MRIs Can Lie: Surgery Alternatives for Knee and Shoulder Pain

Fifteen years ago, when I was training at the Cleveland Clinic to be a sports medicine doctor, a talented orthopedic surgeon, who also happened to be an NBA team physician, recommended a book to me. Its title was What Your Doctor May Not Tell You about Knee Pain and Surgery by Ronald P. Grelsamer, M.D. This book made a significant impression on me and continues to shape how I practice medicine as a sports medicine specialist at Sports Health Northwest.

As the United States continues to see its population aging and more of the baby boomer generation developing knee, shoulder, back, and hip problems, the medical specialty of orthopedics is rapidly growing. Along with a growing number of orthopedic conditions, the time and insurance related pressures on physicians and patients can sometimes result in a pre-mature decision to operate on a knee or other joint like the shoulder. Sometimes highly trained and well-intentioned surgeons and patients place too much emphasis on what the MRI shows. As Grelsamer describes in his book, “MRIs can lie”. MRIs are powerful and valuable tools to help diagnose and treat many conditions, however MRIs are imperfect and can sometimes miss non-surgical causes of knee pain and overread problems like torn cartilage. Also, not all MRIs are equivalent then or today in quality or even the radiologist reading the MRI and writing the report.

Back then, and still today, I commonly see patients who have been told they had a “torn cartilage”. Many elected to have surgery for their torn cartilage only to experience continued knee pain, swelling, stiffness, and even worsening arthritis. Sadly, many of these patients were experiencing pain related to a problem that did not need surgery and the surgery likely made the actual problem worse. Commonly, these patients did not try much in the way of non-surgical treatments, or if they did, it was focused on treating the wrong problem based on an incorrect diagnosis.

There are many causes of knee pain and shoulder pain. Many of these pain generating conditions can effectively be treated non-surgically. Whether it’s a problem with the knee, the shoulder, or any other location, making an accurate diagnosis is paramount. In my practice, I’ve seen many patients who underwent knee surgery for torn cartilage, but the real problem was their patella (kneecap) which with a correct diagnosis, skilled physical therapy and exercise-based regimen could have avoided needless surgical interventions. The MRI for most of these patients picked up and described abnormalities of the meniscus consistent with a tear, but missed the real pain generating problem related to the patella. Another common scenario is the patient with chronic shoulder pain who is active in their 30’s, 40’s, or 50’s and the MRI shows a shoulder labral tear which they have surgery to debride or repair only to still experience persistent pain and limitations. The actual problem commonly would have responded to non-surgical treatment for tendinopathy of the rotator cuff, multi-directional instability, or overuse related arthritis.

A patient in his late 30’s recently saw me for left shoulder pain. He had an MRI from 1.5 years ago and reported an old injury in high school. His main concern over the past year has been intermittent pain along the front of his shoulder when he rides his bike. On weekends, he goes on long bike rides of 50 miles or longer. His shoulder will start to ache during the bike ride and become painful. It improves though during the week, doesn’t interfere with his work, doesn’t keep him awake at night, and is not requiring daily medication for pain. His exam is unremarkable other than he has tenderness along the front of his shoulder when he presses on it or I palpated it and the ball of the shoulder ball-and-socket joint was very mobile contributing to a “loose” shoulder. His MRI showed a labral tear which is a torn piece of cartilage in the shoulder, but his medical exam couldn’t reproduce labral pain. He was entertaining surgery as recommended by a local surgeon, but concerned about down time from work, the surgical risks, and time to recover. His shoulder ultrasound showed normal shoulder rotator cuff and bicep tendon. Upon further discussion about his cycling and other factors influencing his symptoms, it became evident that his underlying problem was his shoulder’s mobility (looseness) and his prolonged, shoulder stress based on its position on the bike during these long rides. Returning to work on stability exercises with his physical therapist and adjusting his bike fit made a positive difference in his shoulder pain and cycling enjoyment. Commonly, these patients failed “conservative” measures in part due to a well-intentioned but incorrect diagnosis based on the MRI result.

Over the past 15 years, musculoskeletal ultrasound has become a powerful tool to help more accurately diagnose knee and shoulder muscle, tendon, and ligament problems in patients so that a more precise initial diagnosis can be achieved resulting in more accurate and focused initial treatment and reduced need for more expensive imaging or unnecessary surgery. Musculoskeletal ultrasound is relatively inexpensive, can be performed in the office, and be utilized to compare the injured side to the unaffected side. Physicians with advanced training in musculoskeletal ultrasound can effectively utilize it to help confirm a suspected diagnosis and even look for other less common causes of pain in areas like the knee and shoulder. In my sports medicine clinic, I’ve found musculoskeletal ultrasound to be a powerful diagnostic tool to increase diagnostic accuracy and help patients get relief of their symptoms faster and without surgery.

When it comes to your quality of life, and pain from your knee or shoulder is limiting your ability to work, do sports, play with your kids, and even perform other routine daily activities, you want relief. At Sports Health Northwest, we want to help you figure out the cause of your pain and get relief from your injury so you can get back in the game or simply return to your previous level of function.

Our goal is to help you non-surgically, utilizing the most effective, innovative, and individualized treatment options available!