We often get a phone call or an email from someone who has a digital shoulder MRI file that shows damage. They have been told recently, the “only way” to fix this damage is with surgery, and as we will see from the research below, the surgery may not offer the results the patient is hoping for.
My Shoulder MRI is bad, my doctor says surgery
Sometimes, someone will have a bad shoulder and a bad MRI and surgery may be the best answer. However, shoulder MRIs may present faulty or inaccurate information. In our many years experience, we have found that when MRI is the sole governing tool relied upon by doctors to recommend treatment, a patient will often be sent to a surgery with a shoulder that is not that bad.
It can be very challenging to convince a patient that what is interpreted on MRI is not really there. When someone comes into our office, it is sometimes after they got their “bad MRI” reading and their orthopedists is recommending that they get on the list for surgery. The reason that this person is in our office is for the various reasons that someone contacts us after a surgical recommendation: They can’t take off time from work. They are involved in a sport and are looking to avoid long surgical recovery times. They provide for or a re a caregiver to a spouse or aging parent. They just don’t want a surgery. Even so. These people looking to avoid surgery, STILL, have a hard time believing that the MRI is not that bad, they can probably avoid the shoulder surgery. Then we tell them they probably should not have gotten the MRI in the first place. The response is usually, “What?”
A study from a group of radiologists cites rising numbers of inappropriately recommended MRIs and surgeries
This study comes straight from a group of radiologists who submitted their paper to the Journal of the American College of Radiology (1) to bring awareness to the inappropriateness of many MRI orders they see. The bullet points are directly from the research:
- “MRI is frequently overused.”
- “We reviewed medical records of 237 consecutive shoulder MRI examinations . . . Of the 237 examinations reviewed:
- 106 (45%) were deemed to be inappropriately ordered, most commonly because of an absent preceding radiograph. (An MRI was ordered because there was no previous MRI).
- Nonorthopedic providers had a higher frequency of inappropriate ordering (44%) relative to orthopedic specialists (17%)
- In the 237 examinations, ultrasound could have been the indicated advanced imaging modality for 157 (66%), and most of these (133/157; 85%) could have had all relevant pathologies characterized when combined with (x-ray).
- While nonorthopedic provider orders were more likely to be inappropriate, inappropriateness persisted among orthopedic providers.”
Stem cell therapy in the shoulder
Does imaging studies truly reflect the patient’s shoulder pain symptoms?
- In the medical journal Shoulder and Elbow, October 10, 2018: (2) Doctors in the United Kingdom made these observations after investigating whether magnetic resonance imaging (MRI) scans can accurately diagnose arthritis of the acromioclavicular joint.
- “MRI is not helpful in making the diagnosis of acromioclavicular joint arthritis. A focused history and clinical examination should remain the mainstay for surgical decision making.
- In the medical journal Arthritis care & research, August 2018 (3), doctors in the United Kingdom looked at common shoulder symptoms and the use of imaging to help with management. They were trying to clear up an unclear situation. Here is what they said: “Shoulder symptoms are common, and imaging is being increasingly used to help with management. However, the relationship between imaging and symptoms remains unclear. This review aims to understand the relationship between imaging-detected pathologies, symptoms, and their persistence.”
- What was the answer of this research? “There was no significant association between most imaging features and symptoms among high-quality, cross-sectional studies.”
- What the MRI shows is not always indicative of what the patients pain and range of motion symptoms are, nor can the MRI predict the persistence of these symptoms.
“Shoulder MRI: What Do We Miss?”
Here is a well cited study in the medical journal American Journal of Roentgenology. The title: “Shoulder MRI: What Do We Miss?” (4)
This study looked at the things radiologists missed on MRIs that orthopedic surgeons picked up during an arthroscopic procedure. Since the surgeons are using the imaging report as a road map for preoperative assessment and planning, the discovery of missed problems can help further the understanding of the accuracy of the MRI and the MRI interpretation. This research review examined shoulder abnormalities that either are not well seen or are not seen at all on shoulder MRI and therefore are misinterpreted.
In regard to problems of the shoulder cartilage, the study authors noted: “Cartilage lesions are difficult to diagnose. . . and . . . “Although MRI is an excellent tool for detecting some abnormalities, there are a number of subtler abnormalities of clinical significance that give radiologists greater difficulty.”
In the Journal of the American College of Radiology, (5) researchers looked to “assess the patterns of Appropriate Criteria application among orthopedic specialists and other fields of medicine for use of MRI and radiography and the subsequent necessity for surgical intervention.”
