On Saturday, the New York Times ran an article called “Sports Medicine Said to Overuse MRIs.” The author of the article and several quoted orthopaedists claim that the field’s reliance on MRIs has crossed the line from appropriate use to overuse. In fact, the article claims that MRIs are “given to almost every injured athlete or casual exerciser.” If this claim is true, it is important for several reasons. First, MRIs are highly sensitive to abnormalities (which may or may not be relevant) so overreliance on MRIs, especially bad ones, can lead to misdiagnosis and unnecessary surgeries. Second, the scans are expensive, and in a healthcare environment where costs are spiraling upward overuse is costly. Finally, if MRIs are truly given to almost everyone, it calls into question the ability of physicians to perform a competent medical exam.
Sports medicine is a somewhat unique subspecialty of orthopaedics because so many of the conditions and injuries we treat involve soft tissues such as ligaments, tendons, and cartilage. Whereas a femur fracture or bone-on-bone arthritis can be clearly seen on an x-ray, soft tissue injuries such as tears of the meniscus or rotator cuff cannot. Because of this, x-rays, while useful for diagnosing or ruling out injuries to surrounding bone structures, often do not give us a complete picture of our patients’ injuries, therefore leading sports medicine orthopaedists to rely more on MRIs than many other orthpaedic surgeons.
On a typical clinic day I see around 40-45 patients, and I generally order 3-4 MRIs. My most important diagnostic tools are the patient history and physical exam, and most conditions can be diagnosed without ever ordering an MRI – and most of these conditions can be treated non-surgically. However, some cases will need surgery, and while I may be confident enough in my diagnosis to operate on someone on the basis of the physical exam alone, I can understand why some of my patients would prefer having an MRI to confirm my diagnosis. Some people simply need to see to believe, while others see me as a relatively young surgeon. These people generally feel more confidence in me and better about their decision to proceed with surgery when they can see an MRI.
There is another reason I sometimes have for ordering an MRI. Even when the patient and I feel confident in my diagnoses, if I recommend surgery, an MRI can help with surgical planning by showing the extent of the injury and any associated injuries that may need to be addressed at the time of surgery. For example, seeing an MRI of a meniscus can help me decide whether I will repair or trim out a tear.
Do some sports medicine specialists over-rely on these scans? I’m sure they do. Do most? I don’t know, but I believe this article raises some questions that should be discussed in the field. MRIs I order are read by a musculoskeletal radiologist, and I would be interested to know if the MRIs in the studies mentioned in the article were read by these as opposed to general radiologists. Financial incentives are another topic for discussion – some surgeons in private practice own their own MRI machines, and the charge is often made that since there is a financial incentive, these doctors often order unnecessary MRIs. As a hospital employee, I do not receive any financial benefit for ordering an MRI, although I would like to believe that if I did it wouldn’t affect my decision-making process. Another issue is that the enormous expense of a new MRI machine means that many offices are still using old machines that simply do not give us the same quality of scans that newer machines can, which sometimes means the patient will have to get a second, clearer MRI. All of these are important issues that I believe doctors and others in the healthcare system should be addressing.
For patients, my advice is to ask questions. If you are concerned about whether or not an MRI is necessary, ask about your physician’s reasons. Ask about the age and quality of the machine, and remember that you are never required to use a specific provider. Ask about the training and experience of the person reading your MRI. In short, if there is anything you are uncomfortable with – ask!