Why You Don’t Need An MRI

If you do not know what an MRI is, then this may not apply to you. If you want to know, an MRI is a non-invasive medical test that will show the internal structures of the body including bone, ligaments, tendons, muscles, blood vessels, and nerves. An MRI scanner creates these images using a large magnet and radio waves. When patients have a known soft tissue injury, or have already had a normal X-ray, they will often assume they need an MRI in order to diagnose their problem and will be confused when one is not ordered.

Bluntly stated, the reason an MRI was not ordered or not ordered yet is because the result will not change the initial treatment. Once the history is taken and the physical exam is complete, the diagnosis is often already made and treatment can be started. Remember, most patients presenting to the orthopedic clinic have common problems that can be effectively treated with a progression of options. You need to trust this is not your physician's first rodeo. An example would be tennis elbow. The diagnosis is often made quickly with history and physical exam, and an MRI is hardly ever ordered. An MRI would help differentiate between inflammation of the tendon(tendinitis), a partial tear of the tendon, or a complete tear of the tendon. However, all these are treated in the same manner with conservative care, so an MRI is not helpful. On rare occasions, conservative care may fail, but the MRI does not have much effect on surgical planning either. Another example would be ankle sprains. In ankle sprains, the ligament is either stretched, partially torn, or completely torn. The initial treatment is the same for all of these and the vast majority heal without surgery. In a small subset of patients, conservative therapy will fail and an MRI will be ordered before surgery to evaluate the ligaments and associated injuries that did not heal as expected and may need to be addressed.

In other cases, an MRI is not needed because the X-ray shows you all you need to know. This frequently occurs with knee pain. On occasion, the physician may be considering a meniscus tear or cartilage injury to be the cause of pain, but the X-ray comes back showing moderate or severe arthritic changes. In these cases, treatment is directed to addressing the arthritis. In many instances, the degree of arthritis assures cartilage damage and meniscus tears, but this does not affect the treatment options. Certain patterns of shoulder arthritis also confirm a rotator cuff tear that is beyond repair and other patterns show a degree of arthritis where a tear would be inconsequential. Lumbar pain is another diagnosis where an MRI may not be ordered. The initial treatment will be conservative if there are not any causes for concern on the physical exam. Although the X-ray does not show the soft tissues, the pattern of wear in the bones can confirm arthritis, disc disease, and stenosis. The first line of treatment for lumbar injuries is often physical therapy and decreasing inflammation. These modalities do not require an MRI to determine the exact location of the problem. If conservative care fails, an MRI will be ordered as a pre-procedure test to act as a ‘road map’ to localize the exact source of pain before giving injections or having surgery. 

It is common that an MRI is not ordered because of the patient's age or disability. For example, many patients past their late 60s have outlived their rotator cuff, and on many occasions what's left to repair is not salvageable. As a result, we will start non-operative care of the presumed rotator cuff tear without the MRI. In most cases an MRI is a preoperative test. If the patient is too old or too sick to consider surgery then the MRI is not useful. Other patients have a degree disability where they would not be considered for surgery or they know they could not complete the therapy required for a successful surgery and the MRI can be avoided.  

In rare cases, a tumor may be suspected from history, physical, exam or X-ray and an MRI needs to be ordered. In these cases, make an informed medical decision with your doctor. It is not uncommon for patients to have anxiety about cancer. Be careful not to go down the rabbit hole and assume every ache and pain could be cancer. If you have concerns, discuss them with your physician and make reasonable decisions.

Be aware that pain does not always correlate with the severity of your illness or the need for surgery. Shoulder bursitis often results in significantly more pain than large rotator cuff tears, and a flare of knee arthritis can often be more painful than a ligament tear. In both cases, treatment can be started without an MRI. An MRI has no benefit in improving pain. In many cases, it is beneficial to try to get some pain relief before proceeding with further testing. On the other hand, your pain may not warrant an MRI. The reason for the MRI may be preoperative testing. If your pain and disability are not to the level of considering surgery then the MRI can often be avoided. 

It is important to be aware that most people do not have normal MRIs once they reach middle age. Almost everyone has degenerative disc disease in their neck and back even if they do not have pain. Many people have arthritis and degenerative meniscus tears in their knees or partial tears in their wrist or elbow without even knowing it. 40% of painless shoulders have a partial thickness rotator cuff tear. This means that not everything we see on an MRI needs to be repaired with surgery. Many things can heal with conservative care. Other things may not heal but the pain will go away if we can get the inflammation to resolve. This also means that on occasion we do not know when the damage occurred. Even when the patient was asymptomatic before the injury, we do not know if they merely aggravated previously asymptomatic tears. In some instances, we can tell by the findings on X-ray or MRI that the process has been going on for years. The injury was just enough to push you over the edge and make your asymptomatic tissue injury symptomatic and painful.

