We get many emails from people asking us about our ability or the ability of stem cell therapy to repair their knee damage. Some of these people have had a recent MRI and a report of what the MRI recorded and what the radiologist interpreted. Some of these MRI reports are deep and comprehensive in their description of an unseeingly insurmountable amount of damage to the person’s knees. The person who sends in the email will sometimes add something in the email to suggest that their MRI is one of the worst that their doctor has ever seen. The funny thing is when we ask, “well how does your knee feel today?” Sometimes we get the answer, “not bad.” How can someone who has one of the worst knee MRIs their doctor has ever seen, have a knee that is “not bad”? That is what a lot of research is focusing on.
We also get emails from people who have terrible knee MRI reports and a have a frozen joint, fused by excessive bone spurring. These people cannot bend their knee. In these situations where knee range of motion is compromised, increasing functional ability may not be a realistic goal of stem cell treatments, a discussion with this person would turn towards an assessment of the treatment’s ability to help with their pain. Not every person with damaged knees is a good candidate for stem cell therapy.
However for the patient who is active, has a good range of motion in their knee, can bend their knee, even with a bad MRI, this person would be considered a realistically good candidate for stem cell therapy.
This article will focus on these people. People who may have a bad MRI and the research that shows the overzealousness of doctors to use the MRI as a justification for a knee surgery or a knee replacement that the patient did not really need to have.
Research: We should manage the patient, not the MRI or the x-ray
I have been providing regenerative medicine injections for more than 20 years. We always treat the patient. We do not treat the MRI. What does this mean? It means that while the MRI is an important tool in seeing what is going on in the knee, it sometimes shows us too much. It sometimes shows us damage that is not bothering or limiting the patient. If you solely relied on what the MRI is showing and never talked to the patient about how their knee felt, there would be a lot more knee surgeries, and a lot more failed knee surgeries and a lot more worse off people. There is a lot of research to back this up.
Should your x-ray send you to MRI or treatment
Challenging determination of of what your x-ray says should not automatically send you to an MRI or surgery. Many patients get an x-ray in the doctor’s office to check for obvious anatomical deformity. In many cases the x-ray reveals the presence of advancing osteoarthritis. Researchers are asking, “then what should the doctor do next?”
In the medical journal Arthritis, (1) researchers investigated the relationships between pain, disability, and radiographic findings in patients with knee osteoarthritis. They questioned the traditional ideas of “what the doctors should do next.”
Research: “. . . treatment of knee osteoarthritis could be planned according to the clinical features and functional status instead of radiological findings.”
- A total of 114 patients with knee osteoarthritis with two-sided knee radiography were assessed with the Kellgren-Lawrence scale.
- The Kellgren-Lawrence scale is a scoring system radiologist use to give a numeric value to the severity of damage recorded by the radiography
- Then the patients were asked to score their levels of pain, stiffness and disability using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).
- WOMAC is a comprehensive questionnaire that asks the patients “how does your knee feel?”
- The average age of the patient in the study was 57 years old and had been diagnosed and seeking treatment for about 4 years.
- The Kellgren-Lawrence grading scale were positively and significantly associated with a degenerative knee condition that could suggest surgery based on the picture alone
- BUT, there was no correlation between how the patient felt (WOMAC score) and the pictures of the damage to their knees (the Kellgren-Lawrence grading scale)
- Conclusions. Knee pain, stiffness, and duration of disease may affect the level of disability in the patients with knee osteoarthritis. Therefore treatment of knee osteoarthritis could be planned according to the clinical features and functional status instead of radiological findings.
Doctors in Austria also have concerns. Writing in the German medical journal Radiologe, (2) they said: “Although knee radiographs are widely considered as the gold standard for the assessment of knee osteoarthritis in clinical and scientific settings they increasingly have significant limitations in situations when resolution and assessment of cartilage is required.” So the scans were found lacking when it came to cartilage problems in terms of assessing treatment recommendations. Next stop: MRI.
Knee MRI to confirm recommendation to surgery?
A bad looking x-ray will typically send a patient to get an MRI. The MRI is typically seen as a justification to a surgical recommendation. In a recent study published in the journal Knee Surgery and Related Research, (3) doctors expressed concerns over treatment recommendations given to patients for their knee pain based on MRI findings. The title of their paper? “Is Knee Magnetic Resonance Imaging Overutilized in Current Practice?”
In this paper the doctors, from South Korea’s leading medical universities examined MRI knee scans of patients to determine if the MRI was helpful in determining treatment, specifically surgical recommendations.
One hundred eighty five patients had an MRI – doctors examining the MRI made recommendations – here is the results:
- 39% of the MRIs were USEFUL – mostly in regard to sports injury where a clear cut defect could be seen 18% were too equivocal to make a determination one way or another.
