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© 2014 New Hampshire Orthopaedic Center
MRI: Not the Whole Story
William P. Rix, MD
MRI is an imaging tool commonly used by orthopedists in making a diagnosis in patients with musculoskeletal complaints. It is frequently mentioned in the media when professional athletes are injured:
“Major League Baseball pitcher John Smith’s production has fallen over the past few games. MRI of his sore shoulder reveals no structural damage and rest is indicated.”
“National Football League lineman Jim White’s episodes of low back pain have limited his starts this season. An MRI showed he will need surgery and will be out for the rest of the season”.
The implication of these common references in the sports media is that an MRI offers the definitive answer for musculoskeletal problems.
MRI is a state-of-the-art imaging technique that depicts the anatomy of our musculoskeletal system in astonishing detail. Despite its unquestionable value, however, it can be confusing and in some cases, downright misleading. This is because the abnormality seen on the scan may not be the cause of the patient’s problem. Remarkable as the technology is, it is no substitute for a good history and physical examination.
To illustrate, let’s look at some actual cases:
• A 50-year-old man was referred to the orthopedist for possible surgery after an MRI revealed a small rotator cuff tear in his shoulder. The patient told the orthopedist that he had experienced sudden onset of severe shoulder pain without injury in a previously normal shoulder. His pain had subsided after 2 weeks, but left him with profound shoulder weakness. The physical examination revealed severe wasting of the supraspinatus and infraspinatus muscles, two important components of the rotator cuff. Because rotator cuff patients usually do not present with such extremes on history or examination, the orthopedist suspected something else was going on. Further muscle testing revealed subtle weakness of the Serratus Anterior, a muscle that holds the scapula (wing-bone) tight to the chest wall, a finding inconsistent with a primary diagnosis of rotator cuff tear. Electrical nerve studies confirmed that this man had inflammation of his brachial plexus, the network of nerves that runs from collarbone to armpit and sends nerves to the shoulder girdle and arm. Though the exact cause of this condition is unknown, the treatment is non-surgical. This man was instructed in an exercise program and his weakness resolved over the next 12 months. The cuff tear was not addressed because it was an incidental finding on MRI and did not contribute to the man`s symptoms.
• A 75-year-old woman experienced severe knee pain when she twisted her leg getting up from the toilet. She arrived at her primary care physician’s office using a walker and unable to bear weight on that leg. A knee x-ray showed no fracture, but an MRI of the knee revealed a torn meniscus (cartilage) and mild-to-moderate arthritis. She was referred to the orthopedist for possible arthroscopic surgery. During the history, the orthopedist noted that the woman was very thin, her diet tended toward “tea and toast” rather than three nutritional meals per day and she smoked, all high risk factors for osteoporosis. The physical examination revealed the knee was non-tender over the torn cartilage area and there was no effusion (water in the knee). These negative findings were unusual for symptoms coming from a torn meniscus as seen on her MRI. Bending and straightening her knee while sitting (hip stationary) caused no pain, but doing the same maneuver in a supine position (hip free to move) reproduced her severe knee pain. The orthopedist became concerned about a hip fracture because hip bone and hip joint conditions sometimes refer pain only to the knee rather than the more common areas of groin and buttocks. An x-ray of her pelvis revealed a non-displaced fragility fracture of the hip, a break that occurs in osteoporotic bone after minor trauma. The danger was that the hip fracture might displace at any time causing pain, blood loss and even death. She underwent same day hip pinning surgery with complete resolution of her pain. She was also counseled on the proper treatment of her osteoporosis. The torn meniscus was not the root cause of this woman`s pain and therefore was ignored.
• Our last example is a 65-year-old man with a six month history of increasing buttocks pain, right greater than left. His pain was worse on walking and better with rest. He had undergone low back (lumbar) surgery 10 years prior and experienced intermittent episodes of backache ever since. An MRI of his lumbar spine showed lumbar stenosis (narrowing) at the site of the old surgery. Spine physical therapy had been ineffective in reducing his pain significantly. He was referred to the orthopedic spine surgeon for possible decompressive surgery at the area of stenosis. The history revealed that the man’s father was “loaded with arthritis” and his brother had undergone both total knee and total hip surgery for debilitating arthritis. The surgeon also noted that the patient, when getting onto the exam table, used his hand to assist in lifting his right leg from the vertical to the horizontal, a move more typical of hip problems than back problems. Physical examination of the hip revealed stiffness, and stressing the hips in rotation reproduced his buttock pain. Dedicated X-rays of his hips revealed bilateral osteoarthritis, right greater than left. Since both lumbar stenosis and hip arthritis can cause buttocks symptoms, further testing were needed to identify which condition was the primary pain generator. An injection into both hip joints with steroid and Xylocaine completely relieved this man’s pain, thus confirming that his buttocks pain was coming from his hips and not from his low back. This man eventually underwent total hip replacement on both sides, as the steroid`s benefit was only temporary. The coexisting lumbar stenosis was not the root cause of this patient’s problem and was left alone.