- Of note: People in the study were patients who already had a “bad” shoulder and this MRI was being ordered to see what was the new source of the patient’s shoulder pain was.
- A total of 475 patients who underwent shoulder MRI were included in this study.
- The researchers found significant associations between a patient having had a prior x-ray, being male, and getting subsequently had a shoulder surgery. Orthopedic specialists ordering MRIs had the highest percentage of patients undergo subsequent surgery (33.3%) compared with the second-most, primary care (18.4%), and all other ordering departments.
- The researchers suggest that if you are a man, had a prior x-ray, had an MRI ordered by an orthopedic surgeon, you were most likely to get a surgery.
“Regardless of MR findings, however, physicians should be cautious when recommending surgery in the patient with a vague clinical picture.”
Here is another 2018 study, this time an MRI of the shoulder where SLAP tear is suspected as not really being helpful to many patients with shoulder pain. This one comes from the University of California at Davis.(6)
Here the researchers offer advice on how to make the MRI more successful at really determining what is going on in the shoulder. HOWEVER, even improving the image of the imaging study by variants in the patient’s position during the MRI, may not help the final outcome of the test, should you have a surgery or not. Here is what the researchers said:
“Regardless of MR findings, however, physicians should be cautious when recommending surgery in the patient with a vague clinical picture.”
How about Rotator Cuff tears?
Here is a study that probably assesses the question about MRI accuracy and what is really happening in the shoulder as good an another. It was published in the Journal of magnetic resonance imaging.(7)
“MRI has become an important diagnostic tool in the evaluation of rotator cuff pathology and the technology continues to evolve. . . . Although MRI findings may be diagnostic in some cases, we find that clinical correlation with history and physical examination is critical to differentiate between anatomic variants, incidental findings, and true pathology. We conclude that good communication between the orthopedic surgeon and the radiologist is necessary to optimize diagnostic yield.”
Anatomic variants and incidental findings?
The point of this article is to demonstrate how MRIs can send you to a surgery you may not need because of challenges with the MRI accuracy and interpretation. MRI is not a gold standard of care, as demonstrated by countless studies questioning MRIs validity in certain diagnostic cases. In our years of experience we have found that because it is difficult to determine what the true source of shoulder pain generator is, our approach is to regenerate the entire shoulder with our treatments and not focus on a single problem such as a tear on MRI or a tear in the labrum, or a developing bone-on-bone situation. This is demonstrated in the videos above.
A study from August 2020 (8) wrote: “When evaluating the rotator cuff, it is important to consider some limitations of MR imaging. The appearance of calcium on MR imaging can be bright or dark and can sometimes be misinterpreted as tears or subacromial bone spurs.”
Why you may not need shoulder surgery: Even with a Bad MRI: Stem Cell Therapy
In our practice, Stem Cell Therapy is a treatment we use for for musculoskeletal disorders including those causing shoulder pain. The excitement in the medical community is focused on how stem cells work, rebuilding the damaged parts of the shoulder from within by turning a diseased shoulder environment into a shoulder joint environment. Numerous studies support the healing effects of stem cell treatments. It should be pointed out as well that some studies suggest limited or little or no positive impact of treatment.
Listen to Dr. Darrow explain
This is an excerpt from Dr. Darrow’s radio show. Here Dr. Darrow discusses an email that was sent in from a person who had a poor shoulder surgery outcome.
The person says: “I agreed to have the surgery and immediately had issues with movement. The doctor said it was a frozen shoulder.” That happened to me too (to Dr. Darrow). I had shoulder surgery done when I was in medical school on my right shoulder because I was very enamored with surgery. I was doing orthopedic surgery at the time. After surgery my shoulder blew up like a balloon and I had a high fever and it took me several years to get that shoulder healed and guess how I healed it? I did it by injecting my shoulder with regenerative medicine injections.
The other shoulder needed surgery because of overcompensation
The person went on to say: “that the doctor said there was nothing he could do but wait and see. I complained to the doctor, he said I would be fine. I eventually hurt my left shoulder from all the overcompensating. The doctor now says I need surgery on that shoulder as well.”
“The doctor did that surgery and said that he couldn’t find anything more (damage that needed repair).”
Dr. Darrow comments: “Maybe because he wasn’t looking at the right things.”
The patient “finally went to well-known surgeon downtown he said I needed a Weaver-Dunn surgery done and he opened me up and decided that it wasn’t damaged like he thought so he didn’t complete the surgery.”
Dr. Darrow comments: “I hear this from patients. They had a surgery and afterwards the surgeon said that there was really nothing there and they closed them back up.”