- 43% were judged “arguably useless. These are the patients who suffered from degenerative joint disease and non-specific chronic pain.
The answer to the question Is Knee Magnetic Resonance Imaging Overutilized in Current Practice? These researchers said yes, and that doctors should re-evaluate the role of MRI in treating chronic degenerative knee pain. If it should have any role at all.
At the beginning of this article I related to you that we get many emails from people who tell us that they have an MRI they can send us. The purpose is to see if we can help them. Sometimes however, they want an opinion to back up the decision to have knee surgery. When we say, we need to do a physical examination, the MRI may not be telling us the truth in the search for their pain source, surprise enters the conversation. How can the MRI be wrong?
Researchers Question MRI Accuracy for Knee Pain Source: “MRI examination is not currently as important for the diagnosis of knee injuries as expected by both medical and lay communities”
Doctors in the Czech Republic had their concerns as well and they published these concerns (4): “Magnetic resonance imaging (MRI) has the highest sensitivity of all methods for the diagnosis of intra-articular knee injuries. In spite of this, its benefit for the decision-making algorithm is questionable.” In other words the MRI is showing a defect in the knee that is being interpreted as the pain source. The decision therefore to go to surgery based solely on this evidence is what they are calling into question.
These researchers examined the medical records of patients who underwent knee arthroscopy who had a pre-operative MRI examination.
They examined patients who had:
- lateral meniscus tears,
- anterior cruciate ligament (ACL) tears,
- and articular chondral lesions, with the diagnostic value of MRI the lowest for cartilage damage.
They concluded “There is no consensus regarding the role of MRI in the diagnosis of intra-articular lesions of the knee. To a certain extent, its use is related to local conditions. It can be concluded that MRI examination is not currently as important for the diagnosis of knee injuries as expected by both medical and lay communities.”
We should note the the x-ray’s inability to properly assess cartilage damage is a primary reason for moving onto an MRI. Here the MRI’s ability to properly assess cartilage damage is also questioned.
In this image, the various soft-tissue components of the right knee are seen from the top or superior view. Looking the knee we see that the medial meniscus occupies the oute right side of the knee, the lateral meniscus occupies the inner left side of the right knee. We also see the close relationship and proximity of the supporting knee ligaments on the out right side, the medial collateral ligament, and the left side lateral collateral ligament. In the center we see the ACL and posterial cruciate ligament.
The accuracy of MRI for the diagnosis of ramp lesions
I see many people who have had an ACL rupture. Some of these people had ACL reconstruction surgery6, some of these people had ACL Reconstruction Revision Surgery, some of these people deciding against the ACL reconstruction for various reasons. One of the tricky problems in people who are ACL deficient or had ACL reconstruction surgery that either failed, weakened or loosened, is the Ramp Lesion.
The ramp lesion is a vertical or longitudinal tears of the peripheral capsular attachment of the posterior horn of the medial meniscus at the meniscocapsular junction (where the meniscus anchors itself to the back of the knee).
A July 2021 study (5) examined 57 patients who had surgical repair of their ACL. In this study two experienced radiologists could only moderately suggest that a ramp lesion existed. This tear is often seen as an undetected source of knee instability in the ACL weak or ACL deficient knee.
Many undetected sources of knee instability because of the meniscus.
How about you? A realistic assessment of your ability to avoid a knee surgery or have a realistic expectation of stem cell therapy success starts with an email.
Do you have questions? Ask Dr. Darrow
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Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician.
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1 Cubukcu D, Sarsan A, Alkan H. Relationships between Pain, Function and Radiographic Findings in Osteoarthritis of the Knee: A Cross-Sectional Study. Arthritis. 2012;2012:984060. doi: 10.1155/2012/984060. Epub 2012 Nov 19. PubMed PMID: 23209900; PubMed Central PMCID: PMC3506881.
2 Wick MC, Jaschke W, Klauser AS. Radiological imaging of osteoarthritis of the knee. Der Radiologe. 2012 Nov;52(11):994-1002.
3. Song YD, Jain NP, Kim SJ, Kwon SK, Chang MJ, Chang CB, Kim TK. Is Knee Magnetic Resonance Imaging Overutilized in Current Practice? Knee Surg Relat Res. 2015 Jun;27(2):95-100. doi: 10.5792/ksrr.2015.27.2.95. Epub 2015 Jun 1.
4. Cellár R, Sokol D, Lacko M, et al. Magnetic resonance imaging in the diagnosis of intra-articular lesions of the knee. Acta Chir Orthop Traumatol Cech. 2012;79(3):249-54.
5 Laurens M, Cavaignac E, Fayolle H, Sylvie R, Lapègue F, Sans N, Faruch M. The accuracy of MRI for the diagnosis of ramp lesions. Skeletal Radiology. 2021 Jul 3:1-9. [Google Scholar]