Physician communication and patient listening is critical in understanding the reason in choosing to order or not to order a test. An example happened many years ago when I was discussing a high school wrestling injury with a mother several years after the fact. She took her son to an orthopedist who said her son had a “sprained shoulder” and prescribed anti-inflammatories, physical therapy, and return to wrestling as the pain allowed. She then took her son to another orthopedist for a second opinion who ordered an MRI and carefully reviewed it with her. The MRI showed the partial thickness rotator cuff tear, the sprained ligaments and the bursitis. He then prescribed anti-inflammatories, physical therapy, and returned to wrestling as the pain allowed. She was unhappy with the first doctor and happy with the second doctor. Either no one explained or she did not understand that the MRI had no effect on the treatment plan. I frequently tell this to residents I am teaching that they need to explain what they would expect to see on a middle aged patient’s MRI and why it is not being ordered. I’ve seen too many patients who were ordered physical  therapy and medicine, but not an MRI  and then see me as a second opinion. They are often angry because the first doctor missed the degenerative meniscus tear, partial thickness rotator cuff tear, degenerative disc disease, etc. that was picked up on an MRI their PCP ordered only for me to explain that those findings are fairly normal in their age group and prescribe the same treatment.

An MRI arthrogram is another type of imaging test which involves an injection of dye into the joint prior to the MRI. This is often done to see labral tears in the shoulder and hip which are often missed on routine MRIs. Simply stated, if the labrum is in place it requires the dye leaking under the surface to see the tear. The primary treatment for labral tears of the hip and shoulder is conservative care. Since this is an invasive test it is not usually ordered until conservative care fails. For athletes who can return to play they can avoid the MRI arthrogram. The test is often ordered when the athlete fails to progress. Ultimately, if the results means surgery it also means the athlete's season is over.

One reason so many patients believe they need an MRI is professional sports. It's frequent to watch the sideline interview of any NFL coach and he will mention that the banged up players will all get MRIs on Monday. Most middle aged patients are not elite athletes, however. The reason the team physician will aggressively order MRIs is because many of these players will play through the pain which could hurt their abilities in the long run. Most normal patients can afford to let the injury cool off and try conservative care. You have the ability to modify your activities whereas a professional athlete needs to be able to perform for the next game or someone else needs to take their place.

Another consideration in MRI use is they are expensive ranging from $1,200 to $4,000. Even if insurance covers the test, you may have co-pays. The physician will help you make an informed decision so you do not waste your money. Your insurance company will not approve the test if it is not within the standard of care. If conservative care usually works, insurance companies will often want you to try conservative care before authorizing the test. Finally, the United States spends a lot of money on healthcare and we can all do our part in improving this. One way we can help is to only order tests when it will affect the treatment plan. 

Lastly, consider how an MRI can act as a placebo or a nocebo. As discussed in my blog post, “Recovery- Winning the Outcome”, both placebos and nocebos have no active properties to affect your health. A placebo will help you heal only because you think it will help you heal. A nocebo does the opposite. In medical studies, a treatment will be compared to a placebo. For example, this is often a sugar pill when studying medicines.Studies show patients can experience improvement just from these placebo sugar pills, but they can also get side effects. This shows the power your beliefs can have on your health. An MRI is only an imaging study. It has no therapeutic properties. As stated before, for the average middle aged person the MRI will list several things wrong with your body. Your physician will then help you decide if these findings are normal for your age or contributing to your pain. For some patients, the MRI can be a placebo. They are told the findings are relatively normal, they gain confidence they will heal with conservative care, are able to better commit to conservative care, and often heal well. For other patients, the MRI can be a nocebo. Despite being told the findings are relatively normal and can heal with conservative care, the patient only focuses on the abnormalities that the MRI shows. The patient then convinces themselves they are in the minority of patients who will need more aggressive treatment like surgery. For this reason, I would caution patients not to get MRIs just out of curiosity for minor injuries. The chairman of my orthopedic training program once told me to never get an MRI of my back once I reached 40 unless I absolutely needed one because I would never be happy with what it showed.