In all three cases, the MRI showed a true structural abnormality that could be corrected surgically. However, one does not operate on an abnormality just because it`s there. It has to be the cause of the patient`s problem. The MRI did not tell the physician if the findings seen on film were actually causing the patient’s symptoms. An MRI cannot stand by itself. It must be ordered and interpreted in the context of a proper history and exam. In these patients, the MRI findings were age-related or post-surgical and not contributing to their complaints.
The proper sequence in arriving at the root of a patient’s orthopedic problem is a thorough history, a proper examination and, usually, an x-ray. If further investigation is needed to come to a specific diagnosis, further testing, including MRI is then employed.
Since the time of Hippocrates, the backbone of delivering good patient care has been the history and physical. It still is.
What is it?
A concussion is an injury to the brain that alters its function, the effects of which are usually temporary. These effects are variable and can include difficulty with concentration, memory, balance, and coordination.
These can range from very subtle, to obvious and severe. Headache, loss of memory, and confusion are often seen. Loss of memory can include events prior to the injury and will often include loss of memory of how the injury occurred.
MOST CONCUSSIONS DO NOT RESULT IN LOSS OF CONSCIOUSNESS.
Things to look for include:
Seizures, altered vision, pupils that don’t appear symmetric, or prolonged loss of consciousness require immediate evaluation
The brain is a very delicate structure encased in a solid container (skull). Anything that causes the brain to knock up against the side of the skull may result in a concussion. A DIRECT BLOW TO THE HEAD IS NOT REQUIRED TO RESULT IN A CONCUSSION, NOR IS DIRECT CONTACT. Rapid deceleration of the head can cause the brain to hit the skull and result in a concussion.
Participation in collision sports such as lacrosse (in this case) is a risk factor. Another very important risk factor is having had a previous concussion.
On field evaluation includes evaluating consciousness and protecting any neck injury. There are various sideline tools used to assess the athletes symptoms and ability to recall or think. These are brief screening tools for the in-game setting which are usually followed by more comprehensive neurocognitive testing.
There is no routine x-ray or medical test to diagnose concussion. CT SCANS AND MRIs ARE TYPICALLY NORMAL with a concussion. If a patient develops specific neurological symptoms such as prolonged or worsening pain, loss of vision, asymmetric pupils, repeated vomiting or seizures CT scans and/or MRI can tell if there is bleeding on the brain that may be the cause.
1. “When in doubt, keep ‘em out”. The first step is removing the athlete from participation as soon as a concussion is suspected.
2. Rest. This includes rest from both physical and mental activity. This includes all “thinking” activities like reading, video games, TV, etc.
3. Tylenol (acetaminophen) is useful for headaches, but NSAIDs such as Ibuprofen (Motrin, Advil), Aleve, and Aspirin are NOT recommended, as this may increase the risk of bleeding.
4. Progression back to activity begins with mental activity first.
5. Some studies have suggested that gentle exercise that keeps the athlete below their symptom threshold might help decrease the possibility of post concussion syndrome and help both athletes and non-athletes return to activity.
Return to Play
Most athletes will have resolution of symptoms after two weeks and a return of their neurological testing to a baseline (“normal”) in 7-10 days. Internationally accepted return to play criteria includes:
Once an athlete has no symptoms at rest, they can then progress through a guided protocol of rehab to return to play. Each stage takes 24 hrs, so that it takes at least 5 days to progress through the protocol prior to full game participation.
Preventative measures are of paramount importance in high risk sports. Players, Coaches, and parents have a role to play in not only recognition of sports concussions, but in changing the behavior and culture that may result in concussion. Many players, coaches, and parents may feel like aggressive behavior is required in certain sports. These feelings are often heard expounded from the sidelines. Proper technique, age appropriate rules for contact, and sportsmanship can result in decreased incidence of concussions.
Helmets and new helmet technology have been shown to decrease the risk of concussion and newer technologies are promising.
