Knees of a 90 year old
We live in amazing times, technology is advancing at an astronomical rate and it’s benefitting us in innumerable facets of our lives. I mean seriously, I have a robot vacuum! One area in particular that we have probably all seen great advances has been in the field of medicine. Today though I’d like to talk about how we don’t quite have it all figured out, specifically in regards to medical imaging.
MRI or magnetic resonance imaging is an absolutely amazing technology. Dating back to the 1970’s it has revolutionized our ability to see within the body. Large magnets create pulses of radio waves, these radio waves of varying pulses give us the ability to visualize soft tissue structures better than ever before. More simply put we can see muscles, ligaments, brain tissues, brain activity, tendon, tumors and a myriad of other “soft tissues” without cutting you open.
However, as with any technology it is a double edged sword. If I had a penny for every patient who collapsed at my feet with an MRI report bemoaning, “I have the biggest bulged disc the doctors ever seen, I’m doomed to surgery” well I’d have a stack of pennies to say the least. Even more, you can fill in bulged disc with any or more of the following; bone spur, meniscal tear, labrum fray, degraded tendon, exploded rotary girder. The rest of this article is dedicated to exploring the other side of the coin. Let’s take a look at a few really relevant body parts.
Spine:
A study by Borenstein et al. is a great one. In 1989 they took a group of individuals (albeit small) that was pain free and gave them all an MRI and recorded the outcomes. 31% of these pain free folks had pathological findings on their MRI. Now the cool part, they followed up 7 years later to see how everyone was doing and as expected over 7 years back pain did pop up throughout the group. However, the following is the conclusion from the authors based on the statistical appearance of pain.
“The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. Individuals with the longest duration of low-back pain did not have the greatest degree of anatomical abnormality on the original, 1989 scans. Clinical correlation is essential to determine the importance of abnormalities on magnetic resonance images.”
The MRI wasn’t able to predict who would have pain even in the presence of pathology!
Now from the heavy hitters over at the New England Journal of Medicine. They rounded up 98 folks without back pain and again offered the free MRI. They also allowed a “blinded” physician to read the results. Meaning he had no idea who the patients were, his job was just to write down what he saw on the scan. Amazingly only 36% of participants DID NOT have disc bulges or protrusions. So 6 out of 10 pain free people had pathology present. Again I’ll let the authors speak for themselves.
“On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.”
Knee:
A recent study by Shivonen et al. wanted to explore the efficacy of knee arthroscopy in individuals with a confirmed medial meniscus tear (the most common type). They took 146 patients without osteoathritis or traumatic tears and divided into two groups. Group 1 received a surgical intervention, meaning they actually resected, “cleaned up” the meniscus in question. Group 2 received a sham surgery as described below.
“For the sham surgery, a standard arthroscopic partial meniscectomy was simulated. To mimic the sensations and sounds of a true arthroscopic partial meniscectomy, the surgeon asked for all instruments, manipulated the knee as if an arthroscopic partial meniscectomy was being performed, pushed a mechanized shaver (without the blade) firmly against the patella (outside the knee), and used suction. The patient was also kept in the operating room for the amount of time required to perform an actual arthroscopic partial meniscectomy.”
Most importantly the results: “In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.” No better than sham surgery! One thing I’d like to note is that these selected patients had failed conservative care, more to come on that in part 2.
A Study by Boden Et al. again was inquisitive of folks who have no knee symptoms. What do their knees look like under the inspection of MRI? In a cohort of 74 volunteers 36% over age of 45 had a confirmed meniscal tear, and an additional 30% (66% total) had meniscal abnormalities that are classified as a suspected tear. So two big takeaways are that “tears” can be uninvolved with pain, and that the MRI isn’t 100% specific to pain or function, the only way to truly know is to “get in there” so to say. Zanetti et al. Took it a different route. They took 57 patients who had symptomatic knees and they did MRI on both knees just for curiosity’s sake. They found that 63% of these patients also had confirmed tears in the pain free knee.
I know what you’re thinking to yourself right now, “wow I’m super glad that Will is lame enough to scour google scholar and convince me I’m bullet proof.” Not so fast….. The biggest take away here is “pain is extremely multi-factorial” We all know someone who had a knee scope and feels great, or someone who has a back surgery and it helped tremendously. Despite the fact that there is extremely scarce evidence to accurately predict who will benefit from surgery (Perhaps another article) there are times that it is necessary and beneficial.
The reality is there are some increased risks with having MRI findings. But, like any other medical condition we’ve got to understand that there are two sides to every coin. There’s physiology AND environment, one without the other usually won’t make changes. If you have a bulging disc, osteoathritis, meniscal tear etc. you should think of it like kindling in a forest. Can it catch fire? You betcha! But every fire needs a spark, and a lot of times you are the one holding the lighter.
Training: Are you keeping the area strong? Are you overdoing it? Get a coach, get advice from a physical therapist. These are very modifiable factors, and a lot of times relative rest will help. Meaning give that knee a break from squats but don’t ignore upper body or hamstring exercises.
Diet: What we eat has a direct correlation to our function and feeling. Going to a more whole foods based diet, slowly and fully chewing your food, even hydrating adequately can all reduce inflammation and improve function of joints and tissues.
Stress: Pain is an output of the brain! We’ve seen great studies using cognitive behavioral therapy or mindfulness practices being effective in Chronic pain patients. Active stress management can definitely be a part of your self care. The body only knows stress, not type so whether it’s physical or mental it adds to the picture.
Sleep: this probably can be bucketed with stress, but if you’re not getting your quality sleep your body’s resiliency and ability to self correct are greatly hindered. Pain and injury prevalence being higher in shift workers shouldn’t be a surprise
These are just a few modifiable factors which can effect your pain experience. Just because your MRI has something doesn’t doom you to surgery or to a life of pain.
Now why did I include this creepy X-Ray? Honestly to put my money where my mouth is, this is an x-ray of my spine, missing in the lateral view were a few old fractures as well. What does this mean to me? Well it explains why I have varying levels of hip rotation, side bending and occasional back pain. It also let’s me know that I do need to take care of myself. Meaning appropriate strength training, including specific mobility work, and not being afraid to get some conservative care if and WHEN I get lumbar flare ups. Our bodies are pretty resilient healing machines if we just give them the time and resources to do so. If you take away anything from this article it’s conversation and understanding. I want more open conversations with your doctor about you as an individual. and even more importantly I’d like more conversations between practitioners. We have a long way to go on having it all figured out and the secular nature of care is only hindering progress and growth.
Sources :
Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331(2):69–73.
Borenstein DG, O’Mara JW, Boden SD, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects. A seven-year follow-up study. J Bone Joint Surg Am. 2001;83(9):1306–11.
Raine Sihvonen, M.D., Mika Paavola, M.D., Ph.D. Arthroscopic Partial Menisectomy versus Sham Surgery for a degenerative Meniscal Tear. N engl J Med. 2013
Marco Zanetti1, Christian W. A. Pfirrmann1 Patients with Suspected Meniscal Tears: Prevalence of Abnormalities Seen on MRI of 100 Symptomatic and 100 Contralateral Asymptomatic Knees. American Journal of Roentgenology. 2003.Read More: https://www.ajronline.org/doi/abs/10.2214/ajr.181.3.1810635