MRI – Is it always black and white?

In orthopedics, an MRI is used to search for physical structures that show damage.
In recent years, however, it has become increasingly recognized that there can often be premature findings and misinterpretations. Sometimes these imaging techniques offer no advantage – in some cases, they can even be a disadvantage for the patient.

Recent studies involving healthy or asymptomatic people have shown that many findings are simply a normal aging process. For example, we know that 88% of 60-year-olds show signs of disc degeneration, and 70% have disc bulging. Even younger populations are affected: 85% of young athletes show vertebral slippage in MRI, and 37% of 20-year-olds have disc degeneration but experience no symptoms.

This is not limited to the back:

• One-third of asymptomatic middle-aged patients show a meniscus tear in the knee.
• From the age of 40, symptom-free patients show 43% signs of osteoarthritis in imaging studies.
• 60% of asymptomatic older adults have a subacromial bursitis in the shoulder.
• Even in younger pain-free patients, MRI shows rotator cuff tears or tendinosis in 65% of cases.
• Labral tears in the hip are found in up to 69% of asymptomatic adults, and even 89% in athletes.
• Even every second symptom-free dancer shows a labral cyst in the hip on imaging.

And these are just a few examples. As if that weren’t enough: Early MRIs can even prolong patients’ recovery time. Findings that are not relevant at the moment can negatively affect patients’ perceptions, causing them to become anxious and fearful. This leads to fear-avoidance behavior.

What is fear-avoidance behavior?

Many back pain patients are uncertain after an MRI with findings such as “facet joint arthritis” and think that if they continue to move and exert themselves, they will damage their back or even make it “more broken“. However, if they knew that many other patients have the same MRI findings and are pain-free, their perception might be different.

Considering that today we know 85% of back pain is classified as complex back pain for which no clear medical cause is found, we need to reconsider whether it is sensible and necessary to perform an MRI in every case. Even if symptoms are present, an MRI is not always needed as an initial assessment. Certainly, there are some exceptions such as after an accident or if a patient has specific warning signs (e.g., prolonged numbness, muscle weakness/paralysis, suspicion of infections/fractures/malignant processes).

According to a 2020 study, there is also a significant variability among those evaluating MRIs. For example, the agreement between radiologists and specialists for shoulder MRIs is only 44%.

The relevance of MRI reports should always be discussed and considered individually with the patient and their symptoms.

It is quite possible that your MRI shows a finding that may sound alarming but is part of the normal aging process, just like how we develop wrinkles or gray hair as we age.

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