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MRI: Not the Whole Story

Originally posted on October 25, 2011

Since we started using MRI routinely to help treat back problems in 1994, success in treatment actually decreased. How can that be? For most orthopedic pathologies, the MRI (magnetic resonance imaging) is the diagnostic tool for physicians to determine the existence and severity of a problem. It is a non-invasive medical test that can help doctors diagnose and therefore know how to treat a variety of medical conditions. It can detect problems that traditional x-rays and CT scans cannot by providing images of soft tissue structures like discs and cartilage. So why then are we having less, not more success in treating back problems?The reason success in treating back pain has gone down is because we see pathology on the scan and feel eager to fix it. And though the surgery takes care of what looks offensive, it often does not solve the core problem, or it creates another set of problems.

MRI, though used routinely has a few shortcomings: First, it’s very expensive. Second, it only focuses on one region of the body- usually the region of pain – and when the area of pain is not the cause of pain, we can be misled. Third, MRI does not look at the body in motion, which is when many problems present themselves. And maybe most important of all, when one can see so much, and so much that looks pathological, who really knows what the culprit is?

Could the same be true for MRIs of the knee? Take George for instance….

I met George some months ago when he first visited me for left knee pain. He had seen his orthopedist for a gradual onset of pain on the inside of his left knee that was preventing him from hiking, his favorite pastime on weekends. His surgeon ordered an MRI of his knee that came back with the result: “likely a tear in the medial meniscus” and “mild degenerative changes”. The meniscus is a cartilaginous ring in the knee. We all have two of them in each knee and it helps with proper joint mechanics, shock absorption, and nutrition and lubrication of the cartilage in the knee. The surgeon told George that surgery was likely inevitable but he could try some physical therapy if he wished. George was scheduled for surgery in three weeks. He also figured that trying some physical therapy prior to his surgery would only help his recovery, so he scheduled with me at the end of that week.

During our first visit, I did an entire biomechanical evaluation of George from his back down to his feet. I looked at his movement in various scenarios to address all things contributing to his knee pain. And we found some interesting findings. On his intake, he noted that he had a history of back pain. And upon examination, I found malalignments throughout his pelvis and significant tightness in his left hip. In analyzing his walking, George’s left foot turned out more than his right, which was likely caused by poor alignment and hip tightness. He also had a fair amount of muscle weakness around his left knee compared to his right. When testing balance on his left leg, George was about as half as efficient as he was on his right. He did not show positive signs when testing his meniscus but those are very inconclusive (accuracy is about 67%). He had tenderness all along the inside of his left knee.

At the end of our first visit together, I corrected malalignments in his pelvis, gave him stretching and strengthening exercises for his lower legs and core muscles, balancing drills, and sent him to the local shoe store to trade out his 2-year-old walking shoes for a pair of proper biomechanical fitting shoes. We continued to work together for 3 additional visits to address hip flexibility, make sure his pelvis stayed in proper position, and to progress his exercises. He noted continued improvement each time we met so that by our 4th visit, he was able to hike with only very mild discomfort towards the end of his hike. His surgery was scheduled for the following week and he very gladly called to cancel. He then came in for 3 additional visits and was able to hike without limitations at the time of discharge. He diligently performed his strength and flexibility exercises on his own throughout the course of treatment.

It is not completely clear whether George, in fact, had a tear in his meniscus. Maybe he did, but other factors clearly contributed to his pain: imbalances in his pelvis and hip, weakness around the knee, a decrease in his left leg balance, and poor shoes all increased stress and discomfort on the inside of his knee. If he had not come to therapy and continued with surgery as his primary intervention, there is a very good chance that without the corrections he received in therapy, he would have continued to have some level of discomfort.

The MRI has been a very valuable tool for physicians in diagnosing orthopedic pathologies. Yet, to get the entire picture of how you are moving and to learn how to take stress off painful areas, have a thorough physical therapy evaluation of all areas involved; make sure everything is working together as it was designed to work. This can allow for optimal healing if surgery is inevitable, and it may prevent invasive procedures altogether, as it did for George.

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