There is lack of conclusive evidence that the use of a mouth guard or specific types of mouth guards reduce the risk of concussion. Mouth guards do, however, reduce the risk of dental trauma which makes them invaluable in that role.
Post Concussion Syndrome is the persistence of any of the following after a concussion: headaches, dizziness, fatigue, irritability, difficulty with concentration and mental tasks, memory impairment, insomnia, and reduced tolerance to stress. It’s suspected if these symptoms persist more than 1-6 weeks after initial injury. Athletes who present initially with more symptoms take longer to recover.
Epilepsy: The risk of developing Epilepsy is doubled in the first 5 years post concussion.
Second Impact Syndrome: This is when an athlete sustains 2 successive injuries before recovery of the first is complete. Younger athletes seem especially susceptible to this, which can be a devastating complication leading to rapid brain swelling and death. Second Impact Synrome highlights the importance of restricting athletes from play until they have NO SYMPTOMS.
CTE (Chronic Traumatic Encephalopathy): This is a degenerative condition of the brain that occurs years after recovery. It is the topic of much conversation and research. Early in CTE, patients can have problems with irritability, depression, and poor memory. Later on, it can affect physical movement and speech. (See Junior Seau, Jim McMahon, both former NFL players)
There are multiple resources available for education for players, parents, coaches, and trainers on this topic which include programs for preseason baseline testing for players which is instituted in many local high schools and routinely at the collegiate and professional levels.
|NCAA Concussion in Sports||www.ncaa.org/wps/portal/ncaahome?WCM_GLOBAL_CONTEXT = /ncaa/NCAA/Academics+and+Athletes/Personal+Welfare/Health+and+Safety/Concussion|
|Centers for Disease Control and Prevention Heads Up Toolkit for High School Sports||www.cdc.gov/concussion/HeadsUp/high_school.html|
|Centers for Disease Control and Prevention Heads Up Toolkit for Schools||www.cdc.gov/concussion/HeadsUp/schools.html|
|Centers for Disease Control and Prevention Heads Up Toolkit for Physicians||www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html|
|Computerized neuropsychological tests|
|U.S. Army Medical Department, Automated Neurocognitive Assessment Metrics (ANAM)||www.armymedicine.army.mil/prr/anam.html|
**The Journal of Bone and Joint Surgery Current Concepts Review, Vol 94, Issue 17
Another I would add to this is sportslegacy.org, which is an organization headed by Chris Nowinski and Dr. Robert Cantu with cutting edge education and policy on this enormously important matter. There are several links and guides to setting up and maintaining an active concussion surveillance and management program for teams and institutions.
What Is It?
An overuse syndrome resulting in painful inflammation at the top of the shin bone where the patellar tendon attaches to the bone in an adolescent or preadolescent athlete.
This condition is marked by pain and tenderness with or without (usually with) a bump at the top of the shinbone (tibia). The pain is often increased with activity (or just after finishing the activity), and is often relieved with rest. It may be associated with a noticeable tightness in the muscles in the front and in the back of the thigh.
An apophysis is a growth plate that does not contribute to the length of a bone. Growth plates are made of cartilage. Cartilage is weaker than bone in the immature skeleton. Apophyses are often found at sites where tendons attach to bone. Apophysitis is inflammation at these attachment sites, the adult equivalent of which is tendonitis.
Repetitive activities, such as jumping, running, pivoting, etc. , coupled with a child who is growing, can lead to increase pull and tension on these delicate areas. This leads to pain and inflammation in those areas. The body may attempt to repair these areas by forming more bone, leading to a lump forming.
Osgood-Schlatters is a clinical diagnosis. A plain X-ray is often obtained to rule out other less common problems and to sometimes confirm the diagnosis. MRI IS NOT NECESSARY TO DIAGNOSE THIS CONDITION.
What Are They?
Otherwise known as “medial tibial stress syndrome”, shin splints refers to pain at the inside back edge of the tibia, or shin bone. Usually the pain is located in the lower 1/3 of the bone, but may occur along a longer length of the bone.
Shin splints occur when too much stress is placed on the muscles and tissues that connect to that area of the bone.
The hallmark of shin splints is pain in the area of the shin mentioned above which begins during prolonged or intensive activity, but can gradually worsen to the point of being constant.
Initially the pain may go away with rest, but it might progress to the point where it lingers even after activity has ended. There may also be swelling in the lower leg that is tender to the touch.
A sudden, traumatic event is NOT how shin splints begin.
