By Phillip Steele, MD RMSK CAQ Sports Medicine
Performance Injury Care & Sports Medicine
Having just finished giving a lecture on “Is it shoulder pain or neck pain” for the 2017 orthopedic update at Nemacolin Woodlands Conference center near Pittsburg Pennsylvania I thought I would share my thoughts on this complicated subject.
It’s not surprising that our current understanding of shoulder and neck pain treatment is evolving. Unfortunately the majority of our understanding is focused on new surgical procedures. Research money is focused on surgical treatment, not in conservative care. With the emphasis of diagnosis in United States relying on MRI based on larger reimbursement, little attention has been paid to ultrasound diagnostic for nerves of the shoulder and neck region. Newer high resolution ultrasound equipment has a higher sensitivity for nerve entrapments through the shoulder and neck than conventional testing such as MRI and nerve conduction test.
In a study of degenerative disc changes to the cervical spine of 497 asymptomatic subjects by MRI, the frequency of all degenerative findings increased linearly with age. Disc degeneration was the most common observation, being present in 17% of discs of men and 12% of those of women in their twenties, and 86% and 89% of discs of both men and women over 60 years of age. They found significant differences in frequency between genders for posterior disc protrusion and foraminal stenosis. The former, with demonstrable compression of the spinal cord, was observed in 7.6% of subjects, mostly over 50 years of age. These results should be taken into account when interpreting the MRI findings in patients with symptomatic disorders of the cervical spine.
Another example or how often MRI scanning is being over utilized is a recent hip MRI study of asymptomatic volunteers. This study showed that 73% of the asymptomatic individuals had abnormal finding and 69% had a labral tear. Once again we have evidence that the physical exam findings, history of the injury and patients symptoms may have a better diagnostic ability than MRI scanning. So if you have hip pain and get an MRI, you have around a 70% chance that the MRI findings might have nothing to do with your pain.
The overall impression is more than ever that MRI can only confirm a physician’s suspicion. MRI can’t help you make the diagnosis. The over utilization of MRI has led to many unnecessary surgeries and procedures. By approaching the neck using an expanded physical exam and a better understanding of other nerve entrapments of the neck and shoulder, we can hopefully find other treatment options for the neck and shoulder. One of the shoulder surgery lectures further cemented that if “your a hammer everything looks like a nail” aspect to health care as surgeons are finally revealing the high rate of surgical failures of rotator cuff surgery with numbers typically greater than 20% in several studies. Maybe MRI just had the wrong diagnosis and we need to look at other potential causes of neck and shoulder pain before jumping on the surgical band wagon.