150. MRIs for the Physical Therapist - Using MRIs as a Piece of the Puzzle

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Welcome to PT Stocks podcast! In this episode, we dive into the fundamentals of using MRIs in physical therapy. MRIs are a great tool, but we need to learn how to use them appropriately to maximize their effectiveness. We'll explore key topics such as common asymptomatic MRI findings, when to order imaging, and how to educate and empower patients. Expect to learn about the cervical and lumbar spine, knee, rotator cuff, and hip labral tears, and get actionable tips on integrating MRI with clinical assessments. Tune in for practical takeaways that will enhance your diagnostic skills without over-relying on imaging.

00:00 Introduction to PT Stocks Podcast

00:55 Understanding MRIs: Asymptomatic Findings

03:42 Clinical Examples of MRI Findings

08:59 When to Order an MRI

12:34 Cases Where MRI May Not Be Needed

14:50 Conclusion and Additional Resources

Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811–816. doi:10.3174/ajnr.A4173

Culvenor AG, Øiestad BE, Østerås N, et al. MRI features of knee osteoarthritis in patellofemoral pain: a cross-sectional case–control study. Br J Sports Med. 2018;52(12):817–823. doi:10.1136/bjsports-2017-098349

Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8(4):296–299. doi:10.1016/S1058-2746(99)90148-9

Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease: a comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. 2006;88(8):1699–1704. doi:10.2106/JBJS.E.00835

Register B, Pennock AT, Ho CP, Strickland CD, Lawand A, Philippon MJ. Prevalence of abnor

