As Physiotherapists, we can refer our patients to have a variety of scans including MRI. But while modern scans can offer better quality images than ever before, the scan is not the whole story. In giving patients the best care, the skill and experience of the clinician will always be the critical element.
Last week I saw a patient of mine, let’s call her Phoebe. Phoebe was in her forties and had been having hip pain. Not severe pain, but a real nuisance. I had already assessed her across a couple of visits. It wasn’t a simple case but we had started a management plan and Phoebe was off to a promising start.
Then, when visiting her GP about something unrelated, Phoebe mentioned her hip and the GP arranged an MRI scan. The good news, she was told, was that the MRI found the problem. The bad news was that she “had torn cartilage in her hip, and needed to see a surgeon.” Phoebe made an appointment with the recommended surgeon and returned to see me later that week.
Phoebe was troubled on that visit. She told me what had happened and showed me the MRI report. The idea of having a damaged joint was stressing her out a bit and, naturally, she did not like the thought of possible surgery. She also felt that she’d been making progress with her exercise program. Looking at the report, I was relieved. It described a small, non-displaced tear of the fleshy rim of cartilage around the hip socket, called the labrum. Nothing else. Now, there was an important fact that I knew that Phoebe didn’t.
Small cartilage tears in the hip are common. They often don’t hurt at all.
If you take a group of people without any hip pain and gave them all an MRI scan, quite a lot of these people will have up a “torn” labrum like Phoebe’s. A quick look on my ipad found a 2012 study (1) that reported labral tears in 69% of pain-free people Phoebe’s age. Similar results have been shown from other studies on the hip (2, 3) and other problems including disc bulges in the back (4) and rotator cuff tears in the shoulder (5).
Phoebe was quite shocked to hear this. Now she “didn’t know what to think!” Thankfully, there was plenty of time for Phoebe and I to discuss the complexities at play and I did my best to answer her questions.
Did I think it “wrong” for Phoebe to be given an MRI?
No. Scans are a useful tool and Phoebe’s doctor was no doubt trying to help her get the best information. Possibly the MRI may have shown up a more worrying problem, or one that we know is clearly associated with pain. I had offered to refer Phoebe for this previously, though felt it non-essential given the unlikelihood of it changing her treatment and the cost.
Was it “wrong” for Phoebe to be referred to a surgeon?
Not exactly. A surgeon could provide further insight by their examination and experience. But for the GP to imply that Phoebe could need surgery, based on the MRI, was misguided. Since the GP in this instance had not assessed Phoebe’s hip and was unable to judge the meaning of the MRI findings accurately, it might have been better not to comment.
The job of a shrewd clinician is to consider all the information available: what the patient tells them in detail, careful physical examination and scans. True, there are times when the scan result will be the main story. But if the scan shows something that cannot reasonably explain a person’s complaint, this should be put aside.
Now, I think that GPs are generally amazing in what they do. They have the difficult task of assisting patients with the staggering range of health problems that come in their door, and often work under considerable time pressure. I would never expect a GP to have the expertise or the time to have given Phoebe’s hip a proper musculoskeletal assessment and to weigh up all the things I’ve mentioned.
With the benefit of a full assessment, I could see that Phoebe’s main area of pain was not anything to do with the hip joint at all. Rather, it was a tricky form of tendon pain where tightness of certain muscles, stiffness in the joint, sensitisation of the nervous system and some less than ideal muscle patterns were all conspiring to cause Phoebe’s pain. To Phoebe’s relief, surgery is not indicated.
The key thing here is that the scan is only one source of information. Not the whole story.
As experienced Physiotherapists, we are well-placed to help you make sense of painful problems like this. We like explaining things too. As with Phoebe, our detailed approach will help you pursue the best course of treatment, whatever that is, without undue worry.
REFERENCES:
1. Register et al (2012) Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. American Journal of Sports Medicine 40(12): 2720-4
2. Schmitz et al (2012) Identification of acetabular labral pathological changes in asymptomatic volunteers using optimized, noncontrast 1.5-T magnetic resonance imaging. American Journal of Sports Medicine 40(6): 1337-41
3. Gallo et al (2014) Asymptomatic hip/groin pathology identified on magnetic resonance imaging of professional hockey players: outcomes and playing status at 4 years’ follow-up. Arthroscopy 30(10): 1222-8
4. Boden et al (1990) Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. Journal of Bone and Joint Surgery Am 72(3): 403-8
5. Moosmayer et al (2009) Prevalence and characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic and clinical study. Journal of Bone and Joint Surgery Br 91(2): 196-200
