Ross Hauser, MD; Danielle Matias, PA-C; Demi Foster, APRN

Among the many controversies in medicine is the controversy surrounding the use of MRIs and their accurate portrayal of what is causing shoulder discomfort. Questioning the accuracy of shoulder MRIs is not a new challenge patients face. Research has been going on for many years talking about how successful or not successful diagnoses are and even if there was a correct diagnosis, was the diagnosed problem causing the patient pain in the first place? Now some say that in a few years, artificial intelligence will be able to clear up images and make better predictions about treatments and outcomes. Well maybe a tear will be more readily recognized and surgery may be more precise, but the question will remain. Is it the tear that is actually causing the pain, is the surgery correcting the pain problem? In many cases, the answer will still be no. The biggest problem may still remain that the doctor and patient think an MRI must be taken to “solve” the patient’s shoulder problem.

Important in this 2023 study was the patient’s overall desire to have an examination, an MRI, a diagnosis, and a treatment.

Having a diagnosis and a treatment is the goal of all patients who are having pain challenges. The problem has always been getting the right diagnosis, and getting the right treatment.

A September 2023 paper from medical universities in Canada, published in the BioMed Central musculoskeletal disorders (1) assessed the current treatment recommendations for patients visiting their primary care physician for shoulder pain. The goals of this research were to understand and help explain the challenging management of shoulder pain considering that 40% of people with shoulder pain remain symptomatic one year after the initial consultation, and, to explore patients’ expectations and experiences of their primary care consultation for shoulder pain.

In this small sample study, 13 people, 8 women, and 5 men; in the age 50 average range were followed. Eleven of the patients initially consulted a family physician or an emergency physician, and two participants initially consulted a physiotherapist. The reasons they sought medical care and what they expected from their clinicians were:

• 1) I can’t sleep because of my shoulder;
• 2) I need to know what is happening with my shoulder;
• 3) We need to really see what is going on to help me!; and
• 4) Please take some time with me so I can understand what to do!

Important in this study was the patient’s overall desire to have an examination, an MRI, a diagnosis, and a treatment. For these patients, there is an expectation that a shoulder MRI must be done and most clinicians may not order one because the shoulder MRI may show too much. What does that mean?

Were the 13 patients helped? This was the concluding findings: “Several participants waited until they experienced a high level of shoulder pain before making an appointment since they were not confident about what their family physician could do to manage their condition. Although some participants felt that their physician took the time to listen to their concerns, many were dissatisfied with the limited assessment and education provided by the clinician. . . “Several participants reported that their expectations were not met, especially when it came to the explanations provided.”

One “unexpected finding” that emerged from this study according to the researchers, was the longer than anticipated waiting period between the onset of shoulder pain and when patients decided to consult their primary care clinician.

“Several participants reported that their expectations were not met, especially when it came to the explanations provided.” My two MRIs were not in agreement with what was happening in my shoulder.

In the above study, we see that people got a diagnosis and people got a treatment. Did that solve their issues? Here is one sample story that may explain why a patient’s expectations were not met by getting an MRI and treatment.

My doctors were not in agreement with what was happening in my shoulder. My two MRIs were not in agreement with what was happening in my shoulder. One MRI says a small labral tear. The other says, no it is a problem of the acromioclavicular joint. With the doctor’s opinions at odds and the MRIs at odds, I cannot get a diagnosis and no one is dealing with my shoulder pain. At present, I get physical therapy which is not helpful.

An inappropriate MRI was ordered because the machine was there.

Notwithstanding, there is pressure on doctors, exhibited on them by patients wanting an MRI. Sometimes because the MRI is there, an MRI can easily be offered and given. Especially in a hospital. In a May 2021 paper, researchers writing in the journal Health Affairs (2) cited that a 20% rise in inappropriate MRIs could be traced to doctors working in hospitals. The researchers write: “Study findings indicate that the odds of a patient receiving an inappropriate MRI referral ( lower back pain, knee pain, and shoulder pain) increased by more than 20 percent after a physician (left private practice and went) to hospital employment. Most patients who received an MRI referral by a (hospital) employed physician obtained the procedure at the hospital where the referring physician was employed. These results point to hospital-physician integration as a potential driver of low-value care.”