Transcript

0:31

Hey everyone. Welcome to PT Stocks podcast. This is Kasey, your host, and if you're tuning in for the very first time, what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals in by ice segments of time. Now, today we're gonna cover more on MRIs things to consider that might be. Both asymptomatic findings on MRI and when to order one with your patients. Before we do that though, if you've been listening to this show for at least three episodes and you found it to be really helpful for you, if you wouldn't mind leaving a review wherever you listen to this, that would mean the world to me.'cause that really does make a big difference in helping the show grow if you've already done so. Thank you so much. I really appreciate you guys taking the time to do that. It means the world to me. But without further ado, we're gonna cover. Common asymptomatic findings with MRIs. And when to order them, because I do feel there's absolutely always a space for imaging, but sometimes as physical therapists or physiotherapists, we can fall in the camp of either relying too much on imaging for our diagnostic abilities. Or completely ignoring that we have it as a tool and as a resource especially when things aren't going the way that we think it should be going. An MRI is a tool, but it's meant to be used in conjunction with other exam techniques. So we're gonna cover common examples of a asymptomatic findings. Good education tools that you can use with your patients as well but also Some examples of when we really should advocate for our patients, having them. So with that I do have an earlier episode on what exactly an MRI is and keep in mind there's so much to MRIs themselves in terms of how they're utilized what exactly they do. If you wanna go back and review that, I will leave the episode number in the show notes.'Cause it is from way back when, but, beyond this. The purpose of this episode is to talk more about clinical examples, so just keep that in mind. Sometimes there's a big mismatch between MRI findings and symptoms. Now within MRI, as I mentioned before, an MRI is a tool. Often our patients may come to us already within an MRI that says, I have this problem, and they may have seen other providers before you that also just use that maybe didn't do any additional tests sometimes. That patient, their symptoms may absolutely correlate with those findings, especially on their functional and clinical exam. Sometimes they don't. So if we were to assume that the imaging tells all, we may miss out an opportunity to find something that does not show up in imaging very well, but does show up on their functional exam. And then guess what? If you are just treating via imaging, you may totally miss that. So it is still important to master the basics in your subjective interview and your objective exam on the patient's history, what they're telling you, pain qualities with their functional exam, and making sure that you're really narrowing in on that, and then see if that matches their imaging. The purpose of this episode is to go over common examples of when it may not match up, which means when I go over those examples. You may want to make sure that you feel very confident in your ability to assess those without imaging so that you don't get caught up in that trap. So some common examples, we are going to start with the cervical and lumbar spine. There's been an article by Icti, I am so sorry, I'm mispronouncing this name, but Icti et al from a 2015 paper in the American Journal of Neuroradiology Radiology. It's called the Systematic Review of Imaging findings of the Spine in Asymptomatic Adults. I'll leave a reference list in this episode, but they were able to basically correlate by age findings of disc degeneration, dis bulge, dys protrusion on their MRIs. In asymptomatic people, that means that they did not have any symptoms. So for instance, someone in their twenties, there's a 37% chance that disc degeneration will show up. 30% chance of a disc bulge, 29% chance of a disc protrusion. These people have no idea that this is a problem all the way up into their forties, sixties, and eighties. Essentially, the occurrence rate of all disc generation, disc bulge and disc protrusion, all increase with age and all of these. Our asymptomatic people. For instance, someone in their eighties has a 96% chance of disc degeneration, 84% chance of a disc bulge, and 43% chance of a disc protrusion. So the key takeaway, this can be a very common aspect of someone's imaging, especially the older they get, it does not necessarily mean that it is driving their symptoms. So make sure that you're assessing them, not assuming, and see if this correlates with their history in their exam. Next one. We're gonna talk about the knee. So Colvin or etal in the British Journal of Sports Medicine 2019 article wrote something called The structural abnormalities detected by MRI are common in people with and without knee pain. So they found that there's cartilage damage in 42% of people without knee pain, bone marrow lesions in 26%. Meniscal tears, 19% synovitis 17%. So even moderate joint degeneration on MRI doesn't necessarily mean pain. Structural damage, quote unquote, is often found in pain-free knees. Next one, the rotator cuff. So there's a couple papers I'm quoting. One is a little older. It's from 1999 by Temple H Etal. Another one is by Yamaguchi Etal from a 2006 paper. They had a test sample of over 400 asymptomatic adults, and they found that partial or full thickness rotator cuff tears were found in 20% of people in their sixties, and over 50% of people over 80 years old. This was a temple off. Yamaguchi had all found that in 23% of people with asymptomatic tear on one side, the opposite or asymptomatic side also had a full tear. So massive rotator cuff tears can exist without any pain or weakness. It's about function and then hip labral tear. Register Atal in 2012 and the American Journal of Sports Medicine found that 69% of asymptomatic hips in young adults with a mean age of about 37 showed labral tears on their MRI. They even found in some populations such as asymptomatic hockey players, up to 89%. So labral tears in the hip may not necessarily be inherently symptomatic, but it could be adopted to sporin load. I could go on in several studies, but basically general degenerative changes. Across all regions, imaging and pain-free individuals, just, it may show osteophytes, joint diffusion, cartilage thinning, tendinopathy, bone spurs. These can be adaptive age related, or activity related. Not inherently painful or bad.'Cause we know that pain is complex. It's influenced by biomechanics, load management, sensitization, psychosocial context, all those things. Structural abnormalities does not necessarily mean mechanical irritability. Some findings may be quiet. While others might provoke