MRI scans in Sports Medicine – use or abuse?

There was an interesting article in the New York Times this week that caught my eye, thanks to an alert from our Publisher at CJSM (thanks, Paul!)

In the article by Gina Kolata, a science journalist for the New York Times, Dr James Andrews, of the Andrews Institute for Orthopaedics and Sports Medicine, was quoted as saying ‘If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI.’

The article claims that Dr Andrews was involved in a piece of research where the pitching shoulders of 31 asymptomatic Professional Baseball pitchers were scanned using MRI, with findings of ‘abnormal shoulder cartilage’ in 90% of the shoulders, and ‘abnormal rotator cuff tendons’ in 87% of the shoulders. There was no indication as to whether or not this research was published.

Other clinicians are subsequently quoted, including Professor Bruce Sangeorzan, Vice Chairman of the Department of Orthopaedics and Sports Medicine at the University of Washington saying ‘an MRI is unlike any other imaging tool we use… It is a very sensitive tool, but it is not very specific. That’s the problem.’

In addition, Professor Christopher DiGiovanni, Sports Medicine and Orthopaedic Specialist at Brown University, is quoted as saying ‘It is very rare for an MRI to come back with the words “normal study” … I can’t tell you the last time I’ve seen it.’

Following quotes from these clinicans, the author goes on to make what some might call a leap of faith in then stating that ‘MRIs are not the only scans that are overused in medicine, but in sports medicine where many injuries involve soft tissues like muscles and tendons, they rise to the fore,’ the statement regarding ‘overuse’ having been drawn, presumably, from inferences from some of the clinicians quoted in the article.

Later on in the article, a retrospective study from 2005 by Bradley and colleagues  of 101 patients with chronic atraumatic shoulder pain is mentioned which examined the effect of pre-evaluation MRI on patient treatment and outcome, and concluded that MRI was not helpful as a screening tool for atraumatic shoulder pain before a comprehensive clinical evaluation of the shoulder.

In addition, another retrospective study from 2007 was mentioned by Tocci and colleagues who set out to prove the alternative hypothesis that rising accessibility of MRI may be resulting in it’s overuse by retrospectively reviewing 221 patients seen over a 3 month period for the treatment of a lower extremity problem. The authors concluded that ‘many of the pre-referral foot or ankle MRI scans obtained before evaluation by a foot and ankle specialist are not necessary.’

The New York Times article certainly seems to have sparked a flame of interest spreading amongst other newspaper and website authors and has been widely quoted in the few days since it has been published.

There is no doubt that there are a number of factors that could lead MRI scans to become overused as an investigation in the assessment of patients seen by Sports Medicine clinicians. These could include improved accessibility to MRI scanners, reduced cost for examinations, inadequate clinician history taking and / or examination skills, laziness on the part of clinicians in performing an appropriate assessment, financial incentives, patient pressure for scans, and defensive medical practice.

However, any clinician worth their salt surely recognises the need for an excellent history, targeted clinical examination, formulation of a differential diagnosis and appropriate investigation on the basis of these.

They would also surely realise issues regarding the sensitivity and specificity of MRI scans for detecting lesions, and the fact that the natural history of some lesions detected by MRI scans that have hitherto been undetectable is not well known, limiting the conclusions that can be drawn from some scans relating to treatment and prognosis.

In addition, the limitations of MRI scanning as a screening tool should also be known by responsible clinicians, although there is no doubt in my mind that some colleagues are using MRI scanning in a non-evidence based way for screening and that this may ultimately lead to unnecessary procedures and psychosocial harm.

I don’t agree with the quote from Dr Andrews implying that if one wants to operate on a pitcher’s shoulder then all one needs to do is order an MRI scan – good surgeons operate on patients, not scans, and should surely follow the time-honoured approach I have highlighted above.

The article by Kolata in the New York Times presents little if any evidence that MRI scans are indeed overused in Sports Medicine, and it is my opinion that the views of a few individuals plus a couple of retrospective studies don’t really form a convincing argument to support the inference in the title of author’s article, that MRIs are indeed overused in Sports Medicine.

It’s interesting that our Specialty was targeted in this article.

Is this a thinly-veiled attack on Sports Medicine clinicians?

What do our readers think?

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About Chris Hughes
Associate Editor, Clinical Journal of Sport Medicine

2 Responses to MRI scans in Sports Medicine – use or abuse?

  1. Douglas B McKeag, IU School of Medicine says:

    Chris –
    I agree with your assessment of the article. Perhaps one way to look at this is to examine the answers to two questions; 1]Is the MRI a useful ‘screening’ tool? Of course not, but then I don’t order an MR to ‘screen’ anybody [done only at NFL combines]. I order it to obtain further info on the patient to determine a treatment plan. That plan includes me dtermining if any MR findings are significant enough to warrant an orthopedic consult. Sometimes they are; many times they’re not. If doctors are truly using it to ‘screen’, then I agree with the author of the article and the claim of overuse. 2]Is too much surgery the result of MR use? Depends on how good your orthopedic consult is. If I determine that too much surgery occurs in my consults, then it’s time to find another orthopedic surgeon. In order words, I am responsible for asking and answering this question. DBMcKeag

    • Chris Hughes says:

      Hi Douglas and many thanks for your comments.

      There are indeed many clinicians involved in elite sport in the UK and around the World who are using MRI as a screening tool during pre-participation evaluation and signing medicals.
      I have heard arguments both for and against the use of imaging for screening players, sometimes based on available evidence and sometimes based on personal opinion. The ‘for’ argument usually centres around the huge cost of players and the possible negative financial consequences of signing a player with a previously undiagnosed condition of possible significance, and that the screening is a specific, targeted form of screening. The ‘against’ arguments include the fact that MRI screening doesn’t fit Wilson’s screening criteria (see http://www.healthknowledge.org.uk/public-health-textbook/disease-causation-diagnostic/2c-diagnosis-screening/principles-methods-applications ), issues related to the sensitivity and specificity of MRI scans, and the uncertainty surrounding the natural history of some lesions found on modern MRI scanning.

      Any of our readers have any thoughts, or examples where MRI screening has had a positive effect on practice and patient care?

      Are we all auditing our own scan results and comparing interpretation with findings at surgery in those patients who go on to have surgery?

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