It is called “low-value care because the MRI in many cases, was not needed to be helpful to the patient’s condition and as we will see, will confuse the issue of treatment.

Inappropriate MRI because of doctor’s experience

Previously the same lead researchers wrote in the Journal of General Internal Medicine (3) that many inappropriate MRIs (23% of claims were classified as inappropriate) could be traced in some instances to “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. ”

Elite rock climbers have a lot of damage seen on MRI, yet have no shoulder pain.

The demonstration that an MRI can show too much damage and may lead to inappropriate surgery can be seen in the shoulders of elite rock climbers. A February 2022 paper in the Orthopaedic Journal of Sports Medicine (4) looked for how prevalent significant degenerative findings were on shoulder MRI in asymptomatic athletes of overhead sports. The researchers “hypothesized that glenoid labrum, long head of the biceps tendon, and articular cartilage pathology would be present in more than 50% of asymptomatic athletes.” To test their theory the researchers recruited 50 elite-level rock climbers (age range, 20-60 years), and performed physical examinations and MRIs.

• MRI evidence of:
  • tendinosis of the rotator cuff was diagnosed in 80% of patients,
  • subacromial bursitis was diagnosed in 79% of patients,
  • and long head of the biceps tendonitis was diagnosed in 73% of patients.
  • Labral tears were present in 69% of shoulders, with discrete labral tears identified in 56%.
• Articular cartilage changes were also common, with humeral pathology present in 57% of shoulders and glenoid pathology in 19% of shoulders.

Hockey players

An October 2019 study in the Orthopaedic journal of sports medicine (5) examined 25 asymptomatic collegiate and professional hockey players (50 shoulders) with no history of shoulder injury, pain, or dysfunction causing them to miss ice time. All 25 players had both shoulders undergo and MRI.  Labral abnormalities were seen in 25% of the shoulders. AC joint abnormalities and rotator cuff findings were noted in 8% and 6% of shoulders, respectively.

MRI of the shoulder can be misleading.

In March 2024, (6) researchers writing in the medical journal Cureus discussed rotator cuff MRI indications: “A multidisciplinary approach encompassing constant update of knowledge, understanding and healthy feedback between the surgeon and the radiologist is a step towards accurate diagnosis. MRI has high sensitivity and specificity for diagnosing rotator cuff tear, but tears have been found even in asymptomatic individuals. Thus, imaging findings alone are deficient to diagnose a rotator cuff tear and clinic-radiological correlation is an important component in the diagnosis of this clinical syndrome.

In October 2023, Italian researchers published in the journal Knee surgery, sports traumatology, arthroscopy (7) a “consensus on diagnosis and treatment of rotator cuff tears. The study focused on selected areas: imaging, prognostic factors, treatment options, surgical techniques.” The consensus came from a group of forty-one shoulder experts. Here we will focus on the statement of MRIs. The experts agreed that “preoperative magnetic resonance imaging is strongly recommended because it allows a careful evaluation of tear characteristics, while the role of ultrasound (imaging for tears) remains debatable.

A February 2022 study in the journal Clinical Orthopaedics and Related Research  (8) wrote: “Surgeons should understand that the pain levels of patients with glenohumeral arthritis may not parallel radiographic severity.” In other words a patient could have more pain than the MRI should suggest they do, or they may be asymptomatic despite MRI revealed damage.

As we have seen in the studies above, an MRI of the shoulder can be misleading. While an MRI can be a helpful tool, we do not order them frequently for patients. As documented, numerous studies done on asymptomatic patients regularly show abnormalities on MRI, including glenoid labrum abnormalities, supraspinatus tendinopathy, and rotator cuff tears. Also documented are the thousands of surgeries based primarily on MRI readings without a correlating physical exam. But it happens all the time that patients are signed up for surgery and say the doctor barely touched them.

Even in cases where the MRI reading notes a “complete tear” of the rotator cuff, a non-surgical consultation may be helpful. In our clinic, we have seen, following an examination, that the tear is not a “complete” tear.

References
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