As with many of the so called “overuse” syndromes, shin splints often begin with an increase in duration, intensity, and repetition of an athletic activity.
Shin splints can occur while doing endurance activities such as running, or during activities requiring cutting, pivoting, jumping and landing like lacrosse, basketball and soccer.
Other causes include:
Both boys and girls are at risk. Beginners or people who have not prepared adequately for increased intensity are at greater risk. Other risk factors include:
As is common with soft tissue conditions, the diagnosis is often a clinical one after careful questioning and a physical examination by a trained sports medicine specialist. However, a stress fracture of the shin bone (tibia) needs to be ruled out by an X-ray and often an MRI scan depending on how suspicious the clinician is and the duration of symptoms.
REST, REST, REST. You may recognize rest as the same treatment for many overuse problems and it is the most difficult for many people.
Rest doesn’t mean do nothing. It means move to low or no impact activities like riding a stationary bike and swimming when you are comfortable enough. As your pain decreases, you can start light impact cross training.
Ice and anti-inflammatory medications can be very helpful to control pain and swelling when it is present.
Wear proper shoes and get evaluated for orthotics, or shoe inserts. They can help prevent the inward turning of the foot and ankle, which quite often contributes to stress on the lower leg.
This overlaps with treatment and includes:
There are two types of heel pain that send patients to the orthopedist: back of the heel pain (Achilles Tendinitis or AT) and bottom of the heel pain (Plantar Fasciitis or PF). The symptoms in both conditions are similar: first step, or start up, pain after getting out of bed in the morning and pain after getting up from prolonged sitting. After a few steps, the pain lessens, but with increased activity through the day it worsens. Usually only one heel is involved, and there is no pain at rest.
The cause is similar in both syndromes. The Achilles tendon (heel cord) attaches the lower calf muscle to the back of the heel bone. Pain in the back of the heel (Achilles Tendinitis) is due to a breakdown of this attachment.The Plantar Fascia is a ligament which attaches the toes to the bottom of the heel bone and supports the arch. Pain at the bottom of the heel (Plantar Fasciitis) is due to a breakdown in this attachment.
The culprit, in many cases, is an over tight Achilles tendon which places extra stresses on attachments to the heel bone. Over time the attachment frays and the body`s effort to repair it stalls.
It is the resultant non healing state of the tendon or the fascia (both termed “tendinopathies”) that causes the chronic heel pain. (Interestingly, these two conditions do not coexist at the same time). Usually the patient endures months of suffering, hoping the problem will resolve, before seeking medical help.
Our goal in treatment is to try and “jump start” the healing process. We use physical therapy, anti-inflammatory medication, shoe inserts, daily heel cord and plantar fascia stretching exercises, and night splints that stretch these soft tissues during sleep. High impact sports are curtailed and behaviors detrimental to healing (smoking, poor nutrition, unsupportive foot wear, excess weight) are addressed.
Steroid injections into the heel cord and plantar fascia are used sparingly, if at all. They delay local healing and may weaken the tissues, predisposing them to rupture. Injections of Platelet Rich Plasma (PRP), a spun down concentrate of a person’s own blood, have been used to treat these conditions. Though considered experimental and somewhat controversial, PRP injections have been shown in some cases to accelerate healing.
Occasionally surgery is used, but more with Achilles Tendinitis than Plantar Fasciitis. (Making an incision in the skin over the back of the heel is much better tolerated than going through the very thick skin and fat pad on the bottom of the heel). Sometimes all it takes to restart healing is to remove surgically the non-healing tissues from the Achilles` or Plantar Fascia`s bony attachments. In other cases, the Achilles tendon may need to be detached, cleaned off, and reattached into a new freshened bed of bleeding bone. This is not done with the plantar fascia for reasons stated above and because the results are less predictable.
Once the AT or PF has resolved, whether through conservative or surgical means, it is important for the patient to be on a maintenance program to prevent recurrence. A one hour program of stretching and brisk walking at least three times a week is highly recommended. Stretching is particularly important because healing tissue(scar) tends to shorten and tighten with time, rendering it more vulnerable to re-tearing.
Other causes of heel pain include stress fractures, pinched nerves, infections, arthritis, and tumors. Although these conditions are always kept in mind when assessing the cause of a patient`s chronic heel pain, they are uncommon. When the diagnosis is AT or PF, early treatment ensures the best possible outcome from these two common, but debilitating conditions that interfere greatly with an active lifestyle, so important to general health and wellness.
© 2014 New Hampshire Orthopaedic Center