons in the world, often jokes, "they didn't have any symptoms until they got their MRI!". How about the rotator cuff? Partial thickness tears were seen to only progress in 16% of participants over 12 months and 25% actually decreased! (Kong, 2018). Frost et al. (1999) showed RC pathology was related to age but did NOT correlate with symptoms or how about Girish et al. (2011) found abnormalities in 96% of the asymptomatic population (!). We can do this for almost every joint. The excellent infographics in this post, many of which have been well-circulated throughout the internet, were originally made by Jorgen Jevne. You can find him on Twitter here.
The point is, we need to continually be reminded that we are not so delicate and that we have an incredible ability to adapt over time. In many cases, the issue is related to three components: 1) load/volume management, 2) pain sensitization to a pattern, and 3) technical inefficiency and/or biomechanical considerations. So, do we ever recommend imaging? Of course, but it is after conservative management has failed or if a patient presents with red flags (weight loss, bowel and bladder dysfunction, upper motor neurological lesions, progressively worsening neurological signs, etc.) and we anecdotally estimate the percentage of our patients who require surgery to be in the single digits. If you are considering surgery or if you have not seemed to have success with conservative efforts elsewhere, see your physical therapist first. In fact, regarding low back pain, seeing your physical therapist first saved on average almost 3000 dollars.
We are not taking the position that MRIs do not have a place in medicine, we are merely suggesting that an MRI alone is often a poor indicator of the pain presentation many patients have. With the addition of creating an increased number of people seeking surgery because of imaging, increased costs associated, as well as the psychological sequalae that often follows imaging, we strongly encourage conservative management in most cases.
If you found this post interesting and have any questions about it, you can contact us here. Additionally, if you would like to schedule a phone consultation (free) or an initial evaluation to have one of our licensed physical therapists evaluate your specific presentation, we can be reached by telephone here as well.
"Our patients are not cars and we are not mechanics" -Jorgen Jevne
Questions? Contact us!