When the MRI Tells Only Part of the Story

From My Clinic Notebook

Not every lesson has an answer. Sometimes it starts with a question. Sometimes it changes the way I think. Sometimes it simply reminds me how much there still is to learn.

THIS MONTH’S OBSERVATION

One conversation seems to find its way into my clinic almost every week. A patient arrives with an MRI report already in hand and, before we’ve talked much about symptoms or examined them, points to a line on the report. “It says I have a meniscus tear.” Or a labral tear, a rotator cuff tear, arthritis. Then comes the question that really matters: “Is this what’s causing my pain?”

It’s a fair question, and one that deserves a thoughtful answer rather than a quick one. MRI has changed medicine for the better — it gives remarkable detail and often answers questions we couldn’t a generation ago. But the image is only one part of the story. The challenge isn’t simply identifying an abnormality; it’s deciding whether that abnormality actually explains why someone hurts.

I’ve seen patients with dramatic-looking findings who run, golf, hike, and lift with little discomfort — and others whose imaging looks unremarkable but whose pain significantly limits their lives. Neither is unusual. Medicine isn’t practiced on images. It’s practiced by listening, understanding goals, examining how people move, and asking whether the imaging truly fits the clinical picture.

What We Know

Research over the past two decades has taught us something that surprises many patients — and occasionally reminds clinicians, too. Age-related changes on MRI become increasingly common, even in people who have no pain.

HIGH CONFIDENCE

MENISCAL TEARS

Common on imaging — and often painless.

—About 35% of adults over age 50 have a meniscal tear visible on MRI.

—Many of these individuals report no knee pain whatsoever.

—Prevalence increases further with age and with osteoarthritis.

HIGH CONFIDENCE

HIP LABRAL TEARS

Frequently found in people with no symptoms at all.

—In one study, ~69% of adults without hip pain had a labral tear on MRI.

—Nearly three of four participants had at least one MRI abnormality despite normal function.

—These findings can cause pain — but must be read in the context of the person, not in isolation.

CLINICAL PEARL

Treat the patient, not the picture.

Question to Consider

If two people can have the same MRI finding but completely different symptoms, what else should we be paying attention to before deciding on treatment?

Medicine is constantly evolving. So are the questions worth asking. I’ll keep sharing what I’m learning — from research, from colleagues, and from the patients who continually remind me that good medicine begins with curiosity. If this perspective resonates with you, I’d be honored to have you join me for the next edition.

UNTIL NEXT TIME,

Melissa Burman, MD

WANT TO READ THE RESEARCH?

HIGH CONFIDENCE

Englund M, et al. Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons. New England Journal of Medicine. 2008.

Register B, et al. Prevalence of Abnormal Hip Findings in Asymptomatic Participants. Clinical Orthopaedics and Related Research. 2012.