symptoms when we are testing for them based on what on imaging. And the MRI sees anatomy not experience, right? So we want to normalize this with our patients, especially if it's a common finding. Don't leave them thinking that they're the only one in the world with this if that's not necessarily true.'cause there's probably a lot of. People doing what they want to be doing, who have similar imaging. We want to help them understand that there is more to meeting their goals than utilizing imaging. It's more about their function, right? And we also wanna make sure that we're empowering our patients. So building out a plan in our clinic on how we're gonna get them to what they wanna do. Now, here's the other flip side of that. When do we order or ask for an MRI? Depending on if you're in a place where you can order MRIs directly, or if you need a doctor referral for an MRI communicate with your medical team regardless. This is important for us as physical therapists to be communicative with people who are outside of our specialty so that we can do right by our patients. So if we are seeing our patient, we could spend way more time with our patient than a lot of providers do, and we're noticing some things. This gives us a chance to advocate for our patient and help out our entire medical team. So starting with our most serious, we always really wanna image is where there's something we're concerned about that's a serious pathology. So if we're suspicious of a fracture. They experienced a high trauma bony tenderness, swelling. We're pretty sure like their symptoms may point to that, even if maybe they had an MRI or an x-ray or maybe they didn't even have an x-ray. We do want to get imaging for those people. So now let's talk about instances where we do maybe one in imaging and maybe even. Most people will start with an X-ray, and then an MRI, especially if we're suspicious of soft tissue, bone marrow, or neural structures. So when I'm saying imaging here I'm referring to all imaging just to be clear, but more serious things that we do absolutely wanna get imaging for are, we're suspicious of a fracture. We might be the first people that see these patients and maybe if they've had a history of high trauma, bony, tenderness, swelling. We wanna make sure that we are getting these people taken care of sooner rather than later. Potential signs of infection. Maybe they have fever, warmth, night sweats things like that. Also may be good too. Rule out if we're suspicious of maybe a tumor. Maybe they have unexplained weight loss or night pains. Systemic symptoms may not be musculoskeletal, but we still need to advocate for our patients, right? The sooner we catch those, the better. If they're having a neurological deficit, if you see foot drop, saddle anesthesia, cardio, Aquinas symptoms those are. Definitely ones that we will want imaging for, probably an MRI for that, especially. Or non mechanical pain. They have pain at rest that's worse at night. Unrelated to movement. Also very appropriate for imaging. Now more on cases where we may need to use a little bit more clinical reasoning. They're borderline, maybe not an immediate, yes, they need imaging, but maybe someone we're keeping an eye on would be for someone who we've rehabbed for six to eight weeks and we haven't seen any change. Despite the fact that our patient is doing what we told them to do, they have good adherence. If we're suspicious of some sort of internal derangement that may change management, such as if they are having. Let's say we're treating their knee and they are catching and locking unable to unlock their knee, things like that. That is definitely going to need some imaging or sudden loss of motion or strain, especially if there's no pain. And if they're planning for a surgical consult that, like for an ACL labrum or cuff tear, they're probably gonna get imaging. So we do always wanna reassess, irritability and functional limitation before escalating to imaging to consider if it is pain limiting or strength limiting too. Now in terms of musculoskeletal pain, these are instances where we don't usually need an MRI. Common examples would be things that are non-traumatic, positionally provoked like patellafemoral pain, tendinopathies, non-specific, low back pain, rotator cuff pain without trauma overuse, joint pain like anterior hip. For some instances, okay, maybe if they have pain in the patellafemoral joint, maybe when to do an MRI to see if there's any anything going on at the kneecap or things like that. But we're probably gonna start off treating them conservatively. And then just like I mentioned before, if they're rehabbing him and we're not really having changes that we want, let's get some more information. Now, obviously this is not holistic and there are so many more instances and nuances that we could talk through in terms of imaging. This topic is large, not only going into. Why maybe some of these things I mentioned before are asymptomatic when they show up on imaging, but also all these different scenarios on when maybe we do need imaging. As always, you need to make sure that you are doing right by the patient that's in front of you. If something just doesn't feel right, can't really put your finger on it. Don't just ignore this feeling, whether it's you're talking to their provider or you're reaching out to a mentor to talk about it, or doing your own research. Do all of these things.'cause the more that we catch those things, those are the patients that we can really make a big difference in their lives with. So don't be afraid to ask questions. Don't assume. That if failure of progression of your patients is a failure of your abilities, it could also be maybe something out of the norm that we are missing. And imaging can be a great tool to use for that, but we don't only wanna use imaging. So that's it for today guys. If you have any questions, feel free to reach out at pt Snacks podcast@gmail.com. If I don't know the answer to your question, I'll find somebody who does. I'll do my best to find somebody who does. But if you guys if you guys are in need of more eu, you wanna take a deeper dive on a lot of these topics that we're going over on the show. Med Bridge is actually offering listeners over a hundred dollars off their years subscription, which is. A really good deal considering they have tons of online CU courses, webinars, and even specialty exam prep courses. So I use them for studying for my OCS and they have a ton of practice tests where you can get used to looking at a screen for long periods of time. Explanations, study chapters, all that kind of stuff. So definitely check out the show notes for your promo code, and if you're a student, you get an even better deal. So definitely go and check that out. Other than that, I hope you guys have a great rest of your day and next time.