The person says: “I still have the pain after both surgeries, so you can imagine that I was done with surgery. I was so upset. I ended up finding a pain doctor who treated my left shoulder with trigger point injections which helped somewhat. That doctor also told me that my other doctors didn’t do me any good started. I started working out with my arms for the first time in years. I did elevated push-ups and my arms were burning the next day. So I went to another orthopedic and he did imaging and said my biceps tendon was torn and the other issues he found would require arthroscopic surgery
I’m 8 weeks out of surgery and in constant pain. The only time i get pain relief is if I do nothing. I’m scared and desperate for some help. When I try to talk to the doctor they immediately talk over me and get me out of there as quick as they can.
I hope that stem cells and platelets can help me. Can you help me please?”
Dr. Darrow answers: Probably I’d have to examine you and see what’s going on. You know how I examine people? I touch them to I find out, with my fingers, what’s going on and find where the pain generator is.
Where Do We Get the Stem Cells for Therapy?
For each treatment, stem cells are taken from the patient’s iliac crest at the back of the pelvis. These cells are valuable because they are undifferentiated cells, meaning that they do not have a tissue type but can grow to become other, more specialized types of cells. If a joint, cartilage, tendon, ligament, or muscle needs regeneration, stem cells can supply the building material.
How Is the Procedure Done?
Please watch the video below:
The Stem Cell Therapy injection procedure is a very simple, in-office procedure with no general anesthesia, as it involves almost no pain. Moreover, it takes only about 30 minutes from start to finish. During bone marrow Stem Cell Therapy, a practitioner will inject lidocaine at the top of the buttocks, at or near the posterior superior iliac spine, to numb the area. A tiny incision (which heals quickly after the procedure) is made to allow insertion of a needle to aspirate bone marrow.
No stitches are necessary. The solution obtained is spun in a centrifuge. The stem cells are then harvested and injected into the target area or joint under ultrasound guidance when required.
Although bone marrow aspiration is typically painful during other procedures such as bone marrow transplantation, it is nearly pain free in this case. A relatively small amount is collected.
The research and clinic observations surrounding stem cell therapy would be too large to fit on one page. I invite you to explore these articles:
- Shoulder Impingement – Subacromial shoulder pain
- Slap Tears and Biceps tendinosis
- Return To Play shoulder surgery fails because of over-expectation of what it can really do
- Treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow concentrate and whole bone marrow injections
Do you have questions? Ask Dr. Darrow
A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025
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. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.
1 Sheehan SE, Coburn JA, Singh H, Vanness DJ, Sittig DF, Moberg DP, Safdar N, Lee KS, Brunner MC. Reducing unnecessary shoulder MRI examinations within a capitated health care system: a potential role for shoulder ultrasound. Journal of the American College of Radiology. 2016 Jul 1;13(7):780-7.
2 Singh B, Gulihar A, Bilagi P, Goyal A, Goyal P, Bawale R, Pillai D. Magnetic resonance imaging scans are not a reliable tool for predicting symptomatic acromioclavicular arthritis. Shoulder & Elbow. 2017 Aug 17:1758573217724080.
3 Tran G, Cowling P, Smith T, Bury J, Lucas A, Barr A, Kingsbury SR, Conaghan PG. What imaging detected pathologies are associated with shoulder symptoms and their persistence? A systematic literature review. Arthritis care & research. 2018 Mar 7.
4 Saqib R, Harris J, Funk L. Comparison of magnetic resonance arthrography with arthroscopy for imaging of shoulder injuries: retrospective study. Annals of The Royal College of Surgeons of England. 2017;99(4):271-274. doi:10.1308/rcsann.2016.0249.
5 Small KM, Rybicki FJ, Miller LR, Daniels SD, Higgins LD. MRI Before Radiography for Patients With New Shoulder Conditions. Journal of the American College of Radiology. 2017 Jun 1;14(6):778-82.
6 Boutin RD, Marder RA. MR Imaging of SLAP Lesions. Open Orthop J. 2018;12:314-323. Published 2018 Jul 31. doi:10.2174/1874325001812010314. 1491
7 Bencardino JT, Beltran LS. Pain related to rotator cuff abnormalities: MRI findings without clinical significance. Journal of Magnetic Resonance Imaging. 2010 Jun;31(6):1286-99.
8 Ashir A, Lombardi A, Jerban S, Ma Y, Du J, Chang EY. Magnetic resonance imaging of the shoulder. Polish Journal of Radiology. 2020;85:e420. – 2163