Evidence Against the Routine Use of MRI for Nonoperative Treatment of Chronic Orthopedic Conditions
Am Fam Physician. 2020 Nov 1;102(9):521-522.
The number of middle-aged and older patients presenting with chronic (i.e., longer than two or three months) back, shoulder, and knee pain will continue to increase with the aging population. Assessing chronic pain can be difficult, and magnetic resonance imaging (MRI) is commonly used to aid in diagnosis and guide treatment. Patients may request an MRI, and some orthopedists require the results before accepting a referral.
It is often assumed that an MRI result will show the cause of a patient's pain and that correcting the pathology can lead to better outcomes. An MRI may show the cause of pain after a traumatic event that causes significant pathology, such as a knee injury causing a large, displaced meniscus tear. However, for chronic pain in older patients who have not had a significant trauma, evidence suggests that the pain may be unrelated to MRI findings and that conditions previously treated with surgery (e.g., herniated disk, degenerative meniscal tears, degenerative rotator cuff tears) can be effectively treated with time, physical therapy, and home exercises.
Abnormal MRI findings are common in asymptomatic individuals, especially as they age. These findings include disk degeneration, protrusions, and annular tears in the back; rotator cuff and labral tears in the shoulder; and meniscal tears in the knee.1–5 The high prevalence of degenerative pathology in the MRI's of asymptomatic individuals dispels the assumption that these findings are responsible for chronic pain.
Studies have shown that most middle-aged and older patients with MRI findings that previously were considered to be operative can improve with conservative management. Patients with back pain and a disk herniation shown on MRI can be successfully treated with an active rehabilitation program, even if they have sciatica.6,7 In fact, disk herniations generally decrease in size with time.8 Chronic rotator cuff and SLAP (superior labrum anterior to posterior) tears can be successfully treated with physical therapy and an exercise program that focus on scapular stabilization.9–12 Older patients with degenerative meniscal tears can be treated nonoperatively with quadriceps and hip abductor strengthening exercises.13
Recent studies have shown that subacromial decompression and partial meniscectomy are no better than placebo shoulder or knee arthroscopy in treating impingement syndrome and degenerative meniscal tears, respectively.14–16 Therefore, outcomes are the same whether or not the pathology is corrected.
For most cases of chronic back, shoulder, or knee pain, MRI is not needed because nonoperative care is usually successful, despite the MRI findings. An abnormal MRI result may make it more challenging to treat a patient nonoperatively when it is assumed that surgery is needed to fix the pathology, even though the abnormal finding may be unrelated to the pain. Placebo-controlled studies suggest that there is a psychological component to recovery, and the primary care physician can play a critical role in fostering a positive mindset for active patient participation. An MRI is generally not needed until at least a few months of rehabilitation are unsuccessful and only if surgery is being considered. Also, MRI is usually not indicated in the setting of arthritis, especially for arthritis in the knee, because weight-bearing radiography is preferred.17
There are cases when MRI is justified expeditiously, such as when a chronic infection or a tumor is suspected. Significant back pain associated with clinical evidence of spinal stenosis or radiculopathy with neurologic findings may warrant an early MRI referral. For the knee and shoulder, a more expeditious MRI may be helpful to rule out surgical pathology in a patient with a prior traumatic injury who is apprehensive about attempting physical therapy.17
Physicians should consider the ramifications before ordering an MRI in the setting of chronic pain. An MRI that is not indicated can lead to a procedure that is not necessary as both patient and physician focus on the abnormal study finding. Most patients improve with conservative management that requires active involvement. Ordering MRIs only when indicated improves outcomes, reduces complications, and decreases treatment costs.
The author would like to thank Brendan Martin, BA, for research assistance and input regarding the editorial content.
Published online August 28, 2020.
Address correspondence to Donald C. Pompan, MD, at firstname.lastname@example.org. Reprints are not available from the author.
Author disclosure: No relevant financial affiliations.
Referencesshow all references
1. Brinjikji W, Leutmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811–816....
2. Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: from mass-screening in one village. J Orthop. 2013;10(1):8–12.
3. Schwartzberg R, Reuss BL, Burkhart BG, et al. High prevalence of superior labral tears diagnosed by MRI in middle-aged patients with asymptomatic shoulders. Orthop J Sports Med. 2016;4(1):2325967115623212.
4. Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359(11):1108–1115.
5. Deshpande BR, Losina E, Smith SR, et al. Association of MRI findings and expert diagnosis of symptomatic meniscal tear among middle-aged and older adults with knee pain. BMC Musculoskelet Disord. 2016;17:154.
6. Gugliotta M, da Costa BR, Dabis E, et al. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open. 2016;6(12):e012938.
7. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14(1):180–191.
8. Cribb GL, Jaffray DC, Cassar-Pullicino VN. Observations on the natural history of massive lumbar disk herniation. J Bone Joint Surg Br. 2007;89(6):782–784.
9. Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013;22(10):1371–1379.
10. Keener JD, Patterson BM, Orvets N, et al. Degenerative rotator cuff tears: refining surgical indications based on natural history data. J Am Acad Orthop Surg. 2019;27(5):156–165.
11. Mathew CJ, Lintner DM. Superior labral anterior to posterior tear management in athletes. Open Orthop J. 2018;12:303–313.
12. Kibler WB, Ludewig PM, McClure PW, et al. Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the ‘Scapular Summit.’ Br J Sports Med. 2013;47(14):877–885.
13. Kise NJ, Risberg MA, Stensrud S, et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. Br J Sports Med. 2016;50(23):1473–1480.
14. Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicenter, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329–338.
15. Paavola M, Malmivaara A, Taimela S, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled trial. BMJ. 2018;362:k2860.
16. Sihvonen R, Paavola M, Malmivarra A, et al. Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Ann Rheum Dis. 2018;77(2):188–195.
17. American College of Radiology. ACR Appropriateness Criteria: chronic knee pain. 2018. Accessed April 14, 2020. https://acsearch.acr.org/docs/69432/Narrative/
Copyright © 2020 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact email@example.com for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions