Your MRI is lying to you.
Or it’s telling you ridiculously important information that will change everything.
Or it’s somewhere in between.
Confused yet?
What is it?
The results of diagnostic imaging (MRI, x-ray, CT scan, ultrasound, etc.) are not black and white.
If you get an MRI today, they will likely find something “wrong” during the scan.
Even if you have no pain at all and no limitations, the imaging will show damaged structures.
This becomes increasingly true the further into your athletic career that you go.
Don’t believe me? Check out the fun facts section for more complete study summaries.
But, here are some highlights:
1) In a group of pain free hockey players and skiers between the ages of 16 and 19, 89% had hip labral tears.
Those who played their sport for 9 years or more were 5x more likely to have a hip labral tear.
2) In a group of 18 healthy male soccer players who had zero pain or symptoms, 15 of them had at least one low back abnormal finding on MRI.
This includes 7 of them who had disc herniations and 4 of them who had pars stress fractures/injuries.
3) In a group of 20 pain-free overhead athletes:
– 8 had rotator cuff tears.
– 5 had Bennett’s lesions
– 36/40 shoulders had joint effusion
4) In a group of pain-free professional baseball players, the labrum was abnormal in 79% of the 28 shoulders.
Why does it matter?
Let’s say you’re a 17 year old high school volleyball player.
You’ve been playing club for forever and now you’re the best outside hitter in the state.
You’re playing one day and you notice your shoulder feels a little off. You shrug it off and throw on some ice after practice.
The next day, though? Sheeeesh.
It’s sharp, it’s dull, it’s achy, it burns. It hurts on the front of the shoulder, the back of the shoulder, and everywhere in between.
You think “there’s no way this is normal.” So, you go to your physician and your mom demands an MRI.
You get it ordered, but you have to wait 3 weeks to get in.
As those 3 weeks go by, you start to feel better and better. By the time the MRI appointment comes by, your shoulder feels 99.9% healed.
But, you already have it scheduled, so why not at least go?
You get the results back and your heart sinks. You see you have a labral tear.
You follow-up with an orthopedic surgeon and he tells you that labrums don’t heal on their own, so you have to get surgery to heal it.
There goes your senior season… right?
Let’s rewind.
This time, let’s go back one year earlier. You’re the same elite volleyball player, just 16 years old now.
You’ve been invited to take part in a research study where you get an MRI on your shoulder and you make some money in return.
You never see the results, but guess what? There’s a labral tear on that same shoulder.
You have no pain, no symptoms, and no issues at all.
Fast forward back to the moment of heartbreak. Here are the facts:
– 1 year ago, you had a labral tear in your shoulder and you had no pain.
– Today, you have a labral tear in your shoulder.
– You had intense pain for a little bit, but time has allowed you to get better and better.
The labral tear was there way before you ever had any pain, you just didn’t know it.
If you had the labral tear for at least a year before you ever had pain, how can you say that the labral tear is what’s causing the pain?
Differentiating between incidental findings and meaningful clinical relevance after pain develops is not black and white.
If you just go off of your MRI, you’re going to have surgery and miss your senior season when you are essentially pain free.
That doesn’t make much sense, does it?
How does this happen?
1) The athletes are truly asymptomatic.
Pain is complex. There is not a 1:1 correlation between mechanical damage and pain perception.
We are not cars. Our wiring is much more complicated.
It seems logical that anytime you have pain there is a damaged body part and that anytime there is a damaged body part, you will have pain.
But, that’s just not the case.
It’s very common for us to have a damaged or abnormal body part and have no pain or restrictions whatsoever.
2) Different athletes have different coping mechanisms
I think it’s important to acknowledge this.
Some athletes are so ignorantly tough that they could be walking around with what someone else calls a 7 out of 10 pain and consider themselves to be pain free.
Pain is super subjective and it makes adding quantifiable research challenging.
3) The structural changes precede the onset of symptoms
It’s plausible that the structural changes could eventually lead to symptoms later down the line.
But, I’m not so sure that’s backed by research.
A study on pain-free elite overhead athletes found that their “abnormal” shoulder still had no issues 5 years down the road during their athletic career.3
My thoughts
Pain is a normal experience for all human beings, but it is exceptionally normal for those trying to push the limits of athletic performance.
When pain does arise, our society craves answers immediately. Surface level logic tells us that imaging gives us those answers. So, we pound the table and demand an x-ray or MRI.
Over-imaging is dangerous.
Several imaging methods (x-ray, CT scan, etc.) expose us to unnecessary radiation.
Imaging is expensive and drives up our healthcare costs.
Maybe most importantly is the damage that it does to an athlete’s psyche. It’s hard to unsee your MRI report.
Even though the findings may have been there for years and be completely unrelated to your current issues, it’s hard to internalize that and ignore it.
Sometimes the findings on MRI/x-ray are super important and can significantly change your course of care.
Sometimes it’s a complete waste of time, money, and mental energy.
It’s not a straight-forward process. It’s an odds-game.
Based on the mechanism of injury, history, and physical exam, what are the possible diagnoses that we’re looking for?
What are the odds that the imaging will find that injury?
What are the odds that if that injury is found, that it could have been there previously without causing any pain or limitations?
What are the odds that finding that injury and deciding that’s what’s causing the pain would alter the decision making moving forward?
Navigating the best course of action is as much of an art-form as a science.
Fun Facts
Stat highlights on findings in pain-free athletes:
1) Asymptomatic skiers and hockey players younger than 19 years old (93 males, 8 females)1:
– Labral tears were identified in 70 hips.
– 89% of the athletes 16 years of age or older had labral tears and 56% of the participants 16 years or younger had labral tears.
– Participants 16 years of older were 7 times more likely to have a labral tear than participants under the age of 16.
– Participants who had participated in their sport 9 years or greater were 4.9 times more likely to have a labral tear compared to participants who had participated less than 9 years
– Average alpha angle was 59°. The alpha angle considered to be positive for hip impingement (FAI) is 55°.
2) Asymptomatic elite male soccer players 16-19 years old (18 athletes)2:
– 15 players (83%) showed ≥1 abnormalities (including facet degeneration, synovial cysts, disc degeneration, disc herniation, and pars injury.
– 5 players showed evidence of disc herniation (27%).
– 7 players had disc degeneration at one or more levels (38%).
– 4 players (22%) presented asymptomatic pars injuries
– 1 player (6%) had mild facet joint arthropathy at L4/L5 and 3 (16.7%) showed evidence of bilateral facet joint effusions.
– Three synovial cysts were identified in 2 players (11%),
3) Asymptomatic elite baseball and tennis athletes ages 18-38 years old (20 athletes)3:
– 8 dominant shoulders (40%) had findings consistent with partial- or full-thickness tears.
– 5 (25%) dominant shoulders had MRI evidence of Bennett’s lesions.
– Rotator cuff findings of partial thickness or full-thickness tears were more common in tennis players (62%) and Bennett’s lesions more common in baseball players (33%).
– 36 shoulders (90%) had joint effusions and 19 (47.5%) had subacromial fluid present.
– 9 shoulders (22.5%) had sclerotic or cystic changes in the greater tuberosity
– 3 shoulders (7.5%) had findings consistent with partial tears of the anteroinferior or superior glenoid labrum.
– At the 5-year follow-up, “none of the interviewed athletes had subjective symptoms or had required any evaluation or treatment for shoulder related problems during the 5-year study period.
– All interviewed participants continued to have asymptomatic shoulders and were still playing their respective sport competitively.
– None of them had appreciable decreases in level of play attributable to their shoulder or arm during this study.
– Three of the 16 players were still playing at the professional level (1 tennis player and 2 baseball pitchers) at this 5-year follow-up.
– Of note, the professional tennis player’s original dominant shoulder MRI revealed signal changes consistent with a small, full-thickness rotator cuff tear.”
4) Asymptomatic professional baseball players 18-22 years old (14 athletes)4:
– 80% of shoulders demonstrated grade 1A or 1B changes in the rotator cuff (suprapspinatus or infraspinatus).
– 2 athletes had partial rotator cuff tears
– “45% of the throwing shoulders and 36% of the nonthrowing shoulders were found to have type 3 labral tears”
– “ The labrum was abnormal in 79% of the 28 shoulders”
That’s it!
Best,
Zach
Dr. Zach Guiser, PT, DPT, CSCS
References:
1. Briggs, K., Philippon, M., Ho, C., & McNamara, S. (2017). PREVALENCE OF ACETABULAR LABRAL TEARS IN ASYMPTOMATIC YOUNG ATHLETES. British Journal of Sports Medicine, 51(4), 303. doi:https://doi.org/10.1136/bjsports-2016-097372.50
2. Carmody S, Rajeswaran G, Mitchell A, et al. Lumbar spine MRI findings in asymptomatic elite male academy footballers: a case series. BMC Sports Sci Med Rehabil. 2022;14(1):184. Published 2022 Oct 24. doi:10.1186/s13102-022-00576-1
3. Connor PM( 1,5 ), D’Alessandro DF( 1 ), Banks DM( 2 ), Tyson AB( 3 ), Coumas JS( 4 ). Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: A 5-year follow-up study. American Journal of Sports Medicine. 2003;31(5):724-727-727. doi:10.1177/03635465030310051501
4. Miniaci A( 1,3 ), Mascia AT( 2 ), Salonen DC( 2 ), Becker EJ( 2 ). Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. American Journal of Sports Medicine. 2002;30(1):66-73-73. doi:10.1177/03635465020300012501