You wake up one morning, and your shoulder hurts. You’re not sure why, and blame it on your sleeping position. Perhaps you bend down to pick something up, and when you stand up your knee hurts. These are very common stories heard from patients in an orthopedic surgeon’s office. The onset of joint pain without significant trauma is very common over the age of 40.
Perhaps you wait a week, or worse, you run off to your primary care doctor immediately. Surely, pain means that something is wrong … right? Well, not so fast. Many of us will have shoulder, elbow or knee pain for no apparent reason as we age. Sedentary behavior is not tolerated well by our joints. Our tendons and muscles like to be exercised. They like the force or stress that resistive exercises provide. A joint supported by weakened muscle is a joint at risk for pain. That being said, even if you do exercise, you are still at risk of developing joint pain. So back to your aching knee or shoulder. What’s your next step?
Let’s say you do go to your primary care doctor or orthopedist. Many of you expect an MRI to be ordered. Some will actually insist on it. I am asking you to think twice before demanding an MRI study. Why? Because almost no one over the age of 40 is going to have a normal knee or shoulder MRI. A good radiologist will be able to find “changes” with almost any study. See this graphic; then let’s consider what it means.
As we mature, various “age appropriate” changes are going to take place. If you are referred for a shoulder MRI, there is a very high probability that the scan will show a labral tear — and there is a nearly 100 percent chance that the “tear” was there long before your pain started. There is also an 80+ percent chance of a disc abnormality on a spine MRI in “normal” people. Meniscus tears are very common in folks who have no knee pain. I know very successful runners with meniscus tears managed without operations and have no ongoing issues. I have treated hundreds of patients with meniscus tears without surgery. Most returned to an active lifestyle. Very few worsened over the years. And it is very unlikely that an operation or earlier imaging would have influenced their ultimate clinical outcome.
The bottom line is that imaging someone after the age of 40 is rarely going to result in an impression that says “normal.” And the changes seen on the MRI might not even be the cause of the pain or correlate with the severity of your pain. More importantly, most of the current research into small degenerative rotator cuff tears or tears of the medial meniscus show that the results of surgery are often no better than placebo. These studies show that physical therapy is as effective as surgery for these age-appropriate findings.
In the majority of circumstances, we do not have to rush into ordering an MRI — unless there is a history of a traumatic injury, like a fall from a ladder, a twisting injury to knee while playing soccer or you fell off your bike most joint pains can be observed clinically for signs of improvement.
Assuming your examination and X-rays do not reveal anything that strongly suggests that imaging would change the treatment recommendations — then observation, benign neglect and physical therapy will ultimately return most of you back to the level of function you had before your shoulder or knee started bothering you.
OK — so you want the MRI anyway. And your physician obliges you. What’s the harm, right? Wrong. After an MRI, you will find out that you have a meniscus tear or a rotator cuff tear. Many of you will be able to take that information in stride and move on, but many of you may not. Every serve or overhead in your tennis game will be affected. Every time your shoulder aches or clicks, you will think your tear became larger. You will stop kneeling or squatting down in fear of making your meniscus “tear” worse. You could be very afraid that you will not be able to go on that vacation you have scheduled in two months. All these “what if” questions start to swirl around your mind.
We haven’t even touched on the issue of potential over-treatment. While it’s true that most degenerative cuff tears and meniscus tears feel better over time ( a few months, not a few weeks) with physical therapy, there are still some patients who will receive treatment recommendations based on their MRI findings. We, as physicians, should strive to treat patients and not imaging study impressions, but that can be a challenge for some. There are most certainly a number of people undergoing surgery for an age-appropriate change before giving non-surgical management a chance to work. Now the risks become real. Anticoagulation for atrial fibrillation is stopped, a DVT might occur, your arthritis might worsen from the loss of meniscal tissue. The risks of an arthroscopy are very real. These are risks that many are willing to assume in the proper context. But they should not be exposed to them unless clinically indicated, and other less risky options have failed to improve their quality of life. The only surgery without risk is a surgery on someone else.
When managing knee, back, elbow and shoulder pain in the middle-age adult and beyond less is often more. Sure, there are times to image these patients. Yes, some may ultimately benefit from imaging and surgery. But the numbers of people who would qualify as appropriate candidates for imaging and/or surgery are far lower than they are today.
Howard Luks is an orthopedic surgeon who blogs at his self-titled site, Howard J. Luks, MD.
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